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Flashcards in OME/Books Deck (115):
1

lab values AIN

WBC CASTS (not just pyelo)
eosinophiluria

2

what drugs cause AIN

tmp/sulfa
penicillin
cephalosporin

3

two nephrotoxic agents that can cause ATN

IV contrast
myoglobin (rhabdo)

rx ATN with aggressive fluids

4

hints of pre renal etiolgy (4)

- BUN:Cr >20
- FeNa <1%
-Urine Na - <10
FeUrea <35%

5

steps to evaluate AKI

1. urine lytes (r/o pre renal)
2. U/S to r/o obstruction
3. use H/P and U/A to evaluate intrinsic
4. absolute last resort is kidney biopsy

6

acute indications for hemodialysis

A E I O U

acidosis
electrolytes (K, Ca)
intoxication
overload
uremia

7

how to manage PPROM >34 weeks

abx
corticosteroids
delivery

8

causes of hypoventilation that can cause respiratory acidosis

opiate overdose (i.e. morhpine)
asthma/COPD severe
musculoskeletal weakness
OSA

9

What to check of you determine you have metabolic alkalosis

urine chloride! and/or give fluids to assess volume responsiveness

urine chloride low <10 in contraction alkalosis (suggests pt is volume down, RAAS is working to reabsorb Na and Cl (which follows Na)) (diuresis, dehydration, emesis/NG suction)

this is called VOLUME RESPONSIVE



10

what if you have met alk and Ucl is >10

this is not volume responsive alkalosis
check for HTN to r/o primary aldosteronism and Barter's Gittlemans

11

what cause of anion gap metabolic acidosis can present with urine crystals

ethylene glycol (antifreeze)

12

anion gap formula
nml anion gap

Na - Cl - HCo3

nml < 12

anything greater than 12 = anion gap

13

Next step to evaluate a non anion gap metabolic acidosis

calculate urine anion gap (Na + K) - Cl

positive - RTA
negative - diarrhea

14

rx for drug induced parkinsonism

dopaminergic NMDA blocker, AMANTADINE

15

woman in first trimester who's been having lots of vomiting presents with confusion, ataxia, nystagmus, and lots of low electrolytes

thiamine deficiency
Wernicke's encephalopathy 2/2 hyperemesis gravidarum

16

if you've ruled out ACS and patient is very suggestive of aortic dissection, what to do next

check Cr to see if they can handle contrast angiography

if not to TEE...but CT with contrast is quicker if they can tolerate

17

how to determine if respiratory acidosis/alkalosis is acute or chronic?

every DIME change (10) in CO2 = .08 change in pH (acute)= .04 change in pH chronic)

18

ddx hypotonic euvolemic hyponatremia

"RATS"
RTA (get urine lytes)
addisons (get cortisol)
thyroid (get TSH)
SIADH

19

rx SIADH

volume restriction
gentle diuresis

20

surrogate for aldosterone

urine Na

21

surrogate for ADH

urine osmolarity

22

what causes cerebellar pontine demyelination

correcting Na (Hyponatremia) too quickly

only correct sodium no more than 0.25/hr, 4-6 points/day

23

what 3 systems does PTH effect?

bone
kidney -> gut (indirectly when kidney turns on 1,25 vit D to stimulate Ca absorption from gut)

24

how does PTH indirectly increase Ca absorption in gut

stimulates kidney to convert 25 to 1 25 vit D to stimulate increased Ca absorption in gut

25

how does PTH effect on bone and gut differ from kidney

PTH increases Ca and Phos in bone and gut, but increases Ca and DECREASES phos in kidney

26

How can granulomatous dx fuck up the Ca PTH system?

granulomas/TB/sarcoid secrete 1 25 vit D which will increase Ca and increase phos in gut

27

albumin correction for Ca

for every 1 decrease in albumin, add 0.8 to Ca

so in hypoalbuminemia, Ca may correct to normal range

28

inflate BP cuff and carpopedal spasm

trousseau's sign (hypocalcemia)

29

tap facial nerve, no dulling of reflex

chvostek's sign (hypocalcemia)

also tetancy, perioral tingling

30

how to correct hypocalcemia (symptomatic)

calcium IVVVVVVV!!!!

31

hypercalcemia symptoms

"stones, moans, groans, bones"
kidney stones, AMS, abdominal pain, bone pain

32

rx hypercalcemia

IV FLUIDS IV FLUIDS IV FLUIDS IV FLUIDS IV FLUIDS, early bisphosphonate...then some meds (calcitnin longterm)

33

MCC cause asymptomatic hypercalcemia

hyperparathyroidism

34

three categoreis of hyperparathyroidism

primary - autonomous adenoma
secondary - early CKD,
tertiary - autonomous multiple adenomas

35

3 glucose tests that you can use to dx diabetes

1. 1 random blood glucose>200
2. two measurements fasting blood glucose>equal to 125 (<100 nml, 100-125 preDM)
3. 1 2hr OGTT>equal200

36

PREFERRED method for DM (90 day average of blood sugar)

HA1c
>6.5 = DM
<5.7 = nml

in between 5.7-6.5 = preDM

37

t1dm antibodies (2)

GAD
IA2

38

rx preDM

lifestyle
metformin!!!!!

