Read and do the questions - Logan Class of December 2011
Read and do the questions. This will help you.
Pre Test
• Briefly outline an organized procedure of abdominal complaints
• Hx
▪ Family, medical, personal
▪ (L)OPPQRST
• Physical Exam
▪ Abdominal exam, Auscultation, Palpation
• List some signs and symptoms of gastrointestinal ds
• Problems with bowl movements (too many/ not enough)
• Vomiting
• Blood in stool
• Loss of appetite
▪ Renal ds
▪ Psycho social
• Esophageal reflux
▪ S&S - chest pain above diaphragm
• Cramping
▪ Colic, pain, (unsatisfied contraction)
• Loss of bowl sounds - silent abdomen
▪ Adynamic ileus (can be serious or not serious)
• Acute low back pain can quite the abdomen
• Some patients will have constipation with back pain….or associate it with that
• Bloating/Gas
▪ Trapped gas from obstruction
▪ Burping/flatulence
▪ Beans & cabbage or possible lactose intolerance can cause cramping and gas
• Liver ds
• Anemia - microcytic, hypochromic
▪ Missing - the heme
• Extreme Weight loss
• Chronic cough - tickle in the back of the throat
▪ Reflux can cause this
• Rebound tenderness
• Gastric ulcer
• Gallbladder problem
• Chronic infection
• Alcohol intolerance
• Food symptoms - irritation
• Lenaing forward with pancreatitis
• Enteritis - peritis (peri anal area)
• Hernia - around belly button - distorts the tissue
• Tired
• Food allergy
• Referred pain
• THERE IS NO SHORTAGE OF SIGNS & SYMPTOMS
• Describe the pathway a button would take if swallowed. (you are to list normal anatomy in order of appearance)
• Tongue - uvula - vestibule - salivary glands
• Oropharynx - tonsil, epiglottis
• Lower esophageal sphincter - poor valve (LES)
• Stomach
▪ Cardiac, fundus, antrum (prepyloric)
• Pyloric valve - great valve
• Duodenum - sphincter of oddi (ampula of vater)
• Jejunum -
• Ileum
• Iliocecal valve
• Cecum
▪ Appendix
• Ascending Colon
• Suspensory ligament - helps for distinction
• Transverse Colon - droop in da loop
• Splenic flexture
• Descending colon
• Sigmoid colon
• Rectum
• Anal sphincter
• Calcification in the right upper quadrant could be from which sources?
• Gall bladder
▪ Gall stones
• Kidney - nephprocalcinosis
▪ Diabetes causes this more often
• Liver
• Renal artery - atherosclerosis
• Hepatic artery - atherosclerosis
• Costochondral calcification - physiologic calcification
• Suprerenal gland - triangel calcification due to hemorrhagic adenopathy
• Duodenum
• Pancreas
• List some organs that play an ancillary role in the physiology of the gastrointestinal tract.
• Gall bladder
• Pancreas
• Liver
• Salivary gland
▪ Fluid medium, lubrication
• Adrenals
• Teeth
• Intestinal flora
• Secretory glands throughout the intestines
• List several kidney functions
• Electrolyte balance
• Water balance
• Urea balance (nitrogenous WASTE removal)
• Acid balance (hydrogen WASTE removal)
• Regulation of blood pressure - indirect/direct
▪ Erythropoeitin, hematopoiesis
• DISRUPTION OF ANY OF THESE IS RENAL FAILURE
▪ Diuresis
▪ Oligouria
▪ Loss of all fxns
• List some signs and symptoms of GU complaints
• Painful urination (UTI)
• Urgency/full bladder
• Feeling of fullness
• Irritation
• Urethral obstruction - palpable bladder
• Incontinence - can't hold it or can't start
• Flank pain
• Nocturia
• Protein or sugar in the urine
• Star/stop due to prostate
• Murphy's punch
• Blood in the urine -
• List 4 studies used to evaluate the GU system
• Urinalysis (fluid biopsy)
▪ Dip stick or full blown w/ culture
• KUB x ray
• IVP - intravenous pylogram
▪ Iodine based molecule
• Endoscopy - Camera
• List 4 disease processes that may be associated with abnormal urinalysis
• Ketonuria
• UTI
• Diabetes
• Ulcer
Jan 17th 2006
5 major functions of the kidney
• Angiotension system (REGULATION OF BLOOD PRESSURE)
▪ RAA system - renin angiotension aldosterone system
• Filtering system
▪ Waste removal
• Hematpoesis
• Fluid balance
▪ 99.998% of the water can be covered if needed
▪ Acid base balance
• Acidosis - too much hydrogen (alkalosis is opposite)
▪ Electrolyte balance
