Day 17 Flashcards

1
Q

Q1-A woman comes to the emergency department with a severe headache starting one day prior to admission. On physical examination she has a temperature of 103°F, nuchal rigidity, and photophobia. Her head CT is normal. LP shows CSF with 1250 white blood cells and 50,000 red blood cells.
What is the most appropriate next step in the management of this patient?

A-Angiography
B-Ceftriaxone and vancomycin
C-Nimodipine
D-Repeat the CT scan with contrast
E-Neurosurgical consultation
A

Ans: B. The number of WBCs in the CSF in this patient far exceeds the normal ratio of 1 WBC to each 500 to 1000 RBCs. With 50,000 RBCs, there should be no more than 50 to 100 WBCs. The presence of 1250 WBCs indicates an infection, and ceftriaxone and vancomycin are the best initial therapy for bacterial meningitis. Contrast is not useful when looking for blood. Try never to answer “consultation” for anything.

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2
Q

Q2-Which of the following is most likely to slow the progression of Parkinsonism?

A-Pramipexole
B-Levodopa/carbidopa
C-Rasagiline
D-Tolcapone
E-Amantandine
A

Ans: C. Only the MAO inhibitors are associated with the possibility of retarding the progression of Parkinsonism.

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3
Q

Q3-A 72-yearold man with extremely severe parkinsonism comes by ambulance to the emergency department secondary to psychosis and confusion developing at home. He is maintained on levodopa/carbidopa, ropinirole, and tolcapone.
What is the most appropriate next step in management?

A-Stop levodopa/carbidopa
B-Start clozapine
C-Stop ropinirole
D-Stop tolcapone
E-Start haloperidol
A

Ans: B. When a patient has very severe parkinsonism, you cannot stop medications because the patient will become “locked in” with severe bradykinesia. Psychosis and confusion are a known adverse effect of antiparkinsonian treatment. Use antipsychotic medications with the fewest extrapyramidal (antidopaminergic) effects.

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4
Q

Q4-A 43-year-old carpenter comes with pain near his ear that is quickly followed by weakness of one side of his face. Both the upper and lower parts of his face are weak, but sensation is intact.
What is the most common complication of his disorder?

A-Corneal ulceration
B-Aspiration pneumonia
C-Sinusitis
D-Deafness
E-Dental caries
A

Ans: A. Corneal ulceration occurs with seventh cranial nerve palsy because of difficulty in closing the eye, especially at night. This leads to dryness of the eye and ulceration. This is prevented by taping the eye shut and using lubricants in the eye. Dental caries don’t happen because although there is drooling from difficulty closing the mouth, saliva production is normal. Rather than deafness, sounds are extra loud. Aspiration does not occur because gag reflex and cough are normal.

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5
Q

Q5-A woman comes to the emergency department with bilateral leg weakness developing over the last few days. She has lost her knee jerk and ankle jerk reflexes. The weakness started in her feet and progressed up to her calves and then her thighs. She is otherwise asymptomatic.
Which of the following is the most urgent step?

A-Pulmonary function testing
B-Arterial blood gas
C-Nerve conduction study
D-Lumbar puncture
E-Peak flow meter
A

Ans: A. The most dangerous thing that can happen with GBS (Gullien Barr syndrome) is dysautonomia or involvement of the respiratory muscles. Peak inspiratory pressure or a decrease in forced vital capacity (FVC) is the earliest way to detect impending respiratory failure. If you wait until there is CO2 accumulation on an ABG, it is too late. Nerve conduction studies are the most accurate test, but their results are not as important as answering the question “Do you know who is going to die from respiratory failure?” Peak flow assesses expiratory function, which is not greatly impaired in GBS; peak flow is best used to assess obstructive disease such as COPD or asthma.

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6
Q

Q6- A diabetic patient is evaluated with a UA(Urine Analysis) that shows no protein. Microalbuminuria is detected (level between 30 and 300 mg per 24 hours).What is the next best step in the management of this patient?

