| 246 USMLE style questions -
15-06-2006, 07:29 PM
USMLE STYLE TEST
You have 246 questions in this exam.
1. Which of the following is/are true relative to the definition, diagnosis and prevalence of hypertension.
1. A BP cuff that is too small (i.e., encircles less than 80% of the upper arm) gives an erroneously low BP reading.
2. The upper normal BP value for a seven-year-old is 135/85.
3. African Americans experience a higher prevalence of hypertension than Caucasians, but appear to suffer less severe end-organ damage.
4. The prevalence of hypertension rises with age.
A. Only choices 1, 2, and 3 are correct
B. Only choices 1 and 3 are correct
C. Only choices 2 and 4 are correct
D. Only 4 is correct
E. All choices are correct
Show answer
Correct Answer: D
2. Which of the following is/are true relative to the causes of high blood pressure:
1. Renal parenchymal disease is the single most common cause of persistent hypertension in the pre-adolescent population.
2. Environmental factors thought to raise BP include obesity, diabetes, high salt intake, physical inactivity and immoderate alcohol consumption.
3. Renal artery stenosis, renal parenchymal disease, endocrine disorders, pregnancy, and drugs, account for the majority of secondary hypertension.
4. A cause for hypertension can be identified in close to 95% of hypertensive adults, if diligently searched for.
A. Only choices 1, 2, and 3 are correct
B. Only choices 1 and 3 are correct
C. Only choices 2 and 4 are correct
D. Only 4 is correct
E. All choices are correct
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Correct Answer: A
3. The work-up of a patient who is referred to you with established hypertension should include:
1. A thorough drug history.
2. Physical examination to include assessment of the skin.
3. Urinalysis, serum electrolytes and creatinine.
4. Assessment of left ventricular heart mass.
A. Only choices 1, 2, and 3 are correct
B. Only choices 1 and 3 are correct
C. Only choices 2 and 4 are correct
D. Only 4 is correct
E. All choices are correct
Show answer
Correct Answer: E
4. The following is/are true regarding the treatment of essential hypertension:
1. The elderly usually require and tolerate larger doses of diuretics and beta blockers than younger adults.
2. Beta blockers should generally be avoided in those with reactive airway disease (asthma).
3. Beta blockers and angiotensin-converting enzyme (ACE) inhibitors should be avoided following myocardial infarction.
4. The slow reduction of medication (step-down therapy) can be attempted in those with essential hypertension who have been under good control for one year.
A. Only choices 1, 2, and 3 are correct
B. Only choices 1 and 3 are correct
C. Only choices 2 and 4 are correct
D. Only 4 is correct
E. All choices are correct
Show answer
Correct Answer: C
5. Which statements are true regarding the increase in glomerular filtration rate (GFR) that occurs after birth?
1. Increased renal blood flow contributes to increased GFR in the neonate.
2. GFR increases immediately after birth, regardless of gestational age.
3. Redistribution of blood flow to the outer renal cortex increases GFR.
4. Renal vascular resistance increases while systemic vascular resistance falls after birth.
A. Only choices 1, 2, and 3 are correct
B. Only choices 1 and 3 are correct
C. Only choices 2 and 4 are correct
D. Only 4 is correct
E. All choices are correct
Show answer
Correct Answer: B
6. Tubular reabsorption of _______________ increases with maturation.
1. Sodium
2. Bicarbonate
3. Potassium
4. Phosphate
A. Only choices 1, 2, and 3 are correct
B. Only choices 1 and 3 are correct
C. Only choices 2 and 4 are correct
D. Only 4 is correct
E. All choices are correct
Show answer
Correct Answer: A
7. A three month old infant born at full term weights 5 kg and has a length of 50 cm. The serum creatinine is 1.0. Which statements are true?
1. This infant has normal renal function.
2. Glomerulogenesis is complete.
3. Tubular maturation is complete.
4. This infant's glomerular filtration rate is approximately 22 mL/1.73 m2/min.
A. Only choices 1, 2, and 3 are correct
B. Only choices 1 and 3 are correct
C. Only choices 2 and 4 are correct
D. Only 4 is correct
E. All choices are correct
Show answer
Correct Answer: C
8. The following statements about congenital nephrotic syndrome of the Finnish type are true.
1. It is caused by a mutation in the nephrin gene on chromosome 19.
2. Maternal alpha feto protein is increased in the second trimester.
3. Steroid therapy is useless.
4. Proteinuria is present prior to age three months.
A. Only choices 1, 2, and 3 are correct
B. Only choices 1 and 3 are correct
C. Only choices 2 and 4 are correct
D. Only 4 is correct
E. All choices are correct
Show answer
Correct Answer: E
9. Factors contributing to renal vein thrombosis include all of the following EXCEPT:
A. Hemoconcentration
B. Increased antithrombin Ill levels
C. Increased platelet activation
D. High molecular weight fibrinogen
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Correct Answer: B
10. Findings in atheroembolic renal disease include:
A. Renal failure
B. Eosinophilia
C. Hypocomplementemia
D. Livedo reticularis
E. All of the above
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Correct Answer: E
11. The most likely diagnosis in a patient presenting with signs and symptoms of small vessel vasculitis, antineutrophil cytoplasmic antibodies (ANCA) in the blood and no evidence of asthma, eosinophilia or necrotizing granulomas is which of the following:
A. Henoch-Schonlein purpura
B. Cryoglobulinemic vasculitis
C. Microscopic polyangiitis
D. Necrotizing granulomatosis (Wegener's)
E. Churg-Strauss syndrome
Show answer
Correct Answer: C
12. A 45-year-old physician has a long history of recurrent kidney stones. Because of his busy schedule as Chief of Medicine he has undergone 11 extracorporeal shock wave lithotripsy (ESWL) treatments to "get rid of the stones". He states that he can handle his stone problem quite well in this manner and that he has seen no reason to have a metabolic work-up. He noticed in recent months, however, that he has to urinate quite often, especially at night, that he has exertional dyspnea and that he is more fatigued than usual. All of the following statements apply to his situation, EXCEPT:
A. ESWL reduces stone activity.
B. ESWL can increase stone activity.
C. Repeated ESWL can cause hypertension and 2o heart failure
D. Repeated ESWL can cause renal insufficiency.
E. Despite a good response to ESWL, a metabolic evaluation is essential.
Show answer
Correct Answer: A
13. Which therapeutic measures correlate best with the prevention of Calcium oxalate stones in patients with idiopathic hypercalciuria?
A. Extracorporeal Shock Wave Lithotripsy.
B. sustained alkalinization of the urine with bicarbonate.
C. a high sodium diet.
D. high dose vitamin C.
E. low sodium and normal protein intake, a high urine volume, thiazide diuretic.
Show answer
Correct Answer: E
14. Which one of the following factors contribute to edema formation in congestive heart failure?
A. Effective arterial blood volume is increased due to renal salt and water retention.
B. Decreased effective arterial blood volume leads to increased aldosterone, ADH, and sympathetic nerve activity.
C. Total peripheral resistance is decreased due to splanchnic vasodilatation.
D. Decreased actual blood volume leads to activation of baroreceptors.
E. The renin-angiotensin system is suppressed.
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Correct Answer: B
15. Which one of the following does not drive potassium into cells?
A. Insulin
B. Increased extracellular pH
C. Epinephrine
D. Increased extracellular sodium concentration
E. Aldosterone
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Correct Answer: D
16. The clinical manifestations of hyperkalemia include all of the following except:
A. Predisposes to digitalis toxicity
B. Predisposes to ventricular fibrillation
C. EKG shows flattened P wave, peaked T wave, and widened QRS complex
D. Weakness
E. Predisposes to cardiac arrest
Show answer
Correct Answer: A
17. Which one of the following statements is false?
A. The main cause of hypokalemia associated with vomiting is not loss of K+ in the vomitus.
B. Diuretics are one of the most common causes of hypokalemia.
C. Renal failure is a common cause of hyperkalemia.
D. Hyperkalemia in diabetes mellitus is at least partially due to inadequate aldosterone formation.
E. Copious watery diarrhea is frequently associated with hyperkalemia.
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Correct Answer: E
18. An elderly woman develops a urinary tract infection, becomes confused, and does not eat or drink for three days at her nursing home. She is found to have a blood pressure of 70/50 mmHg (very low). Which one of the following intravenous fluids would you recommend?
A. One-half normal saline
B. Normal saline
C. 5% dextrose and water
D. Hypertonic saline
E. One-quarter normal saline
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Correct Answer: B
19. Which one of the following statements about hypo- or hypernatremia is true?
A. A patient with frank symptoms of hypo- or hypernatremia should have his/her serum sodium concentrations rapidly (few hours) corrected back to normal levels.
