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169 Cards in this Set
- Front
- Back
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Polycystic Kidney Disease -
What is it |
AD -
b/l cysts progressively develop late onset usu asymp until 30 y/o 50% - ESRD with dialysis by 60 y/o AR - less common more severe often lethal in 1st few years infants and kids renal failure liver fibrosis portal HTN |
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Polycystic Kidney Disease -
Hx/PE |
Hematuria
HTN pain - sharp & localized from ruptured cysts, infection, renal calculi large, palpable kidneys liver cysts berry aneurysms mitral valve prolapse colonic diverticula |
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Polycystic Kidney Disease -
Dx |
US
or CT |
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Polycystic Kidney Disease -
Tx |
Prevent complications,
slow progression to ESRD: early management of UTI - prevent renal cyst infection control BP ESRD - dialysis renal transplant |
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Nephrolithiasis -
MC in what population Risk factors |
MC in older men
risk factors - fam Hx low fluid intake gout postcolectomy postileostomy spec. enzyme d/o RTA hyperparathyroidism |
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Nephrolithiasis -
Hx/PE |
Acute onset
severe colicky flank pain may radiate to testes or vulva n/v pt. freq. shift position |
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Nephrolithiasis -
Dx |
Spiral CT - test of choice
UA - best 1st test KUB renal US IVP - confirm noncontrast abdom CT UA - hematuria altered urine pH |
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Nephrolithiasis -
Tx |
Init Tx -
hydration analgesia < 5mm - can pass thru urethra < 3 cm - ESWL (extracorporeal shock wave lithotripsy) percutaneous nephrolithotomy |
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Nephrolithiasis -
Calcium Oxalate/ Calcium Phosphate Characteristics Tx |
MC (83%)
idiopathic hypercalciuria primary hyperparathyroidism hyperoxaluria hypocitraturia alkaline urine radiopaque Tx - hydration thiazide diuretic |
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Nephrolithiasis -
Struvite (Mg-NH4-PO4) Characteristics Tx |
"Triple phosphate stones"
due to urease-producing org. - Proteus staghorn calculi alkaline urine radiopaque Tx - hydration treat UTI, if present |
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Nephrolithiasis -
Uric Acid Characteristics Tx |
Hyperuricemia
gout high purine turnover states acidic urine (pH < 5.5) radiolucent Tx - hydration alkalinize urine with citrate citrate converted to HCO3 in liver |
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Nephrolithiasis -
Cystine Characteristics Tx |
Due to defect of tubular
amino acid transporter for cystine, ornithine, lysine & arginine (COLA) yellow-brown hexagonal crystal radiopaque Tx - hydration alkalinize urine if neither works - penicillamine |
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Ureteral Reflux -
What is it |
Retrograde flow of urine
from bladder back up due to insuff. submucosal length of ureter => ineffect. restricting retrograde flow during contraction of bladder recurrent UTIs |
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Ureteral Reflux -
Dx Tx |
Dx -
VCUG: Voiding CystoUrethroGram detects abnorm at ureteral insertion site classifies grade of reflux Tx - tx infections aggressively ■ mild reflux - no dilation often resolves spontan ■ mod to severe reflux - surgery (uret. reimplantation) |
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Renal Cell Carcinoma -
What is it Risk factors |
MC kidney cancer (80-90%)
adenocarcinoma arises from tubular epith cells => renal vein => IVC => mets to lung & bone risk factors - men smoking VHL disease |
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Renal Cell Carcinoma -
Hx/PE |
Classic triad -
hematuria flank pain palpable flank mass polycythemia constitutional Sxs enlargement of left testicle |
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Renal Cell Carcinoma -
Tx |
Surgical resection -
curative if local notoriously resistant to chemo & radiation |
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Cryptorchidism -
What is it |
Failure of testes to
descend into scrotum b/l assoc. with oligospermia & infertility risk factor - prematurity |
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Cryptorchidism -
Hx/PE |
Testes can't be manipulated
into scrotal sac with gentle pressure may be palpated anywhere along inguinal canal or in abdomen |
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Cryptorchidism -
Tx |
Orchiopexy -
after 1 y/o & before 5 y/o in 99%, testes descend by 1 yr find later in life - orchiectomy to avoid risk of testicular Ca |
