NEPHOLOGY OON LINIAL PESENTATIONS AND ADINAL ANIFESTATIONS OF ENAL DISEASES- INITIAL EVALUATION AND DEISION-AKING SKILLS GOAL: The residents will learn the evaluation, diagnosis, and management of patients with commonly encountered acute and chronic renal disorders -Asymptomatic patient renal disease prevention - Diabetes -Hypertension -Sickle cell anemia -Symptom evaluation and diagnosis -Fatigue -Anorexia -Weight gain -Pallor -Pruritus -Easy bruising -Increased thirst -Dyspnea -Nausea, vomiting -Diarrhea -Flank pain -Abdominal pain -Alterations in urine output -Hematuria -Urinary urgency, frequency -Swelling -Urinary incontinence -Urinary retention -Lethargy -Seizures -Physical examination abnormalities -Elevated blood pressure -Altered mental status -Eyelid edema -Altered breath sounds, crackles -Edema, anasarca -Flank tenderness -Abdominal mass / palpable kidney NEPHOLOGY LEANING OBJETIVES - manage as the primary physician - co-manage with subspecialist - refer to subspecialist omprehensive clinical skill development for- -History taking -Physical examination and diagnosis -Formulation of complete differential diagnosis -Decision-making for initial evaluation and management -Presentation of findings and articulation of prioritized plan -Ordering and interpretation of appropriate tests to evaluate renal function and pathology -Assessment of need for hospital admission or emergency department referral in the outpatient setting -omprehensive medical care of hospitalized patients with renal disorders -Assessment of the need for referral to subspecialist for evaluation and management -Assessment of need for continued hospitalization of inpatients with renal disorders and transition to outpatient care Learning Objectives- - esidents are expected to learn how to evaluate, diagnose and manage these conditions without subspecialist consultation. They are expected to acquire primary management experience for the majority the conditions in this category. hanges in the condition of the patient may necessitate subspecialist consultation, comanagement and subsequent referral as indicated. - esidents are expected to be able to perform the initial evaluation and establish the diagnosis of patients with these disorders who are then typically co-managed with the consultants. Subspecialist consultation is frequently needed for these conditions to interpret specialized test results, perform procedures, confirm diagnosis and advise during ongoing co-management of the patients. 1
OON LINIAL PESENTATIONS AND ADINAL ANIFESTATIONS OF DISEASE- INITIAL EVALUATION AND DEISION-AKING SKILLS -Bruit over abdomen -ash -Enlarged prostate -Laboratory test abnormalities -Abnormal urinalysis Proteinuria ed cell casts Granular casts Hematuria -ardiomegaly on X -Pulmonary edema on X -Hyperlipidemia -Elevated BUN and creatinine -etabolic acidosis -Electrolyte level abnormalities -Anemia -Hypoalbuminemia -Abnormal SPEP and/or UPEP -Abnormal serum immunoglobulin free light chains NEPHOLOGY - esidents are expected to be able to perform the initial evaluation and management of patients with these disorders who are then typically evaluated further, diagnosed and managed primarily by the subspecialty consultants OON LINIAL ONDITIONS- DIAGNOSIS AND ANAGEENT SKILLS AUTE ENAL FAILUE -Pre-renal failure Volume depletion Low cardiac output Other etiology of pre-renal failure -Intrinsic renal disease Glomerulonephritis Primary glomerular diseases Post-infectious Vasculitis SLE Other etiology enal microvascular disease Preecclampsia Thrombotic microangiopathy Acute tubular necrosis Ischemia Drugs/toxins enovascular obstruction 2
OON LINIAL ONDITIONS- DIAGNOSIS AND ANAGEENT SKILLS Interstitial nephritis Allergic Infections Other etiology Intratubular deposition and obstruction yeloma light chains Uric acid ethotrexate toxicity enal allograft rejection -Post-renal failure (obstruction) Ureteric calculi Extrinsic ureteric compression Bladder outlet obstruction Urethral stricture NEPHOLOGY NEPHOTI SYNDOE -Primary glomerular diseases -Secondary to other diseases Infections Drugs/toxin associated SLE and other connective tissue disorders Amyloidosis Other etiologies ASYPTOATI UINAY ABNOALITIES -Isolated non-nephrotic proteinuria Primary glomerular disease Secondary to systemic disease Diabetes Amyloidosis -Hematuria with or without proteinuria Primary glomerular disease Other etiologies ENAL DYSFUNTION DUE TO SYSTEI DISEASE -SLE -Henoch-Schönlein -Goodpasture s -Systemic vasculitis 3
-ultiple myeloma -Amyloidosis -Light chain deposition disease -ryoglobulinemia -Scleroderma renal crisis -Other systemic diseases NEPHOLOGY SYSTEI HYPETENSION -Essential hypertension -Secondary hypertension -enovascular HTN -Pheochromocytoma -Other disorders -Hypertensive emergencies ELETOLYTE/FLUID BALANE ABNOALITIES -Hyponatremia and hypernatremia -Hyperkalemia and hypokalemia -Hypocalcemia and hypercalcemia -Hyperphosphatemia and hypophosphatemia HONI ENAL FAILUE -Hypertensive nephrosclerosis -Diabetic nephropathy -Polycystic kidney disease -hronic glomerulonephritis -Obstructive uropathy -Other disorders associated with F END-STAGE ENAL DISEASE -Indications/evaluation for renal replacement therapy Hemodialysis enal transplantation Peritoneal dialysis -omplications of ESD and its therapy Anemia due to chronic kidney disease enal osteodystrophy Secondary hyperparathyroidism Vascular access infection Peritonitis 4
enal allograft rejection Infections in immunocompromised transplant patient Other complications of ESD and its therapy NEPHOLOGY LABOATOY TESTS- UNDESTANDING, ODEING AND INTEPETATION SKILLS OUTINE TESTS -Urinalysis with dipstick -Urine sediment -Urine electrolytes -FeNa -Urine osmolality -Plasma BUN/creatinine ratio -24 hour urine collection for creatinine clearance/protein -Urine microalbumin -Serum electrolytes -Serum calcium and phosphorus -Anion gap -Arterial blood gas -EKG -Lipid panel -ES -SPEP -UPEP -Immunofixation electrophoresis -Serum immunoglobulin free light chains -easurement of complement levels and activity -ANA -ryoglobulin screen -Anti-glomerular basement membrane antibodies -ANA -hest X-ay -enal ultrasound OTHE TESTS -Plasma renin activity (after captopril) -enal arteriography and renal vein rennin activity measurement -Kidney biopsy pathologic analysis -Intravenous pyelogram -enal stone analysis esidents are required to develop the skills to understand, order and perform initial interpretation without subspecialist consult requirement esidents are required to understand and be able to appropriately order/request test when indicated Subspecialist consult and co-management or referral are needed for interpretation and further evaluation 5
POEDUES- UNDESTANDING AND PEFOANE SKILLS -Arterial blood gas analysis -Urinary bladder catheterization -Vascular catheter placement (femoral approach) for emergent hemodialysis -enal biopsy -Hemodialysis -Insertion of peritoneal dialysis catheter Learn to perform Learn to perform Learn to perform Observe Observe Observe NEPHOLOGY 6