Comparison: Appendicitis vs. Pancreatitis vs. Cholecystitis

1. PAIN

2. VOMITING

3. FEVER

4. DECUBITUS (Position of Comfort / Posture)

Summary at a Glance

• Murphy's syndrome (S. Das): In acute appendicitis, the invariable sequence is pain first, then vomiting, then fever. This sequence is diagnostically important.
• Pancreatitis pain is uniquely refractory to standard analgesics and is relieved (partially) by leaning forward - a posture not seen in the other two conditions (Bailey & Love).
• Cholecystitis fever is only moderate, distinguished from the higher fever of appendicitis (especially in children) and the SIRS-range fever of severe pancreatitis (S. Das).
• Vomiting is most severe and persistent in pancreatitis; it can persist despite nasogastric aspiration due to ongoing retching (Bailey & Love).
• The contour of the abdomen remains normal in biliary colic and acute cholecystitis, unlike the distension seen in pancreatitis (with ileus) (S. Das).

• Peptic Point - located on the midline in the epigastric region, midway between the xiphisternum and the umbilicus. Tenderness here is elicited in gastric ulcer.
• Duodenal Point - located just to the right of the midline in the epigastric region, at roughly the same level as the peptic point. Tenderness here is characteristic of duodenal ulcer (also called the pyloroduodenal point in some texts).

UTI History Taking - 3rd Year MBBS

PRESENTING COMPLAINTS (with duration)

1. Burning/pain on passing urine (dysuria) - since ___ days
2. Increased frequency of urination - since ___ days
3. Urgency (sudden, uncontrollable desire to pass urine) - since ___ days
4. Passage of blood in urine (haematuria) - if present
5. Suprapubic pain / lower abdominal pain - if present
6. Loin pain / flank pain - if upper UTI (pyelonephritis)
7. Fever with chills - if present (suggests upper UTI)

Dysuria alone is the single most reliable symptom of UTI. Presence of dysuria + frequency predicts UTI in >90% of cases when vaginal symptoms are absent. - Campbell Walsh Wein Urology

HISTORY OF PRESENTING ILLNESS (HPI)

For Dysuria:

• Onset: Sudden or gradual?
• Character: Burning, stinging, or pain? At the start, end, or throughout micturition?
  • Burning throughout urination - typical of cystitis
  • Pain at the end of urination (strangury) - suggests bladder neck/trigone involvement
• Severity: How much is it bothering you?
• Progression: Is it getting worse or better?
• Relieving/aggravating factors: Does drinking water help? Does holding urine worsen it?

For Frequency:

• How many times are you urinating during the day? At night (nocturia)?
• Normal is 4-6 times/day; nocturia: 0-1 times at night
• Is the amount passed each time normal, or are you passing small amounts?

For Urgency:

• Do you feel a sudden urge that you cannot control?
• Have you had any leakage of urine before reaching the toilet? (urge incontinence)

For Urine Appearance:

• Is the urine cloudy or foul-smelling?
• Is there blood in the urine? (gross haematuria)
  • If yes: is it throughout the stream (total haematuria - suggests bladder/kidney) or at the end (terminal haematuria - suggests bladder neck/trigone)?
  • Is blood clots present?

For Loin/Flank Pain (upper UTI):

• Site: unilateral or bilateral?
• Character: dull ache or severe colicky?
• Radiation: does it radiate to the groin? (suggests ureteric calculus as differential)
• Associated with fever, chills, rigors?

For Fever:

• Low grade or high grade?
• Associated with chills and rigors? (rigors suggest bacteraemia/pyelonephritis)
• Time of fever: continuous, intermittent, or remittent?

ASSOCIATED SYMPTOMS (to ask systematically)

NEGATIVE HISTORY (symptoms to ask about and note as absent)

• No vaginal discharge / No abnormal per vaginal symptoms
• No urethral discharge
• No obstructive symptoms (poor stream, hesitancy, dribbling) - if absent, less likely to be BPH/stricture
• No history of renal stones
• No jaundice
• No joint pains / skin rash (to rule out systemic diseases like SLE causing nephritis)

PAST HISTORY

1. Previous episodes of UTI - How many times? How treated? Did they require admission?
2. Previous investigations: Any urine culture done before? What organism? What antibiotic was given? Did it resolve?
3. History of renal stones / kidney disease
4. History of urinary tract surgery / instrumentation - catheterisation, cystoscopy, urethral dilation
5. History of diabetes mellitus - major predisposing factor for complicated/recurrent UTI
6. History of tuberculosis - sterile pyuria can be due to renal TB
7. History of sickle cell disease / anaemia - associated with UTI
8. History of spinal cord injury / neurological disease - neurogenic bladder predisposes to UTI
9. History of STI (sexually transmitted infection) - Chlamydia, Gonorrhoea can mimic UTI
10. History of benign prostatic hyperplasia (BPH) - in elderly males

MENSTRUAL AND OBSTETRIC HISTORY (in female patients - IMPORTANT)

1. Last menstrual period (LMP) - Is the patient possibly pregnant? (Pregnancy is a major risk factor and changes management completely)
2. Any missed period / pregnancy symptoms?
3. Menstrual cycle: Regular or irregular?
4. Post-menopausal status - oestrogen deficiency causes atrophic urethritis, increases UTI risk
5. Number of pregnancies (gravida/para): Pregnancy increases UTI risk due to ureteric dilatation and vesicoureteric reflux
6. Any UTI during previous pregnancies?

