Quiz 1 Flashcards
How many 24 hour urine samples should a patient supply if you are looking for abnormalities in urine (ie. kidney stones)?
Currently there is conflicting opinion regarding whether a single 24-hour urine sample is adequate and reliable to identify abnormalities within the urine. Either one or two 24-hour urine samples with the individual of his/her usual diet should be obtained and measured for calcium, oxalate, citrate, magnesium, sodium, and sulfate but two samples are preferred.
What are the 5 potential components of renal and urinary calculi? What’s the most common metabolic abnormality associated with calcium oxalate stones?
Renal and urinary calculi can be classified into 5 types based on their composition: calcium oxalate (75-80%), struvite (10-25%), calcium phosphate (5-10%), uric acid (5-10%) and cystine (1-2%). Hypercalciuria is the most common metabolic abnormality associated with calcium oxalate stones.
What should you suspect if there is high serum calcium and what else should you test for?
In the presence of elevated serum calcium per blood chemistry, primary hyperparathyroidism should be suspected and PTH levels should be measured; vitamin D levels should be assessed because low vitamin D can mask primary or secondary hyperparathyroidism.
Why is a UA and C&S important?
UA and culture and sensitivity are essential to determine pH and to identify the presence of bacteria, crystals, and red blood cells. Hematuria may be microscopic or gross and may occur with or without infection.
What diagnostic findings will tell you if a kidney stone is alkaline or acidic?
An increase in the urine pH and the presence of crystals may give clues as to the stone’s composition and whether the stone is alkaline or acidic.
What are some differential diagnoses for kidney stones?
Differential Diagnoses: appendicitis, cholecystitis, peptic ulcer, pancreatitis, ectopic pregnancy, dissecting aortic aneurysm, pyelonephritis, UTI, shingles
Common risk factor for kidney stones
One of the most common risk factors for stone formation is reduced urinary flow, and any factor that reduces urinary flow or urinary volume allows stone constituents to supersaturate and increases the risk of kidney stones.
What diagnostic study to use for suspected kidney stone if CT scan not available?
An abdominal xr of the kidneys, ureter, and bladder (KUB) is often the first imaging study used if CT is not available and will identify renal stones that are radiopaque. Only about 60% of stones are found visible on plain films, but it is helpful in documenting the number, size, and location of stones in the urinary tract.
Common symptoms and locations of kidney stones
Renal or ureteral colic is a result of obstruction of the urinary tract by the stone. The obstruction is usually in one or more of 5 locations: the calyx, ureteropelvic junction, at or near the pelvic brim, posterior pelvis, and ureterovesical junction. Fever and chills may be present if infection occurs with the stone.
Differential diagnoses for T2DM
Differential diagnosis for type 2DM include pre-diabetes, gestational diabetes, Cushing syndrome, pheochromocytoma, drug-induced hyperglycemia, acromegaly, glucagonoma, cirrhosis, cystic fibrosis, pancreatitis
How often to monitor DM med regimen? Should you wait any timeframe to intensify treatment?
Evaluate the medication regimen every 3 to 6 months and need to account for new patient factors in glycemic control. Do not delay intensification of treatment if the patient is not achieving glycemic goals.
Initial tx for DM and what lab should you periodically monitor?
Pharmacological therapy is required when lifestyle management does not result in adequate blood glucose control. Metformin is the preferred initial glucose-lowering therapy for adults with type 2 diabetes unless it is contraindicated or not tolerated. Consider periodically measuring vitamin B12 levels in patients treated with metformin since long-term metformin use may be associated with vitamin B12 deficiency.
When should you consider T1DM in older adults?
Although type 1 DM occurs infrequently in older adults, it should be considered in patients with other autoimmune disorders, patients without a family history of type 2 diabetes, or patients of normal weight.
Why, when, and what to expect when ordering the following: ESR, Rheumatoid Factor, Vitamin D level, serum CO2 level, PSA, TSH and T3/T4, HbA1c, creatinine, bone densitometry, UA C+S, helical spiral CT, CBC with diff
Important of American College of Radiology Appropriateness Criteria (understand the categories for procedures as they relate to appropriateness rating and radiation level)
- Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition
- Starting January 2020 the ACR Appropriateness Criteria used by health care providers for determining imaging studies for patient management will become the standard of care for reporting on Medicare patients.
*ACR Practice Guidelines for Communication of Diagnostic Imaging Findings:
Effective communication should
1) promote optimal patient care and support the referring physician/health care provider in this endeavor, 2) be tailored to satisfy the need for timeliness, and 3) minimize the risk of communication errors.
