Renal

Question 1

1. Haematuria (1)
   A 21-year-old man presents with painless haematuria which he has noticed in the
   last 3 days. He suffers from type 1 diabetes which is well controlled, but is otherwise
   fit and healthy. The patient has recently recovered from a mild throat infection.
   Urine dipstick analysis reveals blood and protein in the urine. The most likely
   diagnosis is:
   A. Henoch–Schonlein purpura
   B. Benign prostate hypertrophy
   C. IgA nephropathy
   D. Diabetic nephropathy
   E. Urinary tract infection (UTI)

Answer 1

C

Question 2

2. Hyponatraemia
   A 74-year-old type 2 diabetic woman undergoes a bowel resection for cancer of the
   colon. She is well prior to the operation with well–controlled diabetes and no other
   underlying disease. The operation is successful and the patient is given postoperative
   insulin and IV dextrose. Two days after the operation she becomes very agitated.
   Sodium 124 (135–145)
   Potassium 3.3 (3.5–5.0)
   Urea 3.1 (3.0–7.0)
   Glucose 7.2 (2.5–6.0)
   Serum osmolality 265 (275–295)
   Urine osmolality 150
   The most likely cause of the hyponatraemia is:
   A. Addison’s disease
   B. Syndrome of inappropriate anti-diuretic hormone (SIADH)
   C. Diabetic nephropathy
   D. Excess insulin
   E. Water overload

Answer 2

E

Question 3

3. Fever
   A 16-year-old boy presents with a low-grade fever which started 1 week ago. The
   patient also reports feeling fatigued and indicates pain in his joints. His parents
   mention that he has been visiting the toilet more often than usual. A urine dipstick
   shows trace proteins, while a blood test shows raised eosinophils. The most likely
   diagnosis is:
   A. Acute tubulointerstitial nephritis
   B. Renal failure
   C. Diabetes mellitus
   D. UTI
   E. Reactive arthritis

Answer 3

A

Question 4

4. Pitting oedema
   A 58-year-old African man presents with pitting oedema of his ankles. He suffers
   from recently diagnosed hypertension, but is otherwise healthy. Blood results show
   low albumin and a urine dipstick is positive for protein. The most appropriate
   initial treatment is:
   A. High protein diet
   B. Diuretics
   C. Prophylactic anticoagulation
   D. ACE inhibitor
   E. Bed rest

Answer 4

B

Question 5

5. Flank pain
   A 33-year-old woman presents to accident and emergency with severe right flank
   pain. The pain started 3 hours ago and is not constant, occasionally moving towards
   her right iliac fossa. The patient also feels nauseous and has a low-grade fever. The
   most appropriate investigation is:
   A. Abdominal x-ray
   B. Magnetic resonance imaging (MRI) scan
   C. Intravenous urography
   D. Computed tomography (CT) scan
   E. Abdominal ultrasound (US) scan

Answer 5

E

Question 6

6. Dysuria
   A 42-year-old diabetic Asian male complains of dysuria, increased urinary frequency
   and general malaise for the past six months. In the last few days, he has noticed blood
   in the urine. Examination of the urine shows the presence of neutrophils with no
   organisms detected on urine culture. The most likely diagnosis is:
   A. Tuberculosis
   B. Renal cell cancer
   C. Diabetic nephropathy
   D. Bladder cancer
   E. Nephritic syndrome

Answer 6

A

Question 7

7. Periorbital oedema
   A 17-year-old patient is referred by his GP after presenting with periorbital oedema.
   The patient noticed the oedematous eyes 3 days ago, but reports feeling unwell
   since a throat infection 3 weeks ago with nausea and vomiting in the last week.
   A urine dipstick is positive for protein and blood while serum creatinine and urea
   are mildly deranged. The most likely diagnosis is:
   A. Nephrotic syndrome
   B. Nephritic syndrome
   C. Renal failure
   D. Glomerulonephritis
   E. Von Grawitz tumour

Answer 7

D

Question 8

8. Urinary tract infection in pregnancy
   A 28-year-old woman patient who is 13 weeks pregnant presents for an antenatal
   clinic appointment. The patient feels embarrassed when asked to provide a urine
   sample and produces enough for a urine dipstick test only which is positive for
   leukocytes and nitrites. The patient denies any symptoms. The most appropriate
   treatment is:
   A. Trimethoprim
   B. Quinolone
   C. Tetracycline
   D. Cephalexin
   E. Ampicillin

