GU/renal Flashcards by Conor Barrie

pathophys of rhabdo

from destruction of skeletal muscle due to injury of myocytes

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common causes of rhabdo

drugs of abuse (cocaine, meth), alcohol (direct toxic effect and coma induced muscle breakdown aka passing otu no muscle), medications (antipsychotics, statins, SSRI, huge list), muscle diseases, trauma, NMS, seizures, immobility, infection, strenous physical activity, heat-illness.

** more than 1/2 the time there are multiple causes present

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rhabdo symptoms

weakness, myalgias, malaise, dark brown urine (tea colored urine)

if severe can lead to n/v, abdo pain or even urea induced encephalopathy

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rhabdo cutoffs for dx, IVF and trend, vs admit

> 1000 is dx
5000 probable admit

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dialysis indications in rhabdo?

same as any other pt… AEIOU

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treatment of rhabdo

aggressive IV fluid (Ns or RL), for 24 to 72 hours. target OU of 200 mL per hour or 3 mL/kg/hr.

basically, boluses then 250-500 mL per hour based on pt factors (age, EF etc)

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4 general complications of rhabdo

AKI, DIC, electrolyte abn (K, P, Ca), mechanical complications (compartment syndrome, peripheral neuropathy)

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uremic symptoms

n/v, drowsiness, fatigue, confusion, if untreated coma

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fastest screening test for hyperK?

ECG
detects 50% of levels over 6.5

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creatinine changes required for AKI

Cr increase of 26, over less then 48 hrs

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ACE inhibitor effects on kindeys

decrease GFR, but also decrease glomerular pressure

preferentially vasodilate efferent arteriole

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NSAIDs effect on kidney arterioles

vasoconstrict afferent

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general treatment principles in AKI

target euvolemia, hold insulting meds, relieve/rule out obstruction (u/s and foley)

look for hyper K, metabolic acidosis (WAGMA), proteinuria etc.

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indications for acute dialysis

A: refractory/life threatening acidosis
E: refractory hyper K (>6.5 and not improving)
I: life-threatening ingestion of dialyzable drug (common methanol/ethylene glycol, salicylates, lithium)
O: refractory overload (causing hypoxia)
U: symptomatic uremia (pericarditis, encephalopathy, bleeding)

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hyperkalemic ECG

peaked T waves, prolonged PR, wide QRS and then sinusoidal pattern

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broad definition of cardiorenal syndrome

acute or chronic dysfunction of one organ causes acute or chronic dysfunction of the other

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metformin and contrast CT

if gfr >30 and on metformin go for it, otherwise hold metformin for 48 hrs before and after (if possible)

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define uremia

a (poorly named) clinical syndrome, involves accumulation of urea AND OTHER metabolites in the blood which cause sequalae that are not solely resolved by dialyzing them out, it is the end-point of CKD/ESRD…. interestingly BUN is inaccurate marker of uremia severity

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uremic neurologic complications (3):

uremic encephalopathy, dialysis dementia, peripheral neuropathy

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cardiovascular complications of uremia

elevated troponins, HTN, HF, uremic cardiomyopathy, pulm edema, tamponade, pericarditis, CAD

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unique feature of uremic pericarditis?

aseptic and inflammatory cells dont enter myocardium, so you dont get the ECG changes!

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hematologic complications of uremia? 3

anemia, coagulopathy, immune disorders

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do you remove dialysis line if infected?

generally trial IV abx for 2-3 days first.

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what is Branham sign?

indicates high out put HF/AV fistula steal syndrome, you occlude fistula and look for drop in HR.

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complications during dialysis (4)

hypotension (often due to volume loss), dialysis dysequilibrium (due to osmolar changes, s/s are n/v and HTN, can be life threatneing), air embolism, electrolyte abn

most common organisms in PD peritonitis?

staph and strep, gram neg can occur too

signs/symptoms of PD peritonitis

fever, abdo pain, guarding, peritonitic signs

size of catheter in acute urinary retention

14-16F

what is coude tip catherter?

has angled and firm tip, which should be angled anterioirly to follow the anatomy

Causes of acute urinary retention

normal bladder scan and PVR

scan should be less then 400 mL, PVR should be less than 150 mL

contraindications for urethral catheterization?

recent urological surgery

what is post obstructive diuresis? what to do about it?

after initial drainage of bladder, observe for 2-4 hours, looking for >200 cc/hr of output. if this happens, consult medicine for admission and start volume replacement that is equal to their losses

TOV in urinary retention

should be done in 3 days, remove catheter, aggressive po rehydration, and measure PVR at 4-6 hours. should be less than 150-200 mL.

who is at risk for post obstructive diuresis?

long standing obstruction, poor renal function, HF, AMS and underlying comorbidity.

