Urology Flashcards
What are the indications for dialysis?
AEIOU
Acidosis
Electrolyte abnormalities with ECG changes
Intoxication with SLIME - salicylates, lithium, isopropanol, methanol, ethylene glycol
Overloaded with fluid
Uremic symptoms - pericarditis or encephalopathy
A 62 year old man has a 5 month hx of fatigue, perineal discomfort, lower back pain and loin pain. He experiences pain on micturition. What is the likely diagnosis?
Chronic bacterial prostatitis
60 year old man presents with dysuria and urgency. He gets some suprapubic pain which is relieved when lying supine and occasional terminal haematuria. there is no abnormality on examining the abdomen. What is the likely diagnosis?
Bladder calculi
Painful haematuria suggests this rather than malignancy
72 year old man presents to ED with acute back pain and leg weakness. He has been experiencing hesitancy and dribbling of urine for 12 months. On examination he has spastic paraparesis and palpable bladder. What is the likely diagnosis?
Prostate cancer
Signs of collapsed vertebrae - mets
Spinal cord compression - dorsal, stamping gait due to proprioceptive loss
What is the triad of symptoms associated with renal cell carcinoma?
Haematuria
Loin pain
Abdo pain
What is nephrotic syndrome?
Too much protein excreted by kidney
Patient usually presents with oedema around the eyes and legs
What is the first line treatment for benign prostatic hyperplasia?
Tamulosin - alpha blocker
What is the second line treatment for benign prostatic hyperplasia?
Finasteride
Alpha reductase inhibitor which reduces dihydrotestosterone and therefore prostate volume
What should patients taking finasteride be warned about contraception?
Use barrier contraception as it is excreted in semen and can cause birth defects in the foetus
What factors in the history would make you worry about bladder malignancy?
Painless haematuria
smoking
Palpable mass
Occupational exposure to aniline dyes and rubber
What is the first line painkiller for renal colic pain?
Disclofenac rectally
A 55 year old man presents to his GP with a painless lump in his right testicle which he has noticed over the last few weeks. A blood test shows normal alpha feto protein. He is found to have testicular cancer. What type is he most likely to have?
Seminoma - age and normal AFP
What is paraphimosis?
Complication of urinary catheterisation if the health professional forgets to replace the foreskin
What is the management for paraphimosis?
Attempted reduction by applying cold compresses to area and applying sustained firm pressure
If this fails, surgical management may be required
What is balanitis?
Infection of glans usually caused by streptococcus or staph
Common in diabetics
On which side are varicocoeles most likely to occur?
Left side due to:
Angle at which left testicular vein joins left renal vein
Lack of valves
Which veins are affected in a varicocoele?
Pampiniform plexus
What is the first line treatment for stress incontinence?
Pelvic floor exercises
What treatments are used in urge incontinence?
Bladder retraining
Oxybutynin - anticholinergic
A 21 year old man presents with malaise fever and bilateral large tender testes. What is the likely diagnosis?
Orchitis
A 27 year old man complains that there is a lump on his right testicle which transilluminates relatively poorly. He had a vasectomy two years earlier. Examination reveals a small non tender smooth 1cm mass arising from superior pole of testis. What is the likely diagnosis?
Spermatocoele
What are symptoms of hypercalcaemia?
Bones: arthralgia, pseudogout Moans: depression Stones: renal colic Groans: peptic ulceration Constipation, polyuria and nocturia
What can be a devastating consequence of correcting hyponatraemia too quickly?
Osmotic demyelination syndrome
Central pontine demyelination
What are the 5 Rs of IV fluid therapy?
Resuscitation Routine maintenance Replacement Redistribution Reassessment
Describe how total body water is divided up
Extracellular: 20% Na Cl HCO3
Intracellular: 40% K
What components of the extracellular compartment are there?
Intravascular: haematocrit and plasma
Interstitial
What contributes to plasma oncotic pressure?
Albumin
Haemoglobin
Globulin
Where can fluids be lost from?
Kidney
GIT
Skin
Lungs
What is the average daily intake of water sodium and potassium?
Water 25-35ml/kg/day
Sodium 1mmol/kg/day
Potassium 1mmol/kg/day
What is insensible loss of fluid?
Evaporation of water from lungs and skin
0.5L - 1L/day
How much fluid is lost from the GI tract per day?
100-150ml
What factors can negatively affect fluid balance?
