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Emergency Medicine EOR > Urology and Renal > Flashcards

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)

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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

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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
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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)
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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
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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
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7
Q

What is mixed incontinence?

A

combo of stress/urge = MC

tx: lifestyle modification and pelvic floor exercises = first line

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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

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9
Q

How do you dx incontinence?

A

UA to rule out UTI, postvoid residual volume, urodynamic studies to identify bladder contractions, ultrasonography/cystoscopy

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10
Q

What is stage 1 acute renal failure?

A

normal GFR (>90)

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11
Q

What is stage 2 acute renal failure?

A

early GFR (60-89)

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12
Q

What is stage 3 acute renal failure?

A

moderate GFR (3a 45-59) (3b 30-44)

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13
Q

What is stage 4 acute renal failure?

A

severe GFR (15-29)

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14
Q

What is stage 5 acute renal failure?

A

kidney failure (GFR < 15=dialysis)

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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)
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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
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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
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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
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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

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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
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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
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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

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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
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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
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25
Q

What is post-renal mechanism?

A

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
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26
Q

What is ATN?

A

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
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27
Q

What is interstitial nephritis?

A
  • 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
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28
Q

What is glomerulonephritis?

A

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
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29
Q

What is nephrolithiasis?

A

renal calculi - occur throughout the urinary tract and common causes of pain, infection, and obstruction

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30
Q

What are the characteristics of nephrolithiasis?

A
  • 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
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31
Q

How is nephrolithiasis dx?

A

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
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32
Q

What is the tx of nephrolithiasis?

A

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)
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33
Q

What is cystitis?

A

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
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34
Q

How is cystitis dx?

A
  • 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
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35
Q

What is the tx for cystitis?

A
  • 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
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36
Q

What is orchitis?

A

an inflammation of the testicles

-It can be caused by either bacteria or a virus

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37
Q

What are the characteristics of orchitis?

A
  • 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
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38
Q

How is orchitis dx?

A

UA reveals pyuria and bacteriuria with a bacterial infection

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39
Q

What is the tx of orchitis?

A
  • 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
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40
Q

What are the signs and symptoms of cystitis?

A

dysuria, urgency, frequency, hematuria with no fever, chills, flank pain (nitrite/leukocyte esterase on urine) urine cx = gold standard

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41
Q

What are the signs and symptoms of pyelonephritis?

A

dysuria + fever + flank pain + nausea and vomiting + CVA tenderness + white casts on UA - treat with FQ

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42
Q

What are the signs and symptoms of recurrent UTI?

A

2 uncomplicated in 6 mo/ 3+ complicated in 1 year; relapse = UTI w/in 2 weeks tx; reinfection: different bacteria

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43
Q

What are the signs and symptoms of urethritis?

A

inflammation of urethra caused by infectious/noninfectious causes (trauma/foreign body); usually G/C, dx= NAAT

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44
Q

What are the signs and symptoms of epididymitis?

A

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

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45
Q

What are the signs and symptoms of prostatitis?

A

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

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46
Q

What is prostatitis?

A

ascending infection of gram-negative rods into prostatic ducts

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47
Q

What are the characteristics of prostatitis?

A
  • 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
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48
Q

How is prostatitis dx?

A

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
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49
Q

What is the tx of prostatitis?

A
  • 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
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50
Q

What is epididymitis?

A

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
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51
Q

How is epididymitis characterized?

A

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
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52
Q

How is epididymitis dx?

A

urinalysis reveals pyuria and bacteriuria; cultures are positive for suspected organisms

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53
Q

What is the tx for epididymitis?

A

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
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54
Q

What is pyelonephritis?

A

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
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55
Q

How is pyelonephritis dx?

A
  • CBC shows leukocytosis and left shift
  • UA shows pyuria, bacteriuria, varying degrees of hematuria, WBC casts
  • complicated: ultrasound shows hydronephrosis secondary to obstruction
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56
Q

What is pyelonephritis tx?

A
  • 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
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57
Q

What is hyperphosphatemia?

A
  • the most common cause is renal failure
  • the second most common cause is hypoparathyroidism
  • serum calcium and phosphate is controlled by PTH level
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58
Q

What is the presentation of hyperphosphatemia?

A
  • 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
Q

What are the causes of hyperphosphatemia?

A
  • crash injuries
  • diabetic ketoacidosis
  • nontraumatic rhabdomyolysis
  • overwhelming systemic infections
  • tumor lysis syndrome
  • metabolic or respiratory acidosis
60
Q

What is the tx for hyperphosphatemia?

A

IV hydration and acetazolamide

-phosphate binders

61
Q

What are the pearls of hyerphosphatemia?

A

if suspicious of phosphorus or calcium imbalance always order a PTH level

62
Q

What are the causes of hypophosphatemia?

