NEPHROLOGY-

System Wise 1700-by Sush and Team. 2016

Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal


Dear Plabber,


• This first ever System Wise 1700 document was created thanks to 3 months of daily hard work by the

PLAB Skype group ‘Unity’ which was brought together by Dr Susmita Chowdhury.



The team members were:



& Susmita (Lead/most ignorant as she is working full time in public health for 13 years)
& Asad (Invaluable in IT and all types of support/the heart of the group)
& Manu (Volunteered to solve more questions/pathologist/amazing genuine person)
& Saima (Most concise clear notes/ photographic memory)
& Zohaib (Great research/a surgeon)
& Savia (Great research/multi-tasker with two little ones)
& Shanu (Very helpful after her March exam for those appearing in June)
& Mona (Great contributor in discussions)
& Manisha (Gyne/great discussion contributor)
& Sitara (Good discussion contributor)
& Samreena (Stayed a shorter time but great)

& Sami (Contributed the most early on but too brilliant for the group/still great friends)

& Komal (Knowledgeable sweet supportive girl)

• The main purpose was to break down the 1700 Q Bank System wise.

• We did our own reliable research for the options (OHCM/Patient info etc.) and concluded these keys
below on skype. This can save you 100s of hours of research. But I suggest you also do your own.

• 90% of the document consists of Unity research. We also added information from other circulating
documents and they are referenced as Dr Khalid/Dr Rabia (and her Team).

• However, several keys may be ‘incorrect’ and so please use your own judgment as we take no
responsibility. I suggest cross checking with Dr Khalid’s latest keys (a few of which are still debatable).
Finally decide on your own key.

• Sorry if some members failed to make their answers thorough. The highlights are mostly as per what
the team members wanted to highlight. Blank tables to be ignored.

• Note that some 1700 Questions are missing from here (when members did not do their share).
Questions may not be in order due to merging of documents and there is excess information than
required. Read as much as needed.



• This has been circulated by our team as a generous contribution to the Plabbers’ success and must

not be ‘sold’.


Good luck and best wishes: Sush and Team

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 NEPHROLOGY- System Wise 1700-by Sush and Team. 2016
Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

Q:469 469. A 10yo girl presents with pallor and features of renal failure. She has
hematuria as well as proteinuria. The serum urea and creat are elevated.
These symptoms started after an episode of bloody diarrhea 4days ago. What
is the most probable dx?
a. TTP- women (autoimmune disease)
b. HUS- Haemolytic anaemia, thrombocytopaenia and Renal failure. I
c. ITP- women (autoimmune disease)-
d. HSP- after upper RTI, sore throat, IgA (vasculitis), rash on bottom, non
thrombocytopenic
e. ARF

Clincher(s)
A
B
C
D
E
KEY B
Additional
Information
Reference
Dr Khalid/Rabia KEY- B
Haemolytic Uraemic Syndrome (HUS) is a triad of Haemolytic anaemia,
thrombocytopaenia and Renal failure. It is said to be caused most commonly
by E.coli O:157H7 which binds to endothelial receptors in the GIT, Renal and
central nervous system.

Symptoms [ abdominal pain, pallor due to anaemia, hematuria and
proteinuria, features of renal failure like- nausea/vomiting, swelling of face,
hand, feet or entire body etc. and elevated urea and creatinine etc.] start
around two weeks after an episode of bloody diarrhea. The diarrheoa is
charactised to get bloody after 1-3 days. This scenario is typical for HUS.

It is also known to be precipitated by strept pneumonia and some drugs like
cyclosporin and tacrolimus.



Q:506 506. A 10yo boy is clinically obese and the shortest in his class. He had a renal
transplant last year and his mother is worried that he is being bullied. What is
the most probable dx?
a. Cushing’s syndrome
b. Congenital hypothyroidism
c. Pseudocushing’s syndrome
d. Lawrence moon biedel syndrome
e. Down Syndrome

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 NEPHROLOGY- System Wise 1700-by Sush and Team. 2016
Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal


Clincher(s)
A
B
C
D
E A
KEY
Additional
Information
Reference
Dr Khalid/Rabia a. Cushing’s syndrome
he's on steroids post-renal transplant, Oral steroids is the chief cause of
Cushing's syndrome (OHCM, 8th, page 124). Steroids, causes suppresses supra
renal gland . cushings diseases- from pituitary

Laurance-moon synd. Night blindness due to retinitis pigmentosa, polydactyly
are important features (OHCS/8th/648). With no emphasis on more common
features, Oral-steroid induced (post renal transplant) Cushing makes more
sense.

Congenital hypothyroidism Feeding difficulties, Somnolence, Lethargy, Low
frequency of crying, Constipation

Down’s syndrome he is clinically obese not conganital case,down syndrome

has cardaic problem and characteristic facial feature and mentalyy retarded so
it cant be option,these features are same for lawrence moon but ptnt are
mentally retarded whereas kid is studying in normal school rather than special
one
Pseudocushing’s syndromeit is mainly an idiopathic condition.Some frequently
occurring illnesses can induce a phenotype that largely overlaps with Cushing
syndrome and is accompanied by hypercorticolism



Q:1161 1161. A 14yo boy has been dx with nephrotic syndrome. 5d later he presents
with flank pain, hematuria and fluctuating urea levels. A dx of renal vein
thrombosis is made. What is the most likely cause for renal vein thrombosis?

a. Protein C deficiency

b. Vasculitis

c. Loss of antithrombin III

d. High estrogen levels

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

e. Stasis

Clincher(s)
A
B
C
D
E
KEY C
Additional
Information
Reference
Dr Khalid/Rabia key : c

Complications of nephrotic syndrome include:

• Decreased resistance to infections, due to urinary immunoglobulin

loss.

• Increased risk of arterial and venous thrombosis, due to loss of

antithrombin III and plasminogen in the urine, combined with an
increase in hepatic synthesis of clotting factors. Adults with
membranous nephropathy are at particular risk

• Acute kidney injury

• Chronic kidney disease may occur as a result of an underlying cause

- eg, amyloidosis or diabetes.

Increased risk of osteitis fibrosa cystica and osteomalacia due to loss of vitamin
D-binding protein


Q:1535 1535. A 75yo man has urinary symptoms of hesitancy, frequency and nocturia.
Rectal exam: large hard prostate. What is the most appropriate inv?
a. CA 125
b. CA 153
c. CA 199
d. CEA
e. PSA


Clincher(s)
A
B
C

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

D
E
KEY E
Additional
Information
Reference
Dr Khalid/Rabia Answer: E
Prostate-specific antigen (PSA)

Cancer type: Prostate cancer
Tissue analyzed: Blood
PSA is produced exclusively by epithelial prostatic cells, both benign and
malignant. It is also found in the serum. Serum PSA is currently the best
method of detecting localised prostatic cancer and monitoring response to
treatment but it lacks specificity, as it is also increased in most patients with
benign prostatic hyperplasia.



Q:1554 1554. An elderly lady presents with confusion. She is apyrexial but complains
of dysuria for 2 days duration. What is the definitive dx investigation?
a. Blood culture
b. Urine nitrites
c. CT head
d. ECG
e. IVU


Clincher(s)
A
B
C
D
E
KEY B
Additional
Information
Reference
Dr Khalid/Rabia Key: Urine Nitrites (B)
Reason: According to the OHCM pg. 288, if symptoms are present, dipstick the
urine and treat empirically if nitrites or leucocytes are positive while awaiting
culture of an MSU.
ECG and CT Head are useless tests and IVU doesn’t make sense because we
aren’t looking for an obstructive cause. You only go for imaging studies if it is
recurrent and there is failure with standard treatment. Most accurate test –
URINE CULTURE.

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

Discussion:
Urinary tract infection (UTI) - this implies the presence of characteristic
symptoms and significant bacteriuria from kidneys to bladder. Many
laboratories regard 105 colony-forming units per millilitre (cfu/ml) as the
threshold for diagnosing significant bacteriuria.
Organisms:
Several micro-organisms are known to cause UTI, but the majority of infections
will be produced by three organisms:
* Escherichia coli
* Staphylococcus saprophyticus
* Proteus mirabilis
Infection with less common organisms is more likely to occur in patients who
have underlying pathology and/or frequent infections, are immunosuppressed,
or who are catheterised. Organisms which may produce infection under these
circumstances include:
* Klebsiella spp.
* Proteus vulgaris
* Candida albicans
* Pseudomonas spp.
Signs: Fever, abdominal/ loin tenderness, foul smelling urine.
Symptoms: Frequency, dysuria, urgency, hematuria, suprapubic pain.
Tests:
* Dipstick urine – nitrites or leukocytes positive mean UTI. Treat empirically.
* MSU sample for culture and sensitivity.
* CBC, Urea & Electrolytes, Blood culture if systemically unwell.
Imaging: usually done in males, children or persistent cases.
* USG and refer to urology for assessment.
* CT-KUB.
* Urodynamics.
Management:
* Drink plenty of fluids.
* Trimethoprim 200mg x 12 hourly PO OR Nitrofurantoin 50mg x 6 hourly PO
for 3-6 days OR Amoxicillin 500mg x 8 hourly PO.
* Second-line: Co-Amoxiclav 7 day course PO.


Q:1565 A 75yo man presents with ARF. He has been troubled by recurrent epistaxis
but over the last 3wks he reports to have coughed up blood too. What is the
single most likely positive antibody?
a. P ANCA
b. C ANCA
c. Anti Ro
d. Anti DS DNA
e. Anti centromere
Renal failure and lung- Wegener’s Granulomatosis or Good pastures syndrome
(type 4 collage found in lungs – alveloa- so he is alveolar and basement

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

membrane
Clincher(s)
A
B
C
D
E
KEY B
Additional
Information
Reference
Dr Khalid/Rabia Key: C ANCA (B)
Reason: This patient has Wegener’s Granulomatosis which affects the upper
and lower respiratory tract and presents with renal insufficiency. It is C ANCA
positive and is treated by steroids or cyclophosphamide.

Discussion: Also called granulomatosis with polyangiitis (so vessels affected ).
Affects the upper respiratory tract, lungs and kidneys.
* Nasal obstruction, ulcers, epistaxis. Destruction of nasal septum causing a
characteristic saddle nose deformity.
* Rapidly progressive GN with crescent formation, hematuria and proteinuria
can occur.
* Cough, hemoptysis, pleuritis.
Investigations:
* C-ANCA, Raised ESR and CRP.
* Urine R/E to check for proteinuria or hematuria. If present, renal biopsy to
confirm.
* Chest X-ray – Nodules and fluffy infiltrates of pulmonary haemorrhage.
* CT Scan – Diffuse alveolar haemorrhage.
Treatment:
* Severe disease should be treated with steroids and cyclophosphamide or
rituximab to induce remission.
* Methotrexate or azathioprine for maintenance.
* Patients with severe renal disease may benefit for plasma exchange.
* Co-Trimoxazole should be given as prophylaxis against P. jiroveci infection.



