Clinical Medicine I Exam 2

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It decreases blood calcium

. Which of the following regarding calcitonin is true?

14 yr old boy is evaluated for poor school performance. PMHx: Unremarkable PE: Lethargic, DTR's 3+ Lab: Ca 7.1 mg/dL PO4 6.5 mg/dL Renal function = normal iPTH 10 This patient has? A. Vit D deficiency B. Hypoparathyroidism C. Low calcium intake D. Pseudohypoparathyroidism

UA and C and S Stress Kegel exercises

28 year old female with three children presents with "urinary incontinence." She is otherwise healthy. Vaginal delivery and cough dribble comes out What tests, what type of UI, what best treatment?

Await C&S results before initiating antimicrobial therapy

42 paraplegic male with indwelling urinary catheter is admitted for evaluation of chest pain. He is afebrile and denies chills, nausea vomiting. You notice cloudy urine with sediment in the tubing and bag. Urine dipsitck revealed 1+ leukocyte esterase and 1+ nitrite. What is the next step(S) in managing this patient?

Primary hyperparathyroidism Low

46 yr female is seen as a new patient to establish care. She notes fatigue, constipation, and increasing antacid use. PMHx reveals hx Hodgkin's lymphoma age 15 s/p neck irradiation Baseline laboratory studies with serum calcium of 10.7 mg/dL Physical examination is normal If her iPTH is 65 pg/ml, what is her diagnosis? This patient's serum PO4 would be ? a. High b. Normal c. Low

Urge Bladder training

47 year old male presents because he cannot get to the bathroom in time. Other than a history of interstitial cystitis, he is healthy. No blood no pain Dietary modifications No history of UTI What type of UI, what best treatment?

Specific Gravity

<1.008 is dilute >1.020 is concentrated Increased Dehydration, glycosuria, renal artery stenosis, heart failure, SIADH and proteinuria Decreased Excessive fluid intake, renal failure, pyelonephritis, and diabetes insipidus

Not UTI Order CMP or BMP Microscopy

A 28 year old female presents today with a complaint of fever since yesterday. She also admits mild low back pain and thinks she saw blood in her urine. She was just seen 5 days ago for cellulitis on her left calf and has been taking Bactrim since that time. UA: spec gravity 1.025 Glucose negative Leukocytes negative Nitrites negative Blood 2+ Protein 1+ What would be done?

Adrenalectomy

A unilateral aldosterone-secreting adrenal adenoma is noted on imaging. What is the most appropriate treatment?

Calcium

A what level should be ordered along with an iPTH leve?

Medications that provoke crystal formation

Acetozolamide Topiramate Vitamin C Vitamin D Indinavir Atazanavir Triamterene Probenecid ASA

Thyroid stimulating hormone

Acts directly upon the thyroid tissue to increase output of thyroxine "normal" range ~4.0 - 5.0 mU/L Third-generation assays sensitive to 0.01 A lot of controversy regarding the accuracy of this range. Some say 2.5 - 3.0 mU/L Others say 6 - 8 mU/L (especially as we age)

Urinary Incontinence Transient

Acute Reversible Normal Urinary function intact Affects: Nursing home patients Hospitalized/acute illness Elderly Cognitive impairment

Transient

Acute infection is what UI?

Acute Hypoparathyroidism

Admit—ICU! Be ready to intubate if necessary Endocrinology consult- NOW! MOVE! Could die Normalize serum Mg++ Slow administration of IV calcium gluconate Monitor heart for abnormal rhythms until stable-lead to death

Thyroid

Aids in regulation of the basal metabolic rate Control body temperature Affect protein synthesis Help regulate long bone growth (in conjunction with growth hormone) Regulate protein, fat, and carbohydrate metabolism (lipid metabolism)

Colloid

Albumin-increase solids 5% 25% Blood Products Plasmanate Synthetic Colloids Hespan Dextran What IV fluids are these?

Diabetic foot care

All patients with DM require annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations Screen for peripheral arterial disease (PAD) with the ankle-brachial index (ABI), questions about claudication, and assessment of pedal pulses in patients 50 years of age or younger if the patient has PAD risk factors Referral to podiatry

Glomerular proteinuria

Altered glomerular permeability What proteinuria is this?

Metabolic alkalosis

Anorexia, apathy, confusion, cyanosis, hypotension, loss of reflexes, muscle twitching, nausea, paresthesia, polyuria, vomiting, weakness. What is this?

Lupus Nephropathy

Anti-dsDNA antibodies cross-react with the glomerular basement membrane Autoantibodies form intravascular immune complexes, which are deposited in glomeruli Promote an inflammatory response by activating complement and attracting inflammatory cells-leads to scaring Severe lupus nephritis - proliferation of endothelial/ mesangial/epithelial cells and the production of matrix proteins lead to fibrosis.

Calcium Oxalate

Appearance: "Star", Maltase Cross Pathological Significance: Clumps of this crystals in fresh urine may be related to renal calculi formation. Nephrolithiasis

Respiratory acidosis

Apprehension, confusion, decreased muscle stretch reflexes, diaphoresis, dyspnea, with rapid shallow respirations, nausea or vomiting, restlessness, tachycardia, tremors, warm flushed skin. All causes of what?

Yes

Are both reduced GFR and proteinuria indications of renal dysfunction?

Cardiovascular disease

At least annually, assess cardiovascular risk factors Hypertension Dyslipidemia Family history of premature CAD Tobacco use Albuminuria

Lifestyle measures for UI treatment

Avoid "excessive" and evening fluid intake Avoid alcohol and caffeine Weight reduction Smoking cessation Reduce bladder irritants: citrus, tomatos, spicy foods, corn syrup, soda Be sure toilet is Accessible Avoid constipation: fiber

Functional proteinuria

BENIGN Acute illness Exercise Orthostatic proteinuria What is this?

Bladder training

Best for Urge Incontinence Patient controls the urge to void schedule urination at specific intervals increase interval over time goal 3-4 hours between voiding What medical therapy for UI is this?

Primary aldosteronism

Bilateral idiopathic adrenal hyperplasia is the cause in up to 70% of cases Adrenal Mass

Revascularization= angioplasty with stenting

Bilateral stenosis Unilateral stenosis in solitary functioning kidney Stenosis >80% What is the management?

Physiology of Micturition

Bladder fills neural impulse spinal cord cerebrum Bladder relaxes to allow filling without urge to void Filling continues bladder distends frontal lobe Conscious urge to void & ability to delay urination Urge Cortex spinal cord pelvic nerves detrusor muscle Cholinergic action causes bladder contraction and emptying

ACE inhibitors and ARBs

Block effects of Angiotensin II Cause dilatation of afferent and efferent arterioles Decreased pressure at glomerulus - decreased GFR (or increased creatinine) Increased blood flow to kidney/peritubular capillaries = increased pressure so less sodium and water reabsorbed Decrease proteinuria which is a good thing

GFR (Glomerular Filtration Rate)

Blood filtered by functioning glomeruli per min Can estimate the GFR by using the serum creatinine, age, sex, and race Best test to measure kidney function Lab Report: Value estimated using serum creatinine

Treatment for secondary hyperparathyroidism

CHRONIC KIDNEY DISEASE: Nephrologist Dialysis Renal diet Calcitriol po or IV after dialysis Oral phosphate therapy (Phoslo) Correct the calcium and vit D levels Calcimimetics: (Sensipar/ cinacalcet) MALABSORPTION: Correct the calcium and vit D levels, tx underlying condition if possible Ensure lifelong supplement (Vit D and Ca++) compliance and monitoring

Nephrolithiasis

Calculi in the kidneys Occur throughout the urinary tract Prognosis Approx 80-85% of stones pass spontaneously Approx 20% require hospitalization

Proteinuria

Can be a sign of damage to the kidneys...or not Transient or Persistent

Functional

Can't get to toilet due to physical impairment is what UI?

Venous Catheter

Catheter inserted into vein in neck, chest, or leg

Acute Interstitial Nephritis

Cause Drugs!! NSAIDS, Penicillin, Cephalosporin, Sulfa drugs Symptoms Asymptomatic= Fever, flank pain/lumbar pain, HTN What intrinsic renal disease is this?

Diabetes insipidus

Central: decreased secretion of AVP leads to polyuria and polydipsia with the inability to concentrate urine (serum AVP low) Nephrogenic: decrease in the ability to concentrate urine d/t resistance of AVP action in the kidney (serum AVP high) Urine specific gravity of 1.005 or less and a urine osmolality of < 200 mOsm/kg are the hallmarks of DI (random plasma osmolality is usu. > 287 mOsm/kg) A urine volume of < 2L/24h (in the absence of hypernatremia) essentially r/o DI

Pyelonephritis inpatient treatment

Change to oral therapy once patient is afebrile; It does not need to be the same agent. Revaluate if no improvement after 48-72 hours. Oral therapy for additional 7-14 days 14-21 days if immunocompromised Repeat urine culture 1 wk. after antibiotic completion

Albumin

Clinical Significance: Elevated levels: dehydration Low levels: malnutrition, liver disease, nephrotic syndrome, chronic inflammation Major Function: Transportation protein (Taxi driver) Largest fraction of the plasma proteins. Synthesized by the liver

Oxalate stones

Comes from diet and endogenous metabolic production 40-50% originating from dietary sources—excessive purine Mild hyperoxaluria is usually caused by excessive intake of high-oxalate foods Low-calcium diets may promote hyperoxaluria as there is less calcium available to bind oxalate in the intestine Decrease in calcium promotes more oxalate in urine bc less calcium to bind to oxalate in the intestines

Albumin/Creatinine ratio

Compares amount of albumin in the urine with amount of creatinine in the urine. Body excretes creatinine at a steady state. Using creatinine as a comparison in a specific urine specimen can tell if the body is excreting albumin at an increased rate. 30 mg/gm or higher is elevated - may indicate kidney disease

Metabolic acidosis

Confusion, decreased Muscle Stretch Reflexes, dull headache, hyperkalemic signs and symptoms (including abdominal cramping, diarrhea, muscle weakness, and electrocardiogram changes), hypotension, Kussmaul respiration, lethargy, warm dry skin. What is this?

Lithotripsy Laser

Considered by many to be treatment of choice for proximal ureteral stones Stones free rates are reported to be near 90% Not as good for mid ureteral stones - /< 75%

Bariatric surgery

Considered for adults with BMI > 35 kg/m2 and type 2 DM, especially if DM or associated comorbidities are difficult to control with lifestyle and pharmacological therapy Need lifelong lifestyle support and medical monitoring Insufficient evidence to generally recommend surgery in patients with BMI < 35 kg/m2

Hypothalamus

Consolidates signals derived from upper cortical inputs, autonomic function, environmental cues such as light and temperature, and peripheral endocrine feedback-responds to everything and different cues Delivers precise signals to the pituitary gland, which then releases hormones that influence most endocrine systems in the body

Epithelial cells

Contaminant from urethra, acute tubular necrosis (ATN) on urine microscopy

Recurrent UTI Recommendations

Cystoscopy/imaging if bacteria other than E. coli No spermicide Use lubricants with intercourse Obtain a negative culture before initiating prophylaxis Vaginal estrogen in postmenopausal women with recurrent UTI Pregnant women: offer continuous or post-coital prophylaxis Use nitrofurantoin Do NOT use during the last 4 weeks of pregnancy

Hypoparathyroidism

DEMOGRAPHICS: Rare Genetics can play a role No sex or age predilection exists ETIOLOGY: Autoimmune invasion and destruction Iatrogenic-we did it-pulled thyroid out Mg deficiency (transient)

hypothyroidism, normal pregnancy and hyper-estrogenism status

Decreased levels of T3 present with what conditions?

Cretinism Dwarfism Hypothyroidism Cirrhosis Malnutrition Chronic thyroiditis

Decreased levels of T4 are found with what conditions?

Decreased renal blood flow has what effect on the renin-angiotensin-aldosterone system (RAAS)? A. Activates the RAAS B. Inhibits the RAAS C. Has no effect on the RAAS

SGLT2 inhibitors

Decreases renal absorption of glucose

Alpha-glucosidase inhibitors

Delays absorption of dietary carbohydrates by blocking intestinal alpha-glucosidase enzyme leading to decreased postprandial blood glucose levels

GLP-1 receptor agonists

Delays gastric emptying, stimulates pancreatic insulin response to glucose, reduces glucagon release after meals Loose weight with it-post prandial

Amylin analog

Delays gastric emptying, suppresses glucagon secretion, decreases appetite

Causes of Transient UI

Delirium Infection Atrophy Pharmaceuticals Psychological Endocrine Restricted mobility Stool impaction (DIAPERS)

Creatinine

Derived from muscle tissue in urine composition

Leukocyte Esterase

Detects the presence of esterase in granulocytic WBCs (neutrophils, eosinophils, basophils, monocytes) Trichomonas also has esterase. Leukocyturia: UTI Trichomonas Chlamydia Yeast Inflammation of renal tissues

UTI in Pregnancy

Diagnosis Screen between 12-16 weeks Asymptomatic bacteriuria on two specimens bacterial strain >10,000 Treat for 7 days Nitrofurantoin 100mg BID x 7 days (Best Choice) Amoxi/Clav 500mg BID or 250 TID x 7days Fosfomycin 3g PO x 1 NO Sulfa or quinolones

Urine Microscopy

Direct visualization Requires a fresh sample of 10-15 mL of urine Centrifuge at 1,500 to 3,000 rpm for 5 minutes Transfer sediment to a clean glass slide Apply cover slip before examination

Primary

Disorders that involve the thyroid gland itself are labeled as what and can include iodine deficiency and the various autoimmune processes that activate or destroy the glandular tissue?

Yes

Does microalbuminuria often heralds the onset of diabetic nephropathy?

Cystitis

Dysuria Frequency Urgency Suprapubic pain Hematuria Voiding Decreased amount or inability

Dawn phenomenon morning hyperglycemia

Early morning (4am-5am) release of hormones (GH, cortisol, catecholamines) causes the liver to release glucose into the blood Normal insulin response will lower blood glucose level; insulin deficiency will lead to fasting hyperglycemia in the morning Blood glucose is normal or high at 2am-3am Eat dinner early in the evening

Complications of AKI

Electrolyte abnormalities Hyperkalemia = muscle weakness/paralysis, arrythmias Hypocalcemia = muscle cramps, tetany, seizures, arrhythmias-see more in chronic kidney disease Hyperphosphatemia Metabolic Acidosis-increase breathing Uremia = pericarditis, mental status changes, cardiac arrest, GI bleed Fluid overload = HTN, CHF, pulmonary edema Chronic kidney disease (CKD) Pre-renal= hypovolemic shock, multiorgan system failure

Make sure take calcium and vit D

Elevated PTH and normal Calcium level with bariatric patient should treat how?

Therapeutic strategies for UTI

Empiric therapy Alone (Telephone Treatment) Therapy based on Urinalysis results Therapy based on Culture, with initial therapy while awaiting results Therapy based on Culture, no treatment until results are obtained

Chronic stable hypoparathyroidism

Endocrinology consult, then you manage-do not have to come back to you Normalize serum Mg++,Normalize serum PO4 Lifelong Daily Supplements: Mvits, Vit D, Ca++ , plus high calcium diet, sunshine Monitoring of serum and urine Ca++ levels Avoid phenothiazines, furosemide and glucocorticoids

PG adenoma, PG hyperplasia, PG cancer

Etiology for primary hyperparathyroidism?

Iatrogenic, autoimmune invasion, mg deficiency, hereditary

Etiology for primary hypoparathyroidism?

CKD, vit D or ca malabsorption (bariatric surgery)

Etiology for secondary hyperparathyroidism?

GH Deficiency in Adults

Etiology/pathophysiology: Caused by hypothalamic or pituitary somatotrope damage (GH producing cells in the anterior pituitary Acquired pituitary hormone deficiency follows a typical pattern in which loss of adequate GH reserve foreshadows subsequent hormone defects. The sequential order is: GH - FSH/LH-puberty hormone - TSH - ACTH Clinical presentation: Changes in body composition, metabolism, Quality of life, and cardiovascular function

Proteinuria

First voided specimens are best for detecting significant proteinuria Urinary excretion of >150 mg of protein per day is focused on detection of kidney disease Early detection and treatment = slow progression of CKD Most is due to benign causes

Pyelonephritis

Flank pain and CVA tenderness Fever & Chills + Nausea, vomiting and suprapubic abdominal pain + Hematuria + Elderly may have only GI or Pulm sxs

Thyroxine absorption

Food, other medications or underlying conditions, such as coeliac disease, may impair absorption Ideally it should be taken on an empty stomach, separated from food and other medications by 30 minutes.

Chronic Kidney Disease (CKD)

Formerly known as Chronic Renal Failure Progressive, slow, irreversible decline in kidney function Criteria for diagnosis: GFR less than 60 mL/min/1.73 m² for 3 or more months

Overflow

Frequency during day with a constant drip is what UI?

Chronic kidney disease

GFR less than 60 for > 3 months is representative of what?

Nephrotic syndrome

Generalized edema Heavy proteinuria Hypoalbuminemia-decrease oncotic pressure-water moves out to interstitium get edema-ascites-in the liver-turns on metabolic pathway and lipids go up-cholesterol goes up-foamy urine Hyperlipidemia Lipiduria No HTN Hypercoaguability (loss of anticoag proteins in urine) Infections What is this syndrome?

Hypercalciuria

Genetic origin is suspected Diagnosis Presence of hypercalciuria without hypercalcemia Absence of other systemic disorders Vitamin D over-activity is a possible explanation

Glucose reagent strip

Glucose oxidase: specific for glucose Two step reaction 1. Glucose oxidase converts glucose to gluconic acid and hydrogen peroxide 2. Hydrogen peroxide reacts with chromogen to produce a oxidized colored chromogen

Urinalysis

Gold standard in uncomplicated cystitis is what?

Polycystic Kidney Disease

Hereditary-Autosomal dominant 500,000 people in US 6-8% of people on dialysis Multisystemic and progressive Enlargement of kidneys with multiple cysts Leads to progressive decline in renal function

MRA or Doppler Ultrasonography if experienced

High index of suspicion and diminished renal function What lab tests should be done?

PTH is responding correctly; run other tests to check for other causes of elevated calcium: cancer!; get a PTHrP

High serum calcium and low iPTH means what?

Super-saturation of urine with stone forming salts Lack of inhibitors (magnesium & citrate) in the urine to prevent crystal formation Low fluid intake and low volume urine production

How does kidney stones form as in the etiology behind it?

Overhydration (SIADH and loss of sodium in excess to water)

How does one decrease osmolality?

4, located on the posterolateral lobes of the thyroid

How many parathyroid glands do most people have and where are they located?

Hypercalcemia

Hyperparathyroidism Ectopic PTH Metastasis Immobility Lymphoma Granulomatous Infections Addison Disease Acromegaly Hyperthyroidism Milk-Alkali Syndrome Vitamin D Intoxication All of these cause what?

Hypocalcemia

Hyperphosphatemia will cause acute what and all its ssx?

Prolactinoma in premenopausal women

Hyperprolactinemia in premenopausal women causes hypogonadism, with symptoms that include infertility, oligomenorrhea, or amenorrhea, and less often galactorrhea

Prolactinoma in postmenopausal women

Hyperprolactinemia in these women is recognized only in the relatively unusual situation when a lactotroph adenoma becomes so large as to cause headaches or impair vision or is detected as an incidental finding when a magnetic resonance imaging (MRI) is performed for an unrelated reason

Increased Increased

Hypervolemia total body water and total body sodium is what increased or decreased?

Nephrotic syndrome Cirrhosis Cardiac failure

Hypervolemia with increased total body water and sodium with decreased urine sodium below 20 leads to what conditions?

Acute or chronic renal failure

Hypervolemia with increased total body water and sodium with increased urine sodium of 20 leads to what condition?

Prolactinoma in men

Hypogonadal hypogonadism, manifested as decreased libido, impotence, infertility, gynecomastia, galactorrhea Cancer until proven otherwise

Hyperphosphatemia

Hypoparathyroidism Renal Failure Intake (PO or IV) Acromegaly Metastasis Sarcoidosis Hypocalcemia Acidosis Rhabdomyolysis Lymphoma or Myeloma Hemolytic Anemia All of these can cause what?

