SAQ book Flashcards
CKD Stages: (Based on egfr)
Stage 1: Above 90 Egfr
Stage 2: 60-89
Stage 3a: 45-59
Stage 3b: 30-44
Stage 4: 15-29 (Usually only symptomatic from Stage 4 onwards)
Other than Diabetes, 4 common causes of CKD?
- Hypertension
- Glomerulonephritis
- Pyelonephritis
- Polycystic kidney disease
- Obstructive uropathy
Why is a renal ultrasound arranged in CKD?
- To assess renal size, exclude polycystic kidneys, and exclude obstruction
Medication to add if diabetic and in CKD?
ACE-I (eg. Ramipril is protective)
2 common side effects of ACE-i?
- Dry cough
- AKI
- Urticaria
- hyperkalaemia
- first dose hypotension
2 other blood tests that are important to check regularly in CKD?
PTH
FBC
Calcium
Alkaline Phosphatase
Phosphate
Complications of CKD?
-Anaemia
-Renal osteodystrophy
NB: CKD mx: often requires lowering dose of drug= Gentamicin and Digoxin
- CKD patients are prone to developing Hyperkalaemia= give low potassium diet for all patients.
3 signs of CKD could find on examination?
-Pallor
- purpura
- uraemic tinge
- brown discolouration of nails
-peripheral oedema
Pericardial rub
- pleural effusion evidence
- Tenckhoff catheter (evidence of preparation for renal replacement therapy)
- Proximal Myopathy
Explain basic principles of haemodialysis?
- Blood and dialysis fluid flow either side of a semipermeable membrane.
- Molecules diffuse DOWN their concentration gradient
- Plasma biochemistry changes to become more like the dialysis fluid.
2 complications of Peritoneal Dialysis?
- Bacterial/Sclerosing Peritonitis
- Location infection at catheter site
- Constipation
- failure
what time period determines if organ rejection after renal transplant is acute or chronic?
6 months
why is there a need to be seen by a dermatologist after a renal transplant?
- increased risk of squamous cell carcinoma (due to the long-term immunosuppression)
-Renal replacement therapy: is started when egfr is less than 15+symptomatic. Options:
1)Haemodialysis (involves formation of AV fistula- blood and dialysis fluid flows in opposite directions)
2)Peritoneal Dialysis (tenckhoff catheter- dialysis fluid is introduced into peritoneal cavity
3) Renal transplant: can be from donors: brainstem dead, non-heart beating, living related, living unrelated. Patients must be ABO incompatible with donor. Lifetime immuno-suppression is needed after this.
What form of Hyperparathyroidism has Low calcium and high PTH?
Secondary Hyperparathyroidism (high PTH and low Ca)
give 2 actions of PTH
1) Increase osteoclast activity (results in increased calcium and phosphate released from bone)
2) Increase Calcium and Phosphate Reabsorption via kidney
3) increased hydroxylation of Vit D
At what 2 sites does Hydroxylation of Vit d occur?
- Liver
- Kidney
What term is given to bone disease in patients with renal failure
Renal Osteodystrophy
2 ways to manage Secondary Hyperparathyroidism
- Calcium supplements
- Vitamin D analogues (eg. calcipotriol)
- Restrict dietary phosphates
Tertiary Hyperparathyroidism: levels of calcium and PTH?
Calcium: high
PTH: High
NB: Both is high like Primary Hyperparathyroidism
Reason for why tertiary hyperparathyroidism can develop from secondary?
- Prolonged Tertiary Hyperparathyroidism= causes parathyroid gland to act autonomously (causes hyperplastic change)
NB: in CKD: there is reduced production of erythropoeitin= causing anaemia, therefore treat with Erythropoeitin injections
how can AKI be subclassified?
3 types:
1) pre-renal
2) renal
3) post-renal
2 causes of each type of AKI?
Pre-renal: (dehydration)
1) Hypovolaemia
2) sepsis
3) congestive heart failure
Renal: (intrinsic)
1) Acute tubular necrosis
2)Glomerulonephritis
3) rhabdomyolysis
4) haemolytic uraemic syndrome
5) Pre-eclampsia
6) malignant hypertension
Post-renal: (obstruction)
1)renal calculi
2)ureteric tumours
3) BPH
4) Prostate cancer
triad of conditions in haemolytic uraemic syndrome?
1) AKI
2) haemolytic anaemia
3) thrombocytopenia (LOW platelets)
Other inv. to request in AKI except blood tests?
- Renal USS: to rapidly rule out an obstruction
- CXR
- ECG
- ABG
- Urinalysis
NB: Mx of AKI= is by treatment of underlying cause.
