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  • Question 1 - During your placement on a gastro ward, a patient in their late 60s...

    Incorrect

    • During your placement on a gastro ward, a patient in their late 60s develops excessive diarrhea. Can you identify the location in the gastrointestinal tract where most of the water is absorbed?

      Your Answer: Colon

      Correct Answer: Jejunum

      Explanation:

      The absorption of water in the gastrointestinal tract is facilitated by the absorption of ions across cell membranes. The majority of water is absorbed in the small intestine, particularly in the jejunum.

      Water Absorption in the Human Body

      Water absorption in the human body is a crucial process that occurs in the small bowel and colon. On average, a person ingests up to 2000ml of liquid orally within a 24-hour period. Additionally, gastrointestinal secretions contribute to a further 8000ml of fluid entering the small bowel. The process of intestinal water absorption is passive and is dependent on the solute load. In the jejunum, the active absorption of glucose and amino acids creates a concentration gradient that facilitates the flow of water across the membrane. On the other hand, in the ileum, most water is absorbed through facilitated diffusion, which involves the movement of water molecules with sodium ions.

      The colon also plays a significant role in water absorption, with approximately 150ml of water entering it daily. However, the colon can adapt and increase this amount following resection. Overall, water absorption is a complex process that involves various mechanisms and is essential for maintaining proper hydration levels in the body.

    • This question is part of the following fields:

      • Renal System
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  • Question 2 - A 30-year-old female visits her GP complaining of ankle swelling. During the examination,...

    Correct

    • A 30-year-old female visits her GP complaining of ankle swelling. During the examination, her blood pressure is found to be 180/110 mmHg and a urine dipstick reveals protein +++ levels. She is referred to a nephrologist who performs a renal biopsy. The biopsy results show basement membrane thickening on light microscopy and subepithelial spikes on silver staining. Immunohistochemistry confirms the presence of PLA2. What is the probable diagnosis?

      Your Answer: Membranous glomerulonephritis

      Explanation:

      Membranous glomerulonephritis is the most common type of glomerulonephritis in adults and is the third leading cause of end-stage renal failure. It typically presents with proteinuria or nephrotic syndrome. A renal biopsy will show a thickened basement membrane with subepithelial electron dense deposits, creating a spike and dome appearance. The condition can be caused by various factors, including infections, malignancy, drugs, autoimmune diseases, and idiopathic reasons.

      Management of membranous glomerulonephritis involves the use of ACE inhibitors or ARBs to reduce proteinuria and improve prognosis. Immunosuppression may be necessary for patients with severe or progressive disease, but many patients spontaneously improve. Corticosteroids alone are not effective, and a combination of corticosteroid and another agent such as cyclophosphamide is often used. Anticoagulation may be considered for high-risk patients.

      The prognosis for membranous glomerulonephritis follows the rule of thirds: one-third of patients experience spontaneous remission, one-third remain proteinuric, and one-third develop end-stage renal failure. Good prognostic factors include female sex, young age at presentation, and asymptomatic proteinuria of a modest degree at the time of diagnosis.

    • This question is part of the following fields:

      • Renal System
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  • Question 3 - A 38-year-old male patient complains of a painless lump in his left testicle...

    Correct

    • A 38-year-old male patient complains of a painless lump in his left testicle that he discovered during self-examination. Upon examination, a solid nodule is palpable in the left testicle, and ultrasound imaging reveals an irregular mass lesion. The patient's serum AFP and HCG levels are both normal. What is the probable diagnosis?

      Your Answer: Seminoma

      Explanation:

      A seminoma is the most probable diagnosis for this man based on his age, symptoms, and normal levels of tumour markers. Teratomas and yolk sac tumours usually result in elevated AFP and HCG levels, which are not present in seminomas. Epididymo-orchitis does not cause painless irregular mass lesions.

      Overview of Testicular Disorders

      Testicular disorders can range from benign conditions to malignant tumors. Testicular cancer is the most common malignancy in men aged 20-30 years, with germ-cell tumors accounting for 95% of cases. Seminomas are the most common subtype, while non-seminomatous germ cell tumors include teratoma, yolk sac tumor, choriocarcinoma, and mixed germ cell tumors. Risk factors for testicular cancer include cryptorchidism, infertility, family history, Klinefelter’s syndrome, and mumps orchitis. The most common presenting symptom is a painless lump, but pain, hydrocele, and gynecomastia may also be present.

      Benign testicular disorders include epididymo-orchitis, which is an acute inflammation of the epididymis often caused by bacterial infection. Testicular torsion, which results in testicular ischemia and necrosis, is most common in males aged between 10 and 30. Hydrocele presents as a mass that transilluminates and may occur as a result of a patent processus vaginalis in children. Treatment for these conditions varies, with orchidectomy being the primary treatment for testicular cancer. Surgical exploration is necessary for testicular torsion, while epididymo-orchitis and hydrocele may require medication or surgical procedures depending on the severity of the condition.

    • This question is part of the following fields:

      • Renal System
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  • Question 4 - A 25-year-old suffers a groin stab wound resulting in hypovolaemic shock. What would...

    Incorrect

    • A 25-year-old suffers a groin stab wound resulting in hypovolaemic shock. What would be the probable observation on examining his urine?

      Your Answer: Increased urinary glucose

      Correct Answer: Increased specific gravity

      Explanation:

      When blood pressure drops below the level at which the kidney can regulate its blood flow, hypovolemic shock can lead to a reduction in renal blood flow. This can cause an increase in specific gravity as the body tries to retain water to maintain blood volume.

      The Loop of Henle and its Role in Renal Physiology

      The Loop of Henle is a crucial component of the renal system, located in the juxtamedullary nephrons and running deep into the medulla. Approximately 60 litres of water containing 9000 mmol sodium enters the descending limb of the loop of Henle in 24 hours. The osmolarity of fluid changes and is greatest at the tip of the papilla. The thin ascending limb is impermeable to water, but highly permeable to sodium and chloride ions. This loss means that at the beginning of the thick ascending limb the fluid is hypo osmotic compared with adjacent interstitial fluid. In the thick ascending limb, the reabsorption of sodium and chloride ions occurs by both facilitated and passive diffusion pathways. The loops of Henle are co-located with vasa recta, which have similar solute compositions to the surrounding extracellular fluid, preventing the diffusion and subsequent removal of this hypertonic fluid. The energy-dependent reabsorption of sodium and chloride in the thick ascending limb helps to maintain this osmotic gradient. Overall, the Loop of Henle plays a crucial role in regulating the concentration of solutes in the renal system.

