Internal Flashcards

Question

In conditions with diarrhea, gallstone formation occurs due to: 1) a higher amount of bile is excreted in the faeces 2) endogenous cholesterol production increase 3) loss of bile acid via stool 4) the lithogenicity of the bladder increase A) only answers 1, 2 and 3 are correct B) only answers 1 and 3 are correct C) only answers 2 and 4 are correct D) only answer 4 is correct E) all of the answers are correct

Answer 1

E) all of the answers are correct EXPLANATION In conditions with diarrhea all of the above are involved in contribution of gallstone formation; particularly important is the loss of bile acid, which contributes to the lithogenicity of the bladder.

Answer 2

C) only answers 2 and 4 are correct EXPLANATION A sudden decrease in serum calcium in severe acute pancreatitis means that a significant amount of pancreatic tissue has fallen apart. Because pancreatic tissue is high in fat, endogenous soap (calcium stearate) is formed with calcium. This results in a rapid decrease in calcium levels (characteristic of haemorrhagic and necrotizing pancreatitis).

Answer 3

D) only answer 4 is correct Tinidazole - similar to metronidazole.

Answer 4

C) only answers 2 and 4 are correct EXPLANATION The most common indications for jejunal feeding tube in addition to severe, acute pancreatitis are the difficulty or impossibility of oral nutrition. In the latter case, the situation needs to be considered and resolved as soon as possible. If oral feeding was not restored, PEG insertion is well-founded. In the case of oesophagus stenosis due to tumor the implantation of an expandable metal stent, which is endoscopically placed, restores or significantly improves oral feeding.

Answer 5

D) corticosteroid is indicated for treatment EXPLANATIONPrimary biliary cholangitis (PBC) is an idiopathic cholestatic liver disease, presumably autoimmune in nature. It is predominant in women, and may be associated with scleroderma, the antimitochondrial antibody (AMA), is a typical serological marker of the disease, and may result in elevated levels of serum-IgM. Its treatment is not completely developed, and corticosteroid is not indicated. In its early phase, ursodeoxycholic acid is the most useful medication.

Answer 6

B) metabolic acidosis EXPLANATIONIn severe liver cirrhosis patients, hepatic encephalopathy may be caused by gastrointestinal bleeding, aggressive diuretic therapy, enteral infection, or a large amount of per os protein intake, but not by metabolic acidosis.

Answer 7

D) serum albumin - ascites albumin gradient >11 g/l EXPLANATION In cirrhosis, in which there are no additional complications, ascites develops as the consequence of portal hypertension, and, in such cases, it is typically characteristic of serum albumin - ascites albumin gradient is more than 11 g/l.

Answer 8

E) pruritus EXPLANATION Itchiness may be the primary, early symptom in primary biliary cirrhosis.

Answer 9

D) his protein intake was insufficient EXPLANATION Except in the event of low or diminished protein intake! This does not cause hepatic encephalopathy!

Answer 10

D) autoimmune liver disease EXPLANATION Fatty liver may be caused by metabolic syndrome, coeliac disease, Wilson’s disease and drug-induced liver injury. Autoimmune liver diseases are not associated with the development of fatty liver.null

Answer 11

E) diagnosis is based on detection of HBV RNA EXPLANATION Hepatitis B virus infection is typically preventable in the event of vaccination. Chronic hepatitis develops mostly if and when newborns are infected. HBV incorporates into the host’s genome, therefore it increases the risk of HCC. The diagnostic of chronic HBV infection is based on the detection of HBV DNA, instead of a.

Answer 12

E) usually younger females are affected EXPLANATION The primary biliary cholangitis is typically asymptomatic for a lengthy period of time, therefore, it is usually diagnosed in middle-aged women and not seen in younger women. Itchiness may arise as a primary symptom. The antimitochondrial antibody (AMA) is often positive and circulating immune complexes, and an increased IgM level may also be observed.null

Answer 13

B) IgM EXPLANATION Primary biliary cirrhosis (PBC) is characteristic for the increased serum IgM immunoglobulins.

Answer 14

A) 1., 2. and 3. answers are correct EXPLANATION In immunocompromised patients, chronic hepatitis may be caused by hepatitis B-, C-and E- virus, as well. Hepatitis A-virus does not lead to chronic hepatitis.null

Answer 15

A) 1., 2. and 3. answers are correct EXPLANATION Among the listed statements, the treatment of chronic hepatitis B involves interferon, entecavir and tenofovir.

Answer 16

E) all 4 answers are correct EXPLANATION The most commonly applied therapies in the prevention of the rebleeding of esophageal varices include variceal sclerotherapy or ligation, TIPS implantation, and propranolol and carvediol treatment.

Answer 17

A) 1., 2. and 3. answers are correct EXPLANATION It is true in the case of hepatitis C virus infection, in which it often leads to cirrhosis, over a period of decades, and therefore, increases the risk of HCC. Acute hepatitis is usually symptom-free. If liver cirrhosis is induced by decompensated HCV, the expected survival is shorter than 1-2 years. In the event there is no surgical contraindication, liver transplantation in patients is recommended.null

Answer 18

B) both parts are correct, causative relation does not exist EXPLANATION In approximately 90% of the cases, chronic hepatitis C can be cured with the new direct-acting antiviral therapies inhibiting the replication of the virus. Furthermore, these new medications can be administered to cirrhotic patients who formerly could not benefit from IFN therapy. However, there is no cause-effect relation between the two statements.

Answer 19

C) liver cirrhosis EXPLANATION The case indicates liver cirrhosis.

Answer 20

D) norfloxacin or ceftriaxon EXPLANATION Among the listed medications, norfloxacin or ceftriaxone, are the most recommended treatments for spontaneous bacterial peritonitis.

Answer 21

C) severe steatorrhoea EXPLANATION Abdominal distension and discomfort, ”fullness” feeling and pain under the right ribs are all characteristic to disorders of biliary excretion. However, severe steatorrhoea is characteristic to malabsorption and pancreatic insufficiency. In physiological cases, with a daily 75 g fat intake the daily excreted faeces consists no more than 7 g of fat. However, in cases of malabsorption 20-40% and in cases of pancreatic insufficiences 60% of the daily fat intake can be excreted with the faeces resulting in severe steatorrhoea.

