renal

A 53-year-old man wants to establish care at a new primary care clinic after moving. He reports a history of low back pain after a motor vehicle collision 5 years ago and takes ibuprofen 800 mg three times per day. He reports no fever, blood in urine, or abdominal pain. He reports no tobacco, alcohol, or drug use but says he consumes five to six cups of coffee per day. Today, his vitals are a T of 99.1°F, BP of 144/84 mm Hg, RR of 13/min, HR of 88 bpm, and oxygen saturation of 99% on room air. On physical examination, he has normal bowel sounds in all four quadrants and is not tender to palpation over the entire abdomen. Lungs are clear to auscultation, and auscultation of his chest reveals a regular rate and rhythm without any murmurs. Laboratory results reveal a creatinine of 2 mg/dL, and urinalysis reveals mild proteinuria and hematuria. CT scan of the abdomen without contrast reveals bilaterally reduced kidney size with irregular renal contours and papillary calcifications. Which of the following is the most likely diagnosis?

dx:Chronic interstitial nephritis and papillary necrosis Physical exam is often benign in these patients, with hypertension being the most common physical exam finding. Laboratory abnormalities in patients with analgesic nephropathy include an elevated creatinine and blood urea nitrogen, proteinuria, pyuria, and hematuria. CT abdomen without contrast findings include bilateral small kidney size, papillary calcifications, and kidneys with irregular contours. Treatment involves removing the causal agent and providing supportive measure

A 5-year-old boy has acute onset of hematuria, periorbital edema, and hypertension. He has no other complaints and review of systems is unremarkable. Recent medical history is significant for a "cold" last week. What is the most likely etiology of his hematuria?

poststreptococcal glomerulonephritis PE: hypertension, hematuria, and periorbital edema Labs: proteinuria and red blood cell casts in the urine Most commonly caused by group A beta-hemolytic Streptococcus Management includes mainly supportive measures, e.g., salt and water restrictionIf edema and hypertension present, concurrent furosemide can help Most common infectious cause of acute glomerulonephritis ------------------------------------------------------- IgA nephropathy (B) may also cause gross hematuria. However, hematuria caused by IgA nephropathy begins within 1-2 days of the onset of upper respiratory or gastrointestinal infection.

Polycystic kidney disease (PKD) [autosomal dominant ] Sx: asymptomatic, flank pain or hematuria PE: hypertension, palpable kidneys Diagnosis is made by ultrasound, Treatment is BP control: ACEIs, ARBs Associated with increased risk for berry aneurysm and intracerebral hemorrhage What is the target blood pressure for patients with polycystic kidney disease and resulting hypertension? Answer: < 110/75 mm Hg in patients aged 18 to 50 years with a normal GFR and 130/80 mm Hg in all other patients.

A 35-year-old man presents to the Emergency Department with gross hematuria and worsening right flank pain over the past couple of days. The patient has a history of multiple urinary tract infections and hypertension. In the ED, the patient is found to be hypertensive but afebrile. Urinalysis shows for 2 protein, WBC 3/hpf, RBC > 100/hpf. A kidney ultrasound is seen above. What is most likely the diagnosis? What is the most serious extrarenal complication that can arise from the patient's most likely diagnosis? A 35-year-old woman with no chronic medical conditions presents to the clinic to establish care, reporting no current symptoms. Her family history includes the sudden death of her father 2 years ago at age 55 due to an acute myocardial infarction with underlying cardiac hypertrophy. Vital signs today include a BMI of 21.5 kg/m2, HR of 87 bpm, BP of 155/93 mm Hg, RR of 15/min, T of 98.5°F, and SpO2 of 98% on room air. Physical exam reveals bilateral palpable nontender abdominal masses. Laboratory studies are significant for a GFR of 87 mL/min/1.73 m2. What is the best next step in the evaluation of this patient's findings? You have made a new diagnosis of polycystic kidney disease in one of your primary care patients. Proper maintenance of normal blood pressure should be obtained with which of the following medications?

A 19-year-old man with no significant medical history presents to the emergency department reporting hematuria onset 1 day ago. His vital signs are HR 94 bpm, RR 18/min, BP 130/84 mm Hg, T 101°F, SpO2 98%, and BMI 24.9 kg/m2. He tested positive for influenza 2 days ago. His physical exam is notable for mild periorbital edema and flank pain. His laboratory results show a blood urea nitrogen of 30 mg/dL and creatinine of 1.5 mg/dL, and urine was positive for blood and proteinuria. Which of the following is the most likely diagnosis?

DX: IgA nephropathy children and young adult men presents 24-48 hours after the onset of an upper respiratory infection due to the IgA deposits in the mesangium Patients may present with fever, hypertension, flank or abdominal pain, peripheral edema, periorbital edema, and hematuria but patients at a higher risk of progression should be treated with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB). The goal of therapy is to reduce proteinuria and lower blood pressure. IgA Nephropathy (Berger Disease) History of an upper respiratory infection (URI) 1-2 days ago PE: hematuria and proteinuria Labs: red blood cell casts and dysmorphic red blood cells in urine Diagnosis is confirmed by kidney biopsy Caused by the inflammatory response to the deposition of circulating IgA in the mesangial cells of the glomerulus Most common cause of primary glomerulonephritis in adults worldwide =---------------------------------------------------- Postinfectious glomerulonephritis (E) is seen in children with acute-onset nephritic syndrome following a streptococci infection.

A 68-year-old woman with no significant medical history presents to the clinic with her daughter for cognitive changes. The daughter says that her mother gets "lost" in conversations, and that she would "sleep all day" if permitted. Further questioning reveals a recent history of constipation, as well as passing two kidney stones within the past 12 months. Which of the following electrolyte imbalances is most consistent with these symptoms? A 40-year-old woman with a history of triple negative metastatic breast cancer presents with colicky groin pain and hematuria. A CT scan of the abdomen and pelvis is performed. She also reports several days of constipation, weakness, and confusion. Vital signs are as follows: Temp 37°C, HR 90, BP 110/70, RR 12, and oxygen saturation 99% on room air. Physical examination is within normal limits. Serum calcium is 14 mg/dL. Parathyroid hormone is 5 pg/mL. A PTHrP is pending. Besides starting IV normal saline, long-term therapy with which of the following should be initiated? Which of the following is the first line medical treatment for symptomatic hypercalcemia? Which of the following is the most common cause of hypercalcemia in hospitalized patients vs outpatient ?

Hypercalcemia tx :A medication that may cause osteonecrosis of the jaw= bisphosphonate Fluid rehydration= first line Which of the following is the most common cause of hypercalcemia in hospitalized patients? = Malignancy "stones, bones, abdominal groans, psychic moans, and fatigued overtones." The most accurate measurement of serum calcium is the ionized calcium concentration . Until the primary cause is identified, hypercalcemia is initially managed with fluids and forced calciuresis ECG: shortened QT interval PR prolongation, and QRS widening. Most common causesMalignancy (most common inpatient cause)Primary hyperparathyroidism (most common outpatient cause) Treatment: IV fluids, bisphosphonates, calcitonin bisphosphonates, which may cause osteonecrosis of the jaw. What is the initial treatment for hypercalcemia? Answer: Volume repletion and loop diuretics. Which serum component, if low, may cause a spuriously low total serum calcium reading? Answer: Albumin concentrations lower than 4 g/dL will reduce the total serum calcium level. What is the most common cause for secondary hyperparathyroidism? Answer: Chronic Kidney disease causing decreased levels of 1,25-dihydroxyvitamin D.

A 55-year-old man with a medical history of hypertension presents to the emergency department with worsening diffuse muscle cramps and weakness for the past 2 days. The weakness started bilaterally in his legs but now involves his arms. He reports that exercising is more difficult because of the weakness. The patient reports taking hydrochlorothiazide, which he started 2 weeks earlier for hypertension. Vital signs include a HR of 103 bpm, BP of 142/80 mm Hg, RR of 20/min, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination reveals a distressed man with 3 out of 5 strength in each extremity. The patient has no ptosis, intact cranial nerves, and intact sensation with light touch. Which of the following is the most likely cause of the patient's symptoms?

Hypokalemia In addition to potassium supplementation, what medication can be used to reverse hypokalemic thyrotoxic periodic paralysis? Answer: Propranolol (nonselective beta-blocker).

You obtain an arterial blood gas on a patient in the intensive care unit. The results show a pH 7.32, PaCO2 50 mm Hg, and bicarbonate 24 mmol/L. Which of the following is the most likely cause of this acid-base disorder? What is the most common cause of respiratory acidosis? What is the treatment of a ventilated patient with lab values that demonstrate an acute respiratory acidosis?

Hypoventilation/apnea. What is the treatment of a ventilated patient with lab values that demonstrate an acute respiratory acidosis? Answer: Increase alveolar minute ventilation.

An 18-year-old woman, who was just fired from her job, reports ingesting 50 tablets of 325 mg aspirin three hours prior to arrival in the ED. She has dyspnea and tinnitus but does not have any nausea and vomiting. On physical examination, you find a moderately distressed diaphoretic woman with tachycardia and tachypnea but clear lungs bilaterally and an oxygen saturation of 98%. You ask the nurse to initiate intravenous access, draw labs, and start continuous cardiac monitoring. The arterial blood gas results are called back to you by the lab. Which of the following is the most likely acid-base disturbance in this patient? What medication is used to ion trap aspirin in the urine, thus enhancing elimination? Hemodialysis indications ( 7 )

Metabolic acidosis and respiratory alkalosis dx: Salicylates (aspirin) directly stimulate the respiratory center of the brain to cause hyperventilation respiratory alkalosis. A concurrent metabolic acidosis also develops, primarily from the uncoupling of oxidative phosphorylation, which leads to anaerobic metabolism, lactate production (with development of an anion gap), and hyperthermia. ====metabolic acidosis as defined by a decrease in serum bicarbonate concentration.======= Salicylate Toxicity Aspirin, wintergreen, bismuth subsalicylate Respiratory alkalosis + anion gap metabolic acidosis Hypoglycemia Tinnitus Rx: activated charcoal (if < 2 hour from ingestion), urine alkalinization, K+ Hemodialysis indications ( 7 ) Level > 100 mg/dL Coma Rising levels despite alkalinizatio nKidney failure Pulmonary edema Altered mental status Clinical deterioration What medication is used to ion trap aspirin in the urine, thus enhancing elimination? Answer: Sodium bicarbonate.

