Ditt Step 2 Day 9 Renal

Front 1

What are the classic findings of Henoch-Schönlein purpura?

Back 1

Palpable purpura
GI symptoms (Abd pain, vomiting, guaiac (+) stool, intussesception)
Renal disease
Arthritis/ arthralgia

Front 2

What are Ranson’s criteria in determining the prognosis in pts with acute pancreatitis?

Back 2

criteria at admission: Glucose, AST, LDH, Age, WBC ct

criteria (after 48 hrs): Ca2+ Hematocrit, O2, BUN, Base deficit, sequestration of fluid

Front 3

What is the tx for diarrhea from Entameoba histolytica?

Back 3

Metronidazole

Front 4

What is the tx for diarrhea from
Giardia lamblia?

Back 4

Metronidazole

Front 5

What is the tx for diarrhea from Salmonella ?

Back 5

Fluroquinolones
TMP-SMX (Bactrim)

Front 6

What is the tx for diarrhea from Shigella?

Back 6

Fluroquinolones
TMP-SMX (Bactrim)

Front 7

What is the tx for diarrhea from Campylobacter?

Back 7

Erythromycin

Front 8

Which type of lung cancer is assoc with the following paraneoplastic syndrome
Elevated ACTH → glucocorticoid excess → Cushing’s Syndrome

Back 8

Small cell

Front 9

Which type of lung cancer is assoc with the following paraneoplastic syndrome
Elevated PTH related peptide → hypercalcemia

Back 9

Squamous cell

Front 10

Which type of lung cancer is assoc with the following paraneoplastic syndrome
Elevated ADH → SIADH → hyponatremia

Back 10

Small Cell

Front 11

Which type of lung cancer is assoc with the following paraneoplastic syndrome
Antibodies to presynaptic Ca2+ Channels → Lambert-Eaton Syndrome

Back 11

Small cell

Front 12

Which type of vasculitis would you suspect with:
Weak pulses in upper extremity

Back 12

Takayasu’s Arteritis

Front 13

Which type of vasculitis would you suspect with:
Necrotizing granulomas of lung & necrotizing glomerulonephritis

Back 13

Wegener’s Granulomatosis

Front 14

Which type of vasculitis would you suspect with:
Necrotizing immune complex inflammation of visceral/renal vessels

Back 14

Polyarteritis nodosa

Front 15

Which type of vasculitis would you suspect in young male smokers?

Back 15

Buerger’s Thromboangiitis Obliterans

(Note: do not confuse with Berger's IgA nephropathy, a glomerular disease)

Buerger disease is a segmental, inflammatory, and thrombotic process of the distal most arteries and occasionally veins of the extremities. Pathologic examination reveals arteritis in the affected vessels. The cause is not known but it is rarely seen in nonsmokers. Arteries most commonly affected are the plantar and digital vessels of the foot and lower leg. In advanced stages, the fingers and hands may become involved. Fortunately, the incidence of Buerger disease seems to have decreased in the past decade.

Front 16

Which type of vasculitis would you suspect in young asian women?

Back 16

Takayasu’s Arteritis

Front 17

Which type of vasculitis would you suspect in young asthmatics?

Back 17

Churg-Strauss

Front 18

Which type of vasculitis would you suspect in infants & young children with involved coronary arteries

Back 18

Kawasaki Disease

Front 19

what is the most common vasculitis?

Back 19

Temporal (Giant cell) arteritis

Front 20

Which type of vasculitis is assoc with hep B infection?

Back 20

Polyarteritis nodosa

Front 21

Which type of vasculitis would you suspect with:
Occlusion of the ophthalmic artery, (that can lead to blindness)

Back 21

Temporal (giant cell) arteritis

Front 22

Which type of vasculitis would you suspect with: perforation of nasal septum

Back 22

Wegener’s Granulomatosis

Front 23

Which type of vasculitis would you suspect with:
Unilateral headache, jaw claudication

Back 23

Temporal (giant cell) arteritis

Front 24

Which lipid-lowering drug is assoc with:
SE: facial flushing

Back 24

Niacin (vit B3)
Can tx with aspirin

Front 25

Which lipid-lowering drug is assoc with:
SE: ↑ LFTs, myositis

Back 25

Statins (lovastatin) &
Fibrates (gemfibrozil)

Front 26

Which lipid-lowering drug is assoc with:
SE: GI discomfort, bad taste

Back 26

Bile acid resins (cholestyramine, colestipol, colesevelam)

Front 27

Which lipid-lowering drug has the Best effect on HDL

Back 27

Niacin (vit B3)

Front 28

Which lipid-lowering drug has the Best effect on triglycerides/ VLDL

Back 28

Fibrates (gemfibrozil, clofibrate, bezafibrate, fenofibrate)

Front 29

Which lipid-lowering drug has the Best effect on ↓ LDL/ cholesterol

Back 29

Statins (lovastatin)

Front 30

Which lipid-lowering drug binds C. diff. toxin?

Back 30

Cholestyramine

Front 31

What drugs are known for causing ↑ prolactin levels?

Back 31

Phenothiazines
Risperidone
Haloperidol
Methyldopa
Verapamil

Front 32

What are the side effects of HCTZ?

