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(BQ) Part 2 book “Davidson''s self-assessment in medicine” has contents: Respiratory medicine, nutritional factors in disease, diabetes mellitus, gastroenterology, maternal ophthalmology, maternal medicine,… and other contents.
8 Conway, P Phelan, GD Stewart Nephrology and urology Multiple Choice Questions 15.1 A 45 year old man presents with a 6-week history of bilateral ankle swelling On examination his pulse was 72 beats/min, blood pressure (BP) 126/68 mmHg, jugular venous pressure (JVP) was not elevated and auscultation of heart and lungs was unremarkable He had no stigmata of chronic liver disease Which of the following is the most appropriate initial investigation? A Abdominal ultrasound scan B D-dimer G Echocardiogram D Urinalysis E Urinary sodium formula-derived estimated glomerular filtration rate (eGFR) of 40 mUmin/1 73 m Which person below is likely to have the lowest measured (true) glomerular filtration rate (i.e the eGFR is falsely reassuring)? A A 25 year old male body builder B A 40 year old African American man with II hypertension G A 45 year old woman currently taking trimethoprim for a urinary tract infection D A 56 year old man with type diabetes and an above-knee amputation E An 85 year old woman with hypertension ,1 !' and type diabetes j f ·;I 15.2 A 72 year old man is found to have acute 15.5 A 46 year old man with a 10-year history kidney injury (AKI) Urine microscopy reveals the presence of red cell casts What is the most likely aetiology of his renal failure? of type diabetes presents with a 6-week ;' history of bilateral leg swelling He reports that he had been taking non-steroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis regularly for the past months Investigations reveal: eGFR >60 mUmin/ 73 m2 ; urinalysis: protein 4+, blood negative; protein: creatinine ratio 1680 mg/mmol; and a serum albumin of 14 g/L Serum albumin and urinary albumin: creatinine ratios months previously were 36 g/L and 25 mg/mmol, respectively What is the most likely diagnosis? A Acute tubular necrosis B Haemolytic uraemic syndrome G Microscopic polyangiitis D Sclerodermic renal crisis E Tubulointerstitial nephritis 15.3 Which of the following is maintained in the circulation when transiting through the kidney and not freely filtered acro~s the normal glomerular filtration barrier? A Free light chains B Glucose G Glutamine D Immunoglobulin A (lgA) E Lithium A B G D E Amyloidosis Diabetic nephropathy lgA nephropathy / Minimal change disease Tubulointerstitial nephritis 15.6 A 25 year old man presents with visible 15.4 The following subjects all have a Modification of Diet in Renal Disease (MDRD) haematuria He reports that he had a very sore throat weeks previously, but is otherwise well I 11 • NEPHROLOGY AND UROLOGY His blood pressure and renal function are both normal Protein: creatinine ratio was elevated (100 mg/mmol) What is the most likely diagnosis? A B C D E Bladder cancer lgA nephropathy Polycystic kidney disease (PKD) Post-infectious glomerulonephritis Renal calculus 15.7 A 69 year old man is diagnosed with streptococcal endocarditis and commenced on benzylpenicillin and gentamicin His renal function is normal on admission, but week later it has deteriorated (eGFR 28 mU min/1.73 m 2) Investigations reveal: urinalysis: blood 3+, protein 3+; ultrasound scan: normal-sized kidneys with no hydronephrosis; serum complement level (C3 and C4) is low What is the most likely diagnosis? A B C D E Acute interstitial nephritis Acute tubular necrosis Infection-related glomerulonephritis Microscopic polyangiitis Pre-renal failure 15.8 A 76 year old woman attends her family physician complaining of bilateral leg swelling and vague aches and pains Initial investigations reveal: urinalysis: protein 4+, trace blood; haemoglobin 79 g/L; white cell count 1.9x109/L; platelet count 46 x 109/L; sodium 131 mmoi/L; potassium 4.6 mmoi/L; urea 15 mmoi/L (90.1 mg/dl, BUN 42.0 mg/dl); creatinine 176 11moi/L (1.99 mg/dl); albumin 23 g/L What is the most likely finding on renal biopsy? A B C D E Amyloidosis Cast nephropathy Interstitial nephritis Minimal change disease Thrombotic thrombocytopenic purpura (ITP) 15.9 A 49 year old male presents with deafness, shortness of breath, haemoptysis, reduced urinary output and ankle swelling On examination: BP is 170/100 mmHg; JVP is em above the sternal angle, there are bibasal crepitations in the lungs and he has bilateral leg swelling to the mid-calves Initial investigations reveal: haemoglobin 92 g/L, white cell count 9x 109/L; platelet count 460x 109/L; sodium 142 mmoi/L; potassium 6.8 mmoi/L; urea 45 mmoi!L (270 mg/dl); creatinine 