Q:1703 A 34yo man had a 4mm ureteric stone which he passed in urine. This time he
presents with 3cm stone in the right kidney. Single most appropriate
treatment?
a. No treatment
b. ESWL (extra corp shock wave)
c. Laparotomy
d. Observe
e. Operative stone removal

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

Less than 4-5mm: increase fluid intake; Less then 1-2cm ESWL; if more then
operative – Percutaneous nephrolithotomy
Clincher(s)
A
B
C
D
E
KEY E
Additional OHCM
Information
Initially: Analgesia, eg diclofenac 75mg IV/IM, or 100mg PR. 225 (If CI: opioids)
+ IV fl uids if unable to tolerate PO; antibiotics (eg cefuroxime 1.5g/8h IV, or
gentamicin) if infection. Stones <5mm in lower ureter: ~90–95% pass
spontaneously. fl uid intake.
Stones >5mm/pain not resolving: Medical expulsive therapy: nifedipine
10mg/8h PO 226 or -blockers (tam sulosin 0.4mg/d 227) promote expulsion
and reduce analgesia requirements:228 start at presentation. 229 Most pass
within 48h (>80% after ~30d).
If not, try extracorporeal shockwave lithotripsy (ESWL) (if <1cm), or
ureteroscopy using a basket. 230 ESWL: US waves shatter stone. SE: renal
injury, may also cause BP and DM. 231 Percutaneous nephrolithotomy
(PCNL): keyhole surgery to remove stones,when large, multiple, or complex.
232 Open surgery is rare.
Indications for urgent intervention (delay kills glomeruli): Presence of
infection and obstruction—a percutaneous nephr ostomy or ureteric stent
may be needed to relieve obstruction (p642); urosepsis; intractable pain or
vomiting; impending ARF;obstruction in a solitary kidney; bilateral obstructing
stones. 232
Prevention General: Drink plenty. Normal dietary Ca2+ intake (low Ca2+ diets
increase oxalate excretion). Specifi cally: •Calcium stones: in hypercalciuria, a
thiazide diuretic is used to Ca2+ excretion •Oxalate: oxalate intake;
pyridoxine may be used p312) •Struvite: treat infection promptly •Urate:
allopurinol (100–300mg/24h PO).
Urine alkalinization may also help, as urate is more soluble at pH>6 (eg with
potassium citrate or sodium bicarbonate) •Cystine: vigorous hydration to keep
urine output >3L/d and urinary alkalinization (as above). D-penicillamine is
used to chelate cystine, given with pyridoxine to prevent vitamin B6 defi ciency
PCNL > 2 CM STONE

Renal stones: management

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

Acute management of renal colic

Medication

• the British Association of Urological Surgeons (BAUS) recommend

diclofenac (intramuscular/oral) as the analgesia of choice for renal colic*
• BAUS also endorse the widespread use of alpha-adrenergic blockers to
aid ureteric stone passage

Imaging

• patients presenting to the Emergency Department usually have a KUB x-

ray (shows 60% of stones)
• the imaging of choice is a non-contrast CT (NCCT). 99% of stones are
identifiable on NCCT. Many GPs now have direct access to NCCT

Stones < 5 mm will usually pass spontaneously. Lithotripsy and
nephrolithotomy may be for severe cases.

Prevention of renal stones

Calcium stones may be due to hypercalciuria, which is found in up to 5-10% of
the general population.

• high fluid intake

• low animal protein, low salt diet (a low calcium diet has not been shown
to be superior to a normocalcaemic diet)
• thiazides diuretics (increase distal tubular calcium resorption)

Oxalate stones

• cholestyramine reduces urinary oxalate secretion

• pyridoxine reduces urinary oxalate secretion

Uric acid stones

• allopurinol
• urinary alkalinization e.g. oral bicarbonate

*Diclofenac use is now less common following the MHRA warnings about
cardiovascular risk. It is therefore likely the guidelines will change soon to an
alternative NSAID such as naproxen

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal


Reference
Dr Khalid/Rabia


Q:1072 A 61yo man, known smoker, comes to the hospital with complaints of painless
hematuria, urgency and dysuria. He has been worried about his loss of weight
and reduced general activity. Which inv would be diagnostic of his condition?
a. Urine microscopy
b. IVU
c. CT
d. Cystoscopy
e. US abdomen
f. KUB
g. Cystoscopy with biopsy
h. Mid stream urine for culture
i. Transrectal U

Clincher(s) 61yr,smoker,Painless hematuria,loss of weight
A No signs of uti so microscopy is not required here.
B It is an Xray of urinary tract following injection of contrast.not helpful in this
case
C CT urogram can be diagnostic but its not the first line
D Cystoscopy alone is not beneficial here
E not diagnostic here
KEY G.cystoscopy with biopsy can diagnose tumour and its type

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

Additional
Information

Reference Ohcm page 648
Dr Khalid/Rabia


Q:1186 A homeless lady presents with cough and fever. She complains of night sweats
and weight loss. CXR has been done and shows opacity. What is the next
appropriate management?
a. AFB
b. Mantoux test
c. IFN gamma testing

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d. Bronchoscopy
e. CT

Clincher(s) Cough with fever,night sweats,wight loss,CXR shows opacity
A AFB to detect Mycobacterium TB.diagnostic.
B Can show exposure only
C nterferon-release assays (IGRAs) represent advances in tuberculosis
immunology and evolutionary biology. IGRAs were designed to replace
tuberculin skin test (TST) for the diagnosis of latent tuberculosis infection
because of their logistical advantages and enhanced specificity over TST.
Although IGRAs and TST have been useful in epidemiologic studies, they lack
the sensitivity and reproducibility normally expected from diagnostic tests in
clinical practice
D Used to visualize and detect airway pathology and to look for forign body in
the airway
E Not required
KEY A
Additional
Information
Reference
Dr Khalid/Rabia a. AFB
Mantoux test can only tell you "the exposure which may be the past", can't
confirm active disease
INVESTIGATIONS:
1- CXR
2- Sputum for AFB/culture
3- BAL


Q:1213 What are the side effects of thiazide diuretics?
a. Hypocalcemia
b. Hyponatremia
c. Hypernatremia
d. Hyperkalemia

Clincher(s) Straight foraward
A
B
C
D
E
KEY B

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

Additional
Information

Thiazide diuretics work by inhibiting sodium absorption at the beginning of the
distal convoluted tubule (DCT). Potassium is lost as a result of more sodium
reaching the collecting ducts. Thiazide diuretics have a role in the treatment of
mild heart failure although loop diuretics are better for reducing overload. The
main use of bendroflumethiazide was in the management of hypertension but
recent NICE guidelines now recommend other thiazide-like diuretics such as
indapamide and chlortalidone
Reference BNF page 87
Dr Khalid/Rabia Thiazide diuretics - Bendroflumethiazide, hydrochlorothiazide
Low dose to treat hypertension
Also used in combination with loop diuretics to treat heart failure
(Metolazone)
In case of hypertension, if patient is intolerant to calcium channel blockers,
thiazide diuretics are prescribed.
Side effects include hyponatremia, hypokalemia, hypomagnesemia,
hyperuricaemia, metabolic alkalosis, hypotension, hypovolaemia


Q:1238 A 36yo man has been dx with DI. What electrolyte picture is expected to be
seen?
a. High serum Na, low serum osmolarity, high urine osmolarity
b. Low serum Na, low serum osmolarity, high urine osmolarity
c. Low serum Na, high serum osmolarity, high urine osmolarity
d. High serum Na, high serum osmolarity, low urine osmolarity
e. Normal Na, normal serum osmolarity, normal urine osmolarity


ADH works on water loss (wont take na with it) and there is more water loss
and so more concentration in serum (more Na in serum)
Clincher(s)
A

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

B
C
D
E
KEY
Additional
Information

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Susmita, Asad, Manu, Saima, Zohaib, Savia, Shanu, Mona, Manisha, Sitara, Samreena, Sami and Komal

Reference Ohcm page 232,233
Dr Khalid/Rabia Diabetes Insipidus (D)
Diabetes insipidus is a condition in which your ability to control the balance of
water within your body does not work properly. The kidneys are not able to
regulate the
amount of water that passes out in the urine. This means that the patient
passes large amounts of dilute urine – polyuria.
Because of passing more urine, and therefore losing more fluid from the body,
to try to compensate for this, the patient becomes thirstier and wants to drink
more – polydipsia.
Patients with this condition become dehydrated easily. The levels of sodium
and potassium salts in the blood can also become unbalanced and too high.
- Points to look for:
- Dilute Urine -> Low urine osmolality
- Dehydration -> High serum sodium and hence high serum osmolalityo


Q:1256 26yo man presents with painless hematuria. He has no other complaints and
on examination no other abnormality is found. What is the most appropriate
initial inv to get to a dx?
a. Cystoscopy
b. Midstream urine for culture
c. Abdominal US
d. MRI spine
e. Coag screening

Clincher(s) Young patient,painless hematuria
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia C.Abdominal US. As the patient is young so we can't go for cystoscopy. The
initial investigation in this patient should be abdominal US to exclude any
pathology in the genitourinary tract. PKD can also be suspected here so US
should be done to exclude that aswell first.

Q: 173 A 15yo boy presents with generalized edema. His urinalysis reveals protein
+++, eGFR =110. What is the most likely dx?
a. IgA nephropathy
b. Membranous nephropathy
c. Minimal change disease

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d. PSGN
e. Lupus nephritis


Clincher(s)
A Hematuria, hypertension, oliguria. Post infectious- in nephritic syndrome
B Nephritic syndrome – more in diabetic
C Nephrotic- oedema
D 7-21 days after a streptococcal infection
E More after After drugs (SLE kind)
KEY The key is C. Minimal change disease. [Points in favour: i) Age 15 yrs ii)
Generalized oedema iii) Protein in urine +++ vi) Normal eGFR of 110 (Normal
range- 90 to 120 mL/min)].
Additional Minimal Change Disease (MCD, also known as Nil Lesions, Nil Disease,
Information or lipoid nephrosis) is a disease of the kidney that causes nephrotic
syndrome and usually affects children (peak incidence at 2–3 years of age).[1]

Minimal Change Disease

The three hallmarks of Minimal Change Disease:
diffuse loss of podocyte foot processes,
vacuolation, and the appearance of microvilli.

