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Medicine 2_1

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1. wegeners

patho

1. vasculitis of the kidneys and UPPER

AND LOWER GI tract

2. upper respiratory symptoms, purulent

granulomatosis

1.

2. bloody nasal discharge, oral ulcers, cough,

clinical pres

6. acute kidney injury

1.

2.

3. what decreases

definition

clinical pres

1. rapid decline in renal function, with

increased serum creatinine (>50%

relative inc., or absolute increase of

0.5-1.0mg/dl)

3. hemoptysis, dyspnea, glomerulonephritis,

dx/tx

the probability of

- may be oliguric, anuric, nonoliguric

conjunctivitis, scleritis, arthralgias,

recovery from AKI

2.

dec. urine output, weight gain,

myalgias, tracheal stenosis, constitutional

4.

what is the MCC

edema, due to positive water/sodium

symptoms

death in AKI

balance, azotemia (inc. BUN/Cr)

3. CXR, ESR, anemia, c-ANCA positive,

thrombocytopenia *lung biopsy tx = poor prognosis, ***cyclophosphamide/corticosteroids renal transplant

2.

polyarteritis

nodosa (PAN)

1. HEP B*, HIV, drug reactions -> medium

vessel vasculitis of nervous system/GI

3. increasing age and presence of

comorbid conditions

4. infection, and cardiorespiratory

complications

7. RIFLE criteria of AKI

1.

2.

risk

injury

1. 1.5x increase in serum creatinine or

GFR decrease by 25% or urine output

<0.5 for 6 hours

2. 2x inc. in serum creatinine, or GFR

1. tract/kidney --> PMN invasion and

patho

3.

failure

decrease by 50% or urine output

2. fibrinoid necrosis + intimal proliferation --

clinical pres

4.

loss

<0.5ml/kg/hour for 12 hours

3. > renal artery/AAA/nerve damage,

dx/tx

5.

ESRD

3.

3x inc. in serum creatinine or GFR

NO PULMONARY INVOLVEMENT

decrease by 75%

2. fever, weakness, weight loss, myalgias,

arthralgias, abdominal pain, PERIPHERAL NERVES, HTN,

mononeuritic multiplex, livedo reticularis. diffuse glomerulonephritis

3. biopsy of tissue (NO GRANULOMAS),

mesenteric angiography (look for aneurysms)** ESR, p-ANCA (myeloperoxidase) FOBT tx = corticosteroids, cyclophosphamide

3. behcets

syndrome

1. autoimmune leukocytoclastic venulitis

2. recurrent oral and genital ulcers,

1. arthritis (knees/ankles), eye involvement

patho

clinical pres

2. (uveitis, optic neuritis, iritis,

3. conjunctivitis), CNS involvement (meningoencephalitis, HTN) fever, weight loss, aortic disease

dx/tx

3. PATHERGY TEST -

elevated ESR/CRP, tissue biopsy, steroids

4. buergers

disease

1. patho

1. cigarettes --> small vessel vasculitis of

arms/legs --> gangrene

2. ischemia, cyanotic, distal extremities,

2. ulceration of digits

clinical pres

3. tx

3. tx smoking cessation

5. hypersensitivity

vasculitis

1. patho

2. clinical pres

1. penicillin/sulfa drugs/infection--> small

vessel vasculitis

2. palpable purpura, macules, vesicles,

3. tissue biopsy

3. tx = withdraw offending agent, steroids

dx/tx

4. complete loss of kidney function

(w/ dialysis) for >4 weeks

5. complete loss of kidney function >3

months

8. three possible locations of AKI

prerenal, intrinsic, post-renal

9. what causes

azotemia

catabolic drugs (ie. steroids), GI/soft tissue bleeding, dietary protein intake

10. pre-renal failure

1. patho

2. causes

3. what drugs

should be avoided in patients with

prerenal failure

1. reversible dec. in arterial blood

volume or renal perfusion --> dec.

GFR --> inc. BUN/Cr/uremic toxins

2. hypovolemia, dehydration, excess

diuretics, diarrhea, burns, hemorrhage, CHF, renal artery

obstruction,cirrhosis

3. NSAIDS, ACE inhibitors,

cyclosporin

11. monitoring patient with AKI

daily weights, intake, output, BP, serum electrolytes, Hb, Hct, monitor WBC for infection

12. urine

osmolarity/urine

Na/FeNa/urine

sediment

1. pre-renal

2. ATN

1. >500, <20, <1%, scant

sediment/hyaline casts

2. >350, >40, >1%, full brownish

pigment/granular epithelial casts

13. pre-renal

failure

1. clinical pres

2. dx

1. dry mucus membranes, hypotension,

tachycardia, dec. skin turgor,

oliguria/anuria

2. oliguria (<0.5ml/kg/hr), BUN:Cr >20:1

urine osmolarity >500 dec. urine Na+ <20, FENA <1% urine:plasma Cr >40:1 hyaline urine sediment

14. intrinsic renal

failure

1. ATN, glomerulonephritis, allergic

glomerulonephritis goodpasture's,

1. wegener's granulomatosis, post-strep

patho

2. glomerulonephritis, RAS, TTP, HUS

clinical pres

3. lab findings

2. usually edema, tea colored urine

3. BUN/Cr ratio <20:1, urine Na >40,

FeNA >2-3%, urine osmolality <350 (impaired resorption), urine:plasma Cr

<20:1

15. rhabdomyolysis

1. skeletal muscle breakdown from trauma,

1. crush injury, prolonged immobility,

patho

2. seizures, snake bites, cocaine,

lab findings

statins* --> myoglobin --> ATN/AKI if

>20000

2. elevated CK, hyperkalemia,

hypocalcemia, hyperuricemia

3. IVF, mannitol (osmotic diuresis),

bicarbonate (pushes K+ into cells)

16. ATN

1 . two types of ATN

2. nephrotoxic

agents

1. ischemic (shock, hemorrhage, sepsis,

DIC, heart failure) and nephrotoxic

2. aminoglycosides, vancomycin

radiocontrast NSAIDS + CHF myoglobinuria, chemotherapeutic drugs- kappa, gamma, light chains

17. ATN

1. phases

oliguric - 10-14 days (<400-500ml/day)

diuretic - >500ml/day from fluid/salt overload from oliguric phase recovery phase

18. tests for post- renal failure

palpation of bladder ultrasound of kidney/bladder- residual volume, hydronephrosis, obstruction catheter insertion - voids large urine volume

19. post renal AKI

1. patho

1. urethral obstruction (BPH), kidney

obstruction, nephrolithiasis, neoplasms (bladder, cervix, prostate), retroperitoneal fibrosis

20. AKI

1. Blood labs to

order

2. UA findings

3. how to rule

1. elevated BUN/Cr, electrolytes, K+, Ca2+.

