Urinary

Question 1

how do convoluted tubules regulate body pH

Answer 1

reabsorption of HCO3-

• 90% get reabsorbed in the proximal tubule

Question 2

what is an early indicator of glomerulosclerosis in a diabetic patient?

Answer 2

microalbuminuria

Question 3

over the course of 2 days a pt develops oliguria, hypertension fluid retention, uraemia, haematuria and proteinuria. Which of the following is the most likely diagnosis?

nephrotic syndrome

rapidlt progressive glomerulonephritis

acute nephritic syndrome

chronic kidney disease

Answer 3

acute nephritic syndrome

• haematuria

Question 4

what is the most likely cause of nephrotic syndrome

Answer 4

minimal change disease

Question 5

a pt present swith severe ankle swelling worsenign over the last week and proteinuria. What is the most likely diagnosis?

Answer 5

nephrotic syndrome

Question 6

where in the urinary tract are red blood cells most likely to enter the urine

Answer 6

glomerular basement membrane

Question 9

hypercalcemia question: what are the pts most striking symptoms and lab findings

Answer 9

• bone pain, weakness and constipation
• history of HT and CHD/TIAs
• elevated total serum calcium, PTH and alkaline phosphatase
• low vit D
• despite hypercalcemia, no muscle weakness or altered mental state

Question 10

differential diagnosis for cause of hypercalcemia

Answer 10

• PT tumour
• Bone destruction
• Increased intestinal absorption- Vit D
• Granulomatous disease
• Drugs e.g. thiazide e.g. lithium

Question 11

A56yearoldfemalepatientwasrecentlydischargedfromthehospitalforBell’s palsy and was incidentally found to have hypercalcemia. She has been having pain in her legs, constipation and occasional weakness but denies any kidney stones, significant weight loss or abdominal pain. She reports occasional severe headaches.

Shehasahistoryofdiabetesmellitus,hypothyroidism(status:postradioactive iodine ablation for hyperthyroidism), COPD and hypertension. The patient also has a history of IBS. She has had myocardial infarctions and strokes, and in the past month has been hypercalcaemic on 3 consecutive occasions.

Shewentthroughthemenopauseattheageof51.Shesmokes1-2packsof cigarettes daily (since age 14). Patient denies alcohol consumption but has visited clinic with odour of alcohol on breath on occasion. She has a history of substance abuse (3 incidences of narcotic overdose). She has no evidence of altered mental status. She is not known to be taking any calcium or vitamin D supplements.

Bloodpressure143/93mmHg

Heartrate75bmp

Respiratoryrate18rpm

Answer 11

Bonepain,weaknessandconstipation.

HistoryofHTandCHD/TIAs

Elevatedtotalserumcalcium,PTHandalkalinephosphatase.Serum phosphorous is low normal.

LowtotalvitaminD

Despitehypercalcemia,nomuscleweakness,noalteredmentalstatus.

Question 12

Case study 1: WHAT IS THE DIFFERENTIAL DIAGNOSIS?

Answer 12

• Hyperparathyroidism
• Bone destruction – malignancy or myeloma

• Increased intestinal absorption – vitamin D

• Granulomatous disease
• Drugs – thiazides, lithium
• Hypermagnesemia

Question 13

Case study 1: A SCAN REVEALED THE PRESENCE OF A PARATHYROID ADENOMA. WHAT IS THE PATIENTS MOST LIKELY DIAGNOSIS?

Answer 13

Most likely diagnosis is primary hyperparathyroidism. Based on the elevated PTH and calcium, the low normal phosphorous and the parathyroid adenoma.

Question 14

Primary hyperparathyroidism is definitively diagnosed if

Answer 14

hypercalcemia resolves following surgical removal of the adenoma.

Question 15

EXPLAIN THE MECHANISM BY WITH THE ELEVATED PTH RESULTS IN HYPERCALCAEMIA

Answer 15

released from parathyroid gland

PTH stimulates the bone to:

• increase bone resportion to increase calcium ion release into the blood

PTH release stimulates the kidneys to:

• increase excretion of phosphate, should increase plasma calcium (innervesely proportionate relationship)
• stimulates activation of Vitamin D (1,25-dihydroxycholecalciferol)
  
  • stimulates intestines to absorb more calcium
• increases renal reabsorption of calcium

Question 16

HOW WOULD SUCH A PATIENT BE MANAGED AND WHY?

