Renal (nephro and urology) Flashcards
DDx of urinary frequency (list 6)
UTI, cystitis, urethritis, (pinworms), appendicitis/pelvic abscess, ovarian torsion, PUV, neurogenic bladder, constipation, pregnancy, unstable bladder, behavioural, ectopic ureter, osmotic diuresis, intrinsic renal parenchymal disease, sickle cell anemia/trait, hypercalciuria, urinary calculi, CAH, hypercalcemia (and hypercalciuria), DI, head injury, drugs, psychogenic
How to diagnose / tx pinworms
Diagnose with piece of tape, eggs stick to tape. Tx with albendazole or mebendazole x 1 dose, repeat in 2 weeks.
Findings on microscopy with glomerular causes of hematuria
RBC casts, tea or brown colour, protein +2, dysmorphic RBC’s
Glomerular causes of hematuria
acute post strep GN, other post infectious GN, IgA nephropathy, Alport syndrome, exercise, familial benign hematuria
Microscopic hematuria: 5 signs suggesting need for more GU investigations.
Fever, Edema, Hypertension, Flank Pain, Bruising, Petechiae, Oliguria
Headache, hx of trauma, concern for tumor
2 renal injuries that don’t have hematuria.
1) vascular pedicle injury
2) penetrating trauma
Causes of hypoalbuminemia
- Decreased production: liver disease, malnutrition
- Increased losses: renal (ie. Nephrotic syndrome), GI, skin conditions
- Cardiac/ increased hydrostatic pressure: CHF, venous obstruction
What is Hoagland sign?
bilateral eyelid edema as an early sign of EBV
Causes of rhabdomyolysis
o Traumatic: crush injuries, vascular occlusions and lower extremity compartment syndrome
o Non-traumatic causes: extreme exertion, prolonged seizure, malignant hyperthermia, DKA, hypokalemia, hypophosphatemia, metabolic myopathies, NMS, postarrest, infectious, meds (cocaine, ecstacy, amphetamines, statins, colchicine)
Urinalysis findings in rhabdomyolysis
UA will show red/brown urine, positive for blood (but no RBC’s – myoglobin instead)
4 Causes of urinary retention In a Girl
● UTI ● Constipation ● Pelvic Tumour ● Abdominal mass - rhabdomyosarcoma ● Behavioural/Voluntary
Management of urinary retention?
● Bladder Scan to confirm ● Catheterization to decompress urine ● Massage and warm bath to help her void ● Treat UTI (abx) ● Treat Constipation (enema, stool softeners) ● Urology consult
15 yo male with back pain that is not responsive to analgesics at home. Now coming in because has not peed in 20 hours. 4 DDx
● Abdominal mass ● Severe constipation ● Transverse myelitis ● Spinal cord injury ● Discitis/ osteomyelitis of spinal process ● Kidney stones
Important items on physical exam for HTN
Ht, Wt, BMI, vital signs + UL and LL BP, evaluate for end organ damage, CV (femoral pulses for CoA), neuro, fundi, underlying cause
Investigations to do in severe HTN
- Laboratory studies:
a. Serum: CBC, electrolytes, glucose, urea, creatinine
b. Urine: Urinalysis, toxicology screen if indicated - Imaging studies: ECG (LVH), CXR, +/-echocardiogram if cardiac pathology suspected, CT head for severe neurologic dysfunction, Renal US with doppler for suspected renal artery stenosis
- Additional studies: Consider plasma renin (before initiating therapy), urinary catecholamines, TSH, T4 as indicated
HTN emergency - what 3 tests to do?
A) Labs (Renal function tests (BUN + creatinine), Electrolyte panel (R/O hyperkalemia, ?hyponatremia), CBC/diff
B) Urines: Urine analysis dip + microscopy (for proteinuria +/- hematuria), urine culture,
C) CXR/ECG +/- echo
+/- CT head
HTN emergency - What 2 medications would you use for management?
