Subs 1/5/2016 Flashcards
is growth plate on metacarpals and phalanges proximal or distal
metacarpal - distal
phalanges - proximal
carpal bones
so long to pinkie here comes the thumb
scaphoid lunate triquetrum pisiform
hamate captate trapezoid trapezium
peds uro probs of urethra
posterior urethral valves
hypospadias/epispadias
peds uro probs of bladder
hematuria
(non-glomerular
peds uro probs of ureters
ureteropelvic junction obstruction
ureterovesicular junction obstruciton
ectopic ureter
vesicoureteral reflux
peds uro probs of kidney
malignancy (e.g. wilm’s)
glomerular hematuria
microscopic hematuria
define
dx
manage in peds
rbc’s on UA but not grossly visualize
usually self-limiting in kids so watch and wait… if persists probably congenital defect… surgery?
if blunt trauma - CT scan
macroscopic hematuria
define
dx
manage in peds
grossly visualized
dysmorphic rbc’s or rbc casts - glomerular - u/a kidney bx
normal rbc’s no casts - non-glomerular - us, cystoscopy, ct/mri depending on pretest probability…
modes of kidney imaging for peds and use
US - hydronephrosis (obstruction, refux in peds) VCUG voiding cystourethrogram - reflux (eg diff reflux from obstruction in cause of hydronephrosis on us... essentially injecting dye from urethra to bladder then have kid pee... if contrast in ureters... reflux), also diverticula, big abnorms CT - w iv con for trauma (assess leaks), w/o iv con for stones (want to see radioopaque stones) cystoscopy - intraluminal lesions intravenous pyelogram (never used... basically just a little less definition than CT w contrast) renal bx eg to diff type of glomerular dz after u microsc showed dysmorphic rbc's or rbc casts
posterior urethral valves path pres dx tx
excess tissue blocks urine leaving bladder thru urethra
neonate no urine output, distended bladder
wwo oligohydramnios (low amnionic fl) hydronephrosis if prenatal care)
cr high or normal as mom can clear
us hydro, vcug ro reflux, cath massive output
cath temp, surg perm
hypo / epispadiad path pres dx tx
hypourethral opening ventral
epi urethral opening dorsal peeing in face
neonate by exam or child out of diapers
clinical dx
use foreskin to surg reconstruct urethral opening by out of diapers, SO DONT CIRCUMSIZE
uteropelvic junction obstruction / uterovesicular jo path pres dx tx
urinary pelvis outlet vs ureter bladder junction congenitally narrow, presents as infant or suffices when urinary flow normal
till teen binges alcohol (or challenges buddy to gatorade contest), inc u ouput, colicky andominal pain, spontaneously resolved
us hydro (kidney only for upjo, ureter and kidney for uvjo), vcug ro reflux (more important in uvjo), remal scintigraphy (radionucleotide scan)
surgery, maybe stent
ectopic ureter path pres dx tx
one normal ureter, one implants low
5 yo girl (out of diapers time) w normal u function.. bladder fills, urge to pee (one normal ureter) but constant leak never dry (ectopic ureter below urethral sphincter, maybe in vagina, no control, similar to fistula)
boys asymptomatic as implant above urethral sphincter
us no hydro, vcug no reflux, radionucleotide scan (positron emitting nucleotide tagged to metabolically active pharmaceutical of choice) to id affected kidney and quantitatively compare function to other side…
surg reimplant ureter
vesiculoureteral reflux path pres dx tx
retrograde flow bladder to ureters us hydro if approp prenatal care, recurrent uti's or pyelo wo prenatal care us hydro, vcug reflux abx if minor and may outgrow surg if otherwise
microscopic hematuria in setting of flank trauma
imaging to get
ct w iv con
to eval for kidney inj
intravenous pyelogram
define
use
like an angiogram of the gu system
substance injected iv that moves thru kidney and gu system
look for blockage, duplication, anatomic variants
not really used mich anymore as ct w iv con usually better
most common use for vcug voiding cystourethrogram
kids w uti’s
evals for vesico ureteral reflux
tf
us useful for asdessing solid organs for injury
f
polydipsia polyphagia polyuria weight loss think...
