Neurology 4 mrcp answers book - part 3 ppsx

Chapter IV / Hepatobiliary Diseases Answers Q1 Answer: 4 1- True, like Kupffer cells, Ito cells.. Q4: Answer: 5 1- True, and also less useful in diffuse parenchymal diseases.. Q10: Answ

Chapter IV / Hepatobiliary Diseases Answers

Q1

Answer: 4

1- True, like Kupffer cells, Ito cells

2- True, also removal of IgG complexes and cytokine production

3- True, and also synthesis of extra-cellular matrix and synthesis and release of collagenases and metalloprotease inhibitors

4- False, vitamin K and folic acids are stored in small amounts and hence deficiency occurs relatively rapidly when there is NO supply of them

5- True, and during fasting also, the liver releases glucose

Q2:

Answer: 5

Item 5 is in favor hepato-cellular damage The reverse is true in biliary obstruction

Q3:

Answer: 5

Cimetidin and ACUTE alcohol binge both are enzyme blockers or inhibitors

Other inducing enzymes: meprobamate, INH, phenytoin, primidon and

phenobarbitone

Q4:

Answer: 5

1- True, and also less useful in diffuse parenchymal diseases

2- True, and also CT scan can be combined with splenoportography

3- True, the MRCP (magnetic resonance cholangiopancreaticography )

4- True, PTC or ERCP

5- False, with radioisotope, both are rarely used now days

Q5:

Answer: 4

1- True, can you do in an agitated patient?!

2- True, and it is contraindicated if the platelets less than 100 000/ mm3

3- True, as well as severe anemia, hepatic hydatid cyst, hepatic hemangioma, and bile duct obstruction

4- False, is a contraindication

5- True, as in lumbar puncture

Q6:

Answer: 4

Up to 4 mg of urobilinogen is passed outside in urine every day Other options are true

Q7:

Answer: 4

1- True, due to ineffective erythropoiesis

2- True, may be hemolytic (or hepatocellular)

3- True, and Crigler –Najjar syndrome type I and II.

4- False, it is a DIRECT hyperbilirubinemia, also in Dubin Johnson syndrome

5- True, and other causes of intravascular hemolysis

Q8:

Answer: 5

So we are dealing with a direct hyperbilirubinemia:

1- ? pancreatic carcinoma

2- ? Bile duct stricture from a previous biliary surgery

3- ? metastasis

4- ? any tumor including lymphoma and choledochal cyst

5- False, this and together with polished nails, just indicate itching from

cholestasis BUT with out any additional information for the cause

Q9:

Answer: 5

A tricky question, all are used to stop the bleeding, but terlipressin is given

intravenously (ie systemic measure not a local measure) Other drugs used in the acute setting: vasopressin, glypressin and octreotide Remember: propranolol is used in the primary and secondary prophylaxis against bleeding, not in the acute setting

Q10:

Answer: 4

Esophageal transection is used to arrest acute bleeding episodes in certain situations

It has no place in secondary prophylaxis

Q11:

Answer: 5

Esophageal transaction although has a good result in experienced hands, it should be done only when there is failure of endoscopic hemostasis and TIPSS is not available

or cannot be carried out It carries a risk of future esophageal stricture It is done by a stapling gun

Q12:

Answer: 5

1- True, should be done by an expert

2- True, he results are excellent

3- True, and all coagulation defects should be corrected also beforehand

4- True, unfortunately yes, and necessitates iatrogenic shunt narrowing to lessen the shunt

5-False, this may indicate IN-STENT narrowing and hence venography and

angioplasty should be carried out

Q13:

Answer: 3

1- True, and hence may present with fever only or as an acute sudden hepatic

encephalopathy in a previously well managed and compensated patient

2- True, and hence polymicrobial infection should cast a doubt on the diagnosis and regarded as visceral perforation until proved otherwise

3- False, can be prevented by giving daily norfloxacin 400 mg / day

4- True, and hence the name "SPONTANEOUS".