B. The brain fully compensates for hypenatremia within 2-4 hours by making "idiogenic osmoles".
C. The symptoms of hyper- and hyponatremia are mainly due to central nervous system dysfunction.
D. Hyponatremia due to SIADH is most often due to underlying kidney or liver disease.
E. "Pseudohyponatremia" is as dangerous as true hyponatremia.
Show answer
Correct Answer: C
20. Which of the following is NOT commonly found in chronic urinary obstruction?
A. Nocturia
B. No symptoms
C. Renal failure
D. Microhematuria with dysmorphic red cells
E. Polyuria
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Correct Answer: D
21. A 23-year-old sexually active woman presents with urinary frequency and burning on micturition of 24 hours duration. Her urinalysis shows: Yellow, hazy urine. pH 6. No glucose. Protein trace, blood trace. 20-50 WBC/HPF, 10-20 RBC/HPF. 0-1 squamous epithelial cells and no bacteria. You prescribe trimethoprim/sulfamethoxazole tablets twice a day. The next day she feels much better but her urine culture report reads:"Staphylococcus saprophyticus 100,000 cfu/ml." Which of the following statements is true?
A. She has a bacterial UTI.
B. The urine sample was contaminated and the results from it are unreliable.
C. The hematuria likely signifies the presence of a stone or tumor.
D. The Staphylococcus saprophyticus is likely a skin contaminant.
E. The urinalysis is a laboratory error.
Show answer
Correct Answer: A
22. A 58-year-old woman presents with hematuria and left flank pain. Renal ultrasound shows marked left hydronephrosis. Serum creatinine and CBC are normal. Which of the following is the most relevant diagnostic aid?
A. Renal biopsy
B. Renal arteriogram
C. Palpation for inguinal lymph nodes
D. Antinuclear antibody test
E. Pelvic examination and IVP
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Correct Answer: E
23. A 26 year-old diabetic woman is seen in the ER for sore throat. Rapid strep test is positive for streptococcal pharyngitis and she was started on ampicillin 500 mg four times a day. Three days later, she develops hematuria associated with a low grade fever. On physical examination, she has a maculopapular rash and a temperature of 101oF. Laboratory studies show: serum creatinine 3.6 mg/dl, WBC 8,700 with 56% PMN, 25% lymphs, 3% monos and 15% eosinophils. Urinalysis: pH 6.2, protein 2+, blood 3+, 65 RBCs/HPF, 20-30 WBCs/HPF, 3-4 WBC casts/HPF. Hansel's stain is positive for eosinophils. The most likely diagnosis would be:
A. Diabetic nephropathy
B. IgA nephropathy
C. Acute interstitial nephritis
D. Acute pyelonephritis
E. Acute post-streptococcal glomerulonephritis
Show answer
Correct Answer: C
24. Analgesic nephropathy can be associated with all of the following except:
A. Small kidney size by renal ultrasound
B. Nephritic sediment with RBC casts
C. Increased risk of transitional cell carcinoma
D. Tubulointerstitial fibrosis on renal biopsy
E. Urinary tract obstruction due to papillary necrosis on IVP
Show answer
Correct Answer: B
25. Autosomal dominant polycystic kidney disease is associated with all of the following except:
A. Hypertension is very common
B. Ultrasound is very useful in establishing the diagnosis
C. Renal failure progresses slowly
D. The majority of the patients (>80%) have cerebral aneurysms
E. Lipid soluble antibiotics should be used when the cysts become infected
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Correct Answer: D
26. A 10-month-old boy presents with status epilepticus. His intoxicated mother was unable to provide a history. The child quit seizing after being treated with diazepam. Exam revealed an obtunded child with tachypnea. Screening labs showed Na 140 mEq/L, K 5.5 mEq/L, total CO2 6 mEq/L, Cl 104 mEq/L, BUN 15 mg/dl, creatinine 0.6 mg/dl, glucose 40 mg/dl, Ca 9.5 mg/dl, Mg 1.4 mg/dl, PO4 5 mg/dl, serum osmolality 350 mosm/L. The arterial blood gas showed a pH of 7.0, PCO2 25 mmHg. The patient has a:
A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
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Correct Answer: A
27. The anion gap in the infant above is:
A. 25
B. 30
C. 36
D. None of the above
Show answer
Correct Answer: B
28. What is his possible diagnosis:
A. Septic shock with lactic acidosis
B. Intoxication with methanol
C. Diabetic ketoacidosis
D. Bartter's syndrome
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Correct Answer: B
29. An infant presents to a pediatrician for recurrent vomiting and failure to thrive. The child has been hospitalized by another primary care physician for recurrent dehydration. However, data are not available. Weight and length are below the fifth percentile. Exam shows a normal blood pressure with signs of mild dehydration. Reflexes are markedly increased. The child is hypotonic. Chemistry panel showed Na 140 mEq/L, K 2.2 mEq/L, CO2 50 mEq/L, Cl 78 mEq/L, BUN 20 mg/dl, creatinine 1.0 mg/dI, Ca 9.5 mg/dl, Mg 1.7 mg/dl, PO4 2.8 mg/dl. Arterial blood gas showed pH 7.54, pCO2 60 mmHg, urine chloride was 40 mEq/L and urinary calcium excretion was elevated. What is the nature of the acid-base disorder?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Respiratory alkalosis
D. Metabolic acidosis
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Correct Answer: B
30. The most likely diagnosis in this infant is:
A. Gitleman's syndrome
B. Bartter's syndrome
C. Renal tubular acidosis
D. Contraction alkalosis
Show answer
Correct Answer: B
31. Which one of the following is clearly associated with autosomal recessive polycystic kidney disease?
A. Very large cysts throughout the kidney parenchyma, including cortex and medulla
B. Cerebral aneurysms
C. Gastrointestinal diverticulum
D. Congenital hepatic fibrosis
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Correct Answer: D
32. Which one of the following is true regarding urinary tract infections (UTI) in children?
A. UTI are equally common in boys and girls.
B. UTI are more common in boys during the neonatal period .
C. UTI are always more common in girls throughout childhood.
D. UTI are almost never associated with vesicoureteral reflux in children.
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Correct Answer: B
33. Hemolytic uremic syndrome in children
A. Is usually non-diarrheal.
B. Is most often associated with colitis from enterohemorrhagic E. coli.
C. Is always benign.
D. Is best treated with plasma infusions.
Show answer
Correct Answer: B
34. Which one of the following regarding glomerular filtration rate (GFR) is true:
A. Creatinine clearance is seldom used as a marker of GFR in clinical medicine because it consistently under- estimates true GFR.
B. Two patients with identical serum creatinine concentration always have the same GFR.
C. In advanced renal failure (GFR <15 ml/min), 24-hour urea clearance is useful in conjunction with 24-hour creatinine clearance to estimate GFR.
D. For a given individual, an increase of serum creatinine from 8.0 mg/dl to 10.0 mg/dl represents a loss of greater number of nephrons than an increase of serum creatinine from 1.0 mg/dl to 2.0 mg/dl.
E. Muscle mass is the predominant determinant of creatinine clearance.
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Correct Answer: C
35. A low blood urea nitrogen to serum creatinine ratio (<10:1) is seen in one of the following conditions:
A. administration of corticosteroids for arthritis
B. catabolic state during trauma
C. advanced liver failure
D. high protein diet
E. volume depletion from gastrointestinal bleeding
Show answer
Correct Answer: C
36. Which of the following is most likely to be associated with high urinary sodium concentration (>40 mEq/L):
A. low salt intake in a normal subject
B. severe congestive heart failure
C. diarrhea in an otherwise normal adult
D. acute tubular necrosis
Show answer
Correct Answer: D
37. In a patient with oliguria, which ONE of the following favors the diagnosis of acute tubular necrosis rather than pre-renal azotemia:
A. ratio of urine osmolality to plasma osmolality = 2.0
B. ratio of urine creatinine concentration to plasma creatinine concentration > 50
C. fractional excretion of sodium (FENa) > 2%
D. urinary sodium concentration <5 mEq/L
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Correct Answer: C
38. A patient reports that he has noticed a decrease in urine output for five days. His BUN is 100 mg/dl and his serum creatinine is 7 mg/dl. Which of the following is LEAST useful in establishing the etiology of his renal failure:
A. urine sodium concentration
B. ultrasound of the kidneys
C. intravenous pyelogram
D. urinalysis
E. history and physical
Show answer
Correct Answer: C
39. Which of the following is NOT an indication for urgent dialysis for a patient with renal failure:
A. asterixis and drowsiness
B. pulmonary edema resistant to diuretics
C. pericarditis
D. serum creatinine of 12 mg/dL
E. serum potassium of 9.0 mEq/L
Show answer
Correct Answer: D
40. In the management of patients with chronic glomerulonephritis and chronic renal failure with a serum creatinine of 2.0 mg/dl, which of the following is true:
A. Angiotensin converting enzyme inhibitors are contraindicated because they are toxic to the kidneys in renal failure.
B. Dosage of medications often require adjustment.
C. Nonsteroidal anti-inflammatory agents (arthritis medications) can be used liberally because the chronically diseased kidneys are resistant to the toxic effects of these agents.
