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Diagnostics > Test 4 > Flashcards

Test 4 Flashcards

1
Q

Medications that effect that kidneys

A

NSAIDS
COX-Inhibitors
ACE Inhibitors
ARBS

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2
Q

Flank pain on patient finding often suggests

A

kidney stone

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3
Q

Renal labs

A

urinalysis
serum creatinine
BUN (less)
GFR

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4
Q

GFR

A

Most accurate predictor of kidney disease.

Patient is given a marker that will clear through the glomerular system and measured. Done by a nephrologist.

Hardly used- in hospital, estimated GFR is used

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5
Q

When should you consider a GFR?

A
  • Extremes of age and body size
  • Severe malnutrition or obesity
  • Disease of skeletal muscle
  • Paraplegia/quadriplegia
  • Vegetarian Diet
  • Rapidly changing kidney function
  • Pregnancy
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6
Q

How to diagnose acute renal failure?

A

Serum creatinine

pre-renal - due to n/v and volume depletion
intrarenal - disease process
post-renal - stone, BPH, blocked ureter or urethra

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7
Q

What is creatinine clearance?

A

the measurement used to adjust drug dosages

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8
Q

When do you collect a 24-hr urine?

A

When you want to see more of the whole picture.

Done for:

  • Hematuria
  • Kidney stones
  • Pheochromocytoma (tumor of adrenal glands)
  • Uncontrolled HTN
  • Preeclampsia
  • Kidney disease
  • Multiple myeloma
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9
Q

What can be seen on renal ultrasound

A
  • hydronephrosis (swelling of kidney from build up of urine)
  • urine flow
  • differentiates the renal cortex from renal medulla
  • differentiates cysts from masses
  • can see stones

can be done at the bedside and avoids contrast

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10
Q

what can be seen on a KUB

A

Kidney, ureters, and bladder
-calcifications, stones, neoplasms, tumors, air, soft tissue changes

if the psoas muscle or renal outline is obscured- infection? inflammation? tumor?

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11
Q

CT scan for kidneys

A

watch out on ordering dye

check creatinine, check medications (no metformin), dehydration, allergies, diabetes?, renal disease history, multiple myeloma.

must hydrate before contrast and after

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12
Q

MRA w/o contrast can visualize what?

A
  • renal artery stenosis
  • mapping of vascular anatomy for surgery/procedures
  • assessing previous transplant grafts
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13
Q

MRA w/ gadolinium contrast

A

may cause nephrogenic system fibrosis and renal failure

don’t use on patients in AKI

if used on patient on PD or HD, dialyze immediately after testing

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14
Q

Contrast nephropathy

A

Occurs after any test with contrast. Greatest risk in patient with existing renal disease or diabetes.

defined as increases in creatinine >25-50% or by 0.5-1.0mg/dL

rises over 1-2 days, peaks 4-7 days, normalizes 10-14 days

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15
Q

Renal biopsy performed for?

A
  • AKI with no explanation
  • Nephrotic syndrome
  • Persistent proteinuria
  • Hematuria
  • Confirming a disease
  • Transplant rejection
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16
Q

Contraindications to renal biopsy

A
  • Sepsis
  • Uncontrolled HTN
  • Hemorrhagic diathesis
  • Parenchymal infection or malignancy
  • Solitary or horseshoe kidney
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17
Q

What do you look at on the urinalysis to diagnose UTI

A 
Nitrites
Leukocyte esterase
WBCs
Casts
Bacteria
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18
Q

Types of UA testing

A

1) Dipstick
2) Microanalysis - more accurate, ID protein problems better
3) 24 hour urine - renal secretion over 24hrs

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19
Q

Urine sample sitting out for >1hr causes:

A
  • Increased acidity
  • Casts dissolve
  • Microorganisms grow
  • Ketones and bilirubin decreases

dehydration, fluid overload, food, and medication can give false results and affect UA

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20
Q

Normal urine acid level

A

4.5-8

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21
Q

Normal urine specific gravity

A

1.003 - 1.030

concentrated = >1.020
diluted = <1.005
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22
Q

Normal protein level in UA

A

150mg/24hrs

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23
Q

Overhydrations effect on protein in urine

A

will decrease protein levels in urine

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24
Q

Dehydration effect on protein in urine

A

will increase protein levels in urine

along with contrast dye, stress, infection, and heart failure

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25
Q

Dipstick UA positive for high protein at what level

A

300-500 mg/day

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26
Q

microalbuminuria should be ordered on which patients

A

diabetic

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27
Q

Urine protein 150-300 mg

A

could be tubular or glomerular, overflow of proteinuria.

