Patient Care and Medical Knowledge. Resources

Transcription

1 Patient Care and Medical Knwledge Resurces Utilize the extensive resurces electrnic, paper-based, and persn-based (physician cnsult services, scial wrk, nursing, pharmacy, practice management, ther allied health care prfessinals) available t help residents taking care f patients with nephrlgy related prblems. Cre Knwledge Demnstrate ability t use the serum creatinine cncentratin t estimate Glmerular Filtratin Rate. Explain the assumptin f steady-state cncentratin Discuss shrtcmings f creatinine-based methds f estimating GFR Demnstrate ability t interpret a spt prtein-t-creatinine rati and/r a spt albumint-creatinine rati n a randm urine sample as a marker f kidney damage and a quantitative measure f prtenuia Relate this test t 24-hur urine results. Recgnize that 24 hur urine cllectins fr the purpses f 1. GFR estimatin frm creatinine clearance 2. Diagnsing and fllwing prteinuria are nt superir t the spt tests abve (in the majrity f situatins Knw the patient ppulatin at risk fr chrnic kidney disease Discuss risk factrs fr acute renal failure in ut- and in-patient settings Categrize based n bth frequency f ccurrence and n dminant Pathlgical site(s) f injury. (Pre-renal, Intra-renal [includes vascular, glmerular, tubular and interstitial] and Pst-renal) the causes f - Chrnic Kidney Disease - Acute Renal Failure Define and List the mst cmmn causes f: - Nephrtic syndrme - Rapidly prgressive glmerulnephritis Define and List the mst cmmn causes f - Islated hematuria (i.e. withut ther abnrmalities) - Islated prteinuria (i.e. withut ther abnrmalities) - Hematuria and prteinuria withut a decreased GFR Discuss the physilgical cncept f clearance and apply this t: Native renal functin (GFR) and, Principles gverning slute clearance by peritneal dialysis, intermittent hemdialysis, and cntinuus renal replacement therapy Principals gverning handling f medicatins by the kidney Discuss the pathphysilgy underlying nrmal and abnrmal prteinuria Define nephritic-range prteinuria, glmerular Describe the basic metablic, hmestatic regulatry functins and endcrine functins f the kidney Histry Taking Elicit histry f/distinguish risk factrs fr acute and chrnic renal disease

2 Demnstrate cnsistent ability t use histry and histrical recrds thrughly t determine tempral duratin f kidney disease Elicit specific symptms f a geniturinary systems review Elicit symptms f uremia Elicit symptms f systemic disease and understand the diagnstic and therapeutic imprtance f seeking assciated renal invlvement Elicit medicatin histry (prescribed and ver-the-cunter) and cmpletely explre ptential cntributins and nging risks fr adverse drug effects Elicit family histry f kidney disease Elicit symptms f cmrbid cnditins and cmplicatins related t kidney failure (diabetes, accelerated athersclersis, hypertensin, anemia, salt and water retentin, mineral and bne disease, malnutritin, neurpathy, sexual dysfunctin, electrlyte and acid-base disturbance) Physical Exam Demnstrate perfrmance f physical exam t accurately assess: Bld Pressure Cardivascular system Vlume status: signs f verlad r depletin Signs f Uremia Presence f enlarged urinary bladder Presence f balltable kidneys and/r kidney transplant Evidence f athersclertic disease Evidence fr crmrbid disease (including systemic diseases such as SLE and vasculitis) Evidence f atheremblic disease Signs f cmplicatins f uremia Urinalysis Demnstrate ability t read a urine dipstick Demnstrate ability t recgnize RBCs, WBCs, tubular, transitinal and squamus epithelial cells, and bacteria n micrscpy f urine sediment. Discuss ptential surces f rigin f each cnstituent. Demnstrate ability t recgnize hyaline, granular, and cellular casts (red cells, white cells and tubular epithelial cells). Discuss pathphysilgy f their frmatin and surce f rigin. Demnstrate an ability t interpret quantitative estimates f prteinuria (dipstick, spt prtein-t-creatinine rati, 24 hur urine cllectin) Discuss the pathphysilgy leading t abnrmal prteinuria Integrate Cre Knwledge, Histry Taking, Physical Exam, Serum Chemistries and Urinalysis and, Plan Further Diagnstic Evaluatin

