Exam 3: Lectures

Question 1

Used to differentiate epididymitis v testicular torsion

Answer 1

TWIST score

Question 2

TWIST score:
Testicular swelling is ____ points

Answer 2

2

Question 3

TWIST score:
Hard testicles is ____ points

Answer 3

2

Question 4

TWIST score:
Absent cremasteric reflex is ____ points

Answer 4

1

Question 5

TWIST score:
N/V is ____ points

Answer 5

1

Question 6

TWIST score:
High riding testes is ____ points

Answer 6

1

Question 7

What is the major difference between epididymitis and testicular torsion?

Answer 7

Sudden onset
Lack of creamasteric reflex with torsion
Normal UA/UC with torsion

Question 8

Symptoms:
- Slow onset of testicular pain
- Voiding irritation
- Possible fever and chills
- no N/V
- Mild testicular tenderness
- Scrotum erythema
- Possible LAN
- Positive cremasteric reflex

Answer 8

Epididymitis

Question 9

Symptoms:
- Sudden onset testicular pain
- Generally presents after physical activity
- Afebrile
- Possible N/V
- Equisitely tender testes
- Scrotal edema
- No LAN
- No cremasteric reflex

Answer 9

Testicular torsion

Question 10

Your patient has sudden onset, severe testicular pain. The pain started after basketball practice today. The patient is doubled over and barely lets you exam him. When you attempt a physical exam you find his scrotum to be swollen, the patient near jumps off the table with palpation, and you are unable to illicit a creamasteric reflex. His TWIST score is a 6. He is afebrile, tachycardia and mildly hypertensive. What is your diagnosis and next step?

Answer 10

Testicular torsion with emergent referral to ED or urology

Question 11

33 y/o M presents to the PCP office with 5 days of testicular pain and discomfort. Pain has been gradually increasing, is primarily in his scrotum. He does not recall any injury, does have one new sexual partner that he has not been using condoms with as she told him she was on the pill. He is mildly febrile with low grade temp of 100.4F. He has irritation with voiding and thought he may have a UTI. On assessment, his scrotum is erythamatous, he has mild inguinal LAN, you can illicit a positive cremasteric reflex. You do a UA to r/o UTI and it comes back +2 RBC, +1 WBC, no bacteria, no leukocytes. You send the UA for culture with concern for what diagnosis and underlying cause?

Answer 11

Epididymitis with concern for cause of STI with new partner.

Question 12

33 y/o M presents to the PCP office with 5 days of testicular pain and discomfort. Pain has been gradually increasing, is primarily in his scrotum. He does not recall any injury, does have one new sexual partner that he has not been using condoms with as she told him she was on the pill. He is mildly febrile with low grade temp of 100.4F. He has irritation with voiding and thought he may have a UTI. On assessment, his scrotum is erythamatous, he has mild inguinal LAN, you can illicit a positive cremasteric reflex. You do a UA to r/o UTI and it comes back +2 RBC, +1 WBC, no bacteria, no leukocytes. You send the UA for culture. Culture results positive for E. Coli, what is your treatment of choice?

Answer 12

Cipro 500 mg PO BID for 14 days.

Question 13

33 y/o M presents to the PCP office with 5 days of testicular pain and discomfort. Pain has been gradually increasing, is primarily in his scrotum. He does not recall any injury, does have one new sexual partner that he has not been using condoms with as she told him she was on the pill. He is mildly febrile with low grade temp of 100.4F. He has irritation with voiding and thought he may have a UTI. On assessment, his scrotum is erythamatous, he has mild inguinal LAN, you can illicit a positive cremasteric reflex. You do a UA to r/o UTI and it comes back +2 RBC, +1 WBC, no bacteria, no leukocytes. You send the UA for culture and send your patient for STI serum testing. The culture comes back negative but the urine comes back positive for chlamydia. What is your treatment of choice?

Answer 13

Doxy

Question 14

33 y/o M presents to the PCP office with 5 days of testicular pain and discomfort. Pain has been gradually increasing, is primarily in his scrotum. He does not recall any injury, does have one new sexual partner that he has not been using condoms with as she told him she was on the pill. He is mildly febrile with low grade temp of 100.4F. He has irritation with voiding and thought he may have a UTI. On assessment, his scrotum is erythamatous, he has mild inguinal LAN, you can illicit a positive cremasteric reflex. You do a UA to r/o UTI and it comes back +2 RBC, +1 WBC, no bacteria, no leukocytes. You send the UA for culture and send your patient for STI serum testing. The culture comes back negative but the urine comes back positive for gonorrhea. What is your treatment of choice?