    • This question is part of the following fields:

      • Renal System
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  • Question 5 - A 5-year-old boy presents with symptoms of right sided loin pain, lethargy and...

    Incorrect

    • A 5-year-old boy presents with symptoms of right sided loin pain, lethargy and haematuria. On examination he is pyrexial and has a large mass in the right upper quadrant. What is the most probable underlying diagnosis?

      Your Answer: Grawitz tumour

      Correct Answer: Nephroblastoma

      Explanation:

      Based on the symptoms presented, it is highly probable that the child has nephroblastoma, while perinephric abscess is an unlikely diagnosis. Even if an abscess were to develop, it would most likely be contained within Gerota’s fascia initially, making anterior extension improbable.

      Nephroblastoma: A Childhood Cancer

      Nephroblastoma, also known as Wilms tumours, is a type of childhood cancer that typically occurs in the first four years of life. The most common symptom is the presence of a mass, often accompanied by haematuria (blood in urine). In some cases, pyrexia (fever) may also occur in about 50% of patients. Unfortunately, nephroblastomas tend to metastasize early, usually to the lungs.

      The primary treatment for nephroblastoma is nephrectomy, which involves the surgical removal of the affected kidney. The prognosis for younger children is generally better, with those under one year of age having an overall 5-year survival rate of 80%. It is important to seek medical attention promptly if any of the symptoms associated with nephroblastoma are present, as early detection and treatment can greatly improve the chances of a positive outcome.

    • This question is part of the following fields:

      • Renal System
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  • Question 6 - During a 5-year-old male child's routine check-up, a doctor observes macroglossia, hepatomegaly and...

    Correct

    • During a 5-year-old male child's routine check-up, a doctor observes macroglossia, hepatomegaly and renomegaly along with a characteristic ear crease. The child was born at 38 weeks gestation and had a prolonged spontaneous vaginal delivery. His birth weight was 4 kg (8Ib 13oz). He had neonatal hypoglycaemia during the first 12 hours which was treated with IV dextrose. The doctor suspects Beckwith-Wiedemann syndrome. What childhood cancers are associated with this syndrome?

      Your Answer: Wilms tumour (nephroblastoma)

      Explanation:

      Beckwith-Wiedemann syndrome (BWS) is a rare condition that causes excessive growth in children and increases their risk of developing tumors. It affects approximately 1 in 10,300 to 13,700 people. Symptoms of BWS include large body size, enlarged tongue, protruding belly button or hernia, ear creases or pits, enlarged organs in the abdomen, and low blood sugar in newborns. The most common cancer associated with BWS is Wilms tumor, although other childhood cancers can also occur.

      Wilms’ Tumour: A Common Childhood Malignancy

      Wilms’ tumour, also known as nephroblastoma, is a prevalent type of cancer in children, with a median age of diagnosis at 3 years old. It is often associated with Beckwith-Wiedemann syndrome, hemihypertrophy, and a loss-of-function mutation in the WT1 gene on chromosome 11. The most common presenting feature is an abdominal mass, which is usually painless, but other symptoms such as haematuria, flank pain, anorexia, and fever may also occur. In 95% of cases, the tumour is unilateral, and metastases are found in 20% of patients, most commonly in the lungs.

      If a child presents with an unexplained enlarged abdominal mass, it is crucial to arrange a paediatric review within 48 hours to rule out Wilms’ tumour. The management of this cancer typically involves nephrectomy, chemotherapy, and radiotherapy if the disease is advanced. Fortunately, the prognosis for Wilms’ tumour is good, with an 80% cure rate.

      Histologically, Wilms’ tumour is characterized by epithelial tubules, areas of necrosis, immature glomerular structures, stroma with spindle cells, and small cell blastomatous tissues resembling the metanephric blastema. Overall, early detection and prompt treatment are essential for a successful outcome in children with Wilms’ tumour.

    • This question is part of the following fields:

      • Renal System
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  • Question 7 - During a small bowel resection, the anaesthetist decides to administer an electrolyte-rich intravenous...

    Incorrect

    • During a small bowel resection, the anaesthetist decides to administer an electrolyte-rich intravenous fluid to a 47-year-old man. What is the most suitable option for this requirement?

      Your Answer: 5% Dextrose with added potassium 20 mmol/ L

      Correct Answer: Hartmans

      Explanation:

      While Hartmans solution has the highest electrolyte content, pentastarch and gelofusine contain a greater number of macromolecules.

      Intraoperative Fluid Management: Tailored Approach and Goal-Directed Therapy

      Intraoperative fluid management is a crucial aspect of surgical care, but it does not have a rigid algorithm due to the unique requirements of each patient. The latest NICE guidelines in 2013 did not specifically address this issue, but the concept of fluid restriction has been emphasized in enhanced recovery programs for the past decade. In the past, patients received large volumes of saline-rich solutions, which could lead to tissue damage and poor perfusion. However, a tailored approach to fluid administration is now practiced, and goal-directed therapy is used with the help of cardiac output monitors. The composition of commonly used intravenous fluids varies in terms of sodium, potassium, chloride, bicarbonate, and lactate. Therefore, it is important to consider the specific needs of each patient and adjust fluid administration accordingly. By doing so, the risk of complications such as ileus and wound breakdown can be reduced, and optimal surgical outcomes can be achieved.

    • This question is part of the following fields:

      • Renal System
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  • Question 8 - A 58-year-old man presents to the Emergency Department with a significant amount of...

    Incorrect

    • A 58-year-old man presents to the Emergency Department with a significant amount of blood in his urine over the past two days. He reports having occasional blood in his urine previously, but it has now turned red. He denies any fever but complains of feeling fatigued. The patient has a 25 pack years history of smoking and has worked in a factory that produces dyes for his entire career. The doctor orders a ureteroscopy, which reveals an abnormal growth in his bladder. What is the highest risk factor for the most likely diagnosis in this patient?

      Your Answer: Arsenic

      Correct Answer: 2-naphthylamine

      Explanation:

      The patient’s painless hematuria and fatigue, combined with a history of smoking and occupation in a dye factory, suggest a diagnosis of transitional cell carcinoma of the bladder. This is supported by the observation of an abnormal growth in the bladder during ureteroscopy (First Aid 2017, p219 & p569).