Back 32

AE: “HyperGLUC”
hyperGlycemia
hyperLipidemia
hyperUricemia
hyperCalcemia
also sulfa allergies

Front 33

What diuretic or class of diuretic would be most helpful in pt with Acute pulmonary edema

Back 33

Loop Diuretic – Furosemide

Front 34

What diuretic or class of diuretic would be most helpful in pt with Idiopathic hypercalcinuria
(→ calcium stones)

Back 34

Thiazide Diuretics

Front 35

What diuretic or class of diuretic would be most helpful in pt with Glaucoma

Back 35

Acetazolamide, Mannitol

Front 36

What diuretic or class of diuretic would be most helpful in pt with Mild – mod CHF with expanded ECV

Back 36

Thiazide or Loop Diuretics

Front 37

What diuretic or class of diuretic would be most helpful in conjunction with loop or thiazide diuretic to retain K+

Back 37

K+ sparing diuretic – Spironolactone, Amiloride

Front 38

What diuretic or class of diuretic would be most helpful in pt with Edema due to nephrotic syndrome

Back 38

Loop

Front 39

What diuretic or class of diuretic would be most helpful in pt with ↑ intracranial pressure

Back 39

Mannitol

Front 40

What diuretic or class of diuretic would be most helpful in pt with Mild – mod HTN

Back 40

Thiazide (HCTZ)

Front 41

What diuretic or class of diuretic would be most helpful in pt with hypercalcemia

Back 41

Loop Diuretic

Front 42

What diuretic or class of diuretic would be most helpful in pt with Altitude sickness

Back 42

Acetazolamide

Front 43

What diuretic or class of diuretic would be most helpful in pt with hyperaldosteronism

Back 43

Spironolactone or Eplerenone

Front 44

What are the 2 common disorders that carbonic anhydrase inhibitors (acetozolamide) treat?

Back 44

Glaucoma
Altitude sickness

Front 45

What diuretic is used in the initial stage of ↑ ICP?

Back 45

Mannitol

Front 46

What are the adverse effects of Mannitol?

Back 46

Mannitol draws free water into the vasculature:
Initial dilutional hypOnatremia which may result in pulmonary edema
Ultimately hypernatremia, hyperosmolality

Front 47

Which diuretics lose Ca2+ in the urine and are therefore contraindicated in nephrolithiasis pts? Which diuretics help to retain serum Ca2+?

Back 47

“loops lose Ca2+, thiazides don’t”

Front 48

Which side effect is commonly associated with the K+ -sparing duretic spironolactone?

Back 48

Gynecomastia

Front 49

What bacteria typically causes pyelonephritis?

Back 49

#1 E. coli (ascending infxn most commonly)
others: Staph saprophyticus, Klebsiella, Proteus mirabilis

Front 50

What are the S/S of pyelonephritis?

Back 50

Flank pain
Chills
Nausea/vomiting
Urinary frequency, dysuria, urgency
Fever
Costovertebral angle (CVA) tenderness

Front 51

How many bacteria have to be present in the urine sample to diagnosis pyelonephritis?

Back 51

> 10^5

Front 52

What is the treatment for pyelonephritis?

Back 52

(usually admit pt & give IVF)
Fluoroquinolones
3rd Gen Ceph
if preggers → ampicillin/gentamicin or Ceftriaxone

Front 53

What is the pattern of pain assoc with nephrolithiasis?

Back 53

Colicky flank pain, can extend into groin or genitals
Usually unilateral

Front 54

What is the tx for radiolucent kidney stones? What are these stones made of?

Back 54

Made of: uric acid
Tx: alkalinize urine
Note: uric acid stones are the ONLY stones that be be dissolved with medical therapy

Front 55

What do Proteus & Klebsiella produce that causes the formation of the struvite stone (Mg-NH4-PO4)?

Back 55

urease

Front 56

What studies will you use to diagnose most kidney stones?

Back 56

Xray or CT
Note: if pt has new onset hematuria, need to r/o stones!

Front 57

What should be done in a female smoker over age 50 with hematuria besides a UA?

Back 57

Cystoscopy

Front 58

What class of diuretic is commonly used in pts with renal stones due to hypercalciuria in pts with a normal serum Ca2+ level?

Back 58

Thiazides

Front 59

What is the most common location of renal stone impaction?

Back 59

Ureterovesical junction

Front 60

What intracranial abnormality is assoc with autosomal dominant polycystic kidney disease (ADPKD)?

Back 60

Intracranial aneurysms

Front 61

What should be done next in a pt who is a smoker with flank pain, weight loss, hematuria, and polycythemia?

Back 61

Think cancer
Imaging to evaluated kidneys for tumor

Front 62

What is the most common cause of interstitial nephropathy/nephritis?

Back 62

Medications → NSAIDs, aminoglycosides, β-lactams

Front 63

A pt involved in a motor vehicle accident has a crushed thigh. Your attending advises you to make sure to give the pt enough IVF to maintain a high urine output of 100-200mL/hr. Why did he advise this?

Back 63

Preventing interstitial nephropathy

Front 64

Uncorrected severe benign prostatic hypertrophy (BPH) may cause what?

Back 64

Bilateral hydronephrosis

Front 65

What disease is the mnemonic “Can’t see, can’t pee, can’t hear” for? What does it stand for?

Back 65

Dx: Alport’s Syndrome
Can’t see → cataracts
Can’t pee → nephritis
Can’t hear → high-frequency hearing loss

Front 66

what is the most common nephrotic syndrome in children?

Back 66

minimal change disease
tx: steroids

Front 67

What is the most common nephrotic syndrome in adults?

Back 67

membranous glomerulonephritis

Front 68

Which glomerular disease would you suspect with:

IF: granular pattern of immune complex deposition
LM: hypercellular glomeruli

Back 68

Post-strep glomerulonephritis

Front 69

Which glomerular disease would you suspect with:
IF: linear pattern of immune complex deposition

Back 69

Goodpasture’s Syndrome

Front 70

Which glomerular disease would you suspect with:
Kimmelstiel-Wilson lesions (nodular glomerulosclerosis)

Back 70

Diabetic Nephropathy

Front 71

Which glomerular disease would you suspect with:
EM: loss of epithelial foot processes

Back 71

Minimal Change Disease

Front 72

Which glomerular disease would you suspect with:
Nephrotic syndrome assoc with hepatitis B

Back 72

Membranoproliferative Glomerulonephritis (MPGN)

Front 73

EM: mesangial cell proliferation
IF: IgA deposition

Back 73

Berger’s Disease
(IgA Nephropathy)

Dx: increased serum IgA

Tx: occasionally self-limited; give ACEI and statins for persistent proteinuria
give corticosteroids if nephrotic syndrome develops

Front 74

Which glomerular disease would you suspect with:
Nephrotic syndrome assoc with HIV

