UG key questions

Question 1

A 55 year old man previously with no pre-existing renal disease has a history of recurrent stomach ulcers. Following a Gastroscopy he is found to be positive for Helicobacter pylori. His GP initiates triple eradication therapy with amoxicillin, clarithromycin and a proton pump inhibitor. He remains otherwise well without any new symptoms or intercurrent illness but a random blood test a week later reveals his Urea 24mmol/L, Creatinine 324umol/L, K+ 5.8mmol/L. What is the most likely underlying pathophysiological cause of the renal dysfunction:

Answer 1

1. acute interstitial nephritis
2. probs aar of allergic reaction to drugs given
3. hence intrinsic renal injury

Question 2

A 72 year old man with no pre-existing renal disease has a cardiac arrest but fortunately is successfully resuscitated. He makes a good recovery and is waiting for bypass surgery however 5 days later despite support on the intensive care unit he remains anuric. What is the most likely underlying pathophysiological cause for his renal dysfunction:

Answer 2

no pre-exisiting renal disease

probs acute tubular necrosis

Question 3

A 35-year-old man presents with severe, episodic loin pain which radiates round to the front. He has blood+++, leucocytes ++ on the urine dipstick

Answer 3

renal colic

Question 4

A 30-year-old nulliparous woman presents with severe dysmenorrhoea, heavy & irregular bleeding, pain on defecation and dyspareunia

Answer 4

endometriosis

- growth of ectopic endometrial tissue outside the uterine cavity

Question 5

You are reviewing the medication list of a patient who has been admitted diarrhoea and vomiting. Bloods show acute kidney injury with a creatinine of 190 micromol/L. this medication is usually safe to continue in AKI

Answer 5

low dose aspirin should be okay.

you want to avoid

• NSAIDS
• diuretics
• lithium
• angiotensin II antagonist
• aminoglycosides

Question 6

a woman who is 35-weeks pregnant presents with painless vaginal bleeding. Her blood pressure is 114/78 mmHg and pulse 78/min

Answer 6

placenta praevia
- low lying placenta, maybe covering internal os

placenta should be on the upperside of uterus

Question 7

a woman who is 35-weeks pregnant presents with lower abdominal pain and a small amount of vaginal bleeding. Her blood pressure is 86/60 mmHg and pulse 114/min

abdominal pain likely due to

Answer 7

abdnominal pain, more likely to be due to placental abruption

Question 8

a 20-year-old woman presents with a 1 week history of crampy, constant lower abdominal pain, intermenstrual bleeding, dyspareunia and dysuria

Answer 8

pelvic inflammatory disease

Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum.

It is usually the result of ascending infection from the endocervix.

Causative organisms
Chlamydia trachomatis

+ the most common cause

1. Neisseria gonorrhoeae
2. Mycoplasma genitalium
3. Mycoplasma hominis

Features
- lower abdominal pain
- fever
- deep dyspareunia
- dysuria and menstrual
- irregularities may occur
vaginal 
- or cervical discharge
cervical excitation

Question 9

spironlactone

side effects

Answer 9

aldosterone antagonist act on collecting duct

therefore acts to inhibit the mineralocorticoid receptor in the cortical collecting ducts.

Spironolactone is the drug in question and a known side effect involves breast tissue growth.

Question 10

A 23-year-old man presents to his GP after noticing swelling of his legs. He reports that his urine has become frothy. Blood tests reveal high cholesterol and low albumin.

What pattern of electrolyte abnormalities would the GP expect to see in this patient?

Answer 10

The patient has nephrotic syndrome.

The cardinal features of nephrotic syndrome are:

Oedema
Proteinuria
Hypercholesterolaemia
Hypoalbuminaemia

Question 11

A 45-year-old patient presents to his physician 6 days after his last appointment. He is concerned that he has been passing very small amounts of urine for the past 3 days. He was started on an gentamicin last week for an infection. His physician is concerned about gentamicin-induced nephrotoxicity.

On examination, no abnormalities are noted. His blood pressure and temperature are normal.

His fractional excretion of urine is greater than 4%.

A urine sample is sent to the lab for microscopy, culture and sensitivity.

What is likely to be seen on microscopy if the physician’s suspicion is true?

Answer 11

acute tubular necrosis

The patient was started on gentamicin, a nephrotoxic drug. Reduced urine output after starting a nephrotoxic drug should make one worry about acute tubular necrosis (ATN).

Brown granular casts are seen on microscopy of the urine in ATN.

A fractional excretion of sodium greater than 4% is usually seen in acute tubular necrosis, due to excessive sodium loss.

Nitrites are seen in UTIs.

Question 12

Furosemide

Answer 12

Furosemide is a loop diuretic that prevents reabsorption of sodium, chloride, and potassium by inhibition of the cotransporter in the thick ascending loop of Henle. This causes significant diuresis.

