1.wegeners granulomatosis 1. patho
2. clinical pres 3. dx/tx
1. vasculitis of the kidneys and UPPER AND LOWER GI tract
2. upper respiratory symptoms, purulent bloody nasal discharge, oral ulcers, cough, hemoptysis, dyspnea, glomerulonephritis, conjunctivitis, scleritis, arthralgias, myalgias, tracheal stenosis, constitutional symptoms
3. CXR, ESR, anemia, c-ANCA positive, thrombocytopenia *lung biopsy tx = poor prognosis, ***cyclophosphamide/corticosteroids renal transplant 2.polyarteritis nodosa (PAN) 1. patho 2. clinical pres 3. dx/tx
1. HEP B*, HIV, drug reactions -> medium vessel vasculitis of nervous system/GI tract/kidney --> PMN invasion and fibrinoid necrosis + intimal proliferation --> renal artery/AAA/nerve damage, NO PULMONARY INVOLVEMENT 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. patho 2. clinical pres 3. dx/tx
1. autoimmune leukocytoclastic venulitis 2. recurrent oral and genital ulcers, arthritis (knees/ankles), eye involvement (uveitis, optic neuritis, iritis,
conjunctivitis), CNS involvement
(meningoencephalitis, HTN) fever, weight loss, aortic disease
3. PATHERGY TEST -
elevated ESR/CRP, tissue biopsy, steroids
4.buergers disease 1. patho 2. clinical pres 3. tx
1. cigarettes --> small vessel vasculitis of arms/legs --> gangrene
2. ischemia, cyanotic, distal extremities, ulceration of digits 3. tx smoking cessation 5.hypersensitivity vasculitis 1. patho 2. clinical pres 3. dx/tx
1. penicillin/sulfa drugs/infection--> small vessel vasculitis
2. palpable purpura, macules, vesicles, 3. tissue biopsy
tx = withdraw offending agent, steroids
6. acute kidney injury 1. definition
2. clinical pres 3. what decreases the probability of recovery from AKI 4. what is the MCC death in AKI
1. rapid decline in renal function, with increased serum creatinine (>50% relative inc., or absolute increase of 0.5-1.0mg/dl)
- may be oliguric, anuric, nonoliguric 2. dec. urine output, weight gain, edema, due to positive water/sodium balance, azotemia (inc. BUN/Cr) 3. increasing age and presence of comorbid conditions
4. infection, and cardiorespiratory complications 7. RIFLE criteria of AKI 1. risk 2. injury 3. failure 4. loss 5. ESRD
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 decrease by 50% or urine output <0.5ml/kg/hour for 12 hours 3. 3x inc. in serum creatinine or GFR decrease by 75%
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
Medicine 2_1
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. patho 2. clinical pres 3. lab findings
1. ATN, glomerulonephritis, allergic glomerulonephritis goodpasture's, wegener's granulomatosis, post-strep glomerulonephritis, RAS, TTP, HUS 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. patho
2. lab findings
1. skeletal muscle breakdown from trauma, crush injury, prolonged immobility,
seizures, snake bites, cocaine,
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 out post-renal failure
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 ultrasound 21.UA : urine sediment/protein/blood 1. pre-renal failure 2. ATN 3. acute glomerulonephritis 4. acute interstitial nephritis 5. post renal 1. few hyaline casts/negative/negative 2. muddy brown casts, renal tubular cells/trace/negative 3. dysmorphic RBCs, RBCs with casts, WBCs with casts, fatty casts/4+ protein/3+ blood* 4. RBCs, WBCs, eosinophils/1+ protein/2+ blood 5. +/-RBC+WBC/negative/negative 22.AKI 4. urine chemistry 5. FENa 6. imaging
1. urine Na, urine Cr, 2. must get urine
electrolytes/plasma electrolytes-->
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. volume complications + tx 2. metabolic complciations 3. fatal complications
1. ECF volume expansion causing pulmonary edema - tx =
furosemide
2. hyperkalemia from dec. excretion and shifts from 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 avoided in AKI
2. treatment of fluid overload
3. pre-renal AKI treatment
1. NSAIDs, nephrotoxic agents (aminoglycosides, radiocontrast) 2. diuresis, daily weight
measurement, always consider cardiac function
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 2. post renal AKI tx
1. stop agent, trial of furosemide for oliguria
27.CKD 1. definition 2. MCC
3. how to measure CKD
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. hematologic effects 2. endocrine/metabolic effects 3. sexual effects -also pruritus
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. tx
1. low protein - 0.7-0.8 g/kg body 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
1. how to correct the hyperphosphatemia 2. hypo to correct hypo D3 and acidosis 3. """ anemia 4. """" pulmonary edema 5. """" pruritis
calcium citrate (oral phosphate binder)
2. oral bicarb and oral D3 3. EPO 4. dialysis 5. capsaicin, cholestyramine, UV light 36.1. indicates for emergent hemodialysis AEIOU
Acidosis - intractable metabolic 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 hemodialysis 2. disadvantages of peritoneal dialysis
1. hypotension from rapid removal of intravascular volume, hypoosmolality from solute removal
2. hyperglycemia,
hypertriglyceridemia, peritonitis
