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610 Study Guide # Kidney
- Azotemia, BUN: Cr ratio ● Azotemia: A laboratory diagnosis of elevated BUN & Cr ● Uremia: Is azotemia associated with direct clinical manifestations of renal failure , such as: ○ Pericarditis ○ Increased tendency to bleeding (defective platelet function) ○ Increased liability to infections (defective WBC production) BUN:CR ratio ● Normally, 15: ● In renal failure, both BUN & Cr will increased because of the decreased GFR ● We use BUN:Cr ratio to differentiate between the 3 types of acute renal failure (pre-, intra-, and post-renal) making use of the fact that both urea and creatinine are filtered at the glomerulus but only urea gets reabsorbed, and only creatinine gets secreted at the renal tubules ○ “In the kidney, urea is filtered and reabsorbed.” ○ “In the kidney, creatinine is filtered and secreted, but NOT reabsorbed.” - The different types and causes of acute renal failure -Diagnosing the type of renal failure by: Blood tests (BUN, Cr & BUN:Cr ratio) and urine tests (urine osmolarity, specific gravity, and urine sodium and FENa) ● The most common indicator of acute renal failure is: ○ Azotemia (an accumulation of nitrogenous wastes in the blood) ○ A decrease in glomerular filtration rate (GFR) ○ Clues to the “acuteness”: Normal kidney size, hematocrit, and Ca++ ○ Major causes of acute renal failure (ARF): Prerenal, Renal, and Post-renal Pre-renal Mechanism: Low blood flow getting into the kidney (e.g., low perfusion) Causes:
- Heart failure
- Hypovolemia
- Constrictive pericarditis (liver cirrhosis)
- Renal artery stenosis Blood tests: Urine tests: Renal Mechanism: Problem with the nephron (e.g., glomerulus or tubules) Causes:
- Nephrotoxic medications (Aminoglycosides, Vancomycin)
- Acute tubular necrosis
- Contrast agents
- Cisplatin (chemotherapy)
- Allergic interstitial nephritis
Fever, rash, eosinophils in urine stain by Hansel’s stain), penicillin, sulfa, phenytoin, allopurinol, quinolones, rifampin
- Rhabdomyolysis (e.g., crush injury or recent use of statins > hyperkalemia!) Blood tests: Urine tests: Post-renal Mechanism: Urinary tract obstruction causing back pressure into the kidney Causes:
- Benign prostatic hyperplasia
- Cervical cancer
- Stones (bladder)
- Neurogenic bladder **Blood tests: Urine tests:
- CKD: associated manifestations and their pathophysiological causes. Earliest sign of CKD.** ● Progressive loss of kidney function associated with (pathophysiological causes) : ○ Systemic disease: Diabetes mellitus, Hypertension ○ Kidney disease: Chronic glomerulonephritis, Chronic pyelonephritis, Obstructive uropathies, or vascular disorders
● Clinical manifestations: ○ CKD is defined as GFR < 60 mL/min/1.73m^2 for 3 months or more, irrespective of the cause ○ Initially, no symptoms (only laboratory findings!) ■ Earliest sign: Microalbuminuria, early bone disease, BUN & Cr start to increase ○ Uremia ■ Lethargy ■ Pericarditis ■ Encephalitis ■ Bleeding diathesis ■ Recurrent infections ○ Fluid volume overload ○ Hyper: -kalemia, magnesemia, phosphatemia, and metabolic acidosis ○ Hypocalcemia ○ Osteodystrophy ○ Anemia: Lack of EPO Neurological Disorders
- Neurologic disorders: congenital, traumatic, vascular, infectious, degenerative Congenital ● Neural tube defects ○ Anencephaly ■ The soft, bony component of the skull and part of the brain are missing ■ Results in spontaneous abortion or early neonatal death ○ Spina bifida occulta ■ Failure of fusion of the posterior vertebral laminae. Symptoms due to tethering of spinal cord (gait abnormalities, foot deformities, and bladder sphincter disturbance) ○ Miningocele ■ A sac-like cyst of meninges filled with spinal fluid, protruding through the vertebral defect ○ Meningomyelocele (spina bifida cystica) ■ Hernial protrusion of a meningocele containing a portion of the spinal cord w/ its nerves (worst one!) ○ Encephalocele ■ Herniation of the brain and meninges through a defect in the skull ● Congenital hydrocephalus ○ Characterized by enlargement of the cerebral ventricles due to blockage of where CSF flows ○ Pushes and compresses the brain tissue against the skull cavity ○ If this develops before fusion of the cranial sutures, the skull can expand to accommodate this additional volume ● Cerebral palsy ○ A group of nonprogressive syndromes that affect the brain and cause motor dysfunction beginning in early infancy ○ Causes ■ Prenatal or perinatal cerebral hypoxia, hemorrhage, or infection ○ Types ■ Spastic (70-80%): Hyperactive deep tendon reflexes, clonus, rigidity ■ Dystonic (10-20%): Difficulty in fine motor coordination, stiff, abrupt movements due to basal ganglia injury ■ Ataxic (5-10%): Manifests with gait disturbance and instability Traumatic ● Closed (blunt)/open trauma ● Coup/Countercoup injury ● Focal brain injury ○ ⅔ of head injury deaths ○ Example: Extradural hematoma; Subdural hematoma ■ Extradural hematoma ● Majority: Aterial ● Lucid interval ■ Subdural hematoma ● Majority: Venous