Minimal Change Disease is most common in very young children but can occur
in older children and adults. It is by far the most common cause ofnephrotic
syndrome (NS) in children between the ages of 1 and 7, accounting for the
majority (about 90%) of these diagnoses.[2] Among teenagers who develop NS,
it is caused by minimal change disease about half the time. It can also occur in
adults but accounts for less than 20% of adults diagnosed with NS. Among

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children less than 10 years of age, boys seem to be more likely to develop
minimal change disease than girls. Minimal change disease is being seen with
increasing frequency in adults over the age of 80.
People with one or more autoimmune disorders are at increased risk of
developing minimal change disease. Having minimal change disease also
increases the chances of developing other autoimmune disorders.
Most cases of MCD are idiopathic, but there have been causes of secondary
MCD identified, including medications, immunizations, neoplasm, and
infection. Case reports and literature reviews have shown an association
between MCD and malignancies, particularly hematologic malignancies, such
as Hodgkin’s disease, non-Hodgkin lymphomas, or leukemias. Colorectal
cancer-associated MCD is uncommon and has been reported in only a few
cases to date.[3]

Symptoms[edit]
The symptoms are proteinuria (leakage of protein into the urine)
and edema (water retention). Nephrotic syndrome (NS) is a general term that
refers to the loss of protein in the urine,hypoalbuminemia, and edema. Many
conditions are categorized as nephrotic syndromes—minimal change disease is
unique, because it is the only one lacking any evidence of pathology on light
microscopy (hence the name).
When protein is lost in the urine, the concentration of protein in the blood
decreases, thereby reducing the intravascular Oncotic pressure relative to the
interstitial tissue. The subsequent movement of fluid from the vascular
compartment to the interstitial compartment manifests as the swelling known
as edema. Edema is commonly observed in the feet and legs, particularly in
individuals with poorly functioning venous valves, and in the belly or abdomen
(ascites), and around the eyes, but can occur anywhere, especially in response
to gravity. Additionally, because of this extra fluid that stays in the body,
individuals often gain weight and experience fatigue—in many patients, for
example, clothes and shoes no longer fit. Some people notice that their urine
becomes more frothy or foamy from the excess protein in the urine, and may
find that they urinate less often.

Pathology[edit]
For years pathologists found no changes when viewing specimens under light
microscopy; hence the name minimal change disease. With the advent
of electron microscopy, the changes now known as the hallmarks for the
disease were discovered. These are diffuse loss of visceral epithelial cells foot

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processes (podocyte effacement),[4] vacuolation, and growth of microvilli on
the visceral epithelial cells.
The pathology of minimal change disease is unclear and is currently
considered idiopathic. The pathology does not appear to
involve complement, immunoglobulins, or immune complex deposition.
Rather, an altered cell-mediated immunologic response with abnormal
secretion of lymphokines by T cells is thought to reduce the production of
anions in the glomerular basement membrane, thereby increasing the
glomerular permeability to serum albumin[5] through a reduction
of electrostatic repulsion.[6] The loss of anionic charges is also thought to favor
foot process fusion.[1] The etiological agent is somewhat of a mystery but
viruses such as EBV, and food allergies have been implicated. Also, the
exact cytokine responsible has yet to be elucidated, with IL-12, IL-18 and IL-
13 having been most studied in this regard, yet never conclusively implicated.



Reference ttps://en.wikipedia.org/wiki/Minimal_change_disease
Dr Khalid/Rabia Most common cause of nephrotic syndrome in children is minimal change
disease. There will be hypoalbuminemia and peripheral edema too. Electron
microscopy shows effacement of podocyte foot processes.. MCD has albumin
selective proteinuria. Treatment is with steroids.



Q: 205 46yo man, known case of chronic GN presents to OPD. He feels well. BP =
140/90mmHg. Urine dipstick: protein ++, blood ++ and serum
creatinine=106mmol/L. Which medication can prevent the progression of this
dx?
a. ACEi
b. Diuretics
c. Cytotoxic meds
d. Longterm antibiotics
e. Steroids


Clincher(s)
A Usually in diabetics : ACE in
B
C
D
E
KEY The key is A. ACEI. [renal impairment is delayed by ACEI].

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Additional ACEI prevents progreesion to renal failure in the presence of proteinuria. ohcm
Information pg 294
Except when protein too high
Aci most importantly prevents proteinuria

Reference
Dr Khalid/Rabia


Q: 269 A 66yo man, an hour after hemicolectomy has an urine output of 40ml.
However, an hour after
that, no urine seemed to be draining from the catheter. What is the most
appropriate next step?
a. IV fluids
b. Blood transfusion
c. Dialysis
d. IV furosemide
e. Check catheter


Clincher(s)
A
B
C
D
E
KEY Key = E
Points in favour = Always check catheter for any obstruction or other
abnormality before iv fluids.

Additional As the patient is post surgery, he would have already got enough IV fluids.
Information blood tranfusion also not indicated
you will check catheter as it might not be inserted properly or it came out
which is not collecting the urine and makes us think there is no urine and the
patient might have became anuric.

Reference
Dr Khalid/Rabia


Q: 303 A 34yo African-caribbean man with a hx of sarcoidosis has presented with
bilateral kidney stones. What is the most likely cause for this pt’s stones?
a. Hypercalcemia
b. Hyperuricemia
c. Diet

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d. Recurrent UTIs
e. Hyperparathyroidism

Clincher(s)
A
B
C
D
E
KEY The key is A. Hypercalcemia.
Additional Dysregulated calcium metabolism is a well-recognized complication of
Information sarcoidosis, resulting in hypercalcaemia (prevalence 5–10%), hypercalcuria
(40–62%) and reduced bone density (40–55%).

Hypercalcuria is the most common defect of calcium metabolism in
sarcoidosis, with a prevalence of 40–62% in published series [3, 4]. Clinically
significant hypercalcaemia is less frequent and is generally asymptomatic,
occurring in approximately 5% of patients [5]. Long-standing hypercalcaemia
and hypercalcuria can cause nephrocalcinosis, which accounts for over half the
patients with sarcoidosis who have renal impairment [6] and is the major
cause of chronic renal failure. Other renal complications of sarcoidosis due to
abnormal calcium metabolism include nephrolithiasis in approximately 10% of
patients [7], and more rarely tubular disorders such as nephrogenic diabetes
insipidus [8]. Symptomatic hypercalcaemia presenting with dehydration,
polyuria and an altered conscious state is a rare but recognized complication of
sarcoidosis.

Reference http://rheumatology.oxfordjournals.org/content/39/7/707.full
Dr Khalid/Rabia Hypercalcemia in sarcoidosis is due to the uncontrolled synthesis of 1,25-
dihydroxyvitamin D3 by macrophages. 1,25-dihydroxyvitamin D3 leads to an
increased absorption of calcium in the intestine and to an increased resorption
of calcium in the bone.



Q: 369 A pt presents with complete anuria following prolonged hypotension and
shock in a pt who bled
profusely from a placental abruption. What is the most probable dx?
a. Post viral infection
b. Acute papillary necrosis
c. Acute cortical necrosis
d. HUS
e. Renal vein thrombosis


Clincher(s)

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A
B
C
D
E
KEY The key is C. Acute cortical necrosis.
Additional acute cortical necrosis) is a rare cause of acute kidney failure. The condition is
Information "usually caused by significantly diminished arterial perfusion of the kidneys
due to spasms of the feeding arteries, microvascular injury, or disseminated
intravascular coagulation" and is the pathological progression of acute tubular
necrosis.[1] It is frequently associated with obstetric catastrophes such
as abruptio placentaeand septic shock, and is three times more common in
developing nations versus industrialized nations (2% versus 6% in causes
of acute kidney failure).[citation needed]

Causes[edit]
In adults[edit]

• Pregnancy related (>50% of cases)

• Placental abruption
• Infected abortion
• Prolonged intrauterine fetal death
• Severe eclampsia
• HIV[2]
• Snake bites[3]
• Binge drinking[4]
• Shock
• Trauma
• Sickle cell disease[5]
• Systemic lupus erythematosus (SLE)[6]
• Sepsis[7]
• SLE-associated antiphospholipid syndrome[8]
• Vitamin deficiency[9]
• Pancreatitis[10]
• Malaria[11]
• Meningococcemia[12]
• Drug-induced toxicity (e.g. NSAIDs, Contrast Media, Quinine,[13] or ATRA[14])
Neonatal[edit]

• Congenital heart disease

• Fetal-maternal transfusion

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• Dehydration
• Perinatal asphyxia
• Anemia
• Placental hemorrhage
• Severe hemolytic disease
• Sepsis[7]

Pathophysiology[edit]
The exact pathologic mechanism for RCN is unclear, however the onset of
small vessel pathology is likely an important aspect in the etiology of this
condition. In general the renal cortex is under greater oxygen tension and
more prone to ischemic injury, especially at the level of the proximal collecting
tubule, leading to its preferential damage in a sudden drop in perfusion.
Rapidly corrected acute renal ischemia leads to acute tubular necrosis, from
which complete recovery is possible, while more prolonged ischemia may lead
to RCN. Pathologically, the cortex of the kidney is grossly atrophied with
relative preservation of the gross structure of the medulla. The damage is
usually bilateral owing to its underlying systemic causes, and is most
frequently associated with pregnancy (>50% of cases).[1] It accounts for 2% of
all cases of acute kidney failure in adults and more than 20% of cases of acute
kidney failure during late pregnancy.[15][16]

Diagnosis[edit]
While the only diagnostic "gold standard" mechanism of diagnosis en vivo is
via kidney biopsy, the clinical conditions and blood clotting disorder often
associated with this disease may make it impractical in a clinical setting.
Alternatively, it is diagnosed clinically, or at autopsy, with some authors
suggesting diagnosis by contrast enhanced CT.[17]

Treatment[edit]
Patients will require dialysis to compensate for the function of their kidneys.
Prognosis:
Cortical necrosis is a severe and life-threatening condition, with mortality rates
over 50%.[citation needed] Those mortality rates are even higher in neonates with
the condition due to the overall difficult nature of neonatal care and an
increased frequency of comorbid conditions. The extent of the necrosis is a
major determinant of the prognosis, which in turn is dependent on the
duration of ischemia, duration of oliguria, and the severity of the precipitating
conditions. Of those that survive the initial event, there are varying degrees of
recovery possible, depending on the extent of the damage.

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Reference https://en.wikipedia.org/wiki/Renal_cortical_necrosis
Dr Khalid/Rabia There are 2 reasons for this acute cortical necrosis. i) significant diminished
arterial perfusion of the kidneys due to spasm of the feeding artery secondary
to profuse bleeding from placental abruption ii) DIC secondary to placental
abruption.


Q:386 A 39yo man with acute renal failure presents with palpitations. His ECG shows
tall tented T waves and wide QRS complex. What is the next best step?
a. Dialysis
b. IV calcium chloride
c. IV insulin w/ dextrose
d. Calcium resonium
e. Nebulized salbutamo

Clincher(s) Tall tented t waves and wide qrs and acute renal failure
A Persistent hyper kalemia >7mmol/l needs dialysis
B
C Once cardio protective agent is given then we give this.
D Calcium resonium is a polystyrene cation exchange resin which acts to
remove excess potassium from the body by exchanging it for the cation ion
(Ca++) in the resin. It is a relatively slow method of reducing serum
potassium.


