neph Flashcards
Upper UTI x2
Pyelonephritis
Renal Abscess
Lower UTI x2
Cystitis
Urethritis
UTI
inflammation and infection: kidneys ureters bladder and/or urethra
Most common etiology UTI women
E. coli
Most common etiology UTI men
Proteus
Lower UTI s/s
DYSURIA *
Frequency, Urgency
Hematuria - 40-60%
Nocturia
Your patient is displaying symptoms suggestive of BPH. What is the first test you should order?
UA
Key symptom of lower UTI
Dysuria
Lower UTI: general mgmt x3 choices + what duration? *
trimethoprim-sulfamethoxazole (Bactrim)
ciprofloxacin (Cipro)
amoxicillin/clavulanate (Augmentin)
3 day course: max benefits, min drawbacks (ex: SE, less costly)
Lower UTI: mgmt during pregnancy x3 choices + what duration? *
amoxicillin
nitrofurantoin (Macrobid)
cephalexin (Keflex)
7 - 10 day course
Upper UTI s/s x5
flank, abd, lower back pain
fever, chills
AMS in elderly
AMS causes in elderly
TIA
UTI
drugs (interactions)
pulm infections
Upper UTI treatment x5 choices + what duration? *
2 vs. 6 wk course
heeeey, same as lower UTI +2:
trimethoprim-sulfamethoxazole (Bactrim)
ciprofloxacin (Cipro)
amoxicillin/clavulanate (Augmentin)
fluoroquinolone
aminoglycoside
Hospitalization is indicated for a patient with what kind of UTI?
Upper UTI: pyelonephritis with nausea and vomiting
what is renal insufficiency?
↓ renal fxn = ↓ GFR + ↓ clearance of solutes
can be acute or chronic
renal insufficiency: causes x5
hypertensive (major) nephrosclerosis Glomerulonephritis DM nephropathy interstitial nephritis polycystic kidney disease
comorbs associated with renal insufficiency
HTN
DM
what is acute renal insufficiency?
SUDDEN impairment, REVERSIBLE w tx
BUN: out of proportion to creatinine
causes: obstruction, acute tubular necrosis, contrast media
Is ATN reversible?
Yes. ATN reversible r/t acute renal insufficiency
what is chronic renal insufficiency?
PROGRESSIVE: mo - yrs, irreversible
STEADY ↑ BUN and creatinine
d/t intrinsic damage - progression can be slowed
what causes chronic renal insufficiency?
Intrinsic kidney damage
what is diminished renal reserve? *
first stage of renal failure
50% nephron loss
Creat x2
what is the second stage of renal failure and 2 characteristics?
renal insufficiency
75% nephron loss
mild azotemia
what is End-Stage Renal Disease?
90% nephron damage
azotemia
metabolic alterations
percentage of nephron function in ESRD
10% nephron function
dialysis criteria mnemonic
AEIOU
A cidosis - metabolic; azotemia E lectrolyte abn: Ca, K I ntoxication: AMS O liguria: lt 400 mL/24 hrs U remia
Acute Renal Insufficiency: mgmt
determine & reverse underlying cause (pre, intra, post)
Chronic Renal Insufficiency: mgmt
slow the progression of failure!
control HTN + DM
Δ rx doses
↓ dietary protein under 40 g/day
dietary protein requirement for chronic renal insufficiency?
less than 40 g/day
what is a classic electrolyte imbalance seen in chronic renal failure?
hypercalcemia
expected acid/base imbalance in chronic renal insufficiency + tx?
metabolic acidosis
IV: NS + sodium bicarb
major complication of peritoneal dialysis
peritonitis
acute renal failure: pre-renal causes x6
OUTSIDE kidney
↓ kidney perfusion: shock, dehydration, cardiac failure, burns, diarrhea, sepsis
what is pre-renal acute renal failure?
acute renal failure caused by conditions impairing renal perfusion; no damage to renal tubules
acute only if reversible with correction of underlying cause
What kind of damage do renal tubules sustain from pre-renal causes of acute renal failure?
