Test 4 Flashcards
anaphylaxis pathophysiology
bronchoconstriction, coronary vasoconstriction, peripheral vasodilation
First diagnostics for anaphylactic reaction
pulse ox and EKG
epinephrine works on
alpha and beta adrenergic agonist receptors
epinephrine dosing for adults
0.2-0.5 mg IM, repeat every 5-15 min with max dose of 1 mg
epinephrine dosing for children
0.01 mg/kg IM repeat every 20 min- 4 hours with max dose of 0.5 mg
preferred injection site for epinephrine
vastus lateralis
other medications that can be used for anaphylaxis
diphenhydramine, beta2 agonists
delayed reaction to insect bites can occur
10-14 days after bite with fever, malaise, rash, lymphadenopathy
Local wound care for insect bites
removal of stinger, ice packs, anithistamines, topical steroids, NSAIDs, atbx if needed
There people should be given a medical warning tag, epi pen, and referral for venom immunotherapy
anaphylactic reaction to bees or wasps
common types of spider bites
brown recluse or black widow
Commonly found in the central Midwest south to the Gulf of Mexico. They travel in boxes and packages. They are also found in warm, dry areas such as abandoned buildings, woodpiles, and cellars
brown recluse spider
bite is usually painless with a mild erythematous lesion that may either heal spontaneously or become necrotic
brown recluse
healing time for brown recluse bites
6 weeks to 4 months
systemic symptoms that may occur within 24-48 hours of brown recluse spider bite
fever, chills, N/V, myalgias
treatment for brown recluse spider bite
no medication or antivenom;
tetanus prophylaxis
analgesics
Most venomous spider bite
female black widow
It is most common in the South and West. They tend to live in basements, gardens, woodpiles, and garages.
black widow spider
The bite is mildly to moderately painful with erythema, swelling, and muscle cramps beginning within 30 minutes to 12 hours.
black widow spider
bite from black widow can mimic
acute abdomen/peritonitis
complication of black widow bite
hypertension
black widow bite is fatal in
children and elderly
treatment for black widow bite
wound care,
tetanus prophylaxis,
analgesics,
antivenom is only indicated for severe bite b/c of risk of anaphylaxis
antivenom is only available for this kind of spider bite
black widow
venomous snakes includ
pit vipers and coral snakes
most snake bites occur between
april and october
venomous rattlesnakes and coral snakes have
fangs
the presentation of no envenomation from snake is
minimal pain and swelling
Minimum envenomation from snake presents with
local swelling less than 6 in with no systemic symptoms
Moderate envenomation from snake presents with
local swelling of 6-12 in with systemic s/s
Coral snake bites resemble
scratch marks and are painful
presenting s/s of coral snake bites
neurologic: tremor, dysarthia, dysphagia, diplopia
physical exam for all spider bites
ABCs, vitas, examination of bite and extent to envenomation, tissue damage, neuro exam
diagnostics for snake bite
CBC, CMP, coags, UA, ECG
Management for snake bites
Go to ER for antivenom,
immobilize and elevate extremity ,
observe respiratory status
management for scorpion bites
supportive care
teaching to avoid snake bites
walk with stick tapping ahead;
wear loose, long pants with thick boots,
shine a flashlight
atbx is recommended for these kinds of bites
hand and cat bites. Treat with Augementin
treatment for human or dog bites
Augmentin or clindamycin can be given prophylactically, must be given within 12 hours of bite
common carriers of rabies virus
raccoons, bats, skunks, foxes
most common bacteria from human bites
staph aureus
a bite history includes
time of bite, rabies vaccination of animal, current immunization status, hx of splenectomy or liver disease
assess for this with any bite
compartment syndrome: paresthesias, pain, pallor, paralysis
Management for any kind of bite
irrigate with at least 150 mL of normal saline,
debride tissue, clots, foreign bodies
Wounds involving the hand or foot should be
elevated for 1-3 days
treatment for infected bites
Augmentin 500 mg tid x 5-7 days;
clindamycin + doxycycline;
TMP/SMZ;
ciprofloxacin
can assist in the diagnosis of corneal abrasion
fluorescein dye; abrasion appears as a bright green area
treatment for corneal abrasion
erythromycin or Polysporin ointment, oral analgesics
when to refer for corneal abrasion
if foreign body cannot be easily removed by a cotton tip applicator
most common symptom of corneal abrasion
sever eye pain
risk factors for epistaxis
nasal trauma, rhinitis, drying of mucosa from low humidity, deviation of septum, alcohol, anticoagulant meds
