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Renal Revision Masterclass Dr Vicki Levidiotis May 10th 2010 Sem 8-9 Paper 2 Question 1 • The diabetes complication and control trial (dcct) showed that strict glycaemic control ( hba1c %<7%) did which of the following A) prevented the progression of severe retinopathy B) prevented the onset of macrovascular disease C) reduced the prevalence of hypoglycaemic episodes D) reduced the progression of microalbuminuria E) prolonged life in type 2 diabetes • In the DCCT, intensive intervention resulted in a 63% reduction in retinopathy progression, a 47% decrease in development of severe non-proliferative diabetic retinopathy, a 39% and 54% reduction in microalbuminuria and macroalbuminuria, respectively, and a 60% reduction in clinical neuropathy at 5 years. • Aggressive early intervention before the manifestation of complications yielded the best results. In both intensive and conventional treatment groups in the DCCT, there was approximately a 40% reduction in risk of progression of retinopathy for each 10% proportional reduction in hemoglobin A1c (HbA1c). At the conclusion of the DCCT, participants learned about the results, and all were encouraged and helped to adopt intensive treatment. Paper 2 Question 2 A 76 year old woman who lives in a nursing home has a creatinine, urea and electrolytes drawn because she has been nauseated. The results are as follows – Na 118 (NR 135-145), K 4.6 (NR 3.5-5), Urea 11.5 (NR 5-12), Creatinine 0.08 (NR 0.05-0.10). What further clinical information do you require to interpret this result A– Blood pressure B– Fluid status C– Pulse rate D– Temperature E– Oxygen saturation Question 3 A19 year old student presents to emergency with 2 week history of polyuria, polydipsia, lethargy and a painful paronychia on her left 1st digit. a finger prick glucose is 20 and this is confirmed on a serum glucose as 21.7. Which of the diabetes treatments would be suitable once she has been stabilised? A) actrapid tds, protaphane nocte • B) protaphane nocte • C) gliclazide 160mg bd • D) metformin 1gram bd • E) glimepiride • F) mixtard 30/70 s/c bd • G) insulin pump Paper 2 • QUESTION 4 • An 18 year old receptionist presents with 2 days frequency and dysuria. A urine dipstick shows • • 1+ red blood cells • 1+ protein • 3+ white blood cells • Empiric treatment is: • a) ciprofloxacin • b) trimpethoprim • c) co-trimoxazole • d) amoxycillen • e) nitrofurantoin QUESTION 5 • A subtotal thyroidectomy was performed 8 weeks ago on a 45 year old teacher with congenital heart disease for uncontrollable “amiodarone induced thyroiditis”. He now presents to Endocrine Clinic for a post operative review. • He complains of fatigue, leg cramps and circumoral parasthesiae. Electrolytes • Serum Calcium 1.65 ( 2.13-2.62) • Serum phosphate 2.20 ( 0.73 – 1.37) • Alkaline phosphate 53 IU/L ( < 90) • Serum Albumin 40 g/L ( 35-50) • Urinary Calcium 2.1 mmol/day ( 3.7-6.2) His current medications are-: • Thyroxine 150mcg daily • Amiodarone 200mg bd • Coversyl 8mg daily • Atenolol 100 mg daily • Aspirin 100mg daily Which of the following is the most likely diagnosis • a) Hypoparathyroidism • b) Hyperparathyroidism • c) Osteomalacia • d) Hypothyroidism • e) Transient postoperative hypocalcaemia QUESTION 5 part 2 Which of the following is the most appropriate initial management? a) Oral magnesium b) Oral calcium carbonate and oral 1,25 dihydroxyvitamin D3 ( Calcitriol) c) Intravenous calcium gluconate d) No treatment required QUESTION 5 part 3 Which of the following is the most appropriate long term management? a) oral magnesium b) Oral calcium carbonate and 1.25 dihydroxyvitamin D3 ( Calcitriol) c) Intravenous Calcitriol d) No treatment required QUESTION 6 • Side effects of morphine include which one of the following? • a) renal failure • b) myotonic jerks • c) constipation • d) aplastic anaemia • e) cardiac arrhythmia Paper 1 QUESTION1 A 24 year old male was admitted 2 days ago with acute pancreatitis. His pain has been treated with a pethidine infusion. Which one of the following is true regarding his pethidine infusion a) Pethidine is metabolised to nor-pethidine which may cause seizures. b) Pethidine has fewer side effects when compared to morphine c) Pethidine has an oral bioavailability greater than 50% d) Pethidine is a natural drug derived from the opium poppy