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Erectile Dysfunction -
What is it Risk factors |
10-25% of mid-aged or elderly
fail to init, fill or store risk factors - DM atherosclerosis meds - B-blockers, SSRIs HTN heart dis. spinal cord injury surgery or radiation for prostate cancer |
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Erectile Dysfunction -
Hx/PE |
Ask about -
risk factors meds recent life changes psych stressors psychological - if pt. has nocturnal or early-morning erections situation dependent |
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Erectile Dysfunction -
Dx |
Check for hypogonadism
testosterone levels gonadotropin levels prolactin levels eval for neuro dysfunction - anal tone lwr ext sensations |
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Erectile Dysfunction -
Tx |
Psychotherapy
sex therapy testosterone - if hypogonadism sildenafil - PDE5 inhibitor inc. cGMP => smooth mus relaxation => inc. blood flow in corpora cavernosa |
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Nephritic Syndrome -
What is it |
Manifestation of glomerular
inflammation (glomerulonephritis) |
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Nephritic Syndrome -
Hx/PE |
Hematuria - smoky-brown
HTN oliguria edema - low pressure areas (periorbital, scrotum) |
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Nephritic Syndrome -
Dx |
UA -
hematuria (possible) mild proteinuria dec. GFR inc. BUN/Cr c' ANA ANCA anti-gbm Ab renal Bx |
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Nephritic Syndrome -
Tx (in general) |
Tx HTN, fluid overload
and uremia - salt restriction water restriction diuretics dialysis (if nec.) corticosteroids |
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Postinfectious GN -
What is it |
Nephritic Syndrome
usu assoc. with recent strep infection group A, B-hemolytic |
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Postinfectious GN -
Hx/PE |
Smoky-brown urine
HTN oliguria periorbital edema |
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Postinfectious GN -
Labs & Histology |
Low serum C3
inc. ASO titer lumpy-bumpy immunofluorescence |
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Postinfectious GN -
Tx & Prognosis |
Supportive
almost all kids & most adults have complete recovery |
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IgA Nephropathy (Berger's) -
What is it |
Nephritic Syndrome
MC type worldwide assoc. with URI or GI infections young men |
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IgA Nephropathy (Berger's) -
Hx/PE |
Gross hematuria
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IgA Nephropathy (Berger's) -
Labs & Histology |
Inc. serum IgA
Bx & immunofluorescence - mesangial IgA deposits |
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IgA Nephropathy (Berger's) -
Tx & Prognosis |
Glucocorticoids
20% progress to ESRD |
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Wegener's Granulomatosis -
What is it |
Nephritic Syndrome
granulomatous inflammation of respiratory tract & kidney necrotizing vasculitis paucimmune form of RPGN |
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Wegener's Granulomatosis -
Hx/PE |
Fever
weight loss hematuria respiratory & sinus Sxs cavitary pulmonary lesions - bleed => hemoptysis |
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Wegener's Granulomatosis -
Labs & Histology |
c-ANCA
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Wegener's Granulomatosis -
Tx & Prognosis |
High-dose corticosteroids
cytotoxic agents pts. tend to have freq relapses |
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Alport's Syndrome -
What is it |
Nephritic Syndrome
hereditary boys 5-20 y/o |
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Alport's Syndrome -
Hx/PE |
Asymp hematuria
nerve deafness eye disorders |
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Alport's Syndrome -
Labs & Histology |
GBM splitting on
electron microscope |
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Alport's Syndrome -
Tx & Prognosis |
Progress to RF
anti-GBM nephritis may recur after transplant |
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Goodpasture's Syndrome -
What is it |
Nephritic syndrome
GN & pulmonary hemorrhage men in mid 20's immune form of RPGN |
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Goodpasture's Syndrome -
Hx/PE |
Hemoptysis
dyspnea possible respiratory failure |
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Goodpasture's Syndrome -
Labs & Histology |
Linear anti-GBM on IF
iron-def. anemia CXR - pulmonary infiltrates sputum - hemosiderin-filled macrophages |
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Goodpasture's Syndrome -