5- True, culturing the ascetic fluid in a blood culture bottle gives a high diagnostic yield

Remember: It carries a high mortality and hence should be treated aggressively

Q14:

Answer: 4

Oral neomycin is used as a bowel decontaminant in these cases, and is not a

precipitating factor Other precipitating factors:

a- Uremia: which may be spontaneous or diuretic induced

b- GIT bleeding (upper or lower)

c- Surgery and trauma

d- Surgical or spontaneous porto-systemic shunts

e- Large volume abdominal paracentesis

f- Hypokalemia

g- Sedatives and hypnotics

Q15:

Answer: 5

Remember: a patient with liver cirrhosis who presents with vague symptoms of drowsiness, poor concentration etc, don’t assume that he is decompensating , but first you should exclude many diseases which may resemble hepatic encephalopathy, and then look for any precipitating cause for the encephalopathy, so you should be patient and think well Don't forget DOUBLE PATHOLOGIES eg Cirrhosis patient ,who is alcoholic, and intoxicated after an alcohol binge, sustained a head injury with subdural hematoma formation, and with alcoholic gastritis causing hematamesis, and hypoglycemia may be present as well!

Q16:

Answer: 3

1- True, like hepatitis E infection in pregnancy

2- True, hence you may FORGET the liver problem!

3- FALSE, it is absent in Rye's syndrome, but remember, the patient may DIE before the development of jaundice!

4- True, hence you should be cleaver and anticipate them and correct rapidly them if possible

5- And early contact the hepatic transplant unit

Q17:

Answer: 2

Although it is an intrinsic renal disease, the fractional Na excretion is less than 1 and the Na concentration is less than 10 mmol / L in urine i.e pre-renal failure like picture! Renal dose dopamine has a role in the management, yet the improvement in renal function depends entirely on improvement of the liver function

Q18:

Answer 5

Remember, MACRO-vesicular steataosis is much more common in is a benign condition, yet the MICRO-vesicular type usually occurs in grave diseases like fatty liver of pregnancy

Q19:

Answer: 5

Hemochromatosis causes chronic liver disease, cirrhosis, and hepatocelluar

carcinoma Wilson's disease can cause acute hepatitis, chronic active hepatitis, and cirrhosis

Q20:

Answer: 5

EBV causes acute hepatitis that never progresses to cirrhosis

Q21:

Answer: 4

1- True, so anemia may be MISSED easily

2- Apart from pregnancy (which are commonly seen in the 2nd and 3rd trimesters), if these are seen in a healthy person, it is better to investigate the liver; they are seen in

up to 2% of healthy adults

3- True, as well as prominent gynecomastia

4- False, indicates an advanced disease, and some regards ascites per se is an

indication for hepatic transplantation in cirrhosis

5-True, as well as low grade fever

Q22:

Answer: 5

Unfortunately, hepatitis E in pregnancy carries a mortality rate up to 20% Remember:

up to 80 % of hepatitis C infections will become chronic, and acute infection is

usually asymptomatic The question's options are "long"; this is for teaching purposes only and better not to be put in the answer explanations! In reality, there are no such LONG options!

Q23:

Answer: 5

The 1st 4 items predict a poor response to INF alpha treatment Criteria for initiating INF alpha treatment in chronic hepatitis B infections are:

1- Raised serum aminotransaminases

2- Chronic active hepatitis picture on liver biopsy

3- The infection was not acquired trans-placentally

4- HIV negative status

Q24:

Answer: 5

Hepatocellular carcinoma as a complication is surprisingly uncommon despite the changes in liver histology The disease occurs in exacerbations and remissions and eventually will end with cirrhosis Corticosteroids are effective in the treatment of acute attacks and at prevention of future attacks but they do not prevent the

progression to frank cirrhosis

There are many associations, especially in type I, like ulcerative colitis, nephrotic syndrome, Coombs positive hemolytic anemia, autoimmune thyroid disease …etc

So you should be careful when facing these complications as these will complicate and confuse the picture Type I is ANA and anti-smooth muscle antibodies positive; while type II is anti-LKM antibodies positive

Q25:

Answer: 5

There is proliferation of the endoplasmic reticulum, and together with mitochondrial swelling, are seen only with the aid of electron microscope

Q26:

Answer: 3

Although xanthelasmas are seen and Hypercholestremia is common, it is

predominantly of HDL type and hence is cardio protective! Liver transplantation is the only curative step

Q27:

Answer: 5

Corticosteroids and immune-suppressants are of no value at all Liver transplantation

is the only curative step

Q28:

Answer: 5

The fibrolammellar variant has a good prognosis and is NOT associated with hepatitis

B or C infection or cirrhosis and serum alpha fetoprotein is usually normal

Q29:

Answer: 5

The patient should be ASYMPTOMATIC or at best having very mild symptoms

Q30:

Answer: 5

Pregnancy and oral CCP are risk factors for cholesterol stone formation

Chapter V / Nephrology Answers

Q1:

