(BQ) Part 1 book Macleod''s clinical examination has contents: Approach to the patient, history taking, the general examination, the skin, hair and nails, the endocrine system, the cardiovascular system, the respiratory system, the gastrointestinal system, the renal system.
Macleod’s Clinical Examination John Macleod (1915–2006) John Macleod was appointed consultant physician at the Western General Hospital, Edinburgh, in 1950 He had major interests in rheumatology and medical education Medical students who attended his clinical teaching sessions remember him as an inspirational teacher with the ability to present complex problems with great clarity He was invariably courteous to his patients and students alike He had an uncanny knack of involving all students equally in clinical discussions and used praise rather than criticism He paid great attention to the value of history taking and, from this, expected students to identify what particular aspects of the physical examination should help to narrow the diagnostic options His consultant colleagues at the Western welcomed the opportunity of contributing when he suggested writing a textbook on clinical examination The book was irst published in 1964 and John Macleod edited seven editions With characteristic modesty he was very embarrassed when the eighth edition was renamed Macleod’s Clinical Examination This, however, was a small way of recognising his enormous contribution to medical education He possessed the essential quality of a successful editor – the skill of changing disparate contributions from individual contributors into a uniform style and format without causing offence; everybody accepted his authority He avoided being dogmatic or condescending He was generous in teaching others his editorial skills and these attributes were recognised when he was invited to edit Davidson’s Principles and Practice of Medicine www.drmyothethan.blogspot.com For Elsevier Content Strategist: Laurence Hunter Content Development Specialist: Helen Leng Project Manager: Louisa Talbott Designer/Design Direction: Miles Hitchen Illustration Manager: Jennifer Rose Edited by Graham Douglas BSc(Hons) MBChB FRCPE Consultant Physician Aberdeen Royal Inirmary Honorary Reader in Medicine University of Aberdeen Fiona Nicol BSc(Hons) MBBS FRCGP FRCP(Edin) Formerly GP Principal and Trainer Stockbridge Health Centre, Edinburgh Honorary Clinical Senior Lecturer University of Edinburgh Colin Robertson BA(Hons) MBChB FRCPEd FRCSEd FSAScot Honorary Professor of Accident and Emergency Medicine University of Edinburgh Illustrations by Robert Britton Ethan Danielson Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2013 Clinical Examination Macleod’s Thirteenth edition © 2013 Elsevier Ltd All rights reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Details on how to seek permission, further information about the publisher’s permissions policies and our arrangements with organisations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the publisher (other than as may be noted herein) First edition 1964 Second edition 1967 Third edition 1973 Fourth edition 1976 Fifth edition 1979 Sixth edition 1983 Seventh edition 1986 Eighth edition 1990 Ninth edition 1995 Tenth edition 2000 Eleventh edition 2005 Twelfth edition 2009 Thirteenth edition 2013 ISBN 9780702047282 International ISBN 9780702047299 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Notices Knowledge and best practice in this ield are constantly changing As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility With respect to any drug or pharmaceutical products identiied, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions To the fullest extent of the law, neither the publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein Working together to grow libraries in developing countries www.elsevier.com | www.bookaid.org | www.sabre.org Printed in China The publisher’s policy is to use paper manufactured from sustainable forests Preface The skills of history taking and physical examination are central to the practice of clinical medicine This book describes these and is intended primarily for medical undergraduates It is also of value to primary care and postgraduate hospital doctors, particularly those studying for higher clinical examinations or returning to clinical practice The book is also an essential reference for nurse practitioners and other paramedical staff who are involved in medical assessment of patients This edition has four sections: Section