Nephro Exam Flashcards
1
Q
You have a 56yo pt who has never had HTN problems until very recently. What should you suspect?
A
Renovasc HTN as the cause!
2
Q
HyperK+ is an EMERGENCY. Order of operations for Tx?
A
IV Ca2+ gluconate or CaCl!!
Then:
IV hypertonic glucose +
IV loop or thiazide diuretic
Then:
fix underlying cause +
HD.
3
Q
HypoMg2+ is under __ in what pt popn?
A
1.5 mEq/L usually in EtOHics
4
Q
Why wouldn’t you PTRAS an atherosclerosis-RAS pt?
A
The data says it makes no difference to them, so stick with Rxs.
5
Q
Stones in the kidney do NOT cause pain! They will cause __.
A
Hematuria
6
Q
Physical exam of hydrocele?
A
scrotal swelling/pain that glows red upon transillumination
7
Q
Who is most at risk for cryptorchidism? What else is that a risk factor for?
A
Low birth wt
Hypospadias
8
Q
Why does Type B Lactic Acidosis occur?
A
Alcohol, DKA, CA, or MXR cause either tissue ischemia or decreased metabolism, which increases lactic acid without causing hypoperfusion.
9
Q
Why can CKD cause anemia?
A
dec EPO (only if you r/o other causes please!)
10
Q
We LOVE NCCT for nephrolithiasis! But what two stone types doesn’t it see?
A
Pure matrix stones, or those d/t indinavir
11
Q
Your kidney stone pt is a frequent flyer, or they have a major FamHx of them. What do you need to do?
A
Metabolic workup to figure out why (PTH/Ca2+, 24hr urine, BMP).
12
Q
How do kidney stone pts present? (3)
Where will tenderness to palp be?
A
- Sudden-onset, severe unilat colicky pain, in flank (if upper stone) or groin (if lower stone)
- With N/V, diaphoresis, can’t sit still
- Consequently tachy and HTN
- Abd will be nttp, but +CVAT.
- Testes will NOT be swollen or ttp!!
13
Q
Once the lungs or kidneys appropriately compensate for an acid-base imbalance, the HCO3- and pCO2…
A
…will BOTH be either dec or inc. They won’t be in different directions.
14
Q
Stage __, aka ‘locally invasive RCC’, is Tx’d by __.
A
IVa
En bloc resection.
15
Q
An RCC that’s stage IIIa has reached either __ or __.
A
IVC or main renal vein.
16
Q
You did your metabolic workup on your frequent-flyer kidney stone pt. It came back with high Ca2+. What should you do to Tx it long-term?
A
Prescribe a thiazide, if renal fxn is good with that!
17
Q
Phimosis is normal in infants, up to adolescence. Why should you treat it in adults?
A
If difficulty urinating or making sex fxn abnormal
18
Q
What BMP labs will be LOW in a CKD pt? What would the U/A look like?
A
Hypocalcemia
U/A: Proteinuria, RBC/WBCs or casts.
19
Q
Why does Type A Lactic Acidosis occur?
A
Hypoxia (like shock, poisoning) causes decreased tissue perfusion, so more lactic acid is made.
20
Q
Lab-wise, what three(ish) things are you looking for in an RCC Dx?
A
Anemia, or high RBCs.
Hematuria
High ESR
21
Q
Your pt is a frequent flyer struvite kidney stone pt. What long-term Tx should you consider?
A
ppx abx + urease inhibitor + perc nephrostolithotomy! (same as staghorn Tx)
22
Q
Your pt’s BUN comes back low. What are two reasons could that have happened?
A
Liver disease
SIADH
23
Q
How would you Tx severe or Sx hypoMg2+? What pt popn should you be careful with?
A
1-2g IV Mg2+ over 2-15min
Renal pts
24
Q
What are the seven fxns of the kidneys?
A
A WET BED: Acid-base balance Water balance Electrolyte balance Toxin removal BP control EPO vitD metabolism
25
When we look at an excised Wilms' tumor in histology, what do we like to see? What do we NOT like to see?
Good: classic 'triphasic'
Bad: heterozygous; diffuse anaplasia
26
Sx of hyperCa2+?
"Stones, bones, moans, groans!"
27
HyperK+ ECG looks like...
Flat P's, peaked T's!
28
4 steps of Tx'ing hyperMg2+?
d/c Mg2+ drugs!
Dietary restriction
NS + loop diuretic
HD if needed
29
U/A in a pt with uric acid kidney stones could uniquely show __ and __.
Uric acid crystals
| Low pH urine
30
Imaging shows positive Wilms' tumor Dx. Now what?
Surg:
To see if it's bilat
Liver/lymph node Bx
Tumor resection.
31
Do NOT use hypotonic soln in...
```
Dehydration pts
Hypovol/hypotn
Trauma/burn pts
Liver disease pts
Anyone at risk for inc ICP
```
32
CKD is most common in what pt popns?
African-Americans and Hispanics
33
Tell me five-ish causes of hematuria.
```
SLE/HSP
Nephritis
UTI
CA
Coagulopathy
```
34
___ is the most similar soln to blood. What's another name for it? When would we use it?
LR (Hartmann's soln)
| Use in metabolic acidosis, OB/burns, V/D
35
Goal rate of correction for hypoNa+ is...
4-6mEq/L in a 24hr period (DEFINITELY not >8!)
36
Renal cell carcinoma comes from ___ tissue. Who gets RCC?
