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Question 1
Correct
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A 20-year-old woman presents with weakness and is found to have a serum potassium of 2.2 mmol/l and pH 7.1. Which of the following would be LEAST useful in differentiating between renal tubular acidosis Types 1 and 2?
Your Answer: Osteomalacia
Explanation:Osteomalacia is a marked softening of the bones that can present in both type I and type II Renal Tubular Acidosis (RTA) and will thus not differentiate the two types in any case. The other measures will allow differentiation of the two types.
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This question is part of the following fields:
- Nephrology
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Question 2
Correct
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A 65-year-old gentleman gives a two week history of progressive lethargy and weakness. Eight weeks previously, he was treated for hypertensive heart failure with 120 mg furosemide and 5 mg enalapril daily. His haemoglobin at the time was 12.0, urea 14.2 mmol/l and creatinine 298 μmol/l. His blood pressure in clinic was 148/85 mmHg. His blood results are shown below: Hb 10.2g/dL, MCV 89.2 fl WCC 4.9 x 109/L, Plats 175 x 109/L, Na+ 135 K+ 5.2 mmol/L, Urea 25.2 mmol/L, Creat 600 μmol/L, Assuming that he is not volume overloaded, what would be the most appropriate action?
Your Answer: stop the enalapril and furosemide
Explanation:The patient presents with worsened renal condition from the last consultation when he was started on enalapril (an ACE inhibitor) so this medication should be stopped. Because there is also no fluid overload; furosemide, a diuretic, should also be stopped.
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This question is part of the following fields:
- Nephrology
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Question 3
Correct
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A 30-year-old female presents with polyuria and is passing 4 litres of urine per day. She was recently started on a new medication. Results show: Serum sodium 144 mmol/L (137-144) Plasma osmolality 299 mosmol/L (275-290) Urine osmolality 210 mosmol/L (350-1000) Which of the following drugs was prescribed?
Your Answer: Lithium
Explanation:The patient’s presentation is consistent with diabetes insipidus: eunatreaemia, high serum osmolality, and inappropriately dilute urine, which leads to the suspicion of lithium-induced diabetes insipidus.
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This question is part of the following fields:
- Nephrology
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Question 4
Correct
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A 32-year-old gentleman presents to his GP with a 2 month history of constant abdominal pain and early satiety. He has hypertension for which he takes enalapril. On examination, he has mild tenderness on both flanks. Well-circumscribed masses are palpable in both the left and right flanks. A soft systolic murmur is heard loudest at the apex. His observations are heart rate 67/min, blood pressure 152/94mmHg, temperature 37.2C, respiratory rate 14/min, saturations 97%. Which additional feature is most likely to be found in this patient?
Your Answer: Hepatomegaly
Explanation:This patient shows classic symptoms of autosomal-dominant polycystic kidney disease (ADPKD). The abdominal pain and early satiety is caused by the enlarged kidneys that were apparent from the physical examination. Additionally, hypertension is a common symptom along with the systolic murmur that was heard, suggesting mitral valve involvement. In ADPKD cases, the most common extra-renal manifestation is the development of liver cysts which are associated with hepatomegaly.
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This question is part of the following fields:
- Nephrology
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Question 5
Incorrect
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You are reviewing a 70-year-old gentleman who has been suffering from multiple myeloma for the past 3 years. He presents with lethargy, muscle aches and pain in his lower back. Arterial blood sampling reveals a metabolic acidosis. Serum potassium is 3.1 mmol/l (3.5–4.9), and urine pH is 5.1 (> 5.3). What is the most likely diagnosis?
Your Answer: Renal tubular acidosis-type I
Correct Answer: Renal tubular acidosis-type II
Explanation:This case is most likely RTA type II, due to decreased proximal bicarbonate reabsorption, which leads to metabolic acidosis, hypokalaemia, hyperchloremia, and <6 urine pH .
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This question is part of the following fields:
- Nephrology
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Question 6
Incorrect
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A 66-year-old gentleman is seen in the Emergency Department complaining of muscle weakness and lethargy. Admission bloods show the following: Na+ 138 mmol/L, K+ 6.6 mmol/L, Bicarbonate 15 mmol/L, Urea 9.2 mmol/L, Creatinine 110 µmol/L, An ECG is done which shows no acute changes. What is the most appropriate initial treatment to lower the serum potassium level?
