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Question 1
Correct
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A 58-year-old lady was admitted to hospital with increasing thirst and generalised abdominal pain. She was diagnosed with breast carcinoma three years previously and treated with a radical mastectomy. Investigations showed: Serum corrected calcium 3.5 mmol/L (NR 2.2-2.6) Serum alkaline phosphatase 1100 IU/L Her serum calcium was still elevated following 4 litres of 0.9% saline intravenous infusion. Which of the following is the most appropriate next step?
Your Answer: Pamidronate 60 mg intravenously
Explanation:This case has hypercalcaemia most likely associated with the bony metastases from her pre-existing breast carcinoma. The most appropriate next step is to give Pamidronate 60mg intravenously, a bisphosphonate, to immediately inhibit bone resorption and formation.
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This question is part of the following fields:
- Nephrology
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Question 2
Incorrect
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A 21-year-old woman presents with lethargy and confusion. On examination, you note a purpuric rash covering the abdominal wall and thighs, and a fever of 38C. Investigations reveal haemolytic anaemia, thrombocytopenia, and acute kidney injury. Which feature of the presentation makes the diagnosis of thrombotic thrombocytopenic purpura more likely than haemolytic uremic syndrome?
Your Answer: Acute kidney injury
Correct Answer: Confusion
Explanation:Confusion in the patient refers to neurological symptoms that are more associated with thrombotic thrombocytopenic purpura than with haemolytic uremic syndrome. All the other symptoms present in both conditions similarly.
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This question is part of the following fields:
- Nephrology
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Question 3
Incorrect
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A 30-year-old woman who underwent a live related renal transplant for end-stage renal failure secondary to chronic pyelonephritis 4 months ago, now attends the clinic for routine follow up. She is taking tacrolimus and mycophenolate mofetil (MMF). Her urea and electrolytes are: Na+ 136 mmol/L, K+ 3.7 mmol/L, Urea 7.2 mmol/L, Creatinine 146 μmol/L. She was last seen in clinic 2 weeks previously when her urea was 4.2 mmol/l and creatinine 98 μmol/l. She is clinically well and asymptomatic. On examination she was apyrexial and normotensive. Her transplant site was non-tender with no swelling and there were no other signs to be found. Which initial investigations should be performed first?
Your Answer: Doppler ultrasound scan of the transplant site
Correct Answer: Urine and blood cultures
Explanation:After renal transplant, asymptomatic patients can still have graft dysfunction as an early complication, with rising serum creatinine; therefore, urine and blood cultures should be ordered first. This should be followed by measuring the Tacrolimus levels, as this drug can be directly nephrotoxic. Next, a Doppler ultrasound of the transplant site should be ordered, to check for any obstructions or occlusions.
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This question is part of the following fields:
- Nephrology
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Question 4
Incorrect
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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: Fluoxetine
Correct 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 5
Incorrect
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A 64-year-old woman presents with malaise, ankle swelling and shortness of breath. Her blood pressure is 215/140 mmHg, she has +2 peripheral oedema and the skin over her fingers appears very tight. Fundoscopy discloses bilateral papilledema. Plasma creatinine concentration is 370 μmol/l, potassium is 4.9 mmol/l, haemoglobin is 8.9 g/dl and her platelet count is 90 x 109 /ml. What is the pathological hallmark of this condition?
Your Answer: Autoimmune destruction of red blood cells
Correct Answer: Mucoid intimal thickening of vascular endothelium
Explanation:The history is suggestive of scleroderma renal crisis, where we would expect thrombotic microangiopathy process with vascular endothelium involvement manifesting as mucoid intimal thickening or onion skin effect.
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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 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: Calcium oxalate
Correct 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 7
Incorrect
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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: Herpes simplex virus
Correct 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 8
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 bicarbonate
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 9
Incorrect
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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: Autoimmune destruction of platelets
Correct 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 10
Incorrect
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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: Cirrhosis
Correct 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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