Proximal renal tubular ep.
| Mostly >55yo white men>women, especially if they have a hereditary RCC thing.
37
Non-cardiac Sx of hyperMg2+ include __, __, and __.
Dec DTR
Flaccid paralysis
HA
38
```
Normal ABG values?
pH =
pCO2 =
pO2 =
HCO3- =
```
```
pH = 7.35-7.45
pCO2 = 40 mmHg
pO2 = 100 mmHg
HCO3- = 24 mEq/L
```
39
Normal BUN is ___. Normal Cr is __.
```
BUN= 7-20mg/dL (inc when kidney fxn dec)
Cr= 0.8-1.4 mg/dL (inc when kidney fxn dec)
```
40
We Tx (embolization surg) varicoceles if they...
- Affect fertility
- Are on the R side
- It's bilateral
41
What is the expected compensation for metabolic alkalosis? (actual numbers will be given on test, but know the general concept)
lungs will cause inc pCO2 as compensation.
| For every 1 of HCO3- increased, pCO2 will increase by 0.5ish.
42
Urea is produced by the __, dissolved in the blood, and secreted by the __.
Liver
| Kidneys
43
Acute kidney disease onset is hours or days, is usually reversible, and is d/t... (5)
```
Blood loss,
Obstruction
Rxs
IV contrast
Dehydration
```
44
What three s/s in an RAS pt would make you suspect ischemic nephropathy? +/- __.
Asymmetrical kidney size + Atherosclerosis + Azotemia (unexplained)
+/- proteinuria
45
Gold standard to CONFIRM Dx RAS is...
| Why would I need to confirm it?
Renal artery angio!
| If you're gonna do a surg
46
__ and __ losses will cause metabolic acidosis WITHOUT an anion gap. Give an example of each.
Intestinal (diarrhea, fistula drainage), renal (RTA)
47
Stage V Wilms' Tumor means __.
| Give chemo/rad to anyone Stage...
Bilateral.
Stage III and up.
48
What will metabolic acidosis look like on an ABG?
High H+, low HCO3-. Then lungs will cause dec pCO2 as compensation.
49
If you've done your U/A and HxPE and you think your pt has renal caliculi, you should Dx with ____ unless they are pregnant. What if you can't get that?
NCCT!!
Second-best choice: IVP
50
Excess carbon dioxide will make pH...
decrease (more acidic)
51
What exam findings suggest a kid has a Wilms' tumor?
Smooth/firm abd mass, inc abd girth, +/- HTN, +/- microscopic hematuria
52
HyperK+ is above __. What causes it?
5.0 mEq/L (draw this lab twice!)
Renal disease
Rxs! (ACEi, ARBs, aldosterone antags)
53
What biologic processes will raise pH (more basic)?
Emesis; hyperventilation; urination (lose H+ but bicarb too, so it balances out)
54
What is the expected compensation for respiratory acidosis? (actual numbers will be given on test, but know the general concept)
kidney will cause inc HCO3- as compensation.
| For every 10 of pCO2 increased, HCO3- will increase by 1.5ish (if acute) or 3.5 (if chronic).
55
Why does cryptorchidism happen? (2)
The gubernaculum isn't attached well so it doesn't get pulled down
Abnormal pituitary-hypothal-gonadal axis
56
CKD leads to __. How?
Nephro/glomerulosclerosis and fewer nephrons
d/t dead nephrons --> hyperfiltration by remaining nephrons --> glomerular capillary HTN --> hypertrophy of remaining nephrons --> more dead nephrons :(
57
How do you Tx metabolic acidosis?
Tx the underlying cause!!!
| + NaHCO3 if bicarb is below 18 (until it hits 22mg/dL)
58
Hypospadias can be __, __, or __ location. There are others, but these are the general ones.
Subcoronal
Midshaft
Penoscrotal
59
How come CKD causes VitD-def? What do you do about it?
Kidney does VitD activation.
| Supplement if 25OH (only measure this!) is below 30mg/mL.
60
Hypertonic solns include __, ___, and ___.
| Why don't we use them much?
3% saline, 5% saline, 10% dextrose
| Rarely used d/t lots of complications (pulm edema, severe hypoNa+, etc.)
61
Someone has HTN. What three things do you need to do for this pt?
- find an underlying cause, if there is one.
- fundoscopy to see if it's affecting eyes
- listen for bruits (esp. abd) to see if it's causing stenosis.
62
Why is Stage IV CKD so scary?
HyperK+
Edema
Uremia
63
Where is the external inguinal ring? How do you palpate it?
At the top of the spermatic cord (which connects to a testis)
Feel it while pt is doing a Valsalva like coughing
64
Venous total CO2 normal value? What is basically synonymous with that?
22-32mmol/L
| Bicarb!
65
Cryptorchidism occurs when one of two phases of testicle descent fails. Name each, what they are dependent on.
At what age does this process normally happen?
Transabd - INSL3
Inguinoscrotal - androgens
4-6wks ANTEPARTUM
66
A varicocele is wayyyy more common on what side?
| We're not sure why, but what's the general idea of why?
Left!
Maybe because it's a straight shot from the left testicular vein right into the plexus, or inc pressure from being by the SMA/aorta
67
What is a hydrocele? Besides size, why is it no bueno?
Fluid in the scrotum
| Messes with temperature regulation
68
What does GFR measure?
How well the kidneys are removing wastes and excess fluid from the blood.
