N2 - Aquifer questions wk1-wk4

A 56-year-old woman is being evaluated in the hospital for anemia. She was admitted five days ago with a myocardial infarction. She underwent stent placement and was doing well until last night when she developed lower abdominal cramping and started passing blood clots in her stools. Her medical history is significant for type II diabetes mellitus, hypertension, hypothyroidism, and rheumatoid arthritis. On physical examination, she appears to be in mild distress. Her pulse is 100 beats/minute and blood pressure is 110/54 mmHg. Abdominal exam reveals tenderness in bilateral lower quadrants with no guarding or rigidity. The remainder of her exam is normal.A complete blood count (CBC) obtained today is shown. White blood count (WBC): 5 cells x103/μL Hemoglobin (Hgb): 8 g/dLHematocrit (Hct): 24% Mean corpuscular volume (MCV): 84 μm3 Red blood cell distribution width (RDW): 12 Platelets: 280,000 /mm3A complete blood count obtained at the time of hospital admission is shown. WBC:11 cells 103/μL Hgb:13 g/dL Hct: 39% MCV: 86 μm3 RDW: 11 Platelets:150,000 /mm3 What is the most-likely cause of this woman's anemia? A. Acute blood loss B. Anemia of chronic disease C. Hemolysis D. Hypothyroidism E. Iron deficiency

A. Acute blood loss This woman was admitted with a normal CBC, which suggests that her chronic diseases such as hypothyroidism or rheumatoid arthritis were not contributing to anemia. She developed an acute gastrointestinal bleed during her hospitalization which was likely due to antiplatelet medications used for the management of her myocardial infarction. Her hemoglobin and hematocrit has dropped to 8 g/dL from 13 g/dL in five days, suggesting an acute process. Although hemolysis may cause a similar pattern for the CBC, there are no clues to suggest that there is a cause of hemolysis occurring in this woman at this time.

Which of the following are causes of a microcytic anemia? Select all that apply. A. Anemia of chronic disease B. Vitamin B12 deficiency C. Iron deficiency anemia D. Folic acid deficiency E. Thalassemia F. Sideroblastic anemia

A. Anemia of chronic disease C. Iron deficiency anemia E. Thalassemia F. Sideroblastic anemia

Which of the following are causes of a macrocytic anemia? Select all that apply. A. B12 deficiency B. Folate deficiency C. Liver disease D. Hydroxyurea E. Myelodysplasia F. Reticulocytosis G. Hypothyroidism H. Alcohol

A. B12 deficiency B. Folate deficiency C. Liver disease D. Hydroxyurea E. Myelodysplasia F. Reticulocytosis G. Hypothyroidism H. Alcohol

A 75-year-old man comes to the clinic for a review of the workup of his chronic kidney disease (CKD). His past medical history is significant for hypertension, diet-controlled diabetes mellitus type II, coronary artery disease, and benign prostatic hyperplasia (BPH). His blood pressure and diabetes have been well-controlled by antihypertensive medications and following a diabetic diet. Urinalysis and urine microscopy are normal. His creatinine is 1.5 mg/dL with a GFR of 55mL/min. Renal ultrasound shows normal-sized kidneys with good corticomedullary differentiation, mild hydronephrosis, and normal blood flow per dopplers. What is the most-likely cause of his chronic kidney disease? A. Benign prostatic hyperplasia B. Diabetes mellitus C. Glomerulonephritis D. Hypertension E. Renal artery stenosis

A. Benign prostatic hyperplasia This man has multiple risk factors for CKD, including diabetes mellitus, hypertension, and BPH. In addition, he has coronary artery disease, which increases his risk for renal artery stenosis. However, his urine is bland, and his kidneys appear normal on an ultrasound except for the hydronephrosis. These findings support BPH as the cause for his CKD. Diabetic nephropathy tends to cause larger-than-normal kidneys with poor corticomedullary differentiation and proteinuria.

