Each of the numbered items is followed by lettered answers. Select the ONE lettered answer that is BESTn each case, Item 1 72-year-old man is evaluated for near syncope and a recent fal History is significant for hypertension, hyperipidemia, and coronary artery disease. Medications are lydrochlorothietide, miodipine, carvedilo, pravastatin, and aspirin, The hyrachlo roshiazlde dose was increase from 25 mg to mg month ago. ‘On physical examination, blood pressure is 164/88 min Hg siting and 140/76 mm Hg standing after 3 minutes, and palse rate is 64/min siting andl 66/min standing; other vital signs are normal, Fechymosis is noted over the left elbow. The remainder of the examination, including the neurologic examination, is unremarkable Laboratory studies: Creatinine 1.4 mid (123.8 pmol/L); L month ago: 1.0 mal. (88.4 pmol) 30 mEq. (G0 mmol/);1 month ago» 26 mEq/L. (26 mmol/L) Bicarbonate Potassium 3.0 mEq/l (3.0 mmol/L); month ago, 3.8 mFq/L. (3.8 mmol/l) Sodio 12 mEq/L (132 mmol); 1 month ago 136 mEayt. (136 mmol/L) A 2-ead eleetrocardiogram shows no changes from previous tracings. Vic ofthe flowing the mos appropriate nugeent? 1 recess ydrochirtiaide dose and obtain ambula (8) Oner emery and cadac ene extng (6, Scie itera ent lino 1D) Sched head cr Item 2 An 81-year-old man is hospitalized for an acute onset of fem In his legs and abdomen. History is signifcant for ehironic back pain, for whch he takes daly sbuprofen. He has o other sympioms, On physical examination, vital signs are normal. There is “Peres. Cardiac examination is without extra sounds or mut ius, and the estimated central venous pressure fs nora fhe lungs are ctear on examination. Ascites is noted, There Is S-mm pitting edema ofthe extremities tothe mid thigh. Pboratory studies: ao 21 gyal (21 g/L) oe 2.9 mg/dl (256.4 mol/L) U yd Normal Sale Rood poen Bib Dtcn-cctnineralo 0h nes BHourucine utp ee Poppler ultrasound ofthe kidneys is unremarkable tem flowingls the most appropriate next step in Itt days Sehethiea ea kidney biopsy (6) Start heparin ) Start intravenous glucocorticoids Item 3 A 56-year-old man is seen during a zontine evaluation for stage G4 chronic kidney disease (CKD). History is also sig nificant for hypertension. Medications are losartan, labeta to}, furosemide, and amlodipine. He has no symptoms and remains physically active ‘On phystel examination, blood pressure fs 129/76 mm He, ind pulse rate is 68/min; other vital signs are normal. The physical examination is otherwise unremarkable, Laboratory studies: Hemoglobin Iga. (wog/l) Bicarbonate 19 mmEg/L. (9 mmol (Creatinine mid. (224 umolil) Phosphorus 5.7 mg/l. (.8 mmol/l) Povassium 5.1 mbit 5.1 mmol/L} The addition of which ofthe following will most likely slow progression ofthis patient's CKD? (a) ACE inhibitor > (®) Exytheopoiesis- stimulating e Phosphate binder ) Saxlium bicarbonate Item 4 A 69-year-old woman is evaluated in the emergency department for new-onset dependent edema that began 3 weeks ago. She says It is difficult to walk, and she has gained 4.5 kg (10 Ib) of uid weight. History is significant for obesity and hypertension. Her only mediestion is lisinopril (On physical examination, vital signs are normal. BMI fs 22. There ts no rash. There is 3-mm bilateral dependent edema stopping just below the abdomen; It is equal on both sides. The remainder of the examination is unre mmarkable, Laboratory studies: Albumin Creatinine Urine protein-creatinine ratio 2.1 gidl-(21 g/l) 13 mgial (114.9 umolL) 8700 mgig Kidney biopsy findings are consistent with a diagnosis ‘of minimal change glomerulopathy with superimposed acute ‘tubular necrosis. In addition to initiating diuretic therapy, which of the following fs the most appropriate treatment? yelosporine ” Rela cotaSelf-Assessment Test Item 5 "A@r-yeat-old man is seen for an increase in sera erelinine aroha an abnormal urinalysis found during the evaluation ve ponoctonal gammopathy of undetermined signi ore eouteation revealed an M-protein spike ofS AL, tO" “TiSst plasma cellson bone marrow biopsy. and no eigen, onan, hypercalcemia, or lytic bone lesions on skeet cies, Immuofixatton revealed IgGas the monoclonal SP Hares no constitutional symptoms, no other medical prob- Jems, and takes no medications. “physical examination, vital signs are normal. Trace rower extremity edema is noted, Tae emalnde of the exam ination is unremarkable. Laboratory studies: Alburnin 3.6 pill @6g/) Creatinine {Lb mg/dl. (4.4 mol/L) Urinalysis ‘pAS.5;2+blood: $+ proteln: 5-8 eythrocytes/hpf urine atbumin- 400 mai creatinine ratio Which ofthe following s the most appropriate next diagnostic test? (A) ANCA testing (B)_B,-Mlcroglobutin evels (©) Kidney biopsy {(D) Serum free light chains Item 6 ‘A si-yearold man fs evaluated uring a follow-up Visi or ‘RA nephiropaty found on kidney biopsy 3 months 96> st (Bae time Bsinoptl was initiated. He Isasymptomatc Physical examination and vital signs are unremarkable: Laboratory studies: Current 3 Months Ago Creatinine Lame/dl, (97. 2umol) Potassium 48 mEq/l (4smmol!) Urinalysis 3+ blood; 2 protein 34 protein Urine protein- 700 mB/g 1200 mg creatinine ratio Which ofthe following isthe most appropriate next step in ‘management? (A) Add losartan Add oral glucocorticod therapy (c) Start alternating courses of intravenous an oral gluco cortlcoid therapy {p) Make no changes the current medication regimen ltem 7 's8-year-old woman Is evaluated inthe emergency dePat ae ora T-day history of hearing voices. History is sini raat or bipolar disorder. Medications are lithium carbonate ‘and quetiapine: 92 ‘on physical examination, the patient is dsheveled and tooks chronically ill She is alert and orlented but appears ro ae, Blood pressure is 138/78 mam Hig, and pulbe rss avai yathout orthostatic changes. Tere is no edema. The remainder of the examination s normal Laboratory studies: ‘Blood urea nitrogen mg/dl. (21 mmol/L) Creatinine 0.9 meal. (79.6 mol/L) lectroytes: Sodium 126 mil. (126 mmol/L) Potassium 3.5 mEq/L (3.5 mmoV/L) Chloride ‘94 mEq/L (94 mmol/L) ‘Bicarbonate 26 mEq/L (26 mmol/L) Glucose 186 mg/dl. (8.7 mmol/L) Urine sodium. zmba/L. (2 mmol/L) Urine osmolality 196 mOsm/kg Hj Which ofthe followings the most likely cause ofthis patient's hyponatremia? (A) Hyperzlycerit (@)_ Nephrogeniediabetes insipidus (©) Poiyaipsia {D) Syndrome ofinapp ropeiate anturetc hormone secretion (@) Volume depletion Item 8 ° ‘A year old man s evaluated after passing his second Kid 3 tone. History Is sgnifieant for chronic pancreatitis °° so ey toa past story of alcohol abuse, He bas three tr Fasary el movements cach da. He reports ro fever an wedi Thee sno fay story of key sens Fa artyroiism, or nephrltlass Current medien Peers pancreatic enzymes ad multivitamins. raha examination reveals thin man, Vita signs and the ntmander of te examination are unremarkable Laboratory studies: Calehurn ‘85 mglal.2.L mmolL) Greatinine 0.7 mgid (61.9 umn0l/L) Electrolytes: Sodium. 137 mg/L. (137 mmol/L) Potassium — 3Smbq/L. (3.5 mmol/l) Chloride 108 m/l. (104 mmol/L) piearbonate 21 mqil. (2l mmol/l) Uaeails Specific gravity: pH 5.03 negative dipstick postive for calcium oxabate crystals tn addition to increasing fluid intake, which of the following is the most appropriate management? (A) Add allopurinol (B) Add potassium citrate (C) Adalvitamin (D) Decrease caium intake (6) increase protein intake Item 9 ‘ss pearold man 3 hosptalized. for headache, IpeT A 38 year ld aed err creatine eel. Ye 210-988and pears ate is The 1d four flank dic sand history of poorly controtled type 2 diabetes mellitus and hypertension. Medications are insulin glargine, insulin lspro, {oN ajorvastatin, amlodipine, an! low-dose asprin. ‘On physical examination, blood pressure is 145/94 ram 1g; other vital signs are normal. Funduscopic examination reveals nonproliferative diabetic retinopathy. There is 1-mun_ pitting edema of the lower extremities to the ankles, equal fn both sides. Dorsalis pedis and posterior tibial pulses are {decreased bilaterally and the feet are insensate Laboratory studies: Complete blood count Albumin Creatinine Normal 3.3g/dL G3 g/L) 4.8 mg/dL (159.1 wmmol/1) Hemoglobin A,. 