details the principles of history taking and general examination; Section covers symptoms and signs in individual system examinations; Section reviews speciic situations; and a new Section deals with how to apply these techniques in an OSCE The text has been extensively revised and edited, with two new chapters on the frail elderly and the febrile adult The number of illustrations has been increased and many have been updated Line drawings illustrate surface anatomy and techniques of examination; over 330 photographs show normal and abnormal clinical appearances We recognise the current debate where some decry clinical examination because of the lack of evidence supporting many techniques Where evidence exists, however, we highlight this in a new feature for this edition: evidence-based examination boxes (EBEs) We are convinced of the need to acquire and hone clinical examination skills to avoid unnecessary expensive and potentially harmful over-investigation Nevertheless, there is a need to evaluate rigorously many clinical symptoms and signs It is possible to open this book at almost any page and ind a topic which cries out for evidence-based analysis We continue to hope that the book will stimulate this enquiry and would encourage these responses and incorporate them in future editions This 13th edition of Macleod’s Clinical Examination – full text, illustrations and videos – is available in an online version, as part of Elsevier’s ‘Student Consult’ electronic library It is closely integrated with Davidson’s Principles and Practice of Medicine, and is best read in conjunction with that text G.D F.N C.R Edinburgh and Aberdeen 2013 v Acknowledgements We are very grateful to all the contributors and editors of previous editions; in particular, we owe an immeasurable debt to Dr John Munro for his teaching and wisdom We greatly appreciate the constructive suggestions and help that we have received from past and present students, colleagues and focus groups in the design and content of the book We are particularly grateful to the following medical students who undertook detailed reviews of the book and gave us a wealth of ideas to implement in this latest edition: Alessandro Aldera, University of Cape Town; Sabreen Ali, University of Shefield; Bernard Ho, St George’s University of London; Edward Tzu-Yu Huang, University of Birmingham; Emma Jackson, University of Manchester; Amit Kaura, University of Bristol; Brian vi Morrissey, University of Aberdeen; Neena Pankhania, University of Leicester; Tom Paterson, University of Glasgow; Christopher Roughley, University of Warwick; and Christopher Saunders, University of Edinburgh We wish to thank the many individuals who have provided advice and support: Jackie Fiddes for designing the manikins and for her computer skills; Steven Hill of the Department of Medical Illustration, University of Aberdeen; Jason Powell for his help with illustrations; Victoria Buchan for her help linking the examination videos with the online text; Helen Leng and Laurence Hunter at Elsevier G.D F.N C.R Picture and box credits We are grateful to the following individuals and organisations for permission to reproduce the igures and boxes listed below: Chapter Fig 1.1 WHO Guidelines on Hand Hygiene in Health Care First Global Patient Safety Challenge Clean Care is Safer Care http://www.who.int/gpsc/clean_hands_ protection/en/ © World Health Organization 2009 All rights reserved Box 1.1 Courtesy of the General Medical Council (UK) Chapter Box 2.32 Trzepacz PT, Baker RW, The psychiatric mental status examination 1993 by permission of Oxford University Press USA Box 2.50 Hodkinson HM, Evaluation of a mental test score for assessment of mental impairment in the elderly Age and Ageing 1972 1(4): 233-8 by permission of Oxford University Press Chapter Figs 3.19C and 3.28A–D Forbes CD, Jackson WF Color Atlas of Clinical Medicine 3rd edn Edinburgh: Mosby; 2003 Chapter Fig 5.3 Currie G, Douglas G, eds Flesh and Bones of Medicine Edinburgh: Mosby; 2011 Chapter Figs 6.6D, 6.16A–D and 6.38A Forbes CD, Jackson WF Color Atlas of Clinical Medicine 3rd edn Edinburgh: Mosby; 2003 Fig 6.6E Colledge NR, Walker BR, Ralston SH, eds Davidson’s Principles and Practice of Medicine 21st edn Edinburgh: Churchill Livingstone; 2010 Fig 6.8C Haslett C, Chilvers ER, Boon NA, Colledge NR, eds, Davidson’s Principles and Practice of Medicine, 19th edn Edinburgh: Churchill Livingstone; 2002 Box 6.19 Reproduced by kind permission of the British Hypertension Society Chapter