39.1. complications of dialysis
1. hypotension --> MI, fatigue 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 2. glomerular proteinuria 3. tubular proteinuria 4. overflow proteinuria 1. >150mg protein/24 hours 2. due to glomerulonephritis/glomerular damage--> severe protein loss 3. small proteins filtered through glomerulus are normally reabsorbed -- 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. key features 2. 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 nephrotic syndrome-- also infections, MM, malignant HTN, and transplant rejection 4. dx***** ~ do this diagnostic sequence for hematuria as well, basically any renal failure that there is not a clear etiology
1. captopril, heroin, heavy metals, NSAIDs, penicillamine
4. urine dipstick - >30mg/dl (>1+), 4+ >500 mg/dl
urinalysis - will show RBC casts, WBC casts, fatty casts
*urine micro-albumin - more sensitive than dipstick
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
44.nephrotic syndrome 1. tx
1. treat underlying disease (diabetes, MM, SLE, MCD)
ACE inhibitors/ARBs - dec. urinary albumin limit dietary protein,
treat hypercholesterolemia
vaccinate against pneumococcal/influenza
45.Hematuria 1. definition 2. microscopic vs. gross hematuria 3. painless hematuria - check CBC for IDA 1. hematuria, >3 erythrocytes/HPF on urinalysis
2. glomerular vs nonglomerular (ie. post-renal such as trauma, stones, malignancy)
3. bladder or kidney cancer until proven otherwise
46.common causes for hematuria
cystitis, urethritis, prostatits
47.hematuria 1. causes 2. systemic causes 3. medication causes
1. kidney stones, infection (URI, urethritis, pyelo), bladder or kidney cancer, glomerular disease, IgA nephropathy, trauma, strenuous exercise (ex. marathon), cysts PCKD
2. SLE, rheumatic fever, HSP, wegener's, HUS, goodpasture's, PAN)
3. NSAIDs, cyclophosphamide, analgesics
48.hematuria 1. dx
1. urine dipstick, urinalysis 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 disorders 1. patho 2. clinical pres
1. impairment of selective filtration results in excretion of blood cells/larger proteins, and dec. GFR
2. isolated proteinuria, isolated hematuria, nephrotic syndrome 50.nephritic syndrome 1. patho 2. lab findings 3. clinical findings
1. Post strep + others -->glomerular INFLAMMATION
2. hematuria, AKI, azotemia, oliguria, proteinuria (not nephrotic range ie. <3.5g/24hr) 3. HTN, edema 51.nephrotic syndrome 1. patho 2. causes 3. lab findings
1. abnormal glomerular PERMEABILITY 2. MCD, membranous, diabetes, SLE, drugs, infection, FSGS,MPGN,
3. urine protein>3.5g/24hr, hypoalbuminemia, hyperlipidemia
52.minimal change disease 1. patho 2. diagnosis 3. 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
53.FSGS 1. demographics/clinical pres 2. dx 3. tx
1. blacks, AIDS patients*--> hematuria, HTN--> renal insufficiency within 5 years 2. focal segmental
glomerulosclerosis on light microscopy
3. cytotoxic agents, steroids, immunosuppressive agents, ACE/ARBs 54.IgA nephropathy 1. patho 2. dx 3. tx
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. patho 2. clinical pres 2. dx
1. hep C/B, syphilis, malaria, gold (tx for RA) captopril,
penicillamine, neoplasm, lupus --> glomerular thickening
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*** 58. post-streptococcal GN 1. patho 2. clinical pres 3. dx 4. tx
1. post group B hemolytic strep or impetigo --> 10-14 days
2. hematuria, edema, HTN, low complement***, proteinuria
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 2. clinical pres 3. dx 4. tx
1. IgG anti-GM antibody --> proliferative GN, pulmonary hemorrhage
2. rapidly progressive renal failure, hemoptysis, cough, dyspnea 3. renal biopsy shows linear* immunofluorescence
4. plasmapheresis removes circulating anti-IgG antibodies 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. patho 2. clinical pres 3. dx/tx
1. allergy to meds - penicillin, cephalo, sulfa, diuretics, anticoagulants, phenytoin
infection - legionella, streptococcus CVD - sarcoidosis, SLE, Sjogren's 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. patho/clinical pres 2. causes 3. dx 4. tx
1. inability to secrete H+ at distal tubule--> pH of urine is >6, dec. ECF volume,
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. patho 2. causes 3. 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.analgesic nephropathy patho
nsaids, phenacetin, aspirin etc --> hematuria - renal papillary necrosis***, or interstitial nephritis 68.fanconi's syndrome 1. patho 2. clinical pres 3. dx/tx
1. proximal tubule dysfunction --> defective transport of glucose, amino acids,
phosphate, uric acid, bicarb, sodium, potassium
2. impaired growth, glucosuria, phosphaturia, rickets, osteomalacia, proteinuria,
3. phosphate, potassium ,alkali, salt supplementation, hydration 69.ADPKD 1. patho 2. clinical pres 3. complications 4. dx/tx
1. AUTODOM, AUTOREC--> renal failure from recurrent pyelo/nephrolithiasis 2. hematuria, abdominal pain, HTN, palpable kidneys,
3. intracerebral berry aneurysms, renal failure, kidney stones, MVP/AR, cysts in liver/spleen/pancreas/brain, diverticula, hernias
