Maria Leik Flashcard Set (AGNP) Questions & Answers

Maria Leik Flashcard Set (AGNP) Questions & Answers Acute Renal Failure Symptoms Oliguria, edema, weight gain, lethargy, nausea, loss of appetite Are serum creatinine and eGFR accurate in acute renal failure? Not necessarily Which hormones are secreted by the kidneys and what are their functions ? Erythropoeitin (RBC production), renin & bradykinin (b/p), prostaglandins (renal perfusion), calcitriol/vitamin D3 (bones) Which hormones reabsorb water back into body? ADH and aldosterone What are some waste products of the kidneys? Water-soluble products (creatinine, urea, uric acid) What is the average daily urine output? 1500mL What is oliguria? 400mL daily Serum creatinine definition & levels Male 0.7-1.3mg/dL, Female 0.6-1.1mg/dL Product of creatine metabolism, primarily from muscle so falsely decreased in people with low muscle volume (elderly) What raises serum creatinine? -A decrease in renal function such as renal failure or damage, nephrotoxic drugs Which individuals may have higher serum creatinine levels without renal disease? Individuals males and individuals with more muscle mass such as African Americans What is creatinine clearance (24-hr urine) used for? Detect proteinuria, albuminuria and microalbuminuria What is the relative relationship of creatinine clearance (24 hr urine) to GFR? Creatinine clearance is doubled for every 50% reduction in GFR Is 24 hour urine (creatinine clearance) better than serum creatinine? Yes, more sensitive because reflects 24hr period so relatively constant and not affected by fluid status, diet or exercise eGFR definition Amount of fluid filtered by glomerulus within a certain unit of time, used to evaluate renal function Which test is used to stage chronic kidney disease? eGFR, normal 90mL/min, stage 5 (renal failure 15mL/min) eGFR less reliable in which people? -drastic increase/reduction in muscle mass (bodybuilders, amputees, wasting disorders), pregnancy, acute renal failure -if ate meat within 12 hours of blood test Blood Urea Nitrogen (BUN) definition Not as sensitive as serum creatinine or GFR. Measure of kidney's ability to excrete urea (waste product of protein metabolism) If BUN abnormal what should you do? Check GFR, if normal likely that renal function is normal. Renal failure, high-protein diet, CHF and drugs are other causes of elevated BUN What is BUN-to-creatinine ratio used for? Evaluates dehydration, hypovolemia and acute renal failure. Also used to classify type of renal failure (renal, infrarenal, postrenal) What do epithelial cells in urinalysis mean? Large number- contaminated sample Small number- normal Normal number of leukocytes (leukocyte esterase) present on urinalysis? Less than or equal to 10/mL; presence of leukocytes in urine (pyuria) in males is always abnormal RBCs on urinalysis Less than 5 cells is normal, elevated with kidney stones, pyelonephritis and cystitis. May be contaminated by hemorrhoids or menses. Protein on urinalysis Indicates either pyelonephritis (resolves after treatment) or kidney disease. NOTE: only picks up albumin not microalbumin (Bence-Jones proteins); order 24 hr urine for protein & creatinine clearance Nitrites on urinalysis Formed by certain types of bacteria that break nitrates into nitrites; primarily E. coli Interpretation of Urine for Culture and Sensitivity Greater than or equal to 10^5 (100,000) CFU/mL of a single bacteria. If multiple bacteria than contaminated sample. Lower values indicate bacteriuria. What are casts shaped like on urinalysis? Shaped like cylinders because formed in renal tubules Hyaline casts indicate? Normal, may be seen in concentrated urine WBC casts indicate? Infection (UTI or pyelonephritis) RBC casts indicate? Proteinuria and are diagnostic for glomerulonephritis Urinalysis is more sensitive in males or females? Males Most common bacteria causing UTIs? E.coli, then Staphylococcus saprophyticus, P. mirabilis, and K. pnueumoniae Treatment for uncomplicated UTI (age 18)? Bactrim or Septra (TMP/SMX) x 3 days Sulfa allergic: Nitrofurantoin or Augmentin x 3 days