Obstructive uropathy (note, we're only discussing the mechanical causes of ARU)

Consequence of Obstructive uropathy:
1. Pain (acute)
2. Infection (stasis is the basis for infection) (Acute and chronic)
3. Loss of renal function (chronic)

Complete obstruction:
1 day: renal impairment begins
1 week: irreversible renal damage

Causes of Obstructive Uropathy:
Causes of obstructive uropathy may be grouped into luminal, mural and extramural causes:

1. Luminal causes
- Stones (commonest)
- Foreign bodies
- blood clots

2. Mural causes
- Strictures secondary to infection, trauma (e.g. passage of stones, instrumentation)
- tumours
- dysfunctional sphincters
- urthreitis

3. Extramural causes
- prostate
- tumour
- LN
- fecal loading
- pregnancy
- UV prolapse

Site specific: Causes of mechanical obstruction in

Kidney
Luminal: stones
Mural: tumours, strictures --> PUJO (presents in young patients who suffer a bout of renal colic, loin to groin pain when drinking too much water or taking diuretics or food with similar effects)

Ureters:
Luminal: stones
Mural: tumours, strictures
Extramural: pelvic masses, abdominal masses, tumours, LNs, fecal loading, pregnancy

Bladder:
Luminal: Stones, FB
Mural: strictures, tumours, dysfunctional sphincters, urethreitis
Extramural: prostate, fecal loading, UV prolapse, tumour

BPH:
>50 years old
>67 years old as mean
S/S:
1. ARU
2. LUTS (voiding and irritative symptoms)
3. bladder stones, stasis, infection, hydronephrosis, pyelonephritiis
4. overflow incontinence

Voiding symptoms: frequency, urgency, nocturia

Obstructive symptoms: hesitancy, straining, poor stream, end-dribbling, incomplete voiding

A case of infective endocarditis: TUTORIAL WITH MONICA CHAN

Mr Yong CW, a 37 yo Chinese gentleman with known VSD diagnosed incidentally by 2DE presented with:
1. Fever w/ chills and rigors
2. SOB
3. Cough (dry cough)

Negatives:
1. night sweat
2. history of IVDA, lines, recent dental procedures, antibiotic prophylaxis

O/E: Theoratical
Hands:
1. Janeway lesions (palm, MP, painless)
2. Oslers (Pulp, violaceous, painful)
3. splinter hemorrhages
4. clubbing (subacute infective endocarditis)

Arms:
1. injection marks, lines, tracts

Mouth:
1. oral hygiene

Chest:
1. pneumonia
2. signs of heart failure. Murmurs (changing heart murmurs!)

Abdo:
1. HSM (mild, due to seeding?)

Investigations: (my part) - Lab and imaging studies + others
Biochemical + bloods:
1. Septic W/u with FBC + Blood Cx (3x looking for continous bacteraemia)
2. U/E/Cr
3. LFT
4. Dipstix, UFEME (microscopic haematuria)

Imaging:
1. CXR
2. Serial ECG, looking for PR interval changes)

Thus this patient was managed as per infective endocarditions:
1. DO BLOOD CULTURE BEFORE ANTIBIOTIC THERAPY

EVERTHING ELSE BELOW IS HYPOTHETICAL BECAUSE BLOOD CULTURES ARE NOT BACK YET

Some generalizations:
1. IVDA usually Gram +ve (SA) KIV CAMRSA
2. Native valve: cover SA, Strep and Gram -ve
3. periop/new prosthetic valves: MRSA and cogulase -ve SA

While waiting for blood culture to be back:
EMPIRCAL TREATMENT:

1. native valves: Cover Gram +ve (SA and strep) and Gram -ve
Cloxacillin against SA (poor cover against Strep)
Penicllin against Strep (poor cover against SA)
Gentimicin (gram -ve cover + synergistic effect of shortening bacteraemia)

GloxPenGent

2. Perioperative: MRSA and coagulase -ve staph:
- Vancomycin + gentamicin (cloxacillin cannot cover MRSA)

if IVDA, R sided without pulmonary involvement: 2 weeks
if everything else, 4 weeks

After the cultures return: a more targetted approach:
1. Staph aureus:
- IV cloxacillin (4 weeks) + gentamicin (3-5d to decrease bacteraemia)

2. L sided endocarditis: streptococcus viridans: tend to be sensitive to penicillin but need to look out for MIC :
- Benzylpenicillin high dose for 4 weeks
- low dose Genta for 2 weeks

3. Prosthetic valves perioperatively:
- Vanco: 4-6 weeks
- genta 4-6 weeks
monitor kidney function

MO:
1. Blood Cx
2. empircal treatment
3. blood cx result returns
4. specific treatment
5. blood culture repeat on D2
6. f/u 2DE/TEE

Offer surgical Mx if:
1. abscess
2. involves aortic root
3. valve rupture
4. continuing embolic phenomenon despite ABx
5. continuing bacteraemia despite Abx
6. vegetation >1cm