Most nosebleeds occur from the
anterior plexus (Kiesselbach’s plexus)
initial management of epistaxis
sit straight up, tilt head forward, apply firm pressure to anterior aspect of nose for 15 min
medication for epistaxis
phenylephrine 0.125% 1-2 sprays that acts as a vasoconstrictor, silver nitrate
When to refer for epistaxis
bleeding does not resolve in 15 min
teaching for epistaxis
avoid ASA, vigorous exercise, hot/spicy foods for a week
GCS variables
eye opening, motor response, verbal response
immediate ER referral for head trauma with
AMS; paralysis or paresthesia; Raccoon's sign; Battle's sign; blood in external auditory canal
in elderly, the first sign of head trauma is
confusion, change in behavior
The neuro exam for head injury should include
pupillary response, EOM, Romberg test, gait, finger-to-nose test, memory, and concentration.
diagnostic for head injury
cervical x-ray, head CT,
CBC, CMP, UA, ABG, coags
immediate treatment for head injury
ABCs,
cervical spine stabilization,
assess GCS
high risk patients for heat-related mortalities
those less than 10 and older than 50, those with underlying heart/lung disease or diabetes
quick method to determine TBSA
back of the hand is 1% TBSA
Only involves the epidermis
first-degree
involves the epidermis and portions of the dermis
second-degree (partial thickness)
may look like first degree burns initially, but may show blistering 12-24 hours later. May present as dull or glossy with pink, red, or white pigmentation. Heal spontaneously in less than 3 weeks.
superficial partial-thickness burn
extend into the lower layers of the dermis and can cause scar formation. They usually heal in 3-9 weeks. However, they can cause hypertropic scarring and impaired joint function. These burns are best treated by excision and grafting.
Deep partial thickness
Involve all layers of the dermis and often underlying adipose tissue
third-degree (full-thickness)
Area appears matte with eschar
third-degree
Treatment for mild burns
irrigate with cool tap water, apply thin layer or antimicrobial (sulfadiazine), cover with nonadherant
Management of intact blisters in burns
Do not rupture as they maintain protection
treatment for moderate burns
irrigate with NS, chlorhexidine, debrided, cover with antimircobial, cover with nonadherant.
these kinds of dressings are preferred because they promote re-epithelialization
moist
burns that should be referred
partial-thickness burns greater than 10% TBSA;
Burns on face, hands, feet, genitalia, or major joints;
electrical/chemical burns
immediate referral to a plastic surgeon for
hand and face wounds
wounds involve the epidermis and dermis and may extend through the subcutaneous tissue into muscle and bone
full thickness wounds
diagnostics for lacerations
x-ray to identify bone/tendon involvement;
MRI to r/o osteomyelitis;
CBC
assess this with all lacerations
vascular, neurologic, and musculoskeletal function
wounds with smooth edges that is not grossly contaminated can be
approximated with steri-strips
These kinds of wounds should NOT be closed
crush injuries, bites to hand and feet, cat/human bites, puncture wounds, wounds more than 12 hours old (24 for face)
Should be administered if Tdap status is unknown or if patients has not completed 3 injections
Td and tetanus immune globulin
Td can be given if Tdap has been given within
5 years
these wounds do not need tetanus shot
less than 6 hours old
suggested suture size for scalp, trunk, arms, and legs is size
4-5
suggested suture removal for scalp
7-14 days
suggested suture removal for trunk and upper extremities
7 days
wounds that require atbx therapy
wounds more than 8 hours old;
crushing injuries;
wounds in patients with diabetes
infected wounds can be treated with
TMP/SMZ DS 160/800 bid or clindamycin 300-450 mg tid
acromegaly results from excessive secretion of
growth hormone and insulin-like growth factor (IGF-1)
most common cause of acromegaly is
adenoma of the anterior pituitary
feedback of GH hormone
GHRH and somatostatin secreted from hypothalamus –> GHRH stimulates GH secretion; somatostatin inhibits GH secretion
factors that affect GH secretion
sleep, stress, meals, aging
Manifested as excessive bone and soft tissue growth
acromegaly
common s/s of acromegaly
facial puffiness, enlarged jaw, swelling of hands and feet, hirsuitism
onset of acromegaly is
slow, about 12 years
diagnostics of acromegaly
IGF-1 is a direct indicator of GH levels, oral glucose tolerance test, MRI of pituitary gland
oral glucose tolerance test in those with acromegaly
oral glucose does not suppress GH secretion as it normally should.
