Oxford Summary 4 Flashcards
Adult Severe asthma ≥1 of following:
Previous near- fatal asthma or admission Need ≥ 3 classes of medications Heavy use of B2-agonist Repeated A&E attendances Brittle asthma
adult asthma assessment
Peak expiratory flow rate- PEFR
Symptoms and response to self- treatment
HR and RR
O2 saturation
Adult moderate asthma exacerbation
Increasing symptoms
PEFR >50- 75% of expected
No features of acute severe asthma
Adult acute severe asthma:
any of PEFR 33-50% best or predicted RR ≥25 breaths/min HR ≥110 bpm Cant speak in sentences
Adult life- threatening asthma: any of following with severe asthma
PEFR <33% best/ predicted
O2 sat <92%, feeble respiratory effort, silent chest
Bradycardia, dysrhythmia, hypotension, cyanosis
Exhaustion, confusion, coma
Adult near- fatal asthma
Respiratory acidosis and/ or need for mechanical ventilation
Adult brittle asthma
Type 1: wide PEFR variability despite intense therapy
>40% diurnal variation for >50% in >150 days
Type 2: sudden severe attacks with well-controlled asthma
Asthma Follow-up after treatment or discharge
GP review within 48 hours, check inhaler technique, written asthma action plan, modify treatment
Monitor symptoms and PEFR
Child <2
Moderate asthma
SpO2 ≥92%
audible wheezing
accessory muscles
feeding
Child <2
Severe asthma
SpO2 <92%
marked distress
cyanosis
cant feed
Child <2
Life-threatening asthma
apnoea
poor respiratory effort
bradycardia
Child <2 asthma management
- Intermittent wheezing- due to viral infection, poor response to bronchodilators
- Mild/ moderate wheeze: metered dose inhaler + spacer with face mask
- Severe wheeze: admit
Child 2-5
Moderate asthma definition
SpO2 ≥92%
Able to talk
HR ≤140bpm
RR ≤40/min
Child 2-5
Moderate asthma Tx
Bs agonist: 2 puffs every 2 min with spacer ± mask- max 10
Prednisolone 20mg po
Poor response- admit
Child 2-5
Severe asthma def
SpO2 <92% Cant talk HR >140/min RR >40/min Accessory muscles
Child 2-5
Severe asthma Tx
Oxygen via face mask
B2 agonist: nebulized salbutamol 2.5mg or terbutaline 5mg
Prednisolone 20mg po
B2 agonist+ admit
Child 2-5
Life-threatening asthma def
SpO2 <92% + Silent chest Poor resp effort Agitation Altered consciousness Cyanosis
Child 2-5
Life- threatening asthma Tx
Oxygen
Nebulize: Salbutamol 2.5 mg or Terbutaline 5mg \+ ipratropium 0.25mg
Prednisolone 20mg or IV hydrocortisone 50mg
Repeat B2 agonist+ admit
Child over 5 asthma management
inhaled SABA
Inhaled steroids
LABA
LTRA/ Theophylline
Hypoglycaemia
• Diabetic on insulin/ oral therapy
• Px: coma, fits, odd/ violent behavior, tachycardia, HT
• Young kids can px with behavioural change or headache
• Warning symptoms: sweating, hunger, tremor
• Investigation: blood sugar <2.5mmol/ L
• Action
o Conscious: simple carbs
o Unable to take oral: IM glucagon or IV glucose
o Once conscious: complex carbs like biscuits
o Glucose testing <15min, every hour for 4hrs, every 4hrs for 24hours
Hyperglycaemic Ketoacidotic Coma
• Type 1 diabetic: 2-3hx deterioration after infection
• Px: dehydrated, kussmal breathing, ketotic breath, shock, vomiting, abdominal pain
• Investigation: blood sugar >20mmol/L and ketone in urine
• Action: ABC
o Admit, if shocked lie flat and raise legs
Hyperosmolar hyperglycaemic state (HONK)
• Type 2 diabetic: <1 week deterioration
• Decreased consciousness, dehydration, hypotension
• Precipitated by infection, MI
• Can be presenting feature of T2DM
• Blood sugar >35mmol/L
Action: admit
Myxedema coma
- Px: >65, hx thyroid surgery/ radioactive I2
- Precipitated by: MI, stroke, infection, trauma
- Hypothermia, hyporeflexia, HF, brady, cyanosis, coma, seizures
- Investigation: blood glucose may be low
- Action: keep warm, treat HF with diuretics, opiods, nitrates
