pp

Question 1

conjugated bilirubin causes (2)

Unconjugated bilirubin (2)

Answer 1

1. parenchymal liver disease ( Viral hepatitis, NASH, Alcoholic heptatitis)
2. cholestatic disorders
3. hemolysis
4. ineffective erythropoisis
5. gilbert disease

Question 2

de ritis ratio

decreases in ?

increases in?

Answer 2

De ritis ratio

decreases:

• viral hepatitis
• minor fatty liver disease
• extrahepatic cholestasis

increase:

• alcoholic hepatitis
• necrotic hep
• cirrhosis
• HCC
• liver metastasis

Question 3

which method is used to detect hematuria? and how does it yield the + result?

Answer 3

dipstick

-colour change compare it to color on the box

Question 4

acute nephritis syndrome and nephrotic syndrome are both associated with generalised edema. Through which mechanism does edema develop in these syndrome? ( 2 points)

Answer 4

• Nephritis: Oligo-anuria and volume retension
• Nephrosis: heavy proteinurea and hypoalbuminemia

Question 5

List 3 features that indicate radiologic intervention (stent implantation/angioplasty) in case of renal artery stenosis (3 points

Answer 5

• Very high BP not responding to therapy
• Rapid worsening of renal function not responding to therapy
• Flash pulmonary edemas

Question 6

A young patient on hemodialysis asks for a lab measurement immediately after her dialysis treatment. Laboratory results include eGFR 18 ml/min/1.73m2. After seeing this number, the patient suggests the suspension of dialysis. How would you respond to this request? Explain your answer briefly (2 points

Answer 6

• Reject the idea, because eGFR was designed to assess renal function in steady state conditions and the results are misleading/ should not be used in dialized patients/ more than a single number indicates dialysis ( eg. Anuria

Question 7

Multiple myeloma. What is the mechanism of acute kidney injury in this case? (2p)

Answer 7

• Monoclonal proteins are filtered (light chains) and combined with Tamm-horsfall glycoprotein, they occlude the tubuli

Question 8

Calcium in hypoalbuminemia

Answer 8

The normal range of total Ca is shifted lower ( if albumin decreases by 10 g/l ; normal Ca range goes down by 0.2 mmol/l

Question 9

isostenuria

Answer 9

neither concentrated nor diluted urine

Question 10

6. A 66 year old female patient is admitted to hospital because of chest pain and dyspnea. Her lab parameter on admission include :

Creat= 1666 umol/l CN= 12.5 mmol/l Hgb= 122g/l Na=142 mmol/l K= 4.6 mmol/l BP= 160/84 mmHg HR= 92/min NSTEMI is diagnosed and she undergoes urgeny coronangiography and stent implantation 3 days later lab results include: Creat= 320 umol/l CN=25 mmol/l Hgb= 120 g/l Na= 141 mmol/l K= 4.9 mmol/l She seems to be well hydrated and her BP is 144/80

Q) give the 2 most probable reason for acute kidney injury in this setting? (2p)?

Answer 10

atheroembolisation , contrast nephropathy (ATN)

Question 11

one year later, re- coronarography is planned. Which of the listed should be suggested to the patient before the planned intervention

1. drink a LOT of fluid the dAY BEFORE and on the day of planned intervention, to produce about 3 L of urine / day, To avoid cardiac decompensation
2. continue taking aspirin
3. STOP taking NSAID pain killers
4. STOP ACE-I

Answer 11

1. drink a LOT of fluid the dAY BEFORE and on the day of planned intervention, to produce about 3 L of urine / day, To avoid cardiac decompensation (YES)
2. continue taking aspirin (YES)
3. STOP taking NSAID pain killers ( YES)
4. STOP ACE-I (NOOO)

Question 12

5. A 64-year old patient comes to the nephrology outpatient unit with the following lab parameters

WBC=6 g/l Hgb= 95 g/l Creat=450 umol/l Na= 145 mmol/l K=5.5 mmol/l Ca= 2.6 mmol/l Po4 = 2.05 mmol/l Albumin= 25 g/l (N= 35-50) Urine SG = 1010 g/cm3 Ph= 5.5 CN= 28 mmol/l Blood= negative Protein-creat ratio 300 mg/mmol

Two months ago, his serum creatinine was 98 umol/l a.

• Did he produce diluted or concentrated urine (1p)?
• b. How would you evaluate serum Ca level? (2p)?
• c. You perform a renal US. What is the most relevant differential diagnostic question you would like to answer with the US?(1P)
• d. Based on the US findings and the clinical picture you suspect ?
• e. What is the mechanism of acute kidney injury in this case? (2p)

Answer 12

• a. neither= isostenuria
• b. Its high because in hypoalbuminemia the normal range of total Ca is shifted lower ( if albumin goes down by 10 g/l ; normal range of total Ca goes down by 0.2 mmol/l ; would be 2.4)
• c. Exclude post-renal kidney injury
• d. Multiple myeloma
• e. Monoclonal proteins are filtered (light chains) and combined with Tamm-horsfall glycoprotein, they occlude the tubuli

Question 13

35 year old male patient

creat= 130 umol/l

urine blood ++

urine pro/creat = 65mg/mmol

patient never saw blood in urine

he has undergone urologic evaluation which didnt reveal any reason for bleeding

patient tell you he has similar results years ago but nobody cared/worried about parameters

• How large is the estimated proteinurea?(1p).
• Which glomelular disease is the most probable reason for the lab result?(1p)

Answer 13

How large is the estimated proteinurea?(1p). 650mg/day

Which glomelular disease is the most probable reason for the lab result?(1p) IgA nephropathy

Question 14

list 3 reasons why living donor kidney transplantation is preffered to ceased donor transplantation?

Answer 14

1. better short/long term survival
2. faster recovery of renal function
3. planned surgery (minimal ischemic time)

Question 15

A young man wanted to commit suicide and took 15g paracetamol.

• What is the severe GI complication of the attempt?(1p)
• antidote?

