Post-void residual volume

- Determined by bladder scan

- Interpreted in context of clinical scenario & status of patient
- No absolute value at which catheter must be inserted
- Many pts have long-standing urinary sx & incomplete emptying of bladder, leading to large
capacity bladder over time; these pts w/chronic urinary retention may still present as acute
urinary retention when they can no longer void
- Pt in discomfort who cant void w/any volume on bladder scan may need catheter
- Bladder scan can be inaccurate: body habitus, tissue edema, prior surgery & scarring
- If uncertain about dx of urinary retention, can place urethral catheter & vol of urine drained in
1
st
10-15 mins noted & recorded
o If vol > 400 cc, catheter is left in place
o If vol 200-400 cc, decision to leave catheter in place is guided by clinical scenario
o If vol < 200, catheter is removed
CKD
- Definition: either decreased kidney fn (GFR < 60) or kidney damage (structural or fnal
abnormalities) for at least 3 months
- Causes: DM (MC), HTN, chronic GN, interstitial nephritis, PCKD, obstructive uropathy, causes of
AKI if prolonged and/or if tx is delayed
- Pathophys
o Plasma Cr varies inversely w/GFR
o Cr clearance is MC clinical measure of GFR
o Increase in plasma Cr disease progression
o Decrease in plasma Cr recovery of renal fn
- More common in blacks than whites
- Clinical features
o CV
HTN: secondary to salt & water retention; decreased GFR stimulates RAAS &
aldosterone secretion to increase increase in BP
Renal failure is MCC of secondary HTN
CHF: due to volume overload, HTN, anemia
Pericarditis (uremic)
o GI (usually due to uremia): N/V, loss of appetite (anorexia)
o Neuro
Sx: lethargy, somnolence, confusion, peripheral neuropathy, uremic seizures
Signs: weakness, asterixis, hyperreflexia, restless legs (neuropathic pain in legs
only relieved w/movement), hypocalcemia (lethargy, confusion, tetany)
o Hematologic
Normocytic normochromic anemia: secondary to EPO def
Bleeding secondary to platelet dysfn (due to uremia): platelets do not
degranulate in uremic environment
o Endocrine/metabolic
Ca-PO4 disturbances: hypocalcemia, hyperphosphatemia
Decreased renal clearance of phosphate hyperphosphatemia
decreased renal production of 1,25-dihydroxy vitamin D
hypocalcemia secondary hyperparathyroidism renal
osteodystrophy weakening of bones & possibly fractures
Hypercalcemia can be seen due to long-standing secondary
hyperparathyroidism & Ca-based phosphate binders
Hyperphosphatemia Ca & PO4 precipitates vascular calcifications
that may result in necrotic skin lesions = calciphylaxis
Sexual/reproductive sx: due to hypothalamic-pit disturbances & gonadal
response to sex hormones (decreased testosterone in M; amenorrhea, infertility
& hyperprolactinemia in F)
Pruritus: multifactorial causes, common, hard to tx; dialysis & UV light
o Fluid & electrolyte problems
Volume overload: watch for pulm edema
Hyperkalemia: due to decreased urinary secretion
Hypermagnesemia: secondary to reduced urinary loss
Hyperphosphatemia: decreased renal clearance
Metabolic acidosis: due to loss of renal mass (and thus decreased ammonia
production) & kidneys inability to excrete H+
o Immunologic: uremia inhibits cellular & humoral immunity
- Dx
o UA, CBC (anemia, thrombocytopenia), serum electrolytes
o GFR
Stage 1: > 90
Stage 2: 60-90
Stage 3: 30-60
Stage 4: 15-30
Stage 5: < 15
o Renal US (evaluate size of kidneys, R/O obstruction)
Small kidneys suggestive of chronic renal insufficiency w/little chance of
recovery
Presence of normal-sized or large kidneys does not exclude CKD
Renal bx if needed to determine specific etiology
- Tx
o Diet
Low protein; low-salt if HTN, CHF or oliguria present
Restrict K, PO4, Mg intake
o ACEIs: dilate afferent arteriole of glomerulus
If used soon enough, reduce risk of progression to ESRD b/c they slow
