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  • Question 1 - You are working in a GP clinic. A 32-year-old woman has multiple sclerosis....

    Incorrect

    • You are working in a GP clinic. A 32-year-old woman has multiple sclerosis. After taking a history and examining her, you diagnose her with chronic urinary retention.

      What nerves are most likely affected by demyelination in this case?

      Your Answer: Hypogastric

      Correct Answer: Pelvic splanchnic

      Explanation:

      The pelvic splanchnic nerves provide parasympathetic innervation to the bladder. In cases of chronic urinary retention, damage to these nerves may be the cause. The greater splanchnic nerves supply the foregut of the gastrointestinal tract, while the lesser splanchnic nerves supply the midgut. Sympathetic innervation of the bladder comes from the hypogastric nerve plexuses, and the lumbar splanchnic nerves innervate the smooth muscles and glands of the pelvis.

      Bladder Anatomy and Innervation

      The bladder is a three-sided pyramid-shaped organ located in the pelvic cavity. Its apex points towards the symphysis pubis, while the base lies anterior to the rectum or vagina. The bladder’s inferior aspect is retroperitoneal, while the superior aspect is covered by peritoneum. The trigone, the least mobile part of the bladder, contains the ureteric orifices and internal urethral orifice. The bladder’s blood supply comes from the superior and inferior vesical arteries, while venous drainage occurs through the vesicoprostatic or vesicouterine venous plexus. Lymphatic drainage occurs mainly to the external iliac and internal iliac nodes, with the obturator nodes also playing a role. The bladder is innervated by parasympathetic nerve fibers from the pelvic splanchnic nerves and sympathetic nerve fibers from L1 and L2 via the hypogastric nerve plexuses. The parasympathetic fibers cause detrusor muscle contraction, while the sympathetic fibers innervate the trigone muscle. The external urethral sphincter is under conscious control, and voiding occurs when the rate of neuronal firing to the detrusor muscle increases.

    • This question is part of the following fields:

      • Renal System
      26
      Seconds
  • Question 2 - A 38-year-old man arrives at the emergency department with sudden-onset acute left flank...

    Incorrect

    • A 38-year-old man arrives at the emergency department with sudden-onset acute left flank pain that started an hour ago. He describes the pain as colicky and radiating down to his groin. The man is also experiencing nausea and vomiting and appears restless. He has no significant medical or surgical history and has never been hospitalized before. His body mass index is 31 kg per m2. Upon examination, his heart rate is 94 beats per minute, respiratory rate is 19 breaths per minute, and blood pressure is 136/79 mmHg. Radiographic studies confirm the presence of stones in the left ureter. What is a characteristic of the most common type of kidney stones?

      Your Answer: Diamond-shaped crystals

      Correct Answer: Envelope-shaped crystals

      Explanation:

      The patient displayed symptoms consistent with urolithiasis, specifically ureterolithiasis, as imaging revealed the presence of stones in the left ureter. Kidney stones are commonly composed of calcium oxalate, but can also consist of calcium phosphate, ammonium magnesium phosphate, uric acid, or cystine, depending on urine pH and other factors.

      Uric acid stones are characterized by diamond or rhomboid-shaped crystals and are often found in individuals with hyperuricemia. Calcium oxalate stones, which have envelope-shaped crystals, are the most common type and are associated with low water intake and dehydration. Cystine stones, with hexagonal-shaped crystals, are prevalent in patients with the genetic condition COLA, which impairs the reabsorption of certain amino acids in the proximal convoluted tubule. Ammonium magnesium phosphate stones, also known as struvites, have coffin-lid shaped crystals and are common in individuals with urinary tract infections caused by urease-producing organisms, such as Klebsiella, Staphylococcus saprophyticus, and Proteus mirabilis. Preventive strategies should be a focus of future management for patients diagnosed with kidney stones.

      Renal stones can be classified into different types based on their composition. Calcium oxalate stones are the most common, accounting for 85% of all calculi. These stones are formed due to hypercalciuria, hyperoxaluria, and hypocitraturia. They are radio-opaque and may also bind with uric acid stones. Cystine stones are rare and occur due to an inherited recessive disorder of transmembrane cystine transport. Uric acid stones are formed due to purine metabolism and may precipitate when urinary pH is low. Calcium phosphate stones are associated with renal tubular acidosis and high urinary pH. Struvite stones are formed from magnesium, ammonium, and phosphate and are associated with chronic infections. The pH of urine can help determine the type of stone present, with calcium phosphate stones forming in normal to alkaline urine, uric acid stones forming in acidic urine, and struvate stones forming in alkaline urine. Cystine stones form in normal urine pH.