4. US/CT/MRI
tx = not curable, treat infections/control HTN 70.ARPKD 1. patho 2. clinical pres 3. dx /tx
1. aka "infantile" cysts of the renal collecting ducts, and hepatic fibrosis
2. portal HTN, cholangitis, pulmonary hypoplasia, potter syndrome
3. ultrasound during pregnancy, ultrasound
71.potter syndrome
oligohydramnios --> hypoplasia of the lungs, club feet, abnormal facies
72.renal artery stenosis 1. patho 2. clinical pres 3. dx/tx 1. atherosclerosis/fibromuscular dysplasia -->RAS causes dec. blood flow to JGA --> RAAS --> HTN
2. HTN refractory to medical therapy, may be malignant, abdominal bruit, dec. renal function
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. patho 2. clinical pres 3. dx/tx
1. nephrotic syndrome***, RCC, trauma, preg/OCP, retroperitoneal fibrosis, aortic aneurysm, lymphadenopathy
2. renal failure, flank pain, HTN hematuria, proteinuria
3. renal venography, IVP tx = anticoagulation 74.atheroembolic disease of renal arteries 1. patho 2. risk factors 3. clinical pres
1. showers of cholesterol crystals from plaques in arteries
2. warfarin
3. LIVEDO RETICULARIS, , hollenhorst plaques in the retina, digital cyanosis, elevated creatinine, elevated ESR,
75.hypertensive nephrosclerosis 1. patho
2. clinical pres
1. systemic HTN --> thickening of glomerular afferent arterioles --> proteinuria, / ESRD
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. patho 2. microscopic findings/radio findings
1.. calcium oxalate, or calcium phosphate, inc GI absorption, dec. renal reabsorption, inc. bone reabsorbtion of calcium, primary hyperparathyroidism, sarcoidsosi, malingnacy
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. patho 2. microscopic findings/radio findings
1. persistently acidic* urine (<5.5), hyperuricemia (gout, chemotherapy, leukemia, lymphoma [via purine release]) 2. radiolucent flat square plates
3. requires CT, ultrasound, or IVP for detection
82.struvite stones 1. patho
1. UTI 2/2 urease producing bacteria (proteus, klebsiella, serratia, enterobacter)--> alkalinization of urine--enterobacter)--> ammonia combined with mg/phos-->struvite calculi
83.1. what size stones can pass spontaneously 2. clinical pres of urinary stone 3. dx/tx 1. <0.5cm
2. sudden onset paroxysms of flank pain that radiates anteriorly to the groin, n/v, hematuria***, UTI
3. urinalysis - microscopic or gross hematuria
UA micro- shows crystals possibly
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 urinary tract causes 2. upper urinary tract causes 3. clinical pres
1. BPH, prostate cancer, urethral stricture, neurogenic bladder, trauma (pelvic fracture/bladder cancer)
2. kidney stones, blood clots, sloughed papilla, tumors, strictures, ureteropelvic dysfunction, pregnancy, tumors, AAA, retroperitoneal fibrosis, endometriosis, crohns
3. renal colic/pain, oliguria, recurrent UTI, hematuria, renal failure
87.UTO 1. dx 2. tx
1. renal ultrasound - urinalysis
KUB - shows stones IV contrast urogram cystoscopy
CT scan
2. catheter, urethrotomy, prostatectomy, nephrostomy tube, ureteral stent,
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 cancer 1. dx
1. DRE- 70% have spread if palpable - abnormal DRE --> TRUS
PSA screening/PSA velocity/ PSA density
90.what causes an elevated PSA
prostate cancer, prostatitis prostatic massage
needle biopsy, cystoscopy, BPH, prostatitis, advanced age 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.when is TRUS with biopsy indicated PSA >10 ng/dl (50%) PSA velocity >0.75/year
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. clinical pres 2. paraneoplastic syndromes 3. dx 4. tx
1. HEMATURIA, abdominal/flank pain*, flank mass, weight loss, fever,
paraneoplastic syndromes
2. polycythemia (EPO), PTHrp, renin, cortisol, gonadotropins, fever of unknown origin
3. CT with contrast, abdominal ultrasound 4. surgery***, interferon alpha/2, sunitinib (tyrosine kinase inhibitor)
97. bladder cancer 1. patho 2. risk factors 3. clinical pres
1. typically transitional cell cancers 10% squamous and adeno (transitional cell cancer can occur in the bladder, renal pelvis, or ureter) spreads by local invasion 2. cigarettes, aniline/azo dyes, long term cyclophosphamide treatment,
schistosomiasis
3. painless hematuria, irritable bladder irritation, dysuria frequency
98. bladder cancer 1. dx
2. tx
1. urinalysis/urine culture, urine cytology, IVP, cystoscopy
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 2. ddx for testicular mass 1. uncircumcised, HSV, HPV
2. varicocele, spermatocele, hydrocele, lymphoma
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. patho 2. clinical pres
1. e.coli in children/elderly, in young men - gonorrhea/chlamydia
2. swollen tender testicle, fever, chills, scrotal pain/mass
3. r/o torsion (ultrasound), and abx
103.fluids 1. TBW 2. ICF 3. ECF 4. plasma, interstitial fluid
1. 60% of body weight men, 50% women
2. 2/3 of TBW = 40% of body mass 3. 1/3 TBW = 20% of body mass 4. plasma = 1/3 ECF, 1/12 TBW interstitial fluid = 2/3 ECF
104.fluids 1.
