Physical Examination

The general appearance of the patient is one of the most important factors to consider when examining the patient. The diagnostic possibilities for a patient with ca-chexia are different than a well-nourished patient complaining of flank pain. Patients with classic colic will appear uncomfortable; however, the diagnosis is not always stone disease. A similar appearance can be seen in patients with other urologic problems such as UPJ obstruction or less commonly ureteral tumors. Completely nonurologic problems such as acute appendicitis, gynecologic disorders, or dissecting aortic aneurysms can also present with symptoms of renal colic (Rucker et al. 2004). In all patients, vital signs should be documented. In addition to blood pressure, heart rate, and respirations, the presence of fever is a very important finding. Fever suggests the presence of renal parenchy-mal infection or abscess and overall increases the urgency of the diagnostic evaluation, especially among diabetic patients or those with significant comorbidity (Nickel 2002). Indeed, the presence of upper urinary obstruction in a patient with urinary infection war-

Urgent evaluation

A. Clinical history: consider the following to avoid Pitfalls: (1) Number of renal moieties? (2) History of diabetes? (3) Underlying renal insufficiency. (4) Symptoms of infection (fever, chills, etc.). (5) Is patient pregnant? (6) Prior urologic or surgical procedures? (7) Contrast allergy?

B. Physical examination: consider the following to avoid pitfalls: (1) Surgical abdomen? (2) Signs of sepsis? (3) Is patient pregnant? (4) Signs of fluid overload.

C. Laboratory testing: consider the following to avoid pitfalls: (1) Renal insufficiency. (2) Renal failure. (3) Hyperkalemia. (4) Pregnancy testing. (5) Urinary tract infection. (6) Leukocytosis.

D. Diagnostic imaging: consider the following to avoid pitfalls: (1) Abscess. (2) Air in collecting system (i.e., emphysematous pyelonephritis). (3) Nonurologic causes of symptoms.

Diagnosis

A. Unilateral upper tract obstruction

B. Bilateral upper tract obstruction

Immediate drainage required

Indications:

1) Complete obstruction

2) Obstruction with infection

3) Obstruction with renal failure

4) Obstruction with solitary kidney

5) Obstruction with renal allograft

6) Obstruction with pregnancy

Retrograde stent placement

Percutaneous nephrostomy

Correct problems warranting urgent drainage

Correct problems warranting urgent drainage

No immediate drainage required

Additional workup required

Urologic

treatment

indicated

No primary urologic treatment indicated

No primary urologic treatment indicated

Delayed urologic treatment

Other medical treatment

Diagnostic workup complete

Immediate definitive treatment

Follow-up based on etiology of bstruction

Fig. 10.1. Treatment algorithm for patients with failed upper urinary tract drainage rants a prompt urinary drainage procedure and is considered a true urologic emergency. During the physical examination, symptoms suggestive of fluid overload or uremia should also be documented. The abdomen should also be palpated for the presence of an abdominal mass or associated abnormality, yet a clinically recognized mass aside from UPJ obstruction is a relatively uncommon presentation for upper urinary obstruction related to urologic causes. The examination should also rule out the presence of peritoneal signs (i.e., guarding, rebound tenderness, etc.), which that suggest a surgical abdomen. The presence of a surgical abdomen would frequently imply that the etiology of the patient's presenting symptomatology is entirely unrelated to urinary obstruction and it is likely that the etiology is no-nurologic. Costovertebral angle tenderness may also be present among patients with upper urinary obstruction; however, this is also a nonspecific finding. For pregnant females requiring an urgent evaluation of suspected upper urinary obstruction, the welfare of the fetus should also be documented as part of the initial evaluation. In addition, appropriate safeguards should be undertaken to protect and monitor the fetus throughout diagnostic evaluations and therapeutic interventions at a minimum with documentation of fetal heart tones.

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