Os 214 Renal Exam (b)

OS 214 RAMOS SAGUN

NEPHROLOGY

Dear classmates, Pasensya na po sa samplex na ‘to. Less than half nagbigay. Dr. Dimacali promised before to upload the exam in OSIRIS but she hasn’t done so yet. Yaw naman namin kulitin, halata nay yun di ba. Neway, we tried to make this as informative as possible, despite the kinks. 

5. Treatment options for benign prostatic enlargement include the following except a. alpha adrenergic blockers B b. surgery c. observation and monitoring of symptoms d. radiotherapy 9. On imaging studies using contrast material, urological tumors present as a. filling defects A b. extravasation of dye c. non-visualization of the involved organ d. layering of contrast material 11. A 35-y.o. male presented with painless gross hematuria, a solid mass within the bladder on C ultrasound abd a filling defect in the bladder on KUB-IVP. His surgical pathology report will most probably reveal the following histology: a. Adenocarcinoma b. Rhabdomyosarcoma c. Transitional Cell Carcinoma d. Squamous Cell Carcinoma C. Bladder CA: p.539, Harrison’s Vol. 1 12. 28/M hit by jeepney. CT Scan showed subscapular hematoma on the right kidney. Management? a. nephrectomy C b. c. close observation d. surgical .. Classification of Renal Trauma (trans): Description Management MINOR (nonsurgical) Bed rest, hydrate, Grade 1 Renal contusion transfuse, close Grade 2 Subscapular hematoma Grade 3 Break in the watch parenchyma; does not involve collecting system MAJOR (surgical) Grade 4 break in the collecting Nephroraphy, system  hematuria; partial nephrectomy, extravasation of dye Grade 5 Shattered kidney, renal nephrectomy, hilum trauma, vessel vascular repair injury and ureteropelvic junction disruption VASCULAR Grade 5 (also) Obstructed renal artery 5 Rs: RESUSCITATE, REST, READY (observe), REPAIR, REMOVE (1st 3: for G1-3, 2nd 2: for G4 and 5)

14. The gold standard or best diagnostic tool in assessment of renal injury a. IVP B b. CT Scan of abdomen c. Urinalysis d. Ultrasonography B. CT is the overwhelming leader for diagnosing and staging renal traumatic injuries. Ultrasonography also has limited clinical usefulness in the evaluation of renal trauma. (emedicine) 15. This PE finding in a trauma pt should deter you from inserting a urethral catheter a. palpable hypogastric mass C b. scrotal edema c. blood in the urethral meatus

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d. pelrineal laceration C. nasa trans ito ha… 16. Which among the following are infectious stones? a.cystine C b.uric acid c.struvite d.calcium oxalate C. Struvite are non-calcium caliculi made up of magnesium, ammonium and phosphate. They are infection stones associated with Proteus, Pseudomonas, Providencia, Klebsiella, Staphylococci and Mycoplasma (trans). 25. The following explains voiding dysfunction with failure to empty a. b. c. injury to the pudendal nerve during injury d. failure of sphincter muscles to open due to pelvic nerve injury wala ata sa pilian yung sagot.. The pelvic nerve primarily innervates the detrusor muscle in the bladder wall (not the sphincter; so hindi na puwede yung D) The pudendal nerve provides innervation to the external urethral sphincter (off during voiding so hindi rin puwede C). Injury to spinal cord segments S1-3 will cause (1) Damage to the pudendal nerve causes inability of the external urethral sphincter to contract → unable to prevent constant urine leakage. (2)The pelvic nerve may also be affected preventing active contraction of the bladder. Therefore, while a small amount of urine may accumulate in the bladder, the animal will be constantly dribbling urine.

