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EXAM ON NEPHROLOGY AND UROLOGY PART 2 (150 marks)

NAME: ___________________________________

PHONE NO: ________________________________

EMAIL ID: _________________________________

In MCQs kindly tick () the ONE answer that you think is most correct. For those answering via email kindly make bold and/or underline the correct answer.

NEPHROLOGY/UROLOGY TEST- PART TWO I] NEPHROLITHIASIS (28 marks total)

1. The likelihood of spontaneous passage of a 7mm stone lodged in the upper ureter is approximately A 1% C 25% B 10% D 50% 2. Formulations like Potrate which contain potassium citrate are used in patients with renal stone as they A Act as crystallization inhibitors C Decrease dysuria B Prevent bacterial UTI D All of the above 3. The following diuretic brand can CAUSE kidney stones A AQUAZIDE C AMIFRU B LASILACTONE D BIDURET 4. Uric acid stones which account for 5% of all stones are best picked up by A X-ray KUB C USG KUB B CT-scan KUB D Urine routine examination 5. Calcium containing stones can result from an overdose of A Vitamin A C Vitamin C B Vitamin B12 D Vitamin D 6. Allopurinol (Zyloric) should be used as a preventive drug in patients with uric acid stones A Only if a patient gets stones C Only if 24-hour urinary uric acid that are symptomatic is > 1000mg & stones are recurrent B Only if the patient also has D Only if serum uric acid >8.0 gout 7. A urine examination in a patient with a ureteric colic is most likely to reveal A Occult hematuria C Crystalluria B Pyuria D Proteinuria 8. The following instruction/s to a patient of recurrent nephrolithiasis (calcium stones) by the family doctor will reduce the number of recurrences. A Restrict dietary salt C Switch from non-vegetarian to

B Increase dietary calcium

vegetarian sources of protein D All of the above

MATCH THE FOLLOWING & FILL THE BLANKS BELOW: Type/location/size of stone 1. Upper ureteric >6mm calcium oxalate 2. Lower ureteric >6mm calcium oxalate 3. Staghorn calculus (Struvite carbonate) 4. Uric acid stones of 7mm Correct match: 1= 2= 3= 4= TRUE OR FALSE:
1.

Therapy A] Removal by cysto-ueteroscopy B] Hydration & alkalinization of urine C] Extracorporeal shock wave lithotripsy D] Percutaneous nephrolithotomy & ESWL

Reducing oral oxalate intake, eg. spinach, decreases the recurrence of calcium-containing stones.

2. The dose of hydrochlorthiazide required for prevention of calcium stones is the same as given for hypertension.
3.

Surgical intervention in asymptomatic kidney stones is considered only if the stone size is > 10mm.

4. Giving alpha-blockers like tamsulosin may help the passing out of a ureteric calculus.
5.

A ureteric stone is almost always complicated by a urinary tract infection.

6. Citrus fruit juices cause alkalinization of urine. 7. Patient with one days h/o ureteric colic may not show hydronephrosis on same side as hydronephrosis may take 2-3 days to become apparent. 8. Orlistat, a weight reducing drug, can cause hyperoxaluria & calcium

oxalate stones.

PLEASE SUPPLY THIS INFORMATION: (8 marks)

1.

State the name and phone number of a urologist to whom you would send a patient for cysto-ureteroscopic removal of a lower ureteric stone. ____________________________________________________________________

2. State the name and phone number of a centre where you would refer a patient for ESWL. ____________________________________________________________________

3.

Give two brand names of potassium citrate used to alkalinize urine other than Potrate. 1.______________________________________________________________ 2._______________________________________________________________

4.

