GU Quiz #2

64 y/o caucasian female presents to the emergency department via ambulance. She is hyperventilating, vomiting and complains of abdominal pain. She has type 2 diabetes mellitus but states she could not afford her insulin this month. Besides insulin she also takes 160mg propranolol daily to prevent migraines and Hydrochlorothiazide daily for hypertension. You order a complete metabolic panel, lipase, urinalysis, an arterial blood gas, and urine drug screen. From the result of these labs you diagnose her diabetic ketoacidosis and begin an insulin drip. Also of note, her serum potassium is 2.6mmol/L. Which of the following is NOT a possible contributor to her hypokalemia? A: Propranolol B: Hydrochlorothiazide C: Diabetic Ketoacidosis

A

A 2 year old Asian male presents to the clinic with his parents to be seen for facial edema and upper respiratory symptoms. The parents were giving him Motrin for his sore throat. Physical exam reveals an umbilical hernia that the parents did not notice before. Vital signs are: HR 110 bpm, BP 100/60, RR 24 breaths/min, Temp 98.5F, and weight is 12.5 kg. Urinalysis was normal except for 3+ proteinuria, and on microscopy, there were some free lipids and oval fat bodies seen. Urine protein excretion was 875 mg/day (70 mg/kg/day), which was almost made entirely of albumin. All other labwork was within normal range, including WBC, Hgb, and renal function tests. What is the most likely diagnosis? A. Minimal change disease B. Membranopfoliferative glomerulonephritis (MPGN) C. Focal segmental glomerulosclerosis (FSGS) D. Membranous glomerulonephritis

A

A 45-year-old obese African American male presents to the clinic for his annual physical, and he currently has no complaints. His past medical history is significant for hypertension, hyperlipidemia, and diabetes mellitus type 2. He is currently on furosemide, atorvastatin, lisinopril, and metformin. His blood pressure is 135/86 mmHg, and his BMI is 41. The rest of his physical exam is unremarkable. You conduct a urinalysis and subsequent 24-hour urine, which shows proteinuria of greater than 3g/day. His glomerular filtration rate (GFR) is 145 mL/min. You refer this patient to urology, and a kidney biopsy was performed. He is diagnosed with Focal Segmental Glomerulosclerosis (FSGS). What is the first line treatment for this patient's condition? A. Weight loss and limiting his salt intake. B. High-dose corticosteroids for 3 to 4 months. C. Cyclosporine for 12 months. D. Discontinue his furosemide.

A

A 47-year-old male presents to your clinic with complaint of vomiting for the last 2 days. He states he has not been able to keep fluids down. His vital signs show sitting BP: 105/63 mmHg, sitting HR: 97 bpm, standing BP: 84/52 mmHg, and standing HR: 115 bpm. He denies changes to his urine. After completing his history and physical, you order a basic metabolic panel, a fractional excretion of sodium test (FeNa), and urinalysis with microscopy to check his renal function. His renal labs show: BUN 34 mg/dL, SCr 1.5mg/dL, FeNa 0.6%. What type of casts found in his urine would point towards a diagnosis of prerenal acute kidney injury? A. Hyaline casts B. Granular casts C. Red blood cell casts D. White blood cell casts

A

A 56 year old male smoker with a 40 pack year history arrives to your office with a chief complaint of "feeling bloated all the time" and "decreased urinary frequency" his past medical history is notable for lung cancer that has been in remission for the past two years. The patient states that his symptoms began around 6 months ago and have progressively been getting worse since their onset. He also states that he has gained about ten pounds that he attributes to excess water weight. You decide to run a urinalysis. On the lab results, you notice that urine osmolarity is increased significantly with an increased urine sodium level. After performing a blood draw, you find that the serum osmolarity is above 280 mg/dL. This classic pattern of symptoms leads you to conclude that the patient has what diagnosis? A. SIADH B. Hypercalcemia C. Diabetes Insipidus D. Orthostatic Hypotension

A

A 60-year-old male with a history of alcohol abuse and esophageal varices is brought to the emergency department with the following symptoms: extreme lethargy, confusion, delirium, weakness, and nausea. His vital signs follow: BP 100/60 mmHg right arm, HR 92 bpm, RR 16 breaths/min, T 98.5ºF axillary, O2 97% on room air. Physical exam is remarkable for jaundice, spider angiomas, a distended abdomen, and 3+ pretibial pitting edema. Based on his symptoms and clinical presentation, which of the following electrolyte abnormalities would you expect to see in this patient? A. Hyponatremia B. Hypocalcemia C. Hypercalcemia D. Hyperphosphatemia

A

A 62-year-old male patient named Danny Dial presents to the emergency department today because he suddenly "felt extremely dizzy with a fluttering in his chest." His worrisome wife immediately rushed him to the emergency department. She tells you that her husband is a "bad patient because he has skipped his last 4 dialysis appointments." Danny's past medical history includes hypertension, diabetes, and renal failure. Today, his vital signs are as follows: temperature: 98.4 degrees Fahrenheit; heart rate: 150 beats per minute; blood pressure: 160/104 mmHg; respiration rate: 18 breaths per minute; O2 saturation: 99% on room air. His electrocardiogram (ECG) shows diffuse peaked T waves. You are worried this patient has an electrolyte imbalance. As a wise UNTHSC graduate, you know the MOST important step in treating this patient is to stabilize the cardiac membrane by: A. Administering intravenous (IV) calcium B. Administering intravenous (IV) potassium C. Administering subcutaneous insulin D. Administering steroids

A

A 62-year-old male presents to the emergency department with nausea, vomiting, abdominal pain, and dizziness x9 days. He also noticed that he has been confused more frequently over the past 3 months. His past medical history includes benign essential hypertension which is well controlled on Hyzaar (Losartan and hydrochlorothiazide (50 mg/12.5 mg, 100 mg/25 mg)). Vitals are HR: 76bpm, RR: 16 breaths/min, BP: 116/74 mmHg, Temp: 98.9F, SpO2 98% on room air. Physical exam is unremarkable. urinalysis results are unremarkable, 24 hour urine sodium is checked and reveals a urine sodium >20mEq/L. You also decide to draw labs and the basic metabolic panel results are shown below: Glucose, serum: 86 mg/dL BUN: 12 mg/dL Creatinine, serum: 0.9 mg/dL Sodium, serum: 123 mmol/dL Potassium, serum: 4.2 mmol/dL Chloride, serum: 98 mmol/dL Bicarbonate, serum: 24 mmol/dL You diagnose the patient with euvolemic hyponatremia, which of the following is the most common cause of this: A. SIADH B. Diabetes Insipidus C. Hyperosmolar hyponatremia D. Psychogenic Polydipsia

A

A 69 year old black male with a history of CHF presents to clinic with LLQ pain that is relieved with defecation. He is currently on lisinopril, metoprolol succinate, and spironolactone for his CHF and is responding well to the medications. The rest of his past medical history is unremarkable with renal labs WNL. Upon examination of his stool, you document that it is Bristol Stool Chart type 3 with massive bright red blood per rectum (BRBPR). You decide to do a colonoscopy and diagnose him with diverticular hemorrhage. You also order a CBC/CMP and note that he is anemic and has a BUN/Cr ratio is 35:1. Lastly, you order a FeNa to help you narrow your differential and it returns as 0.08% Which of the following pathologies most likely presents in this fashion? A. Prerenal Acute Kidney Injury B. Intrinsic Acute Kidney Injury C. Postrenal Acute Kidney Injury D. Acute Kidney Injury on Chronic Kidney Disease

A

A 71-year-old diabetic African American male presents to your primary care clinic for his yearly physical. Patient recently moved to Fort Worth from Houston and has chosen you to be his new primary care provider. Patient has a history of T2DM, HTN, HLD, PVD, COPD, and perennial allergies. Current medications include hydrochlorothiazide, carvedilol, amlodipine, Allegra, metformin, atorvastatin, aspirin, and Plavix. You decide to conduct a physical exam. There are no abnormal findings except for diminished sensation in the patient's bilateral feet, which per patient "have been like that for a couple years now, and it's just from my diabetes!" You review patient's old medical records and note that on labs drawn 6 months ago, patient's urine albumin levels were 33 mg/g. You are frustrated the patient's previous provider did not work up the patient for kidney disease, especially considering patient's significant risk factors. Luckily, the patient knew to fast before his appointment, so you order a BMP and urinalysis. All values come back within normal limits except for the following: glucose: 150 mg/dL, creatinine: 2.4 mg/dL, glomerular filtration rate: 58 mL/min , urine albumin: 700 mg/dL. Because patient has had markers of kidney damage for greater than 3 months, it is your job to explain to him his diagnosis of chronic kidney disease. Which of the following is the correct stage of chronic kidney disease for this patient?A. Stage 3a, A3 B. Stage 3a, A2 C. Stage 1, A3 D. Stage 3a, A1

