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level: Level 1

Questions and Answers List

level questions: Level 1

QuestionAnswer
Normal: < 120/80, Stage 1: < 120-140/ 80-90 Stage 2: > 140/90 Rx: > 130/80. HTN Urgency: > 180/110 Asymptomatic HTN Emergency > 180/110 SymptomaticStages of HTN, threshold for treatment
< 149/90 Most pts, ASCD < 10% < 130/80 CVD, CKD, DM or ASCD > 10% < 150/90 if over 60HTN Goals
None: Thiazide, ACE/ARB, CCB AA: Thiazide, CCB CKD: ACE/ARB CVD: BB, CCB CHF: BB, ACE/ARB, Thiazide/Loop Nephrotic proteinuria: < 125/75 Post stroke : CCB ISH/elderly: CCB, PVD: CCBTreatment based of comorbidities
BP > 20/10 above goal, > 160/100 Usually ACE/CCB comboWhen do you start with two medications?
Poor control despite 3 meds ( can try spironolactone 25 m/d) Suspect secondary causes.When do you refer out for HTN?
Resistant HTN Young Spontaneous low KSecondary HTN , when to work up?
Metabolic Syndrome, renovascular ( FMD and AS), polycystic kidney, renal disease, OSA, Pheo, Cushing, hyperthyroid, hyperaldosterone, Scleroderma,What are the secondary causes of HTN?
Renal MRA or angiography- String of beads Presents in young pt, with HTN urgency or Resistant HTN May have unilateral abdominal bruit.How do you dx Fibromuscular dysplasia?
NSAIDS, OCP, Etoh, sympathomimetics, steroids, cocaine, MJ, SSRI, erythopoietin.Which drugs can elevate BP?
Check for end organ damage: Eyes, Heart and kidney Chem 7, Ca, Lipid, UA and EKGWhat is the evaluation for HTN?
Don't work with Crcl < 20, Use loop dosed bid Supplement K when < 3.5 or if on Dig or DM, CAD Avoid: Gout, hyperlipidemia, orthostatic, Lithium, Sulfa allergy Lytes: Increase Ca, glucose, uric acid, lower Mg and K.Thiazide Diuretics in renal disease, what to look for ?
Pregnancy contraindicated Caution with smokers/ AA, hyperkalemia, Bilaeral renal a. obstructions, CHF or low renin state, DM: OK for Cr to increase up to 35%. Cough : Switch to ARBACE/ARB caution/contraindication
Asthma or RAD, Severe PVD, Cocaine: may precipitate MIBB for HTN: When to use caution?
Goal DBP < 105 in 2-6 hours. or < 25% of original BP Can use oral if asymptomatic. Rx: Loop diuretics, BB, CAB or alpha 2 antagonist Avoid Nifedipine.How do you treat a HTN crisis?
Renal US, PRA ( stimulated Plasma renin Acitvity) and plasma aldosterone. See low renin, low K in Hyperaldosteronism. 5% of all resistant HTN.How do you screen for secondary HTN?
Adrenal adenoma Dx with CTCause of hyperaldosterone?
24 urine for metanephrine, VMA and catecholamine. If positive do a CT of adrenals.How do you screen for Pheo?
W/U if present 3x UA and cx. and renal function Repeat UA 6 wk, if positive referralMicroscopic hematuria W/U
Age > 35, analgesic abuse, exposure to chemicals, smoking, chronic UTI or irritating voiding sx, irradiation. W/U will need CT urography and cystoscopy.Risk factors for urologic malignancy
Prerenal: Volume depletion, Decrease CO, peripheral vasodilataiton, meds: ACE, NSAID, Renal vasoconstriction: Contrast. Post renal: Obstruction usually prostate or stone Intrarenal ATN, vascular, Drugs causing interstitial nephritis.Acute renal failure Causes:
High BUN/ Cr ratio FENA: < 1%Prerenal w/u:
Renal usPost renal w/u
FENA > 1% UA ; Large muddy granular cast Referral outIntrarenal ATN w/u
AMG, NSAIDS, ACE/ARB, Amphotericin, Cisplatin, Contrast, PPI, Tenofovir (Prep)Which meds are associated with ATN?
GFR < 60 / 3 moDefinition of CKD
Stage 1: GFR >90 Stage 2: GFR 60-80 Stage 3a GFR 45-60 Stage 3b GFR 30-45 Stage 4 GFR 15-30 Stage 5 GFT < 15 DialysisWhat are the stages of CKD?
Stop offending meds : NSAIDS, AMG, B lactam, TMP Treat UTI, HTN, hpercacemia, hyperphosphatemia Referr to nephrology whten GFR < 30 or rapid decline in kidney functionWork up of CKD
Phosphate binders to keep Ca x P < 55 Use Ca carbonate, Sevelaamer ( Renagel)How do you treat hyperparathyroid in CKD?
Labs: CMP, Lipids, A1c, microalbumin and UA, PTH, Vit D Renal US Hep B,C, HIV SPEP and UPEP rot r/o MM or light chain disease C3 and C4 to r/o Lupus,W/U of CKD
ACE/ARB, CCB, STATINS, BP control, smoking cessation, decrease protein, treat malnutrition, treat metabolic acidosis with bicarb, control osteodystrophy with Vit D, Ca, erythropoietin if anemic, treat hyperphosphatemia,How do you slow the progression of CKD?
Cr< 15, pericarditis, progressive uremic encephalopathy,When do you start dialysis?
UA with C&S Spiral CT, Ca level to r/o hyperparathyroid.Kidney stone w/u