PO4-, albumin, CBC

2. 3+ or 4+ protein suggest intrinsic renal

failure from glomerular injury

3. bladder catheterization, renal

out post-renal

ultrasound

failure

21.

UA : urine

1.

few hyaline

sediment/protein/blood

casts/negative/negative

1. pre-renal failure

2.

muddy brown casts, renal

2. ATN

tubular cells/trace/negative

3. acute

3.

dysmorphic RBCs, RBCs with

glomerulonephritis

casts, WBCs with casts, fatty

4.

acute interstitial

casts/4+ protein/3+ blood*

nephritis

4.

RBCs, WBCs, eosinophils/1+

5.

post renal

protein/2+ blood

 

5.

+/-

RBC+WBC/negative/negative

22.

AKI

1. urine Na, urine Cr,

 

4. urine chemistry

2. must get urine

5. FENa

electrolytes/plasma electrolytes--

6. imaging

>

 

FENa = (UNa/PNa)/(UCr/PCr)

~~ <1% = prerenal failure, >1% = ATN

3.

renal ultrasound - to evaluate

obstruction, hydronephrosis-- CT scan of abdomen/pelvis

23.

AKI

1.

ECF volume expansion causing

 

1.

volume complications

pulmonary edema - tx = furosemide

 

+ tx

 

2.

metabolic

2.

hyperkalemia from dec.

complciations

excretion and shifts from

3.

fatal complications

intracellular metabolic acidosis due to dec. excretion of hydrogen ions

 

hypocalcemia - loss of ability to form vitamin D hyponatremia if drinking plain water hyperphosphatemia hyperuricemia

3.

hyperkalemic cardiac arrest,

pulmonary edema

24.

what is the pathogenesis of AKI related infection/sepsis

uremic end products inhibit immune functions and increased susceptibility to infection

25.

1.

what drugs should be

1.

NSAIDs, nephrotoxic agents

avoided in AKI

(aminoglycosides, radiocontrast)

2.

treatment of fluid

2.

diuresis, daily weight

overload

measurement, always consider

3.

pre-renal AKI

cardiac function

treatment

3.

treat underlying disorder, NS

 

to restore euvolemia/BP, dont give to patinets who have ascites/edema, stop ACE inhibitors/NSAIDS

26.

1. intrinsic AKI tx

1.

stop agent, trial of furosemide

2. post renal AKI tx

for oliguria

2. bladder catheter, uro consult

27. CKD

1.

2. MCC

3. how to measure

CKD

definition

1. dec. GFR <60ml/min or kidney

damage

2. diabetes MCC, HTN 2nd MCC,

chronic glomerulonephritis, interstitial nephritis,

3. Cr clearance, plasma Cr varies

inversely with the GFR

28. CKD

1. clinical

presentation (CV, GI, neuro)

1. HTN 2/2 water/salt retention, dec.

GFR stimulates RAAS CHF from volume overload, HTN, anemia n/v, loss of appetite, lethargy, somnolence, confusion, peripheral neuropathy, uremic seizures, weakness, asterixis

29. radiographic contract induced ATN pathogenesis

rapid spasm of the afferent arteriole prevent with saline hydration

30. azotemia vs uremia

azotemia = elevated BUN uremia = signs/symptoms associated with accumulation of nitrogenous wastes - usually when BUN >60

31. chronic renal

insufficiency

patients renal function is compromised but not failed - serum Cr usually 1.5-3.0

32. CKD

1.

effects

2.

endocrine/metabolic

effects

3. sexual effects

-also pruritus

hematologic

1. normochromic normocytic anemia

(dec. EPO) bleeding 2/2 interference with platelet function

2. hyperphosphatemia--> dec. D3-->

hypocalcemia --> secondary

hyperparathyroidism--> renal

osteodystrophy/bone fractures + calciphylaxis

3. HPG disturbance dec. testosterone,

amenorrhea, infertility, hyperprolactinemia

33. CKD

1. dx

2. radiologic dx`

1. urinalysis, Cr clearance/GFR, CBC

shows anemia/thrombocytopenia,

hyperkalemia, hypocalcemia, hypomagnesemia, hyperphosphatemia, meta. acid

2. renal ultrasound shows small

kidneys suggesting chronic renal disease

34.

CKD

1.

low protein - 0.7-0.8 g/kg body

1.

tx

weight/day

 

low salt diet if HTN/CHF present restrict potassium, phosphate, Mg

ACE inhibitors - reduce risk of ESRD progression, but WATCH FOR

HYPERKALEMIA,

strict blood control with ACE +/-

diuretics, glycemic control, smoking

cessation

35.

CKD

calcium citrate (oral phosphate

1.

how to correct the

binder)

hyperphosphatemia

2.

oral bicarb and oral D3

2.

hypo to correct

3.

EPO

hypo D3 and acidosis

4.

dialysis

5.

capsaicin, cholestyramine, UV

3.

""" anemia

light

4.

"""" pulmonary

edema

 

5. """" pruritis

36.

1. indicates for

AEIOU

emergent

Acidosis - intractable metabolic

hemodialysis

acidosis

 

electrolytes - hyperkalemia (refractor

to

other treatments)

I - intoxications: methanol, ethylene glycol, lithium, aspirin, magnesium containing laxatives

O

- hypervolemia

U

- severe based on clinical

presentation, uremic pericarditis, uremic encephalopathy

37.

vascular access in dialysis

seldinger central catheter

tunneled catheter - used up to 6

 

months

AV fistula - for permanent access

38.

1.

disadvantages of

1.

hypotension from rapid removal of

hemodialysis

intravascular volume, hypoosmolality

2.

disadvantages of

from solute removal

peritoneal dialysis

2.

hyperglycemia,

 

hypertriglyceridemia, peritonitis

39.

1.

complications of

1.

hypotension --> MI, fatigue

dialysis

hyposmolality --> nausea, vomiting first use syndrome - cx pain, back pain, anaphylaxis after using new dialysis machine

sepsis

beta 2 microglobulin amyloidosis peritonitis, hernias, hyperglycemia

40.

proteinuria

1.

definition

1.

2.