Fig 7.24D Forbes CD, Jackson WF Color Atlas of Clinical Medicine 3rd edn Edinburgh: Mosby; 2003 Box 7.7 Reproduced from British Medical Journal Fletcher CM, Elmes PC, Fairbairn AS et al 2(5147):257 1959 with permission from BMJ Publishing Group Ltd Box 7.11 Reproduced from Murray W Johns A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale, Sleep, 1991; 14(6): 540-545 ESS contact information and permission to use: MAPI Research Trust, Lyon, France E-mail: PROinformation@mapi-trust.org Internet: www mapi-trust.org Box 7.17 Reproduced from Thorax Lim WS 58(5):377 2002 with permission from BMJ Publishing Group Ltd Box 7.23 Reproduced from Wells PS, Anderson DR, Rodger M et al, 2000 Derivation of a Simple Clinical Model to Categorize Patients Probability of Pulmonary Embolism: Increasing the Models Utility with the SimpliRED D-dimer, Thromb Haemost 83(3) 416-420 with permission from Schattauer Publishers Chapter Fig 8.10 Reproduced by kind permission of Dr K W Heaton, Reader in Medicine at the University of Bristol © 2000 Norgine Pharmaceuticals Ltd Figs 8.31A&B and 8.32 Forbes CD, Jackson WF Color Atlas of Clinical Medicine 3rd edn Edinburgh: Mosby; 2003 Box 8.15 Reproduced by kind permission of the Rome Foundation Box 8.20 Reproduced from Journal of the British Society of Gastroenterology Rockall TA et al 38(3):316 1996 with permission from BMJ Publishing Group Ltd Box 8.34 Reproduced from Conn HO, Leevy CM, Vlahcevic ZR et al 1977 Comparison of lactulose and neomycin in the treatment of chronic portal-systemic encephalopathy A double blind controlled trial, Gastroenterology 72(4): 573 with permission from Elsevier Inc Box 8.47 Reproduced from Pugh RNH, Murray-Lyon IM, Dawson JL et al Transection of the oesophagus for bleeding oesophageal varices British Journal of Surgery 646-649 1973 with permission from John Wiley and Sons Chapter Fig 9.12 Pitkin J, Peattie AB, Magowan BA Obstetrics and Gynaecology: An Illustrated Colour Text Edinburgh: Churchill Livingstone; 2003 Box 9.4 Reproduced from Barry MJ, Fowler FJ Jr, O’Leary MP et al The American Urological Association symptom index for benign prostatic hyperplasia The Measurement Committee of the American Urological Association J Urol 1992 148(5):1549-57 ESS contact information and permission to use: MAPI Research Trust, Lyon, France E-mail: PROinformation@ mapi-trust.org Internet: www.mapi-trust.org Chapter 11 Fig 11.15 Epstein O, Perkin GD, de Bono DP, Cookson J Clinical Examination 2nd edn London: Mosby; 1997 Box 11.18 Medical Research Council scale for muscle power Aids to examination of the peripheral nervous system Memorandum no 45 London Her Majesty’s Stationery Ofice 1976 © Crown Copyright vii Chapter 12 Figs 12.15A&B Forbes CD, Jackson WF Color Atlas of Clinical Medicine 3rd edn Edinburgh: Mosby; 2003 Fig 12.16 Nicholl D, ed Clinical Neurology Edinburgh: Churchill Livingstone; 2003 Figs 12.27A–D Epstein O, Perkin GD, de Bono DP, Cookson J Clinical Examination 2nd edn London: Mosby; 1997 Chapter 13 Fig 13.20 Scully C, Oral and Maxillofacial Medicine 2nd edn Edinburgh: Churchill Livingstone; 2008 Figs 13.21A and 13.25B Bull TR Color Atlas of ENT Diagnosis 3rd edn London: Mosby-Wolfe; 1995 Chapter 14 Fig 14.2 Colledge NR, Walker BR, Ralston SH, eds Davidson’s Principles and Practice of Medicine 21st edn Edinburgh: Churchill Livingstone; 2010 Fig 14.9A Forbes CD, Jackson WF Color Atlas of Clinical Medicine 3rd edn Edinburgh: Mosby; 2003 Box 14.3 Reproduced from Aletaha D, Neogi T, Silman AJ et al 2010 Rheumatoid arthritis classiication criteria: an American College of Rheumatology/ European League Against Rheumatism collaborative initiative, Arthritis & Rheumatism 2569-2581 with permission from John Wiley and Sons Box 14.13 Reproduced from Annals of the rheumatic diseases Beighton P, Solomon L, Soskolne CL 32(5): 413 1973 with permission from BMJ Publishing Group Chapter 15 Figs 15.7, 15.8, 15.11A&B and 15.12 Lissauer T, Clayden G Illustrated Textbook of Paediatrics viii 2nd edn Edinburgh: Mosby; 2001 Fig 15.17 Child Growth Foundation Fig 15.23 Courtesy of Dr Jack Beattie, Royal Hospital for Sick Children, Glasgow Box 15.4 Reproduced with permission of International Anesthesia Research Society from Current researches in anesthesia & analgesia Apgar V 32(4) 1953; permission conveyed through Copyright Clearance Center, Inc Chapter 16 Fig 16.2 Reproduced from Clarifying Confusion: The Confusion Assessment Method: A New Method for Detection of Delirium Inouye SK, vanDyck CH, Alessi CA et al