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Clin Med Exam 4 > About the flow - Ross > Flashcards

About the flow - Ross Flashcards

1
Q

What can start with intermittent to sever pain in the flank and radiate to the groin?

A

Nephrolithiasis.

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2
Q

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?

A

Nephrolithiasis

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3
Q

What are stone mimics?

A

Renal artery infarction and AAA

Stones do not present first time in men >60 yo and do not cause hypotension.

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4
Q

What are stone risk factors?

A

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.

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5
Q

80% of stones are?

A

Caclium oxalate or calcium phosphate

Supersaturation of dissovlved salts in the urine.

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6
Q

Struvite (mag/ammonium phosphate) make up ___% of stones.

A

10% of stones

Protease urea splitting bacteria (proteus, klebsiella)

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7
Q

Uric acid stones make up ___%. How do they appear on xray?

A

They make up 10% of stones. Gout patients develop stones that are radiolucent.

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8
Q

How do you diagnose nephrolithiasis?

A

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

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9
Q

Plain abdominal radiography has a sensitivity up to 58% so for first timers you should get?

A

A non-contrast CT

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10
Q

A complicated stone is a kidney stone when someone has what?

A

Diabetes, HTN, single or horshoe kidney, or a kidney transplant.

or if they have an abnormal creatinine

These people need immediate imaging.

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11
Q

Those with a history of difficult stones get?

A

Stents lithotripsy.

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12
Q

In uncomplicated nephrolithiaiss and young what imaging and treatment should you give?

A

No need to image immediately, can be deffered until a f/u visit.

KUB (x-ray)

Tx: with pain meds and d/c

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13
Q

What’s an uncomplicated stone?

A

no infection

No hydronephrosis

normal Cr

Don’t CT

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14
Q

Obstructed stones can eventually raise what?

A

Creatinine

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15
Q

Where is the most commonly located stone? 2nd?

A

UVJ - uterovesicular junction - MC

Then pelvic Brim, also UPG (uteropelvic junction)

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16
Q

What are complicated stones?

A

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

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17
Q

What are some CT imaging indications?

A

First time presenters: older

Those with continued pain despite meds

Those you consider other dx

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18
Q

Non-contrast CT tells you what about stones?

A

Gives you size, location, and signs of infection.

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19
Q

Whats a presentation of pregnant women and kidney stones? Whats the first step?

A

Often a complicated presentation with hydronephrosis

First step is to use ultrasound - if hydronephrosis detected discuss with urology.

Possible low dose CT or MRI

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20
Q

A pregnant women is pain with a kidney stone, should you give her NSAIDs?

A

No - 1st trimester of pregnancy - vaginal bleeding.

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21
Q

Stones larger than __ mm need stenting. Or high grade obstructions/proximal stones.

A

Stones larger than 8-10 mm need stenting.

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22
Q

Infected stones need what treatment?

A

Close follow up with urology and treatement with abx.

2nd gen cephalosporin - cefuroxime

Fluroquinolone

As seen by WBC in urine sample - send culture.

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23
Q

Someone with a UTI (positive UA) and a stone will present how? What treatment do they get?

A

Obstructed: large stones, hydronephrosis, elevated Cr

Systemic illness - abnormal vitals and fevers.

All need IV antibiotics and urology consultatoin to remove stone/stent.

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24
Q

Someone with UTI and stones gets what abx? And for how long?

A

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.

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25
Q

How do you treat nephrolithiasis?

A

Treat pain aggressively with NSAIDs, IV lidocaine, IV narcotics

Manage nausea with antiemetics, and consider imaging study

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26
Q

Medical expulsive therapy doesn’t benefit stones smaller than?

A

6mm

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27
Q

What is medical expulsive therapy for nephrolithiasis.

A

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.

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28
Q

How long make it take to pass a stone? Should you try to catch it?

A

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.

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29
Q

People with kidney stones that are discharged should avoid?

A

caffeine, diuretics, excess Vit C

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30
Q

When should you admit a pt with nephrolithaisis?

A

Intractable pain or vomiting,

urosepsis,

one or transplanted kidney with obstructing stone,

ARF,

multiple co-morbidities

Consider if: fever, obsturcting stone with UTI.

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31
Q

How do you differentitate ebtween UTI vs Pyelonephritis vs Urosepsis?