2-year-old boy presents to the clinic reporting new-onset edema in his feet, legs, hands, and face. The boy's parent reports that he is an otherwise healthy and active 2-year-old who is up-to-date on his vaccinations. 2 weeks ago, he and his sister had rhinitis and a cough. 1 week after those symptoms abated, the parent noted the patient had facial swelling. Now the swelling is most prominent in his lower extremities. The patient takes no medications and has no known allergies. His vital signs are within normal limits. Physical exam reveals bilateral periorbital edema and pitting edema of hands, feet, and legs with nonerythematous, nontender skin, normal lung and cardiac sounds, and a normal ENT exam. Laboratory studies show a normal GFR and complement levels. His urinalysis is shown below, along with a CBC. Urinalysis: pH: 6.0 Specific gravity: 1.040 Glucose: 0 mg/dL Protein: 200 mg/dL Bilirubin: 0 mg/dL Urobilinogen: 0 mg/dL Blood: 0 mg/dL Ketones: 0 mg/dL Nitrites: 0 mg/dL Leukocytes: 0 cells/UL Clarity: clear, color yellow Which of the following is the most likely diagnosis?

Minimal change disease True or false: patients with minimal change disease often have hyperlipidemia and thrombocytosis. Answer: True. --------------------------------------- Poststreptococcal glomerulonephritis (E) will demonstrate red blood cell casts or dysmorphic red blood cells on urinalysis and decreased levels of complement C3 and C4.

Which of the following is a known complication of chronic lithium toxicity?*****

Nephrogenic diabetes insipidus History of taking lithium Diagnosis is made by water deprivation test: no change in urine osmolality Most commonly caused by kidney unresponsiveness to ADH Treatment is HCTZ, amiloride, indomethacin What are the two most effective methods of increasing elimination of lithium? Answer: Aggressive fluid resuscitation and hemodialysis. a concentrating defect in the kidneys due to a resistance of antidiuretic hormone. RESULT = dilute urine output and development of hypernatremia. Patients develop polyuria and polydipsia to compensate for the excess fluid loss. However, if patients are unable to keep up with the free water losses, either due to illness or mental disability, dehydration and elevated lithium levels may result. \nonsteroidal anti-inflammatories and angiotensin-converting enzyme inhibitors cause a decrease in lithium elimination chronic ingestions often initially present with neurologic signs such as ataxia, lethargy, neuromuscular excitability (e.g. tremors, clonus) and seizures. What congenital heart anomaly is a possible result of lithium treatment and a reason it is contraindicated in pregnant patients? Answer: Ebstein's anomaly, a congenital malformation in which the septal and posterior leaflets of the tricuspid valve are displaced towards the apex of the right ventricle of the heart.

A 60-year-old man has been bedridden following a stroke several months ago. Urinalysis shows high levels of protein in the urine and nephrotic syndrome is suspected. On physical exam, where would the provider likely detect edema? AHands BLower leg CSacrum DUpper leg What over-the-counter medication can exacerbate edema in patients with underlying heart failure or cirrhosis by increasing renal sodium reabsorption in response to the inhibition of renal vasodilatory prostaglandins?

Sacrum In a non-ambulatory patient, the fluid will collect around thesacrum. although Peripheral and periorbital edema are commonly seen in patients with nephrotic syndrome. What over-the-counter medication can exacerbate edema in patients with underlying heart failure or cirrhosis by increasing renal sodium reabsorption in response to the inhibition of renal vasodilatory prostaglandins? Answer: Nonsteroidal anti-inflammatory drugs.

A 48-year-old man presents with bilateral swollen lower extremities. Which of the following may lead to a false-negative result for proteinuria on a urine dipstick?

Dilute urine

You have made a new diagnosis of polycystic kidney disease in one of your primary care patients. Proper maintenance of normal blood pressure should be obtained with which of the following medications?

Losartan Treatment is BP control: ACEIs, ARBs

A 23-year-old man presents to the emergency room with intermittent severe left-sided flank pain that radiates to his groin. He reports being healthy otherwise and is training for a marathon. He also consumes very little water on a daily basis. Which of the following is the preferred imaging modality to diagnose the suspected condition?

Low-dose computed tomography of the abdomen and pelvis without contrast dx:nephrolithiasic Nephrolithiasis Sx: flank pain radiating to groin PE: patient won't lie still, hematuria Diagnosis: noncontrast helical CT, most common location is the ureterovesical junction (UVJ) Most commonly caused by calcium oxalate Struvite: staghorn calculi, urease-producing bacteria Uric acid: radiolucent on X-ray, gout Cystine: children with metabolic diseases Treatment' < 5 mm: likely to pass spontaneously > 5 mm: medical expulsive therapy (tamsulosin), urology consultation in certain cases > 10 mm: urology consultation, shock wave lithotripsy, ureteroscopy

A patient's arterial blood gas is noted to have a pH of 7.32, pCO2 of 32 mm Hg, and bicarbonate of 16 mmol/L. Which of the following is the correct interpretation of this arterial blood gas?

Pure metabolic acidosis . With normal respiratory compensation, for every 1 mmol/L decrease in HCO3, there should be a 1 mm Hg decrease in pCO2. pCO2 = (1.5 * [HCO3] + 8) +/- 2. In this case, with a HCO3 16 mmol/L, the expected pCO2 is 32 mm Hg (1.5 * 16 + 8). Because the calculated pCO2 and the measured pCO2 are the same, this patient has a pure metabolic acidosis.

A 65-year-old man with significant tobacco use presents with general malaise, unexplained weight loss, and occasional flank pain. Computed tomography of the abdomen shows a localized renal mass in the left kidney. What is the only curative treatment for this condition?

Surgical resection Renal Cell Carcinoma History of smoking Flank pain, flank mass, hematuria Treatment is nephrectomy Originates within the renal cortex Paraneoplastic symptoms • Anemia • Hepatic dysfunction • Fever • Hypercalcemia • Cachexia • Amyloidosis • Polymyalgia rheumatica

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1)Chloramphenicol, an antibiotic, may cause gray baby syndrome (A). Drugs such as bleomycin and amiodarone may cause pulmonary fibrosis (C). Tamoxifen and clomiphene may cause hot flashes (B). 2)What disease is known to be a variant of hemolytic uremic syndrome? Answer: Thrombotic thrombocytopenic purpura. 3)Which antiepileptic medication commonly causes hyponatremia at therapeutic doses? 4)Which of the following medications should be included in the antihypertensive regimen of patients with chronic kidney disease? Lisinopril angiotensin-converting-enzyme (ACE) inhibitors or angiotensin II receptor (ARB) blockers i 5)What is the most important characteristic of kidney lesions that separates typically benign tumors from malignancies? Answer: Presence of measurable contrast enhancement on diagnostic imaging. 6)What are the most common causes of secondary membranous nephropathy? Answer: Infections and carcinomas. 7)Which enzyme is elevated in over 75% of patients with sarcoidosis? Answer: Angiotensin converting enzyme. 8)What kinds of casts seen on microscopic examination of urine can proteinuria and nephrotic syndrome lead to? Answer: Fatty casts. 9)What leads best demonstrate U waves? Answer: Precordial leads (V1 to V6). 10)What percent of body calcium is found in the skeleton? Answer: 98%. 11')What is the advantage of using of an angiotensin converting enzyme inhibitor for the treatment of hypertension in the setting diabetes mellitus? Answer: It is used for primary prevention of diabetic nephropathy and may have a unique cardiovascular benefit in this setting. 12)What is the gold standard imaging modality for diagnosing kidney stones? Answer: Noncontrast CT of the abdomen and pelvis. 13): What formula is used to calculate the serum osmolality? Answer: (2 x Na) + (BUN/2.8) + (glucose/18) + (ethanol/3.7). 14)What volume of urine is considered a normal postvoid residual? Answer: < 50 mL in young adults and < 100 mL in adults over 65 years of age. 15)Which of the following represents the best treatment plan for correction of systemic acidosis in status epilepticus? Watchful waiting for auto-correction of the acidosis once seizure activity is controlled 16)Is the ototoxicity commonly seen in salicylate toxicity permanent? Answer: No. The tinnitus, seen at salicylates levels > 20 mg/dL, is reversible. 17)In addition to potassium supplementation, what medication can be used to reverse hypokalemic thyrotoxic periodic paralysis? Answer: Propranolol (nonselective beta-blocker). 18)When is hydronephrosis expected and relatively considered normal? Answer: In up to 80% of second trimester pregnancies, dilation of the ureters and renal pelvis commonly occurs. 19)Which is the most prevalent non-measured anion in the blood? Answer: Albumin. 20)What is the most common complication of chronic kidney disease? Answer: Hypertension.

facts-3

1)What treatment should be administered to patients with thyrotoxic periodic paralysis? Answer: Potassium supplementation and beta-blockers. 2)What is the most common noncutaneous cancer in American men? Answer: Prostate. 3)What defines metabolic syndrome? Answer: Three or more of the following: fasting blood glucose ≥ 100 mg/dL; high-density lipoprotein level < 40 mg/dL in men and < 50 mg/dL in women; triglyceride level > 150 mg/dL; waist circumference ≥ 102 cm in men and ≥ 88 cm in women; and hypertension ≥ 130/85 mm Hg. 4)Which bacteria are associated with kidney staghorn calculi? Answer: Proteus mirabilis. 5)Varicoceles occur more commonly on the left side because the spermatic vein is connected to the left renal vein whereas the right spermatic vein opens into the larger inferior vena cava. 6)How does serum pH affect potassium shifting? Answer: Acidemia shifts potassium from the intracellular to extracellular space.