If symptoms persist 48-72 hrs after initiating tmt for UTI what should you do? -urinalysis, culture and sensitivity -rule out pyelonephritis -switch to ciprofloxacin or orofloxacin for 7-10 days Phenazopyridine (Pyridium) use known as OTC AZO or Uristat Give in conjuction with abx for UTI, will stain contact lenses and turn urine orange. Avoid pyridium in whom? Individuals with liver/renal disease and G6PD anemia What are complicated UTIs? Males, diabetics, pregnant women, children/elderly, immunocompromised, recurrent UTIs, anatomic renal anomalies Treatment for complicated UTIs? Treat 7 days or longer, urinalysis & urine C/S before and after treatment UTI in males Refer to urologist When do you consider urology in females? After 3 or more UTIs in 1 year or 2 infections in six months Contraindications for nitrofurantoin use? Renal insufficiency Prophylactic abx for UTI recommendations? Typically Bactrim if sulfa allergic Cephalosporin as Nitrofurantoin causes lung problems, chronic hepatitis and neuropathy if used long term Normal WBCs Less than or equal to 10 or 10.5 Normal neutrophils 50-75% of sample What do elevated neutrophils indicate? Serious infection, typically (80% of sample) What does a shift to the left mean? Presence of bands Immature WBCs) or stabs (immature neutrophils) indicates serious infection Can acute pyelonephritis be treated outpatient? Uncomplicated only: immunocompetent adult female without comorbidity/abnormality and compliant Outpatient treatment for Pyelonephritis? Ceftriaxone (Rocephin) IM then Cipro, Levaquin or Bactrim x 14 days -follow up closely in 12-24 hours Which kidney is lower in the abdominal cavity? Right kidney is lower due to displacement by liver Most common type of kidney stone? Calcium oxalate Risk Factors for nephrolithiasis? -family hx, low fluid intake, gout -bariatric surgery (excrete higher levels of oxalate) Labs/Diagnostics for Nephrolithiasis -Renal ultrasound to determine location/size -Urinalysis until episode resolves -Strain urine & then analyze stone after passed Diet modifications for nephrolithiasis -increase fluids to 2L/day -Avoid high oxalate foods like rhubarb, spinach, beets, chocolate, tea, meats When to refer to urology with nephrolithiasis? large stone, unable to pass, acute renal failure When to refer to ER with nephrolithiasis? high fever (possible urosepsis), extreme pain, acute renal failure Rocky Mountain Spotted Fever The classic RASH looks like SMALL RED SPOTS (PETICHIAE) and starts to erupt on both the HANDS and FEET (including the PALMS and SOLES), rapidly progressing toward the TRUNK until it becomes GENERALIZED. The rashes appear on the THIRD 3RD day after the ABRUBT onset of HIGH FEVER (103 to 105 degrees) accompanied by a severe headache, MYALGIA, conjunctival injection (red eyes), nausea/vomiting, and arthralgia. Rocky Mountain spotted fever (RMSF) can be fatal, with a mortality rate ranging from 3% to 9%. In the United States, the highest incidence is in southeastern/south central areas of the country. Most cases of RMSF occur during the SPRING and EARLY SUMMER season. Rocky Mountain Spotted Fever TREATMENT DOXYcycline BID OR TETRAcycline QID (4 times daily) × "21" DAYS. REFER STAT. Actinic Keratosis OLDER to elderly FAIR-skinned adults complain of NUMEROUS DRY, round, and RED-colored lesions with a ROUGH texture that DO NO HEAL. Lesions are SLOW growing. Most common locations are SUN-EXPOSED AREAS such as the cheeks, nose, face, neck, arms, and back. The risk is highest for those with LIGHT-colored skin, hair, and/or eyes. In some cases, a precancerous lesion of SQUAMOUS CELL CARCINOMA is a possibility. Patients with early childhood history of severe SUNburns are at higher risk for squamous cell, basal cell carcinoma, and melanoma. Meningococcemia Symptoms include SUDDEN onset of SORE THROAT, cough, FEVER, HA , STIFF NECK PHOTOPHOBIA, and changes in LOC (drowsiness, lethargy to coma). The appearance could be toxic. In some cases, there is ABRUBT onset of PETECHIAL to HEMORRHAGIC RASHES (PINK to PURPLE colored) in the axillae, flanks, wrist, and ankles (50% to 80% of cases). RAPID progression in fulminant cases results in DEATH within "48" HOURS. The risk is higher for COLLEGE students residing in DORMITORIES (the CDC recommends vaccination for this higher-risk group). It is spread by AEROSOL DROPLETS. RIFAMPIN PROPHYLAXIS is recommended for close contacts. Meningococcemia Treatment ■ Ceftriaxone (ROCEPHIN) 2 g IV every "12" HOURS PLUS VANCOmycin IV every "8-12" HOURS ■ Hospital; isolation precautions; supportive treatment Erythema Migrans (Early Lyme Disease) The classic lesion is an EXPANDING RED RASH with CENTRAL CLEARING that resembles a TARGET. The "BULLS-EYE" RASH usually appears WITHIN "7 to 14" DAYS after a DEER TICK bite (range between "3 to 30" DAYS). The rash feels HOT to the touch and has a ROUGH texture. Common locations are the BELT line, AXILLARY area, BEHIND the knees, and in the GROIN area. It is accompanied by FLU-like symptoms. The lesion SPONTANEOUSLY RESOLVES within a FEW WEEKS. It is most common in the northeastern regions of the United States. Use of DEET containing REPELLENT on clothes and skin can repel DEER TICKS. Erythema Migrans (Early Lyme Disease): TREATMENT ■ EARLY Lyme ONLY: DOXYcycline BID (twice daily) OR TETRAcycline × 14 days (AMOXIcillin if PREGNANT). SHINGLES Infection of the TRIGIMINAL Nerve (Herpes Zoster Ophthalmicus) A sight-threatening condition caused by REACTIVATION of the HERPES ZOSTER virus that is located on the OPTHALMIC branch of the TRIGIMINAL nerve (CN 5). Patient reports SUDDEN eruption of MULTIPLE VESICULAR lesions (ruptures into SHALLOW ULCERS with CRUSTS) that are located on ONE SIDE on the SCALP, FOREhead, and the sides and the tip of the nose. If herpetic rash is seen on the TIP of the NOSE, assume it is shingles until proven otherwise. The EYELID on the same side is swollen and red. The patient complains of PHOTOphobia, eye PAIN, and BLURRED vision. This is more COMMON in ELDERLY patients. Known as *OPHTHALMICUS! REFER to an OPTHALmologist or the ED as soon as possible. Bulla Elevated superficial BLISTER filled with serous fluid and "1 CM" in size. Example: Impetigo, second-degree burn with blisters, SJS lesions Vesicle Elevated superficial skin lesion "1 CM" in diameter and filled with serous fluid Example: Herpetic lesions Pustule Elevated superficial skin lesion "1 CM" in diameter filled with PURULENT fluid Example: Acne pustules Macule FLAT NONpalpable lesion "1 CM" diameter Example: Freckles, lentigenes, small cherry angiomas Papule PALPABLE SOLID lesion up to "0.5 CM" Example: Nevi (moles), acne Plaque FLATTENED ELEVATED lesions with VARIABLE shape that is "1 CM" in diameter Example: PSORIATIC lesions Seborrheic Keratoses Soft and ROUND WART-like FLESHY growths in the trunk that are located mostly on the BACK Lesions on the same person can range in color from light tan to black. It is ASYMPTOMATIC. Xanthelasma Raised and YELLOW-colored soft PLAQUES that are located UNDER the BROW or upper and/ or LOWER LIDS of the EYES on the nasal side. It may be a SIGN of HYPERLIPIDEMIA if present in persons YOUNGER than "40" YEARS of age. Melasma (Mask of PREGNANCY) BROWN to TAN-colored STAINS located on the upper CHEEKS and FOREhead in some women who have been or are PREGNANT or on oral contraceptive pills OCP (estrogen). It is more COMMON in DARKER-skinned women. STAINS are usually PERMANENT but can LIGHTEN over time. Cherry Angioma BENIGN SMALL and smooth ROUND PAPULES that are a BRIGHT CHERRY-RED color. The sizes range from "1 to 4" MM. Lesions are due to a NEST of MALFORMED ARTERIOLES. It is ASYMPTOMATIC. Lipoma Soft FATTY CYSTIC TUMORS located in the SUBCUTANEOUS layer of the skin. These could be of round or oval shape. These tumors can be large and are located mostly on the neck, trunk, legs, and arms. They are PAINLESS unless they become too large or are irritated or ruptured. Nevi (Moles) Round MACULES to PAPULES (junctional NEVI) in colors ranging from light tan to dark brown. Their borders may be DISTINCT or slightly IRREGULAR. Acanthosis Nigricans DIFFUSE VELVETY THICKENING of the skin that is usually located behind the neck