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DIAGNOSIS
DIAGNOSIS
Physical Examination
• Kidney• Urinary Bladder• Female Genitalia– Bimanual examination
• Examination of the Penis, Scrotum, and Testis
• Digital Rectal Exam
Schwartz’s Principles of Surgery 8th ed.
Physical ExaminationKIDNEY• Patient in supine• Palpate just below and parallel to the
12th rib, just reaching the costovertebral angle.
• “capture” the kidney between your two hands on patient’s deep inspiration
• Ask the patient to breathe out and then to stop breathing briefly. Slowly release the pressure of your left hand, feeling at the same time for the kidney to slide back into its expiratory position.
• If the kidney is palpable, describe its size, contour, and any tenderness.
Bate’s Guide to Physical Examination and History Taking
Physical Examination
Urinary Bladder• Can be palpated when there is at least 150mL of urine in
it• Percussion is better than palpation for diagnosing a
distended bladder.• A careful bimanual examination, best done with the
patient under anesthesia, is invaluable in assessing the regional extent of a bladder tumor or other pelvic mass, induration and mobility.
• Tenderness over the suprapubic area may indicate cystitis.
Physical Examination
Female Genitalia• External Inspection– The labia minora,
clitoris, urethral meatus, vaginal opening, or introitus
– Note any inflammation, ulceration, discharge, swelling, or nodules.
– If there are any lesions, palpate them.
Bate’s Guide to Physical Examination and History Taking
Physical ExaminationFemale GenitaliaBimanual Examination• Note any nodularity or tenderness in
the vaginal wall, including the region of the urethra and the bladder anteriorly.
• Palpate the cervix, the uterus, each ovary
• Assess the Strength of the Pelvic Muscles and bladder mobility
• May reveal a variety of abnormalities including benign/malignant masses, unflammatory lesions, pelvic prolapse
Bate’s Guide to Physical Examination and History Taking
Physical ExaminationExamination of the Penis, Scrotum, and Testis• The physical examination of a male patient should be performed with the
patient standing and the physician seated on a stool. • Inspect: the skin of the penis, scrotum, and the surrounding inguinal region • Palpate:
– testicles for masses or tenderness and the size of the testicles should be noted. Normally, have a firm, rubbery consistency with a smooth surface
– The epididymis can be palpated on the posterolateral surface of the testicles– The vas deferens can be felt by gently compressing the scrotum above the
testicles.– The penis should be gently massaged to express any urethral discharge. – The penile shaft and urethra should be palpated along the length of the penis.
• Any nodules or fibrotic plaques on the corporal bodies should be noted.• Hydroceles – a buildup of fluid between the two layers of the tunica
vaginalis– can be confirmed by transilluminating the sac with a penlight.
• Varicoceles – may be palpable in the scrotum and represent dilated veins
Schwartz’s Principles of Surgery 8th ed.
Physical ExaminationDigital Rectal Examination (DRE)• Should be performed in every male
after age 40yrs• the patient leaning over an
examination bench and resting on his elbows or the patient can be lying in a lateral decubitus position
• begins by separating the buttocks and inspecting the anus for pathology, usually hemorrhoids
• Estimation of anal sphincter tone is of great importance
Physical ExaminationDigital Rectal Examination (DRE)• Palpation:
– Using lubrication, the index finger is gently inserted into the rectum.
– The prostate is palpated, and any nodules, indurations or asymmetry should be noted.
– Valsalva will often bring the prostate closer to the anus and facilitate the exam.
• Normally, the prostate is about the size of a chestnut and has a consistency similar to that of the contracted thenar eminence of the thumb (with the thumb opposed against the little finger).
Bate’s Guide to Physical Examination and History Taking
Laboratory Examination• -clean midstream catch is usually adequate• -in children,urine can be collected by placing a urine
collection bag over the urethral meatus
Examination of urine• urinary pH• specific gravity• protein• glucose• ketones• bilirubin• urobilinogen• hemoglobin, leukocytes, and nitritesrelies on color changes produced by chemical
reactions with substances in the urine
Examination of Urine• pH
- will reflect the pH of the serum• Specific gravity – reflects the hydration status of the patient and the
concentrating ability of the kidney• Proteinuria – indicate intrinsic renal pathology or the presence of excess
protein in the serum. • Glucose and Ketones – screening for diabetes– greater than 180 mg/dL
Examination of Urine• Bilirubin and high levels of
Urobilinogen– liver disease or hemolysis.
• Hemoglobin, myoglobin, and red blood cells – can produce a positive result on
dipstick tests for blood. • Leukocytes and nitrites – inflammation, which is most
commonly caused by a bacterial infection.
• Leukocyte esterase, – an enzyme found in neutrophils
Urine Culture
• Greater than 105 organisms/mL – UTI
• 100 organisms/mL of a known urinary pathogen – bacterial infection
• Antibiotic sensitiviy testing
Tests for Kidney Function• Specific gravity– with a progressive decrease in renal function, the
specific gravity does not decrease below approximately 1.015.
• Creatinine clearance– volume of plasma from which creatinine is
completely removed per unit of time and is a clinical approximation of the glomerular filtration rate (GFR) and renal function
– Clearance=UV/P– N: 90 to 110 mL/min
Tests for Kidney Function
• Gold standard for measuring GFR – Inulin is an ideal substance for measuring GFR
because it is completely filtered by the kidney without being secreted or reabsorbed by the tubules.
– Vs.Creatinine • Secreted in small amounts by the proximal tubule.
Therefore, creatinine clearance will slightly overestimate GFR at all levels of kidney function.
• This effect is most pronounced when kidney function is severely compromised, where creatinine clearance can overestimate GFR by as much as 1.5- to twofold.