Serum hypercalcemia

If you have this condition then the Thyroid gland release calcitonin goes to bone and increases osteoblasts while decreasing bone resorption activity of osteoclasts Negative feedback to PG decr release of PTH and inhibits renal tubular reabsorp of calcium/incr calcium urinary excretion What was that initial condition?

Nitrites

In a 25 year old female with dysuria, what differentiates cystitis from vaginitis?

Decreased Decreased

In hypovolemia is the total body water increased or decreased? What about total body sodium?

Elevated Low

In primary hyperthyroid state the labs will show what for T3 and T4 and TSH?

Low Elevated

In primary hypothyroid state the labs will show what for T3 and T4 and TSH?

Elevated

In secondary hyperthyroid state the labs will show what for T3 and T4 and TSH?

Low

In secondary hypothyroid state the labs will show what for T3 and T4 and TSH?

Syndrome of Inappropriate Antidiuretic Hormone

Inability to Suppress Antidiuretic Hormone (ADH) Also Known as Arginine Vasopressin (AVP) Water Intake Exceeds Output Hyponatremia Suspect in Patients with: Hyponatremia Serum Hypoosmolality Urine Hyperosmolality Urine Na >20 mEq/L Serum K+ Normal Serum Uric Acid Low

Primary hyperparathyroidism

Incidence increases with age. Women > men Occasionally familial ETIOLOGY: Parathyroid adenoma (MCC outpatient hypercalcemia)-cancer Neck irradiation (usually appears 3rd decade or greater) Pt < 30 yo: MEN syndrome Familial hyperplasia Parathyroid carcinoma

Lipid metabolism

Increase lipolysis and fatty acid oxidation b. Increase cholesterol synthesis a little, but increase cholesterol clearance even more ---> net effect is to decrease cholesterol

Hypernatremia

Increased Intake (Iv or PO) Decreased Loss Cushing Syndrome Hyperaldosteronism Free Body Water Loss Gastrointestinal Skin Sweating Burns Diabetes Insipidus Osmotic Diuresis All of these can cause what?

UTI in diabetics

Increased incidence of infection Pathogenesis bladder dysfunction altered immune function 98% Klebsiella Increased risk of complications Screen with C&S about every 6 months

hyperthyroidism, severe liver disease, metastatic malignancy, and pulmonary insufficiency

Increased levels of T3 are found in what conditions?

Hyperthyroidism Acute thyroiditis Hepatitis

Increased levels of T4 are found with what conditions?

Thiazolidinediones

Increases insulin sensitivity in peripheral tissues

Re-infection

Infection after 4 weeks of treatment different pathogen

Dexamethasone

Inhibit hormone production & decrease peripheral conversion from T4 to T3

Dipeptidyl peptidase 4 inhibitors

Inhibits DDP-4 activity, prolonging endogenous action of GLP-1, stimulating insulin secretion, and suppressing glucagon release

UI treatment devices

Internal Devices Pessaries External devices Condom catheters Absorbent products Depends etc.

Acute glomerulonephritis

Intrinsic renal glomerulus affected leads to what condition?

Acute interstitial nephritis

Intrinsic renal interstitium affected leads to what condition?

Acute tubular necrosis

Intrinsic renal tubules affected is what condition?

Vasculitis Malignant hypertension Atheroembolic event Renal vein thrombosis

Intrinsic renal vasculature affected leads to what conditions?

Yes

Is Ca++ the ONLY element in the body that has its own regulatory system?

Yes

Is proteinuria associated with more rapid progression of chronic kidney disease?

Mg Puking

It is important to note that sufficient serum what is needed to stimulate PTH release, regardless of the calcium level? And what is caused by this?

Stage 1

Kidney damage with normal or increased GFR (>90 mL/min/1.73 m2) What stage?

Glomerulonephropathy

Kidney disease due to injury at the glomerulus Divided into 2 basic parts: Nephritic Syndrome Nephrotic Syndrome

Stage 5

Kidney failure (GFR <15) What stage?

Acromegaly

Laboratory findings:Serum IGF-I level over 5 x upper limits of normal for ageGH level > 5 ng/dL w/in 3 hours of oral glucose loadSerum glucose 220 mg/dLSerum alkaline phosphatase, AST, ALT normal.Serum BUN 10 mg/dLSerum creatinine 1.0 mg/dLSerum calcium normal.Serum inorganic phosphorous elevated.Serum TSH high and FT4 low.MRI of the brain reveals a pituitary adenoma. What does he have?

Hyperprolactinemia

Laboratory findings:Serum TSH and FT4 are normal.Serum BUN and creatinine are normal.Serum LFT's are normal.Serum calcium is normal.Serum total and free testosterone, LH, and FSH are pending.MRI of the brain reveals a pituitary adenoma. What is this?

Desmopressin or Arginine vasopressin synthetic (ADH)

Laboratory findings:urine specific gravity < 1.005urine osmolality < 200 mOsm/kgserum sodium 150 mmol/Lserum potassium 4.0 mmol/Lserum glucose 100 mg/dLserum BUN 30 mg/dLserum creatinine 1.0 mg/dLMRI of the brain: No mass lesion noted What is most appropriate treatment?

Surgery

Last option when all therapies have failed Determined by impact on patient functional loss or abilities Numerous techniques, with varying degrees of success Disease specific surgeries (bladder suspension, TURP, etc.)

Somogyi Effect Morning Hyperglycemia

Late evening/early morning (2am-3am) hypoglycemia leads to release of hormones (GH, cortisol, catecholamines) which causes the liver to release glucose into the blood Elevation in blood glucose is higher than would occur normally leading to a morning hyperglycemia Blood glucose is low at 2am-3am Eat a bedtime snack

Stress

Leak during physical activity is what UI?

Urge

Leak on route to toilet is what UI?

Casts

Localizes some or all of the disease process to the kidney White blood cell casts: pyelonephritis

More than enough

Low TSH means what with the thyroid hormone?

Protein metabolism

Low levels stimulate protein synthesis & (+) protein balance. b. Excess levels stimulate protein degradation & (-) nitrogen balance

PTH is responding correctly; may run other tests to check for other causes of hypocalcemia (secondary hyperparathyroidism: CKD, etc)

Low or low-norm serum calcium and high iPTH means what?

PTH not responding correctly; have hypoparathyroidism

Low serum calcium and iPTH means what?

Elderly and cardiac comorbidities (increase O2 demand-could get MI)

Lower initiation of thyroxine replacement and maintenance dosing is often required in the what groups?

Hypomagnesemia

Malnutrition Malabsorption Hypoparathyroidism Alcoholism Chronic Renal Tubular Disease Diabetic Acidosis These conditions cause what?

Nephrogenic

Medications Lithium Demeclocycline Aminoglycosides Metabolic Vascular Hgb S ATN Sarcoidosis Idiopathic What is this condition for diabetes insipidus?

UTI in the elderly

Mental Status Change is the best predictor of UTI in Elderly Altered mental status, lethargy & confusion (and falls) Fever is not always reliable May be masked or absent due to medications or other illness Urgency, frequency, dysuria are not reliable In elderly these are common without UTI Pain indicators are different: Irritability, restlessness or decreased appetite

Diabetic Nephropathy

Mesangial expansion-allow proteins through Thickening of glomerular basement membrane Glomerulosclerosis Protein begins leaking into urine-oxidative stress and inflammation and scaring, glomeruli become nonfunctional, GFR decreases Microalbuminuria = overt proteinuria Glucose and protein trigger oxidative stress and inflammation in the tubules

Recurrent disease of nephrolithiasis

Middle-aged, white males, family history of stones Patients with chronic diarrheal states and/or malabsorption, pathologic skeletal fractures, osteoporosis, urinary tract infection, and/or gout Patients with stones composed of cystine, uric acid, calcium phosphate, or struvite

Stage 2

Mild reduction in GFR (60-89) What stage?

Nephrotic Syndrome

Minimal change disease-resolves on own-occurs in children and gone by age 20 Diabetes mellitus SLE Membranous nephropathy: hep B, gold, penicillamine, syphilis, carcinomas Focal glomerulosclerosis: heroin, HIV Amyloidosis What is this?

Iodine

Minimum dietary requirement is 75 mcg/day in extracellular fluid is about 1mcg/dl in thyroid 20-40 times that of plasma is a pivotal component of both T3 and T4 and is therefore required for its production. The only source of this nutrient is through dietary intake. Goiters (extreme enlargements of the thyroid gland) occur in the presence of low iodine these are rarely seen in most industrialized countries since iodine has been added to salt and other food stuffs in order to ensure adequate intake

Stage 3

Moderate reduction in GFR (30-59) What stage?

Replace and recheck levels (K and Mg levels)

Monitor replacement therapy closely what should you do?

Ongoing management

Monitoring of TSH and T4 levels are recommended following dose adjustments, 6 months after initial stabilization and annually thereafter. Specialist endocrine consultation is recommended if responses to therapy are atypical. Certain considerations or underlying causes of hypothyroidism may require specialist input Acute myxedema coma, in pregnancy, hypopituitarism associated cases, congenital and drug-induced cases

Persistent Glomerular Proteinuria

Most common Mostly albumin Excess proteins Is what?

Diabetic neuropathy

Most common complication of DM Screen all type 1 DM patients 5 years after diagnosis and type 2 DM patients at diagnosis and at least annually thereafter for peripheral neuropathy with 10-g monofilament Screen for cardiovascular autonomic neuropathy (orthostasis, resting tachycardia) in patients with more advanced disease (independent risk factor for cardiovascular mortality) Optimize glycemic and blood pressure control Smoking cessation counselling Peripheral neuropathy: venlafaxine (Effexor XR®), amitriptyline (Elavil®*), gabapentin (Neurontin®), valproate (Depakote®), and opioids Gastroparesis: dietary changes, prokinetic agents (erythromycin (E-mycin®); metoclopramide [Reglan®] for severe and unresponsive cases)

Hypoaldosteronism

Most common etiologies: Aldosterone deficiency-Primary (rare) Primary adrenal insufficiency Congenital adrenal hyperplasia Aldosterone synthase deficiency Hyporeninemic hypoaldosteronism due to decreased angiotensin 2 production as well as intra-adrenal dysfunction Renal dysfunction-most commonly diabetic nephropathy ACE inhibitors NSAIDs Cyclosporine

IgA Nephropathy (Berger's Disease)

Most common glomerulonephritis worldwide Signs/Symptoms: asymptomatic gross hematuria with a minor febrile illness (URI), possible HTN, edema IgA deposits in mesangium of glomeruli

Urobilinogen Strip Reaction

Multistix Urobilinogen plus Ehrlich's reagent yields a light to dark pink color 2. Chemstrip Urobilinogen plus diazonium salt yields a pink color 3. Normal: 0.2-1.0 EU (Ehrlich units) 1 EU = 1 mg/dL

Resistance

Mutations in hormone receptors Functional resistance Diabetes type 2

Proliferative diabetic retinopathy

Neovascularization (new, weak-walled vessels that bleed into the vitreous and can grow out into the vitreous as a fibrovascular scaffold and detach the retina leading to vision loss)

Hypercalcemia

Nephrolithiasis Arrythmias Bradycardia AV Blocks These symptoms are a result from what?

SIADH

Nonphysiologic secretion of AVP results in enhanced water reabsorption, leading to dilutional hyponatremia Hyponatremia (serum sodium < 135 mmol/L) with concomitant hypo-osmolality (serum osmolality < 280 mOsm/kg) and high urine osmolality in the absence of clinical evidence of volume depletion and other causes of hyponatremia

ALT

Normal Range: 10-35 IU/L Primarily found in liver Elevated in all forms of liver disease

AST

Normal Range: 8-38 IU/L Present in many tissues but highest concentration in liver, heart, and skeletal muscle. Elevated in viral hepatitis, MI, liver disease

Alkaline phosphatase

Normal range depends upon age; children and adolescentshave higher normal values. Clinical Significance: Found in almost all tissues but highest concentration is in the bone, liver, kidney, and placenta. Elevated Levels: Bone formation, bone cancer, Rickets, bone fractures

Bilirubin

Normal range: 0.1 - 1.2 mg/dL Formed from the breakdown of RBCs and is metabolized in the liver. Total bilirubin = Direct bili + indirect bili Elevated in liver disease, hemolysis Photosensitive: Will breakdown in light Patients usually appear to be jaundice when the level is over 3.0 mg/dL Unconjugated bilirubin causes the jaundice-pushed to skin and light breaks it down and skin yellows Babies liver isn't working fully when born and light turns them yellow

UTI prophylaxis considerations

Offer daily prophylaxis if: ≥2 urinary tract infections in 6months or ≥3 urinary tract infections in 12 months The organism should be identified first by culture Cranberry pills are as effective as prophylaxis Probiotics are NOT effective for UTI prophylaxis

Acute Kidney Injury (AKI)

Often referred to as acute renal failure Abrupt decline in kidney function Criteria for diagnosis: Absolute increase in serum creatinine of 0.3 mg/dL A 50% increase in serum creatinine Reduction in urine output (oliguria)

Beta blockers

Often required short-term for management of palpitations, tremor and sweating symptoms of hyperthyroidism. Propranolol (oral) is most often utilized

T3 (Triiodothyronine)

Only about 20% of gland output Shorter serum half-life Most produced by enzymatic peripheral conversion of T4 by de-iodination Cells have 8x more affinity for it

Pituitary tumor

Optic chiasm lies just above the pituitary Often lose some visual fields Lateral aspect of vision commonly lost with these AKA Bitemporal hemianopsia

Diabetic retinopathy

Optimize glycemic and blood pressure control Initial dilated and comprehensive eye examination by ophthalmologist / optometrist within 5 years after the onset of type 1 DM and shortly after diagnosis of type 2 DM and then annually It takes > 5 years to develop after the onset of hyperglycemia

Hyperparathyroidism

Osteoporosis is most likely to be found in a patient with

AV Graft

Plastic tube connects artery to vein More problems than fistula with clotting, infection

Compliance

Poor adherence is a likely cause of persisting high TSH and low T4 concentrations and should be addressed rather than continued dose increases

Ketones

Positive in: Uncontrolled diabetes Pregnancy Carbohydrate-free diet Starvation.

T4 (Thyroxine)

Primary gland output, about 80% Longer serum half-life Less physiologically active at cellular level Converted to T3 by organs

Calcitonin

Produced/ Secreted by: thyroid gland Stimulus for release: serum hypercalcemia Targets: bone, kidneys Goal: decr serum Ca++ Result: decr serum Ca++ Can be used for treatment of hypercalcemia and osteoporosis

Excess

Production/secretion of endocrine hormones by tumors not subject to normal physiologic feedback regulation

NSAIDs

Prostaglandins cause dilatation of the afferent arteriole = increase renal blood flow Very important in maintaining renal blood flow in those with compromised renal hemodynamics NSAIDs block the production of prostaglandins, thereby decreasing renal blood flow Decrease in GFR = acute renal failure Increase reabsorption of sodium and water = edema, increased blood pressure Don't forget, NSAIDs can be toxic to kidneys = acute interstitial nephritis

Protein reagent strip reaction

Protein accepts ions from the indicator. Strip pad is at a constant pH of 3.0 Negative: Yellow color Positive: Progression of shades of green to final color of blue.

Metformin

Reduces hepatic glucose production, improves peripheral glucose utilization

Treatment for interstitial cystitis

Refer to urology for cystoscopy Dietary modifications (No cranberries, acidic foods...) Behavioral modifications-scheduled bathroom breaks Rx: Amitriptyline 25mg QHS Pyridium PRN or Daily Cranberry pill Alt: Pentosan Polysulfate 100mg TID

Dialysis

Removal of waste and excess water from blood When GFR is <15 (Stage 5 CKD) May wait until GFR <5 if patient is adequately managed medically Peritoneal Dialysis (in 2004, only 10% of US dialysis) Hemodialysis

Hypermagnesemia

Renal Insufficiency Addison Disease Ingestion Hypothyroidism These conditions cause what?

Orthostatic (postural) proteinuria

Results from prolonged standing Confirmed by obtaining a negative urinalysis result after eight hours of recumbence

decrease

Rifampin (Rifadin)- an abx- used for TB Phenytoin (Dilantin)- antiseizure med- Glucocorticoids (like prednisone, Medrol, etc)- all kids of uses! Furosemide (Lasix)- is a loop diuretic Calcitonin (Miacalcin)- for tx hypercalcemia Biphosphonates - for tx osteoporosis; there are many of them (Fosamax, alendronate, etc) PPIs (Nexium, Prilosec, etc) decr serum Ca (inhibit GI absorption) This will do what to serum calcium and/or increase urinary calcium excretion?

UTI due to Candida

Risk factors : - Antibiotic therapy - Old age Treat with antifungals for 7-14 days US if Persistent

Hypoparathyroidism

SIGNS AND SYMPTOMS: all related to hypocalcemia! Impaired BONE: Normal bone structure or hard, brittle bones Impaired MUSCLE CONTRACTION/ RELAXATION: Increased neuromuscular excitability: Muscle cramps spasms hyperreflexia tetany laryngospasm asphyxiationdeath + Chvostek's sign-tap on face and Trousseau's s phenomenon-blood pressure cuff Impaired cardiac contractility and relaxation Flaccid heart muscle: hypotension, bradycardia, possible arrhythmia Increased smooth muscle contractility Abdominal pain, diarrhea Impaired NERVE CONDUCTION: Paresthesias (tingling of lips, toes, and fingers) Mental status changes, fatigue, irritability, seizures Depression or anxiety, personality changes Impaired HORMONE RELEASE and ENZYME ACTIVATION: Low vitamin D/ Ca: Dry hair and skin; brittle nails, defective teeth * possible Kidney stones due to hypercalciuria Cataracts

Differential diagnosis for primay hyperparathyroidism

Secondary hyperparathyroidism Hypercalcemia of malignancy: metastatic tumors: breast, SCC lung, pancreas, thyroid, leukemia, multiple myeloma Most patients who present with non-parathyroidal hypercalcemia suffer from a malignant disease Will have incr PTHrP, low iPTH Granulomatous Disease: sarcoidosis or TB Drugs: thiazide diuretic, lithium, antacids, Vit D intoxication

Parathyroid hormone

Secreted by: parathyroid glands Stimulus for release: serum hypocalcemia Targets: bone, kidneys, and (small intestine) Goal: incr serum Ca++ Result: incr serum Ca++ , decr serum PO4 Measured by: iPTH, nl = 10-65 ng/L

Stage 4

Severe reduction in GFR (15-29) What stage?

Absorption

Small intestine. Needs activated Vitamin D to be absorbed what is this called?

Renal ultrasound or CT for obstruction or abscess (If sepsis suspected get blood culture)

Someone has pyelonephritis and is unresponsive after 3 days of treatment or recurrence what should be done?

Gardnerella vaginalis known as clue cell

Squamous epithelial cell with what and what type of cell?

Calcium

Storage: Intracellular - in the mitochondria and endoplasmic reticulum Extracellular (serum) - in blood: bound to proteins and also free Bone - where the majority of calcium is found

Mixed UI

Stress + Overflow + Urge Detrusor overactivity with sphincter dysfunction Unable to toilet due to Physical impairment Cognitive dysfunction Environmental barriers No underlying dysfunction Diagnosis of exclusion

Complications of Hypoparathyroidism

Stunted growth, mental retardation, calcification of basal ganglia Poor tooth enamel, malformed teeth when occurs in childhood Cataracts If autoimmune etiology: incr risk of pernicious anemia, Addison's disease, vitiligo, hypothyroid (Hashimoto's)

AV Fistula

Surgically created connection of artery to vein in upper arm or forearm Extra pressure in vein so it gets stronger Takes time to mature

Subclinical hypothyroidism

TSH >4 but <7 & fT4 normal

Overt hypothyroidism

TSH >7 & fT4 low

Transient Proteinuria

Temp change in glomerular hemodynamics Generally follows a self-limited course Standing all day or running Dehydration

Urine specific gravity

The density of a solution compared with that of a similar volume of distilled water at similar temperature. Influenced by both the number and size of particles that are present. Aids in evaluation of renal tubular function.