E Can be given if insulin and dextrose can't be given as it helps moves the
potassium inside the cell but can increase the pulse.
KEY B
Additional
Information
Reference
Dr Khalid/Rabia IV calcium chloride (both IV calcium gluconate or IV calcium chloride can be
used) when there is ECG changes.
DX The ECG changes are suggestive of Hyperkalemia.
At potassium level of >5.5mEq/L occurs tall tented T waves and at potassium
level >7mEq/L occurs wide QRS complex with bizarre QRS morphology.


Q:556 . A pt after transurethral prostatic biopsy. What electrolyte imbalance can he
develop?
a. Hyperkalemia
b. Hyponatremia
c. Hypocalcemia
d. Hypernatremia
e. Hypercalcemia

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Clincher(s) Transurethral prostatic biopsy done
A
B
C
D
E
KEY B
Additional
Information
Reference
Dr Khalid/Rabia Transurethral Resection of the Prostate (TURP) Syndrome is a rare but
potentially life-threatening complication of a transurethral resection of the
prostate TURP procedure.
It occurs as a consequence of the absorption into the prostatic venous sinuses
of the fluids used to irrigate the bladder during the operation. Symptoms and
signs are varied and unpredictable, and result from fluid overload and
disturbed electrolyte balance and hyponatraemia. Treatment is
largely supportive and relies on removal of the underlying cause, and organ
and physiological support. Preoperative prevention strategies are extremely
important.



Q:598 A 72yo woman who is taking loop diuretics is suffering from palpitations and
muscle weakness.
What is the electrolyte imbalance found?
a. Na+ 130mmol/l, K+ 2.5mmol/l
b. Na+ 130mmol/l, K+ 5.5mmol/l
c. Na+ 140mmol/l, K+ 4.5mmol/l
d. Na+ 150mmol/l, K+ 3.5mmol/l
e. None


Clincher(s) Loop diuretic electrolyte imbalance
A
B
C
D
E
KEY A
Additional Normal values
Information Na: 135-145mmol/l
K: 3.5-5mmol/l
Reference
Dr Khalid/Rabia Hypokalemia can occur with loop or thiazide diuretics.

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Q:632 A 34yo man complains of arthralgia, abdominal pain and vomiting, a facial rash
that is worse in the summer and hematuria. Urea and creatinine are slightly
elevated with urinalysis demonstrating red cell casts. PMH is remarkable for
childhood eczema. Which inv is most likely to lead to a dx?
a. US KUB
b. Joint aspiration
c. Auto antibodies
d. IVU
e. Renal biopsy

Clincher(s) Arthralgia, abd pain, vomiting,facial rash worse in summer, haematuria ,
urge and creatinine slightly elevated, hvx of childhood eczema
A
B
C
D
E
KEY C
Additional
Information
Reference
Dr Khalid/Rabia Dr Rabia
HSP mostly in children after a viral infection and with a palpable purpura on
buttocks and extensor surfaces. JAKS


Si can't be HSP.
SLE yes I agree a lot of presentations going in favour of SLE. arthralgias rash
photosensitivity renal involvement. I don't recall abdominal pain and vomiting
in SLE.
SLE - Facial Rash, worsen by sunlight, arthralgia, Nephritis, Other immune
problems ( eczema )
Dr Khalid
The key is C. Auto antibodies. [Likely diagnosis is SLE for which auto antibody
(anti ds DNA
antibody) should be done].



Q:689 A 10yo boy presents with generalized swelling. This has been present for 4days
and included swollen ankles and puffiness of the face. It started a few days
after he had a mild cold with runny nose. His only PMH was eczema. Urine
analysis: hematuria, proteinuria 10g/24h, creat
60umol/l and albumin=15g/l. What is the single most likely dx?

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a. IgA nephropathy
b. HSP
c. Minimal change nephropathy
d. Wilson’s disease
e. Cardiac failure

Clincher(s) Swollen ankles, puffiness of face,proteinuria, hx of eczema, low albumin,
mild cold and runny nose.
A Typical pt is young man with episodic hematuria
B Systemic variant of IgA nephropathy with flirting arthritis, extensor purpurin
rash, abd pain and nephritis (JAKS)
C No hx of hematuria
D Not relevant in this scenario
E Not relevant in this scenario
KEY A
Additional Illnesses that can precipitate haematuria include urinary tract infection,
Information pneumonia, staphylococcal infection, acute gastroenteritis, influenza and
glandular fever.
The disease can be highly variable, ranging from microscopic haematuria to
rapidly progressive glomerulonephritis
Tx: BP control with Acei and steroids for immunosuppression.
Reference
Dr Khalid/Rabia the typical presentation of nephritic syndrome as well as we know the patient
upper respiratory tract infection then it lead to immune response

no hematuria in minimal change

HSP presents typically with the following JAKS joints abdomen kidney and skin
arthritis, abdominal pain, haematuria and petechiae
In hsp there is purpura on extensor surfaces, abdominal pain and nephritis
(systemic)

iga nephropathy after 2-3 days of cold infection, post strep glomerulonephritis
after 1-12wks of URTI

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Q: 992 A 27yo man presents with abdominal pain. He says his urine is dark. Exam:
BP=160/105mmHg. What is the most appropriate inv?
a. US
b. Renal biopsy
c. CT
d. Urine protein
e. Urine microscopy



Clincher(s)
A U/s usually confirms
B Unexplained acute kidney injury or chronic kidney
disease, acute nephritic syndromes, unexplained proteinuria and haematuria,
systemic
diseases associated with kidney dysfunction, suspected transplant rejectio

C
D
E
KEY Ans:A
USG will confirm
Abdominal pain, hematuria and hypertension are classic feature of autosomal
dominant polycystic kidney disease. The disease process usually begins before
the age of 30 yrs and renal failure are evident at about 60 yrs of age

Additional Ohcm (p299) or to guide treatment. 29
Information Renal biopsy :
Pre-procedure: Check FBC, clotting, group and save. The physician performing
the procedure should obtain written informed consent. Ultrasound to
delineate
anatomy. Stop anticoagulants (aspirin 1 week, warfarin 2–3 days, low
molecular
weight heparin 24 hours).
Contraindications: • Abnormal clotting • Hypertension >160/>90mmHg •
Single
kidney (except for renal transplants) • Chronic kidney disease with small
kidneys
(<9cm) • Uncooperative patient • Horseshoe kidney • Renal neoplasms.
Reference
Dr Khalid/Rabia


Q:999 999. A 65yo man complains of hematuria, frequency, hesistancy and
nocturia. He reports that on certain occasions he finds it difficult to control the
urge to pass u9rine. Urine microscopy confirms the presence of blood but no

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other features. What is the most porbable dx?
a. BPH
b. Bladder ca
c. Prostatic ca
d. Pyelonephritis
e. Prostatitis

Clincher(s) 65 yr, hematuria , frequency , hesitancy , nocturia, blood in urianalysis
A
B Painless haematuria must be treated as malignancy of the urinary tract until
proved otherwise. Assoc with smoking / occup h/o dyes ,paint (aromatic
amine),schistosmiasis( usually in developing countries ..Squamous cell tumours
usually follow chronic inflammation from stones or indwelling catheters.7th
leading cancer in uk .ranking 4th among males

C Most common cancer in men in uk .over age 65

D Fever , burning micturation , abd pain
E
KEY ANS: C
Reason: Prostatic CA, presents with symptoms of LUTS(lower urinary tract
symp) initially and in locally invasive disease there can be
hematuria,dysuria,incontinence.

Additional
Information Referral guidelines for ca bladder

Patientinfo.co
Current recommendations are for the following patients to be referred
urgently for a urological assessment:

• Adults over 45 years and have unexplained visible haematuria without

urinary tract infection.
• Adults over 45 years with visible haematuria that persists or recurs after
successful treatment of urinary tract infection.
• Adults aged 60 and over and have unexplained non visible haematuria
and either dysuria or a raised white cell count on a blood test.

A non-urgent referral for bladder cancer is recommended for those people

aged 60 and over with recurrent or persistent unexplained urinary tract

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infection.

Reference
Dr Khalid/Rabia


Q:1041 A 79yo man who is being treated with GnRH antagonist for proven
adenocarcinoma of the prostate attends a follow up session. What is the most
appropriate inv?
a. Serum AFP
b. Serum PSA
c. Serum acid phosphates conc
d. Serum ALP isoenzyme conc
e. Trans rectal US

Clincher(s)
A Liver carcinoma – following up patients
B urologists rely on rising PSA results to signal that a radical intervention (usually
either chemotherapy or radiotherapy) is necessary. This is particularly
appropriate for older patients with comorbidities
C
D
E
KEY B
Additional urologists rely on rising PSA results to signal that a radical intervention (usually
Information either chemotherapy or radiotherapy) is necessary. This is particularly
appropriate for older patients with comorbidities, on the basis that they are
likely to die of some other cause before a slow-growing prostate tumour has
an effect on their lifespan. Such 'active monitoring' is also appropriate for any
patient who wishes to avoid the side-effects of interventional management.
Most prostate cancers are adenocarcinomas arising in the peripheral zone of
the prostate gland
Risk factors: Age
Black-african
Family hx
· · Factors such as food consumption, pattern of sexual behaviour, alcohol
consumption, exposure to ultraviolet radiation, chronic inflammation and
occupational exposure have all been considered as possible risk factors
* Local disease:
o Raised PSA on screening.
o Weak stream, hesitancy, sensation of incomplete emptying, urinary
frequency, urgency, urge incontinence.