D. Superimposed urinary tract obstruction is of no consequence because the underlying kidney disease is glomerular in origin.
E. Severe sodium restriction is always necessary because the chronically ill kidneys cannot excrete sodium.
Show answer
Correct Answer: B
41. The most common cause of end stage renal disease in the U.S.A. is:
A. hereditary nephritis
B. sickle cell nephropathy
C. post-infectious glomerulonephritis
D. renal cell carcinoma
E. diabetic nephropathy
Show answer
Correct Answer: E
42. Which of the following is most commonly encountered in a patient with chronic renal failure and bone biopsy showing osteitis fibrosa cystica:
A. increased serum alkaline phosphatase level
B. markedly decreased serum phosphorus concentration
C. increased serum 1 ,25(OH)2D3 level
D. low parathormone level
E. increased serum calcium concentration
Show answer
Correct Answer: A
43. Which of the following is the most common complication of advanced untreated renal failure:
A. erythrocytosis
B. platelet dysfunction favoring bleeding
C. increased peripheral nerve conduction
D. gastrointestinal tumors
E. hypotriglyceridemia
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Correct Answer: B
44. In the evaluation of proteinuria, which of the following is false:
A. Proteinuria as detected by the dipstick methods is quite insensitive, and may miss albuminuria in early diabetic nephropathy.
B. The dipstick method may not detect Bence-Jones proteins in the urine.
C. A random urine sample for protein:creatinine ratio often suffices in following proteinuria in a patient under treatment, as long as there is no substantial change in muscle mass.
D. Similar to sodium, protein excretion in the urine is a good reflection of dietary protein intake.
Show answer
Correct Answer: D
45. Based on the following data (BUN = 40 mg/dl, 24 urine volume = 2 liters, serum creatinine = 2 mg/dL, urine creatinine = 40 mg/dL, serum sodium = 150 mEq/dL, urine sodium = 15 mEq/L) the fractional excretion of sodium (FENa) can be calculated to be:
A. 0.2%
B. 0.5%
C. 5%
D. 20%
E. 50%
Show answer
Correct Answer: B
46. Which one of the following statements is correct:
A. Diabetic nephropathy and proteinuria rarely develop after 10 years duration of diabetes.
B. Patients with type I diabetes and diabetic nephropathy do not have higher risk of death than those without diabetic nephropathy.
C. All patients with diabetic nephropathy have type I DM (diabetes mellitus).
D. Diabetes mellitus is the leading cause of ESRD in the U.S.A.
E. If a patient survives 40 years of DM without developing nephropathy, he or she is at extremely high risk of doing so in the future.
Show answer
Correct Answer: D
47. Which one of the following statements is not correct?
A. Hyperglycemia leads to the accumulation of advanced glycosylation end products (AGE's) in tissues in patients with DM.
B. AGE's accumulation in tissues parallels the severity of renal disease.
C. Decreasing intraglomerular pressure preserves the structure and function of the glomerulus in diabetic patients.
D. AGE's are responsible for end organ damage seen in diabetes.
E. Hypertension does not add any significant risk for developing renal disease in diabetic patients.
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Correct Answer: E
48. Which one of the following is correct:
A. Advanced diabetic nephropathy means development of microalbuminuria.
B. Normal urine albumin excretion in normal people varies between 400-500 mg/24 hr.
C. Microalbuminuria in diabetic patients predicts the development of frank proteinuria and ESRD.
D. Microalbuminuria in diabetic nephropathy patients doesn't become manifest until serum creatinine is higher than 2.0 mg/dL.
E. Once frank proteinuria is established, almost all patients reach ESRD within one year.
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Correct Answer: C
49. Which one of the following is not correct:
A. All patients with type I diabetes of greater than 5 years duration should have an annual screen for microalbuminuria to identify this high risk population.
B. 90-95% of patients with diabetic nephropathy have diabetic retinopathy.
C. The absence of retinopathy should make one suspect a cause of proteinuria other than diabetic nephropathy.
D. Frank proteinuria after only 5 years duration of type I DM is unlikely to be secondary to diabetic nephropathy.
E. If the urinary albumin excretion rate is greater than 30 mg/24 hr in a single urine collection, this microalbuminuria does not need to be confirmed with additional collections since other causes of microalbuminuria (e.g., hypertension, CHF) are rare in di
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Correct Answer: E
50. Regarding the management of diabetes mellitus, all of the following are correct EXCEPT:
A. Dialysis therapy, in patients with diabetic nephropathy and ESRD is not necessary until GFR is less than 5 ml/min.
B. Tight blood sugar control reduces the risk of developing diabetic nephropathy.
C. In diabetic patients with proteinuria and declining renal function, lowering the systemic blood pressure slows the rate of decline in renal function.
D. In patients with microalbuminuria, using ACE inhibitors decreases urine albumin excretion and rate progression to overt nephropathy.
E. Avoiding NSAIDs and radiocontrast media, and properly managing UTIs and neurogenic bladder, are important measures to preserve the remaining renal function in patients with established diabetic nephropathy.
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Correct Answer: A
51. A 22-year- old man presents with the complaint of recurrent blood in his urine. He states that it usually occurs when he gets "the flu". He has no other complaints and he has been in good health otherwise. He is not taking any medication and has no drug allergies. Physical examination including B.P. is normal and he has no edema. Urinalysis reveals trace proteinuria, several dysmorphic RBCs and few RBC casts. BUN is 12 mg/dl and serum creatinine 0.6 mg/dl. Which one of the following is the most likely diagnosis?
A. Nephrolithiasis
B. Minimal change disease
C. IgA nephropathy
D. Focal segmental glomerulosclerosis
Show answer
Correct Answer: C
52. A 7-year-old girl presents with leg edema. She has no other complaint and has been healthy up until now. She is not taking any medication and has no known allergies. Physical examination shows 3+ leg edema. The rest of the physical examination including B.P. is normal. Urinalysis reveals 3+ proteinuria , no RBC, WBC or any casts. BUN and serum creatinine are normal. Serum albumin is 1.5 mg/dl. 24-hour urine collection shows 6.0 gram protein. Which one of the following statements about her disease is true?
A. Renal biopsy will most likely reveal extensive crescent formation in the glomeruli.
B. This is the most common cause of nephrotic syndrome in children.
C. She has about 90% chance of developing end stage renal disease.
D. This disease is highly resistant to steroids.
Show answer
Correct Answer: B
53. Which one of the following statements about post-streptococcal glomerulonephritis is true?
A. It occurs simultaneously with the throat infection.
B. It is associated with low serum complement levels.
C. It commonly progresses to end stage renal disease.
D. Steroids are often needed to treat the disease.
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Correct Answer: B
54. Which one of the following statements about Goodpasture's syndrome is true?
A. It predominantly occurs in persons older than 70 years.
B. Kidney biopsy is the most direct way to make the diagnosis.
C. Anti-GBM antibody titres correlate well with the disease severity.
D. Plasmapheresis is not an effective therapy.
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Correct Answer: B
55. All of the following about systemic lupus erythematosus are true except:
A. It is an immune complex vasculitis process that may cause glomerulonephritis.
B. Women are more commonly affected than men.
C. The glomerular lesions span a spectrum from normal glomeruli to diffuse necrotizing crescentic glomerulonephritis.
D. Plasmapheresis is the best form of therapy.
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Correct Answer: D
56. Membranoproliferative glomerulonephritis (MPGN) is characterized by:
A. Consistently normal serum complement levels.
B. No progression to chronic renal failure.
C. Both mesangial hypercellularity and glomerular basement membrane changes.
D. Steroids are very effective in adult patients.
E. Absence of proteinuria.
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Correct Answer: C
57. A middle aged woman has active stone disease for many years. Her stones are radioopaque, small and occur bilaterally. She has seen a Urologist for this problem who performed a metabolic work-up that showed normal urinary Ca and oxalate excretion. She had been treated, unsuccessfully, with a thiazide diuretic, low sodium diet and high fluid intake. A stone analysis revealed that her stones consisted of Ca-oxalate and a small amount of uric acid. Which of the following treatments will likely be effective in the prevention of further stones?
A. a low Ca diet
B. Allopurinol, a xanthine oxidase inhibitor
C. vitamin C supplement to acidify the urine
D. a high protein diet
E. none of the above
Show answer
Correct Answer: B
58. Distal nephron potassium secretion is increased by which one of the following?
A. Triamterene
B. Increased distal nephron sodium delivery
C. Decreased extracellular pH
D. Spironolactone
E. Vasopressin
Show answer
Correct Answer: B
59. Generalized edema can occur in the setting of high, normal, or low serum sodium concentration.
A. True
B. False
Show answer
Correct Answer: A
60. Generalized edema can occur in the setting of high, normal, or low intravascular volume.
A. True
B. False
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Correct Answer: A
61. Ascites can be a manifestation of right-sided congestive heart failure.
A. True
B. False
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Correct Answer: A
62. The quality of the effective arterial blood volume (EABV) does always positively correlate with the size of the extracellular volume (ECV).