Psych! NONE!
acute renal failure: intrarenal causes x4
renal or intrinsic causes that directly affect renal cortex/medulla:
- nephrotoxic drugs (most common)
- hypersensitivity reaction (ex: to contrast media)
- embolism/thrombosis of renal vessels
- mismatched blood transfusions (RBCs hemolyze then block nephrons)
RESULTS IN NEPHRON DAMAGE - acute tubular necrosis is the most common cause
what is the most common cause of damage to the nephron tubules in acute renal failure?
acute tubular necrosis in intrarenal acute renal failure
what does intrarenal acute renal failure result in?
nephron damage to tubules
ATN = most common cause
most common nephrotoxic drug
aminoglycosides - gentamicin
what is post-renal acute renal failure?
urine flow obstruction; mechanical or functional
acute renal failure: mechanical post-renal causes x4
BPH
tumor
renal calculi
urethra strictures
acute renal failure: functional post-renal causes x2
DM nephropathy
neurogenic bladder
pre-renal ARF BUN/Cr ratio
greater than 10:1
pre-renal ARF urine Na
less than 20 mEq/L
pre-renal ARF specific gravity
1.015+
pre-renal ARF fractional excretion of sodium (FENa)
under 1%
intrarenal ARF vs Postrenal ARF key diagnostic difference
urinary sediment
intra: granular white casts
post: normal
pre-renal ARF: mgmt
expand intravascular volume
dopamine
intrarenal ARF: mgmt
maintain renal perfusion
STOP nephrotoxic drugs
RRT
post-renal ARF: mgmt
remove obstruction
check foley
CT
renal US
most common type of renal calculi
calcium stones - 80%
renal calculi associated with gout
uric acid stones
most common type of renal calculi in women
struvite stone
r/t urease-producing bacteria UTIs
ARF infection: staghorn stones EMERGENCY
renal calculi: s/s x6
passage = pain + bleeding
colic-like FLANK pain, INCREASING intensity
groin/testicular pain
frequency, urgency, dysuria
gold standard for diagnosis of renal calculi
non-contrast CT scan
standard intravenous trio for renal calculi
morphine or hydromorphone (Dilaudid)
toradol (Ketorolac)
metoclopramide (Reglan)
** top 2 priorities in management of renal calculi
ANALGESIA
HYDRATION
what is benign prostatic hypertrophy?
enlargement of the prostate, doy
common in 50+ males
50% of men by 50
80% + of men 80+
benign prostatic hypertrophy: s/s
dysuria frequency, urgency nocturia, incontinence hesitancy start/stop flow, dribbling retention
benign prostatic hypertrophy: diagnostics x4
UA: r/o infection
PSA
transrectal US: if palpable nodule or elevated PSA
normal PSA for 60 - 69
less than 4.5 ng/mL
normal PSA for 70-79
less than 6.5 ng/mL
abnormal PSA value + note
4+ ng/mL
40% w prostate cancer present with normal PSA values
BPH: mgmt - standard of care meds
ALPHA BLOCKERS! relaxes bladder/prostate muscles
terazocin (Hytrin)
prazocin (Minipress)
tamsulosin (Flomax)
alpha blockers MOA
relax muscles of the bladder and prostate
BPH: overall mgmt
** alpha blockers: terazocin (Hytrin), prazocin (Minipress), tamsulosin (Flomax)
5-alpha-reductase inhibitors: finasteride (Proscar), dutaseride (Avodart) - shrink prostates
surgery, TURP, urology referral
MOA 5-alpha-reductase inhibitors
shrink the prostate
What meds worsen BPH s/s? x4
OTC antihistamines, decongestants
- Benadryl, Sudafed, Afrin
- SSRIs
- Diuretics
green discharge is most commonly associated with what STD?
Gonorrhea
Green = Gonorrhea
gonorrhea hallmark s/s women
ASYMPTOMATIC 80%
mucopurulent GREEN vaginal discharge
dysuria
gonorrhea hallmark s/s men
ASYMPTOMATIC (often)
yellow-GREEN/white penile discharge
dysuria
gonorrhea: diagnostics x2
gram stain: discharge = gram neg diplococci + WBC
cervical culture
gonorrhea: treatment **
ceftriaxone (Rocephin) 250 mg IM one
PLUS
azithromycin (Zithromax) 1 g PO once (cover chlamydia)
then report to health department
syphilis: causative agent
Treponema pallidum, a spirochete
primary syphilis: description x2
PAINLESS chancre @ site of exposure
indurated ulcer
secondary syphilis: s/s + description *
- flu-like sx
* * highly variable skin rash: palmar/plantar surfaces + mucous patches
latent syphilis: presentation
seropositive but asymptomatic
tertiary syphilis: complications x6
leukoplakia cardiac insufficiency aortic aneurysm meningitis hemiparesis/hemiplegia
which diagnostic is confirmatory for syphilis?
fluorescent treponemal antibody absorption (FTA-ABS)
+ 85-95% primary, 100% secondary
which lab do you order to rule out syphilis that is NOT diagnostic?
