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  • Question 1 - A 41-year-old gentleman underwent kidney transplantation for end-stage renal disease. Now, 2 months...

    Correct

    • A 41-year-old gentleman underwent kidney transplantation for end-stage renal disease. Now, 2 months after the operation, he has developed fever and features suggestive of bilateral diffuse interstitial pneumonia.   What is the most likely aetiological cause?

      Your Answer: Cytomegalovirus

      Explanation:

      After renal transplantation, cytomegalovirus has been identified to affect 1/4 of the post-op patients. It is the most common viral infection causing morbidity and mortality in post-op patients in the first 3 months.

    • This question is part of the following fields:

      • Nephrology
      13.1
      Seconds

  • Question 2 - A 71-year-old female presents for investigation of fatigue and weight loss. Investigations reveal:...

    Incorrect

    • A 71-year-old female presents for investigation of fatigue and weight loss. Investigations reveal: Haemoglobin 9.0 g/dL (11.5-16.5) White cell count 2.0 x109/L (4-11 x109) Platelet count 250 x109/L (150-400 x109) Total protein 74 g/L (61-76) Albumin 28 g/L (37-49) Urea 16 mmol/L (2.5-7.5) Creatinine 250 mol/L (60-110) Plasma glucose 6.5 mmol/L (3.0-6.0) Urine dipstick analysis: Protein+ & blood+ Renal ultrasound: Normal Which one of the following investigations would be most appropriate for this patient?

      Your Answer: Measurement of anti-glomerular basement membrane (anti-GBM) antibodies

      Correct Answer: Plasma protein electrophoresis

      Explanation:

      This patient’s symptoms of anaemia, leukopenia, and elevated non-albumin protein concentration with fatigue and weight loss, point to myeloma. Thus plasma protein electrophoresis or Serum Protein Electrophoresis (SPE) is indicated when there is suspicion of myeloma.

    • This question is part of the following fields:

      • Nephrology
      53.3
      Seconds

  • Question 3 - A 65-year-old gentleman gives a two week history of progressive lethargy and weakness....

    Incorrect

    • A 65-year-old gentleman gives a two week history of progressive lethargy and weakness. Eight weeks previously, he was treated for hypertensive heart failure with 120 mg furosemide and 5 mg enalapril daily. His haemoglobin at the time was 12.0, urea 14.2 mmol/l and creatinine 298 μmol/l. His blood pressure in clinic was 148/85 mmHg. His blood results are shown below: Hb 10.2g/dL, MCV 89.2 fl WCC 4.9 x 109/L, Plats 175 x 109/L, Na+ 135 K+ 5.2 mmol/L, Urea 25.2 mmol/L, Creat 600 μmol/L, Assuming that he is not volume overloaded, what would be the most appropriate action?

      Your Answer: stop the furosemide

      Correct Answer: stop the enalapril and furosemide

      Explanation:

      The patient presents with worsened renal condition from the last consultation when he was started on enalapril (an ACE inhibitor) so this medication should be stopped. Because there is also no fluid overload; furosemide, a diuretic, should also be stopped.

    • This question is part of the following fields:

      • Nephrology
      52.2
      Seconds

  • Question 4 - A 46-year-old gentleman diagnosed with type 2 diabetes, hypertension, and proteinuria is started...

    Incorrect

    • A 46-year-old gentleman diagnosed with type 2 diabetes, hypertension, and proteinuria is started on Ramipril to prevent development of renal disease. He reports to his GP that he has developed a troublesome cough since starting the medication. He has no symptoms of lip swelling, wheeze and has no history of underlying respiratory disease.   What increased chemical is thought to be the cause of his cough?

      Your Answer: Prostaglandins

      Correct Answer: Bradykinin

      Explanation:

      Ramipril is an ACE inhibitor that blocks the conversion of angiotensin I to angiotensin II as well as preventing the breakdown of bradykinin, leading to blood vessel dilatation and decreased blood pressure. However, bradykinin also causes smooth muscles in the lungs to contract, so the build-up of bradykinin is thought to cause the dry cough that is a common side-effect in patients that are on ACE inhibitors.

    • This question is part of the following fields:

      • Nephrology
      23.5
      Seconds

  • Question 5 - A 35-year-old gentleman is investigated for recurrent renal stones. He has been hospitalised...

    Incorrect

    • A 35-year-old gentleman is investigated for recurrent renal stones. He has been hospitalised on multiple occasions and has required lithotripsy three times. Investigations show the following: Calcium 2.08 mmol/L, Phosphate 0.85 mmol/L, Parathyroid hormone 4.1 pmol/L (normal range = 0.8 - 8.5) 24 hour urinary calcium 521 mg/24 hours (normal range < 300) Which one of the following treatments will most likely reduce the incidence of renal stones?

      Your Answer: Parathyroidectomy

      Correct Answer: Indapamide

      Explanation:

      Indapamide is a mild thiazide-like diuretic with hypotensive effect, and compared to other thiazides, it is reported to also have less metabolic derangements. However, it may have beneficial hypo-calciuric effects that are often associated with thiazides, thus, in this case, we would recommend prescribing this to the patient.

    • This question is part of the following fields:

      • Nephrology
      33.4
      Seconds

  • Question 6 - A 66-year-old gentleman is seen in the Emergency Department complaining of muscle weakness...

    Incorrect

    • A 66-year-old gentleman is seen in the Emergency Department complaining of muscle weakness and lethargy. Admission bloods show the following: Na+ 138 mmol/L, K+ 6.6 mmol/L, Bicarbonate 15 mmol/L, Urea 9.2 mmol/L, Creatinine 110 µmol/L, An ECG is done which shows no acute changes. What is the most appropriate initial treatment to lower the serum potassium level?

      Your Answer: Intravenous calcium gluconate

      Correct Answer: Insulin/dextrose infusion

      Explanation:

      Insulin/dextrose infusion will increase the activity of the sodium-potassium pump in the cells, which will in turn decrease serum potassium levels.

    • This question is part of the following fields:

      • Nephrology
      24.4
      Seconds

  • Question 7 - A 41-year-old female is referred to medical assessment unit by her physician for...

    Correct

    • A 41-year-old female is referred to medical assessment unit by her physician for querying thrombotic thrombocytopenic purpura (TTP) after she presented with a temperature of 38.9C. Her subsequent urea and electrolytes showed deteriorating renal function with a creatinine 3 times greater than her baseline. What is the underlying pathophysiology of TTP?