Tx & Prognosis |
Plasma exchange therapy (plasmapheresis)
pulsed steroids cyclophosphamide may progress to ESRD |
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Nephrotic Syndrome -
What is it |
Inc. permeability of
glomerulus to protein => proteinuria = or > 3.5 g/day hypoalbuminemia hyperlipidemia hyperlipiduria edema predisposed to hypercoag state 1/3 due to systemic dis. - DM SLE amyloidosis |
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Nephrotic Syndrome -
Hx/PE |
Generalized edema
foamy urine if severe - dyspnea ascites inc. susceptibility to - infections ven. thrombosis PE |
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Nephrotic Syndrome -
Dx |
UA -
proteinuria > 3.5g/day lipiduria dec. albumin (< 3g/dL) hyperlipidemia Bx - Dx underlying etiology |
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Nephrotic Syndrome -
Tx (in general) |
Steroids - best init. Tx
cyclophosphamide restrict salt diuretics statins |
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Minimal Change Disease -
What is it |
Nephrotic syndrome
common in children idiopathic etiology |
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Minimal Change Disease -
Hx/PE |
Tendency towards -
infections thrombosis |
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Minimal Change Disease -
Labs & Histology |
Normal under light microscope
electron microscope shows - fusion of epith foot processes |
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Minimal Change Disease -
Tx & Prognosis |
Steroids
excellent prognosis |
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Focal Segmental
Glomerulosclerosis (FSGS) - What is it |
Nephrotic syndrome
idiopathic IVDU HIV |
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Focal Segmental
Glomerulosclerosis (FSGS) - Hx/PE |
Especially common in black men
with uncontrolled HTN |
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Focal Segmental
Glomerulosclerosis (FSGS) - Labs & Histology |
Microscopic hematuria
Bx - sclerosis in capillary tufts |
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Focal Segmental
Glomerulosclerosis (FSGS) - Tx & Prognosis |
Prednisone
cytotoxic therapy Poor prognosis |
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Membranous Nephropathy -
What is it |
Nephrotic syndrome
MC white adult nephropathy MC idiopathic form in adults immune-complex disease |
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Membranous Nephropathy -
Hx/PE |
Associated with -
HBV syphilis malaria gold (drug) penicillamine cancer SLE |
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Membranous Nephropathy -
Labs & Histology |
"spike and dome"
due to granular deposits of IgG and C3 at basement membrane |
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Membranous Nephropathy -
Tx & Prognosis |
Steroids are of little use
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Diabetic Nephropathy -
What is it |
Nephrotic syndome
Diffuse hyalinization nodular glomerulosclerosis Kimmelstiel-Wilson lesions |
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Diabetic Nephropathy -
Hx/PE |
Usually have long-standing,
poorly-controlled DM |
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Diabetic Nephropathy -
Labs & Histology |
Thickened glomerular
basement membrane increased mesangial matrix |
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Diabetic Nephropathy -
Tx & Prognosis |
Tight glucose control
protein restriction ACEIs |
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Lupus Nephritis -
What is it |
Nephrotic & nephritic syndrome
WHO types I-V severity of renal disease determines overall prognosis |
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Lupus Nephritis -
Hx/PE |
Proteinuria
or RBCs in UA |
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Lupus Nephritis -
Labs & Histology |
Mesangial proliferation
subendothelial immune-complex deposits |
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Lupus Nephritis -
Tx & Prognosis |
May reduce dis. progression -
prednisone cytotoxic therapy |
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Renal Amyloidosis -
What is it |
Nephrotic syndrome
primary - plasma cell dyscrasia secondary - infectious inflammatory |
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Renal Amyloidosis -
Hx/PE |
Pts may have multiple myeloma
or chronic inflammatory dis. (RA, TB) |
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Renal Amyloidosis -
Labs & Histology |
Abdom fat Bx
congo red stain apple-green birefringence under polarized light |
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Renal Amyloidosis -
Tx & Prognosis |
Prednisone
melphalan BMT - for multiple myeloma |
