1
Q
when can you conclude that the pt has AKI?
A
if sx are present for less than 3 months with GFR < 60 ml/min and/or markers of kidney damage present
2
Q
what are the markers of kidney damage?
A
protein in urine
- abnormal urinary sediment
- abn kidney biopsy
- abn renal imaging
- electrolyte abn from tubular disorders
- hx of kidney transplantation
3
Q
what does chronic kidney disease entail?
A
1) GFR < 60 ml/min
2) markers of kidney damage
4
Q
whats the prevalence of CKD in US?
A
around 15% of US adults have CKD (so, 1 in 7)
- thats 37 million adults in US
5
Q
what are the top CKD risk factors?
A
- diabetes
- hypertension
- cardiovascular disease
- acute kidney injury
- family hx of kd
6
Q
what is the major etiology of CKD?
A
diabetes (38%) or HTN (26%)
t = 64%
7
Q
what are some clinical presentations of CKD?
A
- edema
- HTN
- decr urine output
- foamy urine
- hematuria
- uremia (raised nitrogen levels)
- pericardial friction rub
- asterixis (hand thing)
- uremic frost (powder foot)
8
Q
what are the 3 simple tests to id most CKD pts?
A
- eGFR (estimated)
- urine albumin-to-creatinine ratio; or urine protein-to-creatinine ratio
- urinalysis
9
Q
what are the limitations of eGFR>
A
not reliable in acute kidney injury
10
Q
in diagnosing CKD, what are the renal ultrasound findings found?
A
- atrophic kidneys
- cortical thinning
- incr echogenicity
- elevated resistive indices
11
Q
What happens to GFR with age?
A
GFR declines by 1 ml/min/year after the age of 30-40
12
Q
what are the majority of deaths in ESRD patients?
A
cardiovascular (54%)
13
Q
what are the indications for dialysis?
A
A: severe acidosis
E: electrolyte disrubances (usually hyperK)
I: ingestion (ethylene glycols, methanol)
O: volume Overload
U: uremia
14
Q
define azotemia
A
elevated BUN without symptoms
15
Q
define uremia
A
elevated BUN w sx (N/V, confusion, pruritus, metallic taste in mouth, fatigue, anorexia
16
Q
what tells you AKI?
A
KDIGO guidelines of 2012
serum creatine vs urine output
-(which is worse)-
17
Q
what are the major risk factors for AKI?
A
old age
- proteinuria
- CKD
- HTN
- DM
- CVD
- exposures to nephrotoxins
- cardiac surgery
- fluid overload
- sepsis
18
Q
what drugs are associated with AIN?
A
- antibiotics
- NSAIDs
- proton pump inhibitors
- can be caused by drugs, inf, or autoimm. do’s
- drugs account for >75% of all cases with antibiotics, NSAIDs and PPIs being the main culprits
19
Q
what are some complications of AKI?
A
- development of CKD
- Progression of CKD
- ESRD
- CVD
20
Q
Whwat are some common diagnostic tests
A
- UA with microscopy
- urine albumin/cr ratio or protein/cr ratio
- renal U/S
21
Q
what kidney disease does this urinary pattern suggest?
renal rubular epithelial cells, transitional epithelial cells, granular casts, or waxy casts?
A
ATN
acute tubular necrosis
22
Q
what kidney disease does this urinary pattern suggest?
WBC, WBC cast, or urine eosinophils?
A
AIN
acute intersitial nephritis or pyelonephritis
23
Q
what kidney disease does this urinary pattern suggest?
dysmophic RBCs, RBC casts
A
vasculitis or glomerulonephritis
24
Q
what kidney disease does this urinary pattern suggest?
proteinuria (<3.5 g/day), hematuria, dysmorphic RBC and RBC casts
A
nephritic syndrome
25
what kidney disease does this urinary pattern suggest?
heavy proteinurea (\>3.5g/day), lipiduria, minimal hematuria
nephrotic syndrome
26
what kidney disease does this urinary pattern suggest?
hyaline cast
non-specific, prenatal azotemia
27
what kidney disease does this urinary pattern suggest?
