Test 1 Notes

Internal Dx II July 7, 2003 History - A.M.P.L.E. - O.P.P.Q.R.S.T. - H.I.S.T.O.R.Y. Physical Examination - Inspection - Auscultation (done before palpation to avoid changing bowel sounds) - Percussion - Palpation Pictures - Pitting Edema o Renal failure most probable cause of death o Maybe CHF - Clubbing o Enlargement of the terminal tuffs (seen on x-ray) o AKA: Hypertrophic Osteoarthropathy  M/c lung disease but  Can be associated with GI and GU problems A.M.P.L.E. - Allergies - Medications - Past Medical History - Last Meal/LMP (onset) - Events of the present illness O.P.P.Q.R.S.T. - Onset - Provocative - Palliative - Quality - Radiation/Region of pain - Setting/Site/Severity - Timing (when does it happen and how long does it last)

Picture - Large smooth dome-shaped mass in the LUQ - Appears pale over lesion - Have pt do a sit up so that abdominal muscles contract - Incisional Hernia (past surgery) o Gets larger when she bears down and painful o Auscultation will hear bowel sounds o Feels like it is filled with air (like balloon) o Very mobile o When blood supply is lost to a hernia is call strangulation - * HISTORY - Hospitalization - Injuries/Immunizations - Sugar Diabetes - Tumors/Trauma - Operations - Review of Systems - Youth Illness Note: EVERY Patient needs a PMH (past medical history) form filled out – MAJOR CYA to avoid lawsuit. 10-Day rule • Can only take X-ray’s first 10 days of cycle • Unless chance Mom’s life is in danger or severe morbidity

Pysical Examination Inspection - Symmetry, size (distension), shape - Lumps, bumps, scars (pt. w/always have bear down to look for hernia), ecchymoses (bruising) Auscultation - Bowel sounds (5-35/minute) o AKA: Borborygmi o Relatively high pitched  use diaphragm o Very high pitched and get faster than 35/minute sign for obstruction o No bowel sounds  Paralytic (Adynamic) Ileus (blunt trauma, post operative) o Early bowel obstruction  Rapid sounds to force fecal bolus o Late bowel obstruction Shuts down and patient vomits (no bowel sounds)

o Adynamic Illius → no bowel sounds b/c no peristalsis

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Bruits o o o o

Swishing Noise Caused by turbulent flow (change in speed of blood flow) Occurs with aneurysm and stenosis M/C in the aorta (infrarenal AAA)

Percussion - Liver, spleen, diaphragm o Size o Diaphragmatic Excursion o Note pitch  LUQ: Not eaten  tympanic (b/c air in the stomach) Eaten  dull o Spleen: dull o Liver: dull o Rest of the abdomen: resonance o Bowel obstruction: dull  Tympanic: proximal  ? : distal Palpation - Organomegaly o Hepatosplenomegaly  Caused by sickle cell, etc.. - Aneurysms o Start in non-tender quadrant and go to tender quadrant o Superficial mass: in abdominal wall o Contraction of abdominal mm  Accentuated: in abdominal wall  If not in abdomen o If mobile: better than mass that is non mobile  Malignant masses do not move b/c not encapsulated and they invade other tumors and inflammatory tumor that makes scar tissue and makes more immobile  Benign tumors grow in the original tissue and do not invade - Palpation of organs o Liver o Spleen - Aorta o Lateral pulsation is not good, could represent AAA o 3.5 cm or less is normal size of aneurysm o AAA produce non-mechanical back pain