Answer 16

parathyroidectomy on cure

Question 17

case study 1 WHAT DO WE NEED TO CONSIDER IN THE LONG-TERM MANAGEMENT OF THIS PATIENT

Answer 17

• To prevent hypocalcaemia after parathyroidectomy calcium and vitamin D supplements can be prescribed.
• Follow up studies include DEXA bone scan to monitor bone mineral density.

Question 19

case study 2 JACK WAS DIAGNOSED WITH MINIMAL CHANGE DISEASE. WHAT SIGNS/SYMPTOMS WOULD YOU EXPECT TO SEE IN A CHILD WITH MCD?

Answer 19

• oedema (periorbital swelling, ankle swelling)
• proteinuria
• hypoalbuminaemia
• hyperlipidaemia

Question 20

case study 2 EXPLAIN THE MECHANISM LEADING TO OEDEMA IN NEPHROTIC SYNDROME

Answer 20

Podocyte damage

Loss of albumin in the urine

Hypoalbuminaemia

Reduced oncotic pressure in capillaries – less water drawn into capillaries from surrounding tissues

Question 21

case study 2: HOW WOULD THE SIGNS/SYMPTOMS HAVE DIFFERED IF HE HAD NEPHRITIC SYNDROME?

Answer 21

• Oliguria/Anuria

• Hypertension
• Heamaturia

Question 22

Case study 3 Martin was diagnosed with type 1 diabetes as a teenager. His diabetes was poorly managed for many years. He eventually went on do develop diabetic nephropathy.

EXPLAIN THE MECHANISM OF

HYPERFILTRATION IN DIABETIC NEPHROPATHY

Answer 22

1. increased blood glucose, result sin icnreases reabsorption of glucose in PCT
2. reabsorption of glucose coupled with sodium absorption
3. reduction in delivery of sodium to macula densa cells
4. vasoconstriction of effrent arteriole
5. increased hydrostratic pressure within glomeurlus and increased GFR

Question 23

NAME THE FORCES WHICH DETERMINE THE NET FILTRATION PRESSURE IN THE GLOMERULUS?

Answer 23

• Hydrostatic Pressure

• Glomerulus
• Bowmanscapsule

• Oncotic pressure - glomerulus

Question 24

HE DEVELOPS STAGE 3 CKD. WHAT ARE THE COMPLICATIONS OF CHRONIC KIDNEY DISEASE?

Answer 24

• Anaemia – EPO deficiency
• CKD bone and mineral disorder
  
  • Lack of active vitamin D – reduced calcium absorption
  • Hyperphosphatemia – phosphate excretion impaired, PTH released
  • Extra skeletal calcification – calcium deposition in soft tissues and arteries
• Hypertension secondary to chronic intravascular volume overload
• Accelerated atherosclerosis/vascular disease
• Metabolic acidosis

Question 25

AS HIS RENAL FUNCTION CONTINUES TO DECLINE, HE DEVELOPS URAEMIA. WHAT SIGNS AND SYMPTOMS ARE ASSOCIATED WITH THIS?

Answer 25

* Fatigue * Itch * Nausea and vomiting * Cramps/restless legs * Altered cognition * Uraemic skin colour changes

Question 26

advantages of hemodyialysis

Answer 26

✚Less responsibility ✚Days off

Question 27

disadvantages of Hemodyialysis

Answer 27

⎯ Travel time/waiting ⎯ ‘tied’ to dialysis times – little travel ⎯ Big restriction on fluid and food intake

Question 28

advantages of Peritoneal dialysis

Answer 28

✚Self-sufficient/independence ✚Less food/fluid restrictions ✚Fairly easy to travel ✚Renal function may be better preserved initially

Question 29

disadvantage sof periotneal dialysis

Answer 29

⎯ Responsibility lies with patient ⎯ Frequent daily exchanges or overnight

Question 30

case study 4 A 62 year old man is 4 days post-colostomy. He is eating a light diet and managing to drink approximately 1 litre per day. His colostomy losses are excessive, he is losing in excess of 1L/day. He is dehydrated and needs IV fluids. His weight is 90kg. WHAT DO YOU NEED TO CONSIDER IN ORDER TO CALCULATE HIS FLUID REQUIREMENTS?

