renal and urology incorrects

Question 1

40 yo man. 4 days of flank pain on the left. fever nausea vomiting
temp is 39.6. pulse rate 118 bpm and BP 90/40. imaging shows obstructed left ureteric stone with severe hydronephrosis.

treated with IV antibiotics and fluids.
next step in management?

Answer 1

Nephrostomy! -> renal pelvis needs to be urgently decompressed w nephrostomy . ureteric stent is more definitive, nephrostomy quicker

septic type picture
obstructed infected stone -> medical emergency

nephrostomy is tube letting urine drain from kidney through back

Question 2

A 63 year old man attends his GP for review following addition of chlortalidone to maximal-dose ramipril for BP control. He also has type 2 diabetes
mellitus and chronic kidney disease, and takes metformin. His creatinine 1 month ago was 115 μmol/L (60–120).His BP is 133/85 mmHg.Investigations:Sodium 135 mmol/L (135–146)
Potassium 4.6 mmol/L (3.5–5.3) Urea 9.0 mmol/L (2.5–7.8) Creatinine 150 μmol/L >148 μmol/L eGFR 44 mL/min/1.73 m2 (>60)

Most appropriate management?

UKMLA ppq

Answer 2

Repeat urea and electrolytes in 2 weeks.

The patient has had a <30% increase in serum creatinine. At this level there is no indication to change treatment, repeat of renal function in 2-4 weeks is reasonable

Question 3

renal stones first line imaging?

Answer 3

non contrast ct of renal tract/KUB

red cells and leukocytes seen

Question 4

what is oral duloxetine used to treat?

Answer 4

STRESS urinary incontinence

Question 5

man due for a ct scan with contrast. has a history of CKD

most appropriate treatment beforehand?

Answer 5

0.9% saline

to expand volume and prevent contrast nephropathy

Question 6

IN a patient collapsed on the floor overnight. AKI diagnosed. most likely cause in the setting of a normal CK?

Answer 6

hypovolemia !!!

Question 7

IgA nephropathy vs PSGN timeline?

Answer 7

Iga - days after eg 2

PSGN = 2 weeks!

Question 8

56 woman. HTN and diabetes. signs of kidney damage

which type of antihypertensive is most appropriate?

Answer 8

Ace inhibitor!!!

Ace inhibitors protect renal function in diabetic nephropathy!! in addition to their antihypertensive effects

Question 9

An 82 year old woman has constipation and passes infrequent, hard stools.
She has hypertension, overactive bladder symptoms and type 2 diabetes
mellitus. She takes amlodipine, doxazosin, gliclazide, metformin and
oxybutynin.

most likely drug causing constipation?

Answer 9

oxybutynin -is an anticholinergic and a frequent cause of constipation

Question 10

You are reviewing the blood results for a 79-year-old man who was admitted to the geriatric ward from his care home yesterday evening having fallen. Urine dip showed no abnormalities on admission.

hypernatremia

raised urea and creatinine. but rise in urea is proportionally higher than rise in creatinine!!!

most likely cause?

Answer 10

dehydration

Question 11

what medications should be avoided in AKI?

Answer 11

ace inhibitors - eg elenapril
NSAIDs except aspirin at cardiac dose
aminoglycosides - gentamicin!!
diuretics
angiotensin 2 receptor antagonists

may have to stop due to increased risk of toxicity:
metformin
lithium
digoxin

if you get a question stating digoxin and elenapril for example, elenapril is the one you withhold!!!

Question 12

CKD first line treatment, what can be added on?

name another drug that all patients with CKD should be started on

most important test in diagnosis CKD?

Answer 12

Ace Inhibitor or arb - if ACR greater than 3mg/mmol

can add sglt2 inhibitor

all started on statin

albumin: creatinine ratio
may be measured on a spot sample if a first-pass early morn sample is not provided (but should be repeated on a first-pass specimen if abnormal)

Question 13

Renal stones management? less than 5mm? less than 20? greater than 20?

Answer 13

less than 5 mm = watchful waiting
5-10mm shockwave lithotripsy
10-20 mm shockwave lithotripsy OR ureteroscopy
> 20 mm percutaneous nephrolithotomy

Question 14

ureteric!!! stone management?

Answer 14

shockwave lithotripsy +/- alpha blockers>< 10mm shockwave lithotripsy +/- alpha blockers
10-20 mm ureteroscopy

not if uyltrasound shows dilatation of renal pelvis, then that is obstruction -> urgent surgical decompression via nephrostomy

Question 15

patient presents with oliguria, fever, joint pain, and a rash (usually maculopapular) after taking co-amoxicalv. and blood tests reveal eosinophilia

most likely diagnosis?

name some other drugs that cause this diagnosis

Answer 15

acute interstitial nephritis

penicillin
rifampicin
NSAIDs!! eg aceclofenac. notttt paracetamol or codeine
allopurinol
furosemide

Question 16

nephrogenic diabetes insipidus treatment?

