Test 4 Flashcards
Medications that effect that kidneys
NSAIDS
COX-Inhibitors
ACE Inhibitors
ARBS
Flank pain on patient finding often suggests
kidney stone
Renal labs
urinalysis
serum creatinine
BUN (less)
GFR
GFR
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
When should you consider a GFR?
- Extremes of age and body size
- Severe malnutrition or obesity
- Disease of skeletal muscle
- Paraplegia/quadriplegia
- Vegetarian Diet
- Rapidly changing kidney function
- Pregnancy
How to diagnose acute renal failure?
Serum creatinine
pre-renal - due to n/v and volume depletion
intrarenal - disease process
post-renal - stone, BPH, blocked ureter or urethra
What is creatinine clearance?
the measurement used to adjust drug dosages
When do you collect a 24-hr urine?
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
What can be seen on renal ultrasound
- 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
what can be seen on a KUB
Kidney, ureters, and bladder
-calcifications, stones, neoplasms, tumors, air, soft tissue changes
if the psoas muscle or renal outline is obscured- infection? inflammation? tumor?
CT scan for kidneys
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
MRA w/o contrast can visualize what?
- renal artery stenosis
- mapping of vascular anatomy for surgery/procedures
- assessing previous transplant grafts
MRA w/ gadolinium contrast
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
Contrast nephropathy
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
Renal biopsy performed for?
- AKI with no explanation
- Nephrotic syndrome
- Persistent proteinuria
- Hematuria
- Confirming a disease
- Transplant rejection
Contraindications to renal biopsy
- Sepsis
- Uncontrolled HTN
- Hemorrhagic diathesis
- Parenchymal infection or malignancy
- Solitary or horseshoe kidney
What do you look at on the urinalysis to diagnose UTI
Nitrites Leukocyte esterase WBCs Casts Bacteria
Types of UA testing
1) Dipstick
2) Microanalysis - more accurate, ID protein problems better
3) 24 hour urine - renal secretion over 24hrs
Urine sample sitting out for >1hr causes:
- Increased acidity
- Casts dissolve
- Microorganisms grow
- Ketones and bilirubin decreases
dehydration, fluid overload, food, and medication can give false results and affect UA
Normal urine acid level
4.5-8
Normal urine specific gravity
1.003 - 1.030
concentrated = >1.020 diluted = <1.005
Normal protein level in UA
150mg/24hrs
Overhydrations effect on protein in urine
will decrease protein levels in urine
Dehydration effect on protein in urine
will increase protein levels in urine
along with contrast dye, stress, infection, and heart failure
Dipstick UA positive for high protein at what level
300-500 mg/day
microalbuminuria should be ordered on which patients
diabetic
Urine protein 150-300 mg
could be tubular or glomerular, overflow of proteinuria.
To determine which, protein electrophoresis should be ordered.
> 300 mg urine protein
glomerular proteinuria
> 350mg urine protein
nephrotic syndrome
Most common cause for glucose in urine
diabetes
less common = fanconi’s syndrome and multiple myeloma
Ketones are commonly present in what population
pregnant women
Nitrites
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
Leukocyte esterase
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
RBC presence in urine
hematuria requires follow up.