Changes in albumin
Changes in potassium
Malnutrition
Why can liver disease lead to oedema?
Reduced albumin levels
Reduces plasma oncotic pressure and intravascular volume
What is crystalloid fluid?
Glucose or salt containing fluids
0.9% saline
Hartmanns solution
5% dextrose
What are colloid fluids?
Microscopic particles: starch or protein suspended in crystalloid Used for Intravascular volume expansion 6% hydroxyethyl starch 4% succinylated gelatin 20% albumin
What is a balanced salt solution?
Crystalloid containing electrolytes in a concentration as close to plasma as possible
Ringers lactate
Hartmanns solution
Which fluids are better for interstitial volume correction?
Crystalloids
What imaging would you do to confirm a suspected prostatic malignancy?
Trans rectal ultrasonography
What is a Gleason score?
Evaluate prognosis of men with prostate cancer using samples from prostate biopsy
Cancers with higher Gleason score are more aggressive and have a worse prognosis, score 1-10
What is goserelin?
LH hormone releasing agonist
Suppress production of sex hormones
What characterises autosomal dominant Polycystic kidney disease?
Multiple bilateral renal cysts
Cyst formation in other organs such as pancreas and liver
Intracranial aneurysms
A 67 year old man is admitted with a ruptured infrarenal abdominal aortic aneurysm and undergoes a successful repair. Post operatively, urine output is poor despite adequate central venous pressure after control of the aneurysm. What is the likely problem?
Acute tubular necrosis
Common after major/emergency surgery when there are periods of prolonged hypotension
Which drugs could precipitate urinary retention?
Anticholinergic - TCAs
Antipsychotics - chlopromazine
Opiate analgesics
What are the 3 most common causes of end stage kidney disease?
Diabetes
Hypertension
Glomerulopathies
What are the different classifications of glomerulopathies? What are characteristics of each?
Nephrotic syndrome: massive proteinuria, hypoalbuminaemia, oedema, lipiduria, hyperlipidaemia
Acute glomerulonephritits (nephritic): haematuria, proteinuria, oedema, HTN, transient renal impairment
Rapidly progressive glomerulonephritits: acute nephritis, focal necrosis, rapidly progressing renal failure
Asymptomatic haematuria/proteinuria
What is the difference between bland and active urine sediments?
Active: cellular elements, red or white cells, or casts. Implies a process actively damaging your kidneys, causing them to bleed or get inflamed
Bland: other elements, crystals, protein, and urinary casts. May imply a more serious, long-standing kidney problem such as uncontrolled diabetes
What are negative prognostic factors for glomerulopathies?
HTN
Greater degree renal impairment
What are pathological changes seen in diabetic nephropathy?
Glomerular basement membrane thickening
Mesangial expansion
Glomerulosclerosis
What is the commonest form of glomerulonephritits worldwide?
IgA nephropathy
What is the definition of chronic kidney disease?
GFR 65 mg/mmol
Protein/creatinine ratio 100mg/mmol
List some causes of chronic kidney disease
Congenital: polycystic kidney disease
Glomerular disease: focal glomerulosclerosis, SLE, wegeners granulomatosis, HUS, TTP
Vascular disease: hypertensive nephrosclerosis, vasculitis
Tubulointerstitial disease: tubulointerstitial nephritis, reflux nephropathy, multiple myeloma
Urinary tract obstruction: calculus disease, prostatic disease, pelvic tumour
What are uraemic symptoms of CKD?
Malaise Loss of appetite Insomnia Nocturia and polyuria Itching Nausea, vomiting, diarrhoea Paraesthesia due to polyneuropathy Restless legs syndrome Bone pain - metabolic bone disease Tetany - hypocalcaemia Peripheral and pulmonary oedema Anaemia symptoms Amenorrhoea/erectile dysfunction
What are red cell and granular casts?
Granular: abnormal cells in tubular lumen, indicate active renal disease
Red cell: glomerulonephritits
What are some complications of chronic kidney disease?
Anaemia Bone disease - renal osteodystrophy Skin disease - itching Nephrogenic systemic fibrosis GI: decreased gastric emptying and increased redux Gout Lipid metabolism abnormalities Hyperprolactinaemia Decreased testosterone - erectile dysfunction Oligomenorrhoea or amenorrhoea Impaired growth in children Abnormal thyroid hormone levels Dialysis dementia Psychiatric problems Median nerve compression Restless leg syndrome Polyneuropathy Calciphylaxis Cardiovascular disease Malignancy
What is renoprotective management for chronic kidney disease?