- Neurotransmitters: role in various neurological and psychological disorders ● Neurotransmitters are released from the presynaptic neuron that interact with the receptors on the postsynaptic neuron of the following cell. ● They can cause an excitatory or inhibitory effect on the next neuron ○ Dopamine deficiency → Parkinsons ○ Deficiency of serotonin (5HT) and norepinephrine → Depression ○ Increased dopamine causes the positive symptoms of schizophrenia ○ Acetylcholine is involved with memory and cognition, deficiency of this in the limbic system can be a cause of Alzheimer's - Concussions and diffuse axonal injury / Intracranial hemorrhages: extradural, subdural, and subarachnoid “Worst HA of my life.” **- Meningitis: differentiation between it and subarachnoid hemorrhage
- Headache** Can be a symptom of an underlying disorder ● Tumor: Chronic, progressive, and neurologic symptoms ● Subarachnoid hemorrhage (SAH)/meningitis: Acute, fever, neck rigidity, +/- ALOC ● Temporal arteritis: Acute, tenderness along the temporal artery Can be disorder in its own right ● (common) Migraine headache A vascular mechanism is involved w/ migraine and cluster HA’s. ○ Adult female, 70-80% unilateral, throbbing pain in and around the eye, episodes (longer) ○ Photophobia & phonophobia, N/V ○ Aura (known as a classic migraine!) ● Cluster headache Vascular spasm in the meningeal vessels and attacks of vasodilation.
○ Male smoker, 100% unilateral, severe and intense pain like an ice-pick in one eye, episodes (short!) ○ Unilateral symptoms (nasal congestion, red eye, myosis) ● Tension headache (the most common type of headache!) >> typically bilateral GI disorders
- Abdominal pain/ Causes of chronic epigastric pain: GERD, peptic ulcer, gastritis, non-ulcer dyspepsia ● GERD - heartburn “metallic taste” “leaky weak esophageal sphincter” - tx: PPI ● Peptic ulcer - ulcer “worse when eating -Tx: ABX if caused by H.Pylori ● Gastritis - inflammation (“hot, red, tender, swollen” of the stomach lining -Tx: ABX if caused by H.Pylori ● Non-ulcer dyspepsia - epigastric pain/discomfort, dx after endoscopy (dx’d after ^ are excluded) - Tx: antacids, H2B, PPIs - IBD (UC/CD), IBS ● Inflammatory bowel disorder: blood in stools, weight loss, fever, abdomen pain, + diarrhea ○ Crohns: Anywhere in GI from mouth to anus, transmural skip lesions, “FISTULA & MASS” ■ Hypocalcemia, Cholesterol gallstones, Ca oxalate kidney stones, Vit b12 malabsorption ○ UC: Colon/rectum, mucosal layer (superficial layer), No fistula & mass ● Irritable bowel syndrome: pain disappears in sleep , abdomen pain, + diarrhea, - - Blood in stool weight loss & fever (predispose to cancer) *Diagnosis by endoscopy, barium study, and serologic tests. **- Intestinal Obstruction: volvulus/intussusception
- Diverticular disease of the colon
- Colon cancer: risk factors, clinical picture, screening** ● Risk Factors: ○ Polyps and FHX of polyps particularly familial adenomatous polyposis ○ low fiber diet ○ more meat consumption ○ lack of exercise ● Clinical Picture: ○ Right side (ascending colon, cecum) → Severe anemia ○ Left side (Descending colon) → Change in stool pattern, pencil shaped stools, bloody stools, unexplained weight loss ● Screening: ○ Colonoscopy (screening: 45+, q10y)
- Ascites: in liver cirrhosis Pediatric Pathophysiology -Congenital cardiac defects ● DiGeorge Syndrome ○ Congenital defects of the parathyroid glands, thymus, and heart ○ Clinical presentation ■ Increased susceptibility to infection (due to thymus aplasia) ■ Abnormal facies ● Lateral displacement of canthi ● Short palpebral fissures ● Micrognathia ● Ear anomalies ● Short philtrum ■ Congenital heart defects (aortic arch anomalies) ● Significant neonatal morbidity and mortality associated with cardiac defects ■ Hypoparathyroidism with hypocalcemia (seizures in infancy) ■ Cognitive or behavioral psychiatric problems ● Down Syndrome ○ Cardiac defects: Ventricular septal defect (VSD) ● Marfan Syndrome ○ Inherited connective tissue disorder affecting skeletal, cardiac, and ophthalmic body systems ○ Occurs in 1:20,000 live births (mostly males!) ○ Clinical presentation ■ Tall stature with arm span exceeding height ● Ask the patient to stand and extend their arms. If you notice that the arm span is more than the height, this is Marfan Syndrome. ■ Thin extremities and fingers ■ Long narrow face ■ Thoracic cage anomalies (pectus cranium or excavatum) ■ Hyperextension of joints ■ Kyphoscoliosis ■ High-arch narrow palate ■ Eye lesions (e.g., ectopia lentis; iridodonesis) ■ Cardiac defects/lesions: Aortic regurgitation, Mitral valve prolapse, Aortic aneurysm ● Turner Syndrome (XO Karyotype) ○ Most common sex-chromosome anomaly of females ○ Occurs in 1:2,000 live births (85% of embryos do not survive to term) ○ Clinical presentation ■ Lymphedema ■ Webbed neck ■ Low hairline ■ Learning disabilities ■ Lack of secondary sexual characteristics ■ “Shield”-shaped chest > widely-spaced nipples ■ Variety of head and neck anomalies ■ Hypertension ■ Cardiac defects: Bicuspid aortic valve, Coarctation of aorta -Acquired heart disease ● Rheumatic fever