Answer 22

E) 90% EXPLANATION In 90% of the cases there is a joint duct and outlet of the ductus pancreaticus and the ductus choledochus resulting in the so-called Ampulla of Vater. Frequently, and accessorial pancreatic duct also exists (duct of Santorini) ending in the ductus pancreaticus in the majority of the cases, however sometimes an independent outlet may also be present. In 5-10% of the cases, when pancreas divisum exists ductus pancreaticus does not communicate with the ductus choledochus (see also BGY-8.27.

Answer 23

A) 1st, 2nd and 3rd answers are correct EXPLANATION Nitrates, chocolate and cholecystokinin decreases, while morphin increases the spasm of the Oddi sphincter. Cholecystokinin has a pivotal role in the postprandial relaxation of the Oddi sphincter. Chocolate also decreases the spasm of the Oddi sphincter. Additionally, nitrates may be therapeutically applied in cases of biliary colic. Contrary, giving major analgeticum (morphin) in cases of biliary colic is not recommended, because it may result in sphincter spasm enhancing the pain, and it may also mask the clinical manifestation of an acute abdominal catastrophe (perforation of the gallbladder).

Answer 24

A) 1st, 2nd and 3rd answers are correct EXPLANATION Indications for endoscopic sphincterotomy during ERCP include choledocholithiasis, Oddi-sphincter-dyskinesis and acute recidive gallbladder attack resulting in acute pancreatitis. Main aim of the intervention is to assure optimal bile excretion and flow and prevent the emergence of a secondary inflammation. Sphincterotomy is indispensable for the proper removal of a stone, however in cases of carcinoma of the pancreatic head only an operation can be curable. In palliative cases sphincterotomy is also inssufficient, since implantation of a stent is also needed.

Answer 25

C) 2nd and 4th answers are correct EXPLANATION Functional examination of the gallbladder and the bile ducts can be carried out using cholescintigraphy, cholangio-CT and cholangio-MR. During cholescintigraphy, isotope-labeled agents which are metabolised by the hepatocytes and secreted into the bile are administered and detected using gamma camera. In the case of obstruction of the bile ducts when ultrasound examination cannot detect the cause of the obstruction or when ERCP is not recommended, cholangio-CT and cholangio-MR might help the diagnosis. Nowadays classical oral or intravenous cholangiocholecystography is only rarely performed. Intravenous urography is a false answer.

Answer 26

D) only 4th answer is correct EXPLANATION In cases of obstructive jaundice, urinary UBG levels decrease in accordance with the extent of the obstruction an after total obstruction, urinary UBG is no longer detectable. The colour of the faeces is becoming lighter as well resulting in acholic faeces. In cases of prehepatic or hepatic jaundice, urinary UBG levels are elevated. In obstructive jaundice, total bilirubin and direct bilirubin levels are elevated, jaundice occurs in cases of partial obstruction as well.

Answer 27

E) all of the answers are correct EXPLANATIONThe most common complication of gallstones is obstructive jaundice, acute panreatitis and cholecystitis. In 15-20% of gallbladder stone cases, choledocholithiasis is present as well, which is the main cause of the obstructive jaundice. Gallstones jammed into the major duodenal papilla causes acute biliary pancreatitis. In some cases, the resence of gallstone or sludge is not present during the diagnosis, because it has already passed over the major duoenal papilla. In 90% of the acute cholecystitis cases, gallstone jammed into the ductus cysticus is the cause. Local irritation and refractory acute inflammations may cause chronic cholecystitis as well. In 4% of the chronic pancreatitis cases gallstones are the main cause of the disease (see also. BGY-8.17.).

Answer 28

D) the statement is false, but the explanation itself is true EXPLANATION Klatskin tumor, located in the porta hepatis, is usually unresectable at the time of the diagnosis. In case of resectable tumor the local resection has to be combined with liver resection, therefore is considered a hardly feasible operation. As palliative therapy the preparation of biliodigestive anastomosis, surgical or endoscopic stent implantation, chemoembolization, or irradiation come into question. Thus the statement is incorrect, the explanation itself is correct.

Answer 29

D) the statement is false, but the explanation itself is true EXPLANATION Although abdominal ultrasound is very efficient in detecting gallbladder stones, in the diagnosis of bile duct stones, despite of good specificity (80 percent) the sensitivity is low (60 percent), therefore ultrasound is unreliable in detecting bile duct stones. In case of suspicion of bile duct stones, exact diagnosis can be expected from invasive methods (ERCP, rarely percutaneous transhepatic cholangiography, PTC). Modern imaging methods (CT, CT-cholangiography, MR) have differential diagnostic role. Therefore the statement is incorrect, the explanation itself is correct.

Answer 30

E) both the statement and the explanation are false EXPLANATIONBile acid treatment dissolves or reduces gallstones in 1-3 years in 50-60 percent of patients. Great disadvantage of stone solution is its expense, and that after the cessation of treatment the stones recur shortly in 30-50 percent of cases. The definitive treatment of cholelithiasis is cholecystectomy. Thus both the statement and the explanation are incorrect (see also BGY-8.20.).

Answer 31

E) all of the answers are correct EXPLANATION All four examinations may help setting the diagnosis. Increased white blood cell count may refer to cholecystitis; elevated serum-amylase may confirm biliary pancreatitis; complete urinalysis, through the changes of bilirubinuria and urobilinogenuria may help differentiate between hepatocellular and mechanical icterus; direct bilirubin level my refer to the severity of jaundice and the extent of mechanical obstruction.

Answer 32

D) hydrops vesicae felleae EXPLANATION 'The symptoms are typical for biliary colic. The painful, fluctuating resistance palpated during physical examination after the colic is gallbladder hydrops, that develops as a consequence of a gallstone stuck in the cystic duct. In old patients the hydrops has to be differentiated from the nontender gallbladder accompanied with escalating jaundice without colic (Courvoisier’s sign), which is typical for carcinoma of the ampulla of Vater and head of pancreas (see also BGY-8.13.).

Answer 33

C) 2nd and 4th answers are correct EXPLANATION Medical treatment consists of complete fasting, fluid and electrolyte replacement, symptomatic treatment (parenteral analgesics and spasmolytics), and in case of inflammatory signs, also parenteral antibiotics. The definitive solution is cholecystectomy. According to the modern surgical approach, the preferred method is the so called early laparoscopic cholecystectomy, i.e. the operation has to be carried out within 24-72 hours after the presentation of symptoms. With early cholecystectomy severe, often life threatening complications (acute cholecystitis, gallbladder perforation, cholangitis, acute pancreatitis) can be prevented, hospitalization is shorter, treatment is less expensive.

Answer 34

C) ERCP EXPLANATION Certain diagnosis is provided by ERCP, that accurately localizes the bile duct obstruction and gives information about the degree of obstruction. If ERCP cannot be carried out due to technical reasons or the general state of the patient, a non-invasive MR-cholangiography may help in the diagnosis. If endoscopy is insolvable (e.g. after Billroth’s II resection of the stomach, significant duodenum stenosis etc.), percutaneous transhepatic drainage may lead to diagnosis and serve as palliative treatment

Answer 35

C) 2nd and 4th answers are correct EXPLANATION Elevated erythrocyte sedimentation rate (ESR) and elevated CEA level may help setting the diagnosis. However, it has to be emphasized, that normal ESR does not exclude the possibility of malignancy; the sensitivity and specificity of CEA in bile duct (Klatskin) tumour is low (high level is found in only 20 percent of cases). CRP and LDH are less helpful in the diagnosis because of low specificity and sensitivity.

Answer 36

D) bile duct tumour (Klatskin) EXPLANATION Besides the anamnesis (old patient, weight loss, jaundice) the dilated intrahepatic bile ducts without extrahepatic dilation refer to proximal hilar bile duct (Klatskin) tumour. Weight loss and the lack of gallstones are against cholecystitis; elderly age, weight loss, dilated intrahepatic bile ducts are against acute hepatitis and primary biliary cirrhosis. In pancreas head carcinoma primarily the extrahepatic bile ducts are dilated.

Answer 37

B) ERCP, stent implantation EXPLANATION In case of resectable tumour the treatment of choice is naturally surgical resection. Klatskin tumour located in the hepatic hilum is often unresectable at the time of diagnosis. Therefore the solution of jaundice and possible palliative treatment may be stent implantation during ERCP. The resectability of the tumour is determined during surgical exploration after the cessation of jaundice.

Answer 38

B) 1st and 3rd answers are correct EXPLANATION Recurring cholangitis may appear in Caroli syndrome, with symptoms like shaking chills and fever and the development of septic state. Recurring cholangitis is caused by stasis and bacterial infection in the dilated bile ducts. Caroli syndrome = cystic dilation of intrahepatic bile ducts. Autosomal recessive.

Answer 39

B) 1st and 3rd answers are correct EXPLANATION In Caroli syndrome both the dilation of intrahepatic bile ducts and bile duct stenosis may be present, thus B is the correct answer.

Answer 40

B) 1st and 3rd answers are correct EXPLANATION Mirizzi’s syndrome is characterized by obstructive icterus and dilated hepatic duct, because the stone in the gallbladder fundus presses the common bile duct, with the mentioned symptoms as consequences. Mirrizi syndrome= stone in cystic duct that compresses the hepatic bile duct.

Answer 41

D) only 4th answer is correct EXPLANATION After cholecystectomy, diarrhoea may develop due to the constant bile flow.

Answer 42

D) only 4th answer is correct EXPLANATION D is the correct answer, because juxtapapillary diverticulum raises the risk of bile duct stone by a supposed bile flow obstruction. It does not cause chronic liver disease, endoscopic papillotomy is not contraindicated anymore, and it is not often associated with bile duct malformations. Juxtapapillary diverticulum=outpouching of duodenal wall??

Answer 43

D) only 4th answer is correct EXPLANATION D is the correct answer, because nonalcoholic steatohepatitis does not cause acalculous cholecystitis. The conditions listed as 1., 2., 3. cause gallbladder dysfunction, and therefore may lead to cholecystitis.

Answer 44

B) cationic trypsin EXPLANATION Cationic trypsin mutations are responsible for two-thirds of hereditary pancreatitis, mutations in other enzymes do not cause pancreatitis. Bile flow is blocked by the obstructed and compressed choledochus by a pancreas head cancer. The cholecyst is intact, stretching, but it cannot compensate to the obstructive icterus. In the other diseases the cholecyst does not expand, because it is inflamed and ill, or there is no distal choledochus obstruction.

Answer 45

B) It encodes a protein called pancreatic secretory trypsin inhibitor. EXPLANATION The human SPINK1 gene is located on chromosome 5, it is 7.1 kilobases long, it contains 4 exons and it encodes a protein of 6.3 kilodaltons, a physiological inhibitor of trypsin named pancreatic secretory trypsin inhibitor. This genetic alteration is present in 16% of the idiopathic patients, but it rarely occurre in cases with hereditary or family accumulation. Unlike PRSS1 gene mutations, that can not be found in healthy people.

Answer 46

D) ERCP EXPLANATION Endoscopic retrograd cholangiopancreatography is still the most sensitive and most specific of the listed imaging techniques in chronic pancreatitis, but it can be soon replaced by dynamic MRCP in this diagnostic function.

Answer 47

A) percutaneous drainage EXPLANATION Percutaneous drainage should not be selected for chronic pseudocysts, because the cyst comes back, since the cavity is usually connected with the pancreatic duct.

Answer 48

E) pancreatic division EXPLANATION Mutations in the CFTR molecule can cause or increase the risk of pancreatitis or cystic fibrosis. The pancreatic division is an anatomical disorder, that is not related to the mutation of the CFTR gene.

Answer 49

D) only the 1. answer is correct EXPLANATION Pancreatic tumors mainly origin from the ductal cells, their prognosis is not good at all. The five-year survival rate is below 5%. They usually develop silently and asymptomatic. The first symptom is often the jaundice of the patient. Cytostatic therapy can lengthen the survival time only minimal. In case of severe stricture of the pancreatic duct pancreatitis may be induced.

Answer 50

D) the first is wrong, the second is correct in itself EXPLANATIONThe bile flow is blocked by the choledochus obstructed and compressed by a pancreas head cancer. The cholecyst is intact, stretching, but it cannot compensate to the obstructive icterus. Cholecyst does not expand in case of pancreatic tail tumors, and there is no distal choledochus obstruction.

Answer 51

D) the first is wrong, the second is correct in itself EXPLANATION Pancreatic calmness and reduction of secretion can be achieved with high-protease pancreatin by inhibiting duodenal CCK release. The lipase has no effect on feedback, and on pancreatogenic pain.