A

An 8-month-old male patient presents to the Emergency Department in a "lethargic" state per his mother after 7 episodes of emesis in the past 3 hours. The mother states that the patient has stopped feeding and wetting diapers. He has been excessively fussy which is "just not him." The baby's vital signs are as follows: temperature: 98.0 degrees Fahrenheit; heart rate: 148 beats per minute; respiration rate: 42 breaths per minute; O2 saturation: 96% on room air. While examining the patient, he cries weakly but does not produce tears. You note that the patient has dry mucous membranes, decreased skin turgor, and a sunken anterior fontanelle. You also note that his diaper is not full, but it is damp with urine. When discussing this patient with your preceptor, they prompt you to give IV fluids. Which of the following is the best option to give to manage this patient at this time? A. Isotonic saline (0.9% NaCl) B. Hypertonic saline (3% NaCl) C. Hypotonic saline (0.45% NaCl) D. Lactated Ringers

A

An 8-year-old Caucasian female presents to the emergency department with a two day history of swelling in her ankles and around her eyes. She also reports urinating very few times in the past two days. Her mother mentions that her daughter had strep throat about two weeks ago, but otherwise has no past medical history. You decide to order a urinalysis with microscopy and it comes back positive for hematuria, proteinuria and shows red cell casts on microscopy. In addition, you decide to order a BMP and find that her serum creatinine is 2.1 mg/dL and her blood urea nitrogen is 30 mg/dL. Which of the following is the most likely diagnosis for this patient? A) Post-infectious glomerulonephritis B) Hemolytic uremic syndrom C) Minimal change disease D) Henoch Schonlein Purpra

A

Jack Skellington is a 36-year-old male who presents to the clinic with hemoptysis, dyspnea and cough. He is a smoker with a 15 pack-year history. You decide to get an arterial blood gas (ABG) and it shows hypoxemia. The complete blood count (CBC) shows hemoglobin of 10 and MCV of 70 micrometers^3. On urinalysis there is hematuria, dysmorphic red cells, RBC casts and proteinuria. Basal metabolic panel (BMP) shows that serum creatinine is 1.7 mg/dL. Chest x-ray shows patchy infiltrates in the central lung fields. You suspect Goodpasture syndrome so you order an ELISA test which is positive for Anti-GBM antibodies. How would you treat this patient? A. Plasmapheresis + prednisolone + cyclophosphamide B. Plasmapheresis + furosemide C. Cyclophosphamide + gentamicin D. Prednisolone + ferrous sulfate + albuterol

A

Lorelai Gilmore a 42 year old female presents to the clinic complaining of "blood in her urine, fatigue, and swollen legs." She states she has no medical conditions and currently only takes an ibuprofen on average 3 times a week for knee pain secondary to an injury when she fell off a ladder 8 months ago. She has no history of tobacco use, does not drink alcohol, admits to 3 cups of coffee a day and says her diet is very healthy for the past 3 years following the birth of her first granddaughter. In office today her vital signs are blood pressure 118/78, heart rate 78bpm, respiratory rate 11 RPM, and temperature 98.6 degrees F. You do a CBC, CMP and UA and find her CBC and CMP show values within normal limits except for a slightly elevated creatinine of 1.3 mg/dL. Her UA indicates proteinuria at 3.3g/1.73 m2/24hrs. You suspect a nephrotic syndrome and after a 24 urine and a renal biopsy you diagnosis the patient with membranous glomerulonephritis. Of the options available, which is the best course of treatment? A: Monitor patient B: Metformin 500mg BID & Lisinopril 20mg C: Amoxicillin 80mg x 10days & Lisinopril 20mg D: Lisinopril 20mg & IV pulse cyclophosphamide + IV methylprednisolone x 5 days

A

Mr. Bence Jones is a 66-year-old African-American male who presents to your clinic as a follow-up to his annual wellness check in July. Based on his age and history of kidney stones, you have been monitoring for signs of possible kidney disease and found his kidney markers to be elevated at his visit in July. He submitted additional labs prior to today's visit so you could discuss the next steps in his care. He is without symptoms or complaint and denies rashes or other skin changes, nausea, vomiting, changes in weight, swelling, insomnia, fatigue, shortness of breath, dysuria, or changes in urine frequency or urgency. Physical exam is unremarkable beyond his elevated blood pressure (BP). He has no additional past medical history, is not on any medications, and denies current over-the-counter medications. Results from his his most recent lab results and those from July are as follows: 7/15/19 10/25/19 Blood urea nitrogen (BUN), mg/dL: 17 16Serum creatinine (SCr), mg/dL: 1.4 1.5Calculated glomerular filtration rate (eGFR), mL/min: 65 69 Fasting blood glucose mg/dL: 87 90 Urinalysis (UA): Urine albumin-to-creatinine ratio (UACR), mg/g: 65 70Casts None NoneRed Blood Cells None None Vital Signs (today's visit): Temp: 98.9°F, HR: 89 bpm, RR: 18 breaths/min, BP: 127/78 mmHg, Height: 5'9", Weight: 217 lbs, BMI: 32.0 Based on the available lab results and vitals, which of the following is the most appropriate initial step for treatment? A. Initiate lisinopril; continue monitoring kidney function and BP to a goal of <130/80 mmHg B. Initiate hydrochlorothiazide; continue monitoring kidney function and BP to a goal of <140/90 mmHg C. Refer to nephrology for management of his chronic kidney disease. D. Initiate valsartan; continue monitoring kidney function and BP to a goal of of <140/90 mmHg

A

Patient presents with weakness, tremors, and tetany. You send for a full chemistry study, and you immediately notice that the patient's magnesium level is 1.2 mg/dL (below normal). Because you listened very attentively to PA Ives' presentation on electrolyte balance and abnormalities. You know that because this patient has hypomagnesemia, you can expect to also see which of the following? A: Hypokalemia and hypocalcemia B: Hyponatremia and hypocalcemia C: Hypokalemia and hypercalcemia D: Hyperkalemia and hypercalcemia

A

Ricky Martin, a 35-year-old Hispanic male, presents to the clinic complaining of a tingling sensation around his lips. He recently moved from Mexico and knows minimal English but has brought his 18-year-old nephew to help with translation. After struggling to obtain the history of present illness, you understand that this has been an ongoing issue for the past week. Other symptoms include muscle cramps and fatigue. He denies any urinary changes, dizziness, and fever. You are told that Ricky recently had neck surgery in Mexico and is concerned that this might be a permanent outcome. Unfortunately, his nephew is unable to explain what type of surgery he had, but repeats the word thyroid. His nephew also reports that his uncle is a landscaper and attributes the muscle cramps with his long work hours. Because of time constraints, you move on to the physical exam. Physical exam reveals the following: T: 98.6F BP: 100/56 P: 98 RR: 16 SpO2: 98% Room Air General: Patient is well appearing, sitting comfortably on the exam table Skin: Soft, smooth, and even to touch, skin turgor is brisk HEENT: No obvious lesions or masses of the face. Pupils are equal, round, and reactive to light and accommodation; Tonsils 2+ bilaterally; External auditory canal patent; Tympanic membranes appear pearly grey; Nasal interior patent with scant rhinorrhea. Neck: No thyroid palpated, thyroidectomy incision appears to be healing well; No masses or lymphadenopathy noted Cardiovascular: Heart has regular rate and rhythm, Cap refill is brisk Lungs: No wheezes, rales or rhonchi auscultated Neuro: Positive chvostek's sign; Facial movements are symmetric Musculoskeletal: 5/5 upper extremities bilaterally; 5/5 lower extremities bilaterally Given his history and physical, you suspect hypocalcemia and order labs to confirm. What is the most likely cause of his symptoms? A) Recent thyroid surgery with possible removal of a parathyroid gland B) Hyperparathyroidism C) Vitamin D deficiency D) Dehydration

A

43-year-old Bob Wilson, who is a body-builder, presents to your emergency room with ascending muscle weakness. His labs show creatinine kinase of 1,000 U/L, increased LDH, and increased ALT. Urine dipstick and microscopy show reddish-brown color with quantitative level of 200 mg/dl and negative for blood. Potassium level is 6.3 mEq/L. You decide to order an EKG, which shows widened QRS and diffuse peaked T-waves. Which of the following is the most appropriate initial treatment for this patient? A. Administer IV insulin and IV fluid. B. Administer IV calcium gluconate and IV fluid. C. Hemodialysis D. Administer furosemide