>150mg protein/24 hours due to

44.

nephrotic

syndrome

1. treat underlying disease (diabetes, MM, SLE,

MCD)

2. glomerular

glomerulonephritis/glomerular

1.

tx

ACE inhibitors/ARBs - dec. urinary albumin

proteinuria

damage--> severe protein loss

 

limit dietary protein,

3.

tubular

3.

small proteins filtered through

treat hypercholesterolemia

proteinuria

glomerulus are normally reabsorbed -

 

vaccinate against pneumococcal/influenza

4. overflow

proteinuria

- but with tubular damage they spill

into urine-- 2/2 sickle cell, urinary track obstruction, interstitial nephritis

4. small protein production

overwhelms tubules (ex. bence jones)

41. nephrotic syndrome

1.

2.

key features

causes

urine protein>3.5g/24 hours,

hypoalbuminemia, edema (2/2 hypoalbuminemia)

exacerbated by inc. aldosterone, hyperlipidemia/lipiduria - inc. hepatic LDL/VLDL synthesis hypercoagulable - loss of anticoagulants in urine

2. diabetes (MCC)*** membranous,

membranoproliferative, minimal change (MCC in children), diabetes, SLE, RA, polyarteritis nodosa, henoch schonlein purpura, wegeners, amyloidosis, cryoglobulinemia,

42. nephrotic syndrome

3. what drugs cause

1. captopril, heroin, heavy metals,

NSAIDs, penicillamine

nephrotic

4.

urine dipstick - >30mg/dl (>1+),

syndrome-

4+ >500 mg/dl

-

also infections,

urinalysis - will show RBC casts,

MM, malignant

WBC casts, fatty casts

HTN, and

*urine micro-albumin - more

transplant rejection

sensitive than dipstick

4. dx***** ~ do this

diagnostic sequence for hematuria as well, basically any renal failure that there is not a clear etiology

Cr, BUN/Cr, CBC (anemia 2/2 renal failure), renal ultrasound, IVP (pyelonephritis), ANA, anti-GBM, hepatitis serology, anti-streptococcal antibody, complement levels, cryoglobulin, serum/urine electrophoresis renal biopsy

43. urinalysis

1. pH

2. specific gravity

3. protein

- also glucose, blood, ketones, nitrite, leukocyte esterase

4. Microscope

1. avg 6.0, range 4.5-8

2. 1.002 - 1.035-- will normally vary

with volume status

3. 1+ = 50-150mg/day, 2+ = 0.5-

1.5g/day, 3+ = 2-5g/day, 4+ =

>5g/day

4. look for casts , cells, bacteria,

WBCs, RBCs, crystals

45. Hematuria

1. hematuria, >3 erythrocytes/HPF on

1.

definition

urinalysis

2.

2.

glomerular vs nonglomerular (ie. post-renal

microscopic

such as trauma, stones, malignancy)

vs. gross

3.

bladder or kidney cancer until proven

hematuria

otherwise

3. painless

hematuria - check CBC for IDA

46. cystitis, urethritis, prostatits

common

causes for

hematuria

47. hematuria

1. causes

1. kidney stones, infection (URI, urethritis,

pyelo), bladder or kidney cancer, glomerular

2.

causes

systemic

disease, IgA nephropathy, trauma, strenuous exercise (ex. marathon), cysts PCKD

3.

2.

SLE, rheumatic fever, HSP, wegener's, HUS,

medication

goodpasture's, PAN)

causes

3.

NSAIDs, cyclophosphamide, analgesics

48. urine dipstick, urinalysis

hematuria

1.

1. dx

RBCs/casts ~ GN pyuria --> send for culture if + for blood, but no RBCs on microscopy~ most likely hemoglobinuria, or myoglobinuria cytology to detect cancer 24 hour urine Cr/protein blood tests - coags, CBC, BUN/Cr IVP, CT scan, ultrasound renal biopsy

49. glomerular

1. impairment of selective filtration results in

excretion of blood cells/larger proteins, and

disorders

patho

2. clinical

pres

1. dec. GFR

2. isolated proteinuria, isolated hematuria,

nephrotic syndrome

50. nephritic

syndrome

1. patho

1. Post strep + others -->glomerular

INFLAMMATION

2. hematuria, AKI, azotemia, oliguria,

2. proteinuria (not nephrotic range ie.

findings

3.

findings

lab

<3.5g/24hr)

3. HTN, edema

clinical

51. nephrotic

syndrome

1. patho

2. causes

3.

findings

lab

1. abnormal glomerular PERMEABILITY

2. MCD, membranous, diabetes, SLE, drugs,

infection, FSGS,MPGN,

3. urine protein>3.5g/24hr, hypoalbuminemia,

hyperlipidemia

4. edema, hypercoagulability, inc. infections

52. minimal change

disease

1.

2.

3.

patho

diagnosis

tx

1. hodgkin's disease*/non-

hodgkin's/idiopathic/post

infectious/rifampin --> systemic T

cell dysfunction--> nephrotic

syndrome

2. no histologic findings of light

microscopy, foot processes fusion on electron microscopy, OVAL FAT BODIES ON URINE ELECTRON MICROSCOPY

3. 4-8 weeks of steroid therapy,

usually full recovery

58. post-

streptococcal

GN

1. post group B hemolytic strep or impetigo --

> 10-14 days

2. hematuria, edema, HTN, low

1. complement***, proteinuria

2.

pres

3. dx

4.

patho

clinical

tx

3. ASO titer*, anti-DNAse B titer, low C3

biopsy shows sub epithelial deposits

4. antihypertensives, loop diuretics, steroids

for severe

59. goodpasture's

syndrome

1. patho

1. IgG anti-GM antibody --> proliferative GN,

pulmonary hemorrhage

2. rapidly progressive renal failure,

2. hemoptysis, cough, dyspnea

clinical

53. FSGS

1. blacks, AIDS patients*-->

pres

3. renal biopsy shows linear*

1.

hematuria, HTN--> renal

3.

dx

immunofluorescence

demographics/clinical

insufficiency within 5 years

4.

tx

4.

plasmapheresis removes circulating anti-

pres

2. focal segmental

IgG antibodies

2. dx

3.

tx

glomerulosclerosis on light

microscopy

3. cytotoxic agents, steroids,

immunosuppressive agents, ACE/ARBs

54. IgA nephropathy

1. patho

2.