Abdominal Exam Tips - Comfortable room temperature - Patient gowned with abdomen exposed - Groin uncovered with genitalia draped - Bladder empty - Start in non-tender quadrant (end up in the tender quadrant) - Use your hand over patients if ticklish (use little firmer touch) - Normal kidney is non-palpable (possible in thin patient) - Normal liver may be palpable (8-12cm in height @ Mid Clavicular line) o Most common cause is alcoholism - A palpable spleen is enlarged - When abdomen is involuntarily flex and is very hard → abdominal rigidity usually caused by peritonitis Abdominal Regions - 4 quadrants o Right upper  Right kidney  Gallbladder  Right renal artery  Transverse colon  Biliary tree  Biliary aa & vein  Pancreas (Head of) o Left upper  Left kidney  Splenic Flexure  Stomach (fundus)  Spleen  Tail of the pancreas  Left renal aa  Aorta o Right lower  Ascending colon  Small intestine  Right ovary  Right kidney  Lower portion of liver  Right common iliac  Cecum  Appendix

o Left lower  Descending colon  Sigmoid colon  Left common iliac vein  Small intestine  Left kidney  Inferior mesenteric artery  Left ovary  Left fallopian tubes  uterus -

9 regions o R/L hypochondriac o Epigastric o R/L lumbar o Periumbilical o R/L pelvic o Suprapubic (AKA Hypogastric)

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6 regions o Epigastric  Duodenum  Pylorus  Liver (left lobe)  Pancreas  Ascending colon  Aorta (Celiac trunk, renal aa. & veins) o RUQ o LUQ o RLQ o LLQ o Suprapubic

Abdominal Exam Tests - Rebound tenderness o Push in an area where there is no pain and then quickly let go and pt will feel pain in a quadrant other than where you pushed (classic is appendix) o Peritonitis (Rovsing’s Sign) → push in quadrant pain and hurt in same area o Pain with recoil palpation  If pain in another quadrant then the test is positive • Peritonitis  If pain in RLQ and doing test in a LQ than can be positive for appendicitis

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CVA (costovertebral angle) tenderness o Kidney disease o AKA- kidney punch or Murphy’s punch test - Shifting dullness o Done while palpation abdomen o Ascites o Fluid shifts in different positions o For small amounts of ascites called “Puddle Sign”  Pt on all fours for ~ 5-10 min  Start out to in and when run into dull mark  Move to different side and repeat  Will end up with outline of the “puddle” - Psoas sign o Appendicitis o Resisted right hip flexion (supine) o Put knee and hip in flexion have pt try resist as Dr tries to extend leg - Obturator sign o Appendicitis o Resisted internal right hip rotation Diagnostic Imaging - Barium swallow o Uses barium sulfate → thick chalky substance o Shows up very white on radiograph o Can do upper GI study with a small bowel follow through - Barium enema o Barium or barium with air → forces barium against the wall o Shows endothelial wall in detail - CT scan with contrast o Iodine based is injected by IV  Vascular tissues Barium - MRI scan with contrast o IV contrast o No real good for hollow organs - Endoscopy o Use of flexible fiber optic microscope o From top EGD (Esophagogastroduedenoscopy) very common o From bottom Anoscopy, Rectoscopy, sigmoscopy, colonoscopy

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KUB (Kidney Ureter Bladder) o X-ray of abdomen (upright and supine) o Cheapest and quick o Not a great tool o Helps see fluid lines o Helps see if a mass is moving around o M/c lesion: calcified lymph node  Follow lumbar or iliac chain  Can also find in mesentery and momentum

Common GI S/SX  Abdominal distension  Abdominal pain  Anorexia  Belching, bloating, flatulence  Bleeding  Constipation/Diarrhea  Nausea/vomiting  Heartburn/indigestion/dyspepsia  Hepatomegaly/splenomegaly  Hernias  Hiccoughs  Jaundice  Rectal Pain/itching Abdominal Distension - Mechanical Obstruction (inside or outside lumen a hollow viscus that physically causes obstruction of fecal matter moving through the viscus) o Neoplasm (intraluminal/extraluminal) (not found usually until late)  Extraluminal • Baby • Hernia • Abscess from appendicitis • Oviarian tumor • Uterian tumor/mass o Post-operative adhesions o Abscess  Appendicitis  Chron’s  Diveritculitis

o Pregnancy o Hernias o Volvulus  Secum  Sigmoid o Intussception  Adhesions  Paralyzed persons (bowel doesn’t work as well)  Kid’s maybe hypermobile bowel (not really sure though)  Trauma  Ischemia -