Labetalol/Nicardipine/Nitroprusside as IV medication that you can titrate
Def of HTN emergency
Significantly elevated BP with evidence of severe symptoms or secondary organ injury (most commonly brain, eyes, heart, kidneys);
What are 6 common causes of secondary hypertension in a child < 1year
- Renovascular disease
- Congenital renal anomalies
- Coarctation of the aorta
- Renal vein thrombosis
- CAH
- BPD
- Renal parenchymal d/o
2 Drugs to treat hypertensive emergency: Name them and 1 adverse effect or contraindication
IV labetalol – CI: asthma, BPD, heart failure
IV nicardipine – can cause reflex tachycardia
IV nitroprusside - methemoglobinemia, cyanide toxicity
What are 6 clinical findings of hypertensive emergency, not including labs
- BP at stage 2 or >180/120 in adolescent
- Neurologic symptoms: lethargy, coma, seizure
- Eyes: papilledema, retinal hemorrhages
- Cardiac: heart failure, peripheral edema
- Renal: oliguria, anuria
DDx of painful scrotal swelling
- testicular torsion
- torsion of appendix testis
- inguinal hernia (incarcerated, strangulated)
- epidydimitis
- orchitis
- lymphadenitis
Complications of undescended testicle if not treated surgically
testicular underdevelopment, infertility, malignancy, hernia, torsion, increased risk of traumatic injury
Need Orchidopexy by 1 year of age
DDx of painless scrotal swelling
- hydrocele
- varicocele
- hernia
- spermatocele
- tumor
Red flags in pediatric varicocele
right varicocele, pre-pubertal
If occurs on the right (connects directly to IVC) –> worry about abdominal mass and IVC obstruction, renal vein thrombosis (get abdo US)
Risk factors for UTI in infants
- Female < 12 mo, male < 6 months
- uncircumcised
- non-black
- fever > 39, > 2 days, no alternate source
When to start empiric tx for UTI (choosing wisely)?
dipstick + nitrite OR LE 2/3+; standard UA >5 WBC/hpf AND bacteria
When to treat UTI with IV antibiotics
< 6 mo, mod/severe dehydration, inability to tolerate PO
Physical exam findings in dehydration
weight loss, HR, pulse quality, mental status, mucous membranes, skin turgor, urine output
Categories of dehydration (by %) and their characteristics
Mild (3-5% volume loss): minimal or absent signs/symptoms
Moderate (6-9%): tachycardia, orthostatic hypotension, dry mucous membranes, prolonged cap refill
Severe (10%+): shock (hypotension, weak pulses, mottling)
Work-up of new suspected glomerulonephritis?
o Urine analysis and microscopy to confirm RBCs, casts
o Urine culture
o Urine protein, calcium, creatinine
o Bloodwork: CBC, lytes, BUN, creatinine, Ca, albumin, protein, ASOT/antiDNAseB, ANA, C3, C4
o Renal ultrasound
Criteria for diagnosis of nephrotic syndrome?
PALE:
o Persistent heavy proteinuria (mainly albuminuria) > 50 mg/kg/day
o Hypoproteinemia (serum albumin <25-30)
o Hypercholesterolemia (lipids)(>250 mg/dL): hypoproteinemia stimulates hepatic lipoprotein synthesis and decreases metabolism of lipoproteins
o Edema
Complications of nephrotic syndrome?
serious bacterial infection (SBP, encapsulated organisms), thrombosis (esp. renal vein thrombosis), complications of steroids
Atypical/concerning features in nephrotic syndrome?
age <12m or >12y, sustained serum creatinine elevation, HTN, gross hematuria, low C3/C4, evidence of specific infection (HBV, HCV, HIV), unresponsive to steroids x 4 weeks
List 3 nephrotoxic meds
NSAIDs, ACE inhibitors, tacrolimus, cisplatin, ifosfamide
Dialysis indications
(AEIOU): ▪ Acidosis ▪ Electrolyte imbalance ▪ Ingestion ▪ Overload (volume) ▪ Uremia
What is the 4-point dehydration scale?
