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ESA3 revision decks > Urinary > Flashcards

Urinary Flashcards

1
Q

how do convoluted tubules regulate body pH

A

reabsorption of HCO3-

  • 90% get reabsorbed in the proximal tubule
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2
Q

what is an early indicator of glomerulosclerosis in a diabetic patient?

A

microalbuminuria

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3
Q

over the course of 2 days a pt develops oliguria, hypertension fluid retention, uraemia, haematuria and proteinuria. Which of the following is the most likely diagnosis?

nephrotic syndrome

rapidlt progressive glomerulonephritis

acute nephritic syndrome

chronic kidney disease

A

acute nephritic syndrome

  • haematuria
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4
Q

what is the most likely cause of nephrotic syndrome

A

minimal change disease

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5
Q

a pt present swith severe ankle swelling worsenign over the last week and proteinuria. What is the most likely diagnosis?

A

nephrotic syndrome

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6
Q

where in the urinary tract are red blood cells most likely to enter the urine

A

glomerular basement membrane

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7
Q
A
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8
Q
A
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9
Q

hypercalcemia question: what are the pts most striking symptoms and lab findings

A
  • bone pain, weakness and constipation
  • history of HT and CHD/TIAs
  • elevated total serum calcium, PTH and alkaline phosphatase
  • low vit D
  • despite hypercalcemia, no muscle weakness or altered mental state
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10
Q

differential diagnosis for cause of hypercalcemia

A
  • PT tumour
  • Bone destruction
  • Increased intestinal absorption- Vit D
  • Granulomatous disease
  • Drugs e.g. thiazide e.g. lithium
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11
Q

A56yearoldfemalepatientwasrecentlydischargedfromthehospitalforBell’s palsy and was incidentally found to have hypercalcemia. She has been having pain in her legs, constipation and occasional weakness but denies any kidney stones, significant weight loss or abdominal pain. She reports occasional severe headaches.

Shehasahistoryofdiabetesmellitus,hypothyroidism(status:postradioactive iodine ablation for hyperthyroidism), COPD and hypertension. The patient also has a history of IBS. She has had myocardial infarctions and strokes, and in the past month has been hypercalcaemic on 3 consecutive occasions.

Shewentthroughthemenopauseattheageof51.Shesmokes1-2packsof cigarettes daily (since age 14). Patient denies alcohol consumption but has visited clinic with odour of alcohol on breath on occasion. She has a history of substance abuse (3 incidences of narcotic overdose). She has no evidence of altered mental status. She is not known to be taking any calcium or vitamin D supplements.

Bloodpressure143/93mmHg

Heartrate75bmp

Respiratoryrate18rpm

A

Bonepain,weaknessandconstipation.

HistoryofHTandCHD/TIAs

Elevatedtotalserumcalcium,PTHandalkalinephosphatase.Serum phosphorous is low normal.

LowtotalvitaminD

Despitehypercalcemia,nomuscleweakness,noalteredmentalstatus.

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12
Q

Case study 1: WHAT IS THE DIFFERENTIAL DIAGNOSIS?

A
  • Hyperparathyroidism
  • Bone destruction – malignancy or myeloma

• Increased intestinal absorption – vitamin D

  • Granulomatous disease
  • Drugs – thiazides, lithium
  • Hypermagnesemia
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13
Q

Case study 1: A SCAN REVEALED THE PRESENCE OF A PARATHYROID ADENOMA. WHAT IS THE PATIENTS MOST LIKELY DIAGNOSIS?

A

Most likely diagnosis is primary hyperparathyroidism. Based on the elevated PTH and calcium, the low normal phosphorous and the parathyroid adenoma.

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14
Q

Primary hyperparathyroidism is definitively diagnosed if

A

hypercalcemia resolves following surgical removal of the adenoma.

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15
Q

EXPLAIN THE MECHANISM BY WITH THE ELEVATED PTH RESULTS IN HYPERCALCAEMIA

A

released from parathyroid gland

PTH stimulates the bone to:

  • increase bone resportion to increase calcium ion release into the blood

PTH release stimulates the kidneys to:

  • increase excretion of phosphate, should increase plasma calcium (innervesely proportionate relationship)
  • stimulates activation of Vitamin D (1,25-dihydroxycholecalciferol)
    • stimulates intestines to absorb more calcium
  • increases renal reabsorption of calcium
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16
Q

HOW WOULD SUCH A PATIENT BE MANAGED AND WHY?

