GU SYSTEM: Consider AAA pressing ureters.

Character of pain: -Loin pain (between the 12th rib and the spine): kidney. Due to stretching of the renal capsule or renal pelvis. Causes: Infection, inflammation or mechanical obstruction. - Constant loin pain, with systemic upset, fever, pain on voiding: Acute infection of the UIT and kidney (acute pyelonephritis). - Chronic dull, aching join discomfort: Chronic infection, adult polycystic kidney disease, chronic urinary tract obstruction - Can be pain free: Chronic obstruction. -Accompanied of haematuria -Renal colic or ureteric colic: is caused by acute obstruction with distension of the renal pelvis and ureter by a stone, blood clot or necrotic renal papilla. -Sudden onset, severe and sustained and may radiate to the iliac fossa the groin and genitalia (specially the testis). Pt restless and nauseated, and often vomitis. -Suprapubic pain or pain passing urine/voiding: bladder. Pain during or immediately after passing urine, often described as a burning sensation felt at the urethral meatus or suprapubically and associated desire to pass urine more often (frequency). Causes: inflammation of the bladder (cystitis), prostatitis and urethritis. Voiding symptoms: LUTS -Storage symptoms: increased frequency with no increased total urine outflow, urgency, nocturia. Causes: bladder, prostate, urethral problems - Voiding phase symptoms: Hesitance or delay in initiating urine flow. Cause: men over 40 is commonly due to bladder outlet obstruction by prostate enlargement. -After micturition: Dribbling and incomplete emptying. Causes: Detrusor dysfunction -Incontinence: Need to void (urge), increased intra-abdominal pressure (SUI), combination of both (mixed) Polyuria: larger volume of urine. Causes: increased fluid intake, diuretic drugs, DM (hyperglicaemia), Adrenal gland (aldosterone hormone), pituitary gland (ADH). Oliguria: low fluid intake, loss of kidney function Anuria: Lower urinary tract obstruction, spinal injury Pnematuria: Passing gas bubbles (fistula between bladder and colon)

Haematuria: Red blood cells in urine, it can be microscopic (detected in urinalysis) or macroscopic (visible to the naked eye) Painless Glomerulonephritis Tumours in kidneys, ureter, bladder, prostate Hypertensive nephrosclerosis Painful Urinary tract infection Renal stones with obstruction May be either Urinary tract infection

Proteinuria: Renal: Glomerulonephritis, DM nephropathy, amyloidosis, SLE Non-renal: Fever, severe exertion, severe hypertension

Past hxx: Hypertension, DM, CV disease, urinary tract stones, surgery, recurrent infections, anaemia. Drug hxx: digoxin, lithium, aminoglycosis, opioids, B-blockers, ACE, NSAIDS. Family hxx: Symptoms Kidney/UUT Pain Swelling Macroscopic haematuria LUT Voiding pain Frequency Urgency Nocturia Hesitance Poor flow Post- micturition dribbling Stress incontinence Urge incontinence General Polyuria Oliguria Anuria Haematuria Pneumaturia Urethral discharge Definition/comments Usually felt in the lumbar region Usually of feet and ankles Blood visible in urine with naked eye Pain passing urine Passing urine more often than usual An uncontrolled need to pass urine Waking to pass urine during the night Delay in initiating urine flow A reduction in urine stream Dribbling after voiding Related to increased IAP Related to abnormal detrusor function Passing a larger volumen of urine tan normal Passing a smaller volume of urine than normal Total absence of urine output Blood in urine Purulent material from urethra, suggesting sexually acquired infection

Infection-Systemic issues affecting: Reactive arthritis, candida, shyphylis (tabes dorsalis/dorsal column), gonorrhea, clamidia, DM (candida), gout, hypertension. Complication: Osteomyelitis, local cancer Bacterial/fungi: fever, pain with urination, itch, rash, hxx, discharge, ascending direction, blood stream, women>men, increased sexual intercourse, elderly, age, reduced fluid intake, medical catetheritation. Obstruction: Upper: kidney stones or urethres, cancer, AAA, blod clot, cysts Lower