Specificity and sensitivity of diagnostic tests
Sensitivity: the ability of the test to determine who has the disease. A highly sensitive test means that there are few false negative results, and thus fewer cases of disease are missed. “Out of people who have the disease, how accurate is the test at detecting it?”
Specificity: the ability of the test to determine who does not have the disease. “Out of people who do not have the disease, how accurate is the test at detecting it?”
Clinical Reasoning Process
Collect H&P, complete physical exam, interpret diagnostic studies
Clinical decision making is multifaceted and encompasses the patient, clinical problem, and the practitioner’s perspectives.
Critical thinking involves application of analysis, evaluation, and inference
consider precision, accuracy, sensitivity, specificity
Differences in types of testing as they pertain to the main areas of the textbook -example,
ultrasound, MRI, vs microscopy
The 4 efficacy indicators for diagnostic tests to be recommended routinely
accuracy, precision, sensitivity, and specificity
When to prescribe more than one anti-diabetic?
Many patients with type 2 diabetes and hemoglobin A1c greater than or equal to 1.5% above glycemic target will require dual therapy and some patients may require triple therapy to achieve glycemic target.
chloride
-Does not provide much information alone
-Can help identify acid-case imbalance and hydration when used in combination with other electrolytes
-electrolyte or acid-base imbalance and 24 hour urine
creatinine
-Diagnoses impaired renal function-Used to estimate GFR
-Can become elevated with use of ACEI, aminoglycosides, certain chemotherapy agents, NSAIDs
creatinine clearance
-Used to measure GFR of kidney
-CrCl not affected if only 1 functioning kidney
-Decreases with age
Estimated GFR
-Used to determine stage of kidney disease
-Utilizes creatinine, age, gender, and body size to calculate
-eGFR <60 for 3 months or more indicates chronic kidney disease
Prostate specific antigen (PSA)
-Screening method for prostate cancer
-PSA elevated in cancer, infection, BPH
- UTI and prostatitis can cause elevations for up to 6 weeks
-Secreted in all males
sodium
-Monitor fluid and electrolytes
-Part of BMP/CMP
-Increased sodium due to increased sodium intake
-Decreased sodium due to: Cushing syndrome, hypoaldosteronism. GI loss, excessivesweating, overhydration, burns, DI, renal insufficiency, diuretic
-Monitor sodium therapy
-Volume depletion, acute renal failure, adrenal disturbances
Urea nitrogen (BUN)
-rough measurement of renal function and GFR
-Dietary protein can affect BUN
-Almost all renal diseases cause inadequate excretion of urea-can be affected by hepatic function
uric acid
-Diagnose gout and monitor treatment
Gout is common metabolic disorder caused by chronic hyperuricemia
-Can be used to evaluate kidney stones
-excreted primarily by the kidney and a lesser amount by the intestinal tract
cytoscopy
-Used to evaluate patient with suspected pathologic conditions involving the urethra, bladder, and lower ureters
-can be used therapeutically
urodynamic studies
-Used to identify problems with bladder function
-Includes urine flow studies, post-void residual, and cystometrogram
-Performed in combination with cystoscopy
renal biopsy
-Diagnose renal disease-Malignancy
-Kidney transplant rejection
renal scanning
-Used to evaluate perfusion, function, and structure of kidneys
scrotal US
-evaluation of scrotum and testes
-doppler evaluates blood flow to the testicles
-used for diagnosis of testicular torsion
substance abuse testing
-Metabolites of illegal drugs
-used for drug screens in pre-employment, narcotic agreements
toxicology
-Drugs of abuse, overdose, poisoning
-Often used in ed when clearing patient for psych delegate
osmolality
-Fluid and electrolyte imbalance
-Used to evaluate diabetes insipidus and SIADH
potassium
-Major cation of the cell
-Acid-base balance, electrolytes
-Renal and adrenal disease
*urinalysis
-Kidney function and metabolic processes
-**UTI= leuk estrace, nitrates, WBC
-Kidney stone - blood, proteinuria
-Diabetes - glucosuria
urine C&S
-Diagnose UTI
-Fever of unknown origin
urinary stone analysis
-Identify composition of kidney stones
-Calcium oxalate and calcium phosphate make up most stones
-Stones <5mm generally will pass; stones >7mm almost always require intervention to pass
pyelography
-X-ray study that uses contrast material to visualize the kidneys,renal pelvis, ureters, and bladder
-Used to assess trauma on urinary system
kidney, ureter, bladder xray (KUB)
-1 view abdominal xray
-Abdominal pain or trauma
-Identify pathologic conditions
-Calculi, obstruction, masses, or ruptured viscus
Mammogram is what type of test?
xray
bone scan is what type of test?
nuclear
doppler is what type of test?
ultrasound
what tests are to be ordered for DM?