69
HyperK+ is above __. What causes it?
5.0 mEq/L (draw this lab twice!)
Renal disease
Rxs! (ACEi, ARBs, aldosterone antags)
70
What happens to the foreskin in paraphimosis?
Stuck behind corona of penis which eventually leads to ischemia/necrosis
71
Microalbuminuria/proteinuria ---> ___ --> __.
Tubular injury --> CKD.
72
[Na+] > __ is hyperNa+. Sx?
145 mEq/L
| fever, sweating, V/D, primary hypodipsia
73
S/S of hypoMg2+ occur under __, and include __, __, and __.
1.0mg/dL
| Lethargy/confusion, tremors/convulsions/hyperreflexia, paresthesia
74
S/S of HypoNa+ set in when [Na+] is...
| What Sx?
125mEq (nausea, malaise)
75
Late-stage bladder CA Sx include __, __, and __.
LE swelling (unilat or bilat)
Bony/pelvic/flank pain
Palpable mass
76
Your pt's BUN comes back elevated. What are three reasons could that have happened?
CHF
RF (dec GFR)
High-protein diet
77
Two lab values that = respiratory acidosis? Why does that occur?
pH <7.35 + paCO2 >45mmHg
| d/t hypoventilation
78
KUB is quick and cheap, so why is it not necessarily a good choice?
Stones are frequently obscured by stool or bowel gas or bone.
79
What part of the kidney does tubular secretion take place in?
From the peritubular capillaries to the renal tubule
80
If the BCG implant fails to shrink the bladder CA, what three chemo options would you consider to start with?
Doxorubicin
Mitomycin
Valrubicin
81
Stage __, aka 'disseminated RCC', is Tx'd by ___.
IVb
It's not. Hello, hospice. Can do palliative radical nephrectomy to help with Sx; chemo/rad are usually pretty useless in RCC.
82
Inappropriate compensation indicates ___, as does a weird...
```
Mixed disorder
Anion gap (alkalosis with gap is mixed.)
```
83
Quick Tx for paraphimosis until surg?
D5W (or sugar)-soaked gauze pad on it
or
Poke it a ton with a 25ga needle
84
Once RAS obstructs the artery >50%, what happens to the kidney?
Hypoxia --> fibrosis, inflammation --> irreparable damage.
85
Locally advanced RCC (has gotten to regional lymph nodes) may cause ___. RCC at this stage needs __ for Dx, and is Tx'd by...
Venous tumor thrombus!
MRI
Radical nephrectomy w/ regional lymph node dissection, +/- IVC thrombectomy if needed
86
An RCC that's stage II has reached...
>7cm.
87
If the primary issue is a pCO2 change...
It's respiratory!
88
RCC Stage ___ and up are not gonna have very good prognoses.
III (it's reached multiple lymph nodes)
89
__ and __ are two antiinfection drugs that can cause radiolucent kidney stones.
Indinavir or sulfadiazine
90
Normal BUN is __, and is part of which lab set?
10-20mg/dL (BMP)
91
What stones are good candidates for extracorporeal shock wave lithotripsy?
Proximal; >5mm, but <2cm (or <1cm if in ureter) IN NONPREGNANT PTS
92
In acidosis, the kidneys...
Bind as much H+ as possible, excrete it with phosphate buffers, and make new bicarb.
93
The classic triad of RCC is in advanced RCC. What is it?
Painless hematuria + flank pain + flank mass
94
Who gets hypoNa+?
- RF
- Cirrhosis
- CHF
- too aggressive rehydration
95
NS is the ONLY soln that ___
... you can give with blood products.
96
What can severe/refractory HTN do to the lungs?
Flash pulm edema!
97
What is the expected compensation for respiratory alkalosis? (actual numbers will be given on test, but know the general concept)
kidney will cause dec HCO3- as compensation.
| For every 10 of pCO2 decreased, HCO3- will decrease by 1.5ish (if acute) or 5 (if chronic).
98
What Rxs put pts at risk for kidney stones?
Thiazides! /diuretics
```
VitD/C
Probenecid
Long-term steroids
Antacids x a ton
Theophylline
Acetazolamide
```
99
ECG of hypoMg2+ will show...
Arrhythmia
Wide QRS
ST depression
100
HyperMg2+ is over __ and is found in what three patients?
2.5mEq/L (Sx at 4mEq/L)
| RF, Antacid abusers, Overcorrected hypoMg2+
101
Besides having them before and FamHx, what conditions (NOT Rxs) put pts at risk for kidney stones?
HyperPTH
HyperCa2+ of malignancy
Sarcoidosis
102
Electrolyte labs tell you about __, ___, and ___.
Volume status, acid-base, and renal fxn.
103
Where are the three abnormal locations that a testicle could be stuck at in cryptorchidism?
Abd, inguinal canal, or high scrotal (most)
104
ECG of a hypoCa2+ pt will likely show...
prolonged QT
105
Who gets hyperNa+? Why?
Diabetes insipidus pts (hypovolemic hyperNa+ - voiding large amounts of DILUTE URINE)
Primary hyperaldosteronism pts - Inc Na+/H2O, dec K+)
Psych/demented/old pts
106
If your pt's Hgb falls below ___, start EPO replacement until it reaches __ mg/dL.
Below 10
| Aim for 11-12 (not above or below!!)
107
Who gets kidney stones?
Old white men > women, especially if they've had them before.
108
Besides FMD pts, what four pt scenarios would get you to choose PTRAS?