progression of proteinuria
Can cause hyperkalemia
o BP control
Decreases rate of disease progression
ACEIs are preferred; diuretics may also be needed
o Glycemic control if pt is diabetic prevents worsening of proteinuria
o Smoking cessation
o Correction of electrolyte abnormalities
Correct hyperphosphatemia w/Ca citrate (phosphate binder)
Tx w/long-term oral Ca & vit D to prevent secondary hyperparathyroidism &
uremic osteodystrophy
Acidosis: tx underlying cause (renal failure); may require oral bicarb
replacement
o Anemia: tx w/EPO
o Pulm edema: arrange for dialysis if condition is unresponsive to diuresis
o Pruritus: try capsaicin cream or cholestyramine & UV light
o Dialysis
o Transplant is only cure
Herpes zoster (shingles)
- Due to reactivation of VZV (stays dormant in DRG & is reactivated in stress, infection or illness;
only in those who have had chickenpox before)
- In pts > 50 yo; if younger, suspect immunosuppressed state
- Contagious when open vesicles present & only for those whove never had chickenpox,
immunocompromised or newborns; not as contagious as chickenpox
- Severe pain (before rash) & rash in dermatomal distribution
- Rash is of grouped vesicles on erythematous base; if severe, low-grade fever & malaise
- MC sites are thorax & trigeminal distribution (esp ophthalmic division), also other CN, arms &
legs
- Not life-threatening even if dissemination occurs; more severe in immunocompromised
- Keep lesions clean & dry
- Analgesic for pain relief, if severe inject triamcinolone in lidocaine
- Antiviral agents (acyclovir) to reduce pain, decrease length of illness & reduce risk of post-
herpetic neuralgia; giving corticosteroids to reduce incidence of post-herpetic neuralgia is
controversial
- Live vaccine is effective in reducing # cases of shingles > 60 yo & reduces severity & duration of
post-herpetic neuralgia in pts who do end up w/shingles; give vacc to all pts > 60 yo who do not
have C/I
Transplant rejection
- Hyperacute
o W/in minutes
o Ab-mediated (type II): presence of preformed anti-donor Abs in transplant recipient
o Occludes graft vessels ischemia & necrosis
- Acute
o Weeks later
o Cell-mediated due to CTL & reacting against foreign MHCs
o Reversible w/immunouppressants (i.e. cyclosporine, muromonab-CD3)
o Vasculitis of graft vessels w/dense interstitial lymphocytic infiltrate
- Chronic
o Months to years later
o Class I MHC non-self is perceived by CTLs as class I MHC self presenting non-self Ag
o Irreversible
o T cell & Ab-mediated vascular damage (obliterative vascular fibrosis)
o Fibrosis of graft tissue & BVs
- GVHD
o Time varies
o Grafted immunocompetent T cells proliferate in irradiated immunocompromised
disease host & reject cells w/foreign proteins severe organ dysfn
o Maculopapular rash, jaundice, hepatosplenomegaly, diarrhea
o Usually in BM & liver transplant (organs rich in lymphocytes)
o Potentially beneficial in BM transplant
Malaria regimens
- Chloroquine phosphate unless resistant
- If chloroquine-resistant quinine sulfate & tetracycline OR atovaquone-proguanil &
meflaquine
- P. falciparum IV quinidine & doxycycline
- Relapses can occur in P. vivax & P. ovale infection due to dormant hypnozoites in liver add 2
week regimen of primaquine phosphate
- Prophylaxis: chloroquine or mefloquine in chloroquine-resistant areas
Travelers diarrhea
Primaquine & G6PD
Acne vulgaris
- Inflamm condition of skin most prevalent during adolescence
- Severe acne more common in M due to more circulating androgens
- Pathogenesis
o Obstruction of sebaceous follicles by sebum proliferation of P. acnes in sebum
non-inflamm comedones or inflamm papules or pustules
o RFs: M, puberty, Cushings syndrome, oily complexion, androgens, meds
- Obstructive type: closed comedones (whiteheads) or open comedones (blackheads)