1260 11moi!L (14.25 rng/dl); albumin 32 g/L Chest X-ray: bi-basal air space shadowing; ultrasound: normal-sized kidneys, no evidence of hydronephrosis No urine is available for urinalysis What is the most appropriate initial investigation from the list below? A Anti-glomerular basement membrane B C D E (GBM)/antineutrophil cytoplasmic antibody (ANCA)/antinuclear antibody (ANA) serology Computed tomography (CT) pulmonary angiography Genetic testing for Alport's disease Plasma protein electrophoresis Renal biopsy 15.1 A 32 year old man is referred to the nephrology clinic for investigation of persistent non-visible haernaturia initially detected at an insurance medical examination He is otherwise well, with no personal or family history of renal disease His BP is 126/68 rnmHg Preliminary investigations reveal: urinalysis: blood 3+, protein negative; creatinine 100 11moi/L (1.13 mg/dl); eGFR > 60 rnUmin/1 73 m What is the most likely diagnosis? A Alport's disease B Bladder tumour C lgA nephropathy D Membranous nephropathy E Vesica-ureteric reflux 15.11 A 75 year old woman has peripheral/ vascular disease and stage CKD with , proteinuria due to lgA nephropathy Her Bf is 136/80 mrnHg on lisinopril 40 mg, amlodj.~ine 10 rng and bendroflurnethiazide 2.5 mg (all once daily) Her renal function has been · relatively stable over the past years w'ith current eGFR 39 mUmin/1.73 m Ultrasound scan revealed that her left kidney length at em was smaller than the right kidney at 11.5 em Magnetic resonance angiography confirmed a 90% stenosis at the ostium of the left renal artery What is the most appropriate management from the list below? A B C D Check plasma renin activity Commence a statin Discontinue lisinopril Perform angiography and stenting to her left renal artery E Start warfarin 15.12 A 62 year old man presents with a large myocardial infarction and undergoes primary coronary angiograplly and stenting Two days later he develops a low~grade fever and dusky discolouration of the toes on both feet, although peripheral pulses are palpable eGFR was 52 mUmin/1 73 rn pre-procedure and T NEPHROLOGY AND UROLOGY • 117 falls to 25 mUmin/1 73 m 2 days later Other investigations reveal: urinalysis: blood 1+, protein 1+; haemoglobin 12 g/L; white cell count 10.6x109/L with eosinophilia; platelet count ?Ox 109 /L Creatine kinase is elevated at 640 U/L What is the most likely cause of his acute kidney injury? A Cholesterol embolisation B Contrast nephropathy C Haemolytic uraemic syndrome D Renal artery thrombosis E Rhabdomyolysis 15.13 A 17 year old male returns from an Outward Bound centre holiday and falls ill with vomiting and bloody diarrhoea His acute illness subsides, but days later he notices that his urinary output has declined and his ankles begin to swell He attends his family physician where his temperature is 38.2°C, BP is 164/92 mmHg and he has bilateral ankle oedema, but no other clinical signs The following investigation results are obtained: urea 36 rnmoi/L (216 mg/dl); creatinine 640 J.!moi/L (7.24 mg/dl); sodium 129 mmoi/L; potassium 6.4 mmoi/L; haemoglobin 64 g/L; white cell count 9.6x 109/L; platelet count 36x 109/L; blood film shows schistocytes; urinalysis: blood 1+, protein negative; stool cultures negative for Escherichia coli 0157 What is the most likely diagnosis? A Haemolytic uraemic syndrome B Lupus nephritis C Malignant hypertension D Pre-renal failure E Thrombotic thrombocytopenic purpura 15.14 A 60 year old man with long-standing stage chronic kidney disease presents with vague bony pain Blood tests reveal eGFR 17 mUmin/1.73 m ; calcium 2.92 mrnoi/L (11.70 mg/dl); phosphate 1.82 mmoi/L (5.64 rng/dl), parathyroid hormone (PTH) is elevated at 156 pmoi/L (14 71 pg/ml), alkaline phosphatase 470 U/L What is this picture consistent with? A Excess vitamin D consumption B Milk alkali syndrome C Primary hyperparathyroidism D Secondary hyperparathyroidism E Tertiary hyperparathyroidism 15.15 A 62 year old man with stage CKD (eGFR 39 mUmin/1 73 rn 2) is noted to have haemoglobin of 79 g/L, white cell count 8.9x109/L; platelet count 146x109/L; mean corpuscular volume (MCV) 76 fl What is the most appropriate investigation? A Bone marrow biopsy B Serum erythropoeitin level C Serum folate studies D Serum iron studies E Ultrasound scan of-abdomen / 11 b 15.16 The Reciprocal creatinine plot shown of 48 year old man would be consistent with the\ natural history of progression of which of the following causes of kidney failure? I' I 71. Q) 'iii () (/) 'iii () e Q 100 '(3 ~ c : ro 125 E 150 e () E Q) c 175 200 1: I ·c: 11: 250 ~ 300 ~ () 400 500 700 1000 16.05.1991 11.05.1995 06.05.1999 01.05.2003 26.04.2007 21.04.2011 T I I • NEPHROLOGY AND UROLOGY dl), increased from 126 iJ.mOI/L (1.43 mg/dl) months previously) Urinalysis: blood 1+, protein 2+, no leucocytes; ultrasound scan of graft revealed no hydronephrosis What is the most likely explanation for the deterioration in renal function? A Adult polycystic kidney disease B C D E Microscopic polyangiitis Multiple myeloma Post -infectious glomerulonephritis Renovascular disease 15.17 A 42 year old woman with lgA nephropathy and stage CKD (eGFR 45 mU min/ I 73 m ) is developing proteinuria (protein: creatinine ratio is I 20 mg/mmol) BP is I 58/86 mmHg and she is commenced on an ACE inhibitor (lisinopril I mg daily) Two weeks later her eGFR has fallen to 37 mUmin/1 73 m2 and her potassium has risen from 5.2 to 5.9 mmoi/L, although BP and protein: creatinine ratio have fallen to 146/82 mmHg and 30 mg/ mmol, respectively She is already on a low-potassium diet What is the most appropriate management? A Acute pyelonephritis B Acute rejection due to non-adheren'ce with immunosuppression C Anti-glomerular basement membrane disease D Chronic allograft injury E Thrombosis in the artery to the graft peritoneal dialysis? 15.21 A previously fit 17 year old male presents with a 2- to 3-week history of arthralgia and more recently has developed a skin rash on the lower legs Just prior to admission to hospital he developed abdominal discomfort with blood-stained stool On examination, he has a widespread non-blanching rash over his limbs Initial investigations reveal: urinalysis: blood 3+; protein 3+; eGFR 46 mUmin/1 ,73 m ; protein: creatinine ratio 220 mg/mmol; haemoglobin 120 g/L, white cell count 12.9x 109 /L; platelet count 259x 109 /L; C-reactive protein 62 mg/L What is the most likely diagnosis? A Fluid removal is achieved by increasing the A Anti-glomerular basement membrane di sease concentration of sodium in the dialysate B Hyperkalaemia is less common than for haemodialysis C It is associated with improved patient survival compared with haemodialysis D It is unsuitable for elderly patients E Peritonitis is usually caused by gut bacteria traversing the bowel wall B C D E A Add a thiazide diuretic B C D E Add a ~-adrenoceptor antagonist Commence calcium resonium Increase the lisinopril dose Stop the lisinopril (~-blocker) 15.18 Which of the following is true regarding 15.19 Which of the following is typical of the development of pre-eclampsia? A Low serum urate level B Maternal history of cigarette smoking C Occurrence in the mother's first pregnancy D Onset of hypertension in the second trimester E Prolonged prothrombin time Haemolytic uraemic syndrome Henoch-Schonlein purpura Post -streptococcal glomerulonephritis Systemic lupus erythematosus ;, ;! f 15.22 A 62 year old man presents witlil' sudden anuria on a background history of sev~ral weeks of 'not passing much urine' He denies dysuria or haernaturia but admits to having a poor stream for many years He is normotensive and otherwise looks well and has no systemic symptoms What is the best initial diagnostic investigation? A Blood test for electrolytes and renal function B C D E CT of kidneys and urinary tract with contrast Renal biopsy Renal ultrasound scan Urinalysis for red cell casts 15.20 A 14 year old boy with end-stage renal disease due to reflux nephropathy received a renal transplant from his mother Aged 17 he transferred to the adult renal service and he left home to go to university the following year Six months later he attends the transplant clinic He is asymptomatic, but his graft function has deteriorated (creatinine 297 llmoi!L (3.36 mg/ 15.23 An 18 year old male presents with haematuria and proteinuria He undergoes renal biopsy which shows a mesangiocapillary glomerulonephritis !Olattern of injury Immunofluorescence shows complement C3 staining with no immunoglobulin depqsition Electron microscopy, demonstrates NEPHROLOGY AND UROLOGY • 119 electron-dense deposits in a ribbon-like pattern in the glomerular basement membrane (so called 'dense deposits') What is the most likely underlying cause of his mesangiocapillary glomerulonephritis? A Autoimmune disease B Genetic defect of alternative complement pathway C Hepatitis B infection D Hepatitis C infection E Monoclonal gammopathy 15.24 A 49 year old woman presents with acute kidney injury after an acute illness manifested by myalgia, diarrhoea and vomiting Her BP is 84/50 mmHg and she has dry mucous membranes She was taking ibuprofen, paracetamol and domperidone during the illness Her renal function improves rapidly with intravenous (IV) fluids Which one of the following findings are likely to be present? A Dense granular ('muddy brown') casts on B C D E urinalysis Hypercalcaemia