Group A

A 45 year old housewife presented with pain and swelling of hand joints and wrist joints of both sides &
right shoulder joint since 4 months. She also has history of morning stiffness. She can perform activities
in the day such as cooking bathing etc only after taking an analgesic. On examination her bilateral meta-
carpo phalangeal joints are swollen. Her investigations suggest Hb=10g/dL; TLC=6000/cumm;
DLC=N68L30M1E1; Platelet count= 4,80,000/cumm; ESR=48mm/hr; CRP=7mg/dL (cut-off 0.5). Her RA
factor is positive in high titres, Serum TSH= 3.0; Blood urea= 26 mg/dL; Serum creatinine=0.8mg/dL; Sr.
Uric acid =6 mg/dL.

Questions

1. What is the clinical diagnosis and what is the approach? Inflammatory polyarthritis likely
Rheumatoid arthritis
2. What is classification criteria used?
3. What are common group of drugs used?
GROUP B

A 30 years old female housewife has noticed that her fingers and toes of the feet become painful,
especially in winters and on exposure to cold since previous two years. She has also noticed that these
turn blue at times. Skin has become tight also over forearms and arms, face and chest. Since last 6
months she notices that she has breathlessness on climbing stairs, walking long distances, but no
breathlessness on doing routine household work or at rest. On specific questioning she also complains
of swallowing difficulty. On cutaneous examination the skin over face is shiny, taut, there is inability to
pinch the skin. There is salt and pepper pigmentation over forehead. The lower eyelids cannot be
retracted. Nose is pinched out with loss of nasolabial folds and there is thinning of lips with purse string
appearance of lips. Her Hb is 9 gm/dl , TLC 5000, DLC N 70 L 26 E 4 M 0, MCV 60 fl on peripheral smear.
Her Reticulocyte count is 0.5%. Serum bilirubin is 1.0mg/dL, AST of 25 and ALT of 32 IU/mL. Serum
albumin is 3.5g/dL. Serum creatinine is 1.0mg/dL. Urine examination is normal.

Questions:

1. What is the clinical diagnosis? What is the classification criteria used?

Diffuse cutaneous Systemic sclerosis
 2. What are the major clinic-pathological types of this disease and the differentiating features?

Features Limited Cutaneous SSc Diffuse Cutaneous SSc

Skin involvement Indolent onset. Rapid onset. Diffuse: fingers,
extremities, face, trunk; rapid
Limited to fingers, distal to progression
elbows, face; slow progression
Raynaud's Precedes skin involvement; Onset coincident with skin
phenomenon associated with critical ischemia involvement, may be mild
Musculoskeletal Early arthralgia, fatigue Severe arthralgia, carpal tunnel
syndrome, tendon friction rubs
Pulmonary fibrosis Occasional, moderate Frequent, early and severe
Pulmonary arterial Frequent, late, may be isolated May occur, often in association with
hypertension pulmonary fibrosis
Scleroderma renal Very rare Occurs in 15%; early
crisis
Calcinosis cutis Frequent, prominent May occur, mild
Characteristic Anticentromere Antitopoisomerase I (Scl-70), anti-
autoantibodies RNA polymerase III

3. What are the various complications associated with this disease?

Skin – Sclerodactyly/ finger deformities/calcinosis cutis
Raynaud’s – digital gangrene/ non –healing ulcers
Lungs- Interstitial lung disease/ respiratory failure
Pulmonary artery hypertension /cardiac failure
Peripheral arthritis
Rarely, Scleroderma renal crisis
GIT- dilation of esophagus/ vascular ectasia/ anemia/ pseudo-obstruction/
Group C

A 24-year-old gentleman, driver by occupation, presented with complains of low back pain and
stiffness for the last eight months. He gives no history of obvious injury. His back symptoms are
worse in the mornings with the stiffness lasting around 2 hours. The back symptoms improve with
exercise. He finds that sitting for long periods of time exacerbates his symptoms. There is no family
history of similar complaints. On physical examination, he is moderately built; has a stiff posture.
His height is 168cm, weight is 73 kg. The systemic examination is within normal limits. He has
no swelling of small joints of the hands and feet, and of the large joints of the appendicular
skeleton. His chest expansion is 1.7cm. Modified Schober test and Gaenslen test are positive.
Laboratory investigations: Hb 13.6 gm%, TC 11600/cu.mm., DC N 74%, L 20%, E 4%, B 0%, M
2%, ESR 45 mm at the end of one hour, C-reactive protein 96 mg/L. Rheumatoid factor 4 IU/ml
(latex method, cut-off < 8 IU/ml), Urine microscopy study is negative.