Annals of Internal Medicine 113 1990 with permission from the American College of Physicians Fig 16.3 Reproduced by kind permission of BAPEN Chapter 19 Fig 19.9 Reproduced with the kind permission of the Resuscitation Council (UK) Box 19.1 Adapted from Hillman K, Parr M, Flabouris A et al 2001 Redeining in-hospital resuscitation: the concept of the medical emergency team Resuscitation 48(2): 105-110 with permission from Elsevier Ltd Box 19.14 Reproduced from The Lancet 304(7872), Teasdale G, Jennett B, Assessment of coma and impaired consciousness: a practical scale, 81–84, 1974 with permission from Elsevier Ltd How to get the most out of this book The purpose of this book is to document and explain how to: • Talk with a patient • Take the history from a patient • Examine a patient • Formulate your indings into differential diagnoses • Rank these in order of probability • Use investigations to support or refute your differential diagnosis Initially, when you approach a section, we suggest that you glance through it quickly, looking at the headings and how it is laid out This will help you to see in your mind’s eye the framework to use Learn to speed-read It is invaluable in medicine and in life generally Most probably, the last lesson you had on reading was at primary school Most people can dramatically improve their speed of reading and increase their comprehension by using and practising simple techniques Try making mind maps of the details to help you recall and retain the information as you progress through the chapter Each of the systems chapters is laid out in the same order: • Introduction and anatomy • Symptoms and deinitions • The history: what questions to ask and how to follow them up • The physical examination: what and how to examine • Investigations: those done at the patient’s side (near-patient tests); laboratory investigations; imaging; and invasive investigations Your purchase of the book entitles you to access the complete text online and to search using key words or using the index You can view all the illustrations and use the hypertext-linked page cross-references to navigate quickly through the book Return to this book to refresh your technique if you have been away from a particular ield for some time It is surprising how quickly your technique deteriorates if you not use it regularly Practise at every available opportunity so that you become proicient at examination techniques and gain a full understanding of the range of normality Ask a senior colleague to review your examination technique regularly; there is no substitute for this and for regular practice Listen also to what patients say – not only about themselves but also about other health professionals – and learn from these comments You will pick up good and bad points that you will want to emulate or avoid Finally, enjoy your skills After all, you are learning to be able to understand, diagnose and help people For most of us, this is the reason we became doctors Boxes and tables Boxes and tables are a popular way of presenting information and are particularly useful for revision They are classiied by the type of information they contain using the following symbols: Causes Clinical features Investigations Evidence-based examination Other information Evidence-based examination Evidence-based examination applies the best available evidence from scientiic method to clinical decision making and is an increasingly essential part of modern clinical practice However, most clinical examination techniques have developed over generations of medical practice without rigorous scientiic assessment To highlight examples where there is evidence-based examination we have included 55 EBE boxes The art of medicine depends on being able to combine scientiic rigour with long-established techniques but this area needs to be re-evaluated and updated constantly as new information comes to light Examination sequences Throughout the book there are outlines of techniques that you should follow when examining a patient These are identiied with a red heading ‘Examination sequence’ The bullet-point list provides the exact order to undertake the examination To help your understanding of how to perform these techniques many of the examination sequences have been ilmed and those marked with the symbol above can be viewed as part of the Student Consult online text ix THE RENAL SYSTEM RENAL EXAMINATION Face and neck • Yellow complexion* • Pallor • JVP • Uraemic foetor* • Gingival hyperplasia Eyes • Hypertensive retinopathy • Diabetic retinopathy • Band keratopathy Lung bases • Crackles in fluid overload • Hyperventilation (acidaemia) Heart Arms • Extra heart sounds • Pericardial friction rub* • Pulse and blood pressure • Arteriovenous fistulae • Carpal tunnel syndrome Abdomen • Inspect scars • Palpate kidneys bladder sacral oedema • Auscultate renal arterial bruits • Rectal examination prostate enlargement Hands • Asterixis • Nail features Beau’s lines splinter haemorrhages pigmentation – ‘brown line’* Muehrcke’s lines General observation • Pallor and tiredness • Breathlessness • Hydration reduced skin turgor in fluid depletion • Bruising* • Itching, scratch marks* (*features of advanced renal failure) 196 Legs • Oedema hypoproteinaemia fluid overload • Peripheral neuropathy* Anatomy ANATOMY The kidneys lie posteriorly in the abdomen, retroperitoneally on either side of the spine at the T12–L3 level (Fig 9.1) and are 11–14 cm long The right kidney lies 1.5 cm lower than the left because of the liver The liver and spleen lie anterior to the kidneys The kidneys move downwards during inspiration as the lungs expand Together, the kidneys receive ~25% of cardiac output Each kidney contains about one million nephrons, each comprising a glomerulus, proximal tubule, loop of Henle, distal tubule and collecting duct (Fig 9.2) Urine is formed by glomerular iltration, modiied by complex Costovertebral angle 11th rib 12th rib Kidney processes of secretion and reabsorption in the tubules, and then enters the calyces and the renal pelvis The primary functions of the kidneys are: • excretion of waste products of metabolism such as urea and creatinine • maintaining salt, water and electrolyte homeostasis • regulating blood pressure via the renin–angiotensin system • endocrine functions related to erythropoiesis and vitamin D metabolism The renal capsule and ureter are innervated by T10–12/ L1 nerve roots; pain from these structures is felt in these dermatomes (Fig 11.28) The bladder acts as a reservoir As it ills, it becomes ovoid, and rises out of the pelvis in the midline towards the umbilicus, behind the anterior abdominal wall The bladder wall contains a layer of smooth muscle, the detrusor, which contracts under parasympathetic control, allowing urine to pass through the urethra (micturition) The conscious desire to micturate occurs when the bladder holds ~ 250–350 ml of urine The male urethra runs from the bladder to the tip of the penis and has three parts: prostatic, membranous and spongiose (Fig 9.3) The female urethra is much shorter, with the external meatus situated anterior to the vaginal oriice and behind the clitoris (Fig 10.20) Two muscular rings acting as valves (sphincters) control micturition: • The internal sphincter is at the bladder neck and is involuntary • The external sphincter surrounds the membranous urethra and is under voluntary control; it is innervated by the pudendal nerves (S2–4) Fig 9.1 The surface anatomy of the kidneys from the back Fibrous capsule Kidney Renal papilla Afferent arteriole Renal pyramids Glomerulus Major calyx Renal columns Collecting tubule Efferent arteriole Distal convoluted tubule Medulla Loop of Henle Ureter Bladder Detrusor muscle Thickwalled segment Renal artery Renal pelvis Cortex Proximal convoluted tubule Renal vein Minor calyx Ureteric orifice Thin-walled segment Internal sphincter Prostate Prostatic urethra External sphincter Membranous urethra Ureter Fig 9.2 A single nephron Spongiose urethra Fig 9.3 The male urinary tract External urethra 197 THE RENAL SYSTEM SYMPTOMS AND DEFINITIONS Severe renal disease may be asymptomatic, or have nonspeciic symptoms, such as tiredness or breathlessness from renal failure or associated anaemia Detection often follows incidental testing of blood and urine Ask about the following symptoms, but always test urine and blood to assess renal function Pain Most kidney disease is painless However, pain may arise from the kidney capsule (loin pain), the ureter (ureteric colic) or the bladder/urethra Renal angle (between the 12th rib and the spine) or loin pain is due to stretching of the renal capsule or renal pelvis Causes include infection, inlammation or mechanical obstruction Constant loin pain, with systemic upset, fever, rigors and pain on voiding, suggests infection of the upper urinary tract and kidney (acute pyelonephritis) Chronic dull, aching loin discomfort may occur with chronic renal infection and scarring from vesicoureteric relux, adult polycystic kidney disease (APKD) or chronic urinary tract obstruction Chronic obstruction may, however, be painfree Dull loin pain also occurs in renal stone disease and some forms of glomerulonephritis, e.g IgA nephropathy It can be dificult to distinguish between renal pain and musculoskeletal conditions, e.g osteoarthritis of the spine Ureteric colic (‘renal colic’) is caused by acute obstruction with distension of the renal pelvis and ureter by a stone, blood clot or, rarely, a necrotic renal papilla • Site – unilateral, in the renal angle and lank area • Onset – sudden • Character – usually very severe and sustained, may vary cyclically in intensity • Radiation – may radiate to the iliac fossa, the groin and the genitalia, especially the testes • Associated features – patient is usually restless and nauseated, and often vomits • Timing – may last for several hours or even days, until the obstructing body reaches the bladder, when symptoms usually resolve • Exacerbating/relieving factors – analgesia with non-steroidal anti-inlammatory drugs (NSAIDs) or opioids is required • Severity – variable, but often very severe and incapacitating • Similar – distinguish from intestinal or biliary colic, appendicitis, torsion of an ovarian cyst, ruptured ectopic pregnancy Test the urine for blood; haematuria (visible or non-visible) is usual and, if absent, casts doubt on the diagnosis (Box 9.1) Patients with loin pain–haematuria syndrome complain of chronic unilateral or bilateral loin discomfort of varying severity Characteristically they have nonvisible haematuria and episodic visible haematuria Dysuria (voiding pain) is pain during or immediately after passing urine, often described as a ‘burning’ sensation felt at the urethral meatus or suprapubically 198 9.1 Renal colic In a patient with acute lank pain, loin tenderness together with microscopic haematuria strongly suggests ureterolithiasis Eskelinen M, Ikonen J, Lipponen P Usefulness of history-taking, physical examination and diagnostic scoring in acute renal colic Eur Urol 1998;34:467–473 Strangury describes slow and painful discharge of small volumes of urine related to involuntary bladder contractions Frequency is a desire to pass urine more often than usual The most common cause of the above symptoms is infection and/or inlammation of the bladder (cystitis) Prostatitis and urethritis produce similar symptoms Prostatitis may cause perineal and rectal pain at the same time Pain localised to the penis indicates local pathology, e.g an inlammatory stricture, stone or, rarely, tumour Testicular and epididymal pain may be felt primarily in the groin and lower abdomen Tenderness and swelling of the testis may be due to acute epididymo-orchitis; in pubertal boys and young men consider torsion of the testis, and be careful to distinguish these conditions from a strangulated inguinal hernia (p 189) Voiding symptoms Lower urinary tract symptoms may be: • during the storage phase of micturition • during the voiding phase of micturition • after micturition • with incontinence Storage symptoms • Frequency – micturating more often with no increase in the total urine output • Urgency – a sudden strong need to pass urine Urgency is due to either overactivity in the detrusor muscle or abnormal stretch receptor activity from the bladder (sensory urgency) Incontinence may occur • Nocturia – waking more than twice at night to void Storage symptoms are usually associated with bladder, prostate or urethral problems, e.g lower urinary tract infection, tumour, urinary stones or obstruction from prostatic enlargement, or are a consequence of neurological disease Voiding phase symptoms Hesitancy is dificulty or delay in initiating urine low In men over 40 this is commonly due to bladder outlet obstruction by prostatic enlargement (Box 9.2) Assess the intrusiveness of this by the International Prostate Symptom Score (IPSS) (Box 9.3) In women these symptoms suggest urethral obstruction from stenosis or in association with genital prolapse (Boxes 9.4 and 9.5) Symptoms and definitions 9.2 Features of bladder outlet obstruction due to prostatic hyperplasia 9.3 The International Prostate Symptom Score The International Prostate Symptom Score (IPSS) reliably assesses the severity of voiding phase symptoms in men >40 years • Slow low • Hesitancy • Incomplete emptying (the need to pass urine again within a few minutes of micturition) • Dribbling after micturition • Frequency and nocturia (due to incomplete bladder emptying) • A palpable bladder Barry