Hyponatraemia Low (< %) fractional excretion of sodium Low urine specific gravity dL), potassium 6.8 mmoi/L, corrected calcium 1.97 mmoi/L (7.90 mg/dL), international normalised ratio (INR) 2.0 Urine dipstick shows haematuria but no proteinuria Direct urinalysis revealed no cells or casts What is the likely cause of his kidney injury? A B C D Acute interstitial nephritis ATN due to viral infection Haemorrhage into the kidneys Pre-renal injury due to dehydration from alcohol E Rhabdomyolysis 15.27 A patient with acute kidney injury has been anuric for 12 hours despite fluid challenges Potassium is 5.2 mmoi/L, urea is very high and a pericardia! rub is audible The patient appears euvolaemic A decision is made to commence haemodialysis due to concerns regarding uraemia and specifically uraemic pericarditis What will the first dialysis session involve? A B C D A large surface area dialyser A short 2-hour session initially Heparin anticoagulation High blood flow rate of 400 mUmin E Ultrafiltration of L (fluid removal) 15.25 A 68 year woman develops malaise and 15.28 In a patient presenting with renal a low-grade fever She has no rash and appears euvolaemic She takes atorvastatin, omeprazole, amlodipine and digoxin regularly and takes ibuprofen intermittently Urinalysis shows some leucocytes but no casts, haematuria or proteinuria She has a creatinine of 320 11moi/L (3.62 mg/dL), which has been 68 11moi/L (0.77 mg/dL) year previously What is the likely cause of renal injury? impairment, which of the following is most helpful in discriminating between AKI and a lat.e presentation of CKD? ) A Acute interstitial nephritis B ATN due to rhabdomyolysis C Glomerulonephritis D Pre-renal injury due to NSAIDs E Urinary obstruction 15.26 A 55 year old man with significant cardiovascular disease and diabetes has acute kidney injury in the context of a viral illness He was at a social gathering where he consumed alcohol and woke the next morning unwell He had fever, aches and pains, headache and felt thirsty He takes atorvastatin, lansoprazole, amlodipine, bisoprolol, warfarin, digoxin regularly He passed a small amount of dark urine His creatinine is 190 11moi/L (2.15 mg/ A B C D Anaemia ;' Hyperphosphataemia I Hyponatraemia Renal biopsy showing interstitial fibrosis and tubular atrophy E Small echogenic kidneys on ultrasound 15.29 A 32 year old man with lgA nephropathy since the age of 18 received a well human leucocyte antigen (HLA)-matched kidney transplant from his older brother He had no pre-formed anti-HLA antibodies and the kidney functioned immediately One week later his urine output is noted to be lower than the previous days and his creatinine is increased, having previously droppetto normal in the first few days post-transplant His BP is 180/90 mmHg, he has dipstick-positive blood on urinalysis and he look§ euvolaemic What is the likely diagnosis? A Acute cellular rejection B BK polyomavirus nephropathy 120 • NEPHROLOGY AND UROLOGY G Hyperacute rejection D Recurrent lgA nephropathy E Renal artery stenosis 15.30 A 56 year old woman with polycystic kidney disease received her second kidney transplant She had pre-formed anti-HLA antibodies (from the first transplant) but the cross-match was negative so she proceeded to transplant using induction therapy (anti-thymocyte globulin; ATG) She had immediate function of the transplant but suffered an acute rejection after months, which was successfully treated with IV glucocorticoids She developed a urinary tract infection (UTI) in the week after the steroids were administered, which cleared with oral antibiotics Her renal function has deteriorated again at months and her serum shows BK polyomavirus on polymerase chain reaction testing A biopsy reveals BK polyomavirus nephropathy Risk factors for BK polyomavirus include which of the following? A Augmented immunosuppression (ATG and high-dose steroids) B Polycystic kidney disease G Presence of anti-HLA antibodies D Previous UTI E Second transplant 15.31 What is the pathogenesis of 'myeloma kidney' (cast nephropathy)? A Glomerular light chain deposition due to light B G D E chains, and rarely heavy chains, often giving a nodular pattern of injury Light chain misfolding, creating glomerular deposits that are Congo red positive Light chains precipitating with Tamm-Horsfall protein in the tubular lumen Proximal tubular injury and dysfunction due to light chain deposition in tubular epithelial cells Tubular damage due to hypercalcaemia 15.32 A patient with known sarcoidosis has developed renal impairment over the past months Corrected serum calciom is slightly high (2.7 rnrnoi/L; 10.82 mg/dl) A renal biopsy is performed and glucocorticoids