Urology and Renal Flashcards
1
Q
What are the average values for acid/base disorders?
A
average values “24/7 40/40”
-24 (HCO3, base) / 7.40 (pH) / 40 (CO2, acid)
2
Q
What is the three step approach to acid-base disroders?
A
Look at your PH (7.35 to 7.45 is normal)
-<7.35 = acidosis
->7.45 = alkalosis
Next look at your PCO2 is it normal, low, or high (35-45 is normal)
- increase CO2 and decrease pH = respiratory acidosis
-decrease CO2 and increase pH = respiratory alkalosis
-if you don’t see a change in the CO2 in relation to the PH then take a look at the HCO3
Finally, look at the HCO3 is it normal, low, or high (20-26 normal)
-decrease HCO3 and decrease pH = metabolic acidosis
-increase HCO3 and increase pH = metabolic alkalosis
3
Q
What is urge incontinence?
A
(detrusor overactivity): MC elderly/nursing home
- sudden urge to urinate, loss of large volumes urine with small post void residual, nocturnal wetting
- dx: urodynamic studies
- tx: 1. bladder training exercises 2. anticholinergics/TCAs
4
Q
What is stress incontinence?
A
(weak pelvic floor) - multiple vaginal deliveries
- etiology: weakness of pelvic diaphragm = loss of bladder support = proximal urethra descends below pelvic floor = increase intraabdominal pressure transmitted to the bladder
- involuntary urine loss in spurts during activities that increase abdominal pressure; small post void volume
- tx: Kegel exercises, vaginal estrogens, pessary, surgery (mid-urethral sling)
5
Q
What is overflow incontinence?
A
(impaired detrusor contractility): can’t empty bladder - high post void volume - diabetic/neurological disorders
- etiology: inadequate bladder contraction or bladder outlet obstruction a urinary retention and subsequent overdistention of bladder
- causes: neurogenic bladder (diabetic, lower motor neuron lesions), medication s(anticholinergics, alpha agonists, epidural/spinal anesthetics), obstruction to urine flow (BPH, prostate cancer, urethral stricture, severe constipation with fecal impaction
- nocturnal wetting: frequent loss of small amount of urine + large postvoid residual
- tx: intermittent self-catherization = best, cholinergic agent to increase bladder contraction and alpha-block to decrease sphincter resistance
6
Q
What is functional incontinence?
A
occurs in pt who have normal voiding systems but difficulty reaching toile 2/2 physical/mental disability
- increased urinary volume and inability to timely urinate
- tx: scheduled voiding times
7
Q
What is mixed incontinence?
A
combo of stress/urge = MC
tx: lifestyle modification and pelvic floor exercises = first line
8
Q
What is nocturnal enuresis?
A
involuntary urination in sleep without urologic or neurologic causes after age 5, wat which time bladder control would normally be expected
9
Q
How do you dx incontinence?
A
UA to rule out UTI, postvoid residual volume, urodynamic studies to identify bladder contractions, ultrasonography/cystoscopy
10
Q
What is stage 1 acute renal failure?
A
normal GFR (>90)
11
Q
What is stage 2 acute renal failure?
A
early GFR (60-89)
12
Q
What is stage 3 acute renal failure?
A
moderate GFR (3a 45-59) (3b 30-44)
13
Q
What is stage 4 acute renal failure?
A
severe GFR (15-29)
14
Q
What is stage 5 acute renal failure?
A
kidney failure (GFR < 15=dialysis)
15
Q
What are the causes of renal vascular disease?
A
Diabetic kidney disease #1
- hypertension
- smoking
- vascular disease aka renal artery stenosis
- glomerular disease
- renal cysts
- genetics (autoimmune, SLE, polycystic kidney disease, alport’s syndrome)
16
Q
What is the presentation of acute renal failure?
A
acute kidney injury or acute renal failure
- an abrupt or rapid decline in renal filtration function
- elevated serum creatinine and decrease GFR
- azotemia a rise in blood urea nitrogen (BUN) concentration
17
Q
What are the prerenal (before the kidneys) injuries?