Anatomy - who are the major occupants of these areas
• Renal Capsule
• This acts as a tight container (so when fluid is held it stretches and stresses this)
▪ Murphy's punch will illicit pain if a condition involves the kidney
• Outermost ring (cortical region) -
• Proximal and distal convoluted tubules
• Cortical glomerulus
• Renal Medulla
• Loop of henle
• Fat in the hilum area
• Renal Pelvis
• Base - or beginning of ureter
▪ Common site of a stuck stone
Blood Flow
Aorta - renal artery - afferent arteriole - glomerulus - efferent arteriole
• The glomerulus is designed to leak, small things (8000 daltons),
• Amino acids, Sugar, bicarbonate, and albumin can pass through the glomerulus
▪ However, PCT recovers this
• Surface area is increased in this area with spacing between cells
• The pressure is what increases or decreases the amount that is secreted
• More stuff - hypertonic solution
• Less stuff - hypotonic solution
• Isotonic afferent and efferent environment (there is proportional loss in the glomerulus. The concentration of fluids may decrease but they all decrease in an equal manner keeping the blood isotonic and not allowing for a hyper or hypo tonic solution.
• Bowman's capsule has a funnel functions and collects everything that is released from the glowerulus.
• GFR - glomerular filtration rate
▪ This is accomplished through billions of these operating at the same time
▪ Movement is monitored with this
• Glomerulus description
• It leaks - vascular tissue
▪ It’s a specialized vascular structure made to leak
Threshold
• Below Tm (low glucose)
• All glucose is returned to the efferent arteriole from the PCT
• Normal Tm (normal glucose) @ threshold
• 1:1 glucose to carrier molecule
• Returns it to the efferent arteriole
• Above Tm (high glucose)
• >1:1 More glucose molecules compared to carrier proteins
• This creates a glucosuria event (sugar in the urine stream)
PCT
• There is a brush border with in the PCT - this increases the surface area
• Specialized cell - mitochondria - lines the inside tubular wall
• This is because there is work that must be done to remove the particles from the PCT back to the Efferent ateriole by the vascular network
• Sodium, potassium, chloride, urea
• Urea - nitrogenous waste & can destabilize membranes (anything that it is up against it will cause it to leak)
▪ A houdini
• Some things can go straight through to the PCT into the urine (alternate pathway)
• Creatine, hydrogen, uric acid can all go from the blood to the PCT (not using the glomerulus)
• Hydrogen can also go through the walls of the DCT into the urine
Loop of Henle
Thin (aka - descending tubule, concentrated segment)
• 1cm thick
• Bulk of water recovery occurs here
• More hypertonic at the end
• Supersaturation leads to precipitates
• Counter current - bodies way to create hypertonic environment, E- regulation. Large amounts of Na+ in peritubular tissue to bring H2O back into body.
Thick (aka - ascending tubule, diluting segment)
• Thick walled
• Water from the wall is put back into the tube to avoid stones form forming
DCT - there are two segments
Proximal
• Has the ability to add water
▪ Working as an anti stone function
Distal
• More collecting duct fxn
• Receptor sites for ADH & aldosterone
• Fine tuning area for water levels
▪ Whether we should keep or let go water
▪ Regulated using Na+ molecules
Collecting Duct
• Introduce Hydrogen
• Reducing systemic acidosis
• Receptor sites for ADH & aldosterone
• Decreasing permeability of this duct
5 hormones that regulate renal function
• Parathormone
• Control bone maturation and bone growth
• Any time the pt. System sees a decline in Ca+ - Parathormone will be released
▪ Weakens the bonds of the crystal lattice to help with the osteoclasts
• ADH
• Anti-diuretic hormone
• Not getting enough water or they are excreting too much
• Diuresis
• Clinical Dehydration will cauwse this to be present
• Aldosterone
• When this elevates Na+ absorbed more in the DCT.
• Na+ removed from the DCT this pulls water with it.