○ A post-infectious inflammatory disease that affects the heart, joints, & CNS ○ It follows group A strep infection of the upper respiratory tract (mostly in 6-15 years of age) ○ The mitral valve is the most commonly affected cardiac structure by rheumatic fever. ○ Diagnosis ■ Upper respiratory infection (URI) with strep followed by fever in 2 weeks ■ Plus 2 major OR 1 major and 2 minor Jones’ criteria (see table below) ○ Lab diagnostics ■ Positive rapid strep assay, Positive throat culture ■ Increased or rising strep antibody titer ■ EKG and echocardiogram Major Criteria: ● Carditis ● Polyarthritis ● Chorea ● Erythema marginatum ● Subcutaneous nodules Minor Criteria: ● Arthralgia without inflammation ● Fever > 102.2 F (39 C) ● Elevated ESR ● Elevated C-reactive protein ● Prolonged PR interval on EKG ● Kawasaki disease ○ Acute febrile disease of unknown etiology causing vasculitis (inflammation of blood vessel lining!) ○ It is the leading cause of coronary artery disease (CAD) in children of an infectious etiology ○ Most commonly noted in children < 2 years of age, mostly in children of Asian ethnicity ○ Clinical picture ■ Patient must have a fever for > 5 days as well as at least 4 of the following criteria: ● Bilateral conjunctival injection without exudate ● Polymorphous rash (urticarial or pruritic) ● Inflammatory changes in oral cavity (strawberry tongue) ● Changes in extremities (erythema, edema) ● Cervical lymphadenopathy ● Elevated ESR and C-reactive protein (CRP) ● Prolonged PR and QT interval ○ Management ■ High dose aspirin therapy (80-100 mg/kg/day) until afebrile for 48 hours , then lower the dose gradually -GI disorders: Pyloric stenosis vs intussusception Pyloric stenosis ● Thickening of the circular muscle of the pylorus causing obstruction and delayed gastric emptying ● Breast feeding delays the presentation ● Clinical picture ○ Presentation is usually between 3 weeks to 4 months of age ○ Projectile nonbilious vomiting (not green in color!) , followed by feeling hungry ○ Failure to thrive and weight loss, eventually becomes dehydrated ○ Visible peristaltic waves ○ Palpable olive-shaped mass (more prominent after vomiting) at the epigastric/RUQ ● Labs/Diagnostics ○ Abdominal ultrasound ○ Upper GI imaging (if ultrasound diagnostic is not enough). It commonly shows “string sign”
narrowed pyloric channel Intussusception ● Acute intestinal obstruction due to telescoping of one part of the intestine into another adjacent segment of the intestine ● The cause is unknown, may be due to an adenovirus. An earlier version of rotavirus vaccine was linked to the condition but no longer used. ● Most causes occur before two years of age ● Clinical picture ○ A previously healthy young child develops acute colicky pain ○ Bilious vomiting (green!) and progressive lethargy ○ Sausage-shaped mass in RUQ ○ Progressive abdominal distention and tenderness ○ Currant jelly stool: LATE SIGN! ○ If not reduced, perforation and shock may occur ● Diagnostics ○ Radiograph or abdominal ultrasound ○ Barium enema
● Croup ○ Parainfluenza viral infection of the larynx that can be mild or severe ○ Clinical picture ■ Recent symptoms of URI with low-grade fever ■ Bark-like cough ■ Dyspnea ■ Stridor (if severe) ■ X-ray: A steeple-shaped narrowing of the trachea Epiglottis ● Bacterial infection ● Supraglottic pathology ● Common in 6 to 10 y/o age ● High fever, DROOLING ● X-ray: Thumb sign Croup ● Viral infection ● Laryngeal pathology ● 3 months to 6 y/o age ● Low fever, BARKING COUGH ● X-ray: Steeple sign MSK disorders: Osgood-Schlatter disease ● Inflammation of the tibial tubercle as a result of repetitive stressors (e.g., avulsion injury) in patients with immature skeletal development ● Peak age: 11 to 14 y/o (associated with rapid growth spurts) ● Point tenderness ● Swelling compared to the unaffected side ● Diagnostics ○ The diagnosis is made clinically ○ Radiographs help rule out more serious causes of pain ● This is a self-limiting condition ○ In lecture: “Reassure the parents that their child who is currently limping, symptoms will disappear with time.”