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o Urinary tract infection.
* Locally invasive disease:
o Haematuria, dysuria, incontinence.
o Haematospermia.
o Perineal and suprapubic pain. o Obstruction of ureters, causing loin pain,
anuria, symptoms of acute kidney injury or chronic kidney disease.
o Impotence.
o Rectal symptoms - eg, tenesmus.
* Metastatic disease:
o Bone pain or sciatica.
o Paraplegia secondary to spinal cord compression.
o Lymph node enlargement.
o Loin pain or anuria due to ureteric obstruction by lymph nodes.
o Lethargy (anaemia, uraemia).
o Weight loss, cachexia
* Abdominal palpation may demonstrate a palpable bladder due to outflow
obstruction.
* DRE may reveal a hard, irregular prostate gland. Indications of possible
prostate cancer are:
o Asymmetry of the gland.
o A nodule within one lobe.
o Induration of part or all of the prostate.
o Lack of mobility - adhesion to surrounding tissue.
o Palpable seminal vesicles.
Differential diagnosis * All other causes of haematuria (eg, urinary tract
infection) and urinary tract obstruction. * Benign prostatic hyperplasia. *
Prostatitis. * Bladder tumours.
INV:
PSA
Transrectal needle biopsy
· Urinalysis to exclude renal and bladder pathology. Urine sent for microscopy,
culture and sensitivities.
· Renal function tests to help exclude renal disease.
MRI should be considered for men with a negative TRUS core biopsy to
determine whether another biopsy is needed
MRI for staging
Bone scan for mets
The National Institute for Health and Care Excellence (NICE) referral
guidelines for suspected cancer state:[11]
* Men presenting with symptoms suggesting prostate cancer should have a
DRE and PSA test after counselling. Symptoms will be related to the lower
urinary tract and may be inflammatory or obstructive. Prostate cancer is also a
possibility in male patients with any
of the following unexplained symptoms: erectile dysfunction, haematuria,
lower back pain, bone pain or weight loss, especially in the elderly.
* Urinary infection should be excluded before PSA testing, especially in men

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presenting with lower tract symptoms. The PSA test should be postponed for
at least one month after treatment of a proven urinary infection.
* If a hard, irregular prostate typical of a prostate carcinoma is felt on DRE,
then the patient should be referred urgently. The PSA should be measured and
the result should accompany the referral.
* Patients do not need urgent referral if the prostate is simply enlarged and
the PSA is in the age-specific reference range.
* In a man with or without LUTS and in whom the prostate is normal on DRE
but the age-specific PSA is raised or rising, an urgent referral should be made.
Symptomatic patients with high PSA levels should be referred urgently.
* If there is doubt about whether to refer an asymptomatic man with a
borderline level of PSA, the PSA test should be repeated after an interval of
one to three months. If the second test indicates that the PSA level is rising,
the patient should be referred urgently.
Rx: low risk localized tumor: active surveillance/surgery (personal preference)
Intermediate to high risk:
· Men with intermediate and high-risk localised prostate cancer should be
offered a combination of radical radiotherapy and androgen deprivation
therapy, rather than radical radiotherapy or androgen deprivation therapy
alone. Brachytherapy (a form of radiotherapy in which radiation is targeted
directly at the prostate gland) in combination with external-beam radiotherapy
is a treatment option for localised prostate cancer.
· Men with intermediate and high-risk localised prostate cancer should be
offered 6 months of androgen deprivation therapy before, during or after
radical external beam radiotherapy.
· Continuing androgen deprivation therapy for up to 3 years should be
considered for men with high-risk localised prostate cancer.
· High-dose rate brachytherapy in combination with external beam
radiotherapy should be considered for men with intermediate and high-risk
localised prostate cancer. Brachytherapy alone should not be offered to men
with high-risk localised prostate cancer.
Locally advanced: pelvic radiotherapy
Metastasis: bilateral orchidectomy
· Urinary tract obstruction, acute kidney injury, chronic kidney disease.
· Sexual dysfunction: erectile dysfunction, loss of libido.
· Metastatic spread: bone pain, pathological fractures, spinal cord
compression.

Reference
Dr Khalid/Rabia


Q:1057 A 30yo man presents to hosp complaining that his urine has been very dark
recently, resembling coffee at worst. He has been under the weather 2wks
back and had taken a few days off work with a sore throat and coryzal
symptoms. Urine dipstick in hosp returns highly positive for blood and protein.

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He is admitted for supportive management and is scheduled for a renal biopsy,
which shows mesangial proliferation with a positive immune-flurescence
pattern. What is the most probable dx?
a. Membranous glomerulonephropathy
b. SLE
c. Wegener’s granulomatosis
d. Post – strep GN
e. IgA nephropathy


Clincher(s)
A
B
C
D
E
KEY Dx is Post strep GN
History of sore throat, mesangial proliferation and immune flouresence
pattern point to post strep GN.
Presentation is usually nephritic syndrome.
Renal biopsy isn’t performed unless atypical presentation.
IF shows IgG and C3 deposits
Serology shows inc ASOT and inc C3
Supportive treatment with more than 95% function recovered

Additional
Information
Reference
Dr Khalid/Rabia


Q:1059 1059. A 10yo boy is brought to the hosp with a rash over his buttocks a/w
abdominal pain and vomiting. In the ED, he is accompanied by his mother and
stepfather. His mother had left him for the weekend with the stepfather and
was called to come back from holiday as he started to have some hematuria
with the rash. Social services had been notified on arrive to hospital. What is
the most probably dx?
a. NAI
b. ITP
c. HSP
d. ALL
e. HUS



Clincher(s) Rash on buttocks ( extensor ), abd pain , vomiting

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A NAI-
B Idiopathic thrombocytopenic purpura –present in women of child bearing age
most common .also occurs in 2-6yrs of children
signs of thrombocytopenia ,minor bleeding , easy bruising , petechia
,heametemsesis , melena.no spleenomegaly
IgG antibodies formed against patients platelets

C Henoch schonlein purpura HSP) is a systemic variant of IgA nephropathy,
causing
a small vessel vasculitis. Features: Purpuric rash on extensor surfaces (typically
on the legs), fl itting polyarthritis, abdominal pain (GI bleeding) and nephritis.
Diagnosis:Usually clinical. Confi rmed with positive IF for IgA and C3 in skin or
renal biopsy(identical to IgA nephropathy). Treatment: Same as IgA
nephropathy. Prognosis:15% nephritic patients  ESRF; if both nephritic and
nephrotic syndrome, 50% ESRF.
D Acute lymphocytic leukemia
E Hemolytic uremic syndrome- follows after diarhhea
KEY C) HSP
HSP is a Small vessel vasculitis with purpura (non blanching purple papules)-
buttocks and extensor surfaces. Young. Glomerulonephritis, arthritis, abd pain
(+_ intussusception) may mimic an acute abdomen. Rx is supportive.

Additional
Information
Reference
Dr Khalid/Rabia

Q: 94 A 64yo man has been waking up in the middle of the night to go to the

bathroom. He also had difficulty in initiating micturition and complains of

dribbling. A dx of BPH was made after a transrectal US guided biopsy and the

pt was prepared for a TURP. What electrolyte abnormality is highly likely due

to this surgery?

a. Hypokalemia

b. Hypocalcemia

c. Hyperkalemia

d. Hyponatremia

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e. Hypernatremia

Clincher(s)
A
B
C
D Absorption of fluid used for bladder irrigation (via 3 way catheter)
to flush out blood clots and IV fluids all may lead to hypervolaemia and
dilutional hyponatremia (Turp Syndrome)

(The liquid (glycine) used for irrigation of the bladder and prostate gets
absorbed by the venous sinuses leading to hyponatremia,fluid overload and in
the some cases glycine toxicity.)

E
KEY The key is D. Hyponatremia.
Additional Post splenctomy they always ask about two complications.
Information 1. Acute gastric dilatation((they will say patient with signs of shock n some
coffee ground color blood was collected on insertion of Ryles tube (NG tube)
after splenctomy)). Here answer will be acute gastric dilatation.
2. Thrombocytosis is second major post splenctomy complication. They will
give u a patient with splenctomy done despite being mobile he developed DVT
what might be the cause. U shud mark splenctomy

Reference
Dr Khalid/Rabia


Q: 96 A 35yo man presented with hematuria, abdominal swelling and has a BP of

190/140. What is the most diagnostic inv?

a. Cystoscopy

b. USG

c. CT

d. Renal biopsy

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e. Urine analysis

Clincher(s) Age and bp is the clincher.

A
B The diagnosis is ADPKD.
C
D
E
KEY The key is B. USG.
Additional The sensitivity of USG for PKD is nearly 100% in those above 20 years of age
Information
Reference
Dr Khalid/Rabia In given case patients age is 35. So the USG diagnostic criteria is: Age 18 – 39

yrs>3 unilateral or, bilateral cysts (here bilateral means if 1 + 1 it is enough).

Autosomal dominant polycystic kidney disease (ADPKD) is the most common

inherited cause of kidney disease, affecting 1 in 1,000 Caucasians. Two disease

loci have been identified, PKD1 and PKD2, which code for polycystin-1 and

polycystin-2 respectively

ADPKD type 1 ADPKD type 2

85% of cases 15% of cases

Chromosome 16 Chromosome 4

Presents with renal failure

earlier

The screening investigation for relatives is abdominal ultrasound:

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Ultrasound diagnostic criteria (in patients with positive family history)

• two cysts, unilateral or bilateral, if aged < 30 years
• two cysts in both kidneys if aged 30-59 years
• four cysts in both kidneys if aged > 60 years



Q: 98 A 65yo man presented with frank hematuria. He has no other urinary

symptoms. What is the most appropriate next step that will lead to the dx?

a. IVU

b. US Abdomen

c. Cystoscopy

d. Mid-stream urine for culture

e. Transrectal US

Clincher(s)
A
B
C Bladder cancer. Age 65, asymptomatic haematuria. ADPKD [at the beginning

there is very few or no symptoms]

D
E
KEY Key is C. Cystoscopy.
Additional Controversy: opinion divided with BPH : Bph with obstructive uropathy
Information causing glomerulonephropathy and accounting for hematuria plus nocturia
also suggesting he must be a diabetic so it's BPH here

Others say: In exams hematuria suggests a more alarming underlying cause like
ca prostate despite da fact that it does occur in BPH as well.

Reference

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Dr Khalid/Rabia


Q: 111 A 15yo male has bilateral ankle edema. His BP=110/70mmHg and urinalysis
shows protein++++.
What is the most likely dx?
a. HUS
b. IgA nephropathy
c. Membranous GN
d. Minimal change GN
e. Nephrotic syndrome


Clincher(s) 15 yr
A
B
C
D Points in favour: i) Age 15 ii) Ankle oedema iii) Normotension iv) Heavy
proteinuria.
Ans. 3. Treatment of choice is steroid (prednisolone). Failure of steroid or
frequent relapse (>3) cyclophosphamide.

E
KEY . The key is D. Minimal change disease.
Additional
Information
Reference
Dr Khalid/Rabia Most common cause of nephrotic in children is minimal change disease. There
will be hypoalbuminemia and peripheral edema too. Electron microscopy
shows effacement of podocyte foot processes.. MCD has albumin selective
proteinuria. Treatment is with steroids.
IgA nephropathy is nephritic and will also show HTN and microscopic
hematuria and follows upper resp tract infection.
Membranous GN also presents as nephrotic but age and since MCD is most
common we choose MCD.
Nephrotic syndrome itself is not a diagnosis.

Minimal change disease(commonest csuse of nephrotic syndrome.in young
agegroup) is the key. Loss of foot processes of podocytes leads to proteinuria
and hence edema.