1) cap refill > 2 sec; 2) dry mucous membranes; 3) no tears; 4) ill appearance (4 features = severe dehydration)
When are Oral rehydration solutions contraindicated?
ORS contraindicated for severe dehydration, vomiting, altered mental status (risk of aspiration), ileus, short gut/ malabsorption
When is zofran recommended? What dose?
Single dose of ondansetron in children > 6 months with vomiting (8-15 kg: 2 mg; 15-30 kg: 4 mg: > 30 kg: 8 mg)
Symptoms of hyponatremia?
generally if Na<125: neurologic (cerebral edema) – nausea, malaise, headache, altered mental status, lethargy, ataxia, seizures, coma, respiratory depression
What are 5 laboratory tests to determine the cause of hyponatremia?
● Serum electrolytes ● Osmolality ● Cr/BUN ● Urine osmolality ● Urine sodium (and calculate FENa) ● Urine analysis
EKG changes seen with hyperkalemia?
initial ECG changes narrow/peaked T waves, shortened QTc then prolongation of PR interval and widening of QRS, then loss of P wave amplitude and eventual “sine wave” pattern where QRS merges with T wave then V fib
Medications associated with hyperkalemia?
NSAIDS, ACEI, angiotensin receptor II blocker, spironolactone, tacrolimus, cyclosporine, propranolol (beta blocker), digitalis
Tx of hyperkalemia?
- Stabilize cardiac membranes (calcium)
- Shift K into intracellular space (insulin/glucose, Ventolin, bicarb if acidemic)
- Elimination (kyaxelate, Lasix, dialysis)
Symptoms of hypocalcemia
o Acute: neuromuscular instability or tetany
o Mild: paresthesias perioral/ hands and feet, muscle cramps
o Severe: seizure, laryngospasm, bronchospasm
What are Chvostek and Trousseau signs?
o Trousseau’s sign: carpopedal spasm with inflation of a BP cuff for >3 minutes
o Chvostek’s sign: contraction of the ipsilateral facial muscle induced by tapping of the facial nerve in front of the ear (present in 10% of normal people)
What ECG change is seen with hypocalcemia?
Prolonged QTc
Name 4 indications for IV calcium
● Hyperkalemia with ECG changes ● Calcium channel blocker overdose ● Beta blocker overdose – really? ● Hypocalcemia with seizures or tetany or prolonged QTc ● Hypermagnesemia
Symptoms of hypercalcemia/ hyperPTH?
bones, stones, groans, psychiatric overtones:
o Moderate: anorexia, irritability, abdominal pain, constipation and weakness
o Severe: progressive weakness, confusion, seizures and coma
o Polyuria can be present
How to calculate anion gap?
Na – (Cl + HCO3)
Normal AG (8-12)= diarrhea, RTA
High AG (> 14-16) = MUDPILES
How to calculate osmolar gap?
Serum osmolarity = 2 x Na + (glucose + BUN +/- ETOH)
Osmolar gap = Osm (measured) – Osm (calc)
Kid with chronic renal failure and epigastric pain/vomiting - 8 clinical/labs/investigations that you want to perform in the ED
Clinical ● Blood Pressure ● HR ● Weight ● Volume status
Tests: ● CBC and diff ● Electrolytes (Na, K, Cl) ● Renal function (Cr, BUN) – GFR by Schwartz formula ● Extended electrolytes (Ca, Mg, PO4) ● Urine analysis ● Renal ultrasound
HUS triad?
Coombs negative hemolytic anemia (MAHA) + thrombocytopenia + AKI
Lab findings in HUS?
fragmented erythrocytes, schistocytes, helmet cells, inc. retic count, inc LDH, dec haptoglobin, normal INR/PTT, DAT negative (in typical HUS)
TTP (Thrombotic Thrombocytopenic Purpura): 5 Features
- Thrombocytopenia
- Microangiopathic hemolytic anemia (MAHA)
- Neurologic symptoms
- Kidney failure
- Fever
How to diagnose HSP?