      1. Arsenic is a carcinogen that raises the risk of angiosarcoma of the liver, squamous cell carcinoma of the skin, and lung cancer.
      2. Aromatic amines, such as 2-naphthylamine and benzidine, are carcinogens that increase the risk of transitional cell carcinoma of the bladder. They are commonly used in dye manufacturing.
      3. Aflatoxins from Aspergillus increase the risk of hepatocellular carcinoma. Aflatoxins are frequently found in crops like peanuts and maize.
      4. Nitrosamines in smoked foods are linked to an increased risk of stomach cancer.
      5.

      Risk Factors for Bladder Cancer

      Bladder cancer is a type of cancer that affects the bladder, and there are different types of bladder cancer. The risk factors for urothelial (transitional cell) carcinoma of the bladder include smoking, which is the most important risk factor in western countries. Exposure to aniline dyes, such as working in the printing and textile industry, and rubber manufacture are also risk factors. Cyclophosphamide, a chemotherapy drug, is also a risk factor for this type of bladder cancer. On the other hand, the risk factors for squamous cell carcinoma of the bladder include schistosomiasis and smoking. It is important to be aware of these risk factors and take steps to reduce your risk of developing bladder cancer.

    • This question is part of the following fields:

      • Renal System
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  • Question 9 - A 6-year-old girl is brought to her pediatrician by her father. Her father...

    Incorrect

    • A 6-year-old girl is brought to her pediatrician by her father. Her father reports that for the past 5 days, she has been experiencing swelling in her lower limbs. The girl is otherwise healthy, has not had any recent illnesses, and her blood pressure during the visit was normal. The results of her urinalysis are as follows:

      Leucocytes: Negative
      Nitrites: Negative
      Urobilinogen: Negative
      Proteins: 3+
      Blood: Negative
      Ketones: Negative
      Glucose: Negative

      What is the most probable diagnosis?

      Your Answer: IgA nephropathy

      Correct Answer: Minimal change disease

      Explanation:

      The boy’s symptoms are typical of nephrotic syndrome, which is characterized by a triad of proteinuria, hypoalbuminaemia, and oedema. Oedema is usually seen in the lower limbs, and proteinuria may cause frothy urine. Minimal change disease, focal segmental glomerulosclerosis, and membranous nephropathy are examples of nephrotic syndrome. Minimal change disease is a common cause of nephrotic syndrome, and it is characterized by effacement of the podocyte foot processes, which increases the permeability of the glomerular basement membrane and causes proteinuria.

      It is important to differentiate nephrotic syndrome from nephritic syndrome, which is characterized by the presence of protein and blood in the urine. Nephritic syndrome typically presents with haematuria, oliguria, and hypertension. Alport syndrome is not a correct answer as it causes nephritic syndrome, and it is a genetic condition that affects kidney function, hearing, and vision. IgA nephropathy is also an incorrect answer as it causes nephritic syndrome and is typically associated with upper respiratory tract infections. A careful history is required to distinguish it from post-streptococcal glomerulonephritis, another cause of nephritic syndrome that occurs after a streptococcal infection.

      Understanding Nephrotic Syndrome and its Presentation

      Nephrotic syndrome is a condition characterized by a triad of symptoms, namely proteinuria, hypoalbuminaemia, and oedema. Proteinuria refers to the presence of excessive protein in the urine, typically exceeding 3g in a 24-hour period. Hypoalbuminaemia is a condition where the levels of albumin in the blood fall below 30g/L. Oedema, on the other hand, is the accumulation of fluid in the body tissues, leading to swelling.

      Nephrotic syndrome is associated with the loss of antithrombin-III, proteins C and S, and an increase in fibrinogen levels, which increases the risk of thrombosis. Additionally, the loss of thyroxine-binding globulin leads to a decrease in total thyroxine levels, although free thyroxine levels remain unaffected.

      The diagram below illustrates the different types of glomerulonephritides and how they typically present. Understanding the presentation of nephrotic syndrome and its associated risks is crucial in the diagnosis and management of this condition.

      [Insert diagram here]

      Overall, nephrotic syndrome is a complex condition that requires careful management to prevent complications. By understanding its presentation and associated risks, healthcare professionals can provide appropriate treatment and support to patients with this condition.

    • This question is part of the following fields:

      • Renal System
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  • Question 10 - A 26-year-old male visits his doctor complaining of fever and coryzal symptoms. He...

    Incorrect

    • A 26-year-old male visits his doctor complaining of fever and coryzal symptoms. He has no significant medical history and is not sexually active.

      During the physical examination, the doctor notes a soft, slightly tender abdomen with no guarding. The patient's temperature is 38.2 ºC.

      To investigate further, the doctor orders a complete blood count, urea and electrolytes, and C-reactive protein. Additionally, a mid-stream urine sample is sent for microscopy, culture, and sensitivity.

      What might be observed in the urine on microscopy?

      Your Answer: Red cell casts

      Correct Answer: Hyaline casts

      Explanation:

      During fever, exercise, or use of loop diuretics, it is normal to observe hyaline casts in urine. Nephritic syndrome is associated with red cell casts, while gout is characterized by needle-shaped crystals. Acute tubular necrosis is indicated by brown granular casts, and pseudogout is identified by rhomboid-shaped crystals.

      Different Types of Urinary Casts and Their Significance

      Urine contains various types of urinary casts that can provide important information about the underlying condition of the patient. Hyaline casts, for instance, are composed of Tamm-Horsfall protein that is secreted by the distal convoluted tubule. These casts are commonly seen in normal urine, after exercise, during fever, or with loop diuretics. On the other hand, brown granular casts in urine are indicative of acute tubular necrosis.

      In prerenal uraemia, the urinary sediment appears ‘bland’, which means that there are no significant abnormalities in the urine. Lastly, red cell casts are associated with nephritic syndrome, which is a condition characterized by inflammation of the glomeruli in the kidneys. By analyzing the type of urinary casts present in the urine, healthcare professionals can diagnose and manage various kidney diseases and disorders. Proper identification and interpretation of urinary casts can help in the early detection and treatment of kidney problems.

    • This question is part of the following fields:

      • Renal System
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  • Question 11 - A 65-year-old woman with chronic kidney failure has been instructed by her nephrologist...

    Correct

    • A 65-year-old woman with chronic kidney failure has been instructed by her nephrologist to adhere to a 'renal diet'. She visits you to gain more knowledge about this.

      What is typically recommended to individuals with chronic kidney disease?