Give two brand names of indapamide (2.5 or 1.5mg). 1.________________________________________________________________ 2.________________________________________________________________

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II] URINARY TRACT INFECTION ( 32 marks total )

1. A bed-ridden male patient of Parkinsonism on an indwelling catheter has a urine culture growth of E.coli with a significant colony count. He has no symptoms related to UTI. For this UTI he should A Be left untreated C Be given frequent bladder washes with antiseptic solutions like Betadine B Be given appropriate antibiotic D Be given a low dose of long based on sensitivity report term antibiotic like nitrofuratoin 2. Pain of prostatitis is located in the A Suprapubic region & urethra C Perineum & low back B Flanks & renal angles D Periumbilical & epigastric region 3. The patient with symptomatic UTI in whom you may not send urine for culture is A A pregnant woman C A diabetic male with recurrent UTI B A non-pregnant woman without D A non-diabetic male with first co-morbid illnesses episode of UTI 4. The commonest organism causing acute uncomplicated cystitis & acute uncomplicated pyelonephritis is A E.coli C Klebsiella pneumoniae B Pseudomonas aeruginosa D Staphylococcus aureus 5. With regards to urine culture & antibiotic sensitivity following statement is correct. A Choose an antibiotic that has C Choose an antibiotic that has low MIC & high diameter of low MIC & low diameter of inhibited zone inhibited zone B Choose an antibiotic that has D Choose an antibiotic that has high MIC & high diameter of high MIC & low diameter of inhibited zone inhibited zone

6. Triple drug kits for vaginitis eg. FAS-3 kit, Zocon-AS, Azithral-XP all contain the following fixed dose combination of Azithromycin (A), Secnidazole (S), Fluconazole (F)A A- 500mg S- 1gm F- 100mg B A- 500mg S- 2gm F- 200mg C A-1gm D A- 1gm S- 2gm S- 2gm F- 150mg F- 100mg

MARK AS YES OR NO Is a USG-KUB mandatory in the following UTI situations? A] UTI with severe colic B] UTI with haematuria C] UTI in a 3 year old child D] Males with first episode of UTI E] Suspected pyelonephritis F] Patients with recurrent UTI _________ _________ _________ _________ _________ _________

TRUE OR FALSE:
1.

Use of condoms by their partners reduces incidence of honeymoon cystitis in women.

2. Vaginitis can cause dysuria.

3. 4.

Nitrofurantoin can be used in pregnancy but not during lactation. In UTI, nitrite-indicator strips are a useful method to detect infection in aymptomatic patients, especially diabetes & pregnant women. A girl studying in the 7th standard comes with a first episode of lower UTI. She must undergo an ultrasound examination as a screening for underlying abnormalities like vesicoureteral reflux & calculi.

5.

6. Approximately 50% of women will experience a UTI in their lifetime.

7. Treatment of catheter-related UTI is effective only after removal of the catheter. 8. Reflux nephropathy due to vesicoureteric reflux is an important cause of hypertension & ESRD in childhood. PRACTICAL INFORMATION (12 marks total) 1. Find the cost of the following (MRP). A] 16 French Foleys catheter. _________________________________ B] 16 French Silicon catheter. _________________________________

2. Given below are doses of certain antibiotics as used in average sized adults with UTI. Guess the generic name of the drug and give one brand name. A] 400mg twice a day- ___________________________________________ B] 325 (200+125) mg twice a day- ________________________________ C] 625 (500+125) mg twice a day- _________________________________ D] 100mg thrice a day- ____________________________________________ E] 100mg twice a day- _____________________________________________

III] PROSTATE and BLADDER ( 22

marks total )

1. 5-alpha reductase inhibitors cause reduction in prostate size by A Inhibiting production of C Blocking the testosterone testosterone receptors on prostatic tissue B Inhibiting conversion of D All of the above testosterone to dihydrotestosterone 2. Which one of the following is not a cause of a clinically significant rise in blood PSA levels? A Prostatitis C Transurethral resection of prostate B Placement of indwelling D Digital rectal examination catheter 3. When you, your parent or your spouse is 80 years old & is detected with a PSA of 30, what line of action is scientifically correct if an asymptomatic cancer localized to the prostate is detectedA Orchidectomy C Local radiotherapy alone B Radical prostatectomy D Watchful waiting 4. In prostate cancer, orchidectomy is done to A Deprive the prostate cancer of C Prevent spread to the scrotum androgens & prevent its which is the commonest site of growth metastases B Cure the prostate cancer D All of the above 5. In symptomatic benign prostatic hyper trophy which of the following is the mechanism of action of alpha-blockers like tamsulosin A Prostate size reduction C Detrusor muscle contraction B Smooth muscle relaxation D All of the above

6. Which of the following is a correct method to diagnose prostatitis?

A Examining mid-stream urine C Examining the first 10ml of sample after prostatic massage urine voided after prostatic massage B Examining semen after D Examining the last 10ml of prostatic massage urine voided after prostatic massage

TRUE OR FALSE
1. In BPH, if the patient has responded well to a combination of finasteride & tamsulosin, the latter may be withdrawn after several months of use. 2. Finasteride & dutasteride are known to marginally increase the incidence of prostate cancer. 3. 20% of patients with carcinoma prostate have a normal PSA.