Gyne/Obstetrics: Red flags: Pelvic pain, pelvic mass, fever, vaginal discharge, bleeding in between periods, bleeding between intercourse, bleeding after menopause. Menstruation: Ask about Menarche Last menstrual period Information to obtain Age at which period began Date of the first day of the last period Number of days the period last Light/normal/heavy Number of days btw each period Bleeding btwn periods or after intercourse Associated with menstruation Birth/miscarriages/abortions Pt trying to become pregnant? Current and previous records Comment Exclude pregnancy. If menopausal, record the age at which periods stopped Normal 4 to 7

Length of period Amount of bleeding Regularity of periods

Erratic bleeding Pain

22-35 normal. Around menopause cycles lengthen until they stop all together Serious underlying disease Adolescents: normal Older women: possible underlying disease How long have they been trying? Hormonal and intrauterine contraception can affect menstruation bleeding patterns

Pregnancies Infertility Contraception: condoms, combined oral contraceptive pill, proges only pill, progest injection, progest inplant, IUD or coil, cervical cap, natural methods, sterilization. Lifestyle

Weight, diet, exx

Rapid weight loss, excessive exercise: oligo-amenorrhea

Obesity: hormonal abnormalies, menstrual changes, and infertility Hormonal disorder: acne, hirtuism

Dyspareunia: Pain during intercourse Vaginal discharge: White or clear discharge (normal), colour, smell, heaviness, duration, associated symtoms, (itchiness, soreness): Vaginal infection (sexually or non-sexually transmitted). Pelvic mass: Pregnancy, uterine fibroids, ovarian masses Incontinence: Prolaps:

PATHOLOGIES: KIDNEY CONGENITAL DISEASE OF THE KIDNEY: Agenesis: Unilateral. Often together with spina bifida. The solitary kidney that undergoes is susceptible to infections and progressive glomerulonephritis. Bilateral. Hupoplasia, ectopic kidney, horseshape kidney. CYSTIC DISEASE OF THE KIDNEY: DISEASE OF THE GLOMERULUS: GLOMERULAR LESIONS IN SYSTEMIC DISEASE: SLE, BACTERIAL ENDOCARDITIS, DM, AMYLOIDOSIS, POLIARTERITIS NODOSA TUBULES AND INTERSTITIUM DISEASE OF THE RENAL BLOOD VESSELS NEOPLASTIC DISEASE URINARY TRACT CONGENITAL ANOMALIES OF THE URINARY TRACT URINARY TRACT OBSTRUCTION

UROLITHIASIS (URINARY CALCULI) INFLAMMATION OF THE URINARY TRACT: CYSTITIS NEOPLASTIC DISEASE OF THE URINARY TRACT SKIN conditions: Psoriasis: Extensor plaques, knees and elbows, scalp and sacrum Eczema: Flexural, antecubital and popliteal fossa, neck and face Systemic: symmetrical -Erithema nodosum: sarcoidosis, TB, post-streptococcal infection, connective tissue disease, drugs -Pyoderma gangrenosum: UC, RA, leukaemia -Butterfly rush: SLE, mitral stenosis -Dry skin: Hypothyroid Asymmetrical: Fungus, bacterial or viral Malignant melanoma: Skin lesion on the back: Has it appeared/changed recently, bigger, itchy, bleeding (malignant melanoma), family hxx of malignant melanoma, pale skin (skin cancers more common with pale skin), irregular and diffuse edge, variations in pigmentation. Metastasice to tissues under it and lung and brain. ABCD: Asymmetry, Border irregularity, Colour, Diammeter > 6 Neurofibroma: A neurofibroma is a benign nerve sheath tumor in the peripheral nervous system Acne: Facial, forehead, nasolabial folds and scalp (seborrhoic dermatitis)/ Acne: pustules and cysts, also affects chest and back/ Rosacea: telagientasia Sun burns Leg ulcers: hospitalisation, inmmobilisation DM Pigmented lesin Striaes Caput medusa Allergies Athletes food: Fungal infection. Common contagious fungal infection of the skin that causes scaling, flaking, and itch of affected areas