A
  • hyperparathyroidism
  • alcoholism
  • burns
  • starvation
  • CKD
  • diuretics
63
Q

What is the presentation of hypophosphatemia?

A
  • anorexia and muscle weakness
  • heart failure
  • seizures and coma
  • osteomalacia
64
Q

What is the tx for hypophosphatemia?

A
  • treat primary cause or disease

- oral phosphate replacement

65
Q

What are the pearls of hypophosphatemia?

A

if suspicious of phosphorus or calcium imbalance always order a PTH level

66
Q

What is hypocalcemia?

A
  • serum total calcium <8.4 mg/dL

- ionized fraction of calcium <4.4 mg/dL

67
Q

What are the causes of hypocalcemia?

A
  • the most common cause is hypoparathyroidism
  • other causes
  • thyroid surgery (injuring the parathyroid gland)
  • renal disease
68
Q

What is the presentation of hypocalcemia?

A
  • trousseau’s sign and chvostek’s sign both seen with low calcium
  • prolonged Q-T interval
69
Q

What is the tx for hypocalcemia?

A

IV calcium gluconate

70
Q

What are the pearls of hypocalcemia?

A
  • 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
Q

What is hypercalcemia?

A
  • serum total calcium >10.5 mg/dL

- ionized fraction of calcium >5.6 mg/dL

72
Q

What are the causes of hypercalcemia?

A

most common is hyperparathyroidism

  • sarcoidosis
  • tuberculosis
  • paget disease
  • metastatic cancers to bone (prostate, breast, ovarian, renal)
  • multiple myeloma
73
Q

What is the presentation of hypercalcemia?

A

“stones, bones, abdominal groans, psychiatric moans”, EKG: shortened QT interval

  • polyuria, constipation, anorexia
  • renal stones
  • muscle weakness, confusion
74
Q

How is hypercalcemia dx?

A
  • ionized calcium level (serum calcium can give you false information)
  • shortened QT interval
75
Q

What is the tx of hypercalcemia?

A
  • intravenous fluids

- furosemid

76
Q

What are the pearls of hypercalcemia?

A

hypercalcemia in the elderly is cancer until proven otherwise
-young adults thick hyperparathyroidism

77
Q

What is hyponatremia?

A

serum sodium of <135 mmol/L

78
Q

What is the cause of hyponatremia?

A

high risk is ETOH, malnourished

79
Q

What is the presentation of hyponatremia?

A
  • 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
Q

What is the tx for hyponatremia?

A
  • acute treatment = 50 mL bolus of 3% saline

- chronic IV NS

81
Q

What is hypernatremia?

A

serum sodium of > 145 mmol/L

82
Q

What are the causes of hypernatremia?

A
  • 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
Q

What is the presentation of hypernatremia?

A
  • confusion
  • neuromuscular excitability
  • hyperreflexia
  • seizures, and coma
84
Q

What is the tx for hypernatremia?

A

IV D5W (5% dextrose in normal saline)

  • or D5W 1/2 NS
  • rapid overcorrection causes cerebral edema and pontine herniation
85
Q

What is hyperkalemia?

A

serum potassium of >5-5.5 mEq/L

86
Q

What are the causes of hyperkalemia?

A
  • seen in the late stages of kidney failure stage 5

- can be seen in spironolactone and ACEI use and acute renal failure

87
Q

What is the presentation of hyperkalemia?

A
  • EKG peaked T-waves

- metabolic acidosis normal anion gap and increased anion gap

88
Q

What is the tx for hyperkalemia?

A

IV insulin, glucose, albuterol, calcium gluconate, lasix

89
Q

What are the pearls for hyperkalemia?

A

hyperkalemia with EKG changes must be treated immediately the next progression is sine waves, V-tach, and V-fib

90
Q

What is hypokalemia?

A

serum potassium of <3.5 mEq/L

91
Q

What are the causes of hypokalemia?

A
  • overuse of diuretics

- Cushing’s syndrome

92
Q

What is the presentation of hypokalemia?

A
  • see U-waves on EKG
  • muscle cramps, constipation
  • can prolong the Q-T interval
93
Q

What is the tx for hypokalemia?

A

IV potassium and oral potassium

-replace magnesium in magnesium deficiency

94
Q

What is fluids and hypovolemia?

A
  • low volume

- low blood pressure

95
Q

What is IV fluids NS 0.9%?

A
  • avoided in CHF can fluid overload

- normal saline

96
Q

What is the tx when someone is vomiting or having diarrhea?

A

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
Q

What is the tx for burn victims or hypovolemia?

A

burn victims or hypovolemia due to fluid shifts

-does not work well with patients with liver disease

98
Q

What are the characteristics of D5W?

A

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
Q

What are the characteristics of 45% normal saline?

A

(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
Q

What is fluid and electrolyte disorders?