MJ, Fowler FJ, O’Leary MP et al The American Urological Association symptom index for benign prostatic hyperplasia J Urol 1992;148: 1549–1557 9.4 International Prostate Symptom Score (IPSS) Symptom Not at all Less than time in Less than half the time About half the time More than half the time Almost always Score 5 5 5 Over the past month, now many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? Quality of life due to urinary symptoms Delighted Pleased Mostly satisied Mixed: about equally satisied and dissatisied Mostly dissatisied Unhappy Terrible If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you inish urinating? Frequency Over the past month, how often have you had to urinate again less than hours after you inished urinating? Intermittency Over the past month, how often have you found you stopped and started again several times when you urinated? Urgency Over the last month, how dificult have you found it to postpone urination? Weak stream Over the past month, how often have you had a weak urinary stream? Straining Over the past month, how often have you had to push or strain to begin urination? Nocturia Total IPSS score: 0–7, mildly symptomatic; 8–19, moderately symptomatic; 20–35, severely symptomatic International Prostate Symptom Score © (I-PSS©) Michael J Barry, 1992 All rights reserved 199 THE RENAL SYSTEM 9.5 Functional assessment of the lower urinary tract it suggests bladder outlet obstruction or abnormalities of the wakening mechanism Frequency/volume chart • Use to monitor micturition patterns, including nocturia, and luid intake • The patient collects his urine, measures each void, and charts it against time over 3–5 days Urine low rate • The patient voids into a special receptacle that measures the rate of urine passage • A low low does not differentiate between poor detrusor contractility and bladder outlet obstruction Urodynamic tests • Invasive tests, necessitating insertion of bladder and rectal catheters to measure total bladder pressure and abdominal pressure and to allow bladder illing • Filling studies determine detrusor activity and compliance • Low detrusor pressures with low urine low suggest detrusor function problems • High detrusor pressures with a low low suggest bladder outlet obstruction 9.6 Causes of urinary incontinence • • • • • • • • Pelvic loor weakness following childbirth Pelvic surgery or radiotherapy Detrusor overactivity Bladder outlet obstruction Urinary tract infection Degenerative brain diseases and stroke Neurological diseases, e.g multiple sclerosis Spinal cord damage Abnormalities in urine volume and composition Healthy adults produce 2–3 litres of urine per day, equivalent to their luid intake minus insensible luid losses through the skin and respiratory tract (500– 800 ml/day) Polyuria Polyuria is an abnormally large volume of urine, and is most commonly due to excessive luid intake Rarely, this is a manifestation of psychiatric disease (psychogenic polydipsia) Polyuria also occurs when the kidneys cannot concentrate urine Causes may be extrarenal, e.g diuretic drugs; hyperglycaemia with glycosuria causing an osmotic diuresis; lack of arginine vasopressin (AVP) from the pituitary gland in cranial diabetes insipidus, or failure of aldosterone secretion by the adrenal gland in Addison’s disease Renal causes occur when the kidney tubules fail to reabsorb water appropriately in response to AVP This occurs in nephrogenic diabetes insipidus, usually due to genetic mutation in the tubular AVP receptor It may also relect chronic tubulointerstitial damage, relux nephropathy, analgesic nephropathy and drugs, e.g lithium Oliguria Oliguria is a reduction in urine volume to 40 years with haematuria (visible or non-visible), because the incidence of these conditions increases with age Distinguish haematuria from contamination of the urine by blood from the female genital tract during menstruation Free haemoglobin in the urine due to haemolysis, myoglobin in rhabdomyolysis and other abnormalities of urine colour may mimic haematuria (Box 9.7) but can be differentiated by urinalysis and urine microscopy (Fig 9.4 and Box 9.8) Proteinuria Proteinuria is excess protein in urine and indicates kidney disease (Boxes 9.9 and 9.10) It is usually • Abdominal surgery • Heart failure asymptomatic and detected by urinalysis Albumin (from plasma) is the main component, although in certain conditions, e.g myeloma, chronic lymphatic leukaemia or amyloidosis, globulins and immunoglobulin light chains (Bence Jones protein) may