B

81 year old male Anthony Hopkins presents with swelling around his eye and in his lower right leg. When asked, he states that he has also been peeing less than usual. His past medical history includes an active diagnosis of diabetes mellitus, for which he takes Metformin, and mild hypertension, for which he takes metoprolol. He was discharged from the hospital just 3 days ago after fracturing his femur in a fall. About a week ago he got an "throat infection that the doctors cleared up," and he does not think he is sick again. He is allergic to penicillin, which gives him an "itchy rash" whenever he takes it. After ordering a throat culture, Anti-streptolysin titers, and a UA, you confirm your diagnosis of post-infectious glomerulonephritis. What is the best treatment for this pt? A. Penicillin V x 10 days and blood pressure control B. Cephalexin x 10 days and blood pressure control C. Prednisone x 7-10 days and blood pressure control D. Clindamycin x 10 days and prednisone x 7-10 days

B

A 28-year-old Asian man presents with hematuria that is accompanied by severe lower back pain. He has not been feeling well recently and reports a 2-day history of sore throat, fever, chills, malaise, headache, and a cough. He denies abdominal pain, dysuria, frequency, or urgency. Vital signs are normal except for a temperature of 101.2ºF. The physical exam reveals erythema and inflammation of the uvula and pharynx and 2+ tonsils with patchy grey-white exudates. The rest of the exam is unremarkable. You order a rapid strep test which is negative. You also order a urinalysis (UA) and a basic metabolic panel (BMP). The UA reveals hematuria and 3+ proteinuria. The BMP shows an elevated serum creatinine of 1.4 mg/dL. What would be the next best step in evaluating this patient? A. Renal biopsy B. Order a spot urine albumin-to-creatinine ratio (UACR) C. Cystoscopy D. Discharge the patient with supportive measures

B

A 36-year-old male hydrocarbon plant worker presents to the clinic complaining of coughing of blood, difficulty breathing, and cough for the last 2 days. He also states he has had intermittent decreased urine output for the past 2 weeks. He only is able to urinate every other day. He smokes 2 ppd for the past 10 years. On physical exam, he appears ill, has tachypnea and inspiratory rales. CBC shows BUN of 34 and Creatinine of 2.8. Urine dipstick shows hematuria and proteinuria. Urine microscopy shows dysmorphic red cells and RBC casts. Chest x-ray shows patchy infiltrates in the central lung fields. + ANCA test and + Anti-GBM antibody on ELISA. Renal ultrasound is normal but renal biopsy shows crescent formation. Which of the following is the most likely diagnosis with the presentation of this patient? A. Wegener Granulomatosis B. Goodpasture Syndrome C. Henoch Schonlein Purpura D. Hemolytic Uremic Syndrome

B

A 45-year-old male presents to the emergency department on a hot day in August complaining of nausea and vomiting for one day. The patient states this began after he went inside after mowing the lawn because he didn't feel well. He also complains of headache, fatigue and muscle weakness and denies vision changes, cough, sore throat, palpitations, dyspnea, abdominal pain and diarrhea. His medications include hydrochlorothiazide, lisinopril and amlodipine for hypertension. Physical exam reveals decreased capillary refill, skin tenting and dry oral mucosa. His vitals are as follows: BP 110/70, HR 102, T 98.7 °F, R 18, O2 98%. Labs reveal a high urine sodium level. What is the most likely cause for the patient's presumed diagnosis? A) Dehydration B) Hydrochlorothiazide C) Hypertension D) Vomiting

B

A 47-year-old Caucasian woman presents to the emergency department complaining of muscle pain in her thighs and shoulders, nausea and vomiting, and dark urine. She mentions that she recently signed up for her first marathon and has been running 5 to 6 miles a day. She used to only run 1 mile a week. You note some muscle tenderness and swelling during her physical exam and decide to order some labs. The results are as follows: calcium 4.5 mg/dL, potassium 6.7 mEq/L, bicarbonate 15 mEq/L, blood urea nitrogen 45 mg/dL, serum creatinine 3 mg/dL, Urine dipstick is positive for the presence of blood. Microscopic analysis reveals 0-1 white blood cells per high power field, 0-1 red blood cells per high power field. Which of the following is the patient at risk for if the correct diagnosis is missed or left untreated? A. Post-renal acute kidney injury B. Acute tubular necrosis C. Pre-renal acute kidney injury D. Acute Glomerulonephritis

B

A 54-year-old Hispanic female presents to your clinic for dialysis consultation for her end stage renal failure. When you ask her about her concerns, she expresses that she wants to avoid using needles because they make her uneasy. She is also on a limited schedule due to work and travels periodically. She does not have anyone to assist her at home currently and would like it to remain so. She expresses that she would like a dialysis option that allows for mobility, flexibility, privacy and independence. She would like an option that is "natural," if available. Based on this information which form of dialysis is the best choice for this patient? A. Home hemodialysis B. Peritoneal dialysis C. In-Center hemodialysis D. Arteriovenous fistula for hemodialysis

B

A 59 year old diabetic patient presents to your clinic after being recently diagnosed with Chronic Kidney Disease (CKD). Her estimated glomerular filtration rate (eGFR) is 40 ml/min and her UACR is 100 mg/g. Her vitals indicated heart rate of 80 bpm, temperature 98.4 degrees Fahrenheit, respirations 14 bpm, blood pressure of 150/90 mmHg. The patient is currently on 1000 mg of metformin for her diabetes with an A1C of 8%. What would be the best medication adjustments to make for this patient? A. Start patient on metoprolol succinate, bumetanide, and increase metformin to 1500 mg. B. Start patient on lisinopril, bumetanide, and cut metformin dose to 500 mg. C. Start patient on lisinopril, Hydrochlorothiazide, and continue on 1000 mg metformin. D. Start patient on hydrochlorothiazide and discontinue metformin.

B

A 59 year-old Caucasian male with a history of diabetes presents to the ED reporting that he has had trouble breathing since noon today and became nauseous to the point of vomiting. He is worried he might be having a heart attack. You decide to obtain an Electrocardiogram (ECG) of the patient to try and identify possibly cardiac abnormalities. You observe on the ECG that the patient has normal PR Intervals and there is no ST elevation in any lead, but you do notice peaked T-waves. You then get a urinalysis, which is protein positive, and the urine albumin/creatinine ratio (UACR) is 85 mg/g. You also obtain a Basic Metabolic Panel and find that the patient's potassium is 6.9 mEq/L, and the serum creatinine is 2.4 mg/dL. The Estimated Glomerular Filtration Rate (eGFR) is 32 mL/min. You decide to initiate lisinopril to address the patient's hyperproteinuria. What pharmacological therapy would be optimal to add based on the ECG and lab findings? A. Hydrochlorothiazide B. Torsemide C. Metoprolol succinate D. Furosemide

B

A 6 year old boy is brought into the office by his mother because of his dark colored urine for 2 days. She is also worried because she thinks her son looks swollen around his eyes and in his legs. You ask the mother more questions and she reports that her son had a strep throat infection two weeks ago in which he was treated with Amoxicillin for. He finished his prescription 5 days ago. His vitals are listed below. On physical examination, he has 1+ pitting edema bilaterally. You order a complete blood count (CBC), basic metabolic panel (BMP), and a urinalysis with reflex to microscopy on positive. The urinalysis with microscopy results show red blood cell casts, hematuria, and proteinuria without infection. His BMP results are Na: 137 mEq/L, K: 3.6 mEq/L, Cl: 98mEq/L, CO2: 25mEq/L, BUN: 27 mg/dL, Cr: 1.7 mg/dL, Ca: 8.6mg/dL, glucose: 87mg/dL.. His complete blood panel showed all aspects to be within normal range. To confirm the proteinuria you order a 24 hour urine collection . What other study should you order that would likely be elevated in this case? Vitals: T:98.8 F P:86bpm R:15bpm BP: 134/80 spO2%: 99 RA a. C3 complement b. ASO- titer c. HLA-DR d. ANCA antibody

B

A 67 year old African American female, who was brought into the clinic by her granddaughter, presents complaining of nausea and vomiting for the past 3 days. According to the granddaughter, she hasn't been able to hold any food down. When talking to your patient she mentions she feels lightheaded and this is the first time she has ever felt like this. She hasn't taken anything since she was nervous it would interfere with her daily medications she takes for her hypertension, which are Hydrochlorothiazide 12.5 mg tab and Amlodipine 5mg. Her vitals are listed below. On physical exam you note the patient's dry and cool skin and loss of skin turgor. You order a complete blood count (CBC), basic metabolic panel (BMP), and a urinalysis. Assuming there is no remarkable past medical history for this patient, what would be the next best test to order to properly diagnose your patient? T: 99.4F P: 103bpm R: 21bpm BP: 134/85 SpO2: 99% RA UA: pale, straw yellow in color, neg WBC, neg heme/protein BMP: Na: 150 mEq/L, K: 4.8 mEq/L, Cl: 99mEq/L, CO2: 25mEq/L, BUN: 47 mg/dL, Cr: 1.7 mg/dL a. Fractional Excretion of Sodium ( FeNa ) b. Fractional Excretion of Urea (FeUr) c. Renal biopsy d. Imaging of Kidneys (US)

B

A 7 year old boy presents to the emergency department accompanied by his dad with complaints of acute periorbital swelling and lower extremity edema onset 1 hour ago while eating dinner. The father is very concerned, stating he has never had symptoms like this and is wondering if he was allergic to something he ate. You ask the father if there as anything new he ate, to which he says no. After gathering further history, the father notes that the patient recently had a sore throat a few weeks ago, but they never brought him in to be treated. Heart rate is 95, blood pressure 125/80, temperature 98.4 degrees Fahrenheit, respirations 20. You do a urinalysis which shows hematuria, proteinuria, and increased serum BUN/creatinine. How do you treat your patient? A. Corticosteroids followed by cyclosporine if steroids fail. B. Amoxicillin for 10 days C. Penicillin V for 10 days D. Send the patient for follow up with allergy testing.