It's definitely nephrotic synd... While minimal change disease is common in
children.. It peaks at 2-3 years old.. This guy being 15 is well above the age
range and we have no other clue pointing to a more specific diagnosis

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Nephrotic syndrom.points of diagnosing is protinurea, bilateral ankle
edema and no hypertentn



Q: 150 A 5yo boy is referred to the hospital and seen with his father who is
worried that he has been listless. He is not sure why his GP suggested he
should come to the ED and is keen to get some tablets and go home.
Exam: tired and irritable, swelling around eyes. Renal biopsy: remarkable
for podocyte fusion on EMicros. What is the most probable dx?
a. NAI
b. Myelodysplastic disease
c. HSP
d. Membranous GN
e. Minimal change GN



Clincher(s)
A
B
C
D
E most common form of nephrotic syndrome in children. facial edema
specially aroud the eyesmailaise n easy fatigueability occurs n same is
happening wd the pt in given senario

KEY The key is E. Minimal change glomerulonephritis. [Podocyte fusion on
electron microscopy]
Additional
Information
Reference
Dr Khalid/Rabia Most common cause of nephrotic syn in children is minimal change
disease. There will be hypoalbuminemia and peripheral edema too.
Electron microscopy shows effacement of podocyte foot processes..
MCD has albumin selective proteinuria. Treatment is with steroids.

Q: 1 A 65yo man presents with painless hematuria, IVU is normal, prostate is mildly
enlarged with mild frequency. What is the most appropriate next step?
a. US Abdomen
b. Flexible cystoscopy
c. MRI
d. Nuclear imaging
e. PSA

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Clincher(s) Painless Haematuria, mildly enlarged, mild frequency
A
B Painless haematuria ! exclude Bladder Cancer
C
D
E
KEY B Definitive inv to exclude Bladder Cancer
Additional
Information

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Reference OHCM 286 , 648
Dr Khalid/Rabia Ans. 1. The key is B. Flexible cystoscopy.
Ans. 2. Painless hematuria in an elderly (here 65 years old man) indicates
carcinoma bladder for which flexible cystoscopy is done.
An elderly gentleman complaining of painless hematuria : always exclude
bladder cancer

The most important and definite Investigation for bladder cancer is a
cystoscopy+ Biopsy.
Initially : Urine microscopy but it does not rule out CA.

Other causes of painless hematuria are rhabdomyolysis , coagulation disorder ,
prostate cancer , hemolytic anemia , renal tumor , and polycystic kidney disease

you can exclude those by absence of :
1- History of crush injury for rhabdomyolysis
2- No bleeding from other orifices for coagulation disorder
3- No symptoms of prostatism for Prostate Cancer
4- No signs of anemia
5- No tenderness in loin or masses (renal tumor)
6- No hypertension (in polycystic kidney)

although other investigations like Mid urine sample , IVU , may show UTI , other
findings like filling defects , etc.. they dont help with diagnosis and prognosis

Diagnosis : Bladder CA. (1 in 10,000)

Most common : Transistional cell CA. 3x in MEN of 50+ age.
Inc factors :
Smoking, schistosomiasis, rubber dye industries, White ppl, recurrent
infections.

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Symptoms :
Painless hematuria (on and off)
Pain in lower abdomen
Treatment :
TUR with 1 chemotherapy within 24 hours. If needed, BCG is used for next
chemo cycles.



Q: 4 79yo anorexic male complains of thirst and fatigue. He has symptoms of
frequency, urgency and terminal dribbling. His urea and creatinine levels are
high. His serum calcium is 1.9 and he is anemic. His BP is 165/95 mmHg. What
is the most probable dx?

a. BPH
b. Prostate carcinoma
c. Chronic pyelonephritis
d. Benign nephrosclerosis


Clincher(s)
A
B
C
D
E
KEY CB
Additional
Information
Reference
Dr Khalid/Rabia First to say in this case (almost all features goes in favour of prostatic
carcinoma like- frequency, urgency and terminal dribbling are features of
prostatism; Age, anorexia and anaemia favours carcinoma prostate diagnosis
and it would be accurate presentation if it was hypercalcaemia. But given
calcium level is of hypocalcaemic level and it is the main cause of discrepancy
of this question). Renal failure can be an association of malignant disease and
can cause high BP. Thirst is a feature of hypercalcaemia (here may be
erroneously calcium level is given in hypocalcaemic level ; probably a bad
recall). Prostate biopsy is the confirmatory diagnosis and others like PSA is
suggestive. This is what I could pointed out. If there is any better explanation
please place it to correct the answer- any one please.


Calciu 2.1-2.6
m mmol/l

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I think this patient has CKD secondary to prostate CA which leads to
hypocalcemia
due to vit D def.
Osteoblastic metastases — Occasional patients with widespread osteoblastic
metastases, particularly those with breast or prostate cancer, have
hypocalcemia.

Diagnosis : Prostate Cancer
Most common CA in men of uk. 1 in 8 men. After 65.
Risk factors: Fatty diet, exposure to cadmium, ageing n family history.

Symptoms :
Poor stream, hesitancy, dribbling, frequency, urgency, poor emptying.

Invs :
Examine. PSA levels.
Confirmatory test : Biopsy.

Grading : Gleason Score.
4 or less - well differentiated. 10 yr risk of local progression 25%
5 - 7 - moderately differentiated. 50% risk
Over 7 - poorly differentiated. 75% risk

Risk assessment PSA levels.
Low - <10 and gleason score 6 or below
Intermediate - psa 10 to 20 or gleason score 7
High - psa >20 or gleason 8 to 10.

Staging : MRI preferred over CT.
Treatment : Surgery. Radical prostatectomy. S/E impotence, incontinence of
urine.
Radiotherapy. External and internal (brachytherapy)
HRT to stop TESTOSTERONE.
Medicines - LHRH. Goserelin, leuprorelin, triptorelin (act on pitutary) and
Flutamide, cyproterone (anti androgenic)
Prognosis : variable. Depends on the stage.
Complications :
UTi, AKI, CKD, sexual dysfunction, metastasis.

Note : Prostate CA has increased risk with HYPERCALCEMIA. Not hypo. So the
statement seems to be wrong. Even BPH has nothing to do with Ca levels.
Benign nephrosclerosis is due to long standing HTN. No link to prostate
found.

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Q: 11 An 80yo man presented with pain in his lower back and hip. He also complains
of waking up in
the night to go to the washroom and has urgency as well as dribbling. What is
the most likely dx?
a. BPH
b. Prostatitis
c. UTI
d. Prostate carcinoma
e. Bladder carcinoma


Clincher(s)
A
B
C
D Age, nocturia, urgency and dribbling points towards prostate pathology. Pain
of lower back and hip points towards bony metastases from prostate cancer.

E
KEY D Symptoms match with PC
Additional
Information
Reference
Dr Khalid/Rabia DISCUSSED IN MCQ 4.
Ans. 1. D. Prostate carcinoma.
Ans. 2. Age, nocturia, urgency and dribbling points towards prostate
pathology. Pain of lower back and hip points towards bony metastases from
prostate cancer.
Ans. 3. Blood test for PSA; Prostate biopsy; MRI [if initial biopsy is negative, to
decide repeat biopsy]. Source NICE.
Ans. 4. Treatment options: 1. Active treatment [i) radical prostatectomy ii)
radical radiotherapy iii) hormone therapy iv) brachytherapy v) pelvic
radiotherapy vi) orchidectomy]
2. Active surveillance
3. Watchful waiting
4. Palliative care [Source: NICE].



Q: 34 A 32yo man presented with painless hematuria. He is hypertensive but the rest
of the exam is
unremarkable. What is the most likely dx?
a. Polycystic kidneys
b. Ca bladder
c. Ca prostate
d. TTP

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e. HUS


Clincher(s) Painless Haematuria , hypertension
A Correct answer
B
C
D
E
KEY A
Additional
Information
Reference
Dr Khalid/Rabia Ans. 1. A.
Ans. 2. Painless haematuria at an younger age with hypertension.
Ans. 3. Renal ultrasound.

• autosomal dominant
• Gross haematuria following trauma is a classic presenting feature of
ADPKD,Advise against participating in contact sports which risk
abdominal trauma
• polycystic kidneys can produce excess erythropoietin and hence raise
Hb
• Angiotensin-converting enzyme (ACE) inhibitors or angiotensin-II
receptor antagonists are the preferred choice



Q: 71 A 75yo alcoholic presents with a mass up to umbilicus, urinary dribbling,
incontinence, and clothes smelling of ammonia. What is the next step in
management?

a. Urethral catheter
b. Suprapubic catheter
c. Antibiotics
d. Condom catheter
e. Nephrostomy


Clincher(s)
A Correct
B
C
D
E
KEY A Alcohol consumption ! retention

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Additional
Information
Reference
Dr Khalid/Rabia Q. 1. What is the key?
Q. 2. What is the cause of this retention?
Ans. 1. The key is A. Urethral catheter.
Ans. 2. Alcohol consumption (it is rather a less common cause of urinary
retention).

ACUTE URINARY RETENTION

Causes of urinary retention

• In men - BPH, meatal stenosis, paraphimosis, penile constricting bands,
phimosis, prostate cancer.
• In women - prolapse (cystocele, rectocele, uterine), pelvic mass
(gynaecological malignancy, uterine fibroid, ovarian cyst), retroverted
gravid uterus.
• In both - bladder calculi, bladder cancer, faecal impaction,
gastrointestinal or retroperitoneal malignancy, urethral strictures,
foreign bodies, stones.
Infectious and inflammatory:
• In men - balanitis, prostatitis and prostatic abscess.
• In women - acute vulvovaginitis, vaginal lichen planus and lichen
sclerosis, vaginal pemphigus.
• In both - bilharzia, cystitis, herpes simplex virus (particularly primary
infection), peri-urethral abscess, varicella-zoster virus.
Drug-related:
Up to 10% AUR episodes are thought to be attributable to drugs. Those known
to increase risk include:
• Anticholinergics (eg, antipsychotic drugs, antidepressant agents,
anticholinergic respiratory agents). Opioids and anaesthetics. Alpha-
adrenoceptor agonists. Benzodiazepines. NSAIDs Detrusor relaxants.
Calcium-channel blockers Antihistamines. Alcohol.
Neurological:
More often causing chronic retention but may cause AUR:
• Autonomic or peripheral nerve (eg, autonomic neuropathy, diabetes
mellitus, Guillain-Barré syndrome, pernicious anaemia, poliomyelitis,
radical pelvic surgery, spinal cord trauma, tabes dorsalis).
• Brain (eg, cardiovascular disease (CVD), MS, neoplasm, normal pressure
hydrocephalus, Parkinson's disease).
• Spinal cord (eg, invertebral disc disease, meningomyelocele, MS, spina
bifida occulta, spinal cord haematoma or abscess, spinal cord trauma,
spinal stenosis, spinovascular disease, transverse myelitis, tumours,
cauda equina).
Other:
• In men - penile trauma, fracture, or laceration.