Answer 14

Cefrtiaxone IM x1 dose in office
OR
Gentamycin and azithromycin if he is allergic to cephalosporins

Question 15

What are the goals of BPH management?

Answer 15

Symptom relief and prevention of obstruction and infection

Question 16

What are the options for symptom relief management?

Answer 16

Alpha blockers and 5ARIs

Question 17

Your 78 y/o M patient has been diagnosed with BPH, with his most bothersome symptom being nocturia. He is looking for symptom management. He has a PMH of HTN. What is your medication of choice?

Answer 17

Alpha blockers: Doxazosin, Tamulosin, or Terazosin

Question 18

You have a 56 y/o M who comes in saying his daughter is a nurse and told him peeing every hour is not normal. He notices he has a weaker stream then before and doesn’t feel he empties his bladder fully. PVR in office in 146 mL. You suspect he has a slightly enlarged prostate. He has PMH GAD and HLD. What would be your choice for medication management?

Answer 18

Finasteride as he does not have HTN and this can help reduce hyperplasia

Question 19

You are concerned your patient may have the beginning stages of BPH based on his HPI. You complete what tool to screen him for treatment?

Answer 19

IPSS

Question 20

You have a 28 y/o M who presents today for STI screening. He primarily engages in sexual activity with other men and is not the best at condom use. He has a new partner and wants to be safe. You screen him for HIV, syphillis, chlamydia and gonorrhea. His RPR is positive, everything else is negative. What is your treatment?

Answer 20

IM PNC G to the buttocks, one time dose now

Question 21

You have a 24 y/o F who comes in for her well woman exam. She endorses having a new sexual partner and is interested in STI screening today. What will you suggest for her?

Answer 21

Gonorrhea and Chlamydia urine testing

Question 22

You have a 24 y/o F who comes in for her well woman exam. She endorses having a new sexual partner and is interested in STI screening today. You collect a urine to complete screening for gonorrhea and chlamydia. She comes back negative for gonorrhea, positive for chlamydia. She is not pregnant. What is your treatment suggestion?

Answer 22

Doxycycline

Question 23

You have a 24 y/o F who comes in for her well woman exam. She endorses having a new sexual partner and is interested in STI screening today. You collect a urine to complete screening for gonorrhea and chlamydia. She comes back negative for gonorrhea, positive for chlamydia. She is 8 weeks pregnant as well. What is your treatment suggestion?

Answer 23

Azithromycin

Question 24

You have a 19 y/o F who comes in seeking birth control. She recently starting seeing a new partner and would like to prevent pregnancy. You offer her STI screening as she endorses inconsistent condom use. Her urine testing comes back positive for gonorrhea. What would you suggest for treatment?

Answer 24

Ceftriaxone, IM today in office

Question 25

You patient comes in with a new noted "bump" on his penis. Upon assessment, you diagnose him with genital warts. What is your treatment of choice?

Answer 25

Imiquimoid topically. If this does not improve, then we could consider cryotherapy

Question 26

Who is at greatest risk for syphillis infection?

Answer 26

Males Men who have sex with men HIV + persons Young adults Persons who have been incarcerated, sex workers, or military service members

Question 27

Who should be screened for gonorrhea and chlamydia?

Answer 27

Sexually active women <24 y/o Women 25+ with RFs

Question 28

What are the biggest risk factors of gonorrhea and chlamydia?

Answer 28

New partner More then 1 partner at a time Partner is STI positive Inconsistent condom use in a non-monogomous relationship

Question 29

Symptoms: - Very ill, toxic-appearing - Febrile - Irritative voiding - Referred prostatic pain - DRE with tender, enlarged, "hot" prostate - No SP tenderness or CVAT tenderness

Answer 29

Acute bacterial prostatitis

Question 30

Symptoms: - Mildly ill, no acute distress - Afebrile - Irritative voiding - Dull peritoneal and SP pain - DRE: normal prostate - SP tenderness with palpation

Answer 30

Chronic prostatits

Question 31

What is the biggest difference between acute and chronic prostatitis?