Back 74

Focal Segmental Glomerulosclerosis (FSGS)

Front 75

Which glomerular disease would you suspect with:
Anti-GBM antibodies, hematuria, hemoptysis

Back 75

Goodpasture’s Syndrome

Front 76

Which glomerular disease would you suspect with:
EM: subendothelial humps & tram-track appearance

Back 76

Membranoproliferative Glomerulonephritis (MPGN)

Front 77

Which glomerular disease would you suspect in pt with Nephritis, deafness, cataracts

Back 77

Alport’s Syndrome

Front 78

Which glomerular disease would you suspect with:
LM: crescent formation in the glomeruli

Back 78

Rapidly Progressive (Crescentic) Glomerulonephritis (RPGN)

Front 79

What glomerular disease would you suspect with:
LM: Segmental sclerosis and hyalinosis

Back 79

Focal Segmental Glomerulosclerosis (FSGS)

Front 80

What glomerular disease would you suspect with:
Purpura on back of arms & legs, abd pain, IgA nephropathy

Back 80

Henoch Schlönlein Purpura

Front 81

What glomerular disease would you suspect with:
Apple-green birefringence with Congo-red stain under polarized light

Back 81

Amyloidosis

Front 82

What glomerular disease would you suspect with:
(+) ANCA

Back 82

Rapidly Progressive (Crescentic) Glomerulonephritis (RPGN)

Front 83

What glomerular disease would you suspect with:
Anti-dsDNA antibodies

Back 83

Lupus Nephritis

Front 84

What glomerular disease would you suspect with:
EM: Spike & Dome pattern of the basement membrane

Back 84

Membranous GN

Front 85

Which disease would you suspect with the finding of Hyaline casts

Back 85

Not indicative of disease

Front 86

Which disease would you suspect with the finding of Granular casts

Back 86

Chronic renal disease

Front 87

Which disease would you suspect with the finding of Red Cell casts

Back 87

Glomerulonephritis or vasculitis

Front 88

Which disease would you suspect with the finding of White Cell casts

Back 88

Tubulointerstitial disease or acute pyelonephritis

Front 89

Which disease would you suspect with the finding of Epithelial cell casts

Back 89

ATN & Acute GN

Front 90

What are the defining characteristics of nephrotic syndrome?

Back 90

>3g/day proteinuria
hypOalbuminemia
hyperlipidemia

Front 91

What are the 3 drugs that can treat just about all the nephritic syndromes?

Back 91

Corticosteroids
ACE inhibitors
Statins

Front 92

What might you see on biopsy of a pt with hematuria & problems breathing (but no upper airway symptoms)?

Back 92

Linear staining of IgG Ab on GBM
Dx: Goodpasture’s syndrome

Front 93

HYQ: glomerulonephritis + bilateral sensorineual deafness

Back 93

Alport’s syndrome

Front 94

What should be in the history of a pt with postinfectious glomerulonephritis?

Back 94

Streptococcal infection w/in the last 3wks (check ASO)

Front 95

What serum marker should tip you off that a pt has lupus nephritis?

Back 95

Anti-DNA antibodies

Front 96

What test might you order in conjunction with the renal biopsy in a pt with hematuria & dyspnea?

Back 96

c-ANCA
dx: Wegener’s Granulomatosis

Front 97

What are the classic characteristics of a pt with minimal change disease?

Back 97

Young child
Edema
HTN
↑ freq of infections

Front 98

A HIV+ patient with nephrotic syndrome most likely has what disease?

Back 98

Focal Segmental Glomerulosclerosis (FSGS)

Front 99

Membranous glomerulonephritis is the most common nephrotic syndrome and has what characteristic on biopsy?

Back 99

Spike & Dome basement membrane thickening

Front 100

What is the biopsy appearance of membranoprolierative glomerulonephritis?

Back 100

Double layer “train track” appearance

Front 101

HYQ: 60yo M smoker is found to have a varicocele that does not empty when the pt is recumbent. What should you be suspicious of in this pt?

Back 101

Renal Cell Carcinoma (RCC) → get CT of the abdomen

Front 102

HYQ: what are the dietary recommendations in the treatment of nephrolithiasis?

Back 102

Adequate dietary Ca2+
↑ fluid intake
↓ Na+ intake
↓ protein & oxalate intake

Front 103

HYQ: a young black male presents with painless hematuria – what should you suspect?

Back 103

Sickle cell trait

Front 104

HYQ: What is the treatment for uric acid renal stones?

Back 104

Alkalinize urine

Front 105

HYQ: what is the most common cause of nephrotic syndrome in African American males?

Back 105

Focal Segmental Glomerulosclerosis (FSGS)

Front 106

What medications are used in the treatment of Wegener’s granulomatosis?

Back 106

Steroids
Cyclophosphamide

Front 107

What is the classic presentation of poststreptococcal glomerulonephritis?

Back 107

Child with brown urine
HTN
Strep infection 1-3wks ago
High serum ASO titer

Front 108

What is the most common cause of morbidity & mortality in pts with SLE?

Back 108

Lupus nephritis

Front 109

Fever + rash + elevated creatinine + eosinophlia → what is the diagnosis?

Back 109

Acute interstitial nephritis (AIN)

Front 110

What is the biggest risk factor for renal cell carcinoma?

Back 110

smoking

Front 111

What are 5 etiologies of temporary hematuria?

Back 111

UTI
Nephrolithiasis
Trauma
Exercise
Endometriosis

Front 112

What are 4 potassium sparing diuretics?

Back 112

Spironolactone
Eplerenone
Amiloride
Triamterene

Front 113

What size calcium renal stone has a 50% likelihood of passing w/o surgical intervention?

Back 113

8-9mm

Front 114

What are the Treatment options for Chronic Kidney Disease?