and on the axilla. It is associated with DIABETES, METABOLIC syndrome, OBESITY, and cancer of the gastrointestinal (GI) tract. Xerosis INHERITED skin disorder that results in extremely DRY skin and may involve mucosal surfaces such as the mouth (xerostomia) or the conjunctiva of the eye (xerophthalmia). Vitiligo HYPOPIGMENTED PATCHES of skin with IRREGULAR shapes. It is PROGRESSIVE and can involve large areas. It can be located ANYWHERE on the body and is more VISIBLE on DARKER skin. TOPICAL STEROIDS ■ AVOID STEROIDS in case of suspected FUNGAL etiology because it will WORSEN the INFECTION. ■ Infants, children, and adults with THIN FACIAL skin: - DO NOT use FLUORINATED topical steroids. USE 0.5% to 1% HYDROCORTISONE. ■ TOPICAL steroids: HPA (hypothalamus-pituitary-adrenal) AXIS SUPPRESSION may occur with excessive or prolonged use. It can cause Striae, Skin Atrophy, Telangiectasia, Acne, and HYPOpigmentation. ■ CHRONIC STEROIDS can cause CATARACTS Melanoma DARK-colored MOLES with UNEVEN TEXTURE, VARIEGATED COLORS, and IRREGULAR BORDERS with a DIAMETER of "6" MM or larger are observed. They may be PRURITIC. If melanoma is in the nailbeds (fungal melanoma), it may be very AGGRESSIVE. Lesions can be located ANYWHERE on the body including the RETINA. Risk factors include FAMILY HISTORY of melanoma (10% of cases), extensive/intense SUNLIGHT EXPOSURE, blistering SUNBURN in childhood, TANNING beds, high nevus count/atypical nevus, and light skin/eyes. Screening for Melanoma The "A, B, C, D, E" of MELANOMA: A (ASYMMETRY) B (BORDER irregular) C (COLOR VARIES in the same region) D (DIAMETER "6" MM) E (ENLARGEMENT or change in size) Other symptoms to watch for include INTERMITTENT BLEEDING with MILD TRAUMA and itching. Vitamin D Synthesis People with DARKER skin require LONGER periods of sun EXPOSURE to produce vitamin D. A deficiency in PREGNANCY results in INFANTILE RICKETS (BRITTLE BONES, skeletal ABNORMALITIES). Basal Cell Carcinoma (BCC) SUPERFICIAL form (30%) of BCC looks like a PEARLY or WAXY skin lesion with an ATROPHIC or ULCERATED center that DOES NOT HEAL. The color could be white, light pink, brown, or flesh colored. It may BLEED EASILY with MILD TRAUMA. This is MORE COMMON in FAIR-skinned individuals with long-term DAILY SUN exposure. An important RISK factor is SEVERE SUNBURNS as a CHILD. Central Depression, Volcano like lesion. *MOST COMMON SKIN CANCER! ACRAL LENTIGINOUS Melanoma This is the most common type of MELANOMA in AFRICAN AMERICANSs and ASIANS, and is a SUBTYPE of melanoma (5%). These dark brown to black lesions are located on the NAILBEDs (SUBUNGAL), palmar, and plantar surfaces, and rarely the mucous membranes. Subungual melanomas look like longitudinal brown to black bands on the nailbed. Subungual Hematomaterm-38 DIRECT trauma to the NAILbed results in PAIN and BLEEDING that is trapped BETWEEN the nailbed and the finger/toenail. If the HEMATOMA involves "25%" of the area of the nail, there is a high risk of PERMANENT ISCHEMIC DAMAGE to the nail matrix if the blood is NOT DRAINED. One method of draining (TREPHINATION) a subungual hematoma is to straighten one end of a steel paperclip or to use an 18-gauge NEEDLE and HEAT it with a flame until it is very hot. The hot end is pushed down gently until a 3 to 4 mm hole is burned on the nail. The nail is pressed down gently until most or all of the blood is drained or suctioned with a smaller needle. Blood may continue DRAINING for "24 to 36" HOURs. Psoriasis An INHERITED skin disorder in which SQUAMOUS epithelial cells undergo RAPID MITOTIC division and ABNORMAL maturation. The rapid TURNOVER of skin produces the classic PSORIATIC PLAQUE. Classic Case The patients complains of PRURITIC ERYTHEMATOUS PLAQUES covered with fine SILVERY WHITE SCALES along with PITTED FINGERnails and TOEnails. The plaques are distributed in the scalp, elbows, knees, sacrum, and the intergluteal folds. PARTIALLY RESOLVING PLAQUES are PINK colored with minimal scaling. Patients with PSORIATIC ARTHRITIS will complain of PAINFUL RED, WARM, and SWOLLEN JOINTS (MIGRATORY arthritis) in addition to the skin