Exploit surgical clinical symptoms

2021-01-26 12:00 AM

However, patients are often unable to accurately describe symptoms because they are often anxious

Ask about diseases and exploit functional symptoms

As the basis for the evaluation of diseases and diagnostic situations. However, patients are often unable to accurately describe symptoms because they often worry excessively and have limited understanding. Therefore, in order to detect the correct symptoms, it is necessary to direct the patient to the questions for diagnostic purposes. The first thing is to make the patient feel comfortable, it is necessary to listen to find out why the patient is seeing a doctor.

Ask disease to find out

The main symptoms and the course of the main symptoms.

Anamnesis

Family history.

Symptoms of the upper urinary tract (pain)

Typical kidney cramps:

Location: Lumbar region, back ribs, pain spreads, downward, out before spreading to the genitals.

Onset suddenly, severe, or occurs when the patient is active (after heavy labor or long distance).

Symptoms accompanying:

Tieu primary, minor lead, bleak.

Vomiting, nausea, bloating.

Examination:

Body: Panic, sweating, sometimes fever.

Lumbar region: spastic spinal muscle spasticity, pelvic lumbar muscle, lateral half-abdomen spastic pain, no peritoneal induction.

Reason:

Due to sudden tension in the renal pelvis station above the block. It can be due to stones, spasms, inflammation. Using pain relievers, smooth muscle relaxants, resting, the patient will relieve or relieve pain.

If the patient has a fever with poor prognosis, it is important to monitor. 

Atypical pain form:

Dull pain in the back daily, weekly pain is detected when palpating the fovea or patient in standing position.

Pain complications:

Anuria due to ureteral kidney stones on single kidney.

Acute bacterial infection:

Fever, back pain, diabetes, kidney failure ... 

Reason:

Kidney pain 2/3 cases due to urinary stones.

32% of kidney stones.

47% of pyelonephritis’s.

95% of ureteral stones.

Congenital malformation: Pyelonephritis junction syndrome

Causes: Urinary tract tumor or extra urinary tract 

Bladder pain:

This is due to overstretching of the bladder, which results in an acute blockage of the bladder neck and urethra.

Sometimes an uncomfortable feeling in the pubic bone is the result of acute cystitis or interstitial cystitis or incomplete obstruction.

Pelvic and genital pain:

Severe pain or dull pain, accompanied by trouble urinating.

Spastic bladder pain that requires urinary urgency (urethral stones, prostate enlargement).

Pain caused by urinary reflux. Sharp pain from below rising gradually up the lumbar fossa. Pain usually occurs before or during urination.

Prostate pain: Pain sensation deep in the anus and episiotomy, pain usually increases in a sitting position.

Testicular pain, epididymis: pain from the scrotum to the groin.

Acute pain is often caused by trauma, testicular torsion, and acute epididymitis.

Chronic pain is usually caused by varicose veins, hydroceles or inguinal hernias.

Symptoms of the lower urinary tract include the bladder - prostate - urethra;

Irritable syndrome:

Urination and urination:

Urinate several times a day - least urine at a time.

Distinguish high urination: (diabetes insipidus)

Cause: The bladder is irritated due to inflammation, foreign bodies, and prostate enlargement tumor stimulates the bladder neck. Sometimes due to urinary frame tumors, diseases in the subframe or ureteral stones close to the bladder. Or the bladder contracts due to nerve causes, and the bladder is reduced in capacity.

Primary pain:

A burning pain when urinating, often accompanied by urination.

The pain can be sharp when urinating the whole time or only painful at first. 

Obstructive syndrome:

Difficult urination:

Difficult urination at first: The patient cannot urinate right away, trying to urinate while urinating. The urine is weak, sometimes it does not fall into the crossbow. Long urination time. After passing urine, I do not feel comfortable.

Causes: The bladder and urethra diseases such as prostate enlargement. Prostate k, bladder neck spasm, bladder neck stiffness, bladder stones, urethral stenosis, nerve bladder.

Consequences of difficult urination:

First stage: The wall of the bladder is thickened due to the increase in contractility to overcome mechanical resistance.

