1
Q
conjugated bilirubin causes (2)
Unconjugated bilirubin (2)
A
- parenchymal liver disease ( Viral hepatitis, NASH, Alcoholic heptatitis)
- cholestatic disorders
- hemolysis
- ineffective erythropoisis
- gilbert disease
2
Q
de ritis ratio
decreases in ?
increases in?
A
De ritis ratio
decreases:
- viral hepatitis
- minor fatty liver disease
- extrahepatic cholestasis
increase:
- alcoholic hepatitis
- necrotic hep
- cirrhosis
- HCC
- liver metastasis
3
Q
which method is used to detect hematuria? and how does it yield the + result?
A
dipstick
-colour change compare it to color on the box
4
Q
acute nephritis syndrome and nephrotic syndrome are both associated with generalised edema. Through which mechanism does edema develop in these syndrome? ( 2 points)
A
- Nephritis: Oligo-anuria and volume retension
- Nephrosis: heavy proteinurea and hypoalbuminemia
5
Q
List 3 features that indicate radiologic intervention (stent implantation/angioplasty) in case of renal artery stenosis (3 points
A
- Very high BP not responding to therapy
- Rapid worsening of renal function not responding to therapy
- Flash pulmonary edemas
6
Q
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
A
• 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
7
Q
Multiple myeloma. What is the mechanism of acute kidney injury in this case? (2p)
A
• Monoclonal proteins are filtered (light chains) and combined with Tamm-horsfall glycoprotein, they occlude the tubuli
8
Q
Calcium in hypoalbuminemia
A
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
9
Q
isostenuria
A
neither concentrated nor diluted urine
10
Q
- 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)?
A
atheroembolisation , contrast nephropathy (ATN)
11
Q
one year later, re- coronarography is planned. Which of the listed should be suggested to the patient before the planned intervention
- 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
- continue taking aspirin
- STOP taking NSAID pain killers
- STOP ACE-I
A
- 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)
- continue taking aspirin (YES)
- STOP taking NSAID pain killers ( YES)
- STOP ACE-I (NOOO)
12
Q
- 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)
A
- 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
13
Q
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)
A
How large is the estimated proteinurea?(1p). 650mg/day
Which glomelular disease is the most probable reason for the lab result?(1p) IgA nephropathy
14
Q
list 3 reasons why living donor kidney transplantation is preffered to ceased donor transplantation?
A
- better short/long term survival
- faster recovery of renal function
- planned surgery (minimal ischemic time)
15
Q
A young man wanted to commit suicide and took 15g paracetamol.
- What is the severe GI complication of the attempt?(1p)
- antidote?
A
• Acute liver failure
What would you suggest as a antidote? • N-acetyl cystein
16
Q
- what does the “window period “mean in the diagnostics of hepatitis B infection? (2p)
A
- HbsAg (hepB surface antigen) has already disappeared
- Anti-Hbs is NOT present yet
17
Q
How can you prove the infection is in the window period ? (1p)
A
• Postive anti-Hbc ( IgM) (anti hepB core antibodies
18
Q
define and which disease is it suspected in
Mcburney point tenderness
cullen sign
klatskin tumor
A
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
19
Q
List 2 extra intestinal skin manifestation of IBD (2)
other manifestations also
A
- erythema nodosum
- pyoderma gangrenosum
- uveitis
- scleritis
20
Q
List the potential treatment options in uncomplicated symptomatic diverticulosis?( 3 points)
A
- Diet: high fiber content, avoid nuts and seeds
- Increase physical activity
- Drug: Rifaximin
21
Q
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) ?
A
a. • Capsule endoscopy
b. Enteroscopy
c. • Anticoagulant • Antiplatelet drugs • NSAIDs
d. CT - angiography
22
Q
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
A
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)
23
Q
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).
A
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
24
Q
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)
A
a. RBC: of diferent shape glomerular origin of bleeding
b. •530 mg/day
c. •IgA nephropathy
d. Dg step: kdney biopsy
Finding: mesangial proliferation
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)
* Generalized atherosclerosis ,
* abdominal bruit
* smaller kidney on ulraround
* hypokalemia.
