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Internal Medicine

What is the definition of acute renal failure? rapid rise in BUN or creatinine over hours or days
What is BUN derived from? protein waste products
How does liver disease effect BUN levels? falsely low
Why does creatinine clearance slightly overestimate GFR? there is some tubular secretion of creatinine; it is not all freely filtered
What is the cause of renal failure in patients with cirrhosis (hepatorenal syndrome)? 1. portal hypertension leads to splanchnic vasodilation 2. decreased volume is sensed by JG apparatus → activation of RAAS 3. renal vasoconstriction → decreased renal perfusion
Patient with drop in oxygen saturation when they sit up orthodeoxia, characteristic of hepatopulmonary syndrome
How would creatinine be effected in a patient with a large renal stone obstructing a ureter? creatinine does not rise if there is a loss of only one kidney
How is postrenal azotemia diagnosed? finding bladder distention or examination, bilateral hydronephrosis, or large volumes or urine after passing Foley
What is the most common cause of intrinsic acute renal failure in hospitalized patients? acute tubular necrosis
1. Patient with fever, rash and oliguria after starting a new drug? 2. What is the best initial test? 1. Allergic interstitial nephritis 2. ↑ WBC on U/A (best is Hansel's stain for eosinophils in urine)
1. Most important initial test to perform in a person who presents with painful muscles and dark urine. 2. Treatment 1. EKG for possible cardiac complications of hyperkalemia 2. Ca2+, hydration, bicarbonate to alkalinize urine
1. What is the metabolic complication of ethylene glycol overdose? 2. Treatment 1. formation of toxic metabolic oxalic acid 2. fomepizole followed by dialysis to remove the ethylene glycole
1. Most common cause of acute hyperoxaluria with metabolic acidosis? 2. Most common cause of chronic hyperoxaluria? 2. 1. ingestion of antifreeze 2. Crohn's disease from fat and calcium malabsorption
Mechanism of action of allopurinol prevents conversion of xanthine to hypoxanthine to uric acid
Most common cause of hypercalcemia hyperparathyroidism
What is the difference in presentation between acute interstitial nephritis (AIN) and direct toxins to the kidney? 1. AIN occurs with the first dose and presents with fever, rash, and eosinophils 2. direct toxins take several days/weeks
What is the least nephrotoxic aminoglycoside tobramycin
What is renal insufficiency? renal failure that is not severe enough to require dialysis; aka azotemia
Patient with recent vascular catheter develops signs of renal failure. atheroembolic disease
Which HIV drug is most associated with neprholithiasis? indinavir (protease inhibitor)
Acute flank pain, hematuria, pyuria and fever: 1. patient with + urine cultures 2. patient with history of diabetes, sickle cell or NSAID use 3. What is the most accurate diagnostic test? 1. acute pyelonephritis 2. papillary necrosis 3. Ct scan
Most likely prevention of contrast-induced renal failure. hydration
1. Patient with edema, hematuria and hypertension 2. What test confirms the diagnosis? 1. glomerulonephritis 2. renal biopsy
1. Patient with sinusitus and renal disease 2. best initial test 3. most accurate test 4. Treatment 1. Wegener's granulomatosis 2. C-ANCA 3. biopsy of kidney or nasal septum/lung 4. cyclophosphamide and steroids
1. Patient with chronic asthma, elevated WBC skin lesions. 2. Treatment 1. Churg-Strauss 2. glucocorticoids and cyclophosphamide
What areas of the body are effected by polyarteritis nodosa? virtually every organ except the lung
1. Palpable purpura with arthralgies 2. What is the pathophysiologic cause 3. Treatment 1. Henoch-Schonlein purpura 2. systemic deposition of IgA 3. supportive because disease is self-limiting
Characteristics of Glomerulonephritis 1. Edema (low oncotic pressure; Salt and water retention) 2. Hematuria with dysmorphic RB cell (red cell squeeze through the glomeruli) 3. Proteinuria < 2g/24hr 4. Fractional excretion of Na <1% (you are retaining it, you can't be excreting it)"
Churg-strauss Syndrome: best lab test? eosinophilia and positive C-ANCA
Churg-Strauss Syndrome: most accurate test Biopsy
Goodpasture Syndrome: best initial test Antibasement membrane antibodies to type IV collagen
Goodpasture Syndrome: most accurate test lung or kidney biopsy; IF shows linear deposit
Goodpasture Syndrome: treatments plasmapheresis and steroid, +/- cyclophosphamide
Polyarteritis Nodosa: best initial test P-ANCA
Polyarteritis Nodosa: most accurate test biopsy (need angiogram done before bx)
Polyarteritis Nodosa: Treatments cyclophosphamine and steroid
Henoch-Schonlein Purpura: Treatments Steroids if disease is severe or porgressive
IgA nephropathy (Berger Disease): best initial test increase IgA
IgA nephropathy (Berger Disease): most accurate test renal biopsy
IgA nephropathy (Berger Disease): Treatments no effective treatment; steroid won't reverse IgA problem; use ACEI or ARBS for proteinuria