Later stage: The bladder is decompensated, the bladder muscle lags, urinary stagnation of urine. The risk of retrograde pyelonephritis, stagnant urine in the bladder, backs up the kidneys.

Urinary retention:

It is the phenomenon of urine in the bladder, but the patient is unable to urinate (to be distinguished from anuria: no urine in the bladder).

Complete urinary retention: Acute.

Painful tenderness in the pubic bone.

Always very sad but can't pee

Examination of the bladder bridge is very tight - press in pain.

Requires urinary drainage or emergency urine drainage.

Incomplete urinary tract: Chronic

This is a constant flow of urine in the bladder> 300 ml.

Urinary incontinence:

Is the phenomenon of urine leaking out of the patient's wishes:

Persistent urinary leakage: Sphincter dysfunction of urethral bladder due to brain damage or prostate surgery damages urethral sphincter system.

It should be differentiated from persistent urine leakage in a child due to a stray ureter or vaginal bladder urine leakage.

Strenuous discharge: Unintentional oozing of urine when the patient is performing strenuous activity. 

Blood in urine:

Red blood cell: Addis residue of erythrocytes> 500,000 RBCs / minute.

Distinguishing red urine is not hematuria due to the red color of food and beverages due to Rifampin phenothiazine, Pyridium. Hemoglobinuria due to rupture of red blood cells.

Look for pink, bright red, crimson, and blood clots urine.

How to initiate, evolve, degree

Need to determine the location of urinary tract bleeding: fibrosis by observation of urine. Three-cup test:

Primary hematuria: Damage to the urethra

Endocortical hematuria: Damage to the bladder.

Total hematuria: Damage to the kidney.

However, severe bladder lesions also urinate whole blood yards.

Other manifestations:

Red bloody urine with cloudy fat cloudiness, nourishing hematuria.

Red urine mixed with egg white slang (hematuria of semen chemosphere).

Pus urine:

White purulent urine with degenerative leukocytes: Addis residue 5000 silver spheres / min.

Distinguishing cloudy urine: Cloudy, cloudy like rice water, cloudy like milk.

White cloudy urine: Small acetic acid phosphate residue: the urine will be clear and sedimentation.

Albumin urine: When heated, Albumin will coagulate into stones floating in the urine.

Urine residue urine: The urine will be heated by heating.

Urination purulent urinary infection N> 105 / ml.

Common diseases of urinary tract infections are stones and urinary tract congenital malformations.

Common bacteria are: E.Coli, Klebsiella, Enterobacter, staphylococcus aureus, proteus, pseudomonas Aeruginosa, group B streptococcus.

Symptoms of genital dysfunction:

Male fertility dysfunction that nouns often call impotence is manifested in many forms: loss of desire, inability to have an erection or maintain an erection. The inability to ejaculate, the ability to perform orgasm and premature ejaculation.

Ask about medical history: Medical and surgical diseases from past and present. There are many medical diseases affecting the urinary system: tuberculosis, diabetes, high blood pressure.

Family History: Provide additional information regarding risk factors and causes.

Medical examination

Systemic symptoms

Rapid weight loss, state of collapse: Common in patients with urology. Subjective patients know how to lose weight quickly, fatigue, anorexia, insomnia. Dehydration anemia, electrolytes such as pyelonephritis, fluid retention, pyelonephritis, kidney failure, high blood urea, cancer.

Persistent high fever of 38 - 39.5 degrees C, with chills accompanied by lower back pain or urination disorders, often manifestations of urinary infections. Includes: pyelonephritis, prostatitis, testicular inflammation, testicular crest. Long-term unexplained fevers or fevers can also be a sign of kidney cancer.

Examination of the urinary system

Principle: Comprehensive examination, examination of both the urinary system and genital system, the primary palpation and assessment of the abdominal wall.

Detection: Pain point, detects lumbar tumors, bladder, prostate with properties: size, shape, density, surface, mobile margin with breathing rhythm and with pulsed parts around. 

Kidney examination with laboratory tests

Lumbar touch test:

Examination:

Examining either side, the physician stands with the patient, the opposite hand is placed in the kidney area (dorsal angle). The other hand is placed above the abdomen parallel to the ribs or along the big straight outer edge. The lower hand is close to the back side, the upper hand presses down normally without feeling.