HD-significant RAS PLUS one of the following:
1) CHF or flash pulm edema
2) Resistant HTN/intolerant to antiHTN Rxs
3) ASx bilat or single-fxning kidney
4) Progressive CKD, bilat RAS (or unilat RAS in single-fxning kidney)
109
What are the two types of lactic acidosis?
Type A Lactic Acidosis (hypoxia)
| Type B Lactic Acidosis (metabolic)
110
ECG of hyperMg2+ will show...
Tall T
Wide QRS
Irreg
Escape beats
111
The biggest complication of CKD is __.
Name 4 others.
Cardiac complications!
HyperK+; imbalanced phosphorus/vitD/Ca2+
Uremic syndrome
Metabolic acidosis
Volume overload
112
Why would a pt have metabolic acidosis WITH an anion gap...?
Gaining acid.
113
Hypertonic soln has a ___ [solute], so solution will...
Higher [ ]
| Draw fluid out of cell
114
IVP is good for seeing ___. What should you take caution with in IVP?
GU structures.
| Check SrCr first d/t dye.
115
What stones are good candidates for ureteroscopy?
Mid/distal; hard, cystine, or impacted stones
116
Normal eGFR is at or > ___. Kidney dysfxn is below ___. Below __ needs HD and/or a transplant.
90mL/min
60
15
117
What are the four reasons metabolic alkalosis could occur?
```
DISK:
Diuretics
Ingestion of too much alkali
Stomach loss of H+ (vomiting)
Kidney loss of H+ (Cushing, primary hyperaldosteronism(
```
118
Most of total body water is...
| How much water do we I&O in a normal day?
Intercellular
| 1600mL in, 1600mL out.
119
U/A in a pt with caliculi will show __ most of the time. You should also look for __, __, and __.
Microhematuria
| the pH, crystals, and bacteria.
120
Tx mild hypoK+ with ___ at a rate of __. Also replete the ___ first!
KCl po on telemetry (no more than 10mEq/hr)
| Mg2+!
121
How do you Tx hypoCa2+?
Severe: IV Ca2+ gluconate + slow Ca2+ infusion after
ASx/mild: po Ca2+.
FIX Mg2+ FIRST!
122
Diabetes is the #1 cause of ESRD so keep your pt's HbA1c below ___!
7!
123
Why do diuretics cause metabolic alkalosis?
```
Contraction Alkalosis (large amounts of bicarbless fluid, or renal compensation causing decreased potassium)
Impaired Cl- reabsorption
```
124
Caution with LR in ___. C/I pt with __.
```
Renal disease (has K+)
Liver disease (can't metabolize lactate); pH >7.5 (will make even more alkalotic
```
125
What are the four 'flavors' of nephrolithiases, in order of most common to least?
Ca2+
Struvite (NH4+-Mg3PO42)
Uric acid (radiolucent!)
Cystine
126
Name two types of hypertensive nephropathy.
Primary glomerulopathy with HTN, and
| Vascular/ischemic renal disease.
127
How do you Tx hypospadias?
Nothing
or keep them uncircumcised
or quick surg +/- testosterone ppx
128
In alkalosis, the kidneys...
Bind as much bicarb as possible, excrete it, and make less bicarb by decreasing glutamine.
129
Normal Cr is __, and is part of which lab set? What does it indicate?
0.7-1.5 mg/dL (BMP)
| eGFR/kidney fxn
130
Normal [K+] is __. Where is it?
<3.5 mEq/L
| Most in muscle.
131
D5W is a __ soln that is C/I with ___.
Isotonic --> hypotonic!
| C/I with blood products!!!!
132
If someone has ESRD, what two comorbidities cause the most morbidity?
DM and atherosclerotic RAS
133
Those most at risk for getting RCC include smokers, the obese, HTN pts, and those who are s/p __ or __.
Kidney transplant or dialysis
134
New anemia + new renal insufficiency is __ until proven otherwise!
Multiple Myeloma!
135
What is azotemia?
The ASx accumulation of toxins/BUN/Cr d/t renal dysfxn
136
What electrolyte changes might you see on the labs of an RAS pt? Why?
HypoK+!
| d/t secondary hyperaldosteronism
137
What is the expected compensation for metabolic acidosis? (actual numbers will be given on test, but know the general concept)
lungs will cause dec pCO2 as compensation.
| For every 1 unit of HCO3- decreased, pCO2 will decrease by 1.2 units.
138
The diagnostic standard for bladder CA is...
What prompts you to order that?
(after Dx, get the usual staging imaging.)
Cystoscopy + Bx
| usually ordered after U/A with cytology comes back suspicious
139
Half-concentrates (hypotonic soln) include __, ___, __, and __.
2. 5% dextrose
0. 45% NS ("half normal")
0. 33% NS
0. 2% NS
140
When might a CCB be a better choice than an ACEi/ARB?
Don't need to monitor Cr/electrolytes as closely because CCB doesn't have the same AKI risk
Good choice for bilat RAS pts
141
Normal protein in urine is about 150mg a day, so anything over ___ is proteinuria d/t kidney dysfxn. Anything over ___ is nephrotic proteinuria (bad!)
1g in 24hr
| 3.5g in 24hr
142
A Cr greater than ___ for women and greater than ___ for men may be an early sign that the
kidneys are not working properly.
1. 2 women
| 1. 4 men
143
What would the urine of a pt with nephrotic syndrome look like?