Non-mechanical Obstruction o Adynamic illius(immobile bowel) o Ascites o Excess gas o Trauma (set-belt injury) o Infection o Peritonitis

Take KUB (kidney, ureters, bladder) x-ray as a start of diagnosing abdominal problems 5-19-03 Abdominal Pain - Burning (sometimes described as gnawing)  PUD  GERD  Can be caused by nicotine, alcohol, mint  Can also be cardiac disease - Cramping usually from organ distension)  Biliary colic (gall bladder disease – esp. gall stones)  IBD  IBS  MESENTERIC ISCHEMIA - Colicky (crescendo – decrescendo pain pattern)  Renal stones (also called renal colic)  Biliary colic (gall bladder disease – esp. gall stones)  Appendicitis - Achy  Constipation  Appendicitis (early stages)  AAA (saccular)

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Knife-like (usually very serious)  AAA (dissecting/saccular rupture)  Pancreatitis (stabbing in the mid back) Sudden onset  Perforation  Obstruction  Pancreatitis  Rupture ectopic

Abdominal Pain patterns Diffuse – visceral pain b/c secondary to organ problem - Early appendicitis  Diffuse (whole belly) or periumbilical pain  After 12 – 24 hours pain becomes the very sharp ½ way b/w ASIS and symphysis pubis  Rebound tenderness with pain in RLQ (24 – 36 hours)  Very high fever  No pain after rupture (80 – 90% mortality) - Organ involvement - AAA - IBD - Peritonitis – if diffuse peritonitis not focal peritonitis - Trauma - Obstruction Focal - Parietal pain - Organ distension - Peritonitis Epigastric - PUD (peptic ulcer disease) - Gallbladder disease - Hepatic disease - Cardiac disease - Pancreatitis RUQ -

Biliary tree disease PUD Pancreatitis – tall end Renal disease Cardiopulmonary disease

LUQ -

PUD Pancreatitis Splenic disease Renal disease Cardiopulmonary disease

RLQ -

Late appendicitis Crohn’s disease Obstruction Reproductive disease AAA

LLQ -

Diverticulosis/itis Obstruction UC Reproductive disease AAA

Periumbilical - Obstruction - Early appendicitis - AAA - Mesenteric thrombosis - Pancreatitis Don’t learn percentages know what is more common (top 3 – 4 causes) -

Non-specific abdominal pain Acute appendicitis Intestinal obstruction (esp. if previous surgery) Urological causes Gallstone disease Colonic diverticular disease Abdominal trauma 3 Abdominal malignancy Perforated peptic ulcer Pancreatitis Ruptured AAA Inflammatory bowel disease Gastroenteritis Mesenteric ischaemia

35% 17% 15% 6% 5% 4% 3% 3% 3% 2% <1% <1% <1% <1%

Abdominal Aortic Aneurysm • Any pt with low back pain over forty you should listen the abdomen for bruits - Focal widening >3.5cm o 2-2.5 cm normal size aorta - > 60 years; M:F = 5:1 - Infrarenal (90%) - Extension into iliac arteries (66%) - Plain film: mural calcifications (75-90%) - CT: perianeurysmal fibrosis (10%), may cause ureteral obstruction (secondary to AAA) - US: 98% accuracy in size measurement - Angio: mural thrombus (80%) o W/in wall of aneurysm is a clot - Complications: o Rupture (25%): into retroperitoneum (usually left), GI tract, IVC o Peripheral embolization (unusual) (can lose a leg or have severe atrophy) o Spontaneous occlusion of aorta (caused by spasm) - Non-mechanical low back pain and patient cannot find a position of comfort and when pain ends the rupture has probably occurred (if it is leaking it will cause pain) - No history of trauma - No pain relief with analgesics - Usually found on lateral lumbar X-ray (usually below renal arteries) (infrarenal) Saccular AAA - Most common - Can hear bruits Dissecting AAA - Patients are extremely sick - Usually die within 10 hours - Bleed to death inside the vessel walls - Does not widen the aorta very much - Thoracic AAA are usually caused by trauma - Lumbar more commonly in elderly (may see calcifications)