Answer 15

• Acute liver failure

What would you suggest as a antidote? • N-acetyl cystein

Question 16

• what does the “window period “mean in the diagnostics of hepatitis B infection? (2p)

Answer 16

• HbsAg (hepB surface antigen) has already disappeared
• Anti-Hbs is NOT present yet

Question 17

How can you prove the infection is in the window period ? (1p)

Answer 17

• Postive anti-Hbc ( IgM) (anti hepB core antibodies

Question 18

define and which disease is it suspected in

Mcburney point tenderness

cullen sign

klatskin tumor

Answer 18

Mcburney point tenderness = right sided tenderness at the outer 2/3 of the way from umbilicus – anterior superior iliac spine line (ASIS)

• in Acute appendicitis

cullen sign : hemmoragic discolouration of skin around umbilicus

• acute hemmoragic pancreatitis

klatskin tumor = type of cholangiocarcinoma develops in cells which line bile ducts in liver , occurs where right and left hepatic bile ducts meet

Question 19

List 2 extra intestinal skin manifestation of IBD (2)

other manifestations also

Answer 19

1. erythema nodosum
2. pyoderma gangrenosum
3. uveitis
4. scleritis

Question 20

List the potential treatment options in uncomplicated symptomatic diverticulosis?( 3 points)

Answer 20

• Diet: high fiber content, avoid nuts and seeds
• Increase physical activity
• Drug: Rifaximin

Question 21

A 56 year old man is sent to gastroenterologist because of producing black stool repeatedly. Gastroscopy, colonoscopy, abdominal CT and US were negative. Lab results show a mild degree iron-defiency anemia. Symptoms persist, and the stool is consistently + for occult blood. (5points

a. What would the next diagnostic approach (1p)?
b. The bleeding was confirmed by this approach. Which method would you suggest as the next diagnostic step (1p).
c. List two groups of drugs the may provoke bleeding and affect the result of the diagnostic procedure? (2)
d. If the patient was hospitalised before the planned diagnostic evaluation because of heavy bleeding (requiring 4 packs of RBC transfusion/day) What would be the first diagnostic tool to identify the source of bleeding(1) ?

Answer 21

a. • Capsule endoscopy
b. Enteroscopy
c. • Anticoagulant • Antiplatelet drugs • NSAIDs
d. CT - angiography

Question 22

Evaluate (true/false) the following statements about celiac disease, with a brief explanation (3p

a. The single peak of incidence of celiac disease in early childhood.
b. celiac disease can be readily managed by drug treatment
c. Untreated celiac disease is associated with increased risk of malignancy

Answer 22

a. The single peak of incidence of celiac disease in early childhood. ( FALSE , there’s a 2nd peak in young adults)
b. celiac disease can be readily managed by drug treatment (FALSE , no drugs are available !!! diet is essential to be kept)
c. Untreated celiac disease is associated with increased risk of malignancy (TRUE , eg: enteropathy- associated T-lymphomas)

Question 23

Does it have any relevance whether a 55 ml min 1,73m2 estimated GFR value belongs to a 23-rearold male or a 82-year-old female? Explain your answer! (3 ponts).

Answer 23

in the young this value is much smaller than the expected 120 ml min 1,73m2, and require further evaluation .

• In the old it is very close to the axpected 60 ml min1,73m2 and represents the physiologic decrease in GFR with aging

Question 24

A25year-old male patient arives at the nephrology outpatient unit. He has had sore throat for 2 days. Yesterdav he saw some blood in his urine. Se creat is 89 umol/l, urine protein-to- creatinine ratio is 53 mg/mmol . Microscopic anaysis of the urine sediment reveals dymorphic red blood cells (RBC3).

a. What does the term “dysmorphic RBCS” mean (1 point)? RBC: of diferent shape glomerular origin of bleedin
b. How large is the estimated daily proteinuria (1 point)?
c. Based on the clinical picture, what is the most probable diagnosis (1 point)?
d. Which diagnostic step can confirm this diagnosis? What would be a characteristic finding? (3 6 points)

Answer 24

a. RBC: of diferent shape glomerular origin of bleeding
b. •530 mg/day
c. •IgA nephropathy
d. Dg step: kdney biopsy

Finding: mesangial proliferation

Question 25

60 -year old man sent to the outpatient clinic because of resistant hypertension.

List four features findings that rase the suspicion of a renovascular hypertension in this case (4)

Answer 25

• Generalized atherosclerosis ,
• abdominal bruit
• smaller kidney on ulraround
• hypokalemia.
• Worsening renal function

Question 26

List the most important differences between induction and maintenance immunosuppression applied for the treatment of a glomerulonephritis! (3 points)

Answer 26

Aim: reach immunologic and clinical remission/. prevent recurrence

• Duration : shorter (some months) vs / longer (more than a year)
• Corticosteroid dose : large dose / vs. preferably steroid free

Question 27

62 year old patient amves at the outpatient unit His past medical history includes hypertension and T2 diabetes mellitus for 15 years. eGFR is 25 ml min 1,73m, protenuia is 11 g/ day previous data about kidney function are not available Abdomial ultrasound reveal that both kidneys length is 8 cm, with 8 mm thick, echogenic parenchyma. -

Would you perform renal biopsy to determine the origin of the kidney disease Explain your answer! 2points)

Answer 27

No because in case of CKD + bilateral small kidneys biopsy is NOT indicated/ not informative

Question 28

List four indications of the acute dialysis treatment! (4 point

Answer 28

• refractory hypervolemia/hyperkalemia/acidosis
• severe uremia
• pericarditis
• certain poisonings (ethylene glycol, methanol)

Question 29

List four lifestyle recommendations you would give to a patient with recurrent Ca-oxalate kidney stone (4 poin

Answer 29

• Increase fluid intake, with even distribution of intake throughout the day , increase fruit consumption (NOT vegetables)
• Protein intake is preferrably fish
• increase citrate intake
• Decrease purine and oxalate intake ( less almond, spinach, potatoes

Question 30

List three conditions which result in steatorhhea (3points

Answer 30

• chronic pancreatitis,
• cholestasis,
• cirrhosis,
• ileum resection

* extensive crohn’s disease

• Malabsorption (including celiac disease)

Question 31

For the diagnosis of which disease do we use urea breath test? What substance do we measure during the test? How is this substance produced (3points)

