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  • Question 1 - You are considering commencing a patient in their 60s on cilazapril. In discussion...

    Correct

    • You are considering commencing a patient in their 60s on cilazapril. In discussion with the patient you mention that this is an ACE inhibitor.
      The patient asks you what 'ACE' is.
      What is the primary function of 'ACE'?

      Your Answer: Conversion of angiotensin 1 to angiotensin 2

      Explanation:

      The Renin-Angiotensin-Aldosterone System

      The renin-angiotensin-aldosterone system is a pathway in the body that regulates blood pressure and fluid balance. It begins with the production of angiotensinogen in the liver, which is then converted to angiotensin 1 by the enzyme renin, produced in the kidneys. Angiotensin 1 is then converted to angiotensin 2 by the enzyme ACE, found in the lungs and kidneys. Angiotensin 2 has several functions, including the stimulation of aldosterone production by the adrenal gland. This hormone promotes the retention of sodium and water in the body, leading to an increase in blood volume and blood pressure.

      This pathway is commonly tested in medical school and beyond due to its clinical relevance in conditions such as hypertension and heart failure. the renin-angiotensin-aldosterone system is crucial in the management of these conditions, as medications that target this pathway can be used to lower blood pressure and improve outcomes.

    • This question is part of the following fields:

      • Nephrology
      16
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  • Question 2 - A 49-year-old man visits his GP complaining of a weak and painful right...

    Correct

    • A 49-year-old man visits his GP complaining of a weak and painful right leg that has been bothering him for a week. Upon examination, the GP observes a foot drop on the right side with 3/5 power for dorsiflexion, as well as a bilateral sensory peripheral neuropathy that is worse on the right side. The GP also notices weakness of wrist extension on the left, which the patient had not previously mentioned. The patient's chest, heart, and abdomen appear normal, and his urine dipstick is clear. His medical history is significant only for asthma, which was diagnosed four years ago.

      The patient's FBC reveals a white cell count of 6.7 x109/l (normal range: 4 - 11), with neutrophils at 4.2 x109/l (normal range: 1.5 - 7), lymphocytes at 2.3 x109/l (normal range: 1.5 - 4), and eosinophils at 2.2 x109/l (normal range: 0.04 - 0.4). His ESR is 68mm/hr (normal range: 0 - 15), and his biochemistry is normal except for a raised CRP at 52 mg/l. Nerve conduction studies show reduced amplitude sensory signals bilaterally and patchy axonal degeneration on the right side with reduced motor amplitude.

      What is the most likely diagnosis?

      Your Answer: eosinophilic granulomatosis with polyangiitis (EGPA)

      Explanation:

      Differential Diagnosis for Mononeuritis Multiplex

      Mononeuritis multiplex is a condition characterized by the inflammation of multiple nerves, resulting in both sensory and motor symptoms. While several conditions can cause this, eGPA is the most likely diagnosis for this patient due to his history of adult onset asthma and significantly raised eosinophil count. The painful loss of function, raised inflammatory markers, and reduced amplitude nerve conduction studies also suggest an inflammatory cause of his neuropathy.

      While amyloidosis is a possibility, the patient has no history of a disorder that might predispose to secondary amyloid, and no signs of systemic amyloidosis. B12 deficiency and diabetes mellitus are unlikely causes of mononeuritis multiplex, as they do not typically present with this pattern of neuropathy. Lyme disease is also unlikely, as the patient has no rash or arthritis and no history of tick bite.

      In summary, while several conditions can cause mononeuritis multiplex, the patient’s history and test results suggest eGPA as the most likely diagnosis. It is important to consider other possibilities, such as amyloidosis, but the inflammatory nature of the patient’s symptoms points towards eGPA as the primary cause.

    • This question is part of the following fields:

      • Nephrology
      61.6
      Seconds
  • Question 3 - A 7-year-old girl presents with oedema and proteinuria of 4.2 g/24 hours. She...

    Correct

    • A 7-year-old girl presents with oedema and proteinuria of 4.2 g/24 hours. She is diagnosed with minimal change disease and started on steroid therapy. What could be the possible reason for her proteinuria?