A
- this is due to decrease blood flow to the kidneys
- remember the nephrons ae intact
- hypovolemia (most common)
- NSAIDs, IV Contrast, ACEI, ARBS (renal artery stenosis)
- treatment-creatine improves with IV fluids
- low blood pressure
- heart failure
18
Q
What are the intrinsic (in the kidneys) injuries?
A
- renal aka intrinsic) direct damage to the kidneys
- nephrotoxic drugs = aminoglycosides (Gentamicin)
- cyclosporine
- tumor lysis syndrome
- vasculitis (SLE, sarcoidosis)
- crystals from gout
- myoglobin from rhabdomyolysis
19
Q
What are the pearls of intrinsic acute renal failure injury?
A
cellular cast is the hallmark = RBC CASTS
-tx: IV fluids remove drugs if present and sometimes lasix to get the kidneys moving
20
Q
What are the postrenal (downstream of the kidney) injuries?
A
- there is some type of obstruction in ureters such as kidney stones
- BPH, tumors
- congenital or structural abnormalities
- remove the obstruction of fix the structural abnormality
21
Q
What are the causes of acute renal failure?
A
rapid but usually reversible reduction in renal excretory function sufficient to cause azotemia
- causes: ATN, interstitial nephritis, glomerulonephritis
- azotemia: retention of nitrogenous waste
- uremia: symptomatic azotemia, with n/v/lethargy
- acute: sudden, hours/days and is reversible
- chronic: progressive, irreversible
- oliguria: urine output < 400 ml/day
22
Q
How is acute renal failure dx?
A
CBC, BUN, Cr, electrolytes (Ca, phosphate), UA, postvoid residual bladder volume
-tx: depends on the cause
23
Q
What is prerenal mechanism?
A
perfusion (50%) - kidney working fine but things that perfuse it aren’t
- ex: volume loss, heart failure, loss of peripheral vascular resistance (sepsis/anesthesia)
- weak, decreased urine output, dizziness, sunken eyes, tachy, orthostatic
- fractional excretion of sodium is normal
- urine specific gravity >1.030, Bun/Cr > 20, urine osm > 500
- tx: fluids, cardiac support, treat shock
24
Q
What is renal mechanism?
A
glomerular, tubular, interstitial
- RC casts = glomerulonephritis
- WBC casts = pyelonephritis
- Muddy casts = ATN
- hyaline casts = normal
- waxy = chronic renal disease
- urine specific gravity <1.010, BUN/Cr < 10, urine osm < 300
25
What is post-renal mechanism?
obstructive - most likely prostate
- usually low/no urine output
- place foley cath to find the source of obstruction; renal US to look for tumor/hydronephrosis
26
What is ATN?
from kidney ischemia/toxins; UA shows muddy brown casts
- damaged tubules means can't concentrate urine = high FENa
- prerenal failure is MC cause
- drugs: amp B, cisplatin, aminoglycosides, NSAIDs, ACE
- aschemic: dehydration, shock, sepsis
- function excretion of sodium >2% + muddy, pigmented granular casts + high urine osm
27
What is interstitial nephritis?
- immune-mediated response
- drugs: PCN, sulfa, NSAIDs, phenytoin
- US: WBC casts + eos + hematuria
- Dx: renal biopsy, discontinue offending drug, steroids, dialysis if needed, usually self-limiting
28
What is glomerulonephritis?
IGA nephrophathy, postinfectious, membranoproliferative
- UA: oliguria, hematuria, RBC casts
- Causes: group A strep, IGA, anti-GBM, ANCA
- post-strep glomerulonephritis = MC infectious cause of acute glomerulonephritis: either from strep pharyngitis or strep skin infection (impetigo) = hematuria, HTN, periorbital edema
- dx: proteinuria + RBC in urine; usually caused by group A beta-hemolytic strep
29
What is nephrolithiasis?
renal calculi - occur throughout the urinary tract and common causes of pain, infection, and obstruction
30
What are the characteristics of nephrolithiasis?