Questions:

1. Patient has been advised HLA B 27 test and he wants to know whether this test will confirm
his diagnosis. How will you explain HLA B27 role in diagnosis to the patient?
This patient has Chronic inflammatory lower backache with raised CRP (2 SpA features). We
need either imaging or HLA B 27 positivity to confidently classify him as Axial Spondyloarthritis.

2. Which is the classification criteria used for this group of disorders?

3. What are the non-articular complications associated with this condition?
Pulmonary – apical fibrosis
Aortic regurgitation/ AV conduction blocks
Uveitis
Concomitant Psoriasis/Inflammatory bowel disease
GROUP D

A 65 year old woman was brought to you with complaints of fever, easy fatigability and cough
with minimal expectoration for past 4 months. Relatives mention that she has lost significant
weight and she was started on combination of four drugs for this illness and the urine was cola
colored since then. However, she hasn’t improved and they want a second opinion.
In past there is history of recurrent sinusitis and she had an episode of epistaxis once. She has
no history of HTN/DM/Hypothyroidism/Pulmonary Koch/Bronchial asthma.

On examination she appears pale with pitting edema over feet. She has left maxillary sinus
tenderness with congestion of nasal mucosa. No clubbing/icterus/LNs/clubbing/cyanosis
On respiratory examination she was tachypneic and she had scattered crepts.
Her investigations are as below Hb =8.8gm% TLC =9800/ml Platelet count = 5.1 lac/ml, BUN= 70
mg% Serum creatinine = 1.7 mg %, Sr Na= 130mEq/L, K= 4.6; Serum TSH = 2.6 mIU/l, Serum
Albumin =2.8gm% Sr Globulin= 4.2gm% ANA – negative, cANCA – strongly positive.
Urine : full of rbcs/ occasional granular casts/ protein 2+
Sputum for AFB - Neg
1. What is the diagnosis? What is the broad classification used for this group of disorders?
Chronic Sinusitis + Cystic disease Lung + Acute glomerulonephritis + cANCA positivity likely
ANCA associated vasculitis- Wegener Granulomatosis

2. Biopsy of the nasal mucosa was obtained, which confirmed the diagnosis. What are the
likely histopathological findings?
Typical pathological findings include granulomatous inflammation, necrosis, and vasculitis,
with minimal or absent immune deposits on immunofluorescence

3. What is the management approach?

Immunosuppression with iv steroids and Cyclophosphamide forms the mainstay of ANCA
associated vasculitis.
Limited disease may be managed with Methotrexate/ azathioprine.
Non- responsive may respond to Rituximab +/- Plasmapharesis
Group E

A 24 year old college student visited you in the medicine OPD with complaints of rash over face for past
four days, exacerbated with sun exposure. The rash extends from her both cheeks to over the bridge of
the nose. She has also developed joint pains, facial puffiness and pedal edema. She has otherwise been
healthy all her life, with no significant medical illness or hospitalization.

On examination, she had a rash involving mid face, sparing the naso- labial folds. She also had pitting
pedal edema, rest general physical was normal. Her chest examination revealed decreased air entry at
the bases associated with stony dullness on percussion at bases. Her cardiac examination was normal
except for tachycardia.

Her investigations revealed: Hb= 9gm% TLC= 4500/ml DLC= N80L10M5E5 ESR =68 BUN = 58 mg% Serum
creat = 1.9mg% RBS = 106 mg% Urine examination Albumin= +++ blood =+ Sugar = Neg Ketones =Neg
Nitrates = neg Microscopy—RBC casts, granular casts

Questions:

1. What is the diagnosis? Which classification criteria is used now?

This patient has Malar rash + Pleural effusion+ Glomerulonephritis likely lupus erythematosus.
We will like to have Immune markers e.g. ANA/ Anti-ds-DNA/ Coomb’s test to confirm our
diagnosis.
2. What are the histopathological types of renal involvement in this disease?
3. What are the treatment modalities are advisable in her case?

Patient has Active lupus nephritis with serositis & malar rash.

