7/20/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 316 A week after an episode of infective diarrhoea, a 10-year-old child presents with fever, hypertension and haematuria You understand that he had been on a school visit to a model farm a short period before he became unwell Blood tests reveal anaemia with an Hb of 8.4 g/dl, and an elevated creatinine of 185 μmol/l A possible diagnosis could be: A Acute interstitial nephritis B Haemolytic–uraemic syndrome C Henoch–Schönlein purpura D Membranoproliferative glomerulonephritis E Post-infectious glomerulonephritis Explanation  The answer is Haemolytic–uraemic syndrome – Haemolytic–uraemic syndrome is characterised by microangiopathic haemolytic anaemia and varying degrees of acute renal failure In many cases, an infectious or immune-complex mediated cause has been proposed Epidemics of bloody diarrhoea related to infection with a specific strain of Escherichia coli (O157:H7) have been documented The bacteria release a verotoxin that damages endothelial cells, particularly those of the kidney The visit to the farm implies haemolytic-uraemic syndrome is the most likely cause as opposed to other inherent or acquired pathology due to medications/infections (the other options) Acute interstitial nephritis (Option A) is incorrect The farm visit makes HUS the most likely cause https://mypastest.pastest.com/Secure/TestMe/Browser/429893 1/2 7/20/2016 MyPastest Henoch–Schönlein purpura (Option C) is incorrect The farm visit makes HUS the most likely cause Membranoproliferative glomerulonephritis (Option D) is incorrect The farm visit makes HUS the most likely cause Post-infectious glomerulonephritis (Option E) is incorrect The farm visit makes HUS the most likely cause 45515 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 2/2 7/20/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 316 A 55-year-old man presents with pain in his right flank, nephrotic syndrome, azotaemia, collateral abdominal veins and gross haematuria On examination, a mass is palpable in the right lumbar area Which one of the following is the most probable diagnosis? A Renal amyloidosis B Polyarteritis nodosa C Renal papillary necrosis D Renal cell carcinoma E Polycystic kidneys Explanation Renal-cell carcinoma (hypernephroma) Diagnosis The classic triad of haematuria, loin pain and abdominal mass, and the other clinical features present in this case are suggestive of renal-cell carcinoma Pathological consequences Renal-cell carcinoma is a highly vascular tumour and can cause obstruction of the renal veins 2918 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/20/2016 MyPastest Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/20/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 316 A 68-year-old man has a new-patient screen carried out by his GP He is noted to have microscopic haematuria His GP also notes a raised ESR and a calcium concentration of 3.1 mmol/l On examination he appears to have a varicocele Which one of the following diagnoses fits best with this clinical picture? A Transitional-cell carcinoma B Wilms’ tumour C Retroperitoneal sarcoma D Renal-cell adenocarcinoma E Urinary tract infection Explanation Renal-cell adenocarcinoma Epidemiology Renal-cell adenocarcinoma makes up 3% of all adult malignancies, with peak incidence being 50–70 years There is a male to female preponderance of 2:1 Clinical features Abdominal mass a presenting feature in 25–45% of cases Varicocele, resulting from obstruction of venous drainage, is found in 2–3% of cases Laboratory features Haematuria is the presenting feature in 50–60% of cases Raised erythrocyte sedimentation rate (ESR) in found in 50–60% of cases Hypercalcaemia occurs due to raised parathyroid-related protein in around 3% of cases https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/20/2016 MyPastest Imaging studies Ultrasound scan, iv pyelography (IVP), abdominal computed tomography (CT) with contrast and magnetic resonance imaging (MRI) Pattern of metastatic spread Commonest sites of metastases are lung (50–60%) and bone (30–40%) Treatment and prognosis Treatment of choice is nephrectomy Prognosis is related to tumour staging: the 5-year survival rate is around 80–100% in those with TNM stage-1 lesions, but this falls to 5–10% in those with stage-4 lesions 2427 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/20/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 316 Which one of the following statements is true regarding retroperitoneal fibrosis? A Bilateral swelling of the legs is often due to inferior vena cava obstruction B Hashimoto’s thyroiditis is a recognised association C Low back pain is the most common presenting symptom D Pizotifen (migraine treatment) is implicated in causing similar disease E Renal failure is due to fibrous tissue infiltrating the kidneys Explanation  The answer is Low back pain is the most common presenting