• Erythropoeitin
• Stimulates the marrow to create new RBC's
• Chronic renal failure can cause anemia
▪ This can cause more infection
• This causes an anemia of under production
▪ Decreased Reticulocyte count
• Renin
• Know the RAA system
• Elevates to preserve tubular flow rate***
▪ It will do it even when it should not do it
Pressures that help or decrease GFR
• Pressure (blood pressure)
• Hydrostatic pressure
• Osmotic pressure
• High enough to leak, but low enough to let is go
• Pressure must be low enough to receive the pressure from the bowman's capsule
• Dehydration
• Higher osmotic pressure - resist fluid out flow
• Hypertensive
• Increased GFR
▪ Higher pressure
▪ Proteins then can leak out
• Stone @ base of bladder
• Cause a back up al the way to the bowman's capsule
• Decrease GFR
• Increased serum levels of urea
▪ Obstruct the system (reduce GFR) - cannot get rid of it
• Alternate input sites are full already
▪ Dehydration
Waste molecules
• Urea
• 10-20mg/dl in the blood
• 100mg/dl is panic level
• Results in the break down or metabolism of proteins
Increase BUN levels
• Hypotension - heart disease medicine (too much)
• Renal artery stenosis (decrease GFR and tubular flow rates)
• Dehydration - norm BP
▪ Increased osmotic pressure
▪ Decreased flow rate
▪ Urea is going back into blood
Decrease BUN
• Impaired ability of the liver to create urea
• Renal failure
▪ Diuresis
▪ More urea delivered to tubules
• Creatinine
• ATP + creatin = ADP + creatinine
• 1.5 mg/dl per deciliter normal - panic is 10mg/dl
• Once converted into creatinine you cannot reabsorb it
• 1/2 renal capacity used on max capacity (there are two kidneys)
▪ Disease can be masked because of this
• Creatinine clearance test
▪ Used for GFR testing
▪ Increased blood levels of creatinine - possibly have renal failure
• Oligouria
▪ 500 ml lost a day
• Anuria
▪ 100ml per 24 hrs or less
• Unusual high elevation in a pt with increased growth hormone could have creatinine
▪ Whether acromegaly or gigantism
• Norm is .5 - 1.5 mg/dl
▪ If low expect a muscle wasting disease
• Creatinine is a more accurate GFR unlike urea which can leak back.
BUN : Creatine should be 20:1
Decreased levels (not proportional)
• Form of Renal failure - Diuresis can cause this be lower
• Glomerular issue possible
• Brisk tubular flow rates
Increased levels (not proportional)
• Dehydration
• Reduced tubular flow rates
• Form of renal failure - Oligouria
Azotemia - (INCREASED UREA LEVELS)
• Renal -
• elevation of creatinine and BUN
• Pre renal -
• heart disease condition that creates hypotension
• BUN and Creatinine increased
• Post renal -
• occlusion
• Elevated BUN
Maculodensa Cells all the Way to Angiotensin II *****KNOW THE WHOLE STORY*****
• All this cell can do is note concentration of Chloride
• Stimulates the JG cells
▪ Juxtaglomerular cells
• They release renin, which is a hormone,
• And is released straight into the blood pool (vascular tree)
• Renin acts as a cleaver…it is looking for angiotensinogen (precurser molecule found in the liver) it is going to cleave off a part of the structure to reveal a binding site
• Now it is called angiotensin 1 - Now it is carried to the Lung
• Here it meets ACE - Angiotensin Converting Enzyme. Now another binding site is exposed and it is now called angiotensin II (Angiotensin 1 + ACE = Angiotensin II
• It is the strongest thing we know for the elevation of aldosterone (targets sodium & is recoverd more from the urine)
• Reduction of Na+ loss and pulls the water with it. Increases the vascular volume increasing the BP in the body
• Increase the hydrostatic pressure in the glomerulus (turns up the leak hose, & increase GFR)
REVIEW
Liver - source of urea
Panic value for creatinine - 10mg/ml
Panic value for urea - 100mg/ml
Put the values together -
• BUN/Creatinine
• 20/1
• The values may go up or down
• Increase
▪ Increase in muscle mass
▪ Renal Failure (oligouria)
• Decrease
▪ Renal failure (diuresis)
Azotemia
• Pre renal, renal & Post renal
Glomerulus - chambers can get larger, but surface area gets smaller due to HYPERTENSION
The above in the review will be hit in exam 1 - Don't get behind!