Postinfectious Glomerulonephritis: characteristics Smoky, cola or tea colored urine; due to strep pyogenes, Hep B and C, CMV, chronic staph infections)
Postinfectious Glomerulonephritis: best initial test ASO (antistreptolysin) test or AHT(antihyaluronic acid) test
Postinfectious Glomerulonephritis: most accurate test renal biopsy; EM shows humps of IgG and C3
Postinfectious Glomerulonephritis: Treatments 1. supportive 2. manage fluid overload and HTN with diuretics
Thrombotic thrombocytopenic Purpura: characteristics Pentad presentation: 1. hemolytic anemia; 2. uremia; 3. thrombocytopenia; 4. fever; 5. neurologic problems
Hemolytic uremic syndrome: characteristics Triad presentation: 1. hemolytic anemia; 2. uremia; 3. thrombocytopenia
In Hemolytic uremic syndrome 1. What antibiotics do you give? 2. How do you treat thrombocytopenia? 1. none; if antibiotics are given, organism may release more toxins as it dies 2. do not transfuse platelets bc they precipitate and worsen the CNS and renal abnormalities
1. crescent formation of glomerulus on biopsy 2. treatment 1. rapidly progressive glomerulonephritis 2. steroids and cyclophosphamide
What are the two common types of amyloidosis? 1. AL from light chains 2. AA from chronic infection or inflammation
What defines nephrotic syndrome? renal disease sufficient to produce a level of proteinuria greater than 3.5 gram per 24 hours, hyperlipidemia, edema and low serum albumin
What is the cause of hyperlipidemia in nephrotic syndrome? loss of lipoproteins on the surface of chylomicrons and LDL so these lipids are not cleared from the bloodstream
Most common form of idiopathic nephrotic syndrome in adults membranous
Cause of casts on urinalysis: 1. hyaline 2. red cell 3. white cell 1. dehydration 2. glomerulonephritis 3. pyelonephritis
Cause of the following casts on urinalysis: 1. broad, waxy 2. granular 1. chronic renal failure 2. acute tubular necrosis
What are the indications for dialysis? A E I O U 1. Acid/base disorders 2. Electrolytes (↑K) 3. Intoxication 4. Overload of volume 5. Uremia (pericarditis, encephalopathy)
Cause of hypocalcemia in renal failure (2)? 1. low vitamin D 2. high phosphate which precipitates calcium
What is used to treat hyperphosphatemia from end-stage renal disease? phosphate binders: 1. calcium carbonate 2. calcium acetate
What is used to treat hyperphosphatemia from end-stage renal disease when calcium mis abnormally high (from vitamin D replacement? 1. sevelamer 2. lanthanum
What happens to the levels of the following electrolytes in ESRD: 1. calcium 2. phosphate 3. magnesium 1. decreases 2. increases 3. increases
1. What is the suggested blood pressure management for those with ESRD? 2. Why? 1. <130/80 2. rapidly progressive coronary artery disease is the most common cuase of death
1. How does ESRD lead to bleeding? 2. What is the treatment? 1. uremia-induced platelet dysfunction 2. desmopressin causes release of subendothelial vWF stores and factor 8
Why can hyponatremia lead to hypertension? "1. as ECT osmolality decreases, water shifts into brain cells increasing the ICP 2. blood pressure increases to maintain cerebral perfusion pressure"
How does hyponatremia effect intracranial pressure? water shifts into the cells leading to increased ICF volume and thus increased ICP
At what level does hyponatremia become symptomatic? < 125
"What is the treatment for: 1. mild hyponatremia 2. moderate hyponatremia 3. severe hyponetremia 1. fluid restriction 2. normal saline (0.9%) + loop diuretic 3. 3% hypertonic saline or V2 receptor-antagonist"
What neurologic disorder is caused by correcting hyponatremia too rapidly? central pontine myelinolysis
Why may hyperglycemia manifest with pseudohyponatremia? ↑ glucose osmotically draws water into the vascular space and dilutes sodium
Most important diagnostic test when a patient has suspected hypokalemia EKG
What acid base status is seen following dehydration? volume contraction → ↑ aldosterone → metabolic alkalosis
How does replacement of B12 in deficient patients lead to hypokalemia? potassium is found mostly intracellularly and with rapid cell production from B12, extracellular K+ moves into cells
How is magnesium related to potassium metabolism? magnesium decreases urinary loss of potassium therefor hypomagnesemia leads to hypokalemia
Rx for hypovolemia from vomiting? 1. GI loss of H+ and volume contraction → ↑ aldosterone → H+ loss and HCO3 retention 2. 2. treat contraction alkalosis with IV normal saline with the addition of potassium to replace K+ loss
Rx for severe hypercalcemia? normal saline followed by furosemide
How do the following effect calcium levels: 1. acidosis 2. alkalosis 1. results in hypercalcemia because albumin binds H+ and releases Ca2+ 2. results in hypocalcemia
Patient with multiple blood transfusions has a seizure and perioral numbness. hypocalcemia from binding of free calcium to citrate