VDRL/RPR
non-treponeal serological test for syphilis
primary, secondary, or early syphilis + duration under 1 year: treatment
pencillin G 2.4 million units IM
late, latent, indeterminate length and tertiary syphilis: treatment
pencillin 2.4 million units IM weekly x 3 weeks
What drug allergy do you care about when treating a syphilis patient, and how do you treat syphilis patients with that allergy?
pencillin
doxycycline 100 mg PO BID
OR
erythromycin 500 mg PO QID
most common bacterial STD in United States
Chlamydia
chlamydia
PARASITIC STD
Chlamydia trachomatis
produces serious reproductive tract complications in men and women
chlamydia: s/s women
ASYMPTOMATIC (often)
dyspareunia
dysuria
postcoital bleeding
chlamydia: s/s men
ASYMPTOMATIC (often)
dysuria
thick cloudy penile discharge
STDs that present often asymptomatic
gonorrhea
chlamydia
top causes of dyspareunia
trichomonas
PID
menopause
chlamydia
most definitive test for chlamydia
culture
… it takes 3 - 9 days
chlamydia: diagnostics
culture
enzyme immunoassay (EIA)
- low cost + takes 30 to 120 mins
chlamydia: treatments top 2 + 3x more
** azithromycin (Zithromax) 1 g PO once
OR
** doxycycline 100mg PO BID x7 days
alts: erythromycin, ofloxacin, levofloxacin (Levaquin)
+ report to health department
what is vulvovaginitis?
inflammation or infection of VULVA & VAGINA
- most commonly bacterial, fungal, protozoan
- top 3: trichomonas, bacteria, and candida
only trichomonas is considered sexually transmitted
trichomonas: presentation x6
malodorous frothy yellow-greenish discharge pruritis strawberry patches on cervix/vagina vaginal erythema dyspareunia, dysuria
You observe strawberry patches on your patient’s cervix. Yiiikes she has…
trichomonas
Bacterial Vaginosis: presentation x2
fishy, watery, gray discharge
vaginal spotting
trichomonas: diagnostic test
microscopic wet prep: NS mixture shows motile TRICHOMONADS
candidiasis: diagnostic test
microscopic wet prep: KOH mixture show PSEUDOHYPHAE
bacterial vaginosis: diagnostic test
microscopic wet prep: NS mixture shows CLUE CELLS
Trichomonas: treatment
metronidazole (Flagyl) 2 g PO once
then 500 mg PO BID x 7 days
bacterial vaginosis: treatment
metronidazole (Flagyl) 2 g PO once
then 500 mg PO BID x 7 days +
gel 0.75%, intravag BID x 5 days
clindamycin (Cleocin) vaginal cream 2%, 5g qHS +
300 mg PO BID x 7 days
candidiasis: treatment
miconazole (Mono-stat) OR clotrimazole
- 5 g intravag qHS x 7 days
terconazole 80mg supp, qHS x3 days
butaconazole: 3 applications
chancroid: s/s in men + women
women: asymptomatic
men: painful ulcer(s) surrounded by erythematous halo
- can be necrotic or erosive, yuck
How do you diagnose chancroid? Definitive diagnosis?
DIAGNOSIS OF EXCLUSION
- definitive dx: morphologically (sens 80+%)
- genitalia +/or unilateral bubo
- painful genital ulcers + tender inguinal lymphadenopathy that aren’t syphilis or HSV
Wat ur pt haz quail egg lymph node in groin da fuuuuu
unilateral bubo - swollen inguinal lymph node associated with chancroid
Chancroid management
same as gonorrhea and chlamydia
herpes
recurrent VIRAL STD
no cure
painful genital lesions
HERPES = HURTS
herpes: transmission
direct contact with ACTIVE lesions
OR
virus-containing fluids (saliva HSV1; cervical secretions HSV2)
herpes: initial s/s
painful/pruritic ulcers x ~12 days
dysuria, fever, malaise
herpes: recurrent s/s
less painful/pruritic ulcers x 5 days
Most definitive test for Herpes
viral culture
herpes: diagnostics x3
Pap
Tzanck stain
Viral culture
herpes: mgmt x4
no cure
acyclovir (Zovirax): topical, oral, IV use
valacyclovir: useful for asx viral shedding HSV2
famciclovir
symptomatic (drying/antipruritic)
30 yo. F presents with 6 month history of three UTIs associated with hematuria. What should be your plan of care?
Refer to a urologist
What is the most common potential complication associated with a TURP?
Impotence
Treatment of choice of uncomplicated cystitis in women?
