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Hematuria & Stones

Clinical Medicine II

Definition of hematuria > 3 RBCs per High Power field in 2-3 properly collected urine over 2-3 weeks (by AUA)
Evaluation of hematuria indications >2 RBCs by HPF
“Clean Catch” Urine sample spread labia/retract foreskin, swab urethral area, start urination, then bring sterile container into stream (don’t stop flow) 1-2 Tbsp of urine
What are some false positives for blood w/ urine dipstick menstrual, myoglobinuria, Hbguria, semen, betadine, bacterial enzymes from vaginal infections, dehydration
Urine Dipstick checks for blood/heme, protein, nitrite, pH, glucose, ketones, bilirubin, leukocytes, specific gravity
3 steps to urinalysis physical color/appearance, specific gravity, microscopic appearance (RBCs, WBCs, mucus, crystals, bacteria)
Colors indicate what, dark yellow, Orange, gree, blue, pink/red/cola-colored Dark: dehydrated, O: foods/meds, bilirubin, Green: foods/meeds, UTI pseudomonas B: F/M, familia hypercalciuria, P/R/C: blood
Usually NOT found in urine hgb, nitrates, WBCs, RBCs >2-3, glucose, ketones, protein, bilirubin
Cath UA indications kids w/ FOD to young to CC, menstruating-UTI, vaginal discharge, to debilitated, sepsis or severe illness
Does degree of hematuria correspond to seriousness of underlying cause no
Suspicions <40 and >40 cause <40: renal stones, UTIs, >40: same, + bladder, kidney, prostate cancers
RBCs + proteinuria means what glomerular source
Why does proteins suggest glomerular source the rents are disrupted and RBCs are damaged: and ↓ of filtration
Color for glomerular hematuria often brown or cola-coloared d/t ↑ transit time, RBC casts and damaged RBCs often found
Causes for glomerular hematuria glomerulonephritis, IaA nephropathy, thin basement membrane nephropathy, hereditary nephritis, lupus, vasculitis, chronic interstitial nephritis
Vasculitis cause of glomerular hermaturia think what – wegener’s granulomatosis
Hereditary nephritis alport syndrome
igA nephropathy Berger’s Disease
If blood is urine is nl suggests what aka no dysmorphic casts extraglomerular hematuria
Causes of extraglomerular hematuria infx, nephrolithiasis (kidney), calculus, malignancy, cystic dz, vascular d/o, endometriosis, BPH, urethritis, urethral trauma
MC cause of hematuria infections, Renal stones, BPH, cancer
Glomerular blood red, smoky brown, no clots, protein could be >500mg/day, dysmorphic RBCs, casts
Extraglomurlar blood red, pink, maybe clots, <500mg/day proteins, nl RBC, no RBC casts
Why would a dipstick be + for blood hemoglobinuria: hemolysis, and Myoglobinuria: rhabdomyolysis
Medications that cause false + rifampin, nitrofurantoin, phenytoin, ibuprofen
What are some food dyes that may cause pseudohematuria beets, rhubarb, berries
Ddx for dysuria, pyuria, fever UTI, pyelo, prostatitis, urethritis, malignancy
DDx for urethral discharge urethrisits, prostitis
DDx for flank pain pyelo, stones, neoplasms, ischemia, GN
DDx for hesitancy, dribbling BPH
DDX for gross, painless hematuria bladder cancer, postinfectious GN
DDx for fevers, rash arthritis GN assoc w/ SLE vasculitis
DDx for pt w/ hematuria and recent ravel schistosoma, Tb
DDx for suprapubic tendernesss UTI
DDx for CVA tenderness pyelonephritis
MC causes of Hematuria UTI, urolithiasis, BPH, Urologic Malignancy
What electrolytes should we remember to check Na, K, Ca, P
If + urine cultures, or stones what should we do repeat UA 2-6weeks, Stones: repeat after stone clearance
Limitations of imaging for IV urogram poor sensitivity to characterize renal parenchymal masses. IV contrast (same as retrograde pyelogram)
When does proteinuria become concerning >500mg/dl
Gold standard for images CT urogram (lg radiation, and expensive) later step
Indications of cystoscopy lower urinary track suspicion, can do biopsy (urether and bladder)
If there is a bladder tumor, what else should we do do upper urinary tract imaging (same cell lines)
What is urine cytology especially good at ↑specific/sensitivity for high grade urothelia carcinoma (limited for low grade dz) (can do urine cytology from cystoscopy)
If no clear cut cause found, what do we do MUST follow up, usually infx/stones though
Nephrolithiasis urinary tract stones: crystalline mineral concentrations (recurrence common)
Stone composition calcium, oxalate, Uric acid, phosphate
Causes of stone development supersturation, deficiency of stone inhibitors, substrate stone formation, ↓ water vol
Risks for Calcium oxalate stones ↓ urine vol, Hyper calcemia, calciruia, oxalurai, hypocitraturia, gouty diathesis (MC w/ 36-70%)
Risks for Calcium phosphate ↓urine, UTI, hyperPTH, distal renal tub acidosis
Mixed oxalate and phosphate risks all of the above
Infectio-related causes of stones called struvite: UTI, urea splitting organisms
Urea splitting organism proteus, klebsiella, pseudomonas, staph,
Uric acid stone RF’s ↓ urine, pH<6, obesity, hyperuricemia, uricosuria, gout alcohol abuse, gongenetial metabolic erros, nephropathy, gouty arthritis
Cystine stone RF’s cystinuria, congenital intestinal tract defect, congenital transport error
Hx of congenital anatomic defects medullary sponge kidney, horseshoe kidney, urethropelvic jxn obstruction
Where is Ca++ absorbed 90% small intestine, 20-40% in pt’s w/ stones
Dietary RF’s drinking <1L of water a day, ↓ vol urine, ↑ animal protein,
Environmental factors for kidney stones hot arid climate, excessive fluid loss from sweating, ↓ urine vol
Signs of kidney stones Severe pain: tachy, HTN, fever: UTI, pylo
What are clinical signs of large stones urinary tract obstruction,
Reccurent stones, what do we do Urology, 24 hr collection, check for Ca+, uricosuria, citraturia analyze stones
What size of stones will uaually pass <5mm
What are some medical expulsive therapies CCBs, alpha-blockers
What do larger stores require llithotripsy or surgical management
What is the preferred tx for most renal stones Extracorporeal shock wave lithotripsy (ESWL)
Most common complication of ESWL pain, hematomas in 5-20%
When do we use percutaneous nephrolithotomy (PCNL) stones >2cm near the pelvis, many complications
Chronic stone management ^fluid 2.5L a days, ↓Na+, diruetics, reduce pH to below 6.0 for struvite stones
Chronic management for uric acid stones allopurinol, high pH, citrate
Why do we alkalize urine to tx chronic stone management cysteine stones, K+ citrate to maintain pH 6.5-7
Created by: becker15
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