Back 114

● Stop smoking!
● aggressive BP control to goal <130/80 (JNC-7). Most need >3 medications (ACE-I or ARB, Β-blockers to reduce CAD risk, Diuretic (usually loop), Dihydropyridine CCB, Clonidine patch, Minoxidil in refractory cases)
● aggressive DM control to HgA1c goal of <6.5% with insulin and oral agents (usually not metformin) (rosiglitazone OK)
●agggressive Lipid control with statins to goal LDL <100 (but <70 is better)
Statins have been shown to ↓ sepsis risk by 63% in pts on hemodialysis (JAMA 2007)
● Anemia aggressive control to goal Hg 11-12
For every ↓ in Hg of 0.5g/dL, increase risk of LVH by 32% (→ increase CAD and CVD risk)
Usually requires iron and erythropoietin
●Vitamin D replacement
●Phosphate binders (Phos-Lo)
●Daily Aspirin 81mg to ↓ endothelial injury CAD risk

Front 115

In pre-renal acute renal failure (ARF) what is the value for the fractional excretion of sodium (FENa)? For the BUN:Cr ratio?

Back 115

Pre-renal = hypotension (not perfusing kidneys)
FENa < 1%
BUN:Cr >20

Front 116

Which test is used for screening diabetic pts for kidney damage?

Back 116

Urine microalbumin

Front 117

What BP medications are renal protective and preferred in the treatment of HTN in chronic kidney disease (CKD) pts?

Back 117

ACE-I and ARBs

Front 118

What drug is used for chronic kidney disease (CKD) to lower their potassium levels on a chronic basis?

Back 118

Sodium polystyrene sulfonate (Kayexalate)

Front 119

What are the indications for dialysis?

Back 119

Severe hypokalemia
Severe metabolic acidosis
Severe fluid overload
Uremic syndrome
Cr >12
BUN >100

Front 120

What is the difference btw hemodialysis and peritoneal dialysis?

Back 120

Hemodialysis: blood is filtered thru a machine – arterio-venous fistulas placed in forearm
Peritoneal dialysis: fluid pumped into peritoneal space, filtered thru peritoneum & then pumped out (osmotic exchange)

Front 121

What are the normal lab values to assess in acid-base disorders?

Back 121

pH 7.35-7.45
pCO2 35-45 mmHg
pO2 75-105 mmHg
HCO3- 22-28 mEq/L

Front 122

Determine acid-base disorder:

pH 7.4 HCO3 23 pCO2 40

Back 122

Normal

Front 123

Determine acid-base disorder:

pH 7.50 HCO3 35 pCO2 42

Back 123

Metabolic acidosis

Front 124

Determine acid-base disorder:

pH 7.33 HCO3 13 pCO2 28

Back 124

Metabolic acidosis, Respiratory compensation

Front 125

Determine acid-base disorder:

pH 7.42 HCO3 32 pCO2 64

Back 125

Combined metabolic alkalosis, Respiratory acidosis

Front 126

Determine acid-base disorder:

pH 7.24 HCO3 18 pCO2 40

Back 126

Metabolic acidosis

Front 127

Determine acid-base disorder:

pH 7.24 HCO3 24 pCO2 54

Back 127

Respiratory Acidosis

Front 128

Determine acid-base disorder:

pH 7.50 HCO3 22 pCO2 22

Back 128

Respiratory Alkalosis

Front 129

Determine acid-base disorder:

pH 7.58 HCO3 36 pCO2 30

Back 129

combined metabolic & respiratory alkalosis

Front 130

Determine acid-base disorder:

pH 7.47 HCO3 14 pCO2 22

Back 130

Respiratory alkalosis, metabolic compensation

Front 131

Determine acid-base disorder:

pH 7.46 HCO3 35 pCO2 53

Back 131

Metabolic alkalosis, respiratory compensation

Front 132

Determine acid-base disorder:

pH 7.39 HCO3 12 pCO2 22

Back 132

Mixed metabolic acidosis, respiratory alkalosis

Front 133

Determine acid-base disorder:

pH 7.34 HCO3 31 pCO2 62

Back 133

Respiratory acidosis, Metabolic compensation

Front 134

Determine acid-base disorder:

pH 7.10 HCO3 15 pCO2 50

Back 134

Combined metabolic & respiratory acidosis

Front 135

What is the differential diagnosis for metabolic acidosis with a normal anion gap? How can serum potassium be useful in narrowing the differential diagnosis?

Back 135

Low serum K+ :
Diuretics
Renal tubular acidosis types I & II
Diarrhea
Fanconi’s Syndrome


High serum K+ :
Addison’s Disease
Renal tubular acidosis (RTA) type IV
K+ sparing diuretics
Hyperalimentation

Front 136

What is the differential diagnosis for elevated anion gap metabolic acidosis with high serum osmolality?

Back 136

“MUDPILERS”
Methanol
Uremia
DKA/ Alcoholic KA
Paraldehyde
Isoniazid
Lactic acidosis
ETOH/ Ethylene Glycol
Rhabdo/ Renal failure
Salicylates

Front 137

What are the common causes of metabolic alkalosis?

Back 137

Dehydration, Vomiting, Diuretics

Front 138

What are the common causes of respiratory alkalosis?

Back 138

Hyperventilation: High altitude, ASA toxicity, Pulmonary Embolism, Asthma

Front 139

What are the common causes of respiratory acidosis?

Back 139

COPD, Respiratory Depression (narcotic OD, neuromuscular dysfunction)

Front 140

What are the common causes of Anion Gap Metabolic Acidosis?

Back 140

“MUDPILERS”
Methanol, Uremia, DKA/ Alcoholic KA
Paraldehyde, Isoniazid, Lactic acidosis
ETOH/ Ethylene Glycol, Rhabdo/ Renal failure, Salicylates

Front 141

What are the common causes of Non-Gap Metabolic Acidosis?

Back 141

Diarrhea, Renal tubular acidosis (RTA), TPN

Front 142

A previously healthy 25yo M came to the hospital with a head injury and is now hypernatremic and has polyuria. What is the diagnosis?

Back 142

Central Diabetes Insipidus (↓ ADH)

Front 143

What complications are avoided with gradual, rather than rapid, correction of rehydration of a hypernatremia pt?