damage to the kidney or stone = darker
bladder cancer = bright red
WBC presence in urine
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
RBC casts
indicated bleeding in the kidneys- usually glomerulus or tubule. Often glomerulonephritis
Bacterial casts
indicates acute pyelonephritis
Epithelial casts
can be benign- associated with tubular necrosis
Bacteria in urinalysis
> 100,000 is usually significant
urine can be colonized and not infected
Causes of delirium and confusion
a medical condition, substance intoxication, withdrawal, or medication side effect
characterized by disturbances of consciousness with reduced ability to focus, sustain, or shift attention
Triad of acute bacterial meningitis
Fever >38 degrees C
Nuchal rigidity
AMS
(Hypothermia in a small percentage)
Lumbar puncture results for bacterial meningitis
- WBCS : 1,000-5,000 cells/mL (percentage of neutrophils usually >80%)
- Protein : >200mg/dL
- Glucose : <40 mg/dL
Lab work to obtain for meningitis
CBC, blood cultures, lumbar puncture (crucial), and consider CT if a mass or high ICP suspected
Clinical features of bells palsy
- 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
Tests for bells palsy
CT, MRI, serological test for Lyme disease
Diagnosing carpal tunnel
- 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
Guillain Barre clinical features
progressive, mostly symmetric muscle weakness with absent or depressed deep tendon reflexes - can progress to complete paralysis with severe respiratory muscle weakness requiring ventilator
Guillain Barre assessment
weakness usually starts in the legs
facial palsy
oropharyngeal weakness
oculomotor weakness
decreased or absent reflexes in arms or legs
Diagnosing Guillain Barre
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
Tension headache
most common headache type
Signs of non-emergent headache
- 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
“SNOOP” red flags for headaches
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
Diagnostics for headache
MRI is preferred for headache
parkinsons affects which age group
progressive neurodegenerative disease
uncommon <40 years old
commonly >60 years with median being 70
manifestations of parkinsons
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
diagnosing parkinsons
based on clinical symptoms
- tremor
- bradykinesia (slow movements)
- rigidity
- postural instability
seizure definition
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
define symptomatic seizure
those that occur in the setting of acute medical illness (hypoglycemia or hyponatremia) or neurological illness/injury (stroke, TBI, meningitis, encephalopathy)
diagnosing a seizure
history, physical, neurological exam along with tests that identify the cause
lab studies (CBC, CMP, electrolytes, kidney and liver function)
urinalysis and toxicology screen
Preferred testing to diagnose seizure
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?
Why is determining type of stroke important
acute ischemic strokes are candidates for IV thrombolytics or thrombectomy
bleeds are not
imaging for stroke
**Noncontrast CT guide acute therapy
tests for stroke
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
what are most subarachnoid hemorrhages caused from?
rupture of saccular aneurysm
symptoms of subarachnoid hemorrhages
sudden, severe headache “worst in my life”
testing for subarachnoid hemorrhages
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
Gold standard for treating cerebral aneurysm
Formal 4 Vessel cerebral angiogram to coil the aneurysm
what is NPH?
normal pressure hydrocephalus.
enlarged ventricle size with normal pressure found in lumbar puncture.
NOT obstructive or non-communicating hydrocephalus which block the CSF
classic triad of NPH
1) Cognitive impairment (dementia)
2) Gait disturbances (THE predominant finding)
3) urinary incontinence (or hesitancy)
is NPH reversible?
yes, with ventriculoperitoneal (VP) shunt
what can occur if NPH is not identified quickly?
patients develop
1) alzheimers disease
2) neurodegenerative dementia within several years of shunt placement
causes of secondary NPH
- subarachnoid hemorrhage
- meningitis
how to diagnose NPH
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
first test for NPH
***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
After MRI, how do you test and treat NPH?
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
What is NEXUS?
National Emergency X-Radiography Utilization Study
a set of validated criteria used to decide which trauma patients do not require cervical spine imaging.
What is the NEXUS criteria?
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
What is the Canadian C-Spine Rules?
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
What is the high risk criteria for Canadian C-Spine Rules?
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.
What is the low risk criteria for Canadian C-Spine Rules?
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.
What if patient meets low risk criteria for Canadian C-Spine Rules?
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
Scholarly article results comparing NEXUS and CCS Rules
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.
shoulder pain can be what two things?
1) intrinsic - specific to the shoulder
2) referred - from neck, chest, abdomen
if shoulder pain has been present for less than two weeks consider what diagnoses?
trauma, fracture, dislocation, fall
this is acute pain
what do you consider with chronic shoulder pain consider what diagnoses?
- rotated cuff injury
- impingement syndrome - nerve impinged
- adhesive capsulitis
- osteoarthritis
if shoulder pain is referred what diagnoses do you consider?
- neural impingement at cervical spine
- peripheral nerve entrapment (distal to spine)
- diaphragmatic irritation (spleen laceration, infection, perforated viscous, ruptured ectopic pregnancy)
Which articular surface of shoulder is often associated with arthritis?
glenohumeral
If you can perform active and passive range of motion in the shoulder, you know that the diagnosis is not what?
related to the bones (i.e. fractures)
What is a Kehrs sign?
left shoulder pain felt when patient is lying flat and legs are elevated.
indicative of spleen injury- referred pain
If capillary refill is delayed, this is indicative of what?