Increase osteoclast activity (calcium absorbed in small intestines as well)

The hormone released from the parathyroid glands acts to?

PTH increases serum calcium

The release of PTH from the parathyroid gland has what effect on serum calcium?

Anion Gap

The sum of all positively charged ions (cations) must be equal to the sum of all of the negatively charged ions (anions) to maintain electrical neutrality in the plasma. In clinical medicine, only sodium, potassium, chloride, and bicarbonate are measured. The difference the sum of the measured cations and the sum of the measured anions is known as the anion gap. Elevated AG DKA: Diabetic ketoacidosis (metabolic acidosis) is the most common cause Lactic acidosis Decreased AG Multiple myeloma

Calorigenesis

The ultimate catabolic hormone in nearly every tissue in the body

Subclinical hypothyroidism

Thought to be an early stage of hypothyroidism Detected by mild elevations in TSH, whilst serum T4 levels remain within normal range. In the absence of symptoms no treatment is required. Continued monitoring and/or screening of antiperoxidase antibodies is recommended initially 3-6 monthly. Treatment commencement is best when persistently elevated TSH levels are >10mU/L.

24 hour voiding diary

Times of voiding Fluid intake Urine volume leaked (drips or more than drips) Number of Accidental leaks Sensation/urge Precipitating factors (exercise, coffee, alcohol...) What clinical test is this for UI?

Respiratory alkalosis

Too little CO2 means what?

Metabolic acidosis

Too little HCO3 means what?

Respiratory acidosis

Too much CO2 means what?

Metabolic alkalosis

Too much HCO3 means what?

Critical illness

Transient endocrine responses occur during critical illness causing abnormalities in thyroid hormones and TSH levels. This is thought due to central inhibition of TSH secretion, accelerated thyroid hormone clearance and altered deiodination processes. Initiation of thyroid therapies should not occur following abnormal thyroid function levels during a period of critical illness without severe thyroid clinical features. Likewise dose adjustments should not be made during periods of illness, rather repeat thyroid function testing is suggested.

Red blood cells

Trauma, inflammation/infection of the GU tract, coagulopathy, hemolysis on urine microscopy

Usually resolves within days-no treatment needed May have recurrences If HTN or more significant proteinuria present, BP needs to be controlled and corticosteroids may be used

Treatment for IgA nephropathy?

Hydrocortisone (steroids increase glucose)

Treatment for adrenal insufficiency?

Dopamine agonist drug (should be first treatment for patients w/hyperprolactinemia of any cause, including lactotroph adenomas of all sizes bc these drugs decrease serum prolactin concentrations and decrease the size of most lactotroph adenomas) Cabergoline Bromocriptine Pergolide Quinagolide

Treatment for prolactinoma?

Pheochromocytoma

Tumors of the sympathetic nervous system that arise from the adrenal medulla and usu. secrete both epinephrine and norepinephrine The excessive norepinephrine causes hypertension and the excessive epinephrine causes tachyarrhythmias Clinical presentation Paroxysms of hypertension, headache, perspiration, palpitations, anxiety, tremor Exercise, bending, lifting, emotional stress, and some medications can precipitate the paroxysms

UTI Septicemia Meningitis, Encephalitis URI Tonsillitis, Otitis media Lab: CBC with differential Blood culture Urinalysis/C&S CSF CXR

Two month-old baby stopped feeding and has a fever of 103. Chest, throat, and TMs are clear and abdomen is soft What are the differential diagnosis What are the lab tests most likely to yield positive results?

Pyelonephritis diagnostic workup

UA- dipstick pyuria (WBC) & hematuria C&S: BEFORE starting the antibiotic!!!! Aids antibiotic selection WBC casts on microscopy CBC Obtain if uncertain diagnosis or possible sepsis Leukocytosis with Left shift (increased bands)

Sodium

Under normal conditions what is the primary determinant of plasma osmolality?

Chronic Kidney Disease

Uremia-build up of toxins in the blood Fatigue Dry skin, pruritis-itch when waste products get high in blood Anorexia Nausea, GI bleeding Neuropathy Confusion, altered mental status Pericarditis, arrhythmias Osteodystrophy Platelet dysfunction These are signs and symptoms of what disease?

Mucus

Uretheral disease on urine microscopy

Urine Albumin

Urine test equal amount of albumin excreted Healthy kidneys do not excrete MUCH albumin Damaged kidneys can allow more albumin to leak into the urine. Independent predictor of CVD and increased mortality in diabetics and nondiabetics Microalbuminuria (now known as moderately increased albuminuria): 30 to 300 mg albumin/L urine Albuminuria: >300 mg/L

Pelvic Muscle/kegel exercises

Use in Stress and Urge Incontinence Motivated patient, careful instruction 75% decrease in episodes Focus on pelvic muscles (Squeeze 10 seconds 5-10 times/d) What medical therapy for UI is this?

Lugol's solution

Used to block thyroid hormone

Percutaneous nephrolithotomy

Uses flexible nephroscope where stones are removed or fragmented with either electrohydraulic or ultrasonic lithotripsy where the fragments are basketed under fluoroscopic guidance

Hyperglycemic hyperosmolar state hyperglycemic syndromes

Usually elderly patient Severe volume depletion occurs over weeks (restricted fluid intake) Hyperglycemia (> 600 mg/dL) High serum osmolality Normal / low serum sodium

Atheroembolic renal disease

Vascular cause of acute kidney injury Emboli - Cholesterol crystals or plaques Causes: Angioplasty Cardiac Catheterization Anticoagulation, Thromboembolic therapy-clot could start moving Aortic Aneurysm-clot could start moving Presentation: Fever, Abdominal pain Worsening hypertension Deteriorating kidney function

Laparoscopic techniques

Viable option for very large or severely impacted mid or proximal ureteral calculi Success rates of 100% with minimal patient morbidity

A1c Fasting lipid profile Liver function tests TSH in type 1 diabetes, dyslipidemia, or women over 50 Urine albumin Serum creatinine

What additional lab evaluation should you do for DM?

Fosfomycin Nitrofurantoin

What antibiotic should be avoided in pyelonephritis?

Prerenal Acute tubular necrosis

What are the common causes of Acute Kidney Injury?

10-65 ng/L

What are the iPTH levels?

Chloride Sodium Potassium

What are the inorganic urine composition?

Life-Threatening Coronary Artery Disease

What are the symptoms of hyperphosphatemia?

CT (with contrast is best)

What evaluation should you get for renal vein thrombosis?

Pharmacology intervention

What intervention should not be done with overflow incontinence?

280-290 mosm/L

What is normal plasma osmolality?

Klebsiella

What is the common pathogen for diabetics with UTI?

H and P UA, 24 hour urine Renal biopsy

What is the evaluation for nephrotic syndrome?

less than 140/90

What is the goal BP for hypertension in diabetic pts?

60-40-20 rule

What is the percent of body weight in water, in ICF, and ECF?

Restore euvolemia (Fluid loss maintenance)

What is the treatment for hypovolemia?

bladder training pelvic muscle exercises pharmacologic agents (treat predominant symptom)

What is the treatment for mixed incontinence?

Pungent

What is the urine order for UTI?

Allopurinol

What medication decreases uric acid excretion

TSH Total T4 Total T3 Free T4 Free T3

What thyroid function tests are there?

What thyroid hormone is the most common type?

Hypocalcemia

Which one is more irritating and deadly-hypocalcemia or hypercalcemia?

Type I DM

associated with HLA DR3-DQ2 and DR4 genes (Caucasians), HLA-DR7 allele (African-Americans), and HLA-DR9 allele (Japanese) Autoimmune destruction of pancreatic beta-cells

Type 2 DM

associated with family history of DM and central obesity Insulin resistance with progressive insulin secretory defect

Hypopituitarisum

can be due hypothalamic or pituitary dysfunction/damage Patients with hypopitutitarism may have single or multiple hormonal deficiencies Laboratory findings depend on hormone involved MRI provides the best visualization of pituitary and hypothalamic tumors Treatment can involve tumor resection and lifetime hormone replacement therapy

Active Vitamin D3

converted in the nephrons of the kidneys to this active form as prompted by PTH. It indirectly helps control the balance of calcium in our body through aiding Ca absorption in the small intestine.

If CO2 INCREASES pH will

decrease

If HCO3 DECREASES pH will

decrease

Base Excess

defined as the amount of H+ ions that would be required to return the pH of the blood to 7.40 if the pCO2 were adjusted to 40. Base excess beyond the reference range indicates metabolic alkalosis if too high (more than +2 mEq/L) metabolic acidosis if too low (less than −2 mEq/L)

Henderson-Hasselbalch equation

describes the derivation of pH as a measure of acidity in biological and chemical systems.

Free T3 lab

direct measurement of free T3 test

Free T4

direct measurement of free T4 test

Total T4

free and protein bound T4 test

Total T3

free and protein-bound T3 test

Overt hypothyroidism

high TSH with decreased serum levels of T4 or T3 Increased TSH if primary hypothyroidism but low or normal in pituitary insufficiency Low or normal fT4, fT3, more often than a low T4, T3 May see: incr LFTs, CK, prolactin; decr Na+ and glucose, anemia (normal MCV)

If CO2 DECREASES pH will

increase

If HCO3 INCREASES pH will

increase

Relapse

infection within 2 weeks of treatment same pathogen

Persistent Tubular Proteinuria

malfunctioning tubule smaller proteins predominate Excess proteins Is what?

measure of the concentration of hydrogen ions (H+) in blood. The pH of blood is usually between 7.35 and 7.45.

TSH

most sensitive determination of hormone status in patients with an intact pituitary

Upper ureter

pain tends to radiate to anterior abdomen Where is stone located?

Lower ureter

pain tends to radiate to ipsilateral groin, testicle in men or labia in women Where is stone located?

Calcitonin

regulates calcium to a lesser extent and its release is stimulated by hypercalcemia.

PTH-related peptide

secreting cancers such as metastatic tumors of breast, SCC lung, pancreas, and multiple myeloma which result in hypercalcemia of malignancy by incr bone resorption thru osteoclastic activating factor or incr vit d synthesis due to PTHrP: (these cancers usually have low or nl iPTH)

Persistent Overflow Proteinuria

small proteins overwhelm ability of tubules to reabsorb filtered proteins Excess proteins Is what?

HCO3

the concentration of bicarbonate, a chemical buffer that attempts to keep the pH of blood from becoming too acidic or too basic.

Primary hyperthyroid

the thyroid gland is being stimulated by a non-TSH source (such as auto-antibodies) the level of T3/T4 may dramatically increase in the serum while the pituitary, sensing an excess of hormone, will respond by dropping TSH output to near zero levels. As described earlier, this results in what?

Secondary hypothyroid disease

thyroid gland is generally completely functional. However, the pituitary gland is unable to produce adequate TSH and/or to appropriately "sense" a drop in serum T3/T4. Because of this the thyroid gland only produces small amounts of T3/T4 due to lack of appropriate stimulation

UVJ

urinary frequency and urgency and lower pelvic pain Where is stone located?

Syndrome inappropriate ADH secretion

well-too much ADH-not going to pee and have hyponatremia-can 3rd space-dilutes solids What condition is this?

Parathyroid hormone

which controls the amount of calcium in our blood, urine, and in bones

Lost

without functional parathyroid glands, the ability to adequately regulate blood calcium levels is what?

Prolactinoma

. D. is a 32 year-old self proclaimed "ladies man" who presents with complaints of sexual dysfunction and headaches. He has also noticed that his vision has changed.PMH: denies chronic medical problemsFH: NCSH: denies use of tobacco, alcohol, illicit drugsMedications: denies chronic medicationsAllergies: NKDA BP - 110/70 mmHgHR - 70 bpmRR - 14/minTemp - 98F (o)Pulse oximetry - 99% RABMI - 24.3 (5'8", 160 lbs)WDWNM in mild distress, converses, cooperative w/ examHEENT reveals visual field deficits but EOMI w/o palsyHeart is RRR w/o mrgLungs are CTA w/o rrwGU exam reveals small testiclesMusculoskeletal w/o cceNeuro - AXOX3, CN 2-12 grossly intact

Acromegaly (Heart is bigger and higher vasculature resistance Macroglossia-enlarged or thickened tongue Dental malocclusion-teeth change and jaw widens Prognathia-jaw line gets bigger Bossing-forehead sticks down)

. T. is a 40 year-old male who presents with enlargement of his hands. He has noticed that the gloves he uses for yard work no longer fit. He has also noticed that his forehead seems swollen. His wife states his voice has become deeper and his shoe size has also increased. PMH: denies chronic medical problemsFH: NCSH: denies the use of tobacco, alcohol, illicit drugsMedications: denies chronic medicationsAllergies: NKDA BP - 150/90 mmHgHR - 80 bpmRR - 14/minTemp - 98.6F (o)Pulse Oximetry - 99% RABMI - 23.8 (6'2", 185 lbs)WDWNM in NAD, converses, cooperative w/ examHEENT reveals coarse facial features w/ mild frontal bossing, prognathia, dental malocclusion, macroglossiaNeck is supple, trachea midlineHeart is RRR w/o mrg, PMI slightly displaced laterally Lungs are CTA w/o rrwMusculoskeletal exam reveals enlarged hands and feet w/ thick fingers and toesNeuro - AXOX3, CN 2-12 grossly intactSkin is very moist w/o lesion

Crystalloid

0.9% Sodium Chloride Normal Saline (NS) Lactated Ringers (LR) Dextrose 5% in Water (D5W) D5LR (Sweet Ringers) D5NS 0.45% Sodium Chloride (½ NS) D5 ½ NS What IV fluids are these?

Renal artery stenosis

decrease in the size of the lumen

Hypocalcemia and hyperphosphatemia

decreased function of the parathyroid glands decreased levels of PTH leads to decreased activity of osteoclasts, decr renal ca reabsorp and urinary PO4 excretion and calcitriol synthesis and calcium absorp leads to?

Hypothalamic-pituitary axis

directly affects the functions of the thyroid gland, the adrenal gland, and the gonads, as well as influencing growth, milk production, and water balance

Carboxyhemoglobin

is a stable complex of carbon monoxide that forms in red blood cells when carbon monoxide is inhaled. COHb should be measured if carbon monoxide poisoning is suspected. COHb is also useful in monitoring the treatment of carbon monoxide poisoning. The reference range of COHb differs among smokers and nonsmokers, as follows: Nonsmokers: <3% Smokers: <12%

Phosphorus

is distributed in the body as phosphate (PO4) Gives rigidity to our bones and teeth 85% in bone stores, rest is extra and intra-cellular Normal blood levels = 2.4-4.1 mg/dL ** lab dependent PTH, which controls Ca++ homeostasis, also affects PO4 phosphate is not a regulator of PTH

Hypothyroidism

is due to either primary disease of the gland, or from secondary defect causing pituitary decreased TSH secretion Primary disease accounts for about 99% of total Goiter Present when due to Hashimoto's, iodine deficiency, drug effects

Creatinine

is produced in your muscles from the breakdown of creatine. Created at a nearly constant rate and almost all is filtered by and excreted through kidneys Good measure of kidney function Doubling represents 50% decrease in GFR Part of a BMP and CMP Reference range: Females 0.5 to 1.0 mg/dL Males 0.7 to 1.2 mg/dL

Acromegaly

is the clinical syndrome that results from excessive secretion of growth hormone (GH) Its annual incidence is six per million people The mean age at diagnosis is 40 to 45 years Occurs in adults after growth plate has closed

Anion gap

is the difference in the measured cations (positively charged ions) and the measured anions (negatively charged ions) in serum, plasma, or urine. The magnitude of this difference (i.e., "gap") in the serum is often calculated in medicine when attempting to identify the cause of metabolic acidosis, a lower than normal pH in the blood. If the gap is greater than normal, then high anion gap metabolic acidosis is diagnosed

Diabetes insipidus

lack of ADH from the brain-see in brain injury, stroke, affect production of ADH-mean not producing ADH-pee a lot What condition is this?

Prerenal

not enough blood to kidney and affect kidney-blood loss, dehydration, CHF, shock Decrease in blood reaching the kidney What classification is this?

Antiplatelet Agents

reduces cardiovascular morbidity and mortality in high-risk patients with previous MI or stroke (benefit in primary prevention is controversial) Low-dose (75-162 mg/day) for primary prevention for men over age 50 years / women over age 60 years with > 1 major risk factor Smoking Hypertension Dyslipidemia Family history of premature cardiovascular disease Albuminuria

Thyrotoxicosis

refers to a series of clinical disorders associated with an increased level of fT4 and T3, fT3: Graves' disease Pituitary hyper-secretion of TSH Pregnancy - increases TSH receptor activity (Beta hCG)-in men means testicular cancer Autonomous toxic adenomas Single (Plummer's disease) Multiple (toxic multi-nodular goiter)

Renovascular hypertension

result of clinically significant renal artery stenosis. A slight amount of stenosis (e.g. 10%) will not reduce blood flow enough to cause renovascular hypertension Stenosis >50% generally required to cause renovascular hypertension and other consequences

Secondary hyperthyroidism

results when the pituitary releases large amounts of TSH regardless of T3/T4 levels. The thyroid gland, having normal functions, responds by producing large amounts of thyroid hormone.

Primary hypothyroidism

results when the thyroid gland is unable to respond to TSH stimulation either due to its surgical absence, insufficient iodine or to receptor blocking auto-antibodies. In these cases, the pituitary gland responds to the low level of T3/T4 by producing large amounts of TSH in a vain attempt to increase production

UA, pregnancy test, clean catch urine, CBC, CMP, culture if UA positive Helical CT Struvite stones Admit her and start analgestic, antibiotics, fluids, and last is surgery

21 y/o female presents to ER with 3 days of "UTI symptoms" she states that she has these often but this one seems worse than normal. She complains of lower pelvic pain that is getting progressively worse. She reports that her pain is a 7/10 and constant. She reports nausea/vomiting, urinary frequency, hematuria and fever off and on. She denies hx of prior stones. She is otherwise healthy. Vitals: 135/80 mmHg, RR: 20, HR: 100, T: 101.6 C, O2sat 98% PE: white female in moderate distress from pain, cant seem to get in a comfortable position Right CVA tenderness Bowls sounds normal x 4 quadrants, no rebound, guarding or tenderness What diagnostic studies done? First line of diagnosis? Which type of stone? How should pt be treated?

Uric acid

36 y/o obese male presents with 4 days of right intermittent flank pain that radiates to the right lower abdomen. He states his pain is a 4/10. He also has nausea and hematuria. He denies fever/chills, vomiting, urinary frequency and states that he is able to tolerate fluids well. He has a hx of gout. Vitals: BP 120/80mmHg, RR: 16, HR: 85 bpm, T: 98.6 F, O2sat: 98% What type of stone at risk for?

Outpatient Increase fluid intake Alpha blockers analgestics-NSAIDs 800 mg Strainer Diet Follow-up soon

55 y/o male with hx of stones presents for what he thinks is another one. He complains intermittent right flank pain with nausea but no vomiting. He states that his pain is ranges from a 4/10- 7/10. He reports hematuria and frequency but no fever. He states that he doesn't have much of an appetite but still eats what he can and is drinking plenty of fluids. UA shows hematuria but with no signs of infection, CBC and CMP are unremarkable. CT shows a 4mm stone in the right ureter. He is requesting a med that he has had before to help the stone pass. He has no other significant PMH. Vitals: BP 120/80 mmHg, RR: 16, HR: 80, T: 98.6 C, O2sat 99% PE: white male in no acute distress but is grimacing from pain no CVA tenderness bilaterally bowel sounds present x 4, no rebound, guarding or tenderness What is the treatment plan for this patient?

Post-streptococcal Glomerulonephritis

60% of cases in children 2-12 Signs/Symptoms hematuria, edema, HTN, oliguria Recent hx of group A β-hemolytic strep infection Antigen-antibody complexes deposit in glomeruli and cause inflammation

UA and C and S Overflow Bladder retraining

67 year old male with BPH presents complaining that he has had to use protective pads for several months due to "dribbling" throughout the day and night. Not painful no blood What tests, what type of UI, what best treatment?