Management of urinary retention with clots or gross hematuria

Insertion 20-24 F triple lumen catheter and irrigate with saline until clots are cleared. If clots persist consult uro

Algo for urinary retention

definition of asymptomatic bacturia

2 clean catch cutlures in women 1 clean catch culture in men without symptoms, only treat if pregnant or about to have invasive GU procedure

which UTI bugs dont produce nitrites?

pseudomonas, enterococcus,

Abx for pregnant cystitis

Macrobid, cefixime, keflex

Ddx for dysuria

pathophys of fournier's gangrene, RF for it?

starts as benign infection or simple abcess, then turns into necrotizing infection, can occur in women too (20% of cases). RF: DM, immuno comp etc

abx for fourniers?

pip-taz, vanco + surgical debridement

balanoposthitis: what is it? s/s tx

inflammation of glans and foreskin treatment: antifungals or abx or steroid cream

phimosis what is it? s/s tx

cannot retract foreskin normal until adolsecne, but only 10% remain unretractable by age 3 tx is steroid cream or circumcision

paraphimosis what is it? s/s tx

fore skin stuck retracted (true emergency) -can lead to ischemia of glans -tx: reduction -- >apply EMLA --> wrap glans for 5 mins with plastic (?coban)--> manual reduction with fingers/thumbs --> doesn't work dorsal block and make a slit.

penile fracture what is it? s/s tx

what breaks in penile fracture?

tunica albuginea

2 main causes of priapism

sickle cell, medications

ischemic vs non ischemic priapism

ischemic --> veno occlusive, low flow non ischemic --> arterial, high flow --> PAINLESS can use blood gas from penis or Doppler to help differentiate too

treatment of priapism

corporal aspiration, irrigation and injection with phenylephrine

torsion ddx

torsion, appendigeal torsion, epididymitis, orchitis, hernia, trauma

time frame to target detorsion

<6 hrs = excellent results

most sensitive finding in to r/o torsion?

cremasteric reflex present bilat = 75-96% sens

exam findings in torsion

swollen, firm, high-riding, transverse lie, absent cremasteric reflex.

how to manually detort?

2/3 of bases --> opening a book, 1/3 of cases = opposite of that, if pain worsens with book opening try the other way

blue dot sign is pathognomonic for?

appendageal torsion

treatment of epididymitis by organisms and age

> 35 treat for e coli and klebiella = levo or cipro < 35 treat for G+C = ctx and doxy

%age of normal u/a in epididymitis?

50%

symptoms of prostatitis

LUTS, back pain, pelvic pain, fever, chills, dyschezia, painful ejaculation

most common organisms for prostatitis? empiric tx for prostatitis?

e colie, then other uropathogens fluoroquinolone for 2 weeks

Does decreasing calcium diet help with stones?

No, does opposite. Causes more calcium release from bones

Composition of kidney stones

80%: calcium phosphate or oxalste 10%: struvite 10%: Utica acid

3 common stone locations

UPJ Pelvic brim UVJ

What %age of pts with renal colic have hematuria?

85%

Most common miss with renal colic

AAA.. remember that it is rare for first time presentation of renal colic in pt > 60

Ddx if renal colic

%age of passage based on stone size

<5 mm, 98% at 4 week 5-7 60% at 4 weeks Should talked to uro about stones >5 and defs >7

mgmt of UTI and kidney stones

if obstruction, AKI, fever, other systemic signs = admission, IV ABX and uro consult for septic stone if UTI and stone, but no other symptoms = oral abx and r/a in 48-72 hrs

% age of kidney stones seen on xray

85% b/c the calcium ones have same density as bone roughly.

general sensitivities and specificity of CT, US and xray for kidney stones

medical expulsion therapy in stones

Tamsulosin is recommended, most impact in stones > 5 mm

reasons for admission with kidney stone?

refractory pain/vomiting, septic stone, single kidney/renal transplant, severe comorbidity, hypercalcemic crisis

avergae time to stone passage

varies, on size and location ,but 7-30 days (lol)