What can cause failure to empty? Suppressed pons, spinal cord injury, injured pelvic nerve, scarred/weak detrusor (hypertrophy causing ischemia or collagen deposition), obstruction of urethral lumen (big prostate) 26. Which is critical in the development of prune belly syndrome? a. deficient abdominal muscles A b. ureteral obstruction c. oligohydramnios d. urethral atresia A. (from WEBMD) Prune Belly syndrome (also called Abdominal Muscle Deficiency Syndrome/Congenital Absence of the Abdominal Muscles/Eagle-Barrett Syndrome, Obrinsky Syndrome). Dr. Anacleto also said twas the muscles

28. Abdominal mass in a newborn male is most likely due to: a. Wilm’s tumor C b. Renal cell CA c. hydronephrosis d. neuroblastoma C. From Nelson: “In the newborn, a palpable abdominal mass is most commonly a hydronephrotic or multicystic dysplastic kidney.” – since the latter is not among the choices, hydronephrosis is the best answer. Hydronephrosis is a consequence of congenital urinary tract obstruction and is its most common clinical manifestation.

30. 18 months boy with 1st UTI episode: best imaging study: a. abdominal x-ray D b. IVP c. DTPA scan d. voiding cystourethrogram D. Nelson: A voiding cystourethrogram (VCUG) is also indicated in all children younger than 5 years with a UTI, any child with a febrile UTI, school-aged girls who have had two or more UTIs, and any male with a UTI.

31.What is the most common cause of HPN on children a. idiopathic A b. renal c. cardiac

OS 214 RAMOS SAGUN

NEPHROLOGY

d. endocrine The most prevalent form of HPN in pediatrics is now primary or essential HPN. Only 5-10% have an identifiable cause.

34. HPN in children a. HPN varies in age group b. Hypertensive urgency should be treated A immediately c. HPN defined as above 85Th percentile for age  > 95th percentile

d. From Nelson: Blood pressure varies with the age of the child and is closely related to height and weight. Significant increases occur during adolescence, and there are many temporary variations before the more stable levels of adult life are attained.

35. 6 y.o. male child sought consult at the ER for headache and vomiting. You suspect hypertension. What are the precautions you will consider in determining the BP to get a reliable determination? a. choose an appropriate cuff D b. have the child seated in a comfortable position c. take the BP after a rest of 3-5mins d. AOTA From Nelson: Accurate measurement of blood pressure requires careful attention to the comfort of the patient, and is highly dependent on the proper use of the equipment… Careful attention to the cuff size is necessary to avoid overdiagnosis… The cuff should completely encircle the upper arm to ensure uniform compression; the inflatable bladder should cover at least two thirds of the length of the upper arm and three quarters of its circumference.

36. A 10 y.o. boy is found to have BP ranging from 135/90 – 145/95 mmHg on 3 occasions. Which of the ff. describes the most appropriate initial testing for this child’s condition? a. CBC, electrolyte concentration, BUN and Crea levels, urinalysis A b. CBC, electrolyte concentration, urine culture c. BUN and Crea levels, urine culture, 24h collection for protein and creatine d. urinalysis, urine culture, 24h urine collection for protein and creatine e. CBC, electrolyte concentration, BUN and Crea levels, DMSA A. From Nelson: Screening tests should include a complete blood count, urinalysis, and determination of serum electrolyte, blood urea nitrogen, serum creatinine, and uric acid levels.

39. The single most important differential diagnosis of post-infectious GN due to group A beta-hemolytic Streptococcus among primary glomerulonephritis is a. membranous nephropathy B b. IgA nephropathy c. thin basement membrane disease d. FSGN B. Both Post-Strep GN and IgA nephropathy present with acute nephritic syndrome (hematuria, hypertension, proteinuria, oliguria). Thin basement membrane disease is a benign condition that only presents with hematuria, without renal impairment or proteinuria. FSGN and membranous nephropathy commonly present with nephrotic syndrome (proteinuria, hypoalbuminemia, edema, hyperlipidemia).