A

parathyroidectomy on cure

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17
Q

case study 1 WHAT DO WE NEED TO CONSIDER IN THE LONG-TERM MANAGEMENT OF THIS PATIENT

A
  • To prevent hypocalcaemia after parathyroidectomy calcium and vitamin D supplements can be prescribed.
  • Follow up studies include DEXA bone scan to monitor bone mineral density.
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18
Q
A
19
Q

case study 2 JACK WAS DIAGNOSED WITH MINIMAL CHANGE DISEASE. WHAT SIGNS/SYMPTOMS WOULD YOU EXPECT TO SEE IN A CHILD WITH MCD?

A
  • oedema (periorbital swelling, ankle swelling)
  • proteinuria
  • hypoalbuminaemia
  • hyperlipidaemia
20
Q

case study 2 EXPLAIN THE MECHANISM LEADING TO OEDEMA IN NEPHROTIC SYNDROME

A

Podocyte damage

Loss of albumin in the urine

Hypoalbuminaemia

Reduced oncotic pressure in capillaries – less water drawn into capillaries from surrounding tissues

21
Q

case study 2: HOW WOULD THE SIGNS/SYMPTOMS HAVE DIFFERED IF HE HAD NEPHRITIC SYNDROME?

A

• Oliguria/Anuria

  • Hypertension
  • Heamaturia
22
Q

Case study 3 Martin was diagnosed with type 1 diabetes as a teenager. His diabetes was poorly managed for many years. He eventually went on do develop diabetic nephropathy.

EXPLAIN THE MECHANISM OF

HYPERFILTRATION IN DIABETIC NEPHROPATHY

A
  1. increased blood glucose, result sin icnreases reabsorption of glucose in PCT
  2. reabsorption of glucose coupled with sodium absorption
  3. reduction in delivery of sodium to macula densa cells
  4. vasoconstriction of effrent arteriole
  5. increased hydrostratic pressure within glomeurlus and increased GFR
23
Q

NAME THE FORCES WHICH DETERMINE THE NET FILTRATION PRESSURE IN THE GLOMERULUS?

A

• Hydrostatic Pressure

  • Glomerulus
  • Bowmanscapsule

• Oncotic pressure - glomerulus

24
Q

HE DEVELOPS STAGE 3 CKD. WHAT ARE THE COMPLICATIONS OF CHRONIC KIDNEY DISEASE?

A
  • Anaemia – EPO deficiency
  • CKD bone and mineral disorder
    • Lack of active vitamin D – reduced calcium absorption
    • Hyperphosphatemia – phosphate excretion impaired, PTH released
    • Extra skeletal calcification – calcium deposition in soft tissues and arteries
  • Hypertension secondary to chronic intravascular volume overload
  • Accelerated atherosclerosis/vascular disease
  • Metabolic acidosis
25
Q

AS HIS RENAL FUNCTION CONTINUES TO DECLINE, HE DEVELOPS URAEMIA. WHAT SIGNS AND SYMPTOMS ARE ASSOCIATED WITH THIS?

A
  • Fatigue
  • Itch
  • Nausea and vomiting
  • Cramps/restless legs
  • Altered cognition
  • Uraemic skin colour changes
26
Q

advantages of hemodyialysis

A

✚Less responsibility

✚Days off

27
Q

disadvantages of Hemodyialysis

A

⎯ Travel time/waiting

⎯ ‘tied’ to dialysis times – little travel

⎯ Big restriction on fluid and food intake

28
Q

advantages of Peritoneal dialysis

A

✚Self-sufficient/independence

✚Less food/fluid restrictions

✚Fairly easy to travel

✚Renal function may be better preserved initially

29
Q

disadvantage sof periotneal dialysis

A

⎯ Responsibility lies with patient

⎯ Frequent daily exchanges or overnight

30
Q

case study 4

A 62 year old man is 4 days post-colostomy. He is eating a light diet and managing to drink approximately 1 litre per day. His colostomy losses are excessive, he is losing in excess of 1L/day. He is dehydrated and needs IV fluids. His weight is 90kg.

WHAT DO YOU NEED TO CONSIDER IN ORDER TO CALCULATE HIS FLUID REQUIREMENTS?