If the kidney is enlarged, there will be a sensation of a tumor on the lower hand: the lumbar test is positive.

Kidney pendulum testing:

The hand below the back of the ribs bounces up slightly and the hand on the stomach pushes down lightly. If the kidney is enlarged you will feel the kidneys bobbing between hands: a positive kidney pendulum test.

The patient can be placed on the opposite side to do the two methods above.

There is a way to examine one hand: Thumb in front, the other four fingers in the back pressed against the back rib. If the kidney is enlarged when the patient breathes, the kidneys will move up and down in the palm of the hand. Usually applied when pediatric kidney examination.

Examination of ureter points:

Upper ureter point: Intersection of a straight line across the navel with a straight, straight muscle.

Middle ureter point: The outer 1/3 point of the horizontal line connecting the 2 upper anterior pelvic spines.

Lower ureter point: close to the bladder, examine through the rectum.

These points are painful in the presence of ureteral stones but are not the point of locating the stone. 

Examination of the bladder in a patient with urinary retention:

A normal bladder is not palpable if it has less than 150 ml of urine. A stretched bladder of about 500 ml is visible in thin patients: a stretched bladder is a mass just above the pubic bone below the navel. Having clear boundaries, knocking chisels, pressing mass causes a feeling of sad urination.

Prostate examination:

Mainly rectal visits.

Posture:

Patient lies on his back, legs wide and folded.

The examiner stands between the thighs or the right side.

Examination:

Use the gloved index finger and lubricate the oil.

The rectal examination did not forget to evaluate the anal sphincter, examine the entire rectal mucosa, pouch with Douglas.

Prostate normal is less than 20 grams (2 -2.5 cm), soft density, clearly defined, painless.

Benign prostatic hypertrophy: On examination the rectum feels mass, soft density is stretched, clear boundaries. Lumps can be large (diameter: 4 - 5 cm, or more)

Distinguishing prostate cancer: prostate has a solid nucleus or a solid unbalanced tumor, the boundary is not clear, does not move.

The rectal examination is a coordinated action when examining the urinary to detect signs of pathology in the low urinary tract such as prostate gland, seminal vesicle, bladder tumor, rectal bladder fistula, urethral fistula.

Examination of the scrotum (urethra and external genitals):

Signs of inguinal or scrotum pathology are common during the emergency or daily examination. Lesions are sometimes in the groin area of ​​the genital system, can be a sign of distant damage such as urinary system, peritoneal digestive system.

Mainly examining when patients have large scrotum, palpation is mainly the thumb gesture to compare with 3-4 fingers of one hand or two hands holding both sides.

The scrotum and inguinal canal are related to the embryo and surgery, so when there are signs of pathology detected in the scrotum, always pay attention to the groin area.

Look for the signs:

Signs of Sebileau testicular clamping: normally the skin and testicular membranes can be clamped between two fingers. When there is water in the testicle membrane, we cannot do this and when the testicles are too large, we cannot do this.

Testicular and Testicular Touching (Chevassu Sign): The crest is normally palpable like a hat on the testicles. The painless soft testicles, the soft oval-shaped testicles are painless.

Touching the seminal cord: Like a smooth, smooth rope rolled under the hand and the venous vessels are also soft and easily squeezed.

The groin is shallow outside the pubic spine 0.5 cm normal hole does not fall into the tip of the index finger. The large groin can enter the scrotum. There are also additional methods of injury determination.

Phototherapy: Using a flashlight to illuminate the light through or not indicates that the scrotum contains a solid or liquid organization.

Testicular hydration to determine whether the water is caused by tuberculosis or cancer.

Biopsy: When examining a patient with an enlarged scrotum, in some cases it is necessary to distinguish:

Enlarged scrotum due to hydrocephalus, large cyst in the epididymis crest, due to inguinal hernia.

Testicular tumor, testicular crest.

Varicose veins. 

Enlarged scrotum with diseases seen in surgical emergencies:

Congested inguinal hernia

Testicular torsion is common in children and teenagers.