Herpes zosters: dermatomal, asymmetrical, thorax and CN V distribution Warts HIV patients: Kaposi's sarcoma. Associated with mortality and morbidity Birth marks High alcohol intake: Palmar erythema: hyperthyroid, pregnancy Pale palms: anaemia Rheumatic nodes/ trophies Nicotine stain Raynaud's disease CLASIFICATIO: INFLAMMATION AND SKIN ERUPTIONS: Psoriasis, eczema and dermatitis Psoriasis: Chronic, non-infectius, inflammatory disease of the skin characterized by erithematous plaques covered with thick scales. % 2 of population. Age: 20-30 y. PF:Family hxx, HLA B27, drugs, UV light, alcohol, stress. Signs & symptoms: extensor surface of elbows, knees, the trunk and the scalp. Associated symptoms: Nail involvement: pitting and onycholysis. Joint involvement: distal arthritis (hands and feet), rheumatological, mutilans (erosive joint destruction with associated deformation), oligoarthropatic (spondylolytic type). Eczema and dermatitis: Non-infective inflammatory condition of the skin. Acute/chronic: acute eczema which with scratching becomes chronic. Types: - Atopic: strong family hxx, hxx of asthma or high fever, uncontrollable itching, remitting/relapsing course, raising rates in general population (5%), high Ig E levels leading to hypersensitivity. Infancy: acute type affecting face and hands, often with secondary infection. Childhood: progression from acute to chronic, affects flexures (antecubital fossa, popliteal fossa, neck, wrists and ankles). Adults: Cronic -Contact dermatitis: dermatitis precipitated by exogenous agents: irritant contact dermatitis (abrasive, acids, alkalis, solvents, or detergents), allergic contact dermatitis (nickel). Lesions localized to the area of contact, common in face and hands. INFECTION: Bacterial infections, viral infections, fungal infections

Bacterial: Staphylococcal infections: Impetigo: superficial, higly contagious, children with poor hygiene, spreads rapidly. Foliculitis: Staphylococcus aureus. Infection of multiple hair follicles, tiny pustules located near neck/back hair follicles, berad area (men), legs (women) Streptococcal: Erysipelas: Superficial celullitis. Uually affects the face or the lower leg and appears as a painful red swollen. Often fever and flu like symptoms. Antibiotic treatment. Necrotising fasciitis: a deep-spreading infection of the fat, fascia and muscles, this is caused by streptococcus pyogenus. High fever, erythema typically affecting the leg. Minor trauma. Toexaemia, multisystem organ failure. Mycobacterial infection: TB of the skin: Reddish-brown plaques. Typically affecting the head and neck Spirochaetal infection: Syphylis: Sexual intercourse. stages: primary, secondary and tertiary. Skin lesions seen in all stages. Appears 4-12 weeks after ponset in the primary stage. Chraracterised by a non-itchy, pink coloured eruption on the trunk, limbs, palms and soles of the feet. Lymphadenopathy, general malaise, warty papules, buccal erosions, disuse patchy alopecia. Lyme disease: Cutaneous systemic infection. Spread by certain ticks. Develop slowly extending erythematous rash at the site of the tick bite. Intermittent systemic symptoms including fever, malaise, HA, neck stiffness and muscle and joint pain. Viral infection Viral warts (verrucae): Common, beningn, hyperkeratotic, papilloma growth caused by infection withhuman papillomavirus (HPV). Possible link between HPV infection of the skin and skin cancer. Types: Common warts (hands, feet, genitalea), plantar warts (often covered with hyperkeratosis, pressure causes inward growth), plane warts (face), genital warts (increased cervical cancer). Molluscum contagiosum Herpex simplex: Acute vesicular eruption of the skin or mucous membranes. Caused by infection with Herpex Simplex Virus (HSV). Highly contagious, transmited by direct contact. The virus penetrates until epidermis or mucous membranes and replicates. Virus goes to dorsal ganglion. Reactivation can occur at any time. Reocurrence precipitated by respiratory infection, sunlight or local trauma. HSV 1: primary, childhood, common cold sore, around the lips. Fever, malaise. 2 weeks.

