About the flow - Ross Flashcards
What can start with intermittent to sever pain in the flank and radiate to the groin?
Nephrolithiasis.
A person presents in no position of comfort. They have intermittent severe pain in the flank. They are pale, diaphoretic but their vital signs are normal. They don’t happen to have blood in the urine. What is this?
Nephrolithiasis
What are stone mimics?
Renal artery infarction and AAA
Stones do not present first time in men >60 yo and do not cause hypotension.
What are stone risk factors?
Obesity, low volume urine, excess dietary meat (purine), excess dietary sodium, insulin resistance, metabolic syndrome, family history, gout, bowel surgery, primary hyperparathyrodism, prolonged immbolizatoin.
IBD - prone to elevated oxylate levels - leads to more stones.
80% of stones are?
Caclium oxalate or calcium phosphate
Supersaturation of dissovlved salts in the urine.
Struvite (mag/ammonium phosphate) make up ___% of stones.
10% of stones
Protease urea splitting bacteria (proteus, klebsiella)
Uric acid stones make up ___%. How do they appear on xray?
They make up 10% of stones. Gout patients develop stones that are radiolucent.
How do you diagnose nephrolithiasis?
UA: microscopic analysis sesnsitivity is 84% - hematuria is usually microscopic, but can detect pyuria as well
CBC: check for mild leukocytosisis up to 15k (look for bands)
BMP: Baseline Cr - during acute obstruction - no rise in Cr - Kidney elevates fxn.
Non-Contrast Ct - 100% sensitivity, 94% specificity
Plain abdominal radiography has a sensitivity up to 58% so for first timers you should get?
A non-contrast CT
A complicated stone is a kidney stone when someone has what?
Diabetes, HTN, single or horshoe kidney, or a kidney transplant.
or if they have an abnormal creatinine
These people need immediate imaging.
Those with a history of difficult stones get?
Stents lithotripsy.
In uncomplicated nephrolithiaiss and young what imaging and treatment should you give?
No need to image immediately, can be deffered until a f/u visit.
KUB (x-ray)
Tx: with pain meds and d/c
What’s an uncomplicated stone?
no infection
No hydronephrosis
normal Cr
Don’t CT
Obstructed stones can eventually raise what?
Creatinine
Where is the most commonly located stone? 2nd?
UVJ - uterovesicular junction - MC
Then pelvic Brim, also UPG (uteropelvic junction)
What are complicated stones?
Stones that cause infection - see this on a UA, potential bacteria or UA in urine
Stones that cause intractable pain
Stones that won’t pass (obstruction) based on size alone
- 98% < 5 mm pass within 4 weeks
60% pass that are 5-7mm
39% pass that are >7cm
What are some CT imaging indications?
First time presenters: older
Those with continued pain despite meds
Those you consider other dx
Non-contrast CT tells you what about stones?
Gives you size, location, and signs of infection.
Whats a presentation of pregnant women and kidney stones? Whats the first step?
Often a complicated presentation with hydronephrosis
First step is to use ultrasound - if hydronephrosis detected discuss with urology.
Possible low dose CT or MRI
A pregnant women is pain with a kidney stone, should you give her NSAIDs?
No - 1st trimester of pregnancy - vaginal bleeding.
Stones larger than __ mm need stenting. Or high grade obstructions/proximal stones.
Stones larger than 8-10 mm need stenting.
Infected stones need what treatment?
Close follow up with urology and treatement with abx.
2nd gen cephalosporin - cefuroxime
Fluroquinolone
As seen by WBC in urine sample - send culture.
Someone with a UTI (positive UA) and a stone will present how? What treatment do they get?
Obstructed: large stones, hydronephrosis, elevated Cr
Systemic illness - abnormal vitals and fevers.
All need IV antibiotics and urology consultatoin to remove stone/stent.
Someone with UTI and stones gets what abx? And for how long?
Ciprofloxacin, 500mg 14 days.
MAny times wbc in urine is inflammatory and not infection: no systemic signs of infection don’t need admission but still need treatment with abx.
How do you treat nephrolithiasis?
Treat pain aggressively with NSAIDs, IV lidocaine, IV narcotics
Manage nausea with antiemetics, and consider imaging study
Medical expulsive therapy doesn’t benefit stones smaller than?
6mm
What is medical expulsive therapy for nephrolithiasis.
Meds the relieve the spasm of the ureter.
Calcium channel blocker (Nifedipine 30 mg x 8 weeks)
alpha blocker are considered superior - tamsulosin .4mg daily x 3 weeks.
How long make it take to pass a stone? Should you try to catch it?
It may take 7-30 days to pass a stone.
Yes - strain urine to save stones as it is helpful to know what kind of stone ie calcium oxalate or uric acid stones.
People with kidney stones that are discharged should avoid?
caffeine, diuretics, excess Vit C
When should you admit a pt with nephrolithaisis?