      Your Answer: Failure to cleave von Willebrand factor normally

      Explanation:

      Thrombotic thrombocytopenic purpura (TTP) is characterised by the von Willebrand factor (vWF) microthrombi within the vessels of multiple organs. In this condition, the ADAMTS13 metalloprotease enzyme which is responsible for the breakdown of vWF multimer, is deficient, causing its build-up and leading to platelet clots that then decreases the circulating platelets, leading to bleeding in the patient.

    • This question is part of the following fields:

      • Nephrology
      24.7
      Seconds

  • Question 8 - A 58-year-old lady was admitted to hospital with increasing thirst and generalised abdominal...

    Correct

    • A 58-year-old lady was admitted to hospital with increasing thirst and generalised abdominal pain. She was diagnosed with breast carcinoma three years previously and treated with a radical mastectomy.   Investigations showed: Serum corrected calcium 3.5 mmol/L (NR 2.2-2.6) Serum alkaline phosphatase 1100 IU/L   Her serum calcium was still elevated following 4 litres of 0.9% saline intravenous infusion.   Which of the following is the most appropriate next step?

      Your Answer: Pamidronate 60 mg intravenously

      Explanation:

      This case has hypercalcaemia most likely associated with the bony metastases from her pre-existing breast carcinoma. The most appropriate next step is to give Pamidronate 60mg intravenously, a bisphosphonate, to immediately inhibit bone resorption and formation.

    • This question is part of the following fields:

      • Nephrology
      22.5
      Seconds

  • Question 9 - A 52-year-old woman with polycystic kidney disease and a slowly rising creatinine, which...

    Correct

    • A 52-year-old woman with polycystic kidney disease and a slowly rising creatinine, which was 320 μmol/L at her last clinic visit 3 weeks ago, is brought into the Emergency Department having been found collapsed at home by her partner. She is now fully conscious but complains of a headache.   What is the most likely diagnosis?

      Your Answer: Subarachnoid haemorrhage

      Explanation:

      One of the most important complications in patients with PKD is being affected by berry aneurysms that may burst, causing a subarachnoid haemorrhage, which seems to be the case in this patient.

    • This question is part of the following fields:

      • Nephrology
      47
      Seconds

  • Question 10 - In diabetes, what is the most common finding on renal biopsy? ...

    Incorrect

    • In diabetes, what is the most common finding on renal biopsy?

      Your Answer: Loss of foot processes

      Correct Answer: Glomerulosclerosis

      Explanation:

      Glomerulosclerosis is the scarring and hardening of the glomeruli known as diabetic glomerulosclerosis occurring in long-standing diabetes.

    • This question is part of the following fields:

      • Nephrology
      11.3
      Seconds

  • Question 11 - A 40-year-old woman presents to her GP with malaise, anorexia, and weight loss....

    Incorrect

    • A 40-year-old woman presents to her GP with malaise, anorexia, and weight loss. Screening blood samples reveals urea of 50.1 mmol/l and serum creatinine of 690 μmol/l. Her past history includes frequent headaches, but nothing else of note. She has, however, failed to attend her routine ‘well-woman’ appointments.   Ultrasound reveals bilateral hydronephrosis and a suspicion of a central pelvic mass.   What diagnosis is most likely to be responsible for this woman’s hydronephrosis?

      Your Answer: Ovarian carcinoma

      Correct Answer: Cervical carcinoma

      Explanation:

      The patient’s history of recent weight loss and malaise, paired with enlarged kidneys and renal failure, as well as a suspected central pelvic mass on ultrasound, gives a suspicion of cervical carcinoma.

    • This question is part of the following fields:

      • Nephrology
      71.7
      Seconds

  • Question 12 - A 25-year-old woman was admitted to hospital with a 3 day history of...

    Incorrect

    • A 25-year-old woman was admitted to hospital with a 3 day history of feeling generally unwell, with fatigue, arthralgia and pruritis. She had recently finished a 5 day course of antibiotics for a urinary tract infection but there was no other significant past medical history. She had no significant findings on clinical examination except for a widespread erythematous rash. Investigation results are below: Haemoglobin (Hb) 12.6 g/dL, White cell count (WCC) 13.0 × 109/l (eosinophilia) Platelets 390 × 109/L, Creatinine 720 μmol/L, Na+ 135 mmol/L, K+ 5.2 mmol/L, Urea 22.0 mmol/L, Urinalysis Protein ++ blood + What is the most important investigation to establish the diagnosis?

      Your Answer: Antistreptolysin-O titre

      Correct Answer: Renal biopsy

      Explanation:

      There is a strong suspicion of drug-induced acute tubulo-interstitial nephritis with the classic triad of symptoms of rash, joint pain and eosinophils in the blood, associated with non-specific symptoms of fever and fatigue. This can be confirmed with renal biopsy showing interstitial oedema with a heavy infiltrate of inflammatory cells and variable tubular necrosis.

    • This question is part of the following fields:

      • Nephrology
      40.4
      Seconds

  • Question 13 - A 63-year-old gentleman is admitted to the Emergency Department, with a past history...

    Correct

    • A 63-year-old gentleman is admitted to the Emergency Department, with a past history of chronic renal failure, who complains of increasing shortness of breath. Bloods reveal a creatinine of 570 μmol/l, urea of 48 mmol/l. He is also anaemic with a haemoglobin (Hb) of 8.9 g/dl. On examination he has a pericardial rub and there are bibasal crackles consistent with heart failure. Which of the following represents the best treatment option for this patient?

      Your Answer: Urgent haemodialysis

      Explanation:

      This case presents with symptoms and lab results suggestive of uremic pericarditis, which is an indication for immediate haemodialysis. Uremic pericarditis is caused by inflammation of the membranes of the pericardial sac, which usually resolves after a period of intensive dialysis.

    • This question is part of the following fields:

      • Nephrology
      37.5
      Seconds

  • Question 14 - Which one of the following is a recognised cause of hypokalaemia associated with...

    Incorrect

    • Which one of the following is a recognised cause of hypokalaemia associated with hypertension:

      Your Answer: Gitelman syndrome

      Correct Answer: Liddle's syndrome

      Explanation:

      Liddle’s Syndrome is an autosomal dominant disorder that presents with hypertension usually in young patients, that do not respond to anti-hypertensive therapy and is later associated with hypokalaemia, low renin plasma, and low aldosterone levels as well. The other conditions listed do not present with hypertension and associated hypokalaemia.