Henoch-Schönlein Purpura

75% between 2-11 yo; M:F is 2:1 Signs/symptoms: Rash on extremities-non blanching bruises-palpable-feel bumps under skin-lower extremities Arthralgias Abdominal pain, bloody diarrhea Hematuria Possible HTN Likely due to IgA deposition in affected tissues-vasculitis affecting skin and mucous membranes

Urine dipstick results usually provide the laboratory information needed to managing young otherwise healthy patients with acute cystitis

A 19-year-old woman comes to the ER with urinary frequency and dysuria. She recently came back from her honeymoon. She denies similar episodes in the past. Her medical history is unremarkable and she takes no medications. Physical exam is normal. A urine dipstick shows 2+ leukocyte esterase and positive nitrites. What should be done?

Start oral Bactrim DS for three days

A 24-year-old woman comes to discuss recent lab results she received from "UTI screening". A month ago, a close friend was admitted to the hospital with a severe UTI that "got into her blood" so she went to a walk in clinic for screening. The patient is asymptomatic and has no past medical history. She is married and monogamous. Her physical exam is normal. Urinalysis showed 1+ leukocyte esterase; and C&S revealed >100,000 CFU of E. coli. What management strategy is appropriate?

Less than 20:1 not prerenal

Take off sulfa Put on something else Fluid status, hyperkalemia, hypertension

Interstitial nephritis

CVA tenderness Vitals Cellulitis check Abdominal Heart Lungs

A 28 year old female presents today with a complaint of fever since yesterday. She also admits mild low back pain and thinks she saw blood in her urine. She was just seen 5 days ago for cellulitis on her left calf and has been taking Bactrim since that time. Would the presence of CVAT help to narrow your differential diagnosis? A. No, it would not since pyelonephritis, glomerulonephritis (GN), and interstitial nephritis (IN) can all have +CVAT B. Yes, it would point to either pyelonephritis or GN being the correct diagnosis. IN does not have +CVAT. C. Yes, it would mean that pyelonephritis is the correct diagnosis. GN and IN do not produce +CVAT.

Dysuria Urinary frequency, urgency Suprapubic pain Fatigue Body aches Fever (more details, had it recently, when took it, medications for it) Social history-sexual Recent skin or throat infection or undercooked meat

A 28 year old female presents today with a complaint of fever since yesterday. She also admits mild low back pain and thinks she saw blood in her urine. She was just seen 5 days ago for cellulitis on her left calf and has been taking trimethoprim/sulfamethoxazole (Bactrim) since that time. What history questions would be important?

A 28 year old female presents today with a complaint of fever since yesterday. She also admits mild low back pain and thinks she saw blood in her urine. She was just seen 5 days ago for cellulitis on her left calf and has been taking trimethoprim/sulfamethoxazole (Bactrim) since that time. Which of the following is MOST LIKELY to be the cause? A. Interstitial nephritis B. Sepsis C. Urinary stone D. Urinary tract infection

Come up with differentials to guide exam and history choices: Kidney stones, UTI, acute interstitial nephritis History and Physical Look at vitals

D (Calcium part of CMP) BMP (does not have calcium)

A 50-year-old otherwise healthy man has a lump on his neck found at physical examination. A fine needle aspirate of this lump shows a follicular neoplasm of the thyroid. He undergoes a total thyroidectomy. Within a day following surgery, he is noted to have tingling sensations and neuromuscular irritability. Which of the following serum laboratory tests should be ordered immediately to determine further therapy for this man? A. TSH B. iPTH C. Mg D. CMP E. Calcitonin F. Iodine G. BMP

Start ciprofloxacin, and order urine culture

A 53 year-old man with BPH comes to the ER complaining of burning with urination and increased frequency. He is afebrile, denies back pain, nausea, or vomiting. His past medical history is significant for hypertension and diabetes. He takes HCTZ, enalapril, ASA, & metformin. On PE his prostate is enlarged, but not tender. Urine dipstick shows 3+ leukocyte esterase. What is the intervention for this?

A 54 year old female with recurrent kidney stones has fever, chills, left flank pain and dysuria for one day. Exam is positive for CVA tenderness. UA is positive for pyuria, WBC casts, and bacteruria.What is NOT true regarding treatment? A. She requires hospitalization and IV antibiotics B. She may be started on oral quinolones C. Changes in Antibiotic may be made once the C&S has returned D. She should begin IV ampicillin and gentamycin immediately

White blood cell casts

A 61 year old has 2 hours of fever, chills, dysuria, and pelvic pain. Presence of which of the following indicated pyelonephritis rather than cystitis?

Ask him to return in the morning for first void If still have protein then do BUN/Creatinine ratio-do anyway bc do not know the guy Maybe infection or fever that caused this-have him repeat it a few times a few weeks apart Ask about PMH-risk factors for diabetes, HT, or lupus Possible sign of underlying renal abnormality Less than 3.5 g/24h nephrotic range

A 62 year old Caucasian male presents for his routine physical. Your MA performs a dipstick UA. The results are below: Color & Appearance Yellow-clear Specific Gravity 1.015 pH 6.5 Protein trace Glucose neg Hemoglobin neg Bacteria neg Leukocytes neg How do you proceed?

Hyperkalemia Multiple myeloma affect kidneys Medicine might cause high K

A 65 year old patient presents to your clinic and complains "I don't feel like myself." He admits to feeling tired and having occasional palpitations for the past 2 weeks. He also admits to a decrease in the amount of urine he produces. The rest of his ROS is unremarkable. PMH is positive for asthma and multiple myeloma. His physical exam shows: General: WDWN male in NAD VS: temp 98.5F, HR 76, RR 12, BP 116/82 Heart: RRR w/o M/G/R Lungs: CTAB w/o wheezes or crackles Abdomen: + BS x 4Q, soft NTND, no HSM, no CVAT EKG: NSR with peaked T waves and widened QRS complexes UA Specific gravity 1.020 Leukocytes neg Blood 1+ Nitrites neg Ketones neg Protein 2+ Microscopy: Granular casts present CMP: Glucose high BUN high Creatinine high Na normal K high What is going on?

UTI Needs fluids and antibiotics and C and S before that

A 78 year old female is brought to the ER today for evaluation after her family found her to be confused and having new episodes of urinary incontinence for the past 2 days. PMH of atrial fibrillation for which she takes coumadin and metoprolol. Her exam is as follows: General: thin woman, alert and oriented to person only. VS: temp 97.9F, HR 86, RR 15, BP 98/62. Lungs: CTAB without wheezes or crackles Heart: Irregularly irregular rhythm without M/G/R Abdomen: soft NTND, + BS x 4Q, no HSM UA Specific Gravity 1.030 Leukocytes 2+ Blood 3+ Nitrites + Ketones + What is this?

Glomerulonephritis-HUS Supportive care-control HTN and fluid overload, dialysis, stop antidarrheals and antibiotics

A 9 year old male presents to your clinic with a complaint of fever and dark urine since yesterday? How would you proceed? History? Mom admits puffiness around his eyes upon awakening this morning. Also, she reports he has had nausea and loose stools for the past week-He is taking Imodium AD. Admits blood in stool, but she attributed it to a fissure he has had in the past. He is also taking ibuprofen for fever Physical Exam? Temp 99.2F, HR 96, RR 16, BP 146/92 Mild periorbital edema noted ENT, skin, heart, lungs, extremities all normal Labs/Diagnostics? UA: trace leukocytes, negative nitrites, 2+ protein, 2+ blood Microscopy: RBC cast CMP: BUN 26 Creatiine 2.6 Bilirubin 1.7 (0.1-1.2)-hemolysis CBC: WBC 15.6-high Hgb 11.7-low Hct 38-low Plt 102-low What is the diagnosis and treatment?

TSH

A change in what level may signify a malfunctioning of the thyroid gland?

Pyelonephritis

A decreased specific gravity of less than 1.008 dilution indicates what?

PTH

A healthy patient has a low serum calcium level of 8.6 mg/dL. If you were able to order other blood work, which hormone level would be elevated in this patient with well-functioning parathyroid glands?

IV fluid

A patient presents A&O x 2. His caregiver reports the patient has been lethargic with increased BP and difficulty standing up out of his wheelchair. His DTRs are 1+. His Ca is 11 and PTH is 100. The first line of treatment is?

Leukocyte Esterase

A positive result on a dipstick for this is diagnostic for UTI what is it?

Myxedema

A severe form of hypothyroidism characterized by dry skin swelling around the lips and nose mental deterioration inelastic edema dry skin and hair loss of mental and physical vigor

Hypovolemia

A state of combined salt and water loss that leads to contraction of the extracellular fluid volume . Intrinsic/Renal Extrarenal Interstitial fluid Vascular fluid/plasma 3rd space

Polycystic Kidney Disease

Abdominal/flank pain (almost always) Palpable abdominal mass(es) HTN Hematuria Usually begin in 20s-30s Associated findings Hepatic/pancreatic/splenic cysts Cerebral aneurysms Cardic valvular disease Increased hematocrit What condition is this?

Diabetic ketoacidosis

Absolute / relative insulin deficiency with counterregulatory hormone excess (glucagon, catecholamines, cortisol, GH), volume depletion, and acid-base abnormalities Decreased ratio of insulin to glucagon promotes gluconeogenesis, glycogenolysis, and ketone body formation in the liver and increases in substrate delivery from fat and muscle (free fatty acids [ketosis], amino acids) to the liver This leads to glucose synthesis and reduced glucose uptake into skeletal muscle and fat and reduced intracellular glucose metabolism As ketone bodies (ketoacids) are buffered by bicarbonate, bicarbonate stores are depleted and metabolic acidosis ensures Precipitated by increased insulin requirements (concurrent illness, failure to augment insulin therapy, omission of insulin dose) Signs of volume depletion, fruity odor to breath, n/v, abdominal pain Kussmal respirations Serum glucose > 250 mg/dL Serum bicarbonate frequently < 10 mEq/L Serum potassium normal to mildly elevated at presentation despite total-body potassium deficit serum sodium decreased (hyperglycemia) BUN elevated due to intravascular volume depletion Positive serum / urine ketones Arterial pH < 7.3 / PaCO2 20-30 mmHg / HCO3- < 21 mEq/L /AG increased (metabolic acidosis) Volume replacement with intravenous crystalloid fluid Intravenous short-acting insulin Correct serum potassium < 3.3 mEq/L Monitor electrolytes (potassium, bicarbonate), acid-base status, renal function (SCr, UOP), and serum glucose Admit to the intensive care unit Identify and treat the underlying cause

Monitoring response to treatment for hypothyroidism

Aim to achieve TSH > 0.5 and up to 2mU/L. Less aggressive targets are utilised in the elderly & those with severe cardiac disease Full replacement doses could aggravate cardiac events Some mild persisting hypothyroidism may persist Normalisation of TSH should occur within first 3 months of initiation of treatment. Free T4 (Thyroxine) concentrations in the high normal range is ideal If Hyperthyroidism occurs, stop Thyroxine for a week, then restart at a lower dose. If symptoms of cardiac ischaemia or arrhythmia worsen, dose increases should be avoided, with appropriate cardiac investigations & management undertaken. Time to reach steady state concentration. Thyroxine's half life is approximately 7 days, therefore steady state would be reached at around 5 weeks. Dose adjustments and repeat Thyroid function tests should take this into accordance.

UTI treatment

Antibiotics Analgesics- Phenazopyridine (Pyridium, AZO Max...) 200mg TID PRN x 3 days maximum Increase water (no carbonated beverages or acidic beverages) Cranberry Pills (Much better than cranberry juice!) +/- Repeat urine culture & sensitivity after antibiotic course If pyelonephritis, repeat infection, or persistent symptoms

Urinary incontinence pharm

Anticholinergics (Oxybutynin, Tolterodine, Trospium, Darifenacin) Variety of preparations: Immediate Release; Extended Release; Transdermal Try different agent if one doesn't work They suppress detrusor contractility Side effects abound!- urinary retention, dry mouth... ALWAYS CHECK PVR PRIOR TO PRESCRIBING! Never use in overflow incontinence! Imipramine: mixed incont. Duloxetine Estrogen Vasopressin

Respiratory Alkalosis

Anxiety, diaphoresis, dyspnea ( increased respiratory rate and depth), EKG changes (hypokalemic)-flat or U wave, hyperreflexia, paresthesia, restlessness, tachycardia, tetany. What is this?

Multiple Endocrine Neoplasia

Autosomal dominant predisposition to tumors of the parathyroid glands (which occur in nearly all patients by age 50 years), anterior pituitary, and enteropancreatic endocrine cells The "3 Ps" The duodenum is a common site of tumors (gastrinomas) in these patients, and carcinoid tumors, adrenal adenomas, and lipomas are more common than in the general population

Renal Artery Stenosis

Background 5% of Americans with hypertension Pathophysiology Endothelial injury and development of atheromatous lesions Fibromuscular dysplasia is a much less frequent cause Lumen size decreases = decreased renal blood flow-hear bruit

Prediabetes

Blood glucose levels above normal but without meeting the criteria for a diagnosis 35% of the U.S. population > 20 years of age and 50% greater than 65 years of age

Intact RBCs (speckled pattern) Hemoglobin (uniform pattern) Myoglobin (uniform pattern)

Blood strip test will test positive for what?

BUN (Blood Urea Nitrogen)

Blood test telling the amount of urea nitrogen in the blood. This is produced by the liver when protein is broken down The nitrogen is then excreted in urine. If kidneys aren't functioning well, you will not get rid of as much nitrogen and BUN levels will rise. Part of a BMP (basic metabolic profile) and CMP (complete metabolic profile)

Dwarfism

Bone age is delayed in patients with all forms of true GH deficiencyIsolated GH deficiency is characterized by short stature, micropenis, increased fat, high-pitched voice, and a propensity to hypoglycemia (d/t unopposed insulin action)If a patient's height is > 3 SD below the mean for age or if the growth rate has decelerated, evaluate for GH deficiencySkeletal maturation is best evaluated by measuring radiologic bone age (degree of wrist bone growth plate fusion)Adequate adrenal and thyroid hormone replacement should be completed prior to GH testingGH deficiency is best assessed by examining the response to provacative stimuliTreat with recombinant GH

Pathophysiology of kidney stones

Breakdown of a delicate balance between solubility and precipitation of salts The kidneys must conserve water, but they must excrete materials that have a low solubility The two opposing requirements must be balanced during adaptation to diet, climate, and activity When the urine becomes supersaturated with insoluble materials, crystals form and may grow and aggregate to form a stone The presence of inhibitors (most commonly urine citrate, also magnesium) , prevent most stone formation Calcium phosphate extends down to the renal papilla and erodes through the epithelium, where it provides a site for deposition of calcium oxalate and calcium phosphate crystals The majority of calcium oxalate stones grow on calcium phosphate at the tip of the renal papilla

Adrenal insufficiency (Addison's disease) (Tan look)

C.K. is a 48 year-old white woman who presents with loss of appetite, progressive fatigue, and mild nausea for the past 5 days. She states she has felt fatigued for about 4 months but is got worse over the last week. She also noticed that despite being inside all day she is getting a tan. PMH: Pernicious anemia; seroconverted PPD treated with INH 6 years agoFH: One sister with Graves disease and one sister with Hashimoto thyroiditisSH: Occasional alcohol, denies tobacco or illicit drug useMedications: Cyanocobalamin 200 mcg IM Q monthAllergies: NKDA BP - 95/75 mmHgHR - 83 bpm Positive orthostatic vital signs RR - 14/minTemp - 98F (o)BMI - 20 (5'6", 124 lbs)WDWNF in NAD who appears fatiguedSkin - generalized bronzing w/ pigmented skin creases of the palms of the hands and knuckles, sparse axillary hairHEENT - oropharynx patent w/ dry mucous membranesNeck / lymph nodes - supple, no thyromegaly or masses; shotty A/P cervical lymphadenopathyHeart - RRR w/o mrg, S1 S2 distinctLungs - CTA w/o rrwBreasts - hyperpigmentation along brassiere lines, very dark areolaeMusculoskeletal - FROM b/l u/l ext.; muscle strength 4/5 throughoutNeuro - AXOX3, CN 2-12 grossly intact

Hematuria

Can be a sign of damage to the kidneys...or not Significant if > 3 RBCs / hpf on 2 occasions Microscopic or Macroscopic Symptomatic or Asymptomatic Transient or Persistent

Peritoneal Dialysis

Can be done at home Must be done daily Automated machines can do it during sleep Catheter is placed in lower abdomen Hyperosmolar fluid (glucose) is introduced Peritoneum serves as the filter Contraindications: Major abdominal issue-surgery, scaring-not going to get this-scaring does not allow fluid to move through it-cellulitis or peritonitis not good candidate Not physically or emotionally capable are out too-psychological and social issues Problem with diaphragm-severe COPD-more pressure on lungs and breathing

Cysteine stones

Caused by an impairment of cystine transport Rare and associated with an inherited disorder of renal, tubular re-absorption of cystine Autosomal recessive disorder Seldom form in adults unless urine excretion is at least 300 mg/day Formed only in patients with cystinuria 10% of stones in cystiuric patients do not contain cysteine Typically have a smooth, ground glass appearance

Renal Vein Thrombosis

Causes: Nephrotic syndrome Invasion of renal vein by renal cell cancer Presentation: Flank pain, hematuria, proteinuria, decline in renal function

SIADH

Central Nervous System (CNS) Disturbances Stroke Hemorrhages Infection Trauma Malignancies Small Cell Carcinoma of the Lung Head and Neck Cancers Medications Carbamazepine (Tegretol®) Fluoxetine (Prozac®) Sertraline (Zoloft®) Methotrexate (Trexall®) Amiodarone (Cordarone®) Ciprofloxacin (Cipro®) Surgery Transphenoidal Pituitary Surgery Pulmonary Disease Pneumonia Hormone Deficiency Hypopituitarism Hypothyroidism Hormone Administration Vasopressin (Pitressin®) Desmopressin (DDAVP®) Oxytocin (Pitocin®) HIV Infection Hereditary SIADH What does all this cause?

Hypertension Nephropathy

Chronic hypertension = medial hypertrophy-increase in number of cells and size and fibroblastic intimal thickening = narrowing of the vascular lumen-less blood flow making it through the vessels and cells die Glomerulosclerosis Ischemic injury, leading to nephron loss. Glomerular enlargement (compensatory response to nephron loss) Combination of hypertrophy and a rise in intracapillary pressure in these glomeruli = segmental sclerosis

Diuretics

Chronic kidney disease causes sodium retention and volume expansion Thiazides - less potent Use in CKD with GFR > 30 Loop Diuretics - more potent Use in all stages of CKD As GFR decreases, hypokalemia is a less frequent side effect

WBC Casts

Clinical Significance: Associated with pyelonephritis (infection or inflammation within the nephron) Mostly composed of neutrophils Bacterial casts may also be seen

RBC casts

Clinical Significance: Indicates bleeding with the nephron Associated with acute glomerulonephritis The blood dipstick reaction will be positive and you should see free-standing RBCs in the urine specimen.

Urine turbidity

Cloudy urine may be due to: Infection Contamination (Mucus or epithelia) Chyluria (lymph in urine- from filariasis) Hyperuricosuria (Diet of high purine foods) Lipiduria Hyperoxaluria

Primary disorder decreased hormone

Congenital or acquired problem of the target gland Concentration of the target gland hormone will be low Concentration of the stimulating hormone will be high (loss of negative feedback)

Metabolic syndrome

Constellation of metabolic abnormalities that confers an increased risk of cardiovascular disease and DM thought to be primarily due to insulin resistance Diagnosis requires > 3 of the folllowing: HDL < 40 mg/dL in males and < 50 mg/dL in females Elevated BP (> 135/85 mmHg) Elevated triglycerides (> 150 mg/dL0 Fasting plasma glucose 100-125 mg/dL (IFG) 2-hour OGTT (2-hour OGTT) of 140-199 mg/dL Waist circumference > 40 inches in males or 35 inches in females Individuals should be counseled regarding diet and exercise to reduce their risk of disease progression; +/- metformin (Glucophage®)

Hyponatremia

Decreased Intake-IV Therapy Increased Loss Addison Disease Gastrointestinal Losses Diuretics Chronic Renal Insufficiency Increased Free Body Water Intake (IV or PO) Hyperglycemia Congestive Heart Failure (CHF) Peripheral Edema Syndrome of Inappropriate Antidiuretic Hormone (SIADH) All of these can cause what?