A-Enalapril
B-Kidney biopsy
C-Hydralazine
D-Renal consultation
E-Low-protein diet
F-Repeat UA annually and treat when trace protein is detected
A

Ans: A. ACE inhibitors or angiotensin receptor blocker (e.g., losartan, valsartan) are the best initial therapy for any degree of proteinuria in a diabetic patient. They decrease the progression of proteinuria and delay the development of renal insufficiency in diabetic patients. Hydralazine is not as effective and has more adverse effects. Low-protein diets are less effective than ACE inhibitors. Do not consult for initiating medications like ACE inhibitors

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7
Q

Q7-A woman is admitted to the hospital with trauma and dark urine. The dipstick is markedly positive for blood.What is the best initial test to confirm the etiology?

A-Microscopic examination of the urine
B-Cystoscopy
C-Renal ultrasound
D-Renal/bladder CT scan
E-Abdominal x-ray
F-Intravenous pyelogram
A

Ans: A. Hemoglobin and myoglobin make the dipstick positive for blood, but no red cells are seen on microscopic examination of the urine. Abdominal x-ray detects small bowel obstruction (ileus) but is very poor at detecting stones or cancer. Renal CT is the most accurate test for stones, but would not be done until the etiology of the positive dipstick had been confirmed as blood.

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8
Q

Q8- A young 25 years’African American man comes for a screening test for sickle cell. He is found to be heterozygous (trait or AS) for sickle cell.
What is the best advice for him?

A-Nothing needed until he has a painful crisis
B-Avoid dehydration
C-Hydroxyurea
D-Folic acid supplementation
E-Pneumococcal vaccination
A

Ans: B. The only significant manifestation of sickle cell trait is a defect in renal concentrating ability or isosthenuria. These patients will continue to produce inappropriately dilute, high-volume urine despite dehydration. Hydroxyurea is used to prevent painful crises when they occur more than 4 times a year. Painful crises rarely occur in sickle cell trait. They do not have hemolysis, so there is no need for additional folic acid supplementation. Splenic function is abnormal only in those who are homozygous, so pneumococcal vaccination is not routinely indicated.

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9
Q

Q9-A patient comes with fever and acute, left lower quadrant abdominal pain. Blood cultures on admission grow E. coli and Candida albicans. She is started on vancomycin, metronidazole and gentamicin, and amphotericin. She has a CT scan that identifies diverticulitis. After 36 hours, her creatinine rises dramatically.
Which of the following is most likely the cause of her renal insufficiency?

A-Vancomycin
B-Gentamicin
C-Contrast media
D-Amphotericin

A

Ans: C. Radiographic contrast media has a very rapid onset of injury. Creatinine rises the next day. Vancomycin, gentamicin, and amphotericin are all potentially nephrotoxic, but they would not cause renal failure with just 2 or 3 doses. They need 5 to 10 days to result in nephrotoxicity. Metronidazole is hepatically excreted and does not cause renal failure.

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10
Q

Q10-A 72-year-old blind man is admitted with obstructive uropathy and chest pain. He has a history of hypertension and diabetes. His creatinine drops from 10 mg/dL to 1.2 mg/dL 3 days after catheter placement. The stress test shows reversible ischemia.
What is the most appropriate management?

A-Coronary artery calcium score on CT scan
B-One to two liters of normal saline hydration prior and during angiography
C-N-acetylcysteine prior to angiography
D-Mannitol during angiography
E-Furosemide during angiography

A

Ans: B. Saline hydration has the most proven benefit at preventing contrastinduced nephrotoxicity. Mannitol and furosemide may or may not prevent nephrotoxicity. There is minimal data to support their use. N-acetylcysteine and sodium bicarbonate have some benefit, but the evidence is not as clear as that with saline. Calcium scoring on CT scan is still considered experimental. It does not provide sufficient information to eliminate angiography.

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11
Q

Q11-A patient with mild renal insufficiency undergoes angiography and develops a 2 mg/dL rise in creatinine from ATN despite the use of saline hydration before and after the procedure.
What do you expect to find on laboratory testing?

