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FERGU > Week 3 PBL > Flashcards

Week 3 PBL Flashcards

1
Q

describe a Hx to evaluate hematuria in a patient

A
  1. onset and duration
  2. trauma
  3. aggravating and alleviating factors
  4. initial verus total hematuria
  5. meds (warfarin, ASA, statins (due to rhabdomyolysis), rifampin)
  6. clots?
  7. tissue fragments?
  8. bleeding elsewhere?
  9. constitutional symptoms (weight loss, night sweats)
  10. previous stone disease
  11. cancer risk factors
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2
Q

what are the most likely causes of painless hematuria?

A

malignancy or BPH

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3
Q

are stones, UTI, or trauma likely to be asymptomatic

A

no–usually symptomatic

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4
Q

what condition is initial hematuria associated with?

A

BPH

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5
Q

what does total hematuria suggest?

A

bleeding from bladder, ureter or kidney

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6
Q

if there are clots in the urine, what condition is ruled out as a diagnosis?

A

glomerulonephritis

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7
Q

if there are tissue fragments in the urine, what diagnosis is more likely

A

bladder tumor

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8
Q

what does bleeding elsewhere, in addition to the hematuria, suggest?

A

coagulopathy

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9
Q

what do constitutional symptoms like weight loss or night sweats suggest in the context of hematuria?

A

malignancy

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10
Q

what is the biggest risk factor for TCC

A

SMOKING

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11
Q

describe a physical exam to evaluate hematuria

A
  1. signs of systemic disease (fever, rash, lymphadenopathy)
  2. signs of medical renal disease (HTN, volume overload)
  3. genital exam to elicit source of blood (i.e not vagina)
  4. palpation for bladder/kidney masses, abdominal masses, pelvic masses, costovertebral angle tenderness
  5. DRE for BPH, prostate masses
  6. urological exam for prostate, flank mass, urethral disease
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12
Q

what patients presenting with proven hematuria get imaging

A

everyone

exception is women younger than 40 who’s bleeding could be due to infection or menstruation

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13
Q

gross, painless hematuria in an adults is _____ until proven otherwise

A

malignancy

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14
Q

what is the most common cause of hematuria in young patients

A

stones or UTI

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15
Q

what are extra-renal causes of hematuria

A

malignancy is most important diagnosis

other common non-malignant causes of extrarenal hematuria are infections (cystitis, prostatitis, urethritis)

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16
Q

what are the most common glomerular causes of hematuria

A

most common = IgA nephropathy

thin basement membrane disease

hereditary nephritis

other mild focal glomuerulonephritis

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17
Q

what are the most common non-glomerular renal causes of hematuria

A

renal stones

pyelonephritis

polycystic kidney disease

renal cell carcinoma

18
Q

list a DDX for flank pain

A
  1. urolithiasis
  2. radicular/muscular
  3. pyelonephritis
  4. herpes zoster
  5. renal abscess
  6. renal vein thrombosis
  7. renal infarction
  8. AAA
  9. retroperitoneal hematoma
19
Q

symptoms and signs of colic related to ureteric calculi

A
  1. pain–most common symptom; location depends on location of the stone and may change as the stone migrates
  2. hematuria–occurs in most patients with kidney stones
  3. other symptoms: nausea, vomiting, pain with urination, impacted stone leading to infection, staghorn calculi becoming lodged in renal pelvis

they can be asymptomatic however

20
Q

where is the pain localized with upper ureter or renal pelvis stones?

A

flank pain

21
Q

where is the pain localized for lower ureter stones?

A

lower abdomen that may radiate to the genitals

22
Q

what symptoms are particularly suggestive of a kidney stone

A

hematuria, flank pain, history of acute onset

23
Q

what imaging test is preferred for stones

A

CT KUB

24
Q

what stones cannot be seen on abdominal Xray

A

uric acid stones and small stones (can be seen on CT KUB tho)

25
Q

what test is used for pregnant women if stones are suspected

A

ultrasonography

26
Q

acute treatment of calculi

A
  1. patients require only pain medication and fluids until stone is passed (i.e NSAIDS, narcotics)
  2. fluids to increase urine flow and facilitate passage of the stone
  3. ALPHA BLOCKERS may help facilitate passage
  4. patients able to tolerate the pain and take oral meds can be managed at home
  5. once the stone is passed, an imaging test is done to ensure passage is complete and no fragments remain
27
Q

what size stones usually pass spontaneously

A

smaller than 5mm, though up to 7mm can often pass spontaneously

28
Q

what are some treatments that can be applied to stones that don’t pass spontaneously

A
  1. shockwave lithotipsy (SWL)
  2. percutaneous nephrolithotomy (PNL)
  3. ureterorenoscopy
29
Q

what is shockwave lithotripsy (SWL)

A

treatment for renal stones

  • SWL is the treatment of choice in many patients
  • large, hard or complex stones, like staghorn calculi
  • xrays or ultrasound are used to pinpoint the location of the stone
  • high energy shock wave is directed toward the stone, passing through the skin and bodily tissue and causing a release of energy at the stone surface
  • this energy causes the stone to break into fragments that can be more easily passed
30
Q

what is a percutaneous nephrolithotomy (PNL)

A
  • extremely large or complex stones that are resistant to SWL may require PNL
  • small instruments are passed through the skin of the back and into the kidney to access the stone directly
  • often used in patients with abnormal kidneys
  • rarely, open surgery is used to access and remove complex stones
31
Q

what is a ureterorenoscopy

A
  • often used to remove stones obstructing the middle and lower portions of the ureter
  • very small telescopic instrument is passed up through the urethra and bladder and into the ureter
  • the telescope is moved through the ureter until it encounters the obstructing stone which is then removed
  • if the stone is too large for intact removal, a HOLMIUM LASER can be applied during the procedure to break the stones into smaller pieces that are easier to extract
32
Q

what is the only curative therapy for RCC

A

surgical resection

33
Q

why cant you use chemotherapy and radiotherapy for RCC

A

because RCC is highly resistant to both

34
Q

what immunotherapies are being used for RCC

A

immunotherapies with interferon-alpha and IL-2 have shown partial response rates of 10-20%

new drugs target the VEGF pathway (sunitinib) or the mTOR pathway

used for people with metastatic RCC

35
Q

how do you rule out metastatic disease before RCC surgery

A 
abdominal CT
chest CT
bone scan
serum electrolytes
liver enzymes and function
head CT/MRI if warranted
36
Q

when can be ipsilateral adrenal gland be spared in RCC surgical treatment

A

it can be safely preserved if it appears normal on CT scan and the tumor is not immediately adjacent to it

37
Q

when can do you a partial nephrectomy

A
  1. for all renal tumors
38
Q

in which patients can a nephrectomy be performed prior to systemic therapy

A

in patients with low volume metastatic RCC

39
Q

what are the parameters of informed consent

A
  1. the patient is informed of treatment options
  2. the nature of the treatments is taken into account by the patient
  3. risks versus benefits are fully discussed with the patient
  4. the choice to undergo treatment is shown by the patient voluntarily
  5. there is no coercion, manipulation, or duress shown by the physician
40
Q

what are indications for urological consultation and possible cystoscopy/ureteroscopy

A
  1. all cases of urinary tract obstruction and suspected renal malignancies are referred to urologists following initial work up
  2. referral to urologist is usually made following initial workup including las tests (urine, blood), ultrasound, and CT KUB/CT IVP
  3. painless hematuria with no US or CT IVP findings indicates C&P or referral to urologist
  4. urologist can perform cystoscopy and/or ureteroscopy to visualize entire urinary tract up to the kidney

FERGU (9 decks)

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