complications of acromegaly
diabetes, HTN, sleep apnea, colon cancer
This disease has a high risk of colon cancer
acromegaly
feedback of adrenal glands
hypothalamus secretes CRH–> pituitary gland secretes ACTH –> adrenal glands secrete cortisol, aldosterone, and androgens
most common manifestation of adrenal crisis is
hypotension
primary adrenal insufficiency most commonly presents with
shock, abd tenderness, fever
in primary adrenal insufficiency this is NOT common
hypoglycemia
when adrenal glands produce too little cortisol (adrenal cortical hypofunction)
Addison’s disease
s/s of addison’s disease
chronic malaise, weight loss, abd pain, muscle cramps, hyperpigmentation, salt craving
Addison’s disease is characterized as
low glucocorticoids, mineralcorticoids, and androgens
Complication of Addison’s disease
adrenal crisis d/t low mineralcorticoids
Diagnostics of Addison’s disease
low levels of cortisol; high ACTH
when adrenal glands produce too much cortisol (adrenal cortical hyperfunction)
Cushing’s disease
common cause of Cushing’s
long-term use of steroids suppress ACTH suppression from anterior pituitary
when steroids can caused HPA suppression and Cushing’s
more than 15 mg/day for more than 3 weeks
s/s of cushing’s
weight gain, loss of menses, HTN, glucose intolerance, insomnia, “moon face”, “buffalo hump”, muscle wasting, hirsuitism, striae
diagnostic for Cushing’s
elevated cortisol in 24-hour urine collection
treatment for Cushing’s
daily ketoconazole; it competes with steroids
A catecholamine-secreting tumor of chromaffin cells, mostly found in the adrenal medulla.
pheochromocytoma
pheochromocytoma causes an abnormal production of
epinephrine and norepinephrine
symptoms of pheochromocytoma are
headache, sweating, tachycardia, HTN
episodes of pheochromocytoma
episodic, last 15-30 minutes, precipitated by position change, Valsalvia, exercise, anxiety
risk factor for pheochromocytoma
family hx
diagnosis of pheochromocytoma
high levels of metanephrines and catecholamines in 24-hour urine collection
most tumors in pheochromocytoma are found in
abdomen or pelvis
most common symptom of primary hyperparathyroidism is
hypercalcemia
the kidney’s role in calcium and phosphorus balance
PTH hormone causes kidneys to reabsorb calcium and excrete phosphorous
primary hyperparathyroidism is the inappropriate secretion of PTH in the setting of
hypercalcemia
primary hyperparathyroidism is mostly caused by
parathyroid adenoma
Excess PTH effect on the bone
increases release of calcium and phosphorus from the bone, causing weak bones
Excess PTH effect on the kidney
increase calcium resorption and phosphorus excretion; eventually causing nephrolithiasis
s/s of primary hyperparathyroidism
weakness, fatigue, anxiety, HTN, CAD, short QT interval, kidney stones, hyporeflexia
band keratopathy, a white cloudiness at the nasal and temporal borders of the cornea is seen in
primary hyperparathyroidism
diagnostics for primary hyperparathyroidism
PTH, serum calcium, albumin, and vitamin D, fasting phosphorus;
Bone mineral density of distal radius;
renal US;
24-hour urine collection for calcium and creatinine
complications of primary hyperparathyroidism
osteoporosis, nephrolithiasis, CVD
criteria for parathyroidectomy
age less than 50;
serum calcium greater than normal;
GFR less than 60;
Tscore less than -2.5
management of primary hyperparathyroidism
monitor calcium and creatinine annually; bone density every 1-2 years; keep vitamin D > 20 ng/mL;
weight bearing activities;
adequate fluid intake
hypercalcemia is serum calcium greater than
5.3 mg/dL
PTH dependent hypercalcemia is d/t
primary hyperparathyroidism, the parathyroid is nonsuppressed.
