DM nephropathy

clinical course:

Stage 1:
  因hyperglycemia->prostaglandin and NO ↑-->hyperfiltration,kidney hypertrophy

Stage 2:
pathology finding:
 GBM thickness,kimmelstiel-wilson nodule

Stage 3:
microalbuminemia= 30-300mg/day or 30-300ug/mg Cr(ACR)


Stage 4:
 macroalbuminemia= >300mg/ day albumin or >500mg/day protein

Stage 5:
ESRD,uremic(fluid retention)

Work up:
spot urine:albumin,Creatinine
24 hr urine

Complication:
-microvascular:眼,neuro,GI
-macrovascular:CAD,CAV

*type 1 DM  with retinopathy(+)-->100% nephropathy(+)
  type 2 DM  with retinopathy(+)-->60% nephropathy(+)

Diagnosis:
Previous diagnosis DM(+),DM retinopathy(+), proteinuria

**if
  late onset DM
  hematuria
  no retinopathy
  heavy proteinuria(>7g/day)
--->survey other causes!!!!


Treatment:
1.ACEI/ARB
2.if HTN: ACEI/ARB+diuretics(keep BP <130/80)
3.Keep LDL<100(70) under statin control
4. 限蛋白飲食:0.8g/kg-day

Bladder tumor

Bladder tumor

Type:
Most comm: UCC(related to smoking, dye, 中藥)
10% squamous cell carcinoma:與chronic cystitis 有關(stone, foreign boday, suprapubil catheter, parasite)
1% adenocarcinoma: 尿道上裂80%有bladder adenocarcinoma


symptom:
painless hematuria, LUTs(if tumor 在接近bladder neck 會刺激的urethra)

diagnosis:
cystoscopy
10% urine cytology (+):多為接近urethra 的tumor


staging:

treatment:
if tumor just involved mucosa layer not invade to muscularis->TURBt (30% recurrent rate)
  muscularis invasion(+)->cystectomy +LND
intravescical injection:
  if low grade->mitomycin C(TURBt 後24小時內)
  if high grade-> BCG

iatrogenic ureter injury

 Iatrogenic  ureter injury

Cause:
1.GU : urteroscopy, open surgery, laparoscopic
2.GYN: hysterectomy
3.CRS: APR, sigmoidectomy

Mechanism:
ligation, clamp, thermal injury, ischemia change, laceration

Diagnosis:
1.seldom noted during operation, always delayed diagnosis(65-80%)
2.sign:flank pain, hematuria, Cr increased, aurea,fever,
3.Image:
     retrograde and antegrade urography
     contrast CT with extravasation


Treatment:
-lower/3 ureter:
     psoas hitch:補3cm
     boari flap:補5cm
--->兩者可補7cm
-middle/3:
     segmental resection:for<1cm injury, 可補3cm
     trans-urtero-ureterostomy

-upper/3:
     free kidney:3cm
     autotransplant

Air emboli

management:
-->prevent further air entry, reduction in volume of air entrained, and haemodynamic support

1.Jugular vein compression
2.100% oxygen supply
3.Keep MAP: IV fluid or inotropic agents
4.左側臥
5.consider anti-coagulant therapy

1.
coffee ground -> vital sign -> okey -> 1. NG  2. lab:CBC( check HB),BUN,Cr 3. PPI
                            -> no okey -> call R

2.
Af



amiodarone :150 mg f/u + ekg monitor

survey sympathic increase underlyine, like pain...

6Amp in D5W 250 glass bottle run 16 cc /hr 前六小時






3.
Vomitting

4.
dizzing

5.
dyspnea


6.hyperglycemia 350 FBS

(1) under insule treatment patient and totally use 30u

1500/30=50
350 -150=200
200 => 4U

(2) new onset
:    0-80: orange juice, milk, and call a doctor
:  80-200: 2U regular
: 201-250: 4U regular
: 251-300: 6U regular
: 301-350: 8U regular
:    >400:10U regular and call a doctor
survey inf. etc...

7.seizure:
最重要的是避免seizure continue or recurrent+survey etiology
Keep ABC
Ativan 1amp IV slow push,間隔2-3min,max:3 amp-->之後考慮depakin or keppra loading

*if status epilepsy :
IV: thiamine 100mg IV à dextrose 50mg IV push
ativan 
depakin or keppra pump
IV run 快一點,record I/O(prevent rhamdomyolysis àAKI)

Check:CBC/DC,electrolyte(Na,Ca,Mg),BS,BUN/Cr,ABG,amonia,drug level(CT)

*if patient have brain injury related history->add anticonvulsant for seizure prophylactic
*注意病人post-ictal意識是否有回復


Intermittent claudication

 CILOSTAZOL TAB 50MG

 overactive bladder

VESICARE TAB 5MG

after load
-
pre load
-ACEI

Prostatitis

Dx:
four glass->two glass(pre- and postmassage test (PPMT))





Chronic pelvic pain syndrome
Patients usually have symptoms consistent with prostatitis, such as painful ejaculation or pain in the penis, testicles or scrotum. They may complain of low back pain, rectal or perineal pain, or even pain along the inner aspects of the thighs. They often have irritative or obstructive urinary symptoms and decreased libido or impotence

BPH

Benign prostate hyperplasia

Prostate function:
1.secrete alkaline 2.PSA

**PSA increased ddx:
 x6:tumor, BPH,prostatitis, infection, trauma, urine routine

Risk:
  1.Age
  2.Testosterone-->DHT(via 5 alpha-reductase)

--->造成muscle, gland 的比例增加
-->造成BPH

Location:
transitional zone(around urethra),median lobe,lateral lobe
S/S:
  1.hematuria 初段尿和末段尿
  2.LUTS syndrome

  -obstruction(voiding):
     Weak voiding strain
     Intermittemt
     Strain to voiding
     Empty incomplete

  -Storage(irritation):
    Frequency
    Urgency
    Nocturia

Evaluation score:"IPSS"

Treatment:

-medication:
     1.alpha-1 blocker
     2.5alpha-reductase inhibitor: side effect:libido
     3.anticholinergic: for urgency (if PVR>100ml才用)

-surgery :TURP
*surgical indication:
     1.aurea episode>3 times
     2.urosepsis
     3.Stone formation
     4.VUR

*TURP complication:
1.TURP syndrome:

S/S:
 hypertension first->then hypotension shock
 hyponatremia->IICP
 pulmonary edema
Treatment:
 IV fluid
2.Bleeding
3.Urine retention due to blood clot
4.incontinence
5.retrograde ejaculation
6.urethra stricture

*TURP拔 foley:
兩個月內會urgency,漏尿,dysuria,hematuria.不可以騎腳踏車or 機車