Heavy proteinuria and lipiduria
144
Normal Ca2+ level is __. Besides Ca2+ itself, what other 3 things are involved in regulating Ca2+ level?
8.5-10.5 mg/dL
| PTH, VitD, phosphate
145
RBC casts in urine sample would suggest ___ while WBC casts would indicate ___.
RBC - glomerulonephritis
| WBC - interstitial nephritis
146
Which type of hydrocele needs surg?
Communicating hydrocele
147
What biologic processes will lower pH (more acidic)?
Hypoventilation
Protein metabolism
Diarrhea
Urination (lose H+ but bicarb too, so it balances out)
148
What is beer potomania syndrome?
HypoNa+ d/t binge drinking (which suppresses ADH, and makes you void the Na+ with H2O)
149
What are the levels of HypoNa+?
severe <120 mEq/L
moderate 120-129 mEq/L
mild 130-134 mEq/L
Acute if <48hrs. Acute is bad
150
RCC often occurs with __.
Paraneoplastic Syndrome!
151
Dx of nephrolithiasis requires __, ___, labs (2), and imaging (4).
HxPE (DO THE PE!!!)
U/A!
Labs: CBC, BMP (to make sure no RF)
Imaging: Get an NCCT! KUB, IVP, US if preg.
152
NS is aka __
| Use when...
0.9% NaCl
| Use when intravascular volume is low!
153
Why do we like extracorporeal shock wave lithotripsy?
It's not very invasive and you can do it outpt
154
Stage IV CKD is defined as ___ and treated by...
GFR 15-29
| HIGH-dose loop diuretic + nephro consult!
155
Diarrhea can cause what acid-base imbalance?
Metabolic acidosis with NORMAL anion gap, d/t loss of bicarb
156
Staghorn caliculi are usually associated with __ infection, and are treated with (3).
Proteus
| Abx + urease inhibitor + perc nephrostolithotomy!
157
Hypospadias can be __, __, or __ location. There are others, but these are the general ones.
Subcoronal
Midshaft
Penoscrotal
158
Excess bicarb will make pH...
increase (more alkalotic)
159
Most bladder CA is of what histology? Who gets it most?
Transitional cell carcinoma!
| White men > women, >55yo
160
Use hypotonic soln in __, __, and __.
HyperNa+
DKA
Hyperosmolar hyperglycemia
161
What are the layers of the scrotum, from testis out?
```
Testis
Tunica vaginalis, visceral layer
Epididymis
Tunica vaginalis, parietal layer
Internal spermatic fascia
Cremasteric muscle
External spermatic fascia
Skin
```
162
The two biggest risk factors for bladder CA are __ and __.
Cig smoking and occupational exposure
163
__ and __ losses will cause metabolic acidosis WITH an anion gap. Give an example of each.
Excess acid anabolism (all the -acidosises besides RTA), impaired acid elimination (kidney dysfxn)
164
Kidney stones over ___ will probably need a procedure to remove them.
5mm
165
S/s of bladder CA include ___, and ___ if it's a lower urinary tract site.
PAINLESS HEMATURIA
| Urinary voiding Sx
166
Who do we hospitalize for kidney stones? (3ish)
Old people or people with comorbidities
Severe Sx/vomiting too much to take po Rx
Emergencies! (sepsis, ARF, anuria)
167
How would you Tx mild hypoMg2+?
po Mg2+ (MagOx, MagTab, SlowMag)
168
How should you examine a varicocele?
| How can you confirm Dx?
In warm room, upright position
| Scrotal U/S or L testicular venogram
169
Osmolality is...
| What does a high osmolality mean?
[solute] per L of soln
| higher mOsm/L = concentrated solute = volume depletion
170
ATN stands for ___. What would it look like on urine labs?
Acute Tubular Necrosis
| Pigmented granular casts
171
For Wilms' tumor imaging: U/S where? CT where?
U/S: IVC, abd
| CT: Chest and liver (mets)
172
If it's your kidney stone pt's first one, and they have no significant FamHx, you only need to give them __ when they leave.
Dietary counseling
173
Anion gap formula and normal values?
Anion gap = Na+ minus (Cl- + HCO3-)
| 8-16 mEq/L is normal.
174
To say someone has hematuria, what do you need to have seen?
>3 RBCs per high-power field on more than one occasion
175
While they're in the ER, how do we Tx kidney stone pts?
IVF
Toradol, or narcotics if need to
Metoclopramide 10mg IV/IM (antiemetic)
+abx if infection.
176
How can SIADH cause hypoNa+?
Excess H2O caused by hypersecretion of ADH
177
Struvite stones are more common in people with __.
UTIs, esp. d/t proteus.
178
What will metabolic alkalosis look like on an ABG?
Low H+, high HCO3-. Then lungs will cause inc pCO2 as compensation.
179
3 findings of ECG with hypoK+?
Flat T, ST depression, U waves.
180
An RCC that's stage IVa has reached...
Adjacent organs
181
Tx RCC under __cm (Stage Ia) with....
| Tx RCC over that (Stage Ib or II)
Partial nephrectomy
| Radical nephrectomy
182
Shock or hypoxia leads to ___. Why? What else also does that?
Metabolic acidosis d/t lactic acid >4mEq/L
| Seizure, exercise
183
Uncontrolled DM or starvation causes ___ d/t ___.
Metabolic acidosis d/t ketone formation
184
Labs of a Wilms' tumor pt are usually normal. __ can occur in the CBC, or __ and __ in the U/A.
