A 24-year-old woman has acute renal failure following postpartum hemorrhage...

A 24-year-old woman has acute renal failure following postpartum hemorrhage. Laboratory studies showed
serum glucose, 150 mg/dL;
sodium, 135 mEq/L;
potassium, 6.5 mEq/L;
chloride, 105 mEq/L; and
bicarbonate, 15 mEq/L.
Therapy should include which of the following?
(A) Decrease potassium chloride to 10 mEq/L
(B) Intravenous 0.9% sodium chloride
(C) 100 mL of 50% glucose water with 10 U insulin
(D) Intravenous calcitonin
(E) Intravenous magnesium sulfate

Answer:

Management of Hyponatremia..

Five days after an uneventful cholecystectomy, an asymptomatic middle-aged woman is found to have a serum sodium level of 120 meq/L.
Proper management would be
a. Administration of hypertonic saline solution
b. Restriction of free water
c. Plasma ultrafiltration
d. Hemodialysis
e. Aggressive diuresis with furosemide

Answer:

Effect on Kidneys After a Massive Blood loss

A 35-year-old man is admitted with systolic blood pressure (BP) of 60 mm Hg and a heart rate (HR) of 150 bpm following a gunshot wound to the liver (CT scan shown in picture below).

Axial image of Computed tomography (CT) scan of abdomen at level of both kidneys shows dense nephrogram, which is attributed to decrease in renal perfusion

What is the effect on the kidneys?
(A) They tolerate satisfactorily ischemia of 3–4 hours duration.
(B) They undergo further ischemia if hypothermia is present.
(C) They can become damaged, even though urine output exceeds 1500 mL/d.
(D) They are affected and cause an increased creatinine clearance.
(E) They are prevented from further damage by a vasopressor.

Answer:

The test of choice for the diagnosis of ureteral obstruction secondary to renal lithiasis is...

The test of choice for the diagnosis of ureteral obstruction secondary to renal lithiasis is
A) Noncontrast helical computed tomography (CT)
B) Ultrasound
C) Intravenous pyelogram
D) Magnetic resonance imaging (MRI)
E) Plain radiographs

Answer and Discussion

Causes Of Nephrotic Syndrome

A 54-year-old female with rheumatoid arthritis is noted to have proteinuria on annual review. Which one of the following drugs is most associated with the development of proteinuria?
A. Ciclosporin
B. Gold
C. Methotrexate
D. Infliximab
E. Sulfasalazine

Answer:

Most Common Cause Of Death In Patients With Chronic Renal Disease.

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?
A. Hyperkalaemia
B. Malignancy
C. Dilated cardiomyopathy
D. Dialysis related sepsis
E. Ischemic heart disease

Answer:

A 63-year-old male with a known history of myocardial infarction, hypertension and peripheral vascular disease is admitted with breathlessness.

A 63-year-old male with a known history of myocardial infarction, hypertension and peripheral vascular disease is admitted with breathlessness. The blood pressure measured 158/96 mmHg. Blood results are shown.below:
Sodium 137 mmol/l, Potassium 4.5 mmol/l
Urea 11 mmol/l, Creatinine 130 mmol/l
Troponin T <0.1ng/l (NR <0.1 ng/l)
Arterial gases (room air): pH 7.31, PaCO2 6.4 kPa, PaO2 7.1 kPa, Bicarbonate 16 mmol/l
Chest X-ray Severe pulmonary oedema
ECG LBBB
Urinalysis Protein nil Blood nil

He was treated with diuretics and then commenced on an ACE inhibitor but after 72 hours the urea was 20 mmol/l and creatinine was 250 mmol/l. Echocardiography revealed mild impairment of left ventricular function.

What is the most probable cause for his presentation?
a. Myocardial infarction.
b. Hypertensive cardiomyopathy.
c. Renal artery stenosis.
d. Cardiac tachycarrhythmia.
e. Myocardial dysfunction secondary to acidosis.

Answer:

Screening For Autosomal dominant polycystic kidney disease (ADPKD)

A 24-year-old man who has a sister with adult polycystic kidney disease asks his GP if he could be screened for the disease. What is the most appropriate screening test?
A. PKD1 gene testing
B. CT abdomen
C. Urine microscopy
D. Ultrasound abdomen
E. Anti-polycystin 1 antibodies levels

Answer: D. Ultrasound abdomen

 Discussion: Ultrasound is the screening test for adult polycystic kidney disease Genetic testing is still not routinely recommended for screening family members .
Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited cause of kidney disease, affecting 1 in 1,000 Caucasians. Two disease loci have been identified, PKD1 and PKD2, which code for polycystin-1 and polycystin-2 respectively.