45. The factors that govern the movement of fluid from the intravascular compartment to the interstitial fluid compartment: a. capillary hydrostatic pressure D d. capillary oncotic pressure c. capillary membrane permeability d. all of the above D. this is from dr. alonzo’s lec

46. Edema in nephritic syndrome and CHF is due to: a. renal sodium retention leading to increased A capillary hydraulic pressure

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b. decreased capillary oncotic pressure due to protein loss c. lymphatic obstruction d. increased capillary permeability A. Extracellular fluid volume expansion, edema, and hypertension developd because of impaired GFR and enhanced tubular reabsorption of salt and water (Clinical Presentations of Acute Nephritic Syndrome and Rapidly Progressive Glomwrulonephritis, Harrison’s 16th Ed, Vol. 2, p.1679.)

48. This patient has a. decreased GFR b. normal GFR c. decreased GFR d. end stage renal disease Answer: Without the case, we can’t give an answer. However, the folowing table might be of help: Table 261-1 Stages of Chronic Renal Disease Stage Description GFR, ml/min per 1.73 m2 At increased risk 90 (w/ CRD risk factors) 1 Kidney damage with 90 normal or increased GFR 2 Kidney damage ith mildly 60 – 89 decreased GFR 3 Moderatley decreased 30 – 59 GFR 4 Severely decreased GFR 15 – 29 5 Renal Failure >15

49. What is this pt’s creatinine clearance based on the 24h urine values? a. 62 mL/min b. 173 mL/min c. 80 mL/min d. 96 mL/min Answer: Without the case, we can’t give an answer. However, the Cockcroft-Gault Equation may help: Cockcroft-Gault Equation (ml/min) (140-age) x body weight (kg) 72 x Pcr (mg/dl) *Multiply by 0.85 for women

50. The patient urine protein creatinine ratio confirms the diagnosis of a. acute nephritis b. nephritic syndrome c. tubulo interstitial disease d. membranous nephropathy Answer: No case. Please just read on the aforementioned disease entities

52. Start of empiric steroid therapy: how much mg/day prednisone should he be started on? a. 10 b. 25 c. 50 d. 60 Answer: Again, no case! Use of prednisone in kidney disease, however, is discussed with regards to minimal change disease, which is higly responsive to steroids, with excellent prognosis.Children: 60mg/m2 of body surface area daily for 4 weeks, followed by 40mg/m2 on alternate days for an additional 4 weeks Adults: 1-1.5mg/kg body weight/day/4 weeks, followed by 1mg/kg/day on alternate days for an additional 4 weeks (P. 1685, Harrisons 16th Ed, Vol 2)

55. A 65 year old with diabetes with history of coronary vessel disease is now seen with BP of 170/100 since last 2 months. He has slightly depressed renal function, high rennin, increased aldosterone and abdominal bruits. What would be the most likely cause of his HPN? a. renin secreting tumor b. renovascular HPN B c. ARF

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OS 214 RAMOS SAGUN

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d. primary hyperaldosteronism We’re not sure but abdominal bruits make the etiology vascular and the presence of a high bp makes the patient hypertensive. In the absece of these findings, the cause will be primary.

56. 35 year old male hypertensive with metabolic alkalosis, kypokalemia, decreased K urine, increased aldosterone (serum), decreased plasma rennin a. Liddle’s syndrome B b. Adrenal Tumor c. Syndrome with mineralocortocoid excess d. B. (trans) Algorhythm for Hypokalemia: A & C exhibit normal to low aldosterone. The pt has ↑aldosterone and ↓ rennin, thus has primary aldosteronism Urine Chloride UCl- < 20 mEq/day

UCl- > 40 mEq/day Hypertension

Vomiting Diuretics Post-hypercapnea

Yes

No

Aldosterone

Bartter’s Syndrome Severe K+ Depletion

High LOW RENIN

Low/Normal HIGH RENIN

1° Hyperaldosteronism Renovascular HPN Malignant HPN Renin-secreting tumor

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Excess Steroids Licorice Liddle’s Syndrome Cushing’s Syndrome

57. Severe Pancreatitis manifests as a. organ failure C b. abscess c. pseudocyst d. AOTA e. A and B C. Severe and Late complicatons include pseudocysts that are an accumul;ation of blood, narcotic debris and fluid in the retroperitoneum. They are rarely palpable (De Gowin’s).