To determine which, protein electrophoresis should be ordered.

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28
Q

> 300 mg urine protein

A

glomerular proteinuria

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29
Q

> 350mg urine protein

A

nephrotic syndrome

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30
Q

Most common cause for glucose in urine

A

diabetes

less common = fanconi’s syndrome and multiple myeloma

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31
Q

Ketones are commonly present in what population

A

pregnant women

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32
Q

Nitrites

A

secreted by gram negative bacteria - indicative of UTI.

false negative if patient having UTI with gram positive bacteria or yeast which do not secrete nitrites

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33
Q

Leukocyte esterase

A

2nd most common marker for UTI

positive in the presence of WBCs, but can have false positive if urine has been sitting out too long.

negative result with clinical signs and symptoms would prompt you to follow up with microscopic analysis and culture

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34
Q

RBC presence in urine

A

hematuria requires follow up.

damage to the kidney or stone = darker
bladder cancer = bright red

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35
Q

WBC presence in urine

A

pyuria is associated with infection (>10 WBCS/mm3)

can also be indicative of non-infectious causes- stone, tumor, foreign bodies.

WBCs can lysis if sitting out too long

Casts of WBCs represent pyelonephritis

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36
Q

RBC casts

A

indicated bleeding in the kidneys- usually glomerulus or tubule. Often glomerulonephritis

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37
Q

Bacterial casts

A

indicates acute pyelonephritis

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38
Q

Epithelial casts

A

can be benign- associated with tubular necrosis

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39
Q

Bacteria in urinalysis

A

> 100,000 is usually significant

urine can be colonized and not infected

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40
Q

Causes of delirium and confusion

A

a medical condition, substance intoxication, withdrawal, or medication side effect

characterized by disturbances of consciousness with reduced ability to focus, sustain, or shift attention

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41
Q

Triad of acute bacterial meningitis

A

Fever >38 degrees C

Nuchal rigidity

AMS

(Hypothermia in a small percentage)

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42
Q

Lumbar puncture results for bacterial meningitis

A
  • WBCS : 1,000-5,000 cells/mL (percentage of neutrophils usually >80%)
  • Protein : >200mg/dL
  • Glucose : <40 mg/dL
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43
Q

Lab work to obtain for meningitis

A

CBC, blood cultures, lumbar puncture (crucial), and consider CT if a mass or high ICP suspected

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44
Q

Clinical features of bells palsy

A
  • sudden onset of unilateral facial paralysis
  • eyebrow or mouth drooping
  • inability to close eye
  • altered or loss of taste on 2/3 of tongue
  • altered lacrimal and salivary galnd secretions
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45
Q

Tests for bells palsy

A

CT, MRI, serological test for Lyme disease

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46
Q

Diagnosing carpal tunnel

A
  • Nocturnal pain or paresthesia in the distribution of the median nerve
  • Nerve conduction studies (NCS)
  • Electromyography (EMG) = used to exclude other conditions such as neuropathy
  • Pain or paresthesia in first three digits and the radial half of the fourth digit
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47
Q

Guillain Barre clinical features

A

progressive, mostly symmetric muscle weakness with absent or depressed deep tendon reflexes - can progress to complete paralysis with severe respiratory muscle weakness requiring ventilator

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48
Q

Guillain Barre assessment

A

weakness usually starts in the legs

facial palsy

oropharyngeal weakness

oculomotor weakness

decreased or absent reflexes in arms or legs

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49
Q

Diagnosing Guillain Barre

A

Electrodiagnostic studies is useful in confirming diagnosis and classifying which type