A. True
B. False
Show answer
Correct Answer: B
63. In order to slow the progression to end stage renal disease in patients with diabetic nephropathy or glomerulonephritis, Calcium channel blockers are superior to angiotensin converting enzyme inhibitors.
A. True
B. False
Show answer
Correct Answer: B
64. The original disease that caused end stage renal failure does not recur in the transplanted kidney because patients are treated with immunosuppressants.
A. True
B. False
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Correct Answer: B
65. Which of the following is incorrect relative to the definition, diagnosis and prevalence of hypertension
A. a BP cuff that is too large gives an erroneous BP reading
B. the upper normal BP value for a seven year old is < 120/80 mmHg.
C. African Americans experience a higher prevalence of hypertension than Caucasians
D. the prevalence of hypertension decreases with age
Show answer
Correct Answer: D
66. Which of the following is incorrect relative to the causes of high blood pressure:
A. Renal parenchymal disease is the single most common cause of persistent hypertension in the pre-adolescent population
B. Factors thought to raise BP include obesity, high salt intake, physical inactivity and immoderate alcohol consumption
C. Renal artery stenosis, renal parenchymal disease, endocrine disorders, pregnancy, and drugs, account for the majority of secondary hypertension
D. A cause for hypertension can be identified in close to 95% of hypertensive adults, if diligently searched for
Show answer
Correct Answer: D
67. The routine work-up of a patient who is referred to you with established hypertension should include
A. Urine toxicology screen
B. IVP
C. Echocardiogram
D. Urinalysis, serum electrolytes and creatinine
Show answer
Correct Answer: D
68. The following is true regarding the treatment of essential hypertension:
A. The elderly need always higher doses of diuretics and beta blockers
B. Beta blockers should generally be avoided in those with reactive airway disease (asthma)
C. Beta blockers and angiotensin-converting enzyme (ACE) inhibitors should be avoided following myocardial infarction
D. The slow reduction of medication (step-down therapy) in those with essential hypertension who have been under good control for one year is contraindicated
Show answer
Correct Answer: B
69. Which statement is incorrect regarding the increase in glomerular filtration rate (GFR) that occurs after birth?
A. increased renal blood flow contributes to increased GFR in the neonate
B. GFR increases immediately after birth, regardless of gestational age
C. Redistribution of blood flow to the outer renal cortex increases GFR
D. Renal vascular resistance increases while systemic vascular resistance falls after birth
Show answer
Correct Answer: B
70. Tubular reabsorption of ________ decreases with maturation
A. Sodium
B. Bicarbonate
C. Potassium
D. Phosphate
Show answer
Correct Answer: D
71. A three month old infant born at full term weighs 5 kg and has a length of 50 cm. The serum creatinine is 1.0. Which statement is false?
A. This infant has normal renal function
B. Glomerulogenesis is complete
C. Tubular maturation is incomplete
D. This infant's glomerular filtration rate is approximately 22 mL/1.73 m2/min
Show answer
Correct Answer: A
72. Which of the following statements about congenital nephrotic syndrome of the Finnish type is false.
A. It is caused by a mutation in the nephrin gene on chromosome 19.
B. Maternal alpha feto protein is increased in the second trimester.
C. Steroid therapy is useless.
D. Proteinuria is present only at age twelve months
Show answer
Correct Answer: D
73. Factors contributing to renal vein thrombosis include all of the following EXCEPT:
A. Hemodilution
B. Decreased antithrombin Ill levels
C. Increased platelet activation
D. High molecular weight fibrinogen
Show answer
Correct Answer: A
74. Typical findings in atheroembolic renal disease include all EXCEPT:
A. Renal failure
B. Eosinophilia
C. Hypocomplementemia
D. Livedo reticularis
E. Nephrotic range proteinuria
Show answer
Correct Answer: E
75. The most likely diagnosis in a patient presenting with signs and symptoms of small vessel vasculitis, antineutrophil cytoplasmic antibodies (ANCA) in the blood and evidence of asthma and eosinophilia is which of the following:
A. Henoch-Schonlein purpura
B. Cryoglobulinemic vasculitis
C. Microscopic polyangiitis
D. Necrotizing granulomatosis (Wegener's)
E. Churg-Strauss syndrome
Show answer
Correct Answer: E
76. A 45 year old physician has a long history of recurrent kidney stones. Because of his busy schedule as Chief of Medicine he has undergone 11 extracorporeal shock wave lithotripsy (ESWL) treatments to "get rid of the stones". He states that he can handle his stone problem quite well in this manner and that he has seen no reason to have a metabolic work-up. He noticed in recent months, however, that he has to urinate quite often, especially at night, that he has exertional dyspnea and that he is more fatigued than usual. All of the following statements apply to his situation, EXCEPT
A. ESWL increases stone activity
B. repeated ESWL decreases stone activity
C. repeated ESWL can cause hypertension and 2° heart failure;
D. repeated ESWL can cause renal insufficiency;
E. despite a good response to ESWL, a metabolic evaluation is essential.
Show answer
Correct Answer: B
77. Which therapeutic measures correlate least with the prevention of Calcium oxalate stones in patients with idiopathic hypercalciuria?
A. low calcium diet;
B. sustained alkalinization of the urine with bicarbonate;
C. a high sodium and animal protein diet, low water intake
D. large quantities of cranberry juice;
E. low sodium and normal protein intake, a high urine volume, thiazide diuretic;
Show answer
Correct Answer: C
78. Which one of the following factors contribute to the increase in peripheral vascular resistance in congestive heart failure?
A. Effective arterial blood volume is increased due to renal salt and water retention
B. Increased renin-angiotensin-aldosterone, ADH, and sympathetic nerve activity
C. Splanchnic vasodilatation
D. Decreased actual blood volume leads to activation of baroreceptors
E. Suppression of the renin-angiotensin system
Show answer
Correct Answer: B
79. Which one of the following does not drive potassium into cells?
A. Insulin
B. Increased extracellular pH
C. Epinephrine
D. Glucagon
E. Aldosterone
Show answer
Correct Answer: D
80. The clinical manifestations of hypokalemia include all of the following except:
A. Decreases digitalis toxicity
B. Predisposes to ventricular fibrillation
C. EKG shows widened QRS complex and U waves
D. Weakness
E. Predisposes to cardiac arrest
Show answer
Correct Answer: A
81. Which one of the following statements is false?
A. The main cause of hypokalemia due to vomiting is loss of K+ in the vomitus
B. Diuretics are one of the most common causes of hypokalemia
C. Renal failure is a common cause of hyperkalemia
D. Hyperkalemia in diabetes mellitus is at least partially due to inadequate aldosterone formation
E. Copious watery diarrhea is frequently associated with hypokalemia
Show answer
Correct Answer: A
82. An elderly woman develops a urinary tract infection, becomes confused, and does not eat or drink for three days at her nursing home. She is found to have a blood pressure of 70/50 mmHg (very low) and her serum Na is elevated to 150 meq/L (NL up to 145). Which one of the following intravenous fluids would you recommend?
A. One-half normal saline
B. Normal saline
C. 5% dextrose and water
D. Hypertonic saline
E. One-quarter normal saline
Show answer
Correct Answer: B
83. Which one of the following statements about hypo- or hypernatremia is true?
A. A patient with frank symptoms of hypo- or hypernatremia should have his/her serum sodium concentrations rapidly (one hour) corrected back to normal levels
B. The brain fully compensates for hypernatremia within 1 hour by making "idiogenic osmoles"
C. Too rapid correction of hypo- or hypernatremia may cause serious neurological complications
D. Hyponatremia due to SIADH is most often due to underlying kidney or liver disease.
E. "Pseudohyponatremia" is as dangerous as true hyponatremia.
Show answer
Correct Answer: C
84. Which of the following is NOT commonly found in chronic urinary obstruction?
A. Nocturia
B. No symptoms
C. Renal failure
D. Red cell casts in urinary sediment
E. Polyuria
Show answer
Correct Answer: D
85. A 23 year old sexually active woman presents with urinary frequency and burning on micturition of 24 hours duration. Her urinalysis shows: Yellow, hazy urine. pH 6. No glucose. Protein trace, blood trace. 20-50 WBC/HPF, 10-20 RBC/HPF. 0-1 squamous epithelial cells and no bacteria. You prescribe trimethoprim/sulfamethoxazole tablets twice a day. The next day she feels much better but her urine culture report reads: "Staphylococcus saprophyticus 100,000 cfu/ml." Which of the following statements is true?
A. The antibiotic treatment should be continued
B. The urine sample was contaminated and the results from it are unreliable.
C. The hematuria likely signifies the presence of a stone or tumor.
D. The Staphylococcus saprophyticus is likely a skin contaminant.
E. The urinalysis is a laboratory error.
Show answer
Correct Answer: A
86. A 58 year old woman presents with hematuria and left flank pain. Renal ultrasound shows marked left hydronephrosis. Serum creatinine and CBC are normal. Which of the following is the least relevant diagnostic aid?