Answer 31

H pylori infection

Labeled radioactive CO2. : the bacteria cleaves it from urea using urease

Question 32

A 44-year-old male patient has been experiencing difficulty of swallowing for months. Swallowing of solid food and liquids are both impeded and he often has regurgitation. He started taking proton pump inhibitors, but it did not relieve his symptoms. Upper endoscopy revealed dilated esophagus with remnants of food in it. No suspicion of a malignant tumor was raised

a. What is the most probable diagnosis according to the clinical picture? (1 point)
b. What is the potential cause of the disorder? (1 point
c. would you confirm the diagnosts? (1 point)

Answer 32

a. Achalasia
b. damage of the myenteric plexus
c. manometry

Question 33

List 2-2 common diseases or conditions that are typically associated with conjugated or unconjugated hyperbilirubinemia in adult patients! Please do NOT list Crigler-Najar, Dubin- Johnson or Rotor syndromes! (4 points)

Answer 33

Conjugated:

• Parenchymal liver disease (viral hepatitis, NASH, alcoholic hepatitis),
• cholestatic disorders

Unconjugated:

• hemolysis ,
• ineffective erytiropoiesis,
• Gilbert’s disease

Question 34

List 4 differences between ulcerative colitis and Crohn’s disease

Answer 34

• Typical location: UC: rectum and proximal (colon) CD: terminal ileum
• Extent of inflammation of the bowel wall: UC: superficial. CD: transmural.
• Continuous vs patchy is also accepted as answer.
• Fistula development: UC: not typical CD: common fistulas
• Occurrence of bloody diarrhea: UC: typical sign, CD: rarely occurs

Question 35

How do you interpret the following findings for Hepatitis B serology

1. Immunized
2. active chronic infection
3. chronic HBV infected
4. previous infection
5. acute window period
6. immunized due to previous Hbv

Answer 35

Question 36

List 4 disorders that are typically associated with acute pain in the lower right quadrant of the abdomen (4 point)

Answer 36

acute appendicitis

• Mesenteric lymphadenitis
• Meckels diverticulum
• Enteritis regionalis ( Morbus crohn)
• Diverticulitis sigmae ( sigmae longata)
• Cecum tumor
• Adnexitis acute • Ovarian cyst rupture • Ureteral stone • Acute cystitis • Extrautering gravidity

Question 37

A 40 year old male patient is sent to the nephrology outpatient unit. lab parameters: creat= 133 umol/l urine blood ++ urine protein-to-creat ratio 90 mg mmol The patient has never seen blood in his urine. He has already undergone urologic evaluation which didn’t reveal any urologic reason for the bleedinh. The patient tells you that he had similar lab remarks years ago, but then nobody cared. Worried about the parameters

• By which method was the hematuria detected?
• How does this method yeild the ++ result?
• How large is the estimated daily proteinurea ?
• Which glomerular disease is the most probably reason for the lab result?
• You perform renal biopsy. What is the characteristic feature under light microscope

Answer 37

Dipstick

Color change- compare it to scale

• 0.9g
• IgA nephropathy
• MESANGIAL proliferation

Question 38

List three features that indicate radiologic intervention (stent implantation/angioplasty) in case of renal artery stenosis (3)

Answer 38

• Severe hypertension (unresponsive to conservative treatment)
• Rapid worsening renal function
• Pulmonary edema

Question 39

A 62 year old male patient arrive at the nephrology outpatient unit with the following lab parameter eGFR= 13ml/min/1.73m2 hbg=109 g/l k=5.5 mmol/l Ca=2.4 mmol/l PO4= 2.7 mmol/l Alb= 36 g/l PTH=680 pg/ml pH= 7.32

• Do these lab parameter justify immediate dialysis treatment (2p)?
• Do you have to start EPO treatment? (2p)
• why is PTH profoundly elevated?
• give 2 drugs that can correct the patients abnormal Ca-PO4 homeostasis? (2)

Answer 39

• No, because there is severe hyperkalemia/acidosis
• No, because EPO is needed if hbg<100 g/l • hbg (109) is in the desired range
• Secondary hyperparathyroidism
• Active vitamin D ( alphacalcidol, calcitriol) • Phosphate-binders ( Ca-carbonate, Ca-acetate)

Question 40

List 3 contraindication of peritoneal dialysis(3p

Answer 40

• Extreme obesity/thiness •
• Poor hygiene
• Anuria
• uncorrected hernia
• abdominal stoma

Question 41

List the 3 most common reasons for lower tract non-hemmorhoid GI bleeding in the elderly

Answer 41

• Diverticulosis • Tumors • Angiodysplasia

Question 42

list 3 signs/symptoms/features affecting 3 different organs that raise suspicion of wilson disease in young patient

Answer 42

1. hepatitis/cirhosis
2. kayser fleischer ring (eye)
3. motor disturbances ( ataxia=loss cordination, dystonia= involuntary contraction, dysarthia- motor speech disorder )

Question 43

A 52 years old male patient is sent to hospital because of the suspicion of a mild acute pancreatitis . There are no …. Of hemmorage complication or shock.

• You ask questions to find the cause of the conditions . which 2 features should your questions focus on in order to find out the most probable? Most common reason for acute pancreatitis? (2p)
• you perform physical investigation and try to find features characteristic for acute pancreatitis (6p)
• Skin colour:
• Abdomen:
• Bowel sound: —— because of a ——
• Presence of defense:
• Liver dulness :

Answer 43

-1. Alcohol consumption 2. Known gallstone

-

• Skin colour: can be jaundice
• Abdomen: bloated
• Bowel sound: diminished because of a refratory ileus
• Presence of defense: No
• Liver dulness : maintained

Question 44

List 2 routine lab alteration ( NOT serology , endocrine panel) that can refer to celiac disease?