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Membranoproliferative
Nephropathy (MPGN) - What is it |
Nephrotic & nephritic syndrome
3 types |
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Membranoproliferative
Nephropathy (MPGN) - Hx/PE |
Immune deposits
low complement associated with HCV slow progression to RF |
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Membranoproliferative
Nephropathy (MPGN) - Labs & Histology |
"Tram tracks" -
double-layered basement memb type I - subendo deposits type II - dec. C3 C3 nephritic factor (IgG autoAb) |
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Membranoproliferative
Nephropathy (MPGN) - Tx & Prognosis |
Corticosteroids
cytotoxic agents |
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BPH -
What is it |
Normal part of aging
seen in > 80% by age 80 pts. usually > 50 y/o |
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BPH -
Hx/PE |
Obstructive -
hesitancy weak stream intermittent stream incomplete emptying urinary retention bladder fullness irritative - nocturia daytime frequency urge incontinence opening hematuria DRE - uniformly enlarged rubbery BPH in central zone (may not be detected on DRE) |
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BPH -
Dx |
R/o possible dangerous causes
DRE UA/UC Cr Not recommended for BPH - PSA & cystoscopy |
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BPH -
Tx |
Mild - reassurance
mod to severe - surgery terazosin finasteride TURP open prostatectomy |
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Prostate Cancer -
What is it Risk factors |
MC cancer in men
second cause of cancer death in men risk factors - age family Hx |
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Prostate Cancer -
Hx/PE |
Usually asymp
rarely causes Sxs until advanced urinary retention dec. force of urine stream lymphedema constitutional Sxs back pain DRE - palpable nodule area of induration early Ca usually not detectable tender prostate = prostatitis |
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Prostate Cancer -
Dx |
Clinical
markedly elevated PSA US-guided transrectal Bx Gleason grade CXR bone scan Gleason grade - based on histology grades 1-5 on two features – level of differentiation structural architecture the two scores are added Poorly differentiated tumors - score 8-10 worst prognosis |
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Prostate Cancer -
Tx |
■ Tx based on -
aggression of tumor pt's risk of dying ■ watchful waiting - elderly & low-grade ■ radical prostatectomy & RT - inc. risk of incontinence inc. risk of impotence ■ PSA - use to eval post-Tx check for dis. recurrence ■ metastasis - chemo & androgen ablation: GnRH agonists flutamide orchiectomy |
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Prostate Cancer -
Prevention |
Annual DRE -
> 50 y/o > 45 y/o if Black > 45 y/o if pos. family Hx also screen with PSA |
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Bladder Cancer -
What is it Risk factors |
2nd MC urologic cancer
MC malig tumor - urinary tract transitional cell Ca men - 60s & 70s risk factors - smoking chronic bladder infections calculous dis. aniline dye hair dye |
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Bladder Cancer -
Hx/PE |
Asymp in early stages
gross hematuria freq. urgency dysuria |
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Bladder Cancer -
Dx |
UA
cytology IVP cystoscopy with Bx - diagnostic may also - US MRI pelvic CT |
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Bladder Cancer -
Tx |
■ superficial -
transurethral resection or intravesicular chemo with mitomycin-C or BCG ■ CIS - intravesicular chemo ■ large, hi-grade recurrent - intravesicular chemo ■ invasive without mets - aggressive surgery RT ■ distant mets - chemo |
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Testicular Cancer -
What is it Risk factors |
Heterogenous group
95% derive from germ cells almost all are malignant MC malignancy in 15-35 y/o seminomas peak at 40-50 y/o Klinefelter's - risk factor cryptorchidism - inc. risk of neoplasia in both testes |
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Testicular Cancer -
Hx/PE |
Painless enlargement of testis
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Testicular Cancer -
Dx |
B-hCG -
inc. in choriocarcinomas inc. in 10% of seminomas AFP - inc. in endodermal sinus (yolk sac) tumors |
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Testicular Cancer -
Tx |
Seminomas -
very radiosensitive also respond to chemo nonseminomatous germ cell - platinum-based chemo |
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SIADH -
What is it What is it associated with |
Euvolemic hyponatremia
