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99 Cards in this Set
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RENAL I, II INCLUDING ELECTROLYTE IMBALANCE
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RENAL I, II INCLUDING ELECTROLYTE IMBALANCE
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If you found sediment in a UA would might you be suspicious of?
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chronic kidney disease, pre/post renal disorders
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If you found hematuria with RBC casts, and proteinuria, what might you be suspicious of?
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glomerulonephritis
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If you found heavy proteinuria and lipiduria, what might you be suspicious of?
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nephrotic syndrome
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What can cause inadequate excretion of urea which leads to a rise in BUN?
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renal disease, high protein diets, dehydration.
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What is creatinine?
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by-product of skeletal muscle contraction and is generally constant. Excreted exclusively by kidney, so impaired renal fx will cause elevation.
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Explain GFR
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index of overall renal fx. measures amount of plasma filtered across glomerular capillaries. Correlates ability of kidney to filter fluids & certain substances.
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What are advantages of ultrasound of the urinary tract?
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dertermine: thickness of renal cortex, medulla, pyramids,kidney size, hydronephrosis and obstruction, masses, lesion, screen for polycystic disease, etc.
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What are advantages / contraindications of intravenous pyelogram (IVP) of the urinary tract?
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assesses kidneys, ureter and bladder, gives detailed view of pelvicaliceal system, size, shape, etc. Uses contrast so contraindicated in some.
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When is CT, MRI useful for imaging urinary tract?
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CT for further eval of abnormalities found by US, IVP.
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When is MRI useful for imaging urinary tract?
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shows loss of corticomedullary fx, renal cysts, CA staging, renal artery stenosis
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What are indications for renal biopsy
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unexplained acute renal failure or chronic kidney disease, acute nephritic syn, unexplained proteinuria, hematuria; previously ID'd & tx'd lesions, systemic disease associated with kidney dysfx, suspected transplant rejection,
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What are contraindications for renal biopsy
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solitary or ectopic diney, horseshoe kidney, oncorrected bleeding disorder, severe uncontrolled HTN, renal infection, renal neoplasm, hydronephrosis, congneital, multiple cysts
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What are some complications for renal biopsy
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hematuria (nearly all pt's) sig bleeding which require transfusion, nephrectomy and mortality
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Define acute urethral syndrome
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frequency and dysuria without demonstrable infection. Etiiology unkown, Tx behavioral, diety, rx
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Define asymptomatic bacteriuria
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bacteria in urine without sx of UTI or pyelonephritis. Common in elderly women, indwelling caths.
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Identify predisposing factors for UTI
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female, incomplete bladder emptying, diminished renal blood flow, intrinsic renal disease
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Identify common uropathogens
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e.coi, proteus, klebsiella, enterobacter, pseudomonas, less common s. aureus
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Identify 3 routes of infection for UTI
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ascending infection (most common), hematogenous spread, lymphogenous, direct extension from other organs
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Describe classic signs and symptoms of lower UTI
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frequency, urgency, dysuria, suprapubic discomfort, gross hematuria
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Describe classic signs and symptoms of upper UTI
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fever, flank px, chills, urgency, frequency, dysuria, NV, diarrhea, tachycardia, CVA tenderness
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Describe the use of urinatry nitrates in diagnosing outpatient UTI
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indicates bacteria in urine
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Describe the use of urinary leukocyte esterase in diagnosing outpatient UTI
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enzyme produced by WBC's suggestive for UTI
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Describe the use of pyuria and bacteriuria in diagnosing outpatient UTI
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>5 WBC significant. Indicative of injury possibly from infection. Bacteria implies infection
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Describe the use of a urine culture in diagnosing outpatient UTI
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used to ID pathogen responsible for infection
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Identify pt's who should have urologic evaluation following UTI
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women with >3 bladder infections in 1 year, persistent bacteriuria, reinfection
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Identify other causes of dysuria that should be considered in the differential dx of UTI
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obstruction, acute urinary retention, prostate problems, STD's
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Describe the approach to tx for low-risk uncomplicated UTI
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short-term abx; fluoroquinolones and nitrofurantioin
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Distinguish between relapse and reinfection in recurrent UTI
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relapse: unresolved or persistent bacteriuria. Reinfection: new pathogens occur following tx
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Describe the role of prophylactic abx in recurrent UTI
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3+ cystitis per year after urologic eval to exclude anatomic abnorm
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Describe an approach to evaluation and management of acute urethral syndrome
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PE. labs: UA, PAP, preg, KOH. Image: IVP, cystogram, MRI, prostate / pelvic US. Mgt: meds, behavioral, diet, referral
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Describe the differing approach to asymptomatic bacteriuria evaluation and managemet in elderly vs. pregnant women
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Tx pregnant women due to complications to fetus, ederly don't need tx.