    • This question is part of the following fields:

      • Nephrology
      5.8
      Seconds

  • Question 15 - A 61-year-old gentleman presents with heart failure and pedal oedema. The oedema occurs...

    Incorrect

    • A 61-year-old gentleman presents with heart failure and pedal oedema. The oedema occurs due to:

      Your Answer: Left heart failure

      Correct Answer: Increased release of renin

      Explanation:

      The oedema is an effect of the a decreased cardiac output that increases renin release which leads to vasoconstriction and sodium and water retention.

    • This question is part of the following fields:

      • Nephrology
      17.7
      Seconds

  • Question 16 - A 11-year-old boy is admitted to the hospital with diarrhoea and lethargy. There...

    Correct

    • A 11-year-old boy is admitted to the hospital with diarrhoea and lethargy. There is a known local outbreak of E coli 0157:H7, and his initial bloods show evidence of acute renal failure. Given the likely diagnosis, which one of the following investigation results would be expected?

      Your Answer: Fragmented red blood cells

      Explanation:

      The likely diagnosis in this case is Haemolytic Uremic Syndrome (HUS), which is generally seen in young children presenting with a triad of symptoms, namely: acute renal failure, microangiopathic haemolytic anaemia, and thrombocytopenia. The typical cause of HUS is ingestion of a strain of Escherichia coli. The laboratory results will usually include fragmented RBCs, decreased serum haptoglobin, reduced platelet count, nonspecific WBC changes, and normal coagulation tests (PTT included).

    • This question is part of the following fields:

      • Nephrology
      22.7
      Seconds

  • Question 17 - A 58-year-old gentleman with a long history of gout presents with loin pain....

    Incorrect

    • A 58-year-old gentleman with a long history of gout presents with loin pain. Other past history of note includes an ileostomy after bowel surgery. There is no history of weight loss from malabsorption syndrome after his bowel surgery. Excretion urography reveals evidence of bilateral renal stones. What is the most likely composition of his renal stones?

      Your Answer: Calcium oxalate

      Correct Answer: Uric acid stones

      Explanation:

      Uric acid stones will most likely be found in this case because of the patient’s long history of gout. Additionally, studies have shown that ileostomy patients have an increased risk for the development of uric acid stones.

    • This question is part of the following fields:

      • Nephrology
      31.9
      Seconds

  • Question 18 - A 70-year-old complains of lower urinary tract symptoms. Which one of the following...

    Correct

    • A 70-year-old complains of lower urinary tract symptoms. Which one of the following statements regarding benign prostatic hyperplasia is incorrect?

      Your Answer: Goserelin is licensed for refractory cases

      Explanation:

      Goserelin (Zoladex) is usually prescribed to treat hormone-sensitive cancers of the breast and prostate not for BPH. All other statements are correct.

    • This question is part of the following fields:

      • Nephrology
      31
      Seconds

  • Question 19 - A 23-year-old student commences chemotherapy for B-type acute lymphoblastic leukaemia. She suffers from...

    Correct

    • A 23-year-old student commences chemotherapy for B-type acute lymphoblastic leukaemia. She suffers from vomiting, but 36 hours later her condition worsens and her bloods reveal a corrected calcium of 2.0 mmol/l and serum potassium of 6.7 mmol/l. Which of the following options is the best way to avoid this problem from occurring?

      Your Answer: Hydration and allopurinol pre-chemotherapy

      Explanation:

      This case is most likely tumour lysis syndrome, often occurring immediately after starting chemotherapy because the tumour cells are killed and their contents are released into the bloodstream. After treating lymphomas or leukaemia, there is a sudden hypocalcaemia, hyperphosphatemia, and hyperkalaemia

    • This question is part of the following fields:

      • Nephrology
      27.1
      Seconds

  • Question 20 - In idiopathic hypercalciuria, what management should be initiated if there is renal stone...

    Incorrect

    • In idiopathic hypercalciuria, what management should be initiated if there is renal stone disease or bone demineralization?

      Your Answer: Cranberry juice

      Correct Answer: Dietary modification and thiazide diuretics

      Explanation:

      Idiopathic hypercalciuria presents with excess calcium in the urine without an apparent cause. Dietary modification is the first step in addressing this condition, however, because hypercalciuria increases the risk of developing renal stones and bone demineralisation, thiazide diuretics should be prescribed to increase calcium reabsorption when these symptoms are also present.

    • This question is part of the following fields:

      • Nephrology
      14.3
      Seconds

  • Question 21 - A 11-year-old boy has a history of tonsillitis followed by haematuria and hypertension...

    Incorrect

    • A 11-year-old boy has a history of tonsillitis followed by haematuria and hypertension about 10 days later.   What would be the characteristic blood test finding in this condition?

      Your Answer: Low C4 level

      Correct Answer: Depressed CH 50 level

      Explanation:

      Because the medical history included tonsillitis followed by haematuria and hypertension, there is a strong suspicion of a case of post-streptococcal glomerulonephritis (PSGN). Patients with PSGN usually have serological findings showing depressed serum haemolytic component CH50 and serum concentrations of C3. Sometimes depressed C4 levels are also apparent, but not always, therefore, the answer to this question is: depressed CH50 level.

    • This question is part of the following fields:

      • Nephrology
      29.9
      Seconds

  • Question 22 - A 61-year-old woman with a history of hypothyroidism and inflammatory arthritis is admitted...

    Incorrect

    • A 61-year-old woman with a history of hypothyroidism and inflammatory arthritis is admitted after slipping on ice and falling over. Some routine blood tests are performed: Na+ 141 mmol/L, K+ 2.9 mmol/L, Chloride 114 mmol/L, Bicarbonate 16 mmol/L, Urea 5.2 mmol/L, Creatinine 75 µmol/L, Which one of the following is most likely to explain these results?

      Your Answer: Conn's syndrome

      Correct Answer: Renal tubular acidosis (type 1)

      Explanation:

      The patient’s underlying arthritis has most likely led to Renal tubular acidosis RTA type 1, which presents with the following symptoms consistent with the presentation of the patient: Normal anion gap metabolic acidosis/acidaemia, hypokalaemia and hyperchloremia. Comparatively, the other conditions are ruled out because Aspirin and diabetic ketoacidosis is associated with a raised anion gap, Conn’s syndrome explains hypokalaemia but not the metabolic acidosis, and RTA type 4 is associated with hyperkalaemia.