Anemia
| Microscopic hematuria, WBCs
185
Dx of RAS by U/S requires...
| What additional info can help you Dx correctly?
3.5+ x flow velocity at stenosis site
| Parvus tardus waveform or resistive indices can help.
186
Your pt is a frequent flyer cystine kidney stone pt. What long-term Tx should you consider?
Penicillamine + high-fluid intake diet
187
What four s/s are indicative of potential renovasc HTN?
1) BP at or > 160/100
2) Fundoscopic hypertensive retinopathy changes
3) Bruits
4) Evidence of atherosclerosis
188
What four BMP labs will be HIGH in a CKD pt?
HyperK+
Hyperphosphatemia
BUN
Cr
189
Describe the difference between the renal artery of atherosclerotic RAS and FMD.
athero- fat + Ca2+ + immune cells
| FMD - string of beads
190
Ureteroscopy will use a basket catch for stones of ___ size. What if it's too big for that?
<5mm
| Bigger --> intracorporeal shock wave or laser lithotripsy +/- stent
191
What electrolyte imbalance is often co-occurrent with hyperMg2+?
HypoCa2+
192
What is Uremic Syndrome?
Azotemia with Sx
193
Your pt is a frequent flyer uric acid kidney stone pt. What long-term Tx should you consider?
K-citrate + allopurinol + limit dietary purines
194
What are three complications of cryptorchidism?
CA, infertility, inguinal hernias
195
Two lab values that = metabolic alkalosis? Why does that occur?
pH >7.45 + HCO3 26mEq/L or more
| d/t vomit/gastric suction/acid loss-base-gain
196
What are normal values for paO2 and paCO2?
```
O2 = 80-100 mmHg
CO2 = 35-45 mmHg
```
197
Normal body pH is ...
| What is a normal bicarb?
7.35-7.45
| HCO3 = 22-26 mEq/L
198
Uric acid stones are more common in people with __, __, or __.
Gout
Hyperuricosuria
Chronic diarrhea
199
Leaky faucet penis =
Gonorrhea
200
How do you find macroalbuminuria?
Spot or 24h urine, >300mg
201
How do you Tx idiopathic hydrocele?
Watch and wait
202
The definitive Dx for renovasc HTN is...
Retrospective!!! If HTN resolves when RAS is Tx'd, it's a positive Dx.
203
What fundoscopy findings would raise concern for HTN progression?
AV nicking, papilledema. Later stage --> stage III-IV hypertensive retinopathy (hemorrhages/exudates)
204
Name six of the AUA guidelines for cryptorchidism you need to know.
- check testes at each well-visit
- refer if no spontaneous descent by 6 months
- U/S and other imaging is useless (fyi - it's actually ok to do)
- hormonal therapy is not recommended.
- urologist should do surg within a year of the failed 6-mo spontaneous descent.
- educate the pt/parents about infertility/CA risk.
205
Milk-alkali syndrome doesn't exist anymore, but why did it used to? What was it?
Too much Ca2+/milk to Tx ulcers --> hyperCa2+ --> inc bicarb reabsorption --> metabolic alkalosis.
206
What does ATII do?
- vasoconstricts efferent arteriole
- inc aldosterone (--> inc BP)
- inc glomerular permeability (--> more protein etc can get through into urine)
- proinflammatory and profibrotic!
207
If you tried IL-2 or interferon-alpha monoclonal antibody Rxs and your pt failed (because most do), what's one last class of Rxs you can try?
Multikinase/VEGFi (Sorafenib, Sunitinib, or Temsirolimus)
208
Hyaline casts in urine sample indicate...
Dehydration
209
Normal Na+ level is __. Where is it found?
135-145 mEq/L
| ECF, maintaining acid-base balance and VOLUME!
210
Name all the possible causes of metabolic acidosis.
```
MUDPILES:
Methanol
Uremia (--> HD stat!!)
DKA
Prop glycol
Isoniazid
LACTIC ACIDOSIS (most)
EtOH
Starvation/salicylates.
```
211
Conservative (noncircumcision) Tx for paraphimosis?
Inj lido 1%, then manually try to push it back
212
The diagnostic standard for RCC is...
CT with contrast!
213
What three urine tests should you get for your CKD pt?
24hr urine + U/A + urine microscopy
214
Most commonly, testicular cancer appears when?
Teenage years
215
Always get an ABG on ___ and __ pts!
Obtunded/unresponsive (esp. if clearly septic) and significant resp. distress!!
216
Define CKD.
GFR < 60mL/min for more than 3 months with persistent proteinuria/hematuria/other urine sediment
217
What popn is less likely to get renovasc HTN?
African-Americans (most likely essential HTN)
218
After six months without spontaneous descent, what is the Tx for cryptorchidism?
Orchiopexy
| can try HcG Rx, but not a high success rate and playing with hormones is scary
219
What's your three-step process for approaching an acid-base imbalance question?
1) acidotic or alkalotic?
2) does the pCO2 account for this?
3) is this appropriate compensation? (if not, whether too high or too low, = NO. No = mixed imbalance!)
220
What four things are we generally looking for on NCCT if we expect renal caliculi?
```
DNRs:
Dilation
Nephromegaly
Rim Sign
Stranding
```
221
What will respiratory acidosis look like on an ABG?
High H+, high pCO2. Then kidney will cause inc HCO3- as compensation.