Lumbar puncture (in all patients) - increased CSF protein with normal WBCs

Albuminocytological dissociation in first week and >75% in 3 weeks

HIV would be alternative diagnosis but WBC count >50

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50
Q

Tension headache

A

most common headache type

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51
Q

Signs of non-emergent headache

A
  • age <50 yrs
  • history of similar headaches and features are typical
  • no abnormal neurological findings
  • no concerning change in usual headache presentation
  • no high risk comorbidities
  • no new finding on history or exam
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52
Q

“SNOOP” red flags for headaches

A

S - systemic symptoms
N - neurological symptoms
O - onset is new (>50yr) or sudden (thunderclap)
O - other associated conditions or features
P - previous headache history progressing or changing

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53
Q

Diagnostics for headache

A

MRI is preferred for headache

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54
Q

parkinsons affects which age group

A

progressive neurodegenerative disease

uncommon <40 years old
commonly >60 years with median being 70

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55
Q

manifestations of parkinsons

A

1) craniofacial - masked facial expression, hypophonia
2) visual - eyelid drooping
3) musculoskeletal - stooped posture, micrographic (handwriting becomes smaller as writing continues)
4) gait - shuffling, short steps, freezing, etc
5) nonmotor - psychosis, depression, anxiety, fatigue, sleep changes, pain and sensory disturbances

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56
Q

diagnosing parkinsons

A

based on clinical symptoms

  • tremor
  • bradykinesia (slow movements)
  • rigidity
  • postural instability
57
Q

seizure definition

A

electric hyper-synchronization in the neuronal networks in the cerebral cortex

for a first seizure, goal is to determine if it was a seizure and determine if it is correctable or could be epilepsy

58
Q

define symptomatic seizure

A

those that occur in the setting of acute medical illness (hypoglycemia or hyponatremia) or neurological illness/injury (stroke, TBI, meningitis, encephalopathy)

59
Q

diagnosing a seizure

A

history, physical, neurological exam along with tests that identify the cause

lab studies (CBC, CMP, electrolytes, kidney and liver function)

urinalysis and toxicology screen

60
Q

Preferred testing to diagnose seizure

A

MRI with or without contrast

secondary = CT

EEG is important when impaired sensorium is persistent

Lumbar puncture if process may be infectious in nature

EKG?

61
Q

Why is determining type of stroke important

A

acute ischemic strokes are candidates for IV thrombolytics or thrombectomy

bleeds are not

62
Q

imaging for stroke

A

**Noncontrast CT guide acute therapy

63
Q

tests for stroke

A

glucose, CBC (note the platelets), troponin, PT/INR, PTT, clotting factors and Xa.

serum electrolytes, LFTs, toxicology screen, etoh level, pregnancy test, ABG, CXR, EEG if seizures are suspected

64
Q

what are most subarachnoid hemorrhages caused from?

A

rupture of saccular aneurysm

65
Q

symptoms of subarachnoid hemorrhages

A

sudden, severe headache “worst in my life”

66
Q

testing for subarachnoid hemorrhages

A

1) noncontrast CT
2) lumbar puncture if CT normal but still suspecting SAH. Lumbar puncture will have elevated opening pressure and elevated RBC count in all tubes

67
Q

Gold standard for treating cerebral aneurysm

A

Formal 4 Vessel cerebral angiogram to coil the aneurysm

68
Q

what is NPH?

A

normal pressure hydrocephalus.

enlarged ventricle size with normal pressure found in lumbar puncture.

NOT obstructive or non-communicating hydrocephalus which block the CSF

69
Q

classic triad of NPH

A

1) Cognitive impairment (dementia)
2) Gait disturbances (THE predominant finding)
3) urinary incontinence (or hesitancy)

70
Q

is NPH reversible?

A

yes, with ventriculoperitoneal (VP) shunt

71
Q

what can occur if NPH is not identified quickly?