2 potentially life-threatening complications of AKI?
- Pulmonary oedema
- Hyperkalaemia
- Haemorrhage
give 2 indications for dialysis in a patient with AKI?
1) Uraemic (either encephalopathy or pericarditis)- uraemia would present with confusion
2) Refractory: Pulmonary oedema/ Hyperkalaemia
Reason for AKI if urine is brown, collapsed on floor for ages?
Rhabdomyolysis= Following prolonged immobility
- Mechanism that causes this: Acute Tubular Necrosis
what blood test would be raised in Rhabdomyolysis?
Creatinine Kinase
What urine test would you request to confirm the diagnosis?
Urinary Myoglobin
What may be seen on urine microscopy?
Muddy brown/granular casts
Which medications would you hold on admission in a person with Rhabdomyolysis?
- metformin- as there is a risk of metabolic acidosis
- lisinopril- is nephrotoxic
Other than prolonged immobility, give 3 causes of Rhabdomyolysis?
- Excessive exercise
- Crush injuries
- Burns
- Seizures
- Neuroleptic malignant syndrome
- Drugs: Heroin, Ecstasy, Statin
3 ECG changes seen in Hyperkalaemia?
(Everything big)
- Tall tented T waves
- Widening of QRS complex
- Flat P waves
Initial treatment for Hyperkalaemia?
- IV Insulin+Dextrose
- Salbutamol Nebulisers
- 10% Calcium Gluconate 10mL over 5 mins (if K+ is more than 7= to protect the myocardium of the heart)
- if hyperkalaemia still remains= Needs Dialysis
What blood tests should you request urgently: for rapidly progressive Glomerulonephritis? (urine shows: positive for blood and protein)
- ANCA
- Anti-GBM
what medication should be started immediately in rapidly progressive Glomerulonephritis?
Steroids
Further inv. to confirm Wegener’s Granulomatosis (Granulomatosis with Polyangitis)
Renal biopsy
NB: about condition: is autoimmune affecting: upper and lower resp. tract+ Kidney
-cANCA
- Renal biopsy: will show Epithelial crescents in Bowman’s capsule.
Define nephrotic syndrome
Triad:
1) Proteinuria (more than 3)
2) Hypoalbuminaemia (less than 30)
3) Oedema
Presentation could be: leg swelling that is worse when standing and walking, resolved when lying flat, + no SOB (as ddx: Heart failure)
Most common cause of nephrotic syndrome in - children - adults?
- Children: Minimal Change Disease
- Adults: Membranous Nephropathy/Glomerulonephritis (Mx: ACE-i/ ARB)
- Elderly: Focal Segmental Glomerulosclerosis
What inv. will give definitive diagnosis for Nephrotic Syndrome?
Renal Biopsy (Almost always the definitive diagnosis)
2 complications of nephrotic syndrome?
- Increased susceptibility to infections
- increased risk of thromboembolism
- hyperlipidaemia
One measure to manage complication of nephrotic syndrome?
- infection: prompt abx. treatment, pneumococcal vaccination
- thromboembolism: avoid prolonged bed rest, and consider anticoagulation
- hyperlipidaemia: treat with statin
2 pieces of Dietary advice: for a patient with nephrotic syndrome?
- Restrict salt intake
- Normal protein intake
serum osmolality formula?
2*Na+urea+glucose
clinical obs. and inv: to determine volume status and cause of hyponatraemia?
- examine for peripheral oedema
- examine jvp
- postural blood pressure
- measure urine output
- cxr: signs of heart failure/pulmonary oedema
What is the risk of correcting hyponatraemia too quickly?
- Central pontine myelinolysis (another word for osmotic demyelination syndrome)
Where is ADH (vasopressin) secreted?
Posterior pituitary gland
How does ADH increase water reabsorption?
Recruits Aquaporin 2 channels: to apical membrane of principal cell of collecting ducts= making it water-permeable.
Urine osmolality is high (relative to serum osmolality)+urinary sodium is high what diagnosis?
- SIADH
name a drug used to treat SIADH?
- Demeclocycline
- Vasopressin (ADH) receptor antagonists
UTIs and Cystitis: classic presentation
- In young female
- Dysuria
- Urinary frequency
Which organism is commonly responsible for infections of the urinary tract?
- e. coli
4 risk factors for UTIs?
- Female
- Sexual intercourse
- Pregnancy
- renal calculi
- long-term catheterisation
- Diabetes
which two things positive indicate UTI?
- Nitrites
- Leucocytes
which abx. to prescribe in UTI and for how many days?