A

UTI - infection of lower tract

Pyelonephritis: infection of upper tract (renal parenchyma)

Urosepsis: pyelo with Bactermia (lactate greater than 2.5)

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32
Q

3 complications of UTI?

A

Acute bacterial nephritis

Renal abscess

Emphysematous

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33
Q

How does someone with cystitis present? What are pitfalls to this presentation

A

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.

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34
Q

Cystitis is?

A

Inflammation of the bladder = UTI

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35
Q

What are UA findings of cystitis? MC bacteria?

A

Hematuria

Pyuria (WBC)

Bacteria associated with infection is most often E.Coli

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36
Q

Leukocyte esterase in a UA tells you?

A

Detects the presence of luekocytes acting on bacteria - for UA of cystitis.

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37
Q

Presence of nitrites in the urine tells you?

A

Urinary pathogens convert nitrates to nitrites in the urine (presence of bacteria) this is ahigh positive predictive value of infection.

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38
Q

What is the treatement for cystitits?

A

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

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39
Q

What is the time difference between complicated and uncomplicated cystitis treatment?

A

Uncomplicated - 3 days

complicated - 14 days.

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40
Q

A person with a UTI and fever, flank pain, and sometimes ill appearing probably has?

A

Pyelonephritis.

41
Q

When should you admit pyelonephritis, when should you d/c?

A

Most can be d/c’d.

Admit if: Can’t tolerate PO fluids or manage pain, pregnancy, elderly.

42
Q

What is the rule of 2 for pyelonephritis?

A

2L of NS

2g of ceftriaxone

2mg of morphine

43
Q

If a patient failed outpatient therapy for pyelonephritis should should the next step be?

A

Consider ultrasound to look for abscess or hydronephrosis

Admit

44
Q

UTI summary

Uncomplicated tx:

Pyelo tx:

Asymptomatic pregnancy tx:

A

Uncomplicated; abx for 3-5 days

complicated; abx for 14 days

asymptomatic bacteruira in prengnacy - treat as UTI.

45
Q

Hydrocele is? What diagnostic test should you consider getting?

A

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.

46
Q

What is the most common misdiagnosis for torsion?

A

Epididymitis.

Epididymo-orchitis.

47
Q

Is epididymitis a gradual or quick onset of pain?

A

Gradual

48
Q

Young people with epididymitis have what etiology?

A

Sterile reflux of urine; then infection (lifting or straining) up to adolesence

49
Q

People younger than 35 have what etiology of epididymitis?

A

STI

50
Q

People older than 35 have what etiology of epididymitis? What if 65+

A

Urinary pathogens.

If older than 65 consider outlet obstruction due to the prostate.

51
Q

A patient presents with dysuria, urgency, and frequency. They also have pain from the inguinal canal to the testis. What’s the dx?

A

Epididymitis.

52
Q

Do epididymyits patients present with discharge or nausea, vomiting, anorexia? Fever?

A

No,

Urethral discharge- think chlamydia

N/v, anorexia - think torsion.

Fever: luekocytosis in 30-50% of patients.

53
Q

How do you w/u a patient you suspect has epididymitis?

A

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

54
Q

Treatment for prepubertal boys with epididymitis is?

A

Assume underlying GU abnormalitiy - scarring or reflux - refer to GU.

55
Q

Treatment for epididymyitis for sexually active males of any age?

A

Ceftriaxone 250mg IM, then doxycycline 10 days.

56
Q

Treatment for men over 35, with one partner or no SA and epididymitis?

A

Probably gram negative in origin. Ofloxacin 250 mg bid or Levofloxacin qd 500 mg 10 days.

57
Q

In general what lifestyle precautions can help epididymitis?

A

Scrotal elevation helpful for pain

No heavy lifting

If over 65 - consider outflow obstruction.

58
Q

Epididymitis tx summary

GU: tx?

NGU: tx?

A

Treat patient and partner

GU: single shot of ceftriaxone 250mg IM

NGU: single dose tx for C. trachomatis: azithromycin 1g or doxycycline and metronidazole.

59
Q

An isolated inflammation of the testicle caused by mumps, or other viral illnesses such as cocksackie, Epstein-Barr, varicella, or echovirus is?

A

Orchitis

60
Q

Orchitis is almost always in associated with what?