B

A 75 y/o Caucasian male with a known history of chronic kidney disease presents to your office for a follow-up. He has a past medical history of hypertension, for which he takes lisinopril 40mg bid. He also has a diagnosis of pre-diabetes which he controls through lifestyle modifications like controlling his blood sugar and regular exercise. He admits to some fatigue during the day but denies dyspnea, nausea, vomiting or skin changes. His renal lab work shows serum creatinine of 1.8 mg/dL, glomerular filtration rate of 51 ml/min and urine albumin/creatinine ratio of 45 mg/g. What stage of chronic kidney disease is this patient categorized as? A. Stage 2, A2 B. Stage 3a, A2 C. Stage 3b, A3 D. Stage 3a, A1

B

A 75-year-old female comes into your office for follow-up with her chronic kidney disease, diabetes mellitus, and hypertension. She is not complaining of any new symptoms today but does state that she continues to feel generally fatigued. You decide to get blood samples and a urinalysis to measure her glomerular filtration rate (GFR) and albuminuria. It is found that her GFR is 65 ml/min, and her albuminuria is 35 mg/g. How would you stage her chronic kidney disease? A. Stage 2, A1 B. Stage 2, A2 C. Stage 3a, A1 D. Stage 3a, A2

B

A 9-year-old boy comes into your clinic accompanied by his mother with concerns of his lower legs looking "way too big for his body" for the past 2 weeks. Upon physical exam, you establish that the patient has significant pretibial edema. You orders labs and urine analysis. Labs show decreased protein in his blood and increased serum cholesterol that you suspect is due to the hypoalbuminemia. The urine analysis shows markedly increased protein in his urine. Upon completion of a 24-hour urine collection, you measure protein at 3.2 g/1.73 m2/24 h. Based on these clinical findings, what is the best initial treatment therapy for this patient? A. None since this amount of protein in the urine is normal for children. B. Immediately start of dose of corticosteroids C. Prescribe Cyclosporine D. Prescribe Doxycycline since high protein often accompanies infection

B

A-67-year old African American male presents to your clinic for an annual well-check with a 10-year history of type 2 diabetes and has recently been diagnosed with chronic kidney disease. He tells you his diabetes is well managed with metformin and his last provider did not tell him much about his chronic kidney disease. He tells you that he is not currently experiencing any symptoms and is feeling "just fine." You decide to order labs to stage his chronic kidney disease and the results revealed: serum creatinine: 1.5 mg/dL, urine albumin creatinine ratio (UACR): 75 mg/g, estimated glomerular filtration rate (eGFR): 85. What stage is his chronic kidney disease? A. Stage G1, A1 B. Stage G2, A2 C. Stage G3a, A1 D. Stage G3a, A2

B

Billy Bob is a 65 y/o male with a history of type 2 diabetes mellitus, hypertension, and hyperlipidemia who presents to the emergency department with complaints of progressively worsening muscle weakness that started x5 hours ago. He states he woke up this morning and felt tingling in his extremities, which eventually progressed to weakness. He also complains of polyuria, palpitations, nausea, vomiting, abdominal pain, and fatigue. His physical exam is notable for ⅖ strength in bilateral lower extremities, ⅗ strength in bilateral upper extremities, decreased skin turgor, and dry mucous membranes. Patient's wife is at bedside and states "Bill, if you weren't so dang distracted by football then you wouldn't be here." Upon further questioning, the patient has not been taking his Metformin or checking his blood glucose levels for the last x3 days. His vitals are noted to be: 90/60 mmHg, 120 beats per minute, 23 breaths per minute, 99.0 F. You order a BMP and urinalysis. It is noted that the potassium is 6.5 mmol/L, glucose is 400 mg/dL, and ketones are present in the urine. Given the patient's history, physical exam, vitals, and lab results, what would expect to see on his EKG? A. Inverted T waves B. Peaked T waves C. QT prolongation D. ST elevation

B

Moira Rose, a 70 year old female presents to your primary care clinic today with complaints of muscle cramping, nausea, vomiting, and small bouts where she "can't move her fingers and toes" - all of which has been going on for about 6 months. Her medical history shows diabetes which she manages with regular insulin, no history of tobacco use, but a drinking habit of 4-5 Old Fashioneds per day. Since you are a thorough, hard-working PA, you decide to draw labs on Mrs. Rose after taking some vitals including her blood pressure, which is 100/70 mmHg and her heart rate is 60 beats per minute. Her electrolytes come back first so you interpret the following: Na+ 140 mEq/L Ref: (135-145 mEq/L) K+ 1.0 mEq/L Ref:(3.5-5.0 mEq/L) Cl- 100 mEq/L Ref: (95-105 mEq/L) CO2 25 mEq/L Ref:(22-30 mEq/L) BUN 10 mg/dL Ref: (8-20 mg/dL) Cr 1.0 mg/dL Ref: (0.7-1.2 mg/dL) Ca2+ 9 mg/dL Ref: (8.5-10 mg/dL) Glucose 99 mg/dL Ref:(65-99 mg/dL) Source: Blood At this point, you have a working differential diagnosis with a clear frontrunner, which is most likely.... A. Hyperkalemia B. Hypokalemia C. Hyponatremia D. Hypernatremia

B

Tim Horton, a 64 year old African American male presents to the Emergency room, via ambulance, complaining of 35 minutes of chest pain and feels like "his heart is skipping a beat." He also complains of leg and arm weakness and says his fingers and toes are tingling. He has a history of chronic kidney disease, heart failure and hypertension. He currently takes Lisinopril, Metoprolol succinate and Spironolactone and states that he takes the medications as prescribed. While you wait for the lab test results, an EKG is done and the results are as pictured. What is the most likely cause of the man's symptoms and what is the best initial treatment? A) Myocardial Infarction; oxygen supplementation and a chewed Aspirin B) Hyperkalemia; IV Calcium Gluconate C) Hypokalemia; IV KCl D) This is a benign EKG and you should wait to assess lab values before initiating treatment

B

Your Stage 4 Chronic Kidney Disease patient with an eGFR of 28 mL/min presents to clinic today with nausea, paresthesias in the fingers, and heart palpitations. You decide to order a Basic Metabolic Panel and an EKG. The EKG was significant for peaked T waves. The results of the BMP are as follows: Na: 137 mEq/L, K: 5.3 mEq/L, Cl: 98 mEq/L, HCO3: 26 mEq/L, BUN: 23 mg/dL, Creatinine: 2.7 mg/dL, Glucose: 93 mg/dL With this information, what medication is most appropriate to begin to treat the patient's hyperkalemia? A. Initiate chlorthalidone 50 mg PO once daily B. Initiate torsemide 10 mg PO once daily C. Initiate lisinopril 40 mg PO BID D. Initiate spironolactone 12.5 mg PO once daily

B

A 34-year-old female presents in the emergency department complaining of worsening back pain on her left side for the past 3 days. She states that pain was initially a 2/10 but has progressed to a 9/10 in the past couple hours. She admits to dysuria, increased frequency of urination, blood in her urine, feeling feverish, and multiple episodes of nausea and vomiting during the last 24 hours. She denies any sick contacts. Her BP is 110/70mmHg, temperature is 39°C (102.2°F), pulse is 98 bpm, and respirations are 20 breaths/min. A physical exam is performed and reveals costovertebral angle tenderness of the left flank. A urine sample was obtained, and the urine is noted to have a pink/reddish color. Urinalysis revealed white blood cell casts. A CBC is ordered and was significant for a leukocyte count of 16,000/cmm. What is the likely diagnosis? A. Cystitis B. Appendicitis C. Pyelonephritis D. Diverticulitis