normal/minimum urine output 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
1. 800-1500 ml/day, minimum = 500-600ml/day 2. 600-900 ml/day
3. urine output 0.5-1.0ml/kg/hour
105.causes of oliguria cardiac failure (low blood flow to
kidney)
ATN/AIN/kidney damage post renal obstruction
106.1. what fraction of intravascular volume is in venous vs arterial system 2. what patients third space fluids
1. 85% venous, 15% arterial 2. liver failure, nephrotic syndrome (hypoosmolar), left sided CHF (pulmonary edema), right sided CHF (anasarca) 107.fluid replacement uses 1. normal saline 2. D51/2NS + 20 mEq kcl/L 3. D5w 4. lactated ringers
1. blood loss or dehydrated, urgent resuscitation
2. standard maintenance - glucose spares muscle breakdown 3. dilute powdered medicines, hypernatremia, only 1/12 remains intravascular
4. intravascular volume, NOT maintenance, trauma resuscitation, DO NOT USE IF PATIENT IS HYPERKALEMIC OR ESRD
108.causes of hypovoluemia
vomiting, diarrhea, NG suction, fistula, ascites, effusions, bowel obstruction, burns, polyuria (ex. DKA), sepsis, retroperitoneal inflammation, trauma, insensible losses (skin 75%, respiratory tract 25%)
109.1. clinical presentation hypovolaemia 2. urine panel findings
altered MS, sleepiness, apathy, coma orthostasis, dec. pulse pressure, dec. CVP and PCWP
poor skin turgor, hypothermia, pale extremities, dry tongue, oliguria, ileus, weakness, ARF (pre-renal azotemia) 2. FENa <1%, BUN:Cr >20, low urine sodium, elevated hematocrit (3% inc for every liter of deficit)
110.1. how does CBC change with dehydration 2. how to correct a volume deficit
1. 3% inc. in hematocrit with each 1L of dehydration
2. bolus LR or NS, monitor
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 111.hypervolemia 1. causes 2. clinical features 3. tx
1. iatrogenic, CHF, nephrotic syndrome, cirrhosis, ESRD
2. weight gain, peripheral edema, ascites, pulmonary edema/rales, JVD, elevated CVP/PCWP, peripheral edema
3. fluid restriction, diuresis, UOP monitor/daily weights, swan ganz catheter placement 112.Na+ concentration is reflection of water homeostasis Na+ content is reflection of sodium homeostasis 1. sodium homeostasis 2. water homeostasis 3. NATREMIA VS VOLEMIA
1. inc. sodium increases ECF, which inc. GFR, dec. in sodium intake causes dec. GFR and reduced sodium excretion 2. osmoreceptors in hypothalamus stimulated by plasma hypertonicity(>295 mOsm/kg), inc. ADH
production -->V2 receptors in collecting ducts,
3. natremia- too much or too little water volemia - too much or too little sodium
113.hyponatremia 1. definition 2. symptomatic hyponatremia level 3. symptoms of hyponatremia 1. plasma Na < 135mmol/L 2. occurs at Na <120mEq/L
3. water shifts and increases ICF volume, leading to cerebral edema--> HA, delirium, twitching, weakness, hyperactive DTR, seizures, coma, n/v ileus, watery diarrhea CV HTN from inc. ICP inc salivation/lacrimation oliguria --> anuria ***** 114.hypotonic hyponatremia 1. hypovolemic hypotonic hyponatremia 2. euvolemic hypotonic hyponatremia 3. hypervolemic hypotonic hyponatremia 1. osmolality <280 mOsm/kg, low urine sodium <10mEq/L, due to extrarenal loss- diarrhea, vomiting, NG suction, diaphoresis, third spacing, burns, pancreatitis.
high urine sodium >20mEq/L -due to diuretic excesses, low aldosterone, ATN
2. no evidence of ECF
expansion/contraction- SIADH, psychogenic polydipsia, post-op hyponatremia, hypothyroidism, oxytocin, D5W, hypotonic solution, water after intense exertion, haldol, cyclophos 3. water retaining states - CHF, nephrotic syndrome, liver disease
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
116.hypertonic hyponatremia
osmotic substances cause water shift out of cells - hyperglycemia, mannitol, sorbitol, glycerol, maltose
117.adjusting Na for glucose
for every 100 of glucose, serum sodium level decreases by 3
118.diagnosis of specific type of hyponatremia
BMP, plasma osmolality, assess volume status (hypo, eu, hyper) urine osmolality
119.hyponatremia 1. treatment
1. 120-130 hold water
110-120 - loop diuretics + saline <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 120.hypernatremia 1. definition 2. hypovolemic hypernatremia cause 1. serum sodium >145 2. diuretics, osmotic diuresis (glycosuria), renal failure, diarrhea, diaphoresis, respiratory losses
3. diabetes inspiidus, respiraotry losses
4. iatrogenic ~ TPN, NaHCO3-, glucocorticoids, saltwater drowning, hyperaldosteronism
121.hypernatremia 1. clinical pres 2. dx
3. tx
1. neurologic symptoms - restlessness, focal neuro deficits, confusion, seizures, coma
tissues, mucous membranes dry, salivation decreases
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. 8.5-10.5
2. corrected = total - [albumin*0.8] 3. high pH calcium binds albumin thus total Ca is normal, but ionized is low
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. clinical pres 2. cardiac manifestations 3. lab workup 4. tx 1. rickets, osteomalacia,
neuromuscular irritability- numbness, tingling, tetany, chvostek's sign,
trousseau's sign, grand mal seizures, basal ganglia calcifications
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 1. clinical pres 2. cardiac findings ECG 3. dx
stones -nephrolithiasis, nephrocalcinosis bones - bone aches/pains, osteitis fibrosa cystica
grunts and groans -muscle
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. intracellular
2. alkalosis, insulin, albuterol 3. acidosis, renal failure 4. kidneys, GI tract
133.hypokalemia 1. causes 2. bartter syndrome
vomiting, NG suction (hypokalemic met alk), diarrhea, laxatives, enemas, diuretics, renal tubular disease, parenchymal disease, glucocorticoids, mg deficiency, insulin administration, insufficient dietary intake 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.what acid base disturbance with diarrhea
hypokalemic non-anion gap metabolic acidosis 135.in a patient who is hypokalemia 1. what does it mean if they are hypertensive 2. what does it mean if they are normotensive 3. what drugs cause hypokalmeia
1. could be excess aldosterone 2. probably renal or GI loss 3. bactrim, ampho B, B2 agonists,
136.hypokalemia ECG findings
T wave flattening, T wave inversions U waves