from nonosmotically-stimulated ADH release associated with - CNS dis. pulmonary dis. ectopic tumor/ paraneoplastic syndromes drugs surgery |
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SIADH -
Dx |
Urine osmolality > 50-100 mOsm/kg
concurrent serum hyposmolarity no physio reason for inc. ADH urinary sodium > 20 mEq/L |
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SIADH
Tx |
Tx underlying cause
and if mild - restrict fluids moderate - NS and furosemide severe (Sxs) - hypertonic saline then furosemide if chronic - demeclocycline or lithium - ADH antag |
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Diabetes Insipidus -
What is it What is it caused by |
Central or nephrogenic
central - post pit. doesn't secrete ADH causes - tumor ischemia (Sheehan's) trauma infection autoimmune d/o nephrogenic - kidneys don't respond to ADH causes - renal dis. drugs (lithium, demeclocycline) |
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Diabetes Insipidus -
Hx/PE |
Polydipsia
polyuria persistent thirst dilute urine if don't have unlimited access to water - dehydration hypernatremia |
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Diabetes Insipidus -
Dx |
Water deprivation test
DDAVP challenge - desmopressin mimics ADH if central - DDAVP challenge => dec. urine output inc. urine osmolarity thus, MRI (to check for mass) if nephrogenic - DDAVP challenge will not dec. urine output |
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Diabetes Insipidus -
Tx |
central -
DDAVP subcutaneously nephrogenic - thiazide diuretics (HCTZ) amiloride chlorthalidone |
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Acetazolamide -
Site of Action Mechanism |
Proximal convoluted tubule
inhibits carbonic anhydrase |
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Acetazolamide -
Clinical Use |
Glaucoma
urinary alkalinization metabolic alkalosis altitude sickness cysteinuria |
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Acetazolamide -
Toxicity |
Hyperchloremic metab acidosis
sulfa allergy |
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Loop Agents
Furosemide Bumetanide Torsemide Ethacrynic Acid - Site of Action Mechanism |
Ascending loop of Henle
Inhibits Na/K/2 Cl cotransport |
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Loop Agents
Furosemide Bumetanide Torsemide Ethacrynic Acid - Clinical Use |
HTN
hypercalcemia edematous states - CHF cirrhosis nephrotic syndrome pulmonary edema |
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Loop Agents
Furosemide Bumetanide Torsemide Ethacrynic Acid - Toxicity |
OH DANG
Ototoxicity Hypokalemia Dehydration Allergy - sulfa (not ethacrynic acid) Nephritis - interstitial Gout |
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Hydrochlorothiazide -
Site of Action Mechanism |
Distal convoluted tubule
inhibits Na+/Cl- cotransporter |
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Hydrochlorothiazide -
Clinical Use |
HTN
CHF idiopathic hypercalciuria nephrogenic diabetes insipidus |
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Hydrochlorothiazide -
Toxicity |
HyperGLUC
hyperGlycemia hyperLipidemia hyperUricemia hyperCalcemia and hypokalemic metab alkalosis hyponatremia sulfa allergy |
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K+ Sparing Agents
Spironolactone Triamterene Amiloride - Site of Action Mechanism |
Cortical collecting tubule
Spironolactone - aldosterone receptor antag triamterene & amiloride - block Na+ channels |
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K+ Sparing Agents
Spironolactone Triamterene Amiloride - Clinical Use |
Hyperaldosteronism
K+ depletion CHF |
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K+ Sparing Agents
Spironolactone Triamterene Amiloride - Toxicity |
Hyperkalemia
gynecomastia antiandrogen effects |
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Mannitol -
Site of Action Mechanism |
Entire tubule
sorbitol stereoisomer osmotic diuretic filtered by glomerulus can't be reabsorbed inc. tubular fluid osmolarity => dec. water reabsorption => inc. urine flow |
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Mannitol -
Clinical Use |
Shock
drug overdose dec. intracranial or intraocular pressure |
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Mannitol -
Toxicity |
Pulmonary edema
dehydration contraindicated in - anuria CHF |
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Renal Tubular Acidosis -
What is it |
Failure of kidneys to
acidify urine net dec. in - tubular H+ secretion or HCO3 reabsorption => nonanion-gap metab acidosis |
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RTA Type I -
What is it |
Distal tubule
H+/K+ pump is broken => failure to secrete H+ serum K+ stays low urinary pH > 5.3 |