are commenced Renal function gradually normalised over a period of several weeks What would the likely initial renal biopsy findings show? A A granulomatous interstitial nephritis Calcium deposition in the tubules Focal segmental glomerulosclerosis (FSGS) Necrotising cresentic glomerulonephritis Widespread interstitial fibrosis and tubular atrophy B G D E 15.33 Patients with advanced liver disease are at risk of developing AKI, termed hepatorenal syndrome Which of the following is true of this syndrome? A Aggressive dialysis may prevent hepatic encephalopathy B lgA deposition is a common cause G Kidney biopsy should be performed for an accurate diagnosis D Outcomes are good with haemodialysis E The aetiology is haernodynamically mediated, so urine sodium will be reduced 15.34 Which of the following is true in diabetic nephropathy? A ACE inhibitors generally cause resolution of proteinuria and stabilisation of renal function B Biopsy is generally needed to confirm the diagnosis G It is an uncommon cause of end-stage renal disease (ESRD) outside of North America D Sodium-glucose co-transporter-2 (SGLTi) inhibitors, such as ernpagliflozin, may bEll associated with improved cardiovasculcit and /, renal outcomes and work by improving'· insulin sensitivity E The natural history is of slow development of rnicroalbuminuria over years, with ov~rt proteinuria and renal impairment at a late stage 15.35 A 23 year woman presents with a facial rash and arthralgia soon after getting married She is found to have an eGFR of 106 mU min/1.73 m , red cell casts in her urine and 5.5 g/24 hrs of proteinuria Renal biopsy confirms lupus nephritis Which of the following is true in this patient? A Best treatment for this patient is with cyclophosphamide gnd glucocorticoids B Mycophenolate mofetil would be the induction agent of choice, along with glucocorticoids G She probably has.mild lupus nephritis that can be managed with an ACE inhibitor alone D She should be referred immediately to the transplant team T NEPHROLOGY AND UROLOGY • 121 E She would be at high risk for recurrence after a renal transplant causing allograft D Ruptured berry aneurysm E Ruptured hepatic cyst loss 15.40 A 65 year man presents with flank 15.36 A 42 year old woman from China presents with slowly progressive renal failure in the context of taking herbal remedies for years containing aristolochic acid Which of the following clinical characteristics is likely in this patient? A Biopsy demonstrating focal segmental glomerulosclerosis B Bland urine sediment with interstitial fibrosis on biopsy c Heavy proteinuria in the nephrotic range D High anion gap metabolic acidosis E Large kidneys on ultrasound scanning discomfort and haematuria He is found to have bilateral polycystic kidneys and some liver cysts on ultrasound scan His renal function is normal, with an eGFR of 90 mUrnin/1.73 m • He gives a family history on his mother's side of 'cysts in the kidney' but no family member ever needed dialysis or a transplant Which of the following is true about his disease? A Any offspring have a 50% chance of developing the condition B He is a good candidate for tolvaptan to slow cyst growth C He is at high risk of liver failure due to a polycystic liver 15.37 A 22 year old man develops diabetes and is found to have renal impairment with small kidneys on scanning, in addition to noted pancreatic atrophy He has a history of gout for years and his father developed ESRD aged 38 His father also had 'renal failure' due to cystic disease and has diabetes A mutation in which gene is likely? D He probably has a mutation in PKD1 E He will probably develop end-stage renal disease within years 15.41 A 75 year old man with hypertension, D.PKD2 heart failure, peptic ulcer disease and osteoarthritis presents with acute kidney injury after being prescribed ibuprofen His usual medicines are lisinopril, furosemide, omeprazole and atorvastatin He has 1+ proteinuria and no haematuria on dipstick What is the mechanism underlying his renal failure? E UMOD A Afferent arteriolar vasoconstriction with A COL4A5 B HNF1-beta C PKD1 15.38 In patients with Alport's syndrome (hereditary nephritis), which of the following statements is true? B A After kidney transplant, patients may develop anti-GBM disease C B All patients harbouring pathogenic COL4A mutations develop progressive chronic kidney disease C Deafness may occur due to otosclerosis D Female carriers of X-linked disease (COL4A5 mutations) not manifest disease E It is always an X-linked condition D E ibuprofen (in context of efferent vasodilatation with lisinopril) Afferent arteriolar vasoconstriction with lisinopril (in context of efferent