Patient should be advised – UV protection

High dose pulse steroids followed by oral steroids & pulse iv cyclophosphamide for induction of
remission followed by oral azathioprine.
Hydroxychloroquine
ACE inhibitors
Osteoporosis prophylaxis
Group F

A 62 year old gentleman weighing 68 kg, presented to you with the following KFT (kidney
function test). His family physician has informed him that he has developed kidney failure. He
claims that all these reports were normal 2 months back when he had undergone cataract
surgery. Examine the lab report and answer the following questions.

BUN/ Creatinine: 82/3.5 mg/dl

Sr sodium/ potassium: 138/5.1 mmol/L

Answers:

A. Tabulate the important syndromes in Nephrology with important clue to diagnosis.

B. Write your approach to Azotemia.

C. Calculate the eGFR in your case.
 Cockcroft-Gault equation —

(140 - age) x lean body weight [kg]

eGFR (mL/min) = ———————————————————
Cr [mg/dL] x 72

Multiply by 0.85 in females.

In this patient: 21
D. How will you differentiate between renal and pre renal cause of Acute kidney injury.

FE Na: (Plasma Cr X Ur Na / Plasma Na X Ur Cr) X 100

Group G

A 42 year man presented with edema of face and limbs for last 1 month. He also has distension
of abdomen and breathlessness for last 2 weeks. On examination Pulse-76, BP-130/80, RR-
30/min , temp-97.4 F. There is mild pallor, bilateral pitting edema and shifting dullness in
abdomen. Lab reports as follows.

CBC: TLC-8000/cmm (N 56%, L 31%), Hb-14 Gm%, TPC-200 X 103/cmm

Urine: Albumin: ++++, Glucose: nil, RBC: nil , Pus cell: 0-2/HPF,
Epithelial cell: 8-10/HPF

RFT: Creat-0.8

Questions:

A. Enumerate the clinical differentiation between Nephrits and Nephrotic syndrome.

B. What is the most probable diagnosis in this case?

Nephrotic syndrome

C. Mention the pathophysiology of your diagnosis leading to various manifestations the

disease.
D. Mention the various histological types and their secondary causes.
Histopathologic type Secondary Cause
Mimimal Change Disease Viral infections
NSAID use
Anaphylaxis, Bee sting
Membraneous SLE
Glomerulonephritis Hepatitis B/ C Malaria
Gold Penicillamine
Focal Segmental HIV disease
Glomerulosclerosis IV Drug abuse
Morbid obesity
Sickle cell disease
Membranoproliferative Hepatitis B / C
Glomerulonephritis SLE
Rheumatoid arthritis
E. How will you manage the case?
- Confirm nephrotic syndrome with quantification of Urinary protein (24hr protein / Urinary
Albumin to Creatinine ratio), and elevated serum cholesterol levels
- Renal biopsy is indicated to establish diagnosis
- Initiate corticosteroid therapy (Oral Prednosolone 1mg/kg/day) usually x 6 weeks. Response
is defined as absence of proteinuria for three consecutive days. In adults response is less
and takes longer, typically 80% over 16 weeks.
- Once remission is obtained, steroid dose needs to be tapered in stepwise manner, usually
over 12 week period.
- Based on steroid trial patients are classified as:
i. Primary steroid responder (response in 4-6 weeks)
ii. Primary responder with infrequent relapse (Initial response and single relapse in 6
months)
iii. Primary responder with frequent relapse (Initial reponse but two or more relapses 6
months)
iv. Steroid dependant (Primary responder, but relapse during steroid tapering)
v. Steroid resistant (No response to steroids)
- In steroid resistant case: Cyclosporine or Tacrolimus, Cyclophosphamide, or Mycophenolate
mofetil based therapies are used in such instance.
Group H

A 23 year-old 9th semester medical student presented with passing dark colored urine in the morning.
She had fever associated with painful swallowing 8-10 days before, which subsided on self medication of
paracitamol, cetirizine and warm saline gargling. On physical examination: PR-76/min, BP-110/76, RR-
16/min, temp-98 F. She weighs 64Kgs. Laboratory studies show her serum creatinine is 1.1 mg/dL
Urinalysis shows 3+ blood, 1+ protein, no glucose or ketones, and hyaline and granular casts. Her
urinary ACR is 1700 mg/gm.