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Identify which pt's with acute pylenophritis should be hospitalized vs. outpatient tx
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Evaluate age and stability of pt's, DM, co-existing renal disease or those not likely to comply should be hospitalized. Common for elderly to get urosepsis
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Describe outpatient tx for acute uncomplicated pyelonephritis
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quinolones or nitrofurantoin. Follow up urine cultures over several weeks post tx.
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Describe the classic clinical syndromes associated with kidney stones, particularly renal colic
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high humidty & temp, diet and fluid intake, cystinuria
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Describe the symptoms associated with nephrolithiasis (kidney stones)
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flank px, NV, constantly moving, may be episodical, may radiate anteriorly and refer into ipsilateral testis or labium
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Describe the gernal approach to diagnosis and management of a pt with acute stone episode
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UA shows hematuria, Ct first line to dx. Encourage fluids, px mgt, strain urine, suergery.
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What is are common complications of kidney stones
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infection and obstruction
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What can a pt do to prevent future or recurring stones?
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modify diet, increase fluids (at meals, 2 hr after eating, prior to sleep & during night). Change sleep posture; typically pt's sleep stone side down
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Identify common causes of metabolic acidosis
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decreased HCO3. DM ketoacidosis, renal insufficiency, starvation, diarrhea
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Identify common causes of metabolic alkalosis
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high HCO3, saline responsive and saline unresponsive
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Define saline responsive in context of metabolic alkalosis
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diuretics vomiting, antacids
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Define saline unresponsive in context of metabolic alkalosis
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Bartter's syndrome, aldosteronism, licorice
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Identify common causes of hyperkalemia
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Vit. D or A excess, hyperparathyroidism, acromegaly, adrenal insuff, tumors, mult myeloma, lymphoma, thiazide diuretic, lithium intake
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Identify common causes of hypokalemia
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malabsorption, short bowel, vit D deficit, alcoholism, chronic renal insuf, diuretic therapy, hypoarathyroidism, sepsis
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Identify common causes of hypernatremia
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most commonly occurs when water intake is inadequate as in pt's with altered mental status
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Identify common causes of hyponatremia
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Hypovolemic: diarrhea, vomiting. euvolemic: endocrine disorders, endurance exercise. Hypervolemic: CHF, liver disease, nephritic syndrome
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What is the most common electrolyte abnormality observed in general hospitalized population
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hyponatremia
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What is the most common reason for hyponatremia
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result from water imbalance not sodium imbalance.