Your Answer: Intravenous calcium gluconate
Correct Answer: Insulin/dextrose infusion
Explanation:Insulin/dextrose infusion will increase the activity of the sodium-potassium pump in the cells, which will in turn decrease serum potassium levels.
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This question is part of the following fields:
- Nephrology
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Question 7
Correct
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A 16-year-old boy suffers recurrent episodes of haematuria following a flu-like illness. He is otherwise well. Physical examination is normal. Urinalysis reveals no proteinuria, blood ++, and 2–3 white blood cells/mm3. What is the most probable diagnosis?
Your Answer: IgA nephropathy
Explanation:IgA nephropathy’s characteristic presentation is haematuria following a non-specific upper respiratory infection as was evident in this case. IgA nephropathy also usually occurs in children and young males, like this patient.
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This question is part of the following fields:
- Nephrology
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Question 8
Correct
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A 28 year old female presents to her GP with joint pain , fever, a butterfly rash and fatigue. She has marked peripheral oedema. She is found to be hypertensive, in acute renal failure, low albumin levels and proteinuria. A renal biopsy is performed and reveals focal glomerulonephritis with subendothelial and mesangial immune deposits. What is the most likely diagnosis?
Your Answer: Lupus nephritis Class III
Explanation:This case presents with characteristic symptoms of SLE and with her renal biopsy results of focal glomerulonephritis, this is clearly Class III SLE.
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This question is part of the following fields:
- Nephrology
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Question 9
Correct
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A 75-year-old lady is referred to hospital from her GP. She has been treated for essential hypertension, with Bendroflumethiazide 2.5 mg once daily and triamterene 150 mg once daily. Routine investigations show: Serum sodium 134 mmol/L (137-144) Serum potassium 5.9 mmol/L (3.5-4.9) Serum urea 7.0 mmol/L (2.5-7.5) Serum creatinine 100 μmol/L (60-110) Her blood pressure is measured at 134/86 mmHg. Her electrocardiogram is normal. The GP has stopped the triamterene today. Which of these is the most appropriate action?
Your Answer: Repeat urea and electrolytes in one week
Explanation:Triamterene is a potassium-sparing diuretic that can cause hyperkalaemia, therefore, it was stopped in this patient. With all other lab results returning normal values and a normal ECG, management will simply require repeating the U & E after one week since the Triamterene has already be stopped.
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This question is part of the following fields:
- Nephrology
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Question 10
Correct
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An 83-year-old gentleman presents to his GP with increasing oedema and ascites. He is hypertensive, for which he takes amlodipine. There is shortness of breath on exercise. His alcohol history is two cans of stout per day. ECG is normal, and CXR reveals normal heart size and no signs of cardiac failure. Serum albumin is 23 g/dl; urinary albumin excretion is 7 g/24 h, with no haematuria. He has mild anaemia with a normal MCV. Total cholesterol is elevated. What diagnosis fits best with this clinical picture?
Your Answer: Nephrotic syndrome
Explanation:Nephrotic syndrome usually presents with the symptoms in this patient: low albumin, abnormal cholesterol, increased urinary albumin excretion, oedema, and as a consequence, hypertension as well.
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This question is part of the following fields:
- Nephrology
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Question 11
Correct
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A 11-year-old boy has a history of tonsillitis followed by haematuria and hypertension about 10 days later. What would be the characteristic blood test finding in this condition?
Your Answer: Depressed CH 50 level
Explanation:Because the medical history included tonsillitis followed by haematuria and hypertension, there is a strong suspicion of a case of post-streptococcal glomerulonephritis (PSGN). Patients with PSGN usually have serological findings showing depressed serum haemolytic component CH50 and serum concentrations of C3. Sometimes depressed C4 levels are also apparent, but not always, therefore, the answer to this question is: depressed CH50 level.