      Your Answer: Low potassium diet

      Explanation:

      Dietary Recommendations for Chronic Kidney Disease Patients

      Chronic kidney disease patients are recommended to follow a specific diet that is low in protein, phosphate, sodium, and potassium. This dietary advice is given to reduce the strain on the kidneys, as these substances are typically excreted by the kidneys. By limiting the intake of these nutrients, patients can help slow the progression of their kidney disease and manage their symptoms more effectively. It is important for patients to work closely with their healthcare provider or a registered dietitian to ensure they are meeting their nutritional needs while following these dietary restrictions. With proper guidance and adherence to this diet, patients with chronic kidney disease can improve their overall health and quality of life.

    • This question is part of the following fields:

      • Renal System
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  • Question 12 - In individuals experiencing abdominal discomfort and nausea, along with recurrent kidney stones and...

    Incorrect

    • In individuals experiencing abdominal discomfort and nausea, along with recurrent kidney stones and urinary tract infections, what structural anomaly might be detected on imaging?

      Your Answer: Kidneys with multiple cysts

      Correct Answer: Fused kidneys crossing anterior to the aorta

      Explanation:

      The presence of abdominal pain, nausea, and recurrent kidney stones and urinary tract infections raises the possibility of a horseshoe kidney, where two kidneys are fused in the midline and pass in front of the aorta. This is a congenital condition that is more prevalent in males and is linked to a higher incidence of urinary tract infections. Unfortunately, there is no cure for this condition, and treatment is focused on managing symptoms.

      Moreover, the identification of numerous cysts in the kidneys suggests the presence of polycystic kidney disease, which is associated with diverticulosis and cerebral aneurysms.

      Understanding the Risk Factors for Renal Stones

      Renal stones, also known as kidney stones, are solid masses that form in the kidneys and can cause severe pain and discomfort. There are several risk factors that can increase the likelihood of developing renal stones. Dehydration is a significant risk factor, as it can lead to concentrated urine and the formation of stones. Other factors include hypercalciuria, hyperparathyroidism, hypercalcaemia, cystinuria, high dietary oxalate, renal tubular acidosis, medullary sponge kidney, polycystic kidney disease, and exposure to beryllium or cadmium.

      Urate stones, a type of renal stone, are caused by the precipitation of uric acid. Risk factors for urate stones include gout and ileostomy, which can result in acidic urine due to the loss of bicarbonate and fluid.

      In addition to these factors, certain medications can also contribute to the formation of renal stones. Loop diuretics, steroids, acetazolamide, and theophylline can promote the formation of calcium stones, while thiazides can prevent them by increasing distal tubular calcium resorption.

      It is important to understand these risk factors and take steps to prevent the formation of renal stones, such as staying hydrated, maintaining a healthy diet, and avoiding medications that may contribute to their formation.

    • This question is part of the following fields:

      • Renal System
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  • Question 13 - A 45-year-old woman visits her doctor for a follow-up appointment after commencing metformin...

    Incorrect

    • A 45-year-old woman visits her doctor for a follow-up appointment after commencing metformin treatment half a year ago. She expresses worry about the potential long-term impact of diabetes on her kidneys, based on information she read online.

      What is the primary mechanism through which kidney damage occurs in this demographic of patients?

      Your Answer:

      Correct Answer: Non-enzymatic glycosylation

      Explanation:

      The non-enzymatic glycosylation of the basement membrane is responsible for the complications of diabetes nephropathy.

      Understanding Diabetic Nephropathy: The Common Cause of End-Stage Renal Disease

      Diabetic nephropathy is the leading cause of end-stage renal disease in the western world. It affects approximately 33% of patients with type 1 diabetes mellitus by the age of 40 years, and around 5-10% of patients with type 1 diabetes mellitus develop end-stage renal disease. The pathophysiology of diabetic nephropathy is not fully understood, but changes to the haemodynamics of the glomerulus, such as increased glomerular capillary pressure, and non-enzymatic glycosylation of the basement membrane are thought to play a key role. Histological changes include basement membrane thickening, capillary obliteration, mesangial widening, and the development of nodular hyaline areas in the glomeruli, known as Kimmelstiel-Wilson nodules.

      There are both modifiable and non-modifiable risk factors for developing diabetic nephropathy. Modifiable risk factors include hypertension, hyperlipidaemia, smoking, poor glycaemic control, and raised dietary protein. On the other hand, non-modifiable risk factors include male sex, duration of diabetes, and genetic predisposition, such as ACE gene polymorphisms. Understanding these risk factors and the pathophysiology of diabetic nephropathy is crucial in the prevention and management of this condition.

    • This question is part of the following fields:

      • Renal System
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  • Question 14 - A 57-year-old man with a history of chronic myeloid leukaemia for which he...

    Incorrect

    • A 57-year-old man with a history of chronic myeloid leukaemia for which he has started receiving chemotherapy presents with left flank pain and oliguria. He has tenderness over his left renal angle. A working diagnosis of kidney stones is made. Both abdominal X-ray and CT scan are unremarkable and no stone is visible.

      What is the most likely composition of his kidney stone?

      Your Answer:

      Correct Answer: Uric acid

      Explanation:

      Stones formed in the urinary tract due to infections with urease-positive bacteria, such as Proteus mirabilis, are known as struvite stones. These stones are caused by the hydrolysis of urea to ammonia, which alkalizes the urine. Struvite stones often take the shape of staghorn calculi and can be detected through radiography as they are radio-opaque.

      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.

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      • Renal System
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  • Question 15 - You have been asked to take a history from a patient in a...

    Incorrect

    • You have been asked to take a history from a patient in a breast clinic at the hospital. You clerk a 68-year-old woman, who had a right-sided mastectomy for invasive ductal carcinoma 3 years ago; she has now presented for follow-up. From your history, you elicit that she has had no symptoms of recurrence, and is still currently taking an aromatase inhibitor called letrozole, due to the findings of immunohistochemistry when the biopsy was taken.

      What is the mechanism of action of this drug?

      Your Answer:

      Correct Answer: Inhibition of the conversion of testosterone to oestradiol

      Explanation:

      Breast cancers that are positive for oestrogen receptors can be treated by reducing oestrogen levels, which can lower the risk of recurrence. Aromatase inhibitors are commonly prescribed to postmenopausal women with oestrogen-positive breast cancer for a period of 5 years, but they can cause side effects such as a decrease in bone density and an increase in osteoporosis risk. Tamoxifen is another medication that can modulate the effect of oestrogen on the breast and is usually prescribed to premenopausal women. Letrozole, on the other hand, does not fall into this category and does not exhibit negative feedback on the HPO axis. Trastuzumab is a drug that binds to HER2 receptors and is used for breast cancers that have a positive HER2 receptor status. Letrozole may be given alongside this drug if the tumour is also oestrogen receptor positive. Letrozole is not a selective progesterone receptor modulator, unlike drugs such as ulipristal acetate.