Answer 30

• Hydration status * His total losses (e.g. vomiting, diarrhoea, blood loss) * His total gains • Calculate his maintenance fluid requirements, replace any fluids lost (look at fluid balance chart)

Question 31

case study 4 A 62 year old man is 4 days post-colostomy. He is eating a light diet and managing to drink approximately 1 litre per day. His colostomy losses are excessive, he is losing in excess of 1L/day. He is dehydrated and needs IV fluids. His weight is 90kg. WHAT VOLUME OF IV FLUID DOES THIS PATIENT REQUIRE?

Answer 31

Fluid Requirements = 30ml/kg/d • = 90 x 30 = 2700ml/day * Patient drinking 1000ml/d * Excess colostomy loses of 1L • 2700ml – 1000 + 1000 = 2700ml/day.

Question 32

case study 4 ## Footnote A 62 year old man is 4 days post-colostomy. He is eating a light diet and managing to drink approximately 1 litre per day. His colostomy losses are excessive, he is losing in excess of 1L/day. He is dehydrated and needs IV fluids. His weight is 90kg. WHAT TYPE OF IV FLUID DOES HE NEED? WRITE A SUITABLE FLUID REGIME

Answer 32

**go with the 111 ratio with sodium, potassium and chloride** * Don’t worry about giving HCO3- they will be able to make their own if its not a large amount * Don’t need tow worry about glucose too much either with requirements because he is eating and drinking 1L Heartmans- enough sodium, chloride and bicarbonate 2L 4% dextrose and 0.18% saline (KCl and NaCl- make up K+ requirements) * Lots of fluid * Some saline he needs but not too much 1L + 2L= closest to 2700ml/day

Question 33

case study 5 ## Footnote Three days after her admission, a 43 year old woman (63kg) with diabetic ketoacidosis has a blood pressure of 88/46mmHg and a pulse of 110bmp. She is tachycardic. Her charts show that her urine output over the last 3 days was 26.5L, whist her total intake was 18L. Over the last 3 days you have managed to stabilise her blood glucose to normal levels. EXPLAIN HOW THIS PATIENT HAS BECOME HYPOTENSIVE.

Answer 33

* DKA causes glucosuria * The glucose transporters are only able to reabsorb a certain amount of glucose Tmax. * glucose remains in urine which results in osmotic diuresis * causes high loss of water in the urine and dehydration occurs

Question 34

case study 5 ## Footnote Three days after her admission, a 43 year old woman (63kg) with diabetic ketoacidosis has a blood pressure of 88/46mmHg and a pulse of 110bmp. She is tachycardic. Her charts show that her urine output over the last 3 days was 26.5L, whist her total intake was 18L. Over the last 3 days you have managed to stabilise her blood glucose to normal levels. WHAT IS HER FLUID DEFICIT OVER THE LAST 3 DAYS?

Answer 34

• Over the last 3 days she has lost 26.5L of urine * Her fluid input has been 18L * This equals a deficit of 8.5L

Question 35

case study 5 Three days after her admission, a 43 year old woman (63kg) with diabetic ketoacidosis has a blood pressure of 88/46mmHg and a pulse of 110bmp. She is tachycardic. Her charts show that her urine output over the last 3 days was 26.5L, whist her total intake was 18L. Over the last 3 days you have managed to stabilise her blood glucose to normal levels. THIS PATIENT IS HYPOTENSIVE AND AT RISK OF HYPOVOLEMIC SHOCK. WHAT FLUIDS WOULD YOU PRESCRIBE FOR HER?

Answer 35

* Fluid loss due to osmotic diuresis * 500ml bolus of Hartman’s (0.9% Saline would also be fine) * Reassess. If further fluids need continue to give 250ml – 500ml bolus and reassess. **Continue until stable or 2000ml provided**

Question 36

WHAT ARE THE SIGNS THE FLUID RESUSCITATION IS HELPING?

Answer 36

Signs of improvement include: • Improved blood pressure * Capillary refill * Improved mental status * Urine output

Question 37

WHAT ARE THE SIGNS THAT YOU HAVE GIVEN TOO MUCH FLUID?

Answer 37

Signs of fluid overload include: * Crackles on lung examination * Respiratory distress

Question 38

case study 6 ## Footnote Mr. Stevens, a 28- year- old male, walks into the accident and emergency after the London marathon. He has not been feeling well since the end of the race. Chief complaint: “I don’t know what’s going on. I have just been feeling dizzy and lightheaded." WHAT ADDITIONAL QUESTIONS WOULD YOU ASK THIS PATIENT?