Answer 44

• Elevated GOT/GPT
• Iron defiency
• Anemia

Question 45

Which esophageal disorder are characterized by this descriptions? (2p)

• A young and healthy male patient start to vomit after alcohol consumption. Vomit becomes bloody. BP and HR remain normal after vomitting

Answer 45

MALLORY-WEIS SYNDROME

Question 46

A middle age male patient experience severe chest after profuse vomiting. Withing 2 hours subcutaneous emphysema, hypotension and tachycardia appear

which esophageal disorder

Answer 46

BOERHAEVE SYNDROME

Question 47

A young female patient is treated with cyclophosphamide and large dose oral corticosteroids for SLE. She experiences retrosternal pain on swallowing. On buccal mucosa and on the oropharynx, white plaque can be seen

Answer 47

Esophageal candidasis

Question 48

A young female patient has difficulty of swallowing both solid food and liquid. She has heartburn despite PPI therapy. Upper endoscopy reveal retained food in the esophagus but no sign of malignancy

Answer 48

ACHALASIA

Question 49

Middle age male undergoes upper endoscopy and biopsy. In the distal esophagus, intestinal metaplasia is observed

Answer 49

BARRETS esophagus

Question 50

What does the term “ isostenuria” refer to? Which number characterises it?(2p)

Answer 50

• Urine osmolality of which is similar to that of the plasma /urine produced by neither concentrating nor diluting kidneys
• Urine SG= 1010-1012
• Urine osm = 290 mOsm/l

Question 51

glomerular proliferation in

• post strep GN
• ANCA vasculitis + good pasture
• SLE nephritis + IgA nephropathy

Answer 51

post strep - endocapillary pro

• ANCA vasculitis + good pasture : extracapillary pro ( cresent formation)
• SLE nephritis + IgA nephropathy: mesangial pro

Question 52

A 68 year old female patient arrives at the nephrology department outpatient unit. She complains about decreased appetite and she lost 5kg over 3 month She has diffuse joint swelling and pain and has subfebrility a couple of time. Her urine output seems normal and she has no peripheral edema. Lab analysis reveals Creat= 361 umol/l Hbg= 103 g/l Alb=34 g/l Proteinuria= 950 mg/day Urine blood ++ According to previous date she had normal kidney function 6 months before

• Which clinical syndrome does the description correspond to?(1)
• list 3 disease (or groups of diseases) that typically manifest as this syndrome? (3)
• you admit the patient to hospital and perform renal biopsy . under light microscopy what’s the expected pattern of proliferation?(1p

Answer 52

• Rapid progressive glomerulonephritis syndrome
• SLE NEPHRITIS , • ANCA vasculitides , • Good pasture syndrome
• Cresent formation/ extracapillary proliferation

Question 53

List 4 typical signs and symptoms of schonlein henoch purpura

Answer 53

• Palpable purpura • Joint pain • Abdominal pain • GI bleeding • Hematuria • Worsening renal function

Question 54

In a patient with acute kidney injury, urine sediment contains hyaline casts, urine Na concentration= 20mmol/l fractional excretion of Na is 0.5%

what type of acute kidney injury do these date reflect?

What would be the appropriate therapy?

Answer 54

• Pre renal
• Saline infusion/ volume replacement

Question 55

25 year old male comes to nephrology , abdominal US reveal bilateral enlarged kidneys with multiple cystic lesions and without visible renal parenchyma

estimated GFR >90 ml/min according to family history many relatives required age dep dialysis at their old age

one of his uncles who has kidney disease deceased due to sudden death

• based on the clinical picture, the diagnosis is ?
• what disease-related abnormality could have been responsible for the sudden death in the family (1)
• how would you screen the patient for the risk of sudden death and what you expect to see in case of an increased risk? (2)

Answer 55

• ADPKD
• intracranial hemmorage / vascular rupture
• skull (angio) MRI , aneurism in willis circle

Question 56

list 4 indication of renal biopsy

Answer 56

1. nephrotic sy
2. nephritic sy
3. RPGN
4. Asymptomatic proteinuria in the 1-3g/day range (particulary if GFR declines or proteinuria increases)
5. AKI not caused by ATN
6. Chronic kidney disease of unknown origin • But not if on US small, scarred kidneys • renal insuffiency of unknown origin (unless US reveal small kidneys with thin parenchyma)
7. Renal transplant dysfunction

Question 57

list 2 groups used for transplant maintence immunosupp

Answer 57

1. corticosteroid: Prednisone
2. mTOR- inhibitor
3. calcineurin inhibitors
4. lymphocyte proliferation inhibitor

Question 58

35 year old patient on 25 gestational week

No previous med conditions are know and this is her first pregnancy

complain of swelling of legs and around eyes

she gained 29 kg

BP 150/95 mmHg

proteinurea= 4g/d

-based on the description one has to consider 2 conditions as the most probable cause ?

Answer 58

• Glomerulonephritis OR preeclampsia

Question 59

what disorder can be diagnosed based on PPI test?

which patients do we use this diagnostic approach?

Answer 59

• GERD
• Patient criteria
  
  • young
  • without alarm signs ( dysphagia, odynophagia, GI bleeding, weight loss, iron def anemia, hematemesis , melena, hematochezia

Question 60

what does tenesmus mean?

in which disease is it a common symptom?

Answer 60

• painful passing of stool
• Ulcerative colitis

Question 61

patient with acute abdomen often undergoes abdominal xray.

which conditions can be detected using this imaging method?

what do we see on xray in these conditions?

Answer 61

1. peroferation - free air under diaphram
2. ileus - multiple air fluid levels throughout abdomen ( ladder like niveaus gas)

Question 62

list 5 conditions associated with acute pain in upper left quadrant of the abdomen

Answer 62

1. gastric peroforation
2. acute pancreatitis
3. kidney stone
4. urether stone
5. hiatus hernia
6. subphrenic abcess
7. splenic infarct
8. splenic rupture
9. MI
10. left sided basal pneumonia

NOT dudenal ulcer, biliary/liver disease, gynecological

Question 63

78 year old female patient arrives due to profuse diarrhea

3 weeks before the symptoms she received 2 diff antibiotic from her GP for suspected UTI

she has been taking Ab for 2 consecutive weeks

stool is green and mucusy

no bloo

BP 100/60

abdomen is diffusely tender, but no defense

Bowel sounds are increased

WBC=21 g/l

hgb=105 g/l

BUN= 13 mmol/l

CRP=105

• what is most probable diagnosis
• apart from I.V fluid administration, which drug should medical therapy include? give 2 possibilities with the way of administration (4)

Answer 63

• c. difficile/pseudomembranous colitis
• metronidazole (I.V /p.O)
• vancomycin only P.O

Question 64

do we have to repeat upper endoscopy in case of

a) gastric
b) dudenal ulcer? explain decision

Answer 64

a) YES for gastric ulcer - due to high risk of malignancy
b) NO for dudenal ulcer - low risk malignancy

Question 65

what is the indication of urgent (within 24hr) ERCP?