      The renin-angiotensin-aldosterone system is a complex system that regulates blood pressure and fluid balance in the body. The adrenal cortex is divided into three zones, each producing different hormones. The zona glomerulosa produces mineralocorticoids, mainly aldosterone, which helps regulate sodium and potassium levels in the body. Renin is an enzyme released by the renal juxtaglomerular cells in response to reduced renal perfusion, hyponatremia, and sympathetic nerve stimulation. It hydrolyses angiotensinogen to form angiotensin I, which is then converted to angiotensin II by angiotensin-converting enzyme in the lungs. Angiotensin II has various actions, including causing vasoconstriction, stimulating thirst, and increasing proximal tubule Na+/H+ activity. It also stimulates aldosterone and ADH release, which causes retention of Na+ in exchange for K+/H+ in the distal tubule.

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      • Renal System
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  • Question 16 - An 80-year-old man is undergoing investigation for haematuria, with no other urinary symptoms...

    Incorrect

    • An 80-year-old man is undergoing investigation for haematuria, with no other urinary symptoms reported. He has no significant medical history and previously worked in the textiles industry. During a flexible cystoscopy, a sizable mass is discovered in the lower part of his bladder, raising suspicion of bladder cancer. A PET scan is planned to check for any nodal metastasis. Which lymph nodes are most likely to be affected?

      Your Answer:

      Correct Answer: External and internal iliac lymph nodes

      Explanation:

      The bladder’s lymphatic drainage is mainly to the external and internal iliac nodes. A man with haematuria and a history of working with dye is found to have a bladder tumour. To stage the tumour, nodal metastasis should be investigated, and the correct lymph nodes to check are the external and internal iliac nodes. Other options such as deep inguinal, para-aortic, and superficial inguinal nodes are incorrect.

      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
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  • Question 17 - In a 70 Kg person, what percentage of the entire body fluid will...

    Incorrect

    • In a 70 Kg person, what percentage of the entire body fluid will be provided by plasma?

      Your Answer:

      Correct Answer: 5%

      Explanation:

      Understanding the Physiology of Body Fluid Compartments

      Body fluid compartments are essential components of the human body, consisting of intracellular and extracellular compartments. The extracellular compartment is further divided into interstitial fluid, plasma, and transcellular fluid. In a typical 70 Kg male, the intracellular compartment comprises 60-65% of the total body fluid volume, while the extracellular compartment comprises 35-40%. The plasma volume is approximately 5%, while the interstitial fluid volume is 24%. The transcellular fluid volume is approximately 3%. These figures are only approximate and may vary depending on the individual’s weight and other factors. Understanding the physiology of body fluid compartments is crucial in maintaining proper fluid balance and overall health.

    • This question is part of the following fields:

      • Renal System
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  • Question 18 - A 25-year-old man visits his primary care physician worried about a lump on...

    Incorrect

    • A 25-year-old man visits his primary care physician worried about a lump on his testes. He has no significant medical history and has recently started a new job after completing his education. His cousin was diagnosed with testicular cancer last year, and he is anxious that he might have the same condition.

      During the examination, the physician observes a diffuse swelling of the testes with tenderness on palpation.

      After prescribing a short course of ibuprofen, the patient remains concerned about testicular cancer and inquires about its presenting features in young men.

      What could be a possible presenting feature of testicular cancer in men in their mid-twenties?

      Your Answer:

      Correct Answer: Hydrocele

      Explanation:

      Testicular cancer in young men may manifest as a hydrocele, which is the accumulation of fluid around the testicle. Therefore, it is important to investigate all cases of hydrocele to rule out cancer. On the other hand, epididymitis, which is usually caused by a bacterial infection, is unlikely to be a presenting feature of testicular cancer. If a male patient presents with frank haematuria, urgent investigation is necessary to rule out bladder cancer. A chancre, which is a painless genital ulcer commonly seen in the primary stage of syphilis, is not a presenting feature of testicular cancer.

      Testicular cancer is a common type of cancer that affects men between the ages of 20 and 30. The majority of cases (95%) are germ-cell tumors, which can be further classified as seminomas or non-seminomas. Non-germ cell tumors, such as Leydig cell tumors and sarcomas, are less common. Risk factors for testicular cancer include infertility, cryptorchidism, family history, Klinefelter’s syndrome, and mumps orchitis. Symptoms may include a painless lump, pain, hydrocele, and gynaecomastia.

      Tumour markers can be used to diagnose testicular cancer. For germ cell tumors, hCG may be elevated in seminomas, while AFP and/or beta-hCG are elevated in non-seminomas. LDH may also be elevated in germ cell tumors. Ultrasound is the first-line diagnostic tool.

      Treatment for testicular cancer depends on the type and stage of the tumor. Orchidectomy, chemotherapy, and radiotherapy may be used. Prognosis is generally excellent, with a 5-year survival rate of around 95% for Stage I seminomas and 85% for Stage I teratomas.

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      • Renal System
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  • Question 19 - A 75-year-old woman is admitted for a laparoscopic cholecystectomy. As part of her...

    Incorrect

    • A 75-year-old woman is admitted for a laparoscopic cholecystectomy. As part of her pre-operative evaluation, it is discovered that she is taking furosemide to manage her hypertension. What percentage of the sodium filtered at the glomerulus will be eliminated?

      Your Answer:

      Correct Answer: Up to 25%

      Explanation:

      Loop diuretics cause significant increases in sodium excretion by acting on both the medullary and cortical regions of the thick ascending limb of the loop of Henle. This leads to a reduction in the medullary osmolal gradient and an increase in the excretion of free water, along with sodium loss. Unlike thiazide diuretics, which do not affect urine concentration and are more likely to cause hyponatremia, loop diuretics result in the loss of both sodium and water.

      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.

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  • Question 20 - A 28-year-old woman with autosomal dominant polycystic kidney disease type 1 is seeking...

    Incorrect

    • A 28-year-old woman with autosomal dominant polycystic kidney disease type 1 is seeking guidance from her general practitioner regarding family planning. She recently lost her father to a subarachnoid haemorrhage, which prompted her to undergo genetic testing to confirm her diagnosis. Despite her desire to start a family with her husband, she is worried about the possibility of passing on the renal disease to her children. On which chromosome is the genetic defect for this condition most commonly found?