Chloride levels monitored by maculodensa cells
When Na+ levels drop
Is there a single urinalysis exam? NO
• Observation (color & clarity & odor (waft))
• Range of color
▪ Straw yellow - dilute
▪ Orangish yellow - normal or other constituents
▪ Red - be concerned about blood (hematuria)
▪ Brown urine - hemolysed sample or bilirubin
▪ Green - (asparagus, Brussel sprouts
• Dip Stick test
• Microscopic exam - centrifuge the sample (normal is acellular and aseptic)
• Low light low power till you see something, then turn it up if you find something
• Culture
• Sterile catch urine
Glucosuria, hematuria, bilirubinurea, Increased WBC
Possible causes of hematuria
• Polycystic disease - hereditary
• Not surprised in the 2nd and 3rd generations
• Tumors
• Logical to have some Red cells
• It takes high blood supply to maintain the tumors
• Trauma - Stone stuck in opening of the renal pelvis causing dilation
• Dometimes the dilateion will cause it to move down the ureter
▪ Can cause leakage of blood
• Nephrocalcinousis
• Dystrophic or metastatic calcification (hyperparathyroidism)
• March hematuria
• Exrecise induced
• Caused by the feet having pressure on then off
• Pregnancy
• Ureteritis
• Bladder Tumor, stone, infection
• Granulomatous disease
• Hydronephrosis - WATER IN THE KIDNEY
• Periureteritis
• Prostate carcinoma or infarct
Hematuria - 3+ clinically significant
• Dark urine - have they had it lately (you cannot say have you had hematuria?
• UTI, difficulty or urgency, honeymoon cystitis, dysuria,
• Easy bruisability
• Prolonged bleeding
• Colicky pain - radiating from loin to groin
• Sore throat, hypertension, signs of edema
Know this for hematuria section & for the test
Triple catch UA
• 3 sterile cups
• Order is important
• Proper cleaning of the periurethral area
• 50 to 100 ml in each
• 1st - start stream then stop
• 2nd - start stream again then stop
• Prostate exam
• 3rd - start & complete urination
Results
• Hematuria in all three
▪ Consider bladder lesion or upper tract pathology
• Terminal or bladder neck hematuria 3rd container (terminal hematuria)
▪ This suggests the bladder neck or prostate
• At start of urination only (initial hematuria)
Think of lesions below the bladder and prostate
The difference between the double and triple catch is the PROSTATE exam
Double Catch - for females
• Hematuria in all three
▪ Consider bladder lesion or upper tract pathology
• Terminal or bladder neck hematuria
▪ Upper UTI or raging bladder infection (concentrate on the bladder & wall)
• Initial hematuria
▪ Usually a urethritis
Intravenous Pyleogram (IVP or IVU)
• Usually an iodine compound
• No recover mechanism so it is pushed out by the kidney
• Cortical portion will be hit first, then the medullary area gets the definition.
• Next to the renal pelvis
• Then through the ureter and into the bladder with larger bladder complex
• This shows if there is filtration and asses RENAL FUNCTION
• Delayed enhancement or no enhancement
• If the above occurs we do a RUP
Retrograde Ureter Pyelogram
• Used with a catheder & camera (cystourethroscope)
• Could be a stone or renal artery dysfunction
CT scanning and arterography - this is the #1 3D imaging (CT)
• If the source of the urinary tract bleeding remains unknown, then CT scanning will be used to see collection point, leakage points, and other.
Renal Biopsy
• In some cases, glomerular lesions may require renal biopsy for definitive diagnosis
Lithotripter - can break up the calcium of a rib
• Used to break up stones
Laser -
• Has to be ventilated
Basket
• Grabs onto the stone to pull it out
Urinalysis
• Anything greater than 3 per high field
• Repeat the test now
• Failed the test twice
• Are there casts (formed in the tubular distribution) present
• CASTS
• Check creatinine or BUN
▪ If greater than 20 BUN
▪ Then use the ASO titer (antistreptolysin)
▪ If positive then
• AGN - Acute glomerular nephritis
• Treat as post streptococcal glomerularnephritis
• NO CLASTS
• Urine culture positive - use AB
• If urine culture is negative continue to IVP or sonography
▪ Look at age
• Greater than 40
• Tumor? - Cystoscopy
• Under 40
• Monitor every 6 months
Screening Tests
• BUN
• Plasma Creatinine
• Creatinine clearance test
Quantitative Screening (glomerular filtration rate)
• Serum creatinine
• Creatinine clearance
Urinalysis
• Fluid biopsy
Tubular function
• Concentrating ability or acid base study
• Glucose reabsorption
• Special studies where indicated
Proteinuria
• The normal healthy glomerulus is going to produce an almost protein free urine (albumin can be in the urine naturally)
• Less than 200mg of protein is leaked daily
• The lining of the tubular distribution is living cells. The fluid is actually touching the oldest layer
• The protein should not be larger than albumin -
• If so it is the glomerulus that is having the issue
• Cannot rely on 1 urine test
• You have to do a 24 hr collection of urine. This is how the study is done to test the glomerulus.