Bactrim
most common cause of metabolic acidosis in patients s/p surgery
circulatory dysfunction with lactic acidosis
differential diagnosis for significant proteinuria
nephrotic syndrome
CHF
DM
50 yo. M diagnosed with uric acid renal calculi. Treatment?
allopurinol
antihypertensive of choice for patients with marked proteinuria
ACE Inhibitors
treatment of hyperphosphatemia in ESRD
calcium citrate
45 yo. M s/p abdominal surgery has now developed ARF with BUN 100 mg/dL and Cr 4.5 mg/dL. Indications for dialysis include
hyperkalemia
metabolic acidosis
encephalopathy
nephrotic syndrome: mgmt
ACE Inhibitors
Protein restriction
NSAIDS
most common complication associated with hemodialysis
hypotension
sensitivity/specificity of a urine dipstick?
+ nitrate: very SPECIFIC, but not sensitive
+ esterase: very SENSITIVE, but not specific
… for bacteruria
Your 29 yo F patient complains that she feels the urge to pee frequently and that it burns when she voids, and that it looks like there is blood in her urine. What are 2 diagnostics you want to order?
UA
dipstick
pyuria on UA
10+ WBC/mL
“it hurts when I pee” song
UTI or STD (G or C)
expected UA finding with upper UTI
WBC casts
UA in lower vs upper UTI
lower: pyuria
upper: WBC casts
You suspect your patient has pyelonephritis, and they have been nauseated and vomited a few times. What is your priority intervention?
admit
renal function in renal insufficiency
less than 20 - 25% of normal
top 2 causes of renal obstruction
kidney stones
enlarged prostate
what are 3 causes of acute renal insufficiency?
obstruction
acute tubular necrosis
contrast media
what type of diet is indicated for ESRD HD patient?
low potassium
anuria
UOP less than 100 mL/24 hrs
oliguria
UOP less than 400 mL/24 hrs
renal insufficiency: 5 complications and their treatments
volume overload: diuretics metabolic acidosis: NS + Na bicarb hypercalcemia (calcitonin, dialysis) anemia azotemia: RRT (dialysis)
azotemia
BUN 100+ mg/dL
renal replacement therapy
is dialysis!!!!!
what is the most common cause of intrarenal acute renal failure?
nephrotoxic agents: ex - aminoglycosides
how do mismatched blood transfusions cause intrarenal renal failure?
the RBCs hemolyze then clog up the nephrons
acute renal failure: diagnostics x5 + key
serum BUN/Cr urine Na specific gravity urinary sediment FENa
intra and post renal are the same and prerenal is different
The only amino acid that becomes insoluble in urine, and why that is important.
cystine - can result in cystine calculi that are difficult to manage
renal calculi: mgmt
1 analgesia (trio) & hydration !!!
depends on stone type, location, extent, etc
diuretics (controversial)
remove obstruction (if preventing outflow or infected)
lithotripsy
cystoscopy
You are ordering the standard IV trio for your poor little patient who is having the worst renal calculi of his life. What is an important consideration about metoclopramide (Reglan)?
metoclopramide is associated with an increased incidence of extra-pyramidal symptoms (ex: tardive dyskinesia)
gonorrhea
BACTERIAL STD: Neisseria gonorrhoeae (gram neg diplococci)
found in GU, oropharynx, anorectum
causative agent of gonorrhea + gram and shape
Neisseria gonorrhoeae (gram neg diplococci)
syphilis diagnostics x3
FTA-ABS (fluorescent treponemal antibody absorption)
non-treponemal:
VDRL/RPR
microhemagglutination assay for antibody to T- pallidum
gonorrhea green vs trichomonas green discharge
gonorrhea: mucopurolent
trichomonas: frothy, malodorous
candidiasis presentation x2
thick white curd-like discharge
vulvovaginal erythema + pruritis
which GU infection has clue cells on wet prep?
bacterial vaginosis
which GU infection has pseudohyphae on wet prep?
candiasis
chancroid
STD caused by Hemophilus ducreyi
(gram neg bacillus)
- well-established co-factor for HIV transmission
- up to 10% also infected with syphilis and HSV
Your patient DEFFO has chancroid. Hoo doggy. What three other infectious diseases pop into your head and what is so significant about them?
HIV: chancroid is a co-factor for transmission
syphilis + HSV: frequent co-infections
HSV1 vs HSV2
1: lips, face, mucosa
2: genitalia
differentials for genital ulcers
herpes, primary syphilis, chancroid
older adults: changes in renal blood flow
diminished up to 10% per decade after 30-40
older adults: kidney changes
↓ size, nephron #/size, # glomeruli 30-40%
older adults: GFR changes
↓ ~10% per decade after 30
most common clinical illness for adults over 65
UTI
top 2 gram neg UTI
E Coli
Pseudomonas
top 4 gram + UTI
Enterococci
Staph (coagulase neg)
Strep agalactiae
Staph aureus
fungal UTI is common especially in what population?
patients with indwelling catheters
old folks + incontinence + confusion = ?
think UTI