facts-1

1)Which of the following disorders causes a normal anion gap metabolic acidosis? Diarrhea Renal tubular acidosis Adrenal insufficiency Chronic kidney disease Intestinal, pancreatic, biliary fistula Hypoaldosteronism Spironolactone, prostaglandin inhibitors, triamterene, amiloride, trimethoprim, pentamidine, cyclosporin 2) How does iron ingestion lead to metabolic acidosis? Answer: Iron, at toxic levels, poisons the cellular mitochondria leading to lactic acidosis. 3)What is Chvostek sign? Answer: Twitching of the ipsilateral facial muscles with tapping of the facial nerve, indicating the presence of hypocalcemia. 4)Which electrolyte imbalance is commonly seen in patients with acute kidney injury? Answer: Hyperkalemia. 5)Metabolic acidosis with elevated anion gap is seen in diabetic ketoacidosis (DKA). anion gap is sodium - (chloride + bicarbonate). A normal anion gap is between 3 and 10 mEq/L. Any value > 10 mEq/L is = elevated anion gap. 6)A 78-year-old man undergoes laparoscopic surgery for a small bowel obstruction. Which metabolic disturbance is he most at risk for postoperatively? hypochloremic, hypokalemic metabolic alkalosis. 7)What is the leading cause of mortality in patients with diabetes? Answer: Cardiovascular disease. 8) In cases of hyperglycemia, should the sodium level be corrected prior to calculating the anion gap? Answer: No, because the chloride level is similarly diluted. 9)What are the two most effective methods of increasing elimination of lithium? Answer: Aggressive fluid resuscitation and hemodialysis. 10) What electrolyte abnormality results in U-waves on an ECG? Answer: Hypokalemia. 11)What are indications for emergent dialysis? Answer: Acidosis, electrolyte disturbance, intoxication, volume overload, uremia (AEIOU). 12)What is the most common benign cause of a primary respiratory alkalosis? Answer: Hyperventilation. 13)gram-negative bacteria are the most common causes of pyelonephritis. 14) How does iron ingestion lead to metabolic acidosis? Answer: Iron, at toxic levels, poisons the cellular mitochondria leading to lactic acidosis. 15)What is the target blood pressure for patients with polycystic kidney disease and resulting hypertension? Answer: < 110/75 mm Hg in patients aged 18 to 50 years with a normal GFR and 130/80 mm Hg in all other patients. 16)What is the approximate duration of action of calcium on cardiac membrane stabilization? Answer: 30 to 60 minutes. 17)Where are propylene glycol and ethylene glycol commonly found? Answer: Antifreeze. 18)Which medication reverses opioid-induced respiratory depression? Answer: Naloxone. 19): What is the pathophysiology behind a contraction alkalosis? Answer: Losses of large volumes of fluids high in sodium and low in bicarbonate. 20:Aside from hypercalcemia, what other electrolyte abnormality is commonly seen in hyperparathyroidism? Answer: Hypophosphatemia.

A 23-year-old woman presents with seizures. The patient received 2 mg of lorazepam by EMS but continues to seize. Serum lab tests show the following: Sodium: 118 mmol/L Potassium: 3.6 mmol/L Chloride: 90 mmol/L Bicarbonate: 21 mmol/L Blood urea nitrogen: 10 mg/dL Creatinine: 1.0 mg/dL Glucose: 89 mg/dL What treatment should be administered next? A 68-year-old woman presents with difficulty walking. Her neurologic examination is notable for ataxia. An MRI of the brain does not show any acute pathology. On laboratory analysis, her sodium is 108 mEq/L. Which of the following is the most appropriate next step in management?

3% hypertonic saline dx: hyponatremia This patient presents with prolonged seizure activity and hyponatremia and should emergently be treated with hypertonic saline . Patients with neurologic symptoms should be aggressively treated with 3% hypertonic saline.

Calcium gluconate dx: hyperkalemia from CKD What is the treatment for hyperkalemia resulting in metabolic acidosis? Answer: Sodium bicarbonate. Calcium A 57-year-old man presents to the ED for shortness of breath. He has a history of hypertension, diabetes, and end-stage renal disease. His ECG is seen above. Which of the following is true regarding his management? Membrane stabilization is a critical first step Calcium (B) does not lower the serum potassium level, but it stabilizes the cardiac membrane by restoring the normal gradient of the resting membrane potential of the cardiac cells. Sodium bicarbonate (D) promotes a shift of potassium into cells. However, sodium bicarbonate should be used with caution when hypertonicity, volume overload, or alkalosis poses a risk to the patient. Administration of an ampule of sodium bicarbonate in this patient could lead to worsening fluid overload and pulmonary edema.

A 67-year-old man with hypertension and end-stage renal disease presents after an incomplete dialysis session secondary to shortness of breath. His vital signs are BP 110/95 mm Hg, HR 50 bpm, RR 22/min, T 37.3°C, and oxygen saturation 99% on 2 L nasal cannula. You obtain the ECG above. Which of the following is the most appropriate next step in this patient's management? say the What is the treatment for hyperkalemia resulting in metabolic acidosis? A 67-year-old man presents with generalized weakness. He has had poor oral intake for several days. An ECG is performed as seen above. Which of the following medications should immediately be administered? A 57-year-old man presents to the ED for shortness of breath. He has a history of hypertension, diabetes, and end-stage renal disease. His ECG is seen above. Which of the following is true regarding his management? AA normal ECG rules out hyperkalemia BCalcium chloride administration will decrease the serum potassium concentration CMembrane stabilization is a critical first step DRepeated doses of IV sodium bicarbonate are recommended until the QRS complex narrows

Which antiepileptic medication commonly causes hyponatremia at therapeutic doses? Oxcarbazepine causes profound hyponatremia < 125 Hyponatremia Excess of water in relation to sodium Sx: asymptomatic, nausea, vomiting, paresthesias, AMS Labs: Na < 135 mEq/L Tx depends on severity and duration, may include hypertonic saline, free water restriction Acute/symptomatic: maximum correction of 4-6 mEq/L in 6 hours Chronic: correct by 4-6 mEq/L in 24 hours Central pontine myelinolysis (dysarthria, dysphagia, paralysis) if corrected too fast Which of the following conditions is this patient at risk for with rapid correction of hyponatremia? hat are the indications for inpatient treatment of hyponatremia? Answer: Acute hyponatremia, symptomatic hyponatremia, or severe hyponatremia (serum sodium < 120 mEq/L).

A 68-year-old woman presents with difficulty walking. Her neurologic examination is notable for ataxia. An MRI of the brain does not show any acute pathology. On laboratory analysis, her sodium is 108 mEq/L. Which of the following is the most appropriate next step in management?

CKD What are the different stages of Chronic Kidney disease and their associated glomerular filtration rate (GFR)? Answer: Stage 1: GFR > 90 , Stage 2: GFR 60-89, Stage 3: GFR 30-59, Stage 4: GFR 15-29, Stage 5: GFR < 15. How long does kidney disease need to be present to be considered chronic? Answer: At least three months.

A 76-year-old man with a history of diabetes presents for establishment of care. His initial blood work reveals a creatinine of 1.79 and a GFR of 48. What stage of chronic kidney disease does he have?

Which one of the following is the most likely cause of acute kidney injury in a patient with eosinophiluria? A 33-year-old woman presents to primary care for a follow-up for her UTI. She was diagnosed with a UTI 5 days ago in the office and was placed on trimethoprim 800 mg/sulfamethoxazole 160 mg twice per day for 7 days. This morning, she awoke with a fever, rash, and bilateral knee pain. She reports no cough, sore throat, or vaginal discharge but still has some dysuria with urination. She has no other significant medical history but had a progestin-containing intrauterine device placed last month for long-term birth control. Today, her vitals are a T of 100.9°F, BP of 164/78 mm Hg, RR of 13/min, HR of 88 bpm, and oxygen saturation of 99% on room air. She has a maculopapular rash over her trunk and extremities, no abdominal tenderness, positive bowel sounds in all four quadrants, and no costovertebral angle tenderness. Bilateral knees are without warmth or erythema, and she maintains full active range of motion. Laboratory evaluation of urine reveals white cells, red cells, and white cell casts. Her creatinine is 3.3 mg/dL and absolute blood eosinophil count is 600/microL. What is the most likely cause of her symptoms?

Acute interstitial nephritis cause penicillins, cephalosporins, sulfonamides (such as trimethoprim-sulfamethoxazole), and NSAIDs Sx: fever, rash Labs: ↑Cr, eosinophiluria, WBCs, white blood cell casts Increased plasma creatinine is noted in all patients Caused by medications (NSAIDS, antibiotics, PPIs, others), infections, autoimmune disorders Tx: discontinue offending medication, if kidney function does not improve consider biopsy and glucocorticoids What is the treatment for acute interstitial nephritis? Answer: Withdrawal of offending medication. Which is the more common cause of interstitial nephritis—drugs or infectious diseases? Answer: Drugs. They cause over 70% of cases. What urine sediment finding is typically seen in acute interstitial nephritis? Answer: White blood cell casts.

A previously healthy 21-year-old man is found unresponsive by his roommates. On arrival to the emergency department, his pupils are pinpoint and oxygen saturation is 88% on room air. A blood gas reveals a pH of 7.25, PCO2 of 60 mm Hg, PO2 of 65 mm Hg, and a HCO3- of 26 mEq/L. Which of the following mechanisms is the most likely cause of his hypercapnia?

Decreased respiratory drive dx: opioid overdose acute respiratory acidosis from hypoventilation. Hypoventilation results from a decreased respiratory rate,

A 57-year-old woman with a long history of poorly-controlled diabetes mellitus presents with worsening edema in her legs and an occasional "wet-sounding" cough. Physical exam shows 2 pitting edema extending to mid-calf bilaterally and trace periorbital edema. Blood tests show hypoalbuminemia and hyperlipidemia and urinary protein excretion is 3.5 grams/24 hours. Which of these complications may occur as a direct result of her new condition?

Deep vein thrombosis hypercoagulable state may occur in patients with nephrotic syndrome triad of hypoalbuminemia, hyperlipidemia, and proteinuria As serum albumin levels drop below 2 grams/dL, patients typically become deficient in antithrombin, protein C, and protein S, which causes an increased propensity to clotting. Nephrotic Syndrome PE will show pitting edema Labs will show proteinuria > 3.5 g/24 hr, hyperlipidemia, hypercoagulability (renal vein thrombosis), fatty casts Minimal change disease: children, preceded by URIRx: steroids Focal segmental glomerulosclerosis: HIV or IVDA, end-stage kidney disease Membranous nephropathy: HBV, HCV, SLE, gold, penicillamine, malignancy What urinalysis finding is present in patients with marked hyperlipidemia from nephrotic syndrome? Answer: Oval fat bodies, lipid deposits in sloughed renal tubular epithelial cells, occur with marked hyperlipidemia.

