CLIPP 31

Question 1

3 things causing conjunctivitis

Answer 1

allergies, infection, chemical irritation

Question 2

bacterial vs viral conjunctivitis

Answer 2

bact more liekly in kids<6yo, hard to sometimes distinguish from viral but bacterial more likely to be bilateral w/ purulent exudate w/ eyelid crusting upon waking. both begin in one eye but have potential to spread.

Question 3

bilat w pharnygitis and pre auriculuar LAD

Answer 3

adenovirus conjunctivitis

Question 4

bilateral periorbital swellig - 3 thigns

Answer 4

sinusitis, allergic rhinits, URI

Question 5

what can be a first sign of hypoalbuminemia

Answer 5

periorbital swelling/edema

Question 6

in periorb swelling due to allergy, what else we woulld expect to see?

Answer 6

urticaria

Question 7

generalized edema in male often best seen in

Answer 7

scrotal region

Question 8

anasarca

Answer 8

severe generalized edema

Question 9

when does peak growth of lymphoid tissue occur and what is its isignificance

Answer 9

b/w 4-6yo, and common to see mildly enlarged tonsils at this age due to frequent uri - pharnygitis unlikely unless exudate or erythema

Question 10

how to assess for fluid wave

Answer 10

To assess for a fluid wave you need an assistant.

With the patient lying supine, have an assistant place her hand and forearm firmly across the vertical midline of the abdomen.
Place your hands on either side of the abdomen.
Tap one side of the abdomen firmly with your fingertips.
If ascites is present, you may feel a fluid wave hit your other hand. (The third hand is necessary to prevent transmission of the fluid wave through adipose tissue.)

Question 11

pitting edema is a feature of

Answer 11

anasarca

Question 12

edema in nephrotic vs nephritic syndrome

Answer 12

edema can signify glomerulonephritis but marked edema is more nephROTICand due to protein (albumin) loss and protein loss in nephROTIC is more than in nephrITIC

Question 13

liver failure and protein

Answer 13

will make less albumin, thus see edema but also jaundice likely

Question 14

most common nephrotic in kids

Answer 14

MCD - The characteristic histologic finding in minimal change disease is fusion and diffuse effacement of the epithelial cell foot processes on ELECTRON microscopy.
As implied by the name, the nephron appears relatively normal on light micros

Question 15

important labs to look into if you have hypoalbuminemia

Answer 15

electrolytes, bun, cr = renal fx
alt, ast, chol, tg, albumin = liver fx
c3/4 = screens for hypocomplemenetmia which is seen in psgn, mpgn, or secondary causes like lymphoma, SLE, HSP, etc
also cbc.

Question 16

mornng urine protein

Answer 16

usually morning urine has least protein

Question 17

orthosatic proteinuria

Answer 17

Orthostatic proteinuria is a frequent finding in adolescents and does not signify renal disease. As much as 1500 mg/1.73 m2 may be excreted in a 24-hour collection, but protein excretion occurs when the patient is standing, not while recumbent. When the first morning urine is checked it should be negative for protein.

Question 18

how much protein might children excrete after a fever or after significant exert - this will clear when stressor is cleared

Answer 18

1+ to 2+ (30-100mg/dl)

Question 19

urine Pr:Cr ratio

Answer 19

urine protein (mg/dL) / urine creatinine (mg/dL) = urine protein:creatinine ratio:

< 0.2 is normal in children older than 2 years (< 0.5 is normal in 6- to 24-month-olds)
> 1.0 is in a suspicious range for nephrotic syndrome
> 2.5 is diagnostic for nephrotic syndrome

Question 20

normal, abnl and nephrOtic range prtein excr in 24h urine

Answer 20

nl - < or = 4
abnl 4-40
nephrotic >= 40
In children it is difficult to obtain accurate 24-hour collections, so a urine protein:creatinine ratio is very useful.