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• In women - postpartum complications (increased risk with instrumental
delivery, prolonged labour and Caesarean section),[2]urethral sphincter
dysfunction (Fowler's syndrome).
• In both - pelvic trauma, iatrogenic, psychogenic.
•

MANAGEMENT: Foleys catheter first line. If contraindicated or failed refer to

urology or try suprapubic catheterization

COMPLICATIONS: UTIs, Renal failure, Post retention diureses and hematuria





Q:1315 A 32yo man presents with 3d of scrotal pain. Exam: thickening of the left
testis and it is hot to touch. What is the most appropriate management?
a. Analgesia
b. Reassurance
c. Antibiotics
d. Referral to surgeon

Clincher(s) Scrotal pain and hot to touch
A
B
C
D
E
KEY C
Additional
Information
Reference
Dr Khalid/Rabia Epididymo-orchitis
Causes :
· In men under 35 years old, infection is most often due to a sexually
transmitted pathogen - eg, Chlamydia trachomatis and Neisseria
gonorrhoeae.
· In men over 35 years old, infection is most often due to a non-sexually
transmitted Gram-negative enteric organism causing urinary tract
infections - eg, Escherichia coli,Pseudomonas spp. Specific risk factors
include recent instrumentation or catheterisation.
· Signs n symptoms :
· It usually presents with unilateral scrotal pain and swelling of relatively
acute onset.
· Acute epididymitis is usually unilateral but is bilateral in 5-10% of the
patients.

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· Tenderness to palpation on the affected side.
· Palpable swelling of the epididymis, starting with the tail at the lower
pole of the testis and spreading towards the head at the upper pole of
the testis with or without involvement of the testicle.
· There may also be urethral discharge, secondary hydrocele, erythema
and/or oedema of the scrotum on the affected side and pyrexia.
Clincher here for making the diagnosis is the unilateral tenderness and
the hot temperature.
Differential would be testicular torsion , but that normally occurs in men
who are younger than 20 years though it can occur at any age.
A painful swollen testicle in an adolescent boy or a young man should be
managed as torsion until proven otherwise


Q:1317 A 32yo man develops hematuria 2wks after a sore throat. What is the
dx?
a. Post infection nephritis
b. IgA nephropathy
c. Membranous nephritis
d. Glomerulonephritis

Clincher(s) Hematuria 2 wks after sore throat
A Present with nephritic picture after strepto infection.
B IgA nephropathy is common in young kids and in20% of adults. In Adults it's
usually assc with hx of NSAIDS or Hodgkin lymphoma.
C Present with picture of nephrotic syndrome
D Broader term for all glomerular disease.
E XX
KEY A
Additional
Information
Reference
Dr Khalid/Rabia In, igA nephropathy,
symptoms appear 1-3 days after the infection, whereas in Post infection,
symptoms appear 1-12 weeks after the sore throat. So, our answer here
should be A.



Q:1318 . An elderly man who has anorexia, prostate symptoms and HTN. There
are small kidneys on US. What is the dx?
a. Hypertensive renal disease
b. Prostate ca
c. BPH

Clincher(s)

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A
B
C Causes hydronephrosis
D
E
KEY A
Additional In Chronic kidney disease the kidneys are usually small, but can be enlarged
Information in infiltrators disorders( amyloid, myeloma),APKD, DM.
Reference
Dr Khalid/Rabia Only Hypertensive nephropathy leads to shrunken kidneys. Prostate
symptoms are not explained by Hypertension nephropathy unless there
is an outflow obstruction and the other two options can be the cause.
Should go with answer A. Needs to be discussed though. NOTE :
Kidney size is increased in the case of diabetic nephropathy.


Q:1345 A 2yo girl has frequency, urgency and burning micturition. She has
some supra pubic tenderness. Which one of the following is the most
appropriate initial inv?
a. Supra pubic aspiration of urine for C&S
b. Clean catch of urine for C&S
c. USG
d. IVU
e. MCUG


Clincher(s)
A
B
C
D
E A micturating/voiding cystourethrogram (MCUG/VCUG) produces X-ray
images of the bladder and urinary tract.
KEY B
Additional
Information
Reference
Dr Khalid/Rabia Urinary tract infections (UTI) are more common in boys until 3 months of age
(due to
more congenital abnormalities) after which the incidence is substantially
higher in
girls. At least 8% of girls and 2% of boys will have a UTI in childhood

Presentation in childhood depends on age:

· infants: poor feeding, vomiting, irritability

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· younger children: abdominal pain, fever, dysuria
· older children: dysuria, frequency, haematuria
· features which may suggest an upper UTI include: temperature > 38ºC, loin
pain/tenderness

NICE guidelines for checking urine sample in a child

· if there are any symptoms or signs suggestive or a UTI
· with unexplained fever of 38�C or higher (test urine after 24 hours at the
latest)
· with an alternative site of infection but who remain unwell (consider urine
test
after 24 hours at the latest)

Urine collection method

· clean catch is preferable
· if not possible then urine collection pads should be used
· cotton wool balls, gauze and sanitary towels are not suitable
· invasive methods such as suprapubic aspiration should only be used if non-
invasive methods are not possible

Management:
· infants less than 3 months old should be referred immediately to a
paediatrician
· children aged more than 3 months old with an upper UTI should be
considered for admission to hospital. If not admitted oral antibiotics such as
cephalosporin or co-amoxiclav should be given for 7-10 days
· children aged more than 3 months old with a lower UTI should be treated
with
oral antibiotics for 3 days according to local guidelines, usually trimethoprim,
nitrofurantoin, cephalosporin or amoxicillin. Parents should be asked to bring
the children back if they remain unwell after 24-48 hours
· antibiotic prophylaxis is not given after the first UTI but should be
considered with recurrent UTIs


Q:1347 A young boy presented to the OPD 12wks after renal transplantation
with fever and pain in lower abdomen. Renal functions were deranged. Renal
biopsy showed immune cell infiltrate and tubular damage. What is the most
probable dx?
a. Pyelonephritis
b. Chronic graft rejection
c. Acute rejection
d. Drug toxicity
e. Graft vs host disease

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Clincher(s)
A
B
C
D
E
KEY C
Additional
Information
Reference
Dr Khalid/Rabia Hyperacute rejection : Within minutes of transplant <24 hrs
Acute: After one week upto 6 months
Chronic : After years due to fibrosis



Q: 312 A 58yo lady presented with urinary incontinence. She looks anxious for her
condition. Urine culture is sterile. Her urodynamic study is normal. What is the
next step?
a. Antibiotics
b. Topical estrogen
c. Systemic estrogen
d. Duloxetine
e. Pelvic floor exercise

Clincher(s)
A No sign of infection
B No indication
C No indication
D Not first indication
E Conservative management is preferred before medication
KEY E
Additional
Information
Reference
Dr Khalid/Rabia


Q: 317 A 44yo man presents with periorbital and pedal edema. 24h urine shows 8g of
protein/d and serum cholesterol=7mmol/L. Renal biopsy results are awaited.
What would be the most likely dx?
a. Minimal change disease

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b. Glomerulonephropathy
c. Membranous glomerulonephropathy
d. FSGS
e. IgA nephropathy
f. Mesangiocapillary

Hypertension in FSGN

Clincher(s)
A
B
C Some people may present as nephrotic syndrome with proteinuria, edema
with or without renal failure. Others may be asymptomatic and may be picked
up on screening or urinalysis as having proteinuria. A definitive diagnosis of
membranous nephropathy requires a kidney biopsy.
D In children and some adults, FSGS presents as a nephrotic syndrome, which is
characterized by edema (associated with weight gain), hypoalbuminemia (low
serum albumin, a protein in the blood), hyperlipidemia and hypertension (high
blood pressure). In adults it may also present as kidney failure and proteinuria,
without a full-blown nephrotic syndrome.
E
KEY C dubious
Additional
Information
Reference wiki
Dr Khalid/Rabia


Q: 329 A man has a BP of 160/90mmHg, proteinuria++. KUB US are equally reduced in
size with smooth borders and normal pelvic calyceal system. What is the cause
of HTN in the pt?
a. Chronic glomerulonephritis
b. Chronic pyelonephritis
c. Bilateral renal artery stenosis
d. Essential HTN
e. Polycystic kidney

Clincher(s)
A
B
C
D
E
KEY A
Additional Renovascular disease (Fig 1) Defi ned as stenosis of the renal artery or one of

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Information its branches. Causes: Atherosclerosis (in 80%: >50yrs, arteriopaths: often co-
existent IHD, stroke or peripheral vascular disease), fibromuscular dysplasia
(10%, younger). Rarer: Takayasu’s arteritis, antiphospholipid syndrome, post-
renal transplant, thromboembolism, external compression. Signs: BP
resistant to treatment; worsening renal function after ACE-i/ARB in bilateral
renal artery stenosis; ‘flash’ pulmonary oedema (sudden onset, without LV
impairment on cardiac echo). Abdominal carotid or femoral bruits, and weak
leg pulses may be found. Tests: USS: renal size asymmetry (affected side is
smaller), disturbance in renal blood flow on Doppler US. CT/MR angiography
are more sensitive. Renal angiography is ‘gold standard’, but do after CT/MR as
it is invasive (p759). : Comprehensive antihypertensive regimens (p134),
transluminal angioplasty } stent placement or revascularization
surgery. Best medical management is probably superior to revascularization in
atherosclerotic disease, see the ASTRAL trial.
Reference ohcm
Dr Khalid/Rabia



Q:338 A 40yo male with pre-existing glumerulonephritis having proteinuria and
hematuria suddenly deteriorates and presents with oliguria and serum
K+=7.8mmol/L, urea=13mmol/L, creat=342mmol/L, GFR=19mL/h. The best
management would be?
a. Calcium supplement
b. Calcium resonate enema 30g
c. 10units insulin with 50% dextrose
d. Nebulized salbutamol
e. 10ml of 10% calcium gluconate
f. Hemodialysis urgent

Clincher(s)
A
B
C
D
E
KEY E
Additional C
Information CKD stage GFR range
Greater than 90 ml/min, with some sign of kidney
1 damage on other tests (if all the kidney tests* are
normal, there is no CKD)
60-90 ml/min with some sign of kidney damage (if
2
kidney tests* are normal, there is no CKD)

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45-59 ml/min, a moderate reduction in kidney
3a
function
30-44 ml/min, a moderate reduction in kidney
3b
function
4 15-29 ml/min, a severe reduction in kidney function
Less than 15 ml/min, established kidney failure -
5
dialysis or a kidney transplant may be needed
a

Reference
Dr Khalid/Rabia



Q: 887
A 60yo man presents with severe colicky pain from his right flank radiating
to his groin. His urinalysis reveals trace blood cells. What is the single most
discriminatory inv?
a. US abdomen
b. XR KUB
c. Colonoscopy
d. Upper GI endoscopy
e. Laproscopy


Clincher(s) Clincher : severe colicky pain, flank pain, traces blood cells in urinalysis


A
B
C
D
E
KEY a as discriminatory, but if intial then X KUB (if CT KUB is given then choose
that for choice investigation for stones)

Additional
Information
Reference
Dr Khalid/Rabia Although xray KUB does not show uric acid stones. Around 80% of renal stones
are calcium and are seen on xrays. Plus, in this patient, pain is radiating from
loin to groin as in uretric stones which are not visualised by US. Colicky pain,
flank pain and blood cells in urine point towards renal pathology. When a renal
pathology is suspected, US KUB is done, not US abdomen.
Colonoscopy, upper GI endoscopy and laproscopy have different indications.