Answer 31

Onset Fevers Prostate tenderness Where the pain radiates

Question 32

In a patient with suspected acute bacterial prostatitis, your UA will show _____ and your UC may show ______.

Answer 32

UA will have heme and WBCs, UC will be Gram -/ E. coli

Question 32

In your patient with chronic prostatitis, the UA will show ______ and the UC will show _____.

Answer 32

UA will generally be normal/unremarkable and UC will grow Gram -/ E. coli

Question 32

When is a CT ab/pelvis or US indicated in a patient with suspected chronic prostatitis?

Answer 32

If the urine is equivocal

Question 33

When is a CT ab/pelvis or US indicated in a patient with suspected acute bacterial prostatitis?

Answer 33

If there is concern for rectal abscess.

Question 34

In the treatment of prostatitis, what is the most significant difference with management?

Answer 34

Length of antibiotic therapy

Question 35

What is your first line medication for management of prostatitis?

Answer 35

Bactrim

Question 36

When is Cipro or Levaquin used in the treatment of prostatitis?

Answer 36

2nd line Allergy to Bactrim Men < 35 y/o Men 35 + with increased risk for STI

Question 37

When treating chronic prostatitis, how long is treatment normally?

Answer 37

4-6 weeks

Question 38

In a patient with prostatitis, when can they resume sexual activity?

Answer 38

When they completed their abx treatment and their UC is negative

Question 39

When a patient comes in c/o ED symptoms, what is the #1 thing you need to rule out?

Answer 39

CVD

Question 40

Aging, cirrhosis, hepatitis, and anticonvulsants can affect SHBG by _____ it, which in turn can present as ED.

Answer 40

Increases the SHBG

Question 41

DM, obesity, nephrotic syndrome, and steroid use can affect SHBG by ______ it, which in turn can present as ED.

Answer 41

Decreases the SHBG

Question 42

The primary medication management of ED is with which medication(s)?

Answer 42

PDE5: Sildenafil, tadalafil, vardenafil

Question 43

When screening for PSA, what is the primary factor in ordering testing?

Answer 43

Joint decision making with patient and provider

Question 44

When is PSA screening recommended by the USPSTF

Answer 44

55-69 y/o 45+ with risk factors 40+ with high risk factors

Question 45

STRAW 10+ is a tool used for what?

Answer 45

Menopause/menstrual life cycle staging

Question 46

What is the average age for menopause?

Answer 46

51 y/o

Question 47

12 consecutive months without a menstrual cycle is considered ...

Answer 47

Menopause

Question 48

What are some of the earlier signs of menopause?

Answer 48

Irregularity in cycle length and frequency Hot flashes Insomnia Decreased libido Mood alteration/irritability

Question 49

As hormone levels continue to decrease in menopause, symptoms women may see include ...

Answer 49

Vaginal atrophy Incontinence Skin changes

Question 50

Menopause puts women at increased risk for what disease processes?

Answer 50

CVD Osteoporosis Dementia/Alzheimer's Cancers (breast, ovarian, endometrial)

Question 51

Hot flashes and cold sweats are considered:

Answer 51

Vasomotor symptoms (VMS)

Question 52

Vulvovaginal dryness, irritation, burning, dysuria, vaginitis, and recurrent UTIs are considered:

Answer 52

Genitourinary symptoms of menopause

Question 53

GSM is treated hormonally by which route of medication

Answer 53

Vaginally

Question 54

What is the primary cause for sleep disturbances in menopause?

Answer 54

VMS

Question 55

What is the primary cause for memory and cognition changes in menopause?

Answer 55

Sleep disturbances

Question 56

When considering menopause treatment, what lab tests would you order and why?

Answer 56

TSH, blood glucose, lipid panel to rule out underlying causes for symptoms

Question 57

How can stress management be helpful in treating postmenopausal symptoms?

Answer 57

Helps to improve VMS, enhance sleep and decrease stress levels

Question 58

What is a modality that is may help with VMS?

Answer 58

Accupuncture

Question 59

How do phytoestrogens work?