1% Antinuclear antibodies Negative Hepatitis Bvirusantibodies Negative Hepatitis Cvirusantibodies Negative HIV antibodies Negative No blood; 3+ protein 700 meg Urinalysis Urine protein- creatinine ratio Kidney ultrasound reveals mildly increased echogenicity tilaterally, and both Kidneys are enlarged at 12 em, In addition fo improved glycemic control, which of the following fs the most appropriate management? (A) Adan ACE inhibitor (8) Obtain ANCA tters (©) Obtain serum and urine protein electrophoresis. (D) Schedule a kidney biopsy Item 10 ‘A.2-year-old woman fs brought {0 the emengeney depart ‘nent by her boyfriend after she was found unresponsive and ying on the ground, She was last seen more than 24 hours go, History is significant for substance use disorder, She has Ro other medical problems and takes no prescription drugs (On physical examination, the patient i intubated and'on Mechanical ventilation, She is minimally responsive. Blood Bressre is 120/75 mm Hg, and pulse rate is 110/min, The Temainder ofthe vital signs and the cardiac, pulmonary, and "abdominal examinations are unremarkable. The neurologic ‘Examination is nonfoeal. Urine output has been <20 ml/h for “The past2 hours, Laboratory studies: 6.9 mgd (1.7 mmol) 40,000 U/L 2.8 mg/dL (247-5 pmol/L) 150 mEq/L (50 mmol/L) 5.5 mBq/L(5.5 mmol/L) Ho mEay/L. (140 mmol/l) 16 mEq/L 46 mmol/L) 5.9 mg/dL (1.9 mmol L) 60 maL/min/1.73 m" filtration rate Urine toxicology sereen Negative Eectrocardiogram reveals normal sinus rhythm; voltage erfteria for left ventricular hypertrophy are present Which of the following isthe most appropriate treatment? (A) Amlodipine/benazepril combination once daly (B) Doxazosin and metoprotol, each once daily (©) Hydralazine three times daly (D) Telmisartan and ramipril, each once daily = e4= 5 Self-Assessment Test Item 21 ‘An 83-year-old man is evaluated fora 1-week history of poor petit, myalgia, fatigue, athraga, and low-grade fever eras previously healthy and active. His only medication is acetaminophen as needed. ‘On physical examination, the patient fs afebrile. ood pressure is 155/95 mm Hg, and pulse rate is 80/mins there Pre no orthostatic changes. There is trace lower extremity ateama, A faint ed-blue reticular rash is present over the Tower extremities Laboratory studies: Hemoglobin 12g/a. (1209/1) Caleium, 98mg (25 mmol) Creatinine Currents3.1 mia. (244 mol.) ‘Baseline 2 months ago:0.9 ma/dL (79.6 umol) Urinalysis 3+ blood; 2+ protein; 20-80 dysmorplnie cerythrocytes/hpf 5-10 leukocytes/hpt Chest radiograph shows no acute infiltrates. Kidney ‘ttrasound shows no masses or obstruction. Which of the following is the most likely diagnosis? (A) ANCA-assoelnted glomerulonephritis {B)_Anti-glomerular basement membrane antibody dlsease (©) Minlmal change glomerulopathy (©) Myeloma cast nephropathy ()_ Proliferative lupus nephritis Item 22 |A79-year-old woman i evaluated In the emergeney depart qhent for worsening confusion over the past days. She also reports lower back pain forthe past months. History Ts ‘nitiant for hypertension and coronary artery disease Seth stenting ofthe left anterior descending artery 2 years ep. Dally medications are metoprolol, hytrochlorothia sale, atorvastatin, low-dose aspirin, and acetaminophen Ther husband confirms that the patient takes all medications as directed. ‘On physical examination, temperature fs normal, blood pressure is 12876 min Hg, ple rate is 7/min, respiration rte is 2o/min, and oxygen saturation is 95% on amblent alt. BMI is 19. There is no abdominal pain. The patient is weak, Confused to time and place, and sleepy but easily arousable The remainder ofthe neurologic examination is normal Laboratory studies: Blood weanitrogen — 3Smgial. (12.5 mmol/L) Creatinine 14 mg/d. 123.8 mmol/L) Electrolytes: Sodium 198 mg/l. (138 mmol/L) Potassium Chloride Bicarbonate 48 makq/L. (48 mmol/l) 1 (102 mmol/L) 14 mkq/l (4 mmol) actate 0.7 mi/.(0.7 mmol/L) Arterial blood gases pH 731 Pc 20 man Hg 2.9 KP) Urinalysis: ‘Specific gravity 1.025; no protein, ketones, cells, orerystals ean Which of the folowing is the most likely diagnosis? (a) DLactieacidosis (8). Propylene glycol toxilty (©) Pyroglutamic acidosis (D) Salleyiate toxiity Item 23 ‘An 18-year-old man is evaluated in the ICU for oligurie ate kidney injury, Eighteen hours ago he underwent epatectomy fora glant fibrolamellar hepatic carcinoma During the procedure he developed coagulopathy and hepatic bleeding and required resuscitation with ght erie of packed red blood cells, multiple units of fresh frozen plasma, and several liters of erystallotd fluids. Ne fe receiving cefepime, gentamicin, propofol, and fentanyl Urine output has decreased to 10 mLJ/h since ICU admis sion 14 hours ago: ‘On plysical examination, the patient is mechanically ventilated, Blood pressure Is 120/70 mm Hg, pulse Tate ts {svmin, and respiation rate is 12/min. Breath sounds are THecreased bilaterally, The abdomen is distended and tense ctr intact midline incision and wall edema, The remainder of the exatnination is noncontw#butory. Laboratory studies: Hemoglobin 10g/a, 1008/1) Creatine kinase 1250 U/ Creatinine 117 maid. (150.8 pmol/L}; on admission: 0,9 mgd. (79.6 mol/L] Potassium 5.2mBq/L (6.2 mmol/L) Urinesodium — <20mEq/L.(20 mmol/L) Urinalysis Specific gravity 1.080; pH 5.5; 4+ blood; trace protein; too murnerous fo count erythrocytes: few hyaline cats Kidney ultrasound reveals normal-szed kidneys and ne hydronephrosis; lange volume of ascites 's noted. Which of the following is the most appropriate diagnostic test to perform next? (a). Fractional excretion of sodium (8) Intra abdominal pressure measurement (©). Usine myoglobin levels (D) Urine stain for eosinophils Item 24 ‘A 45-year-old man fs evaluated for one episode of m: A aeig nematurla, He currently does not see blood it tarine. He reports no flank pain and no associated trum) exertion, He is a nonsmoker and takes no medications: Physical examination and vital signs are normal aboratory studies show a normal serum creat levels urinalysisshows T+blood, no protein, 10-15 isomor txythnacytes/npf 0-2 leukocytes hp, no nitrites, ne kooyte esterase ‘Contrast enhanced CT rogram showsno kidney #0 masses, oF ESsion: nd no Which ofthe following Is the most appropriate diagnostic test to perform next? 1a) Qptoscopy @) Kidney biopsy {©) Kidney and renal vein Doppler ultrasonography (0) Urine cytology Item 25 A 27 year-old woman i evalated fora 6-month history of five, arthrlgs, and mala She hes a history of urinary tract incon. Meieations are an oral contraceptive lll and sseneeded naproxen fo pain “Onpiyscl examination termpersture 6 38:2°C(100 8°), blood pressute i 12/90 mm Hg, and palse rte i 90/min. Cala, hing, and abdominal examinations are normal Laboratory studies show a serum creatinine level of 14 mid (28.8 mol) nals shows 2 blood, 3+ pro- tein, postive leukocyte esterase, no mires, 1015 erythro- «yes hp, 510 leukocytes/hp, and no crystals ‘UrInemierosconyisshown, ch ofthe lowing isthe mos ely dlagusi? Bladder cancer ‘Glomerlonephtts (© Tlsmerstal nephrits Urinary tract infection m 26 ar old woman is evaluated in the ICU for acute ‘ey Mnlury. She was discharged from the hospital 0 aha i8? following elective cholecystectomy. Seven days Xe Was readmitted to the hospital with sepsis. A CT 2 the abdomen with intravenous contrast did not ‘ny abdominal pathology but confirmed pneumonia, Self-Assessment Test She was treated with intravenous flulds, norepineph- rine infusion, vancomycin, and cefepitne. The norepi nephrine was stopped yesterday: History is significant for hypertension and stage Ga chronie kidney disease, Her baseline serum creatinine is 1.4 mgidL (123.8 umol/L) On admission the serum creatinine was 1.9 mg/dl (068 panol/L) ane returned to baseline by hospital day 2; it is 3.1 mg/dL. 074 umol/L) today. Outpatient medications are lisinopril and chlorthalidone. (On physical examination, temperature is.97.6°C (99.7), blood pressure is 140/82 mm Hg, pulse rate is 103/min, and respiration rate is 20/min, Examination of the lungs reveals bilateral crackles, There Is 1+ pedal edema of the ‘extremities, The remainder of the physical examination is noncontributory. Coie tena Current laboratory studies: Serum creatine 3.1 mid (274 pmol/L) Vancomycin trough 25 mig Fractional excretion of 25% sodium Urinalysis Specific gravity LO12; pH15.5; no blood 1+ protein; trace leuko esterase; no nitrites; no glucose 2-4 leukocytes/hpf S-10 renal ‘wiular epithelial cells apf 5-10 coarse granular casts/hpf Kidney ultrasound reveals normal-sized Ktdneys and no ydronephrosis Which of the following isthe most likely cause of this patient’s acute kidney injury? (A) Cefepime (®) Inn venous contrast () Omeprazole (©) Vancomycin Item 27 Oo {An 18-year-old! woman is brought