ADPKD type 1:

• 85% of cases 
• Chromosome 16
• Presents with renal failure earlier

ADPKD type 2: 

• 15% of cases
• Chromosome 4

The screening investigation for relatives is abdominal ultrasound: 

Ultrasound diagnostic criteria (in patients with positive family history) 

 two cysts, unilateral or bilateral, if aged < 30 years 

 two cysts in both kidneys if aged 30-59 years 

 four cysts in both kidneys if aged > 60 years

Anemia In Chronic Renal Disease

One of your patients with chronic kidney disease stage 4 has his annual bloods done. It shows:
Hb 9.4 g/dl
Platelets 166 x 109/l
WBC 6.7 x 109/l
He is currently under the renal team and has recently been started on erythropoietin.
What will his target haemoglobin be?
A. 10-12 g/dl
B. Normal for gender
C. 9-11 g/dl
D. 9-10 g/dl
E. 11-13 g/dl

Answer:

Chronic Renal Disease and Hypertension.

A 45-year-old woman with type 1 diabetes mellitus is reviewed in the diabetes clinic. Three months ago her blood tests were as followed:
K+ 4.5 mmol/l , Creatinine 116 μmol/l , eGFR 47 ml/min

At the time she was started on lisinopril to treat both the hypertension and act as a renoprotective agent. Lisinopril had been titrated up to treatment dose. Her current bloods are as follows:
K+ 4.9 mmol/l , Creatinine 123 μmol/l ,  eGFR 44 ml/min

Of the following options, what is the most appropriate course of action?
A. Stop lisinopril and arrange investigations to exclude renal artery stenosis
B. Switch to a angiotensin 2 receptor blocker
C. Switch to a different ACE inhibitor
D. No action
E. Reduce dose of lisinopril

Answer:

Estimated GFR or eGFR For Staging Chronic Renal Disease.

A 62-year-old man with chronic kidney disease secondary to diabetes mellitus is reviewed. When assessing his estimated glomerular filtration rate (eGFR), which one of the following variables is not required by the Modification of Diet in Renal Disease (MDRD) equation?
A. Age
B. Serum creatinine
C. Ethnicity
D. Gender
E. Serum urea

Answer:

Case Scenarios Of Patients presenting With Hematuria And Their Diagnosis .

A. Transitional cell carcinoma of the bladder
B. Renal stones
C. Chlamydia
D. IgA nephropathy
E. Urinary tract infection
F. Renal cell carcinoma
G. Polycystic kidney disease
H. Goodpasture's syndrome
I. Urethral syndrome
J. Renal vein thrombosis

For each one of the scenarios given below  please select the most likely diagnosis from the list of choices given above:

1. A 14-year-old boy develops visible haematuria following an upper respiratory tract infection.

Answer: IgA nephropathy which is also called Berger's disease.

2. A 60-year-old man presents with visible haematuria for the past three weeks. He has an ache in the left loin but examination is unremarkable other than a left varicocele. He also notes to feeling intermittently hot and sweaty.

Answer: Renal cell carcinoma.

Features of renal cell carcinoma include:

• classical triad: haematuria, loin pain, abdominal mass
• pyrexia of unknown origin
• left varicocele (due to occlusion of left testicular vein)
• endocrine effects: may secrete erythropoietin (polycythaemia), parathyroid hormone (hypercalcaemia), renin, ACTH
• 25% have metastases at presentation

3. 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.

Answer: Chlamydia infection

Features of Chlamydia include: 

•  asymptomatic in around 70% of women and 50% of men
• women: cervicitis (discharge, bleeding), dysuria
• men: urethral discharge, dysuria

Brief Discussion On Hematuria 

Prescribing Drugs in Patients With Renal Failure

A 54-year-old man with stage 4 chronic kidney disease presents for review. Which one of the following drugs is it most important to avoid?

A. Erythromycin
B. Diazepam
C. Rifampicin
D. Tetracycline
E. Warfarin

Answer :

A 34 Year Old Woman Presents With Polyuria And Polydipsia

A 34 year old woman presents to your clinic complaining of polyuria and poldipsia of 4 months duration.  She says she has been urinating a 20-30 times per day. Her past medical history is unremarkable. She takes oral contraceptives and occasionally a multivitamin. Her family history is positive for diabetes and heart disease.
Her initial investigations are :

Na = 143 mEq/l
Normal K, cretinine and glucose.
Urine osmolality = 160mOsm/Kg

Q 1 . What is the most likely diagnosis?

Answer: Diabetes insipidus.