Ace inhibitor Angiotensin receptor blocker Diuretic Calcium channel blocker Statins Stop smoking Treat diabetes
What are treatment aims for chronic kidney disease renoprotection?
BP
What can be complications of haemodialysis?
Hypotension Anaphylaxis to ethylene oxide Hard water syndrome Haemolytic reaction Air embolism
What can be complications of continuous ambulatory peritoneal dialysis?
Peritonitis Infection around catheter site Constipation Pleural effusion Failure of peritoneal membrane function Sclerosing peritonitis
What are contraindications to continuous ambulatory peritoneal dialysis?
Previous peritonitis causing adhesions Presence of a stoma Active intra abdominal sepsis Abdominal hernia Visual impairment - difficulty performing exchanges Severe arthritis
What are complications of renal transplant?
Acute tubular necrosis Technical failures - occlusion or stenosis of anastamosis, urinary leaks Acute rejection Infection - CMV Post transplant lymphoproliferative disorder Chronic allograft nephropathy Malignancy CV disease Post transplant osteoporosis Recurrent disease
What are risk factors for the development of an inguinal hernia?
Make Old age Smoking Family history Prematurity Arterial aneurysm COPD Obesity Pregnancy Peritoneal dialysis Collagen vascular disease Previous open appendectomy
What are the boundaries of hesselbachs triangle?
Inferior: inguinal ligament
Lateral: inferior epigastric artery and vein
Medial: lateral border of rectus abdominus
In which type of inguinal hernia is strangulation most common?
Indirect - narrow neck
Describe what happens when a piece of bowel gets strangulated in an inguinal hernia
Segment of intestine prolapses through defect in anterior abdominal wall
Sequestration of fluid within lumen of herniated bowel
Impaired lymph and venous drainage which compounds swelling
Arterial supply becomes impaired
Gangrene ensues and if left untreated, perforation occurs
What are the different sub classifications of inguinal hernias?
Reducible
Irreducible or incarcerated
Strangulated
What are possible complications of an inguinal hernia repair?
Urinary retention post operative Scrotal haematoma Wound seroma Inguinal wound haematoma Wound infection Division of vas deferens Mesh rejection Dysejaculation post surgery Bowel obstruction post surgery
In which babies are hydrocoeles more common?
Premature
Testes descend late
What are some possible complications of a hydrocoele?
Inguinal hernia Testicular injury from surgery Lower extremity oedema Testicular atrophy Hydronephrosis Infertility
What factors make up nephrotic syndrome?
Proteinuria
Hypoalbuminaemia
Oedema
What can repeated use of sodium chloride cause? And what are some consequences of this?
Hyperchloraemia
Reduce renal blood flow so lead to Hyperchloraemic acidosis
GIT mucosal acidosis
Ileus
What are balanced Crystalloids? What benefits do they have over NaCl?
Hartmanns/ringer lactate
Lower amounts of sodium and chloride compared to other Crystalloids
Contain K, Ca, Mg, lactate, reduce acidosis
What are risks of using 5% dextrose and 0.18% sodium chloride/4% dextrose?
Hyponatraemia in elderly and children with SIADH
Name an isotonic crystalloid fluid which can be used when prescribing fluids
0.9% sodium chloride
Ringers lactate
Hartmanns solution
Name a hypotonic crystalloid fluid which can be used when prescribing fluids
0.18% sodium chloride/4% dextrose
5% dextrose (initially isotonic)
Describe a hypertonic crystalloid solution which can be used when prescribing fluids
3% sodium chloride
Which fluid is most useful to give in hypoglycaemia?
5% dextrose
25% or 50% glucose
Which fluid is most useful to give in a hypotensive patient?
Hartmanns
Ringers lactate
0.9% sodium chloride
Which fluid is most useful in a hyponatraemic patient?
0.9% sodium chloride
What are some indications for IV fluids?
Pre operative resuscitation: before emergency surgery, elective surgery in patient with sepsis
Replacement of abnormal losses: vomiting, diarrhoea, ileostomy bags
Provision of normal daily requirements if patient is nil by mouth
Post operative resuscitation
Electrolyte disorders
What is the constitution of Hartmanns solution?