Diagnosis is clinical
o Obtain UA on first presentation
o If normal – no need for renal function or labs
Initial work-up for kidney stones
- urinalysis
- urine cx
- labs: creat, urea, extended electrolytes
- consider imaging: RUB US, KUB xray, CT 2nd line
Tx of renal stone
o Analgesia: NSAIDs and opioids
o Hydration: IV fluids
o IV antibiotics: cefotaxime (if infected stone)
o Alpha adrenergic blockers: e.g. tamsulosin facilitate stone passage
o Urology consult for admission/stone removal
2 complications of stones
o Acute kidney injury - obstructive
o Hydronephrosis
o Sepsis
2 alternate diagnoses for kidney stones
o Pyelonephritis
o Trauma
o Renal / perinephric abscess
o Renal mass
Management of symptomatic phimosis
betamethasone 0.05% BID x6 weeks, instruct the foreskin as far back as it will go and then apply a small amount
Complications of balanitis?
true phimosis (from scarring) –> urinary obstruction
What are 2 causes of balanitis
Poor hygiene
Local trauma
Bacterial infection
Management of balanitis?
- Antibiotics
- Other mgmt: po abx, warm soaks → if phimosis or recurrent infx then circumcision
2 yo male presenting with balanoposthitis.
What 2 features that would make you refer to urology?
acute urinary obstruction, prolonged/refractory single course, recurrent +/- phimosis
3 causes of priapism in a 6-year-old?
● Trauma ● Leukemic infiltration ● Sickle cell disease ● ingestion sildenafil ● spinal shock
Treatment of priapism
● Treatment: urgency based on time since onset + symptoms (pain = indication)
● Irrigation of the corporal bodies with saline in combination with vasoactive substances (e.g. phenylephrine)
● Urology consultation
o If SCD: add hydration + O2 + analgesia
Causes of epidydimitis
o If sexually active: chlamydia, Neisseria gonorrhea, e coli, mycobacterium, viruses
o If HIV infected: mycobacterium, CMV, cryptococcus *TB!
o Pre-pubertal: viral, chemical irritant, or idiopathic most common (rare – r/o structural abnormalities of the urinary tract)
What is Prehn sign?
Elevation of the testicle may relieve pain in epididymitis
When does ischemia begin in testicular torsion?
ischemia after 6 hours (50% by 12 hours, 10% salvage rate by 24 hours)
Name 3 symptoms of testicular torsion
■ Acute onset testicular pain (often waking up from sleep)
■ Presence of nausea/vomiting
■ Severe pain not improved by any position
■ Sudden enlargement + redness of the hemiscrotum (newborn)
Name 4 physical exam findings of testicular torsion
Enlarged + swollen hemiscrotum Significant tenderness Loss of cremasteric reflex Horizontal lie of the affected testis Hard testicle, high riding testicle
Tx of urethral prolapse
Tx: estrogen cream, sitz baths, excision of prolapsed mucosa if recurrent
Tx of labial adhesions
observation if asymptomatic as resolve by puberty. Topical estrogen cream (Premarin 0.1% BUD for 4-6 weeks) and petroleum jelly
What are three complications of not surgically correcting a testicular trauma?
- Ischemic necrosis
- Secondary infections
- Disruption of testicular function
- torsion
4 ways to manage zipper injury of foreskin
- If fastener is not involved then just cut the cloth of the zipper
- Apply mineral oil for 10-15 minutes followed by traction
- Cut the median bar of fastener with wire cutters, bone cutters or a mini hacksaw
- Place the thin blade of a flathead screwdriver between the faceplates on the side in which the tissue is not entrapped
- Local anesthesia and thin unzip over the entrapped area
2 positions for genital examination
frog-leg or knee to chest position
