Day 17 Flashcards
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
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.
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
Ans: C. Only the MAO inhibitors are associated with the possibility of retarding the progression of Parkinsonism.
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
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.
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
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.
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
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.
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
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
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
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.
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
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.
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
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.
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
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.
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)
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.
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
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.
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
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.
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
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.
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
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.