Back 143

Cerebral edema – seizures, CNS damage

Front 144

Determine the Acid-base disorder:
pH 7.30 HCO3 12 pCO2 26

Back 144

Metabolic acidosis, respiratory compensation

Front 145

Determine the Acid-base disorder
pH 7.25 HCO3 17 pCO2 40

Back 145

Metabolic acidosis

Front 146

Determine the Acid-base disorder
pH 7.23 HCO3 24 pCO2 55

Back 146

Respiratory acidosis

Front 147

What is pseudohyponatremia? How is this different from hyponatremia from hyperosmolality?

Back 147

When the serum volume is expanded by a substance such as lipid or protein (ie multiple myeloma) the amt of sodium per volume of serum may decrease even though the amt of sodium per unity of water in serum is appropriate. This is referred to as pseudohyponatremia
This is different than hyponatremia due to hyperosmolality from elevated glucose or mannitol administration. In the case of hyperosmolality, the increase in serum osmols pulls water out of cells thereby diluting serum sodium. Here the plasma sodium level is expected to fall by 1.6 mEq/L for every increase of 100mg/dL of plasma glucose (which increases to 2.4 mEq/L per 100 after glucose levels exceed 400mg/dL). Use this calculation to determine how much you can expect the sodium to rise as the plasma glucose begins to fall with treatment and water is consequently shifted back into cells

Front 148

What volume status would you expect to find in a pt with hyponatremia due to thiazide diuretics

Back 148

hypOvolemic or euvolemic

Front 149

What volume status would you expect to find in a pt with hyponatremia due to SIADH?

Back 149

Euvolemic

Front 150

What volume status would you expect to find in a pt with hyponatremia due to Hepatic cirrhosis?

Back 150

Hypervolemic

Front 151

What volume status would you expect to find in a pt with hyponatremia due to Addison's disease?

Back 151

Hypervolemic + hypertension

Front 152

What volume status would you expect to find in a pt with hyponatremia due to hypothyroidism?

Back 152

Euvolemic

Front 153

What volume status would you expect to find in a pt with hyponatremia due to renal failure?

Back 153

Hypervolemic

Front 154

What volume status would you expect to find in a pt with hyponatremia due to psychogenic polydipsia?

Back 154

euvolemic

Front 155

What is the differential diagnosis for hypOvolemic hyponatremia based on urine Na+ levels?

Back 155

Urine Na+ <10 mEq/L = Extrarenal losses
GI losses (vomiting, diarrhea, NG tube)
Fluid sequestration (peritonitis, pancreatitis)
Insensible loss (sweating, extensive burns)


Urine Na+ > 20 mEq/L = Renal losses
Diuretics (thiazides)
Salt-losing renal disease
Partial urinary tract obstruction
Adrenal insufficiency (inadequate mineralcorticoid, Addison’s)

Front 156

What is the differential diagnosis for hypervolemic hyponatremia based on urine Na+ levels?

Back 156

Low urine Na+ : CHF, cirrhosis, nephrotic syndrome
High urine Na+ : renal failure

Front 157

What condition may result from the rapid correction of hyponatremia? What are the manifestations?

Back 157

Central pontine myelinosis (osmotic demyelination)


Occurs when sodium is corrected by more than 12-20 mEq/L over 24 hrs or is corrected to above 140
Symptoms are irreversible and typically delayed 2-6 days after the correction of hyponatremia
Dysarthria, dysphagia
Paraparesis or quadriparesis
Behavioral disturbances
Lethargy and coma
Head CT or MRI 4wks after the event reveals areas of demyelination

Front 158

What are the different etiologies of the syndrome of inappropriate antidiuretic hormone (SIADH)?

Back 158

CNS disease: head trauma, brain tumor, stroke, CS infection, pituitary surgery
Pulmonary disease: pneumonia, tumor (small cell)
Drugs: NSAIDs, antidepressants, antipsychotics, antineoplastic agents, carbamazepine, ecstasy, vasopressin, DDAVP
Other: HIV/AIDs, major abdominal or thoracic surgery

Front 159

What are the serum Na+ and urine osmolality expected to be in diabetes insipidus (DI)?

Back 159

Serum Na+ = high
Urine osmolality = low

Front 160

What should happen to a pt’s urine osmolality with nephrogenic DI after ADH administation?

Back 160

Urine osmolality will remain decreased

Front 161

How do you correct central DI?

Back 161

Desmopressin (DDAVP)

Front 162

What is the treatment for nephrogenic DI?

Back 162

Salt restriction, ↑ water intake
Thiazide diuretic +/- Indomethacin
In cases of Lithium toxicity → thiazide + amiloride
Tx underlying condition

Front 163

Though hyponatremia is defined as a serum Na+ of <135, at what serum Na+ does a pt get into trouble and risk seizure?

Back 163

Serum Na+ <120

Front 164

What is the consequence of correcting hyponatremia too rapidly? How rapidly can it safely be corrected?

Back 164

Central pontine myelinolysis
Keep below 12-20 mEq/day

Front 165

How will a large infusion of IV mannitol likely affect the serum Na+ ?

Back 165

Decrease serum Na+

Front 166

Explain how hyponatremia develops despite serum hyperosmolality (>295 Osm/kg)?

Back 166

Another solute pulls H2O out of cells & dilutes the serum sodium

Front 167

How are sodium levels corrected for high glucose?

Back 167

Add 1.6 mEq to the Na+ value for ever 100mg/dL of glucose above normal

Add 2.4 mEq for every 100mg/dL glucose above 400mg/dL

Front 168

What are some causes of Hyperkalemia? (K+ shift OUT of cells)?

Back 168

Low insulin
β-blockers
acidosis
Digoxin
Cell lysis (ie leukemia)

Front 169

What are some causes of HypOkalemia? (K+ shifts into cells)

Back 169

Insulin
β-agonists
alkalosis
cell creation/ proliferation

Front 170

What is the emergency treatment for hyperkalemia?