A-Urine sodium 8 (low), FENa >1%, urine specific gravity 1.035 (high)
B-Urine sodium 58 (high), FENa >1%, urine specific gravity 1.005 (low)
C-Urine sodium 5 (very low), FENa <1%, urine specific gravity 1.040 (very high)
D-Urine sodium 45 (high), FENa >1% urine specific gravity 1.005 (low)

A

Ans: C. Although contrast-induced renal failure is a form of ATN, the urinary lab values are an exception from the other forms of ATN. Contrast causes spasm of the afferent arteriole that leads to renal tubular dysfunction. There is tremendous reabsorption of sodium and water, leading the specific gravity of the urine to become very high. This results in profoundly low urine sodium. The usual finding in ATN from nephrotoxins would be UNa above 20, FENa greater than 1%, but a low specific gravity. Specific gravity correlates with urine osmolality.

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12
Q

Q12-A patient with extremely severe myeloma with a plasmacytoma is admitted for combination chemotherapy.Two days later, the creatinine rises.
What is the most likely cause?

A-Cisplatin
B-Hyperuricemia
C-Bence-Jones proteinuria
D-Hypercalcemia
E-Hyperoxaluria
A

Ans: B. Two days after chemotherapy, the creatinine rises in a person with a hematologic malignancy. This is most likely from tumor lysis syndrome leading to hyperuricemia. Cisplatin, as with most drug toxicities, would not produce a rise in creatinine for 5 to 10 days. Bence-Jones protein and hypercalcemia both cause renal insufficiency, but it would not be rapid and it would not happen as a result of treatment. Treatment for myeloma would end up decreasing both the calcium and Bence-Jones protein levels because they are produced from the leukemic cells. Cancer cells do not release oxalate.

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13
Q

Q13-A patient who is suicidal ingests an unknown substance and develops renal failure 3 days later. Her calcium level is also low and the urinalysis shows an abnormality. What did she take?

A-Aspirin
B-Acetaminophen
C-Ethylene glycol
D-Ibuprofen
E-Opiates
F-Methanol
A

Ans: C. Ethylene glycol is associated with acute kidney injury based on oxalic acid and oxalate precipitating within the kidney tubules causing ATN. Oxalate crystal appears as envelope-shaped crystals. The calcium level is low because it precipitates as calcium oxalate. Aspirin is renal toxic but does not lower calcium levels and has no abnormality on urinalysis. Acetaminophen is hepatotoxic. Ibuprofen and all NSAIDS are renal toxic by constricting the afferent arteriole, causing allergic interstitial nephritis and papillary necrosis. They have no impact on calcium levels and the only time something would be found in the urine is in the case of papillary necrosis. Papillary necrosis causes sudden flank pain and fever. Methanol causes inflammation of the retina and has no renal toxicity. Opiates by injection are associated with focalsegmental glomerulonephritis, not AKI. In addition, that is only with the impurities found with injection drug use, certainly not opiate medications.

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14
Q

Q14-A man comes to the emergency department after a triathlon, followed by status epilepticus. He takes simvastatin at triple the recommended dose. His muscles are tender and the urine is dark. Intravenous fluids are started.
What is the next best step in the management of this patient?

A-CPK level
B-EKG
C-Potassium replacement
D-Urine dipstick
E-Urine myoglobin
A

Ans: B. EKG is done to detect life-threatening hyperkalemia. Your question may have “potassium level” as the answer. CPK level, urine dipstick for blood and myoglobin should all be done, but the EKG will see if he is about to die of a fatal arrhythmia from hyperkalemia. Potassium replacement in a person with rhabdomyolysis would be fatal.

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15
Q

Q15-A patient develops ATN (Acute Tubular Necrosis) from gentamicin. She is vigorously hydrated and treated with high doses of diuretic, low-dose dopamine, and calcium acetate as a phosphate binder. Urine output increases but she still progresses to end-stage renal failure. She also becomes deaf.
What caused her hearing loss?

A-Hydrochlorothiazide
B-Dopamine
C-Furosemide
D-Chlorthalidone
E-Calcium acetate
A

Ans: C. Furosemide causes ototoxicity by damaging the hair cells of the cochlea, resulting in sensorineural hearing loss. This is related not only to the total dose, but how fast it is injected. It essentially “burns” the inner ear. Aminoglycoside antibiotics also cause hearing loss. Furosemide in ATN adds no proven overall benefit. It does add ototoxicity to the gentamicin.