3. tx

dx

1. gross hematuria 5 days after

upper respiratory infection or

exercise -->

2. IgA and C3 on electron

microscopy of kidney biopsy , SERUM COMPLEMENT LEVELS ARE NORMAL

3. steroids

55. membranous

glomerulonephritis

1. hep C/B, syphilis, malaria, gold

(tx for RA) captopril,

1.

patho

penicillamine, neoplasm, lupus --

2.

clinical pres

> glomerular thickening

2.

dx

2.

active urinary sediment,

hypertension, worsening renal function, proteinuria, hypoalbuminemia

3. subepithelial deposits on renal

biopsy, decreased C3

56. hereditary

nephropathy (alports syndrome)

1. patho

2. clinical pres

-no treatment

1. X LINKED OR AUTO DOM

mutation in basement membrane protein

2. hematuria, pyuria, hearing

loss, progressive renal failure

57. membranoproliferative

glomerulonephritis

1. patho

2. dx

1. hep C/V, syphilis, lupus,

cryoglobulinemia

2. tram tracking on renal biopsy

with glomerular basement that stains for C3 and not immunoglobulins DEPRESSED

C3***

60. HIV

nephropathy

1. clinical

pres

2. dx

3. tx

1. proteinuria, edema, hematuria

2. histopath resembles FSGS

3. prednisone, ACE inhibitors, HAART

61. AIN

1. allergy to meds - penicillin, cephalo, sulfa,

1. diuretics, anticoagulants, phenytoin

patho

2. infection - legionella, streptococcus CVD - sarcoidosis, SLE, Sjogren's

3. dx/tx

pres

clinical

2. rash, fever, eosinophilia, pyuria,

hematuria

3. inc. BUN/Cr, urine eosinophils,

proteinuria, hematuria

4. remove offending agent, steroids

62. renal

papillary

necrosis

1. patho

2. tx

1. analgesics, diabetes, sickle, UTO/UTI,

alcoholism, transplant rejection

2. stop offending agent

63. type 1 RTA

1. inability to secrete H+ at distal tubule-->

1. pH of urine is >6, dec. ECF volume,

patho/clinical

pres

2. causes

3. dx

4. tx

hypokalemia, renal stones/nephrocalcinosis (inc. Ca2+/phos excretion),

rickets/osteomalacia

2. congeintal , MM, nephrocaclinosis,

ampho B, lupus/sjogrens, analgesic nephropathy

3. hypokalemic, hypochloremic, non-AG met

acid

4. sodium bicarbonate, phosphate salts (inc.

excretion of titratable acid)

64. type 2 RTA

1.

2.

3.

patho

causes

tx

1. inability to reabsorb HCO3- in the

proximal tubule* leading to inc. bicarb, K+, Na+ in the urine, NO, BASIC URINE,

aminoaciduria, glycosuria, phosphaturia NEPHROCALCINOSIS/NEPHROLITHIASIS

2. fanconi's, cystinosis, wilsons, lead, MM,

nephrotic syndrome, amyloidosis

3. no bicarb, sodium restriction inc.

sodium/bicarb reabsorbtion

65. type 4 RTA

1.

patho/causes

1. interstitial renal disease, diabetic

nephropathy, hypoaldosteronism or resistance to aldosterone -> dec. Na absorption, dec. H+/K+ secretion--> HYPERKALEMIA*, and acidic urine

66. hartnups

syndrome

1. patho

2. clinical

pres

3.

tx

1. AUTO RECESSIVE defect in amino acid

transporter --> dec. tryptophan absorption

and nicotinamide deficiency

2. pellagra (niacin def seen in corn based

diets) - dermatitis, diarrhea, ataxia,

psychiatric

3. give nicotinamide

67. nsaids, phenacetin, aspirin etc --> hematuria - renal papillary necrosis***, or interstitial nephritis

analgesic

nephropathy

patho

68. fanconi's

syndrome

1. proximal tubule dysfunction --> defective

transport of glucose, amino acids,

1. phosphate, uric acid, bicarb, sodium,

patho

2. potassium

pres

3. dx/tx

clinical

2. impaired growth, glucosuria,

phosphaturia, rickets, osteomalacia,

proteinuria,

3. phosphate, potassium ,alkali, salt

supplementation, hydration

69.

ADPKD

1. AUTODOM, AUTOREC--> renal failure

1. from recurrent pyelo/nephrolithiasis

2.

patho

clinical

2. hematuria, abdominal pain, HTN,

pres

palpable kidneys,

3.

3.

intracerebral berry aneurysms, renal

complications

failure, kidney stones, MVP/AR, cysts in

4. dx/tx

liver/spleen/pancreas/brain, diverticula, hernias

4. US/CT/MRI

tx = not curable, treat infections/control

HTN

70. ARPKD

1. aka "infantile" cysts of the renal collecting

1. ducts, and hepatic fibrosis

patho

2. clinical

pres

3. dx /tx

2. portal HTN, cholangitis, pulmonary

hypoplasia, potter syndrome

3. ultrasound during pregnancy, ultrasound

71. oligohydramnios --> hypoplasia of the lungs, club feet, abnormal facies

potter

syndrome

72. renal artery

stenosis

1.

2. clinical pres

patho

1. atherosclerosis/fibromuscular dysplasia

-->RAS causes dec. blood flow to JGA --> RAAS --> HTN

2. HTN refractory to medical therapy, may

3. be malignant, abdominal bruit, dec. renal function

dx/tx

3. renal arteriogram, BUT NO CONTRAST

IN PTS WITH RENAL FAILURE. MRA duplex doppler ultrasound tx = revascularization, by PCI with stent ACE inhibitors, CCBs.

73. renal vein

thrombosis

1. nephrotic syndrome***, RCC, trauma,

preg/OCP, retroperitoneal fibrosis, aortic

1. aneurysm, lymphadenopathy

patho

2. clinical pres

2. renal failure, flank pain, HTN

3. hematuria, proteinuria

dx/tx

3. renal venography, IVP

tx = anticoagulation

74.

atheroembolic

disease of renal arteries

1. patho

1. showers of cholesterol crystals from

plaques in arteries

2.

3. LIVEDO RETICULARIS, , hollenhorst

warfarin

2. plaques in the retina, digital cyanosis,

risk factors

3. elevated creatinine, elevated ESR,

clinical pres

75. hypertensive

nephrosclerosis

1. systemic HTN --> thickening of

glomerular afferent arterioles -->

patho

1. proteinuria, / ESRD

2. clinical pres

2. proteinuria, rising Cr, dec. in renal

function,

76. sickle cell

nephropathy

1. patho

1. sickling of RBCs in microvasculature

leads to infarction mostly in renal papillae

--> nephrotic syndrome, 5% ESRD,

77.

renovascular

hypertension

clinical pres

malignant HTN, sudden onset HTN, HTN suddenly worsened HTN that does not respond to standard medical therapy

78. nephrolithiasis

1. predisposing

conditions

1. low fluid intake, gout, crohns,

hyperparathyroid, type 1 RTA, UTIs (esp proteus), low calcium, high oxalate diet

79. calcium stones

1 calcium oxalate, or calcium phosphate,

1. inc GI absorption, dec. renal reabsorption,

patho

2. inc. bone reabsorbtion of calcium, primary hyperparathyroidism, sarcoidsosi, malingnacy

findings

findings/radio

microscopic

2. bipyramidal or ovals, radiodense on

abdominal radiograph

80. causes of

hyperoxaluria

steatorrhea causes calcium loss small bowel disease, crohns, pyridoxine deficinecy

81. uric acid

stones

1.