• Tamm Horsfall protein - this finding requires us to do nothing as this is normal
Nephrotic Syndrome
• 2.5 grams a day is the least to diagnose this (2500mg) disease
CASTS - MATCHING QUESTION
• Proteinuria
• Precipitation in tubules
▪ Hyaline Casts (associate with proteinurea)
• Glomerular loss of RBC's
• RBC casts
▪ Hemoglobin casts (associated with exercise)
• Loss of WBCs in the tubule
• Leukocyte (pus) casts (associated with infection usually)
• Epithelial desquamation
• Cellular Casts
▪ Finely or coarsely granular casts
• Waxy casts (most mature)
You can tell the maturity of a Cast by the way it looks
• More mature more intact
• Less intact less mature
Hematuria
• Many ways to get blood into the urine - there is a spectrum
• Anywhere from benign to aggressive
GFR - Glomerular Filtration Rate
• Adult Male 125ml a min
• The avg filtration rate from males (this number was take from a healthy army personel
• Adult women
• Lower rates of filtration
• Increase GFR
• Decrease GFR
• Why would it increase
• Why would it decrease
• In some instances people have lost 2/3 of GFR before symptoms occur
90% renal function when lost (you cannot get on the transplant list until this occurs
Rationale of GFR tests
• The substance must be small enough to pass through the glomerular filter
• Measure the concentration of this substance in the plasma (p)
• The maesurement of the concentration of urine (u)
• The measurement of urine flow per minute (v)
• P X GFR = U X V
• Substances used
• Inulin (most acurate)
• Creatinine - most common one used
• Urea
Testing tubular reabsorption
• The counter current multiplier - this is what controls osmolality
• Water can go to or from the vascular tree depending on the pressure gradient itself
• The medullary portion is harder to get urine
• If the counter current multiplier was to be interfered with the urine will hold more water showing signs of diuresis
When Fasting you must not have and fluids the night before (15 hour fast)
Collect it three times
With the fast, we will become even better a filtering
Isothenurea - a kidney that is not keeping up and responding to the drive of the body
It could be insufficient ADH production.
• Patient is unable to concentrate urine in the presence of clinical dehydration.
• Could be many reason for this
Value of Test
• A copius GFR
• A proper amount and distribution of renal blood flow
• Healthy tubular cells
***Assessments of the Kidney's concentration-dilution functions provide the most sensitive (most incidence of true positive) means of detecting early or mild impairment of renal physiology. A patient with completely normal concentrating ability is unlikely to have a serious kidney malfunction
Mess around with the electrolytes
Possible causes of loss of concentrating ability when needed
• Hypokalemia
• Hypercalcemia
• Absence of ADH
• Diminished GFR
• Amyloidosis
• Increased solute load
• Loop diuretics
• Atherosclerotic disease
Metabolic Acidosis in Chroni Renal Failure
• Whole nephrons are destroyed (parallel glomerular and tubular failure)
• The remaining nephrons are largely functionally intact and produce a very acid urine
• The disproportion between total acid output and acid load secondary to diminished tubular mass results in retention and the typical metabolic acidosis of chronic renal failure.
Acid Base Function - Know the concepts not the Exact numbers
• Bicarbonate is an important buffer and is maintained at 25mEg/l
• Important to the normal metabolic processes - it is small and can pass through the glomerular wall
• It can be recovered though
• GFR = about 180L/day
• Therefar, the filtered load of bicarbonate = about 4,500 mEg/day
• About 90% of this is reabsorbed in the proximal convoluted tubule (by mechanism of H+ secretion by the tubule, which titrates bocarbonate
• In the distal tubule H+ secretion reclaims the remainder of bicarbonate (the requirements of Acid-base balance are also met here by H+ secretion in the form of titratable acidity plus ammonium ion secretion
• Acid output by the kidney is limited by two factors:
• The Maximum number of moles of H+ which may be secreted by the tubules
• The minimum pH to which the urine may be driven
• 24 hour urine check:
• 5 to 10 gm NH4Cl is given by mouth to stimulate maximum acidification. Analysis of the 24 hour specimen is then undertaken. Failure to excrete a total of more than 100 mEq of titrate acid + NH3 constitutes reduced capacity for acid excretion.