3 Fr each f the clinical prblems and/r disease prcesses listed belw, describe expected presentatins in terms f symptms, signs, serum chemistries and pattern f urinalysis findings and discuss differential diagnsis Pre-renal renal failure Diabetic nephrpathy Hypertensive nephrsclersis Atheremblic kidney disease Renvascular disease Nephritic Syndrme Nephrtic syndrme Acute tubular necrsis Tubul/interstitial renal diseases Cystic kidney diseases Iatrgenic renal txins (e.g., NSAIDs, cntrast dye, etc.) Renal stne disease Pst-renal renal failure Demnstrate ability t interpret in the cntext f varied clinical presentatins, and in an integrative manner, measurements f serum electrlytes and smlarity, arterial bld gas parameters, urine electrlytes and smlarity. Be able t use these interpretatins t assist in frmulating differential diagnses f patients with: Acute renal failure Chrnic kidney disease Clinical disrders f salt and water metablism Clinical disrders f majr electrlytes (K+, CA2+, Mg2+, PO42-) Clinical acid-base disrders Renal stne disease Define the implicatins fr urgency f diagnstic evaluatin f a decreased GFR f acute r undetermined duratin in cntrast t a chrnic duratin Define the implicatins fr urgency f diagnstic evaluatin f active urine sediment (white and red cells, granular casts, +/- cellular casts) in the setting f a decreased GFR Describe the relative meritis, indicatins fr, and infrmatin gained frm diagnstic imaging studies including ultrasund, CT, IVP, cnventinal and MR angigraphy, MR urgraphy, antegrade and retrgrade urgraphy, cystscpy, and radiistpe studies in investigatins f Hypertensin Hematuria Acute renal failure] Chrnic Kidney Disease A patient with renal cyst, mass r abnrmality f the lwer urinary tract Lwer urinary tract disease Describe, in the cntext f the pretest prbabilities fr specific renal diseases, the discriminant value and apprpriate rdering f the fllwing serlgic tests:

4 Sertrphil cytplasmic antibdy Anti-neutrphil cytplasmic antibdy Anti-glmerular basement membrane antibdy ANA, anti duble-stranded DNA, Anti-cardilipin antibdies Hepatitis serlgies Cryglbulins Serum Prtein Electrphresis Urine Immunelectrphresis Serum and urine esinphils List the indicatins fr renal bipsy List the risks and relative and abslute cntraindicatins f renal bipsy Discuss the implicatins fr patient chice if there is a lw versus high prbability fr underlying treatable disease Discuss the implicatins f the pssibility f a rapidly prgressive yet ptentially treatable underlying disease fr urgency r bipsy. Effective Patient Management Plans Be able t crdinate multidisciplinary care and develp management plans based n medical evidence fr patients acrss the full spectrum f diseases and presentatins that lead t: Acute renal failure Chrnic kidney disease Be able t crdinate multidisciplinary care and develp management plans based n medical evidence fr patients acrss the full spectrum f diseases and presentatins that are lead t: Clinical disrders f salt and water metablism Clinical disrders f majr electrlytes (K+, CA2+, Mg2+, PO42-) Clinical acid-base disrders Infectins f upper and lwer urinary tract Other lwer urinary tract disease Bld Pressure Cntrl Recgnize imprtance f achieving bld pressure cntrl t prevent prgressin f chrnic kidney disease. Knw the evidence fr this Identify bld pressure cntrl targets fr preventing prgressive disease Discuss the rle f cnverting enzyme inhibitrs and/r angitensin receptr blckers in preventing kidney disease prgressin Vascular Risk factr reductin- Identify chrnic kidney disease as an indicatin fr aggressive cardivascular risk factr reductin Develp and apply specific skills apprpriate t the management f: Fluid and electrlytes in patients with Acute Renal Failure Fluid and electrlytes in patients with Chrnic kidney diseases Hypertensive urgencies and emergency Avidance f unnecessary nephrtxic expsures Prphylaxis f radicntrast assciated nephrpathy in at-risk patients Dietary mdificatin in the acute and chrnic renal failure