TASKS (13 marks)

1. Find the full forms of the abbreviations TUNA & TEAP which are newer surgical therapies for BPH. TUNA=______________________________________________________________ TEAP=______________________________________________________________ 2. Find one brand name each for Tamsulosin + finasteride - ____________________________________ Tamsulosin + dutasteride - ___________________________________ Alfuzosin - _________________________________
3.

Find the generic name and give one use of the following brands Tropan - _________________________________________ Urotone - ________________________________________ Urispas - ________________________________________ Roliten - ________________________________________

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IV] CHRONIC KIDNEY DISEASE (30 marks)

Which of the following statements about erythropoietin therapy for anemia in CRF is UNTRUE? A Recombinant human C Erythropoietin works best if erythropoietin is used because blood iron levels are well the major cause of anemia in maintained. Hence, oral iron is CRF is a decline in usually co-administered erythropoietin synthesis by the kidneys B Aggressive elevation of D The target of hemoglobin to be hemoglobin using reached is 13g% erythropoietin can unfortunately increase mortality
1.

2. Which of the following statement SODAMINT tablet is INCORRECT? A Sodamint contains sodium C bicarbonate & is used in CRF patients to combat metabolic acidosis B Administration of Sodamint D helps prevent some of the osteodystrophy of chronic uremia
3.

about the commercial preparation Sodamint helps reduce nausea & anorexia caused by acidosis Sodamint is safe & does not disturb blood pressure control despite its sodium content

If serum creatinine is 4.5, which one of the following oral antibacterials will require dose adjustment? A Cephalexin C Azithromycin B Metronidazole D Chloramphenicol

4. Which of the following statements about diabetic nephropathy (DN) is INCORRECT?

A Type I DM patients are more C In a type II DM patient, lack of likely than type II DM patients diabetic retinopathy virtually to develop DN rules out a possibility of DN B Type II DM is the most common D Another reason for azotemia in cause of ESRD in the world diabetic patient is atherosclerotic renal artery stenosis

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5. Which of these measures does not delay the development of overt diabetic nephropathy?
A Tight glycemic control B Tight blood pressure control (less than 130/80) C Tight lipid levels control (LDL<100) D Oral ACE inhibitors &/or ARBs

A FOUR MARK QUESTION As a family physician of patients with a creatinine of 1.5 to 2.5, what five things can you do to avoid progression of azotemia & prevention of ESRD? (One correct answer provided) 1. Control diabetes well to achieve an HbA1c of 7.0 2. _____________________________________________ 3. _____________________________________________ 4. ______________________________________________ 5. ______________________________________________

TRUE OR FALSE 1. Allopurinol (Zyloric) which is often used in patients of CKD, can be used in its normal dose of 300mf/day, irrespective of serum creatinine. 2. Commonly used drugs like cetrizine & ranitidine do not require dose reductions in patients with CRF. 3. Erythropoietin injections should be kept in the refrigerator.

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TASKS (10 marks) 1. Please visit this website www.kidney.org/professionals/KDOQI/gfr_calculator.cfm and calculate estimated GFR of 1) A 64 year old 46 kg male with S. creatinine of 1.0 2) A 64 year old 110 kg female with S. creatinine of 1.0 Each calculation should be by two methods a) The Cockcroft-Gault formula & b) MDRD method-extended version. 1. a. eGFR= ___________________________________ b. eGFR = _____________________________________ 2. a. eGFR = ______________________________________ b. eGFR = ______________________________________ 2. Please visit the website www.kidney.org and go to a cookbook called Living Well on Dialysis. It has a 7 day sample menu for patients on dialysis. Mention the amount of calories & proteins that they have incorporated in the menu per day. a. Calories = ______________________________________________________ b. Proteins = ______________________________________________________

