Internal Medicine Flashcards
Stage 1/2/3 AKI
Stage 1 –> Cr increase 1.5-1.9x baseline in 7 days, increase of 26 in 48h, or 0.5 urine output for 6-12h
Stage 2 –> Cr increase 2-2.9x baseline in 7 days, or under 0.5 urine output for over 12h
Stage 3 –> Cr increase 3x baseline in 7 days, over 354, initiation of renal replacement, or under 0.3 urine for over 24h or anuric for over 12h
Pre-Renal AKI Categories (i.e. causes)
True intravascular fluid loss –> blood loss, GI losses, decreased oral intake, fever, burns
Decreased ECV –> heart failure, shock, hypoalbuminemia (cirrhosis, malnutrition, nephrotic syndrome)
Impaired Renal Perfusion
–> Macro –> renal artery stenosis, dissection, thrombus
–> Micro –> NSAIDs (afferent constriction) and ACEis/ARBs (efferent dilation), cocaine, hypercalcemia
How to assess for Pre-renal AKI
- Labs?
- Management?
- volume status (JVP, blood pressure, edema, etc.)
- history (not eating/drinking, diarrhea, CHF non-compliance with meds, medications)
- bland urinalysis
- FeNa <1% (tubules are still absorbing Na)
- Urine Na <20 (RAAS is on)
- BUN:Cr high (urea 10x Cr)
- Give fluids if hypovolemic (careful w anuria), give diuretics if overloaded, stop offending meds
Post-Renal AKI Categories
- urethra (stricture, stenosis)
- prostate (BPH, prostatitis, prostate cancer)
- bladder (cancer, stone, clot, neurogenic)
- ureters (cancer, stone, clot, pregnancy, retroperitoneal fibrosis)
How to assess/manage post-renal AKI
- on hx - frequency, urgency, nocturia, hematuria, stones, B symptoms
- in/out foley catheter
- renal ultrasound
- if below bladder –> foley
- if above bladder –> nephrostomy
Renal AKI - Tubular
- Ischemic vs. Toxic
- Acute Tubular Necrosis (ATN) - most common cause of AKI along with pre-renal
- Ischemic –> due to prolonged pre-renal insult, most common, get MUDDY BROWN CASTS
- Toxic –> either exogenous (contrast, NSAIDs, chemo, aminoglycosides, acyclovir, amphotericin, MTX, etc.), or endogenous (Hgb, Mgb (muscle injury!), Ig light chains in multiple myeloma, oxalate crystals from ethylene glycol, urate crystals from tumor lysis/gout)
Labs you would expect for Renal (ATN) AKI
- Muddy brown casts
- FENa >1% (Na not being maximally absorbed)
- Urine Na >20 (RAAS turned off)
- BUN:Cr low (CR 20x urea)
Renal AKI - AIN
- 4 “I”s
- Acute Interstitial Nephritis
- Triad of fever, rash, and eosinophilia
- Infection –> viral i.e. HIV/CMV, TB, fungi, parasites
- Inflammation –> Sjogren’s, SLE, IgG4, TINU
- Infiltration –> sarcoidosis, lymphoma
- Ingestion –> NSAIDs, ABX, PPI, allopurinol (most common)
- Gold standard dx is biopsy
- Will see WBCs, WBC casts, RBCs, sometimes eosinophils
Renal AKI - Vascular
- damage to the microvasculature (larger vessels would be considered pre-renal)
- thrombocytic microangiopathy (TTP/HUS, malignant HTN)
- emboli (cholesterol, artheroembolic)
- scleroderma
- vasculitis
Renal AKI - Glomerular
- Nephrotic vs. Nephritic
- damage to endothelial/epithelial cells, basement membrane, podocytes, mesangium, bowman’s capsule
- may see purpura/active joints
- Nephrotic (mild) –> isolated injury to the filtration barrier leading to protein in the urine
- oncotic pressure in blood decreases leading to edema
- PALE (proteinuria over 3.5g, low albumin, hyperlipidemia, edema)
- Nephritic (severe) –> diffuse glomerular inflammation leading to urine sediment and decreased renal fucntion
- PHAROH (proteinuria, HTN, AKI, dysmorphic RBCs/casts, oliguria, hematuria)