Answer 16

chlorthiazide

Question 17

A 73-year-old woman weighing 60kg admitted to the respiratory ward with CURB-4 pneumonia was initially improving on antibiotics. After two days she began to deteriorate and exhibited increased confusion. You note that in the past 8 hours, she has produced 180mL of urine.

urea from 4.6 on admission to 8.5 now
creatinine from 114 to 137

What feature is mot consistent with diagnosis of aki

Answer 17

decreased urine output!!

Nice have a set criteria to define AKI =

↑ creatinine > 26µmol/L!!!!! in 48 hours

↑ creatinine > 50% in 7 days
↓ urine output < 0.5ml/kg/hr for more than 6 hours

Question 18

A 23-year-old male is admitted with left sided loin pain and fever. His investigations demonstrate a left sided ureteric calculi that measures 0.7cm in diameter and associated hydronephrosis.

management?

Answer 18

nephrostomy!!

An obstructed, infected system is an indication for urgent decompression. This may be achieved by ureteroscopy or nephrostomy. In addition to this the patient should also receive broad spectrum, intravenous antibiotics!

Question 19

elderly 50kg
left hemicolectomy
finished 24 hours ago
passed 240 ml of urine since then

based on the urine output, what stage of aki does this patient have?

Answer 19

Stage 1 Increase in creatinine to 1.5-1.9 times baseline (greater than 1.5 x baseline!!!)
or
Increase in creatinine by ≥26.5 !!!!µmol/L, or
Reduction in urine output to <0.5 mL/kg/hour for ≥ 6 hours

Stage 2 Increase in creatinine to 2.0 to 2.9 times baseline (greater than 2x baseline!!) or
Reduction in urine output to <0.5 mL/kg/hour for ≥12 hours

Stage 3 Increase in creatinine to ≥ 3.0 times baseline!!!, or
Increase in creatinine to ≥353.6 µmol/L or
Reduction in urine output to <0.3 mL/kg/hour for ≥24 hours, or
The initiation of kidney replacement therapy, or,
In patients <18 years, decrease in eGFR to <35 mL/min/1.73 m2

Question 20

A 51-year-old man presents to his GP with groin swelling and burning on urination. He also complains of groin pain and penile discharge. He is sexually active with his wife of 6 years.

On examination, his heart rate is 91/min, respiratory rate is 15/min, blood pressure is 129/84 mmHg, and temperature is 38.3ºC. The right testicle is painful, but this is relieved by elevating the scrotum.

What organism is most likely responsible for his symptoms?

Answer 20

e coli!!!

chlamydia is the most common but in this case patient is married in 50s with wife as only partner

Question 21

patient with history of calcium oxalate kidney stones. what drug can be used as prophylaxis?

what else may also be useful?

Answer 21

bendroflumethiazide, indapamide

thiazide diuretics

potassium citrate may be useful

Question 22

patient with AKI

urine osmolality = 1000 (50-1200)
urine Na+ = 10 ( 40-250)

most likely class of aki?

Answer 22

prerenal disease!!

Prerenal causes include anything that may lead to hypoperfusion of the kidney, such as dehydration, shock or haemorrhage. In a hypovolaemic state, whereby prerenal AKI can occur, the physiological response of the renal system is to retain salt and water in an effort to replenish the deplete circulatory volume. With this concept in mind, urine becomes concentrated (high osmolality) due to the reabsorption of water, and low in sodium, as the mechanism of fluid reabsorption relies on the retention of sodium. Further, prerenal AKI typically responds well to a fluid bolus as this is directly treating the underlying cause of the problem.

Question 23

A 45-year-old man has recently been diagnosed with stage 5 chronic kidney disease (CKD) by a nephrologist. He started taking a new medication 6 weeks ago to treat symptoms that have developed because of his CKD. Over the last 3 weeks, he has developed abdominal pain, back pain, muscle weakness and is feeling quite anxious.

name a medication that would explain this.

Answer 23

calcium acetate

Calcium acetate is a calcium-based binder used to treat hyperphosphataemia. This patient is suffering from symptoms of hypercalcaemia as a result of a side effect of using a calcium-based binder.

Question 24

man undergoes appendicitis. He weighs 75 kg. He initially does not feel able to drink as he is nauseated from the anaesthetic. His pre-operative bloods were normal. What fluid should initially be prescribed to initiate a maintenance regime and how fast should it be given?

Answer 24

Maintenance fluids should be prescribed at a rate of 30 ml/kg/24hr.

Amount: 75 kg X 30 ml = 2250 mL in a 24 hour period

Rate: 2500 / 24 = 93.75 ml/hr.