- stones: caused by increased saturation of urine with stone-forming salts (calcium, oxalate, and other solutes) or possible lack of inhibitors (citrate) in urine to prevent crystal formation
- calcium stones = most common
- calcium (80%)>uric acid (7%)>struvite(10%)>cystine(1%)
- features: asymptomatic until inflammation/complete or partial ureteral obstruction develops
- colicky unilateral back/flank pain radiating to the groin, hematuria, CVA tenderness, and nausea and vomiting, renal colic that waxes and wanes
- hematuria, dysuria, urinary frequency, fever, chills, nausea, vomiting
- signs: diaphoresis, tachycardia, tachypnea, restlessness, CVA tenderness, abdominal distention
31
How is nephrolithiasis dx?
normal serum chemistries (possible leukocytosis)
- UA = microscopic/gross hematuria - leukocytes/crystals
- CT without contrast (spiral CT) can detect stones as small at 1 mm
- a plain film can identify radiopaque stones
- renal US: can identify stones in the kidney, proximal ureter, or UVJ
32
What is the tx of nephrolithiasis?
size indicates management:
- <5 mm: likely to pass on own; lots of fluid; strain urine; adequate analgesics
- 5 - 10 mm: not likely to pass spontaneously; increased fluid and analgesics; elective lithotripsy/ureteroscopy with stone basket extraction
- refer to urology with a 9 mm mid-ureteral stone
- > 10 mm: not likely to mass spontaneously and increased likelihood complications
- treated as an inpatient if can't maintain adequate oral intake; vigorous hydration; ureteral stent/percutaneous nephrostomy = gold standard - use if renal function jeopardized
- ample analgesia (toreador/morphine/meperidine)
- extracorporeal shock wave lithotripsy (ESWL)
33
What is cystitis?
infection of bladder MC caused by bacteria (E. coli) = 80-85% of cases; infection usually ascends from the urethra
- features: frequency, urgency, dysuria, suprapubic tenderness
- often appears following sexual intercourse in women
- the exam usually unremarkable - sometimes suprapubic tenderness
34
How is cystitis dx?
- urine dipstick: nitric, leukocyte esterase
- UA = pyuria, bacteriuria, +/- hematuria
- urine culture positive for the offending organism
- Imaging only warranted in pyelonerphririts, recurrent infection, anatomic abnormalities
35
What is the tx for cystitis?
- uncomplicated: short-term abx: Bactrim or nitrofurantoin 3-5 days, fluoroquinolone are reserved only for people with no alternative options
- postcoital UTI: single-dose TMP-SMX or cephalexin may reduce the frequency of UTi in sexually active women
- rare in men
- Increase fluids, prevention (proper hygiene, void after intercourse)
- hot sits bath/urinary analgesics (phenazopyridine/azo) may provide sx relief (turns pee orange)
- Lower UTI in pregnancy
- nitrofurantoin (macrobid): 100 mg PO BID x 7 days
- cephalexin (keflex): 500 mg PO BID x 7 days
36
What is orchitis?
an inflammation of the testicles
| -It can be caused by either bacteria or a virus
37
What are the characteristics of orchitis?
- commonly caused by ascending bacterial infection from urinary tract
- occurs in 25% of post pubertal males with MUMPS
- unilateral swollen testicle/tenderness with erythema and shininess of the overlying skin, fever/tachycardia
- orchitis is rarely seen without epididmyitis unless the patient has mumps
38
How is orchitis dx?
UA reveals pyuria and bacteriuria with a bacterial infection
39
What is the tx of orchitis?
- if mumps is the causes, treat mumps (+ice/analgesia)
- If bacteria is the cause, treat like epidiymitis
- ceftriazone 250 mg IM + doxy 100 mg bid x 10 days if <35
- cipro 500 mg bid 10-14 days if >35
40
What are the signs and symptoms of cystitis?
dysuria, urgency, frequency, hematuria with no fever, chills, flank pain (nitrite/leukocyte esterase on urine) urine cx = gold standard
41
What are the signs and symptoms of pyelonephritis?
dysuria + fever + flank pain + nausea and vomiting + CVA tenderness + white casts on UA - treat with FQ
42
What are the signs and symptoms of recurrent UTI?