A 22-year-old man comes to your office with fatigue and shortness of breath on exertion. On exam, you notice conjunctival pallor. You obtain a hemogram, which shows the following:Hemoglobin: 10 g/dLHematocrit: 29% Mean corpuscular volume (MCV): 74 μm3 Red blood cell distribution width (RDW): 14% What is the most-likely diagnosis? A. Beta thalassemia B. Hemolytic anemia C. Hypothyroidism D. Iron deficiency anemia E. Sideroblastic anemia

A. Beta thalassemia The man has a low hemoglobin and hematocrit for his age and gender and therefore has anemia. The mean corpuscular volume is low so this is microcytic. Iron deficiency anemia and beta thalassemia minor are microcytic anemias. Sideroblastic anemia, hemolytic anemia, and anemia due to hypothyroidism are either normoytic or macrocytic. *The red cell distribution width (RDW) is at the upper limit of normal; it should be elevated in iron deficiency anemia and is normal in beta thalassemia minor.*

Which of the following is most likely to cause a normocytic anemia? A. Chronic renal failure B. B12 deficiency C. Liver disease D. Hypothyroidism

A. Chronic renal failure

Which of the following additional tests would you obtain to evaluate your pt's chronic kidney disease? Choose the seven best answers. A. Complete blood count (CBC) B. Iron studies C. Bilirubin, AST, ALT, alkaline phosphatase D. Thyroid stimulating hormone level E. Fasting lipid panel F. Parathyroid hormone levels (PTH) G. Spot urine for albumin and creatinine H. Electrocardiogram I. Chest x-ray J. Renal ultrasound K. Echocardiogram

A. Complete blood count (CBC) B. Iron studies E. Fasting lipid panel F. Parathyroid hormone levels (PTH) G. Spot urine for albumin and creatinine H. Electrocardiogram J. Renal ultrasound

Anemia is a common finding in patients with CKD. What is its pathogenesis? Choose the single best answer. A. Decreased erythropoietin production due to diseased, scarred kidneys B. Insensitivity of bone marrow to erythropoietin in uremic environment C. Occult bleeding due to uremic platelet dysfunction

A. Decreased erythropoietin production due to diseased, scarred kidneys

What are the two most common causes of chronic kidney disease? A. Diabetes and hypertension B. Renal artery stenosis and fibromuscular dysplasia C. Amyloidosis and vasculitis D. Hypertension and polyangiitis

A. Diabetes and hypertension

A 53-year-old woman comes to the clinic to follow up on blood work obtained last week. Due to signs and symptoms of anemia, a complete blood count was ordered. Results are shown.White blood count (WBC): 7.4 cells x 103/μL Hemoglobin: 9 g/dLHematocrit: 27% Mean corpuscular volume (MCV): 75 μm3Platelets: 338,000 /mm3. Which test would be most helpful to diagnose iron deficiency in this woman? CORRECT A. Ferritin B. Reticulocyte count C. Serum iron D. Total iron binding capacity E. Transferrin saturation

A. Ferritin

"What is the one best test to evaluate for iron deficiency?" Choose the single best answer. A. Ferritin B. Serum iron C. Total iron-binding capacity D. Transferrin saturation

A. Ferritin serum protein that is an indicator of body iron stores, is the best test to assess iron deficiency. When the ferritin is less than 15 ng/mL (15 μg/L), it is pathognomonic for iron deficiency. Ferritin is higher in elderly patients, so a cutoff of 45 ng/mL (45 μg/L) has been suggested for individuals older than 65.

_____________________ are the inclusions of nuclear chromatin remnant in the red cell that results from incomplete nuclear expulsion as the orthochromatic normoblast exits the bone marrow. They usually are removed by the spleen, so that they are not seen in the blood A. Howell Jolly Bodies B. Microspherocytes C. Tear drop cells D. Rouleaux

A. Howell Jolly Bodies

Which four electrolyte abnormalities might you expect to see in a patient with chronic kidney disease? Select all that apply. A. Hyperkalemia B. Hypokalemia C. Hypercalcemia D. Hypocalcemia E. Hyperphosphatemia F. Hypophosphatemia G. Metabolic acidosis H. Metabolic alkalosis

A. Hyperkalemia D. Hypocalcemia E. Hyperphosphatemia G. Metabolic acidosis

Ms. Winters has both iron and B12 deficiency. Based her lab results results, what would you expect to see on her peripheral blood smear? Select all that apply. A. Hypochromic cells B. Target cells C. Microcytic cells D. Burr cells E. Spur cells F. Macrocytic cells G. Hypersegmented neutrophils