- A1c
- FBG
- glucose tolerance test
- random blood sugar test
what tests require NPO?
what you can’t eat/drink (fasting)
lipids, glucose
what tests require meds beforehand?
biopsy
colonoscopy
UA
CT scan
ECG
gastroscopy
eye tests
blood tests
EEG
MRI
*what tests are ordered for kidney stones?
Urinalysis
Blood Tests (uric acid, Ca)
Abdominal x-ray
CT Scans
kidney stone analysis
what type of test is a renal scan?
nuclear
*carotid artery duplex scan (US)
performed to identify occlusive disease in the carotid artery or its branches. Recommended for patients with CVA, PVD, & neurologic symptoms like TIAs, hemiparesis, paresthesia, dizziness, syncope, or acute speech & visual deficits, and carotid bruit
*DEXA scan
Determine bone mineral content and to diagnose osteoporosis. Specialized X-ray that uses 2 different energies so bones surrounded by soft tissue can be penetrated. Important part of routine screening in post-menopausal women; recommended every 2 years
*know most useful tests to dx RA
Rheumatoid Arthritis Diagnoses
o Antinuclear Antibody - tests multiple antibodies,
not specific
o Rheumatoid Factor - autoantibody
o Inflammatory Markers:
C reactive inflammatory markers= Infection, infarction, autoimmune inflammation. Rises and falls quickly
Erythrocyte Sedimentation Rate, Up to 15 M, up to 20 F. Slower to rise and fall than CRP
Infection, infarction, autoimmune inflammation
o X-ray - inexpensive and easy
o MRI in c-spine abnormalities
o Joint aspiration and synovial fluid analysis
** Initial testing should also include an ESR which will be elevated if the disease is active. CRP is an acute phase reactant which like ESR is reflective of a heightened inflammatory state. The CRP may be evaluated in addition to or in place of ESR as a nonspecific indicator of inflammation. Other tests include a CBC to rule out anemia as potential cause of fatigue and to evaluate for an associated leukocytosis or neutropenia. A platelet count showing normal or high values will become more elevated as joints become more inflamed. In addition joint fluid analysis may aid in distinguishing RA from other causes of joint inflammation such as infection.
** Aspirants from rheumatoid joints will show between 2,000-50,000 WBC per mL with a pronounced neutrophil component.
***Because RF alone is not diagnostic of RA, a more specific test is for circulating anti-CCP antibodies in the peripheral blood. This autoantibody species is more specific for RA than RF and may be detected earlier in the disease process.However, anti-CCP titers correlate less well with severity of disease or prognosis, compared with RF.
*** The preferred initial tests for diagnosing RA is measurement of peripherally circulating RF, an IgM class autoantibody that binds to the Fc portion of IgG molecules. The test result provides both qualitative and quantitative information that is useful in correlating with physical markers of RA. For example, a positive RF titer of greater than 1: 150 indicates a poorer prognosis and is often accompanied by findings of severe disease such as rheumatoid nodules.
*know how to dx hyper- & hypothyroidism
TSH (0.3-5)
Elevated - hypothyroid
Decreased - hyperthyroid
metacognition
Knowledge + cognition
accuracy vs precision
Accuracy: does the test measure what it was designed to measure; proportion of all tests (positive and negative) that are correct.
Precision: does the test reproduce the same results when repeated on the same patient or a sample; a test can be precise but not necessarily accurate if the results differ from reference range.
electrodiagnostic studies
o Tests electrical impulses
o May cause discomfort from stimulation
o Do not move, have caffeine or sedatives before test
o Few complications
o Not invasive, usually do not need written consent
ex: Electromyography (EMG)
Nerve conduction studies (NCS)
Need to know key sign it’s RA and not OA
Osteoarthritis almost never affects the wrist and metacarpophalangeal joints. Osteoarthritis is classically known for affecting the DIP joints with Heberden’s nodes in the fingers. In contrast, the distal joints are less commonly affected in RA.
- RA differential dx
Differential diagnosis for rheumatoid arthritis may include: osteoarthritis, psoriatic arthritis, gout, chronic lyme disease, SLE, infection by human parvovirus B19, polymyalgia rheumatica, Sjogren’s syndrome, sarcoidosis, various neoplasms, septic arthritis, Adult Still’s disease, rubella arthritis, hepatitis B or C.
*What’s important to know about measuring RF to dx RA
It is necessary to interpret both the presence of RF (qualitative) with the dilutional titer (quantitative) because RF may be present in other diseases and its incidence increases with age. It is estimated that only 75% of RA patients are positive for RF.