62. Patient’s hypokalemia is due to: a. decrease intake d. increase GI loss c. increased entry of potassium ions into cells due to acid-base status d. decreased ability of second proton pump in the lumen of collecting tubules, H+K+ATPase Dunno what the case is.. For causes of hypokalemia, see #65.

63. 75 year old man; decreased sensorium, increased sleeping time; stable vital signs; Na: 110 ; Cl: 75 ; K:3.5 a. cerebral salt wasting b. decreased solute intake c. decreased effective circulating volume d. ADH excess This is beyond my powers. Sorry…

65. A patient with severe metabolic acidosis from kidney disease presents with hypokalemia. Which of the following is true regarding this patient? a. total body K is low b. the serum K is low but the intracellular K is B increased c. The patient was given spironolactone d. The beta blocker that the patient was taking for his hypertension caused the low serum K B. Metabolic acidosis with ↓ urine K(<29meq/day) has an extra renal etiology and is suffering from diarrhea (↑K in stool), inadequate diet, chronic sweating.. Metabolic with ↑ urine K (>20) has a renal etiology and may suffer from renal tubular acidosis, DKA glucose infusion, K losing diuretics (thiazides or acetazolamide) Spironolactone is K sparing.

Beta agonists may cause hypokalemia thru transcellular shifts (K goes intracellular)

68. Not a common feature of acute uncomplicated cystitis (AUC) a. hematuria b. dysuria c. vaginal discharge d. flank pain not sure pero baka A.. (trans) Classic presentation of acute uncomplicated cystitis: dysuria, frequency and urgency Suprapubic pain is possible. Urinalysis will show elevated WBC, bacteria, 0 pus cell casts (which are indicative of upper tract pathology)

72. The ff are specific medical treatments for acute uncomplicated pyelonephritis in the Philippine setting except: a. amoxicillin A b. cetriaxone c. cefexime d. levofloxacine e. cefuroxime A. (trans) Tx for AUC cotrimoxazole resistance 80%, ampicillin and amoxicillin have high local resistance of 40-50%. OK to give nitrofurantoin (7days), coamoxiclav, cephalosporin or quinolone (3 days for coamox, ceph and quin). For Acute Pyelonephritis, give empiric antibiotics.

77. The following are true for renal failure in obstructive uropathy except a. Early phase – decreased intratubular pressure, increased renal plasma flow mediated by local prostaglandin production b. intermediate phase – decreased intratubular pressure, decreased renal plasma flow mediated by increased interstitial pressure c. Late phase – normal intratubular pressure, marked by increased renal plasma flow mediated by angiotensin II and thromboxane AII d. NOTA e. AOTA Sorry, this too..

85. In what sort of patient is more recommended to have peritoneal dialysis over hemolysis? a. visual acuity is poor B b. extensive peripheral vascular disease c. extensive prior abdominal surgery d. >80 kg with truncal obesity Harrison’s p. 1663: Peritoneal dialysis is favored in younger patients because of better manual dexterity and greater visual acuity… In contrast, larger patients (>80 kg), patients wth no residual renal function, and patients who have truncal obesity with or without prior abdominal surgery may be more suited to hemodialysis.

89. The probability that a sibling will share all the same major histocompatibility gene is a. 10% B b. 25% c. 50% d. 100% *see figure on p.2, column 1 of Transplantation Immunology and Therapeutics.

92. Common side effect of immunosuppressive agents: a. HPN B b. high risk of infection c. hypercholesterolemia d. nephrotoxicity This is the most probable because there is decreased immunity. Sir also mentioned this.

