Hard Question #3 - USMLE Forums
USMLE Forums Logo
USMLE Forums         Your Reliable USMLE Online Community     Members     Posts
Home
USMLE Articles
USMLE News
USMLE Polls
USMLE Books
USMLE Apps
Go Back   USMLE Forums > USMLE Step 1 Forum

USMLE Step 1 Forum USMLE Step 1 Discussion Forum: Let's talk about anything related to USMLE Step 1 exam


Reply
 
Thread Tools Search this Thread Display Modes
  #1  
Old 09-02-2010
TheOneTheOnly's Avatar
USMLE Forums Scout
 
Steps History: ---
Posts: 21
Threads: 4
Thanked 9 Times in 5 Posts
Reputation: 19
Kidney Hard Question #3

An 18 year-old college freshman notices difficulty in removing and replacing his shoes at the end of the day and his face appears to be "puffy" and swollen. Over the ensuing two weeks he develops noticeable swelling of his legs all the way up to his thighs. Other than tonsillectomy at age 3, he has never had any medical problems and takes no medications.

On physical examination at the health center, his blood pressure is 118/72, pulse 76, respiration 12, and he is afebrile. Weight is 80 kilograms, an increase of 7 kilograms over his usual weight . He appears well, with no evidence of acute illness. The only finding on physical exam is a 3+ to 4+ pitting edema extending all the way up his legs into the presacral area.

Laboratory evaluation reveals:
-CBC normal
-sodium 140 mmol/L, potassium 3.7 mmol/L, chloride 101 mmol/L, CO2 29 mEq/L
-BUN 17 mg/dL (6 mmol/L) [normal 8-25 mg/dL or 2.5-9 mmol/L]
-creatinine 1 g/dL (88.4 μmol/L) [normal 0.6-1.5 mg/dL or 53-132.6 μmol/L]
-urinalysis: pH 5, specific gravity 1.012, 4+ protein with no blood or glucose
-urine microscopy: occasional oval fat bodies and rare hyaline casts

Additional labs:
-serum albumin 1.1 g/dL (11 g/L) [normal 3-5 g/dL or 35-50 g/L]
-calcium 7.9 mg/dL (2 mmol/L) [normal 8.5-10.3 mg/dL or 2.1-2.6 mmol/L]
-phosphorus 3.3 mg/dL (1.07 mmol/L) [normal 3-4.5 mg/dL or 0.97-1.45 mmol/L]
-total cholesterol 393 (10.16 mmol/L) [normal < 200 mg/dL or < 5.2 mmol/L]
-24-hour urine: protein 13.2 g, creatinine 2.248 g
-Complement levels: normal
-Serology: ANA, HBV, HCV negative

What is your preliminary diagnosis?

A. Nephritic syndrome
B. Nephrotic syndrome
C. Acute kidney injury
D. A and C
E. B and C

?????????????
Reply With Quote Quick reply to this message



  #2  
Old 09-02-2010
USMLE Forums Guru
 
Steps History: 1 + CS
Posts: 405
Threads: 55
Thanked 523 Times in 155 Posts
Reputation: 533
Default

B. Nephrotic syndrome

OR

E. B and C

I don't know the exact time criteria for the kidney injury to be called Acute.

It surely seems to be Nephrotic Syndrome though.
Reply With Quote Quick reply to this message
  #3  
Old 09-02-2010
USMLE Forums Guru
 
Steps History: ---
Posts: 487
Threads: 69
Thanked 294 Times in 133 Posts
Reputation: 314
Default

B. Nephrotic syndrome...
__________________
258(1)/237(1)/CS pass(1)/YOG 2011/221(1)/6 months USCE/ 3 months observership/4 US LOR /Need visa
To view links or images in signatures your post count must be 10 or greater. You currently have 0 posts.
Reply With Quote Quick reply to this message
 
  #4  
Old 09-02-2010
USMLE Forums Guru
 
Steps History: 1 + CK
Posts: 373
Threads: 30
Thanked 374 Times in 160 Posts
Reputation: 384
Default

B. Nephrotic syndrome
__________________
Knowing is not enough; we must apply.
Willing is not enough; we must do.
Reply With Quote Quick reply to this message
  #5  
Old 09-02-2010
USMLE Forums Guru
 
Steps History: 1 + CS
Posts: 405
Threads: 55
Thanked 523 Times in 155 Posts
Reputation: 533
Default

In this question i feel the options actually direct you to the correct information, when i was reading the question i was thinking more on Endocrinological terms but the options proved me wrong. Does anyone else feel like that with big questions?
Reply With Quote Quick reply to this message
The above post was thanked by:
bronchiole (09-03-2010)
  #6  
Old 09-02-2010
USMLE Forums Master
 
Steps History: 1+CK+CS+3
Posts: 742
Threads: 137
Thanked 2,429 Times in 441 Posts
Reputation: 2532
Default