diabetes milletus
what are you looking for on renal bx in peds
iga nephropathy (post febrile illness) post strep glomerulonephritis minimal change dz
kid with urti and 2+ proteinuria… next step in mgmt…
repeat u/a 1 wk
if still proteinuria… 24hr u protein
nasal renal think wegener’s
urti kidney dz think rheumatic fever
but mild sx start conservatively…
(med ed q)
painless hematuria suggests…
malignancy or anatomical defect
painless hematuria
palpable flank mass
think…
cancer
wilm’s tumor
renal cell carcinoma
neuroblastoma
painless hematuria
flank mass
peds
think…
wilm’s tumor (nephroblastoma)
most common primary malignancy of childhood
age 2-5 usually
can think neuroblastoma if 1yo and ab mass crosses midline
wilm's tumor aka pres dx prog
nephroblastoma
painless hematuria, flank mass, in child age 2-5 usually (most common primary malignancy in childhood)
htn and fever possible too, making difficult to diff from inflammatory
u/a hematuria
us
ct to assess for distant mets
good prognosis if caught early
painless hematuria flank pain flank mass adult think...
rcc
renal cell carcinoma
renal cancer of adulthood
classically elderly smoker
colicky ab pain w hematuria think…
nephrolithiasis
presentation of pyelonephritis
urgency frequency dysuria cva tenderness bacteria and wbc casts on ua maybe blood too but wbc's predominate
presentation of psgn
post strep glomerulonephritis
hematuria
proteinuria
htn
edema
tf
surgical correction of hypo / epispadias is a surgical emergency
f
no real need until out of diapers, so can wait to perform till newborn is more stable to endure surgery, but should still be done sooner rather than later (eg well before toilet training)
just delay circumcision till after foreskin can be used for reconstruction
cryptorchidism
define
tx
compx
undescended testis
orchiopexy (surgically move testicle into scrotum and tack it down) by age 6-18mos
testicular cancer a risk despite orchiopexy, so teach pubertal and post-pubertal monthly self exams
(sexual function and puberty maintained by other testicle and with orchiopexy)
tf
the risk of testicular cancer remains the same after orchiopexy for cryptorchidism
t
so teach pubertal and post-pubertal self exams
differentiate
varicocele
hydrocele
inguinal hernia
bag of worms
transilluminates
extends to inguinal ring
swelling of testis ddx
acute
torsion
orchiitis
both meed emergent surg referral
chronic
hydrocele (transilluminates)
testicular cancer (does not transilluminate)
swelling of epididymis ddx
epididymitis - tender, acute, swollen
spermatocele - non-tender, stable size, nodular
swelling of scrotal skin ddx
sebaceous cyst
skin cancer
infection
scrotal swelling ddx
skin - sebaceous cyst, skin cancer, skin
infection
cord - inguinal hernia, varicocele, spermatocele
epididymis - epididymitis, spermatocele
testis - torsion, orchitis, testicular cancer
child w recurrent uti’s
suspect. ..
dx. ..
reflux (vesicoureteral)
us (shows nothing) then vcug voiding cystourethrogram
tf
bacteria in urine equals uti
f
can be asymptomatic bacteruria
only treat if pregnant or in context of urethral surgery
to what age cam wetting the bed still be considered “normal development”
age 7
neonate w/o urine output and ele cr and hx of mild oligohydramnios, next step?
in out cath
anytime suspect obstruction
(suspect posterior urethral valves here)
us reasonable but most places delayed as must be ordered so do in out cath at bedside (or us AT BEDSIDE)
urine sodium study to help dx kidney disease
FeNa v1% indicates prerenal
prostate ca path pres dx tx fu
5dht (testosterone)
70yo M (usually die WITH not from, but big deal for those it does affect) asymptomatic screens not recc anymore unless 1st deg relative w prostate ca
obstructive urinary sx
firm nodular prostate on dre
psa ele, 10-12 transrectal bxs (ca nearer periphery) preferred to transurethral
gleason score by adding worst 2 bxs (higher score more like undifferentiated adenocarcinoma)
resection = radiation = brachytherapy == some kind of semisurgical removal
then gnrh analogue (leuprolide)
or antiandrogen (flutamide) to suppress sx
orchiectomy if refractory (delete testisterone.. eg in old guy using penis for urination only)
fu w psa, if ele wo sx tx w antiandrogens, if ele w sx tx w radiation to zap away mets
over 40
frank hematuria
painless
must work up for…
bladder ca
bladder ca
path
pres
transitional cell carcinoma smoking or beta alanine dye exposure painless hematuria plus minus obstructive sx us IF obstructive then cystoscopy and bx transurethral resection, followed by bcg therapy (bacillus calmette-guerin, a live attenuated mycobacterium bovis, don't know why works) or chemo (cisplatin) cystectomy if ca invasive
testicular ca path pres dx tx fu
germ line carcinoma
young male 18-35 painless mass does not transilluminate
us
DONT FNA BX will just seed tract
serum tumor markeds (ldh afp b-hcg not diagnostic, but to track tx and recovery) - then orchiectomy - then path
seminoma - chemo rad, usually cisplatin, track w ldh
non-seminoma
endodermal sinus tumor (yolk sac) track w afp
choriocarcinoma track w b-hcg
teratoma (malignant in men, benign in women) look for mets
rcc renal cell ca
pres
dx
tx
flank pain hematuria palpable flank mass (classic triad but few real pts meet all 3…)
maybe erythrocytosis as kidney makes epo, or anemia if cancer steals blood
ct scan, DONT FNA BX (if obviously cancer… if small cystic want to ro ca can fna)
just resect
suspect rcc (flank pain, flank mass, hematuria, mass on ct) ct guided biopsy or unilateral nephrectomy?