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3. Find two brand names of erythropoietin with the name of the pharma company distributing it and the cost if bought directly from the company. Provide phone number that you will contact to procure it directly. 1. _________________________________________________ 2. _________________________________________________

CRACK THIS ABBREVIATION (Rewrite in full form)

(8 marks)

When a CKD patient progresses to ESRD with GFR <10ml/min, he usually requires RRT in the form of HD or PD. HD is facilitated by creation of a native AVF. _________________________________________________________________ _________________________________________________________________ __________________________________________________________________

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V] MISCELLANEOUS (32 marks total)

1. Which one of these statements about IgA nephropathy (Bergers disease) is INCORRECT?
A It is the most common form of primary glomerular disease in the world, particularly prevalent in Asia B It presents usually with a nephrotic range proteinuria C It is a slowly progressive disease with ESRD occurring in 20-40% of patients by 20 years D Corticosteroids are ineffective and not indicated

2. Which one of the following statements about radiocontrast agent-induced nephropathy (also known as contrast nephropathy) is INCORRECT?
A Presents as an acute (within 24-48 hours) rise in BUN and serum creatinine B The azotemia usually takes months to resolve C Risk factors include preexisting CKD, diabetes mellitus, congestive heart failure and dehydration D N-acetylcysteine may prevent contrast nephropathy

3. All of the following are potential causes of prerenal azotemia except one. Which one?
A Cardiogenic shock following myocardial infarction B Severe gastroenteritis C Variceal hemorrhage D Renal artery embolism

4. Which of the following is not an angiotensin-receptor blocker (ARB)?

A Losartan B Lisinopril C Valsartan D Telmisartan

5. Which one of the following statements about acute interstitial nephritis is INCORRECT?
A NSAID-induced AIN is usually seen after several months of use B Systemic symptoms like fever, rash & arthralgias may accompany renal symptoms like flank pain and oliguria C Eosinophiluria is typical though not pathognomic D Quinolones may cause AIN after just one dose

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6. Which one of the following statements about adult dominant polycystic kidney disease (ADPKD) is INCORRECT?
A Increased BP is often the first sign of ADPKD B Renal transplantation is never a therapeutic option C Each offspring of an ADPKD patient has a 50% chance of being affected too D ADPKD evolves with age and the number of cysts on ultrasound can increase with time

7. Which one of the following does NOT cause hyponatremia?

A Diuretic therapy B Poor oral solid & liquid intake C SIADH D Diabetes insipidus

8. Which of the following does NOT cause hyperkalemia?

A Congestive cardiac failure C Chronic renal failure B Potassium-sparing diuretics like D ACE inhibitors spironolactone

9. Which one of the following statements about indwelling catheterization is INCORRECT?

A A silicon catheter can be kept C Indwelling catheters should be for a longer time (6 to 8 weeks) managed with daily bladder than a regular Foleys catheter washes (2 to 4 weeks) B Suprapubic catheterization is D Frequent daily simple an option in persons with catheterization is an option to severe urethral or bladder long term indwelling outlet narrowing catheterization

10. Of the following, the commonest cause of lower urinary tract obstruction in male infants is
A Ureteric calculi B Posterior urethral valves C Bladder neck obstruction D Bladder diverticuli

11. The commonest primary malignant tumour of the kidney is

A Wilms tumour B Renal cell carcinoma C Transitional cell cancer D Carcinoid tumour

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12. A 12 year old presents with headache & a blood pressure of 210/110 mmHg. There is no h/o recent infection. Urine analysis is normal. The most appropriate next step out of the following is
A Serological markers like serum complement to detect glomerulonephritis B Ultrasonography to detect Wilms tumour C Voiding cystourethrogram to detect uretero-vesical reflux D X-ray KUB to detect nephrocalcinosis

13. A 3 year old boy has cola- coloured urine & facial swellings over the past 3 days and decreased urine volume over past 1 day. On examination -BP 130/80, periorbital oedema, bilateral rales and ankle oedema. Urine analysis reveals 3+ hematuria, 1+ proteinuria & RBC casts. His serum electrolytes & serum albumin are normal. The most likely diagnosis is
A Acute pyelonephritis B Acute tubular necrosis C Nephrotic syndrome D Acute glomerulonephritis