A

patients develop

1) alzheimers disease
2) neurodegenerative dementia within several years of shunt placement

72
Q

causes of secondary NPH

A
  • subarachnoid hemorrhage

- meningitis

73
Q

how to diagnose NPH

A

early identification of classic triad

1) cognitive impairment
2) gait disturbances ***** (is more prominent early on and should be the predominant clinical finding)
3) urinary incontinence or hesitancy

74
Q

first test for NPH

A

***MRI = essential first test for NPH, indicating ventricular megalyopathy with no evidence of CSF obstruction

good prognosis = enlarged subarachnoid space with hydrocephalus

poor prognosis = extensive white matter disease and cortical atrophy

75
Q

After MRI, how do you test and treat NPH?

A

1) Lumbar Puncture - LP helps identify patient that will respond positively to a shunt placement. If test results are positive, this indicates a shunt should be placed.
2) VP shunt - placed if patient has clinical symptoms, MRI, and positive LP test

76
Q

What is NEXUS?

A

National Emergency X-Radiography Utilization Study

a set of validated criteria used to decide which trauma patients do not require cervical spine imaging.

77
Q

What is the NEXUS criteria?

A

Trauma patients who do not require cervical spine imaging require all of the following:

  • alert and stable
  • no focal neurologic deficit
  • no altered level of consciousness
  • not intoxicated
  • no midline spinal tenderness
  • no distracting injury
78
Q

What is the Canadian C-Spine Rules?

A

a set of guidelines that help a clinician decide if cervical spine imaging is not appropriate for a trauma patient in the emergency department. The patient must be alert and stable.

There are 3 rules with high risk criteria and low risk criteria

79
Q

What is the high risk criteria for Canadian C-Spine Rules?

A

is there any high-risk factor present that requires cervical spine imaging?

1) ≥65 years
2) a dangerous mechanism: fall from elevation >3 ft (or 5 stairs), axial load to the head, high-speed motor vehicle collision (e.g. >100 km/hr or ~60 mph, rollover, ejection), motorized recreational vehicles, bicycle collision
3) paresthesias in extremities

If any high-risk factor is present, then cervical spine imaging is warranted.

80
Q

What is the low risk criteria for Canadian C-Spine Rules?

A

is there any low-risk factor present?

1) simple rear-end motor vehicle collision (excludes being hit by a high-speed vehicle, a large vehicle (e.g. bus) or rollover)
2) sitting position in emergency department
3) ambulatory at any time since the injury
4) delayed onset of neck pain
5) absence of midline C-spine tenderness

If the patient does not meet the criteria of a low-risk injury, then cervical spine imaging is warranted.

81
Q

What if patient meets low risk criteria for Canadian C-Spine Rules?

A

If the patient meets the criteria of a low-risk injury, then one should assess on physical exam whether the patient can rotate the neck 45°.

if low-risk injury and the patient can rotate the neck 45° = no cervical spine imaging required

if low-risk injury and the patient cannot rotate the neck 45° = then cervical spine imaging is warranted

82
Q

Scholarly article results comparing NEXUS and CCS Rules

A

This study showed that the two guidelines have the same sensitivity for evaluating which trauma patients need to undergo radiography.

It seems that the NEXUS guidelines have the same effectiveness as CCR for determining which trauma patients need to undergo radiography.

NEXUS also perform better than CCR guidelines in terms of ruling out which cases need no further radiologic investigation.

83
Q

shoulder pain can be what two things?

A

1) intrinsic - specific to the shoulder

2) referred - from neck, chest, abdomen

84
Q

if shoulder pain has been present for less than two weeks consider what diagnoses?

A

trauma, fracture, dislocation, fall

this is acute pain

85
Q

what do you consider with chronic shoulder pain consider what diagnoses?

A
  • rotated cuff injury
  • impingement syndrome - nerve impinged
  • adhesive capsulitis
  • osteoarthritis
86
Q

if shoulder pain is referred what diagnoses do you consider?

A
  • neural impingement at cervical spine
  • peripheral nerve entrapment (distal to spine)
  • diaphragmatic irritation (spleen laceration, infection, perforated viscous, ruptured ectopic pregnancy)
87
Q

Which articular surface of shoulder is often associated with arthritis?

A

glenohumeral

88
Q

If you can perform active and passive range of motion in the shoulder, you know that the diagnosis is not what?