Hypoparathyroidism

Decreased PTH and calcium To rule in or out, you must consider the differential diagnosis of the hypocalcemia Chronic Kidney Disease Malabsorption Mg deficiency Vitamin D deficiency Meds Labs: decr iPTH with decr serum Ca++ Also: incr serum PO4, incr urinary Ca++

Urea

Derived from amino acid's metabolism into ammonia, which the liver converts to this Accounts for nearly 50% of the total dissolved solids in urine

Uric acid

Derived from catabolism of nucleic acids in foods and cell destruction

Negative

Do ppl do better with positive or negative daily electrolyte needs?

Does everyone with proteinuria have reduced GFR?

Does everyone with reduced GFR have proteinuria?

Yes (Medical emergency - Altered level of consciousness, seizures, other features of hypothyroidism Hypothermia, hypercapnia, hypoxia)

Does myxedema coma have a high mortality rate??

Hemodialysis

Done at dialysis center Multiple times weekly, 4 hours each Filtering of blood is done by machine, outside body Special diet Increased protein-increases overall health-more muscle mass-not worried about kidneys not functioning anymore Limit potassium, phosphorus, sodium, liquids 3 access options: AV Fistula - long term AV Graft - long term Catheter - short term

Intrinsic

Due to damage of the kidney itself Can involve vasculature, tubules, interstitium, or glomerulus What classification is this?

Postrenal

Due to obstruction of collecting system ureters-kidney stones has to be both ureters obstructed-BPH-bladder tumor What classification is this?

Causes of non anion gap acidosis with hyperkalemia

Early renal failure Renal disease SLE interstitial nephritis Amyloidosis Hydronephrosis-water in urine Sickle cell nephropathy Acidifying agents Ammonium chloride Calcium chloride Arginine Sulfur toxicity

Increased Neutral Increased (Glucocorticoid deficiency, hypothyroidism, stress, drugs)

Euvolemia total body water and total body sodium is what increased or decreased? And urine sodium?

Evaluate the following labs of a 57 year old, previously healthy, female. Serum sodium level 147 mmol/L Blood urea nitrogen 65 mg/dL Creatinine 2.6 mg/dL Bicarbonate value 29 mmol/L Potassium4.0 mmol/L Urine specific gravity 1.019 A. This patient DEFINITELY HAS kidney impairment B. This patient MAY OR MAY NOT HAVE kidney impairment (we need other lab testing to tell.) She may only have decreased blood flow to her kidneys from dehydration or new onset CHF without actual kidney impairment. C. This patient DOES NOT have kidney impairment and is only dehydrated

Creatinine Clearance

Evaluates the rate and efficiency of kidney filtration The amount of creatinine cleared from the body depends on the rate at which blood is carried to the kidneys and the effectiveness of the glomeruli to filter that blood. Affected when: damaged glomeruli OR decrease in blood flow to the kidneys May be ordered after elevated creatinine is noted or if patient has signs of kidney disease

Urinalysis

Evaluates urine: Appearance color/turbidity Concentration specific gravity Content

TRH from hypothalamus stimulates anterior pituitary to release TSH and that stimulates the thyroid gland to make T3 and T4 which can do negative feedback

Explain the thyroid system

Tubular proteinuria

Faulty reabsorption of normally filtered proteins in the proximal tubule β2 microglobulin and immunoglobulin light chains Caused by Acute tubular necrosis Toxic injury (lead, aminoglycosides) Interstitial nephritis Hereditary metabolic disorders (Wilson's dz, Fanconi syndrome)

Uric acid stones

Form in individuals with persistently acidic urine with or without hyperuricemia Etiologies Dietary excess, gout, myeloproliferative disorders, chronic dehydration, Lesch-Nyhan syndrome, ingestion of uricosuric drugs (salicylates, thiazides), idiopathic Associated with gout and individuals with leukemia Associated with obese patients, due to their higher uric acid generation and acidic urine pH Seen as side effect of some of the HAART medications for HIV (Indinavir) Does not appear to be associated with calcium oxalate stone formation

Struvite stones

Formed by combo of magnesium, ammonium, phosphate Common in those with frequent catheterizations or abnormal urinary tract anatomy Associated with UTI's with urease-splitting organisms (Proteus, Klebsiella, Pseudomonas, Serratia, Enterobacter, Providencia, Staphylococcus, Mycoplasma) Leads to alkaline urine and magnesium ammonium phosphate crystallization

Parathyroid glands

Four parathyroid glands: regulate serum Ca++ Contain Ca++ sensing receptors Produce and secrete parathyroid hormone (PTH) in response to hypocalemia

Thyroxine or T4

Free vs. total T4 Protein binding and transport Peripheral T4 is primarily bound to thyroxine-binding globulin (TBG) in the circulation Normal range fT4=10 - 20 pmol/L Normal range T4= 10 - 25 pmol/L

Interstitial Cystitis

Frequency Urgency Urge incontinence Urethral and pubic pain that improves with voiding Hematuria +/- Autoimmune Altered glycosaminoglycal layer

History for kidney stones

Have they had stone before-what evaluation done-pass on own or treated through surgery-stint-complications-what type of stone? Family history of calculi-doubles rate of lifetime prevalence of these Past medical history-UTI in past, one kidney or 2, medications on, and diet-seen urologist

MRA or CTA (these are with contrast) or doppler ultrasonography if experienced

High index of suspicion and normal renal function what tests should use?

Ureterorenoscopy

Highly effective and superior in treating stones > 1 cm Can combine tx with flexible ureteroscopy and laser lithotripsy and can also be used for the removal of very large (> 2-3cm) or impacted stones Highest stone-free rates and lowest # of required retreatment's for mid-ureteral stones Also one of the preferred methods for distal ureteral stones

Increased content of normal components (Na, K, BUN) Toxic substances in blood (Alcohols, ethylene glycol, acetone) Loss of water in excess to sodium (Dehydration and Diabetes insipidus)

How does one have increased osmolality?

30-300 mg

How much albumin excreted in the urine is moderately increased and a sign of early renal disease?

Very little

How much albumin, protein, do we excrete in our urine?

30 cc/70 kg (or 0.5 cc min per hr)

How much cc should give?

Greater than 150 mg

How much urinary excretion of protein per day means proteinuria?

H and P UA, microscopy (hematuria, moderate proteinuria, RBC casts) BMP (Additional tests may be needed IgA, ASO titer, ANA, ANCA, anti-GBM antibody, CBC, complement)

How to evaluate glomerulonephritis with labs?

Antimicrobial agents Surgical removal

How to treat struvite stones?

Hypocalcemia

Hypoparathyroidism Renal Failure Vitamin D Deficiency Osteomalacia Hypoalbuminemia Malabsorption Pancreatitis Alkalosis All of these cause what?

Hypovolemic shock (Tissue hypoperfusion)

Hypotension Tachycardia Peripheral Vasoconstriction Peripheral Cyanosis Cold Extremities Oliguria Altered Mental Status Organ Dysfunction What does this describe?

Extrarenal losses (Vomiting, Diarrhea, burns, 3rd spacing, pancreatitis, trauma)

Hypovolemia with decrease total body water and sodium with decreased urine sodium below 20 leads to what condition?

Renal losses

Hypovolemia with decrease total body water and sodium with increased urine sodium above 20 leads to what condition?

Refer to nephrologist

IF pt is less than 30 what is the management of CKD in diabetes?

Management of DM

Identify barriers such as income, health literacy, diabetes-related distress, depression, and poverty Diabetes self-management education and support Nutrition therapy goals-individualized Positive messages Practical tools Physical activity Reduce sedentary time Resistance training Smoking cessation Routine vaccinations Flu shot Pneumococcal shot Hep B shot Psychosocial screening HbA1c lowering below 7

Central (Pituitary or neurohypophysis DI)

Idiopathic Neoplasms Pituitary Surgery Head Trauma Infectious Inflammatory Vascular Congenital What is this condition for diabetes insipidus?

Acute prostatitis Urinaylsis and culture Urology evaluation

If a male with perineal, pelvic, or prostatic pain comes in to the office what is the diagnostic and management?

Pyelonephritis

If fever, flank pain, CVA tenderness, nausea, or vomiting are present, suspect what UTI?

Monitor eGFR every 3 months Monitor electrolytes, bicarb, calcium, phosphorus, parathyroid hormone, hemoglobin, albumin

If pt is 30-44 what is the management of CKD in diabetes?

Referral to nephrologist if possibly for nondiabetic kidney disease exists Consider need for dose adjustment Monitor eGFR every 6 months Monitor electrolytes, bicarb, hemoglobin, calcium, phosphorus, PTH Assure vit D sufficiency Consider bone density testing

If pt is 45-60 what is the management of CKD in diabetes?

Primary hyperparathyroidism

If someone had neck irradiation as a child (radioactive iodine to thyroid, hx hodgkins, tx in 1950/60s for LAD and tonsils), they can have what 30 years later?

Repeat testing

If tests are normal for DM, do what at a minimum of 3-year intervals?

Nitrites

If this is positive then UTI is always evident what is this on a dipstick reading?

lipid

If thyroid levels are not functional what level goes up?

Uncomplicated cystitis or STD Dipstick, urinaylsis, and culture STD evaluation Pelvic exam

If woman with unclear history or risk facors for STD what is the diagnostic and management?

Serum hypocalcemia

If you have this condition PG releases PTH Osteoblasts decrease formation and Osteoclasts increase bone resorption activity Increased renal calcium reabsorption leads to decreased ca urinary excretion Incr urinary PO4 excretion Activates vit D to calcitriol Inc ca and PO4 absorption due to calcitriol in small intestines What was that initial condition?

increase

In a healthy body, as PTH levels increase, plasma Ca2+ will _______________. As plasma Ca2+increases, calcitonin secretion will ___________.

Primary hyperparathyroidism Hypercalcemia HYpercalciuria (kidney stones) Bone loss Hypophosphatemia

Incr function of parathyroid glands incr levels of PTH incr activity of osteoclasts and renal ca reabsorp and excret of PO4 and calcitriol synthesis and calcium absorp in small intestines leads to what?

Urinary Incontinence

Increased Detrusor activity Nocturia Decreased Detrusor contractility Bladder capacity Estrogen levels Atrophy Prostatic enlargement obstruction Obesity Pelvic surgery, injury, or radiation Immobility/functional impairment Psychological Disorders Neurological disorders Chronic disease Pharm causes like opioids and alcohol

White blood cells

Infection of the GU tract, interstitial nephritis (analgesic abuse) on urine microscopy

Acute glomerulonephritis

Inflammation of glomerulus Symptoms: Mild edema-peri orbital HTN Possible cola-colored urine Mostly seen in children

Trousseau's phenomenon

Inflation of the BP cuff on upper arm with occlusion of the brachial artery for approx 3 min.....will induce neuromuscular irritability manifesting as spasm--- which you can observe -called carpopedal spasm--- where the wrist and MCP joints flex, the DIP and PIP joints extend, and the fingers adduct

Parathyroid gland producing too much PTH; do imaging studies to check for primary hyperparathyroidism

Initially high nl then high serum calcium and high iPTH means what?

Hyperglycemic Hyperosmolar State

Insulin deficiency, volume depletion (inadequate fluid intake), and acid-base abnormalities Insulin deficiency increases hepatic glucose production (glycogenolysis, gluconeogenesis) and impairs glucose utilization in skeletal muscle Hyperglycemia induces an osmotic diuresis leading to intravascular volume depletion, exacerbated by inadequate fluid intake Absence of ketosis is not understood (insulin deficiency is less severe than with DKA, lower levels of counterregulatory hormones) Classic presentation is an elderly patient with type 2 DM and a several week history of polyuria, weight loss, diminished oral intake -> mental confusion, lethargy, coma Often precipitated by a serious concurrent illness (MI, stroke, sepsis) Hypotension, tachycardia, altered mental status, poor turgor, dry mucous membranes Serum glucose > 600 mg/dL Serum osmolality > 350 mOsm/L Serum bicarbonate normal to slightly decreased Serum potassium normal serum sodium normal to decreased (hyperglycemia) BUN elevated due to intravascular volume depletion (BUN:SCr > 20:1) Metabolic acidosis and ketosis, if present, are mild Substantially higher mortality rate than DKA Fluid losses / dehydration more pronounced than DKA Intravenous fluid administration guided by serum sodium Intravenous rapid-acting insulin Replace potassium Admit to intensive care unit Monitor electrolytes (sodium, potassium), serum glucose, and renal function (BUN, SCr, UOP) Identify and treat the underlying cause

Hypokalemia

Intake (IV or PO) Gastrointestinal Vomitting Diarrhea Diuretics Hyperaldosteronism Cushing Syndrome Licorice Trauma Exogenous Glucose/Insulin Ascites Renal Artery Stenosis Alkalosis Cystic Fibrosis What fluid condition is this?

Hyperkalemia

Intake (PO or IV) Renal Failure Addison Disease Hypoaldosteronism Aldosterone-Inhibiting Diuretics Hemolysis Transfusions Infections Acidosis Dehydration What fluid condition is this?

Hypophosphatemia

Intake (PO) Antacids Hyperparathyroidism Hypercalcemia Alcoholism Vitamin D Deficiency Malnutrition Hyperinsulism Hyperglycemia Treatment Alkalosis Sepsis All of these can cause what?

Hypertension

Lifestyle changes (DASH-dietary approach to stop HTN- diet, moderate alcohol intake, increased physical activity) Pharmacologic therapy with ACE-I or ARB (+/- thiazide diuretic) DM and HTN: SBP goal of < 140 mmHg Lower systolic targets, < 130 mmHg, may be appropriate for certain individuals, such as younger patients, if they can be achieved without undue treatment burden DM: DBP goal of < 90 mmHg Lower diastolic targets, < 80 mmHg, may be appropriate for certain individuals, such as younger patients, if they can be achieved without undue treatment burden BP > 120/80 mmHg - advise on lifestyle changes to reduce BP

Urobilinogen

Like bilirubin, it is a bile pigment that comes from the breakdown of HgB. Exhibits diurnal variation, with the highest levels seen in the afternoon. Approx 50% of this is reabsorbed from the intestine, recirculated through the liver and then excreted back though the bile duct to the intestine.

Carbohydrate metabolism

Low levels stimulate glycogen synthesis and glucose utilization. b. Excess levels stimulate glycogenosis and gluconeogenesis.

Primary aldosteronism

M.G., a 45 year-old male with a past medical history of hypertension, presents to the office with muscle weakness. He moves several times a year for work and has had his hypertension treated primarily by urgent care clinics. He read somewhere that his antihypertensive could make him weak. PMH: hypertension x 10 years, prior hospital admissions for chest painFH: NCSH: smokes 1ppd, denies use of alcohol or illicit drugsMedications: Triamterene, aspirin Allergies: NKDA BP - 160/100 mmHgHR - 80 bpmRR - 14/minTemp - 98F (o)Pulse oximetry - 98% RABMI - 25.7 (6'2", 200 lbs)WDWNWM in NADHEENT - AV-nicking on fundoscopicNeck - supple, no carotid bruitsHeart - RRR w/o mrg; PMI laterally displacedLungs - CTA w/o rrwMusculoskeletal - no cceNeuro - AXOX3, CN 2-12 grossly intact Laboratory findings:Serum sodium 135 mmol/LSerum potassium 3.0 mmol/LSerum glucose 100 mg/dLSerum creatinine 1.0 mg/dLSerum BUN 15 mg/dLSerum Aldosterone 40ng/mLSerum aldosterone:renin activity ratio is > 20

Hypercortisolism (Cushing's disease)

M.K. is a 35 year-old white female who presents with a dull persistent headache, and a significant amount of weight gain over the past six weeks.She states she is depressed and does not have the energy for normal daily tasks. PMH: Denies any chronic medical conditionsFH: One brother with type I DM and HTNSH: Denies use of tobacco, alcohol, or illicit drugsMedications: Ibuprofen OTC prn headacheAllergies: NKDA BP - 185/105 mmHgHR - 85 bpmRR - 14/minTemp - 98.3F (o)BMI - 27.5 (5'0", 141 lbs) Alert but anxious, moderately overweight w/ a round, full faceSkin - dry, thin w/ facial hair growth; hyperpigmentation of the extremities, purple abdominal striae, ecchymosis on arms/handsHEENT - oropharynx patent, moist mucous membranes, hyperpigmented gingivaNeck - thyroid nonpalpable, dorsocervical fat pad notedHeart - RRR w/o mrg, S1 S2 distinctLungs - CTA w/o rrwAbdomen - protuberant but nondistendedMusculoskeletal - diffuse atrophy, proximal muscle weakness noted Neuro - AXOX3, CN 2-12 grossly intact; muscle strength 3/5 throughout, DTRs +2/4 throughout

Ongoing management for hyperthyroidism

Maintenance therapy Usually consists of once daily dosing Usually continued for some time, such as 12 to 18 months in Graves hyperthyroidism, prior to consideration of withdrawal. Permanent hypothyroidism may be associated with RAI and total thyroidectomy Education prior to treatment commencement is required due to probability of hypothyroidism occurring, requiring replacement therapy for reminder of life & long term follow-up.

serum cholesterol and/or triglyceride levels

Many hypothyroid patients have high what levels (not T3 and T4 or TSH other level). Be sure to screen.

Lower urinary tract calculi

May be asymptomatic Sudden interruption of urinary stream as stone acutely obstructs bladder neck Moderate - severe dysuria Frequency, urgency, suprapubic pain Microscopic or gross hematuria

Urolithiasis

May occur in any portion of the urinary tract and may be associated with mild to severe symptoms Most common areas of obstruction include: Ureteropelvic junction (UPJ) The passage of the ureter over the iliac vessels Ureterovesicle junction (UVJ) Occurs in patients with Foreign material in bladder (i.e. left over sutures from GYN surgery, catheter parts left over after removal of catheter) Inadequate bladder emptying as in neurogenic bladder or chronic bladder outlet obstruction (most often due to benign prostatic hyperplasia)

Urge Incontinence

Most common form of incontinence Detrusor Hyperactivity Causes Inflammation/irritation Central impairment High urine volume load Chronic infection Interstitial cystitis Strong "Urge" followed by urine loss Unable to get to toilet quickly enough Unpredictable and abrupt leakage Urinary frequency Physical Exam Delayed leakage on stress test Post-void residual - normal (low)

Overflow Incontinence

Most common incontinence type in men usually due to BPH. Causes Medication: Relaxation of detrusor Neuropathy: Diabetes, MS, etc. Obstruction: BPH, Impaction, Stricture Continuous small leakage or dribble Symptoms mimic stress incontinence (cough and pee) Weak stream Hesitancy Frequency Nocturia Physical Exam: Urinary retention with bladder distention after voiding

Hypoglycemia

Most commonly caused by drugs used to treat DM Whipple's triad: (1) symptoms consistent with hypoglycemia, (2) low plasma glucose (usually < 55 mg/dL, not fingerstick), and (3) relief of symptoms after plasma glucose level is raised If prolonged can be fatal - consider in any patient with altered mental status, seizures - brain cannot synthesize glucose or store more than a few minutes supply as glycogen - requires continuous supply from arterial circulation Neuroglycopenic symptoms - caused by direct CNS glucose deprivation - behavioral changes, confusion, fatigue, seizure, loss of consciousness, death Autonomic symptoms include adrenergic and cholinergic symptoms Adrenergic - mediated by norepinephrine release - palpitations, tremor, anxiety Cholinergic - mediated by acetylcholine release - sweating, hunger, paresthesias Other common signs include diaphoresis, pallor, tachycardia, increased SBP Hypoglycemia unawareness or one or more episodes of severe hypoglycemia should trigger reevaluation of the treatment regimen Insulin-treated patients with hypoglycemia unawareness or an episode of severe hypoglycemia should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce risk of future episodes Ongoing assessment of cognitive function is suggested with increased vigilance for hypoglycemia by the clinician, patient, and caregivers if low cognition and/or declining cognition is found

Deficiency

Most commonly due to destruction of the glandular structure responsible for production (inappropriate autoimmune attack) Also due to defects in enzymatic machinery needed for hormone production or lack of appropriate precursors Iodine deficiency leads to thyroid disorder

Lithotripsy Shockwave

Most effective in fragmenting small </=10 mm stones Leaves residual stone fragments in approx. 35-55% of pts with larger renal stones/proximal ureteral stones Treatment of choice in some centers of distal ureteral stones

Chlamydia

My Patient has: UTI Sx. ( dysuria frequency) Pyuria on dipstick And NO bacteruria! What could it be??