Thyrotoxic Storm
- Risks: recent thyroid surgery, hx radioactive I2
- Precipitated by: MI, stroke, infection, trauma
- Px: fever, agitation, coma, tachy/ AF, D+V, acute abdo, goiter ± thyroid bruit
- Action: admit
Addisonian Crisis: hypoadrenal
- Long-term steroid use stopped suddenly or not in infection
- Can be px of congenital adrenal hyperplasia or addisons
- Px: vomiting, hypotension and shock
- Management: admit and IV hydrocortisone
- Prevention
Scalds and burns assess
- Cause, size, thickness
- Rule of nines to estimate extent of burn
- Partial thickness: red and painful
- Full thickness: painless and white or grey
Scalds and burns action
Remove clothing and place in cold water >10 min or till painless
Don’t burst blisters
Give analgesia
Apply silver suldaziazine cream or paraffin-impregnated gauze and non-adherent dressing, change ever 1-2 days
Scalds and burns normal exam
Warn about headaches, tiredness, dizziness, tinnitus, poor concentration and poor memory for few days
Advice rest and paracetamol
Warning signs: drowsiness, severe headache, persistent vomiting, visual disturbances, behavioural changes
Scalds and burns
rule of 9s for over 10 years old
- Palm and genitals: 1%
- Arm, head: 9% (head 14% in kids)
- Leg, front, back: 18%
Sunburn
Tingling and then erythema 2-12 hours later
Redness maximal at 24hours and fades over 2-3 days desquamation
Severe: blistering, pain, systematic upset. Tx calamine lotion
Predispose to skin cancer and photoaging
Anemia def
Lack of sufficient RBC/ Hb. Males <13g/dL and females <12
Anemia causes
Decreased RBC production
Increased loss/ rate of destruction
Decreased tissue need for O2 - hypothyroidism
Anemia Px
Asymptomatic
Pallor, exertional SOB, tachycardia, palpitations, angina, night cramps, cardiac bruits, high output cardiac failure
Anemia Investigations
Blood film, reticulocyte count Ferritin, folate, B12 CPR/ ESR/ plasma viscosity Hb electrophoresis LFT, TFT, RFT Serum bilirubin
MCV <80 DDX
- Iron deficiency
- Haemoglobinopathy- thalassemia
- Lead poisoning
- Anemia of chronic disorder
- Sideroblastic anemia
MCV normal DDX
- Acute blood less
- Haemolysis
- Uremia
- Anaplastic anemia
- Marrow failure
- Anemia of chronic disease
MCV >100 DDX
Megaloblastic
o Folate deficiency
o B12 deficiency
o Orotic aciduria
Nonmegaloblastic
o Liver disease
o Alcoholism
Reticulocytosis
Iron deficiency ANAEMIA
microcytosis and hypochromia
• Due to chronic bleed, malnutrition, impaired absorption, increased demand
• Findings: low iron and ferritin, high TIBC
• Tx: PO iron- constipation and black stool
• No improvement consider H. Pylori, coeliac disease
B12 deficiency ANAEMIA
Found in liver, kidney, fish, chicken, dairy
Absorption depends on intrinsic factor (parietal cells)
Px: anemia, glossitis, mouth ulcers, peripheral neuropathy, ataxia, optic atrophy, memory loss, SCD
Causes: malnutrition, malabsorption, metformin, PPI and H2 antagonist, pernicious anemia
Tx: hydroxocobalamin IM
Folate deficiency ANAEMIA
- Found in liver, yeast, spinach, nuts
- Px: anemia signs, polyneuropathy, dementia
- Causes: malnutrition, malabsorption, increased need, anticonvulsants, trimethoprim
- Tx: folate 5mg od for 4 months
Thalassaemia AR
α thalassemia: decreased α- globin
o Cis deletions in Asians, trans in Africans
o 4 gene deletion: γ4 (barts hydrops) –> hydrops fetalis
o 3 gene deletion: HbH disease. Excess β globin –> β4
o 1-2 gene deletion: no clinical significance
β thalassemia
point mutation in slice site and promotor sequence
o Mediterranean populations>
o Minor: heterozygote. β underproduced, asymptomatic
o Major: homozygote, β asent severe anaemia- need transfusions 2° haemochromatosis