to the emengeney depart iment by fi¥ends. She is confused and febrile. Her frends state that she tool 3,4-methylenedioxymethamphetamine (ecstasy) ata party and was previously wel. There is no other medical history On physicat examination, the patient is confused and oriented to her name only. Temperature is 38.9 °C (102.0 °F), blood pressure is 148/94 mm He, pulse rate is 108/min, resp ratlon tate fs 20/mnin, and oxygen saturation is 96% breathing 2 L/min oxygen by nasal canniila, The remainder ofthe exain ination is unremarkable Laboratory studies: Blood urea nitrogen Creatinine Hlectrolytes Sodium Poiassium Chloride Bicarbonate Glucose Urine asmotality 11 mg/dl 6.9 mmol) 0.8 mala (90.7 umol/L) 118 mEq/L (118 mmol/L) 8.5 mEq/L (3.5 mmol/L) 88 mEq/L. (88 mmol/L) 21 mbqll. (21 mmol/L) '88 mg/L (4.9 mmol/L) 405 mOstnikg H,0 7P= FI A Es Self-Assessment Test Which of the following is the most appropriate initial treatment? (a) 0.9% sodium chloride, 100 mL (®)_100-mL bolus of 3% saline (©) Fluld restriction (b) Oral urea (€) ‘Tolvaptan Item 28 A 26-year-old woman f evaluated duringa follow-up wisi for Typertension diagnose! { month ago, She sa marathon run pepenith previously normal blood pressure. Family history fet for her mothe who died of a ruptured cerebral Sarg at the age of 50 years. Medications are lisinopril an an oral contraceptive ‘On pliysical examination blood pressure fs 146/92 mm g, and pulse rate I 59/min, A systolic-diastole abdominal ‘rut hat lateraizes tothe left side is heard. There js no ower txtremity ederna,‘Tne remalnder of the examination is une Taboratory studies show a serum creatinine level of 1-4 mgidl. (123.8 uamol/L) (1_month ago: 0.8 resid F7o.7 pmol/L) Urinalysis normal with no blood, protein, or Teakocyte esterase. Pregnancy tests negative ‘A 12-Jealelectrocariegram is norm Which of the following isthe most appropriate diagnostic test to perform next? (A). Plasma aldosterone concentration plasma renin activity ratio (8) Plasma fractionated metanephines (©) Renal artery imaging (D) ‘Transthoracie echocardiography Item 29 |\.75-yeat-old man is evaluated in the hospital for an acute fanterior St-elevation myocardial infarction, He was hos pitallzed for chest pain and shortness of breath 45 ln bites ago. History is significant for stage G4 chronic kidney tisease (estimated glomerular filtration rate, 24 mLfmin’ 173 my), hypertension, and peripheral vascolar disease Medications are lisinopril, metoprolol, furosemide, seve Juaner, sodium bicarbonate, aspin, clopidogrel, and unfrac tionated heparin. ‘On physical examination, blood pressure is 145/88 mm big, pals rate is 94/min, and respiration rate is 18/min, Car fiepalmonary examination reveals jugular venous disten Gon, a grade 2/6 mital regurgitation murmur, an S, gallop. ‘and end-expiratory bilateral basta crackles Which of the following is the most appropriate immediate ‘management? (A) Cardiac catheterization (8) Cardiae magnetic resonance imaging (C)_ Emergent dialysis followed by coronary catheterization {D) Medical management 98 Item 30 ‘36-year-old man is evaluate! in bi emergency departnent for renal colic. He isin otherwise good heath an takes Ne reliations. Physical examination reveals left costovertebral angle tenderness. The remainder of the examination is normal ‘Noncontrast helical CT scan shows an I-mmstone Jeft ureteral pelvi junetion ancl mild left cafiectass ‘Analgesies are Initiated. Which of the following is the most appropriate next step in management? (A). Extracorporeal shock wave lithotripsy (8). Forced diuresis with intravenous norm saline (©) Nifedipine Famsulos Item 34 ‘A.Av-year-old woman is evaluated for a 3-month history of jnereasing nonproductive cough, fatigue, anorexia, andl mat false, History is significant for hypertension. Medicatfons are Tydrochlorothiazide, lisinopril, andl self prescribed vitamin D and ealeium for bone health One pliysieal examination, vitaf signs are normal. Bila eral ernckles are heard on pulmonary auscultation. Trace ‘pedal ecera is present, The remainder of the examination is ‘unremarkable. Laboratory studs: Caleium 11.3 mg/dL. (2.8 mmol/L) Creatinine 1.6 mgidl. (141.4 pmol/L) 1 year ago: 1.0 mg (88.4 pmol/L) Phosphorus 3 A mia (Lt mmol/L) Parathyroid hormone 25. Hyeroxyvitamin D 12 pg/mL (2 ng/t) 43 ngiml. (107.3 nmol/L) Urinalysis Specie gravity 1.010; 1+ proteins 5-20 leakocytes/hpf; occasional granular casts Urine protein. 400 mei, creatinine ratio 24 Flour urine calcium, evated ‘Chest radiograph shows diffuse reticular opacities. Kid ney ultrasound demonstrates nephrocalcinosis. Which of the following isthe most likely cause of this patients findings? (a). Hydrochlorothtazide (8) Primary hyperparaliyroidism (©) Sarcoidosis (0) Vitamin D intoxteation Item 32 'A25 year-old woman fs evaluated inthe emergency JePare ‘decor chest pain aera belted motor veil scent Se TEpregnant a approximately 23 weeks’ gestation. SherePe thoadonal symptoms adisoterwise wel Her ol) ™ ieation sa prenatal vitaminpin y of mal inD iat race ants Kid wt ‘she ents red On physical examination, the patient isafebrile, lood pressure is 102/62 mm Hg, and pulse rate fs 80/min, Pain and bruising over the left chest wall are noted. Abort nal examination findings are consistent with changes of pregnancy, Laboratory studies are significant for a serum sodium. level of 182 mEq/L (132 mmol) Which ofthe following isthe most likely cause ofthis patient's low serum sodium level? (A) Excessive water intake (8). Hypotension-induced antidiuretic hormone release (C)_ Normal physiologic change in pregnancy (0) Syndrome of inappropriate antidiuretic hormone secretion Item 33 A 51-year-old man is evaluated during a routine follow-up visit for stage Gt chronie Kidney disease and hypertension. He is asymptomatic. Medications are valsartan, amlodipine, and furosemide. On physical examination, blood pressure is 140170 mm Hg, and pulse rate fs 70/min, BMI is 32. The remainder of the physical examination is noncontributory. Laboratory studies: HDL-cholesterol LDL cholesterol Total cholesterol Triglycerides 32 mg/dl. (0.83 mmol/l) 19 maya. (3.08 mmol/L) 208 mga (5.39 mmol/L) 289 mgidl- (2.27 mmol/L) Which of the following is the most appropriate ‘management for this patient's dyslipidemia? (8) Gemitbroall (8) Niacin (©) Omega 3 fish oil () Rosuvastatin Item 34 £828 year old man is evaluated in the emengency department ‘or geute right-sided flank pan and blood in the urine. He ports no prior episodes of hematuria or flank pain. He takes ‘nomedietions. ‘On physical examination, vital signs are normal. Costo- ‘erebral angle tenderness is noted, The abdomen is soft and Urinalysis shows $+ blood, trace protein, and too ‘umerous to comnt erythrocytes. ‘kidney ultrasound shows normal-appearing kidneys, ‘Te hycronephrosis, and no nephrolithiass Which of the following is the most ay wriate test to Perforin next? “ pores W) Contrast MRI Cont enhanced helical abdominal Cr Kn, ret, and bladder pan radgraphy Noncntst heal abomia Ct Item 35 ‘A 26-year-old man is evaluated during follow-up visit after presenting to an urgent care clinic for back pain 1 week ago Laboratory studies at that time were significant fora serra creatinine level of mg/l. 128.8 umol/L} other laboratory studies, including ueinalysis, were normal. A urine albumin- creatinine ratio obtained in preparation for this visit Is 10 ‘mig He is a personal trainer, and his daly exercise re ‘men includes weightlifting, He states that his back pain has resolved, He occasionally takes ibuprofen; the last use was | week ago. He takes no over-the-counter supplements, ‘On physical examination today, vital signs are normal BMI is 29. The patient is muscular, without signs of obesity “There is no muscle tenderness. Which ofthe following isthe most appropriate management? (A) Avoid all NSAID medications (8) Measure the serum creatine kinase level (C) Measure the serum eystatin C level (0) Schedtule a kidney biopsy ‘old man is evaluated during 2 follaw-up visit for stones. He had his fist stone 4 yea ago. Despite Increasing his water intake, he has hael two additional epi sodes. Stone analysis has revealed only caleium oxalate, He is in otherwise good health. He has no history of urinary tract infections. There isno family history ofkidney disease, hyper- parathyroldism, or nephrolithisis The physical examination and vital signs are unremark- able. Te patient weighs 80 kg, (176 Ib). be Laboratory studies: Cale 9.6 maid (2.4 mmol/L) Creatinine 0.9 mil. (79.6 ural) Hlecirolytes Sodium 138 mE. (138 mmol/L} Potassium 4.1 MEQ/L UL mmol/L) Chloride 105 mBq / (105 mmol.) Bicarbonate 25 mBaq/L 25 mmol.) Urinalysis Specific gravity 1.008; pH 5.5; no blood, protein, leukocyte esterase, oF nitetes 24 Hour Urine Studies: Volume 2045 ml oH 52 Cale 320 mg/24 h (normal range, <320:mg/24 hi} crate 790 mg/h (normal ange, 300-1100 mg/24 b) Oxalate “2 mygi24h (normal range, 40 me/24h) Soa ‘Mo mig/24 hs (normal range, 40-220 ‘mBq/2¢ h) Urieacid 640 mg/24 in (normal range, <800 mg/24 hy Noncontrast helical CT sean shows a 4-mim stone in the lower pole ofthe left kidney and a 3-mm stone in the mid pole ofthe right kidney. 