A. Renal biopsy
B. Renal isotope scan
C. Palpation for inguinal lymph nodes
D. CAT scan of abdomen
E. Pelvic examination and IVP
Show answer
Correct Answer: A
87. A 26 year-old diabetic woman is seen in the ER for sore throat. Rapid strep test is positive for streptococcal pharyngitis and she was started on ampicillin 500 mg four times a day. Ten days later, she develops hematuria, edema and hypertension. Laboratory studies show: serum creatinine 3.6 mg/dl, WBC 8,700 with 66% PMN, 25% lymphs, 3% monos and 5% eosinophils; Urinalysis: pH 6.2, protein 2+, blood 3+, 65 RBCs/HPF, 20-30 RBC casts/LPF. Hansel's stain is negative for eosinophils. The most likely diagnosis would be:
A. Diabetic nephropathy
B. IgA nephropathy
C. Acute interstitial nephritis
D. Acute pyelonephritis
E. Acute post-streptococcal glomerulonephritis
Show answer
Correct Answer: E
88. Interstitial nephritis can be associated with all of the following except:
A. Small kidney size by renal ultrasound
B. Nephritic sediment with RBC casts
C. Increased risk of transitional cell carcinoma
D. Tubulointerstitial fibrosis on renal biopsy
E. Urinary tract obstruction due to papillary necrosis on IVP
Show answer
Correct Answer: B
89. Autosomal dominant polycystic kidney disease is associated with all of the following except:
A. Hypertension is very common
B. Ultrasound is very useful in establishing the diagnosis
C. Renal failure progresses slowly
D. The minority of the patients have cerebral aneurysms
E. Lipid insoluble (water soluble) antibiotics should be used when the cysts become infected
Show answer
Correct Answer: E
90. A 10 month old boy presents with status epilepticus. His intoxicated mother was unable to provide a history. The child quits seizing after being treated with diazepam. Exam revealed an obtunded child with tachypnea but a NL blood pressure. Screening labs showed Na 140 mEq/L, K 5.5 mEq/L, total CO2 6 mEq/L, Cl 104 mEq/L, BUN 15 mg/dl, creatinine 0.6 mg/dl, glucose 40 mg/dl, Ca 9.5 mg/dl, Mg 1.4 mg/dl, PO4 5 mg/dl, serum osmolality 350 mosm/L. The arterial blood gas showed a pH of 7.0, PCO2 25 mmHg. The patient has a:
A. Metabolic acidosis with NL anion gap
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
E. Metabolic acidosis with increased anion gap
Show answer
Correct Answer: E
91. The anion gap in the patient in question 30 is:
A. 12
B. 15
C. 20
D. None of the above
Show answer
Correct Answer: D
92. What is his possible diagnosis:
A. Septic shock with lactic acidosis
B. Intoxication with rubbing alcohol (isopropyl)
C. Diabetic ketoacidosis
D. Intoxication with wood alcohol (methanol)
Show answer
Correct Answer: D
93. An infant presents to a pediatrician for recurrent vomiting and failure to thrive. The child has been hospitalized by another primary care physician for recurrent dehydration. However, data are not available. Weight and length are below the fifth percentile. Exam shows a normal blood pressure with signs of mild dehydration. Reflexes are markedly increased. The child is hypotonic. Chemistry panel showed Na 140 mEq/L, K 2.2 mEq/L, CO2 50 mEq/L, Cl 78 mEq/L, BUN 20 mg/dl, creatinine 1.0 mg/dI, Ca 9.5 mg/dl, Mg 1.7 mg/dl, PO4 2.8 mg/dl. Arterial blood gas showed pH 7.54, pCO2 60 mmHg, urine chloride was 40 mEq/L and urinary calcium excretion was elevated. What is the nature of the acid-base disorder?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Respiratory alkalosis
D. Metabolic acidosis
Show answer
Correct Answer: B
94. The most unlikely diagnosis in the patient in question 33 is:
A. Gitelman's syndrome
B. Bartter's syndrome
C. Renal tubular acidosis
D. Contraction alkalosis
Show answer
Correct Answer: C
95. Which one of the following is clearly associated with autosomal recessive polycystic kidney disease?
A. Very large cysts throughout the kidney parenchyma, including cortex and medulla
B. Cerebral aneurysms
C. Gastrointestinal diverticulum
D. Congenital hepatic fibrosis
Show answer
Correct Answer: D
96. Which one of the following is true regarding urinary tract infections (UTI) in the neonatal period?
A. UTI are equally common in boys and girls
B. UTI are more common in boys
C. UTI are always more common in girls
D. UTIs never occur in neonates
Show answer
Correct Answer: B
97. Hemolytic uremic syndrome in children
A. Is usually non-diarrheal
B. Must always be treated with antibiotics
C. Is always benign
D. Is best treated with plasma infusions
E. None of the above
Show answer
Correct Answer: E
98. Which one of the following regarding glomerular filtration rate (GFR) is true:
A. Creatinine clearance is seldom used as a marker of GFR in clinical medicine because it consistently underestimates true GFR
B. Two patients with identical serum creatinine concentration always have the same GFR
C. In advanced renal failure (GFR <15 mI/mm), 24-hour urea clearance is useful in conjunction with 24-hour creatinine clearance to estimate GFR
D. For a given individual, an increase of serum creatinine from 8.0 mg/dl to 10.0 mg/dl represents a loss of greater number of nephrons than an increase of serum creatinine from 1.0 mg/dl to 2.0 mg/dl
E. Muscle mass is the predominant determinant of creatinine clearance
Show answer
Correct Answer: C
99. A high blood urea nitrogen to serum creatinine ratio (> 20:1) is seen in one of the following conditions:
A. administration of 2 L iv normal saline
B. anabolic state
C. advanced liver failure
D. low protein diet
E. severe congestive heart failure
Show answer
Correct Answer: E
100. Which of the following is most likely to be associated with very low urinary sodium concentration (< 10 mEq/L):
A. high salt intake in a normal subject
B. severe congestive heart failure
C. furosemide (powerful diuretic) administration
D. acute tubular necrosis
Show answer
Correct Answer: B
101. In a patient with oliguria, which ONE of the following favors the diagnosis of pre-renal azotemia rather than acute tubular necrosis:
A. ratio of urine osmolality to plasma osmolality = 2.0
B. ratio of urine creatinine concentration to plasma creatinine concentration < 20
C. fractional excretion of sodium (FENa) < 1%
D. urinary sodium concentration of 40 mEq/L
Show answer
Correct Answer: C
102. A patient reports that he has noticed a decrease in urine output for 5 days. His BUN is 100 mg/dl and his serum creatinine is 7 mg/dl. Which of the following is LEAST useful in establishing the etiology of his renal failure:
A. urine sodium concentration
B. ultrasound of the kidneys
C. abdominal x-ray (KUB)
D. urinalysis
E. history and physical
Show answer
Correct Answer: C
103. Which of the following is an indication for urgent dialysis for a patient with renal failure:
A. tiredness
B. dyspnea on exertion
C. sinus tachycardia of 110/min
D. serum creatinine of 12 mg/dL
E. serum potassium of 8.0 mEq/L
Show answer
Correct Answer: E
104. In the management of patients with chronic glomerulonephritis and chronic renal failure with a serum creatinine of 2.0 mg/dl, which of the following is false:
A. angiotensin converting enzyme inhibitors are absolutely contraindicated because they are toxic to the kidneys in renal failure
B. dosage of medications often require adjustment
C. nonsteroidal anti-inflammatory agents (arthritis medications) should not be used liberally because the chronically diseased kidneys are sensitive to the toxic effects of these agents
D. superimposed urinary tract obstruction may further aggravate renal insufficiency
E. sodium restriction is not always necessary
Show answer
Correct Answer: A
105. The most common cause of end stage renal disease in the adult (in the U.S.A.) is
A. hereditary nephritis
B. chronic glomerulonephritis
C. post-infectious glomerulonephritis
D. chronic pyelonephritis
E. none of the above
Show answer
Correct Answer: E
106. Which of the following is most commonly encountered in a patient with chronic renal failure and bone biopsy showing osteitis fibrosa cystica:
A. decreased serum alkaline phosphatase level
B. markedly decreased serum phosphorus concentration
C. increased serum 1 ,25(OH)2D3 level
D. high parathormone level
E. increased serum calcium concentration
Show answer
Correct Answer: D
107. Which of the following is the most common complication of advanced untreated renal failure:
A. anemia
B. leukocytosis
C. increased peripheral nerve conduction
D. gastrointestinal tumors
E. hypotriglyceridemia
Show answer
Correct Answer: A
108. In the evaluation of proteinuria, which of the following is false:
A. Proteinuria as detected by the dipstick methods is quite insensitive, and may miss albuminuria in early diabetic nephropathy
B. The dipstick method may not detect Bence-Jones proteins in the urine
C. A random urine sample for protein:creatinine ratio often suffices in following proteinuria in a patient under treatment, as long as there is no substantial change in muscle mass.