    • This question is part of the following fields:

      • Renal System
      38.4
      Seconds
  • Question 3 - A 55-year-old man presents to the emergency department after his GP performed an...

    Incorrect

    • A 55-year-old man presents to the emergency department after his GP performed an ECG due to complaints of palpitations, which showed active changes associated with hyperkalaemia. The emergency department confirms these changes and an arterial blood gas reveals a serum potassium level of 6.9 mmol/l. The patient is promptly initiated on treatment. What intervention will stabilize the cardiac membrane?

      Your Answer: Sodium chloride

      Correct Answer: Calcium gluconate

      Explanation:

      Hyperkalaemia is present in the patient.

      Although all the options are used in treating hyperkalaemia, they have distinct roles. Calcium gluconate is the only option used to stabilise the cardiac membrane.

      Hyperkalaemia is a condition where there is an excess of potassium in the blood. The levels of potassium in the plasma are regulated by various factors such as aldosterone, insulin levels, and acid-base balance. When there is metabolic acidosis, hyperkalaemia can occur as hydrogen and potassium ions compete with each other for exchange with sodium ions across cell membranes and in the distal tubule. The ECG changes that can be seen in hyperkalaemia include tall-tented T waves, small P waves, widened QRS leading to a sinusoidal pattern, and asystole.

      There are several causes of hyperkalaemia, including acute kidney injury, drugs such as potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, and heparin, metabolic acidosis, Addison’s disease, rhabdomyolysis, and massive blood transfusion. Foods that are high in potassium include salt substitutes, bananas, oranges, kiwi fruit, avocado, spinach, and tomatoes.

      It is important to note that beta-blockers can interfere with potassium transport into cells and potentially cause hyperkalaemia in renal failure patients. In contrast, beta-agonists such as Salbutamol are sometimes used as emergency treatment. Additionally, both unfractionated and low-molecular weight heparin can cause hyperkalaemia by inhibiting aldosterone secretion.

    • This question is part of the following fields:

      • Renal System
      20.9
      Seconds
  • Question 4 - You are asked to evaluate a 53-year-old man who has developed sudden right...

    Incorrect

    • You are asked to evaluate a 53-year-old man who has developed sudden right arm pain while in the renal ward.

      According to the patient, the pain started in his right arm within a few minutes while he was resting in bed. He denies any history of trauma. He was recently admitted due to significant edema throughout his body, including periorbital edema.

      Upon examination, his right arm appears pale, cool to the touch, has a capillary refill time of 6 seconds, and no palpable radial pulse. However, his brachial pulse is present.

      The patient is currently undergoing daily blood tests to monitor his renal function. On admission, his urine dipstick showed heavy proteinuria. A 24-hour urine collection was performed, and the results have just been reported:

      Protein 6.2g/L

      What is the probable cause of his right arm pain?

      Your Answer: Factor V Leiden deficiency

      Correct Answer: Antithrombin III deficiency

      Explanation:

      When a patient with nephrotic syndrome experiences symptoms such as those presented in this scenario, the possibility of a vascular event should be considered. The acute onset of symptoms and underlying renal disease suggest the need to differentiate between arterial and venous events, such as arterial thromboembolism or dissection and venous thromboembolism.

      Nephrotic syndrome increases the risk of both venous and arterial thromboses due to the loss of coagulation factors and plasminogen, leading to a hypercoagulable state. In this case, the lack of a radial pulse and cool limb suggest arterial pathology, which is more strongly associated with the loss of antithrombin III than with renal loss of protein S.

      Risk factors such as Factor V Leiden deficiency, the omission of low molecular weight heparin, and immobility in hospital are not specifically relevant to this case.

      Possible Complications of Nephrotic Syndrome

      Nephrotic syndrome is a condition that affects the kidneys, causing them to leak protein into the urine. This can lead to a number of complications, including an increased risk of thromboembolism, which is related to the loss of antithrombin III and plasminogen in the urine. This can result in deep vein thrombosis, pulmonary embolism, and renal vein thrombosis, which can cause a sudden deterioration in renal function.