In 1L: 2mmol Ca 29mmol HCO3 110 mmol Cl 131 mmol Na
What are risks of giving IV fluids?
Hyponatraemia
Sodium/chloride and water overload
Pulmonary oedema
How can you monitor patients receiving IV fluid?
Clinical examination: cap refil, pulse, BP, jvp, skin turgor, auscultate lungs and heart sounds, oedema, urine output Fluid balance charts Regular weighing (daily) Daily U and Es Serum magnesium
Give examples of when fluid resuscitation is useful
Blood loss from injury or surgery
Plasma loss from burns, pancreatitis
GI or renal losses of salt/water
What is the recommendation for IV fluid for resuscitation purposes?
500ml of balanced crystalloid stat (less than 15 mins)
250ml if cardiac failure
What are the principles of fluid replacement?
Daily maintenance requirements
Plus like for like water and electrolyte replacement for any losses
What are the aims of fluid maintenance?
Restore insensible loss 500-1000ml
Provide sufficient water and electrolytes to maintain normal status of body fluid compartments
Sufficient water to enable kidney to excrete waste products 500-1500ml
What signs on clinical examination would make you think that a patient needs some IV fluid?
Systolic blood pressure less than 100 Heart rate more than 90 Cap refil more than 2 secs or peripheries cold to touch Resp rate more than 20 News score 5 or more
How much glucose should be given in IV fluids for maintenance?
50-100g per day
In which patients might you consider prescribing less IV fluid for maintenance?
Old Frail Renal impairment Cardiac failure Malnourished with risk of refeeding syndrome
In which patients should you seek expert help for their fluid prescription?
Gross oedema Severe sepsis Hyponatraemia or hypernatraemia Renal, liver and/or cardiac impairment Post operative fluid retention and redistribution Malnourished and refeeding issues
Why can resuscitation with crystalloid solution lead to pulmonary oedema?
Dilutes plasma proteins so reduces plasma oncotic pressure
How do you calculate a patients ideal body weight from their height?
Male: (Height in cm - 154) X 0.9) + 50
Female: same equation but + 45.5 instead of 50
What fluid should be given to someone with acute hyponatraemia and neurological symptoms?
Bolus doses of hypertonic saline (1.8%)
Assess clinical response
Remeasure Na
A 55 year old male presents with a left testicular swelling. On examination he has a large left testis of approximately 30 ml in volume. The mass is smooth, tender, fluctuant and transilluminates. What is the likely cause?
Hydrocoele
A 32 year old male presents after recently noting a lump in the testis. On examination there is a non tender 2cm solid nodule within the testis. What is the likely diagnosis?
Seminoma (troops and sergeants: troops are 18-25, sergeants are usually 30 plus)
A 40 year old male presents with a lump in the shaft of his penis. On examination there is a non tender, fibrotic nodule in the left lateral half of the penis of 1.5cm diameter. What is the likely diagnosis? What is it associated with?
Peyronie’s disease - fibrotic process in the tunica albuginea
Associated with penile curvature and pain
Can be associated with dupuytrens contracture
Why can a ruptured AAA mimic Ureteric colic?
Pooling of blood from the aorta into the retroperitoneum
What are risk factors for testicular torsion?
Age under 25 Neonate Bell clapper deformity Trauma Exercise Intermittent testicular pain Undescended testicle Cold weather
How do you calculate corrected calcium?
Serum calcium + 0.8 X (4- serum albumin)
What is prehns sign?
Negative Prehn’s sign: no pain relief with lifting affected testicle, testicular torsion which is a surgical emergency
Positive Prehn’s sign: pain relief with lifting affected testicle, which points towards epididymitis
Why is a scrotal biopsy not a good idea for a patient with a suspected testicular tumour?
Tunica albugenia is a natural barrier to local mets so should not be compromised
Lymph drainage of scrotal skin is different to testicle so don’t want to risk spreading it
What are risk factors for testicular cancer?
Cryptorchidism Gonadal dysgenesis FH of testicular cancer Personal hx of testicular cancer Testicular atrophy White ethnicity Chemical carcinogens Low sperm count Rural residence Higher SES Inguinal hernia Genetic abnormality of chromosome 12
What investigations might you order in a suspected testicular tumour?
USS with Doppler CT abdo pelvis Serum beta hCG >0.7 Serum alpha fetoprotein >25 Serum LDH >25 CXR - mets
During what week of development does the processus vaginalis form?