Answer 59

They bind to the ER-beta to help with bone, blood vessel, nervous system and skin health

Question 60

Where are phytoestrogens found?

Answer 60

In plants (legumes, seeds, beans, soy, whole grains, veggies)

Question 61

How does black cohosh work?

Answer 61

It binds to serotonin, dopaminergic, and GABA receptors

Question 62

How do Omega-3 help with menopause management?

Answer 62

Helps with CVD risk protection

Question 63

What are some precautions with black cohosh?

Answer 63

If can be hepatotoxic Needs to be used in caution with SSRI/SNRIs Primarily only helps with VMS

Question 64

How does Rheum Rhaponticum (ERr-731) work?

Answer 64

It binds to the ER-beta to help with bone, blood vessel, nervous system and skin health

Question 65

What is Rheum Rhaponticum (ERr-731) effective in helping with menopause management?

Answer 65

VMS, anxiety

Question 66

When treating menopause symptoms, what is your first line, non-hormonal options?

Answer 66

SSRI

Question 67

When treating menopause symptoms, what is your first line, hormonal options?

Answer 67

HRT (estrogen)

Question 68

Of the HRT routes, which is the first choice and why?

Answer 68

Transdermal as it avoids first pass effect in the liver allowing for lower doses then with oral

Question 69

With HRT, when is vaginal route most effective?

Answer 69

When treating GU/vaginal symptoms/complaints

Question 70

When is oral HRT used?

Answer 70

If not responding well to transdermal

Question 71

What is the use for bioidentical hormones?

Answer 71

When a women needs a HRT that is not available pharmaceutically or has an allergy to the pharmaceutical options, so she needs something more tailored and specific.

Question 72

You 54 y/o F with LMP 15 months ago comes in for concerns about her memory. She has noticed she is having more difficulty with misplacing items and finding the words she is trying to say. She is sleeping about 5 hours a night with difficulty both falling asleep and staying asleep. She has not noticed any recent mood changes or long-term memory loss. What is your next step?

Answer 72

Screen for dementia with the SBT or MMSE depending on time available in office today, however more likely this is sleep related

Question 73

If you are crunched for time and are concerned for memory decline, what are 3 screening options you could use?

Answer 73

SBT, BAS, or the Ottawa screening

Question 74

Your 48 y/o F patient comes in c/o vaginal irritation with intercourse. Her LMP was 10 months ago and she thinks she may be going through "the change" as this was about the time her mother went through menopause. She has no other complaints and would like recommendations on management. You would recommend:

Answer 74

Lubricants, regular sexual activity and vaginal exercises

Question 75

Your 57 y/o F patient is complaining of more increased stress incontinence since going through menopause. She has noticed some vaginal atrophy and dryness. She has noticed some increase in comfort with her estrogen patch, but is still having incontinence. You suggest:

Answer 75

Switching her estrogen patch to a vaginal estrogen ring as the ring can help put a small amount of compression on the urethra to assist with incontinence.

Question 76

When considering women's sexual health in relation to menopause, the most important aspect to assess the effect on is...

Answer 76

The patient's relationships

Question 77

What is the gold standard laboratory test for Hep A?

Answer 77

Anti-HAV IgM

Question 78

Risk factors for Hepatitis A include ....

Answer 78

Occupational exposure Travel to endemic areas IVDU Homelessness

Question 79

What is the incubation period of Hepatitis A?

Answer 79

15-50 days with the average being 28 days

Question 80

How is Hepatitis A treated?

Answer 80

Symptom management It is otherwise a self-limiting disease

Question 81

You have a 42 y/o patient who comes in to the office today. Their sister was recently diagnosed with Hepatitis A. She was visiting for 2 weeks for the holidays. The patient is concerned about contracting Hepatitis A. What can you do for management?

Answer 81

Prophylactic Hepatitis A vaccine

Question 82

Which Hepatitis is often co-infecting with Hepatitis A if travel to areas of endemic Hepatitis were present?

Answer 82

Hepatitis E

Question 83

What assisted with Hepatitis B decline in the past years in the U.S.?

Answer 83

Hepatitis B vaccination

Question 84

Who should be screened for hepatitis B?