2 uncomplicated in 6 mo/ 3+ complicated in 1 year; relapse = UTI w/in 2 weeks tx; reinfection: different bacteria
43
What are the signs and symptoms of urethritis?
inflammation of urethra caused by infectious/noninfectious causes (trauma/foreign body); usually G/C, dx= NAAT
44
What are the signs and symptoms of epididymitis?
dysuria, unilateral corral pain + Prehn's sign = relief with elevation is a classic sign; G/C or E. coli depending on age; treat with FQ/doxy + ceftriaxone
45
What are the signs and symptoms of prostatitis?
sudden onset of fever, chills, and low back pain combined with urinary frequency, urgency, and dysuria; G/C or E.coli (age) - don't massage prostate
46
What is prostatitis?
ascending infection of gram-negative rods into prostatic ducts
47
What are the characteristics of prostatitis?
- acute: sudden onset of fever, chills, and low back pain combined with urinary frequency, urgency, and dysuria
- chronic: variable - asymptomatic = acute symptomatology
- all forms present with irritative bladder symptoms (frequency,. urgency, dysuria) and some obstruction
- physical exam reveals a tender and enlarged prostate on digital rectal exam
48
How is prostatitis dx?
urinalysis will reveal pyuria and hematuria
- -prostatic fluid = leukocytosis, culture typically positive for E. coli in acute infections
- chronic usually have enterococcus
- If you suspect acute prostatitis do not massage the prostate this can lead to sepsis
49
What is the tx of prostatitis?
- men < 35: chlamydia and gonorrhea - ceftriazone and azithromycin (or doxycycline)
- E. coli and pseudomonas in men > 35 - treat with fluoroquinolone or Bactrim for six weeks to ensure eradication fo the infection - culture urine 1 week after the conclusion of therapy
- hospitaliztion in acute - may need parenteral fluoroquinolones
- if fever doesn't resolve in 36 hours, suspect abscess and consult urology
- chronic prostatitis is treated with fluoroquinolones or bactrim x 6-12 weeks
- NSAIDs = effective for analgesia; alpha 1 blocker may be helpful if lower UTI symptoms are present
- chronic, recurrent, resistant prostatitis with/without prostatic calculi may require transurethral resection of the prostate (TURP) for resolution
50
What is epididymitis?
acquired by the retrograde spread of organisms through vas deferens
- the pathogen is based on patient's age and risk factors:
- men< 35 chlamydia and gonorrhea
- men > 35 E. coli
51
How is epididymitis characterized?
dysuria, unilateral dull aching scrotal pain that can radiate up the ipsilateral flank
- swollen epididymis tender; fever/chills
- +prehn's sign = relief with elevation is a classic sign
52
How is epididymitis dx?
urinalysis reveals pyuria and bacteriuria; cultures are positive for suspected organisms
53
What is the tx for epididymitis?
supportive care: bed rest, scrotal elevation, analgesics
- over 35- E.coli
- levofloxacin (Levaquin) 500 mg/day PO for 10 days (21 days if associated prostatitis)
- ofloxacin 300 mg PO BID for 10 days
- under 35 - gonorrhea and chlamydia
- doxycycline 100 mg PO BID for 10 days PLUS ceftriazone 250 mg IM x 1
- refer sexual partner(s) for evaluation and treatment if contact within 60 days of the onset of symptoms
54
What is pyelonephritis?
inflammation of the kidney parenchyma and renal pelvis due to a bacterial infection; more common in diabetics and elderly women
- organism: E. coli
- chronic is the result of progressive inflammation of the renal interstitium caused by a bacterial infection - occurs in patients with anatomic urinary tract abnormalities such as vesicoureteral reflux
- irritative voiding + fever + flank pain + nausea and vomiting + CVA tenderness
- young children: fever + abdominal discomfort
55
How is pyelonephritis dx?
- CBC shows leukocytosis and left shift
- UA shows pyuria, bacteriuria, varying degrees of hematuria, WBC casts
- complicated: ultrasound shows hydronephrosis secondary to obstruction
56
What is pyelonephritis tx?
- outpatient: FQ (cipro/levaquin)/bactrim for 1-2 weeks (longer if immunocompromised)
- inpatient: IV FQ, 3rd/4th gen cephalosporins, extended-spectrum penicillins, gentamycin
- failure to respond = US/imaging
- F/up urine cultures not mandatory following tx in uncomplicated cases
57
What is hyperphosphatemia?
- the most common cause is renal failure
- the second most common cause is hypoparathyroidism
- serum calcium and phosphate is controlled by PTH level
58
What is the presentation of hyperphosphatemia?
- most patients are asymptomatic
- hypocalcemic may have tetany
- major muscle weakness = may manifests as diplopia, low cardiac output, dysphagia, and respiratory depression due to respiratory muscle weakness
- mental status changes = confusion, delirium, and coma
59
What are the causes of hyperphosphatemia?
- crash injuries
- diabetic ketoacidosis
- nontraumatic rhabdomyolysis
- overwhelming systemic infections
- tumor lysis syndrome
- metabolic or respiratory acidosis
60
What is the tx for hyperphosphatemia?
IV hydration and acetazolamide
| -phosphate binders
61
What are the pearls of hyerphosphatemia?
if suspicious of phosphorus or calcium imbalance always order a PTH level
62
What are the causes of hypophosphatemia?
- hyperparathyroidism
- alcoholism
- burns
- starvation
- CKD
- diuretics
63
What is the presentation of hypophosphatemia?
- anorexia and muscle weakness
- heart failure
- seizures and coma
- osteomalacia
64
What is the tx for hypophosphatemia?
- treat primary cause or disease
| - oral phosphate replacement
65
What are the pearls of hypophosphatemia?
if suspicious of phosphorus or calcium imbalance always order a PTH level
66
What is hypocalcemia?
- serum total calcium <8.4 mg/dL
| - ionized fraction of calcium <4.4 mg/dL
67
What are the causes of hypocalcemia?
- the most common cause is hypoparathyroidism
- other causes
- thyroid surgery (injuring the parathyroid gland)
- renal disease
68
What is the presentation of hypocalcemia?
- trousseau's sign and chvostek's sign both seen with low calcium
- prolonged Q-T interval
69
What is the tx for hypocalcemia?
IV calcium gluconate
70
What are the pearls of hypocalcemia?
- if suspicious of phosphorus or calcium imbalance always order a PTH level
- always remember it is the effect on the EKG that counts the most not the serum levels
71
What is hypercalcemia?
- serum total calcium >10.5 mg/dL
| - ionized fraction of calcium >5.6 mg/dL
72
What are the causes of hypercalcemia?
most common is hyperparathyroidism
- sarcoidosis
- tuberculosis
- paget disease
- metastatic cancers to bone (prostate, breast, ovarian, renal)
- multiple myeloma
73
What is the presentation of hypercalcemia?
"stones, bones, abdominal groans, psychiatric moans", EKG: shortened QT interval
- polyuria, constipation, anorexia
- renal stones
- muscle weakness, confusion
74
How is hypercalcemia dx?
- ionized calcium level (serum calcium can give you false information)
- shortened QT interval
75
What is the tx of hypercalcemia?
- intravenous fluids
| - furosemid
76
What are the pearls of hypercalcemia?
hypercalcemia in the elderly is cancer until proven otherwise
-young adults thick hyperparathyroidism
77
What is hyponatremia?
serum sodium of <135 mmol/L
78
What is the cause of hyponatremia?
high risk is ETOH, malnourished
79
What is the presentation of hyponatremia?