A

related to the bones (i.e. fractures)

89
Q

What is a Kehrs sign?

A

left shoulder pain felt when patient is lying flat and legs are elevated.

indicative of spleen injury- referred pain

90
Q

If capillary refill is delayed, this is indicative of what?

A

impingement injury

91
Q

diagnostic tests for shoulder injury

A

1) shoulder series xrays (many views), but obtain at minimum 2 views
2) MRI - visualize better but not definitive
3) US - equal to MRI
4) a lidocaine test would determine if the patient would respond to injection of steroids

92
Q

labs for diagnosing shoulder injury

A

CBC = look for infection

Sedimentation rate = look for inflammation

93
Q

possible differentials for hand injury

A

1) degenerative arthritis (OA)
2) inflammatory arthritis (RA, psoriatic arthritis, lupus, gout)
3) joint infection/viral illness (parvovirus, lyme, septic joint, strep)
4) carpal tunnel

94
Q

morning stiffness lasting more than 60 minutes is indicative of what

A

an inflammatory process

95
Q

the metacarpal joints and wrists are painful in which disease

A

rheumatoid arthritis

RA is usually symmetrical presenting

RA affects more knuckles and wrists

96
Q

distal interphalangeal and proximal interphalangeal joints are painful in which disease

A

osteoarthritis

OA is usually asymmetrical presenting

OA affects more finger tips and distal end of hand

97
Q

Rheumatoid arthritis clinical presentation

A
  • symmetrical hand pain
  • hair loss
  • chest pain
  • fever, weight loss, fatigue
  • can form in any joint but mostly hands, feet, wrists, spines, knees, jaws
  • joint is usually warm
98
Q

Systemic Lupus clinical presentation

A

hand pain PLUS

  • hair loss
  • chest pain
  • fever, weight loss, fatigue
  • abdominal pain - N/V/D
  • personality changes
  • **malar rash “butterfly rash” on cheeks, and photosensitive rashes “I’m allergic to the sun”
99
Q

Reiter’s Disease clinical presentation

A

hand pain PLUS

  • conjunctivitis
  • urethral discharge
  • urethritis
100
Q

Lyme disease clinical presentation

A

hand pain PLUS

  • annular red plaque
  • neurological issues
101
Q

Psoriatic arthritis clinical presentation

A

Hand pain PLUS

-psoriatic plaques on the hands

102
Q

Uveitis, temporal arteritis clinical presentation

A

hand pain PLUS

-eye pain and vision loss

103
Q

Sjorgen’s clinical presentation

A

Hand pain PLUS

-dry mouth

104
Q

Parovirus B19 (Fifths disease)

A

usually in children

  • painful joints
  • mild rash, “slap cheek rash”
105
Q

Diagnostics for hand issues

A

1) xrays - look for joint disease and arthritis
2) rheumatoid factor - positive in 85% w/ RA, but nonspecific to RA and also false negatives can occur
3) anti-citrullinated protein antibody test (CCP) - specific to RA, present in 50-80%
4) antinuclear antibodies - present in RA and systemic lupus
5) C-reactive protein (CRP) - nonspecific indicating inflammation
6) Sed rate - nonspecific indicating inflammation

106
Q

Other diagnostic tests for hand issues

A

CBC - infection

CMP - renal, liver problems (medications can cause issues)

UA - proteinuria and RBC casts may be positive in Systemic lupus

Lyme titer

Parovirus antibodies

107
Q

IgM indicates

A

acute infection still present

Ig”M” = think miserable, patient feels miserable

108
Q

IgG indicates

A

infection is gone and antibodies have developed

Ig”G” = gone, infection is gone

109
Q

American College of Rheumatology Classification for RA

A

Helps diagnose RA - must have 6 out of 10 points to diagnose according to criteria

looks at:

  • Joint involvement (6-10 = RA)
  • Serology (RF and CCP antibodies)
  • Acute Phase Reactants (CRP and ESR)
  • Duration of symptoms (< or > 6wks)
110
Q

How to diagnose carpal tunnel

A

-history and physical exam

history = paresthesia, repetitive motions, weakness or clumsiness of hand, worsening signs and symptoms at night

TINEL or PHALEN tests positive

111
Q

how to treat carpal tunnel

A

1) brace - conservative treatment initially

then steroid injections and then electro-diagnostic studies if treatment not working and considering surgery

112
Q

problems rotating the hip and leg shortening indicate probably what?