symptom – Retroperitoneal fibrosis is one of the multifocal fibrosclerotic syndromes, which also includes mediastinal fibrosis, sclerosing cholangitis and Riedel’s thyroiditis It is more common in males (2:1), with peak incidence in the fifth and sixth decades The process usually begins over the promontory of the sacrum and extends laterally across the ureters and as high as the second or third lumbar vertebra Hence low back is the most common presenting symptom This may be accompanied by fever and weight loss Diagnosis is suggested by the finding at intravenous pyelography of displacement of the ureters toward the midline Thromboembolism and hypertension are recognised complications Methysergide, a semi-synthetic ergot alkaloid used to treat migraine headache, can cause a similar syndrome Other drugs such as ß-blockers (methyldopa and hydralazine) are also implicated Bilateral swelling of the legs is often due to inferior vena cava obstruction (Option A) is incorrect The fibrosing process may surround the inferior vena cava, but obstruction of that vessel is uncommon https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/20/2016 MyPastest Hashimoto’s thyroiditis is a recognised association (Option B) is incorrect Systemic diseases associated with retroperitoneal fibrosis include systemic lupus erythematosus (SLE), scleroderma and carcinoid syndrome, not Hashimoto’s Pizotifen (migraine treatment) is implicated in causing similar disease (Option D) is incorrect Pizotifen is an antihistamine and serotonin antagonist structurally related to the tricyclic antidepressants; its use is not associated with retroperitoneal fibrosis Renal failure is due to fibrous tissue infiltrating the kidneys (Option E) is incorrect The fibrous tissue does not infiltrate the kidneys or the ovaries 45493 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/20/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 316 A 55-year-old man presents with weakness, general malaise and ankle swelling He has been unwell for months, the ankle swelling having developed quite rapidly over the previous weeks On examination he has marked peripheral oedema and 3+ proteinuria without haematuria on dipstick urinalysis His daily urine albumin excretion rate is measured at 6.9 g/24 h, creatinine is 130 μmol/l, serum albumin is 12 g/dl and Hb is 8.9 g/dl Further investigation reveals a paraprotein band in his serum with kappa light chains demonstrated on immunofixation Which one of the following is the most probable cause of the proteinuria? A Cast nephropathy B IgA nephropathy C Light-chain deposition disease D Membranous nephropathy E Minimal-change disease Explanation Renal disease in myeloma The spectrum of renal disease in myeloma comprises a spectrum of presentations including; Cast nephropathy (presents as progressive renal insufficiency with Bence Jones proteinuria – undetectable on urine dipstick – but little in the way of albuminuria) Renal amyloidosis AL (nephrotic syndrome and mild renal insufficiency, associated with glomerular lambda light-chain deposition) Cryoglobulinaemic glomerulonephritis (mild to severe nephrotic syndrome, haematuria is a clue) and light-chain deposition disease Cryoglobulinaemic glomerulonephritis is almost invariably associated with kappa lightchain deposition and rarely coexists with renal amyloid These two entities present with the nephrotic syndrome, thereby distinguishing them https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/20/2016 MyPastest sharply from the much more common cast nephropathy, which is caused by widespread precipitation of light chains in association with Tamm–Horsfall glycoprotein in the tubular lumen Light-chain deposition disease results in mild renal insufficiency (as in this question), whereas cast nephropathy can cause severe renal failure, which is frequently irreversible The principal clue to the diagnosis of cast nephropathy is the absence of significant albuminuria (detected with urine dipstick) in the presence of significant proteinuria as measured by formal 24-h collection (due to filtered light chains) 1550 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/20/2016 MyPastest Up to 30% of patients may have positive hepatitis B surface antigen associated with the condition Primary management is with corticosteroids and cyclophosphamide C-ANCA is associated with Wegener's granulomatosis Anti-GBM antibodies are associated with Goodpasture's Anti-smooth muscle antibodies are associated with autoimmune liver disease Anti-cardiolipin antibodies are associated with SLE and anti-phospholipid antibody syndrome 21086 Next Question Previous Question Tag Question Feedback End Review Difficulty: Difficult Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/20/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 310 of 316 A sales executive attends the nephrology clinic complaining of burning micturition