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208 Cards in this Set
- Front
- Back
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MC cause of death from Acute Renal Failure
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75% Infection
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Prerenal ARF
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Olliguria
High BUN/Cr ratio >20:1 High Urine osm >500 Low FeNa <1% Hyaline casts |
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Renal ARF
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Low BUN/Cr ratio <20:1
Low Urine osm < 350 (water resorption impaired) High FeNa >2% |
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Nephrotoxins
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Aminoglycosides
Radiocontrast NSAID Myoglobin Cisplatin Kappa/Gamma light chains |
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Tests of postrenal failure
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physical - palpate bladder
U/S - obstruction, hydronephrosis catheter - check for urine |
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MC deadly complication of early phase ARF
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hyperkalemic cardiac arrest + pulmonary edema
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Level of symptomatic uremia
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BUN > 60
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Uremia features
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Hypertension
CHF Pericarditis Nausea, Vomiting Loss of apetite Lethargy Restless legs Asterixis Normocytic anemia Bleeding (low platelets) |
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CRF Calcium/Phosphate
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HYPOcalcemia
HYPERphosphatemia High PTH |
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What is calciphylaxis
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Hyperphosphatemia may cause calcium and phosphate to precipitatevwhich causes vascular calcifications that may result in necrotic skin
lesions. |
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Major cause of mortality in CRF
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Infections
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Diet in CRF
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LOW protein
LOW salt (if HTN, CHF) LOW K, PO4, Mg HIGH Ca, Vit D |
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Ace Inhibitors in CRF
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Used early on in CRF, may worsen hyperkalemia!!!
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Treatment of hyperphosphatemia in CRF
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calcium citrate (phosphate binder)
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Treatment of pruritus in CRF
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capsaicin cream
cholestyramine + UV light |
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Life threatening complications in CRF
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Hyperkalemia - get ECG
Pulmonary edema due to volume overload - check for weight gain Infection |
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Indications for dialysis
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Acidosis
Electrolytes - High K presists Intoxication - Methanol, Ethylene glycol, lithium, aspirin Overload - hypervolemia Uremia - pericarditis |
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AV fistula for dialysis
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B/t radial artery and veins in forearm
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How do you know AV fistula is ready to be used
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Audible bruit present
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Benefits of hemodialysis
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More efficient
Initiated more quickly |
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Disadvantages of hemodialysis
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Hypotension (fluid removed)
Hypoosmolarity (solute removed) Req vascular access Req anticoagulation with heparin |
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Advantages of peritoneal dialysis
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Patient can learn to do on own
Mimics kidney physiology more |
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Disadvantages of peritoneal dialysis
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Hyperglycemia/ Hypertriglyceridemia (high glucose load)
Peritonitis Req high motivation Increased abdominal girth |
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Patients on dialysis are lacking in what?
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Erythropoietin
Vit D |
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Complications hemodialysis
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Hypotension - ischemia
Hypoosmolarity - N/V, seizures First use syndrome Hemorrahge/Hematoma Infection Amyloidosis of B2 microglobulin |
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Complications of peritoneal dialysis
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Peritonitis
Abdo/Inguinal hernia Hyperglycemia Protein malnutrition |
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What is First Use Syndrome
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Back pain, chest pain and reare anaphylaxis immediately when a new dialysis machine is used
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MC cause of nephrotic syndrome in adults
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Membranous nephropathy
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MC cause of nephrotic syndrome in kids
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Minimal change disease
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Treatment of asymptomatic transient proteinuria
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No treatment/tests
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Asymptomatic persistent protenuira
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Further workup required
First step is BP check and urine sediment examination |
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Urine dipstick for protein false negative
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Only detects albumin, will not detect globulins (light chains in myeloma)
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Proteinuria on dipstick, next test to order?
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Urinalysis
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Urinalysis confirms protein, next test to order?
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24 hour Urine collection for albumin/cr
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Level of protein for microalbuminuria
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30 - 300 mg
NOT detected by dipstick |
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Most sensitive and specific test for microalbuminuria
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radioimunoassay
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Best test of renal function
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Creatnine clearance
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Best test to detect renal obstruction, masses and cysts
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Renal ultrasound
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Test to detect chronic pyelonephritis
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Intravenous pyelogram
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When to do renal biopsy?