o Marrow expansion skeletal deformities. Chipmunk face, bossing of skull, thinning long bones, splnomegaly
Sickle cell anemia
Point mutation at position 6 of β chai: glutamic acid with valine
When Hbs is deoxygenated it causes sickling of RBC –> shortened life span –> haemolytic aneamia and vasoocclusion
Newborns are asymptomatic because increased HbF
Anticoagulation
Long term indications
Prevent recurrent VTE
Prevent arterial thromboembolism with cardiac disease
Anticoagulation
Short term indications
VTE ≥6weeks after below knee DVT and ≥3 months after proximal DVT/ PE
High risk: mural thrombosis after MI, post surgery
Tell me about NOACs
dabigatran, rivaroxaban
Prevent VTE in non-valvular AF
Fixed dose and do not need monitoring
Not easily reversible
Heparin/ LMWH
Enhances antithrombin activity
Uses:
o Initial tx in VTE
o Cancer/ pregnant VTE management
o When warfarin stopped before surgery
o High risk on PO anticoagulants if INR < than normal
Warfarin
Check baseline FBC, clotting screen, RFT, LFT
+ antiplatelet: only if <12 months after stenting/ ACS
Monitoring: INR 2-3
Candida
Risks:
Genital infection
Intertrigo
Oral
Nappy candidiasis
Chronic paronychia
Systemic candidiasis: immunocompromised- red skin nodules
Moist, opposing skin folds, humidity, poor hygiene
Obesity, DM, pregnancy, neonates
- Pruritis, sore volvovaginitis, white cheesy discharge
- Reddened, moist, glazed area in submammary, inguinal or axillary folds
- Sore mouth, poor feeding in infants, poor oral hygiene, white plaques ± angular stomatitis
- Wet workers at chronic nail fold inflammation
Topical Treatment Fungal Infections
- Mouth: nystatin or miconazole gel or oral suspension
- Genital: imidazole cream or pessaries
- Nail: use lacquer or paint, amorolfine
- Skin: imidazole- cream/spray/powder or terbinafine cream
Systemic Treatment Fungal Infections
• Oral, mucucutaneous, systemic: oral fluconazole 50mg od
• Genital: one dose 150-200mg fluconazole
• Tinea: terbinafine 250mg od or itraconazole 100mg od
• Nail: terbinadine 250mg or itraconazole 200mg bd
• Scalp: oral terfinafine 250mg od or grisofulvin 500mg-1g od
o Griseofulvin is teratogenic
Dermatophyte infection
Corporis- ringworm on trunk or limbs
• Plaques with scaling and erythema, clear center
Cruris- jocks itch
• Associated with tinea pedis
• Upper thigh + scrotum. Red plaque with scaling at edge
Pedis- athletes foot
• Pruitis, maceration between toes
• Risks: swimmers, occlusive footwear, hot weather
Capitis
• Defines, inflamed scaly areas ± alopecia w/ broken hair shafts
Ungulum
• Begins distally and goes proximally
Thickening, yellowing and crumbling of nail plate
Acute PID - chlamydia or gonorrhoea
- Peak age 15-25
- > 10% develop infertility after 1 episode, 50% after 3
- Risk of ectopic
- Hx: fever, acute bilateral pain, deep dyspareunia, dysuria, abnormal vaginal bleeding, discharge
- Ex: pyrexia, bilateral tenderness, discharge, cervical excitation, adnexal tenderness
- Dx: HVS/ endocervical swab, FBC, ESR/CRP
Acute PID Management:
rest, analgesia
o Ofloxacin 400mg bd + metronidazole 400mg 2/52 OR
o 1 dose ceftriaxone 500mg IM then doxycyxline 100mg bd + metronidazole 400mg bd 2/52
o Persistent –> laproscopy
Chronic PID Px:
pelvic pain
dysmenorrhea
dyspareunia ± menorrhagia
Urethritis – males (feamles = mucopurulent cervicitis)
• Discharge and/or dysuria or asymptomatic
• Gonococcal or
• Non-gonococcal- chlamydia, ureaplasma, mycoplasma gentalium, tichomonas vaginalis
o Tx: azithromycin 1g stat
o Persistent/ reccurent: azithromycin 1g stat then 250mg od 4/7 + metronidazole 400mg bd 5/7
Genital Herpes
Primary infection:
asymptomatic, painful genital ulcers on red background ± inguinal nodes, lesions crust then heal.