Treatment for asymptomatic bacteriruia

Obtain UA & C&S prior to starting antibiotics! Antibiotic Choice: Mild infection: oral quinolones 10-14days Severe infection: IV/oral 14-21days

Dyslipidemia

Obtain a fasting lipid panel (FLP) Initial diagnosis Age 40 years Every 1-2 years Monitor statin **compliance** with serum LDL Extremely low, less than daily, statin doses may lower LDL cholesterol significantly There is an increased risk of incident DM with statin use but this increase is far outweighed by the reduction in cardiovascular events

Diabetic nephropathy

Optimize glycemic and blood pressure control Annual quantitative assessment of urinary albumin and eGFR in patients with type 1 DM of > 5 years and in all patients with type 2 DM 2 of 3 spot microalbumin specimens collected within 3-6 month period should be abnormal before considering albuminuria ACE-I / ARB - selective benefit in slowing decline in GFR in patients with albuminuria ACE-I reduces major cardiovascular disease outcomes in patients with DM ARB does not reduce risk of cardiovascular disease events or albuminuria in normotensive patients with type 1 DM or type 2 DM Combining an ACE-I and an ARB provides no additional benefit Smoking tobacco accelerates the decline in renal function - smoking cessation!

Uncomplicated cystitis No urine culture needed

Otherwise healthy woman who is not pregnant, clear history what is the diagnostic and management?

Secondary aldosteronism

Over-activity of the renin-angiotensin system, i.e. renin producing tumors, RAS, fibromuscular hyperplasia

Overload Proteinuria

Overproduction of circulating, filterable plasma proteins Monoclonal gammopathies Bence Jones proteins in multiple myeloma Myoglobinuria in rhabdomyolysis Hemoglobinuria in hemolysis What is this?

Bone density loss and fracture, particulary in elderly women

Overtreatment of hypothyroidism may increase risk of what conditions?

O2 saturation

Oxygen saturation measures how much of the hemoglobin in the red blood cells is carrying oxygen (O2), in percentage

Diabetes insipidus

P. J. is a 23 year-old male who presents with excessive thirst despite drinking large quantities of cold water daily. He states that he seems to urinate the same volume of fluid that he takes in and that his urine is as clear as water. He admits to nocturia and denies dysuria, abdominal pain, fever, dizziness.PMH: Subdural hematoma after a bike crash 3 months agoFH: NCSH: denies the use of tobacco, alcohol, illicit drugsMedications/NKDA: denies chronic medicationsAllergies: NKDA BP - 110/80 mmHgOrthostatic VS negativeHR - 80 bpmRR - 14/minTemp - 98.6F (o)Pulse Ox - 99% RABMI 26.6 (5'8", 175 lbs)WDWNM in mild distress, nontoxic appearing, conversant, cooperative w/ examHEENT - oropharynx patent w/ tacky mucous membranes-dry membrane-not expectedHeart - RRR w/o mrgLungs - CTA w/o rrwAbdomen - NABS x 4 quad, soft, non-tender, mild bladder distention notedMusculoskeletal - no CTENeuro: AXOX3, CN 2-12 grossly intact

Hypocalcemia

Paresthesias Chvostek's Sign-tapping on face get nerve twitch Trousseau's Sign-hand curls up when take BP Video Examples Seizures QT Prolongation These symptoms are a result from what?

Management of diabetes

Patients IGT, IFG, or HbA1c of 5.7-6.4% Intensive diet and physical activity behavioral counseling program targeting loss of 7% of body weight and increasing moderate-intensity physical activity (such as brisk walking) to at least 150 min/week. Metformin (Glucophage®) for the prevention of type 2 DM especially for those with BMI > 35 kg/m2, aged < 60 years, and women with prior GDM At least annual monitoring for the development of DM Screen / treat modifiable risk factors for cardiovascular disease

Chvostek's sign

Percussion on the masseter muscle irritates the facial nerve (CN VII), thus producing a hyperactive masseteric reflex- a twitching of the ipsilateral facial muscles bilaterally!

Urinary stress test

Perform valsalva maneuver, do a sit-up, or cough Results immediate leakage = Weakened muscles stress Incontinence delayed leakage = detrusor hyperactivity Urge incontinence

Diabetic neuropathy

Peripheral diabetic neuropathy commonly causes a peripheral symmetric polyneuropathy (stocking and glove) Risk factors include previous amputation, prior foot ulcer, foot deformity, peripheral vascular disease, visual impairment, peripheral neuropathy from another cause (esp. if on dialysis), poor glycemic control, and smoking Inspection of skin integrity, musculoskeletal deformity, and assessment of pedal pulses Identify loss of peripheral sensation Ankle reflexes 128-Hz tuning fork Pinprick sensation 10-g monofilament

Secondary disorder decreased hormone

Pituitary does not secrete enough stimulating hormone Concentration of BOTH target gland and stimulating hormone will be low

Secondary disorder increased hormone

Pituitary/hypothalamus over-stimulates the target gland Concentration of BOTH the target gland hormone and the stimulating hormone will be high

Acromegaly

Primary GH excess GH-cell adenoma Mixed GH-cell and PRL-cell adenoma Plurihormonal adenoma GH-cell carcinoma Most common cause is somatotroph adenoma of the AP What is this?

Low Elevated

Primary Hyperthyroidism has what TSH levels and what T4/T3 levels?

Blood reagent strip reaction

Principle: Pseudoperoxidase activity of hemoglobin catalyzes a reaction between hydrogen peroxide and a chromogen to produce an oxidized chromogen and water. Results: Yellow: negative Blue: positive

Bilirubin reagent strip reaction

Principle: Conjugated bilirubin (bilirubin glucuronide) reacts with diazonium salt in an acid medium to produce an azodye. False Positives Highly pigmented urines False Negatives Specimen exposure to light (bilirubin will break down in light) High levels of Vitamin C

Leukocyte Esterase Strip Reaction

Principle: Leukocyte esterase catalyzes the hydrolysis of an acid ester to produce an aromatic compound. The aromatic compound combines with a diazonium salt to produce a purple azodye. False Positive: Strong oxidizing agents (bleach) False Negative: High levels of protein, glucose, Vitamin C

Ketone reagent strip reactions

RXN: Sodium nitroprusside reacts with acetoacetic acid (20% of total ketones) in an alkaline medium to produce a purple color. Important Fact: Test doesn't measure beta-hydroxybutyric acid and is only slightly sensitive to acetone.

Renal Artery Stenosis

Refractory hypertension +/- Severely elevated BP (>200/100) New-onset HTN in older patient Acute kidney injury upon starting ACEI Azotemia in a patient with atherosclerotic disease Abdominal bruit What condition is this?

Upper urinary tract calculi

Renal colic Flank pain may radiate to ipsilateral anterior lower abdominal quadrant, groin or scrotum or labia in females Pain NOT improved by lying still Patients are unable to find comfortable position Nausea, vomiting Microscopic or gross hematuria Almost always present Fever or elevated WBC count may reflect infection Must rule out May be asymptomatic if not causing obstruction

Pyelonephritis in Pregnancy

Requires Hospitalization and IV antibiotics Urine culture requirements change to: C&S after treatment to confirm eradication C&S monthly for remainder of pregnancy 20% reoccur- prophylaxis -Nitrofurantoin 100 mg daily Renal ultrasound if unresponsive to treatment

Resin T3 (or T4) Uptake Indirect inverse test of serum thyroid-binding proteins (TBP) It is high when TBP is low A high resin uptake means that a patient's serum TBP is low or T4 is high Used to correct total T4 for the effect of high or low binding Normal range Total T3 = 3.5- 7.0 pmol/L

Monitoring response to treatment with hyperthyroidism

Serum TSH levels often remain suppressed for months following correction of hyperthyroidism, therefore all dosing should be established from interpretation of serum thyroxine (T4) & triiodothyronine (T3) levels. Recommendations are to review dosing for reduction after 3 to 4 weeks to avoid oversupression of thyroid gland. Dose reductions are based on clinical response as well as serum T4 & T3 levels. Essentially if serum thyroid hormone levels have reduced by half the dose can be halved. Subsequent dosing should be assessed every 3 to 6 weeks and individualized to response and serum T4 & T3 levels.

Thyrotoxicosis

Signs/symptoms/findings: Sweating, weight change, anxiety, loose stools/diarrhea, irritability, heat intolerance, weakness, dysmenorrhea, tachycardia, warm moist skin, tremor In Graves': goiter, maybe with bruit, and ophthalmopathy TSH in 1°, T4, fT4, T3, fT3

Hemolytic-Uremic Syndrome

Signs/symptoms: Prodrome of abdominal pain, diarrhea, vomiting followed by HTN, edema, oliguria, GI bleeding Usually result of infection with Shigatoxin-producing organism-toxin-E coli, Shigella- damages endothelium leading to microthrombi and red cell fragmentation

Observation= Doppler every 6 months, correction of dyslipidemia, platelet inhibitor

Stenosis less than 50% what is the management?

Sulfonylureas Meglitinides

Stimulates insulin secretion by interacting with ATP-sensitive potassium channels on pancreatic beta cells

Primary disorder increased hormone

Target gland over-secretes due to pathology directly affecting it Concentration of the target gland hormone will be high The stimulating hormone concentration will be low (d/t increased negative feedback)

Pituitary Adenomas

Term that embodies a number of benign masses of the pituitary-benign not harmful but tumor swollen and fill small space and will get mass effect-seizures Present with: Vision changes/loss Headaches Diplopia CSF Rhinorrhea Hormone deficiencies

Secondary hyperparathyroidism

The parathyroid glands overwork to compensate for long-standing hypocalcemia, triggering the parathyroid to release PTH Chronic Kidney Disease Chronic Malabsorption Pancreatitis, small bowel disease Malabsorption-dependent bariatric surgery Vit D deficiency Poor Ca ingestion

Asymptomatic Bacteriruria

The presence of bacteria in urine of patients who do not have dysuria, frequency, urgency, fever, flank pain, or other UTI symptoms.

Post-Void Residual

The volume of urine left in bladder after voiding Done with bladder U.S. Results < 50-100 Normal (Stress or Urge) 100—400 High (Overflow) > 400cc—very high...Insert Foley catheter! Get urine out or bladder will rupture!

Increase

Thiazide diuretics (HCTZ, chlorthalidone, etc) Lithium - for bipolar disorder (is a mood stabilizer) Antacids (Tums)- for heartburn Vit D intoxication This will do what to serum calcium and/or decrease urinary calcium excretion?

pCO2

This measures the pressure of carbon dioxide dissolved in the blood and how well carbon dioxide is able to move out of the body. Partial pressure

pO2

This measures the pressure of oxygen dissolved in the blood and how well oxygen is able to move from the airspace of the lungs into the blood. Partial pressure 60% become hypoxic

Diabetic ketoacidosis hyperglycemic syndrome

Usually younger patient Fruity breath odor, n/v, abdominal pain, Kussmal respirations Hyperglycemia (> 250 mg/dL) AG metabolic acidosis Positive serum / urine ketones

Opiates Antiemetics NSAIDS Alpha blockers (prazosin, tamsulosin) Steroids

What analgesics can you give for kidney stones?

Fluroquinolones

What antibiotic is only reserved for complicated cystitis?

Sepsis Unknown diagnosis Urinary tract obstruction

What are 3 absolute indications for hospitalization for pyelonephritis?

Reduced lean body mass Increased fat mass with visceral fat Hyperlipidemia LV dysfuntion HTN Increased plasma fibrinogen Reduced exercise capacity

What are GH deficiency clinical presentations in adults?

A low fluid intake A high animal protein diet A high salt diet Increased intake of oxalate-containing foods, particularly spinach A low calcium intake Excessive vitamin D supplementation Excessive sugar intake

What are dietary habits that increase kidney stone formation?

Hashimoto's thyroiditis Sub acute thyroiditis Iodine deficiency Post-ablative Post-surgical Drugs - Amiodarone - Lithium

What are differential diagnosis for hypothyroidism?

Skin turgor Dry mucous membranes

What are less reliable physical exams for fluids?

Pelvic muscle exercises Biofeedback

What are medical therapies for stress incontinence?

Bladder retraining Pelvic muscle exercises Biofeedback

What are medical therapies for urge incontinence?

Excretion of 30-300 mg of albumin per day (Sign of early renal disease)

What are moderately increased albuminuria?

VERY LITTLE Albumin Serum globulins Proteins secreted by the nephron Total of about 150 mg/day

What are normal urinary proteins?

Renal ultrasonography ASO titer Complement 3 and 4 levels Antinuclear antibodies (ANA) Anti-DNA antibodies Antineutrophil cytoplasmic antibody (ANCA) Anti-glomerular basement membrane (anti-GMB) (elevated in Good pasture's) Renal biopsy

What are other tests to evaluate Kidney Disease?

Intra-thyroidal hormone synthesis (iodine concentrations, transport, and organification) Thyroid metabolism (Deiodinases and hepatically metabolized) Thyroid binding proteins

What are other ways to regulate thyroid hormone levels?

Hematuria (kidney stone, malignancy, infection) Leukocyte Esterase (Infection) Glucose (Diabetes)

What are possible urinalysis results with UI and should be treated before the UI?

Decreased Jugular Venous Pressure (JVP) Orthostatic Tachycardia (15-20 bpm) Orthostatic Hypotension (>10-20 mm hg) Decreased Urine Output BUN/Cr Ratio >20:1

What are reliable physical exams for fluid tests?

Fatigue Weakness Cold intolerance Dyspnea on exertion Weight gain Constipation Dry skin Depression Hoarseness Edema Cognitive dysfunction Myalgias Arthralgias Menorrhagia Irregular menses Bradycardia

What are signs and symptoms of Hypothyroidism?

Fever, chills N/V Frequency, urgency, dysuria Hematuria Back pain unilateral Renal colic

What are some ROS questions to ask about with someone with potential kidney stone?

No calcium restriction (high amount leads to osteopenia, hyperoxaluria) Low sodium intake (high amount increases urinary calcium and thiazides) Low protein Increase urine output Thiazide diuretics Oral phosphate

What are some dietary treatment of calcium stones and hypercalciuria?

Ischemic-hypotension Nephrotoxic (Antibiotics-aminoglycosides, iodinated contrast, hemoglobin, myoglobin-hemolytic crisis-remain hydrated to lessen risk for hemoglobin-myoglobin-crushed muscles release myoglobin in massive amounts and end up with significant kidney disease-may never fully regain renal function-rhabdomyalisis-healthy ppl exercising get break down of muscle that causes it)

What are the 2 causes of acute tubular necrosis intrinsic renal AKI?

Thiazides (less potent) Loop Diuretics (more potent and need K supplement)

What are the 2 diuretics for CKD?

Vasculitis Malignant hypertension (rapidly progressive BP elevations with end organ damage)

What are the 2 main causes of vasculature AKI?

Early detection of liver disease Liver disorders, hepatitis, cirrhosis, carcinoma Hemolytic disorders

What are the 3 clinical significance of urine urobilinogen?

Level 1-Physical examination Level 2-chemical examination Level 3-microscopic examination

What are the 3 levels of routine urinalysis?

Electrolytes Basic metabolic panel (BMP) Comprehensive metabolic panel (CMP)

What are the 3 major chemistry panels?

Age over 60 Urinary tract anomaly Immunocompromised

What are the 3 relative indications for hospitalization for pyelonephritis?

Active Vitamin D3 (Calcitriol-need working kidneys) Calcitonin Parathyroid glands: PTH

What are the 3 serum calcium hormones to help with homeostasis?

Interstitial Nephritis Obstructive Uropathy Acute Tubular Injury

What are the 3 tubulointerstitial injury components?

Random specimen 24 hour specimen First morning specimen Catheterized specimen Midstream clean catch specimen Suprapubic aspiration Pediatric specimen Drug specimen

What are the 8 types of urine specimens?

Na+ Glucose K+ Creatinine Cl- BUN (Blood Urea Nitrogen) CO2 Calcium

What are the BMP components?

Na+ Albumin K+ Alkaline phosphatase(ALP) Cl- AST CO2 ALT Glucose Bilirubin Creatinine Calcium BUN Total Protein eGFR

What are the CMP components?

Urinalysis and urine culture Urine cytology if neoplastic cause suspected Renal function: Creatinine & BUN Serum calcium and glucose PSA +/-

What are the UI lab tests?

TMP-SMX Nitrofurantoin Fosfomycin

What are the antibiotic choices for cystitis?

Fluroquinolone Aminoglycosides

What are the antibiotics for pyelonephritis?

Oxybutynin Tolterodine Long acting formulations Patch (Side effects can't pee, see, spit, or shit)

What are the anticholinergics for urge incontinence?

Pseudomonas Klebsiella Enterobacter Serratia Moraxella

What are the atypical bacteria that are urine culture red flags and indicate another underlying cause?

pH protein glucose ketone blood bilirubin urobilinogen nitrite leukocytes specific gravity

What are the big 10 tests for reagent strips?

Diabetes (leading cause) HTN Lupus Chronic Glomerulonephritis Polycystic Kidney Disease Renal Artery Stenosis

What are the causes of Chronic Kidney Disease?

Bacteria Incomplete bladder emptying: obstruction from constipation Vesicureteric reflux -flow from bladder back up into kidneys Neuropathic bladder

What are the causes of UTI under age 2?

Post-infectious IgA nephropathy Henoch-Schonlein Purpura(HSP) Hemolytic Uremic syndrome (HUS) Goodpasture's syndrome (anti body produced cross reacts with tissue in lungs and end up with hemopysis-coughing up blood and kidney disease) SLE-(lupus)

What are the causes of glomerulonephritis?

High serum concentrations of both growth hormone and insulin-like growth factor 1 Growth of many tissues (skin, connective tissue, cartilage, bone, viscera, and many epithelial tissues. The metabolic effects include nitrogen retention, insulin antagonism, and lipolysis.) Soft tissue and skin Macrognathia Macroglossia Dental malocclusion Prognathia Bossing Bone and joints (hypertrophic arthropathy) No change in height Visceral enlargement (Thyroid, heart, lungs, kidneys) Cardiovascular disease (HTN, left ventricular hypertrophy, cardiomegaly) Sleep apnea

What are the clinical features of acromegaly?

Hypoglycemia Progressive weakness and fatigue Low BP and tachy Hyperkalemia Hyperpigmentation Salt cravings Sparse axillary and pubic hair in females Mental confusion and irritability Anorexia Weight loss Vomiting Diarrhea Vitiligo Dizziness/fainting Decreased libido Amenorrhea Lymphadenopathy

What are the clinical manifestations for Addison's disease?

Polyuria, polydipsia, polyphagia Rapid weight loss despite polyphagia Blurred vision Pruritus Weakness Paresthesias Vulvovaginitis Diabetic ketoacidosis (DKA)

What are the clinical presentation for Type I DM?

Polyuria, polydipsia, polyphagia Central obesity Blurred vision Pruritus Fatigue Chronic skin infections Poor wound healing Recurrent candida vaginitis Hyperglycemic hyperosmolar state (HHS)

What are the clinical presentations for Type 2 DM?

Pituitary Adenomas Pancreatic islet cell tumors Gastrointestinal tumors Nonfunctioning pancreatic tumors

What are the common multiple endocrine neoplasia?

Respiratory acidosis CO2 retention via acid drive on ventilation Hypoventilation

What are the compensatins with primary metabolic alkalosis?

Respiratory alkalosis CO2 elimination via acid drive on ventilation Kussmaul respiration

What are the compensations with primary metabolic acidosis?