Question 13

Berger’s disease

Answer 13

IgA nephropathy (also known as Berger’s disease) is the commonest cause of glomerulonephritis worldwide.

It classically presents as macroscopic haematuria in young people following an upper respiratory tract infection.

Question 14

A 28-year-old woman presents with a 3-day history of dysuria and increased urinary frequency. She denies any vaginal discharge or menorrhagia. Urine dipstick is positive for leukocytes and nitrites. Urine culture grows a urease-bacteria that is identified as Proteus mirabilis. She is treated with antibiotics.

Chronic and recurrent infections with this bacteria predispose patients to which of the following types of renal stones?

Answer 14

Recurrent urease-positive bacteria (eg. proteus mirabilis) infections predispose individuals to struvite renal stones

Question 15

Six weeks after the birth of her child, a woman presents with agalactorrhoea, amenorrhoea, intolerance to cold, constipation and weight loss. She suffered a post-partum haemorrhage after delivery. She is subsequently diagnosed with hypopituitarism. What is the likely cause of this?

Answer 15

Sheehan’s syndrome occurs due to pituitary ischaemia secondary to blood loss during or after childbirth.

It presents with symptoms consistent with global hypopituitarism, such as agalactorrhoea (prolactin), amenorrhoea (FSH and LH), cold intolerance and constipation (thyroid hormones) and weight loss (steroid hormones).

Question 16

paraneoplastic tumour

Answer 16

a hormone secreting tumour

Question 17

An 8-year-old boy presents to the GP following 7 days of diarrhoea which his mother mentions has been bloody since yesterday. He has abdominal pain and he is passing scant urine. His mother mentions that she has noticed several bruises but doesn’t recall any trauma. What is the most like causative organism?

Answer 17

E.Coli

haemolytic uraemic syndrome (HUS)

HUS produces a triad of haemolytic anaemia, thrombocytopaenia and acute kidney injury that may lead to renal failure.

Question 18

Sterile pyuria

Answer 18

wbc in urine test with no other apparent abnormalities.

can occur secondary to STI, such as secondary to chlamydia

Question 19

A 56-year-old man has undergone a radical nephrectomy. The pathologist bisects the kidney and identifies a pink fleshy tumour in the renal pelvis. What is the most likely disease?

Answer 19

most renal tumours are brown or yellow in colour.

BUT transitional cell carcinomas are ones that appear pretty in pink.

Question 20

An 80-year-old lady is brought into the Emergency Department after she was found on the floor at home by her daughter after having a fall. She tells you that she was unable to move and so stayed on the floor overnight, but was otherwise well before the incident with no dizziness or chest pain. She is slightly confused and dehydrated, and complains of a hip pain. However, on further investigation you discover there is no fracture, but there are elevated levels of creatine kinase, creatinine, and urea. Her regular medications include simvastatin and amlodipine for hypercholesterolaemia and hypertension.

What is most likely to be the cause of this acute kidney injury?

Answer 20

This lady is likely to have rhabdomyolysis following a fall. The damaged muscles release myoglobin which is nephrotoxic and causes renal ischaemia, the pathology of acute tubular necrosis. The main treatment for acute tubular necrosis is to remove the cause of the renal ischaemia as much as possible. The mainstay of treatment for rhabdomyolysis is intravenous fluids, which also helps treat the acute kidney injury since dehydration is a big part of this pathology.

Question 21

Frank Starling principle

Answer 21

Preload is the same as end diastolic volume. When it is increased slightly there is an associated increase in cardiac output (Frank Starling principle). When it is markedly increased e.g. over 250ml then cardiac output falls.

Question 22

A male neonate is being evaluated for recurrent urinary tract infections. An abdominal ultrasound scan reveals bilateral hydronephrosis, a thickened bladder wall with thickened smooth muscle trabeculations. Voiding cystourethrogram (VCUG) shows reflux.

patient most likely has

Answer 22

Posterior urethral valves= bladder outlet obstruction in male infants, may be diagnosed antenatally by hydronephrosis

Posterior urethral valve is the most common cause of bladder outlet obstruction in newborn males.

It can lead to bladder distension and bilateral hydronephrosis.

Question 23

A 53-year-old woman is attending her GP for a routine “well-woman check”. At the start of the appointment, the doctor uses an automated sphygmomanometer to measure the patient’s blood pressure, which reads 174/96 mmHg. She is informed that the reading is high, likely because she just walked into the clinic, and will be repeated in a few minutes.

Answer 23

The vagus nerve regulates the baroreceptor reflex, correcting an acute decrease in arterial blood pressure

Glutamatergic activation of the caudal ventrolateral medulla by the nucleus tractus solitarii corrects a rise in blood pressure by increasing vagal tone over the heart. This decreases heart rate, reducing cardiac output and in turn decreasing blood pressure. This is the only mechanism in the list which works to decrease raised blood pressure.