Initially prescribe 500 ml and then reassess the patients fluid status and ability to drink. So prescribe 500 ml at a rate of 100 ml/hr.

Question 25

You are reviewing a 65-year-old in the renal clinic. He has been on haemodialysis for chronic kidney disease for the past 6 years. What is he most likely to die from?

Answer 25

ischemic heart disease!!! dialysis = RF

Question 26

In a patient with suspected anaemia of chronic disease secondary to CKD what should be checked before starting epo?

Answer 26

iron status if the ferritin is low -> suggests iron deficiency so replace with oral iron first!!! if ferritin is normal -> EPO

Question 27

recommened water requirement when prescribing maintenance fluids?

Answer 27

25-30 ml/kg/day of water

Question 28

A 73-year-old man undergoes an emergency laparotomy for a perforated bowel. Due to persistent hypotension intra-operatively he receives fluid resuscitation and is started on an infusion of noradrenaline. He is transferred to the intensive care unit post-operatively for ongoing vasopressor support and fluid resuscitation. In total he receives 6 litres of normal saline. arterial blood gas shows metabolic acidosis with raised chloride most likley cause?

Answer 28

fluid resuscitation use of sodium chloride carries this risk!!

Question 29

CKD is linked to what type of hyperparathyroidism?

Answer 29

secondary

Question 30

minimal change disease management?

Answer 30

oral prednisolone!! hh

Question 31

A 56-year-old woman presents to the emergency department with 2 weeks of worsening lethargy and malaise. Her partner notes she has been very confused over the past 24 hours as well. She has a history of type 2 diabetes mellitus and chronic kidney disease (CKD) stage 4. On examination, she has pitting oedema to her mid-thigh and nil else of note. Her blood tests show raised urea and creatinine most appropriate management?

Answer 31

dialysis! haemodialysis) is used when a patient is not responding to medical treatment of complications, for example hyperkalaemia, pulmonary oedema, acidosis or uraemia (e.g. pericarditis, encephalopathy). patient here has uremic encephalopathy

Question 32

CKD is not diagnoses by low egfr alone, there needs to be evidence of end organ damage -> proteinuria or abnormal urea and electrolytes, which are further markers of kidney damage

Question 33

A 72-year-old man is having an elective trans-urethral resection of prostate (TURP) for benign prostatic hyperplasia under spinal anaesthesia. Forty minutes into the procedure he develops headache and visual disturbances. A venous blood gas is sent off, and the main abnormality noted is severe hyponatremia. What is the cause of this presentation?

Answer 33

irrigation with glycine! patient is experiencing TURP syndrome CNS, respiratory and systemic symptoms

Question 34

mechansim of action of desmopressin?

Answer 34

vassopresin v2 receptor AGONIST

Question 35

if a patient weighs 60kg and you need to precribe potassium over 12 hours, what will you give

Answer 35

30mmol potassium is prescribed at a rate of 1 mmol/kg/day

Question 36

A 28 kg 7-year-old boy has to fast for an elective surgery. On examination, he is clinically well and there are no signs of dehydration. His vital signs are normal. What is the amount of maintenance intravenous fluid needed by this patient in 24 hours?

Answer 36

as the patient is a child you use the holiday segar formula First 10!! kg x 100!!! ml/kg = 1000 ml Second 10!!! kg x 50!!! ml/kg = 500 ml subsequent kg (Last 8 kg x 20!!! ml/kg) = 160 ml = 1,660 in total

Question 37

test for adult polycystic kidney disease?

Answer 37

ultrasound abdomen!!! NOT PKD1 gene testing as not recommended routinely

Question 38

A 84-year-old woman admitted for the treatment of a lower respiratory tract infection becomes anuric on the ward for the last 6 hours. Blood tests taken show: Urea 11mmol/L (baseline 5mmol/L) Creatinine 156umol/L (baseline 78umol/L) According to the acute kidney injury (AKI) staging, which stage of AKI is this woman at?

Answer 38

AKI stage stage 2!!! increase in creatining 2x baseline

Question 39

in a pregnant woman, is urteroscopy or lithotripsy preferred for stone removal?

Answer 39

uteroscopy

Question 40

A 39-year-old man presents with six months of polyuria and polydipsia. He has also been experiencing fleeting episodes of arthralgia and lethargy. Past medical history is unremarkable and he is not on any medications. When asked about family history, he states that his parents are okay but remembers his grandma had to have regular removal of her blood throughout her life. He is not sure why as she died from heart disease when he was a child. investigations point to cranial diabetes insipidus what other test is needed to confirm diagnosis?