Asymptomatic bacteriuria in pregnancy must be treated (unlike in non-pregnant women) as it can progress to pyelonephritis in 20-30% of cases. - Harrison's Principles of Internal Medicine 22e

SEXUAL HISTORY (ask sensitively, with appropriate privacy)

1. Is the patient sexually active?
2. Recent change in sexual partner or new sexual partner - increases UTI risk (post-coital UTI/"honeymoon cystitis")
3. History of unprotected intercourse - to rule out STI as cause of dysuria
4. Use of contraceptives: Diaphragm/spermicide use increases UTI risk; condom use is protective
5. In men: any penile discharge? Any partners with known STI?

DRUG HISTORY

1. Current medications - any antibiotics already started? (affects culture results)
2. Cyclophosphamide - causes haemorrhagic cystitis
3. Immunosuppressants - increase infection risk
4. NSAIDs / analgesics - can cause interstitial nephritis mimicking UTI
5. Any known drug allergies? (Especially to sulfa drugs, penicillins, fluoroquinolones - important before prescribing)
6. Oral contraceptive pill use - slightly increases UTI risk

PERSONAL HISTORY

1. Diet: Fluid intake - is the patient drinking adequate water? (dehydration predisposes)
2. Bowel habits: Constipation? (faecal flora close to urethra in women increases ascending infection risk)
3. Hygiene practices: Wiping direction after defecation (back to front = risk in females)
4. Bladder habits: Does the patient delay urination frequently? (urinary stasis predisposes)
5. Occupation: Sedentary work, truck drivers (hold urine for long periods)
6. Smoking/alcohol: Note for general history; less directly relevant but ask routinely
7. Travel history: Geographic exposure (TB-endemic areas for renal TB differential)

FAMILY HISTORY

1. Any family history of renal disease, polycystic kidney disease?
2. Family history of diabetes mellitus?
3. Family history of recurrent UTI (some genetic predispositions exist - P-blood group antigen receptors for E. coli)
4. Family history of urinary tract anomalies or vesicoureteric reflux

SOCIOECONOMIC HISTORY

1. Standard of living; water source (contaminated water?)
2. Toilet facilities available? (lack of access to toilets leads to urine holding)
3. Occupation

SUMMARY OF HISTORY (how to present in viva/ward)

"Mrs. [Name], a [age]-year-old female, presented with a [X]-day history of burning micturition, increased frequency of urination [__ times/day], urgency, and passage of cloudy urine. She also gives a history of lower abdominal pain. There is no vaginal discharge. She has had [X] previous similar episodes, last treated with [antibiotic]. She is a known diabetic on metformin. LMP was [date], she is not pregnant. There is no history of fever, loin pain, or rigors to suggest upper urinary tract involvement."

KEY DISTINGUISHING FEATURES IN HISTORY

IMPORTANT RISK FACTORS TO ELICIT IN HISTORY

MNEMONICS FOR 3RD YEAR VIVA

• Frequency
• Urgency
• Nocturia
• Dysuria

• Fever (high grade with rigors)
• Loin pain (CVA tenderness)
• Lower UTI symptoms (dysuria, frequency)

• Sexual activity
• Trauma/instrumentation
• Obstruction (stones, BPH)
• Diabetes
• Dehydration
• Anomalies (VUR, horseshoe kidney)
• Renal calculi

Abdominal Examination in UTI - MBBS 3rd Year

BEFORE YOU BEGIN

• Position: Patient supine, relaxed, arms by the sides, knees slightly flexed (to relax abdominal muscles)
• Exposure: Nipples to pubic symphysis (fully expose the abdomen)
• Warm hands, stand on the right side of the patient
• Ask about pain site before palpating - always begin away from the painful area

I. GENERAL SURVEY (Before touching the patient)

II. INSPECTION OF THE ABDOMEN

1. Shape / Contour

• Normal contour - typical in uncomplicated cystitis (lower UTI)
• Suprapubic fullness / bulge - suggests bladder distension (urinary retention due to obstruction e.g. BPH, urethral stricture)
• Flank fullness - hydronephrosis, perinephric abscess

2. Skin

• Note any scars (previous surgery - nephrectomy, cystoscopy, catheterisation)
• Herpes zoster vesicles in flank/loin - can mimic UTI pain; prodromal hyperaesthesia before rash
• Surgical stoma - increases UTI risk