D. Protein excretion in the urine is a good reflection of dietary protein intake
Show answer
Correct Answer: D
109. Based on the following data, the fractional excretion of sodium (FENa) can be calculated to be: BUN = 40 mg/dl, 24 urine volume = 2 liters, serum creatinine = 2 mg/dL, urine creatinine = 40 mg/dL, serum sodium = 150 mEq/dL, urine sodium = 15 mEq/L
A. 0.2%
B. 0.5%
C. 5%
D. 20%
Show answer
Correct Answer: B
110. Which one of the following statements is correct:
A. Diabetic nephropathy and proteinuria often develop after 10 years duration of diabetes
B. Patients with type I diabetes and diabetic nephropathy do not have higher risk of death than those without diabetic nephropathy
C. All patients with diabetic nephropathy have type I DM (diabetes mellitus)
D. If a patient survives 40 years of DM without developing nephropathy, he or she is at extremely high risk of doing so in the future
E. Microalbuminuria is an insignificant finding in diabetic patients
Show answer
Correct Answer: A
111. Which one of the following statements is not correct?
A. Hyperglycemia leads to the accumulation of advanced glycosylation end products (AGE's) in tissues in patients with DM
B. AGE's accumulation in tissues parallels the severity of renal disease
C. decreasing intraglomerular pressure preserves the structure and function of the glomerulus in diabetic patients
D. AGE's are responsible for end organ damage seen in diabetes
E. Hyperlipidemia does not add any significant risk for developing vascular complications in diabetic patients
Show answer
Correct Answer: E
112. Which one of the following is correct:
A. Early diabetic nephropathy means development of microalbuminuria
B. Normal urine albumin excretion varies between 400-500 mg/24 hr
C. Microalbuminuria in diabetic patients does not predict the development of frank proteinuria and ESRD
D. Microalbuminuria in diabetic nephropathy patients doesn't become manifest until serum creatinine is higher than 2.0 mg/dL
E. Once frank proteinuria is established, almost all patients reach ESRD within one year
Show answer
Correct Answer: A
113. One of the following is not correct:
A. All patients with type I diabetes of greater than 5 years duration should have an annual screen for microalbuminuria to identify this high risk population.
B. 15-20% of patients with diabetic nephropathy have diabetic retinopathy
C. The absence of retinopathy should make one suspect a cause of proteinuria other than diabetic nephropathy.
D. Nephrotic range proteinuria after only 5 years duration of type I DM is unlikely to be secondary to diabetic nephropathy.
E. If the urinary albumin excretion rate is greater than 30 mg/24 hr in a single urine collection, this microalbuminuria needs to be confirmed with additional collections since other causes of microalbuminuria (e.g., hypertension, CHF) are common in diabetic
Show answer
Correct Answer: B
114. Regarding the management of diabetes mellitus, all of the following are correct EXCEPT:
A. Dialysis therapy, in patients with diabetic nephropathy and ESRD is necessary once the GFR is less than 15 ml/min
B. Tight blood sugar control increases the risk of developing diabetic nephropathy
C. In diabetic patients with proteinuria and declining renal function, lowering the systemic blood pressure slows the rate of decline in renal function
D. In patients with microalbuminuria, using ACE inhibitors decreases urine albumin excretion and rate of progression to overt nephropathy
E. Avoiding NSAIDs and radiocontrast media, and properly managing UTIs and neurogenic bladder, are important measures to preserve the remaining renal function in patients with established diabetic nephropathy
Show answer
Correct Answer: B
115. A 22 year old man presents with the complaint of recurrent blood in his urine. He states that it usually occurs when he gets "the flu". He has no other complaints and he has been in good health otherwise. He is not taking any medication and has no drug allergies. Physical examination including B.P. is normal and he has no edema. Urinalysis reveals trace proteinuria, several dysmorphic RBCs and few RBC casts. BUN is 12 mg/dl and serum creatinine 0.6 mg/dl. Which one of the following is the most likely diagnosis?
A. Nephrolithiasis
B. Minimal change disease
C. Hemorrhagic cystitis
D. Focal segmental glomerulosclerosis
E. IgA nephropathy
Show answer
Correct Answer: E
116. A 7 year old girl presents with leg edema. She has no other complaint and has been healthy up until now. She is not taking any medication and has no known allergies. Physical examination shows 3+ leg edema. The rest of the physical examination including B.P. is normal. Urinalysis reveals 3+ proteinuria , no RBC, WBC or any casts. BUN and serum creatinine are normal. Serum albumin is 1.5 mg/dl. 24 hour urine collection shows 6.0 gram protein. Which one of the following statements about her disease is true?
A. Renal biopsy will most likely reveal extensive crescent formation in the glomeruli
B. This is the least common cause of nephrotic syndrome in children
C. She has about 90% chance of developing end stage renal disease
D. This disease is highly responsive to steroids
Show answer
Correct Answer: D
117. Which one of the following statements about post-streptococcal glomerulonephritis is incorrect?
A. It occurs simultaneously with the throat infection
B. It is associated with low serum complement levels
C. It rarely progresses to end stage renal disease
D. Steroids are not needed to treat the disease
Show answer
Correct Answer: A
118. Which one of the following statements about Goodpasture's syndrome is true?
A. It predominantly occurs in persons older than 70 years
B. Kidney biopsy is too risky to make the diagnosis
C. Anti-GBM antibody titres do not correlate well with the disease severity
D. Plasmapheresis is not an effective therapy
Show answer
Correct Answer: C
119. All of the following about systemic lupus erythematosus are true except:
A. It is an immune complex vasculitis process that may cause glomerulonephritis
B. Men are more commonly affected than women
C. The glomerular lesions span a spectrum from normal glomeruli to diffuse necrotizing crescentic glomerulonephritis
D. Plasmapheresis is rarely indicated
Show answer
Correct Answer: B
120. Membranoproliferative glomerulonephritis (MPGN) is characterized by
A. Consistently normal serum complement levels
B. No progression to chronic renal failure
C. Both mesangial hypercellularity and glomerular basement membrane changes
D. Steroids are very effective in adult patients
E. Absence of proteinuria
Show answer
Correct Answer: C
121. A middle aged woman has active stone disease for many years. Her stones are radioopaque, small and occur bilaterally. She has seen a Urologist for this problem who performed a metabolic work-up that showed normal urinary Ca and oxalate excretion. She had been treated, unsuccessfully, with a thiazide diuretic, low sodium diet and high fluid intake. A stone analysis revealed that her stones consisted of Ca-oxalate and a small amount of uric acid. Which of the following treatments will likely be effective in the prevention of further stones?
A. a low Ca diet
B. Allopurinol, a xanthine oxidase inhibitor
C. vitamin C supplement to acidify the urine
D. a high protein diet
E. none of the above
Show answer
Correct Answer: B
122. Which one of the following statements about diuretic action is false?
A. Amiloride inhibits apical sodium channels in the cortical collecting tubule
B. Spironolactone inhibits K+ secretion
C. Thiazides inhibit Na+/Cl- entry into the distal tubule
D. Furosemide acts primarily in the proximal tubule
E. Acetazolamide inhibits proximal tubule Na+ reabsorption by reducing carbonic anhydrase activity
Show answer
Correct Answer: D
123. Distal nephron potassium secretion is decreased by which one of the following?
A. Furosemide
B. Decreased distal nephron sodium delivery
C. High urine flow
D. Alkaline urine
E. Vasopressin
Show answer
Correct Answer: B
124. Generalized edema can occur only in the setting of low serum sodium concentration.
A. true
B. false
Show answer
Correct Answer: B
125. Generalized edema can occur only in the setting of high intravascular volume.
A. true
B. false
Show answer
Correct Answer: B
126. Ascites is a manifestation of isolated left-sided congestive heart failure?
A. true
B. false
Show answer
Correct Answer: B
127. The quality of the effective arterial blood volume (EABV) never correlates with the size of the extracellular volume (ECV).
A. true
B. false
Show answer
Correct Answer: B
128. In order to slow the progression to end stage renal disease in patients with diabetic nephropathy or glomerulonephritis Calcium channel blockers are inferior to angiotensin converting enzyme inhibitors.
A. true
B. false
Show answer
Correct Answer: A
129. The original disease that caused end stage renal failure does not recur in the transplanted kidney because patients are treated with immunosuppressants.
A. true
B. false
Show answer
Correct Answer: B
130. A 79 y/o diabetic woman is brought to the emergency room from a nursing home because of changes in mental status, obtundation and confusion that began 2-3 days earlier. The patient’s blood tests show the following: serum sodium 148 meq/L (NL ~ 140), serum potassium 5.7 meq/L (NL 3.5-5.5), BUN 152 mg/dL (NL 10-20), blood sugar 70 mg/dL (NL 74-128). Which one of the following changes in serum levels is the most likely explanation for this patient’s changes in mental status?