Abdominal Aortic Aneurysm - S/Sx o Most are asymptomatic (saccular) o Pulsating sensation in the abdomen o Abdominal pain (unchanged by position) o Low Back Pain (unchanged by position) o Bruit o Radiating pain into legs o Cold lower extremities, peripheral pulse loss o Shock o Sudden death - Imaging o Plain films – can see 75% of AAA o MRI o CT -

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Treatment o 3.5-5 cm – careful observation o 5-7cm – elective surgery (10% rupture/year) o >7cm – non-elective surgery (25% rupture/6 months) o If symptomatic → non-elective Surgical procedures o Open laparotomy o Endoscopic stent placement < 50% with rupture survive o Once ruptures you have minutes to a couple of hours to live

Anorexia (unwillingness to eat because of being sick) - Infection - Neoplastic (particularly malignant) - IBD (Inflammatory Bowel Disease) - Constipation - GERD (Gastroesophageal Reflux Disease) - PUD (Peptic Ulcer Disease) - Swallowing disorder Picture of patient - Patient has anorexia, cachexia (muscle wasting typically from malignancy), and ascites - Patient has end stage metastatic cancer

Belching, Bloating, & Flatulence - Aerophagia  swallowing of air (most common reason) - Insoluble carbohydrate ingestion o Bacteria acts on and causes different kinds of gases  CO2, methane, etc… - Malabsorption Syndromes - Lactose intolerance o Lack the enzyme lactase used to digest lactose - Diarrhea GI Bleeding - Upper GI o Ligament of Treats – Suspensory ligament of the duodenum @ the duojejunum junction → junction between the upper and lower GI o Esophageal varicies (dilated esophageal veins)  Causes by portal hypertension  Classically causes coffee ground emesis o Esophageal cancer o Esophagitis o PUD (Peptic Ulcer Disease)  Usually coffee ground appearance o Gastric Cancer o Hiatal hernia  Fundus of stomach loops up toward esophagus o Swallowed hemoptysis  Coughing up of blood from respiratory tract infection o Hematemesis  Vomiting of bright red blood • If bleeding in the mouth esophagus or acutely in the stomach  Acute upper GI bleed above the stomach or massive GI bleed into the stomach • Think esophageal disease o Coffee ground emesis (special type of hematemesis)  Coffee ground appearance  Blood as been around long enough for stomach acids to denature the proteins

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Lower GI o Mesenteric Thrombosis  Thrombosis of mesenteric vascular that results in necrosis  More proximal to aorta the more serious o Meckel’s Diverticulum  No pain but lots of bleeding o Volvulus/Intussception  Volvulus  Portion of valve twists upon itself  Intussception Part telescopes on itself o Colon Cancer o Colonic Polyps o IBD (Crohn’s, UC) o Diverticulosis/itis o Hemorrhoids*  Varicose veins in anus  Most common cause of bleeding from the rectum  BRBPR (Bright Red Blood Per Rectum) o Anal Fissures o Hematochezia  Bright red blood in the rectum  95% from colon (sigmoid)  Most common cause is hemorrhoids o Melena  Black tarry stools  Enzymes have worked on the stool to make it look black  Upper or Lower GI bleed that is chronic in nature that the patient has not vomited up o Blood streaked stool  Something inside the lumen of the colon that is bleeding as feces passes by it  Usually means blood is more distal because it is still red  If proximal bleed the blood would get mixed in and the stool would not be streaked o Occult blood  Cannot be seen  Polyps or cancer  Detected by occult blood testing  Hemoccult or fecal occult blood test or guiac stool test • Must have 3 normal tests to rule out bleeding • 3 positive should be followed up on