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Q: 931 931. A pt had passed a 4mm stone in his urine. He has a 3mm stone in the
renal pelvis found on US.
What is the management?
a. ESWL
b. None
c. Dormier basket
d. Surgery
e. PCNL


Clincher(s)
A
B
C
D
E
KEY B. none
Additional
Information
Reference
Dr Khalid/Rabia If the stone is <5mm in lower ureter ,it will pass spontaneously..
if it is >5mm ---> medical therapy ( nifedipine ,alpha blocker ) if not passed , go
for ESWL ( If < 1cm ) or dormia basket...
PCNL ---> when stone is large ,multiple or complex..
Percutaneous nephrostomy ---> presence or infection or obstruction , to safe
the kidney from reflux damage and save the person from Sepsis ( if pus
collected )



Q: 941 941. A 75yo man comes in complaining of difficulty in passing urine, poor
stream and dribbling at the end of voiding and anorexia. US shows bilateral
hydronephrosis. What is the cause of these
findings?
a. BPH
b. Renal stones
c. Bladder stones
d. Prostatic ca
e. UTI


Clincher(s)
A
B

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C
D
E
KEY d. Prostatic ca

Additional
Information
Reference
Dr Khalid/Rabia bph is common and BOO signs are present with it earlier but here the anorexia
is given which points to carcinoma

• bladder outlet obstruction: hesitancy, urinary retention
• haematuria, haematospermia
• pain: back, perineal or testicular
• digital rectal examination: asymmetrical, hard, nodular enlargement
with loss of median sulcus



Q: 943 A 50yo man presents with the complaints of recurrent UTI and occasional
blood in the urine.
Some unusual cells have been seen in urine on routine exam. Which os the
following inv would
you like to carry out now?
a. Cystoscopy
b. Urine C&S
c. XR KUB
d. US
e. CBC


Clincher(s)
A
B
C
D
E
KEY A- recurrent UTI, painless hematuria (Bl ca)
Additional If frank blood- do cystoscopy
Information
Reference
Dr Khalid/Rabia the unusual cells may indicate malignancy , which in turn can be the cause of
recurrent UTI .US followed by cystoscopy seems to be the appropriate
approach.
unusual cell points towards possible malignancy! may be bladder cancer or
renal cell carcinoma. So we have two options, for bladder cystoscopy and for

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renal cell ca US. Before going to more invasive procedure we can think first
noninvasive procedure. So US is more logical i think. for uti we can do c/s but
that is not the major issue


Q: 989 989. A 45yo known hypertensive man presents with hematuria, proteinuria
and edema. What is the definitive dx test for him?
a. Urine protein
b. Renal biopsy
c. Renal function test
d. Urine microscopy
e. Serum protein



Clincher(s)
A
B
C
D
E
KEY B
Additional
Information
Reference
Dr Khalid/Rabia Pt seems to be suffering from nephritic syndrome , the definitive diagnosis can
be made on renal biopsy.

Q: 990

A 47yo man presents with proteinuria, BP=160/95 mmHg, small kidneys that
have smooth renal pelvis. What is the most probable dx?
a. GN
b. Chronic pyelonephritis
c. Unilateral renal artery stenosis
d. Multiple myeloma
e. ARF


Nephrotic>CRF>shrunken kidney
DM>leading cause of CRF> not small Q
Clincher(s)
A

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B
C
D
E
KEY A
Additional
Information
Reference
Dr Khalid/Rabia GN is a common cause of CKD, presenting with proteinuria, hypertension and
small kidneys. (nephritic syndrome)



Q: 706 A 75yo man with adenocarcinoma of the prostate which has spread outside the
capsule of the gland has ARF. What is the most appropriate next inv?

a. MRI spine

b. Radionuclide bone scan

c. Trans rectal US
d. US pelvis
e. US KUB

Clincher(s) daignosed case of adenocarcinoma prostate and acute renal failure.
A MRI done to rule out bone metastasis, which is not the case here.
B Also done in bone metastasis(no history of bone pain).
C to rule out local invasion of prostate.
D confined to pelvis.
E Most appropriate for evaluation of degree of injury to kidney and ureter due
to reflex uropathy. Prostate carcinoma cause obstructive
nephropathy(hydronephrosis and dilated ureter).
KEY E- USG KUB

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Additional
Information

Reference OHCM
Dr Khalid/Rabia



Q:711 A 32yo miner is rescued after being trapped under a fallen rock for 4h. After
applying a bladder catether, 15-20ml of reddish brown urine was obtained.
HR=120bpm, SBP=100mmHg. What
would be the next appropriate step?
a. Dopamine IV
b. Fluid challenge
c. Furosemide IV
d. 20% Mannitol IV
e. Antibiotics

Clincher(s) H/o trauma and red urine.
A dopamine is given in falling blood pressure due to active haemorrhage

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B Fluid challenge is given in acute renal injury due to penal causes like
trauma(rhabdomolysis)
C fruosemide is advised for pulmonary oedema due to renal failure.
D manitol for reducing cerebral oedema.
E not relevant here.
KEY B- fluid challenge.

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Additional
Information

Reference OHCM pg 292.
Dr Khalid/Rabia

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Q: 716 A 42yo woman with a PMH (past medical hx) of severe headache treated in the
ED presents with signs and symptoms of renal failure. She has been seen by her
GP for HTN and abdominal pain with OP inv pending. Which inv is most likely to
lead to a dx?
a. US KUB
b. CT brain
c. IVU
d. Renal artery Doppler
e. Renal biopsy

Clincher(s) H/o severe headche, HTN and abdominal pain- all suggestive of Polycystic
kidney disease.
A Best investigation is Ultrasound KUB.
B
C
D
E
KEY A
Additional
Information

Reference OHCM pg 312
Dr Khalid/Rabia

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Q: 781 A 50yo newly dx with HTN complains of urinary freq and dysuria. The urinalysis
reveals presence of white cells and protein. Choose the single most appropriate
tx?
a. Imipramine
b. Adjust diuretics
c. Vaginal estrogen
d. Trimethoprim

Clincher(s) UTI
A
B
C
D First line antiobiotic- Trimethoprim.
E
KEY D- Trimethoprim.

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Additional
Information

Reference OHCM pg 289
Dr Khalid/Rabia



Q:794 A young boy presented with bilateral periorbital edema, ankle swelling and
increase in body weight. What is the most likely dx?
a. Chronic heart failure
b. Nephrotic syndrome
c. Renal failure
d. Acute heart failure
e. Glomerulonephritis

Clincher(s) Young age, signs of renal failure.

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A
B Most common cause is nephrotic syndrome due to minimal change disease.

C
D
E
KEY
Additional B
Information
Reference
Dr Khalid/Rabia


Q:865 An 80yo man has a permanent catheter. Catheter specimen urine found lots of
e-coli. What is the single most appropriate management as he wan ts to
atten d his daughter s weddi ng nex t week?
a. Change the catheter

b. Prolonged antibiotics
c. Bladder wash
d. Repeat MSU after wedding
e. Reassure

E coli=uTI
Clincher(s) permenant catheter and Ecoli on finding.
A change catheter for prevention of sepsis due to UTI.
B
C
D
E
KEY A- catheter replacement.
Additional
Information

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Reference
Dr Khalid/Rabia


Q:1360 A 40yo man complains of severe colicky loin pain that radiates to his scrotum.
He is noted to have microscopic hematuria. No masses are palpated. What is
the single most likely cause?
a. Acute cystitis
b. Bladder ca

c. Renal vein thrombosis

d. Acute pyelonephritis
e. Ureteric calculus

Most common stone= oxalate

Clincher(s) severe colicky loin pain and no masses on palpation.
A
B
C
D
E Ureteric calculus.
KEY E- ureteric calculus.

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Additional
Information

Reference OHCM pg 640
Dr Khalid/Rabia

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Q:1415 A pt is on loop diuretics. What effect do loop diuretics produce?

a. Low Na+, low K+

b. Low Na+, normal K+

c. Normal Na+, normal K+
d. High Na+, low K+
e. High Na+, high K+

Clincher(s) mechanism of loop diuretics.
A
B
C
D
E
KEY A- low sodium and low potassium. (Good description below)

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Additional
Information

Reference OHCM pg 304
Dr Khalid/Rabia

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Q: 1416 A 6yo girl is being investigated for renal failure. She is found to have a
congenital abnormality of the insertion of the ureters into the urinary bladder.
What is the single most likely cause for
renal failure in this pt?
a. SLE
b. PKD
c. Wil son tumor.
d. Acute tubular necrosis
e. Reflux nephropathy

Clincher(s) congential malformation of urogenital tract,
A
B
C
D
E
KEY E- reflux nephropathy.
Additional
Information
Reference
Dr Khalid/Rabia

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Q:1444 A 60yo man complains of tiredness, lethargy and itching that is severe after a
hot bath. He also has nocturia, polyuria and nausea and vomiting. Exam: pallor,
pigmentation and generalized
edema. What is the single most likely dx?
a. Hyperthyroidism

b. Lichen planus
c. Lymphoma
d. Eczema
e. Liver failure

f. chronic renal failure.

Hepatorenal syndrome- leads to RF

X Polycythemia- in CRF- so itching after hot bath
Clincher(s)
A
B
C
D
E
KEY F- chronic renal failure.

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Additional
Information

Reference OHCM pg 294
Dr Khalid/Rabia

Q: 1445 A 30yo man complains of vague pain in the loin with BP=140/90mmHg. He is
found to have proteinuria and hematuria. What is the inv to confirm the dx?
a. Abdominal US
b. ANCA
c. ANA
d. Urine microscopy and culture
e. Stool culture

? calculus
Clincher(s) young patient with vague abdominal pain, proteinuria and hematuria with HTN.
always suspect polycystic kidney disease.
A
B
C
D
E

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KEY A usg abdomen
Additional
Information
Reference
Dr Khalid/Rabia

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