OS 214 RAMOS SAGUN

NEPHROLOGY

Drug Y is 30% hepatic metabolism and 70% renal excretion. 94. What is the total systemic clearance for Mr. Smith in comparison with the normal? a. 90% of normal b. 81% c. 72% d. 60% 96. Assuming volume distribution stays the same, what is the half life for drug X for Mr. Smith? a. 111% b. 123% c. 128% D. 167% 96.If you want to maintain the same drug exposure (AUC), how would you adjust the dose( hint: remember the relationship of the dose, AUC and (L)? a. decrease the dose directly proportional to total systemic clearance (If Cl is 80% of normal, dose is 80% of normal) b. Increase the dose by the reciprocal of the total systemic clearance (if Cl is 80% of normal, the dose is 125% of normal) c. decrease the dose to the square of the % total systemic clearance (if Cl is 80% of normal, dose is 64% of normal) d. increase the dose by the square of the reciprocal of % total systemic clearance (if Cl is 80% of normal, dose is 156% of normal). 98. Relative function: 45-55% a. renal obstruction b. pyelonephritis E c. diabetic nephropathy d. renal artery stenosis e. normal kidneys E. kidneys do not contribute equally all the time. they may vary up to this degree.

105. Characterized by abdominal pain, pruritic rashes on buttocks and colored urine a. C b. c. d. HUS e.Post-Strep GN C. HUS = hemolytic uremic syndrome

106. Hydronephrosis, BUN 20, Crea 150 a. Pre-renal C b. Intrarenal c. Post-renal C. in post-renal pathologies, the abnormality/obstruction could be in the ureter, urethra, or prostate gland in the males. hydronephrosis is one of the ultrasound findings in post-renal problems, along with distortion of calices and enlargement of kidney parenchyma. normal crea is <1.2 mg/dL. normal BUN is 10-15 mg/100 mL. increased levels of BUN and creatinine is due to compromised functioning of the kidney(s).

Matching type: 110. hypercalciuria a. Furosemide 111. hypercalcemia b. Acetazolamide 112. cerebral edema c. Mannitol 113. low GFR d. Spironolactone 114. portal Hypertension e. Thiazide E,B,C,D,A

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110. E. Thiazides are mainly used in hypercalciuric patients when they have hypocalcemia. 111. B. Acetazolamide 112. C. Mannitol is an osmotic diuretic that increases water excretion in preference to sodium excretion. it can decrease intracranial and intraocular pressure. 113. D. Spironolactone 114. A. Furosemide, a loop diuretic, is indicated for edema due to CHF, hepatic, or renal disease and for hypertension.

115-120 The ff. are results of ABG taken under different situations. From column A choose the letter corresponding to your interpretation, and from Column B choose the letter corresponding to your diagnosis (in other words, match the 1st A-E with the 2nd a-e given the following lab results)

Column A A. pure respiratory alkalosis B. Primary respiratory acidosis with metabolic acidosis C. Combined Metabolic alkalosis w/ respiratory alkalosis D. high AG metabolic acidosis and respiratory acidosis E. Normal AG metabolic acidosis w/ respiratory alkalosis Column B a. pregnant woman admitted for vomiting b. anxious patient with acute diarrhea c. patient with septic shock prior to intubation d. a mountain climber halfway to the top of Mt. Everest e. acute pulmonary edema w/ hypotension Int 115.

Dx 118.

116.

119.

117.

120.

pH 7 .02 7 .32 7 .60

pCO2 60

HCO3 14

Na 130

Cl 105

14

7

140

122

20

20

140

100

ANS 115-120 C a. pregnant woman admitted for vomiting Pregnant=respiratory alkalosis Vomiting=metabolic alkalosis E b. anxious patient with acute diarrhea Anxious=respiratory alkalosis Diarrhea=non-anion gap acidosis D c. patient with septic shock prior to intubation Infection=respiratory acidosis A d. a mountain climber halfway to the top of Mt. Everest High altitude(low paCO2)=respiratory alkalosis B e. acute pulmonary edema w/ hypotension Pulmonary edema=respiratory acidosis Sorry, the table of the choices are not complete so hindi ko masagutan yung values. The answers for column B are found in Harrisons, Volume I chapter on Acid-Base Balance.