A. hypernatremia
B. hyperkalemia
C. azotemia
D. hypoglycemia
Show answer
Correct Answer: C
131. A 68 y/o, obese woman with type 2 diabetes mellitus x 2 years has had a significant weight loss, pain in several ribs and her lower back. She has ankle edema and is found to have lytic bone lesions on x-ray, normal blood and urinary albumin levels, elevated serum calcium and creatinine, and abnormal results on serum and urine protein electrophoresis. What is the most likely diagnosis?
A. minimal change disease
B. lupus nephritis
C. multiple myeloma
D. diabetic nephropathy
Show answer
Correct Answer: C
132. A 17 y/o female patient is diagnosed by her family physician as having recurrent urinary tract infections over the last 3 months. She is repeatedly treated with antibiotics because she has microscopic hematuria, proteinuria and nocturia, occasional low grade fever, some weight loss. However, she never had dysuria and blood tests and urine cultures were not obtained. She now presents to the emergency room because she feels weak, looks pale and has ankle edema and hypertension. Her serum creatinine is 4.0 mg/dL (NL 1.2), the urinalysis shows large numbers of red cells, red cell casts and 3+ protein, the hematocrit is 25% (NL ~ 45%). Which serious renal disorder (1) should have been diagnosed and treated before and (2) is the likely cause of this patient’s current condition?
A. Pyelonephritis with papillary necrosiss
B. Rapidly progressive, crescentic glomerulonephritis
C. Acute tubular necrosis
D. Acute, post-streptococcal glomerulonephritis
Show answer
Correct Answer: B
133. Which one of the following kidney stones can be dissolved and their formation prevented by lowering the urinary pH?
A. uric acid stones
B. calcium-oxalate stones
C. "Struvite" (triple phosphate or infection stones)
D. Cysteine stones
Show answer
Correct Answer: C
134. Linear immunofluorescence along the glomerular wall is characteristic of which of the following diseases?
A. minimal change disease
B. focal and segmental glomerulosclerosis
C. anti-glomerular basement membrane glomerulonephritis
D. acute postinfectious glomerulonephritis
E. membranous nephropathy
Show answer
Correct Answer: C
135. Normal complement levels (C3/C4) are found in
A. acute postinfectious glomerulonephritis
B. IgA nephropathy
C. lupus glomerulonephritis
D. membranoproliferative glomerulonephritis
Show answer
Correct Answer: B
136. A patient with diabetes mellitus develops nephrotic syndrome. Which one of the following makes membranous nephropathy a less likely diagnosis?
A. RBCs in the urine
B. 24 hour protein excretion of 12 grams
C. fundoscopic evidence of retinopathy
D. family history of diabetes
Show answer
Correct Answer: C
137. In a patient with nephrotic syndrome, the safest treatment to reduce proteinuria is
A. high dose prednisone
B. cyclophosphamide
C. calcium channel blocker
D. angiotensin II blocker
E. cyclosporine
Show answer
Correct Answer: D
138. A 35 year-old white man is referred to you for evaluation of microscopic hematuria detected on routine testing. He has no history of hypertension, headaches, or urinary tract symptoms. His father and paternal aunt have polycystic kidney disease; they developed end-stage renal disease at ages 58 and 62 respectively but are currently doing well. The patient has recently married and is concerned about risks to his future offspring. Blood pressure is normal. The kidneys are not palpable. Urinalysis shows 8-10 RBCs/hpf and no protein.
Which of the following studies is most appropriate now?
A. Genetic analysis
B. Renal ultrasonography
C. Cerebral arteriography
D. Intravenous urography
Show answer
Correct Answer: B
139. Two weeks ago, a 27 year-old man was admitted to the hospital because of progressive fever and weight loss. He had a normal kidney function with a serum creatinine of 1.2 mg/dL but was found to have positive blood cultures (4/4) for alpha-hemolytic streptococci and therapy with ceftriaxone was begun. You are asked to evaluate this patient after two weeks of therapy because serum creatinine has risen to 3.5 mg/dL. His general condition has improved (Tmax 37.2 C) but a diffuse maculopapular rash has developed on the trunk. Repeat blood cultures are negative. The following laboratory results were obtained: Serum creatinine 3.5 mg/dL; Serum electrolytes (mEq/L): Na 137, K 5.6, Cl 95, bicarb 18; Serum complement C3 150 mg/dL (normal 100-233), CH50 150 units/mL (normal 110-190). Urinalysis showed protein 1+, glucose negative, blood 3+, many RBCs, WBCs, and WBC casts.
Which of the following is the most likely cause of the elevation in serum creatinine?
A. Ceftriaxone-associated acute tubular necrosis
B. Glomerulonephritis secondary to subacute bacterial endocarditis
C. Acute interstitial nephritis
D. Intratubular crystal deposition
E. Renal emboli
Show answer
Correct Answer: C
140. Which one of the following disorders is associated with renal papillary necrosis and irregular-shaped small kidneys?
A. Analgesic nephropathy
B. Diabetic nephropathy
C. Medullary sponge kidney
D. Primary hyperparathyroidism
E. Membranoproliferative glomerulonephritis
Show answer
Correct Answer: A
141. All of the following are features of chronic urinary tract obstructions except:
A. nocturia
B. hypokalemia
C. acidemia
D. hypertension
E. azotemia
Show answer
Correct Answer: B
142. 80 year old diabetic male had nocturia 1-2 times per night for the last 3 years, but for the last couple of weeks he has to get up 3-4 times per night to urinate. He is now seen in the emergency room with newly diagnosed renal failure (serum creatinine 4.8 mg/dl), edema, fever, lower abdominal pain, hyperkalemia, and hypertension. He has 3+ peripheral edema, normal albumin and liver enzymes. The most appropriate initial diagnostic test step is
A. fractional excretion of sodium
B. 24 hour collection for creatinine clearance
C. renal ultrasound
D. bladder catheter insertion
E. urinalysis and urine culture
Show answer
Correct Answer: D
143. A patient has the following arterial blood gas results: pH 7.2, [H+] 63 and pCO2 47 mm Hg. The calculated [HCO3-] is:
A. 9 mmol/L
B. 18
C. 24
D. 30
E. 36
Show answer
Correct Answer: B
144. A patient has the following arterial blood gas and venous chemistries: pH 7.2, pCO2 20 mm Hg, [HCO3-] 8 mmol/L, [Na+] 140 mmol/L, [Cl-] 108 mmol/L, [K+] 6 mmol/L. The calculated anion gap is:
A. 12 mmol/L
B. 20
C. 24
D. 26
E. 32
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Correct Answer: C
145. What type of compensation is expected with metabolic acidosis?
A. Renal compensation results in an increase in [HCO3-] and a decrease in pH.
B. Respiratory compensation results in an increase in pCO2 and a decrease in pH.
C. Renal compensation results in a decrease in [HCO3-] and a decrease in pH.
D. Respiratory compensation results in a decrease in pCO2 and an increase in pH.
E. Respiratory compensation results in an increase in pCO2 and an increase in pH.
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Correct Answer: D
146. What type of compensation is expected with respiratory acidosis?
A. Renal compensation results in an increase in [HCO3-] and an increase in pH.
B. Respiratory compensation results in a decrease in pCO2 and a decrease in pH.
C. Respiratory compensation results in a decrease in pCO2 and an increase in pH.
D. Renal compensation results in an increase in [HCO3-] and a decrease in pH.
E. Respiratory compensation results in a decrease in pCO2 and a decrease in pH.
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Correct Answer: A
147. A patient had the following laboratory results: pH 7.25, pCO2 62 mm Hg, [HCO3-] 26 mmol/L. The patient has what acid base disorder?
A. Metabolic alkalosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Respiratory acidosis
E. None
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Correct Answer: D
148. A patient has the following laboratory results: pH 7.5, pCO2 45 mm Hg, [HCO3-] 34 mmol/L. The patient has what disorder:
A. Metabolic alkalosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Respiratory acidosis
E. None
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Correct Answer: A
149. A patient has the following test results. Blood testing shows the following: pH 7.2, pCO2 20 mm Hg, [HCO3-] 8 mmol/L, [Na+] 140 mmol/L, [Cl-] 122 mmol/L, [K+] 3.0 mmol/L. The urine pH was 7.0 and the urine net charge was positive. The urinalysis showed no glucose or ketones. Which diagnosis is most plausible:
A. Proximal renal tubular acidosis.
B. Distal renal tubular acidosis
C. Type IV renal tubular acidosis
D. Diabetic ketoacidosis
E. Methanol ingestion
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Correct Answer: B
150. A patient presents with the following test results. Blood test results included pH 7.55, pCO2 50 mm Hg, [HCO3-] 42 mmol/L, [Na+] 140 mmol/L, [K+] 2.5 mmol/L [Cl-] 86 mmol/L. Urine test results included pH 8.0 and [Cl-] 5 mmol/L. A urine drug screen is negative. The most likely explanation is:
A. Bartter’s syndrome
B. Renal tubular acidosis
C. Diabetic ketoacidosis
D. Diuretic treatment
E. Vomiting
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Correct Answer: E
151. A hypotensive patient with a normal serum sodium concentration is treated with intravenous fluids. Which one of the following intravenous fluids would you recommend?