12th
How long is the inguinal canal in adults?
4-6 cm
What are the boundaries of the inguinal canal?
Posterior wall: transversalis fascia lateral, conjoint tendon medial
Anterior wall: internal oblique lateral, aponeurosis of external oblique
Roof: internal oblique and transversus abdominis muscles
Floor: inguinal ligament and lacunar ligament medially
What are the boundaries of hesselbachs triangle?
Lateral: inferior epigastric artery
Medial: rectus abdominis muscle
Inferior: inguinal ligament
What are contents of the inguinal canal in males and females?
Male: spermatic cord, ilioinguinal nerve
Female: round ligament of uterus, ilioinguinal nerve, genital branch of genitofemoral nerve
What is the contents of the spermatic cord?
3 fascia: external spermatic fascia, cremasteric muscle and fascia, internal spermatic fascia
3 arteries: testicular, vas deferens, cremasteric
3 nerves: sympathetics, ilioinguinal, genital branch of genitofemoral nerve
3 structures: vas deferens, pampiniform plexus, processus vaginus
What is the femoral sheath?
Extension of transversalis and iliopsoas fascia
Encloses proximal parts of femoral vessels
3-4cm inferior to inguinal ligament
What are the borders of the femoral canal?
Anterior: inguinal ligament
Posterior: pectineal ligament
Medial: lacunar ligament
Lateral: femoral vein
What is cloquets node?
Lymph node in inguinal region
Part of deep inguinal node group
Describe pathway of sperm from seminiferous tubule to ductus deferens
Seminiferous tubule to straight tubule to rete testis to efferent ductules to caput epididymis to corpus epididymis to cauda epididymis to ductus deferens
What is the epididymis?
Posterior border of testis
Composed of 3 parts: head, body and tail
Allows space for storage and maturation of sperm
What is the blood supply to the testes? Describe their path
Testicular arteries which arise from abdominal aorta just inferior to renal arteries
Travel retroperitoneally, cross over ureters and external iliacs to pass through deep inguinal ring
Describe venous drainage of the testes
Network of 8-12 veins called pampiniform plexus
Veins converge superiorly forming a testicular vein at deep inguinal ring
Right enters IVC, left drains into left renal vein
Where does lymph drain to from the testes?
Pre aortic nodes
Give some ddx for inguinal swelling
Inguinal hernia Femoral hernia Hydrocoele Cryptorchidism Lymphadenopathy Saphenous varix Femoral artery aneurysm Psoas abscess Lipoma Sebaceous cyst
Give some ddx for scrotal swelling
Testicular tumour Hydrocoele Epididymal cyst Spermatocoele Varicocoele Inguinoscrotal hernia
What questions are important in the assessment of a scrotal lump?
When first noticed
Is it changing
Is it lump reducible
What symptoms are present: Pain, Systemic symptoms, GI/GU disturbances
How was it noticed: Precipitating activity, Recent illness
What are important parts of an examination of a scrotal lump?
Position shape and size Temperature Tenderness Composition: solid/fluid/gas Consistency Fluctuations Translucency Pulsatility Reducibility/cough impulse Relations to the surrounding structures Regional lymph nodes Hernia test: Standing and lying, Getting above it, Cough impulse, Reducibility and control Associated structures: Testes, Lymph nodes Special test: Trans illumination
What investigations can be performed for a scrotal lump?
Ultrasound: for early hernias not so reliable
Doppler/duplex: useful for testes/vascular assessment
CT/MRI:mdeeper anatomy
Laparoscopy
What can be causes of inguinal lymphadenopathy?
Primary: Lymphoma
Secondary: Malignant, Benign
Physiolgical response to infection
What would do to manage a patient with inguinal lymphadenopathy?
Exclude inflamatory cause: Abx/observe
Exclude malignancy: Biopsy, FNAC/Open
What are some causes of a saphenous varix?
Idiopathic
Pregnancy
Pelvic mass
Dvt
What examination feature would make it clear that the patient has a saphenous varix?
Disappears on lying flat
What should be done to diagnose a saphenous varix?
Doppler/duplex
What is the treatment for a saphenous varix?
Endovascular surgery
What are differences between true and false femoral artery aneurysms?
True: Pulsatile, Associated with other aneurysmal diseases –AAA, popliteal
False: Secondary to punctures
What is used to diagnose a femoral artery aneurysm?
Duplex scan
What can be done to treat a true and false femoral artery aneurysm?
True: repair if indicated, >2/3 cm
False: surgical excision/repair
What is cryptorchidism?
Absence of one or both testes from the scrotum
What are problems with cryptorchidism?
Subfertility/sterlity
Torsion
Trauma
Malignancy
By what age should both testes be descended?
2 years
What would you do to investigate a patient who you suspect has a testicular tumour?
CT chest abdo pelvis
Tumour markers
What are the different classifications of hydrocoele?
Vaginal: confined to scrotum (distends tunica vaginalis)
Congenital: communicating with peritoneal cavity
Infantile: extending upwards to internal ring
Hydrocele of the cord: confined to the cord
What can causes of a hydrocoele?
Congenital: communicating
Reactive: tumour, infection, trauma
Idiopathic
What investigations and management should be done for a hydrocoele?
USS/exclude malignancy
Aspiration not helpful
Surgery
What is a varicocoele?
Dilation of pampiniform plexuses of veins
On which side is a varicocoele most likely to occur?
Left
What is a potential long term consequence of a varicocoele?
Infertility
How does a varicocoele usually present?
Painless lump
Bag of worms
May reduce on lying down
What investigations and management should be done for a varicocoele?
USS: Exclude sinister cause
Ligation at deep ring
What can cause epididymo orchitis?
Gonorrhea Chlamydia E coli (most common) Mycobacterium tuberculosis Amiodarone
What time frame do you have to save a testicle which has undergone torsion?
6 hours
After 12 hours, the testis cannot be salvaged
What is the treatment for testicular torsion?
Orchidopexy bilaterally
What is a hernia?
Protrusion of an organ or part of anorgan through a defect in wall of the cavity normally containing it
What are the different clinical classifications of hernias?
Reducible: hernia can be easily manipulated back into place
Irreducible or incarcerated: this cannot usually be reduced manually, adhesions form in hernia sac
Obstructed: With features of bowel obstruction
Strangulated: compromise to blood supply of involved bowel
What does inguinal hernia repair aim to achieve?
Strengthen posterior inguinal wall with mesh
Where anatomically are you likely to find a femoral hernia?
Neck of the sac is below and lateral the pubic tubercle
What is a femoral hernia most likely to contain?
Omentum
Name 3 complications of mesh hernia repair
Recurrence
Mesh infection
Haematoma formation
Seroma formation
A 45-year-old man had developed a direct inguinal hernia several months after having an emergency appendectomy. The examining doctor linked the cause of hernia to accidental nerve injury that happened during appendectomy and weakened the falx inguinalis. Which nerve had been injured?
Ilioinguinal nerve
A 40 years old gentle man presents with painless lump in his scrotum and weight loss. Clinical examination reveals enlarged hard non tender right hemiscrotum. Inguinal lymph nodes were
not enlarged. No cough impulse could be demonstrated. Most likley diagnosis
Seminoma
A patient with a suspected seminoma has non palpable inguinal lymph nodes. This patient is unlikely to have metastatic disease, true or false? And why?
False
Intraabdominal origin, testis have lymph drainage to the lumbar lymph nodes. Thus, infection of the epididymis or testicular carcinoma does not typically cause enlarged inguinal lymph nodes
What structures are at risk during a femoral hernia repair ?
Femoral vein
Accessory obturator artery
What are management steps for testicular torsion?
USS scrorum Analgesia and reassure Abx CT KUB Organize theatre to explore his scrotum
What measurements are required for diagnosis of CKD?
EGFR x2 and albumin creatinine ratio
What is the management for CKD?
Identify/treat cause
Medication
Control BP
ACE if proteinuria
What is Peyronie’s disease?
Fibrosis in plantar fascia and penis
Why does the pain of a ruptured AAA mimic that of ureteric colic?
Pooling of blood from aorta into retroperitoneum
Give 3 drugs which may have to be stopped in AKI due to increased toxicity, but don’t usually worsen the AKI themselves
Metformin
Lithium
Digoxin
Give 3 drugs which should be stopped in AKI as they may worsen renal function
NSAIDs Aminoglycosides ACE inhibitors ARBs Diuretics
What are treatments for hyperkalaemia?
IV sodium gluconate Insulin dextrose infusion Nebulised salbutamol Calcium resonium Loop diuretics Dialysis
What are normal maintenance requirements for fluids and electrolytes?