Constipation/Diarrhea - Constipation  Decrease in the volume of stool o Fecal Impaction  Loss of movement of fecal bolus in the colon  Caused by obstruction  Feces becomes very dry and very hard o Poor Fiber Intake o Poor Fluid Intake o Colon Cancer  Pure constipation  obstruction  Alternating constipation and diarrhea (floods with water to try to get rid of constipation so causes diarrhea and then constipation because stops producing fluid) o IBD o Psychiatric Causes o Meds o Hemorrhoids o Most common cause is probably poor bowel hygiene  Not eating enough fiber or drinking enough water -

Diarrhea o Infection  Viral gastroenteritis (stomach flu)  M/C cause o IBD o IBS  Spastic Colon o Stress o Colon Cancer o Psychiatric Causes o Meds  Parasympathomemetics (stimulate Parasympathetic) o Increase in volume of loose stools o Controlled by parasympathetic, increase in activity causes increase peristalsis

Nausea and Vomiting - Infectious Gastroenteritis → stomach flu o M/c reason - Obstruction o Proximal obstruction (small intestine and up) usually causes o Picture: Volvulus of sigmoid colon - Pregnancy - Severe pain - Cardiovascular Disorders - Meds - PUD - GI Cancer - Psychiatric Disorder Heartburn, Indigestion (dyspepsia or upset stomach) - Gastritis o Overindulgence, eating too much food, fatty meal - GERD/Reflux o Fatty food o Permanent Damage  permanent scarring = Reflux Esophagitis - Excess Intestinal Gas - Gas Entrapments (hepatic/splenic flexures) - Picture: Esophagus and Stomach (Hemorrhagic Gastritis) Hepatosplenomegaly Hepatomegaly  Cirrhosis o Most common cause is alcoholism → alcoholic hepatitis → cirrhosis o Most common cause of hepatomegaly o It takes 70 – 80% of damage to liver to start to see symptoms  Hepatitis  Pancreatic CA  Hepatobiliary CA  Cholangitis o Inflammation of the bile ducts o Associated with a Charcot’s triad  Late right-sided CHF  Infectious mono o Epstein Bar virus  Lymphoma  Leukemia o Affects younger kids and older people

Splenomegaly  Anemias o Not basic iron-deficiency but the more serious anemias  Infectious mono  HIV  Leukemia  Lymphoma  Myeloma o Cancer of the bone marrow (plasmocyts) o Multiple myeloma is the most common primary bone tumor  Polycythemia vera o Severe over production of blood cells

Hernias  Groin o Inguinal (96%)  Direct  Indirect o Femoral (4%)  Occur in women in femoral triangle  Umbilical o Usually in pregnant women  Incisional  Hiatus Hernia examination in men  Fingertip at most dependent portion of scrotum (bottom)  Invaginate scrotal wall to external inguinal ring  Gently insert finger into canal along spermatic cord  Move finger laterally and cephalad  Pt coughs, strains or performs Valsalva maneuver  Findings o Should not feel anything o Inguinal Hernia  Small indirect hernia may slightly tap end of finger  Large indirect hernia may be palpable as mass  Direct inguinal hernia may be felt on pad of finger o Spermatic cord tenderness (Funiculitis) o Spermatic cord lipoma o Hydrocele

Hernias  Indirect inguinal hernia o Most common type, m=f o Through deep (later)(internal) inguinal ring (entrance to canal) o Touches fingertip on examination  Direct inguinal hernia o M>F o > 40 y/o o Through (superficial)(medial) external inguinal ring (exit canal) o Touches side of finger on examination o Easily reduced, rarely enters scrotum  Femoral hernia o Least common, elderly, F>M (3:1) o Through femoral ring/canal o Often asymptomatic (even strangulated), but can be very painful

Hiccoughs -

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Rapid spasm of the diaphragm Transient o High emotion o Temperature change o Gastric distention (overeating, alcoholism) o Alcohol Ingestion o Drinking and eating at the same time o Smoking Persistent o Uremia (Urea in the blood  sign of kidney failure), o Hyperventilation (use bag to increase C02) o IDDM (b/c diabetic neuropathy) o Meds (steroids, barbiturates) o General anesthesia o Thoracic disorder (pneumonia, CA, pleural effusion, pulmonary fluids) o Gastric disorder (PUD, CA, GERD)