( This patient has polyuria with diluted urine and a serum sodium level in the high normal range. A diagnosis of diabetes insipidus can be made if the urine osmolality is less than 250 mOsm/Kg despite hypernatremia. )

Learning Compensated And Poorly Compensated Metabolic/ Respiratory Acidosis

While covering the ER, a 62-year-old female you have known for several years presents with her husband. Your patient appears very lethargic and is unable to give a coherent history. Her husband tells you that she began having stomach pain, nausea, and diarrhea 2 days ago. Although she has not been vomiting, she has been unable to drink or eat much due to nausea.
She takes furosemide for edema and albuterol/ipratropium for COPD.
She smokes a pack of cigarettes per day.
On physical examination, her respiratory rate is 30, pulse 104, blood pressure 112/64, and temperature 37.9◦C.
She is lethargic and disoriented.
Oral mucosa is dry.
Her lungs show diminished air movement bilaterally.
Her abdomen is diffusely tender, but there is no rebound.
Rectal exam is negative for occult blood.
The first laboratory test you have available is a room air arterial blood gas:

•  pH 7.12, 
• PaCO2 33 mm Hg,
• PaO2 80 mm Hg,
• HCO3 10 mEq/L, and 
• oxygen saturation 92%. 

This blood gas is most consistent with which of the following processes?

A) Compensated metabolic acidosis.
B) Compensated respiratory acidosis.
C) Poorly compensated metabolic acidosis.
D) Poorly compensated respiratory acidosis.

Answer And Discussion:

Causes Of Nephrotic Syndrome

Nephrotic syndrome is not a specific disease entity but can be the end result of a number of processes. Which of the following cause nephrotic syndrome?

A) Diabetes.
B) Minimal change disease.
C) Amyloidosis.
D) Systemic lupus erythematosus.
E) All of the above.

Answer And Discussion:

A 5 Year Old Dehydrated Boy Needs Fluid Resustication

A 5-year-old boy presents to the paediatric surgery department with a 24-hour history of abdominal pain. His history and examination findings are consistent with a diagnosis of acute appendicitis. He is dehydrated with an estimated fluid deficit of 15%.
Which of the following is the most appropriate resuscitation fluid?

A:  Packed red blood cells
B:  5% dextrose and 0.45% sodium chloride
C:  10% dextrose and 0.18% sodium chloride
D:  0.9% sodium chloride
E:  3% sodium chloride

Answer And Explanation:

A 25 Year Old Woman With A 2 Day History Of Dysuria And Urinary Frequency

A 25-year-old woman complains of a 2-day history of dysuria, urgency, and urinary frequency. She denies the use of any medications and has no significant past medical history.
On examination, her blood pressure (BP) is 100/70 mm Hg, heart rate (HR) is 90 beats per minute, and temperature is 98°F (36.6°C). The thyroid is normal on palpation. The heart and lung examinations are normal. She does not have back tenderness. The abdomen is non tender and without masses. The pelvic examination reveals normal female genitalia. There is no adnexal tenderness or masses.

1. What is the most likely diagnosis?
2. What is the next step in the diagnosis?
3. What is the most likely etiology of the condition?

Answers And Discussion:

A 74 Year Old Woman With Asymptomatic Bacteriuria

A 74-year-old woman is in your office for a complete physical. On further questioning, she has mentions having had stress urinary incontinence for a number of years, which is unchanged. She reports no fevers, hematuria, dysuria, flank pain, or other symptoms.
You obtain a urinalysis which shows 10–20WBC/hpf and is nitrite positive on dipstick. A culture of the urine shows 100,000 cfu/mL of E. coli.

How should you treat this patient?

A) Trimethoprim-sulfamethoxazole DS 1 tab PO BID for 10 days.
B) Erythromycin 500 mg PO q 6 hours for 14 days.
C) Ampicillin 250 mg PO q 6 hours for 10 days.
D) Ceftriaxone 1 g IM every day for 3 days.
E) With courtesy and respect, but not with antibiotics.

Answer And Discussion:

A Case Of Acute Tubular Necrosis

A 48-year-old man is hospitalized for shock after massive blood loss in a motor vehicle accident.
On the patient’s second day in the hospital, his blood urea nitrogen (BUN) and creatinine levels
begin to rise and he develops pitting edema to his knees. A subsequent urinalysis shows numerous
granular casts.
Which of the following is the most appropriate treatment?

(A) Angioplasty
(B) Broad-spectrum antibiotics
(C) Corticosteroids
(D) Fluids and dialysis
(E) Use of ultrasound to remove blockage

Answer And Discussion: