Case 1 – Dysuria

You are seeing Mrs. Lawrence , a 72 year old female, in your outpatient clinic
today. She tells you that she has discomfort during urination and has difficulty
controlling her urine. Take a focused history of his complaint.
History
Clarifies symptom of dysuria
Onset of dysuria
Urinary frequency
Change in urine color (cloudiness, darkening)
Presence of hematuria (none)
Nocturia
Urgency
Overflow Incontinence
Incomplete voiding
Flank/back pain
Abdominal discomfort/fullness/pain
Nausea and vomiting
Fever
Gastrointestinal symptoms such as pain, diarrhea, blood in stool
Pregnancy history
Current medications (particularly anti-cholinergic medication, estrogen creams)
Past history of urinary tract infections
Past history of urinary incontinence and treatments
Exposure to pool/lake/ocean water
Recent antibiotic use
Effect on daily life
Case 2 – Hematuria
You are seeing Mr. Ali, a 72 year old male, in your outpatient clinic today for
‘bloody urine.’ Take a focused history of his complaint.
History
Onset and duration of hematuria
Progression or worsening of hematuria
Clarifies color of urine (bright red blood)
Urinary frequency
Pain on urination
Urgency
Nocturia
Incomplete voiding
Hesitancy
Penile tip pain
Flank Pain
Abdominal discomfort/fullness
Systemic Symptoms – weight loss, fever, night sweats
Personal history of bleeding diathesis
Personal history of renal stones
Past history of renal disease
Current medications
Surgical history
Smoking history (quantity in pack-years)
Occupational history – especially exposure to exogenous toxins
Concerns as to what is causing the hematuria
Past history of urinary tract infections
Family history of urogenital cancers
Case 3 – Testicular Mass
You are seeing Bill Byrd, a 40 year old man in your outpatient clinic because he
recently noticed a testicular mass. Perform a full genital examination.
Physical Examination
Scrotum
Inspects scrotum for asymmetry and skin lesions
Palpates testicles bilaterally
Comments on masses: size, location, consistency, tenderness, irregular shape
Palpates epididymis for tenderness, enlargement
Penis
Inspects penis for erythema, swelling, deformity
Palpates along penile shaft for irregularity
Examines foreskin for signs of infection
Exposes glans for inspection, and replaces the foreskin after completing the
examination
Examines meatus for discharge
Hernias
Palpates inguinal region bilaterally for presence of hernias
Assesses for hernias with patient standing up
Asks patient to bear down during palpation of scrotum
Digital Rectal Examination
States that a digital rectal examination would be performed as part of the
genitourinary examination
Case 4 – Renal Colic
You are seeing Ms. Hamilton, a 64 year old man, for left sided back pain. She says
it began three days ago and isn’t getting any better. Take a focused history of her
complaint and perform a physical examination.
History
Onset and duration of pain
Progression of pain
Location of pain (unilateral)
Frequency of pain (intermittent)
Quality of pain (sharp)
Radiation (to abdomen and groin)
Flank pain (yes)
Changes in amount of urine
Dysuria
Urgency
Hematura (some darkening)
Post-void dribbling
Fever (recently)
Nausea/vomiting
Diarrhea (none)
Diaphoresis
Current Medications
Diet history (focusing on calcium and oxalate intake)
Personal history of renal stones
Personal history of urinary tract infections
Family history of renal stones
Past medical history
Physical Examination
Inspection/Vitals
Comments on general appearance of patient (uncomfortable, diaphoretic)
Measures heart rate (elevated) and states that temperature should also be measured
Renal Examination
Palpates location of back in which pain is located
Assesses for CVA percussion tenderness
Attempts to palpates for kidneys with patient supine
Auscultates for renal bruits bilaterally
Abdominal Examination
Inspects abdomen for masses, scars
Auscultates in all four quadrants of the abdomen
Palpates all quadrants for tenderness, commenting on absence/presence of guarding
Assesses for rebound tenderness in the left and right lower quadrants
States that they would perform a digital rectal examination as part of the
abdominal examination
Special Maneuvers
Examines for signs of appendicitis: McBurney’s point tenderness, Rovsing’s sign,
Psoas sign