Intractable pain or vomiting,
urosepsis,
one or transplanted kidney with obstructing stone,
ARF,
multiple co-morbidities
Consider if: fever, obsturcting stone with UTI.
How do you differentitate ebtween UTI vs Pyelonephritis vs Urosepsis?
UTI - infection of lower tract
Pyelonephritis: infection of upper tract (renal parenchyma)
Urosepsis: pyelo with Bactermia (lactate greater than 2.5)
3 complications of UTI?
Acute bacterial nephritis
Renal abscess
Emphysematous
How does someone with cystitis present? What are pitfalls to this presentation
Women know more often than men.
Pain with urination, frequency, burning.
Pitfalls: chlamydia gives same symptoms but no WBC in the urine.
Herpes can present this way.
Cystitis is?
Inflammation of the bladder = UTI
What are UA findings of cystitis? MC bacteria?
Hematuria
Pyuria (WBC)
Bacteria associated with infection is most often E.Coli
Leukocyte esterase in a UA tells you?
Detects the presence of luekocytes acting on bacteria - for UA of cystitis.
Presence of nitrites in the urine tells you?
Urinary pathogens convert nitrates to nitrites in the urine (presence of bacteria) this is ahigh positive predictive value of infection.
What is the treatement for cystitits?
Make sure not an upper tract infection first, then
Simple 3 day treatment - Treat with macrobid, keflex if pregnant or quinolone if not pregnant.
Offer candidial treatment
What is the time difference between complicated and uncomplicated cystitis treatment?
Uncomplicated - 3 days
complicated - 14 days.
A person with a UTI and fever, flank pain, and sometimes ill appearing probably has?
Pyelonephritis.
When should you admit pyelonephritis, when should you d/c?
Most can be d/c’d.
Admit if: Can’t tolerate PO fluids or manage pain, pregnancy, elderly.
What is the rule of 2 for pyelonephritis?
2L of NS
2g of ceftriaxone
2mg of morphine
If a patient failed outpatient therapy for pyelonephritis should should the next step be?
Consider ultrasound to look for abscess or hydronephrosis
Admit
UTI summary
Uncomplicated tx:
Pyelo tx:
Asymptomatic pregnancy tx:
Uncomplicated; abx for 3-5 days
complicated; abx for 14 days
asymptomatic bacteruira in prengnacy - treat as UTI.
Hydrocele is? What diagnostic test should you consider getting?
A fluid collection in potential space anterior to the testis between parietal and visceral layers
This will transilluminate. But consider getting an ultrasound to look for malignancy.
What is the most common misdiagnosis for torsion?
Epididymitis.
Epididymo-orchitis.
Is epididymitis a gradual or quick onset of pain?
Gradual
Young people with epididymitis have what etiology?
Sterile reflux of urine; then infection (lifting or straining) up to adolesence
People younger than 35 have what etiology of epididymitis?
STI
People older than 35 have what etiology of epididymitis? What if 65+
Urinary pathogens.
If older than 65 consider outlet obstruction due to the prostate.
A patient presents with dysuria, urgency, and frequency. They also have pain from the inguinal canal to the testis. What’s the dx?
Epididymitis.
Do epididymyits patients present with discharge or nausea, vomiting, anorexia? Fever?
No,
Urethral discharge- think chlamydia
N/v, anorexia - think torsion.
Fever: luekocytosis in 30-50% of patients.
How do you w/u a patient you suspect has epididymitis?
Get a UA - pyuria present in 50%
remember torsion: consider US
Symptoms 2-4 weeks after sexual contact? - think chlamydia.
PCR swab for GC and C. trachomatis or urine PCR
Treatment for prepubertal boys with epididymitis is?
Assume underlying GU abnormalitiy - scarring or reflux - refer to GU.
Treatment for epididymyitis for sexually active males of any age?
Ceftriaxone 250mg IM, then doxycycline 10 days.
Treatment for men over 35, with one partner or no SA and epididymitis?
Probably gram negative in origin. Ofloxacin 250 mg bid or Levofloxacin qd 500 mg 10 days.
In general what lifestyle precautions can help epididymitis?
Scrotal elevation helpful for pain
No heavy lifting
If over 65 - consider outflow obstruction.
Epididymitis tx summary
GU: tx?
NGU: tx?
Treat patient and partner
GU: single shot of ceftriaxone 250mg IM
NGU: single dose tx for C. trachomatis: azithromycin 1g or doxycycline and metronidazole.
An isolated inflammation of the testicle caused by mumps, or other viral illnesses such as cocksackie, Epstein-Barr, varicella, or echovirus is?
Orchitis
Orchitis is almost always in associated with what?
Epididymitis. So treat as an epididymitis.
In ______ the testicle is enlarged and tender. Also typically presents with parotitis. 30-50% will have residual ________
Orchitis or mumps
Residual testicular atrophy.
A male presents with frequency, urgency, and dysuria. They also have pain in the low back perineal area or rectal area and a fever. What 3 possible diagnosis are ther?