vasodilatation with ibuprofen) Afferent arteriolar vasodilatation with ibuprofen (in context of efferent vasoconstriction with lisinopril) Afferent arteriolar vasodilatation with lisinopril (in context of efferent vasoconstriction with ibuprofen) Rhabdomyolysis from the statin 15.42 A 64 year old man has osteoarthritis in his 15.39 A 20 year old woman has a history of A Mitral valve prolapse knees and is prescribed ibuprofen regularly for months He notices some swelling in his ankles and his family physician fil)ds his urine dipstick reveals 4+ protein with r16 blood or white cells His creatinine is normal and his serum albumin is 190 g/L A renal biopsY is performed What is the light microscopy likely to reveal? Myocardial infarction A Fibrin microthrombi in glomerular capillary autosomal dominant polycystic kidney disease (APKD) on her father's side Her paternal grandmother and her father's brother both died suddenly in their 50s What was the likely cause of death? C Pulmonary embolism loops 122 • NEPHROLOGY AND UROLOGY B Intense interstitial inflammation, with 15.47 A 27 year old woman presents as an infiltration of the tubules by neutrophils, lymphocytes and some eosinophils C Necrotising cresentic glomerulonephritis D Normal glomeruli E Tubular dilatation, breaks in the tubular basement membrane, interstitial oedema and sloughing of necrotic tubular cells into the tubular lumen emergency with rigors, flank pain and fever Non-contrast CTKUB reveals an 8-mm stone in the left mid-ureter Which is the optimal management option? A B C D E 15.43 Regarding micturition, which of these Extracorporeal shockwave lithotripsy (ESWL) Percutaneous nephrolithotomy (PCNL) Ureteric stent insertion Ureterolysis Ureteroscopy and laser fragmentation of stone statements is correct? A A low-compliance bladder is required for B C D E voiding to be initiated Contraction of the pelvic floor commences micturition Micturition is initiated when the compliance limit of the bladder is reached Voiding is controlled by the cerebellum Voiding is coordinated by the pontine micturition centre 15.48 In which of the following situations would you consider treating an asymptomatic patient identified to have > 10 E co/i/ml urine? A Healthy 14 year old girl B 24 year old woman, normal ultrasound and flexible cystoscopy in the past C 32 year old pregnant woman D 67 year old man with a urethral catheter in 15.44 What is the optimal imaging to rule out situ ·E 78 year old woman with a ureteric stent in place for retroperitoneal fibrosis bone metastases in a man with prostate cancer? 15.49 Following a trial of treatment with A Contrast-enhanced CT urogram B Dimercaptosuccinic acid (DMSA) static radionuclide scan C Non-contrast CT of kidneys, ureters and bladder (CTKUB) D Pelvic magnetic resonance imaging (MRI) scan E Technetium-labelled methylene diphosphonate (99"'Tc-MDP) radionuclide scan 15.45 A 25 year old woman from Uganda who has recently delivered a baby presents with new continuous incontinence What is she likely to be suffering with? A Duplex kidney with insertion of upper pole B C D E moiety into the vagina Overflow incontinence Stress urinary incontinence Urge incontinence Vesicovaginal fistula a-adrenoceptor antagonist (a-blocker) medication, a 65 year old man is referred by his family physician to urology with poor f~9w terminal dribbling and hesitancy Which o~;he following is the most relevant investigatior? /! A Cystoscopy B C D E MRI pelvis Prostate biopsy Ultrasound prostate Urinary flow test 15.50 A 49 year old woman presents with visible haematuria A cystoscopy is normal, but a contract-enhanced CT scan of chest, abdomen, pelvis reveals a 17 -em left renal mass, consistent with a renal cell cancer What is the best treatment option for this woman? A Cryotherapy B External beam radiotherapy C Open radical nephrectomy D Robotic partial nephrectomy E Tyrosine kinase in~ibitor (TKI) 15.46 What is the most likely Gause of painless, visible haematuria in a 60 year old man? 15.51 A 72 year old fit ex-smoking man is A B C D E identified on flexible cystoscopy to have a 4-cm bladder tumour C)'Stoscopy and transurethral resection of bladder tumour provides tissue that on pathological examination shovys a G3pT2 urothelial cell cancer What is the Ureteric stone Bladder cancer lgA nephropathy Systemic lupus erythematosus Upper urinary tract urothelial cancer / I T NEPHROLOGY AND UROLOGY • 123 optimal management for this muscle-invasive cancer? A Brachytherapy B Chemotherapy (gemcitabine and cisplatin) c Observation with23, 130 Personality disorders, prevalence of, 341 b Pethidine, 42b Phaeochromocytoma, phenoxybenzamine for, 191, 200 Phagocytes, key