Back 170

STAT EKG to identify any EKG changes such as peaked T waves
Repeat K+ level to insure no lab errors/ lysis
D50 1 amp IV followed immediately by 10 units regular insulin IV (drives K+ into cells → 4-6 hr effect)
Calcium-gluconate 1-2 amps (or CaCl 1 amp) to protect myocardium
NaHCO3 50mEq IV over 5 min (drive K+ into cells in exchange for H+ )
Albuterol nebulizer (page RT stat if needed) (drives K+ into cells)
Kayexalate 30g PO4-/PR (exchanges Na+ for K+ in the gut → excretion of K+ → 24 hr effect)
Repeat K+ in 30 min
Consider Lasix 40-80 mg IV to increase K+ wasting in urine. May also use dialysis
Replace magnesium if it is less than 2.0
Determine the cause of hyperkalemia and treat

Front 171

Which lung cancer is highly associated with SIADH as a paraneoplastic syndrome?

Back 171

Small cell lung cancer

Front 172

What is the first agent you should give a pt with hyperkalemia and EKG changes?

Back 172

Calcium gluconate or calcium chloride

Front 173

After having given the calcium gluconate (or calcium chloride) what are the other treatments needed in the hyperkalemic pt?

Back 173

Amp of D50
Bolus of 10 units regular insulin
NaHCO3 infusion
Albuterol nebulizer
Kayexalate
Loop Diuretics
Magnesium
Dialysis

Front 174

What are the two eponym signs of hypOCalcemia?

Back 174

Chvostek’s sign: tap the cheek, facial nerve spasm “Chvostek Cheek”
Trousseau’s sign: carpal spasm when BP cuff is inflated “Trousseau’s, Tighten”

Front 175

Which diuretics lose calcium? Which spare it?

Back 175

“Loops lose Ca2+ Thiazides don’t”

Front 176

What electrolyte abnormality is associated with peaked T waves on EKG

Back 176

hyperkalemia

Front 177

What electrolyte abnormality is associated with flattened T waves on EKG

Back 177

hypokalemia

Front 178

What electrolyte abnormality is associated with U waves on EKG

Back 178

hypokalemia

Front 179

What electrolyte abnormality is associated with QT prolongation

Back 179

hypocalcemia

Front 180

What electrolyte abnormality is associated with QT shortening

Back 180

hypercalcemia

Front 181

How are total Ca2+ levels corrected for low albumin?

Back 181

Add 0.8mg/dL Ca2+ for each 1g/dL Albumin <4

Front 182

HYQ: hyponatremia + low serum osmolality + high urine osmolality:

Back 182

SIADH

Front 183

HYQ: what is the next step in the management of a pt with peaked T waves on EKG due to hyperkalemia?

Back 183

Calcium Gluconate

Front 184

HYQ: What is the most common cause of death in dialysis pts?

Back 184

Cardiovascular Disease

Front 185

What are the distinguishing characteristics of each type of renal tubular acidosis (RTA)?

Back 185

see above

Front 186

What is the consequence of correcting HYPERnatremia too rapidly? How rapidly can it safely be corrected?

Back 186

Cerebral edema
No more than 12-20 mEq/day

Front 187

What is the consequence of correcting hypOnatremia too rapidly? How rapidly can it safely be corrected?

Back 187

Central pontine myelinosis
No more than 12-20 mEq/day

Front 188

What medications can be used to rapidly correct hyperkalemia by shifting potassium into cells?

Back 188

NaHCO3, Albuterol nebs, Insulin (with glucose)

Front 189

What are the causes of euvolemic hypOnatremia?

Back 189

SIADH, hypothyroidism, polydipsia

Front 190

What medications are known for causing hyperkaemia? Hypokalemia?

Back 190

Hyperkalemia: ACEI/ARBs, K+ sparing diuretics, β-blockers, Digoxin

Hypokalemia: Albuterol, Insulin, Loops, thiazides, carbonic anhydrase inhibitors

Front 191

What are the causes of a normal anion gap metabolic acidosis?

Back 191

Diarrhea, RTA, hyperalimentation

Front 192

What medications are necessary in pts with end stage renal dz?

Back 192

Statin
Vit D
Iron
EPO
Phosphate binder
Aspirin
ACEI/ARB
Loop Diuretic

Front 193

What is the treatment for nephrogenic diabetes insipidus?

Back 193

HCTZ +/- Indomethacin
If Lithium toxicity → Thiazide + amiloride

Front 194

How is benign prostatic hyperplasia (BPH) diagnosed?

Back 194

Clinical diagnosis based on symptomatic scoring system

R/O other pathologies that may cause similar symptoms using history and the following tests:
● Digital rectal exam – to detect malignancy
● Urinalysis – to detect hematuria indicating infection, calculi, or prostatitis
● Serum Creatinine – to detect possible renal or prerenal disease

Other useful but optional tests: serum PSA, postvoid residual, maximum urinary flow rate

Front 195

What is the treatment for benign prostatic hyperplasia (BPH)?
(long DIT answer)

Back 195

Alternative Medicine
- Isoflavones as found in soy decrease the growth of hyperplastic prostate tissue in histoculture. Trinovin at 40-80mg/d may help relieve symptoms
- Saw palmetto is as effective as finasteride (Proscar) (Urology 2001;58;71-6), has fewer SE and decreases prostate size without changing PSA values (JAMA 1998;280:1604-9)

Medical intervention
- Nonselective α-blockers: Doxacin (Cardura), Prazosin (minipress), Terazosin (Hytrin)
MOA: ↓ prostate smooth muscle tone → immediate improvement in urine flow
SE: dizziness, postural hypOtenstion, fatigue, asthenia. To reduce SE, dose qHS and titrate dose upward slowly over time (weekly)

-5α-reductase inhibitors: FInasteride (Proscar), Dutasteride (Avodart)
MOA: slowly reduces dihydrotesterone levels → 20% decrease in prostate volume over 3-6mos

Surgical Intervention
- Indications for surgery: failure of medical therapy, refractory urinary retention, inability to express urine without a catheter, recurrent infection, persistent hematuria, bladder stones, or renal insufficiency
- TURP: transurethral resection of the prostate. Most common surgery for BPH. Symptomatic improvement in 88%. SE include excessive bleeding (1%) retrograde ejaculation (70%), impotence (14%), partial incontinence (6%), total incontinence (1%)
- Open prostatectomy: symptomatic improvement in 98% but is invasive and assow with more morbidity than TURP. Usually reserved for those with extremely large prostate or structural problems (protrusion into bladder, large bladder stone, urethral diverticulum)
- Other interventions: transurethral incision of the prostate (TUIP), transurethral microwave thermotherapy (TUMT), transurethral vaporization of the prostate (TUVP), transurethral electrovaporization of the prostate (TVP), transurethral needle ablation of prostate (TUNA)

Front 196

What is the next step in management of a 65yo M that presents to the ER with inability to urinate and painful bladder distention?