2.

findings/radio

findings

microscopic

patho

1. persistently acidic* urine (<5.5),

hyperuricemia (gout, chemotherapy, leukemia, lymphoma [via purine release])

2.

3.

detection

radiolucent flat square plates requires CT, ultrasound, or IVP for

82. struvite stones

1. UTI 2/2 urease producing bacteria

1.

patho

(proteus, klebsiella, serratia, enterobacter)-- > alkalinization of urine--> ammonia combined with mg/phos-->struvite calculi

83. what size

1.

1. <0.5cm

stones can

2. sudden onset paroxysms of flank pain

pass

that radiates anteriorly to the groin, n/v, hematuria***, UTI

spontaneously

2. clinical pres

3. urinalysis - microscopic or gross

87.

UTO

1.

2.

dx

tx

1. renal ultrasound -

urinalysis KUB - shows stones

IV

cystoscopy

CT

2. catheter, urethrotomy, prostatectomy,

nephrostomy tube, ureteral stent,

contrast urogram

scan

88. prostate

cancer

1. risk factors

2.clinical

pres

1. age, AA, high fat diet, family history,

pesticide/herbicide exposure

2. presents late- obstruction of the urethra

occurs, difficulty voiding, dysuria, inc. urinary frequency, after mets- back pain, pelvic pain,weight loss

89.

prostate

1. DRE- 70% have spread if palpable

of urinary

hematuria

cancer

- abnormal DRE --> TRUS

stone

UA micro- shows crystals possibly

1.

dx

PSA screening/PSA velocity/ PSA density

3. dx/tx

urine pH - alkaline suggests infection stone, acidic urine suggests calcium oxalate or uric acid stones, serum chemistry - BUN, Ca, Cr, oxalate, citrate levels KUB- does not show cystine/uric acid stones *CT scan without contrast* IVP renal ultrasound tx = analgesia - IV morphine/ketorolac fluid hydration, ABX for infection >3 days - consider urology consult

84. indications

for admission

for renal

calculi

pain not controlled with oral meds anuria renal colic stone > 1cm

85. renal calculi

prevention

2L/day of water limit animal protein intake if patient has hyperuricosuria thiazide diuretics - dec. urine calcium, allopurinol

86. UTO

1. lower

1. BPH, prostate cancer, urethral stricture,

neurogenic bladder, trauma (pelvic

urinary tract

fracture/bladder cancer)

causes

2.

kidney stones, blood clots, sloughed

2.

upper

papilla, tumors, strictures, ureteropelvic

urinary tract

dysfunction, pregnancy, tumors, AAA,

causes

retroperitoneal fibrosis, endometriosis,

3. clinical pres

crohns

3. renal colic/pain, oliguria, recurrent UTI,

hematuria, renal failure

what causes

90. prostate cancer, prostatitis prostatic massage needle biopsy, cystoscopy, BPH, prostatitis, advanced age

an elevated

PSA

91.

what

diagnostic

studies

1. PSA >10

2. abnormal

DRE

3. PSA <4

DRE negative

4. PSA 4.1-10,

DRE negative

1. TRUS with biopsy

2. TRUS with biopsy

3. annual follow up

4. TRUS with biopsy

92. PSA

adjustments-

age adjusted,

PSA velocity,

PSA density

93. PSA >10 ng/dl (50%) PSA velocity >0.75/year

when is TRUS with biopsy indicated

94. prostate

cancer

1. treatment

1. contained disease - radical prostatectomy

for

locally invasive - radiation and androgen deprivation metastatic - orchiectomy, antiandrogens (flutamide), LHRH agonists (leuprolide), GnRH antagonists (degarelix) estramustine (estrogen+nitrogen mustard)

95.

RCC

1. patho

2. sites of

mets

3. risk factors

1. sporadic, or VHL

2. lung, liver, brain, bone

3. cigarettes, phenacetin PCKD, chronic

dialysis (multicystic kidney disease), heavy

metals (mercury/cadmium), hypertension

96. RCC

1. HEMATURIA, abdominal/flank pain*,

1.

clinical pres

flank mass, weight loss, fever,

2.

paraneoplastic syndromes

paraneoplastic

2.

polycythemia (EPO), PTHrp, renin,

syndromes

cortisol, gonadotropins, fever of unknown

3.

dx

origin

4.

tx

3. CT with contrast, abdominal ultrasound

4. surgery***, interferon alpha/2, sunitinib

(tyrosine kinase inhibitor)

97. bladder cancer

1. typically transitional cell cancers 10%

1. squamous and adeno (transitional cell

patho

2. cancer can occur in the bladder, renal

risk factors

3. pelvis, or ureter) spreads by local invasion

clinical pres

2. cigarettes, aniline/azo dyes, long term

cyclophosphamide treatment, schistosomiasis

3. painless hematuria, irritable bladder

irritation, dysuria frequency

98. bladder cancer

1. urinalysis/urine culture, urine cytology,

1. IVP, cystoscopy

2. tx

dx

2. stage 0 - mucosal limited - intravesical

chemo stage A - lamina propria - transurethral bladder resection Stage B - muscle invasion - radical cystectomy, node dissection ,removal of prostate, uterus, ovaries, anterior vaginal wall, urinary diversion stage C - to pervesicular fat stage D - cystectomy, systemic chemotherapy

99.

testicular

cancer

1. germ cell

2. non-germ

cell

3. risk factors

1. germ cell =

seminomas (radiosensitive),

non-seminomas (embryonal

[necrosis/malig], chorio [mets quickly, yolk sac, teratoma)

2. leydig cell tumors - secrete

androgens/estrogens, precocious puberty/gynecomastia sertoli cells -usually benign

3. cryptorchidism, klinefelter's syndrome

4. dx - testicular exam/ultrasound, b-HCG

(chorio/non-sem), AFP (embryonal), CT

chest

100. penile cancer

1. risk factors

1. uncircumcised, HSV, HPV

2. varicocele, spermatocele, hydrocele,

2. lymphoma

testicular

mass

ddx for

101. testicular

torsion

1. patho

1. twisting of spermatic cord causes

ischemia/infarction

2. acute severe testicular pain,

swollen/tender scrotum, elevated testicles,

3. testicular ultrasound, surgical

emergency - detorsion and orchiopexy

102.

epididymitis

1.

e.coli in children/elderly, in young

1. patho

men - gonorrhea/chlamydia

2. clinical pres

2.

swollen tender testicle, fever,

 

chills, scrotal pain/mass

3. r/o torsion (ultrasound), and abx

103.

fluids

1. 60% of body weight men, 50%

1. TBW

women

2. ICF

2. 2/3 of TBW = 40% of body mass

3.