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RTA Type I -
Causes Complications |
Causes -
usually sporadic lithium amphotericin analgesics collagen vascular dis. cirrhosis chronic urinary tract obstruct sickle cell nephrocalcinosis - also a consequence complication - nephrolithiasis secondary hyperaldosteronism |
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RTA Type I -
Tx Dx/Test |
Tx -
potassium citrate Dx/Test - acid load |
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RTA Type II -
What is it |
Proximal tubule
cells don't reabsorb HCO3 urinary pH init > 5.3 distal tubular cells work OK => urinary pH < 5.3 when serum gets acidic |
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RTA Type II -
Causes Complications |
Causes -
hereditary carbonic anhydrase inhibitors Fanconi's syn multiple myeloma complications - rickets osteomalacia |
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RTA Type II -
Tx Dx/Test |
Tx -
potassium citrate Dx/Test - bicarb load |
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RTA Type IV -
What is it |
Adrenal insensitivity to
angiotensin 2 aldosterone deficient serum K+ is high usually asymp hyperkalemia hyperchloremic metab acidosis (nonanion/normal metab acidosis) |
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RTA Type IV -
Causes Complications |
Causes -
hyporeninemic hypoaldosterone: DM (infarcts JG) ACEIs NSAIDs addison's sickle cell renal insufficiency complication - hyperkalemia |
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RTA Type IV -
Tx Dx/Test |
Tx -
fludrocortisone furosemide - if HTN kayexelate Dx/Test - restrict salt |
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Acute Renal Failure -
What is it |
Rapid dec. in renal function
over days to weeks => accum of nitrogenous products, fluid & electrolyte d/o dev. prerenal caused by - dec. renal plasma flow (inadequate renal perfusion) renal caused by - intrinsic renal dis. or damage postrenal caused by - obstruction of urinary outflow both kidneys must be obstructed to cause significant azotemia |
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Acute Renal Failure -
Hx/PE |
Hx -
uremia: malaise oliguria fatigue anorexia n/v PE - asterixis HTN dec. urinary output inc. RR pericardial friction rub - if uremic pericarditis prerenal - hypovolemia orthostasis oliguria postrenal - anuria distended bladder acute interstitial nephritis - fever rash |
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Acute Renal Failure -
Dx |
CBC
BUN/Cr electrolytes FE(Na) - if oliguric urine sediment - RBC WBC casts eosinophils urinary catheter renal US |
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Acute Renal Failure -
Tx |
■ Balance fluid & electrolytes
■ dialysis if indicated ■ acute/allergic interstitial nephritis - adjust/discontinue offending meds ■ glomerulonephritis - corticosteroids cytotoxics |
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Acute Renal Failure -
Complications |
Chronic renal failure
=> dialysis dialysis - ■ prevent buildup of: K+ H+ toxic metabolites ■ inc. risk for CAD |
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Acute Renal Failure -
What is Prerenal % for FE(Na) What is Prerenal No. for U(Na) What is Prerenal Ratio for BUN/Cr |
FE(Na) is < 1%
U(Na) is < 20 BUN/Cr is > 20 |
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Acute Renal Failure -
FE(Na) - How do you calculate it |
U/P Na
divided by U/P Cr |
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Dialysis -
What are the indications |
AEIOU
Acidosis Electrolyte abnormalities (hyperkalemia) Ingestions Overload of fluid Uremic Sxs - pericarditis encephalopathy bleeding nausea pruritus myoclonus |
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Hyponatremia -
What is it |
Serum sodium < 135 mEq/L
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Hyponatremia -
Hx/PE |
May be asymp
confusion lethargy muscle cramps nausea can progress to - seizures status epilepticus coma |
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Hyponatremia -
Dx |
Classified by -
serum osmolality volume status (by PE) urinary Na+ |
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Hyponatremia -
What are the types of osmolalities |
High -
> 295 mEq/L hyperglycemia hypertonic infusion (mannitol) Normal - 280-295 mEq/L hyperlipidemia hyperproteinemia pseudohyponatremia Low - < 280 mEq/L hypervolemic hyponatremia euvolemic hyponatremia hypovolemic hyponatremia |
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Hyponatremia -
Tx |
Chronic hyponatremia should
be corrected slowly to prevent central pontine myelinolysis |
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Hypervolemic Hyponatremia -
What is it Etiologies Tx |
Inc. in Na+ & total body wt.