Answer: b

Hydroxylates 25 - hydroxycholechalciferol to its active form Remember this

CONVERSION is impaired EARLY in chronic renal failure (not late), so that renal bone disease is almost always seen in established uremias

Q2:

Answer: c

a- True, you should know the size when READING the ultrasound report

b- True, but clinically may not be that apparent

c- False, about 1 million in number

d- True, hence in hypovolemia, there is rapid activation of the renin –angiotensin system

e- True, because of the site and size of the liver This is important when SEEING the nephgrogram phase of IVU

Q3:

Answer: e

Smoking produces SIADH (and makes you urinate less) Remember: polyuria is not a synonym to frequency Frequency is the passage of FRQUENT yet small amounts of urine, but not more than 2 liters / day Polyuria is the passage of more than 3-4 liters per day of DILUTE urine Other causes of polyuria : nephrogenic and cranial diabetes insipidus Remember: one of the earliest abnormalities of early chronic failure is polyuria and NOCTURIA, due to increased osmotic load per nephron and

hyperactivity of the remaining normal nephrons

Q4:

Answer: c

a- True, other disadvantage is that the PRINTED images convey only a fraction of the information gained by performing the investigation in real time

b- True, in clinical practice this is applicable

c- True, and differentiates renal cysts from solid tumors

d- False, the density is INCREASED a tricky one!

e- It is the ratio of peak systolic and diastolic ratio, and influenced by the resistance to flow through small intra-renal arteries, and elevated in many intrinsic renal diseases like acute glomerulonephritis and renal transplant rejection Also, the Doppler study may be used in the detection of renal vein thrombosis and renal artery stenosis

Q5:

Answer: d

You should avoid diuretics before hand Remember contrast nephropathy is

unfortunately a common IATROGENIC mistake Knowing the risk, careful patient selection, with application of certain precautions (like good hydration, avoidance of diuretics, and stopping metformin in diabetics), is important in reducing the risk of contrast nephropathy

Q6:

Answer: e

There is an excellent definition of the collecting system and ureters on the AP films Remember: in any imaging investigation, you should know the availability, cost, advantages, disadvantages, complications

Q7:

Answer: C

a- False, through the skin directly into the kidney

b- False, under ultrasound guide

c- TRUE, you need a large dilated kidney to insert your needle with ease

d- False, used in obstructive uropathy

e- False, an excellent view can be obtained

Q8:

Answer: b

a- False, this is the main indication, especially in children with recurrent UTIs

b- True, also used in the assessment of urinary bladder emptying and urethral

abnormalities

c- False, it is done by directly and retrogradely injecting the dye through a uretheral catheter

d- False, especially in children

e- False, but it is rarely used here

Q10:

Answer: d

There is high risk of contrast nephropathy in certain patients (long standing diabetes, multiple myoloma etc), and risks of intra-arterial "accessing" like local hematoma or bleeding at the femoral entry site, and intra-arterial manipulation like cholesterol atheroembolic disease Therapeutic intervention may be undertaken at the same time

of doing renal angiography like dilatation and stenting of renal artery stenosis and occluding an AV fistula

Q11:

Answer: d

Isolated hematuria with DEFORMED RBCs (ie RENAL hematuria) All other options are true

a- For example, looking for an evidence vasculitis causing a rapidly progressive glomerunephritis which may have an excellent response to immune suppressive therapy

b- Chronic renal failure with small sized kidney is the usual picture, but when the size

is normal, then we have to biopsy the kidney because the etiology might be reversible upon receiving an appropriate therap

c- For example, the presence of hematuria, hypertension ,poor response to steroids d- False

e- True, nephrotic syndromes in adults are not commonly caused by minimal change nphropathy, so we have to know the cause because the management and prognosis are totally different from that of minimal change nephropathy

Q12:

Answer: d

Predicted renal size less than 60% is a contraindication Remember: transplant

rejection is not a contraindication to renal biopsy (it may direct you to what to do next) Biopsy from a single kidney is a relative contraindication and can be done safely by an experienced operator

Q13:

Answer: a

a- False, not all cases, some types don’t not discolor urine

b- True, alkaptonuria

c- True, he is on L-dopa

d- True, he is on rifampicin

e- True, myoglobinuira

Other causes: beetroot, hemoglobinuria, hematuria, and other drugs like senna

Q14:

Answer: d

A/C ratio of less than 2.5 in males and 3.5 in females

Remember: minor leaks of albumin in urine may occur in: After heavy exercise, fever, heart failure, exposure to extreme cold or heat weather, after general (especially abdominal) surgery, extensive burns

Remember: Bence John's protein is POSITIVELY charged but albumin is

NEGATIVLEY charged, and the dipsticks detect negatively charged proteins An example of a clue to BJ proteinuria is the presence of urine protein of 2 g/ d with negative protein dipsticks!