A. Hypochromic cells C. Microcytic cells F. Macrocytic cells G. Hypersegmented neutrophils Because Ms. Winters is iron-deficient, you would expect to see microcytic, hypochromic red blood cells. You can tell a cell is microcytic by comparing the red cell to the size of a lymphocyte. Microcytic cells are smaller than the nucleus of a lymphoctye. The cells of iron deficiency are hypochromic because the hemoglobin content is decreased. Cells are considered hypochromic when the central pallor of the red cell is greater than one third of the diameter of the red cell. Because Ms. Winters is B12-deficient, you would also expect to see some macrocytic red blood cells (larger than the size of a lymphoctye). You may also see hypersegmented neutrophils. These are polymorphonuclear leukocytes that have nuclei with four or more lobes. The cells become hypersegmented, because there is impaired nuclear to cytoplasmic maturation.

A 58-year-old woman with chronic kidney disease stage III, secondary to type II diabetes mellitus, presents to the clinic to establish care. Her blood pressure is 154/86 mmHg. Her body mass index (BMI) is 30 kg/m2. Her hemoglobin A1C is 9.8 mg/dL, and urine protein/creatinine ratio is 1.5 mg/dL. She takes long-acting insulin. In addition to tighter glucose management, which of the following would be the best treatment for diabetic nephropathy? A. Lisinopril B. Pentoxifylline C. Protein restriction D. Simvastatin E. Spironolactone

A. Lisinopril Treatment of diabetic nephropathy focuses on glycemic and blood pressure control. Intensive glycemic control can delay the development of proteinuria and decrease in glomerular filtration rate (GFR). Treatment of hypertension, particularly with blockers of renin-angiotensin, slows loss of renal function. Both angiotensin receptor blockers (ARBs) and angiotensin-converting-enzyme (ACE) inhibitors (such as lisinopril) decrease the development and worsening of proteinuria and slow the loss of GFR. However, using an ACE inhibitor and ARB together does not slow loss of renal function further and is associated with hyperkalemia and increased incidence of acute kidney injury.

Which of the following areas are important to ask about to help determine the cause of the anemia? Select all that apply. A. Menstrual history B. Gastrointestinal symptoms C. Constitutional symptoms D. Past medical history E. Surgical history F. Medications G. Family history H. Current life stressors I. Diet J. Exercise history

A. Menstrual history B. Gastrointestinal symptoms C. Constitutional symptoms D. Past medical history E. Surgical history F. Medications G. Family history I. Diet

You and Dr. Day decide to try to confirm the diagnosis of pernicious anemia. Dr. Day explains that you have the opportunity to contact the lab to "add on" blood additional tests. Which two additional blood tests would you order at this time? Select all that apply. A. Parietal cell antibodies B. Intrinsic factor antibodies C. Schilling test

A. Parietal cell antibodies B. Intrinsic factor antibodies *Parietal cell antibodies* are approximately 85-90% sensitive for the diagnosis of pernicious anemia. However, the presence of parietal cell antibodies is nonspecific and occurs in other autoimmune disorders. *Intrinsic factor antibodies* are only about 50% sensitive, but they are far more specific for the diagnosis of pernicious anemia.

What term is used to describe red blood cells that have been examined in the lab and have many different shapes? A. Poikilocytosis B. Shistocytes C. Anisocytosis D. Burr cells

A. Poikilocytosis **remember POLi = many

Which of the following peripheral blood smear findings can be seen in various hemolytic anemias? Select all that apply. A. Schistocytes B. Spherocytes C. Nucleated red blood cells D. Rouleaux E. Tear drop cells F. Howell Jolly Bodies G. Sickle Cells

A. Schistocytes B. Spherocytes C. Nucleated red blood cells F. Howell Jolly Bodies G. Sickle Cells

What ECG findings can be seen in hypocalcemia? Select all that apply. A. Shortened PR interval B. Prolonged PR interval C. Shortened QT interval D. Prolonged QT interval