99 A 2Fy Fi oN. Self-Assessment Test Which of the following is the most appropriate next step to decrease this patient's stone recurrence? (W) Add atlopurinot (8) Add hydrochlorothiazide (© Add potassium citrate (D) Increase urine volume (&)_ Recommend a low caleturn diet Item 37 A 25-year-old man is evaluated during a physical exam- ination for a new job. He is adopted, with no knowiedge of his biological parents’ medical history. He takes no ‘medications. ‘On piysical examination, blood pressure is 100/60 mm Hg; other vital signs are normal. The remainder ofthe exam- ‘nation, including cardiac examination, 1s unremarkable. Urinalysis shows 2+ blood and no protein Kidney ultrasound shows a 15-cm right kidney, a16-cm Jeft kidney, and multiple eysts bilaterally Screening for PKD mutations is performed, and the KDI variant associated with autosomal dominant polveystic Kidney disease is detected. Which ofthe following is the most appropriate next step In management? (A) Obtain echocardiography (8) Obtain MR angiography of the brain (© Start amlodipine (D) Start tolvapean Item 38 A 44-year-old man Is evaluated during a follow-up visit for membranous glomerulopathy, which was diagnosed last week on kidney biopsy. He has no other perti nent personal or family history. His only medication is furosemide, (On physical examination, vital signs are normal. There Js trace bilateral lower extremity edema to the ankles. The remainder of the examination is unremarkable. Laboratory studies performed before kidney blopsy: Albumin 3.0 g/dL (30 g/L) ‘Total cholesterol, 310 magi. (8.0 mmol/L) Creatinine 0.8 mglaL (70.7 umol/L) Antinuclear antibodies Negative Anti-phospholipase A2 Titers 1:80 receptor antibodies Hepatitis Bsurface Agand Negative Abantibodies Hepatitis CAb antibodies Negative HIV antibodies Negative 24 Hour urine protein (6500 mg/24h excretion Ultrasound of the kidneys shows normal appearance ‘with no evidence of thrombus in the renal veins. {An ACE inhibitor and a statin are initiated. 100 ‘Which of the following isthe most appropriate additional ‘management? (A) Alternating course of glucocorticoids and alkylating agents (8) Anti-double-stranded DNA antibody measurement (©) Cyclosporine (D) Hepatitis B and hepatitis C viral polymerase chain reaction testing (©) Noadditional management at this time Item 39 [A 65-year-old man is seen in the hospital for preopera- tive evaluation prior to an umbilical hernia repalr. Medi cal history is significant for hypertension, hyperlipidemia, and chronic kidney disease. Medications are metoprolol, amlodipine, furosemide, hydralazine, simvastatin, and aspirin (On physical examination, average blood pressure is 150/96 mm Hg, and pulse rate is 54/min; other vital signs are normal. BML 26, Cardiac examination reveals no marmurs, gallops, or rubs. The lungs are clea. The abdomen is non: tender, with a bruit heard over the umbilical reglon, Lower extremity pases are diminished. The remainder ofthe exam- ination is unremarkable, Laboratory studies: ’ Creatinine 1.7 mgd (150.3 mol/L); $ months ago: 1.8 mg/dl. (159.1 pmol/L) HDL cholesterol 46 mg/dL (.2 mmol/L) LDL cholesterol 100 mg/dl (2.6 mmol/l) Total cholesterol 180 mg/dl (4.7 mmol/L) Urine allurnin creatinine ratio 300 ma Abdominal ultrasound with Doppler reveals 75% dstial right renal artery stenosis; there is no aortic aneurysm. Which of the following is the most appropriate next step in ‘management? (A) Begin listnopell (8) Obtain renal intra-arterial angiography (©) Perform pereutancous transluminal renal artery angioplasty and stenting, (D) Perform renal artery surgical revascularization Item 40 A 68-year-old woman Is hospltalized for chest pain. His tory is significant for stage G3 chronic Kidney disease hypertension, coronary artery disease, and type 2 diabetes mellitus. Medications are aspirin, losartan, basal and pram dial insulin, metoprolol, nitroglycerin paste, and unfrac tlonated heparin, (On physical examination, blood pressure is 190/80 mt Hj other vital sigs are normal. S, andS, are normal. There # no §,, lung crackles, or leg edema 5 Laboratory studies show a serum creatinine level 1.8 mg/dl (159.1 pmol/L) and an elevated serum trop levelo co Plectrocandiogram shows a 2-mm St-segment depres son in leads aVE, andl V, throug V, Cardiac catheterization is planned Which of the following is the most appropriate peri procedure management? {A}. Administer furosemide before cantlac catheterization 8) Administer intravenous isotone fluids before and after cardiac catheterization }) Administer oral sodium bicarbonate before catheterization 1D) Initiate hemodialysis following cardiac catheterization Item 41 1 40-year-old woman Is evaluated for arthralgia, dry eyes, ancl dry mouth of several weeks’ duration. She has been tak ing naproxen and acetaminophen daily for about 1 week. Shi has no pertinent personal or family history. (On physical examination, vita signs are normal. Mucous rembranes and conjunetivae are dry. Bilateral parotid glans enlargement is present Laboratory studies Creatinine 0.9 maya, (79.6 nmol/L) Hlectralytes Sodium 138 mq. (138 mmol) Potassium 3.1 mEq/L. @.1 mmol/L) Chloride 118 mba/l. (118 mmol/L) Bicarbonate 12 mFq/. (2 mmol/L) hucase Zi mga. 4) mmol) Usinalysis_pH17.0; no blood, protein glucose, cerythr Kidney wluasound shows echogenic normal-sized ‘Which ofthe following is the most likely cause of the Patient’ laboratory findings? (8). Naproxen (1) ‘Type (hypokatemie distal) renal tubular acidosis (©) Type 2 (proximal) renal tubulor acidosis ‘Type 4 (hyperkalemie distal renal tubular acidosis, Item 42 ‘49-year-old man Is evaluated in the emergeney depar ‘ment for abdominal paln, yomiting, and nausea after binge drinking. History is’ signifleant for alcohol abuse, With numerous hospitalizations for intoxications and Withemwal On physical examination, temperature ‘s normal, blood pressure 's 122/72 mm fig sitting and 100/62 mm He standing, pulse rate ts 100/min sitting and 118/min Standig, respiration rate is 22/min, and oxygen saturation '597% breathing ambient air, BNL is 18, Abdominal exam ination reveals diffuse abdominal tenderness (o palpation; there is no rebound tenderness, ascites, oF evidence of ‘rama, Neurologic examination is normal. There 1s no edema, __ Self-Assessment Test Laboratory studies lectrolytes: Sodium 187 mEq/l, (187 mmol) Potassivm 8.7 mEq/L (3:7 mmol/L) Chloride 96 mEq/L (96 mmol/L} Bicarbonate toma 10 mmol/L) anol 10 mg/dl. (2.2 mmol) Glucose 94 mpd. (5.2 mmolil) Lnetate 0.8 mbq/-(0.8 mmol) Aerial blood gases: pi 7.25 Po, 23 mm Hy (3.1 KPa) Urinals, Speeifle gravy 1.020; pl positive ketones; no blood oF eels Thiamine and B-complex vitamin are administered. Which of the following is the most appropriate treatment? (A) 0.9% saline (B}_ 5% dextrose in 0.9% saline (C)_ 8% dextrose in water with 150 mfg (150 mmol) of soxinn bicarbonate (D) Insulin and 5% dextrose in 0.9% saline Item 43 {A 45-year-old man is evaluated during a follaw-up visit for membranous glomerulopathy diagnosed weeks ago. ile reports persistent lower extremity edema and no weight loss despite adhering to a low-salt diet and taking maximal dose furosemide. He does not have shortness of breath or abdominal dlscomfort. Other medications are enalapril and sirwastatin, (On physical examination, vital signs are normal. The patient weighs 80 kg (176.4 Tb], with a baseline weight of 75 kg (165.91). There ls no rash. Caniac examination is nor- mal, and there is no evidence of jugular venous distention. ‘The lungs are clear on examination, There is pitting edema in ‘the legs bilaterally to just below the patella. Laboratory studies: Albumin 2.9 g/dL 09g/L) Blood urea nitrogen ‘Normat Creatinine 4.0 mg/dl. (88.4 pmol/L) Electrolytes ‘Normal Urinalysis No blood; 4+ protein Urine