* Worsening renal function
26
List the most important differences between induction and maintenance immunosuppression applied for the treatment of a glomerulonephritis! (3 points)
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
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)
No because in case of CKD + bilateral small kidneys biopsy is NOT indicated/ not informative
28
List four indications of the **acute dialysis treatment!** (4 point
* refractory hypervolemia/hyperkalemia/acidosis
* severe uremia
* pericarditis
* certain poisonings (ethylene glycol, methanol)
29
List four lifestyle recommendations you would give to a patient with **recurrent Ca-oxalate kidney stone (4 poin**
* 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
30
List three conditions which result in **steatorhhea (3points**
* chronic pancreatitis,
* cholestasis,
* cirrhosis,
* ileum resection
\* extensive crohn’s disease
• Malabsorption (including celiac disease)
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)
H pylori infection
Labeled radioactive CO2. : the bacteria cleaves it from urea using urease
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)
a. Achalasia
b. damage of the myenteric plexus
c. manometry
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)
Conjugated:
* Parenchymal liver disease (viral hepatitis, NASH, alcoholic hepatitis),
* cholestatic disorders
Unconjugated:
* hemolysis ,
* ineffective erytiropoiesis,
* Gilbert's disease
34
List 4 differences between ulcerative colitis and Crohn's disease
* 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
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
36
List 4 disorders that are typically associated with acute pain in the lower right quadrant of the abdomen (4 point)
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
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
Dipstick
Color change- compare it to scale
- 0.9g
- IgA nephropathy
- MESANGIAL proliferation
38
List three features that indicate radiologic intervention (stent implantation/angioplasty) in case of renal artery stenosis (3)
* Severe hypertension (unresponsive to conservative treatment)
* Rapid worsening renal function
* Pulmonary edema
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)
* 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)
40
List 3 contraindication of peritoneal dialysis(3p
* Extreme obesity/thiness •
* Poor hygiene
* Anuria
* uncorrected hernia
* abdominal stoma
41
List the 3 most common reasons for **lower tract non-hemmorhoid GI bleeding** in the elderly
• Diverticulosis • Tumors • Angiodysplasia
42
list 3 signs/symptoms/features affecting 3 different organs that raise suspicion of wilson disease in young patient
1. hepatitis/cirhosis
2. kayser fleischer ring (eye)
3. motor disturbances ( ataxia=loss cordination, dystonia= involuntary contraction, dysarthia- motor speech disorder )
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 :
-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
44
List 2 routine lab alteration ( NOT serology , endocrine panel) that can refer to celiac disease?
* Elevated GOT/GPT
* Iron defiency
* Anemia
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
MALLORY-WEIS SYNDROME
46
A middle age male patient experience severe chest after profuse vomiting. Withing 2 hours subcutaneous emphysema, hypotension and tachycardia appear
which esophageal disorder
BOERHAEVE SYNDROME
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
Esophageal candidasis
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
ACHALASIA
49
Middle age male undergoes upper endoscopy and biopsy. In the distal esophagus, intestinal metaplasia is observed
BARRETS esophagus
50
What does the term “ isostenuria” refer to? Which number characterises it?(2p)
* 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
51
glomerular proliferation in
- post strep GN
- ANCA vasculitis + good pasture
- SLE nephritis + IgA nephropathy
post strep - endocapillary pro
- ANCA vasculitis + good pasture : extracapillary pro ( cresent formation)
- SLE nephritis + IgA nephropathy: mesangial pro
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
- Rapid progressive glomerulonephritis syndrome
- SLE NEPHRITIS , • ANCA vasculitides , • Good pasture syndrome
- Cresent formation/ extracapillary proliferation
53
List 4 typical signs and symptoms of schonlein henoch purpura
• Palpable purpura • Joint pain • Abdominal pain • GI bleeding • Hematuria • Worsening renal function
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?
* Pre renal
* Saline infusion/ volume replacement
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)
- ADPKD
- intracranial hemmorage / vascular rupture
- skull (angio) MRI , aneurism in willis circle
56
list 4 indication of renal biopsy
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
57
list 2 groups used for transplant maintence immunosupp
1. corticosteroid: Prednisone
2. mTOR- inhibitor
3. calcineurin inhibitors
4. lymphocyte proliferation inhibitor
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 ?
- Glomerulonephritis OR preeclampsia
59
what disorder can be diagnosed based on PPI test?
which patients do we use this diagnostic approach?
* GERD
* Patient criteria
* young
* without alarm signs ( dysphagia, odynophagia, GI bleeding, weight loss, iron def anemia, hematemesis , melena, hematochezia
60
what does tenesmus mean?
in which disease is it a common symptom?
* painful passing of stool
* Ulcerative colitis
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?