A. Shortened PR interval D. Prolonged QT interval

You are caring for a 58 y/o patient with chronic renal failure. His labwork reveleals hyperkalemia with a K+ of 5.9. According to the MedU module, which EKG abnomalities may be associated with a potassium of this level? A. Tall, pointed T-waves B. PR interval prolongation C. P-waves flattened D. Sine waves

A. Tall, pointed T-waves

What is the most common cause of post renal kidney failure? A. Bladder infection B. Benign prostatic hyperplasia C. Hypovolemia D. Diabetes

B. Benign prostatic hyperplasia

A 45-year-old woman with stage 3 chronic kidney disease, secondary to lupus nephritis, presents to the emergency department with confusion. Her husband reports that she has been complaining of nausea and itching for several weeks. Diphenhydramine has not alleviated the itching. Her physical exam is significant for lethargy, orientation to person only, excoriations on all of her extremities, a pericardial friction rub, asterixis, crackles at the lower lung fields, and pitting edema of the lower extremities to the knees. Her labs are significant for sodium 135mEq/L, potassium 5.5mEq/L, creatinine 5mg/dL [creatinine was 2.5mg/dL six months ago], HCO3 20 mEq/L, and an anion gap of 14. What is the pathophysiological mechanism of her acute state? A. Decreased cardiac output from non-ischemic cardiomyopathy B. Inability of the kidney to excrete organic waste products C. Inability of the liver to excrete nitrogenous waste products D. Ingestion of ethanol, leading to accumulation of ketones E. Poor oral intake, leading to accumulation of ketones

B. Inability of the kidney to excrete organic waste products This woman is presenting with a constellation of symptoms and findings consistent with uremia. Given the chronicity of her nausea and itching, her kidneys have been declining over several months. Uremia is caused by the kidneys' inability to excrete organic waste products. While poor oral intake could result in a starvation ketosis, which would worsen her anion gap metabolic acidosis, it would not explain her other symptoms of itching, friction rub, or asterixis. Hepatic encephalopathy, which occurs with liver failure, is caused by the liver's inability to excrete nitrogenous waste products, however, she has no signs of advanced liver disease (jaundice, ascites, spider angiomata). Ingestion of too much ethanol can cause a ketosis, which would worsen her anion gap metabolic acidosis, does not explain her other symptoms. Non-ischemic cardiomyopathy would explain the volume overload, however, it would not explain her neurological symptoms

You are the AG-ACNP caring for a 62 year old patient with stage 3 (moderate) chronic kidney disease. Based on his clinical staging, you know his GFR must be: A. ≥ 90 ml/min B. 60-89 mL/min C. 30-59 mL/min D. 15-29 mL/min

C. 30-59 mL/min

Anemia is defined as: A. A hemoglobin < 10.5g/dL in women and hemoglobin < 12.5g/dL in men B. A hemoglobin < 8g/dL C. A hemoglobin < 12.5g/dL in women and hemoglobin < 13.5g/dL in men D. A hemoglobin < 9 g/dL in women and hemoglobin < 10.5 g/dL in men

C. A hemoglobin < 12.5g/dL in women and hemoglobin < 13.5g/dL in men

Which of the following is NOT a potential cause for pre-renal kidney failure? A. Renal artery stenosis B. Atherosclerotic disease C. Glomerulonephritis D. Fibromuscular dysplasia

C. Glomerulonephritis

Which of the following is a cause of a microcytic anemia? A. Vitamin B12 deficiency B. Folic acid deficiency C. Sideroblastic anemia D. Golgi body anemia

C. Sideroblastic anemia

1Typically, a patient will present with hypovolemic shock (confusion, dyspnea, diaphoresis, hypotension and tachycardia) after losing what percent of his/her circulating blood volume? A. 10% B. 15-20% C. 30% D. 40%

D. 40%

"Chipmunk face" (secondary to maxillary marrow hyperplasia and frontal bossing) is caused by which type of anemia? A. Anemia of chronic disease B. Iron deficiency anemia C. Alpha thalassemia D. Beta thalassemia