and passage of blood in the urine He says he was on a tour of North Africa a month earlier, during which he was camping He says he swam in local pools and streams to get clean The symptoms have occurred over the past week If untreated, what is the most probable complication that this condition can cause? A Nephrotic syndrome B Acute renal failure C Acute interstitial nephritis D Acute tubular necrosis E Hydronephrosis Explanation Urinary schistosomiasis This patient most probably has urinary schistosomiasis Symptoms Urinary schistosomiasis starts with frequency, dysuria and haematuria Painless terminal haematuria is usually the first and most common symptom Complications In advanced disease, pyelonephritis, hydronephrosis or pyonephrosis may lead to hypertension or uraemia 1472 Next Question https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/20/2016 MyPastest Previous Question Tag Question Feedback End Review Difficulty: Difficult Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/20/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 311 of 316 A 57-year-old diabetic woman with a history of dysuria and suprapubic pain is admitted to the Emergency Department; the pain has now extended to involve the left loin region and there is associated haematuria and oliguria Which one of the following is the most likely cause of this problem? A Renal infarction B Renal papillary necrosis C Diffuse glomerulosclerosis D Renal calculus E Acute tubular necrosis Explanation Renal papillary necrosis Epidemiology and aetiology Urinary tract infections are relatively more common in women with diabetes Untreated infections in people with diabetes can result in renal papillary necrosis Consequences of renal papillary necrosis It results in linear breaks at papillary bases Ureteric obstruction may result if the papillae have sloughed off 2933 Next Question Previous Question Tag Question https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top Feedback End Review 1/2 7/20/2016 MyPastest Difficulty: Difficult Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/20/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 312 of 316 A patient is diagnosed with membranous nephropathy With which one other condition is this condition associated? A Asthma B Malignancy C Hepatic fibrosis D Liver cancer E Diabetes mellitus Explanation Malignant complications in membranous nephropathy Epidemiology Membranous nephropathy is associated with malignancy, especially in the elderly Series have reported rates of malignancy ranging from 5% to 11%, with the greatest risk in those at the upper end of the age range However, different inclusion criteria have sometimes been used to assess risk, eg some series have included tumours recognised long after a diagnosis of renal disease has been made, when the association may be coincidental Organs implicated Most reported tumours have been of solid organs but haematological malignancies are also implicated Prognosis Very often, the disease is advanced and obvious by the time that nephrotic syndrome or a heavy proteinuria is recognised https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/20/2016 MyPastest In some cases, effective treatment of the malignancy has led to an improvement in the nephrotic syndrome or proteinuria Treatment considerations The use of alkylating agents or corticosteroids to treat membranous nephropathy is not recommended in this setting, unless it would be appropriate for treatment of the malignancy itself 3617 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/20/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 313 of 316 A 75-year-old man presents for the 4th time this year with fever and signs of infection One previous admission was for right lower lobe pneumonia, the rest for urinary tract infection He has a history of hypertension for which he takes ramipril and amlodipine and he suffered an inferior myocardial infarction years ago, since then he has been taking simvastatin 40mg daily On examination his BP is 134/82 mmHg He is pyrexial 37.9o C and has a pulse of 90/min His cardiovascular and respiratory examination is normal There is suprapubic tenderness on abdominal palpation; PR reveals a smoothly enlarged prostate Investigations; Hb 12.5 g/dl WCC 13.1 x109/l PLT 247 x109/l Na+ 139 mmol/l K+ 4.9 mmol/l Creatinine 149 μmol/l Urine blood ++, protein ++ What next additional investigation would you recommend to elucidate the cause of his recurrent UTI? A Post-void residual bladder volume measurement B Cystoscopy C IVU D PSA measurement E CT pelvis Explanation https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/20/2016 MyPastest If the suspicion is of prostatic hypertrophy, then post-void residual volume is the best way to estimate the degree of bladder obstruction PSA may be slightly elevated, but measuring it wouldn’t contribute towards determining the cause of the recurrent