Stone < 4 mm, may take up to 4 wks.Which stone pass on own?
Strain urine Indomethacin 100mg did, Tamsulosin 4 mg/d x 4 wk.Treatment of kidney stone
Persistent pain > 4 wks Stone > 10 mm Need stereoscopy first then lithotripsy. Monitor: renal function, periodic image for stone location and hydronephrosis.When do you refer for kidney stone?
Primary hyperparathyroid ( Ca < 11), Malignancy (Ca>13), Vit D box, Renal failure, Meds: Thiazide, Lithium, TheophyllineHypercalcemia causes
Repeat test with ionized Ca level Corrected Ca= Serum Ca + .8 ( nl albumin x 4 - pt's albumin) Causes: Increase protein or dehydrationCause and w/u of pseudohypercalcemia
Ca < 12 Asymptomatic Constipation, fatigue, depression, polyuria, polydypsia, kidney stoneHypercalcemia Sx
Ca < 12 : Find and remove underlying cause and hydrate 8 glasses water/d Ca 12-14: Usually symptomatic. IVF and biophosphante Ca > 14 : Usually comatose HemodyalysisHypercalcemia Treatment
Repeat ionized Ca, PTH,Vit D, BMP Second line: Alk Phos, SPEP,CXR ( look for granuloma)W/U of hypercalcemia
Ca level < 8.5Define Hypocalcemia
Low PTH ( surgery, autoimmune, radiation) Low Vit D/Ca ( malnutrition, ETOH) Low albumin Low Mg Loop diuretics PancreatitisCauses of hypocalcemia
Mild: Perioral numbness, paresthesia in hand and feet, cramps fatigue Severe: Neuromuscular irritability/ Tetany/SeizureWhat are the sx of hypocalcemia
Trousseau sign: metacarphophalangeal spasm with cuff inflated above SBP for 3 min Chvostek sign: contraction of ipsilateral face muscle with tapping facial n. EKG: Prolongation of QTWhat are the signs of hypocalcemia?
Repeat level with ionized Ca Check corrected Ca: Add 0.8 to Ca level for each 1 g/dL that albumin is below 4 Check PTH, Cr, Vit D, Mg, and Alk Phos ( elevated in Vit D def and hyperparathyroid from osteomalacia)W/U of hypocalcemia?
First correct low Mg and low Vit D Ca > 7.5: Oral replacement Ca < 7.5 IV replacementTreatment of hypocalcemia?
K > 5.5Definition of Hyperkalemia
Pseudokyperkalemia: most common; Repeat Release from cell: hyperglycemia, acidosis, BB, Exercise Decrease urine excretion: Low aldosterone ( ACE, NSAIDS, Spironolactone, Heparin), dehydration, Renal insufficiency Obstruction.Causes of hyperkalemia
K > 7 : Progressive muscle weakness to paralysisWhat are the sx of hyperkalemia?
Peaked T wave, Short QT initially then prolonged QT Leads to arrhythmiasWhat is the EKG sign of hyperkalemia?
R/O reversible causes ( drugs, diet, urine obstruction) K < 6.5 or chronic : Diuretics ( thiazide or loop) Laxatives or Kayexalate ** Kayexalate: Has been associated with intestinal necrosis ( rare) K > 6.5 : Calcium gluconate IV, Insulin and glucose IV, Albuterol Low K dietWhat is the treatment of hyperkalemia?
K < 3.5Definition of Hypokalemia
Vomiting, Diarrhea, DiureticsWhat are some of the causes of hypokalemia?
Progressive muscle weakness to paralysis N/V/Anorexia/ IleusWhat are the symptoms of hypokalemia?
Uwaves, St depression and QT prolongation.What is the EKG sign of hypokalemia?
Repeat and check Mg level Check for Sx EKGHypokalemia evaluation
Remove cause if known K 3-4: Oral KCL 10-20 bid K < 3 : IV KCL or oral 40 mEq tid-qid Treat until level > 3.5Treatment of hypokalemia
Hyperglycemia, diuretics, High TG and protein, Volume overload or depletion, SIADH ( CNS and malignancy)Hyponatremia causes
r/o pseudohyponatremia: Glucose: for each100 increase, Na decrease 1.6 Assess extracellular volume: Edema, Dehydrated? Check Osmo: 2(Na) + glucose/18 + BUN/2.8 ( Nl 285-295)Hyponatremia workup
Osmo > 300 Cause: GlucoseHypertonic hyponatremia
UNa < 10 Cause: diuretics, GI loses Treat with IV NSCause and treat low volume hyponatremia
CHF, Cirrhosis Treat with water restriction and liberal Na intakeCause and treat high volume hyponatremia
Always represents a water deficit. Always hyperosmolar Dementia, no access to water, ADH abnormality or CNS disease ( Diabetes Insipidus.What is the cause of hypernatremia?
Drugs: Laxative/antacids containing Mg Renal failureWhat is the cause of hypermagnasemia?
Muscle weakness progressive to paralysis, sedation, loss of reflex and nausea.Syptoms of hypermagnesemia
Remove underlying cause Hydrate CalciumTreatment of hypermagnasemia
Diuretics, ETOH , Insulin, Gentamycin and CisplatinWhat causes hypomangasemia?
Low Ca and Low KWhat other electrolyte abnormalities do you see with hypo Mg?
Cramps and arrythmiasWhat are sx of low Mg?