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IM - STONES AND OBSTRUCTIONS - NEOPLASMS

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tonystep1's version from 2017-07-31 16:32

STONES AND OBSTRUCTIONS CLINICAL FEATURES AND DIAGNOSIS

Question Answer
Nephrolithiasis risk factorslow fluid intake , family history, Conditions known to precipitate stone formation (e.g., gout, Crohn's disease, hyperparathyroidism, type 1 RTA) , Medications (e.g., loop diuretics, acetazolamide, antacids, chemotherapeutic drugs that cause cell breakdown [uric acid stones] ) , Male gender (three times more likely to have urolithiasis) , UTIs
Urinary Tract Obstruction risk factorsMore common in men (due to BPH and prostate cancer)
Nephrolithiasis clinical featuresRenal colic , Location of pain-begins in the flank and radiates anteriorly toward the groin , Nausea and vomiting are common , Hematuria (in over 90% of cases) , UTI
Urinary Tract Obstruction clinical featuresRenal colic and pain pain may manifest only during urination. or maybe asymptomatic if chronic.Oliguria, recurrent UTIs, Hematuria and Proteinuria, and Renal failure maybe present.
Nephrolithiasis Diagnostic examsCT scan (spiral CT) without contrast most sensitive // Urinalysis // Examine the urinary sediment // Urine culture/ 24 urine // Serum Chem // IVP // Renal US
Urinary Tract Obstruction Diagnostic examRenal ultrasound is the initial test-it shows urinary tract dilation. It is very sensitive and specific for identifying hydronephrosis.// Urinanalysis // KUB // IVP gold standard //
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STONE AND OBSTRUCTIONS TREATMENT AND MANAGEMENT

Question Answer
Nephrolithiasis General measuresAnalgesia // Antibiotics// Vigorous fluid hydration // Out patient management
Nephrolithiasis Admission CriteriaPain not controlled with oral medications // Anuria (usually in patients with one kidney) // Renal colic plus UTI and/or fever // Large stone (> l em) that is unlikely to pass spontaneously
Neprholithiasis mild to moderate painhigh fluid intake, oral analgesia while waiting for stone to pass spontaneously (give the patient a urine strainer)
Nephrolithiasis Severe pain (especially with vomiting)Prescribe IV fluids and pain control.// Obtain a KUB and an IVP to find the site of obstruction.// If a stone does not pass spontaneously after 3 days, consider urologic surgery.
Procedure Best for stones that are >5 mm but < 2 cm in diameterExtracorporeal shock wave lithotripsy
Procedure Best for stones > 2 em in diameterPercutaneous nephrolithotomy
Lower urinary tract obstructionUrethral catheter-for acute obstruction//Dilatation or internal urethrotomy-if cause is urethral strictures//Prostatectomy-if BPH is the cause
Upper urinary tract obstructionNephrostomy tube drainage-for acute obstruction//Ureteral stent (through cystoscope)-if ureteral obstruction
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NEOPLASMS RISK FACTORS

Question Answer
Prostate Cancer Risk factorsAge (most important risk factor)// African American // High fat diet// Positive Family History//Exposure to herbicides and pesticides
Renal Cell Carcinoma Risk factorsCigarette // Phenacetin analgesic use// Adult polycystic kidney disease // Chronic dialysis (multicystic disease develops) // Exposure to heavy metals (mercury, cadmium)
Bladder Cancer Risk FactorsCigarette smoking (major risk factor) // Industrial carcinogens (aniline dye, azo dyes)
Testicular CancerCryptorchidism-surgical correction does not eliminate risk // Klinefelter's syndrome
Penile Cancer Risk FactorsIt is associated with herpes simplex virus and HPV 18 infection
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NEOPLASMS CLINICAL FEATURES

Question Answer
Early Prostate CancerIt is most commonly asymptomatic. Cancer begins in the periphery of the gland and moves centrally.
Late Prostate CancerSymptoms due to obstruction of the urethra occur: difficulty in voiding, dysuria, and increased urinary frequency. bone pain from metastases (most commonly vertebral bodies, pelvis, and long bones in legs), weight loss
Renal Cell CarcinomaHematuria is most common symptom (gross or microscopic // Abdominal or flank pain // Abdominal (flank) mass // Weight loss, fever // Paraneoplastic syndromes (uncommon)
Bladder CancerInitial presenting sign is hematuria in most cases (painless hematuria is the classic presentation).
Testicular CancerPainless mass/lump/firmness of the testicle-because of lack of pain, may go unnoticed by patient until advanced
Penile CancerIt presents as an exophytic mass on the penis
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NEOPLASMS DIAGNOSIS

Question Answer
Prostate Cancer DRE findingsCarcinoma is characteristically hard, nodular, and irregular.// Normal prostate feels like a thenar eminence. Cancer feels like a knuckle.// When palpable, 60% to 70% have spread beyond the prostate.
Prostate Cancer PSA findings and indications Use as a screening test is controversial // If PSA level > 10 ng/ml. TRUS with biopsy is indicated, regardless of DRE findings // If PSA is <4.0 ng/ml and ORE is negative. annual follow-up is indicated
Prostate Cancer indications for TRUS with biopsy PSA > lO ng/dL (or possibly lower) // PSA velocity >0.75 per year // Abnormal DRE
Renal Cell CarcinomaInitial test is Renal ultrasound-for detection of renal mass // Abdominal CT (with and without contrast)-optimal test for diagnosis and staging; perform if ultrasound shows a mass or cysts
Bladder CancerUrinalysis and urine culture // Urine cytology // IVP // Cystoscopy and biopsy (definitive test) // Chest radiograph and CT scan-for staging
Testicular CancerPhysical examination (testicular mass) // Testicular ultrasound-initial test for localizing the tumor // Tumor markers Beta HCG or AFP // CT scan and chest radiograph for staging
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Testicular Cancer DDx

Question Answer
Testicular TorsionClinical features include acute severe testicular pain, swollen and tender scrotum, and an elevated testicle (as twisting occurs, the testicle moves to a higher position in scrotum).
EpididymitisClinical features include a swollen, tender testicle; dysuria; fever/chills; scrotal pain; and a scrotal mass
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