A

acid-base disorders

101
Q

What is dehydration?

A
  • metabolic acidosis

- low pH and low CO2

102
Q

What is severe diarrhea?

A
  • cholera
  • rotavirus
  • norovirus gastroenteritis
  • DKA
  • burns
103
Q

What is the tx for dehydration?

A

IV normal saline 0.9%

104
Q

What is diabetes insipidus?

A
  • 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
Q

What is the tx for diabetes insipidus?

A

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
Q

What is SIADH?

A
  • 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
Q

What is the tx for SIADH?

A

usually restrict water intake during the day

  • vasopressin-2 receptor antagonists
  • demeclocycline
108
Q

What is the presentation of suprapubic pain?

A
  • 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
Q

How is suprapubic pain dx?

A
  • urinalysis in all cases
  • pregnancy test in all females
  • pelvic US in females
  • CT scans if needed
110
Q

What are the pearls of suprapubic pain?

A
  • urinalysis in all cases pregnancy test in all females

- pelvic UTS and CT scans if needed

111
Q

What is the presentation and cause of flank pain?

A
  • 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
Q

What are other causes of flank pain?

A
  • pyelonephritis
  • glomerulonephritis
  • renal tumors
  • abdominal aortic aneurysms
113
Q

What is the workup and treatment for flank pain?

A
  1. urinalysis
  2. renal ultrasound
  3. CT scan WITHOUT contrast so the stone can be seen
114
Q

What are the pearls of flank pain?

A
  • 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
Q

What is glomerulonephritis?

A

damage of renal glomeruli by deposition of inflammatory proteins in glomerular membranes as a result of immunologic response

116
Q

What are the characteristics of glomerulonephritis?

A
  • 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
Q

How is glomerulonephritis dx?

A

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
Q

What is the tx for glomerulonephritis?

A

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
Q

What is testicular torsion?

A

twisting of spermatic cord = compromised blood flow + ischemia (SRUGICAL EMERGENCY)

120
Q

What are the characteristics of testicular torsion?

A
  • 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
Q

How is testicular torsion dx?

A

testicular doppler = best initial test; radionuclide scan demonstrates decreased uptake in affected testes = gold standard

122
Q

What is the tx for testicular torsion?

A
  • 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
Q

What is the key history with hematuria?

A

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
Q

What are the key physical exam of hematuria?

A

vital signs, lymph nodes (pelvis), abdominal exam, genitourinary/rectal exam; extremities

125
Q

What are the ddx of hematuria?

A

bladder CA, renal cell carcinoma, nephrolithiasis, prostate CA, acute glomerulonephritis, coagulation disorder, polycystic kidney disease, nephrolithiasis, UTI, pyelonephritis

126
Q

How is hematuria dx?

A

cystoscopy, US renal/bladder, CT abdomen/pelvis, UA, prostate biopsy, CBC, CMP, PT/PTT, PSA

127
Q

What is urethritis?

A

infection of the urethra with bacteria = STI (chlamydia, gonorrhoeae, trichomonas, HSV = MC causes)
-presents with dysuria and urethral discharge (purulent, whitish, mucoid)

128
Q

How is urethritis dx?

A

UA/urine culture

129
Q

What is the tx for urethritis?

A

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)

130
Q

What is a hernia?

A

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

131
Q

What is an umbilical hernia?

A

congenital and appears at birth; may resolve on own; sometimes need surgery

132
Q

What is a diaphragmatic/hiatal hernia?

A

protrusion of stomach through diaphragm via esophageal hiatus = can cause GERD - tx with acid reduction possibly need surgery

133
Q

What is an incisional hernias?

A

associated with vertical incisions, esp with obesity

134
Q

What is a cystocele hernia?

A

hernia of the urinary bladder; prolapse of the bladder into the anterior wall of the vagina

135
Q

What is a rectocele hernia?

A

herniation of rectum into the posterior wall of the vagina

136
Q

What is an indirect inguinal hernia?

A

passage of intestine through the external inguinal ring at the inguinal canal, may pass into the scrotum

137
Q

What is a direct inguinal hernia?

A

passage of intestine through the external inguinal ring at hesselback triangle - rarely enters the scrotum

138
Q

What is a femoral hernia?

A

least common - passage through the femoral ring

139
Q

What is ventral hernia?

A

occurs when there is weakening in the anterior abdominal wall and may be either incisional or umbilical

140
Q

What is a strangulated hernia?

A

a hernia becomes strangulated when the blood supply of its contents is seriously impaired

141
Q

What is an obstructed hernia?

A

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

142
Q

What is an incarcerated hernia?

A

a hernia so occluded that it cannot be returned by manipulation, it may or may not become strangulated

143
Q

How is a hernia dx?

A

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

144
Q

What is the tx of a hernia?

A

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

Emergency Medicine EOR (12 decks)

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