ECF

3. 1/3 TBW = 20% of body mass

4.

plasma,

4. plasma = 1/3 ECF, 1/12 TBW

interstitial fluid

interstitial fluid = 2/3 ECF

104.

fluids

1.

800-1500 ml/day,

1.

minimum = 500-600ml/day

normal/minimum

2. 600-900 ml/day

urine output

3. urine output 0.5-1.0ml/kg/hour

2.

insensible loss

3.

what is the best

way to assess volume status - lower extremity edema may not be volume overload, TBW may be high, but patient may be intravascularly

 

105.

causes of oliguria

cardiac failure (low blood flow to kidney) ATN/AIN/kidney damage post renal obstruction

106.

1.

what fraction of

1. 85% venous, 15% arterial

intravascular

2. liver failure, nephrotic syndrome

volume is in venous vs arterial system

(hypoosmolar), left sided CHF (pulmonary edema), right sided CHF

2.

what patients

(anasarca)

third space fluids

107.

fluid replacement uses

1.

blood loss or dehydrated, urgent

resuscitation

1. normal saline

2.

standard maintenance - glucose

2. D51/2NS + 20

spares muscle breakdown

mEq kcl/L

3.

dilute powdered medicines,

3. D5w

hypernatremia, only 1/12 remains

4. lactated ringers

intravascular

 

4.

intravascular volume, NOT

maintenance, trauma resuscitation, DO NOT USE IF PATIENT IS HYPERKALEMIC OR ESRD

108.

causes of

vomiting, diarrhea, NG suction, fistula, ascites, effusions, bowel obstruction, burns, polyuria (ex. DKA), sepsis, retroperitoneal inflammation, trauma, insensible losses (skin 75%, respiratory tract

hypovoluemia

25%)

109.

1.

clinical

altered MS, sleepiness, apathy, coma orthostasis, dec. pulse pressure, dec. CVP and PCWP

114. hypotonic

1.

osmolality <280 mOsm/kg,

presentation

hyponatremia

low urine sodium <10mEq/L, due

hypovolaemia

1.

hypovolemic

to extrarenal loss- diarrhea, vomiting, NG suction, diaphoresis, third spacing,

2.

urine panel

poor skin turgor, hypothermia, pale extremities, dry tongue, oliguria, ileus, weakness, ARF (pre-renal azotemia)

hypotonic

findings

hyponatremia

 

2.

euvolemic hypotonic

burns, pancreatitis. high urine sodium >20mEq/L -

2.

FENa <1%, BUN:Cr >20, low urine

hyponatremia

sodium, elevated hematocrit (3% inc for

3.

hypervolemic

due to diuretic excesses, low aldosterone, ATN

every liter of deficit)

hypotonic

110.

1.

how does CBC

1.

3% inc. in hematocrit with each 1L of

hyponatremia

2.

no evidence of ECF

change with

dehydration

expansion/contraction- SIADH, psychogenic polydipsia, post-op hyponatremia, hypothyroidism, oxytocin, D5W, hypotonic solution, water after intense exertion, haldol, cyclophos

dehydration

2.

bolus LR or NS, monitor

2.

how to

HR/BP/UOP/weight, maintain UOP at 0.5-1ml/kg/hr, replace blood with crystalloid 3:1 ratio Then maintenance D51/2NS with 20mEq KCl/L

 

correct a

volume deficit

 

3.

nephrotic syndrome, liver disease

water retaining states - CHF,

 

iatrogenic, CHF, nephrotic syndrome,

111.

hypervolemia

1.

 

1.

causes

cirrhosis, ESRD

115. isotonic hyponatremia (pseudohyponatremia)

any condition that causes inc protein/lipid levels --> inc. in plasma solids lower plasma sodium concentration but the amount of sodium is normal

2.

clinical

2.

weight gain, peripheral edema, ascites,

features

pulmonary edema/rales, JVD, elevated

 

3.

tx

CVP/PCWP, peripheral edema

 

3.

fluid restriction, diuresis, UOP

monitor/daily weights, swan ganz

116. hypertonic

osmotic substances cause water shift out of cells - hyperglycemia, mannitol, sorbitol, glycerol, maltose

catheter placement

hyponatremia

112.

Na+

1.

inc. sodium increases ECF, which inc.

concentration

GFR, dec. in sodium intake causes dec.

 

is reflection of water homeostasis Na+ content is reflection of

GFR and reduced sodium excretion

117. adjusting Na for glucose

for every 100 of glucose, serum sodium level decreases by 3

2.

osmoreceptors in hypothalamus

stimulated by plasma hypertonicity(>295 mOsm/kg), inc. ADH

production -->V2 receptors in collecting ducts,

natremia- too much or too little water

3.

118. diagnosis of specific type of hyponatremia

BMP, plasma osmolality, assess volume status (hypo, eu, hyper) urine osmolality

sodium homeostasis

119. hyponatremia

1.

120-130 hold water

1.

sodium

volemia - too much or too little sodium

1.

treatment

110-120 - loop diuretics + saline

homeostasis

 

<110 or symptomatic - give hypertonic saline to inc. serum sodium by 1-2 mEq/L/hr, DO NOT INC. SODIUM MORE THAN 8mmol/L during first 24 hours- OR GET PONTINE MYELINOLYSIS

2.

water

homeostasis

 

3.

NATREMIA

VS VOLEMIA

 

113.

hyponatremia

1. plasma Na < 135mmol/L

 

1. definition

2. occurs at Na <120mEq/L

 
 

2. symptomatic

3. water shifts and increases ICF volume,

120. hypernatremia

1. serum sodium >145

hyponatremia

leading to cerebral edema--> HA, delirium, twitching, weakness,

1. definition

2. diuretics, osmotic diuresis

level

2. hypovolemic

(glycosuria), renal failure,

3. symptoms of

hyponatremia

hyperactive DTR, seizures, coma,

n/v ileus, watery diarrhea

CV

HTN from inc. ICP

inc

salivation/lacrimation

oliguria --> anuria *****

hypernatremia cause

diarrhea, diaphoresis, respiratory losses

3. diabetes inspiidus, respiraotry

losses

4. iatrogenic ~ TPN, NaHCO3-,

glucocorticoids, saltwater drowning, hyperaldosteronism

121. hypernatremia

1. neurologic symptoms - restlessness,

1. focal neuro deficits, confusion, seizures,

clinical pres

dx

2. coma

3. tissues, mucous membranes dry, salivation decreases

tx

2. urine volume low, urine osmolality

>800mOsm/kg

3. hypovolemic - give NS to restore

hemodynamics isovolemic - DDAVP for DI, oral fluids, D5W IV hypervolemic - diuretics, D5W, dialyze if ESRD

122. water deficit

calculation

water deficit = TBW (1-[actual Na/desiredNa)

123.

calcium

1. normal

range

2. corrected

calcium

3. effect of pH

1.