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No cause identified by less invasive tests
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Symptomatic proteinuria what vaccinations are recommended
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Influenza and Pneumococcus due to increased infections
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Best test to detect bladder cancer
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Cystoscopy = perform if suspicion is high even if cytology is negative on urine specimen
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What cancer is associated with Minimal Change disease
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Hodkin's and non Hodkins lymphoma
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Treatment of Minimal Change disease
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Steroids 4-8 weeks
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Treatment of Poststreptococcal GN
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Supportive - antihypertensives, loop diuretics
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Meds causing interstitial nephritis
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NSAIDs
penicillins furosemide, thazide sulfonamides phenytoin |
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Treatment Type I RTA
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Sodium Bicarb (acidsosis0
Phosphate salt (excrete acid) |
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Treatment Type II RTA
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Sodium restriction (increases Na and Bicarb reabsorption)
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Hartnup disease defect
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Auto recessive
Decreased neutral aa absorption - tryptophan (nicotinamide deficiency) |
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Hartnup disease features
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dermatitis
diarrhea ataxia psychiatric disturbance |
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Fanconi syndrome pathogenesis
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proximal tubule defect (one of the causes of type 2 RTA)
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Fanconi syndrome features
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glycosuria
phosphaturia (rickets, osteomalacia) proteinuria polyuria dehydration hypokalemia |
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Treatment of Fanconi anemia
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Phophate
Potassium Alkali Salt Supplements Hydration |
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Confirmation test for polycystic kidney disease
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U/S kidneys
CT/MRI alternative |
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Diagnosis of medullary sponge kidney
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Intravenous Pyelogram
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Treatment of simple renal cysts
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No Treatment (asymptomatic)
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Gold standard test for Renovascular HTN
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Renal arteriogram - CONTRAINDICATED in renal failure
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In Renovascular HTN what test can be done in a patient with renal failure
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MRA (dye is not nephrotoxic)
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Noninvasive study for renovascular HTN in people with good renal function
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Captopril renal scintigram (scan)
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Diagnostic test for renal vein thrombosis
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renal venography (definitive study) or IVP
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Treatment in renal vein thrombosis
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Anticoagulation to prevent PE
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Risk Factors for Kidney stones
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Low fluid intake (MC and preventable risk factor)
Fm Hx Gout, High PTH, type 1 RTA Loops, acetazolamide Chemo Male UTI |
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Which stones cannot be detected by KUB
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Uric acid - radiolucent
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What imaging is ordered for uric acid stone
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CT
U/S kindneys IVP |
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What stones are MC in people with chronic UTI
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Struvite (staghorn) due to PESK
Proteus Klebsiella Serratia Enterobacter |
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Hexagon stone
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Cysteine
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Envelope stone
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Uric acid
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What vitamin defciency causes calcium oxalate stones
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Pyridoxine
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Best initial test for kidney stones
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KUB x ray
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Best test for kidney stones
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CT (even radiolucent stones)
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Best test for defining degree of urinary tract obstruction
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IVP - good for deciding if patient needs procedural therapy
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Treatment of kidney stones
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1st - Analgesia (Morphine, Ketorolac)
Fluid hydration Ab's if infected/UTI |
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When to admit someone with kidney stone?
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Pain not controlled with oral med
Anuria (one kidney) Renal colic + UTI and or Fever Large > 1cm stone |
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Best method of treatment for stones >0.5cm but < 2cm
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ESWL
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Best method for treatment of stones >2cm
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Percutanous nephrolithotomy
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Best initial test for urinary tract obstruction
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Kidney Ultrasound
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What patients is IVP contraindicated in?
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Pregnant
Allergies to contrast Renal Failure |
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Best test for lower urinary tract obstruction
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Voiding cystourethrography
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When is Transrectal Ultrasound of Prostate indicated?