- acute can cause coma, brainstem, herniation, seizures
- death not seen in chronic hyponatremia
- chronic hyponatremia can have motor and gate problems which makes them at increased risk of falls
- correcting chronic low sodium can lead to osmotic demyelination syndrome
- simultaneous low K+, sodium < 105
80
What is the tx for hyponatremia?
- acute treatment = 50 mL bolus of 3% saline
| - chronic IV NS
81
What is hypernatremia?
serum sodium of > 145 mmol/L
82
What are the causes of hypernatremia?
- usually caused by limited access to water or an impaired thirst mechanism, and less commonly by diabetes insipidus
- unreplaced water such as from vomiting or diarrhea
- heavy skin sweating
- diabetes insipidus
- elderly lack of thirst
- DKA or hyperosmolar hyperglycemic
- serum sodium concentration will rise because of an osmotic shift of water from vascular volume into the cell
83
What is the presentation of hypernatremia?
- confusion
- neuromuscular excitability
- hyperreflexia
- seizures, and coma
84
What is the tx for hypernatremia?
IV D5W (5% dextrose in normal saline)
- or D5W 1/2 NS
- rapid overcorrection causes cerebral edema and pontine herniation
85
What is hyperkalemia?
serum potassium of >5-5.5 mEq/L
86
What are the causes of hyperkalemia?
- seen in the late stages of kidney failure stage 5
| - can be seen in spironolactone and ACEI use and acute renal failure
87
What is the presentation of hyperkalemia?
- EKG peaked T-waves
| - metabolic acidosis normal anion gap and increased anion gap
88
What is the tx for hyperkalemia?
IV insulin, glucose, albuterol, calcium gluconate, lasix
89
What are the pearls for hyperkalemia?
hyperkalemia with EKG changes must be treated immediately the next progression is sine waves, V-tach, and V-fib
90
What is hypokalemia?
serum potassium of <3.5 mEq/L
91
What are the causes of hypokalemia?
- overuse of diuretics
| - Cushing's syndrome
92
What is the presentation of hypokalemia?
- see U-waves on EKG
- muscle cramps, constipation
- can prolong the Q-T interval
93
What is the tx for hypokalemia?
IV potassium and oral potassium
| -replace magnesium in magnesium deficiency
94
What is fluids and hypovolemia?
- low volume
| - low blood pressure
95
What is IV fluids NS 0.9%?
- avoided in CHF can fluid overload
| - normal saline
96
What is the tx when someone is vomiting or having diarrhea?
hydration needs due to vomiting, diarrhea, hemorrhage, or even shock
- lactated ringers (LR)
- isotonic crystalloid contains sodium chloride, potassium chloride, calcium chloride, and sodium lactate in sterile water
- most similar to the body's plasma and serum concentration
97
What is the tx for burn victims or hypovolemia?
burn victims or hypovolemia due to fluid shifts
| -does not work well with patients with liver disease
98
What are the characteristics of D5W?
5% dextrose in water
- hypotonic solution with 5% dextrose
- 170 calories per liter
- often used for diabetic patients NPO before surgery
- contraindicated in renal failure, cardiac compromise, and increased intracranial pressure
99
What are the characteristics of 45% normal saline?
(aka 1/2 normal saline)
- a hypotonic solution of sodium chloride dissolved in sterile water
- tx: cellular dehydration
- hypernatremia or DKA
- avoided in patients with burns, trauma, deplete intravascular fluid levels
- water to shift from the extracellular fluid compartment to the ICF compartment
100
What is fluid and electrolyte disorders?
acid-base disorders
101
What is dehydration?
- metabolic acidosis
| - low pH and low CO2
102
What is severe diarrhea?
- cholera
- rotavirus
- norovirus gastroenteritis
- DKA
- burns
103
What is the tx for dehydration?
IV normal saline 0.9%
104
What is diabetes insipidus?