Pathologies associated with nephrotic vs nephritic syndrome
Nephrotic –> membranous nephropathy, FSGS, minimal change disease, amyloid (can be secondary to cancer, HIV, NSAIDs, heroin, obesity, SLE, HBV/HCV, syphilis, solitary kidney)
Nephritic –> ANCA vasculitis/pauci-immune, anti-GBM Ab disease, cryoglobulinemic vasculitis, post-infectious GN
Inbetween –> IgA nephropathy, SLE nephritis, MPGN
Treatment for the different classes of Renal AKI
Tubular –> supportive
AIN –> withdraw culprits
Vascular –> treat underlying cause
GN –> call nephro
Acute indications for dialysis
Acidemia (refractory metabolic acidosis)
Electrolyte imbalance (refractory hyperkalemia)
Ingestion (methanol, ethylene glycol, ASA, Li)
Overload (refractory volume overload)
Uremia (pericarditis, encephalopathy - can both cause asterixis)
Urinalysis Findings
Leukocyte esterases –> pyelonphritis (AIN)
Calcium oxalate cyrstals –> ethylene glycol poisoning
Hyaline Casts –> non-specific but could indicate volume depletion
RBC Casts –> glomerulonephritis
WBC Casts –> AIN/pyelonphritis
Fatty Casts/ Frothy urine –> proteinuria (nephrotic syndrome)
Consequences of AKI
- dyspnea, orthopnea, PND
- edema
- oliguria
- uremic encephalopathy (confusion), nausea, malaise
- pleuritic chest pain (pericarditis)
- bleeding due to uremic platelets
ABC MOVIE
Airway, Breathing, Circulation
Monitors, Oxygen, qVitals, IVs, ECG
Signs suggestive of:
- ACS
- PE
- Pneumothorax
- Aortic Dissection
- Tamponade
- Esophageal Rupture
(Chest Pain Emergencies)
- ACS –> pressure pain in L shoulder/arm/jaw, cool periphery, worse with exertion and better with rest, known angina, associated with nausea/ diaphoresis/lightheadedness
- PE –> tachycardia, increased JVP, loud S2, DVT signs, risk factors (cancer, surgery, immobility, smoking)
-PTX –> emphysema, no breath sounds, trachea, not midline, increased JVP, hx of a thoracic procedure
- Aortic Dissection –> tearing pain to the back, neuro changes, asymmetric BP in both arms
- Tamponade –> increased JVP, quiet heart sounds, pulsus paradoxus (drop of BP more than 10 on inspiration), pericardial effusion
Esophageal Rupture –> emesis, hx of esophageal pathology or intervention
Chest pain ddx - non-emergencies
- angina, peri/myocarditis, arrythmias
- pneumonia, bronchitis, empyema
- GERD, gastritis, PUD, pancreatitis, biliary
- Chostochondritis, muscle pain, rib fracture
- anxiety
DDx of SOB emergencies/ non-emergencies
- acute COPD/asthma exacerbation, aspiration pneumonia, pulmonary edema, PE, PTX
- ACS, tamponade
- stable COPD/asthma, ILD, valvulopathy, pericardial effusion, arrythmia, CHF, anemia, NMJ, diaphragm acidosis, anxiety, central issue
*with COPD –> wheeze, bilateral edema
DVT Signs
- leg swelling
- erythema
- calf pain
- hemoptysis
- presyncope
- palpitations
- chest pain
Treatment for Aspiration Pneumonitis
- oxygen and supportive treatment
- fluids PRN
- consider ABX
- swallowing assessment
Fever DDx
- Infection (any -itis you can think of i.e. meningitis if neck pain/stiffness and headache)
- Malignancy
- PE/DVT
- Autoimmune
- Drugs (ABX, anti-epileptics/psychotics, SSRIs, cocaine, blood transfusions)
- Endocrine
Giving ABX for an unidentified infection
- Only give broad spectrum ABX for an unknown source infection IF the patient is unstable - if that patient is stable just wait for susceptibility results
Pyelonephritis Signs
- broad treatment?