Prostatitis, urethritis, cystitis
Acute prostatitis presents with?
Perineal, suprapubic and or genital tenderness
Who’s at risk for prostatitis?
Lower tract obstructions - receptive intercourse, indwelling catheters - people with enlarged prostates to begin with.
How do you diagnose prostatitis?
Clinical diagnosis - the prostate will be boggy and painful (not needed)
UA is usually negative,
How do you differentitate acute prostatits and SIRS?
Assess for systemic inflammatory response (SIRS) with lactate
What is the treatment for acute prostatitis?
Floroquinolone 2-4 weeks, possible STI tx.
Patient must return for follow up after abx course is done and needs to have a culture to see if they are cured.
Urethritis can be classified as?
Gonococcal (little pink dots) or non-gonococcal (NGU)
Urethritis in younger patients is most like from? Older patients?
Younger - STD
older - bacteria such as e. coli
You decide to get a UA on your urethritis patient, what would you expect to see?
WBC >5 with bacteria.
An infection at the tip of the penis, that is typically candidiasis, non vesicular, itchy, and not painful is probably?
Balantitis.
Balantitis can be the presenting symptom of?
Diabetes
A 14 year old male presents with one hour history of scrotal pain and vomiting. No fever no urinary sxs. On exam cremasteric reflex is absent and painful tescticle has a horizontal lie. Appropriate managment?
Call urology - Testicular torsion.
Testicular torsion peaks at what ages? Its 10 times more likely in what?
peak 1st year and puberty
10 times more likely in undescended testis
Painful inguinal mass + empty scrotum?
Torsion
Testicular torsion presents with?
Severe pain, abrupt onset. Usually starts int he scrotum, but can be inguinal or abdominal.
Nausea, vomiting, and anorexia are common. And 50% of patients have a history of similar pain that resolved spontaneously.
A bell clapper deformity with inadequate friction of tunica vaginalis to the scrotal wall is?
Torsion
How do you test for torsion in the physical exam?
Start on unaffected side, early testis is firm, and higher with transverse lie.
Is pain relieved with elevation?
Then check cremaster reflex and do an abdominal exam.
A swollen, tender, firm hemiscrotum that is high-riding with a transverse testicle is? Also presents with loss of cremasteric reflex on affected side.
Torsion
There is an average of 80-100% salvage rate if testicle fixed within? So first step would be?
6 hours.
poor if over 12 hours.
First step is to get GU involved, then US
What’s a similar presenting syndrome of testicular torsion that is a self limited diagnosis, and presents with a blue dot sign.
Testicular appendix
Do you need to US testicular appendix?
Yes, still need to check/ rule out torsion
Your patient presents with pain and itching in the genitalia. Soon after he has fever, chills, and massive perineal swelling. He also has swelling in his abdomen, back and thighs. You palpate crepitus. Whats the dx?
Fourniers gangrene
What labs do you get for fournier’s gangrene?
lactate and a CBC for bandemia.
What is the treatment for Fournier’s gangrene?
Admit to hospital.
Fluid resuscitation: treat for sepsis
Gram-pos, gram neg, and anerobe abx
Piperacillin-tazobactam 3.375 mg IV q6 and clindamycin 600 OR
Meropenem 500 mg IV q8 plus vancomycin and clindamycin 600
Surgical consult
Foreskin is stuck at the base of the penile head - Edema and venous engourgement cause edema and gangrene
Paraphimosis - must reduce foreskin.
Phimosis causes? Tx?
Infectious or congenital, may need dorsal slit.
Priapism: typically low flow state. Has blood engorged where?
Engorged with stagnant blood in the corpora cavernosa.
Priapism can be caused by what meds? What disease?
HTN meds: hydralizine, CCBs
Neuroleptics: trazadone, citalopram, erectile meds
Dz: sickel cell.
Treatment for priapism?
Non-invasive terbutaline 5-10 mg po q 15
Pseudophedrine 60-120 mg
or Penile block with 1% lidocaine around shaft. Aspiration of blood with injection of epinephrine, phenylephrine into corpus cavernosus.
Priapism tx in sickle cell?
Hydration and aspiration.
GU trauma occurs where? What do you need
Tunica albuginea or both corpus cavernosus rupture (tears)
Need a uroogist and a retrograde urethrogram.
Testicular mass FYI
Unexplained testicular mass should be approached as a tumor
Hemorrhage into a neoplasm can present as pain or acute torsion
Epididymitis or hydrocele not resovled in 2 weeks should be evaluated with doppler as this could be a misdiagnosis.
Vaginal or urtheral burning ddx?
Urethritis, vaginitis
Hematuria ddx?
Infection, stone, GN, trauma, cancer
Retention ddx?
Infection, BPH clot or neuropathic.
Frequency ddx?
Stone or infection
If a patient says they can’t urinate what test should you run?
Do a post void residual (ultrasound or bladder scan) before cath
If greater than 300 cc unlikely pt will be able to void spontaneously.