Answer 38

* When did his symptoms start? How long have they been present? * Exacerbating/relieving factors * Progression of his symptoms * How long was his run? How much fluid did he drink? What types of fluids did he drink? * Has this occurred to him during other races? * Any other associated symptoms? * PMH, PSH, Meds, Allergies, FH

Question 39

case study 6 ## Footnote SamStevensisa28-year-oldCaucasianmalewhopresentsdizzyandlightheadedto accident and emergency. The day of the marathon was hotter than expected and the day was unusually sunny. He remembers that it was extremely uncomfortable to run under those conditions, but he kept going and started to fall behind the other runners. He states that the dizziness and light-headedness started at the halfway point of the marathon. He was extremely hot, sweaty and thirsty, and rapidly drank a few bottles of water that were offered to him by the volunteers. After running a bit further, he became dizzy, lightheaded, and slightly disoriented. He was able to finish the race at a walk and immediately had a drink of water. Later that day, he was still feeling hot, dizzy, and lightheaded, so he decided to go to A&E. Samhasnosignificantmedicalorsurgicalhistoryanddoesnottakeanymedications, herbal supplements, or over the counter preparations. He has no allergies to medications and his parents are alive with no significant medical history. Sam is single, but he is in a mutually monogamous relationship. He has no history of sexually transmitted diseases. Samhasaveryhealthylifestyle.Hedoesnoteatanyprocessedfoodsormeats, exercises regularly, and does not drink, smoke or use any drugs. WHAT IS THE PRESENTING COMPLAINT FOR THIS PATIENT? WHAT ARE THE KEY FEATURES OF THIS PRESENTATION? HOW WOULD YOU WRITE THIS IN THE NOTES?

Answer 39

• “This is a 28-year-old man with no past medical history presenting with dizziness, light headedness, and high temperature after running a marathon”.

Question 40

WHAT IS THE EFFECT ON BLOOD VOLUME AND PRESSURE OF A SIGNIFICANT DECREASE IN BOTH WATER AND SALT IN THE BODY?

Answer 40

* Loss of sweat decreases ECF volume and increases its osmolarity. * The kidneys can compensate when volume is lost by retaining extra Na+ and water from the glomerular filtrate. * Dehydration reduces the volume of ECF. * Initially, some compensation for decreased ECF volume occurs because of movement of water from the body cells into the blood, but when the dehydration continues and becomes more severe, the compensation is inadequate, blood volume falls, and blood pressure decreases.

Question 41

case study 6 ## Footnote WHAT COULD ACCOUNT FOR SAM’S HIGH PULSE RATE AND DIZZINESS/LIGHT-HEADEDNESS?T

Answer 41

* the fall in blood pressure elicits a sympathetic reflex as the body attempts to return blood pressure to normal by inducing vasoconstriction and increasing the heart rate. * Therefore, Sam’s racing pulse is the result of a sympathetic reflex. * The reduction in blood pressure is likely to make Sam feel dizzy and lightheaded because of reduced perfusion to the brain.

Question 42

case study 5- YOU DECIDE THAT MR. STEVENS (dehydration after maration) NEEDS AN INTRAVENOUS FLUID INFUSION. WHAT FLUID WILL YOU ADMINISTER TO THE PATIENT TO TREAT HIS CONDITION? EXPLAIN THE RATIONALE BEHIND YOUR CHOICE.

Answer 42

An isotonic saline solution (0.9% sodium chloride) should be administered first to correct extracellular fluid depletion and increase volume. A strongly hypotonic solution would cause water to shift from within the blood to the cells. This would be beneficial for the cells, but blood volume may not be stabilized. A dextrose solution could be proscribed once circulating volume has been restored.

Question 43

HOW WOULD FLUIDS SHIFT IN THE BODY IF YOU GAVE HIM HYPOTONIC (0.45% NACL- hypotonic) SALINE OR 5% DEXTROSE (D5W)? WHAT WOULD HAPPEN TO THE VOLUME OF HIS CELLS?

Answer 43

* The ECF osmolality would drop, and water would flow into the ICF. * Lower ECF osmolality would cause cell volume to increase.

Question 44

WHAT DO YOU THINK WOULD HAPPEN TO THE PATIENT IF HE WERE GIVEN HYPERTONIC SALINE (3% NACL)? DESCRIBE THE SHIFT IN FLUID COMPARTMENTS AND THE VOLUME OF HIS CELLS

Answer 44

ECF osmolality will increase. Water will flow out of the ICF. Cell volume will shrink.