- central which is decreased ADH which is the most common
- head trauma, brain tumor, autoimmune
- kidney related drugs like lithium and demeclocycline hyperparathyroidism
- Dx: fluid deprivation test
- low urine osmolarity
105
What is the tx for diabetes insipidus?
desmopression (DDAVP) can treat central not kidney related
- kidney related low Na+ diet and HCTZ
- if they need IV fluids D5W 1/2 NS
106
What is SIADH?
- increase ADH from the pituitary gland
- can be from an ectopic site (Small Cell Lung CA)
- present with hyponatremia
- inability to dilute serum by excreting water through the kidneys
- in other words too much water in the serum
- medications: carbamezepine, HCTZ, NSAIDs, TCA
107
What is the tx for SIADH?
usually restrict water intake during the day
- vasopressin-2 receptor antagonists
- demeclocycline
108
What is the presentation of suprapubic pain?
- tenderness in the suprapubic area in males is specific to the bladder and other organs around the area such as colon, prostate
- females suprapubic tenderness can be bladder, uterus, colon
- in other words, everybody should be worked up for bladder problems such as cystitis so a urinalysis is always required
109
How is suprapubic pain dx?
- urinalysis in all cases
- pregnancy test in all females
- pelvic US in females
- CT scans if needed
110
What are the pearls of suprapubic pain?
- urinalysis in all cases pregnancy test in all females
| - pelvic UTS and CT scans if needed
111
What is the presentation and cause of flank pain?
- kidney disorders usually present with flank tenderness
- pain can extend to the center of the abdomen
- kidney stones that have entered one of the ureters can cause severe flank pain
- in hydronephrosis, the kidney's outer covering and renal capsule is stretched causing rapid swelling of the kidney producing severe pain
- kidney stones can cause excruciating pain sometimes radiates to the groin and testicles
- renal or ureteral colic is because of the ureters contacting down on the stone
- wave type of pain
112
What are other causes of flank pain?
- pyelonephritis
- glomerulonephritis
- renal tumors
- abdominal aortic aneurysms
113
What is the workup and treatment for flank pain?
1. urinalysis
2. renal ultrasound
3. CT scan WITHOUT contrast so the stone can be seen
114
What are the pearls of flank pain?
- all flank tenderness should be treated as a kidney problem until proven otherwise
- urinalysis on all patients
- renal UTZ or CT scan for kidney stones
- always remember other causes such as pyelonephritis, tumors, and aneurysm
115
What is glomerulonephritis?
damage of renal glomeruli by deposition of inflammatory proteins in glomerular membranes as a result of immunologic response
116
What are the characteristics of glomerulonephritis?
- 60% in kids; excellent prognosis in kids and worse in adults esp with preexisting renal disease
- cause: hematuria, Henoch-Schonlein purpura, post infectious GN, IgA nephropathy, hereditary nephritis, and others
- features: hematuria, urine = tea/cola-colored, oliguria/anuria, edema of face and eyes in the morning and of the feet/ankles at night, HTN is common
117
How is glomerulonephritis dx?
hematuria, RBC casts, proteinuria, HTN, decreased GFR
- antistreptolysin-O titer is increased in 60-80% of cases; a common cause of GN is a streptococcal infection
- UA reveals hematuria (>3 RBCs/high power field) and misshapen RBCs, RBC casts, proteinuria (1-2 g/24 hours)
- serum complement often decreased
- renal biopsy may be done to determine exact diagnosis or severity
118
What is the tx for glomerulonephritis?
steroids and immunosuppressive drugs to control inflammatory response; dietary management (salt and fluid intake decreased); dialysis if symptomatic azotemia present
- medical: ACE-I = renoprotective (reduce urinary protein loss) in chronic GN
- use meds as appropriate for hyperkalemia, pulmonary edema, peripheral edema, acidosis and HTN
119
What is testicular torsion?
twisting of spermatic cord = compromised blood flow + ischemia (SRUGICAL EMERGENCY)
120
What are the characteristics of testicular torsion?