222
Use 3% saline at ___mL if ASx <130mEq Na+
| Use 3% saline at __mL if any Sx and Na+<130.
50mL
| 100mL, repeat in half hour
223
Kidney failure is stage __ CKD, measured by...
V
| GFR <15 or on HD
224
Tx hypoNa+ by relieving Sx, avoiding __, and decreasing __.
```
Osmotic demylination (central pontine) d/t overcorrection
Dec ICP
```
225
Sx of hyperNa+?
| How do you Tx it, and at what rate?
AMS and all sorts of neuro issues.
Monitor q2hr; use D5W 3-6mL/kg/hr + desmopressin if DI pt
1-2 mEq/L/hr is ideal rate
226
RAS in women <40yo should add __ onto your DDx.
Fibromuscular dysplasia
227
Most common abd tumor in peds is __, then __.
Neuroblastoma, then Wilms' tumor
228
Usually Stage IVb RCC is pretty untreatable, but if your pt has minimal tumor burden (kidney gone), and only lung or node mets, then you can consider ___.
IL-2 or interferon-alpha monoclonal antibody Rxs.
(Still, only 15% will respond to that).
229
Why would a pt have metabolic acidosis WITHOUT an anion gap...?
Losing bicarb.
230
Two lab values that = respiratory alkalosis? Why does that occur?
pH >7.45 + paCO2 <35mmHg
| d/t hyperinflation
231
What's the difference between a BMP and CMP?
CMP is + LFTs
232
How does a unilateral stenotic renal artery affect the RAAS?
| What mediates unilateral RAS?
Affected side - Dec pressure distal to the stenosis --> inc renin --> inc ATII
ATII--> vasoconstriction at efferent arteriole and inc aldosterone --> inc BP!
Unaffected side - natriuresis.
Renin is ALWAYS elevated! (RENIN-MEDIATED)
233
First-line Tx for RAS is...
Rxs.
(ACEi or ARB +/- CCB, +/- statin, +/- antiplt)
Then give them to Nephro!
234
What is uremia and how do you measure it?
Bad inflammation d/t lots of accumulated toxins
| Measured with Cr and urea.
235
In men, ___ can be an additional Sx that tips you off to RCC.
Varicocele esp. in L side
236
Bladder CA that IS muscle-invasive (stages __ and up) are Tx'd with neoadjuvant chemo (__, __, __, __) and then...
T2
MVAC (MTX, Vincristine, Adriamycin, Cisplatin), then
Radical cystectomy w/ regional lymph node dissection!
237
Name/briefly describe three places stones can get stuck.
UPJ (ureteropelvic junction) - upper; won't pass on its own
UVJ (ureterovesicular junction) - lower; most are here.
Pelvic brim - middle, where ureter goes over iliac artery
238
What is a crystalloid IVF? Give an example or three.
Soln does cross cell membrane (requires more product)
| IV NS, D5W, LR
239
Cardiac Sx of hyperMg2+ include __, __, and __.
Brady, hypotn, cardiac arrest
240
You did your metabolic workup on your frequent-flyer kidney stone pt. It came back with high PTH. Tx the hyperparathyroidism-- but why did that cause stones in the first place?
Resorptive hypercalcuria
241
What part of the kidney does tubular reabsorption take place in?
From the renal tubule to the peritubular capillaries
242
Your pt has HTN, so you put them on either an ACEi or ARB. Suddenly they get azotemia. What is going on?
Bilateral renovasc HTN (or unilateral, if they only had one working kidney to start with)
This is CLASSIC board question for Renal Artery Disease!
243
What is third spacing? Give two examples.
When fluid overload goes into tissue - eg in trauma, burns, sepsis
Pleural effusion and ascites
244
What kills most RF patients?
CVA or MI.
245
Hyperventilation leads to ___.
| Hypoventilation leads to ___.
```
Hyper = resp alkalosis
Hypo = resp acidosis
```
246
What imaging could you order to confirm hydrocele?
Scrotal U/S
247
We only really revasc HD-significant stenosis. What is that defined as?
70% blocked (as seen on angio)
-OR-
50-70% blocked (as seen on angio) PLUS one of the following: 10mmHg or less resting gradient, 20mmHg or less systolic/hyperemic gradient, or 0.8 renal fraction flow.
248
Do all renovasc HTN pts have renal dysfxn?
No!
249
Who gets Wilms' tumors most often?
Kids <6yo, male>female
250
What are the two most common causes of ESRD?
Diabetic glomerular disease, and
| Hypertensive nephropathy
251
CKD Sx start at stage ____ and include... (7ish)
Stage III or IV
| N/V, sleep issues, encephalopathy, muscle twitch/cramp, swollen LE, pruritis.
252
How can hyperglycemia cause hypoNa+?
High SrGlu --> released H2O --> diluted Na+ as a side effect
| so, caution with administration of hypertonic mannitol, you may cause hypoNa+
253
What is the most common cause of hypoK+?
Rxs! d/c these first!
| Loop/thiazide diuretics, insulin, b-adrenergic
254
U/A in a pt with infection + kidney stones could show __ and __. Infected stones need to be admitted, that's bad!!
Pyuria WITH bacturia (pyuria alone could be no infection)
High pH urine
Nitrates/leukocyte esterase
255
Hypotonic soln has a ___ [solute], so solution will...
Lower [ ]
| Cause cell swell
256
What are some options for Tx'ing phimosis?