Renal Tubular Acidosis
• We are really talking about a medullary problem
• The glomerulus is targeted (this is a cortical problem usually)
• Proximal and distal CT is also taken out since it is in the cortex too.
• This is a tubule that cannot eliminate H+
• What kind of urine is produced?
• ALKALINE urine
• The acid is still in the body
• If the tubules are damaged the urine will be alkaline even though there is acidic conditions in the tubules
• In the proximal tubule
• The body cannot recover bicarbonate (over buffered urine)
• Distal tubule
• The H= is not allowed to enter urine (blood keeps the acid load and urine is denied)
• There is an over buffered urine since there is no H+ to mix with it
• 4th type is acidosis with hyperkalemia (found with diabetics)
Renal Failure Review
• Oligouria
• Diuresis
• Types of renal failure
• Acute - oligouria
• Clinical profile
▪ Pain in high hip pockets or flank pain
▪ Not going to the bathroom
▪ Hydrosatic pressure increased in the kidney causing deep pitting edema
▪ High BP
▪ Wt gain
▪ Puffyness (usually in kids)
▪ Dependent edema - when standing - legs
• Goes to the lowest spot on the body
• Collect in pleural space then - causing kusmal breathing
• Trouble maintaining BBBarrier
• Death finally from acidosis
• Obstruction is most painful
• Decreased appetite - satiety center is inhibited
• Experience a depression of the motor function of the GI tract and have trouble clearing waste (uresa)
• Sometimes vomiting present
• Azotemia
▪ Prerenal
▪ Heart disease
• Hypotension, stenosis of the renal artery,
• Drug induced hypotension
▪ Renal causes
• Renal failure
• Renal stenosis
▪ Post renal
• Obstructive events
• Bladder stone
• Bilateral ureter stones
• Retroperitoneal fibrosis restriction
• Murphys Punch could be positive
Acute Glomerular nephritis - not a kidney infection, hypersensitivity to strep and our anti bodies
• Rises rapidly
• Effects children more often (can be seen in adults)
• Males effected more often than females
• Precipitan - stimulates the immune response at the glomerular membrane saying that here is an invader when there really is not.
▪ More fluid leads to glomerular occlusion and holes are smaller
• Strep can get in through inhalation, a cut or any other way. It does not matter. You just have to have the sensitivity
• Flu like symptoms
• Irritation of the mucous membrane
• Negative rxn to murphy's punch
• Wt gain
• Elevation of BUN and Creatinine
Casts cause you to look back intime
• Granular -
• Chronic - diuresis
1. Diabetic
1. hypertension
1. Glomerular nephritis (Autoimmune)
1. Polysistic disease
1. Long term drugs that effect the kidneys (nephrotoxins)
1. Aminoglycosides
1. Streptomycin
1. NSAIDS
• Glomerular nephritis
• Tubular failure
Chronic Renal Failure
• Is not common but can occur
• Diabetic or hypertension
• Renalpolycystic disease
• S & S of Diabetes
• Change in urination (too much) (diuresis or polyuria)
• Drinking a lot of water (polydipsia)
• UA - glucose, ketones, (hyperglucose urea)
• Glomerular hydrostatic pressure increased (GFR and increased tubular flow rates)….early on
• Later on….glomerular can swell
• Diabetic Neuropathy
• Acute renal failure aka oliguria
• Then they are normal (MIDDLE GROUND)
• Then Chronic renal failure aka diuresis
Late
• Reduced GFR
• Azotemia - collection of BUN in patient
• Hypernatrimia
• Polydipsia
▪ Oliguria, decreased urine output, increased renin, stimulates thirst
• Oligouria
• Anemia present (due to fibrotic repair)
▪ Decreased hematopeitin
▪ Underproduction & Overdestruction
• Not CUREABLE
▪ This is because the diseases that cause it cannot be cured (diabetes, glomerular nephritis…inflammation of the basement membrane of the glomerulus…sensitivity reaction)
Early
• High tubular flow rates
• Hyponatrimia (Na+ loss)
• Dehydration
• Polyuria
• Polydipsia
▪ Aldosterone driven elevation
• Diarrhea
Management of chronic renal failure
▪ Pt. With this early on should increase water intake and increase vitamins (calcium, vit D, loading activities), potassium rich foods if passing through them fast,
▪ Exercise can help the renal function
▪ Reduce nitrogenous waste (shift their diet)
▪ Reduce acid load
▪ Aluminum base antacids bind to phosphates
Dialysis - fancy filter for the patients blood (like a water filter)
Urinary Tract Infection UTI
• Lower urinary tract infection
• Ureter, bladder, (prostate)
• Upper urinary tract infection
• Kidneys
• Double catch for women, triple catch for men
For test two remember the thinking process & then there will be more detail on what different UTI's look like
Upper UTI
• Usually a single organism phenomena
• ECOLI is the bigger player (some worse then other)
▪ 95% of UTI are traced back to this
• Frequently occuring in the GI tract
▪ How does it get there?