- Gastroenteritis (best sign to check for dehydration is urine output) TESTICULAR TORSION (USUALLY D/T TRAUMA, WHEN TESTICLES BECOME TWISTED). Narrows the blood vessels, severe pain, so severe that it leads to loss of cremasteric reflex. Skin Disorders -Skin Infections Onychomycosis ● Involves the nail plate. ● Thickening of the nail with yellowish or white discoloration distally d/t hyperkeratotic debris accumulation. ● You CANNOT just treat topically; you need to treat systemically. Hirsutism ● Causes ○ Idiopathic hirsutism ○ Polycystic ovary syndrome ● Happens to females only. Development of androgen-dependent terminal hair. Fungal skin infections ● Some are yeast-like, such as Candidiasis (prefers wet, hidden areas). ● Others are mold-like, causing Tinea. ○ If on the trunk, Tinea Corporis (ringworm). ○ Tinea Capitis (head, scalp) ○ Tinea Pedis (foot/athlete’s foot)
○ Tinea Cruris (groin) -Allergic skin disorders Contact dermatitis ● Acute or chronic allergic skin condition, inflammation at the site of contact with chemical allergens. ● Type IV (cell mediated, delayed reaction ). ○ Ex : Poison Ivy ● Redness, pruritus, vesicles. ● Sharp defined borders. ● Linear or shaped configuration. Eczema (atopic dermatitis) ● Chronic allergic skin condition to an allergen that is present around you (environmental). ● Usually seen on the flexor side of joints. ● Red, shiny, or thickened patches ● Inflamed/scabbed lesions with erythema/scaling (Psoriasis). ● Dry, leathery lichenification -Skin cancer Basal cell carcinoma (most common skin malignancy type) Diagnosis: biopsy Treatment: Skin removal Melanoma If you suspect melanoma, you need a deep skin biopsy QUIZ 9 : Obstructive Uropathy
- In BPH, the enlarged prostate compresses the urethra and may cause the following symptoms EXCEPT__. a. Increased urinary stream force
- In the pathophysiology of Acute Post-streptococcal Glomerulonephritis, which two antigen-antibody complexes become trapped in the glomerulus. a. IgG & C
- You’re providing an in-service to a group of nurses about the different types of kidney stones, You explain to the attendees that the most common type of kidney stone is made up of: a. Calcium and oxalate
- Acute poststreptococcal glomerulonephritis (APSGN) is most common in which population group? a. Male children
- Which of the following is a classical manifestation of urinary tract stones? a. Colic QUIZ 10 : Genitourinary Infections
- What is the type of bacteria that most often cause cystitis? a. Gram-negative facultative anaerobic bacteria
- What organism causes 80%-85% of UTIs? a. E. coli
- A predisposing factor to pyelonephritis is a. Pregnancy
- What is the gold standard for diagnosing Chlamydia? a. Nucleic acid amplification
- Urinary tract infections and sexually transmitted diseases (STDs) can present with similar manifestations. The major distinguishing factor between the two is: a. The presence of discharge in STDs QUIZ 11 : Neurologic (Cerebrovascular) Disorders
- Why is it important to determine the cause of stroke before treatment? a. tPA is the gold standard for treating ischemic stroke but will increase hemorrhaging if given to a patient with a hemorrhagic stroke
- What is the most common cause of hemorrhagic stroke? a. Uncontrolled hypertension
- What neuroimaging tool is used to differentiate between ischemic and hemorrhagic stroke? QUIZ 12 : Psychiatric Disorders
- Which of the following are positive symptoms of schizophrenia? a. Hallucinations and delusions
- Which neurotransmitter is abnormally increased in people with schizophrenia? a. Dopamine
- The Rorschach (inkblot) test is a diagnostic tool used for psychiatric disorders? a. Schizophrenia
- Which of the following psychiatric disorders etiology is 100% due to life events?