3. Movements with Respiration

• Normal in uncomplicated UTI
• Restricted abdominal wall movement with deep inspiration suggests peritoneal irritation (e.g. perinephric abscess)

4. Visible Pulsations / Peristalsis

• Not typically relevant to UTI; note if present to consider other diagnoses

III. PALPATION

A. Superficial Palpation (all 9 regions)

• Guarding / rigidity - absent in simple cystitis; may be present in perinephric abscess or if UTI complicated by peritonitis
• Tenderness map:

B. Deep Palpation

• Normally the bladder is not palpable when empty
• If the bladder is palpable as a smooth, rounded, midline suprapubic mass - indicates urinary retention (>300 mL of urine retained)
• The mass arises from the pelvis into the abdomen, is dull to percussion, and the patient may feel urge to urinate on palpation

"Bimanual examination, or renal ballottement, can be performed by placing the non-examining hand posteriorly at the costophrenic angle and palpating for the kidney with the examining hand through the anterior abdominal wall. Deep inspiration can help inferiorly displace the kidney to aid in exposure." - Campbell Walsh Wein Urology

• Left hand: placed posteriorly under the loin at the costovertebral angle (CVA) - between the 12th rib and the lateral border of erector spinae
• Right hand: placed anteriorly in the corresponding flank
• Ask patient to take a deep breath - kidney descends
• Ballot the kidney between the two hands

IV. PERCUSSION

1. Suprapubic Percussion

• Percuss from the umbilicus downward toward the pubis
• Dullness above the pubic symphysis - confirms bladder distension / urinary retention
• Normal finding: resonant (when bladder is empty)

2. Renal / Flank Percussion

• Percuss the flanks in all four quadrants

3. Murphy's Kidney Punch / Fist Percussion (CVA Tenderness) - ★ KEY SIGN ★

"The classic presentation (of pyelonephritis) is an abrupt onset of chills, fever, and unilateral or bilateral flank or costovertebral angle pain and/or tenderness." - Campbell Walsh Wein Urology

• Ask patient to sit upright (or lean forward)
• Place one hand flat over the costovertebral angle (CVA) - angle between the 12th rib and lateral border of erector spinae muscle, posteriorly
• Strike the back of your placed hand with the ulnar border of your other fist
• Elicit from both sides; compare

• Ball of the fist directly percussed over the CVA from behind

Important: CVA tenderness is absent in uncomplicated cystitis. Its presence immediately suggests upper urinary tract involvement.

V. AUSCULTATION

• Bowel sounds: Normal in UTI; reduced / absent in paralytic ileus (suggests complicated peritonitis)
• Renal bruit: Over the renal angles / epigastrium - a bruit here suggests renal artery stenosis (relevant as a cause of recurrent/resistant hypertension + UTI)
• Absent bowel sounds in a febrile patient with flank pain - may indicate retroperitoneal or peritoneal extension of infection

VI. SPECIAL MANOEUVRES / ADDITIONAL EXAMINATION

1. Deep Palpation for Ureteric Tenderness

• Upper ureteric point: At the junction of lateral border of rectus abdominis and the umbilical horizontal plane (at the umbilical level, 2 cm lateral to midline)
• Middle ureteric point: At the junction of a line joining the ASIS and the pubic tubercle, at the lateral border of rectus abdominis
• Lower ureteric point: Only accessible on per rectal / per vaginal examination

2. Psoas Stretch Test (in suspected perinephric abscess / retroperitoneal irritation)

• Patient in lateral decubitus
• Extend the hip passively - pain suggests irritation of psoas (perinephric collection)

3. Per Rectal Examination (in male patients)

• Assess the prostate gland: size, consistency, tenderness
• Exquisitely tender, swollen prostate = acute prostatitis (UTI variant in males)
• Enlarged, smooth, non-tender prostate = BPH (predisposing factor for UTI in males)

4. Per Vaginal Examination (in female patients)

• Vaginal discharge? (suggests vaginitis / STI as differential, reduces UTI probability)
• Cervical excitation tenderness? (suggests PID - important differential)
• Assess for pelvic organ prolapse (can cause incomplete bladder emptying → recurrent UTI)
• Urethral palpation: urethral diverticulum, Skene's gland abscess

VII. FINDINGS SUMMARY TABLE

HOW TO PRESENT IN VIVA

"On abdominal examination, the patient was febrile and appeared ill. The abdomen was flat with no visible distension. On palpation, there was deep tenderness in the right lumbar and right iliac fossa regions. The kidney was ballottable and tender on the right side. Bladder was not palpable. On percussion, there was positive right-sided costovertebral angle tenderness (Murphy's kidney punch positive on the right). Bowel sounds were present. These findings are consistent with right-sided acute pyelonephritis."