protein creatinine ratio 6100 mag Doppler ultrasound of the lower extremities performed ‘3 weeks ago showed no evidence of deep venous thrombosis. Which of the following is the most appropriate ‘management? (A) Add metolazone (8) Change furosemide to bumetanide (©) Hospitalize for intravenous diuresis (D) Repeat lower extremity Doppler ultrasonography Item 44 A 27-year-old woman Is evaluated for proteinuria identified fn urinalysis performed fora lif insurance exarnination. She 101Self-Assessment Test reports no symptoms. History Is significant for premature birth, 2-year history of hypertriglceridemia and prediabetes, and a 5-year history of obesity The remainder of her medical history i unremarkable. Her only medication is gernibrozil On physical examination, vial signs are normal. BMI is 7. The remainder ofthe examination Is unremarkable, Laboratory studies; Albumin 3.8 gidl-(38 g/L) Creatinine 1.0 mg/dl (88.4 umol/L) Hemoglobin A, 6% Urinalysis [No blood; 3+ protein Urine protein-creatinineratio 2100 mg/g Kidney ultrasound shows normal-appearing kidneys ‘with no masses or hydtronephross Which of the following isthe most likely diagnosis? (A) Diabetic nephropathy (®) Lipoprotein glomerulopathy (C)_ Minimal change glomerulopathy (0) Secondary focal segmental glomerulosclerosis Item 45 ‘A 38-year-old woman is evaluated during 2 follow-up visit for primary membranous glomerulopathy. Diagnosis was made by kidney biopsy 4 months ag, and she was found to be positive for anti-phospholipase A2 receptor (PLA2R) antibodies. Medications are furosemide, losartan, and si vastatin, Recent age- and sex-appropriate cancer screening {ests were normal (On physical examination, vital signs are normal. There 's pitting lower extremity edema to the mld shins bilaterally Laboratory studies: Albumin 2: gidL (21 git) ‘otal cholesterol, 288 mg/dl. (7.5 mmol/L) Creatinine Limg/dl. (97.2 umol/l) Urine protein-creatinine ratio 9135:maig Which of the following complications is this patient at sreatest risk for developing? (a) Gout (8) Malignancy (© Renal cell carcinoma (D) Nenous thromboembolism Item 46 A 50-year-old man is evaluated for elevated blood pressure ‘measurements despite an increase in his hydrochlorothiazide dose 1 month ago. History is significant for hypertension and hyperlipidemia, Medications are hydrochlorothiazide and alorvastatin, On physical examination, blood pressure is 150/92 mm 1g, and pulse rate fs 69/min. BMT 30. The remainder af the examinalion is normal Laboratory studies show a serum creatinine level of LO mid (88.4 pmol/), a serum potassium level of 3.4 mEq/L (mmol/L), anda urine abumin-creatinine ratioof $50 mag, 102 In addition to weight loss, which ofthe following is the ‘most appropriate management? (A) Add amlodipine (@) Add losartan (©) Add spironolactone (D) Schedule follow-up vist for 3 months Item 47 |A37-year-old woman Is evaluated fora headache lasting 1 day She in the third trimester of her first pregnancy: Until now, the pregnancy has been unremarkable, including blood pres sure and urine protein measurements, Her only medication isa prenatal vitamin. (On physical examination, blood pressure is 166/215 mm 1g; other vital signs are normal. ‘There is no papllledema, Cardiac examination is normal, On abdominal examination, the patient has a gravid uterus consistent with her stage of pregnancy, and there is no abdominal tenderness, Laboratory studies: Hemoglobin 12.3 gidL (23 g/t) Platelet count 70,000/L (70 10°71) Alanine aminotransferase 72 U/L Aspartate aminotransferase 80 U/L Bilirubin Normal Creatinine 1.4 nya. 123.8 pmol/L) Electrolytes Normal Peripheral blood smear Normal Urinalysis 2+ proteln Which of the following isthe most likely diagnosis? (A) Chronic hypertension (8). Eelampsia (©) Gestational hypertension (D) HELP syndrome (© Preeclampsia Item 48 .A29-year-old man is evaluate inthe emergency department fora3-week history of headaches. He reports a painful burn ng sensation in his toes and feet forthe past few years, pat ticulary after he exereises atthe gyn, and states tat he does not sweat as much after exereise compared with his peers. He takes no medications Family history isnotable forthe fo Jowing: His maternal grandfather and maternal granduncle had similar burning sensatonsin their fet for years and died from strokes in their erly 40s; and his mother has occasional burning sensations inher feet as well as corneal dystrophy On piysial examination, blood pressure i 160/95 mm Ha; other vial signs are normal, Numerous angiokeratoma cover the sternal area are present, Reduced pain and tempers tue sensition inthe lower extremities bilaterally is ntcd Laboratory studies show a blood urea nitrogen kvel of 60 mpl. (214 mmol/L) and a serum creatinine evel of 44.1 mg/d. (962.4 umoV/L); urinalysis shows 2+ blood and 3 protein Kidney ultrasound shows increased echogenicity ! bilateral kidneysWhich of the following Is the most likely diagnosis? (A) Fabry disease (®)_ Hereditary nephritis (©) Medullary cystic kidney disease {D) Tuberous sclerosis complex. Item 49 58-year-old woman is evaluated In the emergency depart iment for fever and dysurla of 24 hours’ duration, History Is significant for frequent urinary tract infections. The patient takes no medications ‘On physical examination, the patient appears ill. Tem: ate 538, 3 °C (10.0 °F), blood pressure is 148/84 mim Hi pulse rte fs 98/min, and respiration rate is i/min, Abdom nal examination reveals right costovertebral angle tenderness. The remainder ofthe examination is unremarkable Urinalysis migidl. (97.2 umolil) Specific gravity 1.010; pH 8.0; trace blood. trace protein; 2+ leukocyte esterase; 2+ nitites: 3-4 erythrocytes/hp; 10-12 leukocytes apf positive for bacteria Absiominal radiograph shows a staghorn calculus in the ight kde Empirie antibiotic therapy i initiated. Which of the foo ‘management? ing Is the most appropriate next step in (4) Chronic antibiotic suppression (©) Potassium eitate administration (0) Stone removal (D) Urease inhibitor admunistntion (© Urinary acidieation [item s0 78-year-old woman is evaluated In the emergency depart ment far severe pain in the left hip after a fal. History is significant for end-stage kidney disease 2s of 18 months ago, Iypertension, and peripleral vascular disease, Medications ae isinopril, amlodipine, sevelamer, and epoetin alfa. She is also receiving morphine for the hip pat, On physical examination, blood pressure Is 182/70 mam He, and pulse rte is 72/min; other vital signs are normal. The left lower extremity is externally rotated at the hip. Peripheral Puls are diminished. The remainder ofthe physical exam, ation is noncontribatory. Laboratory studies: Alkaline phosphatase 78 U/L Calcium 9:7 mil. @4 mvt) Phcsphhors 4.2mg/dl(L4 mmollL) Faruthyroid hormone 62 p/m (62 ngit) Fyctroxyeitamin D2 git (80 nmol/L) Radiographs of the hips show a left hip facture and ‘aletied arteries, Which of the following is the most likely diagnosis for the underlying bone disease? (a). Adynamic bone disease (8). Mleroglobulin-assoctated amyloidosis (©) Osteitis fibrosis eystica (0) Osteomalacia Item 54 ‘A 72-year-old man is hospitalized for a I-week history of ‘worsening shoriness of breath; he also has worsening lowe extremity edema despite an inerease in his furosemide dose 2 days ago. History i significant for hypertension, stage Gia ehonie kidney disease, and heart fallure with a preserved ejection fraction, Outpatient medications are amlodipine, isinopril furosemide, and low-dose aspirin (On physical examination, blood pressure is 12/60 mm Fg, and pulse rate fs 97/min. BML is 28, Cardiae examination reveals an elevated jugular venous pressure and an 8. Breath sounds sre diminished at the jung bases. There is 2+ pitting edema ofthe lower les, Laboratory studies: Blood urea nitrogen 64 mg/dL (22.8 mmol/L);2 weeks ag, 40 mgd. (4.3 mmol/L) inine 2.3;mgydl. (209.3 umol/l); 2 weeks ago, 1.9 mg/dl (168 jumgl/L) 120 mEq/l. (130 mmol/L); 2 weeks ago, 133 mEq/L. (133 mmol/L) Specific gravity 1.00% 1+ protein; few hyaline casts a Sodan Urinalysis, Chest radiograph shows bibasiar effusions and vascular congestion, ‘Which of the following isthe most appropriate treatment? (A) Add conivaptan {B) Add dobutamine infusion (© Increase furesernide (D) Start ultrafiltration Item 52 A 62-year-old woman is evaluated for fatigue and weakness, History is significant for stage G4 chronic kidney disease and hypertension, Her only medication fs amlodipine. On