Answer 84

Persons at increased risk of exposure Pregnant women (with each pregnancy) Patients greater then 18 y/o (only need this once to establish immunity) Infants born to HBsAg positive moms

Question 85

Lab interpretation: - HBsAg - Total Anti-HBc - Anti- HBc IgM - Anti-HBs (HBsAb)

Answer 85

Not immune, no immunized, not infected with Hepatitis B, is at increased risk for disease at this time

Question 86

You are screening your 18 y/o M patient prior to starting college. Your patient comes in with the following labs: - HBsAg - Total Anti-HBc - Anti-HBc IgM - Anti-HBs (HBsAb) What is your next step?

Answer 86

Start the Hep B vaccination process (booster if has documented Hep B x3 series or catch up full series if no documented Hep B)

Question 87

Lab interpretation: + HBsAg - Total Anti-HBc - Anti-HBc IgM - Anti-HBs (HBsAb)

Answer 87

Early acute Hepatitis B

Question 88

Your patient has the following labs: + HBsAg - Total Anti-HBc - Anti-HBc IgM - Anti-HBs (HBsAb) What would you like to do next?

Answer 88

Run replication studies for Hepatitis B to help guide treatment

Question 89

Lab interpretation: + HBsAg + Total Anti-HBc + Anti-HBc IgM - Anti-HBs (HBsAb)

Answer 89

Acute Hepatitis B infection

Question 90

Your patient comes in with these labs: + HBsAg + Total Anti-HBc + Anti-HBc IgM - Anti-HBs (HBsAb) What do you want to do next?

Answer 90

Order replication tests and co-infection testing, treat the underlying infection. Prophylactically test partners for immunity if needed as well and treat them with vaccination if not immune.

Question 91

When do you treat for Hepatitis B?

Answer 91

ALT >/= 2x the upper limit HBV DNA >20,000 with or w/o +HBeAg

Question 92

Lab interpretation: - HBsAg + Total Anti-HBc + Anti-HBc IgM - Anti-HBs (HBsAb)

Answer 92

Recovering acute infection

Question 93

Lab interpretation: - HBsAg + Total Anti-HBc + Anti-HBc IgM + Anti-HBs (HBsAb)

Answer 93

Recovering acute infection

Question 94

In recovering Hepatitis B, what do you expect to see with the Anti-HBs (HBsAb) value?

Answer 94

It may be positive or negative depending on how far along the patient is in the recovery process and if they have built up antibodies at that time

Question 95

Lab interpretation: - HBsAg + Total Anti-HBc - Total Anti-HBc IgM + Anti-HBs (HBsAb)

Answer 95

Recovered infection

Question 96

Lab interpretation: + HBsAg + Total Anti-HBc - Total Anti-HBc IgM - Anti-HBs (HBsAb)

Answer 96

Chronic Hepatitis B infection

Question 97

Your patient comes in with the following labs: + HBsAg + Total Anti-HBc - Total Anti-HBc IgM - Anti-HBs (HBsAb) What would you like to do next?

Answer 97

Test for replication levels and co-infection to guide treatment.

Question 98

Your male patient comes in with the following labs: + HBsAg + Total Anti-HBc - Total Anti-HBc IgM - Anti-HBs (HBsAb) You test for replication and co-infection with the following labs: + HBeAg - Anti-HBe HBV DNA 21,000 ALT 100 (3x greater then upper limit) Anti-HCV negative Anti-HAV negativ - HIV What do you chose to treat with?

Answer 98

Peg-INF, Tenofovir, or Entecavir

Question 99

Your male patient comes in with the following labs: + HBsAg + Total Anti-HBc - Total Anti-HBc IgM - Anti-HBs (HBsAb) You test for replication and co-infection with the following labs: + HBeAg - Anti-HBe HBV DNA 21,000 ALT 100 (3x greater then upper limit) Anti-HCV negative Anti-HAV negativ + HIV HIV DNA: 3,000 What do you choose to treat with?

Answer 99

Tenofovir with Lamuvidine or Emtricitabine

Question 100

How long will you treat your patient for Hepatitis B?

