CBM Final PDF

18.01.2023 16:51 Content Question 1 20 out of 20 points View Rubric You are asked to see a 78-year-old man who is admitted to the hospital from a skilled nursing facility. He has altered mental status and his caregiver notes he has not been eating or drinking for past several days. Physical exam...

18.01.2023 16:51 Content Question 1 20 out of 20 points View Rubric You are asked to see a 78-year-old man who is admitted to the hospital from a skilled nursing facility. He has altered mental status and his caregiver notes he has not been eating or drinking for past several days. Physical exam: Orthostatic hypotension, tenting of his skin, and dry mucous membranes. Labs: Serum creatinine 2.3mh/dL (normal 0.5-1.0 mg/dL) BUN high at 59mg/dL (normal 5-20mg/dL) He is given 2L normal saline and his serum creatinine decreases to 1.3mg/dL the following morning. What type of acute kidney injury does he have? Explain why with clinical clues. Selected Answer: In this case, we are observing that the old man hasn't been eating or drinking for the last few days, hence the patient suffers from water, salt, and protein deficiency. Altered mental status, tenting of the patient's skin, and dry mucous membranes are indicators of dehydration. Because of the dehydration, the patient is suffering from hypovolemia and that leads to prerenal acute kidney injury. Orthostatic hypotension occurs due to peripheral vasodilation again due to hypovolemia. Moreover, when we look at the laboratory values, his serum creatinine levels can be increased due to dehydration and low blood volume. His BUN is the indicator of kidney injury, in this case prerenal acute kidney injury caused by dehydration and later on hypovolemia. When he is given saline his creatinine level is decreased, which supports the patient suffering from prerenal acute kidney injury. Prerenal AKI due to volume depletion Clinical clues: Correct Answer: Hypovolemia Signs of volume depletion (orthostatic hypotension) Acute kidney injury (creatinine value) Prerenal reversible injury Response Feedback: When they give the patient volume to re-expand his vascular space and restore his volume status, his creatinine value goes down. It means that he has got a reversible injury. [None Given] Question 2 5 out of 10 points Case I -A 30-year old male is noted to have microscopic hematuria and 2+positive-dipstick proteinuria on screening labs for a life insurance policy. It was confirmed on a repeat urinalysis 3 months later. His serum creatinine is normal. Case II – A 53-year-old women with a history of hypertension is noted to have a serum creatinine of 1.7mg/dL. Her urinalysis is unremarkable. In review of her past records, her serum creatinine was elevated to 1.7mg/dL 5 month prior. Which one of these patients has chronic kidney disease? [--] Selected Answer: Case 2 Correct Answer: Evaluation Method Exact Match Question 3 https://ieu.blackboard.com/ultra/courses/_28437_1/cl/outline Correct Answer Case Sensitivity Both 7 out of 10 points View Rubric 1/5 18.01.2023 16:51 Content Which clinical/lab clues do help you to diagnosis of the case above? Selected Answer: Correct Answer: Response Feedback: In the second case, we are seeing that women suffering from hypertension. Over time, untreated hypertension can damage the renal blood vessels as in the case. The uncontrolled high blood pressure damaged the arteries of the kidney, which lead to kidneys having inadequate blood supply, and that ended up with kidney disease. Furthermore, the case indicates that her serum creatinine level is high for 5 months, according to the aforementioned information we can understand that this patient is suffering from chronic kidney disease. In the first stages of chronic kidney disease urinalysis can be normal, as in his patient. I. microscopic hematuria II. 2+positive-dipstick proteinuria III. 3 months history IV. High creatinine V. 5 months history [None Given] Question 4 5 out of 5 points View Rubric Which diagnostic test/s do you need to confirm your diagnosis of the case above? Selected Answer: Correct Answer: According to our lectures, we would conduct urinalysis to check whether there is any proteinuria or hematuria. Creatinine, albumin creatinine ratio, leukocyte esterase, nitrite, and bilirubin would also be checked. Glomerular filtration rate (GFR) should be measured. Electrolyte levels in blood including sodium, potassium, phosphate, bicarbonate, calcium, and alkaline phosphatase as well as BUN, iron and ferritin levels should be tested. Parathyroid hormone (PTH) levels get affected by kidney function alteration, therefore it should also checked. Furthermore, a renal ultrasound can be conducted to look for structural abnormalities. These will surely help for confirming my diagnosis for this patient, but if need for further