Answer 8

D

Question 9

9. Distress
   A 32-year-old builder presents in accident and emergency in a distressed state. He
   reports suffering from chest pain for the last 2 weeks, the pain is sharp and only
   occurs when he moves heavy objects. He has a family history of cardiovascular
   disease and is worried about a heart attack. His blood gas findings are as follows:
   pH = 7.47; PCO2 = 3.3; PO2 = 15.3; bicarbonate = 17.53. The most likely diagnosis is:
   A. Respiratory acidosis with metabolic compensation
   B. Acute metabolic acidosis
   C. Respiratory alkalosis with metabolic compensation
   D. Metabolic acidosis with respiratory compensation
   E. Acute respiratory alkalosis

Answer 9

E

Question 10

10. Nocturia
    A 21-year-old woman complains of urinary frequency, nocturia, constipation and
    polydipsia. Her symptoms started 2 weeks ago and prior to this she would urinate
    twice a day and never at night. She has also noticed general malaise and some pain
    in her left flank. A urine dipstick is normal. The most appropriate investigation is:
    A. Serum phosphate
    B. Serum calcium
    C. Parathyroid hormone (PTH)
    D. Plasma glucose
    E. Serum potassium

Answer 10

B

Question 11

11. Breathlessness
    A 58-year-old man presents with breathlessness, he reports feeling unwell over the
    last three months with nausea, vomiting and difficulty breathing. You notice his
    ankles are swollen and he has bruises on his arms. The patient mentions he has not
    been urinating as often as normal. The most appropriate investigation is:
    A. Urine microscopy
    B. Renal ultrasound
    C. Serum electrolytes, urea and creatinine
    D. Renal biopsy
    E. Chest x-ray

Answer 11

C

Question 12

12. Abdominal pain
    A 24-year-old man presents with a four-month history of abdominal pain which
    has been getting worse. The patient describes the pain as generalized, dull in
    character and does not radiate but often occurs alongside loin pain. An irregular
    mass is palpable in both flanks and a mid-systolic click can be auscultated. The
    most appropriate investigation is:
    A. MRI scan
    B. Abdominal US scan
    C. Excretion urography
    D. CT scan
    E. Abdominal x-ray

Answer 12

B

Question 13

13. Proteinuria
    A 55-year-old woman is seen in clinic, she has a ten-year history of type 2
    diabetes treated with glibenclamide. Her blood pressure is 148/93 with new onset
    proteinuria, her serum results show elevated lipid levels, glycated haemoglobin of
    5.5 per cent and fasting glucose of 6.0 mmol/L. A renal biopsy shows the presence
    of Kimmelstiel–Wilson lesions. The most appropriate management is:
    A. Increase oral hypoglycaemic dosage
    B. ACE II antagonists
    C. Start cholesterol lowering therapy
    D. Start ACE inhibitors
    E. Start renal dialysis

Answer 13

D

Question 14

14. Weight loss
    A 52-year-old man complains of a 3-week history of malaise and shortness of
    breath. He has lost weight in the last few months but attributes this to a loss of
    appetite possibly due to stress at work. On examination, he has a palpable mass in
    the right lumbar region. He has no urinary symptoms. However, the urine dipstick
    detected blood. The most likely diagnosis is:
    A. Renal abscess
    B. Renal cyst
    C. Renal carcinoma
    D. Adrenal tumour
    E. Pyelonephritis

Answer 14

C

Question 15

15. Hypercalciuria
    A 37-year-old man presents with a 5-day history of haematuria. Abdominal
    examination is unremarkable. Urine analysis reveals hypercalciuria and excretion
    urography reveals small calculi within the papilla of the patient’s right kidney. The
    patient has presented several times in the past with UTIs and renal stones, but is
    otherwise healthy. The most likely diagnosis is:
    A. Medullary sponge kidney
    B. Renal cell carcinoma
    C. Medullary cystic disease
    D. Horse-shoe kidney
    E. Tertiary hyperparathyroidism

Answer 15

A

Question 16

16. Long-term ibuprofen use
    A 38-year-old woman presents to her GP with a 2-week history of dysuria,
    haematuria and shortness of breath. She suffers from chronic headaches and has
    been taking ibuprofen in order to treat them. She has a history of cardiovascular
    disease in the family and a friend recommended she use aspirin to keep healthy. The
    most appropriate investigation is:
    A. Retrograde pyelography
    B. Renal biopsy
    C. Abdominal x-ray
    D. Antegrade pyelography
    E. CT scan of the kidney