    • This question is part of the following fields:

      • Nephrology
      52.1
      Seconds

  • Question 23 - A 3-year-old boy presents with recurrent urinary tract infections. What is the most...

    Incorrect

    • A 3-year-old boy presents with recurrent urinary tract infections. What is the most common cause for this problem in a child of this age?

      Your Answer: Posterior urethral valves

      Correct Answer: Vesicoureteric reflux

      Explanation:

      Vesicoureteral reflux is the condition when the urine flows backwards from the bladder into the kidneys, which is the most common cause of UTI in patients this age.

    • This question is part of the following fields:

      • Nephrology
      7.2
      Seconds

  • Question 24 - A 41-year-old gentleman required high doses of intravenous diuretics after his renal transplant...

    Incorrect

    • A 41-year-old gentleman required high doses of intravenous diuretics after his renal transplant for the purposes of fluid management. Soon after administration he developed hearing loss, tinnitus, and vertigo.   Which diuretic is most likely to have caused this?

      Your Answer: Acetazolamide

      Correct Answer: Furosemide

      Explanation:

      Furosemide is a loop diuretic that is known to have significant ototoxicity side-effects although the mechanism is not fully known.

    • This question is part of the following fields:

      • Nephrology
      13.7
      Seconds

  • Question 25 - A 15-year-old boy presents with hypertension and acute renal failure after an episode...

    Correct

    • A 15-year-old boy presents with hypertension and acute renal failure after an episode of diarrhoea. What is the most likely diagnosis?

      Your Answer: Haemolytic–uraemic syndrome

      Explanation:

      The likely diagnosis in this case is Haemolytic Uremic Syndrome (HUS), which is generally seen in young children presenting with a triad of symptoms, namely: acute renal failure, microangiopathic haemolytic anaemia, and thrombocytopenia. The typical cause of HUS is ingestion of a strain of Escherichia coli causing diarrhoea in these cases as well.

    • This question is part of the following fields:

      • Nephrology
      9.3
      Seconds

  • Question 26 - A 30-year-old female presents with polyuria and is passing 4 litres of urine...

    Correct

    • A 30-year-old female presents with polyuria and is passing 4 litres of urine per day. She was recently started on a new medication.   Results show: Serum sodium 144 mmol/L (137-144) Plasma osmolality 299 mosmol/L (275-290) Urine osmolality 210 mosmol/L (350-1000)   Which of the following drugs was prescribed?

      Your Answer: Lithium

      Explanation:

      The patient’s presentation is consistent with diabetes insipidus: eunatreaemia, high serum osmolality, and inappropriately dilute urine, which leads to the suspicion of lithium-induced diabetes insipidus.

    • This question is part of the following fields:

      • Nephrology
      18.5
      Seconds

  • Question 27 - A 63-year-old woman visits the diabetes clinic for review. She has had type-2...

    Incorrect

    • A 63-year-old woman visits the diabetes clinic for review. She has had type-2 diabetes for 9 years and is now on insulin therapy. She has diabetic nephropathy, as exemplified by hypertension and proteinuria (urinary PCR 155); a recent creatinine level was 205 μmol/l and eGFR 24 ml/min.   Which of the following options best fits her prognosis or management?

      Your Answer: Her systolic BP target should be 140 mmHg

      Correct Answer: Treatment with ARB or ACE-I may slow further deterioration in renal function

      Explanation:

      Treatment with ARB or ACE-I may slow further deterioration in renal function in this patient, as studies have shown that blocking of the RAS in type 2 diabetic patients improve renal function.

    • This question is part of the following fields:

      • Nephrology
      42.5
      Seconds

  • Question 28 - A 75-year-old lady is referred to hospital from her GP. She has been...

    Correct

    • A 75-year-old lady is referred to hospital from her GP. She has been treated for essential hypertension, with Bendroflumethiazide 2.5 mg once daily and triamterene 150 mg once daily.   Routine investigations show: Serum sodium 134 mmol/L (137-144) Serum potassium 5.9 mmol/L (3.5-4.9) Serum urea 7.0 mmol/L (2.5-7.5) Serum creatinine 100 μmol/L (60-110)   Her blood pressure is measured at 134/86 mmHg. Her electrocardiogram is normal. The GP has stopped the triamterene today.   Which of these is the most appropriate action?

      Your Answer: Repeat urea and electrolytes in one week

      Explanation:

      Triamterene is a potassium-sparing diuretic that can cause hyperkalaemia, therefore, it was stopped in this patient. With all other lab results returning normal values and a normal ECG, management will simply require repeating the U & E after one week since the Triamterene has already be stopped.

    • This question is part of the following fields:

      • Nephrology
      31
      Seconds

  • Question 29 - A 33-year-old Afro–Caribbean gentleman with a 5 year history of HIV infection presents...

    Incorrect

    • A 33-year-old Afro–Caribbean gentleman with a 5 year history of HIV infection presents with swollen ankles. He has been treated with highly active antiretroviral therapy (HAART) for 2 years, with partial response. His plasma creatinine concentration is 358 μmol/l, albumin is 12 g/dl, CD4 count is 35/μl and 24 hour urine protein excretion rate is 6.8 g. Renal ultrasound shows echogenic kidneys 13.5 cm in length. What would a renal biopsy show?

      Your Answer: Focal necrotising crescentic nephritis

      Correct Answer: Microcystic tubular dilatation and collapsing FSGS

      Explanation:

      HIV-associated nephropathy (HIVAN) show typical findings of scarring called focal segmental glomerulosclerosis (FSGS) and microcystic tubular dilatation, prominent podocytes, and collapsing capillary loops.

    • This question is part of the following fields:

      • Nephrology
      37.4
      Seconds

  • Question 30 - Which is the most severe form among the following? ...

    Correct

    • Which is the most severe form among the following?

      Your Answer: Class IV: diffuse proliferative glomerulonephritis

      Explanation:

      The classes refer to the WHO classification of glomerulonephritis in SLE patients.
      class I: normal kidney
      class II: mesangial glomerulonephritis
      class III: focal (and segmental) proliferative glomerulonephritis
      class IV: diffuse proliferative glomerulonephritis
      class V: diffuse membranous glomerulonephritis
      class VI: sclerosing glomerulonephritis

      Class IV: diffuse proliferative glomerulonephritis is the most common and the most severe form, where more than 50% of the glomeruli are involved.

    • This question is part of the following fields:

      • Nephrology
      14.3
      Seconds

  • Question 31 - Which of the following types of renal stones are said to have a...

    Incorrect

    • Which of the following types of renal stones are said to have a semi-opaque appearance on x-ray?

      Your Answer: Xanthine stones

      Correct Answer: Cystine stones

      Explanation:

      Only cystine stones are semi-opaque because they contain sulphur. All the other stones will appear either radio-lucent or radio-opaque.

    • This question is part of the following fields:

      • Nephrology
      9
      Seconds

  • Question 32 - A 61-year-old gentleman presents with pain in his right flank and haematuria. A...

    Incorrect

    • A 61-year-old gentleman presents with pain in his right flank and haematuria. A CT scan of the abdomen reveals a large 8 × 8cm solid mass in the right kidney and a 3 × 3cm solid mass occupying the upper pole of the left kidney. What is the most appropriate treatment for this patient?

      Your Answer: Right radical nephrectomy followed by interleukin-2

      Correct Answer: Right radical nephrectomy and left partial nephrectomy

      Explanation:

      This patient presents with the classic triad of renal carcinoma: haematuria, loin pain and a mass in the kidneys. Management will entail right radical nephrectomy because of the 8x8cm solid mass and a left partial nephrectomy of the 3x3cm solid mass.

    • This question is part of the following fields:

      • Nephrology
      26.5
      Seconds

  • Question 33 - A 71-year-old woman with a medical history of a blood transfusion in the...

    Correct

    • A 71-year-old woman with a medical history of a blood transfusion in the early 1980s presents with a 10 month history of malaise and is noted to have impaired renal function. Her urine sediment reveals red cell casts. The results of immunological investigations are as follows: serum IgG 6.5 g/L (normal range 6-13), IgA 1.5 g/L (normal range 0.8-4.0), IgM 5.7 g/L (normal range 0.4-2.0), serum electrophoresis shows a faint band in the gamma region, complement C3 1.02 g/L (normal range 0.75-1.65), complement C4 <0.02 g/L (normal range 0.20-0.65), and rheumatoid factor 894 IU/L (normal range <40). Which of the following investigations is likely to be most important in making a definitive diagnosis?

      Your Answer: Cryoglobulins

      Explanation:

      The patient’s history of a blood transfusion and lab results showing a markedly low C4 (with normal C3), elevated rheumatoid factor, and elevated serum IgM is highly suggestive of hepatitis C-associated cryoglobulinaemic vasculitis. Testing for Cryoglobulins will confirm this suspicion.

    • This question is part of the following fields:

      • Nephrology
      35
      Seconds

  • Question 34 - An 83-year-old gentleman presents to his GP with increasing oedema and ascites. He...

    Correct

    • An 83-year-old gentleman presents to his GP with increasing oedema and ascites. He is hypertensive, for which he takes amlodipine. There is shortness of breath on exercise. His alcohol history is two cans of stout per day.   ECG is normal, and CXR reveals normal heart size and no signs of cardiac failure. Serum albumin is 23 g/dl; urinary albumin excretion is 7 g/24 h, with no haematuria. He has mild anaemia with a normal MCV. Total cholesterol is elevated.   What diagnosis fits best with this clinical picture?

      Your Answer: Nephrotic syndrome

      Explanation:

      Nephrotic syndrome usually presents with the symptoms in this patient: low albumin, abnormal cholesterol, increased urinary albumin excretion, oedema, and as a consequence, hypertension as well.

    • This question is part of the following fields:

      • Nephrology
      41.2
      Seconds

  • Question 35 - A gentleman arrives at the renal clinic for review. He has longstanding chronic...

    Correct

    • A gentleman arrives at the renal clinic for review. He has longstanding chronic renal failure and is unfortunately suffering from metabolic bone disease. His GP has asked for an explanation of the causes and features of metabolic bone disease. Which of the following best describes the biochemical changes involved?

      Your Answer: Phosphate excretion is decreased, parathyroid hormone levels are increased and 1,25-OH vitamin D levels are decreased

      Explanation:

      The patient’s chronic renal failure causes decreased renal hydroxylation of vitamin D which leads to decreased calcium absorption in the gut. Simultaneously, there is also decreased renal excretion of phosphate, and this combination of factors results in increased PTH levels.

    • This question is part of the following fields:

      • Nephrology
      26.2
      Seconds

  • Question 36 - Following a road traffic accident, a gentleman is brought to A&E. He is...

    Incorrect

    • Following a road traffic accident, a gentleman is brought to A&E. He is found to have oliguria and diagnosed with acute renal tubular necrosis.   What is the most common complication and cause of death in this condition?

      Your Answer: Electrolyte abnormalities

      Correct Answer: Infection

      Explanation:

      In patients with acute renal tubular necrosis, infection in the form of gram-negative septicaemia is the most common cause of death, especially while the patient is awaiting spontaneous recovery of their renal function.

    • This question is part of the following fields:

      • Nephrology
      15.4
      Seconds

  • Question 37 - A 64-year-old woman presents with malaise, ankle swelling and shortness of breath. Her...

    Incorrect

    • A 64-year-old woman presents with malaise, ankle swelling and shortness of breath. Her blood pressure is 215/140 mmHg, she has +2 peripheral oedema and the skin over her fingers appears very tight. Fundoscopy discloses bilateral papilledema.   Plasma creatinine concentration is 370 μmol/l, potassium is 4.9 mmol/l, haemoglobin is 8.9 g/dl and her platelet count is 90 x 109 /ml.   What is the pathological hallmark of this condition?

      Your Answer: Stenosis of one or both main renal arteries

      Correct Answer: Mucoid intimal thickening of vascular endothelium

      Explanation:

      The history is suggestive of scleroderma renal crisis, where we would expect thrombotic microangiopathy process with vascular endothelium involvement manifesting as mucoid intimal thickening or onion skin effect.

    • This question is part of the following fields:

      • Nephrology
      37.8
      Seconds

  • Question 38 - Which one of the following statements regarding minimal change glomerulonephritis is incorrect? ...

    Incorrect

    • Which one of the following statements regarding minimal change glomerulonephritis is incorrect?

      Your Answer: Has a good prognosis

      Correct Answer: Hypertension is found in approximately 25% of patients

      Explanation:

      Hypertension and haematuria are not common presentations in minimal change glomerulonephritis, all other statements are correct.