A 26-year-old woman is found to have a blood pressure of 160/90 mm Hg. Similar values are obtained on two subsequent visits. She denies episodic headaches, palpitations, and diaphoresis. She is not obese. On abdominal exam, she is found to have a renal bruit. No abdominal masses are palpated. Her serum creatinine is 1.5 mg/dL. What is the most likely diagnosis?

Fibromuscular dysplasia (FMD) noninflammatory, nonatherosclerotic disease that results in arterial occlusion, stenosis, and dissection. women younger than 35 years with unexplained hypertension. mean age of diagnosis is 52 years The renal arteries and extracranial cerebrovascular arteries are most commonly affected a Hypertensionis the most common finding in renal FMD. Flank pain or abdominal pain can result from renal or mesenteric artery ischemia, aneurysm, or dissection. extracranial cerebrovascular FMD include headache, pulsatile tinnitus, and neck pain Renal Artery Stenosis Causes: atherosclerosis, fibromuscular dysplasia Fibromuscular dysplasia: young women Refractory HTN Dx: MRA, doppler US, CTA, renal angiography Angioplasty Unilateral renal artery stenosis: ACEIs, ARBs What is the most common cause of renal artery stenosis? Answer: Atherosclerosis.

Which of the following is the first line medical treatment for symptomatic hypercalcemia? A 72-year-old African-American man presents to the emergency department for disorientation. According to his family, the patient has been progressively more withdrawn, apathetic, and complaining of progressive nausea, vomiting, anorexia, drowsiness, and lethargy during the last few months. His past medical history includes type-2 diabetes controlled with diet and metformin, and an uncomplicated appendectomy 15 years ago. Vital signs are within normal range. On physical examination, he is disheveled, disoriented, drowsy, and dehydrated. Laboratory results reveal hemoglobin 13 g/dL, platelets 310,000, sodium 145, potassium 4.9, chloride 101, calcium 14.1, glucose 91, BUN 8, and creatinine 0.8. Which of the following is the most appropriate next step in management? A 63-year-old man with prostate cancer and bony metastasis presents with nausea, decreased oral intake, constipation, generalized fatigue, and mild confusion. His vitals are T 37.1°C, HR 102 bpm, BP 95/57 mm Hg, RR 20/min, oxygen saturation 96%, and finger stick blood glucose 102 mg/dL. On examination, he has slow mentation, normal pupil size, dry mucous membranes, and decreased bowel sounds. A chemistry panel shows the following: Sodium: 133 mEq/L Potassium: 3.3 mEq/L Chloride: 97 mEq/L Bicarbonate: 23 mEq/L Blood urea nitrogen: 27 mg/dL Creatinine: 2.2 mg/dL Calcium: 13.1 mg/dL Magnesium: 2.1 mg/dL Which of the following treatments should be initiated immediately?

Fluid rehydration dx: hypercalcemia What are the most common ECG findings in hypercalcemia? Answer: Shortening of the QTc interval, PR prolongation, and QRS widening.

You examine an eight-year-old girl in the pediatric intensive care unit who is complaining of abdominal pain. She has been in the unit for six days for close monitoring and pain control after her spinal surgery. She has been immobilized since the day of surgery and now complains of nausea, constipation, and abdominal pain. Her ECG shows a shortened QT interval. Which of the following electrolyte abnormalities can explain her findings?

Hypercalcemia Immobilization can cause hypercalcemia due to increased bone resorption What is the initial treatment for hypercalcemia? Answer: IV hydration.

A patient is found to be hyponatremic. Laboratory evaluation reveals low serum osmolality, urine sodium concentration > 20 mmol/L, and a fractional excretion of sodium (FENa) > 1%. He appears to be "fluid overloaded." Which of the following is the most likely cause of this hyponatremia?

Hypertensive nephropathy Hyponatremia Excess of water in relation to sodium Sx: asymptomatic, nausea, vomiting, paresthesias, AMS Labs: Na < 135 mEq/L Tx depends on severity and duration, may include hypertonic saline, free water restrictionAcute/symptomatic: maximum correction of 4-6 mEq/L in 6 hoursChronic: correct by 4-6 mEq/L in 24 hoursCentral pontine myelinolysis (dysarthria, dysphagia, paralysis) if corrected too fast What causes hypovolemic hyponatremia with elevated urine sodium >20? Answer: Renal sodium loss from thiazide diuretics, osmotic diuresis, nephropathy, or mineralocorticoid deficiency.

A 65-year-old man with a medical history of hypertension on amlodipine presents to the clinic for follow-up. The patient was recently treated with scheduled ibuprofen for right knee pain. His creatinine increased to 1.8 mg/dL following use of the ibuprofen but has now returned to his baseline of 0.8 mg/dL following discontinuation of the ibuprofen. Vital signs include a HR of 80 bpm, BP of 120/80 mm Hg, RR of 20/min, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination reveals no erythema or warmth of either knee and no lower extremity edema. Which of the following best explains the patient's transient acute kidney injury?

Impaired afferent arteriolar vasodilation

A 47-year-old man presents with hiccups for three days. He is unable to stop them with any home remedies. His physical examination is benign. Which of the following is a potential cause of hiccups?

In the metabolic category, hyponatremia and hypocalcemia are two possible causes of hiccups. Hiccups A rare manifestation of serious pathology Rx: chlorpromazine, metoclopramide What is the only FDA approved treatment of hiccups? Answer: Chlorpromazine.

A 43-year-old woman presents to the emergency department via EMS following a motor vehicle collision. She has multiple lacerations that are still actively bleeding. She reports no significant medical history, and her only medication is oral birth control. Vitals are a T of 98.4°F, BP of 90/60 mm Hg, RR of 13/min, HR of 101 bpm, and oxygen saturation of 99% on room air. On physical examination, her mucous membranes and skin are dry. She has multiple contusions and lacerations over her torso and extremities, decreased lung sound on the right, and regular heart rhythm without murmurs. Laboratory results reveal a hemoglobin of 7.8 g/dL. CXR in the trauma bay reveals a right-sided hemothorax, and a chest tube is placed. She is at high risk for acute kidney injury due to poor perfusion. Which of the following is a diagnostic criterion for acute kidney injury, according to Kidney Disease: Improving Global Outcomes guidelines?

Increase in serum creatinine by ≥ 0.3 mg/dL within 48 hours Acute kidney injury (AKI) . Diagnostic criteria for AKI include an increase in serum creatinine by ≥ 0.3 mg/dL (≥ 26.5 micromol/L) within 48 hours, an increase in serum creatinine to ≥ 1.5 times baseline known or presumed to have occurred within 7 days, or a urine volume < 0.5 mL/kg/hour for 6 hours. Management involves finding the underlying cause, removing any potential insults, and hydration. Potential insults include hypotension, NSAIDs, contrast dyes, and nephrotoxic medications. True or false: in a patient with bilateral renal artery stenosis, starting an angiotensin-converting enzyme (ACE) inhibitor can lead to acute kidney injury. Answer: True.

A 45-year-old woman who receives chronic dialysis missed her last two scheduled sessions of dialysis. Which of the following compensatory mechanisms would be expected in this patient?

Increased respiratory rate to decrease CO2 and increase the serum pH Will respiratory compensation lead to a normal pH in an acidemic patient? Answer: No. Neither respiratory nor renal compensation completely normalizes the pH.

A 69-year-old man presents to the emergency department complaining of nausea and vomiting for three days. His past medical history is significant for hypertension, diabetes, hypothyroidism and hyperlipidemia. His medications include lisinopril, levothyroxine, glipizide and atorvastatin. Lab work reveals a creatinine of 3.2. He previously had normal kidney function. Which of the following medications should be discontinued?

Lisinopril should be discontinued in the setting of acute kidney injury. What is the advantage of using of an angiotensin converting enzyme inhibitor for the treatment of hypertension in the setting diabetes mellitus? Answer: It is used for primary prevention of diabetic nephropathy and may have a unique cardiovascular benefit in this setting.

Which of the following is a common cause of hypomagnesemia?

Malnutrition dx: Hypomagnesemia Malnutrition, alcohol use Hypocalcemia Hypokalemia ↑ QT interval, dysrhythmias Neuromuscular symptoms (e.g., tremor, tetany)

A pH of 7.1, HCO3 of 15 mEq/L, and PCO2 of 30 mm Hg is best described by which of the following primary acid-base disorders?

Metabolic acidosis Acute Respiratory and Metabolic Acidosis and Alkalosis (Normal ABG values pH 7.35-7.45; PaCO2 35-45 mm Hg; bicarbonate 22-26 mEq/L) Respiratory AcidosispH < 7.35; PaCO2 > 45 mm Hg; bicarbonate normal Respiratory AlkalosispH > 7.45; PaCO2 < 35 mm Hg; bicarbonate normal Metabolic AcidosispH < 7.35; PaCO2 normal; bicarbonate < 22 mEq/L Metabolic AlkalosispH > 7.45; PaCO2 normal; bicarbonate > 26 mEq/L

A patient with a history of diabetes mellitus, hypertension, coronary artery disease and hypothyroidism is being discharged after a cardiac catheterization with placement of a drug eluting stent. Which of the following medications must be temporarily held post catheterization?

Metformin withheld for 48 hours after the administration of a contrast agent. Intravascular administration of iodinated contrast media to patients who are receiving metformin can result in lactic acidosis. Continued intake of metformin after the onset of contrast induced nephropathy can result in a toxic accumulation of the drug and subsequent lactic acidosis. Can metformin be prescribed to patients with chronic kidney disease? Answer: Yes. Metformin can be safely used in patients with a GFR > 45 mL/min as long as there is not evidence of ongoing decline in renal function

A 29-year-old woman presents to the emergency department with a complaint of bloody diarrhea and abdominal cramping. Recently, she ate a rare hamburger at a birthday party for her 4-year-old son. He ate hot dogs instead, and has not been ill. A stool specimen is positive for Escherichia coli O:157. Which one of the following should you do next?*******? What disease is known to be a variant of hemolytic uremic syndrome?