prolongation of the QU interval (also seen with quinidine) 137.what electrolyte to monitor in patients on digoxin
monitor K+, hypokalemia predisposes to digoxin toxicity
monitor Ca, hypercalcemia predisposes to digoxin toxicity
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. ECG
3. tx
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. causes 2. clinical pres 3. tx 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 acid causes
1. diarrhea (HCO3- loss), pancreatic fistulas, small bowel fistulas, ureterosigmoidoscopy
proximal RTA (MM, cystinosis, wilsons), distal RTA (SLE, sjogrens, ampho B), acetazolamide (CA inhibitor)
152.1. metabolic acidosis clinical pres 2. dx
1. hyperventilation - kussmaul respirations when pH <7.2,
acidosis--> dec. response to
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 acidosis 1. tx
1. sodium bicarbonate(but takes 24 hours to get to brain)
H+ = 24[PaCO2/HCO3-] ~ so while patient gets bicarb, PaCO2 is still very low --> severe intracranial alkalosis
mechanical respiration for respiratory fatigue 154.metabolic alkalosis 1. definition 2. first step in evaluation 3. causes: saline sensitive 4. causes: saline resistant 5. how high should respiratory compensation be
1. inc. blood pH, inc. HCO3-2. is the patient volume expanded or contracted
3. loss of gastric H+, ECF volume contraction
saline sensitive- urine Cl < 10mEq/L, ECF contraction, hypokalemia: vomiting,, NG, diuretics, villous adenoma (high chloride diarrhea)
4. urine Cl>20mEq/L, ECF expansion, primary hyperaldosteronism, cushings, K+ deficiency, Bartter's syndrome, diuretic abuse
5. PaCO2 to 50-55, if higher there is probably resp acid as well
155.metabolic alkalosis 1. dx 2. tx
1. inc. HCO3-, inc. pH, hypokalemia, PaCO2 is elevated, urine chloride (high or low)
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. definition 2. compensation 3. causes 4. clinical pres
1. blood >40mmHg, reduced blood pH 2. acute - 1mmol/L for every 10mmHg PaCO2
pH inc. by 0.08
chronic - 4mmol/L for every 10mmHg PaCO2
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 1. definition 2. compensation 3. causes
1. inc. blood pH, dec. PaCO2
2. acute: HCO3- dec by 2 mmHg for every 10 mmHg dec in PaCO2, blood pH inc by 0.08
chronic: HCO3- dec by 5 mEq/L for every 10 mmHg dec in PaCO2 and blood pH dec. by 0.02
3. alveolar hyperventilation - anxiety, PE, pneumonia, asthma, sepsis, hypoxia, mechanical ventilation, pregnancy (inc. progesterone), cirrhosis, salicylates,
159.respiratory alkalosis 1. clinical pres 2. tx
1. dec. cerebral blood flow
(vasoconstriction), lightheadedness, dizziness, anxiety, paresthesias, perioral numbness, tetany, arrhythmias
2. correct underlying cause, inhaled CO2, or breathing into paper bag
160.anemia 1. compensatory mechanisms 2. when to transfuse 3. clinical pres
1. inc. CO (HR*SV), inc. extraction ratio, right shift of hemoglobin curve (via inc. 2,3 DPG), expansion of plasma volume 2. Hb concentration<7g/dl or inc. oxygen carrying capacity (CAD or pulmonary disease)
3. depends on patient, they may be asymptomatic at Hb 7 or 8: headache, fatigue, poor conc, diarrhea, nausea, pallor(conjunctiva), hypotension, tachycardia, jaundice (if hemolytic, blood in stool
161.anemia 1. dx 2. tx
1. reticulocyte index (>2% impliese excessive RBC destruction)
hb*3 = hct, iron, B12, folate, EPO (ESRD) 2
162.pseudoanemia decrease in hemoglobin/hct 2/2 dilution
acute volume infusion or overload
163.after patient is found to have anemia what is next lab test
retic, B12, folate
164. cryoprecipitate-components+what is it used to treat
VIII, XIII, fibrinogen, vWF-used for hemophilia A, DIC, vWD
165.how much change in CBC with 1 unit of PRBCs and 1 unit of platelets
1 unit or PRBCs- inc. Hb 1, inc Hct 3
1 unit of platelets - inc platelet count by 10,000
166.blood products for massive blood loss
1:1:1 - platelets:FFP:PRBCs 167.hemolytic transfusion reactions: intravascular hemolysis 1. patho 2. symptoms/complications 3. tx
1. ABO mismatched blood --> anti-# IgM--> complement activation, C9 punches holes in RBCs
2. fever, chills, n/v, flank pain, chest pain, dyspnea,
hypovolemic shock, hypotension, tachycardia, DIC, renal failure, hemoglobinuria (ATN) 3. stop transfusion, fluid replacement, epinephrine, dopamine/norepi for pressure control 168.hemolytic transfusion reactions: extravascular hemolysis 1. patho 2. clinical pres + tx
1. minor antigen reaction -occurs 3-4 weeks after transfusion, previous exposure creates memory-B cells that will produce Ig against antigen and lead to splenic/liver/bone marrow sequestration 2. late onset -- fever, jaundice, anemia tx none 169.anemia 1. interpretation of reticulocytes 2. microcytic anemia ddx 1. >2 excessive RBC
destruction or blood loss with bone marrow response <2 inadequate RBC production (take a look at slide)
2. IDA, thalassemias, sideroblastic (lead, B6 def, alcohol)-->accumulated porphyrins/iron in mitochondria
170.anemia
1. macrocytic ddx 2. normocytic ddx
1. B12/folate deficiency, liver disease (up to 115) due to altered lipoprotein synthesis), stimulated erythropoiesis (polychromatophilic RETICS), myelodysplasia
2. aplastic anemia, bone marrow fibrosis, tumor, AOCD, renal failure (inflamm/malig)
171.evaluation of suspected
hemolytic anemia
first retic >2,
then check haptoglobin, LDH, bilirubin
172.microcytic anemia 1. causes 2. clinical pres 3. dx 4. tx
1. chronic blood loss, menstrual bleeding, GI blood loss,
infants/toddlers drinking human milk (low iron), rapid growth in adolescents, pregnancy
2. pallor, fatigue, generalized weakness, DOE, orthostasis
3. dec. ferritin, inc. TIBC, inc. transferrin, inc RDW, microcytic hypochromic RBCs on smear, stool guaiac
4. ferrous sulfate - SE = constipation, nausea, dyspepsia
iron dextran- IV or IM
173.beta thalassemia (cooley's anemia) 1. patho beta thal 2. demographics 3. clinical pres + tx
1. deficient beta chain, excess alpha chains aggregate and damage membranes
2. mediterranean, middle eastern, and indian ancestry
3. severe hypochromic microcytic anemia, hepatosplenomegaly***, marrow expansion, FTT, skull xray shows "crew cut"
4. HbF/HbA2 elevated - peripheral smear shows microcytic hypochromic RBCs with target cells
tx = frequent PRBCs
174.alpha thalassemia 1. patho 2.
