Nephronlithiasis

Renal colic

Epi dermiology and risk factor

10 % of population ( twice common in man )

Recurrence 50 % at 5 yrs

Peak incidence 30 -50 years of age

Clinical features

Urinary obstruction   upstream distention of ureter or  collecting  system  severe colicky pain

Writhing nerve comfortable .nausea vomiting.hematuria  (90%  microscopic) disphoresis .tachycardia. tachypnea

Occasionally gross symptomsof trigonal irritation (frequency.urgency )

Fever chills .rigors insecondary pyelonephritis

Differential diagnosis of renal colic

Acute uretheral obstruction (other causes )

UPJ obstruction sloughed papillae

Clot colic from gross hematuria

Extrinsic (eg tumour

Acute abdomen billary .bowel .pancrea.

Gynaecological –ectopic pregnancy.tortion rupture of ovarian cyst

Pyelonephritis (fever .chills .pyuria )

Radiculitis-herpes never root compression

Investigation

Screening lab

C B C_elevated W B Cin presence of fever suggest infection

Electrolyte Cr BUN_ toasses renal function

Urinary R &m ( WBC sRBC scrystal )C&S

Imaging

Non crystal spiral  CT is thestudy of choice

Abdominal ulterasoundmay demonstrate stone  or hydronephrosis

Interavenous pylogram (not used verymuch anymore

Strain all urine )stone analysis

Management

Analgesic.antimatic Iv fluidsurological consult is indicate.

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A –blocker helpful to increase stone passage in select cases

Disposition

See admission criteria (sidebar ) most patientcanbe dischargeensure patient is stable .has adequate analgesia. And is able to tolerateoral meds. Follow up with family doctor in24 -48 hours 

Post Operative Care
pain management should be continuous from or to post-anesthetic unit to hospital ward and home 
pain service may assist with management of post operative inpatients.

Post-Operative nausea and Vomiting

more likely occur if young age female gender eye / middle ear / gynecological surgery, obese , history of post-anesthetic nausea / Vomiting.

Some anesthetic agents tend to cause more nausea post-operatively than other (e.g) opioids, nitrous oxide.

Hypertension and bradycardia must be ruled out. 

Pain/surgical manipulation also cause nausea.

Often treated with   dimenhydrinare (gravol.tm  ) metoclopramide (maxeran. tm) (not with bowel obstruction) prochlorperazine ( stematil ,tm) ondansetron (zofran.tm) granisetron.

post operative confusion and agitation .

ABCs first-confusion or agitation can be caused by airway obstruction, hypercapnea, hypoxemia.

Neurologic status (glassgow coma scale.pupils) residual paralysis from anesthetic.

Pain distended bowel /bladder.

Fear anxiety/separation from caregives/language barriers. 

Metabolic disturbance (hypoglycemia, hypercalcemia, hyponatremia-especially post TURP). 

Intracranial cause (stroke, raised intracranial pressure).

Drug effect (ketamine, anticholinergics).

Elderly patients are more susceptible to post-operative delirium. 

Shoulder Dystocia

Definition

-Impaction of anterior shoulder of fetus against symphysis pubis after fetal head has been delivered

-Life threatening emergency

Etiology epidemiology

-Incidence 0.15-1.4% of deliveries

-Occurs when breadth of shoulder is greater than biparietal diameter of the head

Risk factor

-Maternal: obesity, Diabetes, multiparity

-Fetal: prolonged gestation, macrosomia

Labour :

-Prolong 2^nd stage

-Prolonged deceleration phase (8-10 cm)

-Instrumental midpelvic delivery

Clinical feature

-“Turtle sign” (head delivered but retracts against inferior portion of pubic symphysis)

Complications:

Chest Compression by vagina or cord compression by pelvis can lead to hypoxia

Danger of brachial plexus injury (Erb palsy: C5-C7.klumpke;s palsy: C8-TI )

-90% resolve within 6 months

Fetal fracture (clavicle, humerus, cervical spine )

Maternal perineal injury, may result in PPH

Intrapartum fetal hypoxia of trauma

Treatment

Goal: to displace anterior shoulder from behind symphysis pubis; follow a stepwise approach of maneuvers until goal achieve (see box)

Other option when ALARMER fails :

-Cleidotomy (deliberate fracture of neonatal clavicle)

-Zavanelli maneuver: replacement of fetus into uterine cavity and emergent C/S

-Symphysiotomy

-Abdominal incision and shoulder disimpaction via hysterotomy - Subsequent vaginal delivery 

Prognosis

-90%of shoulder dystocias will resolve with McRobert’s maneuver and suprapubic pressure

-1%risk of long term disability for infant.