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16
Q

Q16-What is the most common cause of death from PCKD (Poly Cystic Kidney Disease)?

A-Intracerebral hemorrhage
B-Infection
C-Malignancy
D-Renal failure

A

Ans: D. Renal failure occurs in PCKD from recurrent episodes of pyelonephritis and nephrolithiasis causing progressive scarring and loss of renal function. PCKD does not have malignant potential. Only 10% to 15% of affected people have cerebral aneurysms, most of which do not rupture. Connective tissue is weak throughout the body.
These patients may have:
• Liver cysts (most common site outside the kidney)
• Ovarian cysts
• Mitral valve prolapse
• Diverticulosis

17
Q

Q17-A patient is admitted with vomiting and diarrhea from gastroenteritis. His volume status is corrected with intravenous fluids and the diarrhea resolves. His pH is 7.40 and his serum bicarbonate has normalized. Despite vigorous oral and intravenous replacement, his potassium level fails to rise.
What should you do?

A-Consult nephrology
B-Magnesium level
C-Parathyroid hormone level
D-Intracellular pH level
E-24-hour urine potassium level
A

Ans: B. Hypomagnesemia can lead to increased urinary loss of potassium. If magnesium is replaced, it will close up the magnesium-dependent potassium channels and stop urinary loss. Although magnesium is necessary for parathyroid hormone release, this would have nothing to do with potassium levels. Try not to consult on Step 2. You are supposed to handle anything that is based on knowledge. Consultations are generally indicated only for procedures such as catheterization or endoscopy. Although there will be increased potassium on a 24-hour urine with hypomagnesemia, there is no point in performing this test because you still have to detect and treat hypomagnesemia.

18
Q

Q18-A woman with End stage renal disease and glucose 6-phosphate dehydrogenase deficiency skips dialysis for a few weeks and then is crushed in a motor vehicle accident. She istaking dapsone and has recently eaten fava beans. What is the most urgent step?

A-Initiate dialysis
B-EKG
C-Bicarbonate administration
D-Insulin administration
E-Kayexalate
F-Urine myoglobin
A

Ans: B. All of these interventions may be helpful in a person with life-threatening hyperkalemia. The most important step is to determine if there are EKG changes from hyperkalemia. If the EKG is abnormal, she needs calcium chloride or gluconate in order to protect her heart while the other interventions are performed. Kayexalate and dialysis take hours to remove potassium from the body. Bicarbonate and insulin work in 15 to 20 minutes, but they are not as instantaneous in effect as giving calcium.

19
Q

Q19-A 50 year’s old man comes to the emergency department with excruciating pain in his left flank radiating to the groin. He has some blood in his urine. What is the most appropriate next step in the management of this patient?

A-Ketorolac
B-X-ray
C-Sonography
D-Urinalysis
E-Serum calcium level
A

Ans: A. Ketorolac is an NSAID that is available orally and intravenously. It provides a level of analgesia similar to opiate medications. When the presentation of nephrolithiasis is clear, it is more important to provide relief for this excruciating form of pain than to obtain specific diagnostic tests

20
Q

Q20-What is the most accurate diagnostic test for nephrolithiasis?

A-CT scan
B-X-ray
C-Sonography
D-Urinalysis
E-Intravenous pyelogram
A

Ans: A. The CT scan for nephrolithiasis does not need contrast and is more accurate(sensitive) than an x-ray or sonogram. Intravenous pyelogram (IVP) needs intravenous contrast and takes several hours to perform. Urinalysis and straining the urine may show blood or the passage of a stone, but will not help manage acute renal colic. X-ray has a false negative rate between 10% and 20%. X-rays of the abdomen are useful only in detecting an ileus.

21
Q

Q21- A woman with her first episode of renal colic is found to have a 1.8 cm stone in the left renal pelvis. She has no obstruction and her renal function is normal (normal BUN and creatinine). What is the most appropriate next step in the management of this patient?