Complications: retention, aseptic meningitis
Genital Herpes management
refer, acyclovir if within 5days, analgesia, ice packs, 5% lidocaine ointment for symptom relief
Recurrent: less severe. Tx with acyclovir 400mg bd
Neonatal: vesicular lesions> systemic. Prevent with CS
Public lice Tx
- Melathion 0.5% to dry hair and wash after 12hours
- Permethrin 1% cream to damp hair and wash after 10min
- Phenothrin 0.2% to dry hair and wash after 2 hours
- Carbaryl 0.5-1% to dry hair wash after 12hours
Chlamydia
• Men: asymptomatic> urethritis
• Women: asymptomatic > discharge, PCB/ IMB, PID, dysuria
o Mucopurulent cervicitis, hyperaemia and odema of cervix ± contact bleeding, tender adnexae, cervical ex.
• Neonates: conjunctivitis, pneumonia, otitis media, pharyngitis
• Dx: swab or first catch urine for NAAT
• Tx: doxycycline 100mg bd 1 week OR erythromycin 500mg qds 2/52 OR azithromycin 1g stat po
Gonorrhoea
Male vs Female presentation
Men:
o Urethral: discharge, dysuria, prostitis, stricture> asym
o Rectal: asym> discharge, pain
o Pharyngeal: asymptomatic
Women: asymptomatic, discharge, lower abo pain, dysuria, bleeding, PID, bartholin gland abscess, miscarriage, preterm
Gonorrhoea
Dx
Tx
Dx: first-catch urine NAAT, swab
Tx: ceftriazone 500mg IM once + azithromycin 1g stat po
Trichomanis Vaginalis
- Neonates: opthalmia neonatorum- discharge from eyes <21 days old
- Men: dysuria, urethral discharge > asymptomatic
- Women: asymptomatic, discharge, mucopurelent yellow- white, smelly discharge, soreness, pruitis, abdopain, dysuria
- Ex: strawberry cervix, pH >4.5,
- Tx: metronidazole po 2g state or tinidazole 2g state
- Persistent: higher dose
Genital warts
Due to HPV
Px: asymtpmpatic> pruitis, discharge, warts
Management: podophyllotoxin, imiquimod, excision, cryotherapy
Syphilis Teponema pallidum Incubation 9- 90 days Dx: VDRL, TPHA Stages
- Primary: chancre at site
- Secondary: 4-8 weeks later. Fever, malaise, lymphadenopathy, conylomata lata, rash, alopecia
- Tertiary: 2-20 year later- gummas in connective tissue
- Quarternary: CV or neurological complications
Sore Throat
70% are viral and rest are bacterial eg
group A β- haemolytic
Sore Throat PC
• Painful swallowing, tonsillar exudate
• Headache, N & V
• Abdominal pain
Persistent feverglandular fever in YA
Sore Throat Dx
Investigations
• Throat swab cant distinguish commensal from infectious
• Rapid antigen test: low sensitivity and limited usefulness
Sore Throat Complications
rare
- Quinsy or peritonsillar abscess- adults>
- Retropharyngeal abscess
- RF
- Acute glomerulonephritis
Tell me about quinsy
o Unilateral swelling, difficult swallowing, trismus
o IV abx ± incision and drainage
Glandular fever (infectious mononucleosis)- EBV
Teens or YA with sore throat >1 week
Droplet or direct contact with 4-14 day incubation
Px
Dx
Px: sore throat, malaise, fatigue, lymphadenopathy, splenomegaly, palatal petechiae, rash
Dx: FBC for atypical lymphocytes and monospot for Ig
Glandular fever
Tx
Comp
Management:
o Rest, fluids, analgesia, salt water gargles
o Avoid alcohol
o If severe: prednisolone
o 2° infections treated with Abx- not amoxicillin
Complications o 2° infections, pneumonitis o Rash with amoxicillin o Hepatitis, jaundice Neurological disturbances
Tonsillectomy Indications
Recurrent acute tonsillitis: >5 attachs for 2 years
Airway obstruction
Chronic tonsillitis: >3 months + halitosis
Recurrent quinsy
Unilateral enlargement- exclude malignancy
Tonsillar tumour
elderly