Monitor blood urea nitrogen/creatinine levels DX:Hemolytic Uremic Syndrome (HUS) Patient presents with bloody diarrhea Labs will show anemia, renal failure, thrombocytopenia (ART) Most commonly caused by E. coli O157:H7 Treatment is supportive Avoid Abx "ART" Escherichia coli O:157 is an increasingly common cause of serious gastrointestinal illness. Hemolytic uremic syndrome is caused primarily by Shiga toxin-producing Escherichia coli O157:H7 this patient is at risk of renal failure and her renal function should be monitored. Renal function should be monitored by trending her BUN/creatinine levels. What disease is known to be a variant of hemolytic uremic syndrome? Answer: Thrombotic thrombocytopenic purpura. (TTP)

A 40-year-old woman presents to her primary care provider with abdominal pain that has slowly worsened over the past year. She reports having intermittent hematuria. She has a history of recurrent urinary tract infections. Her blood pressure is 145/92 mm Hg, pulse is 72 beats/min, respiratory rate is 18 breaths/min, and temperature is 98.6°F. On exam, palpable masses are noted in the bilateral flanks, and an enlarged, nodular liver is noted. Which of the following is the most likely diagnosis?

Polycystic kidney disease Polycystic Kidney Disease Sx: asymptomatic, flank pain or hematuria PE: hypertension, palpable kidneys Diagnosis is made by ultrasound, may be incidentally discovered on imaging Most commonly caused by autosomal dominant disorder Treatment is BP control: ACEIs, ARBs Associated with increased risk for berry aneurysm and intracerebral hemorrhage ----------------------------------------------------- Hydronephrosis (A) is caused by obstruction of urine outflow. Hydronephrosis can be caused by calculi, neoplasms, and benign prostatic hypertrophy. Hydronephrosis does not typically produce bilateral flank masses or intermittent hematuria

A 70-year-old man with a history of chronic kidney disease, hypertension, and type 2 diabetes mellitus presents to his nephrologist's office for follow-up. His vital signs are HR 84 bpm, RR 18/min, BP 124/82 mm Hg, T 98.3°F, SpO2 98%, and BMI 30 kg/m2. The patient is currently on hemodialysis 3 days per week. His medications include insulin aspart, insulin glargine, linagliptin, metoprolol, and lisinopril. Laboratory results show an estimated glomerular filtration rate of 20mg/mmol, blood urea nitrogen of 25 mg/dL, creatinine of 1.9 mg/dL, serum calcium of 8.6 mg/dL, serum phosphate of 6.0 mg/dL, and magnesium of 2.4 mg/dL. His serum phosphate levels remain elevated despite implementing phosphate restrictions in his diet. He is asymptomatic and reports no symptoms of muscle cramps or weakness, paresthesias, or circumoral numbness. Which of the following is the best next step in managing his condition?

Phosphate binder (sevelamer) and lanthanum. Phosphate binders are divided into two groups: calcium-containing binders, such as calcium carbonate and calcium acetate, What is the mechanism of action of sevelamer? Answer: It binds dietary phosphate in the intestinal lumen, causing limited absorption and decreased serum phosphate concentrations. dx:hyperphosphatemia phosphate concentration of 3.5-5.5 mg/dL Patients are generally asymptomatic but may present with symptoms of hypocalcemia such as muscle cramps or spasms, paresthesias, circumoral numbness, or QTC prolongation

A patient is found to have the following basic metabolic panel results: sodium 143 mmol/L, potassium 3.6 mmol/L, chloride 107 mmol/L, bicarbonate 14 mmol/L, BUN 16 mg/dL, creatinine 1.2 mg/dL, and glucose 92 mg/dL. Which of the following is a possible cause of these laboratory results?

Salicylate toxicity metabolic acidosis as defined by a decrease in serum bicarbonate concentration . The anion gap is calculated using the formula Na - (Cl + HCO3) and a normal anion gap is 10 +/- 2. What formula is used to calculate the serum osmolality? Answer: (2 x Na) + (BUN/2.8) + (glucose/18) + (ethanol/3.7). -Metabolic acidosis and respiratory alkalosis-

A 16-year-old boy presents to the emergency department with a report of a 2-day history of diffuse abdominal pain, nausea, vomiting, polydipsia, polyuria, and weakness. His blood pressure is 120/80 mm Hg, heart rate is 110 bpm, respiratory rate is 22/min, and temperature is 36.8°C. Initial laboratory studies reveal sodium 132 mEq/L, potassium 5.4 mEq/L, and glucose 500 mg/dL. Arterial blood gas demonstrates pH of 7.0, bicarbonate of 9 mEq/L and partial pressure carbon dioxide of 35 mm Hg. What are the corrected values of serum potassium and serum sodium?

Potassium 3.0 mEq/L and sodium 138 mEq/L dx: Diabetic Ketoacidosis\ dilutional hyponatremia. The true serum sodium value can be calculated by adding 1.6 mEq/L to the sodium value for every 100 mg/dL of glucose above 100 mg/dL. The corrected serum potassium in acidosis can be determined by subtracting 0.6 mEq/L from the initial potassium value for every 0.1 decrease in pH from 7.4. 5.4 - 0.6 x ((7.4-7.0)/0.1)) = 3.0

Which one of the following disease processes is most likely to result in a chronic respiratory acidosis? AAirway foreign body BAspirin overdose CHigh altitude DPulmonary fibrosis

Pulmonary fibrosis a form of restrictive lung disease, causes a chronic respiratory acidosis Which drugs can cause an acute respiratory acidosis? Answer: Opioids, benzodiazepines, barbiturates, alcohol.

A 60-year-old man with a history of hypertension and diabetes mellitus type 2 presents to your office for his annual exam. He reports noncompliance with his routine medications and has been taking ibuprofen daily for the past six months due to headaches. Which of the following is the most useful initial imaging study to evaluate this patient for chronic kidney disease?

Renal ultrasound : How is chronic kidney disease staged? Answer: By estimating the glomerular filtration rate.

A 74-year-old man presents to the clinic with worsening nocturia and urinary hesitancy. The symptoms have been present for 3 years but have worsened over the past month. The patient reports no abdominal pain, fever, or weight loss. Vital signs include a HR of 80 bpm, BP of 120/80 mm Hg, RR of 20/min, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination reveals a soft and nontender abdomen and a diffusely enlarged and nontender prostate on digital rectal examination. The patient's creatinine today is 2.8 mg/dL, and it was 1.4 mg/dL 6 months ago. His prostate-specific antigen is 3.0 ng/mL. Postvoid residual volume is 500 mL. Which of the following is the most appropriate next step in his evaluation?*****

Renal ultrasound dx;it can confirm the presence of urinary tract obstruction and hydronephrosis. Patients who have urinary tract obstruction and hydronephrosis due to bladder outlet obstruction from benign prostatic hyperplasia are often temporarily treated with urinary catheterization. What volume of urine is considered a normal postvoid residual? Answer: < 50 mL in young adults and < 100 mL in adults over 65 years of age.

A 45-year-old man presents to the clinic for an annual physical examination. He has a previous medical history of hypertension, well controlled on losartan. He reports no previous surgical history or urinary complications. He reports having mild right-sided back pain for the last 3 months with no aggravating or alleviating factors. His sexual history is negative, and his family history is unknown. Vital signs include a HR of 62 bpm, BP of 110/75 mm Hg, RR of 14/min, oxygen saturation of 99% on room air, and T of 98.6°F. Physical examination is within normal limits. An ultrasound is ordered to evaluate his back pain and reveals three renal cysts on the right kidney and two renal cysts on the left kidney. What is the most serious extrarenal complication that can arise from the patient's most likely diagnosis?

Ruptured cerebral aneurysm and intracerebral hemorrhage dx: Autosomal dominant polycystic kidney disease (ADPKD)

Which of the following is the most common solid renal tumor of childhood? A three-year-old boy, with a history of hypospadia, presents with abdominal pain. Examination reveals normal temperature, stable weight, and a nontender left abdominal mass. Further abdominopelvic, cranial nerve and neuromuscular examination is unremarkable. Urinalysis reveals scant red blood cells. Which of the following is the most likely diagnosis? What are congenital abnormalities commonly associated with this dx?

Which of the following is the most common solid renal tumor of childhood? Nephroblastoma, or Wilms tumor sx: asymptomatic abdominal mass to abdominal pain, anorexia, abdominal distention, vomiting, and hematuria. What are congenital abnormalities commonly associated with Wilms tumor? Answer: Horseshoe kidney, duplicate collecting system, hypospadia and cryptorchidism. Wilms Tumor (Nephroblastoma) Patient will be < 15 years old Abdominal pain, anorexia, abdominal distention, vomiting, or hematuria PE will show abdominal mass Diagnosis is made by US (initial) and CT characterizes Treatment is surgical resection, chemotherapy, and radiation therapy Most common solid kidney tumor of childhood Associated with WAGR, Denys-Drash, Beckwith-Wiedemann WAGR syndrome: Wilms tumor, aniridia, genitourinary anomalies, and intellectual disability (formerly referred to as mental retardation) What is the peak age for presentation with a Wilms tumor? Answer: The third year of life.

urine microscopy of a patient with an elevated creatinine reveals muddy brown cellular casts. What is the most likely diagnosis?

dx: Acute tubular necrosis Most common cause of intrinsic kidney failure Types: ischemic and nephrotoxic Nephrotoxins: aminoglycosides > contrast agents Inability to concentrate urine (urine osmolality = serum osmolality) Granular muddy-brown casts is responsible for many cases of acute kidney injury in the hospital setting. ATN occurs when there is decreased blood flow to the kidney usually secondary to a drop in blood pressure or secondary to nephrotoxins. What antibiotic class commonly causes acute tubular necrosis? Answer: Aminoglycosides.