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This question is part of the following fields:
- Nephrology
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Question 12
Correct
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A 71-year-old woman with a medical history of a blood transfusion in the early 1980s presents with a 10 month history of malaise and is noted to have impaired renal function. Her urine sediment reveals red cell casts. The results of immunological investigations are as follows: serum IgG 6.5 g/L (normal range 6-13), IgA 1.5 g/L (normal range 0.8-4.0), IgM 5.7 g/L (normal range 0.4-2.0), serum electrophoresis shows a faint band in the gamma region, complement C3 1.02 g/L (normal range 0.75-1.65), complement C4 <0.02 g/L (normal range 0.20-0.65), and rheumatoid factor 894 IU/L (normal range <40). Which of the following investigations is likely to be most important in making a definitive diagnosis?
Your Answer: Cryoglobulins
Explanation:The patient’s history of a blood transfusion and lab results showing a markedly low C4 (with normal C3), elevated rheumatoid factor, and elevated serum IgM is highly suggestive of hepatitis C-associated cryoglobulinaemic vasculitis. Testing for Cryoglobulins will confirm this suspicion.
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This question is part of the following fields:
- Nephrology
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Question 13
Correct
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A 23-year-old pregnant woman presents with glycosuria. What is the most likely mechanism?
Your Answer: Reduced renal reabsorption
Explanation:Throughout pregnancy the tubular reabsorption of glucose is less effective than in the non-pregnant state, this leads to glycosuria.
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This question is part of the following fields:
- Nephrology
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Question 14
Incorrect
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A 71-year-old female presents for investigation of fatigue and weight loss. Investigations reveal: Haemoglobin 9.0 g/dL (11.5-16.5) White cell count 2.0 x109/L (4-11 x109) Platelet count 250 x109/L (150-400 x109) Total protein 74 g/L (61-76) Albumin 28 g/L (37-49) Urea 16 mmol/L (2.5-7.5) Creatinine 250 mol/L (60-110) Plasma glucose 6.5 mmol/L (3.0-6.0) Urine dipstick analysis: Protein+ & blood+ Renal ultrasound: Normal Which one of the following investigations would be most appropriate for this patient?
Your Answer: Measurement of anti-neutrophil cytoplasmic antibodies (ANCA)
Correct Answer: Plasma protein electrophoresis
Explanation:This patient’s symptoms of anaemia, leukopenia, and elevated non-albumin protein concentration with fatigue and weight loss, point to myeloma. Thus plasma protein electrophoresis or Serum Protein Electrophoresis (SPE) is indicated when there is suspicion of myeloma.
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This question is part of the following fields:
- Nephrology
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Question 15
Correct
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A 26-year-old patient, previously fit and well, is admitted with fluctuating confusion and frank haematuria. He has recently been complaining of generalised malaise and joint pains. Examination reveals jaundice, splenomegaly, and petechiae. His blood pressure is 155/84 mmHg, temperature 37.9oC. Initial investigations reveal: Haemoglobin 9.5 g/dL, White cell count 12 × 109/L, Platelets 40 × 109/L, Creatinine 142 μmol/L, Sodium 139 mmol/L, Potassium 4.5 mmol/L, Urea 9.2 mmol/L, Lactate dehydrogenase 495 U/l (10–250) Urinalysis Protein ++, blood +++ Blood film shows schistocytes What treatment should NOT be given to this patient?
Your Answer: Platelet transfusion
Explanation:There is a strong suspicion of Thrombotic Thrombocytopenic Purpura (TTP) in this patient as he presents with neurological changes (from confusion to convulsions and coma), fever, haemolysis, thrombocytopenia, and renal failure. Additionally, TTP cases may present with jaundice, splenomegaly, and hypertension as seen in this patient. With a diagnosis of TTP, recent studies have shown that platelet transfusion is not recommended in this case because it has been shown to increase the risk for arterial thrombosis and mortality possibly due to increased aggregations.
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This question is part of the following fields:
- Nephrology
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Question 16
Correct
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A 61-year-old gentleman presents with heart failure and pedal oedema. The oedema occurs due to:
Your Answer: Increased release of renin
Explanation:The oedema is an effect of the a decreased cardiac output that increases renin release which leads to vasoconstriction and sodium and water retention.
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This question is part of the following fields:
- Nephrology
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Question 17
Correct
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Which one of the following statements is true regarding autosomal recessive polycystic kidney disease?