C

A 35-year old male presents to your office with painless hematuria that started 2 days ago. He denies any increased frequency, urgency, discharge, flank pain, or dysuria. However, he states he recently started dating someone and is worried he may have a sexually transmitted disease. When questioned about his sexual history, he states that this new female partner is the first person he has had intercourse with in the last 12 months and they had vaginal intercourse only. The patient states he is heterosexual and used a condom. He works as a plant manager for Citgo Oil and has worked there for almost 8 years. He has a 10-pack year smoking history and states to drink "a few beers" on Thursdays and Fridays after work. He denies any illicit drug use. He has no significant past medical history and takes no medications. He states to have a non-productive dry cough but states that he has had it for a while and believes it is related to his smoking. Vitals and lab work are shown below. T: 98.4F P: 84bpm R: 18bpm BP: 138/85 SpO2: 99% RACBC: Hgb 11g/dL, HCT: 45%, MCV: 74fL BMP: Na: 150mEq/L, K: 4.9mEq/L, Cl: 96mEq/L, CO2: 24mEq/L, BUN: 35.2mg/dL Cr: 2.0mg/dLUA: Blood-tinged urine on appearance, gross hematuria, RBC casts on urine sediment, 4+ protein, specific gravity 1.028What is the most appropriate next step?A. Start antibiotics to clear infection B. Start intensive intravenous fluids to prevent kidney damage and correct electrolyte imbalances C. Chest x-ray to rule out alveolar involvement D. Lung biopsy to determine disease process

C

A 35-year-old Asian female with a history of Celiac Disease presents to the ED complaining of "blood in her pee that has been going on for awhile". She stated that she noticed the "coca-cola looking" blood in her urine right after she was diagnosed with a respiratory infection a few weeks ago. She reported that she was not initially concerned because she thought it was blood from her menstrual cycle but now recognizes that the blood is coming from her urine, making her very nervous. Associated complaints include "foamy" urine. After history, physical exam and appropriate diagnostic tests are taken, the patient is diagnosed with IgA nephropathy. What is the most specific test in order to diagnose IgA nephropathy? A. Urinalysis (UA) B. Basic metabolic panel (BMP), specifically the serum creatinine C. Immunofluorescence (IF) Microscopy D.Renal Biopsy

C

A 36-year-old Caucasian male presents to your clinic for a post-operative appointment. He was recently diagnosed with a pituitary adenoma which was successfully removed 5 days ago via a transsphenoidal ablation. He is now complaining of worsening headache, nausea and a 5 lbs weight gain in the last 5 days. He denies vomiting, diarrhea or constipation. You do a complete physical exam including an extensive neurological exam without significant findings. You have a suspicion based on his recent surgery, and you decide to order a basic metabolic panel (BMP) and a urinalysis. Glancing over the BMP, you notice that serum potassium is 3.7 mEq/L, serum sodium is 105 mEql/L, BUN is 7 mg/dL, serum creatinine is 0.8 mg/dL, serum chloride is 100 mEq/L, serum bicarbonate 24 mEq/L and serum glucose is 75 mg/dL. Urine sodium is 23 mEq/L. Based on these results and the patient's history, what is the most likely electrolyte disorder? A. Hypokalemia B. Hyperkalemia C. Hyponatremia and Euvolemia D. Hyponatremia and Hypovolemia

C

A 41-year-old G2P2 nonsmoker female patient presents to the clinic with a 1 month history of significant fatigue that did not improve after taking a vacation from work. When asked about additional symptoms, she also notes recent weight loss, subjective fever, body aches, and a history of an upper respiratory-like illness that has been present for about 2 months. Vital signs: Heart Rate: 78bpm, Blood Pressure: 130/82, Temperature: 100.5 F Respiratory Rate: 13, labored, O2sat per pulse oximeter: 97% Room Air. Physical exam shows clear rhinorrhea, conjunctivitis, and a cough. The gingiva and oropharynx are erythematous. You order a chest x-ray that shows multiple poorly-defined nodules in the lower lung fields with central necrosis. BMP shows elevated BUN and Creatinine. Of these, what is the most likely condition and what would be a good next step test? A. Goodpasture syndrome; UA looking for WBC casts B. Goodpasture syndrome; ANCA looking for +ANCA C. Wegener's Granulomatosis; ANCA looking for +ANCA D. Wegener's Granulomatosis; UA looking for macroscopic hematuria

C

A 6-year-old Caucasian boy presents to your pediatric clinic with multiple purple skin lesions that spread throughout his body. The mother states this has never happened before and the symptoms started five days ago with an itchy rash that progressed to multiple parts of the body, followed by swelling in the knees and abdominal pain causing him to vomit. The child has an unremarkable social and medical history including no known allergies. He also has not taken anything for his symptoms because his mother is afraid to give him medicine. Upon physical exam, you note the purple lesions are palpable and resemble purpura which are predominantly on the extensor surfaces of the arms, legs, and buttocks. The knee joints and abdomen are tender to palpation and his vomiting subsided over the past two days. Based on age and symptoms what is his most likely diagnosis? A. Goodpasture syndrome B. Wegener Granulomastosis C. Henoch-Schonlein Purpura D. IgA Nephropathy

C

A 6-year-old male presents to the emergency department with lower extremity edema. His mother reports she was getting him ready for soccer practice when she noticed his legs were very swollen. Patient denies any injury, trauma, or pain. He is sitting on the exam table with his arms crossed and head down, he reports "I just want to go to soccer practice! I had to miss the last 3 weeks because of my throat and vacation!" When he looks up you notice periorbital edema. His vital signs demonstrate hypertension with a blood pressure reading of 128/80 mmHg. With further questioning, Mom reports that she thinks the pediatrician said he had strep pharyngitis 3 weeks ago and was given a prescription for amoxicillin to be taken once a day for 10 days. She reports "He took almost all of it! We just didn't get the last 5 days because we went on vacation, but he felt better so I'm sure it is gone!" With this information what labs do you want to order? A. urinalysis (UA), complete metabolic panel (CMP), and antinuclear antibody (ANA) titer. B. urinalysis (UA), complete metabolic panel (CMP), and Antistreptolysin O (ASO) titers. C. urinalysis (UA), basic metabolic panel (BMP), and Antistreptolysin O (ASO) titers. D. urinalysis (UA), basic metabolic panel (BMP), and antinuclear antibody (ANA) titer.

C

A 62-year-old African American male with a 12-year history of type 2 diabetes comes to the clinic for a follow up from his diabetic check-up last week, where he had a blood pressure of 168/90 mmHg and an HgbA1c of 10%. You had ordered a 24-hour urine collection at his previous appointment, which the patient successfully completed. His vitals today are as follows: T 98.8F, BP: 164/88 mmHg, R: 16 breaths per minute, O2 99% on room air, Wt: 200 lbs, Ht: 6'1''. His 24-hour urine collection results revealed that he is excreting 120 milligrams of albumin per day and his glomerular filtration rate (GFR) is 90 mL/min. You suspect your patient is asymptomatically suffering from diabetic nephropathy. You plan on repeating these measurements and following your patient closely to confirm the diagnosis, but what stage of diabetic nephropathy would you suspect your patient to be in? A. Stage I B. Stage II C. Stage III D. Stage IV

C

A 64-year-old male presents to the Emergency Department with difficulty breathing, syncope, and generalized weakness. He has hypertension which is managed with amiloride. His vitals are as follows: T 98.4F, P 48 bpm, BP 130/92 mmHg, RR 14 breaths per minute, spO2 98% on room air. You order an electrocardiogram (EKG) and basic metabolic panel (BMP). The EKG shows diffuse peaked T-waves, QRS widening, and PR prolongation. The BMP results are as follows: Sodium 136 mEq/L, Potassium 7.2 mEq/L, Chloride 98 mEq/L, Bicarbonate 25 mEq/L, Blood Urea Nitrogen 12 mg/dL, Creatinine 0.8 mg/dL, Serum Glucose 85 mg/dL. You order a re-draw of the BMP and it comes back with the same results as the first time. Based on the most likely diagnosis, what is the next best step for this patient? A. Administer IV insulin and dextrose B. Administer furosemide C. Administer IV calcium-gluconate D. Administer albuterol nebulizer