physical examination, blood pressure Is 195/85 mm. Hg: other vital signs are normal. There is no jaundice. Con junctval rim pallor is noted, and there ls no scleral eterus. Laboratory studies: Hemoglobin 85 gidL (65 g/1) Leukoeyte count Norma Mean corpuscular volume 80 fl Platelet count Normal Reticuloeyte count eof erythrocytes ‘tin 30 ng/ml (30 ng/L) Transferrin saturation 0% Fstimated glomerular ftration rate 18 mLImin/1.78 Stoo! testing for occult bloc Negative Colonoscopy performed! at age 60 years was normal 103 Ee Raa FT Self-Assessment Test wi of the following s the most appropriate treatment? fant (4) Blood transfusion (8) Bore marrow biopsy (©) Frythropoietin-stimulating agent (D) on supplementation fens? ‘A 45-year-old woman is evaluated for the recent onset of resistant hypertension. During her last visi, chlorthalidone ‘yas added to her medicatlon regimen. She reports no symp- toms, and review of the systems is otherwise unremarkable. Current medieations are metoprolol, amlodipine, hyral zine, an chlorthalidone. ‘On physical examination, blood pressures 160/96 mm Hg, and pulse rate fs 65/min; other vital signs are normal BMI is 234, There is no proptosis. The thyroid gland Is not enlarged The remainder ofthe examination is unremarkable, Laboratory studies: Bicarbonate ‘34 mEq/L (24 mmol.) Creatinine (0.8 mal. (70.7 umol/L) Povassium 2.9 mEqiL. (2.9 mmol/L) Urine albuimin-creatinine ratio 10 mg/g Which of the following is the most appropriate diagnostic test to perform next? (A) Kidney ultzasonography with Doppler (8) Plasma aldosterone concentration/plasma renin actlv ity tatto (©) Plasma fractionated metaneplirines, (D) Polysomnography gens ‘A 28-year-old woman is evaluated In the emengency depart rent for muscle cramps and weakness. She notes @ weight loss of 15 kg (33 Ib) over the past $ months; baseline weight ‘was IIS ke (254 Th). She reports no abxloninal pain ot dar thea. She has a 1-year history of type 2 diabetes melts, for ‘which she takes metformin, ‘On physical examination, emperature fs normal, blood ppresste fs 122/72 mam Hg, pulse rate fs 100/min, andl respira tion rate is 1/min, BMI 5:36. Muscle strength ofthe lower and "upper extremities is 4/5. Other than weakness, neurologic ‘examination fs normal, Laboratory stucles: Electroytes: Sodium 138 mg/l. (£38 mmol/L) Potassium 2.4 mbq/L (24 mmol/l) Chloride 52 mEq/L (92 mmol/L) Bicarbonate 34 mbq/L (34 mmol/L) Arterial blood gases pi 7580 Peo, 45 mm Hg (6.0 kPa) Usine Sodium 440 mai. (40 mmol/L) Urine potassium 660 mEq/L (60 mmol/L) Urine chloride 5 mkqil. (5 mmol/L) 104 “Which ofthe following isthe most likely diagnosis? ol (8) Cushing syndrome us (@) Gitelman syndrome (©. Primary hyperaldosteronism | (D) Surrepttions vomiting Item 55 o [A 64-year-old man is evaluated for a 2-month history of Increasing fatigue and bjlateral swelling of the submandlo lular region. History fs significant for autoimmune panete: atts trented with prednisone 2 years ago, hypertension, and Allergic thinttis, Medications are losartan and fluticasone propionate. ‘On physleal examination, blood pressure s 48/84 mm ig, and puise rate is 28/min, There fs no rash. Hed and neck: cextmination reveals bilateral submandibular gland swelling, ‘Trace edema of the ankles Is present, The remainder of the examination is normal Laboratory studies: Hemoglobin r2gidl (120 g/t) Leukocytecount 10,000/1. (10 x10"/L); 38% eosinophils Platelet count 180, 000/qL (180 10%/1) cs 65 mg/dl. (650 m@/L) cs 7 maya. (70 mg/l) eatinine 3.1 mg/d. (274 mol/L}; 6 months ‘ago: 1.8 mg/dL. (159.1 mol/L) eG 2600 mg). 26 g/l) Wee 500 Vim. (500 KU/L) Antinuclear 1-640 antibodies Urinalysis, Specific gravity 1.010; trace protein; 6-10 leukocytes/npf Kidney ultrasound demonstrates bilateral markedly enlarged kidneys measuring 15 cm in si with hyperechole cortex and peripheral cortical nodules, Which of the following isthe most likely diagnosis? (A). igG4-related disease (@) Lupus nephritis () Sarcoidosis (D) Sjogren syndrome Item 56 ‘A 70-year-old man is evaluated for new-onset swelling land fatigue for several weeks’ duration, as well as right knee pain occurring during the same time period. History is significant for stage Ga chronic kidney disease and knee osteoarthritis, Medications are lisinopril and. ovet= te-counter naproxen. ‘On physical examination, blood pressure is 150/80 mm, and pulse rate is 70/min; other vital signs are normal. BM! [s 30. There are no lung erackles or jugular venous dist sion, The bladder is not palpable. There 1s no abdominal brit, Examination of the right knee reveals erepitus 3”Laboratory studies: Blearbonate 23 m/l, (23 mmol/L) Creatinine 2.4 mpd, (212.2 mol/L}: baseline, 1.8 mg? 159.1 molt) 5.6 mEq/L 6.6 mmol/L) No blood; trace protein Potassium Urinalysis Which of the following ‘management? the most appropriate (8) Discontinue naproxer (8) Obtain CT angiography ofthe renal arteries brain kieney blopsy Siart furosemide Item 57 A.40-year-old man is evaluated during a follow-up vist for kidney transplant he received 2 years ago. story is also significant for hypertension. Medications are tacrolimus, mycophenolate mofetil, prednisone, and nifedipine. (On physical examination, blood pressure is 150/95 mm gy other vital signs are normal. BML Is 26. The cardiovascular and pulmonary exarnlnations are normal The abdomen and renal allograft are nontender to palpation, Trace pedal edema is noted, Laboratory studies: Potassium 5,6mEqIL.(5.6 mmol/L) Sodium Normal Estimated glomerular filtration 90 mL/min/1.73 mé Duplex ultrasound of the kidneys shows no evidence of transplant renal artery stenosis, Which ofthe following is the most appropriate treatment? (A) Chlorthalidone (8) Fludrocortisone (©) Sodium polystyrene sulfonate () Spironolactone Item 58 ‘A8-year-old woman Is evaluated in the emergency depart ‘ment for lower extremity weakness, nausea, and increased soinnolence occurring during the past 24 hours. She had ‘constipation for 3 days, for whic she drank one bottle of ‘nil of magnesia each night. History is significant for hyper "esto as well as stage G4 chronic kidney disease secondary ‘o autosomal dominant polycystic kidney disease. Her only "medication i Hisinoprl (On physical examination, temperature s36.6°C (97.9 °R), blood pressure is 94/54 mm Hi, pulse rate fs 58/min, resp ‘ation rate fs 16/min, and oxygen saturation is 92% breathing, tmnblent air, Bilateral flank fullness is present. Deep ten: lon reflexes are diminished diffusely Strengit in the lower extremities i315. Self-Assessment Test Laboratory studies: Gah Creatinine 8.0 migil, (2 mmol/L) 3.9 mia (44.8 umol) Hleeiolytes Sodium 188 mq/L (138 mmol/L) Potassium 2.7 mig (3.7 nmol/L) Chloride 104 mEQy]. (04 mmol/l) Blearbonate Magnesium Phosphorous 22 mBq. (22 mol!) 8.1 mgiall (3.3 mmol/l) 1.4 mgydl. (14 mmol/L) In addition to administration of 0.9% saline and furosemide, which of the following isthe most appropriate treatment? (A) Hemodialysis (8) Intravenous caleiwn (©) Intravenous potassium (D) Intravenous sodiom bicarbonate (©) Ora sodium polystyrene sulfonate Item 59 A 72-year-old man is evaluated in the hospital after devel- ‘oping acute Kidney injury 2 days following coronary artery bypass grafting. He is curtently on mechaniea! ventilation and requlres vasopressors for hypotension. He underwent coronary anglography 12 hours prior (o surggry. The serum creatinine has incrensed from 0.8 mid. (70.7 pmol/l) at baseline to 2.2 mgd 194.5 umol/L), and urine output has decreased 10350 mi/24 h, History Is significant fr type2dia betes mellitus and coronary artery disease. Current medica ‘Hons are intravenous furosemide, insulin, propool, fentanyl and norepinephrine (On physical examination, che patlent is intubated and rechanically ventilated. A urinary catheter Is in place. Tent peralure Is 37.9°C (100.2 °F), blook pressure is 98/60 mm Hi, pulse rate is 105/:min, respiration rate is 28/min, and oxygen saturation is 96% on 30% Fi, There is no rash, Decreased ‘breath sounds are heard jn the lung bases. "the remalnder of the examination is nonconisibutory Which of the following isthe most appropriate test to perform next? (A) Examination of urine sediment (8). Fractional excretion of sodtumn (©) Kidney ulirasonography (D) Measurement of central venous pressure Item 60 ‘A 42-year-old woman is evaluated during a routine visit, She recently had her blood pressure measured at her workplac Iwo measurements were taken, and both were elevated. The patient feels wel, and review’ of systems is unremarkable, Family history Is significant for hypertension in her father, ‘mother, and «wo siblings; stroke in her father: and heart fll- lure in her mother. She takes no medications ‘On physical examination, the average of three blood pressure measurements is 128/78 mm Hg. BMI is $0, The remainder of the examination is normal, 105, = <i i 3 H = Self-Assessment Test Laboratory studies: Bicarbonate Creatinine Potassium Urine albismin-creat 24 mii 24 mmol/L) 60.9 maid 79.6 wmol/L) 4,0 mEq/L (4,0 mmol) neratio 10: mag Blectrocardiogram reveals normal sinus rhythm and positive voltage criteria for left ventricular hypertrophy. Which of the following isthe most appropriate test to perform next? (A). 