    • This question is part of the following fields:

      • Nephrology
      7
      Seconds

  • Question 39 - A 23-year-old pregnant woman presents with glycosuria. What is the most likely mechanism?...

    Correct

    • A 23-year-old pregnant woman presents with glycosuria. What is the most likely mechanism?

      Your Answer: Reduced renal reabsorption

      Explanation:

      Throughout pregnancy the tubular reabsorption of glucose is less effective than in the non-pregnant state, this leads to glycosuria.

    • This question is part of the following fields:

      • Nephrology
      17
      Seconds

  • Question 40 - A 72-year-old woman is admitted with general deterioration and ‘off-legs’. On examination in...

    Correct

    • A 72-year-old woman is admitted with general deterioration and ‘off-legs’. On examination in the emergency department, she looks dry and uremic.   Investigations reveal:
      • K+ 7.2 mmol/L
      • Na+ 145 mmol/L
      • Creatinine 512 μmol/L
      • Urea 36.8 mmol/L
      Which TWO of the following measures are most appropriate in her immediate management?

      Your Answer: ECG & IV Calcium gluconate bolus

      Explanation:

      First and foremost, the patient should be put on ECG monitoring to identify the cardiac state, and because of the markedly raised serum potassium, a calcium gluconate bolus will have the immediate effect of moderating the nerve and muscle performance.

    • This question is part of the following fields:

      • Nephrology
      23.8
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  • Question 41 - A 60-year-old gentleman is found dead in his apartment. He was known to...

    Correct

    • A 60-year-old gentleman is found dead in his apartment. He was known to be suffering from primary systemic amyloidosis. What is the most probable cause for his death?

      Your Answer: Cardiac involvement

      Explanation:

      Primary amyloidosis is characterised by abnormal protein build-up in the tissues and organ such as the heart, liver, spleen, kidneys, skin, ligaments, and nerves. However, the most common cause of death in patients with primary amyloidosis is heart failure.

    • This question is part of the following fields:

      • Nephrology
      11.2
      Seconds

  • Question 42 - A 20-year-old woman presents to casualty with flank pain and a 48 hour...

    Correct

    • A 20-year-old woman presents to casualty with flank pain and a 48 hour history of dysuria. Her past medical history includes polycystic ovarian syndrome. She is not in a steady relationship at present. There is haematuria and proteinuria on urine dipstick testing. Examination reveals a pyrexia of 38.1 °C and flank pain. What diagnosis fits best with this clinical picture?

      Your Answer: Pyelonephritis

      Explanation:

      The patient presents with flank pain and fever with haematuria and proteinuria associated with a social history of not being in a steady relationship. This patient is a young presumably sexually active female, so the diagnosis is most likely pyelonephritis which has an increased incidence in young sexually active women or men of >50 years of age.

    • This question is part of the following fields:

      • Nephrology
      39.4
      Seconds

  • Question 43 - A 28 year old female presents to her GP with joint pain ,...

    Correct

    • A 28 year old female presents to her GP with joint pain , fever, a butterfly rash and fatigue. She has marked peripheral oedema. She is found to be hypertensive, in acute renal failure, low albumin levels and proteinuria.   A renal biopsy is performed and reveals focal glomerulonephritis with subendothelial and mesangial immune deposits.   What is the most likely diagnosis?

      Your Answer: Lupus nephritis Class III

      Explanation:

      This case presents with characteristic symptoms of SLE and with her renal biopsy results of focal glomerulonephritis, this is clearly Class III SLE.

    • This question is part of the following fields:

      • Nephrology
      26.6
      Seconds

  • Question 44 - A 26-year-old patient, previously fit and well, is admitted with fluctuating confusion and...

    Incorrect

    • A 26-year-old patient, previously fit and well, is admitted with fluctuating confusion and frank haematuria. He has recently been complaining of generalised malaise and joint pains. Examination reveals jaundice, splenomegaly, and petechiae. His blood pressure is 155/84 mmHg, temperature 37.9oC.   Initial investigations reveal: Haemoglobin 9.5 g/dL, White cell count 12 × 109/L, Platelets 40 × 109/L, Creatinine 142 μmol/L, Sodium 139 mmol/L, Potassium 4.5 mmol/L, Urea 9.2 mmol/L, Lactate dehydrogenase 495 U/l (10–250) Urinalysis Protein ++, blood +++ Blood film shows schistocytes   What treatment should NOT be given to this patient?

      Your Answer: Antiplatet agents

      Correct Answer: Platelet transfusion

      Explanation:

      There is a strong suspicion of Thrombotic Thrombocytopenic Purpura (TTP) in this patient as he presents with neurological changes (from confusion to convulsions and coma), fever, haemolysis, thrombocytopenia, and renal failure. Additionally, TTP cases may present with jaundice, splenomegaly, and hypertension as seen in this patient. With a diagnosis of TTP, recent studies have shown that platelet transfusion is not recommended in this case because it has been shown to increase the risk for arterial thrombosis and mortality possibly due to increased aggregations.

    • This question is part of the following fields:

      • Nephrology
      30.4
      Seconds

  • Question 45 - A 3-year old boy presents with an abdominal mass. Which of the following...

    Incorrect

    • A 3-year old boy presents with an abdominal mass. Which of the following is associated with Wilm’s tumour (nephroblastoma)?

      Your Answer: Autosomal dominant polycystic kidney disease

      Correct Answer: Beckwith-Wiedemann syndrome

      Explanation:

      Beckwith-Wiedemann syndrome is a inherited condition associated with organomegaly, macroglossia, abdominal wall defects, Wilm’s tumour and neonatal hypoglycaemia. Wilm’s tumour is a kidney cancer that usually occurs in children. The causes are unknown, however, risk factors include race and family history. Of note, Wilm’s tumour can occur as part of the following syndromes: WAGR syndrome, Denys-Drash syndrome, and Beckwith-Wiedmann syndrome and not the other listed options in this question.

    • This question is part of the following fields:

      • Nephrology
      9.8
      Seconds

  • Question 46 - Which of the following is most helpful in differentiating chronic from acute renal...

    Incorrect

    • Which of the following is most helpful in differentiating chronic from acute renal failure?

      Your Answer: Anaemia

      Correct Answer: Kidney size at ultrasound scan

      Explanation:

      The size of the kidneys on ultrasound would differentiate chronic from acute renal failures. Chronic renal failure is more associated with small-sized kidneys.

    • This question is part of the following fields:

      • Nephrology
      7.8
      Seconds

  • Question 47 - Of the following disorders, which one causes acute tubular damage? ...