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PSA > 10, regardless of DRE
Abnormal DRE, regardless of PSA |
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How often would you follw up someone with PSA <4 and Negative DRE
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Annually
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If you can palpate a cancer on DRE what is the likelihood it has spread outside of the prostate
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70-80%
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Treatment of localized prostatic cancer
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Radical prostatectomy EXCEPT those < 10 years of life left, watchful waiting
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Treatment of locally invasive prostate cancer
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Radiation + Androgen deprivation (non curative)
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Treatment of metastatic prostate cancer
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Decrease testosterone (orchiectomy, antiandrogens, LH agonists)
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Treatment of RCC
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radical nephrectomy - remove kidney, adrenal, Gerota fascia, and nodes along hilum
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Best test for diagnosing Transitional Cancer of the bladder
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Cystoscopy + Biopsy
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Treatment of Stage 0 TCC of bladder
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Intravesical Chemotherapy
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Treatment of Stage A TCC of bladder (involves lamina propria)
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Transurethral resection of tumor
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Treatment of Stage B and C TCC of bladder (muscle invasion/perivesicular fat invasion)
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Radical cystectomy + LN dissection + Remove prostate/uterus/ovaries/vaginal wall
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Germ cell tumor subtypes (95%)
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Seminoma - radiosensitive
Nonseminoma - Embryonal, Choriocarcinoma, Teratoma, Yolk Sac |
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Non Germ cell testicular tumor subtypes
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Leydig cell - most benign,if not surgical resection
Sertoli cell - benign |
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Which testicular tumor has high B-HCG
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Choriocarcinoma
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Which testicular tumor has high AFP
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Embryonal
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Treatment of testicular cancer
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Surgical removal of testicle (orchiectomy) via transinguinal approach (avoid seeding via scrotal approach)
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Seminoma treatment
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Inguinal orchiectomy + radiation (very sensitive)
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Nonseminoma treatment
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Orchiectomy + retroperitoneal LN dissection
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What reduces risk of penile cancer
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Circumcision
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What increases risk of penile cancer
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HSV
HPV 18 |
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Treatment of testicular torsion
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Surgery < 6hours, BILATERAL orchioplexy to the scrotum if viable
Orchiectomy if nonviable testicle |
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MC organisms causing epidydimitis in children and elderly?
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E. Coli
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MC oraganism causing epidydymitis in young males
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Chlamydia and Gonorrhea
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Treatment of subclavian steal
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Surgical bypass
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Definitive test for identyfing stenosis of vessels in head and neck
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Magnetic resonance arteriogram
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Contraindications to TPA
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Uncontrolled HTN
Bleeding Anticoagulation Recent trauma/surgery |
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What medication should be avoided 24 hours post tPA
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Aspirin
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What is the agent of choice for lowering BP in a stroke patient
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Nitroprusside
- treat if >160-180/>105 |
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When do you use mannitol in a stroke situation?
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with increased ICP
NEVER prophylactically |
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When do you use steroids in a stroke situation?
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NEVER, harmful not helpful
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2 types of hemorrhagic stroke
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Intracerebral hemmorhage - bleed into the parenchyma
Subarachnoid hemmorhage - bleed into CSF outside parenchyma |
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What is the association between cocaine and stroke
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Young patients
ICH, SAH and Ischemic Stroke |
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Best initial test for SAH
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CT non contrast
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Best definitive test for SAH
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Lumbar Puncture
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What is the best test for identifying site of bleeding in SAH
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Cerebral Angiogram
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What psychiatric diagnosis is Tourette's associated with
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OCD and ADHD
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Treatment of Tourette's
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1st - Pimozide, Haloperidol
2nd - Clonidine |
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Most important risk factor for dementia
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Increasing age
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What area of the brain is affected by Biswanger disease (vascular dementia)
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Subcortical white matter degeneration
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Why is donezepil preferred over tacrine in Alzheimers Disease
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1x/day dosing
more improvement in congitive and behavioral domains less SE |
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How many times a day is Tacrine dosed
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4x/day
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Has ginko and lecithin been proven to be effective in Alzheimers
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NO
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What vitamin may be beneficial in Alzheimers
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Megadose >2000 units Vitamin E
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Is HRT good for Alzheimers?
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Associated with lower risk of developing Alzheimers
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What medication class exacerbates symptoms of Dementia with Lewy bodies
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Neuroleptics
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Features of Delirium
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Rapid deterioration of MS (hour-days)
Fluctuating LOC Abnormal vital signs |
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What time of day is delirium the worst?