Later testicular stamping in inguinal scrotal injury.

Testicular misplaced. 

Penis examination:

Examination of the foreskin - foreskin stenosis (phimosis, paraphimosis).

Examination of the urethra - a disease of low-deflection urinary tract (hypospadias, epispadias).

Pathologies that cause penile curvature, erectile dysfunction, and penile trauma. 

Means of diagnosis

Biological test

Body function studies:

Is necessary in urological surgery, especially in cases of kidney resection.

Overall rating:

Quantification of blood creatinine is a very valuable test: normally <100 mmol / l indicates very accurate kidney function, blood urea amount bt <8 mmol / l

Studies of endogenous urea and creatinine clearance allow for very accurate assessment of renal function.

In case of renal failure, it is necessary to make electrolytes including: Na +, K +, Ca ++, Cl-, alkaline reserve, blood pH.

Evaluate individual kidney function:

Sometimes it is necessary to evaluate the function of each kidney separately.

The endogenous creatinine clearance in adult adults is 60 ml / min, with each kidney decreasing with age.

Renal failure when this clearance is <20 ml / mn, and <10 ml / mn, requires dialysis. To evaluate the function of each kidney, it is necessary to pass the catheter to each ureter to collect urine and the risk of infection is so great that this test is rarely used.

Based on an angiogram. Through the image of a contrast agent: the drug concentration is concentrated in each kidney; the thickness of the kidney parenchyma is determined relatively the function of each kidney.

However, in order to more accurately determine the function of each kidney, radioisotope imaging is required.

Urine bacteria test:

To determine whether there is a urinary tract infection, the number of bacteria> 100,000 / ml and the urinary leukocyte is increased, with degenerative leukocytes.

Culture of urine bacteria as antibiotics.

Some things to note:

Negative urine leukocytosis and urine cultures can be due to the following reasons: either antibiotic was used prior to culture or some bacteria must be stained or specially prepared to receive know them. Before cases of purulent, negative urine cultures, it is necessary to find TB bacteria. 

Some other bacterial tests:

Urethral implantation, fresh screening.

Urinalysis at the beach.

Urine test after prostate massage.

Semen culture.

Some other biological tests:

Quantification of sex hormones - adrenal glands.

Quantitative Marqueurs tumoraux.

Diagnostic imaging tests

Supersonic:

It is a non-dangerous, painless test and is very valuable in exploring the morphology of the urinary system. Always the first test of choice in a probe, giving much needed information, especially morphology.

In the high part: Shows the morphology and thin thickness of the renal parenchyma and calyx: the renal pelvis, ureter.

In the lower part: bladder - prostate, two seminal vesicles - testicles.

Unprepared urinary system:

Requires enema before taking 2 movies: 1 straight, 1 inclined. It shows the following information:

Kidney shadow: Normal or deformed.

Pelvic urinary muscle ball

Contrast pattern of stones either in the kidneys, or in the urinary tract.

Status of bone reticulum: density enhancement or resorption image.

Venous urography (UIV):

Up to now, UIV is still a simple and basic method for assessing renal excretion function, normal shape or pathology of renal stations, pyelonephritis, ureter, bladder, urethra.

Conducting technique:

Have the patient fast for 12 hours.

Enema of the colon before the procedure.

Have the patient urinate or urinate first.

Contraindicated in cases of high blood urea> 0.8 g / l and allergic to iodine.

Inject the contrast agent intravenously in the amount proportional to the patient's weight.

Photograph 1 film very soon: 15 - 20 seconds after injection allows the kidney artery image to be seen.

1 film after 2-3 minutes allows visualization of renal parenchyma and thereby assess the function of 2 kidneys.

Films from 3 minutes onwards allow to see pyelonephritis, ureter.

You can use 2 balls pressed into the ureter in the same pelvic joint to keep the contrast in the pyramid station to allow better visibility.

Photograph of the entire ureter requires many films because the ureter is rarely seen clearly on 1 film.

UIV will be terminated by scans of the low part of the secretory tract and films in the patient's urinary tract.