hypocalcemia is serum calcium less than
4.4 mg/dL
hypocalcemia can result from
increased calcium loss in circulation, decreased entry of calcium, or inadequate PTH produciton
s/s of hypocalcemia
muscle weakness, seizures, AMS, hyperreflexia, coarse/dry hair and nails
carpal spasm occurring after occlusion of the brachial artery with a BP cuff for 3 minutes
Trousseau’s sign with hypocalcemia
contraction of the facial muscle in response to tapping of the facial nerve against the bone anterior to the ear
Chvostek’s sign in hypocalcemia
Diagnostics in hypocalcemia
high phosphate, low calcium, low vitamin D
treatment for hypocalcemia
vitamin D
hypernatremia is sodium greater than
145 mEq/L
secretion of ADH
water loss, high osmolality –> stimulate thirst receptors, ADH secreted from posterior pituitary –> stimulates renal absorption of sodium and water
s/s of hypernatremia
neuro signs are intially seen: agitation, irritability, confusion;
muscle tremor, hyperreflexia, dehydration
treatment for hypernatremia
hypotonic saline (0.45% NaCl or D5W)
those at high risk for hypernatremia
elderly, those on diuretics/laxatives
hyponatremia is serum sodium less than
135 mEq/L
response of ADH to hyponatremia
usually ADH is suppressed to allow diuresis
chronic hyponatremia causes
fluid to seep into the cells leading to swelling.
meds that can caused hyponatremia
ACEI, thiazide diuretics, NSAIDs, SSRIs
excess production of ADH leading to hyponatremia and increased urine osmolality
SIADH
s/s of hyponatremia
headache, blurred vision, lethargy, weakness
Refer to ER is serum sodium is less than
125 mEq/L
If asymptomatic with serum sodium greater than 125 mEq/L, management consists of
fluid restriction (1000-1500 mL/day), dietary sodium restriction, and loop diuretics.
hyponatremia is common in
elderly, endurance runners
feedback of thyroid hormones
hypothalamus secretes TRH –> anterior pituitary secretes TSH —> thyroid secretes T3 and T4.
The synthesis of T3 and T4 requires
iodine intake
Most T3 and T4 is
bound to proteins; but free T4 is always maintained at a constant level.
Hyperthyroidism is characterized by TSH less than
0.3
Graves disease is most common in
women 20-40
When thyroid stimulating antibodies or immunoglobulins compete with TSH for TSH receptors on the thyroid and increase the production of thyroid hormones.
Grave’s disease
Subacute thyroiditis is caused by
postviral illness
majority of causes of subclinical hyperthyroidism is caused by
nodules or multinodular goiters
Diagnostics for hyperthyroidism
thyroid peroxidase (TPO), thyroid US, radioactive iodine reuptake scan
Normal or high radioactive uptake during the scan indicates
Grave’s disease or toxic multinodular goiter
Decreased or zero radioactive uptake during the scan indicates
thyroiditis
symptomatic treatment of hyperthyroidism is treated with
beta blockers
major side effect of antithyroid drugs
agranulocytosis, liver failure
instructions about radioactive iodine
no kissing or sharing food for 5 days;
wash dishes in dishwasher;
no close contacts with kids less than 8 for five days;
flush toilets twice
complications of hyperthyroidism
afib, angina, osteoporosis
s/s of thyroid storm
fever, profuse sweating, tachycardia, confusion
causes of goiter
Grave’s, iodine deficiency/excess, thyroiditis
Nontoxic goiter is mostly caused by
autoimmune thyroiditis
meant when thyroid nodules are “hot”
concentrate iodine
meant when thyroid nodules are “cold”
don’t concentrate iodine
in goiter, lab studies may show
high or normal TSH
when the thyroid gland enlarges in response to increased TRH and TSH production
nontoxic goiter
treatment is only necessary when goiter
is symptomatic
treatment for goiter
levothyroxine (T4) can suppress TSH, although controversial
hypothyroidism is characterized as TSH of
greater than 4
most common cause of hypothyroidism
chronic autoimmune thyroiditis where autoantibodies destroy thyroid tissue
drugs that can cause hypothyroidism
amiodarone, lithium, IV contrast
tender thyroid gland is suggestive of _____; whereas a nontender thyroid gland is suggestive of _______
subacute thyroiditis; chronic autoimmune thyroiditis
treatment for hypothyroidism
synthetic T4 (levothyroxine)
average T4 replacement for hypothyroidism
1.6 mcg/kg/body weight per day (about 50 mcg/day)
those who should be started on a lower dose of levothyroxine
heart disease or afib
dosing instructions for levothyroxine
taken on an empty stomach
steady state of TSH when taking levothyroxine is not seen for
at least 6 weeks
Dessicated thyroid (Armour) is
combination of T3 and T4
dessicated thyroid (Armour) has a black box warning not recommending it for
weight reduction
subclinical hypothyroidism is
elevated TSH with normal T4.