Trimethoprim
Nitrofurantoin
Amoxicillin
- 3 days
- If symptoms occurs despite abx= do a MSU
Any advice to prevent recurrence of UTIs?
- Keep well hydrated
- Drink lots of cranberry juice
- Post-coital voiding
- Wipe front to back
- Avoid spermicide
Pyelonephritis classical presentation?
- Young female
- fever
- RUQ pain
- loin pain
- rigors
- vomiting
- Urine dipstick: positive for= WCC+ Nitrites
Pyelonephritis: steps you would do to see this patient?
- assess ABC
- full history and exam
- IV access and give fluids IV
- urine dip
- request relevant inv.
- start empirical abx.
- start empirical abx if necessary
4 investigations to request for pyelonephritis? (can treat with: IVco-amoxiclav)
- FBCs
- U and E’s
- CRP
- Urine MC and S
- Blood cultures
- Renal Ultrasound
signs of anaphylaxis on patient?
-Airway: stridor, hoarse voice, obvious swelling of tongue/throat
-Breathing: Tachypnoea, cyanosis, wheeze
- Circulation: Tachycardia, Hypotension, pale appearance, may feel clammy
Anaphylaxis: which route will you give adrenaline? What conc. and how much?
- IM
- Concentration: 1:1000
- Volume: 0.5ml
2 contraindications to renal biopsy?
- single functioning kidney
- systolic BP: more than 160
- diastolic BP: more than 90
- CKD with small kidneys
- abnormal coagulation studies: therefore patients on anticoagulation should stop them well in advance of biopsy procedure
- After biopsy: bed rest is advised+ pressure dressing applied. patients should avoid heavy lifting and strenuous activity for following 2 weeks
2 complications to renal biopsy?
- Macroscopic haematuria (bleeding)
- pain
- infection
- formation of AV aneurysm
- rare cases: death
1 histological finding: in IgA nephropathy (NB: is associated with Henoch- Schloein Purpura- HSP)
- IgA deposits
- mesangial proliferation
give 3 other causes of a purpuric rash (apart from HSP) ?
- Meningococcal Septicaemia
- DIC
- TTP
- ITP
Rheumatoid Arthritis: immunological investigation to request?
Immunological= Antibody
1) Anti-CCP: specific
2) Rheumatoid Factor
3 findings expected to see in hands of rheumatoid arthritis?
- Swan neck deformity
- ulnar deviation
- Boutteneire’s
- z shaped finger
Rheumatoid Arthritis: 3 abnormalities seen on X-ray of hands?
LESS
- Loss of joint space
- bony Erosions
- Soft tissue swelling
- oSteopenia (juxta-articular)
4 extra-articular features of Rheum arth?
- Scleritis
- rheumatoid nodules
- anaemia
- Raynaud’s
- Pleural Effusion
- carpal tunnel Syndrome
What condition presents with: palpable spleen, neutrophil of 1.10(low), splenomegaly
Felty’s syndrome
rheum arth classic px:
- symmetrical polyarthritis
- refer all suspected patients to rheum for further assessment
what condition presents with: bone pain, tenderness, proximal myopathy+ waddling gait
Osteomalacia: most commonly secondary to vit d deficiency
Neuro: Subarachnoid Haemorrhage classical presentation?
- worst headache ever, ‘thunderclap’ ‘being hit by a baseball bat’
- came on suddenly
- neck stiffness+ coryzal symptoms
Differentiating between: arterial and venous intracranial haemorrhage?
Subarachnoid haemorrhage= arterial
NB: Epidural= arterial
Subdural= venous
what is type of aneurysm that commonly causes Subarachnoid haemorrhage?
- Berry aneurysm
name a condition associated with this aneurysm?
Polycystic Kidney disease
- also: coarctation of aorta, Ehlers-Danlos syndrome
Name 4 other symptoms/signs other than headache, a patient with subarachnoid haemorrhage will present with?
- Vomiting
- Nausea
- Seizures
- Focal neuro signs eg. hemiplegia, dysphasia
- photophobia
what is Kernig’s sign and what does it demonstrate?
- Demonstrates meningeal irritation
- is + in meningitis
- Hip and Knee is bent to 90 degrees and if +, there will be pain by straightening knee.
Subarach: what imaging would you request and what would it classically show you?
- CT Head
- Blood appears white(haemorrhage), which will be mixed in with CSF
- will lie within: interhemispheric fissure, basal cisterns and ventricles.
What further test would you perform for subarachnoid haem. if CT was normal?
- Lumbar puncture (only after 6 hours and if non contrast CT is normal.
- NB: would ask the lab to analyse for: Xanthochromia
What 4 bones meet at the Pterion?