diagnosis emerges, we can also perform a renal biopsy. First line I. Renal ultrasound II. eGFR Then I. Urinanalysis: albumin-creatinin ratio in the 1st morning sample, II. Albumin III. Blood test for electrolyctes including HCO3, Ca, Na, alkaline phosphatase , iron studies, intact PTH Response Feedback: [None Given] Question 5 https://ieu.blackboard.com/ultra/courses/_28437_1/cl/outline 8.2 out of 10 points View Rubric 2/5 18.01.2023 16:51 Content As a result of the tests you asked above, which findings should you expect to confirm your diagnosis? Selected Answer: Correct Answer: Response Feedback: In the second case, this patient is suffering from chronic kidney disease due to untreated hypertension. When we look at it, we can see that serum creatinine level is tested, urinalysis is conducted and results support our diagnose. As indicated, serum creatinine level is high, hence we would expect decreased glomerular filtration rate. As the patient's condition gets advance, the glomerular filtration rate decreases more while proteinuria increases, thus an elevated albumin-creatinine ratio would also be observed. Reduced kidney mass will lead to elevated phosphate, and decreased calcium levels. Elevated PTH, elevated urea andelevated potassium are also from expected findings. I. Polycystic kidneys/Hydronephrosis/Small kidneys with thinned cortices II. Decreased <GFR 60mL/min1.73m2 for >3 months document at least 2 measurements separated by at least2 weeks What about imaging findings? Question 6 5 out of 5 points View Rubric A 28-year-old nursery schoolteacher developed a marked change in the color of her urine (“colacolored”) 1 week after she contacted impetigo from one of her students. She also complained of a new onset of global headaches and fluid retention in her legs. Examination revealed a blood pressure of 158/92 mm Hg, resolving honey-crusted pustules over her right face and neck, 1+ pitting edema of her ankles, and no cardiac murmur. Write the patient’s illness script. Selected Answer: A 28-year-old nursery school teacher, who had a impetigo contact, represents with; acute gross haematuria, global headaches, bilateral leg edema; moreover, +1 pitting edema on her ankles, resolving honey-crusted pustules over her right face and on her neck as well as grade 1 hypertension have been observed during examination. Correct Answer: A 28-year-old women is nursery schoolteacher who has recent contact history of a student with impetigo, who represent with acute global headache, macroscopic hematuria, leg edema, stage 1 hypertension, pustules traces over her right face and neck, and 1+ pitting ankles edema. [None Given] Response Feedback: Question 7 https://ieu.blackboard.com/ultra/courses/_28437_1/cl/outline 10 out of 10 points View Rubric 3/5 18.01.2023 16:51 Content Urinalysis revealed 2+ protein and numerous red cells and red cell casts. Her serum creatinine was elevated at 1.9 mg/dL. Serum complement levels (CH50, C3, and C4) were low. According to the laboratory results of the case, what is your diagnosis, explain with its rationale? Selected Answer: According to the case and the test results, we can say that this patient suffers from acute post-streptococcal glomerulonephritis. It is an immunologic response caused by a streptococcal infection, which is caused by impetigo on her face and neck for this patient. This patient has “cola-colored” urine as gross haematuria, high blood pressure, and also mild edema which is seen in post-streptococcal glomerulonephritis. This disease also leads to proteinuria as in our patient which was revealed in urinalysis. Moreover, red blood cell casts, increased serum creatinine level, and decreased complement levels can be seen as the indicator of post-streptococcal glomerulonephritis Correct Answer: Poststreptococcal glomerulonephritis. Poststreptococcal glomerulonephritis results from a skin infection with a nephritogenic strain of group A (β-hemolytic) streptococci such as type 12. The abrupt onset of hematuria (“cola-colored” urine), edema, and variable degrees of hypertension most commonly occur 7–14 days after streptococcal pharyngitis or impetigo and can occur sporadically or in clusters. Significant glomerular damage can lead to rapid progression to oliguria and acute kidney injury. [None Given] Response Feedback: Question 8 10 out of 10 points View Rubric A 48-year-old white man presents to the emergency department with unremitting right flank pain. He denies dysuria and fever. He reports significant nausea without vomiting. He has never experienced anything like this before. On examination, he is afebrile, and his blood pressure is 160/80 mm Hg with a pulse rate of 110/min. He is writhing on the gurney, unable to find a comfortable position. His right flank is mildly tender to palpation, and abdominal