      Your Answer:

      Correct Answer: Chromosome 16

      Explanation:

      The patient’s autosomal dominant polycystic kidney disease type 1 is not caused by a gene on chromosomes 13, 18, or 21. It is important to note that nondisjunction of these chromosomes can lead to other genetic disorders such as Patau syndrome, Edward’s syndrome, and Down’s syndrome. The chance of the patient passing on the autosomal dominant polycystic kidney disease type 1 to her children would depend on the inheritance pattern of the specific gene mutation causing the disease.

      Autosomal dominant polycystic kidney disease (ADPKD) is a commonly inherited kidney disease that affects 1 in 1,000 Caucasians. The disease is caused by mutations in two genes, PKD1 and PKD2, which produce polycystin-1 and polycystin-2 respectively. ADPKD type 1 accounts for 85% of cases, while ADPKD type 2 accounts for 15% of cases. ADPKD type 1 is caused by a mutation in the PKD1 gene on chromosome 16, while ADPKD type 2 is caused by a mutation in the PKD2 gene on chromosome 4. ADPKD type 1 tends to present with renal failure earlier than ADPKD type 2.

      To screen for ADPKD in relatives of affected individuals, an abdominal ultrasound is recommended. The diagnostic criteria for ultrasound include the presence of two cysts, either unilateral or bilateral, if the individual is under 30 years old. If the individual is between 30-59 years old, two cysts in both kidneys are required for diagnosis. If the individual is over 60 years old, four cysts in both kidneys are necessary for diagnosis.

      For some patients with ADPKD, tolvaptan, a vasopressin receptor 2 antagonist, may be an option to slow the progression of cyst development and renal insufficiency. However, NICE recommends tolvaptan only for adults with ADPKD who have chronic kidney disease stage 2 or 3 at the start of treatment, evidence of rapidly progressing disease, and if the company provides it with the agreed discount in the patient access scheme.

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  • Question 21 - A 72-year-old man, with a past medical history of diabetes, hypertension and stable...

    Incorrect

    • A 72-year-old man, with a past medical history of diabetes, hypertension and stable angina visits his family physician for a routine check-up. He is currently taking metoprolol, daily aspirin and insulin glargine. He lives alone and is able to manage his daily activities. He used to work as a teacher and his wife passed away from a stroke 5 years ago. During the examination, his heart rate is 60 beats per minute, respiratory rate is 14 breaths per minute and blood pressure is 125/80 mmHg. What is the direct effect of the metoprolol medication on this patient?

      Your Answer:

      Correct Answer: Decrease in renin secretion

      Explanation:

      During the patient’s regular follow-up for diabetes and hypertension management, it was noted that both conditions increase the risk of cardiovascular complications and other related complications such as kidney and eye problems. To manage hypertension, the patient was prescribed metoprolol, a beta-blocker that reduces blood pressure by decreasing heart rate and cardiac output. Additionally, metoprolol blocks beta-1 adrenergic receptors in the juxtaglomerular apparatus of the kidneys, leading to a decrease in renin secretion. Renin is responsible for converting angiotensinogen to angiotensin I, which is further converted to angiotensin II, a hormone that increases blood pressure through vasoconstriction and sodium retention. By blocking renin secretion, metoprolol causes a decrease in blood pressure. Other antihypertensive medications work through different mechanisms, such as calcium channel blockers that dilate arterioles, ACE inhibitors that decrease angiotensin II secretion, and beta-blockers that decrease renin secretion.

      The renin-angiotensin-aldosterone system is a complex system that regulates blood pressure and fluid balance in the body. The adrenal cortex is divided into three zones, each producing different hormones. The zona glomerulosa produces mineralocorticoids, mainly aldosterone, which helps regulate sodium and potassium levels in the body. Renin is an enzyme released by the renal juxtaglomerular cells in response to reduced renal perfusion, hyponatremia, and sympathetic nerve stimulation. It hydrolyses angiotensinogen to form angiotensin I, which is then converted to angiotensin II by angiotensin-converting enzyme in the lungs. Angiotensin II has various actions, including causing vasoconstriction, stimulating thirst, and increasing proximal tubule Na+/H+ activity. It also stimulates aldosterone and ADH release, which causes retention of Na+ in exchange for K+/H+ in the distal tubule.

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  • Question 22 - An elderly man of 74 years old complains of symptoms and displays signs...

    Incorrect

    • An elderly man of 74 years old complains of symptoms and displays signs of benign prostatic hyperplasia. Which structure is most likely to be enlarged in his case?

      Your Answer:

      Correct Answer: Median lobe of the prostate

      Explanation:

      Prostate carcinoma commonly develops in the posterior lobe, while BPH often causes enlargement of the median lobe. The anterior lobe, which contains minimal glandular tissue, is rarely affected by enlargement.

      Benign prostatic hyperplasia (BPH) is a common condition that affects older men, with around 50% of 50-year-old men showing evidence of BPH and 30% experiencing symptoms. The risk of BPH increases with age, with around 80% of 80-year-old men having evidence of the condition. Ethnicity also plays a role, with black men having a higher risk than white or Asian men. BPH typically presents with lower urinary tract symptoms (LUTS), which can be categorised into obstructive (voiding) symptoms and irritative (storage) symptoms. Complications of BPH can include urinary tract infections, retention, and obstructive uropathy.

      Assessment of BPH may involve dipstick urine testing, U&Es, and PSA testing if obstructive symptoms are present or if the patient is concerned about prostate cancer. A urinary frequency-volume chart and the International Prostate Symptom Score (IPSS) can also be used to assess the severity of LUTS and their impact on quality of life. Management options for BPH include watchful waiting, alpha-1 antagonists, 5 alpha-reductase inhibitors, combination therapy, and surgery. Alpha-1 antagonists are considered first-line for moderate-to-severe voiding symptoms and can improve symptoms in around 70% of men, but may cause adverse effects such as dizziness and dry mouth. 5 alpha-reductase inhibitors may slow disease progression and reduce prostate volume, but can cause adverse effects such as erectile dysfunction and reduced libido. Combination therapy may be used for bothersome moderate-to-severe voiding symptoms and prostatic enlargement. Antimuscarinic drugs may be tried for persistent storage symptoms. Surgery, such as transurethral resection of the prostate (TURP), may also be an option.

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  • Question 23 - A patient in his 60s is recovering on the ward following a kidney...

    Incorrect

    • A patient in his 60s is recovering on the ward following a kidney transplant. Six days after the operation he still requires dialysis, however he is not in any pain and the graft was a very good HLA match from a deceased donor. His renal function test results are shown below.