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Sundowning - night
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What can you test with the Doll's Eye reflex
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Check if brainstem is intact - also intact if respiraiton is normal
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Cause of bilateral fixed + dialated pupils
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Sever anoxia
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Cause of unilateral fixed + dialated pupil
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Herniation with CNIII compression
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Cuase of pinpoint pupils
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Narcotics
Intracerebral hemmorhage |
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GCS - Eye opening categories (out of 4)
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No Opening - 1
Open to PAIN - 2 Open to VOICE - 3 Open Spontanously - 4 |
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GCS - Motor response categories (out of 6)
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No movement - 1
Decerebrate (extension) - 2 Decorticate (flexion) - 3 Withdraw to pain - 4 Localize to pain - 5 Obeys command - 6 |
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GCS - Verbal response categories (out of 5)
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No sound - 1
Inconmprehensible - 2 Inappropriate words - 3 Appropriate confused - 4 Appropriate orientated - 5 |
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Describe locked in syndrome
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Fully aware
Capable of feeling pain Completely Paralyzed |
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What area is affected in Locked In syndrome
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Ventral pons
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Features of Uncal (transtentorial) Herniation
- uncus compresses midbrain |
CN III compression - Ipsilateral anisocoria, sluggish pupil, dialated
Contralateral hemiparesis |
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Features of Tonisllar herniation
- cerebellar tonsils compress medulla |
compression of cardiorespiratory centres - rapid death
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Braindeath criteria
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Irreversible abscence of brain and brainstem function (apnea)
No brainstem reflex (gag, caloric, cornea, doll's eye) Core temp > 32 Clinical or Imaging evidence of cause of braindeath x2 repeated exams or EEG (isoelectric activity - silence) |
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Who has right to turn off life support in braindeath
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Physician (in most states)
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What is vegetative state
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Complete coma
Eyes Open and appear aawke Random head/limb movements |
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Most common presenting complaint in MS
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Decreased sensation or parasthesias
Fatigue |
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Features of Optic Neuritis in MS
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monoocular vision loss
pain on eye movement central scotoma decreased light reaction |
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Features of Internuclear Opthalmoplegia
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Ipsilateral medial rectus palsy (adduction defect)
Horizontal nystagmus of abducting eye |
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What is needed for MS diagnosis
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2 episodes of symptoms
2 white matter lesions |
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Laboratory diagnosis of MS
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2 episodes of symptoms
At least 1 white matter lesion on MRI Abnormal CSF |
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Which variant of MS appears later in life > 40 years old
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Primary Progressive
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Test of choice for MS diagnosis
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MRI - number of lesions not necessarily proportional to severity or speed of disease progression
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EMG of MS patients what do you see
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Evoked potentials show slow conduction due to demyelination
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Treatment of Acute MS attack
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High dose IV corticosteroids shorten duration but not alter disease course
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How long does an untreated MS attack take to resolve
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approx. 6 weeks
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What is the most effective MS treatment
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Interferon B-1a
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What should be used for primary progressive
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Immunosuppresants like MTX or Cyclophosphomide
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What is seen on CSF of patients with Guillian Barre
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Elevated Protein with NORMAL cell count
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Rx of Guillian Barre
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IV Immunoglobulin or Plasmapheresis
No STEROIDS, harmful |
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MC adult primary CNS tumor
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Glioma
Meningioma 2nd |
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Features of Myelofibrosis
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Teardrop cells
Splenomegaly Bleeding, Infections |
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What does myelofibrosis often progress to?
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AML, poor prognosis
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Rx of Myelofibrosis
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Multiple transfusions
EPO Splenectomy (pain paliation) BM transplant |
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Define Essential Thrombocytosis
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Plt > 600,000
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Features of Essential Thrombocytosis
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Thrombosis (VVA)
Bleeding (defective platelets) Splenomegaly Pseudohyperkalemia Increased Bleed Time |
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What is erythromelalgia
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Burning pain and erythema of extremities due to microvascular occlusions
- feature of essential thrombocytosis |
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Rx of Essential Thrombocytosis
|
Antiplatelet Drugs - Anagrelide or Low dose ASA
Hydroxyurea (severe disease) |
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Causes of Myelodysplastic Syndromes
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Idiopathic MC
Radiation Immunosuppresants |
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What is seen in a Myelodysplastic BM
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Dysplastic cells with blasts or ringed sideroblasts
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What is seen in a Myelodysplastic peripheral smear?
