Nephrology - January 2013

14 Questions | Total Attempts: 252

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Nephrology - January 2013

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Questions and Answers
  • 1. 
    A 69 y/o woman with hx of chronic bronchitis, HTN and mild CKD is admitted to the hospital with COPD exacerbation and pulmonary infection.  She is treated with albuterol, corticosteroids and TMP-SMX (Bactrim).  The patient improves over the course of 7 days.  Blood work from admission and on HD #7 is shown below.   Admission   HD #7 Na 140   138 K 4.5   6.3 BUN 28   32 Creatinine 1.5   1.7               Which of the following is the most likely cause of the patient’s hyperkalemia?
    • A. 

      Acute adrenal insufficiency

    • B. 

      Corticosteroid therapy

    • C. 

      Renal failure

    • D. 

      TMP-SMX therapy

  • 2. 
    A 35 y/o male without significant PMHx presents to the ED with cough and shortness in breath for one week.  He reports occasional blood tinged sputum.  He denies malaise, weight loss, fevers or joint pain.  On exam, BP is 140/80, pulse is 80, O2 saturation is 97% on ambient air.  Labs show a BUN of 48, creatinine of 3.5 and normal electrolytes.  UA shows 1+ protein, moderate blood, 3-4 RBC casts and 2-3 granular casts per HPF.  CXR shows bilateral infiltrates.  Urine protein/creatinine ratio is 0.6.  ELISA for anti-GBM is positive.  ANCA is not detectable.  Renal biopsy shows crescents in the glomeruli on light microscopy and linear IgG staining along the glomerular capillaries.  What is the best management strategy for this patient?
    • A. 

      Hemodialysis

    • B. 

      Intravenous prednisolone

    • C. 

      Observation

    • D. 

      Plasma exchange, prednisolone and cyclophosphamide

  • 3. 
    A 61 y/o woman with HTN, DM2, ischemic cardiomyopathy and chronic renal insufficiency reports pain in her right knee c/w osteoarthritis.  She is prescribed celecoxib 200 mg daily.  After two weeks, she presents to the ED with dyspnea, lower extremity edema and fatigue.  Blood pressure is 188/100 (previously 140/84), BUN is 67, creatinine of 3.9 (baseline 1.9).  What is the mechanism by which the celecoxib caused the acute on chronic renal insufficiency?
    • A. 

      Acute popillary necrosis with renal obstruction

    • B. 

      Acute tubular necrosis from drug induced nephrotoxicity

    • C. 

      Acute allergic interstitial nephritis

    • D. 

      Hemodynamic renal insurriciency from prostaglandid manipulaiton

  • 4. 
    Questions #4 and #5 are based on the following case: An 80 y/o female with a hx of depression presents to the ED with weakness and dizziness.  She takes furosemide 20 mg daily for lower extremity edema.  She reports that her PCP placed her on HCTZ 25 mg daily for HTN one week prior.  She denies any fevers, chills, nausea, vomiting, night sweats or rashes.  She is thirstier than usual.  BP laying down is 100/60, dropping to 84/40 on standing.  Lungs are clear.  No edema is noted.    Serum   Urine Osm 260   200 Na 125   50 K 3.4     BUN       Creatinine 0.8       Which of the following is the patient’s most likely diagnosis?
    • A. 

      Adrenal insufficiency

    • B. 

      Furosemide-induced hyponatremia

    • C. 

      HCTZ induced hyponatremia

    • D. 

      Hypothyroidism

    • E. 

      SIADH

  • 5. 
    Patient's weight is 60 kg.  What is the next step in management?
    • A. 

      NS (0.9%) at 125 mL/hour

    • B. 

      D5 1/2 NS at 50 mL/hour

    • C. 

      Restrict Free H2O intake

    • D. 

      Salt tabs

  • 6. 
    A 35 y/o otherwise healthy man is referred to you for hypertension.  BP is 190/55.  Labs show hypokalemia (2.1) and an elevated HCO3 (36).  Renal function is WNL.  Plasma rennin is 0.5 ng/mL/hr (low).  Plasma aldosterone level is 22.5 (high).  Aldosterone/Renin ratio is 45.  After 3 days of oral salt loading, the patient undergoes a 24 hour urine collection, yielding a n elevated urine aldosterone level (>14).  What is the next step in work up?
    • A. 

      Bilateral renal vein sampling

    • B. 

      Captopril renal scan

    • C. 

      CT of the abdomen

    • D. 

      Renal artery angiogram

  • 7. 
    Questions #7 and #8 are based on the following case:   A 37 y/o male presents to the ED with painless swelling on both ankles and a 10 lb weight gain over the past 3 months.  During a physical examination last year, 2+ protein was noted on a dipstick urinalysis, but the patient declined further work up as he was feeling well.  No family history of renal disease.  BP is 120/80.  Exam is notable for edema in his legs up to the mid thighs.  Labs show a normal CBC.  Glucose is 80, creatinine is 1.1, BUN 28, Albumin 2.6, total cholesterol of 325, triglycerides of 800.  Complement levels are normal.  UA shows 4+ protein.  Microscopy shows 0-2 erythrocytes/hpf, hyaline casts, oval fat bodies and fatty casts.  Protein/creatinine ratio is 6.  Renal biopsy is performed.  What is the most likely biopsy finding?  
    • A. 