- Inflammatory type: lesions progress from papules/pustules to nodules to cysts to scars
- Tx
o Mild to moderate acne
Start w/topical benzoyl peroxide
Add topical retinoids if benzoyl peroxide fails
Add topical erythromycin or topical clindamycin
o Moderate to severe nodular pustular acne
Systemic abx: tetracycline, minocycline, doxycycline, erythromycin, clindamycin,
TMP-SMX
Add oral retinoids (isoretinoin) for severe recalcitrant nodular acne not
response to systemic abx
Extremely teratogenic so all F must have 2 neg pregnancy tests before
starting
F pts should also use 2 forms of birth control for 1 month prior to
starting med through 1 month after stopping med
Indication for surgery in mucormycosis: as soon as dx is suspected
HIV vs AIDS infections
Guillain-Barre syndrome
- Inflamm demyelinating polyneuropathy that affects motor nerves
- Preceded by viral or mycoplasmal infection of upper resp or GIT (Campylobacter, CMV, hepatitis,
HIV)
- Can also occur in Hodgkins disease, lupus, after surgery or after HIV seroconversion
- Abrupt onset w/rapidly ascending weakness/paralysis of all 4 extremities; progresses to involve
respiratory, facial & bulbar mm
- Usually symmetric
- Weakness can be mild or severe, progresses from distal to central mm
- Extremities may be painful but sensory loss is NOT typical
- Sphincter control & mentation spared
- Autonomic features (arrhythmias, tachycardia, postural hypotension) dangerous complications
- Dx by CSF analysis (elevated protein, normal cell count) & electrodx studies (decreased motor
nerve conduction velocity)
- Carefully monitor pulm fn; mech vent may be necessary
- Administer IVIG if pt has significant weakness; if progression continues, plasmapheresis may
reduce severity of disease
- Do NOT give steroids; usually harmful & never helpful in GBS
Albumin-cytologic dissociation
CLL
- MC leukemia after age 50
- Monoclonal proliferation of lymphocytes that are morphologically mature but functionally
defective (do not differentiate into Ab-manufacturing plasma cells)
- Least aggressive type of leukemia; these patients survive longer than those w/acute leukemias
or CML
- Course is variable: may follow prolonged indolent course; many patients die of other causes
- Same as indolent NHL B-cell neoplasm small lymphocytic leukemia; considered same disease at
different stages
- Asx at time of dx, discovered on routine CBC (lymphocytosis)
- Generalized painless lymphadenopathy, spenomegaly
- Frequent respiratory or skin infections due to immune deficiency
- More advanced: fatigue, weight loss, pallor, skin rashes, easy bruising, bone tenderness, abd
pain
- Dx
o CBC: WBC 50,000-200,000
o Anemia, thrombocytopenia, neutropenia
o PBS: absolute lymphocytosis (almost all WBCs are mature, small lymphocytes), smudge
cells (fragile leukemic cells that are broken when placed on glass slide)
o Flow cytometry shows clonal population of B cells
o BM bx: presence of infiltrating leukemic cells in BM
- Tx
o Chemo has little effect on overall survival but is given for sx relief & reduction of
infection; pts observed until sx develop
o Px is variable depending on # LN sites involved & presence/absence of
anemia/thrombocytopenia
Alport dx & tx
Trigeminal neuralgia DOC
Diabetes & pre-diabetes dx
Diabetes meds
Metabolic syndrome
Ekgs: pericarditis vs anteroseptal vs lateral vs inferior MI
Pericarditis ddx
Constrictive pericarditis
Pericardial tamponade
Kayexelate, how to tx hyperkalemia
Jnc
Young pts which bp meds first
Hearing loss
Pericardial effusion
Syphilis, rpr or vdrl +, stages
PCI
How to tx acute STEMI
What thrombolytic therapy if cant do cath
Pancreatic pseudocyst vs abscess
PFT values in OLD & RLD
Cervical spine involvement in RA
Sleep apnea & GH in kids
Disseminated gonococcal infection
Blood cultures need to specify media