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Describe signs and symptoms of hypokalemia including EKG changes
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muscle spasms, convulsions, prolonged QT interval, Chvostek sign: contraction of facial muscle, Trousseaus sign: carpal spasms post brachial artery occlusion
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Describe signs and symptoms of hyperkalemia including EKG changes
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GI, renal, neurologic, constipation, polyuria, NV, anorexia, fatigue, weak, stupor, coma, ventricular extra systoles & idioventricular rhythm
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Identify labs that might be obtained to evaluate renal disease
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UA: sediment - chronic kidney disease, pre/post renal. Hematuria, proteinuria - glomerulonephritis
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Define oliguria and identify it's association with renal failure
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scanty urine production results in ineffeicient excretion of products of metabolism
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Define azotemia and identify its association with renal failure
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(Syn of uremia) Excess of urea and other nitrogenous waste in the blood
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Define Uremia
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excess of urea and other nitrogenous waste in blood. Complex of sx due to severe persisting renal failure - relieved by dialysis
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Define prerenal causes of acute renal failure
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Most common cause of acute renal failure. Poor vascular resistance or low cardiac output. hemorrhage, GI losses, dehydration, burns, trauma, peritonitis
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Define postrenal causes of acute renal failure
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obstruction of urinary tract or flow from kidneys. bladder ureter renal pelvises obstruction, BPH in men, anticholinergic drugs, CA, clots, stones or strictures
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Define intrinsic causes of acute renal failure
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account for 50% of renal failure. Considered after pre/post-renal excluded. Site of injury: tubules, interstitium, vasculature, glomeruli.
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Discuss the 3 types of intrinsic causes of acute renal failure
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1.acute tubular necrosis: ischemia, nephrotoxins 2.Acute glomerularnephritis: post-strep, callagen vascular disease 3.Acute interstitial nephritis: allergic rxn, drug rxn
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Identify important systemic diseases associated with renal insufficiency
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DM, amyloidosis, HIV, collagen-vascular diseas, sickle cell, drug hypersensitivity, heavy metals, polycystic kidney, renal artery stenosis
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Identify general principles of treatment of acute tubular necrosis in acute renal failure
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goal is to hasten recovery, avoid complications. prevent fluid overload & hyperkalemia.
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Identify general principles of treatment of interstitial nephritis in acute renal failure
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acute dialytic therapy, supportive measures and removal of inciting agent
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Identify general principles of treatment of glomerulonephritis in acute renal failure
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depending on severity; high dose steroids and cytotoxic agents. Plasma exchange in Goodpasture's disease
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Identify general principles of management of chronic renal failure
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Diet: protein, salt, water, potassium, phosphorus and magnesium restrictions, dialysis and transplant
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What is the criteria for initiation of dialysis
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GFR > 10ml/ min or serum creatinine 8mg/dL. DM pt's start FGR 15mL/ min or creatinine 6mg/dL.
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What might be other indications for dialysis other than chronic renal failure
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uremice symptoms such as pericarditis, encephalopathy, coagulopathy, fluid overload, unresponsive to diuresis, refractory hyperkalemia, severe metabolic acidosis and neurologic sx's such as seizure or neuropathy
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Define nephritic syndrome
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inflammatory process causing renal dysfunction over days to wks. Sx: acute glomerul. hematuria, HTN and renal failure
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Define nephrotic syndrome
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1/3 pt have renal disease. peripheral edema-hallmark, albuminuria, increased lipids. Can result from DM glomer., SLE, amyloidosis, renal vein thrombosis, toxic agents
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What is an important sign of renal disease, urinary tract disease or hematologic disorder
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hematuria
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What are common causes of hematuria
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renal & bladder CA: extraglomerular: cysts, calculi, interstitial nephrities, renal neoplasms. Glomerular: IgA nephropathy, thin GBM, systemic nephritic syndromes
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Describe an approach to working up a pt with hematuria
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ask about meds, hx stones diseases or malignancy. pt's on anticoagulation get complete eval
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Define proteinuria: Know that it is associated with virtually all kidney diseases as well as certain functional disorders
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Protein in urine. Associated with virtually all kidney diseases, acute illness, exercise, orthostatic DM, bence jones proteins associated with multiple myeloma
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Describe the findings of isolated proteinuria and its apparent relation to postural factors
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generally <30 y/o resulting ion excretion abnormal amounts of urinary proteins. Confirmed by measuring 8h overnight supine urinary proteine excretion
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Describe an approach to working up a pt with proteinuria discovered during a randome urine examination
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Usually glomerular; elevated BUN & creatinine, abnormal urinary sediment. After dipstick, 24h urine, renal biopsy as indicated
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Describe the routine hx, pe and labs of pt's with BPH
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hx: obstructive, irritative voiding PE: obstructive or irritative Labs: UA, serum creatinine, PSA optional
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Define obstructive symptoms in context of BPH
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hesitancy, decreased force and caliber of stream, sensation of incomplete bladder empyting, double voiding, (twice in 2hr) straining to urinate and postvoid dribbling - of urine not b-ball
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Define irritative symptoms in context of BPH
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urgency, frequency and nocturia
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Describe the medical option of a-blockers for treating BPH
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give prostate and bladder neck contractile response to agonists
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Describe the medical option of 5a-reductase inhibitors for treating BPH
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block conversion of testorterone to dihydrotestosterone impacting epithelial component of prostate resulting in reduction in size and improvement in sx's
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Describe the medical option of phytotherapy for treating BPH
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use of plants or plant extracts suc has saw palmetto verry. MOI unknown.