treated for subclinical hypothyroidism is indicated when
TSH greater than 10
complication of congenital hypothyroidism (Cretinism)
mental retardation
risk factors for thyroid cancer
hx of head or neck radiation, family hx, age younger than 20 or older than 60, male
____ has been associated with an increased risk of malignant transformation of a thyroid nodule
elevated TSH
characteristics of a malignant thyroid nodule on ultrasound
increased vascular flow to nodule, hypoechoic, irregular margins
gynecomastia is caused by an increase in the ratio of
estrogen to androgen
gynecomastia is diagnosed as a palpable mass of tissue at least _____ in diameter
0.5 cm
Gynecomastia differs from female breast development in that there is no
progesterone
drugs that can cause gynecomastia
spironolactone, cimetidine, ketoconazole, 5-alpha-reductase inhibitors
characteristics of gynecomastia
bilateral, centrally located to nipple area, symmetrical, tender
breast development
thelarche
Tanner stages
thelarche, pubarche, menarche
first sign of puberty in males
testicular enlargement at 11 years average
Precocious puberty is defined as the onset of secondary sexual development before the age of ___ in girls and ___ in boys.
8; 9
Gonadotropin-dependent precocious puberty (central precocious puberty) is
caused by early maturation of the HPA axis
Gonadotropin-independent precocious puberty is
caused by excess secretion of sex hormones by tumor
In Gonadotropin-dependent precocious puberty, the LH levels are
elevated
In Gonadotropin-independent precocious puberty, the LH levels are
normal or low
If secondary sexual findings is noted, then next step is
radiographic assessment of bone age; abnormal if bone age is more than 20% older than age
Delayed puberty is the absence of sex characteristics by the upper 95th percentile age for boys which is ___ and girls which is ____
14; 12
delayed puberty is usually caused by
defective gonadotropin secretion from anterior pituitary
feedback of GnRH secretion
hypothalamus secretes GnRH –> anterior pituitary secretes LH and FSH –> stimulate testosterone, estrogen, and progesterone release
primary hypogonadism shows FSH and LH levels that are
high
secondary hypogonadism shows FSH and LH levels that are
low or normal
causes of secondary hypogonadism
constitutional delay, congenital GnRH deficiency, hypothyroidism, hyperprolactinemia.
the physical exam for delayed pubtery
height, weight, arm span, secondary sex characteristic staging
Patients with constitutional delay of puberty typically have bone ages of
12 to 13.5 years but rarely progress beyond this age.