Your Answer: May be diagnosed on prenatal ultrasound
Explanation:Autosomal recessive polycystic kidney disease (ARPKD) is less common than ADPKD (dominant form) but can already present with symptoms and be diagnosed on prenatal ultrasound.
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This question is part of the following fields:
- Nephrology
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Question 18
Correct
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A 74-year-old widow is undergoing haemodialysis for chronic renal failure. What is the most common problem that can arise in this case?
Your Answer: Protein–calorie malnutrition
Explanation:Protein-calorie malnutrition is observed in almost 50% of dialysis patients, contributing to increased morbidity and mortality. All the other complications listed can usually be prevented thanks to modern-day dialysis techniques.
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This question is part of the following fields:
- Nephrology
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Question 19
Correct
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A 41-year-old gentleman underwent kidney transplantation for end-stage renal disease. Now, 2 months after the operation, he has developed fever and features suggestive of bilateral diffuse interstitial pneumonia. What is the most likely aetiological cause?
Your Answer: Cytomegalovirus
Explanation:After renal transplantation, cytomegalovirus has been identified to affect 1/4 of the post-op patients. It is the most common viral infection causing morbidity and mortality in post-op patients in the first 3 months.
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This question is part of the following fields:
- Nephrology
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Question 20
Correct
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A 22-year-old gentleman presents to A&E for the third time with recurrent urinary stones. There appear to be no predisposing factors, and he is otherwise well; urine culture is unremarkable. The urine stones turn out to be cystine stones. What is the most likely diagnosis in this case?
Your Answer: Cystinuria
Explanation:Cystinuria is strongly suspected because of the recurrent passing of cystine stones and otherwise non-remarkable medical history of this young adult patient. Like Cystinuria, all the conditions listed are also inherited disorders, however, the other differentials usually present in the early years of childhood, usually with failure to thrive.
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This question is part of the following fields:
- Nephrology
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Question 21
Correct
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A 41-year-old female is referred to medical assessment unit by her physician for querying thrombotic thrombocytopenic purpura (TTP) after she presented with a temperature of 38.9C. Her subsequent urea and electrolytes showed deteriorating renal function with a creatinine 3 times greater than her baseline. What is the underlying pathophysiology of TTP?
Your Answer: Failure to cleave von Willebrand factor normally
Explanation:Thrombotic thrombocytopenic purpura (TTP) is characterised by the von Willebrand factor (vWF) microthrombi within the vessels of multiple organs. In this condition, the ADAMTS13 metalloprotease enzyme which is responsible for the breakdown of vWF multimer, is deficient, causing its build-up and leading to platelet clots that then decreases the circulating platelets, leading to bleeding in the patient.
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This question is part of the following fields:
- Nephrology
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Question 22
Correct
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A 15-year-old boy presents with hypertension and acute renal failure after an episode of diarrhoea. What is the most likely diagnosis?
Your Answer: Haemolytic–uraemic syndrome
Explanation:The likely diagnosis in this case is Haemolytic Uremic Syndrome (HUS), which is generally seen in young children presenting with a triad of symptoms, namely: acute renal failure, microangiopathic haemolytic anaemia, and thrombocytopenia. The typical cause of HUS is ingestion of a strain of Escherichia coli causing diarrhoea in these cases as well.
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This question is part of the following fields:
- Nephrology
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Question 23
Correct
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A 61-year-old woman with a history of hypothyroidism and inflammatory arthritis is admitted after slipping on ice and falling over. Some routine blood tests are performed: Na+ 141 mmol/L, K+ 2.9 mmol/L, Chloride 114 mmol/L, Bicarbonate 16 mmol/L, Urea 5.2 mmol/L, Creatinine 75 µmol/L, Which one of the following is most likely to explain these results?
Your Answer: Renal tubular acidosis (type 1)
Explanation:The patient’s underlying arthritis has most likely led to Renal tubular acidosis RTA type 1, which presents with the following symptoms consistent with the presentation of the patient: Normal anion gap metabolic acidosis/acidaemia, hypokalaemia and hyperchloremia. Comparatively, the other conditions are ruled out because Aspirin and diabetic ketoacidosis is associated with a raised anion gap, Conn’s syndrome explains hypokalaemia but not the metabolic acidosis, and RTA type 4 is associated with hyperkalaemia.