C

A 65-year-old Hispanic woman walks into the ER complaining of a sudden onset of fever and rash. She recently started taking amoxicillin for a urinary tract infection. She has a history of diabetes that is controlled on metformin. You run a urinalysis and it comes back positive for hematuria, pyuria, eosinophils, and white blood cell casts. You send labs and get back a fractional excretion of sodium (FeNa) of 1.5%, Blood Urea Nitrogen of 42 mg/dL, and a Serum Creatinine of 1.7%. You ordered a renal ultrasound and it does not show any evidence of hydronephrosis. What is the most likely diagnosis? A. Prerenal Acute Kidney Injury (AKI) B. Intrinsic renal Acute Kidney Injury-Acute tubular necrosis (ATN) C. Intrinsic renal Acute Kidney Injury-Acute Interstitial Nephritis (ATIN) D. Post renal Acute Kidney Injury

C

A 66-year-old male with a 30 pack-year history was brought to the emergency room by his wife. She explains he had new-onset nausea and vomiting that started 1 week ago and now says he has "seemed confused and unsteady on his feet these past two days, and today doesn't seem like himself". During your interview, she tells you that he went to his Primary Care Provider 2 weeks ago for the first time "in a while" because he was feeling fatigued and short of breath. He had brushed it off for a few months as just "a part of old age", but she made him go in when he started getting pain in his chest. She said it was a good thing he had her still telling him what to do after all these years, because he was diagnosed with small cell lung cancer. They have not started treatment yet due to insurance, but now she is worried that something might have gone wrong with the cancer and "doesn't want to wait around like he did last time". You perform a full history and physical, and you order appropriate labs. Which of the following lab results support the most likely diagnosis? A. Euvolemic hyponatremia with decreased serum osmolality (sOSM), decreased urine volume, normal urine Sodium (Na), and increased uric acid levels B. Hypervolemia with decreased urine Na, increased sOSM, and normal potassium (K+) C. Euvolemic hyponatremia with decreased sOSM, decreased urine volume, increased urine Na, and decreased serum uric acid levels D. Hypovolemic hypernatremia with decreased urine volume, decreased urine Na, and elevated uric acid levels

C

A 68 year old African American female with a past medical history of hyperlipidemia and obesity is evaluated in the hospital 3 days following surgical repair of an abdominal aortic aneurysm. She currently complains of nausea, vomiting, fatigue, and constipation. Her vitals include: BP: 90/60, HR: 90 bpm, Temperature: 97.6F, RR: 17 breaths/minute, SPO2: 98% on room air. You follow up with labs to assess her kidney function and the results are as follows: GFR: 40, BUN: 35 mg/dL, serum creatinine: 1.9 mg/dL, fractional excretion of Na: 2.5%. Her UA with microscopy is unremarkable except for muddy brown casts and a urine specific gravity of 1.002. Compared to post-op day one, her GFR has decreased, serum creatinine increased, and her fractional excretion of Na has increased. You follow up with a renal ultrasound to check for any possible abnormalities and it is found to be unremarkable. Which of the following is the most likely etiology of her current state? A. Upper urinary tract obstruction B. Dehydration C. Ischemic acute tubular necrosis D. Nephrotic syndrome

C

A 72-year-old man, Randy Renal, presents to the clinic today with a fever of 100.8F, night sweats, and unintentional weight loss of 10 lbs in the last month. He tells you that he has recently been treated for an upper respiratory infection twice in the past 4 months, and he mentions he has been coughing up blood. On physical exam, you notice bilateral conjunctiva of the eyes and palpable purpura on the skin. When performing the lung exam, you note bilateral wheezing. Being the astounding PA that you are, you decide to order a chest x-ray and labs for workup. When they return this is what they show: Chest x-ray interpretation: Chest x-ray shows bilateral opacity of the lower lung fields with at least 2 ill-defined nodules presenting with central necrosis. Urinalysis: Specific gravity: 1.030, microscopic hematuria, 3+ proteinuria, and red cell casts present. ANCA: (+) Anti-GBM: (-) ANA (antinuclear antibody): (-) Anti-dsDNA: (-) Hemoglobin: 12 g/dL Serum Creatinine: 1.6 mg/dL After reviewing the results, it is most likely that Randy Renal has which of the following? A. Goodpasture syndrome B. Lupus C. Wegener Granulomatosis D. Henoch Schonlein Purpura

C

A 77-year-old Caucasian female presents to the emergency department after falling at home and hitting her head 2 hours ago. Her son informs you that she has a history of worsening unsteadiness over the past several months and has fallen twice in the past 4 weeks although previously without injury. He is concerned about her memory and states she often seems "out of it." On exam, she is disoriented to time and place and has severe contusions on her forehead and right arm. Her history is significant for hypertension, hyperlipidemia, and depression which began after her husband's death 6 months prior. Current medications include lisinopril, metroprolol succinate, rosuvastatin, and sertraline. Her vitals are stable with HR 95, RR 18, BP 145/92, SpO2 97% and temperature 37 C. Head CT shows no fracture or other abnormality, however BMP shows moderate hyponatremia at 125 mEq/L. Urinalysis reveals a mid-range osmolality of 523 mOsm/kg and high urine sodium of 44 nmol/L. Based on these findings you diagnose your patient with SIADH. Which component of her history is most likely to be the underlying cause of this condition? A. Lisinopril B. Head trauma C. Sertraline D. History of hypertension

C

An 11-year old male presents to your family care clinic for generalized edema and fatigue 3 weeks after having a URI. His vitals are T 98.8F, BP 112/72 mmHg, P 74 bpm, R 16 breaths/min, Wt. 125lbs. Ht. 5'6". Upon physical exam you find peripheral edema in his hands and feet as well as mild periorbital edema. You order a urine dipstick which shows 4+ selective proteinuria (1000mg/dL). Seeing this, you order a urinalysis with microscopy which shows 'frothy' yellow urine, an albumin-to-creatinine ratio of 325 mg/g, lipiduria with oval fat bodies, negative RBC and negative WBC. A 24-hour urine collection shows severe proteinuria (3.2 g/1.73M^2/24hrs). You start him on a short course of corticosteroids and he returns after one week showing significant improvement. What is the most likely diagnosis for this patient? A) Nephritic Syndrome B) Focal Segmental Glomerulonephritis C) Minimal Change Disease D) Rhabdomyolysis

C

An 84 year old woman presents to the emergency department accompanied by her daughter. The daughter states her mom has been acting confused the last 24 hours and is more lethargic than usual. Past medical history includes acute gastroenteritis one week ago with severe nausea and vomiting; however, the patient does not have any chronic medical problems. The patient does not currently take any medications. Physical exam reveals sunken eyes and capillary refill of 5 seconds. Vitals are as follows - temperature: 98 degrees Fahrenheit; blood pressure: 118/78 mmHg supine, 94/68 mmHg standing; heart rate: 78 bpm supine, 110 bpm standing; respirations: 16 breaths per minute; oxygen saturation: 97% on room air. You obtain a CBC, CMP, urine osmolarity and urine electrolytes. CBC values are within normal limits, CMP shows serum sodium of 120 mEq/dL, urine osmolarity is 200 mOsm/L, and urine sodium is 18 mEq/L. All other values are within normal limits. Based on the history, physical exam, and lab results, what electrolyte disturbance does this patient most likely have? A. Hypervolemic hyponatremia B. Hyperosmolar hyponatremia C. Hypovolemic hyponatremia D. Euvolemic hyponatremia

C

Christopher Robin is an 8-year-old male who is brought to the ER by his mother complaining of significant swelling around his eyes since he woke up this morning. She tried giving him some Benadryl thinking it was some sort of allergic reaction, but it didn't help. He denies shortness of breath, rhinorrhea, coughing, sneezing, pruritus, and sore throat. Past medical history and family medical history are non-contributory. He has no known drug allergies. Vital signs are: 110/60 mmHg, 78 beats per minute, 16 breaths per minute, and 98.6F. Significant exam findings include moderate periorbital edema and 1+ bilateral lower extremity pitting edema. Urinalysis with microscopy results indicate proteinuria and oval fat bodies. Lab results include albumin 2.8 g/dL, total cholesterol 250 mg/dL, LDL cholesterol 165 mg/dL, and HDL cholesterol 32 mg/dL. Which of the following increases your clinical suspicion for the most likely etiology of this patient's nephrotic syndrome? A. Peripheral and periorbital edema B. Proteinuria C. Age D. Hyperlipidemia

C

Edward Cullen is a 13 yo male who comes to the clinic with his mom today complaining of bloody diarrhea x 1 week. His mom notes he's been extra "moody" this week and that he seems very tired. You perform a physical exam which is normal with the exception of some pallor to his face and you decide to order multiple labs. Some of the results are listed after the vital signs: Vital Signs: heart rate 80bpm, respiration rate 16 breaths per min, blood pressure 144/86 mmHg, temperature 99.1F, oxygen 99% on room air CBC:RBC: 4.28 (Low)Hemoglobin: 11.5 g/dL (Low)Hematocrit: 38% (Low) BMP:Serum Creatinine 2.5 mg/dL (Elevated)BUN: 60 mg/dL (Elevated) Based on this information, what is the best treatment for this patient? A. Plasma exchange + prednisolone B. Eculizumab only C. Eculizumab + meningococcal vaccine D. IV "pulse" cyclophosphamide + IV methylprednisone + lisinopril