Q15:

Answer: b

a- False, the commonest causes

b- TRUE, toxic and ischemic types

c- False, almost always reversible causes

d- False, uncommon

e- 5% only for acute glomerulonephritis, and 10% for acute interstitial diseases

Q16:

Answer: d

Complicated acute renal failure may have a mortality approaching 50-70% even at best centers Other statements all are true

Q17:

Answer: e

Also by impaired consciousness causing aspiration Don’t simply assume that the respiratory rater is rapid because of uremic acidosis; always look for the above causes

in the appropriate clinical setting

Q18:

Answer: e

Hypophosphatemia may cause hemolysis and anemia and usually seen in those with aggressive dialysis whether hemo- or peritoneal Notice that hyperphosphatmeia is more common than hypophosphatemia in renal failures in genrral

Q19:

Answer d

Dipstick analysis of urine is done every day in labs for protein, glucose, bilirubin , ketones …etc; however, many doctors don’t know the FACTORS that influence the interpretation of such tests A difficult question I agree, just written for teaching purposes Significant glycosuria and contrast media in urine can cause abnormally HIGH specific gravity

Q20:

Answer: e

In the appropriate clinical setting suspecting UTI, a rapid and relatively cheap way of confirming UTI is the dipsticks for leukocyte esterase (from WBCs lysis) and nitrite (

by the action of nitrate reductase on nitrate forming nitrite), yet many factors

unfortunately affect the interpretation of these tests Medications which discolor urine will give false POSITIVE results for nitrite

Q21:

Answer: e

Calorimetric reagent strips are used for the detection of urinary PROTEINS

Q22:

Answer: d

It is very important in the follow up of both types of diabetes It is defined as either" persistent proteinuria between 30-300 mg / day or between 20-200 microgram / minute on 2 or more occasion, at least 6 months apart " ACE inhibitors are very important in the management, even in those with normal blood pressure It is a very powerful predictor for the future development of overt diabetic nephropathy and atherosclerosis Remember: neither the mechanism of the microalbuminuria nor an explanation for these associations has been found Remember: urinary protein of more than 300-500 mg/ day is a FRANK proteinuria and is dipstick positive

Q23:

Answer: e

Between 0.5-2 grams / day is considered as "source equivocal " and may be

glomerular or tubular, so further investigations are required

Q24:

Answer: e

Lab features suggestive of pre-renal failure:

1-high specific gravity, usually more than 1.018

2-urine osmolality more than 500 mosm / Kg (usually more than 600)

3-urinary sodium less than 20 meq / L (usually less than 10)

4-fractional sodium excretion less 1

5-urine sediment: normal clear hyaline casts

While in established acute tubular necrosis:

1-less than 1.010

2-less than 320(usually around 280)

3-more than 20

4-more than 1.

5-muddy brown granular casts with tubular epithelial cells………respectively

Q25:

Answer: b

a- True, both are responsible for up to 65% of cases

b- True, although useful, unfortunately it s a late sign

c- True, raised PTH per se, high calcium by phosphate product, and "unknown

toxins"

d- True, due to diarrhoea, vomiting, and salt loosing nephropathy

e- True, unfortunately

Q25:

Answers: e

These factors should always be looked for as their removal may profoundly slow the progression of the renal failure These includes:

1-urinary tract infection

2-urinary tract obstruction

3-nephrotoxic medications

4-any infection (hyper catabolic state)

5-hypertension

6-reduced renal perfusion: due to drug induced hypotension, renal artery stenosis, sodium and water depletion, and cardiac failure

Q26:

Answer: b

The half life of insulin is prolonged and hence the total daily doses should be reduced for fear of hypoglycemia

Q27:

Answer: d

Option "d" is wrong Those with tubulo-interstital diseases, renal cystic disease, obstructive uropathy and reflux nephropathy have what is called salt loosing

nephropathy; hence water and salt loss may be profound and may further deteriorate the picture, so these should be replaced carefully

Q28:

Answer: e

Difficult question, but you should know these figures as these reflect the advances in renal replacement regimens and the overall outcome is not that gloomy as it was in the past and many patients with CRF now have a good quality of life for many years

Q29:

Answer: e

It may be done every day (usually in those with severe hypercatabolic state) or every other day

Q30:

Answer: e