14. A 3 year old boy presents with a 3 day history of abdominal pain and difficulty in walking. Findings include BP of 120/80, diffuse abdominal tenderness, purpuric rash of the hands & ankles, diffuse periarticular tenderness and swelling of the ankles. The most likely diagnosis is
A SLE B Kawasakis disease C Henoch-Schonlein purpura D Juvenile rheumatoid arthritis

15. Which of the following regarding poststreptococcal glomerulonephritis (PSGN) is/are TRUE
A Acute phase of PSGN usually resolves in 6-8 weeks B Microscopic hematuria may persist for 1-2years E All of the above C Serum C3 level are usually reduced in the acute phase D The best single antibody titer to document cutaneous streptococcal infection is the DNase B antigen

16. Which one of the following renal diseases does not cause secondary hypertension?
A Renal artery stenosis B Acute pyelonephritis C Chronic glomerulonephritis D Obstructive uropathy

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17. The most common presenting symptom/sign in a child with minimal change nephrotic syndrome is
A Fever B Throat or skin infection C Edema D Headache & hypertension

18. The treatment of choice of minimal change nephrotic syndrome is

A Masterly inactivity B Corticosteroids C Diuretics D Short-term dialysis

19. Which of the following may be used as a diagnostic tool for renal artery stenosis?
A Conventional renal angiography B Renal MRA with contrast C Renal CT angiography D All of the above

20. Which of the following statements about minimal change nephrotic syndrome (MCNS) is incorrect?
A Though the diagnosis is confirmed by electron microscopy, a renal biopsy is not routinely performed in children B A renal biopsy is almost always required in adults suspected of MCNS C Patients of MCNS on treatment should be monitored with daily home testing of proteinurea D In children with MCNS relapse occurs in less than 10% of patients

21. Metformin is stopped 2 days pre- and post- contrast procedures as

A It can cause an additive effect to the nephrotoxicity due to contrast B It can cause lactic acidosis if acute kidney injury occurs due to contrast C It can worsen the oral contrast mediated diarrhea D All of the above

22. Blackwater fever refers to

A Acute tubular necrosis in falciparum malaria resulting in dark urine due to hemolglobinuria & renal failure B ESRD in chronic malaria infection C Severe hemolytic anemia in vivax or falciparum malaria with hemoglobinuria D All of the above

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TRUE OR FALSE 1. More than 90% children with nephrotic syndrome due to minimal change disease will have a complete resolution of proteinuria within two months of starting steroid therapy. 2. Minimal change disease is the commonest cause of idiopathic nephrotic syndrome in adults. 3. Urine examination for Bence-Jones proteins should be considered obsolete.

Give the full forms of the following commonly used abbreviations in nephrology 1. LUTS -____________________________________ 2. CAPD - ___________________________________ 3. DRE - _____________________________________

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This is a CT scan film of a 55 year old hypertensive whose father and two siblings have died of end stage renal disease

Q1) What is the diagnosis? Ans. Q2) What one investigation should the 30 year old son of this patient get done? Ans.

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Film A Severe abdominal colic since 3 weeks in a 40 year old. A)

Q1) State diagnosis? Ans. Q2) State your choice of therapy? Ans.

Film B 60 year old with chronic abdominal pain in the left lumbar region. B)

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Q1) Can the lesion pointed out be the cause of the pain? Ans.

Q2) Has contrast been given for this scan? Ans.

A TWO MARK MURDER MYSTERY A man is arrested in suspicion of murdering his business partner. He claims that he was running the Mumbai marathon at the time the murder occurred. Two findings on his urine examination done the morning after the murder prove his innocence. What were these two findings? 1. _____________________________________ 2. _____________________________________

TWO FUN QUESTION FOR TWO MARKS 1. An anagram of the word URINATE is a constituent drug in the brand NEFROSAVE and in the drink REDBULL. What constituent are we talking about? ____________________________________________________________

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2. State a use of vinegar in relation to diagnostic nephrology. ____________________________________________________________

THANK YOU! N.B. This question and answer sheet is to be submitted by 2nd June 2010.