1. alpha chain decrease, beta tetramers
175.what is the consequence of frequent transfusions in beta thal patients
iron overload and hemochromatosis tx -= desferoxamine 176.what type of microcytic anemia is inc. RDW characteristic of IDA 177.thalassemia minor 1. patho 2. clinical pres
1. heterozygous beta-chain thalassemia 2. asymptomatic, mild microcytic hypochromic anemia
3. dx = hemoglobin electrophoresis
178.what is next diagnostic test in patient who has IDA, but does not respond to iron
hemoglobin electrophoresis- to rule out alpha/beta thalassemia 179.alpha thalassemia 1. one mutation/deletion clinical pres 2. alpha thalassemia trait clinical pres 3. HbH disease 4. 4 alpha loci mutations
1. mutation/deletion of only one alpha locus- asymptomatic, normal
hemoglobin/hematocrit
2. two alpha loci mutations- mild hypochromic anemia
3. hemolytic anemia, splenomegaly, microcytic hypochromic anemia, HbH on gel electrophoresis
tx = PRBC transfusions 4. hydrops fetalis fatal at birth
180.sideroblastic anemia 1. patho 2. dx 3. tx 1. hereditary
acquired - chloramphenicol, INH, alcohol, lead*, collagen vascular disease, myelodysplasia
2. inc. serum ferritin**, inc. serum
iron*, BASOPHILIC STIPPLING,
normal TIBC, TIBC saturation normal/elevated
ringed sideroblasts on marrow biopsy 3. remove offending agent, B6 supplementation 181.anemia of chronic disease 1. patho 2. dx 3. tx
1.chronic infection, TB, lung abscess, cancer, RA, SLE, trauma-->IL6/ cytokines + HEPCIDIN*** are suppressive effect on EPO (dec. retics) and dec. iron absorption from the gut 2. low serum iron, low TIBC, low serum transferrin, INCREASED SERUM FERRITIN, normochromic, normocytic 3. no treatment, do not give iron
182.aplastic anemia 1. patho
2.clinical pres
1.radiation, chloramphenicol, sulfonamides, gold, carbamazepine, parvo B19, hep C, hep B, EBV, HZV, HIV, benzene, insecticides--> bone marrow failure-->pancytopenia 2. fatigue, dyspnea, petechiae, easy bruising, inc. infections (neutropenia), 3. normocytic, normochromic anemia, bone marrow shows hypocellular marrow, absence of progenitors tx = bone marrow transplant, PRBC/platelt transfusion,
183.pernicious anemia
autoimmune destruction of parietal cells and intrinsic factor leads to impaired absorption of B12 in terminal ileum
184.B12 deficiency 1. function of b12 2. dietary sources/storage 3. causes of deficiency
1. homocysteine to methionine, methyl malonyl CoA to succinyl CoA
2. meat, fish- about 3 years supply in the liver
3. pernicious, gastrectomy, poor diet content (vegan), alcoholism, crohns disease, ileal disease, diphyllobothrium latum, blind loop (bacterial overgrowth
185.b12 deficiency 1. clinical pres
1. anemia, stomatitis, glossitis, neuropathy (B12*** vs folate), demyelination (pos. columns, corticospinal tracts, spinocerebellar tracts), ataxia, upper motor neuron signs, urinary/fecal incontinence, dementia
186.b12 deficiency 1. dx
2. schilling test 3. tx
1. peripheral smear shows megaloblastic anemia - hypersegmented PMNs, serum B12 <100 pg/ml, elevated methylmalonic acid, elevated homocysteine, anti-intrinsic factor
2. IM dose of unlabeled B12 to saturate binding sites, oral dose of radioactive B12, measure radio B12 in urine and plasma, repeat oral B12 with intrinsic factor- if it is pernicious, adding intrinsic factor will increase serum conc
3. IM cyanocobalamin once/month 187.folate deficiency 1. sources/storage 2. clinical pres 3. dx/tx
1. raw green vegetables, 3 months worth of stored folate
2. inadequate diet, alcoholism, long term oral ABX, pregnancy, hemolysis, MTX, phenytoin, hemodialysis
3. serum folate, elevated homocysteine ONLY,
tx= dietary folic acid
188.causes of hemolytic anemia
immune hemolysis, mechanical hemolysis (prosthetic valves, MAHA), burns, toxins (snake bites/recluse spider), sickle cell anemia, HbC, spherocytosis, PNH
G6PD, pyruvate kinase
189.intravascular vs
extravascular
intravascular = inside circulation
extravascular = within reticuloendothelial system (spleen/bone marrow/liver)
190.lab studies for hemolytic anemia
elevated retic, inc. LDH, dec.