      Your Answer: Glomerular proteinuria

      Explanation:

      Glomerular Proteinuria and Minimal Change Disease

      Glomerular proteinuria is a condition characterized by the presence of protein in the urine due to damage to the glomeruli, the tiny filters in the kidneys responsible for removing waste from the blood. This condition can be caused by primary glomerular disease, glomerulonephritis, anti-GBM disease, immune complex deposition, and inherited conditions such as Alport’s syndrome. Additionally, secondary glomerular disease can result from systemic diseases like diabetes.

      One type of glomerulonephritis that is particularly common in children is minimal change disease. This condition has a good prognosis and can often be treated effectively with steroids. It is important to promptly diagnose and treat glomerular proteinuria to prevent further damage to the kidneys and maintain overall kidney function.

    • This question is part of the following fields:

      • Nephrology
      11
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  • Question 4 - A 59-year-old man is undergoing his routine dialysis treatment when he suddenly experiences...

    Incorrect

    • A 59-year-old man is undergoing his routine dialysis treatment when he suddenly experiences intense chest pain and difficulty breathing. He has been on dialysis for the past nine years and uses a fistula for the procedure. So far, there have been no issues with the dialysis machine or circuit. After the session, his blood pressure is 150/85 mmHg, and an ECG is performed. What could be the probable reason for his chest pain?

      Your Answer: Pulmonary embolism

      Correct Answer: Acute coronary syndrome

      Explanation:

      Acute coronary syndrome is the most common cause of chest pain and shortness of breath in dialysis patients due to their increased risk of coronary disease. Air embolism, hypotension, massive haemolysis, and pulmonary embolism are also possible causes but are less likely. Air embolism is rare but can occur in patients with central lines, while hypotension is more common in the elderly and new starters on dialysis. Massive haemolysis is rare but serious, and pulmonary embolism can occur if there is a known thrombus in the fistula.

    • This question is part of the following fields:

      • Nephrology
      20
      Seconds
  • Question 5 - A 39-year-old man is discovered on the roadside after a single-vehicle car accident....

    Correct

    • A 39-year-old man is discovered on the roadside after a single-vehicle car accident. The duration of his lying there is uncertain. Upon the arrival of paramedics, his GCS is 10, and his blood pressure is 92/66 mmHg with a pulse of 96 bpm. Upon arrival at the Emergency department, his blood test results reveal a urea level of 44 mmol/l (normal range: 2.5 - 7.5) and a creatinine level of 620 µmol/l (normal range: 60 - 110). A catheterization procedure produces 50 mls of brown-colored urine. What additional blood test should be requested to determine the cause of his kidney dysfunction?

      Your Answer: Creatine kinase

      Explanation:

      Rhabdomyolysis and Compartment Syndrome

      Rhabdomyolysis is a condition that can occur as a result of various factors, including trauma, crush injury, compartment syndrome, ischaemia, severe electrolyte disturbances, bacterial and viral infections, inherited metabolic disorders, and certain drugs. In order to diagnose rhabdomyolysis, a CK test should be requested.

      One of the common causes of rhabdomyolysis is trauma, such as a road traffic accident. In such cases, it is important to rule out compartment syndrome, which can develop due to the effects of rhabdomyolysis on muscle fibres. Compartment syndrome is characterized by a disruption to the oxygen supply to the muscle, leading to ATP depletion and a build-up of intracellular calcium. This can cause myocyte swelling and impaired function, leading to hypovolaemia and excess fluid sequestration.

      Restoring the blood supply can cause reperfusion injury, which can further damage the myocytes and cause them to swell further, leading to the development of compartment syndrome. Therefore, it is crucial to address compartment syndrome in trauma patients in order to improve their clinical picture. By the causes and effects of rhabdomyolysis and compartment syndrome, healthcare professionals can provide appropriate treatment and management for their patients.

    • This question is part of the following fields:

      • Nephrology
      25.8
      Seconds
  • Question 6 - A 50-year-old man is struggling with hypertension that is not responding to his...

    Correct

    • A 50-year-old man is struggling with hypertension that is not responding to his current medications. His GP added ramipril to his amlodipine and doxazosin two months ago, but his blood pressure remains high at 162/75 mmHg. The GP decides to increase the ramipril dose to 1.25 mg once daily. However, the patient already has mild renal impairment due to his hypertension, so the GP follows NICE guidance and orders further renal function testing in two weeks. Unfortunately, the patient's creatinine level has increased from 150 to 210 μmol/L. What should the GP's next course of action be?