Quote:
Originally Posted by donofitaly View Post
In this question i feel the options actually direct you to the correct information, when i was reading the question i was thinking more on Endocrinological terms but the options proved me wrong. Does anyone else feel like that with big questions?
Yes, definitely. That's a correct strategy to let the options save you.
Read here
Let the Options Save You
Reply With Quote Quick reply to this message
The above post was thanked by:
bronchiole (09-03-2010)
  #7  
Old 09-02-2010
USMLE Forums Guru
 
Steps History: 1 + CS
Posts: 405
Threads: 55
Thanked 523 Times in 155 Posts
Reputation: 533
Thumbs Up

Thanks a lot for the post Raheed. I really need to inculcate the discipline of reading through all the options instead of just choosing the first one that seems feasible to me without looking at the rest of them.
Reply With Quote Quick reply to this message
  #8  
Old 09-02-2010
USMLE Forums Scout
 
Steps History: Not yet
Posts: 17
Threads: 0
Thanked 0 Times in 0 Posts
Reputation: 10
Default

I think the answer seems obvious. Nephrotic fits all the criteria (hypoalbuminemia, hypercholesterolemia, no signs of nephritis). Nothing is suggestive of AKI (BUN, Cr within normal range). Answer B. Since I cannot find a way to deviate in this one, lets discuss wat could be the cause of nephrosis in an 18yr old.
Reply With Quote Quick reply to this message
  #9  
Old 09-02-2010
USMLE Forums Scout
 
Steps History: Not yet
Posts: 17
Threads: 0
Thanked 0 Times in 0 Posts
Reputation: 10
Default

FSGS
In favour of - "Possible substance abuse" (Guess I'll leave someone in this thread to find that), HIV
Against - Hypoalbuminemia (it is non selective proteinuria in FSGS), no haematuria, no hypertension

Diffuse membranous GP
SLE, Captopril, gold, HBV, malignancy - all unlikely in this kid

MPGN
HBV, HCV, Ht, possible nephritic, low complements - ruled ou

MCD - Most likely
Reply With Quote Quick reply to this message
  #10  
Old 09-03-2010
ashishkabir's Avatar
USMLE Forums Master
 
Steps History: 1+CK+CS+3
Posts: 625
Threads: 19
Thanked 371 Times in 220 Posts
Reputation: 391
Default

Quote:
Originally Posted by pretk View Post
FSGS
In favour of - "Possible substance abuse" (Guess I'll leave someone in this thread to find that), HIV
Against - Hypoalbuminemia (it is non selective proteinuria in FSGS), no haematuria, no hypertension

Diffuse membranous GP
SLE, Captopril, gold, HBV, malignancy - all unlikely in this kid

MPGN
HBV, HCV, Ht, possible nephritic, low complements - ruled ou

MCD - Most likely
Yeah MCD was my analysis too, but I thought that was mostly young girls. Still, it fits best with these symptoms. Nephrotic syndrome, B.
Reply With Quote Quick reply to this message
  #11  
Old 09-03-2010
USMLE Forums Scout
 
Steps History: Not yet
Posts: 17
Threads: 0
Thanked 0 Times in 0 Posts
Reputation: 10
Default

Just to discuss more.. Lets say if the urinalaysis part was not mentioned in the question and the patient also has signs of difficulty in vision, what other possibility can be thought of? (All other lab values stand as they are)
Reply With Quote Quick reply to this message
  #12  
Old 09-03-2010
TheOneTheOnly's Avatar
USMLE Forums Scout
 
Steps History: ---
Posts: 21
Threads: 4
Thanked 9 Times in 5 Posts
Reputation: 19
Default

Quote:
Originally Posted by pretk View Post
Just to discuss more.. Lets say if the urinalaysis part was not mentioned in the question and the patient also has signs of difficulty in vision, what other possibility can be thought of? (All other lab values stand as they are)


This is exactly what we need more of, DISCUSSION!
Reply With Quote Quick reply to this message
  #13  
Old 09-03-2010
USMLE Forums Newbie
 
Steps History: Not yet
Posts: 1
Threads: 0
Thanked 0 Times in 0 Posts
Reputation: 10
Default

While reading it at first I thought it to be Acromegaly/Myxoedema..
But after the Lab investigation part..I think it's B..
But how can we exclude option E?
pls help
Reply With Quote Quick reply to this message
  #14  
Old 09-03-2010
USMLE Forums Scout
 
Steps History: Not yet
Posts: 17
Threads: 0
Thanked 0 Times in 0 Posts
Reputation: 10
Default

AKI is characterised by elevated BUN Cr. Since they are normal it is not AKI. (I just mentioned that in my prev post)
Reply With Quote Quick reply to this message
  #15  
Old 09-03-2010
USMLE Forums Guru
 
Steps History: 1 + CS
Posts: 405
Threads: 55
Thanked 523 Times in 155 Posts
Reputation: 533
Default

Quote:
Originally Posted by pretk View Post
AKI is characterised by elevated BUN Cr. Since they are normal it is not AKI. (I just mentioned that in my prev post)
This clears the confusion, the answer has to be Nephrotic Syndrome.
Reply With Quote Quick reply to this message



  #16  
Old 09-04-2010
dranant's Avatar
USMLE Forums Scout
 
Steps History: Not yet
Posts: 55
Threads: 25
Thanked 12 Times in 6 Posts
Reputation: 22
Smile B...............would be the answer.