In special cases when the kidneys absorb the drug slowly, it is possible to take films in late then after 60 ', 90', 120 '... or take intravenous drip UIV with the dose of 2 to 3 times higher than normal.

Upstream pyelonephritis (UPR):

Conducted by cystoscopy, find the side ureter to capture the catheter to the ureter, pump 12-15 ml, preferably a monitoring pump on the fluorescence screen. Capture movies in the required images.

An UPR scan is an infection-prone procedure, especially in cases of obstruction. Therefore, absolute sterility is required.

Point:

When taking UIV kidney drug without drug absorption or pyelonephritis, ureter is unknown.

Look for fistula to circulate from the kidney to the lymphatic tract. 

Downstream ureter pyelography (UPD):

Indicated in cases of ureteral obstruction. The kidneys are drained through a catheter. 

Upstream cystography:

Insert the catheter into the bladder, and inject the contrast through the catheter with the right amount. 

Upstream urethra scan:

Pump contrast agent upstream from the mouth of the penis for a film in two straight and steep positions.

Indications for the detection of pathologies:

Stenosis of the urethra.

Leakage of the episiotomy or urethral fistula - rectum, urethral diverticulum

Image of urethral deformation in prostate tumor pathology.

Computer tomography (CT scanner):

At the waist:

Allows for a clear analysis of kidney tumors, distinguishing kidney follicles and gives information for the diagnosis of malignancies in the kidney.

For local invasive imaging of malignancies:

Allows unobstructed uric acid stones clearly.

Distinguish between a thrombus and a secretory tumor.

In the subframe area: for very clear pictures of bladder and prostate tumors, however, local invasive imaging and especially lymph nodes are uncertain.

Lymphatic system scan:

Let’s see pelvic and abdominal lymph nodes.

Indicated to find pathological nodes in cancer cases.

However, this test has many obstacles: it is very difficult to perform, causes pain and is not easy to read results, especially in elderly patients who are at risk for circulatory respiratory complications. 

Radioisotope imaging:

Kidney radioisotope imaging to know the function of each kidney.

Bone system radioisotope imaging is often used to detect cancer metastases in the bone, especially prostate cancer.

Magnetic resonance imaging (MRI):

Less commonly used in urology because it produces images similar to scanners.

Angiography:

Is a test that gives very good results.

However, there are many limitations: Requires taking a lot of film, injecting a large amount of contrast medicine. Especially. is to prick the body of a large artery, which will cause pain and danger to the patient.

Indications are mainly: Kidney tumors and cancer. 

Aortic scan:

Nominated:

Detecting blood clots in the kidney vein

Research on the relationship between renal tumor and inferior vena cava. Detect cancer infiltration into the aorta. 

Instruments and endoscopy tests

Indications: There are many types of urethral catheters and ureter used in the diagnosis and treatment of urinary tract diseases.

Diagnose:

The catheter is placed into the bladder to take urine for a test, measure the amount of urine in the bladder, inject a contrast agent into the urethra, the bladder to scan ...

Treatment:

Urinary catheterization for urinary retention, nerve bladder ...

Urinary catheterization in some obstructive ureter diseases,

Types of catheters:

Pipe diameter sizes are typically numbered according to the French index (Fr). The 3 Fr spec tube is 1 mm in diameter, 1 Fr = 0.33 mm in diameter. The average catheter size to order for an adult is 18 - 22 Fr.

Tests

Urethritis - bladder

Pain is less in women than in men. Requires either local anesthesia or general anesthesia.

Allows viewing of urethral mucosa and bladder, allows UPR scan.

Danger: Easy to cause bacterial infection, urethral injury.

Ureteroscopy: For cystoscopy to detect tumours in the lumen of the ureter and treat ureteroscopy stone obstruction.

Percutaneous pyelogram.

Doppler

Pathology and cytology: commonly used in the diagnosis of bladder and prostate cancers.

Exploration of bladder kinetics and kinetics:

Allows measurement of pressure in the bladder and urethra during bladder tightening and during urination.

Note the change in pressure when taking different drugs.

Allows to study the operation of the sphincter system and learn its mechanism of action.