      Other complications of nephrotic syndrome include hyperlipidaemia, which can increase the risk of acute coronary syndrome, stroke, and other cardiovascular problems. Chronic kidney disease is also a possible complication, as is an increased risk of infection due to the loss of urinary immunoglobulin. Additionally, hypocalcaemia can occur due to the loss of vitamin D and binding protein in the urine.

      It is important for individuals with nephrotic syndrome to be aware of these potential complications and to work closely with their healthcare providers to manage their condition and prevent further complications from occurring. Regular monitoring and treatment can help to minimize the risk of these complications and improve overall health outcomes.

    • This question is part of the following fields:

      • Renal System
      60.5
      Seconds
  • Question 5 - An 82-year-old man is admitted to the neurology ward and complains to the...

    Correct

    • An 82-year-old man is admitted to the neurology ward and complains to the nurse that he is experiencing difficulty urinating. He expresses significant distress and reports feeling pain due to urinary retention. To alleviate his discomfort, the nurse places him in a warm bath, which finally allows him to relax his sphincter and urinate.

      What nervous structure was responsible for maintaining detrusor capacity and causing the patient's difficulty in urinating?

      Your Answer: Hypogastric plexuses

      Explanation:

      The superior and inferior hypogastric plexuses are responsible for providing sympathetic innervation to the bladder, which helps maintain detrusor capacity by preventing parasympathetic contraction of the bladder.

      Bladder Anatomy and Innervation

      The bladder is a three-sided pyramid-shaped organ located in the pelvic cavity. Its apex points towards the symphysis pubis, while the base lies anterior to the rectum or vagina. The bladder’s inferior aspect is retroperitoneal, while the superior aspect is covered by peritoneum. The trigone, the least mobile part of the bladder, contains the ureteric orifices and internal urethral orifice. The bladder’s blood supply comes from the superior and inferior vesical arteries, while venous drainage occurs through the vesicoprostatic or vesicouterine venous plexus. Lymphatic drainage occurs mainly to the external iliac and internal iliac nodes, with the obturator nodes also playing a role. The bladder is innervated by parasympathetic nerve fibers from the pelvic splanchnic nerves and sympathetic nerve fibers from L1 and L2 via the hypogastric nerve plexuses. The parasympathetic fibers cause detrusor muscle contraction, while the sympathetic fibers innervate the trigone muscle. The external urethral sphincter is under conscious control, and voiding occurs when the rate of neuronal firing to the detrusor muscle increases.

    • This question is part of the following fields:

      • Renal System
      36.2
      Seconds
  • Question 6 - A 49-year-old man with a history of chronic alcohol abuse presents with abdominal...

    Correct

    • A 49-year-old man with a history of chronic alcohol abuse presents with abdominal distension and is diagnosed with decompensated alcoholic liver disease with ascites. The consultant initiates treatment with spironolactone to aid in the management of his ascites.

      What is the mode of action of spironolactone?

      Your Answer: Inhibition of the mineralocorticoid receptor in the cortical collecting ducts

      Explanation:

      Aldosterone antagonists function as diuretics by targeting the cortical collecting ducts.

      By inhibiting the mineralocorticoid receptor in the cortical collecting ducts, spironolactone acts as an aldosterone antagonist.

      Loop diuretics like furosemide work by blocking the sodium/potassium/chloride transporter in the loop of Henle.

      Thiazide diuretics, such as bendroflumethiazide, block the sodium/chloride transporter in the distal convoluted tubules.

      Carbonic anhydrase inhibitors, like dorzolamide, act on the proximal tubules.

      Amiloride inhibits the epithelial sodium transporter in the distal convoluted tubules.

      Spironolactone is a medication that works as an aldosterone antagonist in the cortical collecting duct. It is used to treat various conditions such as ascites, hypertension, heart failure, nephrotic syndrome, and Conn’s syndrome. In patients with cirrhosis, spironolactone is often prescribed in relatively large doses of 100 or 200 mg to counteract secondary hyperaldosteronism. It is also used as a NICE ‘step 4’ treatment for hypertension. In addition, spironolactone has been shown to reduce all-cause mortality in patients with NYHA III + IV heart failure who are already taking an ACE inhibitor, according to the RALES study.

      However, spironolactone can cause adverse effects such as hyperkalaemia and gynaecomastia, although the latter is less common with eplerenone. It is important to monitor potassium levels in patients taking spironolactone to prevent hyperkalaemia, which can lead to serious complications such as cardiac arrhythmias. Overall, spironolactone is a useful medication for treating various conditions, but its potential adverse effects should be carefully considered and monitored.