unilateral nephrectomy
(per online meded)
ct bx complicated by bleeds often… nephrectomy serves dx and tx… can bx if eg only one kidney, poor surgical candidate, to bx mets…
uti sx without uti
and painless hematuria
think…
bladder ca
tf
urine cytology is sensitive for bladder
f
sn is poor
do a cystoscopy
define glaucoma
optic neuropathy
traditionally associated with inc intraocular pressure but not necessarily always
closed angle glaucoma path pres dx tx
-inc intraocular pressure with pupil dilation… causes optic neuropathy… a medical emergency
eg dilation w low light (movie), constricted iris presses against lens, dec outflow of posterior chamber, inc pressure, baloons iris out so anterior angle closes off too, blocking trabecular meshwork to canal of schlemm so aqueous really can’t get out, inc inc pressure,
-pain headache rigid irritated eyeball, dilated nonreactive pupil because mechanically can’t constrict against pressure
-dx clinical and/or measure intraocular pressure
-tx constrict (produce miosis) w drops - activate alpha (2), block beta, laser peripheral iridotomy to drain thru hole
NEVER ATROPINE - anticholinergic, dilates/mydriasis, worsens glaucoma
(peri)orbital cellulitis
pres
dx
tx
inlammation in eye region…
can they move eye? eomi?
if yes, peri - abx for skin fluora (staph, strep)
if no, orbital - ct scan to look for abscess, extent
incision and drainage, f/u DM/DKA/mucor – amphotericin if positive, abx for normal skin fluora if not (ceftri and vanc…)
corneal abrasion path pres dx tx
something scratches cornea
eg job where goggles should be worn
painful red tearing
irrigate much (prelim tx before dx!)
fluorescien dye under blue light (slit lamp) to visualize abrasions
sx if extensive, otherwise expect spontaneous healing after irrigation, maybe ppx antibiotics while allow to heal…
retinal detachment path pres dx tx
trauma (mva) or htn crisis (high pressure pops retina off)
“floaters” - mild detachment
“curtain coming over vision” - severe
(constant… if comes and goes think amaurosis fugax - impending retinal artery occlusion… like tia for eye)
fundoscopic exam - can see detachment… retinal distortion and folding…
spot-weld back on w laser
retinal artery occlusion path pres dx tx
eye stroke (vs amaurosis fugax = eye tia)
acute unilateral painless vision loss
(for bilateral, both retinal arteries would have to be occluded simultaneously…)
no fnd’s (diffs retinal artery occlusion from occipital stroke)
CHERRY RED SPOT ON FOVEA - think retinal artery occlusion
clinical dx
tx intra arterial tPA, hyperventilate/apply global pressure to try to dilate and move clot more distally for less vision loss as temporizing measure
cherry red spot on fovea think…
retinal artery occlusion
tPA, hyperventilate/apply global pressure to try to dilate and move clot more distally for less vision loss as temporizing measure
cataract path pres dx tx
age, dm
chroinc progressive vision loss, night time vision loss, “white thing” in anterior chamber
clinical dx
resect
white thing in anterior eye chamber think…
cataract
macular degeneration path pres dx tx
80% dry (atrophic), small % progress to wet
20% wet (neurovascular / exudative)
chronic progressive loss of central vision
clinical dx
blood/fluid/exudate w wet
pigment change / drusen (yellowish subretinal extracellular material deposits)
no good existing tx for dry… nutrition supplements and clinical trials…
for wet - nutrition supplements, intravitreal VEGFinhibitor injection, thermal laser photocoagulation, photodynamic therapy – all effort to thrombose neovascular tissue…
macula
fovea
define
macula is pigmented (yellowish to absorb excess blue and uv light light natural sunglasses) center of retina, w structures specialized for high-acuity vision such as the….