    Incorrect

    • Of the following disorders, which one causes acute tubular damage?

      Your Answer: Dehydration

      Correct Answer: Myoglobinuria

      Explanation:

      Myoglobinuria is the condition when there is degeneration of necrosed muscle that it is excreted in the urine. This condition would then cause acute tubular damage leading to renal failure.

    • This question is part of the following fields:

      • Nephrology
      11.8
      Seconds

  • Question 48 - Which one of the following statements is true regarding autosomal recessive polycystic kidney...

    Incorrect

    • Which one of the following statements is true regarding autosomal recessive polycystic kidney disease?

      Your Answer: Is due to a defect on chromosome 16

      Correct Answer: May be diagnosed on prenatal ultrasound

      Explanation:

      Autosomal recessive polycystic kidney disease (ARPKD) is less common than ADPKD (dominant form) but can already present with symptoms and be diagnosed on prenatal ultrasound.

    • This question is part of the following fields:

      • Nephrology
      19.5
      Seconds

  • Question 49 - A 30-year-old woman who underwent a live related renal transplant for end-stage renal...

    Incorrect

    • A 30-year-old woman who underwent a live related renal transplant for end-stage renal failure secondary to chronic pyelonephritis 4 months ago, now attends the clinic for routine follow up. She is taking tacrolimus and mycophenolate mofetil (MMF). Her urea and electrolytes are: Na+ 136 mmol/L, K+ 3.7 mmol/L, Urea 7.2 mmol/L, Creatinine 146 μmol/L. She was last seen in clinic 2 weeks previously when her urea was 4.2 mmol/l and creatinine 98 μmol/l. She is clinically well and asymptomatic. On examination she was apyrexial and normotensive. Her transplant site was non-tender with no swelling and there were no other signs to be found. Which initial investigations should be performed first?

      Your Answer: Mycophenolate mofetil levels

      Correct Answer: Urine and blood cultures

      Explanation:

      After renal transplant, asymptomatic patients can still have graft dysfunction as an early complication, with rising serum creatinine; therefore, urine and blood cultures should be ordered first. This should be followed by measuring the Tacrolimus levels, as this drug can be directly nephrotoxic. Next, a Doppler ultrasound of the transplant site should be ordered, to check for any obstructions or occlusions.

    • This question is part of the following fields:

      • Nephrology
      53
      Seconds

  • Question 50 - You are reviewing a 70-year-old gentleman who has been suffering from multiple myeloma...

    Incorrect

    • You are reviewing a 70-year-old gentleman who has been suffering from multiple myeloma for the past 3 years. He presents with lethargy, muscle aches and pain in his lower back.   Arterial blood sampling reveals a metabolic acidosis. Serum potassium is 3.1 mmol/l (3.5–4.9), and urine pH is 5.1 (> 5.3).   What is the most likely diagnosis?

      Your Answer: Renal tubular acidosis-type IV

      Correct Answer: Renal tubular acidosis-type II

      Explanation:

      This case is most likely RTA type II, due to decreased proximal bicarbonate reabsorption, which leads to metabolic acidosis, hypokalaemia, hyperchloremia, and <6 urine pH .

    • This question is part of the following fields:

      • Nephrology
      25.8
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  • Question 51 - A 21-year-old gentleman presents with facial and ankle swelling. This has slowly been...

    Incorrect

    • A 21-year-old gentleman presents with facial and ankle swelling. This has slowly been developing over the past week. During the review of systems, he describes passing ‘frothy’ urine. A urine dipstick shows protein +++.   What is the most likely cause of this presentation?

      Your Answer: Membranous glomerulonephritis

      Correct Answer: Minimal change disease

      Explanation:

      Minimal change glomerulonephritis usually presents as nephrotic syndrome wherein the patient (usually a young adult) will present with proteinuria, oedema, and impaired kidney function, which were evident in this patient.

    • This question is part of the following fields:

      • Nephrology
      38.7
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  • Question 52 - A 74-year-old widow is undergoing haemodialysis for chronic renal failure. What is the...

    Correct

    • A 74-year-old widow is undergoing haemodialysis for chronic renal failure. What is the most common problem that can arise in this case?

      Your Answer: Protein–calorie malnutrition

      Explanation:

      Protein-calorie malnutrition is observed in almost 50% of dialysis patients, contributing to increased morbidity and mortality. All the other complications listed can usually be prevented thanks to modern-day dialysis techniques.

    • This question is part of the following fields:

      • Nephrology
      13
      Seconds

  • Question 53 - A 32-year-old gentleman presents to his GP with a 2 month history of...

    Incorrect

    • A 32-year-old gentleman presents to his GP with a 2 month history of constant abdominal pain and early satiety. He has hypertension for which he takes enalapril. On examination, he has mild tenderness on both flanks. Well-circumscribed masses are palpable in both the left and right flanks. A soft systolic murmur is heard loudest at the apex. His observations are heart rate 67/min, blood pressure 152/94mmHg, temperature 37.2C, respiratory rate 14/min, saturations 97%. Which additional feature is most likely to be found in this patient?

      Your Answer: Angiofibromas

      Correct Answer: Hepatomegaly

      Explanation:

      This patient shows classic symptoms of autosomal-dominant polycystic kidney disease (ADPKD). The abdominal pain and early satiety is caused by the enlarged kidneys that were apparent from the physical examination. Additionally, hypertension is a common symptom along with the systolic murmur that was heard, suggesting mitral valve involvement. In ADPKD cases, the most common extra-renal manifestation is the development of liver cysts which are associated with hepatomegaly.

    • This question is part of the following fields:

      • Nephrology
      30.3
      Seconds

  • Question 54 - A 53-year-old gentleman presents with several months’ history of generalised swelling, fatigue, dyspnoea...

    Incorrect

    • A 53-year-old gentleman presents with several months’ history of generalised swelling, fatigue, dyspnoea and several episodes of haemoptysis. There is no significant past medical history and he did not take any regular medication. He smokes 20 cigarettes per day and drinks 14 units of alcohol per week. On examination, he is grossly oedematous and has ascites. Cardiorespiratory examination is unremarkable and there are no neurological signs or rashes. Investigation results are below: Haemoglobin (Hb) 10.2 g/dL, White cell count (WCC) 6.0 × 109/L, Platelets 380 × 109/L, Mean corpuscular volume (MCV) 90fl Na+ 145 mmol/L, K+ 3.7 mmol/L, Urea 8.2 mmol/L, Bilirubin 16 μmol/L, Creatinine 180 μmol/L, Albumin 22 g/l Aspartate transaminase 32 iu/l Alkaline phosphatase 120 iu/l Urinalysis: Protein +++ 24 h urinary protein excretion: 5g Chest radiograph: Enlarged right hilum Echocardiogram: Mild left ventricular impairment, no valve lesion Abdominal ultrasound scan: Normal-sized kidneys, no abnormality seen A renal biopsy was performed. What is it most likely to show?