Answer 52

C) 2., 4., 6., 8., 9., 10. and 11. answers are correct EXPLANATION It does not means a good prognosis at the 48. hour of the observation, if hematocrit, urea nitrogen, calcium, arterial pO2, bicarbonate, albumin and C-reactive protein are significantly impaired.

Answer 53

B) 20–30% EXPLANATIONBased on data in the literature, 20-30% of patients with Type 1 diabetes, and 40% of patients with Type 2 diabetes are found to develop diabetic nephropathy. Prevalence of DM1 in gen pop: 0.2%

Answer 54

C) administration should be suspended by two days prior to the examination EXPLANATIONType 2 diabetic patients treated with Metformin should suspend taking the medicine by two days prior to any examination that uses contrast agent. In addition to monitoring the blood glucose levels closely, if necessary, insulin therapy may be transiently applied. It is essential to control the renal function after the procedure, and Metformin therapy could be continued after 48 hours from the examination only if the GFR is above 30 ml/min/1.73 m2; as if GFR is below that value the use of Metformin is contraindicated. Addition of iodinated contrast agents intravenously could be nephrotoxic, and the deterioration of renal function may lead to the accumulation of Metformin to toxic levels thus leading to lactic acidosis. In diabetic patients with renal failure as hypoglycemic treatment the sulphanylurea class drug Gliquidone (or possibly Gliclazide), pioglitazone, certain DPP-4 inhibitors, and insulin could be administered.

Answer 55

C) in the stage of microalbuminuria EXPLANATION Stages in the development of diabetic nephropathy: I. Hyperfiltration, hypertrophy II. Glomerular tissue damage without clinical symptoms III. Incipient nephropathy (microalbuminuria) IV. Overt diabetic nephropathy V. Renal insufficiency

Answer 56

B) increased protein intake EXPLANATIONStages in the development of diabetic nephropathy: I. Hyperfiltration, hypertrophy II. Glomerular tissue damage without clinical symptoms III. Incipient nephropathy (microalbuminuria) IV. Overt diabetic nephropathy V. Renal insufficiency

Answer 57

B) approx. 5 years after the diagnosis was established EXPLANATIONSee the explanation of question 10.3.

Answer 58

A) upon establishing the diagnosis

Answer 59

B) if the patient has diabetic retinopathy but no haematuria

Answer 60

B) is a chronic kidney disease caused by NSAIDs EXPLANATION The occurrence of analgesic nephropathy is especially common in countries where different pain relievers are available ‘over the counter’ without prescription. Amongst analgesics, those ones that contain phenacetine or combined formulas possess nephrotoxic effects. In analgesic nephropathy, as a consequence of chronic analgesic effect (most commonly after taking phenacetine or combined medications, less often in the case of taking regularly NSAIDs for years) predominantly papillanecrosis and chronic tubulointerstitial damage develop (urine concentrating ability decreases, macroscopic haematuria and sterile pyuria are present etc.), and calcification of the necrotic papillae is also commonly observed. In overt nephropathy, progression of kidney involvement can be attenuated by the cessation of analgesic abuse, or it could be even prevented in the case of minor changes. For the early diagnosis of analgesic nephropathy, taking detailed history from the patient seems essential, and in suspect cases renal ultrasound or CT scan examination is required. Examinations of i.v. urography and cystography are not suitable for the diagnosis of analgesic nephropathy.

Answer 61

A) answers 1., 2. and 3. are correct

Answer 62

C) answers 2. and 4. are correct EXPLANATION The light microscopy analysis of IgA nephropathy most frequently indicates mesangial proliferative glomerulonephritis that features both mesangial cell and matrix proliferation. The immunohistology shows IgA and C3 deposition mainly in the mesangium. By electronmicroscopy, the mesangial immune deposits are also apparent. The disease regularly begins and later resumes with macroscopic haematuria following an upper respiratory infection. Clinically, it is characterized by mild proteinuria and haematuria of typically glomerular origin with dysmorphic RBCs (‘Mickey mouse cells’). Nephrotic syndrome may be observed in less than 5% of cases. Long-term follow-up data revealed that majority of patients have slow progression to which the onset of hypertension is contributing as well. Acute post-streptococcal glomerulonephritis is caused by the so-called nephritogenic strains of the β-haemolytic streptococci. Clinical symptoms typically manifest 10-14 days after acute tonsillitis, and 14-21 days after skin infectious disease (pyoderma). At that time, inflammatory signs or fever could not be observed. Typical laboratory findings include the increase of Antistreptolysin O titers and the decrease of complement levels in the serum. Initial symptoms may be symmetrical eyelid oedema and headache due to the development of hypertension.

Answer 63

A) answers 1., 2. and 3. are correct EXPLANATION Beside the gradual loss of tubular and glomerular functions, the concomitant loss of endocrine function also develops during the development of chronic renal failure. In the conservative treatment of chronic renal failure, the control and correction of anaemia, bone metabolism disorders (hypocalcaemia and hyperphosphataemia due to reduced vitamin D synthesis), potassium metabolism disturbances (hyperkalaemia), and fluid imbalance (compensatory polyuria) is mandatory. The primary cause of anaemia in chronic renal failure is the decreased production of erythropoietin by the medullary interstitial cells. To the development of anaemia, contributions of the bone marrow depressing effect by uraemic toxins (to which the developing metabolic acidosis also contributes), the short life-span of erythrocytes, and disturbed absorption of iron and B12 in uraemia are also present.

Answer 64

A) answers 1, 2 and 3 are correct EXPLANATION Alterations in chronic kidney failure described by ultrasound are as follows: the length of the kidney is usually < 10 cm; the parenchyma is hyperreflective; the parenchyma thickness is < 10 mm; the surface of the kidneys is finely roughened, while in certain diseases it shows deeper incisions (e.g. chronic pyelonephritis, analgesic nephropathy). In acute kidney injury normal or enlarged kidney size could be found.

Answer 65

B) answers 1. and 3. are correct EXPLANATION Significant bacteriuria in young women should be treated only if they are pregnant or have complaints suggesting urinary infection. The presence of haematuria per se is not indication for antibiotic treatment.