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This question is part of the following fields:
- Nephrology
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Question 24
Correct
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A 21-year-old gentleman presents with facial and ankle swelling. This has slowly been developing over the past week. During the review of systems, he describes passing ‘frothy’ urine. A urine dipstick shows protein +++. What is the most likely cause of this presentation?
Your Answer: Minimal change disease
Explanation:Minimal change glomerulonephritis usually presents as nephrotic syndrome wherein the patient (usually a young adult) will present with proteinuria, oedema, and impaired kidney function, which were evident in this patient.
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This question is part of the following fields:
- Nephrology
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Question 25
Correct
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A 58-year-old gentleman with a long history of gout presents with loin pain. Other past history of note includes an ileostomy after bowel surgery. There is no history of weight loss from malabsorption syndrome after his bowel surgery. Excretion urography reveals evidence of bilateral renal stones. What is the most likely composition of his renal stones?
Your Answer: Uric acid stones
Explanation:Uric acid stones will most likely be found in this case because of the patient’s long history of gout. Additionally, studies have shown that ileostomy patients have an increased risk for the development of uric acid stones.
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This question is part of the following fields:
- Nephrology
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Question 26
Correct
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A 52-year-old woman with polycystic kidney disease and a slowly rising creatinine, which was 320 μmol/L at her last clinic visit 3 weeks ago, is brought into the Emergency Department having been found collapsed at home by her partner. She is now fully conscious but complains of a headache. What is the most likely diagnosis?
Your Answer: Subarachnoid haemorrhage
Explanation:One of the most important complications in patients with PKD is being affected by berry aneurysms that may burst, causing a subarachnoid haemorrhage, which seems to be the case in this patient.
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This question is part of the following fields:
- Nephrology
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Question 27
Correct
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A 35-year-old gentleman presents to the Emergency Department with abdominal pain. This started earlier on in the day and is getting progressively worse. The pain is located on his left flank and radiates down into his groin. He has no history of this pain or any other condition. Examination reveals a gentleman who is flushed and sweaty but is otherwise unremarkable. What is the most suitable initial management?
Your Answer: IM diclofenac 75 mg
Explanation:Because of the patient’s presentation with flank pain that radiates to the groin, we are suspecting renal colic. We should follow guidelines for acute renal management and prescribe IM diclofenac for immediate relief of pain.
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This question is part of the following fields:
- Nephrology
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Question 28
Correct
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A 63-year-old gentleman is admitted to the Emergency Department, with a past history of chronic renal failure, who complains of increasing shortness of breath. Bloods reveal a creatinine of 570 μmol/l, urea of 48 mmol/l. He is also anaemic with a haemoglobin (Hb) of 8.9 g/dl. On examination he has a pericardial rub and there are bibasal crackles consistent with heart failure. Which of the following represents the best treatment option for this patient?
Your Answer: Urgent haemodialysis
Explanation:This case presents with symptoms and lab results suggestive of uremic pericarditis, which is an indication for immediate haemodialysis. Uremic pericarditis is caused by inflammation of the membranes of the pericardial sac, which usually resolves after a period of intensive dialysis.
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This question is part of the following fields:
- Nephrology
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Question 29
Correct
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Which of the following is most helpful in differentiating chronic from acute renal failure?
Your Answer: Kidney size at ultrasound scan
Explanation:The size of the kidneys on ultrasound would differentiate chronic from acute renal failures. Chronic renal failure is more associated with small-sized kidneys.
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This question is part of the following fields:
- Nephrology
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Question 30
Correct
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A 60-year-old gentleman is found dead in his apartment. He was known to be suffering from primary systemic amyloidosis. What is the most probable cause for his death?
Your Answer: Cardiac involvement
Explanation:Primary amyloidosis is characterised by abnormal protein build-up in the tissues and organ such as the heart, liver, spleen, kidneys, skin, ligaments, and nerves. However, the most common cause of death in patients with primary amyloidosis is heart failure.
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This question is part of the following fields:
- Nephrology
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SESSION STATS - PERFORMANCE PER SPECIALTY