Answer 40

serum ferritin!!! hereditary hemochromatosis is a cause of cranial diabetes insipidus if it was nephrogenic diabetes insipidus instead: - anti ro and anti la if suspecting sjogrens as cause - short synacten test if suspecting adrenocortical insufficiency as cause

Question 41

A 23-year-old man presents to his GP with testicular pain. He reports pain in the left testicle, with associated swelling that has come on over the course of the day. He reports feeling generally unwell and a little nauseous. On examination, the left testicle is swollen and erythematous. It is tender to palpation, particularly over the top of the testicle, but the pain eases when the testicle is lifted. What management is most appropriate at this stage?

Answer 41

IM ceftriaxone single dose + 10-14 days oral doxycyline pain that eases with lifting points to epidiymo-orchitis!! and torsion would be more acute pain

Question 42

Renal colic is in a patient with past medical history of gastrointestinal peptic ulcer bleed caused by long-term naproxen use pain management?

Answer 42

IV paracetamol!! us this if NSAIDs contraindicated as you cant use IM diclofenac also use if insufficient pain relief

Question 43

acute urinary retention after starting a drug for BPH. what is the class of drugs.

Answer 43

GnRH AGONISTS - eg goserolin / zoladex cause 'tumour flare' when started, resulting in bone pain, bladder obstruction and other symptoms

Question 44

A 58-year-old man with a history of type 2 diabetes mellitus and hypertension presents to his GP with fatigue and occasional ankle swelling. He is being evaluated for chronic kidney disease. His blood pressure is 145/85 mmHg, and his eGFR is 50 mL/min/1.73 m², with an albumin-to-creatinine ratio of 35 mg/mmol. His current medications include metformin and amlodipine. What is the most appropriate medication to add to his regimen?

Answer 44

lisinopril!!! Patients with chronic kidney disease should be started on an ACE inhibitor if they have an ACR > 30 mg/mmol

Question 45

A 35-year-old woman presents with a one week history of progressive leg swelling. Her past medical history includes type 2 diabetes which is diet-controlled. On examination, there is bilateral pitting oedema up to her knees and periorbital oedema. Her observations are heart rate 88/min, blood pressure 151/91mmHg, oxygen saturations 97%, temperature 37.1ºC, and respiratory rate 14/min. Urine dipstick shows protein +++. Two days later, she complains of left-sided flank pain and haematuria. What complication has occurred?

Answer 45

renal vein thrombosis!! patient has nephrotic syndrome which puts her in a hypercoagulable state due to loss of antithrombin III also risk of deep vein thrombosis, pulmonary embolism other complications: hyperlipidaemia increasing risk of acute coronary syndrome, stroke etc chronic kidney disease increased risk of infection due to urinary immunoglobulin loss hypocalcaemia (vitamin D and binding protein lost in urine)

Question 46

in a patient with adult polycystic kidney disease!!! that has CKD being treated, what other drug can be used to slow the progression of cyst development and renal insufficiency?

Answer 46

Tolvaptan

Question 47

A 49-year-old woman presents to the emergency department with confusion and dark, reduced urine output. She is a long-distance cyclist. Yesterday she had very sore muscles but trained anyway. She has a past medical history of resolved breast cancer and she had a kidney stone of 5mm removed 1 year ago. normal sodium, hyperkalemia raised urea and creatinine She is given 500mL of normal saline over 20 minutes, but she still has a low urine output. most likely cause of symptoms?

Answer 47

acute tubular necrosis!!! secondary to rhabdomyolysis. poor response to fluid challenge indicates cause of AKI is intrinsic and therefore not prerenal eg dehydration

Question 48

A 57-year-old man presents to his GP with urinary symptoms, including frequent urination and discomfort. He also reports experiencing looser stools since completing a course of co-amoxiclav for a urinary tract infection (UTI) three weeks ago. The man last ejaculated five days ago. The GP plans to request a prostate-specific antigen (PSA) test but then decides to delay it. His BMI is 31.8 kg/m². Which element in his history is the most likely reason for the GP delaying the PSA test?

Answer 48

his recent infection!!! you shouldnt do the test within 6 weeks of a UTI or prostatitis once more than 48 hours since last sexual encounter, you can do the test

Question 49

diabetes insipidus is characterised by _ plasma osmolality and _ urine osmolality

Answer 49

high, low

Question 50

A 78-year-old woman presents to the emergency department with confusion. She has a long-term catheter in situ that her son emptied 8 hours ago. On examination, she appears clinically dehydrated. She weighs 50kg and the catheter bag contains 250ml of urine. Blood tests are taken and compared with tests done 2 days ago: creatinine 2 days ago was 100 but now 134 Alongside antibiotics, she is diagnosed with acute kidney injury and commenced on intravenous fluids. What factor supports this diagnosis?

Answer 50

absolute increase in creatinine (>26)

Question 51

a patient requires fluid replacement and 1L of 0.9% sodium chloride supplemented with 40 mmol of potassium is prescribed. What is the shortest time period over which this bag of fluid can be administered safely?