- dysuria, lower back pain, fever
- start Ceftriaxone 2g IV q24h
- consider IV fluids if they seem dry and not at risk for fluid overload
Altered LOC DDx
Drugs –> opioids, benzos, alcohol (intoxication AND withdrawal), anti-emetics/psychotics
Infection –> all
Metabolic –> hypoNa/K/Mg/Ca/glycemia/thyroid, hyperCa/capnia/thyroid, uremia, HE, hemolysis *ALWAYS CHECK GLUCOSE
Structural –> stroke, seizures, ACS, urinary retention/constipation
Drugs that:
- Increase HR and BP
- Increase RR
- Increase temperature
- Dilate Pupils
- Increase bowel sounds
- Increase sweating
- Stimulants, anticholinergics
- Stimulants
- Stimulants, anticholinergics
- Stimulants, anticholinergics
- Stimulants, cholinergics
- Stimulants, cholinergics
- Anticholinergics - antipsychotics, oxybutinin
Stimulants - cocaine, epinephrine, amphetamines
Drugs that:
- Decrease HR and BP
- Decrease RR
- Decrease temperature
- Constrict pupils
- Decrease bowel sounds
- Decrease sweating
- Sedatives, Opioids
- Opioids
- Sedatives, Opioids
- Opioids, cholinergics
- Sedatives, Opioids, anticholinergics
- Sedatives, Opioids, anticholinergics
- Opioids - morphine, heroine (give narcan)
Sedatives - benzos, barbituates, Z drugs, antihistamines
Cholinergics - donepizil
ABX that cover Pseudomonas
- Pip-tazo
- Ceftazidime (3) and Cefipime (4)
- Ciprofloxacin (needs high dosing -750mg BID)
- Meropenem and Imipenem
ABX that cover MRSA
- Vancomycin, Daptomycin, Linezolid (all pure gram +)
- Clindamycin
- Ceftaroline
- Doxycycline
- Septra (TMP-SMX)
Difference between Pip-tazo and Amox-clav
Difference between Meropenem and Imipenem
- only pip-tazo can cover pseudomonas
- only imipenem can cover enterococci
Use ___ above the diaphragm and ____ below the diaphragm
- clindamycin (gram +s except MRSA and anaerobes)
- Metronidazole (exclusively covers anaerobes)
ABX that cover C.diff
- Vancomycin (PO) or Metronidazole (PO/IV)
Cephalosporins that cover anaerobes
- Cefoxitin and Cefotetan (both 2nd gen)
Only ABX that cover ESBL
Carbapenems
ABX for VRE
- Daptomycin and Linezolid
- Sometimes ampicillin and ceftriaxone if enterococcal endocarditis
Penicillin Allergies
- under 1% of people actually have an IgE reaction and 80% will lose it within 10 years
- allergy is to the side chain, so can use other B-lactams with different side chains
- Ask: in the last 5 years, anaphylaxis or angioedema, severe cutaneous reaction, treatment needed for reaction
Treatment of shock with ABX
- want IV ABX within 1 hour
- delay = mortality
Risks for MRSA
- IV drug use, hemodialysis, skin disease, venous catheters and other foreign bodies (pacemakers), surgery, hospitalization
Intrinsic vs Acquired Resistance
- intrinsic - klebsellia pneumoniae and ampicillin
- acquired - alterations in binding, plasmids (ESBL w enterobacter), chromosomes (Amp-C SPACE)
Concentration dependent vs. time dependent ABX
- Conc –> fluoroquinolones, aminoglycosides
- Time –> B-lactams, vanco
Bacteriocidal vs. Bacteriostatic ABX
Cidal - MBC = MIC, B-lactams and fluoroquinolone, better for serious infections especially if immunocompromised
Static - MBC»_space; MIC, clindamycin and tetracyclines, requires an intact immune system
High Oral availability
Clindamycin, Fluoroquinolones, Fluconazole, Linezolid, Metronidazole, TMP-SMX, Voriconazole
Gram (+) vs Gram (-)
(+) –> thick peptidoglycan externally
(-) –> outer membrane, thin peptidoglycan, lipopolysaccharides, porins