feature of, 22 , 25 Pharmacovigilance, voluntary reporting of, 7, 10 Phencyclidine, 42b Phenoxybenzamine, for phaeochromocytoma, 191 , 200 Phenytoin in cerebellar function , 310, 322 zero-order drug kinetics in, 6, Phosphate in urine, 408b in venous blood, 405b-406b Phosphodiesterase inhibitor, 138 Phosphodiesterase (PDE4), in apremilast, 287, 296 Photo-ag eing, 362-363 Photocoagulation, pan-retinal, 332, 3321, 335 Photodynamic therapy for basal cell carcinoma, 353, 3531, 362-363 for Bowen's disease, 3461, 358- 359 with verteporfin, 335 Phylloquinone see Vitamin K Pigbel, 95 Pilocarpine, 298 for Adie's pupil, 333 Pin-prick testing, for dissociated sensory loss, 299, 313 Pioglitazone, 219 Piperacillin, 274 Piperacillin/tazobactam, 91 for neutropenic fever, 266, 27 Pituitary adenoma, 232 , 242 Pituitary apoplexy, 192, 202 Pityriasis rosea, 363-364 Pityriasis versicolor, 354, 3541, 363-364 Placebo or 'Novotreat', 29, 31 Plantar reflexes , upgoing , 304 , 317 Plaque psoriasis, adalimumab for, 352, 362 Plasma osmolality, 407 Plasmodium knowles! infection, primates and, 81 , 92 Plasmodium vivax, 105-106 Platelet count, CML and, 264, 272-273 Platelets, reference range of, 409b-41 Ob Pleural effusion right-sided, 157 , 1571, 175 cessation of apixaban for, 157, 175 transudative, hypothyroidism and, 164, 179 Pleural fluid, analytes in, 409b Plummer-V1nson syndrome, 235-236 PMF see Progressive massive fibrosis Pneumocystis jirovecii, 180 Pneumocystis jirovecii pneumonia, 97 , 97f, 101 Pneumonia, 178 drug-induced chronic eosinophilic , 170, 182 falls and, 379, 382 hospital-acquired Acinetobacter and, 167, 180 local antibiotic policy for, 166-167 , 180 mortality from, 167, 180 interstitial bronchoscopy and, 176 CT appearance of, 160, 176 lymphocytic, 182 Pneumonitis, hypersensitivity, 171- 172, 183 Pneumothorax, 17 left-sided, 157, 1571, 175 therapeutic aspiration for, 158, 1581, 175-1 76 primary spontaneous, intercostal chest drain for, 173- 17 4, 184 secondary spontaneous, 59, 68-69 POCT see Point -of-care test Point-of-care test (POCT), 107-111 Poisoning, 37-44 Poly ADP ribose polymerase (PARP) inhibitors, mechanism of, 18, 21 Polyarticular joint involvement, in gout, in older woman, 286, 294-295 Polycystic kidney disease, adult, 117-118, 11 71, 126 Polycystic ovarian syndrome (PCOS), hyperandrogenism and , 189, 198 Polycythaemia rubra vera (PRV), ischaemic stroke and, 261, 270 Polymerase chain reaction (PCR), for Cyclospora cayetanensis infection, 75, 87 Polymorphic eruption of pregnancy, 350, 361 Polymorphic light eruption, 363- 364 causi ng photo -aggravation of psoriasis, 347, 3471, 359 diagnosis of, 345-358, 3451 Polymyalgia, 292 Population health and epidemiology, 28-31 Porphyria cutanea tarda, investigations for, 351 , 351 I, 357, 361, 365 Porphyrin plasma scan, 351, 351 I, 357, 361 , 365 Posaconazole, 27 Positron emission tomography (PET) scan for inflammation site identification, 74, 86-87 for pulmonary nodule, 156, 1561, 163-164, 175, 178 179 Post-concussion syndrome, 310, 322 Post-head injury, anosmia and ageusia caused by, 307, 320 Post-menopausal osteoporosis, 280, 291 Post-partum blues, 343 Post-polio syndrome, 174, 184 Post-test probability, of hip fracture, 1, 3-4 Post-transplant lymphoproliferative disorder, 372, 375 Post-traumatic stress disorder (PTSD), 337, 342- 343 Postural hypotension, 143 accompanied by tachycardia, in joint hypermobility, 284, 293 Potassium, 108, 112 in DKA management, 215, 222 plasma concentration of, 110, 113 in urine, 408b in venous blood, 403b - INDEX • 439 Potency, of drug, 6, PPCI see Primary percutaneous coronary intervention PPis see Proton pump inhibitors Pralidoxime, 42b Prazocin, 49 Pre-diabetes, diagnostic cut-offs in, 413b Predictive value, of test, , 1t, Prednisolone, 25, 39b, 74, 87, 162-165, 170, 179, 371 for alcoholic hepatitis, 258-259 drug-induced diabetes caused by, 215, 221-222 for EMV infection, 74, 86 for liver capsule pain, 395, 399, 400b oral, for asthma, pregnancy and, 164-165, 179 pustular psoriasis and, 356, 3561, 364 for rheumatoid arthritis, 279, 291 Pre-eclampsia, 118, 126 during pregnancy, with renal disease, 371, 374 Pre-frail, 378, 381, 381b Pregabalin, 397- 398 for neuropathic pain, 400b Pregnancy acitretin, 351, 361-362 acute fatty liver of, 367, 369 aortic dissection and, 139, 150 autoimmune hepatitis in, azathioprine monotherapy for, 246, 254-255 avoiding unprotected sex during, 105-106 bariatric surgery and, 204, 208 community-acquired pneumonia during, treatment of, 367, 369 diabetes during, medication for, 367, 369 diffuse symmetrical goitre and, 187, 196 epilepsy during, folic acid for, 366, 368 infections in, 86b w ith lupus nephritis, 367, 