• Poor Hygiene
• Blood distribution (not often, but usually upper and cortical base)
• Often ascending infections
• May have had burning at first, but now have flank pain on the affected side
• High grade fever, shaking chills
• High levels of normal UA
• Microscopic exam
• > 5 WBCs & > 20 of same bacteria per field
• Casts may be present (inflammation of the parenchymal tissue)
• Hematogenous spread if cortical
• Culture
• More than 100,000 colonies of the same organism
• Dipstick
• Large numbers of WBCs
• Ascending would effect medullary area
• Normally this is an ascending problem that is spread through reproduction through a bio film (it widens its zone of conquering)
Lower UTI
• Pain on urination
• Urethritis - will hurt with the passage of urine through the urethra
• Cystitis
• Pain w/ urination, Bladder contraction, ache after urination (post void ache)
• All phases of urination
• Ureteritis
• Lower than the flank but not timed with urination
• Gender Bias
• Female to male
• 10:1 more often
• Why female?
▪ Anatomy causes this due to the closeness of the urethra & anus
▪ The length of the urethra (secretions of anti bacterial properties)
• The proximity and length of the tissue (normal function?)
▪ Prostatic secretions help the men
▪ Urinary obstruction (stasis)
• Stone disease
• Increase in bacterial growth
▪ Urinary retention -
▪ Honeymoon cystitis - increased damage to the UT
• Post coital micturation -use bathroom right afterwards
• REDUCES it by 70%
• Increase hydration
• Cranberry juice
• Age bias
• Older…. > 64 yoa has the highest incidence of UTIs
• Trapping urine in the bladder from an enlarged prostate
Strep throat is the most common infection next to UTI
If it is a bacterial issue then an antibiotic may be needed
Catheterization, flex fiber optic studies…these can help the spread of UTI
Teflon now used on a catheterization, lubricants, clean prep and sterile
Cranberry juice, must be at least 10% juice to work
• Works to remove the film from the ureters
• Target audience (look for the people who will go to the health store compared to the people who would not do that)
• 3 8oz glasses a day
• For 5 to 7 days
Prostatitis - causes UTI in the males more often
Prostatic hypertrophy - residual urine causing opportunity for bacterial over growth
Bladder distention - causes a stretch on the BV and now it is harder to keep blood supply and immunity up
Diabetes mellitus - patient is spilling sugar (this is a rich energy source for bacteria) and it is harder to fight off this infection since immunity is slightly lowered already
Pregnancy - the bladder is getting pushed down from the uterus into the pelvic floor, the bladder cannot empty fully
Hypertension - decreased compliance
Misc - abnormal communication - Fistulas - urination smells like feces
Adolescent spike - Ages 18 months - 2 years
• They can be vocal with NO and is a sign of their independence
• Bubble baths can cause infection
• Back to front…not good…..
• Front to back good!
Hydration helps to reduce the symptoms if not take them all away
Upper UTI
Ascending infections so the right kidney actually gets infected more often since it is lower.
Medullary or parenchymal portion - from ascending infection (most typical)
Cortical - hematogenous delivery most likely
3 day course of antibiotics is the best medical treatment
END OF TEST 1 INFORMATION
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