WBCs, RBCs, bacteria
urinary tract infection
28
FeNa or FeUrea is only valid in which type of patients, oliguric or non-oliguric pts?
oliguric pts only (\<400-500 ml/day)
29
what is the purpose of ordering a FeNa or FeUrea?
to differentiate prerenal azometia from intrinsic renal injury (ATN usually)
30
define anuria, oliguria, polyguria, numerically
a: \<50 to 100 ml/day
O: \<400-500 ml/day
P: \>3K ml/day
31
what are the dietary sources of Vitamin A?
eggs, dairy products,
meat, oily salt-water fish
- dark green and yellow veggies
- tomatoes
32
what is the dietary source of vitamin D?
fortified milk, orange juice, cereal;
cod liver oil
swordfish, salmon, herring, trout
egg yolks, muschrooms
33
what is the dietary source of Vitamin E
wheat germ, sunflower seeds, almonds, peanuts, sunflower oil, avocado,
abalone, atlantic salmon, rainbow trout
34
sources of vit K?
green leafy vegetables
fruits
dairy products
vegetable oils and cereals
intestinal microflora
35
what is the source of B1
aka thiamin
- whole and enriched grains, lean pork, legumes
36
what is the source of vitamin B2?
riboflavin
dairy products,
meat, poultry,
wheat germ,
leafy vegetables
37
what is the source of B3?
aka niacin
- meats, poultry, fish,
- legumes, wheat
all foods except fat
38
what is the source of B6?
animal products, veggies, whole grains
39
what are the sources for B9?
folate
- leafy veggies (destroyed in cooking)
- fruits
- whole grain, wheat germ
- beans and nuts
40
what is the source for B12?
cobalamin
eggs, dairy products
liver and meats
**none In plants; vegans need supplements**
41
what is the source for vitamin C?
fruits and veggies
42
what are the sources for calcium?
dairy products
dark leafy veggies (collard, kale, spinach, swiss chard, turnip and mustard green)
tofu, **broccoli**, cauliflower, flax seed, beans and lentils
43
what is the source of iron?
dark leafy veggies (collards, kale)
broccoli, cauliflower
nuts, seeds, legumes (lentils and tofu), quinoa, fortified cereal (cream of wheat)
lean meat, clams, oysters, dried prunes and raisins
44
what aids and what inhibits absorption of iron?
vitamin C aids in non-heme iron
caclium inhibits both heme and non-heme
45
role of vitamin A
retinol/ retinoic acid
vision
- embryo devel; maintenance of epithelia; cell growth, prolif and diff
46
role of vitamin D
aka cholecalciferol; ergocalciferol
- bone metabolism
- calcium homeostasis
47
role of vitamin E
tocopherols
ROS scavenger (membrane antioxidant)
48
role of vitamin K
blood cotting factors ( II, VII, IX, X)
49
Role of B1
aka thiamine
- carb metabolism
- aa metabolism
50
role of B2
riboflavin
- oxidoreductase, FMN, FAD
51
Role of B3
niacin
- oxidoreductase, NAD, NADP
52
role of B6
pyridoxine
- carb, lipid, and aa metabolism
- synthesis of neurotransmitters, sphingolipids, and heme
53
role of B9
folic acid
- one-C-transfer rx
- choline synthesis of aa
- synthesis of purins and pyrimidine (thymine)
54
what is the role of B12
cobalamin
- heme structure, folate recycling
55
role of Vitamin C
ascorbic acid
- antioxidant fx
- collagen synthesis
- bile acid synthesis
- nt synthesis
56
role of calcium
muscle contraction, cell transport, bone metab
57
role of iron
hemoglobin, myoglobin and cytochromes a, b, and c
58
BMI ranges
obese \>30
over weight 25-29.9
healthy 18-25
59
how do you counsel pts about food choices?
follow healhty eating pattern
- focus on variety, nutrient density and amount
- limit calories from added sugars and saturated fats and reduce sodium intake
- shift to healthier food and beverage choices
60
vaccine
a product that stimulates a persons immune system to produce immunity to a specific disease, protecting the person from the disease
\*initiates the immunization process
61
vaccination
the process of getting a vaccine into the body or the act of introducing a vaccine into the body to produce immynity to a specific disease
- needle; nose
62
immunity
when a person is protected from getting a disease by virtue of receiving a vaccine or by previously having the disease in question
63
immunization
the process whereby a person is made immune or resistant to an infectious disease either by receiving a vaccine or by having the infectious disease. immunization describes the actual changes the body goes through after receving a vaccine
64
what is active immunization?
- antigen is administered to host to induce formation of antibodies and cell-mediated immunity
65
what are vaccines with sub-unit angtigens?
- includes the "parts" that best stimulate immune response
66
what type of vaccine are pathogens surrounded by a polysaccharide capsule and are immunogenic
conjugated vaccines
67
facts on live attenuated vaccines
aka version of microbe weakened in lab
- stronger mucosal immunity develops
- not if immunocompromised
- not if they have received blood products in recent past
68
examples of conjugate vaccines
meningococcal
pneumococcal
haemophilus flu type B
HepB
Flu
HPV
69
non-conjugate, inactivated or killed vaccines
HepA
Polio
rabies
70
live, attenuated vaccines
MMR
Varicella
rotavirus
influenza
zoster
71
toxoid vaccines
tetanus
diptheria
72
what are preventitive services?
screenings
immunizations
general health guidance
counseling to reduce risk
73
what is primary intervention and some examples
intervention to PREVENT disease
- vaccines, diet counseling, tobacco counseling
74
what is secondary intervention and examples
screening test for a disease early while pt may still be asymptomatic or before onset of diease
- BP checks
- Labs
- mammograms
75
what is tertiary prevention and examples
clinical intervention that prevent progression or disease or reduce complication (tx of pt condition)
- medications
- chemotherapy
76
when should people get check ups?