1. peroferation - free air under diaphram
2. ileus - multiple air fluid levels throughout abdomen ( ladder like niveaus gas)
62
list 5 conditions associated with acute pain in **upper left quadrant of the abdomen**
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
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)
- c. difficile/pseudomembranous colitis
- metronidazole (I.V /p.O)
- vancomycin only P.O
64
do we have to repeat upper endoscopy in case of
a) gastric
b) dudenal ulcer? explain decision
a) YES for gastric ulcer - due to high risk of malignancy
b) NO for dudenal ulcer - low risk malignancy
65
what is the indication of urgent (within 24hr) ERCP?
Biliary pancreatitis
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
- (rapid progressive glomerulonephritis syndrome)
- ANCA vasculitis, SLE nephritis, Goodpasture syndrome
- (extracapillary / crescent formation)
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
(prerenal; (saline) infusion / volume replacement)
68
List 5 conditions that are typically and often associated with acute pain in the upper right quadrant of the abdomen.
* 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)
69
15. What is the gold standard elective endoscopic treatment of oesophageal varices
ligation
70
List four disorders that are typically associated with acute pain in the **lower right quadrant** of the abdomen!
* Acute appendicitis
* , mesenteric lymphadenitis ,
* Meckel-diverticulitis,
* enteritis regionalis,
* diverticulitis sigmae
* coecum tumor
* ovarian cyst tumor
* ureteral tumor
* acute cystitis
71
pancreatitis etiology
1. alcohol
2. obstuction (gallstone)
3. iatrogenic.
4. viruses
5. trauma
5. drugs
72
peptic ulcer etiology
1. h.pylori
2. NSAIDS
73
peptic ulcer complication
1. bleeding
2. stenosis
3. peroforation
74
complication of barret esophagus
AC of esophagus
75
diagnosis of gall stone
US
MRCP
76
biopsy will be made incase of gastric ulcer or dudenal ulcer? or both?
gastric ulcer - high risk malignancy
77
triple therapy of H.pylori
1. clarithromycin
2. ppi
3. amoxicillin ( or metronidazole). for 10-14 days
78
achalasia causes and diagnosis
- Viral
- idiopathic
- autoimmune
- familial
loss/damage of myenteric plexus
- chagas --\> megaesophagus (secondary esophageal achalasia)
\* manometry, endoscopy, CT
79
how to estimate daily protein activity
protein/creatinine x 10
24 h urine collection
80
cullen sign
periumbilical hemmorage
in acute pancreatitits/paniculitis
81
grey turner sign
flank hemmorage
(acute pancreatitis
82
psoas sign
patient lie on his left side which right hip is extended backwards
- pain may indicated inflammed appendix overlying the psoas m
83
rovsing sign
right lower quadrant pain elicited by palpation of the left lower quadrant
in acute appendicitis
84
obturator sign
supine patient, flex the knee and hip --\> external/internal rotate the flexed right hip
85
pain gets worse in
- gastric ulcer
- dudenal ulcer
gastric - by eating
dudenal - in between meal
86
reffered pain from intestine
mediastinum
87
most common cause of mechanical ileus
1. adhesion
2. hernia
3. malignancy
88
list 2 endogenous substances, the serum level of which are used by lab to estimate GFR
1. creatinine
2. cystatin c
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
0.1% of the filtered Na is excreted
refer to enhanced Na resoprion and Pre-renal origin of AKI
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?
- nephrotic sy
- 9.7 g/day
1. diuretic
2. ACE-I
3. ARB
4. Statin
5. Anticogulants
91
list 4 types of donors in kidney replacement?
1. living related donor
2. living unrelated donor
3. deceased donor after circulatory death
4. donor after brain death
92
68 year old female with breast cancer. her lab result suggest SIADH
## Footnote
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
* 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
93
3 most common causes of mechanical ileus in adult
1. adhesion
2. malignancy
3. hernia
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
No, gluten free diet eliminates atropy even in affected individuals
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)
No, the source of bleeding is probably varices that may rupture
96
histologic origin of klatskin tumor and location
chlangiocarcinoma
confluence of right and left hepatic biliary ducts
97
US reveal **focal thickening of sigmoid colon wall**
list 3 disease that may cause such an alteration
1. diverticulitis
2. crohns disease
3. sigmoid tumor
98
which 2 disease are distinguished by non-invasive fecal calprotectin test
IBD and IBS
- Found in inflammed areas of bowel in IBD
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 ?