Obstruction Hematuria Infection Hypertension

What are the complications caused by nephrolithiasis?

Always culture to identify the organism-C and S Initiate treatment immediately (prior to culture) Oral route preferred 7-14 day course is standard Complete imaging workup if under 2 years old

What are the considerations for pediatric UTI?

IGF-1 OGTT with GH levels Pit MRI

What are the diagnositc evaluation for acromegaly?

serum prolactin concentration above the normal range (>20) Repeat test if slightly elevated

What are the diagnositcs of prolactinoma?

Evoked GH <3 ng/mL MRI

What are the diagnostic evaluation for GH def in adults?

Urinalysis/dipstick Urine microscopic Urine Culture and Sensitivity Pregnancy test

What are the diagnostic evaluation for UTI?

High risk race/ethnicity (Black, Latino, Native, Asian) Women delivered a baby weighing more than 9 pounds HTN HDL cholesterol low and triglyceride high History of CVD

What are the diagnostic evaluation for diabetes in adults?

Hemoglobin A1c Fasting plasma glucose 2-hour oral glucose tolerance test Random plasma glucose

What are the diagnostic evaluation tests for DM?

CBC (Leukocytosis, platelet) Electrolytes (sodium, calcium, potassium) Uric acid Urinalysis (RBC, WBC, sedimentation for crystals) 24 hour urine X 2 (During normal diet and fluid consumption-urine pH and creatinine) Stone analysis Parathyroid hormones and Vitamin D

What are the diagnostic studies to get for kidney stones?

Decrease protein intake (0.8 g/kg) Decrease calcium (1000-1500mg/day) Decrease sodium intake (less than 2g/day) Restricted potassium Decrease phosphorus (0.8 to 1g/day) Max caloric intake of 30 to 35 kcal/kg/day Max fat intake less than 30% daily energy intake with sat fat limited to less than 10%

What are the dietary recommendations for patients with GFR less than 60 on dialysis?

Sodium: Potassium Chloride Carbon dioxide

What are the electrolyte panel components?

UA (not a great way) Urine albumin 24 hour urine for protein CMP with GFR (definitely order) (Renal biopsy-rare)

What are the evaluation tests for chronic kidney disease?

Renal ultrasound-test of choice MRA of brain (high risk pts only previous rupture, FHx of rupture, signs/sxs)

What are the evaluations for Polycystic Kidney Disease?

UA, microscopy (hematuria, proteinuria, eosinophils, WBC casts) Creatinine Biopsy (to differentiate between ATN, glomerulonephritis and interstitial nephritis)

What are the evaluations for acute interstitial nephritis?

Central and Nephrogenic Diabetes Insipidus

What are the excretion of free water components?

BUN Creatinine GFR Creatinine Clearance Albumin Albumin/Creatinine ratio Urinalysis Urine microscopy

What are the fundamental labs of the renal system?

Hyperventilation Salicylate intoxication (aspirin) CNS disorders Hyperexcitability Psychogenic paroxysmal hyperventilation Artifical ventilation

What are the initiating events for primary respiratory alkalosis?

Chronic potassium ion depletion Protracted vomiting Dehydration and depletion of ECF fluid

What are the initiating events of the primary metabolic alkalosis?

Diabetes mellitus and ketoacidosis (larger than normal anion gap) Severe shock or heart failure and lactic acidosis (septic patients) Diarrhea and loss of bicarb Renal tubular acidosis and retention of H ions

What are the initiating events with primary metabolic acidosis?

Glargine Detemir NPH Humulin

What are the intermediate and long-acting insulins for DM?

Elevated BUN, creatinine Eosinophilia (80% of cases)-(inflammation) Elevated sed rate-(non specific marker of inflammation) Microscopic hematuria, proteinuria

What are the lab findings for atheroembolic renal disease?

Helical (spiral) CT (first thing done) (detects renal/ureteral calciuli) KUB (detects radioplaque calculi) Ultrasound IVP (less dense calculi-point of obstruction) (golden standard) Retrograde pyelography (removal of stone and stint placement)

What are the lab imagining tests for kidney stones?

Recheck calcium if high Still elevated do PTH incr iPTH with incr serum calcium decr serum PO4 incr urinary Ca and PO4 Possible incr ALP +/- incr 25 (OH) vit D (Consider PTHrP, BUN/Cr, 24 hr urine for Ca and Cr)

What are the lab results for primary hyperparathyroidism?

incr iPTH Low serum Ca Incr serum PO4 incr urine Ca and PO4 incr BUN/Cr

What are the lab results for secondary hyperparathyroidism?

Increased BUN, creatinine, potassium, phosphate, magnesium Decreased pH, bicarb (metabolic acidosis with increased anion gap) BUN/Creatinine ratio 10-15/1 UA shows granular/renal epithelial casts Urine osmolality low (<350 mOsm/kg) FENa high (>2%) (tubules don't function to reabsorb sodium like they normally would)

What are the lab results in AKI intrinsic renal?

Serum glucose high Serum bicarb less than 10 Serum K normal to mildly elevated Serum Na decreased BUN elevated Positive serum/urine ketones Acidosis

What are the lab values for diabetic ketoacidosis? Serum glucose, bicarb, K, Na, BUN, urine, and pH

Serum glucose over 600 Serum osmolality over 350 Serum bicarb normal Serum K normal Serum Na normal BUN elevated Acidosis and ketosis mild

What are the lab values for hyperglycemic hyperosmolar state? Serum glucose, osmolality, bicarb, K, Na, BUN, pH, and ketosis?

Incr iPTH Incr serum ca Eventual incr urine ca Decr serum PO4 Nl to incr vit d Incr ALP Normal renal fxn

What are the lab values for primary hyperparathyroidism?

Incr iPTH Nl to low serum ca (etiology dependent) +/- Incr urine ca +/- Incr serum PO4 (esp if CKD) +/-Decr vit D Possible incr ALP Abnormal renal fxn (if CKD)

What are the lab values for secondary hyperparathyroidism?

BUN/creatinine, urine osmolality will vary based on extent of obstruction Increased BUN, creatinine, potassium, phosphate, magnesium Decreased pH, bicarb (metabolic acidosis, increased anion gap)

What are the labs for postrenal AKI?

increased BUN, creatinine, potassium, phosphate, magnesium Decreased pH, bicarb (metabolic acidosis with increased anion gap) BUN/Creatinine ratio is >20:1 Urine osmolality high Fractional excretion of sodium low (<1%)

What are the labs for prerenal acute kidney injury?

Decr iPTH Decr serum ca Decr,nl, or incr urinary ca Incr serum PO4 +/-Decr vit D NL ALP Normal renal fxn

What are the labs for primary hypoparathhyroidism?

Elevated when there is decreased blood flow to kidneys Congestive Heart Failure Shock Dehydration Elevated when there is excessive protein breakdown High protein diet

What are the limitations of BUN?

Skeletal mineralization Muscle contraction/relaxation Nerve conduction Hormone release Blood coagulation Activation/release of enzymes

What are the many roles of calcium?

Calorigenesis Protein Metabolism Carbohydrate Metabolism Lipid Metabolism

What are the metabolic effects of T3 and T4 hormones?

Carbimazole Proplythiouracil (reserved for management of hyperthyroidism in pregnant women or when Carbimazole isn't tolerated. Also inhibits peripheral conversion of T4 to T3)

What are the oral treatments for antithyroid agents that block thyroid hormone synthesis?

Urea (main component) Creatinine Uric acid

What are the organic urine composition?

Endogenous solutes Mannitol

What are the osmtic diuresis components?

Urine color, clarity, specific gravity

What are the physical examination of urine?

Skin pigmentation changes in volar hand creases, nails, gums

What are the physical exams for adrenal insufficiency?

ACEI and ARBs

What are the preferred agents for diabetic kidney disease and CKD with proteinuria?

Lungs Kidneys

What are the primary organs involved in acid-base disorders?

PaCO2 down Hydrogen down pH high

What are the resultant effects with primary respiratory alkalosis with PaCO2, hydrogen, pH

Decreased fluid intake (most common) Males Meds (loop diuretics, antacids, chemotherapeutic drugs) Gout (uric acid stones) Hypercalcemia PCKD UTI's (i.e. urea splitting organisms) Obesity

What are the risk factors for getting a kidney stone?

Weight Loss despite increased appetite Weakness Tremor Heat intolerance Palpitations-atrial fib Craving carbohydrates Dry eyes Muscle weakness Increased sweating Frequent bowel movements Frequent urination Anxiety Emotional lability Less frequent and lighter menstrual cycles Erectile dysfunction Gynecomastia (related to estrogen-testosterone broken down predominately by the liver and estrogen backs up to produce estrogen)

What are the signs and symptoms of Hyperthyroidism?

Tetany (NOT trousseas- no bp cuff) + chvostek Depression Kidney stones (etiology of hypoparathyroidism dependent). May have hypercalciuria Sinus brady Brittle nails cataract

What are the signs and symptoms of hypocalcemia?

Most asymptomatic Hypercalcemia an incidental on labs PTH is high Osteoporosis

What are the signs and symptoms of primary hyperparathyroidism?

Bone/joint pain renal osteodystrophy nephrolithiasis calcification of eyes, skin, arteries, tissues

What are the signs and symptoms of secondary hyperparathyroidism?

Delirium Severe tachycardia Vomiting Diarrhea Dehydration High fever, in many cases

What are the signs and symptoms of thyrotoxicosis?

bones, stones, abdominal groans, psychic moans with fatigue overtones Muscle contraction/relaxation 1+ reflex Palpitations HTN Osteoporosis Kidney stones Peptic ulcer disease

What are the symptomatic patients symptoms with primary hyperparathyroidism?

Tetany Seizures Arrythmias

What are the symptoms caused by hypomagnesemia?

Ssx hypercalcemia (bones, stones, abd groans, psychic moans, fatigue overtones), possible severe bone issues: osteitis fibrosa cystica, osteoporosis

What are the symptoms for primary hyperparathyroidism?

Ssx hypocalcemia: muscle cramps to tetany + Chvostek & trousseau Kidney stones

What are the symptoms for primary hypoparathyroidism?

Bone issues (renal osteodystrophy or osteitis fibrosa cystica,) metastatic calcifications, kidney stones ** More likely if etiology is ckd

What are the symptoms for secondary hyperparathyroidism?

Diaphoresis Flushing Nausea Muscle Weakness Chest Pain

What are the symptoms of hypermagnesemia?

Symptoms Rare Improved Outcomes Muscle Weakness Rhabdomyolysis

What are the symptoms of hypophosphatemia?

Correct underlying cause IV hydration Antibiotics Blood transfusion Treat heart failure/valvular disease

What are the treatments for Prerenal Acute Kidney Injury?

Incr water intake and exercise Avoid thiazide diuretics large doses of Vit D Ca immobilization Long term serum Ca, iPTH, and DEXA monitoring Estrogen Calcitonin, Bisphosphonates

What are the treatments for asymptomatic pts with primary hyperparathyroidism?

Stable-surgical or partial parathyroidectomy Unstable-endocrinology consult NOW Treat hypercalcemia large doses of IVF Lasix

What are the treatments for symptomatic primary hyperparathyroidism?

Transient (acute) Chronic (Urge Stress Overflow Mixed: Urge and stress Functional)

What are the two types of Urinary incontinence?

Aspart Lispro Regular Humulin

What aree the rapid acting insulins?

S. epidermitis

What bacteria is most commonly seen with catheterized patients?

S. saprophyticus

What bacteria is nitrite negative and associated with honeymoon cystitis?

Tumor Pregnancy Diabetes Illness (hospital sick)

What causes increase in thyroid hormones not related to diseases?

COPD Weak respiratory muscles (neuromuscular diseases) (Guillian Barre, Graves disease) Barbiturate poisoning (opioids, benzodiazepine, Benadryl)

What causes primary respiratory acidosis?

Urinary stress test Voiding diary Urodynamic testing

What clinical tests should be done with UI?

Life-threatening Arrythmias (Brady, Ventricular arrhythmia, asystole)

What conditions does hyperkalemia cause?

Risk factor (Prostate disease, anal sex, infected partner)

What do most men with a UTI have?

Increased BUN, creatinine, potassium, phosphate, magnesium Decreased pH, bicarb (metabolic acidosis with increased anion gap), calcium, hematocrit

What do the labs show for Chronic Kidney Disease?

CNS disease Hypoxia Anxiety Mechanical Ventilators Progesterone Salicylates/Sepsis

What does CHAMPS mean with respiratory alkalosis?

Contraction Licorice* Endo: Conn's/Cushing's/Bartter's)* Vomiting Excess Alkali* Refeeding Alkalosis* Post-hypercapnia Diuretics

What does CLEVER PD with metabolic alkalosis?

Glomerulonephritis

What does RBC on an urine microscopy cast indicate?

Pyelonephritis

What does WBC on an urine microscopy cast indicate?

Albumin and intact globulins (not as sensitive to all proteins evaluation with 24 hr urine or urine protein to urine creatinine ratio)

What does a dipstick evaluation detect with proteinuria?

Infection

What does a high pH on a dipstick indicate?

Tall peaked T waves

What does an EKG for hyperkalemia look like?

Flattened T waves or inversion and merges with U waves

What does an EKG look like for hypokalemia?

Pseudomonas

What does blue-green colored urine indicate?

Bile Myoglobin

What does brown colored urine indicate?

Bile Melanin Methylglobin

What does brown-black colored urine indicate?

Carbamazepine Aspirin Toluene Methanol Uremia Diabetic Ketoacidosis Paraldehyde or Phenformin ingestion Iron or Isoniazid Lactic Acidosis Ethylene glycol or Ethanol Ingestion Solvent or Salicylate Ingestion

What does catmudpiles mean with high anion gap metabolic acidosis?

Dehydration UTI

What does gold colored urine indicate?

Hyperalimentation Acetazolamide Renal Tubular Acidosis Diarrhea Uretero-Pelvic Shunt Post-Hypocapnia Spironolactone

What does hardups mean with normal/non-anion gap acidosis?

Increased mortality Arrythmias (VF and AF) Weakness and paralysis

What does hypokalemia cause?

Metformin/Methanol Uremia DKA Propofol INH/Iron Lactic acidosis/Linezolid Ethylene glycol Salicylates/Starvation

What does mudpiles mean with anion gap metabolic acidosis?

Bile Phenazopyridine

What does orange colored urine indicate?

Hematuria Hemoglobinuria Myoglobinuria Porphyria

What does red colored urine indicate?

Turbidity - clear Color - pale to light yellow Odor- Urine-like pH - 4.6 - 8.0 Specific Gravity - 1.005 - 1.030 Protein - none Glucose - none Ketones - none Blood - none Nitrites (enterobacteria) - none Leukocyte esterase - none

What is a normal urinalysis for turbidity, color, odor, pH, specific gravity, protein, glucose, ketones, blood, nitrites, leuckocyte esterase?

>150

What is a positive glucose number on a dipstick?

ASO titer

What is a test that tests for streptolysin O enzyme seen in patients with recent strep infection or rheumatic fever?

Congenital hypothyroidism

What is among the most common congenital diseases, incidence of 1/4000 newborns and is tested for when babies are born?

Hyperkalemia

What is an expected laboratory finding for adrenal insufficiency?

Turbidity - cloudy Color - deep amber pH - Increased Specific Gravity - may be elevated Protein -negative Glucose -negative Ketones - negative Blood -present in 50% of UTIs Nitrites (enterobacteria)- positive in 25% of UTIs Leukocytes- present

What is an urinalysis that indicates UTI for turbidity, color, odor, pH, specific gravity, protein, glucose, ketones, blood, nitrites, leuckocyte esterase?

Specific gravity pH Contents

What is evaluated on a urine dipstick?

Cataracts Ulcers Skin: striae, thinning, bruising Hypertension/ Hirsutism/ Hyperglycemia Infections Necrosis, avascular necrosis of the femoral head Glycosuria Osteoporosis, obesity Immunosuppression Diabetes

What is the CUSHINGOID mneomonic for Cushing's disease?

Mental status change

What is the best predictor of UTI in Elderly?

GFR

What is the best test to measure kidney function?

Dorsocervical fat pad (buffalo hump) Truncal obesity Moon facies Thimbing of limbs central fat deposition Abdominal striae

What is the clinical presentation of cushing's disease?

E. coli

What is the common pathogen for young women and elderly with UTI?

Metabolic alkalosis HCO3 retention via PaCO2 effect on renal proximal tubules

What is the compensation with primary respiratory acidosis?

Metabolic acidosis HCO3 elimination via reverse PaCO2 effect on renal proximal tubules

What is the compensation with primary respiratory alkalosis?

GFR less than 60 for 3 or more months

What is the criteria for diagnosis for Chronic Kidney Disease?

UA-hematuria, moderate proteinuria (<2 gm/d) Serum IgA level elevated

What is the diagnosis for Henoch-Schonlein Purpura?

MRI

What is the diagnosis for pituitary adenomas?

UA shows proteinuria Anemia, thrombocytopenia Elevated bilirubin

What is the diagnosis lab for HUS?

UA shows blood and proteinuria <1 gm/day, elevated serum IgA, elevated BUN and creatinine, complement levels normal

What is the diagnosis lab for IgA nephropathy?

UA shows blood, protein, RBC casts ; elevated ASO titer, decreased complement (C3, C4), elevated creatinine and BUN

What is the diagnosis tests for post-streptococcal glomerulonephritis?

Maternal history of diabetes or gestational diabetes during the child's gestation

What is the diagnostic evaluation for diabetes in children?

Elevated plasma fractionated free metanephrines Urinary assay for total metanephrines (unbound catecholamines)

What is the diagnostic evaluation for pheochromocytoma?

Grave's - autoimmune disorder Thyroiditis - autoimmine (Hashimoto's) - subacute (viral or inflammatory) Toxic Nodule Toxic Multinodular Goiter Exogenous Overuse Drugs-Amiodarone Pituitary tumor-secretes TSH Small Cell Lung Tumor

What is the differential diagnosis for hyperthyroidism?

Renal Ultrasound Doppler ultrasonography (flow through artery-see bruit) CT Angiography MR Angiography (MRA) Renal Arteriography (aka Renal Angiography and considered gold standard but invasive and risky)

What is the evaluation for renal artery stenosis?

Gastrointestinal (Vomiting and Diarrhea) Skin (Febrile illness, hyperthermia, burns, diaphoresis) Respiratory (hypervent and mechanical) Excessive Fluid Accumulation (Third Spacing) (Sepsis, burns, pancreatitis, malnutrition, peritonitis) Hemorrhage (Intra and extracorporeal)

What is the extrarenal components that cause hypovolemia?

Aminoglycoside with or without ampicillin (avoid aminoglycosides in renal disease) (3rd generation cephalosporin-ceftriaxone or quinolones other medications can take)

What is the first choice IV antibiotic for pyelonephritis inpatient treatment?

Respond to hypocalcemia to raise serum calcium levels

What is the function of PTH?

Urine culture and sensitivity (Guides antibiotic selection and identifies bacteria)

What is the gold standard test in pyelonephritis?

Calcium and hematocrit (AKI vs CKD in terms of lab is calcium decreased in CKD bc no activation of vitamin D and low calcium and for hematocrit kidneys make EPO but if CKD then decreased EPO so decreased hematocrit)

What is the lab values that will be decreased with chronic kidney disease and not with AKI?

greater than 200 mg/dL

What is the level of 2-hour oral glucose tolerance test and random plasma glucose is diagnosed as diabetes?

140-199 mg/dL

What is the level of 2-hour oral glucose tolerance test and random plasma glucose is diagnosed as prediabetes?

greater than 126 mg/dL

What is the level of Fasting plasma glucose is diagnosed as diabetes?

100-125 mg/dL

What is the level of Fasting plasma glucose is diagnosed as prediabetes?

GH replacement

What is the management for GH def?

Medical Management -dialysis if needed No more invasive vascular procedures Surgery to resect aortic aneurysm

What is the management for atheroembolic renal disease?

Treat underlying cause Anticoagulation

What is the management for renal vein thrombosis?