impingement injury
diagnostic tests for shoulder injury
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
labs for diagnosing shoulder injury
CBC = look for infection
Sedimentation rate = look for inflammation
possible differentials for hand injury
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
morning stiffness lasting more than 60 minutes is indicative of what
an inflammatory process
the metacarpal joints and wrists are painful in which disease
rheumatoid arthritis
RA is usually symmetrical presenting
RA affects more knuckles and wrists
distal interphalangeal and proximal interphalangeal joints are painful in which disease
osteoarthritis
OA is usually asymmetrical presenting
OA affects more finger tips and distal end of hand
Rheumatoid arthritis clinical presentation
- 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
Systemic Lupus clinical presentation
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”
Reiter’s Disease clinical presentation
hand pain PLUS
- conjunctivitis
- urethral discharge
- urethritis
Lyme disease clinical presentation
hand pain PLUS
- annular red plaque
- neurological issues
Psoriatic arthritis clinical presentation
Hand pain PLUS
-psoriatic plaques on the hands
Uveitis, temporal arteritis clinical presentation
hand pain PLUS
-eye pain and vision loss
Sjorgen’s clinical presentation
Hand pain PLUS
-dry mouth
Parovirus B19 (Fifths disease)
usually in children
- painful joints
- mild rash, “slap cheek rash”
Diagnostics for hand issues
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
Other diagnostic tests for hand issues
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
IgM indicates
acute infection still present
Ig”M” = think miserable, patient feels miserable
IgG indicates
infection is gone and antibodies have developed
Ig”G” = gone, infection is gone
American College of Rheumatology Classification for RA
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)
How to diagnose carpal tunnel
-history and physical exam
history = paresthesia, repetitive motions, weakness or clumsiness of hand, worsening signs and symptoms at night
TINEL or PHALEN tests positive
how to treat carpal tunnel
1) brace - conservative treatment initially
then steroid injections and then electro-diagnostic studies if treatment not working and considering surgery
problems rotating the hip and leg shortening indicate probably what?
hip fracture
pain in buttock or lower back with hip discomfort usually indicates what
sciatica
hip pain and patient has artificial joints, be sure to make sure the patient doesn’t have what?
an infection of the artificial joint. Recent viral or bacterial infection can spread to artificial joint
paresthesia of hip indicates what
possible pinched nerve
diagnostics for hip injury
1) xray - 3 views
2) CT - better definition. add contrast to look at vessels and blood flow
3) MRI
4) compartment pressure measurement
labs for hip injury
CBC = infection, inflammation
CRP = infection, inflammation
Sed Rate = inflammation
could rule in gout or RA
Contraindications for arthrocentesis or joint aspiration
1) cellulitis - never aspirate through cellulitis
2) suspected infected joint - done by orthro
Diagnostics on aspirate of joint
- cell count, WBCs with differential
- gram stain and culture/sensitivity
- crystals (gout)
Differentials for pediatrics complaining on knee pain
1) osgood-schlatters
2) patellar tendinitis
3) osteochondritis dissecans
4) patellofemoral syndrome
Differentials for anterior knee pain
1) osgood-schlatters
2) patellar tendinitis
3) patellofemoral syndrome
4) prepatellar bursitis
5) osteoarthritis
Diagnosing patellar tendinitis
-from overuse causing anterior knee pain
1) ultrasound
2) MRI
Diagnosing patellofemoral pain syndrome
-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
Diagnosing prepatellar bursitis
“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
Causes of posterior knee pain
1) bakers cyst
2) posterior cruciate ligament tear
Causes of medial knee pain
1) medial meniscus injury
2) medial cruciate ligament tear
3) bursitis
Causes of lateral knee pain
1) lateral cruciate ligament tear
2) lateral meniscus injury
3) iliotibial band syndrome
McMurray test indicates issue with what
meniscus
Lachman test indicates issues with what
ACL
Drawer test indicates issues with what
ACL or PCL
Varus stress test indicates issues with what
MCL
radiating back pain into leg along dermatome indicates what?
possible ruptured disc
loss of bowel and bladder with lower back pain indicates what
EMERGENCY
Cauda Equina syndrome
straight leg raise test
used to determine possible herniated disc
+ = when leg is elevated, pain is noted when leg is between 30-60 degrees
Definitive diagnoses of herniated disc requires which scan
MRI
what is nursemaids elbow
a subluxation injury of the radial head usually occurring in children 6mo-5years
How to treat nursemaids elbow
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
Education for parents after nursemaid elbow treated
do not pull on childs arm or swing them by arms.
monitor for neuromuscular changes in the arm