UTIs If there is significant evidence of chronic urinary retention then combination alpha blocker / 5-alpha reductase inhibitor therapy, intermittent catheterisation or TURP would be potential options 22500 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/20/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 314 of 316 You are asked to see the relatives of a 68-year-old man who has undergone surgery for repair of a ruptured aortic aneurysm Prior to surgery he was well, with a creatinine of 119 μmol/l at baseline Although the operative procedure went well, the period of acute hypotension has resulted in an episode of acute tubular necrosis (ATN) and he has undergone renal dialysis on a number of occasions in the past week Which one of the following most accurately represents the chance of recovery of renal function to the level where dialysis is not required? A 0% B 95% C 5% D 50% E 25% Explanation Acute tubular necrosis Aetiology Acute tubular necrosis (ATN) usually occurs after an acute ischaemic or toxic event In the present case, a period of severe hypotension resulting from the ruptured aneurysm was the underlying cause Treatment considerations Only around 5% of patients require long-term renal replacement therapy Prognosis Around 50% have some impairment of renal function on a permanent basis; around https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/20/2016 MyPastest another 5% undergo a slow deterioration in their renal function Prognosis of ATN is poorer in patients with severe sepsis or trauma, where mortality rates can approach 50–60% Infections are the leading cause of death in acute renal failure 8271 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/20/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 315 of 316 A patient presents with acute tubular necrosis Which one of the following is the most likely finding? A Urinary sodium < 20 mmol/l B Haemoglobin 10.0 g/dl C Urinary osmolality < 320 mosmol/kg D Proteinuria 3.2 g/day E Urine : plasma urea of 9:1 Explanation Acute tubular necrosis Pathological mechanism In acute tubular necrosis, the injured tubular cells fail to reabsorb sodium, tubular concentrating ability is lost, and urea clearance is low Laboratory features Small amounts of ‘tubular’ proteinuria (3 g suggests a glomerular leak A low urinary sodium concentration and high urine plasma (urea) are typical of prerenal uraemia 3618 Next Question Previous Question Tag Question https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top Feedback End Review 1/2 7/20/2016 MyPastest Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/20/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 316 of 316 A 58-year-old woman has been treated for months for reflux disease by her GP She also has a history of hypertension, Raynaud syndrome and telangiectasia Autoimmune screening reveals positive extractable nuclear antibody to SCL 70 Renal function testing reveals a creatinine of 215 μmol/l Which one of the following is the most likely cause of her renal dysfunction? A Wegener’s granulomatosis B Membranous glomerulonephritis C Systemic sclerosis D Rheumatoid arthritis E Lupus Explanation Systemic sclerosis Clinical features Oesophageal dysmotility, telangiectasia, Raynaud’s phenomenon and renal dysfunction are all features of systemic sclerosis There is also likely to be calcinosis Investigations Autoimmune testing involves anti-nuclear antibody testing Rheumatoid factor is positive in 30% Anti-SCL 70 is positive in around 30% of patients Management Treatment centres around symptom relief with the use of proton-pump inhibitors to treat reflux disease, oxygen therapy, renal replacement therapy and lung or kidney https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/20/2016 MyPastest transplant if required There are no proven disease-modifying drugs for this condition Complications Unfortunately, renal involvement in systemic sclerosis carries a poor prognosis, with rapid worsening of renal function and hypertension that is poorly responsive to therapy Associated pulmonary fibrosis and hypertension and cardiac fibrosis make treatment more difficult still 2434 End Session Previous Question Tag Question Feedback End Review Difficulty: Easy Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 ... inspiratory crackles over both lung bases Investigations: Hb 10 .4 g/dl WCC 12 .2 x109/l PLT 11 0 x109/l Na+ 14 1 mmol/l K+ 5.4 mmol/l Creatinine 2 01 μmol/l Urine protein ++, blood +++ Renal biopsy necrotising... (https://www.pastest.com/help) © Pastest 2 016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/20/2 016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 14 of 316 A 21- year-old woman... contraceptive and ramipril 10 mg daily for her blood pressure On examination her BP is 15 5/92 mmHg Abdominal examination is unremarkable Investigations: Hb 10 .9 g/dl, WCC 8.9 × 10 9/l, PLT 13 4 × 10 9/l,