      Your Answer: Refer to renal services for further investigation

      Explanation:

      Possible Renal Artery Stenosis in Resistant Hypertension

      When a patient experiences a rise in their serum creatinine of more than 30% after starting an ACE inhibitor, it may suggest that they have underlying renal artery stenosis causing their resistant hypertension. However, a rise of less than 23% can be considered normal, and it is recommended to repeat blood tests in two weeks to ensure that the creatinine levels are not increasing.

      A renal ultrasound may not provide a clear answer, and it is ideal to perform an angiogram to confirm the diagnosis. This can be done as a CT or MR angiogram for planning purposes, or as a combined angiogram with or without angioplasty if renal artery stenosis is found. Therefore, it is important to consider the possibility of renal artery stenosis in patients with resistant hypertension and a significant rise in serum creatinine after starting an ACE inhibitor.

    • This question is part of the following fields:

      • Nephrology
      22
      Seconds
  • Question 7 - A patient in his 60s visits his GP clinic complaining of general malaise,...

    Incorrect

    • A patient in his 60s visits his GP clinic complaining of general malaise, severe itch, and breathlessness that have been progressively worsening for several months. Upon conducting blood tests, the following results were obtained: adjusted calcium of 2.0 mmol/L (normal range: 2.2-2.4), phosphate of 2.8 mmol/L (normal range: 0.7-1.0), PTH of 12.53 pmol/L (normal range: 1.05-6.83), urea of 32.8 mmol/L (normal range: 2.5-7.8), creatinine of 540 µmol/L (normal range: 60-120), 25 OH Vit D of 32 nmol/L (optimal level >75), and eGFR of 8 ml/min/1.73m2. What is the most effective treatment for this patient?

      Your Answer: Adcal D3

      Correct Answer: Dialysis

      Explanation:

      Dialysis as the Best Option for CKD 5 Patients with Severe Symptoms

      Patients with CKD 5 and an eGFR less than 15 ml/min/1.73m2 are likely to benefit most from dialysis, especially when they experience severe symptoms. Itch, for instance, is a common symptom of uraemia that can be very difficult to treat. On the other hand, breathlessness is often due to fluid buildup in the peritoneum and pleurae, which can be addressed by dialysis. While patients with CKD 5 are regularly reviewed by a renal department, the decision to start dialysis is usually made in a non-emergency setting.

      In cases where patients experience side effects that are difficult to treat without dialysis, supplementing calcium or vitamin D may not significantly change their current condition. Moreover, supplementing phosphate would be inappropriate as most patients with CKD 5 already have high serum phosphate levels and should be on a low phosphate diet. Therefore, dialysis remains the best option for CKD 5 patients with severe symptoms, as it can effectively address the underlying causes of their discomfort.

    • This question is part of the following fields:

      • Nephrology
      23.5
      Seconds
  • Question 8 - A 15-year-old girl comes to the clinic complaining of myalgia and brown-coloured urine....

    Correct

    • A 15-year-old girl comes to the clinic complaining of myalgia and brown-coloured urine. She has been diagnosed with rhabdomyolysis for the fourth time, and the cause is still unknown.

      What investigation should be considered at this point?

      Your Answer: Muscle biopsy

      Explanation:

      Investigating Recurrent Rhabdomyolysis: Genetic Causes and Diagnostic Tests

      Rhabdomyolysis is a condition characterized by the breakdown of muscle tissue, leading to the release of muscle fibers into the bloodstream. This can cause kidney damage and other complications. In some cases, rhabdomyolysis may be caused by genetic polymorphisms or mutations that affect processes such as ATP production and calcium movement. Patients who have had recurrent episodes of unexplained rhabdomyolysis, especially those without obvious traumatic, drug-related, or toxic cause, should be investigated for genetic causes. Muscle biopsy is a useful diagnostic test in these cases.

      Other diagnostic tests may also be helpful in certain situations. For example, the Gal-1 PUT test can be used to diagnose galactosaemia, a rare genetic disorder that can cause rhabdomyolysis in infants. Renin and aldosterone levels may be useful if primary hyperaldosteronism causing hypokalaemia is suspected as the cause of rhabdomyolysis, but this is rare in children. GFR testing is only necessary if there is renal impairment, and haemodialysis may be necessary in cases of severe renal failure.