Inc. greater in TBW etiologies - edematous states: renal failure nephrotic syndrome cirrhosis CHF Tx - restrict salt and water |
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Euvolemic Hyponatremia -
What is it Etiologies Tx |
Total body Na+ normal
total body water has inc. etiologies - SIADH hypothyroidism renal failure drugs psychogenic polydipsia adrenal insufficiency Tx - restrict salt and water |
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Hypovolemic Hyponatremia -
What is it Etiologies Tx |
Dec. in total body Na+
and total body water more Na+ than water is lost etiologies - diuretics vomiting diarrhea third spacing dehydration Tx - replete volume with normal saline |
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Hypernatremia -
What is it |
Serum Na+ > 145 mEq/L
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Hypernatremia -
Hx/PE |
Thirst
oliguria or polyuria (depends on etiology) mental status changes weakness focal neuro deficits seizures "doughy" skin |
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Hypernatremia -
Dx |
Measure urine vol.
measure urine osmolality hypervolemic hyperNa+ - inc. aldosterone or excess Na+ (IV saline) min vol (500 mL/day) of max concentrated urine (> 400 mOsm/kg) - adequate renal response inadequate free water replaced fluid loss from - dec. intake diuretics glycosuria 3rd spacing lg vol of dilute urine - diabetes insipidus |
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Hypernatremia -
Tx |
■ Tx underlying causes
■ replace free water deficit - isotonic fluids ■ correct gradually over 48-72 hrs (to prevent neuro damage secondary to cerebral edema) |
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Hypercalcemia -
What is it What causes it |
Serum Ca2+ > 10.2 mg/dL
> 15 mg/dL = medical emergency MCC - hyperparathyroidism malignancy common causes - CHIMPANZEES Calcium supplementation Hyperparathyroidism Iatrogenic (thiazides) Immobility Milk alkali syndrome Paget's dis. Addison's Acromegaly Neoplasm Zollinger-Ellison syndrome Excess vitamin A Excess vitamin D Sarcoidosis and other granulomatous dis. |
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Hypercalcemia -
Hx/PE |
"Bones, stones, abdom groans,
psych overtones" fractures kidney stones n/v constipation anorexia weakness fatigue altered mental status |
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Hypercalcemia -
Dx |
EKG - short QT
total Ca2+ ionized Ca2+ albumin phosphate PTH PTHrP vit D TSH serum immunoelectrophoresis |
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Hypercalcemia -
Tx |
IV hydration
then furosemide if severe or refractory - calcitonin bisphosphonates (pamidronate) glucocorticoids dialysis |
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Hypocalcemia -
What is it What causes it |
Serum Ca2+ < 8.5 mg/dL
caused by - hypoparathyroidism (postsurgery, idiopathic) malnutrition hypomagnesemia acute pancreatitis medullary thyroid cancer (excess calcitonin) vit D def. pseudohypoparathyroidism renal insufficiency serum Ca2+ may be falsely low in hypoalbuminemia |
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Hypocalcemia -
Hx/PE |
Abdom muscle cramps
tetany perioral & acral paresthesias convulsions dyspnea Chvostek's sign Trousseau's sign EKG - prolonged QT |
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Hypocalcemia -
Dx |
Ionized Ca2+
Mg2+ PTH albumin calcitonin if post-thyroidectomy - check operative note to determine no. of parathyroid glands removed |
