Work-Ups Flashcards
AKI
1- r/o post-renal by H&P, US, bladder cath
2- UA (benign, muddy brown casts, WBC, RBC)
3- Urine studies & BMP to calc FeNa
Hematuria
1- UA and urine cx
- If infection - treat UTI
- If RBC casts or proteinuria - intrinsic labs (ANA, ANCA, complement, anti-glomerular BM) & poss renal biopsy
- If neither - coagulation panel
2- If coags normal …KUB for stones –> IVP, CT, urine cytology
3- May need cystoscopy with biopsy if still suspect cancer
Solitary Pulmonary Nodule
1- look for old CXR to compare
2- If old CXR unavailable, new nodule or changed in size for > 2 yrs … CT
3- If looks benign on CT - follow q 3 mo
If looks malignant - biopsy + resection
Suspected PE
1- Calc modified Well’s
2- If score 4 or less than unlikely –> D-dimer
(if high D-dimer do CT)
3- If score >4 then right to CT
4- If cannot do CT –> leg US for DVT –> V/Q scan
Jaundice
1- H&P, hepatic function panel
- Normal LFTs/ high bili –> fractionated bilirubin to decide if conjugated or unconjugated
- If abnormal LFTs must decide hepatic v. cholestatic
HEPATIC - viral serology (hepatitis, CMV, herpes), AMA, SMA, ANA, ceruloplasmin, iron panel, alpha 1 anti-trypsin
CHOLESTATIC - US or CT to look at ducts –> ERCP if needed
Fecal Occult Blood
1- CBC (look for iron def anemia)
2- If anemic then colonoscopy
If not anemic and < 40 yo - f/u and repeat FOBT
If not anemic and > 40 - colonoscopy +/- EGD if upper signs and sx too
Solitary Thyroid Nodule
1 - FNA
2 - If benign FNA then observe and repeat FNA or US if remains
If malignant - surgery
If indeterminate - thyroid scan
3- Cold –> surgery
Hot –> close observation
Cushing Syndrome
1- overnight dexamethasone suppression test or 24-hr free urinary cortisol level
2- If normal - STOP WORK UP - no Cushing
If abnormal - measure ACTH
3- High ACTH - high dose dexamethasone suppression test –> if suppression then pituitary MRI
If no suppression then ectopic –> chest and abdomenl CT
4- Low ACTH - adrenal pathology (tumor, hyperplasia) –> image adrenals
Adrenal Insufficiency
1 - Meas plasma cortisol
2- If low, meas ACTH, aldosterone and renin
3- Low ACTH –> pituitary MRI
High ACTH = problem with adrenals
Syncope
1- H&P, routine labs, ECG, orthostatic vitals
2- If suspect cardiac - ECHO, halter monitor or event monitor
3- If do not suspect cardiac …
STOP IF FIRST EPISODE
Tilt table + psych eval if recurrent
Monoarticular Arthritis
1- synovial fluid analysis
WBC > 5000 - inflammatory –> cx, crystals, AI
WBC < 2000 - not inflammatory -
- bloody? trauma or tumor
- non-bloody? Xray
Polyarticular Arthritis
1- H&P, ESR
2- Non-inflammatory (no erythema or swelling or elev ESR) - OA
If inflammatory - consider fluid aspiration and determine acute v chronic
Hyponatremia
1- serum OSM
HIGH - hyperglycemia, glycerol
NORMAL - Pseudohyponatremia
LOW - true hyponatremia
2- Assess volume status
LOW - measure urine Na (renal losses or extra-renal losses)
NORMAL - SIADH, psychogenic polydipsia
HIGH - CHF, nephrotic syndrome, hepatorenal
Hypokalemia
1- H&P - true depletion or known redistribution (insulin, alkalosis, epi)
2- If true … urine K+
Urine K < 20 then extra-renal loss
Urine K > 20 - renal loss
3- Either way get ABG
Hyperkalemia
1- H&P true excess or know redistribution (acidosis, insulin def, beta blocker, digitalis overdose)
2- Check Cr for renal function
3- If not in renal failure … check aldosterone
HIGH or NORMAL - K sparing diuretic or tubule disorder
LOW - ACE, Addison, hyporenin hypoaldosteronism