Answer 65

Biliary pancreatitis

Question 66

68-year-old female patient arrives at the nephrology outpatient unit. She complains about decreased appetite, and she lost 5 kgs over 3 months. She has diffuse joint swelling and pain and she has had subfebrility a couple of times. Her urine output seems normal, and she has no peripheral oedema. Laboratory analysis reveals

creat: 362 umol/l, hgb: 101 g/l, alb: 35 g/l, proteinuria 790 mg/day, urine blood: ++. According to previous data, she had normal kidney function six months before.
- Which clinical syndrome does the description correspond to? (1 point
- List three diseases (or groups of diseases) that typically manifest as this syndrome (3 points
- You admit the patient to hospital and perform renal biopsy. Under light microscopy, what is the expected pattern of proliferation? (1 points

Answer 66

• (rapid progressive glomerulonephritis syndrome)
• ANCA vasculitis, SLE nephritis, Goodpasture syndrome
• (extracapillary / crescent formation)

Question 67

In a patient with acute kidney injury urine sediment contains hyaline casts, urine Na concentration is 20 mmol/l, and fractional excretion of Na is 0.5%.

What type of acute kidney injury do these data reflect? What would be the appropriate therapy? (2 points

Answer 67

(prerenal; (saline) infusion / volume replacement)

Question 68

List 5 conditions that are typically and often associated with acute pain in the upper right quadrant of the abdomen.

Answer 68

• acute occlusion of the cystic duct,
• acute cholecystitis,
• empyema of the gallbladder,
• choledocholithiasis,
• duodenal ulcer, gastric ulcer,
• acute pancreatitis,
• ureteral stone,
• acute appendicitis with retrocecal appendix,
• liver abscess,
• right-sided basal pneumonia / pleurisy)

Question 69

15. What is the gold standard elective endoscopic treatment of oesophageal varices

Answer 69

ligation

Question 70

List four disorders that are typically associated with acute pain in the lower right quadrant of the abdomen!

Answer 70

• Acute appendicitis
• , mesenteric lymphadenitis ,
• Meckel-diverticulitis,
• enteritis regionalis,
• diverticulitis sigmae
• coecum tumor
• ovarian cyst tumor
• ureteral tumor
• acute cystitis

Question 71

pancreatitis etiology

Answer 71

1. alcohol
2. obstuction (gallstone)
3. iatrogenic.
4. viruses
5. trauma
6. drugs

Question 72

peptic ulcer etiology

Answer 72

1. h.pylori
2. NSAIDS

Question 73

peptic ulcer complication

Answer 73

1. bleeding
2. stenosis
3. peroforation

Question 74

complication of barret esophagus

Answer 74

AC of esophagus

Question 75

diagnosis of gall stone

Answer 75

US

MRCP

Question 76

biopsy will be made incase of gastric ulcer or dudenal ulcer? or both?

Answer 76

gastric ulcer - high risk malignancy

Question 77

triple therapy of H.pylori

Answer 77

1. clarithromycin
2. ppi
3. amoxicillin ( or metronidazole). for 10-14 days

Question 78

achalasia causes and diagnosis

Answer 78

• Viral
• idiopathic
• autoimmune
• familial

loss/damage of myenteric plexus

• chagas –> megaesophagus (secondary esophageal achalasia)

* manometry, endoscopy, CT

Question 79

how to estimate daily protein activity

Answer 79

protein/creatinine x 10

24 h urine collection

Question 80

cullen sign

Answer 80

periumbilical hemmorage

in acute pancreatitits/paniculitis

Question 81

grey turner sign

Answer 81

flank hemmorage

(acute pancreatitis

Question 82

psoas sign

Answer 82

patient lie on his left side which right hip is extended backwards

• pain may indicated inflammed appendix overlying the psoas m

Question 83

rovsing sign

Answer 83

right lower quadrant pain elicited by palpation of the left lower quadrant

in acute appendicitis

Question 84

obturator sign

Answer 84

supine patient, flex the knee and hip –> external/internal rotate the flexed right hip

Question 85

pain gets worse in

• gastric ulcer
• dudenal ulcer

Answer 85

gastric - by eating

dudenal - in between meal

Question 86

reffered pain from intestine

Answer 86

mediastinum

Question 87

most common cause of mechanical ileus

Answer 87

1. adhesion
2. hernia
3. malignancy

Question 88

list 2 endogenous substances, the serum level of which are used by lab to estimate GFR

Answer 88

1. creatinine
2. cystatin c

Question 89

patient with acute kidney injury the fractional exc of Na is 0.1%

what does the number refer to

what may be the cause of AKI

Answer 89

0.1% of the filtered Na is excreted

refer to enhanced Na resoprion and Pre-renal origin of AKI

Question 90

44 female patient complaining of bilateral peripheral edema

labs:

creat=68 umol/l

Hgb= 122 g/l

albumin = 23g/l

urine pro/creat = 970 mg/mmol

urine blood -

q) which clinical syndrome?
q) how large proteinurea in grams ?
q) list 4 meds used for symptomatic treatment?

Answer 90

• nephrotic sy
• 9.7 g/day

1. diuretic
2. ACE-I
3. ARB
4. Statin
5. Anticogulants

Question 91

list 4 types of donors in kidney replacement?

Answer 91

1. living related donor
2. living unrelated donor
3. deceased donor after circulatory death
4. donor after brain death

Question 92

68 year old female with breast cancer. her lab result suggest SIADH

q) list 2 groups of diseases (apart from malignancy) that are often ass. with SIADH (2)
- what is the volume status of patient with SIADH
- how does serum Na change
- urine osmolality in SIADH

Answer 92

• pulmonary disease:
  
  • Pneumonia (viral/bacterial)
  • Abscess
  • Tuberculosis
  • Aspergillosis
  • Positive-pressure ventilation Asthma
  • Pneumothorax
  • Mesothelioma
  • Cystic fibrosis
• disease of CNS:
  
  • Encephalitis
  • Meningitis
  • Head trauma
  • Brain abscess
  • Brain tumors
  • Guillen-Barré syndrome
  • Acute intermittent porphyria
  • Subarachnoid hemorrhage
  • Subdural hematoma
  • Cavernous sinus thrombosis
  • Multiple sclerosis
  • Stroke – ischemic, hemorrhage
  • Delirium tremens
• euvolemic
• decreased se Na in SIADH (urinary increases>20%)
• high urine osmolality