Answer 66

A) answers 1, 2 and 3 are correct ``` EXPLANATION Acute (hypersensitive) tubulointerstitial nephritis is usually caused by drugs which can act as haptenes (e.g. β-lactam antibiotics, sulphonamides, NSAIDs, diuretics, allopurinol etc.). As a result of immune response, the symptoms of fever, maculopapular rash, arthralgia, eosinophilia, eosinophiluria, sterile pyuria, and urinary leukocyte cylinders may develop. Hypertension is not typical in this disorder. ```

Answer 67

C) answers 2. and 4. are correct

Answer 68

B) answers 1. and 3. are correct

Answer 69

E) all of the answers are correct EXPLANATION In chronic kidney disease, the development of renal failure could be prevented by attenuating the disease progression, thus commencement of renal replacement therapy may be delayed. In addition to specific treatments (e.g. efforts to maintain euglycaemia in diabetic nephropathy), non-specific therapeutic options also play important roles, including: 1. Antihypertensive treatment: decreases the systemic and glomerular hypertension 2. RAAS inhibitor treatment: additionally to decreasing the systemic and glomerular pressure it has other favourable effects 3. Dietary protein restriction: reduces hyperfiltration induced by excessive protein intake, and decreases the excretion of nitrogen metabolites 4. Optimal blood pressure control with drugs having neutral effects on metabolism is an important factor in the treatment of hypertension related to the renal disease in order to decrease renal progression 5. Statin treatment beside the diet could decrease renal progression not only by decreasing dyslipidaemia, but also by other pleitropic beneficial effects, for example by reducing the proteinuria

Answer 70

A) answers 1., 2. and 3. are correct

Answer 71

E) all 4 answers are correct EXPLANATION Hyperkalaemia may develop from iatrogenic causes or as a consequence of certain disease states, leading to possibly life-threatening condition. Intravenously administered calcium may be used to prevent cardiac arrhythmias. During acute treatment, higher potassium level could be primarily lowered by using insulin + glucose infusion, furosemide, and physiological saline infusion, and inhaled beta receptor agonists. In chronic therapy, dietary potassium restriction and potassium-binding resins could be applied. If these conservative methods are ineffective, dialysis may be necessary

Answer 72

A) both are correct, there is a causal relationship between the two, EXPLANATIONSee explanation for question 10.3.

Answer 73

C) the first is correct, the second is incorrect

Answer 74

C) the first is correct, the second is incorrect EXPLANATIONSee explanation for question 10.34

Answer 75

C) hyperparathyroidism, pancreas neuroendocrine tumor, pituitary adenoma EXPLANATION Multiple endocrine neoplasia type 1 (MEN1) is an endocrine tumor syndrome with autosomal dominant inheritance. The disorder is caused by the mutations of the MEN1 gene encoding menin protein. Its main manifestations are primary hyperparathyroidism (in about 90% of cases), pituitary adenoma (in 30-75% of cases) and neuroendocrine tumor of the pancreas (in 10-60% of cases). Primary hyperparathyroidism usually appears as the first component of the syndrome, in young (20-30-year-old) adults. In patients suffering from MEN1 syndrome foregut carcinoid tumor (thymus, bronchus, stomach), adrenocortical tumor (most commonly hormonally inactive adenoma) and non-endocrine tumors (lipoma, angiofibroma, collagenoma) may also appear, but these tumors are considered accessory components of the syndrome. Patients and relatives carrying the disease causing mutation have to be screened regularly for these tumors. Pheochromocytoma and medullary thyroid cancer are components of multiple endocrine neoplasia type 2 (MEN2), not MEN1. Leydig cell tumor is also not a component of MEN1 syndrome, but Carney complex

Answer 76

C) investigation of the serum growth hormone (GH) concentration during oral glucose tolerance test EXPLANATION In normal patients - a high glucose in blood would cause GH production to decrease. In acromegaly (incr. GH after fusion of growth plates) GH stays elevated during OGTT. Growth hormone (GH) secretion is characterized by a diurnal rhythm and pulsatile excretion. The most important characteristic of diurnal rhythm is GH secretion during night sleep and consecutive high serum GH level, while pulsatile excretion manifests itself in high GH peaks about 13 times a day. Because of the intense variability of GH secretion, the determination of morning serum GH level and diurnal rhythm of serum GH is not suitable for diagnosing acromegaly. Serum GH measurement after the administration of growth hormone-releasing hormone (GHRH) is used to examine the GH-producing ability of the pituitary; it is applied not in the diagnosis of acromegaly, but in GH deficiency. For the confirmation or exclusion of acromegaly the most commonly used and most reliable method is serum GH determination during oral glucose tolerance test (OGTT). Acromegaly is confirmed, if serum GH level remains above 1 ng/ml in blood samples taken every 30 minutes for two hours after the administration of 75 grams of glucose. If OGTT is not feasible (e.g. in diabetic patients) GH profile examination is recommended (e.g. serum GH measurement every 30 minutes 7-12 times).

Answer 77

D) pheochromocytoma EXPLANATION Diarrhea is a leading symptom of carcinoid syndrome evolving in case of carcinoid tumors. Gastrinoma, besides other symptoms (like recurrent multiple peptic ulcers that hardly react to treatment), is also characterised by diarrhea. Diarrhea is also common in case of medullary thyroid cancer with multiple metastases and significantly elevated serum calcitonin level. In contrast to these three tumors, pheochromocytoma is characterized by constipation due to the mesenteric vasospasm caused by catecholamine overproduction.

Answer 78

D) investigation of serum cortisol in morning hours EXPLANATION For the screening of Cushing’s syndrome we use tests that determine the daily integrated cortisol secretion, the diurnal rhythm of cortisol secretion, and the feed-back regulating function of the pituitary-adrenal axis. These tests include the examination of 24 hour urine cortisol, diurnal rhythm of serum or saliva cortisol (in samples taken at midnight and between 8-9 o’clock in the morning), and serum cortisol level after the administration of low dose dexamethasone (in the so-called low dose overnight dexamethasone test serum cortisol is measured from a sample taken between 8-9 o’clock in the morning, after having administered 1 mg dexamethasone the previous midnight). Stressful circumstances can significantly increase serum cortisol level, and on the other hand Cushing’s syndrome can be present without the significant elevation of morning serum cortisol (because of the lack of diurnal rhythm, i.e. failure of the physiologic decrease of cortisol level after the morning hours). Thus serum cortisol examination in the morning alone is not sufficient for the screening of Cushing’s syndrome in the clinical practice.