C

Nancy is a 72 year old female who comes into the Emergency Department complaining of severe nausea and vomiting for the past 48 hours. She states that she has been unable to hold any food or liquids down during that time. She reports that she is currently taking lisinopril for hypertension but has no other chronic conditions that she is aware of. Vital signs include BP 110/64 mmHg, P 80 bpm, R 15 breaths/min, T 98.8°F (38°C), Wt. 145 lbs. Ht. 5'6", SpO2 98% on room air. In addition to her vitals, you order labs which show BUN 50 mg/dL, SCr 1.8 mg/dL, FeNa 0.6%, and a urine analysis which shows hyaline casts, 0-1 RBCs, negative WBCs, negative heme/protein. Lucky for you, Nancy is a "regular" at this Emergency Department so you look at her previous labs from 2 months ago to compare, which show BUN 25 mg/dL and SCr .8 mg/dL, and similar UA results. Based on her history and results, what is the likely diagnosis? A) Post-renal Acute Kidney Injury B) Chronic Kidney Disease C) Pre-renal Acute Kidney Injury D) Acute Tubular Necrosis

C

Roxanne is an 88 yo female who presents to clinic c/o nausea and vomiting for the past 28 hours. She believes it may have something to do with the buffet night they had at her nursing home two days ago. Since her symptoms began, she has not been able to keep any food or liquids down. You take her vitals and notice the following: BP 128/90 (but upon standing, her BP was 105/78), Temp 100.1 F, RR 16, HR 88 After calling her nursing home, you suspect that she has viral gastroenteritis (which is currently rampant among the residents) and you want to begin treating her. Before administering fluids though, you get a urinalysis (UA) to ensure she has adequate kidney function and a CMP to assess electrolyte levels. To your surprise, her labs show an elevated BUN (32mg/dL), elevated Serum Creatinine (1.45 mg/dL), and hypernatremia (Na 149 mEq/L) but her UA is normal. You diagnose Roxanne with prerenal acute kidney injury (AKI). Based on this case, what is the most likely cause of Roxanne's prerenal AKI? A. Altered renal hemodynamics B. Renal vascular obstruction C. Decreased intravascular volume D. Decreased effective blood volume

C

Sally is a 68 year-old African American female who was diagnosed with chronic kidney disease (CKD) two weeks ago and she has returned to the clinic for a follow-up. Her past medical history includes diabetes mellitus that is well managed with glipizide and her A1C 7.5%. Her GFR has steadily declined over the past 5 years from 99mL/min to 50mL/min. Urine albumin to creatinine ratio (UACR) at her previous appointment was 400 mg/g. A basic metabolic panel reveals her serum creatinine is 1.6 mg/dL and UACR is confirmed to be 412mg/g today. Which of the following is true regarding the management of Sally's chronic kidney disease? A) Advise the patient that they do not need to restrict NaCl intake. B) Avoid putting the patient on an ACE inhibitor or angiotensin receptor blocker (ARB). C) Begin the patient on an ACE inhibitor or angiotensin receptor blocker. D) Spironolactone is not indicated for chronic kidney disease.

C

You have an elderly African American patient in the hospital who was recently treated for diabetic ketoacidosis. On day two of her treatment, one of the nurses pulls you aside to inform you that the patient's urine output has dropped off. Concerned, you both decide it's best to take some tests to check for Acute kidney injury. You decide to order an eGFR, urine analysis, BMP, BUN/Creatinine, urine Na, osmolality, FeNa, and FeUN. You also intend to take an ultrasound of the kidneys to rule out a postrenal cause. Her urine analysis comes back first, and the test results come back as follows: Protein ++, RBCs +++, WBCs +, RBC casts ++++, WBC casts O, granular casts +. Based on your current knowledge of her labs, which of the following diagnoses is the most likely cause of her AKI? A. Ischemic tubular necrosis B. Acute allergic interstitial nephritis C. Acute glomerulonephritis D. Nephrotic syndrome

C

Your patient Wilma Jones has recently progressed from chronic kidney disease to end stage renal disease. It is your job now to break the news of her new diagnosis and the next steps in managing her care. It is important to be thorough because you know she likes to ask a ton of questions. Which of the following statements is correct concerning dialysis? A. Potential for infection is only possible with the hemodialysis and not peritoneal dialysis. B. Even though both hemodialysis and peritoneal dialysis have the same efficacy, hemodialysis is chosen by patients more due to better quality of life. C. Graft is known to have a higher risk of thrombosis compared to a fistula. D. Graft is the least preferred type of access due to high risk of infection.

C

Your patient is a 10 year old male that is brought into the clinic by his parents. They state that today he randomly began to have swelling around his eyes and in his legs. They also tell you that their son's urine is brownish red colored. When assessing the patient's vitals you notice that the patient is mildly hypertensive. All other aspects of the patient's exam are unremarkable. The parents deny any hospitalizations in the last 8 years and besides a "pretty bad sore throat that was treated" a couple weeks ago he is in good health. You decide to order a basic metabolic panel and urine dipstick. Urine dipstick shows 2+ blood and 1+ protein. Urinalysis with microscopy and 24-hour urine collection is then ordered and, when results return, it is positive for proteinuria (80mg/1.73m^2/24hrs), gross hematuria, and red blood cell casts. Basic metabolic panel shows an elevated BUN 78mg/dL, elevated serum creatinine 2.5mg/dL, sodium 130mEq/L, potassium 5mEq/L and bicarbonate of 15mEq/L. You suspect that the patient has acute post-infectious glomerulonephritis (APIGN) which is confirmed by ASO titers. The parents are concerned about how this happened to their son. You explain to them that a majority of children recover spontaneously, and explain APIGN can occur 2 weeks after _______? A: a Group B B-hemolytic streptococcal pharyngeal infection. B: an Escherichia coli strain 0157:H7 infection C: a Group A B-hemolytic streptococcal pharyngeal infection. D: Staphylococcus aureus

C

A 4 year-old Caucasian girl presents to the emergency room with her mom with swelling in her legs and around her eyes which developed suddenly today, and she also has a sore throat. She mentions that her daughter has only used the restroom 2 times all day, and she was only able to provide a tiny urine sample for the urinalysis at your clinic. When you ask about the child's medical history, she has no drug allergies and finished a 10-day prescription of cefdinir 2 days ago for strep pharyngitis. Her vitals are: BP 115/85 mmHg (normal range is 95-110/60-75 mmHg), Temperature 38 degrees Celsius, HR 115 bpm, O2 sat 98% on RA. You order labs and a throat culture, and the results are: sodium: 140 mEq/L, potassium: 4.2 mEq/L, BUN 24 mg/dL, creatinine 1.8 mg/dL, UA: microscopic hematuria, and the throat culture is positive for group A streptococcus. What is the treatment of choice based on your diagnosis? A. Pen V x 10 days plus lisinopril B. Clindamycin x 10 days plus prednisone C. Clindamycin x 10 days plus nifedipine D. Amoxicillin x 10 days plus enalapril

D

A 42 yo female presents to the emergency department with altered mental status, headache, and complains of visual disturbances. She is febrile and on exam you note diffuse petechiae and purpura. A urine dipstick is positive for urine blood and protein is 2+. Which of the following is true concerning the condition most likely causing these findings? A) Prior to admission, she was likely having diarrhea linked to Shiga toxin exposure B) The treatment of choice for this condition is Ecluizumab and a meningococcal vaccination C) This condition is typically self-limited and does not usually require any medical intervention D) This condition has a high mortality rate and this patient will need plasmapheresis and corticosteroids

D

A 52-year-old male presents to clinic complaining of fever, fatigue, and night sweats. He reports an unintentional weight loss of 10 pounds in the last 4 weeks but that he really hasn't been that hungry. Two weeks ago, he was diagnosed with a viral upper respiratory infection with rhinorrhea and cough. He states both symptoms are still present and that he has recently "coughed up some blood" and had epistaxis. On urinalysis, he has proteinuria, microscopic hematuria, and red blood cell casts. You order a basic metabolic panel and a series of other tests. You diagnose him with Wegener Granulomatosis. What must you order to confirm your diagnosis? A. Chest radiograph B. ANCA C. ANA D. Kidney biopsy