    • This question is part of the following fields:

      • Renal System
      18.3
      Seconds
  • Question 7 - An 71-year-old man arrives at the emergency department complaining of severe back pain...

    Incorrect

    • An 71-year-old man arrives at the emergency department complaining of severe back pain that started 2 hours ago. The pain is radiating from his flank to his groin and comes and goes in waves. He had a kidney stone 2 months ago. A CT scan reveals a hyperdense calculus in his left ureter. His serum calcium level is 2.1 mmol/L (normal range: 2.2-2.6) and his urine calcium level is 9.2 mmol/24hours (normal range: 2.5-7.5). What medication is the most appropriate to reduce the risk of further renal stones?

      Your Answer: Furosemide

      Correct Answer: Bendroflumethiazide

      Explanation:

      Thiazide diuretics, specifically bendroflumethiazide, can be used to decrease calcium excretion and stone formation in patients with hypercalciuria and renal stones. The patient’s urinary calcium levels indicate hypercalciuria, which can be managed with thiazide diuretics. Bumetanide and furosemide, both loop diuretics, are not effective in managing hypercalciuria and renal stones. Denosumab, an antibody used for hypercalcaemia associated with malignancy, is not used in the management of renal stones.

      Management and Prevention of Renal Stones

      Renal stones, also known as kidney stones, can cause severe pain and discomfort. The British Association of Urological Surgeons (BAUS) has published guidelines on the management of acute ureteric/renal colic. Initial management includes the use of NSAIDs as the analgesia of choice for renal colic, with caution taken when prescribing certain NSAIDs due to increased risk of cardiovascular events. Alpha-adrenergic blockers are no longer routinely recommended, but may be beneficial for patients amenable to conservative management. Initial investigations include urine dipstick and culture, serum creatinine and electrolytes, FBC/CRP, and calcium/urate levels. Non-contrast CT KUB is now recommended as the first-line imaging for all patients, with ultrasound having a limited role.

      Most renal stones measuring less than 5 mm in maximum diameter will pass spontaneously within 4 weeks. However, more intensive and urgent treatment is indicated in the presence of ureteric obstruction, renal developmental abnormality, and previous renal transplant. Treatment options include lithotripsy, nephrolithotomy, ureteroscopy, and open surgery. Shockwave lithotripsy involves generating a shock wave externally to the patient, while ureteroscopy involves passing a ureteroscope retrograde through the ureter and into the renal pelvis. Percutaneous nephrolithotomy involves gaining access to the renal collecting system and performing intra corporeal lithotripsy or stone fragmentation. The preferred treatment option depends on the size and complexity of the stone.

      Prevention of renal stones involves lifestyle modifications such as high fluid intake, low animal protein and salt diet, and thiazide diuretics to increase distal tubular calcium resorption. Calcium stones may also be due to hypercalciuria, which can be managed with thiazide diuretics. Oxalate stones can be managed with cholestyramine and pyridoxine, while uric acid stones can be managed with allopurinol and urinary alkalinization with oral bicarbonate.

    • This question is part of the following fields:

      • Renal System
      28.7
      Seconds
  • Question 8 - A 47-year-old man is under the care of an ophthalmologist for open angle...

    Correct

    • A 47-year-old man is under the care of an ophthalmologist for open angle glaucoma. He visits his GP to express his worries about the medication prescribed after reading online information. What is the medication that the ophthalmologist has prescribed, which can function as a diuretic by acting on the proximal convoluted tubule of the kidney?

      Your Answer: Acetazolamide (carbonic anhydrase inhibitor)

      Explanation:

      Diuretic drugs are classified into three major categories based on the location where they inhibit sodium reabsorption. Loop diuretics act on the thick ascending loop of Henle, thiazide diuretics on the distal tubule and connecting segment, and potassium sparing diuretics on the aldosterone-sensitive principal cells in the cortical collecting tubule. Sodium is reabsorbed in the kidney through Na+/K+ ATPase pumps located on the basolateral membrane, which return reabsorbed sodium to the circulation and maintain low intracellular sodium levels. This ensures a constant concentration gradient.