Answer 79

E) SIADH (syndrome of inappropriate antidiuretic hormone secretion) ``` EXPLANATION Polyuria (and polydipsia) are well-known symptoms of diabetes insipidus and diabetes mellitus; in total central diabetes insipidus the lack of antidiuretic hormone (ADH) can cause as much as 18-20 liters of urine daily. Primary aldosteronism with prolonged hypokalemia and primary hyperparathyroidism with prolonged hypercalcemia cause the insensitivity of the vasopressin receptors of the kidney tubules (renal diabetes insipidus), and thus lead to polyuria in these diseases. Out of the listed diseases only SIADH (syndrome of inappropriate ADH secretion) is not associated with polyuria. ```

Answer 80

E) all four answers are correct EXPLANATION All four listed symptoms are characteristic for Graves’ disease (diarrhea, tachycardia, pretibial myxedema, fine hand tremor).

Answer 81

E) all four answers are correct EXPLANATION All of the listed hormones are glycoprotein hormones (TSH, LH, hCG, FSH). The common trait of this hormone family is that all members consist of two subunits; the alpha-subunit is identical in all four hormones, while the different beta-subunits are responsible for the specific biological effect of the various glycoprotein hormones.

Answer 82

E) all four answers are correct EXPLANATION The members of the chromogranin family are proteins stored in the secretory granules of neuroendocrine cells; during hormone release they are let out of the cells together with the hormones and get into the blood, where their concentration can be determined. Chromogranin A examination is used as a specific serum marker of neuroendocrine tumors. High serum chromogranin A concentration is found in carcinoid tumors, gastrinoma, insulinoma and pheochromocytoma. Examination of serum chromogranin A helps in the diagnosis of all four listed tumors.

Answer 83

E) all four answers are correct EXPLANATION Thyrotoxic crisis is a life-threatening state, for which the use of all listed therapeutic tools may be necessary. For the inhibition of thyroid hormone synthesis thyrostatics, for the moderation of the increased adrenergic activity beta-adrenergic receptor blockers, and iodine products are given. The elimination of thyroid hormones can be facilitated with plasmapheresis. Besides the listed therapeutic tools, the administration of glucocorticoids and the correction of fluid and electrolyte balance is necessary.

Answer 84

B) answers 1. and 3. are correct EXPLANATION Subacute granulomatous thyroiditis (de Quervain’s thyroiditis) is a disease associated with the painful swelling of the thyroid gland and fever. Its cause is unknown; upper airway inflammation often precedes its development. The most important laboratory sign is the significantly elevated ESR; thyroid hormone examinations may show different alterations depending on the phase of the disease. At the beginning of the disease hormone levels respective of primary hyperthyroidism are found (suppressed serum TSH and elevated free T4 and free T3), while later these become normal, and a transient primary hypothyroidism evolves (high serum TSH, low free T4 and free T3). The transient primary hypothyroidism heals spontaneously, and the subacute granulomatous thyroiditis does not cause sustained or permanent primary hypothyroidism. After healing recurrence is very rare.

Answer 85

B) answers 1. and 3. are correct EXPLANATION In case of differentiated thyroid cancer radioiodine ablation is applicable after total (near total) thyroidectomy. Its condition is high serum TSH level, that can be achieved by the discontinuation of thyroid supplementation for a certain time, or the administration of TSH products prior the radioiodine ablation. Without thyroidectomy the high radiation dose used against cancer would cause the radiation injury and severe inflammation of the thyroid gland and the neck region. For this reason radioiodine ablation can only be applied after a total (near total) thyroidectomy.

Answer 86

B) answers 1. and 3. are correct EXPLANATION Primary adipsia evolving because of the injury of the hypothalamic thirst center leads to severe neurological symptoms. Due to the lack of thirst fluid intake is dangerously decreased, that may cause severe hypernatremia and consecutive central nervous system symptoms, coma and death. Long-term prognosis is pronouncedly bad, though the attending care of the patient to reach sufficient fluid intake may reduce the risk of severe hypernatremia. In vigilant patients the most simple primary treatment is giving water through nasogastric tube. In contrast to hypernatremia in primary adipsia, ADH overdosage causes hyponatremia.

Answer 87

C) the first clause is correct, the second clause is incorrect EXPLANATION The first statement is true, the second is false. In contrast to Addison’s disease, for the treatment of secondary adrenal insufficiency presenting as part of panhypopituitarism, mineralocorticoids are rarely used, but similar doses of glucocorticoids are given in both secondary adrenal insufficiency and Addison’s disease. In contrast to Addison’s disease involving insufficient adrenal glucocorticoid, mineralocorticoid and androgen synthesis, in secondary adrenal insufficiency the production of mineralocorticoids regulated by the renin-angiotensin system is not disturbed. Thus mineralocorticoid substitution is rarely needed in secondary adrenal insufficiency.

Answer 88

A) both are correct, with cause-effect relationship EXPLANATION Both parts of the sentence are true, with cause-effect relationship. In untreated primary hypothyroidism, hyperprolactinemia and in women galactorrhea-amenorrhea syndrome are often present. This can be explained by the stimulating effect of the enhanced thyrotropin-releasing hormone (TRH) on prolactin secretion.

Answer 89

C) acute gout attack EXPLANATION The most common cause of secondary gout is diuretic treatment (thiazides, furosemide, etacrin acid). These diuretics inhibit the tubular secretion of urate, paving the way for an acute gout attack

Answer 90

B) diuretic treatment

Answer 91

B) 24-hour urine urate output should be measured, and a uricosuric medication should be started in case of a low value. Treatment of hyperuricemia may require inhibition of urate synthesis (allopurinol) as well as promotion of urate excretion (probenecide, sulfinpyrazone, benzbromarone). Angiotensin-receptor blockers also have some uricosuric effect. If low urate excretion is observed despite high serum urate levels, uricosuric agents are suggested. Urate concentration can reach high values in the urine, therefore, alkalization is required to prevent urate stone formation. It must be noted, that a sudden change in serum urate levels (due to either allopurinol or an uricosuric drug) may provoke an acute gout attack. Therefore, starting treatment with low dose of the drugs is necessary, and the dose has to be titrated up gradually.

Answer 92

A) decreased renal elimination of uric acid 90% due to decr. renal excretion, 10% due to increased production of urate (i.e. D)). Urate precipitates better in low pH, low temp and with high urate conc. (i.e. in peripheral extremities and kidneys)

Answer 93

D) ochronosis EXPLANATION Ochronosis is a syndrome caused by the accumulation of homogentisic acid and its derivatives in connective tissues. It is caused by the disturbed catabolism of tyrosine (homogentisate oxidase defect, alkaptonuria). The disease results in early appearance of joint degeneration (arthrosis).