Px unilateral swelling, dysphagia, sore throat, earache
Hoarseness
Causes:
Local: URTI, laryngitis, trauma, ca, hypothyroidism, acromegaly
Neurological: laryngeal nerve palsy, MND, MG, MS
Muscular dystrophy
Functional problems
• Psychological stress –> hysterical paralysis of vocal cord adductors –> whisper or loss of voice
• Young women. Speech therapy and psychological support
RULE OUT CA
Hoarseness Assessment
Weight dysphagia lumps TFT CXR
Laryngitis
- Hoarseness, mailase ± fever, pain on talking
- Viral and self limiting 1-2 weeks >
- Can get 2 bacterial infection
- Tx: rest, OTC analgesia, phenoxymethylpenicillin 250qds
Laryngeal carcinoma
- Men>
- Pc: hoarseness then stridor, dysphagia, pain
- Management: laryngoscopy and bx, surgery ± RT
Post Laryngectomy problems
Permanent tracheostomy, stenosis at site
Excessive secretions
Recurrent pneumonia
Vocal cord nodules
Can cause hoarseness
Due to overuse
Visualized with laryngoscope
Tx: rest or surgery
Stridor
Inspirational noise due to narrowing of lyarynx or trachea
Children
Signs of severe airway narrowing
Distress, pallor, cyanosis
Increased RR, use of accessory muscles and tracheal tug
Laryngomalacia (congenital laryngeal stridor)
Small babies due to floppy aryatic fold and small airway
Louder during sleep, excitement, crying and URTI
Adult epiglottitis
More rare than in children
Less likely to cause obstruction
Tx: IV Abx
Croup: viral infection
- Starts with mild fever + runny nose
- Oedema and secretions –> barking cough and stridor
- Cough starts at night and worse with crying
- Recurrent attacks a/w viral URTI
- Tx: steam, dexamethasone 0.15mg/kg PO or prednisolone 1-2mg/kg
Acute epiglottitis in children
Bacterial infection, more rare with Hib vaccine
Can obstruct airway. Don’t examine bc can cause this
Stridor, drooling, fever and upright leaning forward
Tx: IV Abx
Acute sinusitis ≥1: maxillary, frontal, ethmoid or sphenoid Follows URTI- 10% after tooth infection Px: Management: most resolve in 7-10 days
Px: frontal headache/ facial pain, worse on movement ± purulent nasal discharge, fever
Management: o Analgesia, fluids and steam o Decongestants o Beclometasone 2 puffs in each nostril bd o Amoxicillin 500mg tds
same tx for chronic sinusitis
Chronic/ recurrent sinusitis
> 3 months of symptoms or >3 episodes in a year
Px: post-nasal drip, frontal headache/ facial pain, blocked nose
A/w: nasal polyps and vasomotor rhinitis
Non-allergic rhinitis
Hay fever: rhinitis, conjunctivitis, wheeze, due to pollen
Same tx as allergic
Topical chromone eye drops- nedocromil
Rhinitis
• Inflammation of nasal mucosa
• Allergic or non-allergic (vasomotor- physical/ chemical triggers)
Symptoms
Signs
Management
Sx
Nasal discharge, itching, sneezing ± nasal blockage
Moderate/ severe if ≥1: abnormal sleep, impairment of daily activities, problems at work/ school
Signs
Swollen inferior turbinates, nasal airway, pale mucosa, discharge
Management if allergic: exposure, saline nose drops ± steam inhalation, drugs
Medications for allergic rhinitis
- Nasal steroids
- Oral steroids
- Oral antihistamine: loratadine 10mg od
- Topical AH: azelastine nasal drops- rescue- fast acting
- Leukotriene R antagonist: montelukast 10mg od
- Topical/ oral decongestants: ephedrine nasal drops tds/ qds
- Topical anticholinergics: ipratropium bromide nasal spray
- Topical chromones: sodium cromoglicate or nedocromil sodium nasal spray
Earache
Local causes:
o Outer ear: otitis externa, furunclosis, impacted wax, pinna pain, malignant disease of ear