Back 196

Decompression of bladder with 14-18 French Foley catheter (may downsize to 10-12 French if necessary)

If h/o BPH, may require a cath with a firm Coude tip to “power-through” the narrowed urethra

Is unable to pass urethral cath, then suprapubic cystostomy (usually under US guidance)

If unable to pass urethral cath and no one trained in suprapubic cath placement will be available for hours, then aspirate the bladder with a spinal needle

Front 197

What are the common antibiotics use to treat uncomplicated cystitis?

Back 197

(1) TMP-SMX (Bactrim)

(2) Fluoroquinolones: Ciprofloxacin (Cipro), Levofloxacin (Levaquin), Moxifloxacin (Avelox)

(3) Amoxicillin

(4) Cephalexin (Keflex, 1st Gen Ceph)

Front 198

What are the risk factors for developing bladder cancer?

Back 198

Tobacco smoking
Shistosomiasis
Alanine dye
Cyclophosphamide (Cytoxan)
Recurrent UTI
Petroleum byproducts
Male sex

Front 199

What is the primary lab screen for bladder cancer?

Back 199

Hematuria on urinalysis

Front 200

What is the primary study done to confirm the diagnosis of bladder cancer?

Back 200

Cystoscopy with biopsy

Front 201

What are the treatment options for urethritis?

Back 201

Ceftriaxone (Rocephin, 3rd Gen) + doxycycline or azithromycin
Be sure to also treat partners

Front 202

What are classic s/s of benign prostatic hyperplasia (BPH)?

Back 202

Urinary hesitancy
Frequency
Nocturia
Urgency
Weak stream

Front 203

Name the 2 classes of medications used to treat BPH:

Back 203

Nonselective α-1 receptor blockers: Doxacin (Cardura), Prazosin (minipress), Terazosin (Hytrin)
↓ prostate smooth muscle tone → immediate improvement in urine flow
SE: dizziness, postural hypOtenstion, fatigue, asthenia

5-α reductase inhibitors: FInasteride (Proscar), Dutasteride (Avodart)

saw palmetto

Front 204

A 60yo M presents to the clinic for a Well-Male Exam and on digital examination a hard nodule is palpated on the prostate. Lab workup shows an ↑ PSA. What is the next step in the management of this patient?

Back 204

Transrectal US-guided prostate biopsies
(think: Prostate Cancer)

Front 205

How can testicular torsion be differentiated from epididymitis?

Back 205

see above

Front 206

Treatment of Testicular Torsion vs Epididymitis?

Back 206

Tx of Torsion: surgical detorsion with bilateral orchiopexy within 6hrs

Tx of Epididymitis: depends on age:

Age <35 yrs : most likely GC/Chlamydia
➔ Ceftriaxone IM (Rocephin, 3rd Gen) then doxycycline x10days

Age >35 yrs or h/o anal intercourse = Enterobacteriaceae
➔ Fluoroquinolone x10-14 days [Ciprofloxacin (Cipro), Levofloxacin (Levaquin), Moxifloxacin (Avelox) ]

Front 207

What drugs are commonly used to treat testicular cancer?

Back 207

“Eradicate Ball Cancer”
Etoposide
Bleomycin
Cisplatin

Front 208

In a pt suspected of having prostate cancer, what might an elevated alkaline phosphatase indicated?

Back 208

Prostatic metastasis to bone

Front 209

What are 2 common side effects of radical prostatectomy?

Back 209

incontinence
impotence

Front 210

A sexually-active homosexual man arrives at the ER because of sudden severe testicular pain that occurred while he was playing soccer 30min ago. Before that time, he had no dysuria or increased frequency of urination or testicular pain. What is the likely diagnosis?

Back 210

Testicular torsion

Front 211

What is the next step in the management of testicular torsion confirmed with U/S?

Back 211

Manual detorsion then surgery

Front 212

What is the most common germ cell tumor (GCT) of the testis?

Back 212

Seminoma

Front 213

What are the characteristic features of a varicocele?

Back 213

What it is: Dilation of pampiniform plexus in scrotum (“testicular mass”)

S/S: Dull aching scrotal pain usually on the left (left-sided varicoceles are 10 times more common than right-sided)
Note: Right-sided varicocele may point to a renal cell carcinoma (the tumor is compressing the IVC or gonadal vein causing the variocele)
Testicular atrophy on the affected side
Infertility is common – varicoceles are present in 25% of infertile men vs only 11% of fertile men

Dx: Color Doppler U/S shows retrograde flow to the scrotum

Front 214

Undescended testes put a pt at higher risk for what?

Back 214

Testicular cancer

Front 215

WTQ: 18yo M comes to the office c/o dull aching & fullness of the scrotum. Exam shows soft left-sided srotal swelling; transillumination testing is negative. The scrotal swelling increases when the patient performs the Valsalva maneuver. The PE is otherwise unremarkable. What is the most likely cause of his condition?

Back 215

cause: dilation of the pampiniform plexus
Dx: Varicocele

notes: pts with varicocele classically present c/o dull, aching pain in the testis. Varicocele is most common on the left side. If results from a swelling of the pampiniform plexus of veins and feels like a "bag of worms" on exam

Front 216

What medications are known for causing erectile dysfunction?