A

hip fracture

113
Q

pain in buttock or lower back with hip discomfort usually indicates what

A

sciatica

114
Q

hip pain and patient has artificial joints, be sure to make sure the patient doesn’t have what?

A

an infection of the artificial joint. Recent viral or bacterial infection can spread to artificial joint

115
Q

paresthesia of hip indicates what

A

possible pinched nerve

116
Q

diagnostics for hip injury

A

1) xray - 3 views
2) CT - better definition. add contrast to look at vessels and blood flow
3) MRI
4) compartment pressure measurement

117
Q

labs for hip injury

A

CBC = infection, inflammation
CRP = infection, inflammation
Sed Rate = inflammation

could rule in gout or RA

118
Q

Contraindications for arthrocentesis or joint aspiration

A

1) cellulitis - never aspirate through cellulitis

2) suspected infected joint - done by orthro

119
Q

Diagnostics on aspirate of joint

A
  • cell count, WBCs with differential
  • gram stain and culture/sensitivity
  • crystals (gout)
120
Q

Differentials for pediatrics complaining on knee pain

A

1) osgood-schlatters
2) patellar tendinitis
3) osteochondritis dissecans
4) patellofemoral syndrome

121
Q

Differentials for anterior knee pain

A

1) osgood-schlatters
2) patellar tendinitis
3) patellofemoral syndrome
4) prepatellar bursitis
5) osteoarthritis

122
Q

Diagnosing patellar tendinitis

A

-from overuse causing anterior knee pain

1) ultrasound
2) MRI

123
Q

Diagnosing patellofemoral pain syndrome

A

-pain around patella aggregated by weight bearing activities. MOST COMMON cause of anterior knee pain

classic presentation = pain in anterior knee worsening with squatting and descending stairs

J-sign = patella jumps laterally when knee is fully extended

124
Q

Diagnosing prepatellar bursitis

A

“housemaid’s knee”, occurs from being on their knees a lot

1) must aspirate to determine if aseptic, septic, or crystal-induced (gout)
2) plain xrays to rule out other causes
3) MRI or US

125
Q

Causes of posterior knee pain

A

1) bakers cyst

2) posterior cruciate ligament tear

126
Q

Causes of medial knee pain

A

1) medial meniscus injury
2) medial cruciate ligament tear
3) bursitis

127
Q

Causes of lateral knee pain

A

1) lateral cruciate ligament tear
2) lateral meniscus injury
3) iliotibial band syndrome

128
Q

McMurray test indicates issue with what

A

meniscus

129
Q

Lachman test indicates issues with what

A

ACL

130
Q

Drawer test indicates issues with what

A

ACL or PCL

131
Q

Varus stress test indicates issues with what

A

MCL

132
Q

radiating back pain into leg along dermatome indicates what?

A

possible ruptured disc

133
Q

loss of bowel and bladder with lower back pain indicates what

A

EMERGENCY

Cauda Equina syndrome

134
Q

straight leg raise test

A

used to determine possible herniated disc

+ = when leg is elevated, pain is noted when leg is between 30-60 degrees

135
Q

Definitive diagnoses of herniated disc requires which scan

A

MRI

136
Q

what is nursemaids elbow

A

a subluxation injury of the radial head usually occurring in children 6mo-5years

137
Q

How to treat nursemaids elbow

A

reduce the elbow back in to place with supination and then hyperpronation, do not do more than 2-3 times if cannot get it to go back in place.

patient shoulder be able to use their arm again within minutes- tell them to give you a “high five”

use ibuprofen and rest and ice

138
Q

Education for parents after nursemaid elbow treated

A

do not pull on childs arm or swing them by arms.

monitor for neuromuscular changes in the arm

Diagnostics (4 decks)

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