D. Beta thalassemia

Which of the following statements about phosphate binders (such as calcium carbonate and calcium acetate) in chronic kidney disease is FALSE? Choose the best answer. A. Calcium carbonate and calcium acetate must be taken with meals so that phosphate binding is effective B. The goal serum phosphorus level in chronic kidney disease is, 2.5-4.5 mg/dL (0.81-1.45 mmol/L) C. Most patients with CKD and hyperphosphatemia cannot achieve target phosphorus levels with dietary restrictions alone D. Calcium carbonate and calcium acetate must be taken on an empty stomach so that phosphate binding is effective

D. Calcium carbonate and calcium acetate must be taken on an empty stomach so that phosphate binding is effective

Which of the following questions is the most helpful to ask when interviewing a patient with suspected anemia. A. Do you exercise regularly? B. Do you have any current significant life stressors? C. Did you have the flu shot this year? D. Do you have any family history of anemia?

D. Do you have any family history of anemia?

Which four electrolyte abnormalities might you expect to see in a patient with chronic kidney disease? A. Hypocalcemia, Metabolic acidosis, Hypokalemia, Hypophosphatemia B. Hyperphosphatemia, Hypercalcemia, Hypokalemia, Metabolic alkalosis C. Hypocalcemia, Hyperphosphatemia, Hyperkalemia, Metabolic alkalosis D. Hyperkalemia, Hypocalcemia, Hyperphosphatemia, Metabolic acidosis

D. Hyperkalemia, Hypocalcemia, Hyperphosphatemia, Metabolic acidosis

Hyperkalemia may be treated in all of the following ways EXCEPT: A. Sodium polystyrene sulfonate B. Dialysis C. Insulin D. Lisinopril

D. Lisinopril

You tell Ms. Winters, "We have your results. There are two reasons why your blood count is low. First, you have iron deficiency. Second, your vitamin B12 is low. Both iron and B12 are needed to produce red blood cells." You go on to explain that you have discovered Ms. Winters has pernicious anemia. Which of the following treatments are appropriate at this time? Select all that apply. A. Intravenous iron infusion B. Whole blood transfusion C. Packed red blood cell transfusion D. Oral iron therapy E. Oral B12 replacement F. Intramuscular B12 replacement G. Oral folic acid replacement

D. Oral iron therapy E. Oral B12 replacement F. Intramuscular B12 replacement

An 84-year-old woman comes to the clinic with concern for fatigue for the past six months. Otherwise, a review of systems is negative. On physical examination, her vital signs show pulse is 99 beats/minute, blood pressure is 122/76 mmHg, oxygen saturation is 98% on room air. She appears slightly pale, but is otherwise comfortable. Cardiovascular and pulmonary examination is otherwise normal. Her complete blood count (CBC) is as follows: White blood cell (WBC): 3.2 cells x 103/μL Hemoglobin: 7.5 g/dL Hematocrit (Hct): 22% Mean corpuscular volume (MCV): 84 μm3 Red blood cell distribution width (RDW): 20 fLPlatelet (Plt): 128,000 mm3 Given your concern for a chronic normocytic anemia, you obtain a reticulocyte count, which is 0.05%. What is the next-best diagnostic test at this time? A. Esophagogastroduodenoscopy (EGD) B. Iron studies C. Lactate dehydrogenase (LDH) (serum) D. Peripheral smear E. Thyroid stimulating hormone (TSH)

D. Peripheral smear The most-likely cause of this is a primary bone marrow disorder, such as myelodysplasia, bone marrow infiltration, myeloma, or aplastic anemia. The next step in diagnosis would be to order a peripheral smear.

Laboratory testing on an anemic patient revealed cells that were slightly larger than mature red blood cells and slightly bluish when stained. The AG-ACNP know that this is most consistent with which type of cell? A. Sickle cell B. Shistocyte C. Platelet D. Reticulocytes

D. Reticulocytes

A 52-year-old woman with stage 4 chronic kidney disease, secondary to hypertensive nephropathy, presents to establish care. Her blood pressure is 154/86 mmHg on 12.5mg of hydrochlorothiazide. Her urine protein/creatinine ratio is 1. What is the best treatment for her hypertension? A. Increase the dose of the hydrochlorothiazide and add lisinopril B. Increase the dose of the hydrochlorothiazide and add losartan C. Stop the hydrochlorothiazide and start chlorthalidone D. Stop the hydrochlorothiazide and start lisinopril E. Stop the hydrochlorothiazide and start losartan