Jaundice -

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Yellow color of the skin and sclera because of the build up bilirubin Can cause uncontrolled itching Direct Bilirubin o From Liver o Extrahepatic obstruction (outside liver)  Calculi, neoplasm, stricture (of collecting duct system from a tumor or passage of a stone)  Metastatic CA, pancreatic CA (in head of the pancreas) o Hepatocellular disease  Hepatitis (alcoholic and non-alcoholic form)  Cirrhosis o Meds (eg. Estrogen) o Jaundice of pregnancy (hormonal cause) Indirect Bilirubin o Away from liver o Hemolysis  Congenital anemias (sickle cell)  Acquired anemias o Poor marrow production o Neonatal Jaundice (treatment by putting under UV light) o Impaired conjugation of bilirubin from meds

Rectal Pain and Itching -

Hemorrhoids (m/c organic cause  dilated rectal veins (varicose veins of butt)  internal/external) Anal Fissure (babies, people with chronic constipation/ diarrhea, anal sex, Crohn’s, UC, etc) Fecal Impaction Prostatitis Pelvic Inflammatory Disease Endometriosis

END GI MATERIAL

GU Signs and Symptoms -

CVA (costovertebral angle) pain Dysuria Polyuria Urethral discharge Impotence Hematuria Oliguria/Anuria Pelvic Pain Proteinuria Scrotal Swelling

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Main partes of GU: kidney, ureter, bladder, urethra Functions: Rid of excess fluids, filter things out of the body that are water soluble Blood pressure is regulated by kidneys as well as electrolyte balance and acid/base balance Micturition: reflex that tells you to pee Common congenital anomalies → renal cyst, double ureters, only one kidney/ureter

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CVA Pain -

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Nephrolithiasis (kidney stones  Ca+ based – 80%) – Murphy’s punch test: kidney infection Pyelonephritis → infection of renal pelvis – upper UTI o Most common from a poorly treated or untreated lower UTI Glomerulonephritis (inflammation of glomerulus- aseptic inflammation  post strep infection) o This is why pt with strep throat must complete their antibiotics o Mistaken for kidney stone Renal Cancer → AKA: hypernephroma old term – one of the fastest growing metastasis Renal abscess → people with chronic renal disease, diabetics (most common), IV drug users, patients with TB Spinal disorder

Dysuria -

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Painful urination Cystitis (Urinary Bladder Infection) o Infasimatacis Cystitis  Air in the bladder wall o E. Coli most common bacteria to cause infection o Diabetics get cystitis a lot o More common in women  Urethra is shorter in women – shorter pathway for bacteria  Wiping from P to A instead of A to P  Holding the urge to pee Urethritis o Usually infectious o Causes: Gonorrhea (gonococcal urethritis), Chlamydia (Most Common) (non-specific or non-gonococcal urethritis) Vaginitis o Inflammation of the vaginal introitus (opening)  Poor hygiene  Fungal Infection  Candida Albicans (Yeast Infection) Prostatitis o Bacterial Prostatitis (Septic) o Septic Prostatitis  Both very painful  Can be caused by stones Chemical Irritants o Latex on a condom, Meds, Laundry Detergents, Lubricants, Douche, Deodorant spray Urethral Diverticulum o Outpouching from a hollow viscus in the ureter (rarely urethra)  Can become infected and cause pain  Can be from high pressure in the system (stone), congenital weakness in the wall Bladder CA o Usually asymptomatic o Very aggressive

Polyuria -

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Excess production of urine Relative term compared to how much pt used to produce Cystitis/ Lower UTI o Heightens micturation reflex Upper UTI Diabetes Mellitus o Glucose changes the osmolality of the blood o Patient pees a lot o Triad:  Polyuria  Polyphagia  Polydipsia Diabetes Insipidus o Lack of anti-diuretic hormone which causes more diuresis (excess production of urine) Meds (diuretics) o Blood pressure control, congestive heart failure (increase in volume lowers ejection volume) Anxiety o Got to pee when you get nervous Hypokalemia and other electrolyte imbalances o Low serum potassium level