Back 216

Most antidepressants esp SSRIs
Spironolactone
Sympathetic blockers: clonidine, guanethidine, methyldopa
Thiazide diuretics, β-blockers
Ketoconazole
Cimetidine (but NOT ranitidine or famotidine)
Antipsychotics

Front 217

What are the treatments for a pt with erectile dysfunction (ED)?

Back 217

First line = Phosphodiesterase inhibitors:
Sildenafil (Viagra)
Vardenafil (Levitra)
Tadalafil (Cialis)

Second line= Penile self-injectable drugs: Papaverine, phentolamine, alprostadil, Vacuum & constriction devices

Third line: penile prothesis implantation

Other: Androgen replacement if hypogonadism

Front 218

What is the classic presentation of the most common renal tumor in children?

Back 218

Mc renal tumor in kids → Wilm’s Tumor

Presentation:
Most common age: 2-4 yrs
Palpable flank mass (most common presenting symptom)
Abdominal pain (30%)
Hematuria (12-25%)
Hypertension (25%)

Possible multiple other assoc congenital anomalies including WAGR syndrome
Wilm’s tumor
Aniridia
GU abnormalities
Retardation (mental)

Front 219

At what age should nocturnal enuresis be treated? What are the treatment options?

Back 219

Enuresis cannot be diagnosed until 5yrs of age (chronological and developmental)
Treatment is usually delayed until the child is at least 7yrs

First line → behavioral interventions
Start toilet training if not yet attempted
Motivational therapy (ie star charts)
Restrict fluids before bed (with a compensatory increase in daytime fluids)
Nighttime chaperone to the toilet or scheduled wakening to void using alarm clock
Enuresis alarm (pad with alarm device) in bed for classic conditioning. This is most effective long-term therapy

Second-line → Pharmacologic interventions
High likelihood of recurrence upon discontinuation
Imipramine (tofranil) for short-term (up to 6wks)
Desmopressin (DDAVP) orally (FDA 2007: intranasal desmopressin is no longer indicated for enuresis due to risk of hyponatremic seizures)
Indomethacin suppository


Posterior Urethral Valves
Most common obstructive urethral lesion in infants and newborns
Abnormal tissue folds in the distal prostatic urethra → thick-walled bladder and weak urinary stream and obstruction (bilateral hydronephrosis, megaureter, UTI)
Diagnosed with a voiding cystourethrogram
Definitive care → transurethral ablation of the abnormal tissue or urinary diversion (vesicostomy)

Front 220

In a pt with a varicocele, what is the scrotal mass made of?

Back 220

Dilation of pampiniform plexus

Front 221

What is the most common physical exam finding/ presenting symptom of a child with Wilm’s tumor?

Back 221

Palpable flank mass

Front 222

At what age would a normal child have to be before diagnosis of a nocturnal enuresis could be made?

Back 222

5 years of age

Front 223

A 4yo M is dx with a UTI. What study should be performed?

Back 223

VCUG

Front 224

What are the recommended therapies for nocturnal enuresis?

Back 224

Enuresis alarm
Imipramine (Tofranil) < 6wks

Front 225

What is the classic presentation of a varicocele?

Back 225

Scrotal mass that transilluminates
Infertility
Scrotal pain
Testicular atrophy

Front 226

3yo with am abdominal mass + hematura + HTN. What is the most likely diagnosis?

Back 226

Wilm’s tumor

Front 227

HYQ: A pt has signs of peritonitis and his clinical scenario favors rupture of the bladder (blunt trauma to fully distended bladder). What portion of the bladder must have been injured to allow for a chemical peritonitis to have developed?

Back 227

Dome of the bladder (only part of bladder covered by peritoneum)

Front 228

HYQ: What is the next step in the management of a woman with an uncomplicated cystitis?

Back 228

Treat empirically

Front 229

HYQ: Newborn males has a distended palpable bladder and oliguria. What is the most common cause of congenital urethral obstruction?

Back 229

Posterior urethral valves

Front 230

What is the treatment for epididymitis?

Back 230

Age <35 yrs : most likely GC/Chlamydia
Ceftriaxone IM (Rocephin, 3rd Gen) then doxycycline x10days

Age >35 yrs or h/o anal intercourse = Enterobacteriaceae
Fluoroquinolone x10-14 days
Ciprofloxacin (Cipro)
Levofloxacin (Levaquin)
Moxifloxacin (Avelox)

Front 231

What is the treatment for prostatitis?

Back 231

Age <35 yrs : most likely GC/Chlamydia
Ceftriaxone IM (Rocephin, 3rd Gen) then doxycycline x10days

Age >35 yrs or h/o anal intercourse = Enterobacteriaceae
Fluoroquinolone x 4-6 weeks

The key is to realize for prostatitis (not epididymitis), need to tx with fluoroquinolone for 2 months if >35yrs

Front 232

What labwork is included in the work-up for erectile dysfunction?

Back 232

Total testosterone
Prolactin level
TSH
+/- PSA

Front 233

What is the treatment for urethritis in men?

Back 233

Ceftriaxone IM (Rocephin, 3rd Gen) then doxycycline x10days

Front 234

How doe the signs and symptoms of testicular torsion differ from epidiymitis?

Back 234

see above

Front 235

What is the defining characteristic of a hydrocele?

Back 235

transillumination

Front 236

WTQ: A newborn infant is found to have a scrotal mass. The mass is cystic & transilluminated with light. He is born without any other complications. The vital signs are wnl. Other physical examination is unremarkable. What is the most appropriate next step in management?

Back 236

next step: reassurace & observation

dx: Hydrocele - a fluid collection within the processus or tunica vaginalis - the peritoneal projection that accompanies the testis during its descent into the scrotum

when the processus vaginalis fails to obliterate, peritoneal fluid may accumulate within the processus vaginalis causing a communicating hydrocele - it will transilluminate

most hydroceles will resolve spontaneously by age of 12mos

if it doesn't resolve, then it should be removed surgically due to risk of inguinal hernia