Answer 51

4 hours the maximum recommended rate of potassium infusion via a peripheral line is 10 mmol/hour, whereas rates above 20 mmol/hour require cardiac monitoring

Question 52

The eGFR is often inaccurate in people with extremes of muscle mass. Body builders often have an inappropriately low eGFR.

Question 53

presence of protein in urine dipstick rule out pre renal and post renal cause of AKis and lack of nitrites will rule out infection. Acute interstitial nephritis is an inflammatory process so there is a higher white cell content in the urine dipstick while acute tubular necrosis is not so the urine has no cellular component.

Question 54

A 65-year-old woman with chronic kidney disease is reviewed in a renal outpatient clinic. On review, she remains asymptomatic and feels well in herself. The results of her recent blood tests are shown below: Calcium 2.05 mmol/L (2.1-2.6) Phosphate 1.89 mmol/L (0.8-1.4) The previous calcium and phosphate results were normal. What is the most appropriate management of these results?

Answer 54

recommend low phosphate diet!!! first line before you try phosphate binders!!! you only admit for IV calcium replacement if calcium is below 1.9

Question 55

why is urine osmolality low, urine sodium high in acute tubular necrosis?

Answer 55

Kidneys can no longer concentrate urine or retain sodium

Question 56

A 56-year-old man has 3 days of headache, fever, neck stiffness, and drowsiness. He has a pulse of 110 bpm, blood pressure of 90/60 mmHg, and a temperature of 39.1ºC. A non-blanching purpuric rash is seen on the trunk. He receives IV fluids, oxygen, and amoxicillin with ceftriaxone. Initial tests show high urea and creatinine and then over the next two days these improve. most likely diagnosis?

Answer 56

reduced renal perfusion due to infection!! pre-renal disease shows good response to fluid challenge so not intrinsic causes such as acute interstitial nephritis due to amoxicillin

Question 57

A 45-year-old man attends the emergency department with acute-onset loin-to-groin pain. He states he has had similar pain before, but never as bad as this. A set of observations are carried out on his arrival: Blood pressure: 110/85 mmHg Heart rate: 119 bpm Temperature: 38.6ºC Oxygen saturation: 98% on air Respiratory rate: 22/min Given the most likely diagnosis, what is the definitive management?

Answer 57

IV antibiotics and urgent renal decompression obs paint septic picture

Question 58

A 73-year-old lady is undergoing chemotherapy for treatment of acute leukaemia. She develops symptoms of renal colic. Her urine tests positive for blood. A KUB x-ray shows no evidence of stones. (radioluscent!!) what type of kidney stone most likely?

Answer 58

uric acid stone Chemotherapy and cell death can increase uric acid levels also associated with metabolic disorders

Question 59

A 16-year-old boy presents with renal colic. His parents both have a similar history of the condition. His urine tests positive for blood. A KUB style x-ray shows a relatively radiodense!! stone in the region of the mid ureter.

Answer 59

cysteine stone associated with inherited metabolic disorder

Question 60

You are reviewing the blood results of a 54-year-old woman. Her eGFR is unexpectedly low. She has no past medical history and takes no regular medications. She had a blood test done a month ago which showed a normal eGFR. What is most likely to have caused this?

Answer 60

eating red meat the evening before the test

Question 61

What is the most likely outcome following the diagnosis of minimal change nephropathy in a 10-year-old male?

Answer 61

full recovery but with later recurrent episodes

Question 62

when estimating egf, what variables are required?

Answer 62

eGFR variables - CAGE - Creatinine, Age!!, Gender, Ethnicity urea not required!!

Question 63

A 31-year-old man presents to the emergency department with severe stabbing left-sided abdominal pain. A subsequent CT confirms the diagnosis of renal colic secondary to numerous bilateral calculi. Which of the following investigations should be followed up urgently?

Answer 63

urea and electrolytes to assess renal function and rule out AKI not calcium

Question 64

You are asked to review an 81-year-old man on your ward who was admitted 3 days ago with acute diverticulitis. Since admission, he has also developed stage 3 acute kidney injury (AKI). The nurses report that over the past day he has become much more confused and lethargic. He has also been complaining of significant nausea. An ECG from earlier in the day is normal but a chest X-Ray showed right-sided consolidation. His blood gas is shown below: pH 7.34 (7.35-7.45) pO2 10.9 kPa (10-14) pCO2 5.1 kPa (4.5-6.0) HCO3- 24 mEq/L (22-26) Na+ 137 mmol/L (135-145) K+ 5.2 mmol/L (3.5-5.0) Cl- 105 mmol/L (95-105) Urea 12.1 mmol/L (2.0-7.0) Creatinine 312 umol/L (55-120) Which of the following features in this patient, combined with his symptoms, would be an indication for dialysis?