Question 21

1+ protein

2+ pritine

Answer 21

30mg/dl on 2 random urines collected a week apart if urine SG < or = 1.015
100mg/dl if SG >=1.015

Question 22

3 things that can cause nephrOtic syn

Answer 22

change in size of cap pores, change in hemodyn capillary flow so larger things get through, change in polyanion charge

Question 23

any dz causing __ of ___ can cause proteinuria

Answer 23

inflammatio nof renal parenchyma - ie, nephritis - pyelo or glomerulonephrits
pyelonephritis (A). White blood cells and white blood-cell casts would be seen with a urinary tract infection, which would cause a positive leukocyte esterase test on the dipstick.

While acute glomerulonephritis (B) results in varying degrees of proteinuria, red blood cells and red blood cell casts would also be present, which would have caused a positive heme test on the dipstick. (Katie’s dipstick was negative for heme.) Link to a photo of tea-colored urine from a patient with acute poststreptococcal glomerulonephritis

Question 24

tea colored urine

Answer 24

consider impetigo, strep throat.
can tx both those w/ abx and in case of st it will minimize chance of rhematic fever but neither tx will decree change of PSGN

Question 25

Elevated antistreptolysin-O (ASO) titer
Positive streptozyme test
Elevated anti-DNAase B antibodies, or
Low C3

Answer 25

PSGN

Question 26

what cholesterol finding in nephrotic

Answer 26

high, and high tg - liver overcompensates for low protein by making other proteins like lipid ones and also clearance is decr

Question 27

how does albumin leaking cause nephrOtic issues

Answer 27

albumin out, decr plasma colloid oncotic pressures so blood out, –>intravasc hypovolemia, activates RAAS, keep salt and water–>edema

Question 28

mechanism of hyponatremia in nephrotic syn

Answer 28

fluid overload ( as you lose protein, you get intravasc hypovol see slide 27, and then activate RAAS), and in come cases, excess lipids–>milky hue

Question 29

this is a relatively frequent complication in adults w/ nephrotic syn

Answer 29

renal vein thrombosis
-Urinary loss of proteins that inhibit coagulation (antithrombin III) or increased fibrinolysis
Destabilization of platelets by hyperlipidemia
Increased fibrinogen levels, and
Increased blood viscosity due to a rise in the hematocrit (especially if diuretics are used without albumin replacement).
Intense, prolonged therapeutic use of corticosteroids, which are themselves thrombogenic, adds to the risk of thrombosis for patients with nephrotic syndrome.

Question 30

typical tx primary nephrotic syn

Answer 30

corticosteroids, salt restrict 1500-2000mg/d

Question 31

why not add album or lasix in nephrotic tx

Answer 31

albumin could expand volume intramuscularly too fast –>plum edema, and lasix could lead to dangerous hypovol

Question 32

bx in fsgs

Answer 32

On biopsy, most of the glomeruli in FSGS appear normal or show mesangial proliferation, while others, especially juxtamedullar glomeruli, show segmental scarring in one or more lobules.

Question 33

while on tx for nephrotic sun, whats something to look for

Answer 33

infection - spontaneous perotnitis esp frequently

Question 34

pt in remission from nephrotic tx should get

Answer 34

Polyvalent pneumococcal vaccine
Two doses of varicella vaccine (if not already immunized)
An annual influenza vaccine

Question 35

aso titer in psgn

Answer 35

high - recent strep infxn would –>high anti body level against strep antigens, of which ask is one

Question 36

nephrITIC syn typically presents w/

Answer 36

proteinuria, hematuria, and hypertension

Question 37

tea or cola urine

Answer 37

PSGN

Question 38

sign of pedal edema

Answer 38

outgrow nshoes

Question 39

nephrotic syn defn

Answer 39

Nephrotic syndrome is defined as proteinuria > 50mg/kg. However, this cannot be detected with a UA. A UA dipstick will show high albumin concentration (graded as 3+ or 4+), and is used as a screening tool. Additional testing will be needed to confirm the diagnosis.