How can alcoholism lead to hypocalcemia low magnesium from malnutrition prevents the release of parathyroid hormone from the thyroid gland
How does hyperglycemia manifest with hyponatremia? high glucose level causes a transcellular shift of water out of the cell into the vascular space, diluting the sodium
Rx for: 1. mild hypovolemic hypernatremia 2. severe hypovolemic hypernatremia 1. D5 1/2NS 2. D5W
Treatment for nephrogenic diabetes insipidus HCTZ, amiloride, NSAIDs
What effect does insulin have on potassium levels? insulin causes uptake of potassium by cells
Patient with muscle weakness and peaked T waves on EKG. What is the treatment? 1. calcium chloride protects heart 2. insulin + glucose shift K+ into cells 3. Kayexalate removes K from body"
"Which fluid should be given: 1. hypovolemia with alkalosis 2. hypovolemia with acidosis 1. normal saline 2. lactated ringer
1. What is the tonicity of sweat? 2. What are the resulting sodium levels in the body? sweat is mostly free water (hypotonic) and results in hypernatremia
How do you diagnose SIADH? elevated urine osmolality (>100) in a patient with hyponatremia
Treatment for SIADH 1. severe disease 2. chronic disease in which underlying cause can't be corrected 1. 3% hypertonic saline 2. V2 receptor antagonists (conivaptan and tolvaptan)
How fast can hypo or hypernatremia be corrected? ~ 0.5 mEq per hour
How does aldosterone effect K+ concentration? causes hypokalemia mainly from K+ secretion from colon and small part from kidneys
What are the EKG findings of patients with suspected hypokalemia? T-wave flattening and U-waves
What action does Kayexalate have? resin that absorbs 1 mEq K per g and releases 1 mEg Na
1. Asymptomatic hyperkalemia with nonanion gap metabolic acidosis 2. How do you confirm the diagnosis? 3. Treatment 1. aldosterone deficiency 2. Presence of high urine sodium with oral salt restriction. 3. Fludrocortisone
What electrolyte changes are seen with volume contraction? 1. K secretion 2. Na+ absorption 3. HCO3 absorption 4. H+ secretion
What is the anion gap a measure of? 1. gauge of the unmeasured anions in the bloodstream 2. positively charged cations - negatively charged anions
In normal anion gap metabolic acidosis, how can one determine if the cause is due to renal or intestinal HCO3 loss? 1. determine urine anion gap (Na + K) - Cl 2. positive gap indicates renal tubular acidosis
1. What are the main cations of the blood? 2. What are the main anions? 1. Na+, K+, Ca2+ 2. HCO3-, Cl-, albumin, lactate, ketoacids
What acid/base disturbance do salicylates create? respiratory alkalosis + metabolic acidosis
1. What is the composition of most renal stones? 2. What electrolyte irregularities increase stone formation? 1. calcium oxalate 2. increased calcium, decreased oxalate
What causes struvite stones? urinary infections with urease positive organisms
Radiolucent stones uric acid
Extra-renal manifestations of adult polycystic kidney disease 1. hepatic cysts 2. hypertension 3. berry aneurysms 4. mitral valve prolapse
What degree of proteinuria distinguishes nephritis from nephrotic syndrome? >3g/day = nephrotic
What is the FeNa in glomerulonephritis? FeNa < 1 because there is salt and water retention
What is the difference between Henoch-Schonlein purpura and IgA nephropathy? both occur from IgA deposition but IgA nephropathy only effects the kidneys
Patient with recent viral illness 1. Develops hematuria 1-2 days later 2. Develops hematuria 1-2 weeks later 1. IgA nephropathy 2. poststreptococcal glomerulonephritis
1. Why must one biopsy in lupus nephritis? 2. What is the treatment? 1. to determine if there is sclerosis or proliferative disease 2. sclerosis does not need therapy; proliferative disease is treated with steroids and mycophenolate
1. How is nephrotic syndrome diagnosed? 2. How is the cause of nephrotic syndrome determined? 1. protein:creatinine ratio of >3.5 2. renal biopsy
What is the diagnosis of SIADH based on? elevated urine osmolality and urine sodium in a patient with hyponatremia
1. Patient with flattened T waves and U waves present 2. What causes the U wave 1. hypokalemia 2. purkinje fiber repolarization
What is the maximum oral dose of potassium? no max dose because gut cannot absorb it fast enough to overload kills
What is the problem in renal tubular acidosis: 1. Type I 2. Type II 3. Type IV 1. impaired distal secretion of H+ 2. impaired proximal absorption of bicarbonate 3. aldosterone deficiency
1. What 2 things cause normal anion gap metabolic acidosis? 2. What laboratory test helps distinguish between the two? 1. diarrhea and renal tubular acidosis 2. urine anion gap
1. How do you quantify oliguria? 2. How do you quantify anuria? 1. <400 mL per 24 hours 2. <100 mL per 24 hours
1. When is Winter's formula used? 2. What is Winter's formula? 1. to determine if the is appropriate respiratory compensation for metabolic acidosis 2. (1.5 x HCO3-) + 8 ± 2



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