Answer 64

urea level patient has uremic encephalopathy

Question 65

A 47-year-old male has been nil by mouth for 3 days awaiting bariatric surgery that has been repeatedly postponed, he is to be prescribed IV dextrose to ensure his glucose requirements are being met. His weight is 150kg, which of the following is an acceptable daily amount of glucose for him to be given?

Answer 65

100 When prescribing fluids, the glucose requirement is 50-100 g/day irrespective of the patient's weight

Question 66

name the 2 types of kidney stones that are radiolucent

Answer 66

cysteine and xanthine

Question 67

A 54-year-old woman with a history of chronic kidney disease stage 3a and asthma returns to her GP for a follow-up. She is currently taking salbutamol and the maximum dose of ramipril. Her blood and urine test results are as follows: Hb 132 g/L (115 - 160) Platelets 234 * 10 9/L (150 - 400) Ferritin 132 ng/mL (20 - 230) Vitamin D 67 nmol/L (> 50) Creatinine 112 µmol/L (55 - 120) eGFR 47mL/min/1.73m² (> 90) Urine albumin : creatinine ratio 97 mg/mmol (< 3) What is the most appropriate medication to add to her regimen?

Answer 67

dapagliflozin SGLT-2 inhibitors are beneficial in proteinuric CKD, regardless of diabetic status

Question 68

Acute graft failure happens within months eg 2 months!! and is usually asymptomatic and is picked up by a rising creatinine, pyuria and proteinuria when does chronic graft rejection occur?

Answer 68

chronic -> after 6 months

Question 69

A 24-year-old patient is being seen in the emergency department. You are the medical student and are asked to run the patients arterial blood gas sample. The results are as follows: pH 7.31 pCO2 4.1 kPa pO2 13.1 kPa HCO3 17 mmol/L Na 141 mmol/L K 4 mmol/L Chloride 115 mmol/L Which of the following could be a cause of the patients ABG results? Diabetic ketoacidosis Salicylate overdose Renal tubular acidosis Lactic acidosis Methanol poisoning

Answer 69

renal tubular acidosis This patient has an anion gap of: (141+4)-(115+17) = 13. (normal is 8-14!!) This is a normal anion gap. The patient is acidotic. Therefore this patient has an acidosis with a normal anion gap. There are several causes of this including: Hyperchloraemia Renal tubular acidosis Addison's disease Diarrhoea - NOT vomiting Causes of a raised anion gap metabolic acidosis lactatic acidosis: shock, hypoxia, sepsis (acidosis occurs here due to hypoperfusion of organs) ketones: diabetic ketoacidosis!! alcohol urate: renal failure acid poisoning: salicylates, methanol 5-oxoproline: chronic paracetamol use learn what causes each type!

Question 70

A 72-year-old man with chronic kidney disease presents to the emergency department with palpitations. His bloods are as follows: Na+ 144 mmol/L (135 - 145) K+ 6.5 mmol/L (3.5 - 5.0) The team stabilises him initially and considers calcium resonium to reduce his potassium levels. Why is the rectal enema preferred over the oral formulation for this medication?

Answer 70

The enema directly binds potassium in the large intestine, enhancing excretion

Question 71

A 59-year-old man with a past medical history of chronic kidney disease stage 4 and diverticular disease is admitted with abdominal pain. On examination, he is tender in the left iliac fossa with localised guarding. His heart rate is 112 bpm, his blood pressure is 126/82 mmHg and his temperature is 38.4ºC. A blood test is performed and shows the following: WBC 19.2 * 109/L (4.0 - 11.0) Urea 8.1 mmol/L (2.0 - 7.0) Creatinine 131 µmol/L (55 - 120) CRP 147 mg/L (< 5) Given the likely diagnosis, which of the following is necessary before diagnostic imaging?

Answer 71

1L intravenous 0.9% sodium chloride at a maintenance rate of 1 mL/kg/hour for 12 hours pre and post-procedure. this patient is likely sufferring from acute diverticulitis but needs a CT abdomen and pelvis to make a diagnosis however background of CKD so needs volume expansion with 0.9% saline to prevent contrast induced nephropathy if on metformin, Patients who are high-risk for contrast-induced nephropathy should have metformin withheld for a minimum of 48 hours and until the renal function has been shown to be normal coronary angiography is one procedure involving contrast

Question 72

An 8-year-old boy presents to the general practitioner with his mother with a 2-day history of a rash over his legs. His mother reports that overall, her son has been unwell for 2 weeks, having had a cold before the onset of his rash. On examination, his cardiorespiratory examination is unremarkable. He complains of generalised abdominal pain but has a soft abdomen with no guarding or palpable masses. There is a palpable purpuric rash over his lower limbs and buttocks. Urinalysis blood ++ Given the likely diagnosis, what parameter should be frequently monitored?