369 methotrexate during, 366-368 w ith renal disease, 371, 374 respiratory rate during, 366, 368 rheumatoid arthritis and, 281, 291 sodium valproate on, 8, 11 spider naevi during, 367, 369 ulcerative colitis during, methotrexate for, 367-369 Pregnancy-associated dissection, 150 Preload, stroke volume and, 60, 69 Premature ovarian failure, karyotype for, 189, 198 Pressure bandage and immobilisation (PBI), 47, 49 Prick testing for latex rubber allergy, 362 for urticaria, 361 Primary adrenal failure, 193 Primary biliary cholangitis, 246, 254 alkaline phosphatase (ALP) level in, 24 7, 255 ERCP for, 250, 257 Primary biliary cirrhosis (PBC), 245, 253 Primary hyperparathyroidism, parathyroid surgery for, 190, 199 Primary immune deficiency, 22, 25-26 Primary percutaneous coronary intervention (PPCI), 139-140, 150-151 ' 366-368 Primary sclerosing cholangitis, 247, 256 Primary Sjogren's syndrome (PSS), 286, 288, 294, 297 malignancy and, 289, 297- 298 Primary spontaneous pneumothorax (PSP), intercostal chest drain for, 173- 174, 184 Primates, Plasmodium knowlesi infection and, 81, 92 Procainamide, intravenous bolus dose of, 39-40, 40b Procyclidine, 40b, 45b Progesterone in pregnancy, 411b in venous blood, 403b-404b Progesterone dermatitis, 364 Progressive degenerative disorder, 311, 322- 323 Progressive massive fibrosis (PMF), 171, 182-183 Prolactin (PRL), 193, 389 for pituitary macroadenoma, 193, 202 in pregnancy, 411b in venous blood, 403b-404b Prolonged post-ictal dysphasia, 302, 315 L Propionibacterium acnes, 289, 297 Propofol, for intracranial pressure, 63, 71 Propranolol for post-partum thyroiditis, 186, 195 for variceal haemorrhage, 252, 259-260 Proprioception testing, for Dissociated sensory loss, 299, 313 Prostate cancer, 130 Prostate ultrasound, 130 Protease inhibitors (Pis), 101, 101 b Protein in urine, 408b in venous blood, 4o5b-406b Protein energy malnutrition, 30 Proteinase 3-positive ANCA-associated vasculitis (AA\!j, 288, 297 Prothrombin complex concentrate, 275 Prothrombin time (PT), reference range of, 409b-41Ob Proton pump inhibitors (PPis), 226, 236 causing lichenoid reactions, 364- 365 for gastrointestinal bleeding, 57, 66 Prucalopride, 232, 241 PRV see Polycythaemia rubra vera Pseudoephedrine, 42b Pseudogout, 294 Pseudo-hallucination, 341 Pseudomonas aeruginosa, cyst1c fibrosis and, 166, 180 Pseudoseizures, pregnancy and, 366, 368 Psi/ocybe semilanceata ('magic mushrooms'), 45b Psoas abscess, mycobacterial testing of, 167, 181 Psoralen and ultraviolet A (PUVA), for palmoplantar pustulosis, 349, 3491, 360 Psoriasis, 363-364 Psoriasis area and severity index (PAS!), 351, 362 Psoriatic arthritis, 289, 2891, 298, 298b PSP see Primary spontaneous pneumothorax PSS see Primary Sjogren's syndrome Psychiatric disorders biological basis of, 339, 343 prevalence of, 341b Psychiatric history, 336-340 Psychiatric interview, 336-340, 340b Ptosis, wound botulism and, 82, 93 PTSD see Post-traumatic stress disorder Puberty, in male, 370- 373 Puerperal psychosis, 338-339, 343 Pulmonary embolism, sinus tachycardia in, 137, 148 suspected, physical examination for, 2, Pulmonary fibrosis, idiopathic, 159, 1591, 169, 176, 181 Pulmonary hypertension, 172- 173, 183 bosentan for, 173, 184 transthoracic echocardiography for, 173, 183- 184 Pulmonary infarction, 178 Pulmonary Langerhans cell histiocytosis, 182 Pulmonary nodules PET scanning in, 156, 1561, 163-164, 175, 178- 179 risk of malignancy in, upper lobe distribution and, 163, 178 Pulmonary oedema acute, treatment for, 142, 152 Hantavirus infection and, 82, 93 Pulmonary thromboembolism, 162-163, 178 CT pulmonary angiogram for, 172, 183 thrombolysis for, 172, 183 Pulmotrauma, 61 , 71 Pulseless electrical activity (PEA) cardiac arrest, 133, 144 Pulsus paradoxus, 138, 148 Punched out erosions, 291 Pustular plantar foot rash, 295 Pustular psoriasis, prednisolone and, 356, 3561, 364 Pyogenic liver abscess, 249, 257 Pyrexia, post-cardiac arrest and, 61, 70 Pyridoxine see Vitamin Q QT prolongation, moxifloxacin and, 7, 11 Quadrantanopia, right inferior, 304, 318 ... Vitamin (riboflavin), 20 9b Vitamin (niacin, nicotinic acid , nicotinamide), 20 9b Vitamin (pyridoxine), 20 9b Vitamin 12 (cobalamin), 20 9b deficiency, 26 8, 27 5 pregnancy and, 26 3, 27 2 reference range... insufficiency, 28 2, 29 2 metabolism, 28 2, 29 2 in osteoporosis, 28 6, 29 1 , 29 4 supplementation, for chronic tiredness, 20 4 -20 5, 20 8 supplements for, 159, 1 62 in venous blood, 405b-406b Vitamin E (tocopherol),... Ureteric stent, insertion of, 122 , 130 Urethral catheterisation, 123 , 131 Uric acid, testing of, 28 9, 29 8 Urinalysis, 115-1 24 , 408 Urinary flow test, 122 , 130 Urinary incontinence for magnetic