Water: 25-30 ml/kg/day
Sodium, potassium and chloride: up to 1 mmol/kg/day
Glucose: 50-100 g/day
What are signs and symptoms of salt and water retention?
Breathlessness Cough Pink frothy sputum Chest pain Oedema Tachycardia High BP Raised JVP Gallop rhythm Crackles Pleural effusion Ascites
What are signs and symptoms of salt and water depletion?
Malaise Weakness Dizziness Syncope Skin tugor down Sunken eyes Tachycardia Postural BP drop Hypotension Urine output
What are causes of hyperkalaemia?
Excess intake: IV or oral, dietary
Excess production: haemolysis, rhabdomyloysis, tumour lysis, crush injury, burns
Redistribution: acidosis, insulin deficiency, b blockers, digoxin
Diminished excretion: AKI, CKD, Addison’s, Renal tubular acidosis, NSAIDs, cyclosporine, ACEi, ARB, spironolactone
What are the clinical manifestations of hyperkalaemia?
Cardiac arrhythmia and arrest
Ascending muscle weakness
How do you manage hyperkalaemia?
Calcium gluconate, insulin and dextrose, salbutamol nebs, sodium bicarbonate, calcium resonium, haemodialysis
What are causes for hypokalaemia?
Decreased intake
Gastro losses: vomiting, diarrhoea, draining tubes, laxatives
Urinary losses: diuretics, conns, hypomagnesaemia
Increased translocation into cells: beta agonists, insulin excess, alkalosis
Increased sweat loss
Dialysis
What are clinical manifestations of hypokalaemia?
Severe muscle weakness Muscle cramps Resp failure Ileus Cardiac arrhythmia and ECG abnormalities
What ECG changes are present in hypokalaemia?
Small or absent t waves Prominent u waves First or second degree AV block Slight st depression QT prolongation, can induce torsades and VF
What is the treatment for hypokalaemia?
Supplemental potassium at a rate of no more than 20 mmol per hour and monitor cardiac rhythm
What are causes of hyponatraemia?
Isotonic: hyperproteinaemia, hyperlipidaemia
Hypotonic hypovolaemic: dehydration, diarrhoea, vomiting, diuretics, ACEi, nephropathy, mineralocorticoid deficiency
Hypotonic euvolaemic: SIADH, post op, hypothyroidism, psychogenic polydipsia
Hypervolaemic: congestive heart failure, liver disease
What is acute hyponatraemia?
Drop in sodium more than 10 mmol/L in 24 hrs
What are symptoms of hyponatraemia?
Nausea and vomiting Confusion Headache Cardio respiratory distress Abnormal somnolence Seizures Coma
How do you manage severe symptoms of hyponatraemia?
3% normal saline, restrict fluids if hypervolaemic
Monitor sodium levels every 4 hours
Aim for maximum increase 8 mmol/24 hrs and 8 mmol next 24 hrs
Stop infusion if sodium 130 or more than 8mmol increase
What is central pontine myelinolysis?
Rapid correction of hyponatraemia
Leads to coma and paralysis
What are causes of hypernatraemia?
Water deficient Loss of thirst mechanism GI loss Loop diuretic Diabetes insipidus Hyperglycaemic hyperosmolar non ketotic coma
What investigations should be done for hypernatraemia?
Glucose
Serum osmolality
Urine osmolality
If DI suspected: desmopressin test
What is the treatment for diabetes insipidus?
Treat cause
Replace fluid - 0.45% saline 5% dextrose
What is a normal anion gap?
8-16
How do you calculate anion gap?
Sodium - (chloride and bicarbonate)
What are some causes of a raised anion gap?
Methanol Uraemia DKA Isoniazid Lactic acidosis Ethanol Renal failure Salicylates
What causes of metabolic acidosis would result in a normal anion gap?
Renal tubular acidosis
Addison’s
Acetazolamide
Diarrhoea
What is management for severe metabolic acidosis?
Check glucose for DKA
Measure creatinine and urine output
Oral sodium bicarbonate/IV
Low gcs/encephalopathy - dialysis
What are some respiratory causes for respiratory acidosis?
Obstructive sleep apnea
Obesity hypoventilation
Respiratory depression
Respiratory muscle weakness - Guillain barre, chest wall abnormality
What are some causes of metabolic alkalosis?