haptoglobin, dec. hb/hct, inc. retic count, schistocytes (intravascular),
spherocytes/helmet cells (extravascular), sickled RBCS, heinz bodies (G6PD), elevated indirect bilirubin , direct coombs positive, (in AIHA)
191.smear findings for hemolytic anemia
schistocytes, helmet cells
192.sickle cell anemia 1. patho 2. what triggers sickling 3. correlation of sickle crisis and age of death 4. treatment of aplastic crisis
1. AR - substitution of uncharged valine for negative glutamic acid at 6th position of the beta chain
2. acidosis, hypoxia, changes in temperature, dehydration, infection 3. >3 crises/year - median age of death - 35 years
4. 2/2 parvo b19, - blood transfusion and patient recovers in 10-14 days
193.sickle cell anemia 1. clinical pres 2. painful bone crisis 3. hand foot syndrome 4. acute chest syndrome
1. jaundice, pallor, gallstone disease (pigmented),
high output heart failure aplastic crisis (parvo)
2. painful bone crisis - tibia, humerus, self limiting in 2 -4 days
3. painful swelling of dorsa of hands and feet from avascular necrosis of metacarpal and metatarsal bones
4. repeated episodes of pulmonary infarctions- cx pain, respiratory distress, pulmonary infiltrates, hypoxia
194.sickle cell anemia 1. splenic disease 2. avascular necrosis 3. priapism + treatment 4. CVAs
1. multiple splenic infarctions cause functional asplenia by age 4 years (non-palpable)
2. most commonly in the hip and shoulder 3. vasoocclusion --> erection, lasting between 30 mins and 3 hours
tx = hydralazine, or nifedipine, or anti-androgen
4. cerebral thrombosis especially occurs in children 195.sickle cell anemia 1. renal complications 2. extremity complications 3. abdominal complications 4. infectious complications
1. renal papillary necrosis with hematuria, 2. chronic leg ulcers
3. abdominal crisis - mimics acute abdomen 4. functional asplenia leads to increased risk for - h.flu, s.pneumo, neisseria meningitidis (encapsulated bacteria)
196.1. sickle cell anemia diagnosis 2. sickle cell pain crisis tx 3. sickle cell tx
1. anemia, sickle peripheral smear, howell jolly bodies hemoglobin electrophoresis 2. hydration, IV fluids, morphine, keep patient warm, supplemental O2
3. avoid high altitudes (low O2 tension), maintain fluid intake, vaccination against h.flu, s.pneumo, n.mening, hydroxyurea (inc. HbF), blood transfusion , bone marrow transplant
197.hereditary spherocytosis 1. patho 2. clinical pres 3. dx 4. tx
1. AUTOSOMAL DOMINANT - mutation in spectrin--> splenic trapping and destruction (extravascular)
2. hemolytic anemia, jaundice,
splenomegaly, gallstones*, hemolytic crisis (2/2 parvo b19)
3. osmotic fragility to hypotonic saline, elevated retic, elevated MCHC >36%, spherocytes on smear, direct coombs negative
4. splenectomy
folate supplementation (prevents aplastic crisis)
198.causes of spherocytosis
hereditary spherocytosis, G6PD, ABO incompatibility, hyperthermia, AIHA
199.G6PD deficiency 1. patho + triggers 2. clinical pres 3. peripheral smear findings 1. x linked disorder
infection- G6PD cannot generated NADPH to reduce glutathione
OXIDIZING DRUGS- sulfonamides, nitrofurantoin, primaquine, dimercaprol, fava beans, infection
2. episodic hemolytic anemia, dark urine, jaundice on exam,
peripheral smear shows BITE CELLS, HEINZ BODIES (Hb precipitates), PRUSSIAN BLUE STAIN POSITIVE tx = avoid triggers, maintain hydration, RBC transfusion
3. bite cell from removal of heinz bodies by splenic macrophages 200.AIHA 1. patho 2. warm AIHA 3. cold AIHA
1. autoantibodies against RBC membrane antigens (IgG anti-Rh) leads to destruction of RBCs
2. leukemias, lymphomas, CLL, collagen disease, alpha methyl dopa -->IgG--> extravascular hemolysis --> splenomegaly 3. mycoplasma, infectious mononucleosis --> IgM* binds to RBC membrane---->
intravascular hemolysis 201.AIHA 1. clinical pres 2. dx 3. tx
1. fatigue, pallor, jaundice,
2. microspherocytes, elevated reticulocytes direct coombs test positive - IgG- warm AIHA
RBCs covered with complement alone - it is cold AIHA
3. often self limiting
warm - glucocorticoids, splenectomy, azathioprine/cyclophosphamide, RBC, folate supplementation
cold - avoid cold exposure, RBC transfusions, chemotherapeutic, 202.paroxysmal nocturnal hemoglobinuria 1. patho 2. clinical pres 3. complications 4. tx
1. deficiency in proteins that link complement inactivating proteins to blood cell membranes-->complement mediated intravascular lysis,
hypercoagulable state, bone marrow aplasia
2. chronic paroxysmal intravascular hemolysis, inc. LDH, normochromic normocytic anemia, pancytopenia, venous thrombosis, abdominal, back pain, muscle pain
3. aplastic anemia, myelodysplasia, myelofibrosis, acute leukemia 4. glucocorticoids, BMT
203.1. HIT type 1 + tx 2. HIT type 2 + tx
1. heparin causes platelet aggregation, <48 hours after initiating heparin, no treatment is needed