therapy for delayed puberty should be restricted to
boys older than 14 and girls older than 12
those with hirsuitism needs this to be ruled out
ovarian or adrenal tumors
An indicator of severe hirsuitism (hyperandrogenism)
virilization: deepening voice, balding, increased muscle mass, clitoromegaly
diagnostics for hirsuitism
serum total testosterone
oral contraceptive role in hirsuitism
inhibit LH secretion, this reducing testosterone
Vitamin D of less than 20 ng/mL can be a cause of
secondary hyperparathyroidism
vitamin D insufficiency is levels less than ___; vitamin D deficiency is levels less than ____
30 ng/mL; 20 ng/mL
dosages of vitamin D
50,000 IU of vitamin D3 three times a week for 4 weeks
Obstructive symptoms of BPH
urinary hesitancy, dribbling, decreased force of stream
irritative symptoms of BPH
frequency, urgency, nocturia
drugs that can cause symptoms of BPH
anticholinergics and sympathomimetics
physical exam with BPH
enlarged, nontender, smooth prostate
diagnostics for BPH
bladder ultrasound to determine post-void residual
BPH is not a risk factors for
prostate cancer
Progression of BPH and risk of prostate cancer can be decreased by
finasteride
Work by lowering bladder neck and ureteral resistance in BPH
alpha adrenergic antagonist therapy
direct alpha adrenergic antagonist
tamsulosin;
only act on smooth muscle of the prostate
indirect alpha adrenergic antagonist
doxazosin;
act on all smooth muscle causing vasodilation
shrink prostate gland by decreasing DHT levels
5alpha-reductase inhibitors: finasteride
these two meds showed a higher risk reduction in BPH symptoms than when used alone
doxazosin and finasteride
causes of acute and chronic prostatitis
gram negative: E. coli, Proteus, Klebsiella
s/s of acute prostatitis
fever, chills, malaise, arthralgias, urinary sympoms
s/s of chronic prostatitis
may be asymptomatic; may have recurrent UTI or urogenital symptoms
physical exam with acute prostatitis
prostate is enlarged and tender. Avoid massaging to minimize risk of bacteremia.
physical exam with chronic prostatitis
may have normal prostate; may feel tender.
this should not be checked as it may appear elevated with prostatitis
PSA level
diagnostic for prostatitis
acute: UA will show pyuria; Urine culture
chronic: prostatic specimen through urologist
treatment for acute prostatitis
TMP/SMZ or fluoroquinolone for 2-6 weeks
treatment for chronic prostatitis
TMP/SMZ or fluoroquinolone for at least 6 weeks
teaching for prostatitis
sitz baths; avoid coffee, tea, alcohol; stool softeners; use condoms during therapy
risk factors for prostate cx
men older than 65, Black, family history
most common type of prostate cancer
adenocarcinoma
difference between symptoms of BPH and prostate cancer
symptoms increase in intensity in 1-2 month intervals with prostate cancer whereas in BPH it is slow progression
physical exam with prostate cancer
firm, indurated, asymmetric nodule on prostate
screening for prostate cancer
recommended in all men starting at 50; 45 for black men; 40 for men with family hx
PSA levels with prostate cancer
If less than 2.5 normal;
greater than 4 is abnormal- refer for biopsy;
greater than 10 indicative of cancer
risk factors for renal cell carcinoma
tobacco use; black; leather tanning and shoe-making; exposure to asbestos, gas, petroleum; family hx
risk factors for bladder cancer
white male;
smoking;
ingestion of red meat
symptoms of renal tumor
flank pain, hematuria, renal mass; however most are not diagnosed until it has metastasized
occurs in those ages 3-4 and is usually unilateral
Wilms tumor
s/s of bladder cancer
painless hematuria that continues throughout urination
trx for bladder cancer
transurethral resection of bladder tumor
diagnostic for bladder/renal cancer
UA, urine cytology, CBC, diagnostic ultrasound, cystoscopy, spiral CT
loss of urine associated with activities that increased intra-abdominal pressure such as coughing, sneezing.
stress incontinence
involuntary loss of urine usually preceded by a strong, unexpected urge to void.
