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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
infrarenal - disease process or kidney stone
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 posts 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 urien

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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 and 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

34
Q

RBC presence in urine

A

hematuria requires follow up.

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

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

36
Q

RBC casts

A

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

37
Q

Bacterial casts

A

indicates acute pyelonephritis

38
Q

Epithelial casts

A

can be benign- associated with tubular necrosis

39
Q

Bacteria in urinalysis

A

> 100,000 is usually significant

urine can be colonized and not infected

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

41
Q

Triad of acute bacterial meningitis

A

Fever >38 degrees C

Nuchal rigidity

AMS

(Hypothermia in a small percentage)

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
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

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
45
Q

Tests for bells palsy

A

CT, MRI, serological test for Lyme disease

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
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

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

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

50
Q

Tension headache

A

most common headache type

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
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

53
Q

Diagnostics for headache

A

MRI is preferred for headache

54
Q

parkinsons affects which age group

A

progressive neurodegenerative disease

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

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

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

Diagnostics (3 decks)

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