Question 93

3 most common causes of mechanical ileus in adult

Answer 93

1. adhesion
2. malignancy
3. hernia

Question 94

38 year old female patient comes due to bleeding and occasional diarrhea.

she started gluten-free diet 6 months ago, because she read that her symptoms could correspond with celiac disease

would you perform endoscopy and biopsy in that patient to confirm or rule out celiac disease? explain

Answer 94

No, gluten free diet eliminates atropy even in affected individuals

Question 95

patient with liver cirhossis comes to hospital because of vomitting indigested blood at home

his vital parameters are stable

would you insert nasogastric tube before endoscopy to prove the bleeding? (explain ) (3)

Answer 95

No, the source of bleeding is probably varices that may rupture

Question 96

histologic origin of klatskin tumor and location

Answer 96

chlangiocarcinoma

confluence of right and left hepatic biliary ducts

Question 97

US reveal focal thickening of sigmoid colon wall

list 3 disease that may cause such an alteration

Answer 97

1. diverticulitis
2. crohns disease
3. sigmoid tumor

Question 98

which 2 disease are distinguished by non-invasive fecal calprotectin test

Answer 98

IBD and IBS

• Found in inflammed areas of bowel in IBD

Question 99

24 year old male complaininf of abdominal pain

It started around umbilicus hours ago and has moved toward lower right quadrant.

He has decreased apetite, some nausea and he vomited once.

He didnt pass stool in the last 24 hours

physical investigated reveal sub-febrility (37.3)

decreased bowel sound

abdominal tenderness with muscle guarding, but without muscular defense in lower right quadrant

• diagnosis?
• describe 2 techniques to provoke pain in this disease (apart from direct pressure)
• what would the appearance of muscular defense refer to ?

Answer 99

• acute apendicitis
• psoas : patient lying on left side–> extend right hip causes –> right lower quadrant pain
• obturator sign: supine patient, flex right knee and hip –> slowly internal/external rotate–> RLQ pain
• blumberg : apply pressure to sigmoid colon–> sudden release of pressure –> pain in cecal region
• rovsing sign: palpate lower left quadrant and compress descending colon –> pain in right lower quadrant
• muscular defense refers to ?
  
  • peroferation
  • peritonitis

Question 100

dipstick for protein detection

Answer 100

1. most sensitive to albumin
2. cannot detect Ig (bence -jones protein)
3. sensitivity is highly dependent on urine concentration

Question 101

dipstick is NOT sensitive for

Answer 101

• glomerular disease
• overflow proteinurea
  
  • Multiple myeloma : bence jones proteins not detected by dipstick
  • rhabdomyolysis
  • IV hemolysis
• post renal proteinurea

Question 102

62 year olf female with RPGN syndrome, what immunoserology would you do ?

Answer 102

• ANA (anti-nuclear antibodies) :
  
  • SLE
• ANCA (anti-neutrophilic cytoplasmic autoantibody)
  
  • ANCA vasculitis
• Anti-GBM:
  
  • good pasture syndrome
• Anti-dsDNS
  
  • SLE

Question 103

Biopsy revelead light microscopy with GN associated cresent formation

what patterns can we expect with immunofluresence assays?

what typical illness they are associated with?

Answer 103

• granular immune complex deposition
  
  • SLE (full house)
    
    • IgG, A, M , c3, c5b-c9. ( LOW c3, c4)
  • IgA nephropathy:
    
    • IgA , C3, c5b-c9
  • post strep GN:
    
    • IgG, M , c3, c5b-c9
• granular –> IgA nephropathy, SLE, post strep GN (immune complex deposit in subendothelium)
• linear –> goodpasture sy (antibody bind collagen of BM)
• pauci–> ANCA vasculitis (wegners, microscopic polyangitis) - NO antibodies nor immune complex

Question 104

CI of renal biopsy

Answer 104

1. uncooperative patient
2. solatiry kidney
3. multiple renal cyst
4. renal neoplasm
5. acute pyelonephritis
6. bleeding diathesis (uncontrolled)
7. uncontrolled hypertension

Question 105

kidney biopsy indications

Answer 105

1. nephrotic syn: NOT indicated in children with first episode likely Minimal change disease
2. proteinurea in range of 1-3 g/d : with worsening kidney function OR proteinuria
3. Nephritic syn
4. RPGN
5. AKI : if suspicion of a disease other than ATN or if suspected ATN is not resolving in 2-3 weeks
6. transplanted kidney dysfunction

Question 106

protein concentration of 120 mg/mmol in urine

how much is the daily protein excretion in grams?

Answer 106

1.2g/ day

Question 107

3 goals for care of Chronic kidney patients

Answer 107

1. slowing the progression of kidney disease
2. prevent cardiovascular complications (eg HTN) of kidney disease
3. preparation for renal replacement therapy ( dialysis or TX) : kidney replacement indication eGFR<20 ml/min
4. medication (EPO , VIT D)

Question 108

CI of peritoneal dialysis

Answer 108

non cooperative

inadequate hygiene

abdominal hernia

anuria

stoma: colostomy

overweight patient

Question 109

what does negative cross examination mean for recipient in case of kidney transplantation

Answer 109

to check that the recipient serum DOESNT contain donor HLA-antigen specific antibodies ( antibody against HLA antigen of the donor)

Question 110

3 liver replacement therapies

Answer 110

1. liver transplant
2. prometheus: Prometheus system is a plasma filtration treatment coupling adsorption and hemodialysis (FPSA) aimed to blood purification in liver failure.
3. plasmapheresis

Question 111

list 2 substances that are used to measure/estimated glomerular filtration in clinical practice

Answer 111

1. creatinine
2. Cystatin C

Question 112

23 year old female arrive to nephrology outpatient because of excessive swelling in her legs

lab results reveal eGFR>90 ml/min/1.73m2

Na=134 mmol/l

K=3.9 mmol/l

albumin 23 g/l

cholesterol 9.7 mmol/l

TG= 3.6 mmol/l

urine blood -

protein ++++

1. which clinical syndrome does it correspond to? (1)
2. which method was used to detect hematuria? (1)
3. in this clinical syndrome how large is the daily proteinurea (1)
4. how do the 3 primary glomerular diseases potentially causing this clinical syndrome respond to Corticosteroid monotherapy (3)

