A 19 year old female comes to your clinic.

She is referred for hypokalemia, You do

following investigations :-

Urine: K+ = 67 mmol/l, Na+ = 44 mmol/L, Osmolality = 713 mOsm/kg

Serum: K+ = 2.9 mmol/L, cl- = 97 mmol/t, Na+ = 138 mmoi/L HCo3 = 32

osmolality 297 mOsm/kg

Her vital signs include heart rate 71 beats per minute, blood 114/73, T37.1 degrees , 02

.saturation 99% on room air, and respiratory rate 16 breaths per minute

)What is her TTKG (Trans Tubular Potassium Gradient ?

A. Greater than 7 and this indicates inadequate aldosterone

B. Greater than 7 and this indicates adequate aldosterone

C. Can not be calculated from the above information

D. Less than 2 and this indicates inadequate aldosterone

E. Less than 2 and this indicated adequate aldosterone

?Which of the following diagnoses might explain her hypokalemia

A. Diarrhea

B. Distal renal tubular acidosis (Type 1

C.Conn's syndrome

D. Bartter syndrome

E.Any of the above

?Which ofthe following investigations suggests Tubular as a cause of Acute Kidney injury

A. Serum Urea to Creatinine Ratio > 80

B. Urine microscopy shows rbc casts and dysmorphic rbc X

C. Renal ultrasound shows hydronephrosis

D.Fractional Excretion of Sodium is 3.1%

E.Urine microscopy shows hyaline casts

? : Which of the following is not an indication for dialysis

A. Severe metabolic acidosis

B. Uremic pericarditis

C. Severe hyperkalemia

D. Ethylene Glycol Toxicity

E. Severe respiratory acidosis

l(QUESTIONS 5 and 6) A 19 year old woman is referred for consultation, to your outpatient
clinic. The reason for referral is chronic hyponatremia. She has no known significant past
medical history, She is on no medications. She does not use any alcohol, drugs and does not
:smoke. She hands you blood work, whichincludes

Hb 13.1 g/dL, wbc 7.2, platelet count normal

Na+ 125 mmo!/L, <+ 5.6 mmoi/L, 96 mol/L, HCO3- = 19 mmol/i, = 265 m0sm/kg

You would like to investigate her hyponatremia. :5

You do not think this is pseudohygonatremia and notice her serum osmolality is normal. You
do a physical examination and note her to be euvolemic.

) Which of the following diagnoses is NOT likely? (EASY

A. Hypothyroidism

B. Adrenal insufficiency

C. failure Heart failure

D. Psychogenic polydypseia

E. SIADH

?Which of the following mechanisms would NOT describe her hyperkalemia :6

A.She eats 10 tomatoes and 15 bananas a day

B. She has a deficiency of cortisol or aldosterone

She injects herself with her sister's insulin

D. She has severe kidney disease

E. She has renal tubular acidosis type 4

?Which of the following statements about Starling's forces is true

A Lasix causes an increase in the Capillary hydrostatic pressure and therefore edema

B. She may have liver disease, which could cause decreased production of abumin, leading
to increased oncotic pressure in the capillary and therefore edema

C She may have sepsis, which would increase Kuf (Gitration coefficient), leading to
.decreased edema

D. She may have heart failure, causing increase in capillary hydrostatic pressure and the
.odema

E. Her ederna is likely due to anaphylaxis, which increases edema by increasing interstitial
fluid oncotic pressure

: Which of the following statements about her Ramipril is true?

A. Ramipril increases angiotensin il production, leading to efferent arteriole constriction

B. Ramipril increases angiotensin ti production, leading to afferent arteriolar constriction .

C. Ramipril decreases angiotensin il production, leading to afferent arteriolar constriction

D. Ramipril decreases angiotensin il production, leading to efferent arteriolar dilatation

E. Ramipril increases GFR by directly inhibiting renin at the macula densa

?What is the rate of death from a kidney biopsy :

A. 20%

B. 10%

C. 1%

D. < 0.1%

E. Nobody has ever died from a kidney biopsy

:Which of the following characteristics make serum Creatinine a suboptimal

measurement of kidney function?

A. Freely filtered at the glomerulus

B. Not metabolized in the renal tubules

C. Secreted in the renal tubules

D. Not reabsorbed in the renal tubules

E. Is a more accurate measure of GFR than inulin clearance

If Ux = urinary concentration of substance x (mmol/L), V = urinary volume (ml/min), Px = :

plasma concentration of substance x (mmol/L), what is the formula for urinary clearance
?of

Urinary clearance of x = UxV/Px

B. Urinary clearance of x = PxV/Ux

C. Uninary clearance of x = PxUx/V

D. Urinary clearance of x = Ux/PXV

E. The urinary clearance of x can't be determined by any of the above

______________________________________________________________

FOR QUESTIONS 1 and 2) Mark Smith is a 42 year old man, admitted to Al-Shifa hospital (
after a motor vehicle accident. He has multiple injuries, including a right femur fracture,
multiple rib fractures a pulmonary contusion the and a splenic laceration, As the resident on
call, you are the first doctor to see him, when he is brought into the trauma bay in the Al-
Shifa hospital, He is on no medications and has no medication allergies. He has a medical
history that includes appendectomy, tonsillectomy and fever as a child. His blood work

:shows

Нь 8.7 g/dl, Cr 3.2 mg/dl

Na+ 140 mmol/L, K+ = 5.1 mmot/l, Cl- = 89 mmol/L, HCO3 15 mmo/l

Arterial gas shows: = 7.10, pCO2 - 30, HCO3 14

His BP = 80/41, heart rate = 125 beats per minute, T = 37.1 degrees celsius, 16 breaths per
minute

O2 saturation 92% on room air. You ask the nurse to do postural vitals, but the patient is
unable to sit given his multiple Fractures

: Given the above clinical story, which intravenous fluid plan is the most acceptable?
D5W
A. DAY at 125 ml,/hour IV

B. 45% NS with 1t bolus over 30 minutes, then 125 mL/hour IV

.C. No intravenous fluids, give patient 80 mg IV Lasix now

.D. 0.9% NS with bolus over 30 minutes, then reassess to determine response(

.E. Insert nasogastric tube, give patient 3 Liters water by nasogastric tube

You stabilize the patient. The new set of vital signs show BP 110/70, heart rate 8S beats :2
:per minute respiratory rate 16 breaths per minute. His morning blood work shows

Na 160 mmol/L, K+ 3.8 mmol/1, 121 mmol/1, HCO3 28 mmol/l, Albumin= 3.9 g/dl.

?Which of the following statements is true

A His body has ECF volume expansion

B. His body has an excess of free water

C. His body has ECF volume contraction

D. His body has a deficit of free water

E. He has increased anion gap metabolic acidosis

‫وين بداية قصة االخ مدحت ما بعرف‬

Which of the following is NOT a possible cause of Midhat's health problem

A. Lactic acidosis from metformin

B. Diabetic ketoacidosis

Cyanide poisoning

Partial small bowel obstruction with excessive vomiting

E. Ethylene glycol ingestion

You ask the nurse to give 3L of normal saline IV to Mr. Midhat over 6 hours. However, :
the nurse makes a mistake and instead gives 1 liter of 0.45% saline. How much of the 1L of
?0,45% saline stays in the plasma

A. 250 ml

B. 750 mi

C. 166 ml

D. 333 ml

E. 1000 m