A 58-year-old woman presents to the nephrology clinic as a new patient. She recently relocated to the area and is establishing care. She presents with records from her prior nephrologist, although she reports her last visit was over a year ago. She reports her initial symptoms were diffuse swelling, fatigue, and noticing a lot of bubbles in her urine that sit on top of the toilet water. She reports no urinary burning, urgency, incontinence, changes in frequency, or hematuria. She also reports no abdominal pain or flank pain. Her medical history includes type 2 diabetes mellitus, which she reports was diagnosed 3 years ago and is well controlled. She reports no history of smoking. Her BMI is within normal limits, and she reports no changes in her weight. She enjoys walking and swimming for exercise. Her blood work is notable for albumin 2.7 g/dL, total cholesterol 240 mg/dL, HDL cholesterol 34 mg/dL, LDL cholesterol 155 mg/dL, triglycerides 271 mg/dL, and an elevated titer of circulating phospholipase A2 receptor antibodies. Her urinalysis is notable for 24-hour protein collection 4 g/day and the presence of oval fat Maltese cross-shaped bodies. Her kidney biopsy reveals increased capillary wall thickness, and staining with silver methenamine reveals a spike and dome pattern. Which of the following is the most likely diagnosis?

type of nephrotic syndrome Primary membranous nephropathy proteinuria > 3 g/day,hypoalbuminemia, hyperlipidemia, urinary oval fat bodies, and edema. Membranous nephropathy is the most common cause of primary nephrotic syndrome lab findings include hypoalbuminemia, hyperlipidemia, and an elevated titer of circulating phospholipase A2 receptor (PLA2R) antibodies. Kidney biopsy findings include increased capillary wall thickness without inflammatory changes or cellular proliferation. Staining with silver methenamine reveals a spike and dome pattern from subepithelial immune complex deposits. Treatment • Supportive care: dietary restriction of sodium and protein, antihypertensives, renin-angiotensin system inhibitors, lipid therapy, anticoagulants, treatment for edema • Based on risk of progression, treat with immunosuppressives

Which of the following represents the best treatment plan for correction of systemic acidosis in status epilepticus?

Watchful waiting for auto-correction of the acidosis once seizure activity is controlled normally Treatment of status epilepticus involves stabilizing the patient and rapid administration of a benzodiazepine such as midazolam. This is followed by administration of an intravenous anticonvulsant such as phenytoin. Correction of the systemic acidosis found in status epilepticus is not necessary since the acidosis is thought to have anticonvulsant effects. Also, the acidosis corrects itself quickly once seizure activity has ceased, and treatment with alkalinizing agents often leads to a rebound systemic alkalosis. TreatmentFirst-line: benzodiazepines (e.g., lorazepam)Second-line: phenytoin or fosphenytoin, valproic acid, levetiracetamThird-line: pentobarbital, propofol, phenobarbital Should phenytoin be administered to a patient in status epilepticus who currently has therapeutic blood levels of phenytoin? Answer: Yes, as data suggest that blood levels of phenytoin above the therapeutic range (20-30 μg/dL) are more effective in stopping seizures.

An 18-year-old woman presents to the ED with dark-colored urine and malaise for the past three days. Her vital signs are BP 155/85 mm Hg, HR 80 bpm, RR 16/min, and T 36.7°C. On exam, you note 1+ pretibial edema. Urinalysis reveals proteinuria, hematuria, and red blood cell casts. Which of the following is the most likely diagnosis Evidence of what type of cells on urine microscopy is specific for glomerulonephritis? Answer: Red blood cell casts. A 9-year-old boy presents with complaints of low back pain for one week and dark urine. History reveals pharyngitis 2 weeks ago. The patient is afebrile with a BP of 124/88 mm Hg (elevated for his age) and a weight of 119 pounds. On exam, the location of the pain is at the right flank. Urinalysis is positive for leukocytes and moderate microscopic hematuria. Microscopic examination of urine reveals red blood cell casts. Which of the following laboratory tests should be serially measured to aid in confirmation of the diagnosis?

acute glomerulonephriti UA: hematuria, proteinuria, and red blood cell casts are highly suggestive Edema, HTN Do antibiotics reduce the incidence of poststreptococcal glomerulonephritis? Answer: No. Which of the following laboratory tests should be serially measured to aid in confirmation of the diagnosis? Antistreptolysin O (ASO) antibody dx:

A 67-year-old man presents to his primary care provider with dyspnea and fatigue. He has a past medical history of hypertension, diabetes mellitus, and stage 3 chronic kidney disease. A CBC shows a hemoglobin of 9 g/dL, hematocrit of 28%, total iron-binding capacity of 220 mcg/dL, mean corpuscular volume of 80 fL, mean corpuscular hemoglobin concentration of 31 g/dL, and ferritin of 310 ng/dL. A peripheral blood smear shows normocytic, normochromic red blood cells with few reticulocytes. Which of the following is the most appropriate management? ACyanocobalamin BDarbepoetin CFerrous gluconate and darbepoetin DRed blood cell transfusion

anemia of chronic disease and should be managed with darbepoetin. Epoetin alpha and darbepoetin are two erythropoiesis-stimulating agents commonly used. Both drugs have a black box warning for increased risk of thromboembolism, myocardial infarction, and stroke when used to target Hgb levels > 11 g/dL. , total iron binding capacity is usually normal to decreased; mean corpuscular volume and mean corpuscular hemoglobin are slightly decreased. Serum ferritin levels are usually increased Recombinant human erythropoietin and other erythropoiesis-stimulating agents are the standard of care for anemia in CKD maintain Hgb levels between 10.5 and 11.5 g/dL. Hgb levels greater than 13 g/dL are associated with increased morbidity and mortality. What is the most common complication of chronic kidney disease? Answer: Hypertension. Anemia of Chronic Disease Associated with infection, rheumatologic disorders, IBD, malignancy, CHF, kidney disease Inflammation -> elevated hepcidin -> iron sequestered in reticuloendothelial macrophages Labs: normochromic normocytic anemia, low serum iron and TIBC, high or normal ferritin Treat underlying disorder

A 12-year-old girl presents to the emergency department with diffuse abdominal pain, nausea, and vomiting. History is significant for polyuria, polydipsia and a 7 lb weight loss in the last month. Her labs are notable for venous blood gas with a pH of 7.2, and electrolytes with a bicarbonate of 15 mEq/L, glucose of 350 mEq/L, and a potassium of 3.2 mEq/ L. A bolus of normal saline 20 mL/kg is administered, and an insulin drip is started with normal saline 0.45%. Electrolytes are rechecked in 2 hours and reveal a potassium of 2.8 mEq/L. Which of the following findings is expected to be seen on this patient's ECG? A 55-year-old man with a medical history of hypertension presents to the emergency department with worsening diffuse muscle cramps and weakness for the past 2 days. The weakness started bilaterally in his legs but now involves his arms. He reports that exercising is more difficult because of the weakness. The patient reports taking hydrochlorothiazide, which he started 2 weeks earlier for hypertension. Vital signs include a HR of 103 bpm, BP of 142/80 mm Hg, RR of 20/min, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination reveals a distressed man with 3 out of 5 strength in each extremity. The patient has no ptosis, intact cranial nerves, and intact sensation with light touch. Which of the following is the most likely cause of the patient's symptoms? In addition to potassium supplementation, what medication can be used to reverse hypokalemic thyrotoxic periodic paralysis?

Flattening T wave dx; Hypokalemia (potassium<3.5 mmol/L) Hypokalemia History of diuretics use, diarrhea, vomiting Weakness, hyporeflexia, cramping, paresthesias ECG will show U waves, T wave flattening, ST depression, QT prolongation Treatment is potassium replacement along with magnesium What leads best demonstrate U waves? Answer: Precordial leads (V1 to V6). In addition to potassium supplementation, what medication can be used to reverse hypokalemic thyrotoxic periodic paralysis? Answer: Propranolol (nonselective beta-blocker).

Hyperkalemia

A 58-year-old woman with a history of hypertension, diabetes type 2, and renal failure on hemodialysis presents to the emergency department with a chief complaint of muscle weakness. She has a long history of non-compliance and often misses dialysis treatments. Her ECG is seen above. Which of the following is the most likely diagnosis?

Decreased membrane excitability tx:Calcium gluconate, albuterol, regular insulin and glucose, furosemide When should serum potassium be measured after beginning treatment for hyperkalemia? Answer: 1-2 hours after initiating therapy. dx: hyperkalemia Hyperkalemia History of kidney failure, DKA, rhabdomyolysis, tumor lysis Lethargy, weakness, paralysis PE will show bradycardia, hypotension, cardiac dysrhythmia ECG will show peaked T waves, prolonged PR, wide QRS Treatment is calcium gluconate, insulin, albuterol, bicarbonate Which classes of antihypertensives are contraindicated in the setting of hyperkalemia? Answer: Angiotensin converting enzyme inhibitors and angiotensin II receptor blockers. What is the treatment for hyperkalemia resulting in metabolic acidosis? Answer: Sodium bicarbonate. What other medications may be administered for hyperkalemia? Answer: High dose nebulized albuterol will shift potassium intracellularly while furosemide will aid in potassium elimination. How does insulin work to treat hyperkalemia? Answer: Insulin drives potassium intracellularly to transiently drop serum potassium levels. How does serum pH affect potassium shifting? Answer: Acidemia shifts potassium from the intracellular to extracellular space.

A 55-year-old man with stage III chronic kidney disease presents to the emergency department after a syncopal episode. He complains of cramping and weakness in his arms and legs for two days. A 12-lead ECG obtained in triage is shown above. Which of the following is the most likely cause of this patients ECG changes? What combination of medications is appropriate for the treatment of this patient? When should serum potassium be measured after beginning treatment for hyperkalemia? A 67-year-old man with hypertension and end-stage renal disease presents after an incomplete dialysis session secondary to shortness of breath. His vital signs are BP 110/95 mm Hg, HR 50 bpm, RR 22/min, T 37.3°C, and oxygen saturation 99% on 2 L nasal cannula. You obtain the ECG above. Which of the following is the most appropriate next step in this patient's management?

A 55-year-old man presents to the clinic for an annual follow-up of his well-controlled medical conditions. He is currently taking metformin, sitagliptin, lisinopril, aspirin, and atorvastatin. Vitals today include a HR of 87 bpm, RR of 17/min, BP of 139/81 mm Hg, T of 98.8°F, and SpO2 of 99% on room air. Which one of the following components of urine analysis is the best indicator of early-stage kidney disease in this patient?