2. corrected = total - [albumin*0.8]

3. high pH calcium binds albumin thus

total Ca is normal, but ionized is low

8.5-10.5

124. PTH

1. actions

1. inc bone resorption, inc Ca2+

reabsorption at the kidney, dec. PO4- reabsorption, inc. gut activation of D3 ==== inc plasma Ca2+, dec. plasma PO4-

125. calcitonin

1. actions

1. dec bone resorption, dec kidney Ca2+

reabsorption,inc kidney PO4-

reabsorption, dec gut absorption of Ca2+ ===== dec plasma Ca2+ and dec. plasma

PO4-

126. vitamin D

1. actions

inc. bone resorption, inc Ca2+

reabsorption, dec. PO4- reabsorption, inc. gut Ca2 reabsorption, inc. gut PO4- reabsorption

127. hypocalcemia

1. causes

1. hypoparathyroidism (iatrogenic MCC),

acute pancreatitis (deposition), renal insufficiency (dec. D3 ESRD), hyperphosphatemia (ESRD), pseudohypoparathyroidism (resist to PTH), hypomagnesemia (dec. PTH secretion), D3 deficiency, malabsorption (short bowel), transfusion (citrate binds Ca), osteoblastic mets, hypoalbuminemia, digeorge (no thymic shadow)

128. hypocalcemia

1. rickets, osteomalacia,

1. neuromuscular irritability- numbness,

clinical pres

2. tingling, tetany, chvostek's sign, trousseau's sign, grand mal seizures, basal

3. ganglia calcifications

4.

manifestations

cardiac

lab workup

tx

2. LONG QT***

3. BUN, Cr, magnesium, albumin, ionized

calcium, amylase, lipase

4. IV calcium gluconate, oral calcium

supplements, vitamin D, thiazide diuretics

(dec. urinary calcium), magnesium

129. hypercalcemia

1. causes

2. what drugs

cause

hypercalcemia

- sarcoidosis

-familial

hypocalciuric

hypercalcemia

(low urine

Ca2+

1. hyperparathyroidism(inc. Ca, dec PO4),

pagets disease of bone, acromegaly,

addisons, metastatic

cancer(prostate=osteoblastic, kidney=osteolytic), MM (lysis of bone tumor, release of OAF), PTHrp (lung cancer)

2. milk-alkali syndrome, vitamin D

intoxication, thiazide, lithium (inc. PTH)

130. hypercalcemia

clinical pres

stones -nephrolithiasis, nephrocalcinosis

1. bones - bone aches/pains, osteitis fibrosa

2. cystica grunts and groans -muscle

findings ECG

3. dx

cardiac

pain/weakness, pancreatitis, PUD, gout,

constipation psychiatric overtones- depression, fatigue, anorexia, sleep disturbances, anxiety, lethargy - other- polyuria/polydipsia, hypertension, weight loss,

2. SHORT QT***

3. same workup as hypocalcemia, +

radioimmunoassay of PTH (PTH vs PTHrp)

131. hypercalcemia

1. tx

1. IV fluids

diuretics - furosemide BISPHOSPHONATES (pamidronate) calcitonin glucocorticoids hemodialysis phosphate- risk of metastatic calcification

132.

potassium

1. where is it

located in the body

2. hypokalemia

causes

3.

hyperkalemia

causes

4. potassium

secretion`

1.

2. alkalosis, insulin, albuterol

3. acidosis, renal failure

4. kidneys, GI tract

intracellular

133. hypokalemia

vomiting, NG suction (hypokalemic met

1. alk), diarrhea, laxatives, enemas, diuretics,

causes

2. renal tubular disease, parenchymal disease, glucocorticoids, mg deficiency, insulin administration, insufficient dietary intake

syndrome

bartter

2. autosomal recessive defect in salt

reabsorption in thick ascending limb - hypokalemia, met. alk, inc.urine chloride

(>20)~ key to distinguish from contraction

alkalosis

134. hypokalemic non-anion gap metabolic

what acid

base

acidosis

disturbance

with

diarrhea

135. in a patient who is hypokalemia

1.

could be excess aldosterone

2.

probably renal or GI loss

3.

bactrim, ampho B, B2 agonists,

1.

what does

it mean if they are hypertensive

 

2.

what does

it mean if they are normotensive

 

3.

what drugs

cause

 

hypokalmeia

136. hypokalemia

T

wave flattening, T wave inversions

ECG findings

U waves

prolongation of the QU interval (also seen with quinidine)

137. monitor K+, hypokalemia predisposes to digoxin toxicity monitor Ca, hypercalcemia predisposes to digoxin toxicity

what

electrolyte to

monitor in

patients on

digoxin

138. hypokalemia

1. clinical

pres

2. tx

1. arrhythmias (prolongs conduction),

weakness, fatigue, paralysis, cramping, ileus, polyuria, polydipsia, N/V

2. identify cause, adjust drugs, oral KCL, 10

mEq KCL inc. K+ by 0.1mEq/L, monitor K+ and EKG max 10 mEq/hr in peripheral IV line

max 20 mEq/hr in central line add 1% lidocaine to dec. pain

139. hyperkalemia

1. causes

1. renal failure, addison's, K+ sparing

diuretics (spirono), hyporeninemic hypoaldosteronism, ACE inhibitors***, transfusion, acidosis, rhabdo, hemolysis, burns, insulin deficiency (dec. NAK ATPase activity), bactrim

140. pseudohyperkalemia

prolonged tourniquet use with or without repeated fist clenching--> acidosis/K+ loss from cells`` also hemolysis during venipuncture

141. hyperkalemia

1. clinical pres

2.