urge incontinence
an involuntary loss of urine associated with incomplete emptying
overflow incontinence
DIAPPERS for incontinence
Delirium; Infection; Atropic vaginitis; Pharmaceuticals; Psychological; Excess urinary output; Restricted mobility; Stool impaction
Diagnostics for urinary incontinence
UA, C&S, BUN/creatinine, postvoid residual, cystoscopy
a PVR greater than ____ is considered abnormal
100 mL
treatment for incontinence
time void every 2 hours, smoking cessation, pelvic muscle exercises, pessary placement;
meds for stress incontinence
alpha adrenergic agonist (Sudafed), estrogen, tricyclic antidepressant
meds for urge incontinencne
anitcholinergic/antimuscarinic agents: Detrol & Oxybutynin
Meds for overflow incontinence
alpha adrenergic blockers (doxazosin or tamsulosin); alpha5 reductase inhibitors (finasteride)
BPH can cause this type of incontinence
overflow
risk factors for stone formation
family history; insulin-resistance; HTN; gout; primary hyperparathyroidism (high calcium); obesity; dehydration
Foods that can cause uric acid stones
seafood, meats
foods that can cause oxalate stones
cola, chocolate
Meds that can cause stone formation
HCTZ, antacids
Most common type of urinary calculi in women
calcium oxalate stone
Most common type of urinary calculi in men
uric acid stones
s/s of nephrolithiasis
N/V, hematuria, dysuria, renal colic
s/s of urolithiasis
dysuria, frequency, urgency, hematuria
diagnostics for urolithiasis
UA, urine C&S, serum calcium, intact PTH
urine pH less than 6.5 indicates what type of stone
calcium oxalate
with urolithiasis, urine pH greater than 6.5 indicates
infection and f/u culture is necessary
diagnostic for nephrolithiasis
renal ultrasound, KUB, noncontrast CT
differential diagnosis for urolithiasis
gastroenteritis, appendicitis, abd aneurysm, ectopic pregnancy, peptic ulder
Urinary stones less than ___ pass spontaneously, whereas urinary stones greater than ____ need surgical intervention
4 mm; 6-8 mm
treatment for calcium oxalate stones
thiazide diuretic;
low calcium, protein, and sodium diet
treatment for uric acid stones
allopurinol;
decrease purine intake;
increasing fluids
In post-streptococcal glomerular nephritis, it is usually preceded by a hx of
GABHS skin or throat infection 1-3 weeks prior
post-streptococcal glomerular nephritis is most common in
children 5-12 years old; those older than 60
symptoms of post-streptococcal glomerular nephritis
edema, gross hematuria & proteinuria, HTN
diagnostic for post-streptococcal glomerular nephritis
UA;
streptozyme test that measure 5 different streptococcal antibodies
treatment for post-streptococcal glomerular nephritis
control HTN;
sodium and water restriction;
Loop diuretics
Proteinuria is defined as urinary protein excretion of more than
150 mg/day
Drugs that can cause proteinuria
lithium, cyclosporine, NSAIDs
Diagnostic for proteinuria
1+ protein on urine dipstick x 2;
CBC, CMP, lipid panel;
24-hour protein and creatinine urine collection
those with proteinuria should be tested for
Bence Jones proteins to r/o multiple myeloma
Those with proteinuria need to be started on
ACEI or ARB, low sodium diet
these people have high rates of hematuria
long distance runners
Oliguria is defined as urine output of less than
400 mL in 24 hours
Anuria is defined as urine output of less than
200 mL in 24 hours
Prerenal ARF is caused by
dehydration and hypotension
Intrarenal ARF is caused by
nephrotoxins (IV contrast, aminoglycosides
postrenal ARF is caused by
BPH, bladder dysfunction or strictures, nephrolithiasis
All patients with acute renal failure should be
hospitalized
ESRD is a GFR of less than
15%
Most common indicator of CKD is
proteinuria
Best measure of kidney function
GFR
Stage II kidney disease is GFR
60-89 mL/min
Stage III kidney disease is GFR
30-59 mL/min
Diet education for those with CKD
protein and phosphorus restriction; avoid salt substitutes as they contain high amount of potassium;
glycemic control;
increase calcium
Vitamin D deficiency with CKD
give 50,000 IU of vitamin D2 monthly for 6 months
testicular torsion is most commonly seen in
the left testicle
s/s of testicular torsion
extremely painful, N/V, abdominal pain
physical exam with testicular torsion
swollen and red scrotum, tender spermatic cord, absent cremasteric reflex
Diagnostic for testicular torsion
Doppler US shows diminished blood flow
Treatment for testicular torsion
must be sent to ER and treated within 6 hours
testicular cancer is common in men ages
20-39 years old
risk factors for testicular cancer
Caucasian;
cryptorchidism;
family hx;
scrotal trauma
S/S of testicular cancer
testicular mass; swelling; sensation of fullness
common causes of epididymitis in young men
Chalmydia and gonorrhea
common causes of epididymitis in men older than 35
gram negative organisms;
TURP
S/S of epididymitis
fever, chills, penile discharge, lower abd pain
Physical exam with epididymitis
scrotum is red, enlarged, and tender.