Vomiting
Conns
Cushing’s
Excess alkali ingestion
What is the AKIN criteria for AKI?
Stage 1: creatinine raised 1.5-2x, urine
What are potential complications of AKI?
Hyperkalaemia
Pulmonary oedema
Acidosis
Uraemia
What are the principles of managing AKI?
Fluid management Manage complications Look for and treat cause Manage medicines Fluid balance assessment Daily U and Es Nephrology specialist input
What are some systemic causes of haematuria?
Coagulation disorders
Sickle trait
Vasculitis
Sub-acute bacterial endocarditis
What are some renal causes of haematuria?
Infection Glomerular disease Malignancy Infarction Trauma Cystic disease Vascular malformations
What are some Ureteric causes of haematuria?
Calculi
Malignancy
What are some bladder causes of haematuria?
Infection
Malignancy
Calculi
What are some outflow tract causes for haematuria?
Prostate malignancy
Trauma
Prostatitis
What investigations might you do for haematuria?
Urine dip and microscopy culture and sensitivity PSA HB electrophoresis FBC, U and Es, coag studies PCR/ACR Ultrasonography CT-U MRU Cystoscopy Renal biopsy
What cell type does a renal cell carcinoma originate from?
Proximal renal tubular epithelium
What factors increase the risk of renal cell carcinoma?
PCKD Middle aged man Tuberous sclerosis Smoking Von Hippel Lindau syndrome
What are symptoms of a renal cell carcinoma?
Haematuria
Loin pain
Abdominal mass
What are risk factors for bladder cancer?
Smoking Age >55 Pelvic radiation Systemic chemotherapy Male Chronic bladder inflammation FHx Transitional cell: Exposure to aniline dyes in printing and textile industry, Rubber manufacture, Cyclophosphamide Squamous cell: Schistosomiasis,BCG treatment
What are symptoms of bladder cancer?
Dysuria
Presence of risk factors
Painless haematuria
What stage is a bladder tumour if it has invaded into the muscle?
At least 2
What can cause acute urinary retention in a man?
BPH Meatal stenosis Paraphimosis Penile constricting bands Phimosis Prostate cancer Bladder calculi, Bladder cancer, Faecal impaction, GI/ retroperitoneal Ca, Urethral strictures, Foreign bodies, Stones
What can cause acute urinary retention in a woman?
Prolapse (cystocele, rectocele, uterine)
Pelvic mass (gynaecological malignancy, uterine fibroid, ovarian cyst)
Retroverted gravid uterus
Bladder calculi, Bladder cancer, Faecal impaction, GI/ retroperitoneal Ca, Urethral strictures, Foreign bodies, Stones
What drugs can cause acute urinary retention?
Anticholinergics Opioids and anaesethetics Alpha adrenoceptor agonists Benzo NSAID Calcium channel antagonist
What drugs can lead to chronic urinary retention?
Antispasmodics
Antihistamines
Anticholinergics
Botulinum toxin
What factors increase the risk of prostate cancer?
Increasing age
Obesity
Afro-Caribbean ethnicity
Family history: around 5-10% of cases have a strong family history
What can be symptoms of prostate cancer?
Bladder outlet obstruction LUTS Haematuria Haematospermia Pain: back, perineal, testiular DRE: asymmetrical hard nodular enlargement and loss of median sulcus
What investigations can be done for prostate cancer?
PSA (normal in 30% of cancers) TRUSS TRUSS biopsy X-rays Bone scan CT-MRI
What are treatment options for prostate cancer?
Watchful waiting
Radical prostatectomy
Radiotherapy
Hormonal therapy
What is IgA nephropathy?
Mesangioproliferative glomerulonephritits
Commonest cause of glomerulonephritits worldwide
Mesangial deposition of IgA complexes
How might IgA nephropathy present?
Young male
Recurrent macroscopic haematuria
Associated mucosal infection: URTI
Renal failure
What is trousseau’s sign?
Hypocalcaemia, carpal spasm occurs after inflating a blood pressure cuff above systolic pressure
What is chvosteks sign?
Spasm of facial muscles following tapping over facial never seen in hypocalcaemia
What is L’Hermitte’s sign?
Multiple sclerosis, lesion of dorsal columns of spinal cord at cervical level
On flexing neck, shooting sensation down spine
What is kernigs sign?
Pain and resistance to knee extension when hip is flexed to 90 degrees and patient lying supine. Sign of meningism