      In summary, recurrent rhabdomyolysis should be investigated for genetic causes, and muscle biopsy is a useful diagnostic test in these cases. Other diagnostic tests may be helpful in certain situations, but their use should be guided by the patient’s clinical presentation and history.

    • This question is part of the following fields:

      • Nephrology
      9.4
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  • Question 9 - A 40-year-old male visits his doctor two days after finishing a marathon. He...

    Correct

    • A 40-year-old male visits his doctor two days after finishing a marathon. He expresses worry about the reddish-brown hue of his urine and his overall feeling of illness. What is the pigment responsible for the urine discoloration?

      Your Answer: Myoglobin

      Explanation:

      Rhabdomyolysis and Myoglobinuria

      Rhabdomyolysis is a common condition that occurs after extreme physical exertion, such as running a marathon. It is characterized by the breakdown of muscle tissue, which releases myoglobin into the bloodstream. Myoglobin is a small molecule that is normally found in muscle cells, but when released into the circulation, it can cause urine to turn a dark color.

      There are several causes of rhabdomyolysis and myoglobinuria, including trauma, compartment syndrome, crush injuries, ischemia, severe electrolyte imbalances, bacterial and viral infections, and inherited metabolic disorders like McArdle’s disease. In rare cases, certain drugs like barbiturates and statins can also cause rhabdomyolysis.

      It is important to recognize the signs and symptoms of rhabdomyolysis, such as muscle pain, weakness, and dark urine, as it can lead to serious complications like kidney failure if left untreated. Treatment typically involves addressing the underlying cause, such as rehydration and electrolyte replacement, and may require hospitalization in severe cases.

    • This question is part of the following fields:

      • Nephrology
      7.2
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  • Question 10 - As a locum GP, you come across a 40-year-old woman who is experiencing...

    Correct

    • As a locum GP, you come across a 40-year-old woman who is experiencing chills, pelvic discomfort, and painful urination. This patient has no history of diabetes. What are the possible urinalysis results that you might expect in this scenario?

      A) Haemoglobin: Negative, Urobilinogen: Negative, Bilirubin: Negative, Protein: +, Glucose: +++, Nitrites: Negative, Leucocytes: +, Ketones: Negative

      B) Haemoglobin: Negative, Urobilinogen: Negative, Bilirubin: Negative, Protein: Negative, Glucose: +, Nitrites: +++, Leucocytes: ++, Ketones: +++

      C) Haemoglobin: +++, Urobilinogen: Negative, Bilirubin: Negative, Protein: Negative, Glucose: Negative, Nitrites: +++, Leucocytes: +++, Ketones: Negative

      D) Haemoglobin: Negative, Urobilinogen: Negative, Bilirubin: Negative, Protein: Negative, Glucose: Negative, Nitrites: ++++, Leucocytes: Negative, Ketones: +++

      E) Haemoglobin: Negative, Urobilinogen: +, Bilirubin: +, Protein: Negative, Glucose: Negative, Nitrites: +++, Leucocytes: Negative, Ketones: Negative

      It is important to note that the urinalysis results may vary depending on the individual patient's condition and medical history. As a healthcare professional, it is crucial to conduct a thorough examination and analysis to determine the appropriate diagnosis and treatment plan for the patient.

      Your Answer: C

      Explanation:

      Urinalysis Findings in Urinary Tract Infection

      Urinary tract infection (UTI) is a common condition that can be diagnosed through urinalysis. Nitrites and leucocytes are typically present in large amounts in the urine of patients with UTI. Blood may also be present due to inflammation in the bladder or contamination from menstrual bleeding. In some cases, a small amount of glucose may be detected as the body responds to infection by releasing cortisol and adrenaline, which can increase blood glucose levels. However, the presence of protein on urinalysis is usually based on measurement of albumin only, and bacterial proteins are not typically detected using this method. Overall, urinalysis can provide valuable information for diagnosing and managing UTI.

    • This question is part of the following fields:

      • Nephrology
      88
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Nephrology (8/10) 80%
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