- every 3 yrs for people less than 49 yo
- every year for \>50 yo
77
when should men and women consider colonoscopies?
50-75 yo
78
screening for lung cancer, female and male
low dose lung CT for ages 55-74 yr w at least 30 pack years of smoking
79
pap smear age
21-65
80
breast cancer screen
50-65 but can start as early as 40yo
81
CVS risk assesment
screen for diet, smoking, physical activity, HTN, dyslipemia, DM, obesity
pts aged 20+ should get screened every 3-5 years
82
immunization age for Td/Tdap?
HPV?
Zozster vaccine
pneumococcal vaccine
hep b
every 10 years
up to age 26
50y and older
19-64 if at incr rate; all 65+
65+
83
steps of Type I immediate hypersensitivity
step 1: antigen exposure
step 2: IgE cross-linking on mast cell/ basophile surfaces
step 3: histamine, leukotriene, prostaglandin, tryptase (mediators) release
step 4: symptoms of urticaria, rhinitis, wheezing, diarrhea, vomiting, hypotension, anaphylaxis within min of exposure
\*may have sx return 4-8 hours after exposure
eg: pollen allergies, dust mite allergy, bee sting
84
how to treat type I
antihistamines
85
type II cytotoxic hypersensitivity
IgM or IgG ab destroys cells by:
- opsonization
- complement-mediated
- ab-dependent cell cytotoxicity
egs: ABO mismatch, grave's dz, myasthenia gravis
86
tx for type II
acetylcholinesterase inhibitors; plasmapheresis
87
steps to Type III
step 1) antigen-ab complex formation
step 2) complexes activate complement and neutrophil infiltration of tissue
3) tissue inflammation leading to sx of fever, urticaria, generalized lymphadenoapthy, arthritis, glomerulonephritis, vasculitis
**eg: SLE, RA, farmers lung**
88
tx for Type III
supportive, avoidance of antigen
89
type IV cell-mediated hypersensitivity
step1: antigen exposure activates sensitized T-cells
steps2: T-cell activation leads to tissue inflammation 48-96 hours after exposure to antigen
**eg: poison Ivy rash, PPD testing for TB**
90
HIV/AIDS presentation
flu-like sx: myalgias, fever, anorexia
91
HIV.AIDS diagnosis
ELISA
western blot
HIV RNA viral load
92
aids diagnosis
CD4 \< 200 cells/mm3
93
MS
presentation
diagnosis
tx
- demyelination disorder of CNS
vision changes, vertigo, Lhermitte's sign (flex neck + electricity)
MRI, CSF
immunosuppressive, IV steroids, PT
94
psoriasis diagnosis
ausptiz sign: pinpoint bleeding after removal of scale
95
RA
presentation
tx
- inflm. dz affecting synovial membranes
- jt swelling, warmth, red, and decr. ROM
- **morning stiffness \> 1 hr**
- PIP, MCP, wrist, knee ankle
tx: DMARDs, NSAIDs, steroids, PT
96
Stiffness difference between RA and osteoarthritis
RA: morning
Osteo: "evening" stiffness
97
what is the genetic component for SLE?
HLA-DR2 and -DR3
98
SLE presentation
- pleuritis, pericarditis, myocarditis
- oral aphthous ulcers
- arthritis
- photosensitivity
- hemolytic anemia
99
what makes up motivational interviewing?
- patient-centered
- goal directed
- non-confrontational
100
general techniques for motivational interviewing
OARS
open-ended Qs
affirmations
reflective listening
summaries
101
stages of change
precontemplation
contemplation
preparation
action
maintenance
102
describe precontemplation
pt is NOT considering change
- physicians goal: incr awareness of why they should consider change
\*\*establish rapprt, ask permision to talk about shit, build trust, offer facts, express concern
103
describe contemplation
- pt is considering possibliity of making change, but still uncertain
- physicians goal: acknowledge everyone is uncomfortable w change, weigh pros and cons, reinforce pts power in making choice
104
describe preparation
- pt is committed to making a change in the near future but still considering what to do
- ps goals: offer advice and expertise regarding tx options, consider barriers and brainstorm steps in overcoming them, discuss whats worked in the past, encourage pt to let friends know
105
describe action
- pt is actively making changes
- ps goals: acknowledge difficulties, identify high-risk situations, identify new reinforcers for positive change
106
describe maintenance
pt has made change
ps goals: affirmation and develop plan for any regression
107