fovea at center of macula, high conc cones for central high-resolution color vision in good light
how to constrict pupil pharmacologically
activate alpha (2) block beta
eye drop form
what is a “cloud” settling at the top of pts vision in setting of retinal detachement
blood settling at bottom of retina
how does fluorescein dye visualize corneal abrasions
dyes exposed basement membrane
most common bug in adult pink eye
adenovirus
prevent shingles
Zostavax vaccine for adults who had chicken pox as kid
varicella vaccine to prevent children from ever getting chicken pox
presentation of neisseria gonorrhea conjunctivitis
purulent conjunctivitis, can lead to blindness
neonate day 2-5 from mom w gonorrhea
presentation of chlamydia conjunctivitis
purulent conjunctivitis, can lead to systemic dz, eg pna
neonate day 7-14 from mom w chlamydia
presentation of gonorrhea vs chlamydia conjunctivitis
both purulent conjunctivitis
gon neonate day 2-5 can lead to blindness
chlam neonate day 7-14 can lead to systemic dz like pna
tf
fever and leukocytosis w (peri)oribital cellulitis
t
chalazion
noninfectious obstruction of an eyelid gland
“stye”
fever or leukocytosis w chalazion?
no
noninfectious obstruction of an eyelid gland
“stye”
hordeolum
infectious obstruction of eyelid hair follicle
looks like chalazion but will rupture w pus after 1-2 days
tf
fever and leukocytosis w hordeolum
f
infectious obstruction of eyelid hair follicle
looks like chalazion but will rupture w pus after 1-2 days
no fev leuk
dacrocystitis
a stye/chalazeon (noninfectious blockage) of the lacrimal duct (superomedial eyelid) … maybe red and tender but no fev leuk
tf
fev leuk w glaucoma
f
fev leuk w eye sx start thinking (peri)orbital cellulitis…
tf
orbital cellulitis can peresent w nonreactive dilated pupil
t
infection can affect cranial nerves eg produce pupillary afferent defect
expect swollen erythematous hot systemic signs of infection (fev leuk) too
amblyopia path pres dx tx
cortical blindness (brain pathway does not develop or degenerates)
child w strabismus or cataracts
dx clinical
no tx
so ppx by correcting precpitating dz (strabismus, cataracts)
strabismus
presentation
dx
tx
lazy eye - light shined at eyes does not reflect back from same positions on eyes
clinical dx
tx surgery within 6 mos (to avoid cortical blindness amblyopia) for congenital,
patch good eye for acquired…
congenital cataract path pres dx tx
TORCH infection if present at birth galactosemia (sorbital pathway...) or other metabolic dysreg if not present at birth cloudy front of eye clinical dx - can see it resect
retinoblastoma path pres dx tx
Rb gene
all white retina (no red reflex when light shined in eye)
clincal dx
surgery (remove eye?) DON’T radiate, may provide second hit to other eye and tumor and removal of that eye too
f/u osteosarcoma peripuberty
retinopathy of prematurity path pres dx tx
premie gets inc FiO2 for immature lungs causes growths on retina.. clincal dx laser ablation of growths f/u bronchopulmonary dyslplasia w cont FiO2 intraventricular hemorrhage w us necrotizing enterocolitis (bloody bm) put npo
5 types of neonatal conjunctivitis
onset
discharge
tx
- chemical (silver nitrate… was hoped to reduce chlamydial conjunctivits… it doesn/t), v24hr, bilateral non-purulent discharge, don’t give silver nitrate, ppx gonorrheal and chlamydial w topical erythromycin
- gonorhea, 2-7days, bilateral purulent, ppx w topical erythromycin, tx w ceftriaxone, cx on chocolate agar and get pcr (destroys eye, fast blindness)
- chlamydia, 5-14 days, unilateral mucoid progress to bilateral purulent, tx w oral erythromycin, cx and pcr, f/u systemic infection eg pna
- hsv herpes… acyclovir
- other bacterial, 5-14 days, treat as if gonorrhea (can cause rapid blindness) w ceftri, change abx when get cx and sensitivities
white thing in newborn back of the eye
vs
white thing in newborn front of the eye
rb
cataract