A

• Hydration status

  • His total losses (e.g. vomiting, diarrhoea, blood loss)
  • His total gains

• Calculate his maintenance fluid requirements, replace any fluids lost (look at fluid balance chart)

31
Q

case study 4

A 62 year old man is 4 days post-colostomy. He is eating a light diet and managing to drink approximately 1 litre per day. His colostomy losses are excessive, he is losing in excess of 1L/day. He is dehydrated and needs IV fluids. His weight is 90kg.

WHAT VOLUME OF IV FLUID DOES THIS PATIENT REQUIRE?

A

Fluid Requirements = 30ml/kg/d • = 90 x 30 = 2700ml/day

  • Patient drinking 1000ml/d
  • Excess colostomy loses of 1L

• 2700ml – 1000 + 1000 = 2700ml/day.

32
Q

case study 4

A 62 year old man is 4 days post-colostomy. He is eating a light diet and managing to drink approximately 1 litre per day. His colostomy losses are excessive, he is losing in excess of 1L/day. He is dehydrated and needs IV fluids. His weight is 90kg.

WHAT TYPE OF IV FLUID DOES HE NEED? WRITE A SUITABLE FLUID REGIME

A

go with the 111 ratio with sodium, potassium and chloride

  • Don’t worry about giving HCO3- they will be able to make their own if its not a large amount
  • Don’t need tow worry about glucose too much either with requirements because he is eating and drinking

1L Heartmans- enough sodium, chloride and bicarbonate

2L 4% dextrose and 0.18% saline (KCl and NaCl- make up K+ requirements)

  • Lots of fluid
  • Some saline he needs but not too much

1L + 2L= closest to 2700ml/day

33
Q

case study 5

Three days after her admission, a 43 year old woman (63kg) with diabetic ketoacidosis has a blood pressure of 88/46mmHg and a pulse of 110bmp. She is tachycardic. Her charts show that her urine output over the last 3 days was 26.5L, whist her total intake was 18L. Over the last 3 days you have managed to stabilise her blood glucose to normal levels.

EXPLAIN HOW THIS PATIENT HAS BECOME HYPOTENSIVE.

A
  • DKA causes glucosuria
    • The glucose transporters are only able to reabsorb a certain amount of glucose Tmax.
  • glucose remains in urine which results in osmotic diuresis
  • causes high loss of water in the urine and dehydration occurs
34
Q

case study 5

Three days after her admission, a 43 year old woman (63kg) with diabetic ketoacidosis has a blood pressure of 88/46mmHg and a pulse of 110bmp. She is tachycardic. Her charts show that her urine output over the last 3 days was 26.5L, whist her total intake was 18L. Over the last 3 days you have managed to stabilise her blood glucose to normal levels.

WHAT IS HER FLUID DEFICIT OVER THE LAST 3 DAYS?

A

• Over the last 3 days she has lost 26.5L of urine

  • Her fluid input has been 18L
  • This equals a deficit of 8.5L
35
Q

case study 5

Three days after her admission, a 43 year old woman (63kg) with diabetic ketoacidosis has a blood pressure of 88/46mmHg and a pulse of 110bmp. She is tachycardic. Her charts show that her urine output over the last 3 days was 26.5L, whist her total intake was 18L. Over the last 3 days you have managed to stabilise her blood glucose to normal levels.

THIS PATIENT IS HYPOTENSIVE AND AT RISK OF HYPOVOLEMIC SHOCK. WHAT FLUIDS WOULD YOU PRESCRIBE FOR HER?

A
  • Fluid loss due to osmotic diuresis
  • 500ml bolus of Hartman’s (0.9% Saline would also be fine)
  • Reassess. If further fluids need continue to give 250ml – 500ml bolus and reassess. Continue until stable or 2000ml provided
36
Q

WHAT ARE THE SIGNS THE FLUID RESUSCITATION IS HELPING?

A

Signs of improvement include:

• Improved blood pressure

  • Capillary refill
  • Improved mental status
  • Urine output
37
Q

WHAT ARE THE SIGNS THAT YOU HAVE GIVEN TOO MUCH FLUID?

A

Signs of fluid overload include:

  • Crackles on lung examination
  • Respiratory distress
38
Q

case study 6

Mr. Stevens, a 28- year- old male, walks into the accident and emergency after the London marathon. He has not been feeling well since the end of the race. Chief complaint: “I don’t know what’s going on. I have just been feeling dizzy and lightheaded.”

WHAT ADDITIONAL QUESTIONS WOULD YOU ASK THIS PATIENT?