Albuminuria dx:Diabetic nephropathy

previously healthy 14-year-old girl presents with diarrhea for five days. She has not been eating or drinking well during that time. Her serum pH is 7.29. Basic metabolic panel results are as follows: sodium 140 mEq/L, potassium 3.0 mEq/L, chloride 100 mEq/L, bicarbonate 19 mEq/L, and glucose 89 mg/dL. What is her anion gap?

Anion gap = Na+ - (Cl- + HCO3-) 21 mEq/L Which is the most prevalent non-measured anion in the blood? Answer: Albumin.

When considering the most common kidney cancer in adults, the histology report of this patient's biopsy would most likely describe abnormalities of which of the following cells?

Epithelial cells of the proximal convoluted tubule

A 53-year-old man is brought into the ED confused and disoriented. His partner reports he was feeling weak and nauseous and had multiple episodes of vomiting. On further questioning, he also reports an increase in hiccuping, a metallic taste in his mouth, and general pruritus. His blood pressure is 160/90, and he is tachypneic at 30 breaths per minute. Heart rate is 94 beats per minute. He is afebrile. On exam, dependent edema is noted. Multiple screening tests are sent, and they are notable for an elevated serum creatinine level of 2.1 mg/dL with an estimated glomerular filtration rate of 50 mL/min and blood glucose of 280 mg/dL on metabolic panel. His urinalysis is positive for protein. What is the most likely underlying cause for his presenting symptoms? A patient presents with vomiting, rapid breathing, and confusion after a week of not using his prescribed medications. You order serum electrolytes, serum creatinine and urea nitrogen, arterial blood gases, lactate levels, and a toxicology screen. You calculate an anion gap to be >18 mEq/L. Which of the following tests is most likely to be useful in evaluating the etiology of suspected metabolic acidosis?

Diabetes mellitus Ketones metabolic acidosis

A 35-year-old man presents to the clinic describing severe nausea, vomiting, and diarrhea for the past 1 day after eating at a new restaurant. He states he has been unable to keep any food or liquids down over the past several days. He describes associated symptoms of abdominal pain and fatigue. He reports no previous medical history and does not take any medication regularly. Vital signs include a HR of 112 bpm, BP of 88/56 mm Hg, RR of 16/min, oxygen saturation of 98% on room air, and T of 99.6°F. Serum creatinine is 1.9 mg/dL. On physical examination, he appears pale with decreased skin turgor and dry mucous membranes. Which of the following laboratory findings will be associated with the patient's most likely diagnosis?

Fractional excretion of sodium < 1% dx:Acute kidney injury Prerenal is the most common form of acute kidney injury,

What concomitant electrolyte disorder should be suspected in a patient with hypokalemia who does not respond to potassium repletion? Which of the following historical or physical exam findings is most consistent with a diagnosis of hypomagnesemia?

Hypokalemia is associated with hypomagnesemia, weakness, fatigue, muscle cramping, and paresthesias. At very low levels, cardiac dysrhythmias, rhabdomyolysis, and hypotension can occur. What treatment should be administered to patients with thyrotoxic periodic paralysis? Answer: Potassium supplementation and beta-blockers. Which of the following historical or physical exam findings is most consistent with a diagnosis of hypomagnesemia? Hyperreflexia muscle cramping, weakness, hyperreflexia, ataxia, and seizures. Electrocardiogram findings include QT prolongation, premature ventricular contractions, and tachydysrhythmias such as atrial fibrillation, multifocal atrial tachycardia, ventricular tachycardia or fibrillation, and torsades de pointes. dx: Hypomagnesemia Malnutrition, alcohol use Hypocalcemia Hypokalemia ↑ QT interval, dysrhythmias Neuromuscular symptoms (e.g., tremor, tetany)

An 80-year-old woman with a history of end-stage kidney disease, type 2 diabetes mellitus, and hypertension presents to the emergency department for evaluation of altered mental status. Her medications include insulin lispro, insulin glargine, and lisinopril. Her vital signs are HR 60 bpm, RR 16/min, BP 117/70 mm Hg, T 98.3°F, SpO2 98%, and BMI 22 kg/m2. Her laboratory results show an estimated glomerular filtration rate of 16 mg/mmol, blood urea nitrogen of 24 mg/dL, creatinine of 1.6 mg/dL, serum calcium of 8.4 mg/dL, magnesium of 4.5 mg/dL, and serum phosphorus of 5.0mEq/L. Her complete blood count shows a normal white blood cell count. Which of the following clinical findings do you expect to see on her physical exam? AHyperreflexia BHyporeflexia CNystagmus DTachycardia ETremor What is the treatment for life-threatening hypermagnesemia? What endocrine disorder is associated with hypermagnesemia?

Hyporeflexia dx hypermagnesemia (4-5 is normal) decreased deep tendon reflex, altered mental status, confusion,flaccid paralysis, weakness, hypotension, and bradycardia Laboratory findings may show elevated blood urea nitrogen (BUN), creatinine, phosphate, and potassium and a low serum calcium. ECG = increased PR interval, broadened QRS complexes, and QT prolongation Treatment • Crystalloid • Loop diuretic (e.g., furosemide) • Calcium What endocrine disorder is associated with hypermagnesemia? Answer: Hypoparathyroidism. What is the treatment for life-threatening hypermagnesemia? Answer: Intravenous calcium (either calcium chloride or calcium gluconate) and dialysis.

A 35-year-old woman presents to the emergency department after she collapsed at work. According to her husband, she suffers from a mood disorder that causes her to have "wild mood swings and reckless behavior." She was diagnosed a year ago and since has been treated with several medications. Her symptoms today consist of nausea, vomiting, fatigue, tremor, and hyperreflexia. Lab results show an elevated BUN and creatinine, low sodium, and elevated drug levels. All other results are normal. Which of the following medications is most likely the cause of her symptoms?

Lithium Toxicity Kidney excretion Predisposing factors: NSAIDs, kidney failure, dehydration, thiazide diuretics Acute: GI Sx Chronic: neurologic Sx Complications: diabetes insipidus, syndrome of irreversible lithium-effectuated neurotoxicity (SILENT) ECG: bradycardia, T wave flattening, and QTc prolongation IV fluids (mild-moderate) Avoid diuretics Hemodialysis (serious) What congenital heart anomaly is a possible result of lithium treatment and a reason it is contraindicated in pregnant patients? Answer: Ebstein's anomaly, a congenital malformation in which the septal and posterior leaflets of the tricuspid valve are displaced towards the apex of the right ventricle of the heart.

A 65-year-old man presents to his primary care clinic for a 3-month follow-up. He was diagnosed with stage 2 chronic kidney disease 3 months ago. He reports no headache, fatigue, or any other symptoms. He has a medical history of diabetes mellitus and hypertension and takes metformin 1,000 mg twice daily, exenatide 10 mcg subcutaneously twice daily, and hydrochlorothiazide 25 mg daily. He reports no smoking, drinks two beers per week, and does not use drugs. Today, his vitals include a T of 97.8°F, BP of 122/78 mm Hg, RR of 12/min, HR of 87 bpm, and oxygen saturation of 99% on room air. Physical examination reveals a man with obesity. His lungs are clear to auscultation bilaterally, there is no swelling in his lower extremities, and his heart rate is regular without murmurs, gallops, or rubs. His laboratory results reveal a finger stick glucose of 122 mg/dL, his urine is without any proteinuria or glucosuria, and his GFR today is 55 mL/min/1.73 m2. He asks if he should follow any specific diet, given his new diagnosis. Which of the following is a recommended dietary intake for patients with this new diagnosis?

Potassium intake between 40 and 70 mEq/day and a low-salt diet (< 2 g/day) are recommended. Patients with CKD are at increased risk of disorders of fluid and electrolyte balance, such as hyperkalemia

A 35-year-old woman presents to the ED with muscle cramping and tingling around the mouth. She underwent an uncomplicated thyroidectomy for papillary thyroid carcinoma three days ago. Which of the following physical findings are likely to be present? A 45-year-old man presents to the emergency department with muscle cramping and altered mental status. The patient has a past medical history of papillary thyroid cancer and is one week status-post total thyroidectomy. ECG reveals a markedly prolonged QT interval. Which of the following is the most likely to be seen on laboratory evaluation? what is the intervention ? What is the treatment for acute hypoparathyroidism? : What is the most common cause of hypocalcemia?

Tapping on the facial nerve results in twitching of the facial musculature dx: hypocalcemia surgery removed parathyroid hahaha What is the most serious ECG finding in hypocalcemia? Answer: QT interval prolongation. What is the treatment for acute hypoparathyroidism? Answer: Intravenous calcium gluconate. : What is the most common cause of hypocalcemia? Answer: Advanced chronic kidney disease. DiGeorge Syndrome : In hypocalcemia, what do you give to stabilize the heart? Answer: Calcium gluconate.

Which of the following medications can cause hyperkalemia? AFurosemide BHydrochlorothiazide CRegular insulin DTrimethoprim-sulfamethoxazole

Trimethoprim-sulfamethoxazole elevations of both creatinine and potassium. ----------------------------------------------------- Furosemide (A) is a loop diuretic agent that can cause hypokalemia and is often used in the treatment of hyperkalemia with preserved renal function. Hydrochlorothiazide (B) is a diuretic, antihypertensive agent that can lead to hypokalemia. Insulin (C) can cause transient hypokalemia by shifting potassium into cells, and it is a mainstay of hyperkalemia treatment.

Flank pain, hematuria, palpable abdominal renal mass Tobacco use dx:Renal Cell Carcinoma History of smoking Flank pain, flank mass, hematuria Treatment is nephrectomy . When considering the most common kidney cancer in adults, the histology report of this patient's biopsy would most likely describe abnormalities of which of the following cells?Epithelial cells of the proximal convoluted tubule What is the most common histological subtype of renal cell carcinoma? Answer: Clear cell carcinoma, which also carries the worst prognosis. What is the most common type of kidney cancer in adults? Answer: Renal cell carcinoma. What is the most important characteristic of kidney lesions that separates typically benign tumors from malignancies? Answer: Presence of measurable contrast enhancement on diagnostic imaging.