Answer 72

blood pressure!! Patients with active Henoch-Schonlein purpura: blood pressure and urinanalysis should be monitored to detect progressive renal involvement monitor for 6-12 months

Question 73

patient with hyperkalemic ecg changes. first step in management?

Answer 73

IV calcium gluconate!!! to stabilise the myocardium insulin and dextrose come later

Question 74

A 45-year-old man undergoes a renal transplant from a deceased donor due to renal failure. The on-call doctor is asked to review the patient 2 hours after the procedure. His observations show temperature of 40ºC, heart rate 114/min, respiratory rate 23/min, saturations of 97% in room air, blood pressure of 81/62mmHg. Considering the most likely diagnosis, what is the appropriate management for this patient?

Answer 74

remove transplant hyperacute transplant rejection occurs within hours of transplant - preexistng antibodies no treatment! transplant must be removed

Question 75

what is the most common extra renal manifestation of APKD?

Answer 75

liver cysts!! even more than subarrachnoid hemorrhage other associations: cardiovascular system: mitral valve prolapse!!!!, mitral/tricuspid incompetence!!, aortic root dilation, aortic dissection cysts in other organs: pancreas, spleen; very rarely: thyroid, oesophagus, ovary

Question 76

A 64-year-old man presents with a 4-week history of leg swelling and weight loss. On examination, you note pitting oedema to the groin. Urinary protein in 24 hours 3.6g (<0.15) Chest x-ray 3x2cm spiculated mass in the right lung midzone most likely diagnosis?

Answer 76

membranous glomerulonephritis it is frequently associated with malignancy !!!

Question 77

You receive a call from the Biochemistry Lab. A blood sample you have taken from a patient is reported to have a potassium level of 6.4mmol/L. What is your first step?

Answer 77

perform an ecg!! the Renal Association recommend all patients with a serum K+ of 6.0 or more to undergo an urgent ECG. All patients with severe hyperkalaemia (≥ 6.5 mmol/L) or with ECG changes should have emergency treatment

Question 78

A 72-year-old man is brought into the Emergency Department following a fall at home. He complains of pain around his hip but otherwise appears well. Past medical history includes type 1 diabetes mellitus (T1DM) and hypertension for which he takes insulin, ramipril and amlodipine. Capillary glucose is found to be 6 mmol/L. Hb 136 g/L Male: (135-180) Platelets 200 * 109/L (150 - 400) WBC 5.2 * 109/L (4.0 - 11.0) Na+ 141 mmol/L (135 - 145) K+ 4.5 mmol/L (3.5 - 5.0) Urea 7.5 mmol/L (2.0 - 7.0) Creatinine 140 µmol/L (55 - 120) Calcium 1.95 mmol/L (2.1-2.6) Phosphate 1.5 mmol/L (0.8-1.4) Creatine kinase 245 U/L (35 - 250) What is the most likely cause of his renal impairment?

Answer 78

chronic kidney disease!!! hypocalcemia is an indication that cause of renal impairment is crhonic and not acute thus rules out dehydration

Question 79

A 3-year-old, originally presented with persistent haematuria, undergoes a renal biopsy showing splitting on the lamina densa resulting in an abnormal glomerular-basement membrane. Whilst under investigation, the child develops swallowing issues and a recurrent cough. CT chest showed the presence of oesophagus and tracheobronchial leiomyomatosis. A potential genetic cause is suspect and testing identifies an X-linked dominant inherited protein defect, confirming the syndrome responsible for the child issues. What other feature is most associated with this child's likely syndrome?

Answer 79

sensorineural hearing loss!! most likely alport syndrome

Question 80

patient with chrons needing dialysis. first line option?

Answer 80

heamodialysis!! (this is the one requiring a fistula) not peritoneal dialysis is usually first line for independent patients!! but not for him as he has chrons

Question 81

Salicylate posioning treatement?

Answer 81

IV sodium bicarbonate remember the posioning causes metabolic acidosis

Question 82

A 56-year-old female presents to the emergency department with muscle cramps and pains associated with tachycardia. An electrocardiogram shows tall tented T waves, flattened P waves and a shortened QT interval. The doctor commences the patient on treatment. What is the role of calcium resonium in the management of this patient?

Answer 82

initial management of hyperkalaemia includes administration of calcium gluconate which stabilises the cardiac membrane. it does not affect electrolyte levels!! Calcium resonium removes potassium from the body!!

Question 83

how long does it take a fistula to mature?

Answer 83

2 months!!! 6-8 weeks

Question 84

Light microscopy shows a thickened glomerular basement membrane in all glomeruli, with subepithelial spikes visible on silver staining. Immunostaining is positive for PLA2R antibodies. +ve blood and proteins what is the condition?

Answer 84

membranous glomerulonephritis

Question 85

diabetic nephropathy kidney USS findings?