A. Isotonic saline
B. Hypotonic saline
C. Hypertonic saline
D. 5% dextrose in water
E. water
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Correct Answer: A
152. Which one of the following statements is true about hyponatremia?
A. Hyponatremia in the setting of a low urinary sodium concentration is always associated with extracellular fluid volume depletion.
B. SIADH and primary polydipsia associated hyponatremia are due to an increase in body sodium and water, but the water increase exceeds that of the sodium increase.
C. Hyponatremia associated with extracellular fluid volume depletion can be due to both primary renal or extrarenal losses of sodium and water.
D. Hyponatremia is always treated with water restriction.
E. The urine sodium concentration is always high in hyponatremia.
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Correct Answer: C
153. The criteria for diagnosis of SIADH are:
A. Low serum osmolality and hyponatremia
B. Urine which is less than maximally dilute
C. Urine sodium matches intake
D. Absence of other disorders impairing urine dilution and improvement in hyponatremia after water restriction
E. All of the above
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Correct Answer: E
154. A 75 year old woman develops altered mental status and a serum sodium concentration that is markedly elevated at 165 mEq/L. She had surgery for a hip fracture several days ago and her serum sodium concentration was normal at the time of admission for the surgery. She is making about 200 ml of urine a day. Her GFR is 50% of normal. She is only taking narcotics for pain and SQ heparin. A Dobhoff tube was placed earlier today to start feeding, but she has not received anything through it as of yet. The most likely cause of her hypernatremia is which one of the following?
A. Renal insufficiency induced nephrogenic diabetes insipidus
B. Central diabetes insipidus due to her hip surgery
C. Administration of intravenous normal saline without administration of any free water
D. Physical inability to reach water coupled with altered thirst due to pain medications
E. Hyperaldosteronism
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Correct Answer: D
155. Which one of the following statements is true about edema formation?
A. It can only occur when effective arterial blood volume is reduced.
B. It can only occur in the setting of elevated circulating aldosterone and vasopressin levels.
C. Increased vascular permeability to proteins is a common factor in most cases of edema formation.
D. Effective arterial blood volume can not be reduced in the setting of high actual blood volume.
E. Enhanced proximal and distal nephron sodium and water reabsorption is a common feature of edema formation in the setting of reduced effective arterial blood volume.
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Correct Answer: E
156. A patient is seen with marked edema and a 24 hr urine protein excretion of 12 grams. The serum albumin concentration is modestly reduced and the blood pressure is 180/120. GFR is 90% of normal. The edema formation in this patient is most likely due to which one of the following?
A. Reduced GFR
B. Hepatic dysfunction
C. Peripheral vasodilation
D. An intrinsic renal defect in sodium and water excretion
E. Poor cardiac output
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Correct Answer: D
157. Which one of the following factors stimulates cellular uptake of potassium?
A. ß-adrenergic antagonists
B. Insulin
C. Acidemia
D. Mineralocorticoid antagonists
E. Vasopressin
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Correct Answer: B
158. Distal nephron potassium secretion is increased by which one of the following factors?
A. Hypokalemia
B. Triamterene or amiloride
C. Increased tubule fluid flow rate
D. Spironolactone
E. Acidemia
Show answer
Correct Answer: C
159. A 50 year old male with a 20 year history of diabetes is referred to you for evaluation of serum creatinine of 4.0 mg/dl. He was seen by an ophthalmologist last month and was told that his eyes were "clean" on fundoscopic examination. Two months ago his serum creatinine was 1.0 mg/dl. On examination his BP was 160/100 mm Hg. Fundus showed no evidence of diabetic retinopathy. Urine analysis showed 2+ blood and 3+ protein on dipstick. Urine microscopy showed dysmorphic RBCs. Which of the following statements is true?
A. The most likely diagnosis is diabetic nephropathy
B. This patient requires urgent kidney biopsy
C. The rate of raise in serum creatinine seen in this patient is typical of diabetic nephropathy
D. here is no correlation between the presence of diabetic retinopathy and nephropathy
E. Nephrotic range proteinuria is never seen in diabetes.
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Correct Answer: B
160. Oval fat bodies are seen in
A. Acute tubular necrosis
B. Minimal change disease
C. Papillary necrosis
D. Loin pain hematuria syndrome
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Correct Answer: B
161. A 70 year old male was admitted to the hospital for osteomyelitis. On admission, his serum creatinine was 0.8 mg/dl. He was started on Clindamycin and gentamicin iv and ibuprofen 600 qid for pain. He underwent surgical debridement on day 2 of hospitalization. Seven days later his serum creatinine was 3.0 mg/dl. Dipstick was negative for blood and protein. His urine microscopy showed muddy brown casts and 1-3 RBCs and WBC per hpf. The most likely diagnosis is
A. Postinfectious glomerulonephritis
B. Acute interstitial nephritis
C. Acute tubular necrosis
D. Dehydration
E. Multiple myeloma
Show answer
Correct Answer: C
162. Vesicoureteral reflux (VUR) in children:
A. Never resolves spontaneously
B. Always requires surgery for correction
C. Is usually a developmental problem with resolution over time
D. None of the above
Show answer
Correct Answer: C
163. Juvenile nephronophthisis is associated with all of the following except:
A. Anemia
B. Hypertension
C. Poor growth
D. Polyuria
Show answer
Correct Answer: B
164. Which of the following does NOT fall into the pre-renal causes of acute renal failure?
A. Congestive heart failure
B. Sequestration of fluid in "third space" following extensive burn injury
C. Acute renal vasoconstriction from nonsteroidal anti-inflammatory drugs
D. Aminoglycoside nephrotoxicity
E. Acute gastrointestinal hemorrhage
Show answer
Correct Answer: D
165. Which of the following is TRUE regarding acute tubular necrosis (ATN)?
A. Large volume fluid resuscitation is helpful in all phases of ATN in improving renal function
B. The duration of the oliguric maintenance phase of ATN can last as short as 24 hours and as long as 24 days; recovery in renal function is still possible under these circumstances
C. Oliguria (less than 500 ml of urine per day) is a prerequisite for ATN
D. Transient polyuria (> 6 liters of urine per day) is a consistent feature during the recovery from ATN
E. After an episode of ATN, the patient always recovers his/her renal function completely
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Correct Answer: B
166. Which of the following is FALSE regarding acute renal failure?
A. History is often helpful in establishing the etiology
B. Acute renal failure is a laboratory diagnosis and often cannot be ascertained by clinical assessment alone
C. Clinical acute renal failure is often multifactorial
D. If the patient is anuric and in the absence of creatinine loss from other parts of the body, serum creatinine concentration must increase with time
E. Adjustment of medication dosages is unnecessary in acute renal failure
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Correct Answer: E
167. Which is the LEAST life-threatening complication of acute renal failure?
A. Hypoxemia from pulmonary edema as a result of fluid overload
B. Blood urea nitrogen concentration over 100 mg/dl
C. Hyperkalemic changes on electrocardiogram
D. Seizure
E. Pericarditis from uremia
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Correct Answer: B
168. Which of the following does NOT mediate or exacerbate chronic renal failure?
A. Matrix degradation in the glomeruli
B. Long term uncontrolled hypertension
C. Chronic usage of nonsteroidal anti-inflammatory agents
D. Loss of the majority of the nephron mass
E. Overactivity of angiotensin II locally in the glomeruli
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Correct Answer: A
169. Which of the following is FALSE regarding chronic renal failure?
A. Renal function may continue to deteriorate despite the apparent disappearance of immunologic insult from lupus nephritis
B. Acute renal failure can superimpose on chronic renal failure
C. serum creatinine value of less than 1 mg/dl rules out the presence of impaired glomerular filtration rate (i.e., rules out chronic renal failure)
D. Chronic renal failure is often clinically silent until the impairment in renal function becomes severe (e.g., glomerular filtration rate below 10% of normal)
E. Chronic renal failure is often multifactorial
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Correct Answer: C
170. Which of the following is the LEAST important in the management of chronic renal failure?
A. Rigorous control of systemic blood pressure
B. Lowering of serum calcium
C. Adjustment of medication dosages because some medications may accumulate in the body as a result of chronic renal failure
D. Treatment with angiotensin blockers
E. Avoiding volume depletion
Show answer
Correct Answer: B
171. Which of the following is NOT a recognized complication of chronic renal failure?
A. Decreased production of erythropoietin by the kidneys resulting in normochromic normocytic anemia
B. Increased aggregation by uremic platelets
C. Autonomic neuropathy leading to dysregulation of blood pressure and impotence
D. Diffuse inflammation of the gastrointestinal tract
E. Left ventricular hypertrophy of the heart
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