5 Anemia and irn deficiency in kidney disease Ca, Phsphrus and parathyrid hrmne in kidney disease Upper and lwer urinary tract infectin Nephrlithiasis Recgnize the need fr crdinated disease-specific management plans in: - Patients with varius glmerulnephritides - Patients with renal vasculitis - Patient with lupus nephritis - Patients with acute interstitial nephritis - Patients with prgressive chrnic kidney diseases Dialysis fr End-stage renal disease (ESRD) and Acute Renal Failure Knw the apprpriate GFR fr initiating timely (well enugh in advance f anticipated end-stage kidney disease): Patient educatin regarding ESRD Renal replacement mdality selectin Transplant evaluatin Vascular access preparatin Discuss referral f chrnic kidney disease patients t nephrlgy clinic Be able t describe: Indicatins fr dialysis acute and chrnic Relative advantages/ disadvantages f hemdialysis vs. peritneal dialysis Cncept f adequate/ptimal dialysis Preferred vascular access fr maintenance hemdialysis The large burden f mrbidity accruing frm catheter-related infectins Relative merits f cntinuus renal replacement (CVVHD) vs. Intermittent hemdialysis in acute renal failure Kidney Transplantatin Recgnize the need fr early kidney transplant evaluatin t: Facilitate early identificatin f ptential living dnrs Facilitate preemptive transplantatin where pssible Facilitate early activatin f suitable patients n cadaveric wait-list (UNOS listing criteria GFR< 20 cc/min) Be able t describe: Side effects, drug interactins and bld level mnitring f cmmn transplant immunsuppressive drugs Discuss antibitic and antiviral prphylaxis pst transplant Differential diagnsis and investigatin f increased creatinine in transplant patients and the rle f transplant renal bipsy

6 Recgnize the symptms and signs and discuss the diagnsis, management, and preventin f: Acute rejectin Cyclsprin nephrtxicity Chrnic allgraft nephrpathy Cytmegalvirus infectin Other pprtunistic infectins Allgraft pyelnephritis Pst-transplant lymphprliferative disease Neplasia skin, ther Athersclertic vascular disease Hypertensin Pst-transplant bne disease Recurrent kidney disease Drug Dsing Be able t access infrmatin t guide: Drug dsing adjustments based n GFR Drug interactins in patients with kidney diseases Prcedures Perfrm a dipstick urinalysis and prepare urine sediment fr micrscpy Perfrm bladder catheterizatin Practice Based Learning and Imprvement Be able t access and utilize the extensive resurces electrnic, paper-based, and persnbased (physician cnsult services, scial wrk, nursing, pharmacy, practice management, ther allied health prfessinals) available t help residents taking care f patients with nephrlgy related prblems Be able t access clinical practice guidelines: Natinal Kidney Fundatin K/DOQI clinical practice guidelines fr standards f care in chrnic kidney disease and maintenance dialysis patients Perfrm independent research fr evidence-based practice in respnse t specific clinical questins arising frm patient-care experiences Engage actively in feedback Interpersnal and Cmmunicatin Skills Effectively crdinate multidisciplinary invlvement (primary in-patient service, physician cnsult services, scial wrk, nursing, pharmacy, practice management, ther allied health prfessinals) in patient care

7 Cmmunicate effectively with patients, family members, dieticians, scial wrk, nursing, ther physicians, ther prviders in the care f ESRD patients Crdinate effectively multidisciplinary patient care Accurately describe the risks and benefits f renal replacement therapy fr infrmed cnsent Discuss the impact f renal replacement therapy n quality f life Prfessinalism Discuss ethical principles in clinical practice Describe present appraches t cunseling patients n end-f-life decisin making in ESRD (including withdrawal frm dialysis) System Based Practice Review the epidemic grwth in end-stage renal disease and describe cntributins f diabetes and/r hypertensin Describe individual and scietal csts f ESRD Acknwledge the extent f undiagnsed and inadequately treated chrnic kidney disease Discuss the systematic scpe fr preventin f ESRD