Answer 16

E

Question 17

17. Oliguria
    A 64-year-old man is undergoing treatment for polycythaemia vera with chemotherapy,
    he has no other medical problems. Shortly after starting treatment, the patient becomes
    lethargic, feels unwell and suffers weight loss. He attributes this is to the chemotherapy.
    After 2 weeks, the patient becomes oliguric, complains of bilateral flank pain and
    becomes oedematous. The most likely diagnosis is:
    A. Analgesic nephropathy
    B. Renal infarction
    C. Hyperuricaemic nephropathy
    D. Acute tubulointerstitial nephritis
    E. Chronic renal failure

Answer 17

C

Question 18

18. Collapse
    A 67-year-old diabetic female is brought into accident and emergency following a
    collapse at her home. She was found by her daughter who said she saw the patient
    going to the toilet and then hearing her collapse. The patient did not lose consciousness
    and appears well. Her supine blood pressure is 100/70 and standing 115/79. Urine
    dipstick is positive for glucose, nitrates, leukocytes and haematuria. The most likely
    diagnosis is:
    A. Diabetic ketoacidosis
    B. UTI
    C. Orthostatic hypotension
    D. Diabetic nephropathy
    E. Hypoglycaemia

Answer 18

B

Question 19

19. Sacral oedema
    An 18-year-old man presents with general malaise and lethargy for the last 2 weeks,
    he denies any weight loss and has maintained a good appetite. On examination, there
    are no abnormalities except for sacral oedema and a polyphonic wheeze. Urine
    dipstick is positive for protein only and blood pressure is 140/90. The most likely
    diagnosis is:
    A. Nephritic syndrome
    B. Nephrotic syndrome
    C. Goodpasture’s disease
    D. Thin-basement membrane nephropathy
    E. Minimal change glomerulonephritis

Answer 19

E

Question 20

20. Haematuria (2)
    A 6-year-old has a sore throat and has been given antibiotics. Three weeks later, he
    represents feeling feverish with nausea, vomiting and tea-coloured urine. Urine
    dipstick confirms haematuria and protein. Blood pressure is 100/60 mmHg. The most
    likely diagnosis is:
    A. Nephritic syndrome
    B. UTI
    C. Acute tubulointerstitial nephritis
    D. Minimal change glomerulonephritis
    E. Post streptococcal glomerulonephritis

Answer 20

E

Question 21

21. Haematuria (3)
    A 21-year-old man complains his urine has turned a faint red in the last week. He
    denies any significant changes in his diet or lifestyle and has no other medical
    problems except for sensorineural deafness diagnosed when he was young. On
    examination, you notice retinal flecks and urine dipstick confirms protein and blood.
    The most likely diagnosis is:
    A. Alport’s syndrome
    B. Benign familial haematuria
    C. Wolfram syndrome
    D. IgA nephropathy
    E. Down’s syndrome

Answer 21

A

Question 22

22. Chronic cigarette smoking
    A 65-year-old overweight man presents with a 2-week history of haematuria.
    The patient denies any other symptoms and his blood pressure is 128/83 mmHg. He
    suffers from no other medical problems but admits to being a chronic smoker since
    the age of 16. He has tried to lose weight using herbal remedies for three years, but
    he has only noticed significant weight loss in the last week despite stopping the
    remedies months ago. The most likely diagnosis is:
    A. Chinese herb nephropathy
    B. Bladder cancer
    C. Schistosomiasis
    D. Acute tubulointerstitial nephritis
    E. Renal cancer

Answer 22

B

Question 23

23. Abdominal aortic aneurysm rupture
    A 53-year-old man with HIV suffers a ruptured aortic aneurysm and is rushed into
    theatre, he undergoes a successful operation and is recovering on the wards in a
    stable condition. One day after the operation, he becomes oliguric with mildly
    elevated urea and creatinine. After 1 week, he becomes polyuric with a GFR of 30.
    The most likely diagnosis is:
    A. Haemolytic–uraemic syndrome
    B. Acute tubular necrosis
    C. SIADH
    D. HIV nephropathy
    E. Acute renal failure