      Hb 93 g/L
      Plts. 232 x 109
      Na+ 151 mmol/l
      K+ 5.7 mmol/l
      Urea 7.9 mmol/l
      eGFR 27 mL/min/1.73m2

      What could be the probable reason for his abnormal renal function tests?

      Your Answer:

      Correct Answer: Delayed graft function

      Explanation:

      Delayed graft function (DGF) is a common form of acute renal failure that can occur following a kidney transplant. In this case, delayed graft function is the most likely explanation for the patient’s symptoms. It is not uncommon for patients to require continued dialysis after a transplant, especially if the donor was deceased. However, if the need for dialysis persists beyond 7 days, further investigations may be necessary. Other potential causes, such as Addison’s disease or hyper-acute graft rejection, are less likely based on the patient’s history and the characteristics of the transplant.

      Complications Following Renal Transplant

      Renal transplantation is a common procedure, but it is not without its complications. The most common technical complications are related to the ureteric anastomosis, and the warm ischaemic time is also important as graft survival is directly related to this. Long warm ischaemic times increase the risk of acute tubular necrosis, which can occur in all types of renal transplantation. Organ rejection is also a possibility at any phase following the transplantation process.

      There are three types of organ rejection: hyperacute, acute, and chronic. Hyperacute rejection occurs immediately due to the presence of preformed antibodies, such as ABO incompatibility. Acute rejection occurs during the first six months and is usually T cell mediated, with tissue infiltrates and vascular lesions. Chronic rejection occurs after the first six months and is characterized by vascular changes, with myointimal proliferation leading to organ ischemia.

      In addition to immunological complications, there are also technical complications that can arise following renal transplant. These include renal artery thrombosis, renal artery stenosis, renal vein thrombosis, urine leaks, and lymphocele. Each of these complications presents with specific symptoms and requires different treatments, ranging from immediate surgery to angioplasty or drainage techniques.

      Overall, while renal transplantation can be a life-saving procedure, it is important to be aware of the potential complications and to monitor patients closely for any signs of rejection or technical issues.

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  • Question 24 - Which serum protein is most likely to increase in a patient with severe...

    Incorrect

    • Which serum protein is most likely to increase in a patient with severe sepsis?

      Your Answer:

      Correct Answer: Ferritin

      Explanation:

      During an acute phase response, ferritin levels can significantly rise while other parameters typically decrease.

      Acute Phase Proteins and their Role in the Body’s Response to Infection

      During an infection or injury, the body undergoes an acute phase response where it produces a variety of proteins to help fight off the infection and promote healing. These proteins are known as acute phase proteins and include CRP, procalcitonin, ferritin, fibrinogen, alpha-1 antitrypsin, ceruloplasmin, serum amyloid A, serum amyloid P component, haptoglobin, and complement.

      CRP is a commonly measured acute phase protein that is synthesized in the liver and binds to bacterial cells and those undergoing apoptosis. It is able to activate the complement system and its levels are known to rise in patients following surgery. Procalcitonin is another acute phase protein that is used as a marker for bacterial infections. Ferritin is involved in iron storage and transport, while fibrinogen is important for blood clotting. Alpha-1 antitrypsin helps protect the lungs from damage, and ceruloplasmin is involved in copper transport. Serum amyloid A and serum amyloid P component are involved in inflammation, while haptoglobin binds to hemoglobin to prevent its breakdown. Complement is a group of proteins that help to destroy pathogens.

      During the acute phase response, the liver decreases the production of other proteins known as negative acute phase proteins, including albumin, transthyretin, transferrin, retinol binding protein, and cortisol binding protein. These proteins are important for maintaining normal bodily functions, but their production is decreased during an infection or injury to allow for the production of acute phase proteins.

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  • Question 25 - A 40-year-old man visits his doctor for a routine check-up and is informed...

    Incorrect

    • A 40-year-old man visits his doctor for a routine check-up and is informed that his cholesterol levels are elevated. He has a significant family history of high cholesterol and genetic testing reveals that he is heterozygous for the affected allele. If he has a child with a woman who does not carry the affected allele, what is the probability that their child will inherit the condition?

      Your Answer:

      Correct Answer: 50%

      Explanation:

      Familial Hypercholesterolaemia: Causes, Diagnosis, and Management

      Familial hypercholesterolaemia (FH) is a genetic condition that affects approximately 1 in 500 people. It is an autosomal dominant disorder that results in high levels of LDL-cholesterol, which can lead to early cardiovascular disease if left untreated. FH is caused by mutations in the gene that encodes the LDL-receptor protein.

      To diagnose FH, NICE recommends suspecting it as a possible diagnosis in adults with a total cholesterol level greater than 7.5 mmol/l and/or a personal or family history of premature coronary heart disease. For children of affected parents, testing should be arranged by age 10 if one parent is affected and by age 5 if both parents are affected.

      The Simon Broome criteria are used for clinical diagnosis, which includes a total cholesterol level greater than 7.5 mmol/l and LDL-C greater than 4.9 mmol/l in adults or a total cholesterol level greater than 6.7 mmol/l and LDL-C greater than 4.0 mmol/l in children. Definite FH is diagnosed if there is tendon xanthoma in patients or first or second-degree relatives or DNA-based evidence of FH. Possible FH is diagnosed if there is a family history of myocardial infarction below age 50 years in second-degree relatives, below age 60 in first-degree relatives, or a family history of raised cholesterol levels.

      Management of FH involves referral to a specialist lipid clinic and the use of high-dose statins as first-line treatment. CVD risk estimation using standard tables is not appropriate in FH as they do not accurately reflect the risk of CVD. First-degree relatives have a 50% chance of having the disorder and should be offered screening, including children who should be screened by the age of 10 years if there is one affected parent. Statins should be discontinued in women 3 months before conception due to the risk of congenital defects.

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  • Question 26 - A 22-year-old man is referred to a cardiologist by his family physician due...

    Incorrect

    • A 22-year-old man is referred to a cardiologist by his family physician due to consistently high cholesterol levels in his blood tests. During the assessment, the cardiologist observes yellowish skin nodules around the patient's Achilles tendon and white outer regions of the iris. The cardiologist informs the patient that he has inherited the condition from his biological parents and that there is a 50% chance of passing it on to his offspring, regardless of his partner's status. The patient reports a paternal uncle who died at 31 due to a heart-related condition. The cardiologist recommends treatment to manage cholesterol levels and prevent future cardiovascular events. What is the most likely underlying pathology in this patient's condition?