* 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
100
dipstick for protein detection
1. most sensitive to albumin
2. cannot detect Ig (bence -jones protein)
3. sensitivity is highly dependent on urine concentration
101
dipstick is NOT sensitive for
* glomerular disease
* overflow proteinurea
* Multiple myeloma : bence jones proteins not detected by dipstick
* rhabdomyolysis
* IV hemolysis
* post renal proteinurea
102
62 year olf female with RPGN syndrome, what immunoserology would you do ?
* ANA (anti-nuclear antibodies) :
* SLE
* ANCA (anti-neutrophilic cytoplasmic autoantibody)
* ANCA vasculitis
* Anti-GBM:
* good pasture syndrome
* Anti-dsDNS
* SLE
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?
* 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
104
CI of renal biopsy
1. uncooperative patient
2. solatiry kidney
3. multiple renal cyst
4. renal neoplasm
5. acute pyelonephritis
6. bleeding diathesis (uncontrolled)
7. uncontrolled hypertension
105
kidney biopsy indications
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
106
protein concentration of 120 mg/mmol in urine
how much is the daily protein excretion in grams?
1.2g/ day
107
3 goals for care of Chronic kidney patients
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)
108
CI of peritoneal dialysis
non cooperative
inadequate hygiene
abdominal hernia
anuria
stoma: colostomy
overweight patient
109
what does negative cross examination mean for recipient in case of kidney transplantation
to check that the recipient serum DOESNT contain **donor HLA-antigen specific antibodies ( antibody against HLA antigen of the donor)**
110
3 liver replacement therapies
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
111
list 2 substances that are used to measure/estimated glomerular filtration in clinical practice
1. creatinine
2. Cystatin C
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)
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
113
list 3 indication of renal biopsy (3)
* 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
114
list 3 CI of renal biopsy
* Uncooperative patient
* Single kidney
* Multiple renal cysts
* Renal neoplasm
* Acute pyelonephritis
* Uncontrolled bleeding diathesis
* Uncontrolled blood pressure (BP \> 160/95 mmHg)
115
list 3 indications in which **asymptomatic bacteruria** has to be treated with antibiotics
Asymptomatic bacteriuria
- do we need urine culture?
– No antibiotics? – No
EXCEPTIONS:
1. pregnancy,
2. renal transplants,
3. planned urologic intervention
116
for how long can patient survive on **peritoneal dialysis** and on **hemodialysis** on average (2p)
HD: 5-10 years (but some patients lived 30 years)
PD: 20.4 months ( 5-10 years). NOT SURE ABOUT THIS 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)
* 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
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)
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)
119
–EPO to consider or avoid:
previous stroke,
cancer
120
–EPO resistance:
–iron deficiency,
B12 / folic deficiency,
malnutrition,
infection,
hyperparathyroidism,
hypothyroidism, bleeding, hemolysis, cancer, hematological diseases
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
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
122
Compare crohns disease and Ulcerative colitis (4)
* ileocecal involvement
* skip lesions
* gross rectal bleeding
* application of TNF alpha Inhibitors
* 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
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
* 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
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)
* 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
125
list induction therapy
► **IL-2R antibody** (anti-CD25α) monoclonal Basiliximab (Simulect)
► **Anti CD-52 monoclonal antibody** Alemtuzumab (MabCampath)
► **Anti-thymocyte polyclonal antibody immunglobulines** Thymoglobulin ATG-Fresenius = Grafalon
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?
* 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
127
LIST 3 potential treatments for patients with crohns disease-associated perianal lesions ( simple or complex)
1. Anti-TNF-alpha drugs
2. antibiotic
3. fistuletomy
4. mesenchymal stem cell
128
list 3 radiologic diagnostic methods that can be used to diagnose renal artery stenosis?
* doppler US
* CT-angiography
* MRI-angiography
* (scintigraphy)
129
list 3 conditions/substances that typically result in acute hemmoragic erosive gastropathy
* NSAID
* Alcohol
* biliary reflux
* shock
* sepsis
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
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**
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)
* liver cirhosis
* 3 lab measurement from ascites fluid:
* WBC
* chemistry ( albumin, protein, LDH)
* culture
* gram stain
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?
* Wilson disease
* urine copper excretion (HIGH)
* serum ceruloplasmin (LOW) - protein that carries copper in the bloodstream
* serum copper low
* kayser fleisher ring
133
list 2 conditions in which you initiate antibiotic for a patient with acute pancreatitis(2)
* biliary pancreatitis with cholangitis
* superinfection
* pneumonia
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)
* 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)
mrts
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