Answer 23

B

Question 24

24. C-ANCA positive assay
    A 64-year-old woman with type 1 diabetes presents to clinic with several months
    of sinus problem and a 4-day history of oliguria. Her blood pressure is 137/80,
    serum results show mildly elevated urea and creatinine, absence of anti-GBM
    antibodies, while a C-ANCA assay is positive. Red blood cell (RBC) casts are present
    in the urine and her renal biopsy reveals glomerular crescents. The most likely
    diagnosis is:
    A. Post-streptococcal glomerulonephritis
    B. Goodpasture’s syndrome
    C. Minimal change glomerulonephritis
    D. Rapidly progressive glomerulonephritis
    E. Wegener’s granulomatosis

Answer 24

E

Question 25

25. Abdominal bruits
    A 68-year-old obese Asian man is seen in the hypertension clinic. His blood
    pressure is 151/93 and he suffers from poorly controlled type 2 diabetes. Blood
    results demonstrate elevated serum urea and creatinine. An ultrasound scan shows
    asymmetry between the two kidneys and on examination audible abdominal bruits
    are auscultated. Urine dipstick did not detect any blood or protein. The best
    investigation is:
    A. CT angiography
    B. Doppler ultrasonography
    C. Abdominal x-ray
    D. Renal arteriography
    E. Renal biopsy

Answer 25

D

Question 26

26. Suprapubic pain
    A 63-year-old woman presents in accident and emergency with a 3-day history of
    worsening abdominal pain and mild flank pain. Examination reveals pain in the
    suprapubic region, but otherwise the abdomen is soft with no masses. The patient
    denies any other symptoms, such as dysuria, but mentions she has had difficulty
    passing urine in the last week and is only able to provide a small urine sample which
    is odorous and bloody. She has no other medical problems, but admits to being a
    long-term smoker. An ultrasound scan of renal system is most likely to show:
    A. Bladder dilation
    B. Ureteral stricture
    C. Bilateral hydronephrosis
    D. Renal cysts
    E. Renal cancer

Answer 26

C

Question 27

27. Type 1 diabetes
    A 19-year-old man is recently diagnosed with type 1 diabetes and attends your
    clinic to ask about possible complications in the future. He mentions an uncle who
    has end-stage renal disease due to poorly controlled diabetes and specifically
    enquires about testing for early signs of renal impairment. The most appropriate
    investigation is:
    A. Blood pressure
    B. Microalbuminuria
    C. Serum creatinine
    D. Serum electrolytes
    E. Urine dipstick for glucose

Answer 27

B

Question 28

28. Periorbital oedema
    A 21-year-old man presents with lethargy over the last week, he has periorbital
    oedema and proteinuria. The patient mentions he has been to hospital a number of
    times in the past due to the same symptoms as well as mild eczema. Light microscopy
    of a renal biopsy showed normal morphology. Electron microscopy of the renal
    biopsy reveals the diffuse effacement of the epithelial podocytes. The most appropriate
    treatment is:
    A. Cyclosporin
    B. No treatment
    C. Probenecid
    D. Renal transplant
    E. Oral prednisone

Answer 28

E

Question 29

29. Hyperphosphataemia
    A 49-year-old woman attends your clinic suffering from chronic renal failure due to
    progressive glomerular disease. She appears well and her blood pressure is 141/92 mmHg.
    Blood tests reveal elevated phosphate, serum creatinine and urea, while calcium levels are
    low. Her estimated glomerular filtration rate is 35 mL/min/1.73 m2. You also notice the
    patient’s cholesterol levels are moderately raised. The most appropriate management is:
    A. Sevelamer
    B. Parathyroidectomy
    C. Oral vitamin D
    D. Cinacalcet
    E. Renal dialysis

Answer 29

A

Question 30

30. Rigors
    A 66-year-old woman with poorly controlled type 2 diabetes presents to accident and
    emergency with a 2-day history of severe pain in the right flank, nausea and fevers
    that come and go. On examination, the patient appears unwell, sweaty and has
    visible rigors with a temperature of 38°C. The patient denies any recent travel. Urine
    dipstick is positive for protein, blood, leukocytes and nitrates. A CT scan of the
    abdomen reveals gas in the renal parenchyma area. The most likely diagnosis is:
    A. Renal stones
    B. Renal infarction
    C. Diabetic nephropathy
    D. Renal TB
    E. Pyelonephritis

Answer 30

E