D. Stop the hydrochlorothiazide and start lisinopril This woman is spilling protein in her urine, so an angiotensin converting enzyme inhibitor (ACE-I), such as lisinopril, or angiotensin receptor blocker (ARB), such as losartan, is required. ACE-Is are less expensive than ARBs, so should be tried first. ARBs are appropriate for use in patients who cannot tolerate ACEIs because of side effects, such as cough, or allergic reactions, such as angioedema. Thiazide diuretics such as hydrochlorothiazide and chlorthalidone are not effective with stage 4 and stage 5 chronic kidney disease (CKD).

A 63-year-old man with stage 3 chronic kidney disease (CKD), secondary to hypertension, presents for a routine follow-up. His blood pressure is 134/72 mmHg. His physical exam is within normal limits. His labs are significant for a potassium of 5.0 mEq/L and phosphorus of 5 mg/dL. What is the explanation for his hyperkalemia and hyperphosphatemia? A. Excess dietary potassium and phosphorus B. Excess intestinal absorption of potassium and phosphorus C. Impaired intestinal absorption of potassium and phosphorus D. Impaired renal absorption of potassium and phosphorus E. Impaired renal excretion of potassium and phosphorus

E. Impaired renal excretion of potassium and phosphorus Patients with CKD have a decrease in nephron mass and impaired renal potassium excretion. This can lead to hyperkalemia. Hyperphosphatemia can occur with CKD due to an inability of the kidney to excrete excess dietary phosphorus. The intestinal tract functions normally in patients with CKD. CKD patients have to limit their dietary intake of potassium and phosphorus, however, hyperkalemia and hyperphosphatemia are secondary to impaired excretion and can occur even when patients are eating a "normal" amount of these electrolytes.

A 45-year-old woman comes to your clinic with complaints of fatigue and shortness of breath on exertion for the past three weeks. She has a history of hypertension and obesity, and underwent gastric bypass surgery five years ago. She stopped taking her medications three years ago due to financial reasons. On physical examination, her pulse is 89 beats/minute and her blood pressure is 100/50 mmHg. She has conjunctival pallor, cheilosis, and glossitis. Cardiac examination reveals a systolic murmur over the mitral area. Neurological examination reveals loss of proprioception. What is the most likely cause of this woman's symptoms? A. Folic acid deficiency B. Hemolytic anemia C. Hypothyroidism D. Iron deficiency anemia E. Vitamin B12 deficiency

E. Vitamin B12 deficiency This woman's history of gastric bypass surgery suggests malabsorption of nutrients needed for hematopoiesis, along with no access to vitamin supplements for three years. Cheilosis or angular cheilitis is an inflammatory lesion at the corner of the mouth, which often occurs bilaterally. It can be associated with malnutrition or deficiencies of iron or vitamin B12. Glossitis, an inflammation or infection of the tongue, is associated with iron deficiency anemia, pernicious anemia, B-vitamin deficiencies, as well as aphthous ulcers. A functional systolic murmur in the mitral or aortic area frequently occurs in anemic patients. One of the peculiar signs of vitamin B12 deficiency is the loss of proprioception and vibratory sensation which is caused by subacute combined degeneration of the spinal cord.

Anemia is common finding in patients with CKD due to inability of the kidneys to produce sufficient quantity of erythropoietin. True False

True

Individuals with chronic illnesses such as diabetes and hypertension can donate blood as long as these conditions are controlled. True False

True

Studies have shown increased mortality in CKD patients with any degree of hyperphosphatemia True False

True

What are three causes of normocytic anemia? • Anemia of chronic disease • Sickle cell disease • Renal failure • Blood loss • Hemolytic

• Anemia of chronic disease • Anemia of renal failure (renal failure, erythropoietin deficiency, chronic renal insufficiency) • Hemolysis • Hypothyroidism • Acute blood loss (blood loss) • Primary bone marrow disorder (bone marrow suppression, aplastic anemia) • Testosterone deficiency • Combined microcytic and macrocytic anemia • Early presentation of a microcytic or macrocytic anemia