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NURS 5410: Common and Chronic Health Problems 2 > Exam 3: Lectures > Flashcards

Exam 3: Lectures Flashcards

1
Q

Used to differentiate epididymitis v testicular torsion

A

TWIST score

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2
Q

TWIST score:
Testicular swelling is ____ points

A

2

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3
Q

TWIST score:
Hard testicles is ____ points

A

2

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4
Q

TWIST score:
Absent cremasteric reflex is ____ points

A

1

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5
Q

TWIST score:
N/V is ____ points

A

1

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6
Q

TWIST score:
High riding testes is ____ points

A

1

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7
Q

What is the major difference between epididymitis and testicular torsion?

A

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

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8
Q

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

A

Epididymitis

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9
Q

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

A

Testicular torsion

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10
Q

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?

A

Testicular torsion with emergent referral to ED or urology

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11
Q

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?

A

Epididymitis with concern for cause of STI with new partner.

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12
Q

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?

A

Cipro 500 mg PO BID for 14 days.

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13
Q

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?

A

Doxy

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14
Q

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?

A

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

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15
Q

What are the goals of BPH management?

A

Symptom relief and prevention of obstruction and infection

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16
Q

What are the options for symptom relief management?

A

Alpha blockers and 5ARIs

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17
Q

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?

A

Alpha blockers: Doxazosin, Tamulosin, or Terazosin

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18
Q

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?

A

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

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19
Q

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?

A

IPSS

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20
Q

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?

A

IM PNC G to the buttocks, one time dose now

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21
Q

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?

A

Gonorrhea and Chlamydia urine testing

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22
Q

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?

A

Doxycycline

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23
Q

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?

A

Azithromycin

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24
Q

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?

A

Ceftriaxone, IM today in office

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25
Q

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?

A

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

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26
Q

Who is at greatest risk for syphillis infection?

A

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

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27
Q

Who should be screened for gonorrhea and chlamydia?

A

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

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28
Q

What are the biggest risk factors of gonorrhea and chlamydia?

A

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

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29
Q

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

A

Acute bacterial prostatitis

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30
Q

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

A

Chronic prostatits

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31
Q

What is the biggest difference between acute and chronic prostatitis?

A

Onset
Fevers
Prostate tenderness
Where the pain radiates

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32
Q

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

A

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

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32
Q

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

A

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

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32
Q

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

A

If the urine is equivocal

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33
Q

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

A

If there is concern for rectal abscess.

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34
Q

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

A

Length of antibiotic therapy

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35
Q

What is your first line medication for management of prostatitis?

A

Bactrim

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36
Q

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

A

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

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37
Q

When treating chronic prostatitis, how long is treatment normally?

A

4-6 weeks

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38
Q

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

A

When they completed their abx treatment and their UC is negative

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39
Q

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

A

CVD

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40
Q

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

A

Increases the SHBG

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41
Q

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

A

Decreases the SHBG

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42
Q

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

A

PDE5: Sildenafil, tadalafil, vardenafil

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43
Q

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

A

Joint decision making with patient and provider

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44
Q

When is PSA screening recommended by the USPSTF

A

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

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45
Q

STRAW 10+ is a tool used for what?

A

Menopause/menstrual life cycle staging

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46
Q

What is the average age for menopause?

A

51 y/o

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47
Q

12 consecutive months without a menstrual cycle is considered …

A

Menopause

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48
Q

What are some of the earlier signs of menopause?

A

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

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49
Q

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

A

Vaginal atrophy
Incontinence
Skin changes

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50
Q

Menopause puts women at increased risk for what disease processes?

A

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

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51
Q

Hot flashes and cold sweats are considered:

A

Vasomotor symptoms (VMS)

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52
Q

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

A

Genitourinary symptoms of menopause

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53
Q

GSM is treated hormonally by which route of medication

A

Vaginally

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54
Q

What is the primary cause for sleep disturbances in menopause?

A

VMS

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55
Q

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

A

Sleep disturbances

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56
Q

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

A

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

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57
Q

How can stress management be helpful in treating postmenopausal symptoms?

A

Helps to improve VMS, enhance sleep and decrease stress levels

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58
Q

What is a modality that is may help with VMS?

A

Accupuncture

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59
Q

How do phytoestrogens work?

A

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

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60
Q

Where are phytoestrogens found?

A

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

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61
Q

How does black cohosh work?

A

It binds to serotonin, dopaminergic, and GABA receptors

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62
Q

How do Omega-3 help with menopause management?

A

Helps with CVD risk protection

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63
Q

What are some precautions with black cohosh?

A

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

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64
Q

How does Rheum Rhaponticum (ERr-731) work?

A

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

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65
Q

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

A

VMS, anxiety

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66
Q

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

A

SSRI

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67
Q

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

A

HRT (estrogen)

68
Q

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

A

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

69
Q

With HRT, when is vaginal route most effective?

A

When treating GU/vaginal symptoms/complaints

70
Q

When is oral HRT used?

A

If not responding well to transdermal

71
Q

What is the use for bioidentical hormones?

A

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.

72
Q

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?

A

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

73
Q

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

A

SBT, BAS, or the Ottawa screening

74
Q

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:

A

Lubricants, regular sexual activity and vaginal exercises

75
Q

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:

A

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.

76
Q

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

A

The patient’s relationships

77
Q

What is the gold standard laboratory test for Hep A?

A

Anti-HAV IgM

78
Q

Risk factors for Hepatitis A include ….

A

Occupational exposure
Travel to endemic areas
IVDU
Homelessness

79
Q

What is the incubation period of Hepatitis A?