      Your Answer: Crescent formation

      Correct Answer: Thickened glomerular basement membrane with deposits of IgG and C3

      Explanation:

      Renal biopsy in this patient will most likely show thickened glomerular basement membrane with deposits of IgG and C3 as a result of membranous glomerulonephritis that has caused the nephrotic syndrome in this patient. Membranous glomerulonephritis in this case is most likely associated with an underlying bronchial carcinoma, consistent with the patient’s smoking history and physical presentation.

    • This question is part of the following fields:

      • Nephrology
      45.3
      Seconds

  • Question 55 - A 50-year-old gentleman with renal cell carcinoma has a haemoglobin of 19 g/dl....

    Correct

    • A 50-year-old gentleman with renal cell carcinoma has a haemoglobin of 19 g/dl. Which investigation will conclusively prove that this patient has secondary polycythaemia?

      Your Answer: Erythropoietin level

      Explanation:

      Erythropoietin (EPO) is used to distinguish between primary and secondary polycythaemia. Secondary polycythaemia can be caused by tumours in the kidney that may secrete EPO or EPO-like proteins.

    • This question is part of the following fields:

      • Nephrology
      11.1
      Seconds

  • Question 56 - A 57-year-old man, who suffers from biventricular cardiac failure, comes to his doctor...

    Correct

    • A 57-year-old man, who suffers from biventricular cardiac failure, comes to his doctor for a review. His symptoms are currently well controlled; he is taking Ramipril 10mg, Spironolactone 25mg, Bisoprolol 10mg, and Furosemide 40mg. His main complaint is of painful gynaecomastia that he says has developed over the past 6 months. Physical exam reveals a blood pressure of 125/80 mmHg and no residual signs of cardiac failure. Renal function is unchanged from 6 months earlier, with stable creatinine at 125 µmol/l. Which of the following is the most appropriate next step?

      Your Answer: Change the spironolactone to eplerenone

      Explanation:

      Spironolactone is an aldosterone antagonist diuretic that is well-known to cause gynaecomastia because it increases testosterone clearance and oestradiol production. The patient’s primary complaint of gynaecomastia should immediately prompt discontinuation of spironolactone and replacement with Eplerenone, which lacks the antiandrogenic effects, and thus there is less risk of gynaecomastia.

    • This question is part of the following fields:

      • Nephrology
      34.6
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  • Question 57 - A 21-year-old woman presents with lethargy and confusion. On examination, you note a...

    Incorrect

    • A 21-year-old woman presents with lethargy and confusion. On examination, you note a purpuric rash covering the abdominal wall and thighs, and a fever of 38C. Investigations reveal haemolytic anaemia, thrombocytopenia, and acute kidney injury.   Which feature of the presentation makes the diagnosis of thrombotic thrombocytopenic purpura more likely than haemolytic uremic syndrome?

      Your Answer: Fever

      Correct Answer: Confusion

      Explanation:

      Confusion in the patient refers to neurological symptoms that are more associated with thrombotic thrombocytopenic purpura than with haemolytic uremic syndrome. All the other symptoms present in both conditions similarly.

    • This question is part of the following fields:

      • Nephrology
      27.4
      Seconds

  • Question 58 - A 15-year-old girl is referred to the paediatric unit with reduced urine output...

    Correct

    • A 15-year-old girl is referred to the paediatric unit with reduced urine output and lethargy. She has been passing bloody diarrhoea for the past four days. On admission she appears dehydrated. Bloods show the following: Na+ 142 mmol/L, K+ 4.8 mmol/L, Bicarbonate 22 mmol/L, Urea 10.1 mmol/L, Creatinine 176 µmol/L, Hb 10.4 g/dL, MCV 90 fl Plt 91 * 109/L, WBC 14.4 * 109/L, Given the likely diagnosis, which one of the following organisms is the most likely cause?

      Your Answer: E. coli

      Explanation:

      The likely diagnosis in this case is Haemolytic Uremic Syndrome (HUS), which is generally seen in young children presenting with a triad of symptoms, namely: acute renal failure, microangiopathic haemolytic anaemia, and thrombocytopenia. The typical cause of HUS is ingestion of a strain of Escherichia coli.

    • This question is part of the following fields:

      • Nephrology
      20.2
      Seconds

  • Question 59 - A 63-year-old gentleman with chronic kidney disease secondary to diabetes mellitus is reviewed....

    Incorrect

    • A 63-year-old gentleman with chronic kidney disease secondary to diabetes mellitus is reviewed. When assessing his estimated glomerular filtration rate (eGFR), which one of the following variables is not required by the Modification of Diet in Renal Disease (MDRD) equation?

      Your Answer: Ethnicity

      Correct Answer: Serum urea

      Explanation:

      A formula for estimating glomerular filtration rate (eGFR) is the Modification Diet of Renal Disease (MDRD) equation which takes into account the following variables: serum creatinine, age, gender, and ethnicity. Thus, serum urea is not required in this formula.

    • This question is part of the following fields:

      • Nephrology
      22.8
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  • Question 60 - A 35-year-old gentleman presents to the Emergency Department with abdominal pain. This started...

    Incorrect

    • A 35-year-old gentleman presents to the Emergency Department with abdominal pain. This started earlier on in the day and is getting progressively worse. The pain is located on his left flank and radiates down into his groin. He has no history of this pain or any other condition. Examination reveals a gentleman who is flushed and sweaty but is otherwise unremarkable. What is the most suitable initial management?

      Your Answer: Immediate abdominal ultrasound

      Correct Answer: IM diclofenac 75 mg

      Explanation:

      Because of the patient’s presentation with flank pain that radiates to the groin, we are suspecting renal colic. We should follow guidelines for acute renal management and prescribe IM diclofenac for immediate relief of pain.

    • This question is part of the following fields:

      • Nephrology
      36.3
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Nephrology (24/60) 40%
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