      The physiological effects of commonly used diuretics vary based on their site of action. furosemide, a loop diuretic, inhibits the Na+/K+/2Cl- carrier in the ascending limb of the loop of Henle and can result in up to 25% of filtered sodium being excreted. Thiazide diuretics, which act on the distal tubule and connecting segment, inhibit the Na+Cl- carrier and typically result in between 3 and 5% of filtered sodium being excreted. Finally, spironolactone, a potassium sparing diuretic, inhibits the Na+/K+ ATPase pump in the cortical collecting tubule and typically results in between 1 and 2% of filtered sodium being excreted.

    • This question is part of the following fields:

      • Renal System
      33.5
      Seconds
  • Question 9 - A 75-year-old male ex-smoker presents to a urologist with a complaint of painless...

    Correct

    • A 75-year-old male ex-smoker presents to a urologist with a complaint of painless haematuria that has been ongoing for 3 weeks. He has experienced a weight loss of 5 kg over the past two months. During an urgent cystoscopy, a suspicious mass is discovered and subsequently biopsied. The histology confirms a transitional cell carcinoma of the bladder. A CT scan of the abdomen and pelvis reveals multiple enlarged lymph nodes. Which lymph node is the most probable site of metastasis?

      Your Answer: Internal and external iliac lymph nodes

      Explanation:

      The external and internal iliac nodes are the main recipients of lymphatic drainage from the bladder, while the testes and ovaries are primarily drained by the para-aortic lymph nodes.

      Bladder Anatomy and Innervation

      The bladder is a three-sided pyramid-shaped organ located in the pelvic cavity. Its apex points towards the symphysis pubis, while the base lies anterior to the rectum or vagina. The bladder’s inferior aspect is retroperitoneal, while the superior aspect is covered by peritoneum. The trigone, the least mobile part of the bladder, contains the ureteric orifices and internal urethral orifice. The bladder’s blood supply comes from the superior and inferior vesical arteries, while venous drainage occurs through the vesicoprostatic or vesicouterine venous plexus. Lymphatic drainage occurs mainly to the external iliac and internal iliac nodes, with the obturator nodes also playing a role. The bladder is innervated by parasympathetic nerve fibers from the pelvic splanchnic nerves and sympathetic nerve fibers from L1 and L2 via the hypogastric nerve plexuses. The parasympathetic fibers cause detrusor muscle contraction, while the sympathetic fibers innervate the trigone muscle. The external urethral sphincter is under conscious control, and voiding occurs when the rate of neuronal firing to the detrusor muscle increases.

    • This question is part of the following fields:

      • Renal System
      51.6
      Seconds
  • Question 10 - A 54-year-old individual visits their GP complaining of lower back pain, fatigue, weight...

    Incorrect

    • A 54-year-old individual visits their GP complaining of lower back pain, fatigue, weight loss, and visible haematuria. After ruling out a UTI, the GP refers them through a 2-week wait pathway. An ultrasound reveals a tumour, and a biopsy confirms malignant renal cancer. What is the probable histological type of their cancer?

      Your Answer: Transitional cell carcinoma

      Correct Answer: Clear cell carcinoma

      Explanation:

      Renal cell cancer, also known as hypernephroma, is a primary renal neoplasm that accounts for 85% of cases. It originates from the proximal renal tubular epithelium and is commonly associated with smoking and conditions such as von Hippel-Lindau syndrome and tuberous sclerosis. The clear cell subtype is the most prevalent, comprising 75-85% of tumors.

      Renal cell cancer is more common in middle-aged men and may present with classical symptoms such as haematuria, loin pain, and an abdominal mass. Other features include endocrine effects, such as the secretion of erythropoietin, parathyroid hormone-related protein, renin, and ACTH. Metastases are present in 25% of cases at presentation, and paraneoplastic syndromes such as Stauffer syndrome may also occur.

      The T category criteria for renal cell cancer are based on tumor size and extent of invasion. Management options include partial or total nephrectomy, depending on the tumor size and extent of disease. Patients with a T1 tumor are typically offered a partial nephrectomy, while alpha-interferon and interleukin-2 may be used to reduce tumor size and treat metastases. Receptor tyrosine kinase inhibitors such as sorafenib and sunitinib have shown superior efficacy compared to interferon-alpha.

      In summary, renal cell cancer is a common primary renal neoplasm that is associated with various risk factors and may present with classical symptoms and endocrine effects. Management options depend on the extent of disease and may include surgery and targeted therapies.

    • This question is part of the following fields:

      • Renal System
      26.3
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Renal System (4/10) 40%
Passmed