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Describe the surgical options for treatment of BPH
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Many surgical options including prostatectomy or less invasive ones like stents, balloon dilation, hyperthermia, etc.
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Describe the typical clinical presentation, diagnostic tests and general principals of tx of prostate cancer
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PE: vague Dx: abnornal PSA, biopsy, US, MRI. Tx: stage 1st., prostatectomy, radiation, surveillance, cryosurgery
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Describe the different types of prostatitis
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acute bacterial prostatitis, chronic bacterial, nonbacterial, that really big irritating one...:)
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Describe Sx, Dx, and tx if any, for testicular torsion
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sx: 10-20 y/o, acute px swelling within testis, lack of voiding. Dx: examine "high lie" in relation to other testis
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Describe Sx, Dx, and tx if any, for epididymitis
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Sx: fever, irritative voiding, px of scrotal contents. Dx: leukocytosis and L. shift, gram stain for STD, US. Tx: elevate scrotum, ID bugs - STD: abx 10-21 days, non-STD: abx 21-28 days
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Describe Sx, Dx, and tx if any, for varicocele
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Sx: mostly L.side. sudden onset should think retroperitoneal malignancy. Tx: diminishes in size or disappears when pt is supine
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Define epididymitis
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acute infection of epididymis
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Define hydrocele
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collection of fluid between 2 layers of tunica vaginalis
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Define varicocele
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engorgement of the internal spermatic veins above the testis
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Define spermatocele
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cyst of the epididymis containing sperm
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Describe age and clinical presentation of pt's with testicular tumors. Know that cryptorchidism is a risk factor!
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late teens early 20's, painless enlargement of testis, mass, gynecomastia, 50% have cryptorchism
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What different cell types are involved with testicular cancer
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95% are germ cell tumors: seminoma and nonseminoma. Rest are nongerminal neoplasms: leydig cell, sertoli cell or gonadoblastoma.
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What am I? This is a surgical emergency: seen in teens / young adults, acute px, dx with US, irreversible damage with eschemia >6 hrs.
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testicular torsion
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What can cause scrotal swelling?
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hydrocele, inguinal hernia, varicocele, spermatocele, epididymitis, testicular CA, torsion or trauma
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Name that incontinence! more common in elderly, usually reversible and not caused by urinary tract problems:
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Transient
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Name that incontinence! most common in elderly, leakage delayed seconds after stress, can result from bladder stones or tumor
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Detrusor overactivity AKA urge incontinence. Tx: behavioral, void every 1-2 hrs, antispasmodics or TCA's
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Name that incontinence! 2nd most common cause in older women. instantaneous leakage of urine with increaed intra-abd stress: cough, normal post-void residual
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stress. Tx: kegal exercises, estrogen, surgery, a-agonist if not contraindicated
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Name that incontinence! 2nd most common in men, rare in women. caused by prostatic enlargement, stricture. post-void dribbling, urge, etc.
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urethral obstruction. Tx: alpha blocker, surgery, 5a-reductase inhibitor
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Name that incontinence! least common, idiopathic or sacral nerve dysfunction. Frequency, nocturia, small volume.
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Detrusor underactivity. Tx: mechanical - double voiding, suprapubic pressure, intermittent or indwelling caths, cholinergic agents
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