o Middle ear: otitis media, barotrauma, myringitis, mastoiditis
Earache
Referred pain:
o CN 5: dental abscess/ caries, impacted molar teeth
o CN 7: HSV infection, Ramsay Hunt
o CN 10: tumour piriform fossa, larynx or post-croicoid
o CN 11: tonsillitis/ quinsy/tumour base of tongue, tonsil
o CN 2/3: cervical spondylosis
Myringitis
Inflammation of tympanic membrane
If vesicles- mycoplasma or viral URTI (ramsay hunt similar)
Discharge from ear: otorrhea
Causes: otitis externa, media, cholesteatoma
Exclude perforated drum
If clear- might be CSF leak so test for glucose
Ear wax
Only problem if deafness, pain, discomfort, tinnitus
Tx: ear syringing. Not if deaf in other ear, hx perforation of ear drum, px mastoid operation, middle ear disease
Otitis externa
Def:
Risks:
Adults> a/w eczema of ear canal
swimming, humidity, narrow ear canal, hearing aid, trauma
Acute otitis externa: <6 weeks
Px:
pain, discharge, hearing loss ± lymphadenopathy
Ear canal: red, swollen, inflamed
Chronic otitis externa: >3 months
Discharge ± hearing loss
Leads to canal stenosis and permanent hearing loss
Severe necrotizing form can occur in diabetics/ immunocom
otitis externa management:
analgesia, ear drops- aluminium acetate and Abx and/or steroid drops (locorten- vioform)
No response: otosporin (neomycin, hydrocortisone, polymyxin B- antifungal) ± oral antibiotic
Furunculosis: boil in ear canal
Px:
Tx:
severe pain worse with moving tragus or jaw
Tx
No cellulitis: analgesia, hot compressions. If not working- topical abx and steroid drops hentisone, 3 drops qds 7days
Cellulitis: flucloxacillin 250-500mg qds 7 days
Chondrodermatitis nodularis helicis (CNH)
Pressure on ear –> tender lump with scarring on outer helix
Advice relief ± topical steroid/ antiobitotic, if fails-cryotherapy or surgical removal
Infection of pinna due to ear piercing or lacteration
No treatment –> cauliflower ear
Pseudomonas> treat with ciprofloxacin 500-750mg bd PO
Acute suppurative otitis media
Acute inflammation of middle ear
Can be viral/ bacteria- parental smoking increases risk
Px:
Tx:
Px: unilateral pain ± fever
o Discharge pain relief- spontaneous drum perforation
o Red, bulging drum, pus if perforated
Management
o 80% resolve in ~4days- fluids, analgesia
o Amoxicillin tds if bilateral or acute + otorrhea, severe, immunosuppression, CF
Chronic suppurative otitis media
• Drainage >1 month a/w perforation drum + CHL
• Not painful
• Type
o Central perforation: “safe disease”. Tx like otitis externa
o Attic/ marginal perforation: “unsafe” a/w cholestaetoma
Serous/ secretory otitis media (glue ear)
• Non-infected fluid due to obstruction/ dysfunction of Eustachian- 2° to ear/ through infection, tonsillar hyperplasia
• Most common cause of hearing loss in children
• Common in down syndrome or cleft lip/ palate
• Px: deafness ± pain, difficulty with speech ± behavior issues
• Signs: dull, concave drum with visable BV ± fluid level/ air bubbles behind drum
• Tx: symptomatic- resolve alone, referral if not resolved
o Grommets: air-conducting tubes inserted through eardrum. Most extruded spontan <9months
Mastoiditis Rare complication of acute OM PC Signs Tx
PC: persistent, throbbing pain, cream, profuse discharge, worse CHL, fever, malaise
Signs: tenderness ± swelling over mastoid, ear sticking out, red/bulging or perforated drum
Tx: IV abx
Cholestaetoma
Stratified squamous epithelium growing in middle ear
Damage to facial nerve, semicircular canals –> vertigo