- asymmetric high riding testicle "bell clapper deformity" negative Prehn's sign (lifting of testicle will not relieve pain), teenage males
- sudden, severe pain and swelling in the testicle are symptoms, associated with nausea and vomiting
- very tender to palpation, cremaster reflex absent
- blue dot sign: tender nodule 2 to 3 mm in diameter on the upper pole of the testicle
- more common in patients with a history of cryptorchidism
121
How is testicular torsion dx?
testicular doppler = best initial test; radionuclide scan demonstrates decreased uptake in affected testes = gold standard
122
What is the tx for testicular torsion?
- surgical emergency: repair within 4-6 hours, a longer wait may affect fertility
- followed by elective surgery on contralateral testes which is also at risk for torsion
123
What is the key history with hematuria?
amount, duration, presence of clots, associated sx (fevers, weight loss, night sweats, renal colic, dysuria, irritative voiding sx), timing along the stream where blood appears (initial vs terminal vs throughout); meds (blood thinners, NSAIDs); hx vigorous/prolonged exercise, trauma, smoking, stones, cancer, sex, easy bleeding/bruising)
124
What are the key physical exam of hematuria?
vital signs, lymph nodes (pelvis), abdominal exam, genitourinary/rectal exam; extremities
125
What are the ddx of hematuria?
bladder CA, renal cell carcinoma, nephrolithiasis, prostate CA, acute glomerulonephritis, coagulation disorder, polycystic kidney disease, nephrolithiasis, UTI, pyelonephritis
126
How is hematuria dx?
cystoscopy, US renal/bladder, CT abdomen/pelvis, UA, prostate biopsy, CBC, CMP, PT/PTT, PSA
127
What is urethritis?
infection of the urethra with bacteria = STI (chlamydia, gonorrhoeae, trichomonas, HSV = MC causes)
-presents with dysuria and urethral discharge (purulent, whitish, mucoid)
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How is urethritis dx?
UA/urine culture
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What is the tx for urethritis?
sexually active pt with sx treated presumptively for STDs (ceftriaxone 250 mg + azithromycin 1 g PO once or doxy 100 mg PO bid x 7 days)
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What is a hernia?
protrusion of organ or structure through wall that normally contains it; various types can entrap intestines and cause obstruction
-hernias of various types can entrap the intestines and cause an intestinal blockage - this is called an "incarcerated hernia" and is a medical emergency
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What is an umbilical hernia?
congenital and appears at birth; may resolve on own; sometimes need surgery
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What is a diaphragmatic/hiatal hernia?
protrusion of stomach through diaphragm via esophageal hiatus = can cause GERD - tx with acid reduction possibly need surgery
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What is an incisional hernias?
associated with vertical incisions, esp with obesity
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What is a cystocele hernia?
hernia of the urinary bladder; prolapse of the bladder into the anterior wall of the vagina
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What is a rectocele hernia?
herniation of rectum into the posterior wall of the vagina
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What is an indirect inguinal hernia?
passage of intestine through the external inguinal ring at the inguinal canal, may pass into the scrotum
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What is a direct inguinal hernia?
passage of intestine through the external inguinal ring at hesselback triangle - rarely enters the scrotum
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What is a femoral hernia?
least common - passage through the femoral ring
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What is ventral hernia?
occurs when there is weakening in the anterior abdominal wall and may be either incisional or umbilical
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What is a strangulated hernia?
a hernia becomes strangulated when the blood supply of its contents is seriously impaired
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What is an obstructed hernia?
this is an irreducible hernia containing intestine that is obstructed from without or within, but there is no interference to the blood supply to the bowel
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What is an incarcerated hernia?
a hernia so occluded that it cannot be returned by manipulation, it may or may not become strangulated
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How is a hernia dx?
history and physical exam, including an attempt to reduce the mass
-ultrasound - especially in the male child where other scrotal masses (hydrocele, varicocele) are considered
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What is the tx of a hernia?
if the patient is otherwise well, refer non-urgently to surgery for definitive surgical repair
-if concerned for hernia incarceration or strangulation, refer immediately to surgery
