CLIPP 31 Flashcards
3 things causing conjunctivitis
allergies, infection, chemical irritation
bacterial vs viral conjunctivitis
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.
bilat w pharnygitis and pre auriculuar LAD
adenovirus conjunctivitis
bilateral periorbital swellig - 3 thigns
sinusitis, allergic rhinits, URI
what can be a first sign of hypoalbuminemia
periorbital swelling/edema
in periorb swelling due to allergy, what else we woulld expect to see?
urticaria
generalized edema in male often best seen in
scrotal region
anasarca
severe generalized edema
when does peak growth of lymphoid tissue occur and what is its isignificance
b/w 4-6yo, and common to see mildly enlarged tonsils at this age due to frequent uri - pharnygitis unlikely unless exudate or erythema
how to assess for fluid wave
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.)
pitting edema is a feature of
anasarca
edema in nephrotic vs nephritic syndrome
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
liver failure and protein
will make less albumin, thus see edema but also jaundice likely
most common nephrotic in kids
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
important labs to look into if you have hypoalbuminemia
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.
mornng urine protein
usually morning urine has least protein
orthosatic proteinuria
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.
how much protein might children excrete after a fever or after significant exert - this will clear when stressor is cleared
1+ to 2+ (30-100mg/dl)
urine Pr:Cr ratio
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
normal, abnl and nephrOtic range prtein excr in 24h urine
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.
1+ protein
2+ pritine
30mg/dl on 2 random urines collected a week apart if urine SG < or = 1.015
100mg/dl if SG >=1.015
3 things that can cause nephrOtic syn
change in size of cap pores, change in hemodyn capillary flow so larger things get through, change in polyanion charge
any dz causing __ of ___ can cause proteinuria
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
tea colored urine
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
Elevated antistreptolysin-O (ASO) titer
Positive streptozyme test
Elevated anti-DNAase B antibodies, or
Low C3
PSGN
what cholesterol finding in nephrotic
high, and high tg - liver overcompensates for low protein by making other proteins like lipid ones and also clearance is decr
how does albumin leaking cause nephrOtic issues
albumin out, decr plasma colloid oncotic pressures so blood out, –>intravasc hypovolemia, activates RAAS, keep salt and water–>edema
mechanism of hyponatremia in nephrotic syn
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
this is a relatively frequent complication in adults w/ nephrotic syn
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.
typical tx primary nephrotic syn
corticosteroids, salt restrict 1500-2000mg/d
why not add album or lasix in nephrotic tx
albumin could expand volume intramuscularly too fast –>plum edema, and lasix could lead to dangerous hypovol
bx in fsgs
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.
while on tx for nephrotic sun, whats something to look for
infection - spontaneous perotnitis esp frequently
pt in remission from nephrotic tx should get
Polyvalent pneumococcal vaccine
Two doses of varicella vaccine (if not already immunized)
An annual influenza vaccine
aso titer in psgn
high - recent strep infxn would –>high anti body level against strep antigens, of which ask is one
nephrITIC syn typically presents w/
proteinuria, hematuria, and hypertension
tea or cola urine
PSGN
sign of pedal edema
outgrow nshoes
nephrotic syn defn
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.