A-Wait for it to pass; hydrate and observe
B-Lithotripsy
C-Surgical removal
D-Hydrochlorothiazide
E-Stent placement
A

Ans: B. Lithotripsy is used to manage stones between 0.5 and 2 to 3 centimeters. Small stones (less than 5 mm) will spontaneously pass. Stones larger than 2 centimeters are not well-managed with lithotripsy because the fragments will get caught in the ureters. These large stones are best managed surgically. Stent placement relieves hydronephrosis from stones caught in the distal ureters. Stones halfway up the ureters are treated with lithotripsy. Those halfway down the ureter are removed from below with a basket.

22
Q

Q22-A man with a calcium oxalate stone is managed with lithotripsy and the stone is destroyed and passes. His urinary calcium level is increased. Besides increasing hydration, which of the following is most likely to benefit this patient?

A-Calcium restriction
B-Hydrochlorothiazide
C-Furosemide
D-Stent placement
E-Increased dietary oxalate
A

Ans: B. Hydrochlorothiazide removes calcium from the urine by increasing distaltubular reabsorption of calcium. Furosemide increases calcium excretion into the urine and can make it worse. Calcium restriction actually does not help decrease overexcretion of calcium into the urine. In fact, it can make it more likely to form a stone. This is because calcium binds oxalate in the bowel. When calcium ingestion is low, there is increased oxalate absorption in the gut because there is no calcium to bind it in the gut. Stent placement is done when there is an obstruction in the ureters, especially at the ureteropelvic junction. Hydrochlorothiazide desaturates the urine of calcium. The risk of stone formation is increased if there is a dietary decrease in calcium, increase in oxalate, or decrease in citrate.

23
Q

Q23-A woman finds a hard, nontender breast mass on self-examination. There is no alteration of the mass with menstruation. She is scheduled to undergo a FNA biopsy. Which of the following is most likely to benefit the patient?

A-Mammography
B-BRCA testing
C-Ultrasound
D-Bone scan
E-PET scan
A

Ans: A. If breast biopsy is going to be performed, what is the point in doing a screening test like mammography? The answer is: 5% to 10% of patients have bilateral disease. In addition, there is a huge difference in the management of the patient if there is a single lesion or multiple lesions within the same breast. BRCA testing confirms an extra risk of cancer compared to the general population, but will add nothing to a patient who must already undergo biopsy. Ultrasound is useful in evaluating whether masses that are equivocal by clinical examination are cystic or solid. Bone scan is used after a diagnosis of breast cancer is made to exclude occult metastases. PET scan helps determine the content of abnormal masses within the body or enlarged nodes without biopsy. However, PET scan does not eliminate the need to establish an initial diagnosis with biopsy.

24
Q

Q24-Which cancer screening method lowers mortality the most? (i.e.,Which of the following is most likely to benefit the patient?)

A-Pap smear
B-Colonoscopy
C-Prostate-specific antigen (PSA)
D-Mammography above age 50
E-Mammography above age 40
A

Ans: D. Controversy may surround the question of how early to begin mammography. Recommendations have recently changed to start mammography at age 50, instead of 40. However, it is not controversial that there is a greater mortality benefit in screening those above age 50. This is because the incidence of breast cancer is greater above age 50. Hence, if you screen 1000 women above age 50, you will detect more cancer than screening 1000 women above age 40.

25
Q

Q25-Which of the following is most likely to benefit an asymptomatic patient with multiple first-degree relatives with breast cancer?

A-Tamoxifen or raloxifene
B-BRCA testing
C-Aromatase inhibitors (anastrazole, letrazole)
D-Dietary modification (low fat, soy diet)
E-HER-2/neu testing, Estrogen and/or progesterone receptor testing

A

Ans: A. Both selective estrogen receptor modulators (SERMs), tamoxifen and raloxifene, result in a 50% to 66% reduction in breast cancer when compared with placebo. The benefit is greatest in those with 2 first-degree relatives with breast cancer (motheror sister). SERMs are amazingly underutilized in preventing breast cancer. Aromatase inhibitors are very useful in preventing metastases in those with proven breast cancer, but they are not proven to benefit those who are asymptomatic. Dietary modification is unproven. HER-2/neu testing is useful to guide the use of trastuzumab, which will block this receptor in those with proven cancer, but not as prophylaxis. Estrogen and progesterone receptor testing has no place in managing asymptomatic women. These tests are used in those proven to have cancer.