HSV 2: genital herpes. Herpes Zoster (Singles): Acute vesicular eruption in a dermatomal distribution. Reactivation of the varicella zoster virus (chicken pox). The virus remains dormant in the dorsal ganglia. Fungal infections: Dermatophyte infections: Athletes foot: Humid and sweaty conditions, including occlusive footwear. Candida Albicans: yeast-type fungus. Commensal vagina and alimentary canal. PF: obesity, humidity, diabetes and oral antibiotics. Types: Genital (Thrust, white-yellowish plaques on the inflamed mucous membranes, itchy/discomfort, vaginal discharge), oral (white plaques on the tongue or inside the cheecks), intertrigo (2 skin surfaces in contact: under the breast, interdigital), parenchyma (nailfolds), systemic (HIV), mucocutaneous (Addisons disease). Infestations: Insect bites: Pediculosis (lice): Scabies: DISORDERS OF SWEAT AND SEBACEOUS STRUCTURES: Acne vulgaris, Rosacea Acne vulgaris: Inflammatory disorder of the pilosebaceous apparatus characteristic of papules, pustules, nodules, cysts and scars. Common in adolescents. Cause: androgen sensitive sebaceous glands with hyper-responsiveness to testosterone. Common in back, shoulders, upper chest and back. Rosacea: Chronic inflammatory disease of the face characterized by erythema, telangiectasea and pustules. Affects middle age or elderly. DISORDERS OF PIGMENTATION: Hypopigmentation, hyperpigmentation Hypopigmentation: Vitiligio: Characterised by the appearance of symmetrical white or pale macules on the skin. Cause: Autoinmmune disease of melanocites. Often associated with other autoinmmune diseases (Anaemia perniciosa, Thyroid, Addisons). Family hxx. Affcts all races, more common in dark skin individuals. !0-30 y. Hands, wrists, kees, neck and areas around the orifices (mouth). Albinism: Autosomal recesive. Lack of pigmentation in the skin, hair, eyes. Melanocyte number is normal but production of melanine fails because of defect in the enzyme tyroxine. Hyperpigmentation:

Freckels: Small, light-brown, well-demarcated macules that darken to exposure to sunlight. Contain normal numbers of malanocytes but melanin production is increased. Common in childhood. Lentigines: More scattered and they do not darken in the sun. Outline more irregular. Increased numbers of melanocytes. Childhood. Drug-induced pigmentation. Other causes: Addisons disease. BLISTERING DISORDERS: TUMOURS: Bening tumours of the skin, Naevi, Malignant melanoma, Malignant epidermal tumours, other tumours of the skin Epidermal tumours: Seborrhoeic warts: Bening tumours of basal keratinocytes. Trunk, face and arms. Elderly. Greasy looking. Well defined edges. Actinic keratosis: roughened, scaly, brownish-to-red lesions, usually less than 1 cm around, bleeds when rubbed. Sun exposed areas (hands, face, scalp), middle age and elderly. Considered as premalignant. Skin tags: Bening, pedinculated polyps, few millimeters in length. Elderly or mild-age. Neck, axillae, groin and eyelids. Cysts: Naevi: Bening, coloured. Proliferation of the cells of the skin. Often congenital (birthmarks), they may be acquired. Congenital naevi: over 1 cm, hairy, have a risk to malignant changes. Blue naevi: solitary, found in extremities Halo naevi: wjite halo of pigmentation surrounds the naevi. Beckers naevi: rare, unilateral, upper back and chest, hyperpigmentation and hairy. Familial dysplasic naevus syndrome- familial condition, increased risk of developing malignant melanoma. Malignant naevi: Larger than normal, irregular edges, surface and pigmentation. Vascular naevi: congenital or developmental soon after birth. Malignant melanoma: Melanocytes. Caucasian race. Males-back, female-legas, repetitive exposure tu UV radiation. PF: Family dysplasic naevus syndrome, multiple melanocyte naevi, congenital naevus, previous malignant melanoma, immunosupression, fair skin. Breslow classification method. Diagnosis: Size (increased), shape (irregular), colour (irregular

pigmentation), inflammation (at the edge of the lesion), bleeding lesion, itchiness (common syptom). Malignant epidermal tumours: Basal cell carcinoma: A malignant tumour that arises from the basal keratinocytes of the epidermis.Most common form of human cancer. Face of elderly people. Very invasive, they dont tend to metastasize. PF: UV, X-Ray, chronic scarring, genetic predisposition. Sun exposed sites, around the nose. Squamous cell carcinoma: Derived from keratinocytes. Face of the elderly and middle-age. Male>female. Localy invasive and can metastasize. PF: UV, chemical, X-ray, smoking, HVP Bowens disease: lower leg, elderly. Previous exposure to arsenicals. Slowly extending, pink or lightly pigmented, scaly plaques. Remains in situ for many years but has capacity to become squamous cell carcinoma. Other tumours of the skin: Kaposis sarcoma: HIV