predominate Suspect these conditions if the urine dipstick test is negative but other tests suggest proteinuria, since the stick reagents are albumin-speciic Proteinuria up to g/24 h is non-speciic Values greater than this indicate a glomerular abnormality, most commonly glomerulonephritis or diabetic 201 THE RENAL SYSTEM nephropathy Radioimmunoassay techniques can detect albumin excretion rates as low as 30 mg/day Microalbuminuria (30–300 mg/day) occurs early in diabetic nephropathy, and is a risk factor for myocardial infarction, stroke and venous thromboembolism Proteinuria may occur in normal patients with febrile illness Orthostatic proteinuria is proteinuria 2 g/day suggests glomerular disease Blood The test does not differentiate between haemoglobin and myoglobin If you suspect rhabdomyolysis, measure myoglobin with speciic laboratory test Bilirubin and urobilinogen Bilirubin not normally present Urobilinogen may be up to 33 µmol/L in health Abnormalities of bilirubin and urobilinogen require investigation for possible haemolysis or hepatobiliary disease Leukocyte esterase Indicates presence of leukocytes in urine Seen in urinary tract infection or inlammation, stone disease and urothelial cancers Nitrite Most Gram-ve bacteria convert urinary nitrate to nitrite A positive result indicates bacteriuria, but a negative result does not exclude its presence *Use freshly passed urine (Fig 9.12) 207 THE RENAL SYSTEM 9.17 Urinary tract infection in women In a woman with one or more relevant symptoms (dysuria, frequency, haematuria, back pain), the probability of (culturepositive) urinary tract infection is ~50% This increases to ~80% with a positive dipstick urinalysis for nitrite and leukocyte esterase Bent S, Nallamothu BK, Simel DL et al Does this woman have an acute uncomplicated urinary tract infection? In: Simel D, Rinne D (eds) The rational clinical examination New York: JAMA and Archives Journals/ McGraw-Hill Professional, 2008, pp 675–685 Fig 9.12 Stix testing of urine 9.18 Biochemical and serological investigations 208 Investigation Indication/comment Plasma urea/creatinine Levels generally ↑ as GFR ↓, but values are affected by diet and muscle mass and not measure renal function accurately Creatinine clearance A good measurement of GFR, but requires a 24-hr urine collection and a blood sample Estimated glomerular iltration rate (eGFR) Calculate the eGFR from an equation Normal eGFR is ~100 ml/min/1.73 m2 Chronic kidney disease (CKD) is classiied on the basis of the eGFR as follows: Stage Description GFR ml/min/1.73 m2 CKD1 Kidney damage with normal or ↑ GFR ≥90 CKD2 Kidney damage with mild ↓ GFR 60–89 CKD3 Moderate ↓ GFR 30–59 CKD4 Severe ↓ GFR 15–29 CKD5 End-stage kidney disease (dialysis-requiring ) 90% are radio-opaque), gas in the urinary collecting system Ultrasound scan Assesses kidney size/shape/position; evidence of obstruction; renal cysts or solid lesions; stones; ureteric urine low; gross abnormality of bladder, post-micturition residual volume Used to guide kidney biopsy Doppler ultrasound of renal vessels Assesses renovascular disease, renal vein thrombosis Arterial resistive index may indicate obstruction IV urography Haematuria; renal colic; renal mass; renal, ureteric or bladder stones; cysts; tumours; hydronephrosis NB In many hospitals IVU has been replaced by CT and other imaging forms CT urogram Stone disease; renal mass; ureteric obstruction; tumour staging; renal, retroperitoneal or other tumour masses or ibrosis Angiography/CT or MR angiography Hypertension ± renal failure, renal artery stenosis; angioplasty and/or stenting Isotope scan Suspected renal scarring, e.g relux nephropathy; diagnosis of obstruction Assessment of GFR in each kidney - measures renal uptake and excretion of radio-labelled chemicals Renal biopsy Used to diagnose parenchymal renal disease 209 This page intentionally left blank ... Box 14 .13 Reproduced from Annals of the rheumatic diseases Beighton P, Solomon L, Soskolne CL 32(5): 413 19 73 with permission from BMJ Publishing Group Chapter 15 Figs 15 .7, 15 .8, 15 .11 A&B and 15 .12 ... herein) First edition 19 64 Second edition 19 67 Third edition 19 73 Fourth edition 19 76 Fifth edition 19 79 Sixth edition 19 83 Seventh edition 19 86 Eighth edition 19 90 Ninth edition 19 95 Tenth edition... Stationery Ofice 19 76 © Crown Copyright vii Chapter 12 Figs 12 .15 A&B Forbes CD, Jackson WF Color Atlas of Clinical Medicine 3rd edn Edinburgh: Mosby; 2003 Fig 12 .16 Nicholl D, ed Clinical Neurology