Urethral Discharge • • • • • • • •

Fluid from the urethra when not urinating Can be bloody, clear, pus, can have an odor Prostatitis o Bacterial Infection (septic and aseptic) o Prostatic fluid and/or WBC UTI o Milky discharge (composed of pus) Interstitial Cystitis o Most common in Diabetics Vaginitis o Yeast infection Gonococcal Urethritis o “The clap” NGU- Nongonococcal urethritis (Chlamydia) o M/C STD

Impotence (Erectile dysfunction, Ejaculatory dysfunction) -

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Inability to attain or maintain an erection Autonomic NS controls erection  parasympathetic controls or maintains erection  sympathetic (stress) keeps from getting erection Psychogenic o M/C cause of impotence o Stress Diabetes Mellitus o M/C other than psychogenic o Poor blood supply o Micro neuropathies & Micro vasculopathies Vascular Insufficiency o Smokers Medications o Parasympatholytic and Pathomimetic Neurologic disease o Quadriplegic, Paraplegic, Cauda Equina Syndrome, Cancer, Chronic heart Disease Systemic disease Prostatectomy o Cut regional nerves

Hematuria -

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Two types o Gross o Microscopic M/C causes is menstruation Painless has worse prognosis (CA, don’t notice, chronic) T.I.C.S. o Trauma  Renal damage  Severe Exercise o Tumor  Bladder Cancer  Renal cell carcinoma o Infection  Glomerulonephritis → infectious and noninfectious • Secondary to strep throat  Pyelonephritis • Infection of the kidneys

o Calculi  Kidney stones • Calcified stones (gallstones made with cholesterol) • Form b/c of stasis in system that slows the urine down o Cysts (renal)  Over 50% of population has renal cysts o Surgery o Sickle Cell Disease (Ischemia, Infarction, and Infection)  Due to abnormally shaped RBC Oliguria/anuria • • • • • • • • • • •

Reduced/failure to urinate < 300 ml = anuria < 600 ml = oliguria Renal failure = DM o TX: dialysis, transplant Kidney failure = uremia o Affects BP, acid/base balance, electrolytes ↓ fluid intake = usu oliguria o can only go w/o fluid for 48-72 hrs Strenuous exercise Sweat the most when sleeping (besides exercise) CHF can cz renal failure Pre-renal failure = m/c not enough blood going to kidneys Intrarenal failure = problem in actual kidney Postrenal failure = obstruction past the kidneys

Pelvic Pain • •

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referring anteriorly M/c cz = constipation (lt side) Pelvis is triangle b/w both ASIS and pubic symphysis Dysmenorrhea o Painful menstruation (outside normal) o Cz: thyroid problem, infection, premenopause, fibroids, endometriosis Fibroids o Benign tumor of uterus (leiomyoma → smooth muscle tumor with fibrous tissue) o Found on plain films of lumbar spine – very common o Possible to become malignant o Can be very large → can make women think they are pregnant Adhesions after surgery Cystitis → m/c cause = e. coli Endometriosis o Abnormal deposition of endometrial tissue outside of the uterus IBD → Chron’s, Ulcerative Colitis

Proteinuria • • • • • • • • • • • • • •

Not normally in urine b/c it’s too large Occurs w/damage to basement membrane Malignant HTN → ↑ BP, enough to cz tissue damage Idiopathic proteinuria o Ok if everything else has been ruled out o Ok if it’s mild Nephrotic syndrome → classically associated with proteinuria o Diffuse swelling associated with proteinuria o Associated with renal failure Malignant HTN CHF Diabetes mellitus sickle cell disease Idiopathic proteinuria Pyelonephritis Pregnancy Myloma Leukemia Lyphoma

Scrotal Swelling • Testicular torsion o Spermatic cord & vessels twist • Epididymitis • Trauma • Hernia • Tumor • Varicocele → “bag of worms”, varicose veins • Hydrocele → fluid filled, tubular cysts **END TEST ONE**