24-Hour ambulatory blood pressure monitoring, (8). Plasma aldosterone concentration/plasma renin activity ratio (©) Polysomnography (D) ‘Thyrold-stimulating hormone measurement Item 61 |A 46-year-old man is evaluated during a follow-up visit for recently diagnosed hypertension. Hydrochlorothiazide, 25 magi, was initiated month ago. He tries to adhere toa low sodium, low fat diet. The patient is black ‘On physical examination, te average of three blood pressure measurements is 47/97 mm Hg, and pulse rate is Faimin, The remainder ofthe examination is normal. ‘Laboratory studies shaw a serum creatinine level of 1.2mg/l (106.1 mol/}aserum potassium level of 3.5 mEa/L (G5 mmol/L), anda urine albumin-creatinine ratio of 15 me/e, Which of the following isthe most appropriate next step in ‘management? (A) Add amlodipine (B) Addiisinoprit (©) Inerease hydrochlorothiuzide (D)_ Reassess blood pressure In 3 months Item 62 A 28-year-old) woman Is evaluated during a follow-up visit for elevated blood pressure measurements during pregnancy. She is at 12 weeks’ gestation of her first preg. hhaney. She feels well, and the pregnancy has been oth: terwise uncomplicated, She did not have routine medical cae before her pregnancy. Family history is significant for hypertension in her father and sister. Her only medication isa prenatal vitamin. ‘On physical examination, blood pressure is 155/95 mm her vital signs are normal. Funduscopic, neurologic, diac examinations are normal Laboratory studies are noma Which ofthe following is the most likely cause of this patient's elevated blood pressure? (A) Chronic typertension (8) Gestational hypertension (€)_ Notmal physiologle changes in pregnancy (D) Preeclampsia 106 Item 63 73-year-old woman is hospitalized for an elevated serum, creatinine level that has been unresponsive to intravenons fluids, She was evaluated in the emergency department 2 days ago for weakness. myulga, arthralgia, and cough and admitted to the hospieil, She hs no other medical history tnd takes no medications (On physical examination, the patients afebrile. Blood pressure is 155/95 mm Hi, pulse rate s 70/min, and oxygen Sattration is 98% breathing? | of axygen per minute by nasal eanmula, Cardiac examination is normal, without evidence of jugular venous distention. Dullness to percussion and dirin ished breath sounds are present atthe posterior lung bases bilaterally. There i pliting lower extremity edema, Laboratory studies: Hemoglobin Creatinine 9.9 gia (99 g!1) Baseline 6 months ago: 0.7 mg/dl (61.9 umol/L) Emergency department: 4.1 mg/dl (36244 umolit) Hospital day 1 4.3 mg/dl (980.1 umol/L) ‘Aniinuclear Negative antibodies [Antimyeloperoxidase Positive antibodies Antiproteinase 3 Negative . antibodies Urinalysis 3+ blood 2+ protein Chest radiograph shows diffuse infiltrates at the tung bases bilaterally “Kidney biopsy shows necrotizing and erescentic lo: _merulonephiritis with linear staining for IgG on immuno! Which ofthe following Is the most appropriate disgnostic test to perform In this patient? (A) Anti-double-steanded DNA antibodies (8) Anti-glomerutar basement membrane antibodies (C)_Anti-phospholipase A2 receptor antibodies (O) Antihisione antibodies Item 64 [A 24-year-old woman is evaluated during a follow-up visit for elevate blood pressure measurements found on two ep arate occasions. The measurements were 144/94 mm tig and 1142/92 mm Fig, She states that going to the doctor makes het nervous, so she had her blood pressure measured a the local pharmacy, which was <130/80 mm Hg. Review of systems is btherwise unremarkable. She has no other pertinent personal ‘or family history. She takes no medications. ‘On physical examination, the average of three blood pressure measurements is 143/93 mm Fg, and pulse rate #8 ‘80/min; other vital signs are normal. BMIis 21. The remaindet ‘of the examination is normal Laboratory studies show a serum creatinine level of 0.8 mg/dl. (70.7 mol/L), and a urine albumin-creatinine ratio fs undetectable; pregnancy test results are negative Flectrocardiogram is normal.Which of the following Is the most appropriate next step in ‘management? (A)_ Begin hydrochlorothiazide (8) Obtain echocardiography (©) Perform 24-hour ambulatory blood pressure monitor ing (D) Recheck blood pressure in 8 months Item 65 A.79-sear-old woman is evaluated for hyperkalemia, She was admitted to the surgical ICU after having anv urgent partial colectony for a ruptured diverticulum with pertonits. She ‘was treated with Intravenous fluids, antibiotles, and vaso pressor therapy. Today, postoperative day 1, she #s oligurie ‘with urine output <5 mL for the past 4 hours. She is now ‘weaned off the vasopressor therapy” History is significant for hypertension and stage Gd chronle kidney disease. Outs tient medications are amlodipine, irbesartan, and faro le, Current medications are morphine, propotol, cefotax ime, anel metronidazole, (On physical examination, the patient Is intubated and ‘mechanically ventilated. A urinary catheter isin place. Tem. perature is 38.9 °C (102.0 *F), blood pressure i 108/70 mm Hag, and puise rate is 101/min, There is generalized anasarea, The abdomen is distended andl quiet Laboratory studies: Creatinine 8.6 mgd. (918.2 uml); baseline 2.0 mg. (176.8 mol/L) Hlectrolytes: Sodium 142 mbit. (142 moll) Potassivm ZL mE qil. (7.1 ramol/L} Chloride 102 mg/L (102 ramol/L) Total bicarbonate 17 mEq/l (17 mmol/L) Arterial pH 7.5 Usinesediment Brown granular casts Blectrocardiogram shows peaked T waves with QRS F140 ms {In addition to intravenous calelum, Insulin, and dextrose, hich of the following isthe most appropriate treatment? (A). Continuous renal replacement therapy B) Hemodialysis, (©) teavenous furosemide 1D}. Sodium bicarbonate 2) Sodium polystyrene sulfonate enema Item 66 A 35-year-old man is evaluated for a 4-month history of persistent fyperkalemia. He also has long-standing type 2 Uiabetes mellitus complicated by retinopathy and nephropa: hy. Medications are basal and prandial insulin, atorvastatin snd asprin. ‘On physical examination, vital signs are normal, Now: brolierative retinopathy is noied on funeuscopie examina: ion. The remainder of the physical examination is nancon rlbutory Self-Assessment Test Laboratory studies: Creatinine Electrolytes: Sodium Potassium hloride Blearbonate Estimated glomerular filtration rate 1.9 mga (168 mol/l) 138 mEq/L (138 mmoW/L} 5.4 mEq/L (6.1 mmol/L) 112 mg/l. {12 mmol) 8 mEq/L (28 mmol/L) 49 min 1.73 Grinalysts 1pHS.0; no blood, protetn, shucose, erythrocytes, or Teukocyies Calculated urine anion gap Positive ‘Which of the following is the most likely cause of the patient's acld-hase disorder? (A) Chronic kidney disease (8) Type (hypokalernie distal) re (C) Type 2(proximal) (D) Type 4 thyperkalemic distal) renal tubular acidosis sal tubular acidosis nal tubular acidosis Item 67 21-year-old woman is evaluated duringa follow-up visi for 4-year history of systemic lupus erythematosus. At the time (of dlagnosis, she presented with a malar rash and arthritis, along with positive antinuclear and anti-deuble-stranded DNA antibodies. Medications ate hydroxychloroquine, low= dlose prednisone, caleium, and vitamin D, She currently feels ‘well and is asymptomatic Vital signs are normal, and the physical examination is unremarkable Laboratory studies: a 40 gral (400 mg) a 8 mgidl. (80 mg/L) Anti-double-stranded DNA Positive (titer 1:320) antibodies Urinalysis 2+ blood; 2+ protein; ‘dysmorphie erythrocytes ocasts Urine protein-creatinine ratio 600 maf Kidney ultrasound shows kidneys of normal size and echogentely, Which of the following is the most appropriate next step in ‘management? (A) Begin pulse glucocorticotds followed by eyclophosphia- mide (8). Begin