Answer 94

A) 20–40 U The average daily insulin secretion of a healthy adult is 20-40 U. Endogenous insulin is produced by β-cells and secreted to the portal circulation from which it reaches the liver. 50% of all insulin is bound by the liver and exerts its effects, whereas the remaining 50% reaches peripheral tissues. Exogenous insulin treatment provides a completely different route. From the subcutaneous tissues insulin reaches the pulmonary and the systemic circulation, and then it reaches the liver through the hepatic artery. This results in peripheral hyperinsulinism and hepatic hypoinsulinism. As compared to the physiologic secretion, larger doses of insulin are required to achieve adequate insulin effect. Exogenous insulin need may be smaller if the patient still has endogenous insulin secretion. Basal insulin need: 60% prandial, 40% basal

Answer 95

E) all of the listed

Answer 96

E) all of the listed above

Answer 97

A) intensive conservative treatment in type 2 DM: ANY of the listed.

Answer 98

C) glucagon EXPLANATION Alcohol influences the activity of various enzymes, therefore, alcoholics tend to have depleted hepatic and muscular glycogen sto'res. Glucagon enhances glycogenolysis and glyconeogenesis in the liver.

Answer 99

C) sugar cubes, coffee sugar, granulated sugar, food containing complex carbohydrates EXPLANATION The digestion of polysaccharides is impeded by α-glucosidase enzyme inhibitors, and remains incomplete. They are not degraded into absorbable glucose.

Answer 100

A) answers 1,2 and 3 are correct

Answer 101

B) all answers are correct

Answer 102

B) all answers are correct

Answer 103

B) all answers are correct

Answer 104

D) Adalimumab EXPLANATION Adalimumab is a TNF-alpha inhibitor. Anti TNF agents can cause SLE, therefore they are contraindicated in SLE. The other agents can be used in the therapy of SLE.

Answer 105

A) Polyarteritis nodosa EXPLANATION Polyarteritis nodosa is usually ANCA-negative, the others are ANCA-associated. Granulomatous vasculitis and Wegener-granulomatosis are two names of the same disease.

Answer 106

C) Anti-beta2-glycoprotein I EXPLANATION Among many similar-sounding antibodies beta-2 glycoprotein I is the correct. It is a cofactor of cardiolipin, autoantibodies are formed against it. There is anti-annexin V, but there is no anti-apexin V, and cardiotliptin is an obviously mistake, too.

Answer 107

B) Anti-U1 RNP EXPLANATION Anti-U1-RNP is the most specific (near 100%) autoantibody of MCTD with a diagnostic value. Others can occur too in a small number of MCTD patients, but they are not specific.

Answer 108

C) Sclerosis multiplex EXPLANATION Sclerosis multiplex affects the nervous system, the others are truly polysystemic.

Answer 109

B) HLA-A1-B8-DR3 EXPLANATION The HLA-A1-B8-DR3 genetic constellation is typical in many autoimmune diseases. DQ2 is typical in celiac disease, B27 in spondylarthropathies, B7 in psoriasis.

Answer 110

E) Sjögren’s syndrome EXPLANATIONPrevalence of Sjögren syndrome can approach 0,5-1%, the others are much less common.

Answer 111

E) Esophageal dismotility EXPLANATIONEsophageal dismotility is truly an organic symptom of systemic sclerosis, but is not among the major and minor ACR diagnostic criteria.

Answer 112

D) Beta receptor blockers EXPLANATION All agents are vasculoprotective, but beta-blockers enhance Raynaud’s phenomenon and microvascular disorders, therefore they are contraindicated in scleroderma.

Answer 113

B) Intensifying weakness of distal muscles EXPLANATION In poly-dermatomyositis, intensifying weakness of proximal muscles is typical.

Answer 114

D) Infliximab EXPLANATION Infliximab is a TNF inhibitor, there were clinical tests using it in Sjögren’s syndrome, but it was ineffective.

Answer 115

B) Swelling of the back of the hand EXPLANATION Swelling on the back of the hand is in this criteria system. Swelling of the fingers is in the Kahn-system, the others are parts of MCTD, but are not in any criteria system.

Answer 116

A) 1. and 3. are correct ``` EXPLANATION Wegener granulomatosis (granulomatous vasculitis) affects the small vessels, MPA is ANCA-associated. PAN is not ANCA-associated, Takayasu-arteritis affects the large vessels and Churg-Strauss syndrome is ANCA-associated. ```

Answer 117

E) all answers are correct

Answer 118

C) Goal of ventilation is controlled hypercapnia.

Answer 119

D) Increased FiO2 (inspired oxygen fraction) shifts the curve to the right

Answer 120

C) Effects of succinylcholine can be counteracted with neostigmine. Succinylcholine = depolarizing agent.

Answer 121

D) antihistamines

Answer 122

C) insulin, if blood glucose is >10mmol/L high blood glucose worsens survival (but so does strict glucose control). Blood glucose should be kept <10mM.

Answer 123

A) enteral nutrition parenteral supplementation of nutrition indicated after 7 days, if goal not reached with enteral nutrition. But, If enteral nutrition is NOT POSSIBLE - then parenteral nutrition within 3 days.

Answer 124

B) High inspiratory pressures should be avoided at all costs, since pressure correlates with barotrauma and mortality.

Answer 125

D) renal replacement therapy

Answer 126

D) adenosine therapy EXPLANATION The 2015 ERC guideline’s tachycardia algorithm advises in the case of arrhythmia to assess whether the patient is stable or unstable. Signs of shock, syncope, myocardial ischemia or heart failure verify the patient is unstable. Since the aforementioned patient has stable vitals, synchronized DC shock is not advised. The tachycardia is narrow QRS and regular, therefore supraventricular, indicated a treatment of adenosine 6mg (repeated as a 12mg dose if needed). Since circulation is maintained, BLS is not indicated in this scenario. Amiodarone is not first line treatment in supraventricular tachycardia.

Answer 127

D) give atropine

Answer 128

B) Invasive ventilation with high PEEP and volume controlled mode He has ARDS (CXR image)

Answer 129

RC) Smoking cessation in the preoperative period (1-2 week prior) Smoking has to be stopped atlas 8 weeks prior. This bco if stopped just 2 weeks before - it can cause incr. mucus etcetc..