39

order of rx for DM

lifestyle metformin (unless CKD/CHF/liver dz bc it can cause lactic acidosis), then 2nd agent, then insulin (add rx if re check A1c is not at goal)

40

when to immediately start insulin

A1c > 9

41

DM rx with side effect of diarrhea, lactic acidosis

biguanides! (metformin)

42

DM rx with side effect hypoglycemia

sulfonylurea (glyburide)

43

MOA sulfonylurea

increase insulin release from pancreatic BETA cells

44

MOA metformin

increase insensitivity

45

MOA TZD (glitazones)

activate PPAR (peroxisome proliferator activated receptrs) -> increase insulin sensitivity

46

DM rx with side effect CHF, water retention, edema

TZDs/glitazones

47

side effect GLP-1

weight loss

48

MOA GLP-1 (-utides)

incretin effect, increase insulin secretion via glucose, increase glucose sensitivity

49

MOA a-glucocidase inhibitor (acarbose)

block intestinal absorption of glucose

50

DM rx side effect rx foul smelling diarrhea/flatuelence

acarbose

51

DM rx side effect euglycemic DKA

SLGT-2 inhibitors (flozin)

52

MOA gliflozin (SLGT2)

inhibit Na Glucose transport protein

53

Goal A1c for DM

<7%

54

rx DM proteinuria

ACEI

55

how to screen DM nephropathy and treat it

monofilament screen
rx gabapentin

56

adverse effect acyclovir

crystalline nephropathy

GIVE WITH LOTS OF FLUIDS

57

lab post strep glomeruloneph

low complement C3
RBC casts
proteinuria

58

left sided varicocele that fails to empty with recumbency
hematuria
smoking hx

watch out for RCC
causing obstruction

59

intermittent headaches, nausea, dizziness...dx and hematologic side effect

carboxyhemoglobin

SECONDARY POLYCYTHEMIA

shifts o2 curve to the left, so kidney thinks they're hypoxic

60

rouleaux formation smear

multiple myeloma

61

diplopia, tinnitus, dilated/segmented fundoscopic findings, paresthesias, hepatosplenomegaly, anemia

M SPIKE

waldenstrom
(hyperviscosity syndrome, neuropathy, infiltrative diseas)

IGM, not IGg, IGa like multiple myeloma

62

leukomoid reaction vs CML

leukomoid-high LAP (leukocyte alk phos), metamyelocytes>myelocytes) more mature
CML - low LAP, myelocytes>metamyelocytes less mature

63

what drug can increase serum levels of digoxin?

amiodarone

64

DM patient checks glucose at lunch and is high...how to adjust insulin management?

adjust BREAKFAST dose
(now is a product of insulin/food from previous meal)`

65

how does sepsis affect blood sugar

hypoglycemic

66

non DM, hypoglycemic low c-peptide

insulin injection exogenous

67

non dm hypoglycemic, elevated C peptide

elevated C peptide = endogenous production

screen for sulfonylurea use

68

non dm hypoglycemic, elevated C peptide, negative sulfonylurea use

screen for insulinoma!

69

3 things to watch when treating DKA

1. glucose - IV insulin (watch for hypokalemia)
2. gap - FLUIDS FLUIDS FLUIDS
3. K - replete when get low from insulin

monitor for gap and K with BNP

70

treating DKA, as glucose goes down, what fluids to start

d5w

71

T2DM, AMS, coma, no acidosis/ketones, glucose 800-1000

hyerglycimc hyperosmolar non ketotic coma

72

rx HHNKC

LOTS OF FLUIDS
IV insulin

73

erythematous skin rash, raised sharply demarcated edges, rapid early onset, early fever

erysipelas 2/2 group a strep (lymphadenitis)

74

places where infective endo emboli can end up

skin (jane way lesions, painless)
nails (splinter hemhorrages)
septic emboli causing acute limb ischemia

75

rheumatologic manifestations of infective endo (3)

glomerulonephritis
roth spots
osler nodes

76

empiric rx for IE

vanc, gent + something

77

who needs abx prophylaxis for IE?

bad valve AND right procedure

bad valve - congenital heart, prtosthesis, hx of IE

right procedure - dental, lungs (bronch)

78

major Duke criteria

bactermia
endocardial involvement (on echo/new mitral regurg)

79

minor duke criteria

fever
predisposing condition
immune phenomena
positive blood cultures
positive echo