Answer 112

1. nephrotic sy
2. dipstick
3. proteinurea >3g/day
4. primary glomerular diseases causing nephrotic syndrome

• primary membranous glomerulopathy (usually anti-PLA2-R antibody + ) - DOESNT respond well to CS monotherapy! (steroid + cyclophosphamide/cyclosporine in therapy resistance case of rituximab) spontaneous remission may occur
• Minimal change nephropathy - usually responds well to steroids ( incase of steroid dependence/resistance use cyclosporine)
• focal segmental glomerulosclerosis- longer term steroid therapy required ( incase of steroid resistance/dependence - cyclosporine/MMF )

cyclosporine - calcineurin inhibitor

Question 113

list 3 indication of renal biopsy (3)

Answer 113

• Nephrotic syndrome
• Nephritic syndrome
• RPGN
• Asymptomatic proteinuria in the 1-3g/day range (particulary if GFR declines or proteinuria increases)
• Acute kidney injury (intrinsic)
  
  • If there is a suspicion that it is not caused by acute tubular necrosis
• Chronic kidney disease of unknown origin
  
  • But not if on US small, scarred kidneys
• Dysfunction of transplanted kidney

Question 114

list 3 CI of renal biopsy

Answer 114

• Uncooperative patient
• Single kidney
• Multiple renal cysts
• Renal neoplasm
• Acute pyelonephritis
• Uncontrolled bleeding diathesis
• Uncontrolled blood pressure (BP > 160/95 mmHg)

Question 115

list 3 indications in which asymptomatic bacteruria has to be treated with antibiotics

Answer 115

Asymptomatic bacteriuria

• do we need urine culture?

– No antibiotics? – No

EXCEPTIONS:

1. pregnancy,
2. renal transplants,
3. planned urologic intervention

Question 116

for how long can patient survive on peritoneal dialysis and on hemodialysis on average (2p)

Answer 116

HD: 5-10 years (but some patients lived 30 years)

PD: 20.4 months ( 5-10 years). NOT SURE ABOUT THIS QUESTION

Question 117

63 year old male patient is sent to the emergency unit because of progressive weakness.

lab results revel

hgb=98g/l, creat=980 umol/l

CN= 40 mmol/l

Na= 135 mmol/l

K=8.5 mmol/l

urine blood + , proteim +

on ECG sinus bradycardia, wide QRS and peaky T waves are present.

1. which drug would you administer first to start the treatment of the severe hyperkalemia withing 2-5 mins?
2. How would you continue the drug treatment to decrease K level further in the next 10-20 mins (drug groups accepted (2)
3. give 3 therapeutic options that act slower (typically beyound 1 hour ) (3)

Answer 117

• severe hyperkalemia treatment within 2-5 mins:
• If ECG changes, severe symptoms present:
  
  • give 10 ml of 10% Ca-gluconate, 10 ml/10 min (membrane stabilization, its effect last for 20-60 minutes)
• 2. how to continue drug treatment to decrease K further in next 10-20 mins (drug groups)
     * short acting Insulin (4 to 10U/h)+ 10% dextrose iv. – monitoring of Se glucose
     
     • Hemodialysis
       * β2 agonist by nebulizer (albuterol/salbutamol) - act in 30 mins
• 3. act slower (typically beyound 1 hour ):
     * Diuretics: furosemide, thiazide
     * resin (sodium/calcium polystyren-sulfonate) 15-60g/day (per os OR as retention enema)
     * patiromer

Question 118

61 year old female patient with stage 4 CKD is reffered to nephrologist.

lab results: hbg=115g/l

mcv=85fl

Ca=2.08 mmol/l

PO4=2.15 mmol/l, albumin 42g/l

• In which range does GFR vary in stage 4 CKD ? (1)
• evaluate the Ca and PO4 level (2)
• which lab parameter would you measure firsl to evaluate the potential bone-mineral disorder? (1)

Answer 118

in CKD stage 4 : GFR = 15-29

• Ca is lower than normal value
• PO4 is higher than normal value
• lab parameter to evaluate potential bone-mineral disorder?
  
  • vitamin D, PTH , calcium, (NOT sure)

Question 119

–EPO to consider or avoid:

Answer 119

previous stroke,

cancer

Question 120

–EPO resistance:

Answer 120

–iron deficiency,

B12 / folic deficiency,

malnutrition,

infection,

hyperparathyroidism,

hypothyroidism, bleeding, hemolysis, cancer, hematological diseases

Question 121

50 year old male patient is sent to hospital because of suspicion of a mild acute pancreatitis. There are no signs of hemmoragic complications or shock.

1. you ask questions to find out the cause of the condition. which 2 features should your questions focus on in order to find out most probable/most common reason for the acute pancreatitis (2)
2. you perform physical investigation and try to find features characteristic for acute pancreatitis (5)

• skin color
• inspection of abdomen
• bowel sound
• presence of defense

Answer 121

1. alcohol, gallstone

2.

• skin color : can be jaundice
• inspection of abdomen : bloated
• bowel sound : Diminished bowel sound because of refractory ileus
• presence of defense : No
• liver dullness : maintained

Question 122

Compare crohns disease and Ulcerative colitis (4)

• ileocecal involvement
• skip lesions
• gross rectal bleeding
• application of TNF alpha Inhibitors

Answer 122

• ileocecal involvement:
  
  • found in crohns disease (50%)
• skip lesions: found in crohns disease
• gross rectal bleeding: found in UC
• application of TNF alpha Inhibitors: BOTH

Question 123

18 year old male patient arrive at outpatient unit because of new onset jaundice. Two days before the appearance of jaundice he performed some strenous exercise. lab results:

hgb=154g/l , MCV=92fl, PLT=286 g/l , GOT-24, GPT 18, ALP=86, LDH=112

total bilirubin=60 umol/l

conjugated bilirubin= 8umol/l

albumin=45g/l

INR=1.01

Abdominal US reveal normal liver size and biliary tract

• evaluate bilirubin levels:
• the most probable cause of jaundice in this setting
• the reason for the disorder
• treatment:
• prognosis

Answer 123

• evaluate bilirubin levels: elevated
• the most probable cause of jaundice in this setting: Gilbert disease (unconjugated bilirubin)
• the reason for the disorder : mutation in UGT1A1 gene (glucuronosyl transferase UGT enzyme)
• treatment: No treatment , only if jaundice is significant phenobarbital may be used(aids conjugation)
• prognosis: excellent prognosis

Question 124

24 year old male patient comes to outpatient clinic because of abdominal pain. the pain started around umbilicus some hours ago and moved towards the LRQ.