When pain is relieved with scrotal elevation (Prehn’s sign)
epididymitis
Doppler US with epididymitis shows
normal blood flow
medication for orhcitis and epididymitis
ceftriaxone, doxycycline, or levofloxacin
education for epididymitis
scrotal elevation
complication of epididymitis and orchitis
infertility
Systemic, blood-borne infection that results in an acute inflammation of one or both testicles.
orchitis
orchitis has similar signs and symptoms as
epididymitis
causes of orchitis
may coexist with prostatitis or epididymitis; STDs
The major classes of drugs that can affect erectile function are
antihypertensives, antidepressants, alcohol
medications used to facilitate erection
PDE5 inhibitors:
sildenafil (Viagra),
vardenafil (Levitra),
tadalafil (Cialis)
PDE5 inhibitors are contraindicated in those taking
nitrates
Education for sildenafil (Viagra) and vardenafil (Levitra)
have a short duration of action; take on empty stomach; avoid taking with high fat meal
Education for tadalafil (Cialis)
longer half-life for 24-36 hours. No dietary restrictions
Patients taking SSRIs who have side effects of sexual dysfunction
take with buproprion
most common organisms in UTI
gram negative : E. coli, Klebsiella, Enterobacter
Any UTI in a male less than 50 years old is
considered complicated`
common causes of urethritis
chlamydia and gonorrhea
s/s of urethritis in males
dysuria, burning on urination
Discharge with gonococcal urethritis is most often ___, whereas that with NGU tends to be ____.
purulent; clear or mucoid
complicated UTIs occur in those
with urologic abnormalities, underlying disease (DM, renal failure), pregnancy, catheter, advanced age
Four variables predict the presence of UTI
cloudy urine, malodorous urine, dysuria, nocturia
UA in UTIs show
pyuria, high nitrates, hematuria
avoid this medication pyelonephritis is suspected
nitrofurantoin
Medication for UTI
nitrofurantoin x 5 days, TMP/SMZ DS x 3 days, fluoroquinolones x 3 days
Recommended treatment duration for those with UTI who have DM.
10-14 days
medication for UTI in children
third generation cephalosporins (cefexime, cefdinir); aminoglycosides
Not recommended for trx of UTI in children d/t high resistance
amoxicillin and ampicillin
s/s of pyelonephritis
UTI symptoms with fever, chills, flank pain, CVA tenderness, N/V
Diagnostic for pyelonephritis
UA and Urine culture
treatment for pyelonephritis
fluoroquinolones or TMP/SMZ for 7 days
asymptomatic bacteruria refers to a colony count of at least ___ in the absence of symptoms
100,000/mL
diagnosis of asymptomatic bacteruria in women
two clean catch urine specimens with more than 100,000 of bacteria
risk factors for asymptomatic bacteruria
advanced age; nursing home; incontinence; women with diabetes; pregnancy
screening and treatment is indicated in these people with asymptomatic bacteruria
pregnant women and those undergoing urologic surgery
avoid these eye drops with corneal abrasions
steroids
where to avoid giving lidocaine and epi
fingers, toes, penis, nose
treatment for most typical spider bites
supportive
important to differentiate spider bites from
MRSA
home remedy for bee/wasp stings
meat tenderizer paste
s/s of UTI in elderly
confusion, AMS
foods to avoid with incontinence
alcohol, caffeine, carbonated, spicy foods
avoid these drugs with renal failure
NSAIDs, amnioglycosides, IV contrast
blood under the finger or toe
subungual hematoma
suggested suture removal for lower extremities
8-10 days
suggested suture removal for face
5 days