Answer 100

For 12 months after the patient has established a normal ALT and an undetectable viral load (HBV DNA)

Question 101

Lab interpretation: - HBsAg + Total Anti-HBc - Total Anti-HBc IgM - Anti-HBs (HBsAb)

Answer 101

False positive or prior infection. Retesting and further workup is indicated

Question 102

Lab interpretation: - HBsAg - Total Anti-HBc - Total Anti-HBc IgM + Anti-HBs (HBsAb)

Answer 102

Immune to Hepatitis B

Question 103

You have a 17 y/o F patient who comes in for her pre-college physical exam. Her school requires immunization records. As she is a nursing major they would also like titers for MMR, varicella, Hepatitis B. You run the titers. Her hepatitis panel comes back first and these are the results: - HBsAg - Total Anti-HBc - Total Anti-HBc IgM + Anti-HBs (HBsAb) - Anti-HCV What is your next step?

Answer 103

Provide a copy of titers showing immunization to the patient to submit for her college. She needs no further interventions.

Question 104

What Hepatitis if often seen as a co-infection with Hepatitis B?

Answer 104

Hepatitis D

Question 105

How are patients protected against Hepatitis D?

Answer 105

Hepatitis B vaccination helps cover against both Hep B and Hep D

Question 106

You complete routine labwork on your 33 y/o M patient for his annual wellness exam. He has no PMH, endorses a long-time monogamous male partner. His ALT comes back at 167. What is your next test?

Answer 106

Run a hepatitis panel

Question 107

Why is screening for Hep B and Hep C a recommendation by USPSTF?

Answer 107

They are commonly asymptomatic diseases but can cause significant damage to the liver

Question 108

How is Hep C treated?

Answer 108

Based on the genotype

Question 109

What is the most common Hepatitis C genotype?

Answer 109

Type 1 with subclasses of a and b

Question 110

What is the incubation period for Hepatitis C?

Answer 110

2-26 weeks with the average being 2-12 weeks

Question 111

Who should be screened for Hepatitis C?

Answer 111

Everyone 18+ at least one time Pregnant women Persons with increased risk factors Persons with elevated ALT

Question 112

Your patient is screened for Hep C. Their Anti-HCV comes back positive. Do they have Hep C? Why?

Answer 112

They do not have Hep C. They have been exposed or previously treated.

Question 113

Your patient is screened for Hep C. Their Anti-HCV comes back positive. What do you order next?

Answer 113

HCV RNA to confirm diagnosis and Genotyping to guide treatment

Question 114

You patient is HCV + and HIV +. They are HCV Genotype 1a. Your treatment of choice would be...

Answer 114

Ledipasvir/Sofosbuvir for 8 weeks

Question 115

Your HCV + patient is seeking treatment, but is concerned for cost. They currently are un-insured. They are Genotype 1a for HCV with an RNA of 150,000. What medication is the cheapest for them and how long will they need to be on it?

Answer 115

Sofosbuvir/Velpatasvir for 12 weeks

Question 116

What is the most important aspect when it comes to treating Hepatitis C?

Answer 116

Medication adherence

Question 117

Can a patient receiving Hepatitis treatment drink alcohol?

Answer 117

No, it is not recommended at there is already a liver insult and you do not want to further the injury

Question 118

When completing a workup when concerned for liver disease, what are the important first steps?

Answer 118

Detailed H&P Labs: CBC with diff, CMP, PT/INR, TSH w/ reflex

Question 119

Your patient comes back positive for elevated ALT on their lab work. You run a hepatitis panel which is negative, what would you like to do next?

Answer 119

Updated lipid panel ESR (sed rate) Full LFTs (including GGT) Bilirubin (w/ fraction) Iron studies Ceroplasmin Alpha-1 antitrypsin ANA and RF (rheum factor)

Question 120

You complete a full panel of labs for elevated ALT. All labs are negative. What would you do next?

Answer 120

Order an US or CT and refer to a GI/hepatologist

Question 121

Your patient has an ALT of 240, jaundice of his sclera, with a negative hepatitis panel. He has PMH of ETOH abuse with presently endorses drinking 1 pint of vodka and 10 beers a day. You suspect ETOH cirrhosis. How would you treat him?

Answer 121

Refer to GI, encourage/support ETOH cessation

Question 122

Your patient with mildly elevated ALT of 100 has a negative lab work up. You send them for US of RUQ that shows NAFLD. What is your management?

Answer 122

Lifestyle modifications (diet and exercise) Avoiding hepatotoxic agents

Question 123

Your patient tests positive for Wilson's disease. What team members would you add to their care team?