- Parietal
- temporal
- sphenoid
- frontal
What are the differences in the shape of haematoma on CT head scan: between extradural and subdural haematoma?
- Extradural: lens shaped/bi-convex
- Subdural: crescent-shaped
Other CT changes seen in Extradural Haem. (trauma)
- Midline shift
- Compression of the ventricles
4 risk factors of stroke?
- diabetes
- heart disease (eg. AF/valvular)
- peripheral vascular disease
-previous TIA - cocp
- excess alcohol
difference between TIA and stroke?
TIA: lasts for less than 24 hours
Stroke: lasts for more than 24 hours/or leads to death within the 24 hours
signs of a stroke?
- one sided sensory loss
- dysphasia
- homonymous hemianopia (vision)
What is the most common cause of cerebral infarct and what surgical technique can be used to manage it?
- Carotid artery Atherosclerosis
- Mx: Carotid Endarterectomy= in cases of severe stenosis
Ischaemic stroke, apart from medical mx, what else can be considered in managing this patient?
- admission to stroke unit
- swallow assessment
- physio
- skincare
Primary prevention of stroke?
- lowering BP
- Stopping smoking
- well-controlled diabetes
- reducing cholesterol and lipids
- improving diet and exercise.
what is epilepsy?
Transient occurrence of intermittent, abnormal electrical activity of part of the brain.
what is an aura?
is part of the seizure; often precedes other things.
- is a disturbance of a sensation- often a strange feeling/smell/taste/flashing light
what is todd’s palsy?
- is T emporary weakness, following a seizure.
Different types of seizures?
- Partial seizure: symptoms from 1 hemisphere (focal)
- partial with secondary generalisation: seizure starts focally, then spreads= causing a generalised seizure.
- absence seizure: generalised seizure, brief pauses (for eg. stops talking for a period, then continues from where they stopped)
2 metabolic causes for seizures?
- Hypoglycaemia
- uraemia (also presents with confusion and seizures)
- Hypo/hypernatraemia
- Water intoxification
airway adjunct to use in a fitting seizure patient- where they are not maintaining their airway?
Nasopharyngeal airway
causes of epilepsy?
- Structural brain abnormality
- metabolic abnormalities
- drugs
- alcohol (or from withdrawal)
- hypoxia
- most are: idiopathic
define status epilepticus timing:
- If seizure lasts more than 5 mins, or has repeated seizure within 5 min period without person returning back to normal.
- Aim: to stop seizure activity as soon as possible.
Describe bitemporal Hemianopia visual loss?
- loss of vision in the lateral half of both eyes
- ’ Tunnel vision; - not as wide
NB: affects the optic chiasm
most likely cause for: Bitemporal Hemianopia and the compression at the optic chiasm?
Pituitary gland adenoma- functioning or non-functioning depends on: if endocrine symptoms are present or not?
Retinal field affected in bitemporal hemianopia?
Medial (is opposite to the actual vision loss that happens in the person= which is lateral- in bitemporal hemianopia)
Info about Bitemporal hemianopia?
HAEM: Young man presenting with rubbery lymph nodes, painless on palpation diagnosis?
Lymphoma (type of blood cancer)
list 3 symptoms of lymphoma?
B symptoms:
- Night sweats
- Weight loss
- Fever
- Tiredness
- Alcohol induced pain at node sites
2 signs on examination: Lymphoma?
- Enlargement of lymph nodes
- Splenomegaly
- Hepatomegaly
What is the name of the cell that suggests Hodgkin’s Lymphoma?
- Reed Sternberg cell
What staging system is used for Hodgkin’s Lymphoma?
- Ann Arbor
State 2 investigations to STAGE Hodgkin’s:
- Bone marrow biopsy
- CXR
- CT chest/abdomen/pelvis
Presentation: Dyspnoea, swelling of face+ congested veins in neck and chest (while being investigated for Hodgkin’s?
- Superior vena cava obstruction: is an oncological emergency; headaches that are often worst in the morning
- Mx: Endovascular stenting
3 signs patient with Microcytic Anaemia will present with?
- Pale Conjuctiva (of eye)
- Tachypnoea
- ## Tachycardia
1 cause of iron-deficiency anaemia, other than heavy bleeding?
- Poor diet
- Malabsorption eg. coeliac disease
Name 2 more specific signs: on examination of someone with: CHRONIC iron-deficiency anaemia?
- Angular Cheilitis (Mouth ulcers)
- Koilonychia (Spoon nails)
- Atrophic Glossitis (smooth tongue with less filiform papillae
2 common side effects of ferrous sulphate (oral iron)
- black stools
- constipation
- nausea