      Your Answer:

      Correct Answer: Defective low-density lipoprotein receptors

      Explanation:

      The patient’s symptoms and signs suggest that they may have one of the familial dyslipidemias, likely familial hypercholesterolemia. This is supported by the presence of Achilles tendon xanthomas and corneal arcus in a relatively young patient, as well as the cardiologist’s statement that there is a 50% chance of inheritance if the mother is normal, indicating an autosomal dominant inheritance pattern. Familial hypercholesterolemia is caused by defective or absent LDL receptors.

      Other familial dyslipidemias include dysbetalipoproteinemia, which is caused by defective apolipoprotein E and has an autosomal recessive inheritance pattern, hypertriglyceridemia, which is caused by overproduction of VLDL and has an autosomal dominant inheritance pattern, and hyperchylomicronemia, which is caused by deficiency of lipoprotein lipase or apolipoprotein C-II and has an autosomal recessive inheritance pattern. Hyperchylomicronemia is not associated with a higher risk of atherosclerosis, unlike the other forms of familial dyslipidemia.

      Familial Hypercholesterolaemia: Causes, Diagnosis, and Management

      Familial hypercholesterolaemia (FH) is a genetic condition that affects approximately 1 in 500 people. It is an autosomal dominant disorder that results in high levels of LDL-cholesterol, which can lead to early cardiovascular disease if left untreated. FH is caused by mutations in the gene that encodes the LDL-receptor protein.

      To diagnose FH, NICE recommends suspecting it as a possible diagnosis in adults with a total cholesterol level greater than 7.5 mmol/l and/or a personal or family history of premature coronary heart disease. For children of affected parents, testing should be arranged by age 10 if one parent is affected and by age 5 if both parents are affected.

      The Simon Broome criteria are used for clinical diagnosis, which includes a total cholesterol level greater than 7.5 mmol/l and LDL-C greater than 4.9 mmol/l in adults or a total cholesterol level greater than 6.7 mmol/l and LDL-C greater than 4.0 mmol/l in children. Definite FH is diagnosed if there is tendon xanthoma in patients or first or second-degree relatives or DNA-based evidence of FH. Possible FH is diagnosed if there is a family history of myocardial infarction below age 50 years in second-degree relatives, below age 60 in first-degree relatives, or a family history of raised cholesterol levels.

      Management of FH involves referral to a specialist lipid clinic and the use of high-dose statins as first-line treatment. CVD risk estimation using standard tables is not appropriate in FH as they do not accurately reflect the risk of CVD. First-degree relatives have a 50% chance of having the disorder and should be offered screening, including children who should be screened by the age of 10 years if there is one affected parent. Statins should be discontinued in women 3 months before conception due to the risk of congenital defects.

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  • Question 27 - A 65-year-old man is undergoing assessment for polycythemia and has no history of...

    Incorrect

    • A 65-year-old man is undergoing assessment for polycythemia and has no history of smoking. What type of solid-organ cancer could be a possible cause?

      Your Answer:

      Correct Answer: Renal cell carcinoma

      Explanation:

      Renal cell carcinoma has the potential to secrete various hormones such as erythropoietin, PTHrP, renin, or ACTH. This can lead to secondary polycythemia, hypercalcemia, or other related conditions. On the other hand, small cell lung cancer can cause ectopic secretion of ACTH or ADH, but not erythropoietin. Pituitary tumors, on the other hand, may secrete prolactin.

      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.

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  • Question 28 - A 49-year-old woman is having surgery to remove an adrenal adenoma on her...

    Incorrect

    • A 49-year-old woman is having surgery to remove an adrenal adenoma on her left side. During the procedure, the superior adrenal artery is damaged and begins to bleed. What is the origin of this vessel?

      Your Answer:

      Correct Answer: Inferior phrenic artery

      Explanation:

      The inferior phrenic artery gives rise to the superior adrenal artery.

      Adrenal Gland Anatomy

      The adrenal glands are located superomedially to the upper pole of each kidney. The right adrenal gland is posteriorly related to the diaphragm, inferiorly related to the kidney, medially related to the vena cava, and anteriorly related to the hepato-renal pouch and bare area of the liver. On the other hand, the left adrenal gland is postero-medially related to the crus of the diaphragm, inferiorly related to the pancreas and splenic vessels, and anteriorly related to the lesser sac and stomach.

      The arterial supply of the adrenal glands is through the superior adrenal arteries from the inferior phrenic artery, middle adrenal arteries from the aorta, and inferior adrenal arteries from the renal arteries. The right adrenal gland drains via one central vein directly into the inferior vena cava, while the left adrenal gland drains via one central vein into the left renal vein.

      In summary, the adrenal glands are small but important endocrine glands located above the kidneys. They have a unique blood supply and drainage system, and their location and relationships with other organs in the body are crucial for their proper functioning.

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  • Question 29 - A 60-year-old patient visits the renal clinic after being diagnosed with stage 4...

    Incorrect

    • A 60-year-old patient visits the renal clinic after being diagnosed with stage 4 chronic kidney disease due to hypertension and diabetes. She inquires about the recommended diet for her condition.

      What dietary advice should be provided to the patient?

      Your Answer:

      Correct Answer: Low protein, phosphate, potassium and sodium

      Explanation:

      For individuals with chronic kidney disease, it is recommended to follow a diet that is low in protein, phosphate, potassium, and sodium. This is because protein can produce ammonia, which is not effectively excreted by the kidneys in CKD. Phosphate can combine with calcium to form kidney stones, while sodium can raise blood pressure and further damage the kidneys. Potassium is also not efficiently eliminated by failing kidneys and can lead to irregular heartbeats.

      Dietary Recommendations for Chronic Kidney Disease Patients

      Chronic kidney disease patients are recommended to follow a specific diet that is low in protein, phosphate, sodium, and potassium. This dietary advice is given to reduce the strain on the kidneys, as these substances are typically excreted by the kidneys. By limiting the intake of these nutrients, patients can help slow the progression of their kidney disease and manage their symptoms more effectively. It is important for patients to work closely with their healthcare provider or a registered dietitian to ensure they are meeting their nutritional needs while following these dietary restrictions. With proper guidance and adherence to this diet, patients with chronic kidney disease can improve their overall health and quality of life.

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  • Question 30 - A 49-year-old man with a history of chronic alcohol abuse presents with abdominal...

    Incorrect

    • 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:

      Correct 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.

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Renal System (4/12) 33%
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