A 60-year-old man presents to the clinic reporting abdominal pain and unintentional weight loss over the past few months. He has a history of hypertension and has smoked one pack of cigarettes per day since he was 18 years old. His only medication is amlodipine 5 mg once daily. He works as a mechanic. Vital signs include a HR of 80 bpm, RR of 14/min, T of 98.6°F, and a BP of 142/90 mm Hg. A computed tomographic image of the patient's abdomen and pelvis is included above. Which of the following additional signs and symptoms are classic findings in a patient with this pathology? Which of the following is the most important risk factor for the development of the suspected disease?

A 56-year-old woman is following up in the clinic after starting a new antihypertensive medication. The patient previously had well-controlled hypertension with a recent sudden increase despite continued medical management. Her medical history also includes diabetes mellitus type 2, claudication, hyperlipidemia, and stable angina. Currently, she is being treated with metformin, sitagliptin, aspirin, atorvastatin, lisinopril, hydrochlorothiazide, and labetalol. Vitals today include a BMI of 25 kg/m2, HR of 87 bpm, RR of 17/min, BP of 187/112 mm Hg, T of 98.8°F, and SpO2 of 99% on room air. Which of the following is most likely revealed with a history and physical exam?

Continuous periumbilical bruit dx:Renal artery stenosis older than age 55 years with an onset of severe hypertension Renal Artery Stenosis Causes: atherosclerosis, fibromuscular dysplasia Fibromuscular dysplasia: young women Refractory HTN Dx: MRA, doppler US, CTA, renal angiography Angioplasty Unilateral renal artery stenosis: ACEIs, ARBs What guidelines exist for attempting antihypertensive therapy before deeming hypertension to be resistant? Answer: Concurrent use of adequate doses of three antihypertensive agents from different classes, including a diuretic.

A 31-year-old man presents with 10/10 flank pain that radiates to his testicle. He has no significant past medical history. Temperature and vital signs are normal. Examination reveals no edema or skin lesions. Urinalysis is positive for a microhematuria. Further evaluation would most likely reveal which of the following abnormalities?*****

Enlarged renal pelvis and proximal ureter dx;Hydronephrosis s the distension of the renal calyces and pelvis due to obstruction of distal urinary flow which commonly accompanies hydroureter. Major childhood causes include congenital ureteropelvic junction abnormalities, urethral valves and urethral stricture. Major adult causes include urolithiasis, benign prostatic hyperplasia and other bladder outlet obstruction, prostate carcinoma, bladder prolapse and retroperitoneal or pelvic neoplasms. Acute hydronephrosis leads to changes in renal function and acute renal failure, while chronic forms cause infection and sepsis, renal scarring, permanent nephron loss and calculous formation Renal pelvic or superior ureteral obstruction causes flank pain, while inferior ureteral obstruction refers pain to the ipsilateral testicle or labia. Severe pain usually is the result of acute complete or partial bilateral stone obstruction Hematuria suggests urolithiasis as the cause. Renal ultrasonography is the initial test of choice to diagnose the level of urinary tract obstruction. If unremarkable, intravenous pyelography or CT scanning may be necessary. Treatment is geared at treating the underlying etiology. When is hydronephrosis expected and relatively considered normal? Answer: In up to 80% of second trimester pregnancies, dilation of the ureters and renal pelvis commonly occurs.

A morbidly obese 32-year-old woman has a 4-month history of hypertension that has been nonresponsive to multiple antihypertensive medications. Blood pressure readings over the past month have an average diastolic pressure of 115 mm Hg. Her serum creatinine is 1.2 mg/dL. Which of the following diagnostic tests is most appropriate at ruling-in the most common cause of this refractory hypertension?

Gadolinium-enhanced magnetic resonance angiography dx: Renal Artery Stenosis

You are called to examine a one-week-old boy in the ED for seizures. At home, the mother noticed jittery bilateral leg movements that cannot be stopped when the legs are held. The neonate was born full-term to a 25-year-old G2, P2 mother with limited prenatal care. There were no complications at delivery. At the ED, the vital signs are normal with a normal neurologic examination. You note abnormal facie consisting of a small mouth, cleft palate, low set ears, and a widened distance between the inner canthi with short palpebral fissures. Which of laboratory finding is most consistent with the diagnosis?

Hypocalcemia dx: DiGeorge syndrome. arises from a failure of migration of neural crest cells into the third and fourth pharyngeal pouches microdeletions involving chromosome 22q11. Patients typically present in the first week after birth with signs of hypocalcemia such as tetany or seizures that is secondary to hypoplastic or absent parathyroid glands. Characteristic facial features include a small mouth, a submucous cleft palate, abnormal and low set ears, upturned nose, and a widened distance between the inner canthi with short palpebral fissures. Cardiac defects are frequently present and manifest as outflow tract or aortic arch abnormalities such as truncus arteriosus, tetralogy of Fallot, or interrupted aortic arch. The thymic hypoplasia results in an immune defect that is highly variable. Diagnosis is established by fluorescence in situ hybridization with DNA probes specific for 22q11. In hypocalcemia, what do you give to stabilize the heart? Answer: Calcium gluconate. DiGeorge Syndrome History of congenital heart disease Recurrent infections PE will show hypoplasia of thymus and parathyroids Labs will show hypocalcemia CXR will show absent thymic shadow Most commonly caused by 22q11 deletion

A patient presents with complaints of edema, malaise and sudsy urine. A microscopic urinalysis shows oval fat bodies and a Maltese cross pattern under polarized light. These findings are most consistent with which of the following diagnoses? What is first-line therapy in a child with idiopathic ---- syndrome? Proteinuria, hypoalbuminemia, edema and hyperlipidemia are characteristic clinical features of what type of kidney disease? What is the leading primary cause of nephrotic syndrome in adults?

Nephrotic syndrome Lipiduria is highly sensitive for nephrotic syndrome.Oval fat bodies are renal tubular cells which have absorbed filtered lipids, indicating high levels of excess lipids in the urine Nephrotic syndrome can also lead to the loss of protein S, protein C, & antithrombin III, predisposing the patient to what serious complication? Answer: Arterial or venous thrombosis. Renal vein thrombosis is the most common thrombotic sequelae. Nephrotic Syndrome PE will show pitting edema Labs will show proteinuria > 3.5 g/24 hr, hyperlipidemia, hypercoagulability (renal vein thrombosis), fatty casts Minimal change disease: children, preceded by URIRx: steroids Focal segmental glomerulosclerosis: HIV or IVDA, end-stage kidney disease Membranous nephropathy: HBV, HCV, SLE, gold, penicillamine, malignancy high urine protein excretion (>3.5 g/24 hr), peripheral edema, and metabolic abnormalities (hypoalbuminemia, hypercholesterolemia). What is first-line therapy in a child with idiopathic nephrotic syndrome? Answer: Glucocorticoids. What is the leading primary cause of nephrotic syndrome in adults? Focal segmental glomerulosclerosis. It is the most common primary glomerular disease leading to end stage renal disease in the United States.

A 4-year-old girl presents to the pediatric emergency department for evaluation of eye swelling with onset 3 days ago. Her mother reports the eye swelling appears to be worse in the morning. She has also noticed the patient's urine is foamy. The girl's vital signs are HR 88 bpm, RR 16/min, BP 116/77 mm Hg, T 100°F, SpO2 99%, and BMI 23 kg/m2. The patient is currently ill with an upper respiratory infection. Her laboratory results show a serum albumin of 3.0 g/dL, urine with 4 proteinuria, and RBC ≤ 2/hpf. Which of the following is the best next step in managing her condition?

Prednisone dx: minimal change disease type Nephrotic syndrome periorbital edema that worsens in the morning, generalized edema, and frothy urine. Laboratory findings include evidence of serum hypoalbuminemia,proteinuria, hyperlipidemia, and normal kidney function. Kidney biopsy may reveal normal glomeruli on light microscopy, but electron microscopy will show the loss of podocyte foot processes. What is the recommended dose of prednisone for the treatment of minimal change disease? Answer: 60 mg/m2/day orally.

A 50-year-old woman with a medical history of hypertension on amlodipine and diabetes mellitus on metformin presents to the emergency department with right flank pain, nausea, and sweats for the past 7 days. The patient has been nauseous and has lost weight. She was treated for a urinary tract infection with antibiotics 3 weeks ago. Vital signs include a HR of 120 bpm, BP of 120/80 mm Hg, RR of 20/min, oxygen saturation of 98% on room air, and T of 101.5°F. Physical examination reveals a mildly distressed and diaphoretic woman with right costovertebral angle tenderness. The patient's laboratory studies are below: White blood cell count: 18,000/µL Creatinine: 1.5 mg/dL BUN: 35 mg/dL Urinalysis: 1,000 WBC/hpf, 200 RBC/hpf, and many bacteria Which of the following is the most likely diagnosis?

dx: Renal abscess CT scan of the abdomen with contrast is the best imaging modality and reveals intrarenal walled-off cavities. The diagnosis should be suspected in patients with pyelonephritis who are slow to respond to antibiotics. The causative organism in cases that arise as a complication of pyelonephritis are usually gram-negative enteric bacilli, such as Escherichia coli. In cases due to hematogenous spread, the patient will often have recent positive blood cultures and the most likely pathogen is Staphylococcus aureus. treatment Enterobacteriaceae if the abscess is suspected to be related to a pyelonephritis infection. Examples of appropriate regimens include cefepime or piperacillin-tazobactam. However, if the abscess is associated with recent Staphylococcal bacteremia, then therapy should include coverage against Staphylococcus aureus. Nafcillin is adequate if there are blood cultures confirming methicillin-sensitive Staphylococcus aureus, but vancomycin is indicated if the blood cultures show methicillin-resistant Staphylococcus aureus. The need for surgical drainage varies based on the size of the abscess. Immediate drainage is recommended for abscesses ≥ 5 cm in diameter, while smaller abscesses can initially be treated with a trial of antibiotic therapy. Smaller abscesses require drainage if the clinical symptoms and radiographic findings persist after several days of antimicrobial therapy.