Manual stretching, cool it on the aggressive jerking off, circumcision
257
Mg2+ levels are controlled by __ and __.
Int absorption and renal excretion.
258
How does bilateral stenotic renal artery affect the RAAS?
| What mediates bilateral RAS?
Transiently inc renin/ATII/aldosterone, then inc volume --> dec renin
VOLUME-MEDIATED
259
Repeated and continued activation of the RAAS --> ____.
Microalbuminuria and proteinuria!
260
What are you listening for when you auscultate for bruits in a HTN pt? What would the presence of it indicate?
A systolic-diastolic bruit near epigastrium
| FMD! (could also be other RAS)
261
Common causes of hypoCa2+ include __, __, ___, __, and __.
- Parathyroid disease/ectomy
- Thyroid disease/ectomy
- CRF
- VitD-def
262
In what two cryptorchidism situations would you get endocrine labs in addition to calling a consult? (they can interpret)
Cryptorchidism with hypospadias, or you can't feel either testicle
263
What is a colloid IVF? Give an example or two. When would we use it?
Soln that is too big to cross the cell membrane
Albumin, dextran
Used in shock to inc fluid very quickly
264
Define staghorn stone. What are they made of?
Upper urinary tract stones that involve the renal pelvis and extend into at least 2 calyces, WITH INFECTION.
Struvite
265
Two pathognomic physical exam findings of hypoCa2+ are __ and __!
Chvostek (facial tap)
| Trousseau (wrist thing)
266
Why do kidney stones occur?
Ca2+, PO43-, and uric acid get supersaturated in the urine when you're in a low-flow state
267
Under 115mEq, a hypoNa+ pt becomes at risk for... (4ish)
- HA
- Lethargy/coma
- Respiratory arrest
- Pulm edema
268
Let's say you can't get a 24hr urine for whatever reason. How can you check for proteinuria and what level is your cutoff?
Spot urine - prot:Cr >0.2 is abnormal.d\
269
ADH is secreted by ___. Malfunction of that = __.
| What causes it to be released?
Posterior pituitary
Dysnatremia
Dec blood volume
270
What will respiratory alkalosis look like on an ABG?
Low H+, low pCO2. Then kidney will cause dec HCO3- as compensation.
271
You see that the pH is off. So it's alka/acidosis. Great. Then, ask yourself...
"Does pCO2 explain the problem?"
(ie, if the pt is acidic, is the pCO2 high?
If the pt is alkalotic, is the pCO2 low?)
```
No? = metabolic
Yes? = respiratory.
```
272
Paraphimosis is an EMERGENCY. Who gets it?
Partially circumcised/uncircumcised men
273
Besides PTRAS, the number-one recommendation for FMD pts is __.
Balloon angioplasty + bailout stent!
274
3 Tx options for hyperCa2+?
- NS
- Salmon calcitonin + bisphosphonate
- Zoledronic acid
275
U/S is really only a great choice if stone is... (5)
- in a pregnant lady or peds
- in the actual kidney (not ureter)
- if you think there's hydronephrosis going on.
- if you think it might actually be reproductive system or GB.
- if your pt is a repeat offender and you expect this.
276
Nothing you've tried has worked and you can't get into the OR for your paraphimosis pt. What do you do?
Dorsal slit procedure. Or try DIY.
277
The scrotum should be __ and __ compared to the rest of the skin.
Darker
| Rugated
278
What stones are good candidates for perc nephrostolithotomy? What if that fails?
Proximal; >2cm; anything complex.
Only other option is open nephrostomy (rare).
279
Why might you go for renal artery bypass over revasc/just Rx? (3ish)
If there's evidence of athero in the aorta, or:
- complex FMD
- atheroRAS that hits smaller branches of artery too
280
The paroxysm of pain lasts about ___ in nephrolithiasis pts.
20-60min
281
What part of the kidney does glomerular filtration take place in?
Glomerular capsule
282
Bladder CA that is NOT muscle-invasive (stages __, __, and __) are Tx'd with surg (__ or __), or with ___ placement.
Ta, T1, or CIS
Endoscopic TURBT, or radical cystectomy
Intravesicle instillation of BCG or chemo
283
Hypoalbuminemia will cause a ___ lab!
PseudohypoCa2+! Correct it first!
284
"Bag of worms" =
Varicocele (dilation of pampiniform plexus)
285
The most common cause of RAS is __!
Atherosclerosis of the renal artery!
286
What other two electrolyte imbalances can cause hypoK+?
HypoMg2+ and hyperaldosteronism
287
For microalbuminuria, you could use a spot test, a dipstick, or a 24hr urine. What would a + be on each?
Spot - 30-300mg/L
Dipstick - +1
24h - 30-300mg/24hr
288
The most useful imaging tools to INITIALLY Dx RAS are __ and __, then U/S, then captopril scintigraphy/renography (rarely used). What are important to note about the top two choices?
```
MRA (gad needed so avoid in CrCl<30!!!)
Spiral CT (dye needed so only for CrCl>60!!)
```
289
The main procedure chosen for RAS revasc is __.
| Who especially is a good candidate?
PTRA+/-stent
| FMD pts
290
Two lab values that = metabolic acidosis? Why does that occur?
pH <7.35 + HCO3 22mEq/L or less
| d/t GI/acid gain-base loss
291
If the primary issue is a HCO3- change...
It's metabolic!
292
Why do cryptorchidism pts get inguinal hernias?
Patent processus vaginalis