examination is benign. Urinalysis is significant for 1+ blood, and microscopy reveals 10–20 red blood cells per high-power field. What is the most likely cause of this patient’s situation? Explain. Selected Answer: According to the given information, this patient suffers from renal stone disorder. We can clearly say that the patient's race and age increased the possibility of renal stones. He complains about tender and unilateral flank pain, which indicates the presence of a stone. Fragments of this renal pelvis stones may break than can travel down, which causes a colic type of pain, therefore the tenderness and writhing with pain can be observed. Colic can also be indicative of acute obstruction and as a consequence of obstructed kidney, renin production is increased which leads to hypertension. Hematuria, which is commonly indicative of renal stones also supports the diagnosis. Moreover, due to lack of fever and vomiting, urinary infections seem insignificant. Correct Answer: The most likely cause of this patient’s situation is nephrolithiasis. This patient is presenting with his first episode of renal stone disease. At least 75% of stones are calcium containing and reflect idiopathic hypercalciuria. Hyperparathyroidism and hyperuricosuria are other important causes of calcium stones. Other types of stone are uric acid stones, cysteine stones, and struvite stones. If the patient is able to collect a passed stone, an analysis of its composition would be helpful in diagnosing the subtype and tailoring treatment. [None Given] Response Feedback: Question 9 https://ieu.blackboard.com/ultra/courses/_28437_1/cl/outline 9 out of 10 points View Rubric 4/5 18.01.2023 16:51 Content For confirmation of the most likely diagnosis of the case above, which tests should you order, explain why? Selected Answer: According to our lectures, we would conduct urinalysis to check proteinuria, hematuria, leukocytes, creatinine, albumin creatinine ratio, esterase, nitrite, bilirubin, and pH. We expect creatinine to be high due to obstructed kidney. Moreover for this case, checking for crystals is particularly important as well as Complete Blood Count (CBC) and CReactive Protein (CRP) to detect whether there is any stone-related infection. Electrolyte levels in blood including sodium, potassium, phosphate, bicarbonate, calcium, and alkaline phosphatase levels should also be measured, because electrolyte imbalance is expected. Furthermore, a non-contrast CT can be conducted to examine the stones. Correct Answer: Non contrast abdominal CT. Because it is better than US and KUB X-ray for confirmation of the stones. [None Given] Response Feedback: Question 10 How do you manage the patient above? 10 out of 10 points View Rubric Selected Answer: We should confirm our diagnose before starting the treatment. Renal stones can be really painful as we can also observe in this patient, thus the first thing to do would reliving the patient with appropriate painkillers. Thereafter type of the stone that the patient has, should be determined and further examination of the stone should be conducted. According to the size of the stone sound wave treatment or surgical removal may be needed. As I have mentioned, the best appropriate treatment would be planned after a detailed examination of the stone and by a urologist. Moreover, increasing the fluid intake, avoiding high salt intake, limiting foods with high oxalate content as well as having arranged amount of calcium on the diet can be recommended for decreasing the risk of further stone formation. Correct Answer: After effective pain control is achieved, the patient may return home, and the need for adequate hydration with at least 2 L/day should be reinforced. Hydration may dilute unknown substances that predispose to stone formation and minimize the likelihood of Ca2+ precipitation in the nephron. High-protein diets in known stone formers are inadvisable since they predispose to recurrent calcium nephrolithiasis. This results from a transient increase in calcium resorption from bone and increased filtration through the nephron in response to a protein load that stimulates the GFR. A high-sodium diet should be avoided because Na+ predisposes to Response Feedback: Ca2+ excretion and increases the saturation of monosodium urate, which acts as a nidus for calcium oxalate stone formation. Dietary calcium restriction is not recommended because it can actually increase oxalate absorption and thus may not decrease urinary calcium excretion. Finally, citrate supplementation may be considered because of the ability of citrate to chelate calcium in solution, forming soluble complexes as opposed to calcium oxalate or phosphate. [None Given] Wednesday, 18 January 2023 16:50:43 o'clock TRT https://ieu.blackboard.com/ultra/courses/_28437_1/cl/outline 5/5