A. Tabulate the important syndromes in Nephrology with important clue to diagnosis.

B. Identify the likely renal syndrome in her and justify your answer.
a. Nephritic Syndrome (Non-nephrotic range proteinuria, Hematuria, active urinary
sediments)
b. is defined as presence of proteinuria with evidence of active glomerular inflammation
(hematuria, presence of urinary casts, low complement levels) with or without
hypertension or azotemia.
c. Previous streptococcal infection hence likely post-streptococcal GN (or DPGN)

C. Tabulate the underlying histopathological subtypes and mention their secondary causes ?
Sno Histopathologic type
1 Cresentric
glomerulonephritis (RPGN)
Secondary Cause
Anti-GBM disease
Immune complex CGN (IgAN,
Lupus, Other immune complex)
Pauci-immune CGN (ANCA, WG,
Microscopic polyangitis)
 Group I

A 60 year old man presented with painless hematuria today morning. There was history of dysuria and
frequency for last 1 month. On examination PR-76/ min, BP-146/80, RR 16/min, Temp-97 F. There was
mild supra pubic tenderness and median lobe of prostate was palpable per rectally.

A. Define hematuria and significant hematuria.

Hematuria: urine RBC> 2-5/HPF
Significant hematuria:
Urine RBC> 100/ HPF in isolated sample

>hematuria in 3 urine analysis

Gross hematuria, visible to naked eye.

B. How will you approach a case of Hematuria?

False
Hematuria
Myoglobinuria

Painful Painless

Stone
Glomerular (Microscopic H) Nonglomerular (Gross H)
Obstructive uropathy
Old- malignancy bladder
Infection (TB, Filaria,
Children
Schisto)
Idiopathic
Trauma
Cong. anamoly

Without pyuria
With pyuria

UTI (upper/lower) With RBC cast Without RBC cast

Interstitial nephritis AGN IGA nephrothay
AGN Heriditary nephritis (Alports)

Thin basement membrane dis

Auto immune (ANA/ANCA/Anti GBM)

C. Mention 4 differentials in this patient.
Malignancy (bladder)
Obstructive uropathy (prostate)
UTI
Interstitial nephritis
Group J

A 54 year old person, weighing 56 kg, who is a known case of polycystic kidney disease, presented to
you with increased swelling of face, limbs and abdomen for 1 month. He has stopped antihypertensives
before 6 months and not visited his physician for more than 1 year now. He complaints of severe
lethargy and vomiting for past 1 month, He is having intermittent hematemesis for last 3 days. His last
RFT was done 8 months before which shows (RFT: BUN/Creat- 73/4.4 mg/dl, Na-132, K-5.8mmol/L). His
last USG abdomen shows B/L polycystic kidney disease, Rt kidney 11X 11.4 cm, Lt-12X 13 cm, corti-
comedulary differentiation could not be appreciated, features suggestive of early CKD. His present lab
investigations reveals:

CBC: N 65%/ L 28%, Hb-8 gm%, TPC- 210X103/cmm

LFT: T Bil- 1.8mg/dl, AST 40 , ALT 34, ALP 132 IU

RFT: BUN/Creat- 213/13.2 mg/dl, Na-132, K-5.8mmol/L

A. Classify CKD and this patient is in which stage?

B. Mention the life threatening conditions in this patient.

Life threatening Management Other complications

Complications
Metabolic Hyperkalemia Calcium gluconate Hyperphosphatemia
complications Glucose-Insulin infusion Hypocalcemia
Diuretics, Terbutaline Hypermagnesemia
Renal replacement therapy
Metabolic acidosis Bicarbonate infusion
Cardiovascular Acute Pulmonary edema Oxygen, Diuretics Pericarditis
complications Arrythmias Amiodarone
 Gastrointestinal GI hemorrhage IV Proton pump inhibitors Nausea
complication Vomiting
Neurologic Seizures Benzodiazepines Irritability
complications Barbiturates Delirium
Hematologic Bleeding Fresh frozen plasma Anemia
complications

C. Discuss your immediate and definitive management plan

Immediate:
Diuretics (frusemide, metolazone)
Treatment of hyperkalemia
Treat the fluid overload, anf potassium: Hemodialysis
Definitive:
Medical: Erythropoitin, Iron, Vit D3
RRT
Hemodialysis/PD
Renal transplant