A

Epididymitis. So treat as an epididymitis.

61
Q

In ______ the testicle is enlarged and tender. Also typically presents with parotitis. 30-50% will have residual ________

A

Orchitis or mumps

Residual testicular atrophy.

62
Q

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?

A

Prostatitis, urethritis, cystitis

63
Q

Acute prostatitis presents with?

A

Perineal, suprapubic and or genital tenderness

64
Q

Who’s at risk for prostatitis?

A

Lower tract obstructions - receptive intercourse, indwelling catheters - people with enlarged prostates to begin with.

65
Q

How do you diagnose prostatitis?

A

Clinical diagnosis - the prostate will be boggy and painful (not needed)

UA is usually negative,

66
Q

How do you differentitate acute prostatits and SIRS?

A

Assess for systemic inflammatory response (SIRS) with lactate

67
Q

What is the treatment for acute prostatitis?

A

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.

68
Q

Urethritis can be classified as?

A

Gonococcal (little pink dots) or non-gonococcal (NGU)

69
Q

Urethritis in younger patients is most like from? Older patients?

A

Younger - STD

older - bacteria such as e. coli

70
Q

You decide to get a UA on your urethritis patient, what would you expect to see?

A

WBC >5 with bacteria.

71
Q

An infection at the tip of the penis, that is typically candidiasis, non vesicular, itchy, and not painful is probably?

A

Balantitis.

72
Q

Balantitis can be the presenting symptom of?

A

Diabetes

73
Q

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?

A

Call urology - Testicular torsion.

74
Q

Testicular torsion peaks at what ages? Its 10 times more likely in what?

A

peak 1st year and puberty

10 times more likely in undescended testis

75
Q

Painful inguinal mass + empty scrotum?

A

Torsion

76
Q

Testicular torsion presents with?

A

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.

77
Q
A
78
Q

A bell clapper deformity with inadequate friction of tunica vaginalis to the scrotal wall is?

A

Torsion

79
Q

How do you test for torsion in the physical exam?

A

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.

80
Q

A swollen, tender, firm hemiscrotum that is high-riding with a transverse testicle is? Also presents with loss of cremasteric reflex on affected side.

A

Torsion

81
Q

There is an average of 80-100% salvage rate if testicle fixed within? So first step would be?

A

6 hours.

poor if over 12 hours.

First step is to get GU involved, then US

82
Q

What’s a similar presenting syndrome of testicular torsion that is a self limited diagnosis, and presents with a blue dot sign.

A

Testicular appendix

83
Q

Do you need to US testicular appendix?

A

Yes, still need to check/ rule out torsion

84
Q

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?

A

Fourniers gangrene

85
Q

What labs do you get for fournier’s gangrene?

A

lactate and a CBC for bandemia.

86
Q

What is the treatment for Fournier’s gangrene?

A

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

87
Q

Foreskin is stuck at the base of the penile head - Edema and venous engourgement cause edema and gangrene

A

Paraphimosis - must reduce foreskin.

88
Q

Phimosis causes? Tx?

A

Infectious or congenital, may need dorsal slit.

89
Q

Priapism: typically low flow state. Has blood engorged where?

A

Engorged with stagnant blood in the corpora cavernosa.

90
Q

Priapism can be caused by what meds? What disease?

A

HTN meds: hydralizine, CCBs

Neuroleptics: trazadone, citalopram, erectile meds

Dz: sickel cell.

91
Q

Treatment for priapism?

A

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.

92
Q

Priapism tx in sickle cell?

A

Hydration and aspiration.

93
Q

GU trauma occurs where? What do you need

A

Tunica albuginea or both corpus cavernosus rupture (tears)

Need a uroogist and a retrograde urethrogram.

94
Q

Testicular mass FYI

A

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.

95
Q

Vaginal or urtheral burning ddx?

A

Urethritis, vaginitis

96
Q

Hematuria ddx?

A

Infection, stone, GN, trauma, cancer

97
Q

Retention ddx?

A

Infection, BPH clot or neuropathic.

98
Q

Frequency ddx?

A

Stone or infection

99
Q

If a patient says they can’t urinate what test should you run?

A

Do a post void residual (ultrasound or bladder scan) before cath

If greater than 300 cc unlikely pt will be able to void spontaneously.

Clin Med Exam 4 (15 decks)

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