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Hypocalcemia -
Tx |
Tx underlying d/o
oral calcium supplements if severe - IV calcium |
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Hypomagnesemia -
What is it What is it caused by |
Serum Mg2+ < 1.5 mEq/L
causes: ■ dec. intake: malnutrition alcoholism malabsorption short bowel syndrome TPN ■ inc. loss: diuretics diarrhea vomiting ■ miscellaneous: DKA pancreatitis |
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Hypomagnesemia -
Hx/PE |
Sxs usu related to
concurrent hypocalcemia and hypokalemia anorexia n/v muscle cramps weakness if levels very low - paresthesias irritability confusion lethargy seizures arrhythmias |
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Hypomagnesemia -
Dx |
Check for concurrent
hypocalcemia & hypokalemia EKG - prolonged PR & QT |
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Hypomagnesemia -
Tx |
IV or oral Mg2+
hypokalemia & hypocalcemia won't correct if Mg2+ not corrected also |
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Hyperkalemia -
What is it What is it caused by |
Serum K+ > 5 mEq/L
causes - ■ spurious - hemolyzed blood draw fist clenched during blood draw extreme leukocytosis extreme thrombocytosis rhabdomyolysis ■ dec. excretion - renal insufficiency mineralocorticoid def. RTA type 4 drugs - heparin spironolactone triamterene ACEIs trimethoprim NSAIDs ■ cellular shifts - tissue injury insulin def. drugs - succinylcholine digitalis arginine B-blockers ■ iatrogenic |
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Hyperkalemia -
Hx/PE |
Muscle weakness starts > 6.5
MCC of death - abnorm cardiac conduction May be asymp n/v intestinal colic areflexia weakness flaccid paralysis paresthesias |
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Hyperkalemia -
Dx |
Verify with repeat blood draw
(if need to) EKG - tall peaked T prolonged PR wide QRS loss of P can => sine waves, ventricular fibrillation, cardiac arrest |
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Hyperkalemia -
Tx |
Emergent Tx if -
> 6.5 mEq/L or prolonged PR or wide QRS C BIG K Calcium gluconate or CaCl Bicarb or Insulin and Glucose Kayexalate and loop diuretics Ca gluconate or CaCl - immediate but short-lived bicarb not in same IV line as Ca (forms CaCO3 precipitate) insulin & glucose - takes 30-60 min. to work give sorbitol to prevent constipation If RF or severe, refractory - dialysis |
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Hypokalemia -
What is it What is it caused by |
Serum K+ < 3.5 mEq/L
causes - ■ transcellular shifts - insulin B2-agonists alkalosis periodic paralysis ■ GI losses - diarrhea chronic laxative abuse vomiting NG suction ■ renal K+ losses - diuretics primary mineralocorticoid excess secondary hyperaldosteronism drugs DKA hypomagnesemia RTA Types 1&2 ■ licorice ■ clay |
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Hypokalemia -
Hx/PE |
Sxs start when K+ <2.5 - 3.0
muscle weakness cramps ileus fatigue hyporeflexia paresthesias if severe - flaccid paralysis cardiac arrhythmia |
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Hypokalemia -
Dx |
24-hour or spot urine K -
to distingish renal from GI losses EKG - flattened T U wave ST depression followed by AV block and cardiac arrest |
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Hypokalemia -
Tx |
Tx underlying d/o
oral or IV K+ too fast => fatal arrhythmia max 10 meq/hr use 1/2 NS or NS replace Mg2+ monitor EKG and plasma K+ freq. during replacement |