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Normal MCV
Low Retic Howell Jolly bodies Basophilic Stippling Large agranular platelets |
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Rx of Myelodysplastic syndromes
|
RBC/Plt transfusions
EPO G-CSF (adjunct) VIt supplements B6, B12, Folate Immunosuppresants BM transplat (only cure) |
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Major Criteria of Polycythemia Vera
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Elevated RBC mass
O2 Sat >92% Splenomegaly (2 major + 2 minor for dx) |
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Minor Criteria of Polycythemia Vera
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Thrombocytosis >400
Leukocytosis >12 x 10 (9) LAP >100 B12 > 900 (2 major + 2 minor for dx) |
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Clinical features of PV
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Headache,Pruritus, Dizzy, Weak, Dyspneic (all due to hyperviscosity)
DVT, CVA, MI, Portal V thrombosis Bleeding (GI/GU, ecchymoses) Spleno/Hepatomegaly Hypertension |
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Lab features of PV
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Elevated RBC count, Hb, Hct
Thrombocytosis, Leukocytosis Low EPO High B12 Hyperuricemia |
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How do you confirm diagnosis of PV
|
BM Biopsy
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Rx of Polycythemia Vera
|
Repeat phlebotomy
Hydroxyurea or Rec Interferon ALFA (for myelosuppresion) |
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Subtypes of Hodgkins Lymphoma
|
Nodular Sclerosing MC, women
Mixed Cellularity (lots of RS cells) Lymphocyte predominant (few RS cells) Lymphocyte depleted (worst prognosis) |
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What is Ann Arbor Staging (Hodgkins lymphoma)
- B symptoms worsen prognosis |
Stage 1 - single node
Stage 2 - >2 node, same side of diaphram Stage 3 - both sides of diaphram Stage 4 - disseminated |
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Hodgkin's Features
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Painless lymphadenopathy
Continuous spread |
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Dx of Hodgkin's Lymphoma
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LN Biopsy with RS cells + presence of inflammatory cell infiltrates (NOT seen in Non-Hodgkin's)
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Rx of Hodkin's Lymphoma
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Stage 1, 2, 3A - Radiotherapy
Stage 3B, 4 - Radiotherapy + Chemotherapy |
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Risk factors for Non Hodgkin's Lymphoma
|
HIV/AIDS
Immunosuppresion (organ transplant recipients) EBV, HTLV-1 infection H. Pylorii gastritis (gastric lymphoma) Hashimoto's/Sjorgens (assoc with MALToma) |
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Immune causes of platelet destruction
|
ITP
HIT 2 Drugs SLE HIV assoc |
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Non Immune causes of platelet destruction
|
HUS
TTP DIC HIT 1 |
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Features of HIT1
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<48 hours, direct platelet aggregation
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Treatment of HIT 1
|
No treatment necessary
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Features of HIT 2
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3-12 days, Ab mediated platelet injury
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Treatment of HIT 2
|
Stop Heparin asap
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Mechanism of ITP
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IgG against platelets
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Acute form of ITP features
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Children
Preceeded by viral infections Self limited 80% |
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Chronic form of ITP features
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Adults (MC women 20-40)
Rarely remits spontanously |
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What do you see in bone marrow in patients with ITP
|
Increase megakaryocytes and platelet assoc-Ig G
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|
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Rx of ITP
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Corticosteroids
IV Immune Globulin (binds IgG) Splenectomy (chronic ITP) |
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Mechanism of TTP
|
Hayline microthrombi occlude small vessels and cause mechanical damage to RBC
|
|
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TTP Prognosis
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Life threatning if untreated within MONTHS
|
|
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Lab features of TTP
|
normal PT and PTT (no consumption of clotting factor)
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Features of TTP
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Fever
Anemia (hemolytic) Renal failure Thrombocytopenia Neuro sx transiently |
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Rx of TTP
|
Large volume Plasmapheresis ASAP
2nd line - steroids + splenectomy |
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Role of transfusions in TTP
|
CONTRAINDICATED
|
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Features of Bernard Soulier syndrome
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Auto RECESSIVE
def GP1b-IX (platelet adhesion) |
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Features of Glanzmann's Thromboasthenia
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Auto RECESSIVE
def GPIIb-IIIa (platelet aggregation) |
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Features of Von Willebrand
|
Auto DOMINANT
def vWF factor (platelet aggregation and adhesion) MC inherited bleeding disorder |
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Cliniical features of Von Willebrand
|
epistaxis
easy bruising scratches/cuts gingival bleeds menorrhagia |
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Random causes of impaired platelet function
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Uremia
NSAID Aspirin |
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Laboratory features of Von Willebrand
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Inc Bleeding Time
Inc aPTT (but can be N) Low ristocetin platelet aggregation Low fVIII |
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Rx of Von Willebrand
|
DDAVP - induces vWF secretion
Factor VIII concentrate |
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Do you use cryoprecipitate in Von Willebrand
|
NO - risk of viral transmission
|
|
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Clincal features of Hemophilia
|
Hemarthosis (MC knee)
Intracranial bleed (must evaluate all head trauma urgently) Hematomas Hematuria Hemospermia |
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How do you detect presence of Factor VIII Inhibitor
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Mix normal plasma with hemophiliac - PTT should normalize if not an INHIBITOR is present
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Lab features of hemophilia
|
Inc aPTT
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Rx hemophilia acute hemarthosis
|
Analgesia with codeine/acetaminophen
Immobilize, ice, non weight bearing |
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Rx hemophilia A
|
Factor VIII concentrate
DDVAP in mild disease |
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Is DDVAP treatment helpful in hemophilia B?
|
No, only helps fVIII release
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