| | ENURESIS
Doorway information about patient
You will be speaking with mother of a 5-year-old boy who wets his bed frequently.
Approach to the patient
-Enuresis- is nocturnal urinary incontinence in children age >=5 years . It occurs in up to 15 % of children at age 5 years and is more common in boys . Enuresis can be categorized as -primary- (patient has never had a sustain period of nocturnal continence0 or -secondary-(incontinence after the patient has had a period of dryness lasting >= 6 months) and -monosymptomatic- (isolated incontinence) or -nonmonosymptomatic- ( nocturnal incontinence associated with additional symptoms [eg, daytimeincontinence , urinary hesitancy , feeling of incomplete emptying , abdominal pain]). Secondary enuresis is often due to -psychological stress- or an underlying -medical problem-.
Differential diagnosis
Causes of secondary enuresis
Etiology : Associated symptom
Psychological stress : Behavior regression , mood lability
Urinary tract infection : Dysuria , hesitancy ,urgency , abdominal pain.
Diabetes mellitus : Polyuria , polydipsia , polyphagia , weight loss , lethargy , candidiasis
Diabetes insipidus : Polyuria , polydipsia
Obstructive sleep apnea : Snoring , dry mouth , fatigue , hyperactivity , irritability
the patient (and child ) should be queried about additional symptoms that may suggest a neurologic disorder (eg , spinal dysraphism). urinary tract infection , encopresis / constipation , or metabolic disorders (eg, diabetes mellitus , diabetes insidious). recent psychological stressors should be noted . Enuresis can also be associated with abnormal fluid intake (eg, psychogenic polydipsia ) , obstructive sleep apnea , and irritative lower gastrointestinal disorders (eg, pinworms). Genitourinary cause of enuresis are often associated with daytime incontinence , holding maneuvers , abnormal voiding (eg, interrupted micturition , weak stream ) , and frequent small-volume voids.
HISTORY AND PHYSICAL EXAMINATION
Practice pediatricians often have the parents keep a log of the child’s daily fluid intake and voiding habits (i.e., timing , volume , voiding symptoms). In the Step 2 CS exam , such follow-up is not possible ,m but you may ask about the patient’s recollection of these factors.
History
History of present illness
. Has your son ever been consistently dry at night or has he always wet the bed ?
. How many times a night & how many mights a week dose he wet the bed?
. How much fluid dose he drink during the day? what time of day dose he drink the most ? How much dose he drink before going to bed?
. Tell me about his bathroom habits: How often dose he go , & with how much volume?
. When he goes , dose he have drubbing , stopping the stream , or pain? When he is done, dose he feel like he still has to go?
. Dose he lose control of his bladder during the day?
. Dose he ever have to run to the bathroom?
. Dose he have difficulty initiating the stream?
. Dose he have problems associated with bowel movements?
. How has this problems affect you & your family?
. Are you aware of any stressful situations or incidents tat could be causing this problem?
. What do you think may account for this problem , or what are you concerned about for your child?
. Is there anything you’ve tried so far to deal with this problem?
Past medical history
. Has he been diagnosed with any other medical conditions?
. Has he had any urinary tract infections?
. Has he had any surgeries or injury to his nervous system?
. Were there any complications during pregnancy or delivery?
Social history
. Who dose he live with?
. Would you describe your son as playful & social or shy & quiet?
Most children with enuresis have normal findings on physical examination, Remember that you are -not permitted- to perform genitourinary , rectal , pelvic , or inguinal hernia examinations (if these are necessary , you may include them in the Diagnostic Study/ Studies section of your documentation).
Physical examination
General
. Review vital signs & growth / weight chart (if available).
HEENT
. Examine tonsils & adenoids for hypertrophy (suggesting obstructive sleep apnea)
Gastrointestinal
. Palpate abdomen of retained stool.
Musculoskeletal
. Inspection spine for deformities.
Neurologic
. Perform sensory , motor & reflex examination of the lower extremities.
Closing the encounter
Although psychological stress is a common cause of enuresis , be careful to remain non-accusatory and non-judgmental . If you identify signs of an underlying medical disorder , these should be discussed with the parent , but explain your degree of uncertainty and the need for confirmatory tests (eg, “Excessive fluid intake with frequent , large-volume urination may be a sign of diabetes or a kidney problem , but there are other possible explanations as well . We will need to do additional tests before I can give you a definite diagnosis”)
Keep in mind that parents may be more anxious about health problems in their children than they would be for a similar problem in themselves. Avoid giving false reassurance , but sure them that you will work with them to identify the problem and provide appropriate care . It may be helpful to note that enuresis is common and often resolves spontaneously.
Diagnostic studies
Depending on the clinical findings , the initial evaluate may include a -urinalysis- on first -morning void . Additional studies that may be considered include :
. Serum glucose and electrolytes
. Serum creatinine
. Urine culture
. Complete blood count and hemoglobin electrophoresis (for sickle cell anemia)
. Abdominal x-ray(for retained stool)
. Renal ultrasound
. Voiding cystourethrogram
. MRI of the spine
| | |
|
|
|
頂端 
加到"我的最愛"
主題管理：
總固頂 
取消總固頂 
Message
查看
搜尋
通訊錄
複製
引用
回覆
2018/05/24 09:58pm 
IP: 已設定保密