e) The dose of pethidine should be increased in the patient with renal failure Paper 1 QUESTION 2 • A 25 year old type I diabetic woman is brought to the ED confused and drowsy. She had attended a party the previous night and may have forgotten some of her insulin doses. Her BP is 80/60, pulse 120 BPM and she is afebrile. She has ketones in her urine and her capillary blood glucose is 36 (NR <8). The most important principal of her initial management is a) – Lowering her blood glucose b) – Replenishing her intravascular volume c) – Correcting her acid base imbalance d) – Correcting her Potassium status e) – Treating an infection Paper 3 Question 1 • A 30 year old lawyer has had type 1 diabetes for 20years. She has been on basal bolus actrapid and bedtime protaphane most of that time. her overall control has been poor with hba1c% approximately 8.9%. Fortunately to date there has been no evidence of diabetes complications. She now wishes to become pregnant but knows her control must be between 6-7%. • Which treatment could you discuss with her to achieve this? Paper 3- Question 2 • A 80 year old retired gardener presents with a 2 year history of pelvic pain localized to the left side. It is particularly bad at night but has become an increasing problem during the day. Over the counter analgesics have been unhelpful. He also complains of “getting old” with a sore left shoulder and reduced hearing. His past history includes diet controlled type 2 diabetes, hyperlipidaemia and gout. There is no relevant family history. His medications are –: Simvastatin 10mg • Panandol, • panadeine, • non steroidal anti inflammatory drugs.(NSAIDS) His examination is unremarkable. Paper 3 • You arrange an x ray of his pelvis and the result is shown. The left hemipelvis is sclerotic. The cortical bone is thickened particularly in the region of the ileo-pectineal line where the trabeculae are course. • What is the most likely diagnosis? • a) Osteoarthritis • b) Fracture • c) Avascular Necrosis of the Left Femoral Head • d) Pagets Disease • e) Sacro ileitis Paper 3- Question 2 part 2 Biochemistry of the above condition would include: a) Incr. Calcium , low phosphate, high PTH , incr ALP b) Normal Calcium, normal phosphate, normal PTH, increased ALP c) Normal Calcium , normal phosphate, low PTH , normal ALP d) Low Calcium , High Phosphate, low PTH, normal ALP Paper 4- Question 1-part 1 Mr. Brown is admitted to the medical ward with community acquired pneumonia.He is commenced on intravenous antibiotics and chest physiotherapy, with oxygen therapy via humidification. According to his fluid balance chart, Mr. Brown has drunk 1 litre since his admission, 8 hours ago. He has voided 3 times, to a total of 200mls. Your first response is to • a) examine the patient • b) order blood tests • c) question his nurse • d) Take a urine test. Paper 4- Question 1-part 2 On examination, you discover Mr. Brown has a palpable bladder. He becomes very uncomfortable as you palpate his lower abdomen. His most immediate problem is likely to be • a) urinary tract infection (UTI) • b) bladder tumour • c) constipation • d) acute urinary retention Paper 4- Question 1-part 3 • The immediate management is • a) more UTI specific antibiotics • b) referral to surgeons • c) urinary catheterization • d) laxatives Paper 4- Question 1-part 4 Halfway through the insertion of an indwelling catheter, Mr. Brown becomes dyspnoeic and distressed. Your first action is to: • a) Continue the procedure • b) Sit the patient up • c) Increase the oxygen concentration • d) Call a Medical Emergency Team response Paper 4- Question 1-part 5 Mr. Brown settles easily. Your next decision should be to: • a) Abandon the procedure • b) Continue the procedure • c) Reposition semi-recumbent and continue the procedure after his distress settles • d) Abandon the procedure and arrange for Urology to insert a suprapubic catheter Paper 4- Question 2 • The most appropriate method of reducing indwelling catheter induced urethral meatus irritation is • a) oral analgesics • b) topically applied anesthetic gel • c) anchoring the catheter to the upper thigh • d) hanging the drainage bag below the level of the umbilicus. Paper 4- Question 3 • The most common complication following urinary catheter insertion is: • a) urinary retention • b) urinary tract infection • c) urethral perforation • d) haematuria