2. heparin induces PF4 release and triggers formation of heparin PF4 complexes--> IgG antibody mediated platelet activation/endothelial activation and intravascular thrombin generation--> vascular thrombosis*** 3-12 days after starting heparin--heparin should be DC 204.1. causes of bone marrow failure 2. causes of bone marrow invasion 3. causes of bone marrow injury
1. aplastic anemia, congenital aplastic anemia (fanconi's), congenital intrauterine rubella
2. tumors, leukemia, fibrosis
3. gold, ethanol, cancer chemotherapy, benzene, chloramphenicol, radiation, infection
205.paroxysmal nocturnal hemoglobinuria 1. diagnosis
Ham's test*** - patients cells placed in acidified serum, triggering alternate complement pathway causes lysis of PNH cells
sugar water test- patients blood + glucose - causes hemolysis
flow cytometry shows low CD55, and CD59 206.platelet disorders 1. causes of thrombocytopenia 2. causes of thrombocytosis 3. qualitative platelet disorders 4. hereditary platelet disorders
1. decreased production, increased destruction, sequestration 2. reactive - IDA, splenectomy, rebound, inflammatory disease, autonomous - myeloproliferative, polycythemia vera, essential thrombocytosis, CML
3. ASA, NSAIDs, antibiotics, high dose PCN, uremia (effects vwF XIII), liver disease (TPO), marrow disorders (leukemia etc), multiple myeloma, ITP, cardiopulmonary bypass (causes partial degranulation)
207.1. what causes increased platelet destruction 2. dilutional thrombocytopenia 3. thrombocytopenia in pregnancy
1. ITP, infection, drug induced, HIT type 2, HIV associated
thrombocytopenia DIC, TTP, HIT type 1
2. post hemorrhage, post transfusion 3. incidental finding, or
pre-eclampsia/ecclampsia, or HELLP syndrome
208.thrombocytopenia 1. clinical pres
1. cutaneous petechiae bleeding, purpura, ecchymosis with minor trauma, mucosal bleeding, epistaxis, menorrhagia, hemoptysis, GI/GU bleeding 209.immune thrombocytopenic purpura 1. patho 2. clinical pres 3. dx
1. acute post viral, or adult chronic--> autoimmune antibody against hosts platelets which are then removed by splenic macrophages
2. petechiae/ecchymoses on the skin, minimal bleeding symptoms, mucous membrane bleeding, NO
SPLENOMEGALY***
3. platelets <20,000, remainder of blood count normal, dec. platelets on blood smear, inc megakaryocytes on bone marrow, anti-platelet IgG... 210.immune thrombocytopenic purpura 1. tx
corticosteroids, IVIG (saturates RES), splenectomy, (70-80% effective), platelet transfusions
romiplostim, eltrombopag-thrombopoietin receptor agonists
211.thrombotic thrombocytopenic purpura 1. patho 2. clinical pres 3.dx tx
1. ADAMTS13 defect cannot break down vWF multimers-->hyaline microthrombi occlude small vessels causing mechanical damage to RBCs 2. hemolytic anemia (MAHA), thrombocytopenia, ARF, fever, fluctuating neurologic signs 3. tx = plasmapheresis****, corticosteroids, splenectomy, NO PLATELET TRANSFUSION 212.heparin induced thrombocytopenia 1. patho 2. dx/tx 3. complications
1. unfractionated heparin (15%), rarely LMWH--> drop in platelets a few days after administration--> platelet aggregation/activation+procoagulant release leads to venous
thrombosis/DVT/PE****
2. antiplatelet factor IV or serotonin assay
tx= STOP HEPARIN, give direct thrombin inhibitor to bridge to warfarin (lepirudin, argatroban, rivaroxaban)
3. heparin induced thrombocytopenia and thrombosis (HITT)- 25% mortality rate
213.bernard soulier 1. patho
2. dx
1. AR- Gp1bIX defect leads to platlet adhesion to subendothelium dysfunction
2. abnormally large platelets, mildly low platelet count
214.glanzmann's thrombasthenia
1. AR - GpIIb-IIIa deficiency 2. prolonged bleeding time, platelet count normal 215.von willebrand's disease 1. patho 2. sub regions of factor VIII 3. type 1/2/3 4. clinical pres
1. defect in factor VIII or vWF 2. coagulant portion, and antigenic portion (= vWF)
3. type 1 = dec. vWF, type 2 =
qualitative abnormalities of vWF, type 3 = absent vWF
4. cutaneous/mucosal bleeding, epistaxis, easy bruising, excessive bleeding with minor trauma, menorrhagia, GI bleeds
216.von willebrand's disease
1. dx 2. tx
1. prolonged bleeding time, dec. vWF, dec. factor VIII, reduced ristocetin induced platelet aggregation
2. DDAVP induces endothelial release of vWF(type 1/2)
factor VIII concentrates, - after trauma/during surgery
cryo - has risk of viral transmission avoid NSAIDs/aspirin
217.hemophilia A 1. patho 2. clinical pres 3. dx
1. XLR - deficiency in factor VIII 2. hemarthrosis, knees most commonly , progressive joint destruction (2/2 recurrent hemarthrosis), intracranial bleeding,
retroperitoneal/intramuscular hematomas
3. prolonged PTT, low VIII, normal vWF
tx = analgesia (NOT
ASPIRIN/NSAIDS), VIII concentrate for acute bleeding/dental work, DDAVP for mild disease