      Post-infectious glomerulonephritis

    • B. 

      Alport's syndrome

    • C. 

      Membrano-proliferative glomerulonephritis

    • D. 

      Membranous glomerulonephritis

  • 8. 
    Renal biopsy results confirm your suspicion.  Patient denies use of NSAIDS.  Hepatitis B and C testing is negative.  Age appropriate screening for malignancy is also negative.  What is the next step in management?
    • A. 

      Furosemide and ACEI

    • B. 

      Monthly infusion of albumin

    • C. 

      Oral Prednisone

    • D. 

      Warfarin

  • 9. 
    A 25 y/o woman with a history of EtOH intoxication requiring multiple hospitalizations is brought to the ED after a week of binge dirnking.  On physical examination, her BP is 120/75, pulse of 85 and weight is 70 kg.  She is lethargic and mumbling incoherently.  She has a witnessed tonic-clonic seizure in the ED that is terminated with diazepam.  Labs are significant for a osmolality of 230, serum Na of 110 and a glucose of 92.  Alcohol is 250.  Renal function is WNL.  What is the next step in management for this patient?
    • A. 

      Hypertonic saline (3%) at 135 cc/hour

    • B. 

      Hypertonic saline (3%) at 200 cc/hour

    • C. 

      Isotonic saline (0.9%) at 100 cc/hour

    • D. 

      Isotonic saline (0.9%) at 1000 cc/hour

  • 10. 
    Questions #10 and #11 refer to the following case:   A 27 y/o woman is 30 weeks pregnant and presents to her OB/Gyn for routine follow up.  BP is 150/105.  She was previously normotensive.  UA reveal 1+ proteinuria with a SG of 1.020.  No cells noted.  Uric acid level is 5.  Platelets and LFT’s are WNL.  A 24 hour urine collection yields 1.1 grams of protein. What is the most likely diagnosis?  
    • A. 

      Chronic Hypertension

    • B. 

      Gestational Hypertension

    • C. 

      Normal BP for pregnancy

    • D. 

      Preeclampsia

  • 11. 
    The patient is placed on bed rest and antihypertensive medications are started.  What is the first line agent?
    • A. 

      Captopril

    • B. 

      High dose furosemide

    • C. 

      MgSO4 (IV)

    • D. 

      Methyldopa

    • E. 

      There is no safe anti-hypertensive medications in pregnancy

  • 12. 
    A 36 y/o male with a hx of asthma presents with a complaint of red urine.  He describes 5 days of nasal congestion and dry cough that is now starting to improve.  He denies sore through, fever, chills, myalgias, cervical lymphadenopathy and flank pain.  No familial history of renal problems.  UA shows 1+ protein, no bacteria, leukocyte esterase or nitrites.  There are 30-50 RBC’s but no WBC’s.  Renal function is unaffected.  What is the most likely diagnosis?
    • A. 

      IgA nephropathy

    • B. 

      Nephrolithiasis

    • C. 

      Transistional Clel Carcinoma of the bladder

    • D. 

      Wegener's granulomatosis

    • E. 

      Post-infectious glomerulonephritis

  • 13. 
    18 y/o male s/p craniotomy is delivered to the ICU for further management.  The patient underwent surgery with general anesthesia and is somewhat lethargic but breathing on his own, on 6 liters of O2.  An ABG is drawn and labs are sent, showing the following:   pH = 7.22 pCO2 = 36 pO2 = 250 Na = 141 K = 3.4 Cl = 104 HCO3 = 15 BUN = 18 Creatinine = 1.1   What is the underlying Acid/Base disturbance?
    • A. 

      Gapped Metabolic Acidosis with appropriate respiratory compensation

    • B. 

      Gapped Metabolic Acidosis with respiratory acidosis

    • C. 

      Gapped Metabolic Acidosis, Non-Gapped Metabolic Acidosis and appropriate respiratory compensation

    • D. 

      Gapped Metabolic Acidosis with underlying metabolic alkylosis and respiratory compensation

  • 14. 
    A patient is evaluated for abnormal laboratory values.  ABG shows pH = 7.30, PCO2 = 31, PO2 = 85, Na = 139, K = 2.5, Cl = 110, HCO3 = 18, Normal renal function.  Urine electrolytes show Na = 50, K = 10 and Cl = 55.   What is the most likely explanation of this ABG?
    • A. 

      Acetazolamide

    • B. 

      Chronic diarrhea

    • C. 

      Ureteroenteric Fistula

    • D. 

      Renal Tubular Acidosis

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