Creatinine Urinary albumin excretion Potassium

What is the management of CKD in Diabetics?

Supportive mostly Avoid direct trauma Treat HTN (ACEI or ARB) +/- Low protein diet Low sodium diet Care with nephrotoxic meds Monitor electrolytes Dialysis or renal transplant

What is the management of Polycystic Kidney Disease?

Low sodium and protein diet Thiazide diuretics (Dietary restriction of calcium increases risk of stone formation)

What is the management of hypercalciuria?

3 days

What is the maximum dose for Azo an analgesic for UTI?

Scheduled toileting

What is the medical therapy for overflow incontinence?

Pit microsurgery

What is the most appropriate therapy for acromegaly?

Pit resection

What is the most appropriate treatment for Cushing's disease?

Dopamine agonist

What is the most appropriate treatment for Prolactinoma?

Parathyroid adenoma (less than 30 years old)

What is the most common cause of outpatient asymptomatic hypercalcemia?

Diabetic neuropathy

What is the most common complication of DM?

Urge Incontinence

What is the most common form of incontinence?

IgA Nephropathy (Berger's Disease)

What is the most common glomerulnephritis worldwide?

Overflow Incontinence

What is the most common incontinence type in men?

Calcium oxalate

What is the most common kidney stone?

Mixed

What is the most common type of UI in women of all ages?

iPTH

What is the most frequently ordered parathyroid hormone test?

Increased fluid intake

What is the most important prevention of kidney stones?

8.8-10.2 mg/dL

What is the normal blood levels for calcium?

2500 mL/day

What is the normal intake for fluids?

1400-2300 mL/day

What is the normal output for fluids?

4.5-8

What is the normal pH range for urine?

greater than 6.5%

What is the percentage of A1c that is diagnosed as diabetes?

5.7-6.4%

What is the percentage of A1c that is diagnosed as prediabetes?

Edema Hypertension Fever Abdominal/flank pain Dark/Brown/Red Urine

What is the presentation of intrinsic renal AKI?

1.003-1.030

What is the range for specific gravity for urine?

PaCO2 retention

What is the resultant effect with primary respiratory acidosis?

Specialized urine dipstick Urine sample for microalbumin-creatinine ratio (should be measured if regular urine dipstick measures 1+ or greater)

What is the screening for microalbuminuria?

Neurologic Altered Mental Status

What is the symptoms of hypernatremia?

Fluids Analgesics Lithotripsy or ureteroscopy

What is the treatment for 5-10 mm stones?

Erythropoiesis-stimulating agents (ESAs) (If hemglobin less than 10 g/dL) Administer iron if have IDA (transferrin sat less than 25% and ferritin less than 500) Epoetin (SC injection weekly) Darbepoetin (SC infection every 2 to 4 wks)

What is the treatment for Chronic Kidney Disease?

Low protein diet Control HTN Tight glycemic control Erythropoetin, Calcium and Vitamin D supplements Monitor medications (no NSAIDS) Dialysis Transplant

What is the treatment for Chronic Kidney Disease?

Supportive maintain fluid and electrolyte balance control HTN transfusion if necessary

What is the treatment for HUS?

corticosteroids for renal disease (not for dermal/GI/joint symptoms)

What is the treatment for Henoch-Schonlein Purpura?

Metformin first then start insulin

What is the treatment for Type 2 diabetes?

Hydration Ureteral stent Percutaneous Nephrostomy (gold standard) Lithotripsy Strong analgesies Antibiotics for infection

What is the treatment for a stone greater than 10 mm?

Remove inciting agent Supportive care, rarely prednisone

What is the treatment for acute interstitial nephritis?

Fluro (6-12 weeks)

What is the treatment for bacterial prostatitis in men?

Central-desmopressin Nephrogenic-thiazide diuretic and indomethacin

What is the treatment for central and nephrogenic diabetes insipidus?

C&S is necessary prior to treatment (Organisms that make UTI more worrisome: Proteus, Klebsiella, Pseudomonas, serratia, enterococci, staphylococci and fungi.) Start empeirc tx with a broad spectrum antibiotic: (i.e. fluoroquinolone, ceftazidime. ) Tx for 7-14 days Follow-up urine culture-after treatment

What is the treatment for complicated UTI?

Fluoro (7-14 days)

What is the treatment for complicated cystitis in men?

IV fluid Short acting insulin Monitor electrolytes Acid-base status Renal function Serum glucose

What is the treatment for diabetic ketoacidosis?

Supportive HTN, fluid overload Steroids and cytotoxic drugs for SLE, Goodpasture's, Wegener's

What is the treatment for glomerulonephritis?

Volume expansion Bisphosphonates Decrease 1,25(OH)2D by glucocorticoids, chloroquine, ketoconazole

What is the treatment for hypercalcemia?

Citrate Thiazide Alkali

What is the treatment for hypercitraturia?

Higher mortality Fluid losses IV fluid IV rapid acting insulin Replace K Monitor electrolytes (sodium, potassium), serum glucose, and renal function (BUN, SCr, UOP))

What is the treatment for hyperglycemic hyperosmolar state?

C-Big-K-Drop-Down-Big Calcium Bicarbonate Insulin/Glucose Kayexalate (lacik) Diuretics Dialysis Big beta agonist

What is the treatment for hyperkalemia?

AVOID Mg++ in Renal failure Cease Therapy Loop Diuretic Dialysis

What is the treatment for hypermagnesemia?

Volume Expansion Dialysis Restrict Intake Phosphate Binders Calcium Carbonate Sevelamer HCl (Renagel®)

What is the treatment for hyperphosphatemia?

Oral antithyroid medications Radioactive iodine Thyroidectomy (Choice of therapy reflects cause of hyperthyroidism, initial or recurrent presentation, age, cardiac disease and management, iodine exposure, medication use influencing thyroid function and medication adherence history Dosing is generally based on severity of symptoms, gland size and medical urgency)

What is the treatment for hyperthyroidism?

Check albumin calcium gluconate elemental calcium (tums) Vitamin D2 or D3

What is the treatment for hypocalcemia?

Oral glucose IV glucose followed by glucose infusion SC or IM glucagon

What is the treatment for hypoglycemia?

Treat the Cause KCl PO or IV Treat Low Mg

What is the treatment for hypokalemia?

Magnesium Sulfate Magnesium Oxide Magnesium Chloride Magnesium L-lactate

What is the treatment for hypomagnesemia?

Oral Replacement Keep in Mind Na and K+ IV Replacement CONSULT Pharmacy

What is the treatment for hypophosphatemia?

Replacement therapy Thyroxine (first line) Liothyronine (T3) (shorter duration and rapid) (for severe cases or myxoedema coma)

What is the treatment for hypothyroidism?

Steroids for SLE and minimal change disease Control HTN Treat infections ACEI or ARB for diabetics-prevention

What is the treatment for nephrotic syndrome?

Treat Obstruction alpha-antagonists Double voiding Intermittent self-catheterization

What is the treatment for overflow incontinence?

Alpha blockers Calcium channel blockers Beta blockers prior to surgery Surgical removal of pheochromocytoma

What is the treatment for pheochromocytoma?

Supportive care Decrease sodium intake Diuretics Ace inhibitors

What is the treatment for post-streptococcal glomerulonephritis?

Relieve obstruction

What is the treatment for postrenal AKI?

Conservative TX vs surgery Meds: estrogen, biphosphonate, etc Acute: iv fluids, lasix, possible dialysis

What is the treatment for primary hyperparathyroidism?

Normalize mg Maintain serum ca, vit D levels Decr pH levels (diet, phoslo) Rx HCTZ Acute: IV ca gluconate Possible intubate

What is the treatment for primary hypoparathyroidism?

Etiology dependent; Maintain serum ca levels Large doses vit d Renal diet (low ph), phosphate binders (phoslo)

What is the treatment for secondary hyperparathyroidism?

Fluids Strain urine and analysis Analgesics Alpha blocker

What is the treatment for stones less than 5 mm?

Pelvic muscle exercises Estrogen cream Pessary (if pelvic floor prolapse) Biofeedback or Electrical stimulation Anticholinergics Surgery

What is the treatment for stress incontinence?

Complete removal by urologist Prevent new stone by preventing UTIs Urease inhibitor acetohydroxamic acid Antibiotics

What is the treatment for struvite stones (infection stones or triple phosphate stones)?

Anti-thyroid agents are given (High dose Propylthiouracil (PTU)-deactivate thyroid-prevent conversion to T4 and T3) Dexamethasone (usually IV, possible oral tapering required) Iodine Propranolol Lithium (may be used as adjunct to above) Avoid aspirin, as it displaces T4 from TBG, incr fT4 Definitive treatment with radioactive iodine after patient euthyroid

What is the treatment for thyrotoxicosis?

TMP/SMX or fluro (7 days)

What is the treatment for uncomplicated cystitis in men?

Behavioral therapy Bladder training (50% cure) (More effective than medication) Pelvic floor exercises: Kegel (81% reduction vs. 69% with medication) Biofeedback May help to learn Kegel Anticholinergics (after failure with the above)

What is the treatment for urge incontinence?

Raise urine pH Lower excessive urine uric acid Increase fruits and vegetables (alkali rich foods) Reduce acid foods Citrate salts and bicarb Allopurinol

What is the treatment for uric acid stones?

Remove offending agent Supportive care Dialysis

What is the treatment in intrinsic renal AKI?

Penicillamine Tiopronin (drug of choice-covalently binds to cysteine) Potassium citrate (raises pH) High urine output

What is the treatment of Cystinuria?

SLOW Volume Replacement Do Not Exceed 0.5 mEq/hr, only half the free water deficit in first 24 hours. If exceeded will get CNS issues Rule of thumb: For every 3 mEq of NA >150, you have a 1L free water deficit.

What is the treatment of hypernatremia?

Low oxalate Normal intake calcium and magnesium Low fat Cholestyramine (oxalate binding resin) Fluid intake Citrate

What is the treatment of hyperoxaluria?

Treat the Cause Fluid Restriction 500-800 ml/day Potassium Replacement Diuresis Isotonic Saline Vaptans Vasopressin receptor antagonists (VRA) Tolvaptan/Conivaptan Demeclocycline (induces nephrogenic diabetes insipidus) (dehydration due to the inability to concentrate urine)

What is the treatment of hyponatremia/SIADH?

Serum osmolality (Increased hyperglycemia, azotemia, alcohol) Urine osmolality (malnutrition, reset osmostat) Urine electrolytes (Na, K, Cl)

What is the work-up of hyponatremia?

24-Hour Urine Volume Osmolality Fluid Deprivation Test Desmopressin Challenge (>50% Increase Central <50% Nephrogenic) Pituitary MRI

What is the workup for diabetes insipidus?

Lifestyle Medical Therapy Pharmacologic Surgical (last resort)

What is treatment for UI?

High serum cortisol after dexamethasone administration

What laboratory findings are expected with Cushing's disease?

Increased GH level 3 hours after oral glucose load (Negative feedback)

What laboratory findings are expected with acromegaly?

Low urine specific gravity and low urine osmolality

What laboratory findings are expected with diabetes insipidus?

Macrovascular (CAD, cerebrovascular, PAD) Microvascular (retinopathy, nephropathy, neuropathy) Neural

What lesions with hyperglycemia are there?

Protein

What may be elevated in UTI on a dipstick?

Diuretics

What medication causes decreased levels of potassium?

HCTZ

What medication decreases urine calcium excretion?

Alkali

What medication increases urine citrate excretion?

Venlafaxine Amitriptyline Gabapentin Valproate Opioids

What medications are used for diabetic neuropathy?

Dosages need to be adjusted or avoided (Antibiotics, hypoglycemic agents, statins, analgesics, antihypertensives, H2 blockers-all need to be adjusted) (Avoided is metformin, sulfonylureas, aminoglycosides, long-term or high dose NSAIDs) Use creatinine clearance to adjust meds (decreased muscle mass in elderly creatinine may not be reliable-lower initially)

What needs to be done with meds in chronic kidney disease/renal insufficiency?

Blood

What on a dipstick is positive in 50% of UTIs?

Fundoscopic exam Inspect gingiva Dentition Mucous membranes Skin exam Foot exam-inspection Acanthosis nigricans Necrobiosis lipoidica diabeticoum Diabetic dermopathy Candidiasis

What physical exam components should you do with DM?

Above 20:1 (decreased blood flow to the kidneys-indicates not enough blood to kidneys= dehydration)

What ratio of BUN/Creatinine indicates decreased blood flow to the kidneys?

Mineralocorticoid Deficiency Tubulointerstitial injury Excretion of Free Water Osmotic Diuresis Other Diuresis (diuresis medications) Antibiotics (Bactrim)

What renal components cause hypovolemia?

Family or personal history of autoimmune diseases Women in postpartum period Medications (lithium) Age over 65

What risk are increased risks seen in pts with hypothyroidism?

Culture and Sensitivity

What should you always do in men with a UTI?

Image (renal ultrasound and cystogram-MCUG or VCUG or radionuclide scan-DMSA scan)

What should you do with All children 2 months to 2 years of age with first UTI Children not improving after 48 hours of treatment?

Sweating, weight loss, tachycardia, anxious, tremor, exopthalamus, diarrhea

What signs and symptoms are most likely in a patient with undetectable TSH but high T4 and T3?

Struvite

What stone has a pH above 7.2?

Calcium

What stone has a pH btw 5.5-5.8?

Uric acid or cystine

What stones have a pH less than 5.5?

Substantial hyperlipidemia Hyponatremia (inappropriate production of ADH) Elevated serum creatine kinase Macrocytic anemia Prior thyroid injury Pituitary or hypothalamic disorders Irregular heart rates Anxiety Weight changes Sleep disturbances Weakness Changes in weight Changes in bowel habits Heat/Cold intolerances Unexplained or rapid hair loss Menstrual dysfunction

What symptoms would occur and can occur by itself or with other symptoms that you would consider screening for thyroid dysfunction?

Endoscopic Transsphenoidal Resection

What technique do you do to remove a pituitary macroadenoma?

Anti-glomerular basement membrane (anti-GMB)

What test is used to test for Good pasture's?

Radiolucent

What test should you get for cysine stones?

Radiopaque

What test should you get for struvite stones?

Radiolucent

What test should you get for uric acid stones?

Radiopaque

What testing should you do to see calcium oxalate and phosphate stones?

Antinuclear antibodies and Anti-DNA antibodies

What tests are used to test lupus which affects the kidneys?

Tertiary

What thyroid disorders are not common and general occur in concert with a host of other neurologic and endocrine conditions. When they do occur they are generally due to abnormal thyrotropin regulating hormone (TRH) which is produced by the hypothalamus.

Secondary

What thyroid disorders are related to the pituitary gland which plays a role in the regulation of many of the bodies hormones. Thyroid stimulating hormone, or TSH, is produced by the pituitary gland in response to decreasing serum levels of the thyroid hormones T3 and T4 which it monitors continuously. This is referred to a positive feedback system since the increase in TSH released into the bloodstream results in an increased production of thyroid hormones. When T3 and T4 become normalized or overly elevated the pituitary responds by reducing or even stopping TSH production. The drop in TSH and subsequent drop in T3 and T4 production is referred to as a negative feedback system. Both the positive and negative feedback mechanisms help to ensure that the right amount of thyroid hormone is always present. A pituitary gland that inadequately or over-produces TSH results in a secondary disorder and might be seen in pituitary adenomas or similar

Doxycycline or Azithro

What treatment is need for chlaymida?

Post-void residual (PVR)

What urodynamic test should be done before antibiotics with UI?

Delayed DTR relaxation Coarse dry skin Bradycardia Puffy face Periorbital edema Loss of lateral third of eyebrows Slow movement and speech Diastolic hypertension Ascites Pericardial effusion Galactorrhoea (pit adenoma producing prolactin-drug spirolactone)

What would you find on a long standing or severe hypothyroidism exam?

Hyperactivity Warm moist skin Tremor Tachycardia Systolic hypertension Rapid speech Hyper-reflexia Goiter? Fine thin hair Muscle weakness Eyelid retraction Lid lag Exophthalmos (Grave's) Increased skin pigmentation (Grave's) (Melanocytes in Addison's produced by ACTH) Hyperkinetic

What would you find on a physical exam for hyperthyroidism?

Compensation

When a primary acid-base disorder exists, the body attempts to return the pH to normal via the "other half" of acid base metabolism.

Stones greater than 8mm Worsening pain Vomiting Fever Infection Can't tolerate fluids Renal deterioration Obstruction of kidney

When should you admit someone with a kidney stone?

Pyelonephritis Suspected Cystitis persistent or symptoms recur after tx. UTI symptoms with normal dipstick Immunosuppressed or elderly

When should you order Culture and Sensitivity?

Fluid overload (not responding to diuretics) Hyperkalemia Metabolic acidosis Severe uremia

When to consider dialysis in AKI?

Calcitriol

Which hormone acts directly on the small intestines to increase calcium absorption?

A, B, C, D, F (A- cloudy = decr vit d synthesis = decr gut Ca absorption B- PPI will decr Ca absorption due to decr stomach acid (acid needed for proper Ca absorption) C: could damage duodenum where Ca is absorbed, also would have diarrhea which can further lower Ca D: could cause losses of Mg, which would further decr the PTH, thus even lower Ca F: puberty results in incr skeletal demands for Ca)

Which of the following condition(s) increases the likelihood of a patient with iatrogenic hypoparathyrodism suddenly developing symptoms of hypocalcemia? (may be more than one) A. A move to London B. Rx of omeprazole (Prilosec) C. Development of Celiac disease D. Gastritis with continual emesis E. Vitamin D intoxification F. Hitting puberty

Sarcoidosis Incr PTH Vit D intoxification (not HCTZ b/c that doesn't incr GI absorption- just renal.)

Which of the following condition(s) or medications potentially increases GI calcium absorption? (may be more than one) HCTZ Furosemide Sarcoidosis Increased PTH Vitamin D intoxification

Which of the following is TRUE of Nonselective NSAIDs and selective COX-2 inhibitors? A. COX-2 inhibitors have a black box warning for increased risk of CV events, but nonselective NSAIDs do not. B. COX-2 inhibitors are a better choice for patients who have GERD or renal impairment. C. COX-2 inhibitors are a better choice for patients at risk for bleeding. D. COX-2 inhibitors are better at providing pain relief than nonselective NSAIDs.

Urine Microscopy Findings

White Blood Cells Normal values Men - < 2 per high power field (HPF) Women - < 5 per HPF Does not always mean infection "Kidney stones" can cause pyuria Bacteria 5 bacteria per HPF -bacteriuria Represents 100,000 colony-forming units (CFU) per mL Compatible with a UTI Contamination? Gram staining is not routinely done Epithelial cells (contamination) Red Blood Cells-always cancer unless proven otherwise Gross hematuria vs. microscopic hematuria Even a few RBCs is significant Followed to clearing Dysmorphic RBCs Suggest glomerular disease Also used to identify other casts, crystals

Men Pregnant women Children Hospitalized or in long term health care

Who has complicated UTIs?

Immunosuppressed Risk of bacterial endocarditis About to undergo urinary tract surgery or renal transplant Pregnant

Who should you treat for asymptomatic bacteruria?

AVP is produced in the hypothalamus and can be secreted into circulation

Why do lesions of the posterior pituitary rarely cause permanent diabetes insipidus?

GH secretion has a pulsatile secretion

Why is a single random GH level insufficient to make the diagnosis?

Act quickly Initially, consider one of 3 locations (pre-renal, renal, post-renal) HISTORY and physical exam are critical Creatinine and electrolytes are vital labs (Consider kidney problem in children with HTN/proteinuria)

You have a patient present with acute kidney injury (Creatinine - 3.3), how do you proceed?

Stress Incontinence

Younger women Cause: Impaired urethral closure Insufficient pelvic support Sphincter opens during bladder filling Intra-abdominal pressure (obesity/pregnancy) Males after TURP or prostatectomy Loss of bladder control during PA Obesity, prego Physical Exam Immediate leakage on stress test Post-void residual - normal (low)

Overarching Principle Homeostasis

a relatively stable state of equilibrium or a tendency toward such a state between the different but interdependent elements or groups of elements of an organism, population, or group.

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