Answer 123

Referrals to: GI for management Genetics for detailed interpretation and education of results Nutritionist for low copper diet assistance

Question 124

Your patient with Wilson's disease needs what plan for the PCP?

Answer 124

Low copper diet

Question 125

What is the first symptom to present for a patient with CKD?

Answer 125

Fatigue

Question 126

When assessing CKD on labs, what lab value is of concern?

Answer 126

eGFR

Question 127

When assessing AKI on labs, what lab value is of concern?

Answer 127

Creatinine

Question 128

Lab interpretation: eGFR >/= 90

Answer 128

G1, Normal

Question 129

Lab interpretation: eGFR 60-89

Answer 129

G2, mild kidney disease

Question 130

Lab interpretation: eGFR 45-59

Answer 130

G3a, mild-moderate kidney disease

Question 131

Lab interpretation: eGFR 30-44

Answer 131

G3b, moderate-severe kidney disease

Question 132

Lab interpretation: eGFR 15-29

Answer 132

G4, severe kidney disease

Question 133

Lab interpretation: eGFR

Answer 133

G5, ESRD

Question 134

What are the general causative agents of CKD?

Answer 134

Uncontrolled DM, HTN Glomerular nephritis Polycystic kidney disease FH of CKD

Question 135

You complete annual labs on a 72 y/o F with PMH T2DM, HTN, and smoking. Pt is currently an active smoker, 1/2 PPD. She drinks primarily coffee and tea, only consumes about 1 cup of water/day. She has a Cr of 1.8 and eGFR of 57. Last year, her annual labs showed a Cr of 0.8 and an eGFR of 62. Would you be concerned for CKD and when would you complete a workup?

Answer 135

Primary concern would be for AKI on CKD. Would encourage lifestyle modifications, improve hydration and repeat labs in 3 months

Question 136

In 3 months, your 72 y/o F patient returns to follow up on her recent labs. Her Cr has improved to 1.0, eGFR continues to remain low at 56 now. Are you concerned for CKD?

Answer 136

Yes, she is presently G3a. Would want CKD workup with referral to nephrology

Question 137

When completing CT imaging of a patient with AKI or CKD, would you suggest a dry CT or CT w/ contrast? Why?

Answer 137

Dry CT (no contrast) as IV contrast can continue to damage kidney function

Question 138

Your 45 y/o M patient with PMH T1DM and FH of CVD and MI at young age presents to PCP after seeing cardiology. The cardiologist wants to complete a CT angiogram. The patient has known CKD2 with eGFR of 70. You want to protect his kidney to the best of your ability. You would suggest...

Answer 138

IVF prior to and after CTA at infusion center

Question 139

As a PCP, what is the best way to help prevent and manage CKD for your patients?

Answer 139

Educate on risk reduction of modifiable risk factors

Question 140

What are the modifiable risk factors of CKD?

Answer 140

Diet and exercise Smoking cessation Avoiding nephrotoxic agents Management of HTN, DM, and HLD Weight control

Question 141

What are the diet recommendations for a patient at high risk for CKD?

Answer 141

Hydration Weight management Low salt Low protein

Question 142

You have a 69 y/o F patient with well controlled HTN and T2DM. She is on Farxiga (dapagliflozin) for her T2DM and lisinorpil for HTN. Her annual lab-work shows Cr 1.0, BUN 13, eGFR 65, A1C 6.5%, and BP in office today is 122/68. Would you make any medication adjustments today?

Answer 142

No. ACEI are helpful with kidney protection and SGLT2's are indicated in patients with CKD as long as eGFR >30

Question 143

Gross hematuria Masses or cysts on kidney US Nephrolithiasis Hydronephrosis Bladder changes Lower urinary tract symptoms with known CKD ^Reasons for referral to...

Answer 143

Urology

Question 144

eGFR <30 Decrease in eGFR >/= 5 points Proteinuria without DM diagnosis Pt with DM and >3g proteinuria CKD with unclear cause CKD with complications Polycystic kidney disease Kidney transplant Kidney stone CKD with electrolyte imbalances ^Reasons for referral to...

Answer 144

Nephrology

Question 145

CKD is treated primarily in the _______ setting whereas AKI is treated primarily in the _______ setting.