Answer 130

B) Metabolic acidosis needs to be corrected according to the following equation: NaHCO3 mmol = -BE x 0,3 x kg Correction of metabolic acidosis is only advised in severe hyperkalemia and hemodyn. install. Correction is not based on calculation. It is based on pH.

Answer 131

C) 2000 ml isotonic, balanced crystalloid therapy is needed with further therapy based on monitored parameters.

Answer 132

B) 900 mOsm/l osmolarity infusion can be administered through a peripheral line. Needs to be below 850mOsm/L.

Answer 133

C) Etomidate-fentanyl iv. induction and sevoflurane maintenance for valve replacement operation for a cordal rupture causing cardiogenic shock

Answer 134

B) persistent respiratory failure, reintubation

Answer 135

A) large amount of normal saline infusion AG = (Na+ + K+) – (HCO3- + Cl-), normal value: 8-16 mmol/L

Answer 136

B) Average survival time after lung transplantation is 15 years. average: 5-10 years.

Answer 137

A) Insertion of the epidural catheter can be done through a Touhy needle.

Answer 138

A) Bradycardia hyperdynamic shock = distributive type of shock. Common causes Sepsis or SIRS. TACHYCARDIA with hypotension.

Answer 139

B) 1st, 3rd and 6th answers are correct Se at 4) inneholder POTASSIUM.

Answer 140

A) 1st, 2nd, 3rd and 6th answers are correct

Answer 141

C) 1st, 3rd, 4th and 5th answers are correc

Answer 142

A) 1st, 2nd and 6th answers are correct ``` The following are distributive (vasodilator shock) shock types: sepsis, toxic shock syndrome, chemical intoxications, anaphylaxia, neurogenic shock, endocrine shock (thyrotoxicosis, diabetic ketoacidosis). ``` Burns: hypovolemic shock.(DKA can also cause hypovolemic shock)

Answer 143

D) all of the answers are correct

Answer 144

C) ataxia teleangiectasia

Answer 145

C) 15–17 weeks chorionic villous sampling; 10-12 weeks

Answer 146

B) Gardner syndrome Gardner= GI polyposis. VHL=tumors and cysts everywhere. (AD) Neurofibromatosis = most common tumor syndrome - alterated RAS signaling. (AD)

Answer 147

B) Klinefelter syndrome

Answer 148

C) the frequency of carriers is 1/500

Answer 149

E) Rett syndrome EXPLANATION Four main disorders constitue the trinucleotide repeat disorders: fragile X syndrome, myotonic dystrophy, Huntington’s disease and Friedreich’s ataxia.

Answer 150

D) von Hippel–Lindau disease Cowden - mutation of PTEN - predisp. to breast cancer. Li fraumeni = mutation of p53

Answer 151

B) detection of Clostridium difficile A+B toxins in stool specimens EXPLANATION Clostridium difficile is naturally present in the guts of some humans therefore stool culture does not confirm the diagnosis. Detection of toxin in diarrheic stool proves pathogenic role of Clostridium difficile. If the toxin is detectable from stool with normal consistency it means carrier state.

Answer 152

B) flucloxacillin EXPLANATION Antistaphylococcal penicillins are the most effective antibiotics against Staphylococcus aureus therefore this group of antibiotics is the best first choice in severe infections. If the patient has penicillin allergy (which has been confirmed) then first generation cephalosporins or glycopeptides could be used.

Answer 153

C) clinical features

Answer 154

D) ceftriaxone

Answer 155

C) Streptococcus pneumoniae

Answer 156

D) yersiniosis

Answer 157

C) rheumatic fever EXPLANATION In bacterial endocarditis splenomegaly, septicemia and splenic infarction caused by septic emboli are common, and these can be diagnosed by physical examination and ultrasonography. In subacute bacterial endocarditis, which used to be considered as a distinct entity, the Schottmueller triad is a usual abnormality. The heart disease is associated with splenomegaly and hematuria; this latter is caused by renal infarctions due to septic embolization. Splenomegaly can also occur is various forms and stages of malignant lymphomas. In typhoid fever, it is a characteristic sign (see BGY-19.1. question). Rheumatic fever is not associated with splenomegaly.

Answer 158

D) epidemic typhus Epidemic typhus= Caused by ricketsia species. Does not cause leukopenia. Typhoid fever = caused by salmonella. Causes leukopenia.

Answer 159

C) chronic diuretic administration EXPLANATION The long-term administration of thiazide-type diuretics decrease urate clearance, resulting in hyperuricemia

Answer 160

A) nephrotic syndrome EXPLANATION Isolated ascites means that pathological fluid accumulation occurs only in the abdominal cavity without being part of a generalized edema (such as in nephrotic syndrome). Isolated ascites is expected to occur in conditions marked with B, C and D.

Answer 161

D) to confirm that retrosternal pain is caused by reflux disease

Answer 162

B) hemorrhagic gastritis EXPLANATION All conditions listed may result in upper gastrointestinal bleeding in alcoholics, the most common of them being erosive hemorrhagic gastritis.

Answer 163

D) cyclosporine A

Answer 164

E) gallstones

Answer 165

A) in acute tubular necrosis EXPLANATION In acute tubular necrosis the kidneys are incapable of concentrating or diluting glomerular filtrate, therefore, urine is isostenuric (its gravity is 1010, equivalent with that of the protein- free plasma)

Answer 166

E) spironolactone EXPLANATION Thiazide type as well as loop diuretics deplete extracellular volume and increase water reabsorption in the proximal tubules, therefore, they may paradoxically decrease urine output in diabetes insipidus, especially if the lack of ADH is incomplete. The aldosterone-antagonist diuretic spironolactone has no such effect.

Answer 167

C) schistosomiasis

Answer 168

H) trimethoprim EXPLANATION Drugs listed in alphabetical order are all diuretics, except for trimethoprim, an antibacterial agent (Question 84 H). More than one diuretic (such as aldactone, furosemide) can be administered intravenously. None of the drugs listed is nephrotoxic in therapeutic dose (Question 85 D).

Answer 169

D) Oradexon (dexamethasone) glucocorticoids: casues elevated PLT count, increased coagulability and vessel wall damage.

Answer 170

C) answers 2 and 4 are correct

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