He has decreased apetite and some nausea, he vomitted once. he didnt pass stool in the last 24 hrs. physical exam reveal subfebrility (37.7), decreased bowel sounds and abdominal tenderness with muscle guarding, but without muscular defense in the LRQ.

• what is the most probable diagnosis based on this description:
• describe 2 techniques that may be used during physical investigation, to provoke pain in this disease(apart from direct pressure)
• what would the appearance of muscular defense refer to? (2)

Answer 124

• acute appendicitis
• psoas sign: extension of right hip causes right lower abdominal pain
• obturator sign: internal movement of the hip joint, while the right knee is flexed
• rovsing sign : palpation of left lower quadrant , compressing descending colon –> pain in RLQ (but this is direct pressure ?)
• muscular defense
  
  • peroforation
  • peritonitis

Question 125

list induction therapy

Answer 125

► IL-2R antibody (anti-CD25α) monoclonal Basiliximab (Simulect)

► Anti CD-52 monoclonal antibody Alemtuzumab (MabCampath)

► Anti-thymocyte polyclonal antibody immunglobulines Thymoglobulin ATG-Fresenius = Grafalon

Question 126

52 year old patient is sent to nephrology, because of progressive chronic kidney disease due to chronic interstitial nephritis. His eGFR is 14 ml/min

He is interested in renal transplantation and asks some questions. answer them briefly

• can he be put on transplant waitlist before he starts dialysis?
• can he be transplanted before starting dialysis treatment?
• will his original kidneys removed before/during transplantation?

Answer 126

• can he be put on transplant waitlist before he starts dialysis? YES
• can he be transplanted before starting dialysis treatment? YES
• will his original kidneys removed before/during transplantation? NO

Question 127

LIST 3 potential treatments for patients with crohns disease-associated perianal lesions ( simple or complex)

Answer 127

1. Anti-TNF-alpha drugs
2. antibiotic
3. fistuletomy
4. mesenchymal stem cell

Question 128

list 3 radiologic diagnostic methods that can be used to diagnose renal artery stenosis?

Answer 128

• doppler US
• CT-angiography
• MRI-angiography
• (scintigraphy)

Question 129

list 3 conditions/substances that typically result in acute hemmoragic erosive gastropathy

Answer 129

• NSAID
• Alcohol
• biliary reflux
• shock
• sepsis

Question 130

45 year old male patient arrives to nephrology dep with following lab:

creat=380 umol/l

hbg=130g/l

k=5.9 mmol/l

Ca=2.4 mmol/l

PO4=2.1

alb=36g/l

PH=7.35

One month old lab results show no renal impairment. US reveal normal kidney size, without any hydronephrosis.

As a potential reason for acute kidney injury, you suspect acute tubular necrosis(ATN)

1. List 3 potential substances (drug/toxin) the exposure to which is a common cause for ATN(3p)
2. list 2 labratory measurements with results (high/low) that support the diagnosis of ATN and make pre-renal kidney injury less probable. (2)
3. incase of ATN what is the characteristic feature of the ..
4. based on your findings the diagnosis of ATN is established, should you perform biopsy to confirm diagnosis

Answer 130

1. aminoglycosides
2. vancomycin
3. hem pigment
4. ethylene glycol
5. contrast material
6. heavy metals

• list 2 labratory measurements with results (high/low) that support the diagnosis of ATN and make pre-renal kidney injury less probable. (2)
  
  • high urine Na+ (> 40 mmol/l)
  • FE Na > 2%
  • low urine osmolality (< 350 mOsm/l)
  • CN/Creat < 20 (mg/dl!)
• incase of ATN what is the characteristic feature of the ..:
  
  • dark „muddy brown”, granular casts
• based on your findings the diagnosis of ATN is established, should you perferm biopsy to confirm diagnosis - NO

Question 131

q) which disease is typically ass. with spontaneous bacterial peritonitis
q) you perform paracentesis because of suspected spontaneous bacterial peritonitis, list 3 lab measurement you would ask from ascitis fluid (3)

Answer 131

• liver cirhosis
• 3 lab measurement from ascites fluid:
  
  • WBC
  • chemistry ( albumin, protein, LDH)
  • culture
  • gram stain

Question 132

a 21 year old man come to you because of prograssive gait disturbances . when you ask him about family history, he mentions one of his relatives has acute liver disease and died of that

• based on this info which disease is suspected?
• what would be the first lab measurement to confirm diagnosis? what is the expected result of it (low/high) (2)
• what opthalmologic consequences?

Answer 132

• Wilson disease
• urine copper excretion (HIGH)
• serum ceruloplasmin (LOW) - protein that carries copper in the bloodstream
• serum copper low
• kayser fleisher ring

Question 133

list 2 conditions in which you initiate antibiotic for a patient with acute pancreatitis(2)

Answer 133

• biliary pancreatitis with cholangitis
• superinfection
• pneumonia

Question 134

52 year old female due to …. kidney injury . His estimated GDR (based on CKD is 11ml/min)

he has produced very little urine in past 2 days (50/ml/day)

• how should you interpret the eGFR. what is the true GFR? (2)
• due to her persistent anuria, dialysis treatment is indicated. She mentions that she would prefer peritoneal dialysis on the long run. How can we manage the patients volume hemostasis (remove excess fluid) using PD (2)
• would you suggest PD to this patient ? explain (2)

Answer 134

• in AKI eGFR is less accurate (and should not be used )
• incase on anuria, the true GFR=0
• PD fluid has very high glucose concentration
• osmotic activity of glucose draws the fluid from blood component to peritoneum compartment
• No, because of anuria/volume removal could be only through an unpredictable way (the osmotic activity of PD fluid)