3. tx

ECG

1. muscle weakness, dec. DTR,

respiratory failure, n/v, intestinal

colic, diarrhea

2. K+ > 6.0 tall peaked T waves,

QRS widening, PR

prolongation,loss of P waves, sine wave pattern, vfib

3. IV calcium gluconate*** -

stabilizes resin myocardial membrane Glucose and insulin sodium bicarbonate - inc. pH (emergency only) kayexalate - GI potassium exchange resin hemodialysis diuretics - furosemide

142. hypomagnesemia

1. causes

2. renal causes

3. clinical pres

4. relationship

between mg and k

5. ECG changes

- tx = oral or parenteral Mg

1. malabsorption, prolonged

fasting, fistulas, TPN w/o mg,

alcoholism

2. SIADH, diuretics, bartter's,

gentamicin, ampho B, cisplatin,

renal transplant

3. COEXISTING HYPOCALCEMIA,

neuromuscular/CNS hyperexcitability, muscle twitching,

weakness, tremors, hyperreflexia, seizures, altered mental status

4. when Mg or K decreases, the

other ion decreases

5. prolonged QT, T wave flattening,

torsade de pointes

143. hypermagnesemia

1. causes

2. clinical pres

3. ECG changes

4. tx

1. renal failure***, early burns,

severe acidosis, trauma/surgical

stress, adrenal insufficiency,

rhabdomyolysis

2. nausea, facial paralysis, loss of

DTRs (first), somnolence, death

from respiratory failure/cardiac arrest

3. hyperkalemia type changes- inc

PR interval, widened QRS, elevated

T waves

4. calcium gluconate for

cardioprotection, saline/furosemide, dialysis,

intubation

144. hypophosphatemia

1. causes

2.clinical pres

1. alcohol abuse (dec. intestinal

abs), vitamin D deficiency, malabsorption, excessive use of

antacids, hyperalimentation or starvation hyperglycemia, osteomalacia, ATN, RTA, hypokalemia, hypomagnesemia

2. encephalopathy, confusion,

seizures, paresthesias, muscle weakness, myalgias/rhabdo, bone pain, rickets/osteomalacia hemolysis, RBC dysfunction, WBC dysfunction, platelet dysfunction cardiomyopathy/myocardial depression

145. hyperphosphatemia

1.

2. clinical pres

3. tx

causes

1. renal insufficiency,

bisphosphonates,

hypoparathyroidism, D3

intoxication, calcinosis, PO4 enemas, D3 overdose,

2. metastatic calcification, soft tissue

calcifications, serum * calcium > 70 = likelihood for precipitates to form hypocalcemia --> neuromuscular irritability/tetany

3. phosphate binding antacids w/

aluminum hydroxide or carbonate, hemodialysis

146. metabolic acidosis

1. criteria

2. anion gap

3. AG metabolic

acidosis causes

1. dec. pH, dec. bicarbonate conc

2. AG = Na+ - (Cl + HCO3-)

- reflects unmeasured ions, proteins,

phosphates, organic acids, sulfates

3. ketoacidosis - diabetic, starvation,

alcohol abuse lactic acidosis - renal failure- dec. NH4+ excretion,

retention of organic ions, sulfate, phosphate

147. effect of acidosis on the body

right shift oxygen hemoglobin curve depresses CNS, dec. pulmonary blood flow, arrhythmias, myocardial function impairment, hyperkalemia

148. effects of alkalosis on the body

dec. cerebral blood flow left shifts oxygen hemoglobin dissociation curve, arrhythmias, tetany, seizures

149. how to tell if met.acid is a mixed disorder

delta AG < delta HCO3- ~~ AG acid + high AG acid delta AG > delta HCO3- ~~ met alk + high AG acid

150. salicylate toxicity

acid/base

disturbance

primary resp. alk, primary met.acid `

151.

1.

non-AG met

1.

diarrhea (HCO3- loss), pancreatic

acid causes

fistulas, small bowel fistulas, ureterosigmoidoscopy proximal RTA (MM, cystinosis, wilsons), distal RTA (SLE, sjogrens, ampho B), acetazolamide (CA inhibitor)

152.

1.

metabolic

1.

hyperventilation - kussmaul respirations

acidosis

when pH <7.2, acidosis--> dec. response to

clinical pres

2.

dx

catecholamines***-->lactic acidosis, -->

 

dec. CO --> hypotension-->worsening acidosis

2.

history, AG,

expected PaCO2=1.5(HCO3-)+8+/-2 if more than expected there is also resp.acid b/c of inadequate compensation ***inadequate compensation is a sign of impending resp. failure ***PaCO2 less than expected, patient has met acid + resp. alk

153.

metabolic

1.

sodium bicarbonate(but takes 24 hours

acidosis

to get to brain)

1.

tx

H+ = 24[PaCO2/HCO3-] ~ so while patient gets bicarb, PaCO2 is still very low --> severe intracranial alkalosis mechanical respiration for respiratory fatigue

154.

metabolic

1. inc. blood pH, inc. HCO3-

alkalosis

2. is the patient volume expanded or

1. contracted

definition

2. first step in

3.

loss of gastric H+, ECF volume

evaluation

contraction

3.

causes:

saline sensitive- urine Cl < 10mEq/L, ECF

saline

contraction, hypokalemia: vomiting,, NG,

sensitive

diuretics, villous adenoma (high chloride

4.

causes:

diarrhea)

saline

4.

urine Cl>20mEq/L, ECF expansion,

resistant

primary hyperaldosteronism, cushings, K+

5.

how high

deficiency, Bartter's syndrome, diuretic abuse

should

respiratory

5.

PaCO2 to 50-55, if higher there is

compensation

probably resp acid as well

be

155.

metabolic

1.

inc. HCO3-, inc. pH, hypokalemia,

alkalosis

PaCO2 is elevated, urine chloride (high or

1. low)

2. tx

dx

2. NS + potassium if saline sensitive, if

saline resistant can address underlying cause or spironolactone Ammonium chloride for severe (risk of tox in patients with liver failure)

156.

respiratory

acidosis

1. blood >40mmHg, reduced blood pH

2. acute - 1mmol/L for every 10mmHg

1.

definition

PaCO2

2.

pH inc. by 0.08

compensation

chronic - 4mmol/L for every 10mmHg

3. causes

PaCO2

4. clinical pres

3. COPD, airway obstruction, myasthenia,

brainstem injury, narcotic overdose, respiratory fatigue

4. somnolence, confusion, myoclonus with

asterixis, HA, confusion, papilledema

157. respiratory

acidosis

1. treatment

1. patency of airway, supplemental oxygen

(if PaO2<60***can exacerbate acidosis in

COPD), correct reversible causes, improve

alveolar ventilation, naloxone, bronchodilators intubation/mech vent (if PaCO2>60, no improvement with supplemental oxygen, obtunded, deteriorating mental status)

158. respiratory

alkalosis