Bacterial agents of Infective Endocarditis:
1. IVDA: staphylococcal aureus
2. Dental procedure: strept viridaans (alpha hemolytic?), HACEK (hemophilus, actinobacillus, cardiobacterium, eikenella, kingella)
3. Early Prosthetic valves: MRSA, coagulase -ve (staph epidermidis)
4. Late prosthetic valves: Strep viridans
5. Strep bovis (gamma hemolytic?)
6. enterococcus

DUKES CRITERIA FOR ENDOCARDITIS:
2 major, 1 major 3 minor, 5 minor

Major criteria (3 in all)
1. Histopathological evidence of thrombus (not applicable. post op)
2. TEE echo: new oscillatory lesion/thrombus on valve or new prosthetic valve dehiscence
3. Blood Cx +ve for viridans, SA, HACEK on 2x blood Cx 12 hours apart

Minor criteria (5 in all)
1. fever
2. immunologic response (janeway/osler)
3. embolisation evidence (splenomegaly eg.)
4. TEE not fulfilling major
5. blood Cx not fulfilling major

Goldberger's triad of dilated cardiomyopathy:
1. V1S + V6R > 35mm
2. poor R wave progression
3. Isoelectic limb leads

CT contraindications: RAMA:
1. renal
2. asthma
3. metformin
4. contrast allergy

Causes of post-operative Fever

Common causes of POF (post op fever):
WIND: atelectasis
WATER: UTI
WALK: DVT
WOUND: surgical wound infection
WEIRD DRUGS: drug fever

the most common cause of POD1 POF = ATELECTASIS
if the fever spikes daily not responsive to AB = intraperitoneal abscess

dieulafoy

A hypothetical case

A 32 year old gentleman with no past history of alcoholism or smoking presented at the ED for haematemesis and malaena for 2 days (not a local case). He denied severe retching or vomiting prior to the onset of his complaint. This obviosu case of BGIT was complicated by cardiovascular embarrassment with low BP, sinus tachycardia and AMS.

PCTs and fluids were given.

The GI team was called in. The working diagnosis was that of peptic ulcer disease involving an artery resulting in BGIT.

An OGD was done asap and a gastric artery aneurysm (aka Dieulafoy lesion aka Exculceratio Simplex) was found in the upper half of the stomach along the lesser curvature (classic site).

Endoscopic sclerotherapy was performed and the patient was discharged well.

Notes:
Dieulafoy lesions are relatively rare (duh. any weird names are usually rare)
Extragastric invovlement is possible:
- Duodenum is next commonest
- Colon
- Esophagus
- Jejunum

http://www.aao.org/publications/eyenet/200901/am_rounds.cfm

3 causes of eyeball bruit we discussed today:
1. anaemia (very severe)
2. temporal arteritis
3. CCF: carotid cavernous fistula

Pathway:

Posterolateral hypothalamus --> 1st order neurone

1st order neuron terminates at ciliospinal center of BUDGE at C8-T2 (T1)

2nd order neuron: from Ciliospinal centre of BUDGE enters cervical sympathetic chain

Terminates at the superior cervical ganglion at the bifurcation of CCA at C3-C4

3rd order neuron (post ganglionic pupillomotor fibres) exit the ganglion and ascends via ICA entering cavernous sinus, briefly joining CN6 before entering orbit via SOF with CNV1 via the long ciliary nerve which innervates the pupillary dilator and Mullers

3rd order neuron (post ganglionic sudomotor and vasomotor) branch off the ganglion and travel along ECA to innervate the face.

Clinical S/S:

- miosis (paralysis of pupillary dilator)

- enopthalmos (loss of tone of the muscles of the floor of orbit

- partial ptosis (loss of tone of superior tarsal muscle of Muellers)

- slight elevation of lower lid (upside down ptosis due to loss of tone of lower tarsal muscles)

Features would be seen in congenital horners: heterochromia

Diagnosis:

2 tests: cocaine 4% or adrenaline 1:1000

These tests help us determine whether it is above or below the superior cervical ganglion

For example, with a lesion distal to the superior cervical ganglion:

addition of cocaine 4% will:

affected eye --> no changes

unaffected eye --> dilates

for a lesion proximal to the superior cervical ganglion:

affected eye --> dilates

unaffected eye --> dilates

Another example with adrenaline 1:1000 eyedrops:

Distal lesion:

affected eye --> dilates

unaffacted eye --> no changes

Proximal lesions:

affected eye: no change

unaffected eye: no change

Thus if a patient presents with unilateral partial ptosis with upside down ptosis: check for vasomotor and sudomotor changes to determine level. If you suspect the patient having a lesion proximal to the superior cervical ganglion: look at the neck. In the local context, most probably due to pancoast tumour. So what you should do:

1. ask about sudomotor and vasomotor symptoms (to confirm suspicion of level)

2. offer to do and actually inspect and examine the lower neck for signs of SVCO and cervical lymphadenopathy

3. offer to examine the upper chest

4. offer confirmatory tests: 4% cocaine and 1:1000 adrenaline, of which the affected eye will dilate with 4% cocaine but will not with 1:1000 adrenaline