Answer 85

large/normal sized kidneys on ultrasound!!! whereas most patients with chronic kidney disease have bilateral small kidneys

Question 86

A 52-year-old woman with a history of rheumatoid arthritis presents to the Emergency Department with swelling in her hands and feet. She was successfully treated for malaria two weeks ago in Nigeria. She currently takes the combined oral contraceptive pill (COCP), and ibuprofen for muscle pain. Urinalysis results are shown below: Blood negative Protein +++ Nitrites negative Blood test results are as follows: Hb 118 g/L (115 - 160) Albumin 18 g/L (> 30) Triglycerides 2.28 mmol/L (< 1.7) Given the likely diagnosis, what drug should be initiated as prophylaxis to manage this patient?

Answer 86

enoxaparin!!! -> LMWH nephrotic syndrome described

Question 87

PSGN develops 1-2 weeks after URTI. IgA nephropathy develops 1-2 days after URTI

Question 88

Elevations of CK that are 'only' 2-4 times that of normal are not supportive of a diagnosis of rhabdomyolysis and suggest another underlying pathophysiology such as?

Answer 88

exercise induced CK elevation

Question 89

a negative urine disptick but urine microscopy that shows. hyaline casts may be due to the use of what medication?

Answer 89

loop diuretics - furosemide!!!

Question 90

name a benign cause of microscopic hematuria on urine dipstick

Answer 90

exercise

Question 91

management for ascites?

Answer 91

spirinolactone

Question 92

A 21-year-old female complains of dysuria for the past week, despite just completing a three day course of trimethoprim. Urine dipstick is positive for blood + and leucocytes +. A MSSU shows no organism. most likely diagnosis?

Answer 92

chlamydia

Question 93

HIV is associated with what type of nephropathy?

Answer 93

FSGS

Question 94

You review a 42-year-old woman six weeks following a renal transplant for focal segmental glomerulosclerosis. Following the procedure she was discharged on a combination of tacrolimus, mycophenolate, and prednisolone. She has now presented with a five day history of feeling generally unwell with anorexia, fatigue and arthralgia. On examination her sclera are jaundiced and she has widespread lymphadenopathy with hepatomegaly. What is the most likely diagnosis?

Answer 94

cytomegalovirus!! CMV is the most common and important viral infection in solid organ transplant recipients

Question 95

In patients with troublesome gynaecomastia on spirinolactone, what can you give instead?

Answer 95

eplerenone

Question 96

vomiting causes what electrolyte disturbance

Answer 96

Hypochloraemia, hypokalaemia and metabolic alkalosis hypochloremia due to loss of hydrochloric acid

Question 97

Mary is a 75-year-old woman who presented to her GP with breathlessness and fatigue on a background of type 2 diabetes and chronic kidney disease. After further investigation, she was found to have diabetic nephropathy and anaemia alongside this. Her anaemia was investigated and she was found to be iron deficient. Her blood tests showed the following: Iron 7 umol/l (10-30) Transferrin 6 g/l (2-4) Ferritin 8 ug/l (15-200) Which of the following would be the most appropriate course of action?

Answer 97

refer for endoscopy and colonoscopy due to age

Question 98

An 8-year-old boy presents to his general practitioner accompanied by his mother. She has grown increasingly concerned about his urine frequency and colour. In the last two days he has passed urine just twice per day, and when he does it is very dark in colour, with some specks of blood visible in it. On examination, he looks alert and comfortable, but his blood pressure is high for what is expected at his age. He is otherwise fit and healthy, except for a febrile illness he had two weeks ago. His urine dipstick shows the following: Protein +++ Blood +++ Leucocytes - Glucose - Nitrites - What is the most likely diagnosis?

Answer 98

PSGN IgA nephropathy only causes haematuria, whilst post-streptococcal glomerulonephritis causes haematuria AND proteinuria. PSGN also causes HTN

Question 99

causative organsim for peritonitis in peritoneal dialysis?

Answer 99

staph epidermis

Question 100

evere hyperkalaemia in the context of an AKI requires immediate discussion with critical care/nephrology to consider haemofiltration/haemodialysis

Question 101

granulomatis with polyaangitis renal biopsy findings?

Answer 101

crescentic glomerulonephritis

Question 102

side effects of erythropoeitin?

Answer 102

Bone aches, flu-like symptoms and skin rashes

Question 103

A 55-year-old man presents with progressive weakness and dyspnoea and a full examination is performed. Massive hepatomegaly is detected and on further investigation, his renal function is reduced with heavy proteinuria however his liver function tests appear to be normal. He is a type 2 diabetic and was just this year diagnosed with chronic obstructive pulmonary disease (COPD). There is no ongoing family history of any conditions. Which of the following is the most likely underlying diagnosis?

Answer 103

Amyloidosis!!! the most common presenting features of amyloidosis are those of breathlessness and weakness lack of family history and late presentation age rules out APKD