A

15-50 days with the average being 28 days

80
Q

How is Hepatitis A treated?

A

Symptom management
It is otherwise a self-limiting disease

81
Q

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?

A

Prophylactic Hepatitis A vaccine

82
Q

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

A

Hepatitis E

83
Q

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

A

Hepatitis B vaccination

84
Q

Who should be screened for hepatitis B?

A

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

85
Q

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

A

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

86
Q

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?

A

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

87
Q

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

A

Early acute Hepatitis B

88
Q

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

A

Run replication studies for Hepatitis B to help guide treatment

89
Q

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

A

Acute Hepatitis B infection

90
Q

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

A

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.

91
Q

When do you treat for Hepatitis B?

A

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

92
Q

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

A

Recovering acute infection

93
Q

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

A

Recovering acute infection

94
Q

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

A

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

95
Q

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

A

Recovered infection

96
Q

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

A

Chronic Hepatitis B infection

97
Q

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?

A

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

98
Q

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?

A

Peg-INF, Tenofovir, or Entecavir

99
Q

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?

A

Tenofovir with Lamuvidine or Emtricitabine

100
Q

How long will you treat your patient for Hepatitis B?

A

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

101
Q

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

A

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

102
Q

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

A

Immune to Hepatitis B

103
Q

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?

A

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

104
Q

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

A

Hepatitis D

105
Q

How are patients protected against Hepatitis D?

A

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

106
Q

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?

A

Run a hepatitis panel

107
Q

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

A

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

108
Q

How is Hep C treated?

A

Based on the genotype

109
Q

What is the most common Hepatitis C genotype?

A

Type 1 with subclasses of a and b

110
Q

What is the incubation period for Hepatitis C?

A

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

111
Q

Who should be screened for Hepatitis C?

A

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

112
Q

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

A

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

113
Q

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

A

HCV RNA to confirm diagnosis and Genotyping to guide treatment

114
Q

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

A

Ledipasvir/Sofosbuvir for 8 weeks

115
Q

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?

A

Sofosbuvir/Velpatasvir for 12 weeks

116
Q

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

A

Medication adherence

117
Q

Can a patient receiving Hepatitis treatment drink alcohol?

A

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

118
Q

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

A

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

119
Q

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?

A

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

120
Q

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

A

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

121
Q

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?

A

Refer to GI, encourage/support ETOH cessation

122
Q

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?

A

Lifestyle modifications (diet and exercise)
Avoiding hepatotoxic agents

123
Q

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

A

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

124
Q

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

A

Low copper diet

125
Q

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

A

Fatigue

126
Q

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

A

eGFR

127
Q

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

A

Creatinine

128
Q

Lab interpretation:
eGFR >/= 90

A

G1, Normal

129
Q

Lab interpretation:
eGFR 60-89

A

G2, mild kidney disease

130
Q

Lab interpretation:
eGFR 45-59

A

G3a, mild-moderate kidney disease

131
Q

Lab interpretation:
eGFR 30-44

A

G3b, moderate-severe kidney disease

132
Q

Lab interpretation:
eGFR 15-29

A

G4, severe kidney disease

133
Q

Lab interpretation:
eGFR </= 15

A

G5, ESRD

134
Q

What are the general causative agents of CKD?

A

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

135
Q

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?

A

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

136
Q

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?

A

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

137
Q

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

A

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

138
Q

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…

A

IVF prior to and after CTA at infusion center

139
Q

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

A

Educate on risk reduction of modifiable risk factors

140
Q

What are the modifiable risk factors of CKD?

A

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

141
Q

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

A

Hydration
Weight management
Low salt
Low protein

142
Q

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?

A

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

143
Q

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

A

Urology

144
Q

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…

A

Nephrology

145
Q

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

A

CKD: inpatient
AKI: outpatient

146
Q

Elevated Cr with:
-Cr increase >/= 0.3 in 48 hours
OR
-Cr increase >/=1.5x baseline in 7 days
OR
-Urine output </= 0.5mL/kg/hr in 6 hours
OR
-BUN:Cr ratio >20:1

A

Diagnostic criteria for AKI

147
Q

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

A

Pre-renal

148
Q

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

A

Intrinsic

149
Q

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

A

Post-renal

150
Q

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

A

Pre-renal

151
Q

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

A

Intrinsic

152
Q

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

A

Post-renal

153
Q

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?

A

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

154
Q

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?

A

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

155
Q

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

A

NephrItic causes of glomerular disease in CKD

156
Q

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

A

NephrOtic causes of glomerular disease in CKD

157
Q

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

A

NephrItic GN

158
Q

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

A

NephrOtic GN

159
Q

Mind trick reminders:
NephrItic

A

Inflammation, infection, intrinsice

160
Q

Mind trick reminders:
NephrOtic

A

Outside kidney

161
Q

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

A

Repeat to confirm

162
Q

Mind trick reminders:
If eGFR confirmed…

A

US and UA to determine cause/tx

163
Q

Mind trick reminders:
Asymmetric kidney =

A

Prior

164
Q

Mind trick reminders:
Prior PYlonephritis

A

PYuria and asymmetric kidney

165
Q

Mind trick reminders:
Prior Calculi

A

Asymmetric and Crystalluria

166
Q

Mind trick reminders:
Normal kidney

A

DM

167
Q

Mind trick reminders:
Small kidney

A

Small blood flow (HTN, ischemia)

168
Q

Mind trick reminders:
Small kidney, small protein

A

HTN

NURS 5410: Common and Chronic Health Problems 2 (6 decks)

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