A
  • When did his symptoms start? How long have they been present?
  • Exacerbating/relieving factors
  • Progression of his symptoms
  • How long was his run? How much fluid did he drink? What types of fluids did he drink?
  • Has this occurred to him during other races?
  • Any other associated symptoms?
  • PMH, PSH, Meds, Allergies, FH
39
Q

case study 6

SamStevensisa28-year-oldCaucasianmalewhopresentsdizzyandlightheadedto accident and emergency. The day of the marathon was hotter than expected and the day was unusually sunny. He remembers that it was extremely uncomfortable to run under those conditions, but he kept going and started to fall behind the other runners. He states that the dizziness and light-headedness started at the halfway point of the marathon. He was extremely hot, sweaty and thirsty, and rapidly drank a few bottles of water that were offered to him by the volunteers. After running a bit further, he became dizzy, lightheaded, and slightly disoriented. He was able to finish the race at a walk and immediately had a drink of water. Later that day, he was still feeling hot, dizzy, and lightheaded, so he decided to go to A&E.

Samhasnosignificantmedicalorsurgicalhistoryanddoesnottakeanymedications, herbal supplements, or over the counter preparations. He has no allergies to medications and his parents are alive with no significant medical history. Sam is single, but he is in a mutually monogamous relationship. He has no history of sexually transmitted diseases.

Samhasaveryhealthylifestyle.Hedoesnoteatanyprocessedfoodsormeats, exercises regularly, and does not drink, smoke or use any drugs.

WHAT IS THE PRESENTING COMPLAINT FOR THIS PATIENT? WHAT ARE THE KEY FEATURES OF THIS PRESENTATION? HOW WOULD YOU WRITE THIS IN THE NOTES?

A

• “This is a 28-year-old man with no past medical history presenting with dizziness, light headedness, and high temperature after running a marathon”.

40
Q

WHAT IS THE EFFECT ON BLOOD VOLUME AND PRESSURE OF A SIGNIFICANT DECREASE IN BOTH WATER AND SALT IN THE BODY?

A
  • Loss of sweat decreases ECF volume and increases its osmolarity.
  • The kidneys can compensate when volume is lost by retaining extra Na+ and water from the glomerular filtrate.
  • Dehydration reduces the volume of ECF.
  • Initially, some compensation for decreased ECF volume occurs because of movement of water from the body cells into the blood, but when the dehydration continues and becomes more severe, the compensation is inadequate, blood volume falls, and blood pressure decreases.
41
Q

case study 6

WHAT COULD ACCOUNT FOR SAM’S HIGH PULSE RATE AND DIZZINESS/LIGHT-HEADEDNESS?T

A
  • the fall in blood pressure elicits a sympathetic reflex as the body attempts to return blood pressure to normal by inducing vasoconstriction and increasing the heart rate.
  • Therefore, Sam’s racing pulse is the result of a sympathetic reflex.
  • The reduction in blood pressure is likely to make Sam feel dizzy and lightheaded because of reduced perfusion to the brain.
42
Q

case study 5- YOU DECIDE THAT MR. STEVENS (dehydration after maration) NEEDS AN INTRAVENOUS FLUID INFUSION. WHAT FLUID WILL YOU ADMINISTER TO THE PATIENT TO TREAT HIS CONDITION? EXPLAIN THE RATIONALE BEHIND YOUR CHOICE.

A

An isotonic saline solution (0.9% sodium chloride) should be administered first to correct extracellular fluid depletion and increase volume.

A strongly hypotonic solution would cause water to shift from within the blood to the cells. This would be beneficial for the cells, but blood volume may not be stabilized. A dextrose solution could be proscribed once circulating volume has been restored.

43
Q

HOW WOULD FLUIDS SHIFT IN THE BODY IF YOU GAVE HIM HYPOTONIC (0.45% NACL- hypotonic) SALINE OR 5% DEXTROSE (D5W)? WHAT WOULD HAPPEN TO THE VOLUME OF HIS CELLS?

A
  • The ECF osmolality would drop, and water would flow into the ICF.
  • Lower ECF osmolality would cause cell volume to increase.
44
Q

WHAT DO YOU THINK WOULD HAPPEN TO THE PATIENT IF HE WERE GIVEN HYPERTONIC SALINE (3% NACL)? DESCRIBE THE SHIFT IN FLUID COMPARTMENTS AND THE VOLUME OF HIS CELLS

A

ECF osmolality will increase. Water will flow out of the ICF. Cell volume will shrink.

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