Answer 145

CKD: inpatient AKI: outpatient

Question 146

Elevated Cr with: -Cr increase >/= 0.3 in 48 hours OR -Cr increase >/=1.5x baseline in 7 days OR -Urine output 20:1

Answer 146

Diagnostic criteria for AKI

Question 147

AKI cause/type: Decreased perfusion to the kidney (hypotension, blood loss, etc.)

Answer 147

Pre-renal

Question 148

AKI cause/type: Acute tubular necrosis, acute interstitial nephritis, glomerular nephritis, intratubular obstruction

Answer 148

Intrinsic

Question 149

AKI cause/type: Obstruction (calculi, tumor, clot, BPH)

Answer 149

Post-renal

Question 150

CKD cause/type: Decrease perfusion (CHF, cirrhosis)

Answer 150

Pre-renal

Question 151

CKD cause/type: Vascular, glomerular, tubular (polycystic kidney disease)

Answer 151

Intrinsic

Question 152

CKD cause/type: Chronic calculi, tumor, prostate CA, significant BPH, fibrosis

Answer 152

Post-renal

Question 153

You are working in urgent care. A 47 y/o M comes in today for fatigue. He was working the past 3 days as an EMT with a busy call schedule and not much time for hydration. He is on amlodipine for his BP and has been taking it. Today in office, his BP is 90/52, his skin tugor is tented and he is in no acute distress. He notes he has been voiding less. You draw labs and find his Cr to be 1.7 and BUN 30. You suggest him going to the ED for fluids, but he declines. You give him a pitcher of water and monitor in the clinic. His BP improves and he voids prior to leaving. You know most likely is experiencing which type of AKI with improvement in symptoms with fluid challenge?

Answer 153

Pre-renal AKI evidenced by decreased BP (perfusion), decreased urine output and improvement with fluid challenge

Question 154

Your patient calls the office for decreased voiding over the past 2 days. You order labs for them to complete prior to their ECV at 2pm. Labs result with Cr 1.3 and BUN 22. You suspect mild AKI. At their appointment, pt is in no acute distress, endorses last void at 6am and poor PO intake recently. VSS, BP is 120/68. They note they have been having mild headaches today and did take Advil 600mg at 12pm. What would you recommend for AKI management?

Answer 154

Encourage PO intake (8-10 glasses of water) Tylenol for headaches (avoid Advil as it is nephrotoxic) Follow up in 3 days

Question 155

Infection, inflammation and intrinsic: -Post-infectious GN -Anti-glomerular basement membrane -Lupus nephritis -Wegner's disease -Endocarditis -Vasculitis

Answer 155

NephrItic causes of glomerular disease in CKD

Question 156

Outside the kidney (non-inflammatory) -HTN -DM -HIV -Focal, segmental GN -Minimal-change disease

Answer 156

NephrOtic causes of glomerular disease in CKD

Question 157

Elevated BP eGFR out of range Mild-moderate proteinuria (0.3-3.0) UA with RBC, casts, and WBC

Answer 157

NephrItic GN

Question 158

Normal BP (unless underlying HTN) Normal eGFR Significant proteinuria (>/= 3.0) UA with macros only

Answer 158

NephrOtic GN

Question 159

Mind trick reminders: NephrItic

Answer 159

Inflammation, infection, intrinsice

Question 160

Mind trick reminders: NephrOtic

Answer 160

Outside kidney

Question 161

Mind trick reminders: Always start with eGFR, if azotemia (<60)...

Answer 161

Repeat to confirm

Question 162

Mind trick reminders: If eGFR confirmed...

Answer 162

US and UA to determine cause/tx

Question 163

Mind trick reminders: Asymmetric kidney =

Answer 163

Prior

Question 164

Mind trick reminders: Prior PYlonephritis

Answer 164

PYuria and asymmetric kidney

Question 165

Mind trick reminders: Prior Calculi

Answer 165

Asymmetric and Crystalluria

Question 166

Mind trick reminders: Normal kidney

Answer 166

DM

Question 167

Mind trick reminders: Small kidney

Answer 167

Small blood flow (HTN, ischemia)

Question 168

Mind trick reminders: Small kidney, small protein

Answer 168

HTN