plaques. Psoriasis: Special Findings KOEBNER phenomenon ■ KOEBNER phenomenon: NEW PSORIATIC PLAQUE form OVER areas of SKIN TRAUMA. Psoriasis: Special Findings AUSPITZ sign ■ AUSPITZ sign: PINPOINT areas of BLEEDING REMAIN in the skin when a PLAQUE s REMOVED. Psoriasis Treatment ■ Topical STEROIDS ■ Topical RETINOIDS (TAZOROTENE) ■ TAR preparations (PSORALEN drug class). Psoriasis: Complications ■ GUTTATE psoriasis (DROP-SHAPED lesions): SEVERE form of psoriasis resulting from a BETA-HEMOLYTIC STREPTOCOCCUS Group A infection (usually due to STREP throat). Black Box Warning BLACK BOX Warning (Topical TACROLIMUS) ■ RARE cases of MALIGNANCY (including skin and lymphoma). Use SUNblock. AVOID if patient is IMMUNOCOMPROMISED. - SEVERE disease: ANTIMETABOLITES (i.e., METHOTREXATE), BIOLOGICS/ANTI-TUMOR NECROSIS FACTOR (TNF) agents BLACK BOX Warning (BIOLOGICS/ANTI-TNF agents) ■ HUMIRA, ENBREL, and REMICADE are associated with HIGHER risk of serious/fatal INFECTIONS, malignancy, TB, fungal infections, SEPSIS, etc. (BASELINE PPD, CBC with differential). ■ GOECKERMAN regimen (UVB light and TAR-derived topicals) may induce REMISSION in SEVERE cases. ... Medications Topical steroids, topical retinoids (tazorotene), tar preparations (psoralen drug class). Actinic Keratoses PRECANCEROUS precursors to SQUAMOUS CELL carcinoma. Classic Case Older to elderly adult complains of numerous DRY ROUND and red-colored lesions with a ROUGH texture that DO NOT HEAL; lesions SLOW growing; most common locations are SUN EXPOSED areas such as the cheeks, nose, face, neck, arms, and back; highest risk if LIGHT-colored skin, hair, and/or eyes; a PRECANCEROUS lesion of SQUAMOUS CELL carcinoma. Early childhood history of frequent SUNBURNS places person at higher risk. Actinic Keratoses: Treatment If there are only a SMALL number of lesions, they can be treated with CRYOTHERAPY. With LARGE numbers, FLUOROROURACIL cream 5% (5-FU cream), a TOPICAL ANTINEOPLASTIC agent, is used over SEVERAL WEEKS. Tinea Versicolor A superficial skin infection caused by YEASTS PITYROSPORUM ORBICULAR or PITYROSPORUM OVALE. Classic Case Complains of MULTIPLE HYPOPIGMENTED round MACULES on the chest, shoulders, and/or back that "appear" AFTER skin becomes tan from SUN exposure; ASYMPTOMATIC. Tinea Versicolor: Labs Potassium hydroxide (KOH) slide: hyphae and spores ("spaghetti and meatballs"). Tinea Versicolor: Medications Topical selenium sulfide OR ketoconazole (Nizoral) shampoo or cream BID × 2 weeks. Oral antifungals have also been used. Atopic Dermatitis (Eczema) A chronic inherited skin disorder marked by extremely PRURITIC rashes that are located on the hands, flexural folds, and neck (older child to adult). The rashes are exacerbated by stress and environmental factors (i.e., winter). The disorder is associated with atopic disorders such as asthma, allergic rhinitis, and multiple allergies (family history). Classic Case Infants up to age 2 years have a larger area of rash distribution compared to teens and adults. The rashes are typically found on the cheeks, entire trunk, knees, and elbows. Older children and adults have rashes on the hands, neck, and antecubital and popliteal space (flexural folds). The classic rash starts as multiple small VESICLES that RUPTURE, leaving PAINFUL, bright RED, WEEPY lesions. The lesions become LICHENIFIED from chronic itching and can persist for months. FISSUREs form that can be secondarily infected with bacteria. Atopic Dermatitis (Eczema) Treatment ■ Topical steroids are FIRST-line treatment. - MILD: HYDROcortisone 1% to 2.5%. - MEDIUM: TRIAMcinolone (KENAlog. ■ Medium to HIGH potency (HAlog) use × "10" DAYS and TAPER to WEAKER steroids, then STOP. ■ Systemic oral ANTIhistamines for PRURITIS (Benadryl, hydroxyzine). ■ Skin lubricants (Eucerin, Keri Lotion, baby oil). AVOID drying skin/XEROSIS since it will exacerbate eczema (i.e., no hot baths, harsh soaps, chemicals, wool clothing). ■ Hydrating baths (avoid hot water/soaps) followed immediately by application of skin lubricants (Eucerin, Keri Lotion, Crisco). Do not wait until skin is dry before applying.