pulse glucocorticoid followed by raycophenolate mofetil (©) Increase oral prednisone dose and add mycophenolate siofetil (D) Schedule a kidney biopsy Item 68 ‘A 45-year-old man Is seen for a routine evaluation of bis blood pressure. He has gained 1.5 kg (3.8 1b) since his fast visit 107 z ed8 weeks ago. History is significant forstage 4 chronic kidney’ tisease, hypertension, type 2 diabetes melts, and coronary frtery disease, Medications are amleipine, isinopril, carve lio, chlorthatidone, basal al prandial insubin, atorvastatin, unl low-dose aspirin ‘On physical examination, blood pressure is 165/100 ram bg, pulse rate is 8/min, and respiration rate is t6imin. There is bilateral leedema, The remainder of te physical exam ination is noncontibutony, Laboratory studies: Blood urea nitrogen Creatinine 14 mga. (15.7 mmol) 2.8 mg/dl. 247.5 umol/L) 5.4 mbq/L (5.4 mmol) 26 mnLimnin/.73 wt glomerular filtration Urinalysis Normal Inaddition to maintaining alow sodium diet, which of the following is the most appropriate treatment ofthis patient's blood pressure? (A) Add hydralazine (B) Add losartan {C)_ Stop amlodipine: begin spironolactone (0) Stop ehlorthalidones begin furosemide item 69 A 52-year old wo is hospitalized for a toe ulcer ancl foot pain oceurting for L month, History is significant for stage Ge Chtomie kidney disease (estimated ar filtration rate, 22 mLimin/1.73 1m) and type 2 diabetes mellitus. Medica tions are lisinopril, sevelamer, sodium bicarbonate, insulin slargine, and insulin aspart ‘Om physical examination, vital signs are normal. A Toul-smelting toe weer Is present. Probe-to-bone test ls pos ‘A plain radiograph, shows changes compatible with osteomyelitis. The patient undergoes wound debridement ‘and bone biopsy Bone eultures are pending apy i to be aminisieved. Xl empirle antibiotic ther- Which ofthe following isthe most appropriate venous, access strategy? (8). Arteriovenous gratt creation followed by peripherally inserted central eatheter placement in apposite arm (8). Peripheraly inserted central catheter in the dominant (C)_Periphetlly meerted central catheter in the nondom (©) Tunseled internal jugular central venous catheter Item 70 A 5-year-old woman is evaluated for elevated blood pressure found for the first time at her previous visit | month ago. She has a 7-year history of type 2 diabetes mellitus without retinopathy, as well as hyperlipidemia, Medications are met formin and atorvastatin. 108 ‘On physical examination, blood pressures 48/94 mm Hg, (confirmed by home ambulatory blood pressure monitoring), ‘and pulse ates 74/min other vital signs are normal. BML is 32 ‘The remainder of the physical examination fs unremarkable. Laboratory studies show a serum creatinine level of ‘0.9 mg/dl. (79.6 umol/L),aserum potassium level of3.8 mEq/l. (@.8mmol/l), and a urine albumin-creatinine ratio of 50mg, ‘The patient Is instructed in appropriate Mfestyle modl- ‘ations Which of the following is the most appropriate treatment? (a) Begin amlodipine (8) Begin chlorthatidone (©) Begin losartan (0) Remensure blood pressure in 2 months item 71 'A-50-year-old man is evaluated during a routine follow-up Visit. History is signifeant for chronic kidney disease, Jong standing hypertension, and HIV infection. His antiret- ‘oviral regimen was recently adjusted (0 2 once-a-day dos- ing, with the integrese inhibitor rategravir discontinued and olutegravir started 3 weeks ago. In adaltion to dolutegravis, current metlicationsare abactr, lamivudine, nd lisinopril ‘Physical examination and vita signs are normal Laboratory studies: Serum creatinine 1.5 mg/dL (182.6 pmol/L}; baseline, 13 gid (114.9 umol/L) Urinalysis No blood, protein, or erythrocytes Urine alburain- 100 mgig (unchanged from baseline) creatinine ratio Which of the following isthe most appropriate next step in ‘management? (8). Discontinue lisinopril (B)_ Measure a 24-hour urine creatinine clearance (C)_ Reassess the serum creatinine level in L week {D) No further assessment Item 72 ‘A-42-year-ol woman fs evaluated in the emergency depart tment for tight flank pain of 3 hours’ duration. History isslgnit- rt for migraines, There sno family histoty of kciney stones. ‘Medications re as-needed sumatriptan and dally topirarmate. ‘On physical examination, right costovertebral angle ten: sderness is present Laboratory studies: Creatinine ectrolytes Sodan Potassitm Chloride Bicarbonate Urinalysis 0.8 mala. 70.7 uno) 138 mBq/1. (138 menol/L) 3.5 mb. (3.5 mmol) 104 maki. (104 mmol/L} -abmbaq/. (21 minoV/L) ‘Specie gravity 1.008: pH 6.5: 1+ bloat negative leukocyte esterase; negative nitrites; 20-20 erythrocytes/pf; 1-3 Teulkocytes/hnpf; amorphous crystalso com Noncontrast helen! CT'scan shows a S-mm stone in the right proximal ureter Which of the following isthe most likely composition of | this patients kidney stone? (A) Calcium oxalate (8). Calcium phos © Cystine (0) Struvite © Urieacla Item 73 77-year-old man is evaluated for & 2-month history of ‘worsening fatigue. inereasing frequency of urination, nocturia, and anorexia. History ts signifleant for hyper tension, hypertriglycerldemia, gastroesophageal reflux disease, and depression. He has been taking low-dose aspirin and valsartan for mote than 10 years, omeprazole and St, John’s wort for 8 months, and fenofibrate for 2 months. On physical examination, blood pressure fs 150/79 ram. 4g, and pulse rate fs 82/min. The remainder ofthe examin ‘ion is unremarkable Laboratory studies Creatinine 2.8 mg/dl (247.5 umol/.), 9 months ago: 1.2 mgyal (106.1 mol/L) Specific gravity 1.008; trace blood, 2 protein; 3S erythrocytes/hpf 5-7 leukocytes pt alysis Kidney ultrasound shows 9-em kidneys without hydro nephiosis or caleull bilateral. Which ofthe following is the most likely cause of the Patient's kidney findings? (a) Aspicin 1B) enofibant (© Omeprazole (D) St John’s wore Item 74 A.54-year-ok man fs evaluated in the emergency department ‘ova 5-day history of fever, fatigue, and bleeding gums. He ‘was previously feling wel, He takes no medications. ‘On physical examination, the patient is pale and th ‘and appears chronically il. Temperature Is 39.0 °C (102.2°F) blood pressure is 104/62 mo Hg, pulse rate is 108/min, resp "ation mate is 2/min, and oxygen saturation is 96% breathing aunbient ai, BMI Is 2. Petechiae are present on the conjunc ‘iva, forearms, and distal legs. Cardiac examination reveals ‘achyeardia. There is no hepatesplenomegaly ‘There Is no edema, Laboratory studies: Hemoglobin Leukocyte count Platelet count Creatinine 8.8 gid (88 9/1) 111,000/ 11 10°/1), 98% blasts 28,000 11 (28 10"/L) 1.2 mga 106.1 pmol/L) Electrolytes Sodium 134 mEq/L (34 mmol/L) Potassium 6.4 mEq/l. (6.4 mmol/L) Chloride 104 mg/L (108 mmol/L) Bicurbonate 21 mEq/L. (21 mmol/L) Electrocardiogram reveals sinus tachyeattla but is oth enwise normal iB 2 Which of the following isthe most appropriate next step in ‘management? (A) Administer intravenous 0.9% saline (B) Administer intravenous calelum gluconate (C)_Ordera plasma potassium measurement (D) Start inated albuterol (©) Start sodium bicarbonate Item 75 A 65-year-old woman is evaluated for a 3-month history of Increasing fatigue, History Is significant for stage Ga chronic kidney disease and hypertension. Medications are sodium Dlearbonate,sevelane, furosemide, losartan, and amlodipine (On plisteal examination, blood pressure is 120/60 mn Hig, and pulse rate Is 75/min; other vital signs are normal. Conjunctival rim pallor is noted . Laboratory studies: rnoglobin ‘Mean corpuscular volume do Ferritin 600 ng/ml. (600 j/L) Transferrin saturation 10's ated glomerular flttion 25 maL/mmin/L.73.m 8.5 will (85 gi ‘Stool qualae testing is negative Colonoscopy performed within the past 5 years was normal Which of the following isthe most appropriate treatment? (A) Discontinue losartan (B) Schedule packed red blood cell transfusion (©) Start an erytiropotesis-stimulating agent (D) Start intravenous iron Item 76 52-year-old woman is evaluated in the emergency depart ment for 8 2-day history of lower extremity weakness and nausea. She reports no dliarrhes, History i significant for hypertension treated with amlodipine, She has a history of alcohol abuse. (On physical examination, vital signs are normal. Ora eurofogie examination, lower extremity strength is 4/5. The remainder of the examination is mremarkable, Laboratory studies: o Albumin 3.0 gil (30 pit) Caietum 8.4 mg/dl (21 mmol/L) Creatinine 0.7 mg/dl (61.9 umol/.) 109