Infected = discharges
Signs:
Tx:
perforation of pars flaccida of ear drum with pearly white discharge + conductive hearing loss
Tx: suction
Tympanosclerosis
Thickening and calcification of tympanic membrane due to scarring from reccurent ear infections or grommet insertion
Asymptomatic> no tx
Renal Stones
Risks
- Fhx: X-linked nephrolithiasis, cystinuria, hyperoxaluria
- Anatomically abnormal kidney: horseshoe, medullary sponge
- Metabolic disease: gout, hypercalcaemia/ calcuria, cysinuria, renal tubular acidosis
- Dehydration, immobilization
- Chronic UTI
- Drugs: allopurinol, aspirin, steroids, loop diuretics
Renal Stones Px
• Pain ± N/V, radiates to tip of penis/ testis or labia majora o Loin pain= kidney stone o Renal colic= ureteric stone o Strangury= bladder stone o Interruption of flow= urethral stone
Renal Stones
Immediate management
Investigations: urine dipstick for RBC, WBC
Analgesia- diclofenac 75 mg IM/ 100 PR ± antiemetic
Admit if: fever, oliguria, poor fluid intake, preggos, >24hrs
Renal Stones Investigations
- U&E, creatinine, eGFR, Ca2+, PO43-, alk phos, uric acid, albumin
- Urine: M, C&S, cysteine “spot test”, TPCR, , Ca2+, PO43, uric acid, sodium excretion
- Xray KUB, USS for urate and xanthine stones
Calcium oxalate: (80% hypercalcuria w/o hypercalcaemia) prevention:
o Potassium citrate- urinary alkalization
o Avoid chocolate, tea, rhubarb, spinach, nuts, beans
o Bendroflumethiazide 2.5mg od if hypercalcuria
o Pyridoxine if hyperoxaluria
Calcium phosphate prevention:
o Low calcium diet, avoid vit D supplements
o Bendroflumethiazide 2.5mg od
Staghorn/ triple phosphate prevention:
Ca2+, Mg2+, ammonium
A/w proteus species and urinary stasis UTI
Urate prevention:
o Avoid beer, allopurinol
o Potassium citrate to alkalize urine (ph >6.5)
Cysteine prevention:
potassium citrate to alkalize urine (ph >6.5)
Hyperoxaluria
1° - 2 types
2° to gut resection/ malabsorption or increased spinach/ vit C
Type 1: calcium oxalate stones all over body. Px renal stones and nephrocalcinosis in kids. 80% CRF
Type 2: more benign, nephrocalcinosis and no CRF
Cystinuria
Most common aminoaciduria
Px: stones at 10-30 years
Urine: increased cysteine, ornithine, arginine, lysine
Haematuria
Frank or microscopic
Investigations: MSU for M, C&S, U&E, creatinine, eGFR
Causes Kidney: stones, infection, GN, tumour Ureter: stones, tumour Bladder: UTI, stones, tumour, chronic inflammation Prostate: prostatitis, tumour Urethral inflammation
Hypernephroma: clear cell AC of tubular epithelium who PC Dx Tx
Males, 50’s
Px: haematura, loin pain, abdo mass, anaemia, L varicoile
Investigations:
o Urine: RBCs
o Bloods: PCV, anemia, hypercalcaemia
o USS, CXR
Management: surgery ± CT, RT or biological therapy
Bladder cancer
TCC most common in UK, SCC most common worldwide
Risks: male, smoking, aromatic amine exposure, Schistosomiasis, chronic UTI, urinary stasis
PC
Dx
Tx
Px: haematuria, recurrent UTI, pain, frequency, obstruction
Dx: MSU- M, C&S, microscopic haematuria
Management:
o T1: confined to mucosa/ submucosa. Tx TURBT ± CT
o T2: invasion of CT. Tx TURBT ± RT
follow up with cystoscopy for T1 and T2
o T3: invasion into muscle. Tx radical cystectomy ± RT
o T4: beyond bladder. Tx TURBT for symptoms, RT ± CT
Sterile pyuria:
WBC in urine and no UTI
DDx
Inadequately treated UTI Appendicitis Calculi, renal TB, papillary necrosis, interstitial nephritis, cystitis, polycystic kidney Bladder tumour, cystitis due to RT Prostitis