80

cushing syndrome vs cushing disease

cushing disease = ACTH secreting tumor (like small cell cancer)
cushing syndrome = anything leading to cortisol excess (elevated cortisol leading to supressed ACTH)

81

how to approach possible elevated cortisol

Low Then High
low dex
ACTH level
high dose dex
low dose dex

82

hypercortisol, low dose dex fails to suppress, normal ACTH

adrenal tumor
dx CT/MRI then resect

83

hypercortisol, lose dose dex fails to suppress, low ACTH, high dose suppression does suppress

cushing disease (ACTH secreting tumor)

84

what to order along with low dose dex for initial work up

24 hour urine cortisol
late night salivary cortisol

85

low cortisol due to ADRENAL problem

addison's disease
(low cortisol, low aldosterone)

86

why are addison's patients hyperpigmented

no cortisol, so lots of ACTH made which is linked to melanin

87

orthostasis, hyperpigmentation, low Na, high K

addison's disease

88

first step in diagnosing addison's

early am cortisol

89

if you get low am cortisol then give acth stim test and get increase in cortisol?

problem with anterior pituitary
think pan hypopit
get an MRI
give cortisol

90

if you got a low am cortisol, then give acth stim test and NO increase in cortisol

problem with adrenal
CT MRI
give cortisol and FLUDROcortisol (to increase aldosterone)

91

hypertension, hypokalemia, refractory HTN despite many medications

Conn's syndrome

92

first step in evaluating for Conn's

aldosterone: renin ratio

93

aldo:renin ratio < 10, symptoms of refractory HTN, hypoK

renin is driving aldosterone since they're both increased

renovascular HTN, fibromuscular dysplasia, or atheroscleosis

94

aldo:renin ratio > 30, what to do next

salt suppression test
(salt load should decrease aldosterone normally, but it fails in Conn's)

95

after salt suppression test fails to suppress, next step?

MRI for possible aldosterone secreting tumor WITH adrenal sampling before resection

96

patient with paroxysmal headaches and HTN and palpatiations
what 2 things we can order?

24 hour urine metanephrine
or plasma free catecholamines in acute crisis

after this then get CT/MRI to find mass in abdomen and then adrenal vein sampling

97

how to rx pheochromocytoma preop

alpha blockade (to prevent HTN crisis)
then beta blockade to prevent unopposed alpha
then resect

98

how do you handle adrenal incidentaloma from other scan

r/o Conns, cushings, pheo with 24 hour urine

rx with either watch and wait (<4) or resect if functioning

99

besides autoimmune what other things can cause primary adrenal insufficiency

TB/infection

100

24 cortisol high, low dose fails to suppress, ACTH level high, what to do net

high dose suppression to find ACTH producing tumor (Cushing disease)

101

how to confirm laterality of adrenal tumor

MIBG Scan adrenals (adrenal vein sampling possible, but very invasive)

102

how does rhabdo cause acute renal failure

accumulation of myoglobin filtration causes ATN

103

what can cause HTN crisis in occult pheochromocytoma besides seeding the pheo tumor?

ANESTHETIC AGENTS
tumor palpation/positional changes
surgical procedures

104

how to treat hypernatremia 2/2 hypovolemia (mild and severe)

mild - .45% saline
severe - IV NS to restore volume THEN .45% saline

105

nasal congestion, rhinorrhea, sneezing , drainage, no obvious trigger ERYTHEMATOUS nasal mucosa
dx and rx

non allergic rhinitis
intransal histamine/glucocorticoids

106

nasal congestions, rhinorrhea, drainage, allergic trigger, PALE BLUISH mucosa
dx and rx

allergic rhinitis

intranasal glucocorticoids/antihistamines

107

patient with on antihistamine develops acute urinary retention

detrusor hypocontractility due to anticholinergic affects

108

when to prescribe fibrate (i.e. gemfibrozil) for hyper TGD

TGD>1000

if < than 1000
LIFE STYLE MOD
(weight loss, REDUCE ETOH, exercise) + statin

109

anticoagulation for DVT in patient with ESRD

UNFRACTIONATED heparin bridge to warfarin

LMWH (enoxaparin) or ravaroxabon c/i in ESRD

110

alcoholic with hypocalcemia
underlying cause

hypomagnesemia (decreased release of PTH and PTH resistance)

111

hyperthyroidism, RAIU shows DECREASED uptake...what to order next

serum thyroglobulin

high - thyroiditis, iodide exposure
low - exogenous hormone

112

RA drug that cuases oral ulcers and hepatotoxicity

methotrexate

113

RA drug that cuases alopecia, bone marrow suppression (macrocytic anemia, leukpenia, thrombocytopenia)

MTX

give with folic acid

114

RA patient with splenomegaly and neutropenia

Felty syndrome

115

rx TTP

plasma xchange