D

A 56 year old, postmenopausal female, comes to your primary care clinic complaining of muscle aches, severe abdominal pain, and feelings of anxiety for the past 2 weeks. She complains that it extremely painful to urinate and the pain is so bad she cannot endure it. During your physical exam, the patient has positive CVAT on the right. You draw labs and find that she has increased levels of an electrolyte that fits her clinical picture. Which of the following is the most likely cause of this patient's electrolyte imbalance? A. Low vitamin D levels B. High phosphate C. Hypothyroidism D. Hyperparathyroidism

D

A 57 year old African American male presents to your emergency room complaining of vomiting over the last 5 days. No blood or mucous was noted in his vomit. Additionally, he has been complaining of difficulty catching his breath over the last 5 days. No fever was reported, and other than generalized fatigue, no other symptoms were noted at this time. A BMP with estimated glomerular filtration rate was conducted and was shown to have a BUN of 60 mg/dL, and a serum creatinine of 1.8 mg/dL. Furthermore, the estimated GFR was 55. Afterwards, a urinalysis was conducted, and all values were found to be within normal limits except for an elevated level of albumin in his urine, which were found to be 75 mg/g. After looking at this patient's past medical history, it was confirmed that he has been having declining renal function over the past 8 months. A diagnosis of chronic kidney disease has been made. At this time, what stage chronic kidney disease would you classify this patient as? A: Stage 1, A2 B: Stage 2, A1 C: Stage 3a, A1 D: Stage 3a, A2

D

A 59-year-old man with a 12-year history of diabetes and hypertension presents to his PA with complaints of fatigue and weight gain of 10 lbs over the past 2 months. He denies any changes in his diet and takes his diabetes medications correctly, but does state that he does sometimes get nauseous and doesn't eat. He has noticed that his legs are more swollen at the end of the day, but improves with elevation and rest. His past urinalysis in 2018 showed his GFR as being 45mL/min and his albumin-to-creatinine ratio as 10mg/g. His vitals are BP 160/100 mmHg, P 80 bpm, R 15 breaths/min, T 98.8°F (38°C), Wt. 260 lbs. Ht. 5'11", BMI 36.3, SpO2 98% on room air. A urinalysis was done and his GFR is 30mL/min, albumin-to-creatinine ratio is 20mg/g with hyaline casts and no evidence of hematuria or pyuria. Based on his diagnosis of chronic kidney disease, what stage is he at based on the KDIGO criteria and how likely is he to progress to kidney failure? A) Stage 2, A1 - higher likelihood of progressing to kidney failure B) Stage 3a, A1 - lower likelihood of progressing to kidney failure C) Stage 3b, A2 - moderate likelihood of progressing to kidney failure D) Stage 3b, A1 - lower likelihood of progressing to kidney failure E) Stage 3b, A3 - higher likelihood of rapidly progressing to kidney failure

D

A 62-year-old male presents to the clinic as a new patient for his annual physical. Vitals are as follows: BP 138/90 mmHg, RR 16 breaths per minute, HR 72 beats per minute, T 98.2F, and O2 is 98% on room air. On physical exam, he is well-appearing and in no apparent distress. Lungs are clear to auscultation bilaterally and the heart has a regular rate with no murmurs, rubs, or gallops. He tells you that he was recently diagnosed with stage 3 chronic kidney disease and was prescribed lisinopril and torsemide. He was also referred to a dietician for nutritional support. You look at the comprehensive metabolic panel that was drawn earlier today for the physical and notice that his serum creatinine is about 20% higher than his last recorded lab value of 1.2 mg per dL. All other lab values are unremarkable. What should you do based on the abnormal lab result? A. Send the patient to the emergency room B. Refer the patient to nephrology C. Repeat lab values D. Nothing needs to be done

D

A 68 African-American male presents to the emergency room with his daughter. She states that he saw blood in his urine and is concerned. She has also noticed that he has been confused lately and has had trouble sleeping. Her mother mentioned to her that he also has been feeling nauseated and has vomited over the past week and refuses to eat. Today, the patient has had loose stools. The patient takes Metformin only when he feels his "sugars are too high" and not as recommended by his primary care physician. Additionally, he takes amlodipine and hydrochlorothiazide (HCTZ). He is a former smoker, with a 40 pack year history. His father passed away in his 60s from renal cell carcinoma. The PA student triaging the patient makes a list of differential diagnoses, with chronic kidney disease being at the top of his list. Which of the following risk factors are not strongly associated with adverse renal and cardiovascular outcomes of chronic kidney disease? A. Age B. Family History C. Smoking D. Hyperalbuminemia

D

A 74 year old Caucasian female presents to your primary care clinic for a routine evaluation of her stage 3 chronic kidney disease. In addition to chronic kidney disease, she has a past medical history of hypertension and diabetes mellitus. She has no complaints currently. During her most recent visit her serum creatinine was 1.5 mg/dL and her estimated glomerular filtration rate was 52 ml/min. You order labs and find that her serum creatinine is holding stable at 1.5 mg/dL, but her estimated glomerular filtration rate has dropped to 48 ml/min. She is currently taking metformin 1000 mg BID, lisinopril 40 mg BID, and hydrochlorothiazide 12.5 mg once daily. What medication changes should be made for her chronic kidney disease management? a. Discontinue metformin and add insulin b. Add losartan c. Discontinue lisinopril d. Discontinue hydrochlorothiazide and add torsemide

D

A 76-year-old female presents to the emergency room. She reports having several episodes of vomiting for the past two days and has not been able to keep food or liquids down. She is weak and lethargic. Past medical history includes osteoporosis and hypertension. Basic metabolic panel reveals serum sodium of 126 mEg/L, serum potassium of 3.7 mEg/L, blood urea nitrogen of 20 mg/dL and serum creatinine of 1.1 mg/dL. What physical exam finding would support your diagnosis of hypovolemic hyponatremia? A) 2+ pitting edema and jugular venous distention. B) Twitching of the facial muscles when tapping over distribution of facial nerve (positive Chvostek's sign) C) Ascites and jaundice. D) Blood pressure of 122/82 mmHg (sitting) and 98/64 mmHg (standing).

D

A patient presents to your clinic for abdominal pain and vomiting. While interviewing the patient, you notice purple skin lesions on the extensor surfaces of their arms and legs. While raising their arms and legs to show you the lesions, they express that they've also been experiencing pain in their joints. You suspect Henoch Schonlein Purpura, and order a UA, skin biopsy, and renal biopsy. Which of the following patient profiles and lab findings would have the best prognosis for this disease state? A) A 35 year old patient with nephrotic range proteinuria B) A 15 year old patient with 70% crescents on renal biopsy C) A 60 year old patient with asymptomatic hematuria and proteinuria D) A 7 year old patient with focal glomerulonephritis who has had Henoch Schonlein Purpura 3 times

D

An 81-year-old African American female presents to the clinic for a follow up appointment to go over lab results that you ordered at her last visit to assess her kidney function. Her Glomerular Filtration Rate (GFR) is 13 mL/min and her albumin-to-creatinine ratio is 200 mg/g. You inform her that she is in Stage 5 kidney failure and will need to be treated with dialysis. What is some important and correct patient education that you should discuss with her in order for her to decide on which form of dialysis she should use? A. Tell her peritoneal dialysis is the better option over hemodialysis and she should really choose this option B. Inform her that since she has had multiple abdominal surgeries she should be placed on peritoneal dialysis C. Inform her peritoneal dialysis is a catheter placed in the peritoneal cavity that requires the patient to come to the clinic three times a week. D. Inform her peritoneal dialysis is a continuous form of dialysis that requires everyday use and can be done at the patient's home. Hemodialysis requires access to a blood vessel and for the patient to come in three times a week.

D

Sam Johnson is a 65 year-old-male that presents to Baylor ED with persistent diarrhea for the past 2 days. He says he is "really thirsty now." Denies urinary symptoms, fever, or chills. You are able to obtain his records because his primary care provider uses Baylor's electronic medical records as well. He has no pertinent past medical history and is not currently on any medications. His last physical was 1 month ago, and his Complete Blood Count (CBC), Complete metabolic panel (CMP), Urinalysis (UA), and lipids were all normal at that time. After determining the source of the diarrhea was a self-limiting food poisoning, you decide to order blood work to make sure the patient is stable. You order a CBC, CMP, and UA.You also check serum creatinine (SCr), fractional excretion of sodium (FeNa), and a renal ultrasound because you are worried about his fluid loss and subsequent kidney injury. Patient's physical exam was normal except for loss of skin turgor and heart rate of 115 BPM. Lab results were as follows BUN: 47 mg/dL and SCr: 1.6 mg/dL. UA with microscopy was unremarkable: negative for blood, protein, casts, and white blood cells. Patient's renal ultrasound was normal. Based on your suspected diagnosis of acute kidney injury, what is his most likely fractional excretion of sodium (FeNa)? A. 5% B. 3% C. 1.5% D. 0.2%

D