Definitely Nephrotic syndrome......................B.
__________________
IF YOU THINK,YOU CAN--YOU CAN
To view links or images in signatures your post count must be 10 or greater. You currently have 0 posts.

IF YOU THINK,YOU CAN"T --YOU CAN"T....
To view links or images in signatures your post count must be 10 or greater. You currently have 0 posts.
Reply With Quote Quick reply to this message
  #17  
Old 09-04-2010
USMLE Forums Guru
 
Steps History: 1 + CS
Posts: 405
Threads: 55
Thanked 523 Times in 155 Posts
Reputation: 533
Default

When will the answer be posted by the question guy?
Reply With Quote Quick reply to this message
  #18  
Old 09-07-2010
TheOneTheOnly's Avatar
USMLE Forums Scout
 
Steps History: ---
Posts: 21
Threads: 4
Thanked 9 Times in 5 Posts
Reputation: 19
Default ANSWER+EXPLANATION (From MedicalExams.com)

Quote:
Originally Posted by donofitaly View Post
When will the answer be posted by the question guy?

Right now! haha. Great discussion everyone, let's see how you all did!

The correct answer is Choice B.

This young man has nephrotic syndrome, which is characterised by:

-heavy proteinuria (> 3.5 g / 1.73m2 / day)
-hypoalbuminemia due to urinary protein losses
-edema due to salt and water retention and reduced oncotic pressure
-hyperlipidemia
-lipiduria

There are a number of pointers to his not having nephritic syndrome:

-his urinary protein losses are too high
-he does not have acute kidney injury
-he does not have hematuria
-he has severe hyperlipidemia which is not a component of nephritic syndrome

Nephrotic syndrome results from glomerular damage which leads to an increase in glomerular permeability. This causes proteins
and other large substances that would normally not be filtered to pass into the urine. Although albumin is easily measured and
most talked about, you should not forget that other proteins including immunoglobulin and complement proteins are often being
lost as well.

Nephrotic syndrome results from primary or secondary glomerular damage, primary causes being diagnoses of exclusion when no
secondary casue can be found. Pathologically the glomerular manifestations include:

-focal segmental glomerulosclerosis (FSGS) in up to 35% of cases
-membranous nephropathy in up to 33% of cases
-minimal change disease in up to 15% of cases
-membranoproliferative glomerulonephritis in up to 14% of cases

Secondary causes include:

-Diabetes mellitus
-Infections such as hepatitis B & C, HIV, mycoplasma
-Sjogren's syndrome
-SLE
-Sarcoid
-Malignancy including lymphoma and myeloma
-Obesity
-Drugs such as gold/penicilliamine/NSAIDs/antibiotics/tamoxifen

Patients should be referred to a nephrologist for investigation and likely renal biopsy. While this is pending, management often
involves salt and fluid restriction, diuretics for edema, statins for hyperlipidemia, and angiotensin ceonverting enzyme inhibitors in
an attempt to reduce protein spillage.

Nephrotic syndrome patients are at risk of DVT (1.5%) or renal vein thrombosis (0.5%), as well as infection (loss of
immunoglobulins and complement).

Suggested References
Hull RP, Goldsmith DJ. Nephrotic syndrome in adults. BMJ 2008; 336: 1185-1189.
Reply With Quote Quick reply to this message
  #19  
Old 09-07-2010
TheOneTheOnly's Avatar
USMLE Forums Scout
 
Steps History: ---
Posts: 21
Threads: 4
Thanked 9 Times in 5 Posts
Reputation: 19
Default

thoughts??
Reply With Quote Quick reply to this message
  #20  
Old 09-07-2010
USMLE Forums Veteran
 
Steps History: 1 + CS
Posts: 216
Threads: 56
Thanked 116 Times in 56 Posts
Reputation: 116
Cool

good discussions man! when's the next question? i've gotten all three right so far, albiet I guessed the first 1!
Reply With Quote Quick reply to this message
  #21  
Old 09-07-2010
TheOneTheOnly's Avatar
USMLE Forums Scout
 
Steps History: ---
Posts: 21
Threads: 4
Thanked 9 Times in 5 Posts
Reputation: 19
Default

Quote:
Originally Posted by Dr_Kal_El View Post
good discussions man! when's the next question? i've gotten all three right so far, albiet I guessed the first 1!
I'll put a new one up today! Good stuff, and if you don't know guessing is the only answer!
Reply With Quote Quick reply to this message



Reply

Tags
Pathology-, Renal-, Step-1-Questions

Quick Reply
Message:
Options

Register Now

In order to be able to post messages on the USMLE Forums forums, you must first register.
Please enter your desired user name, your email address and other required details in the form below.
User Name:
Password
Please enter a password for your user account. Note that passwords are case-sensitive.
Password:
Confirm Password:
Email Address
Please enter a valid email address for yourself.
Email Address:
Medical School
Choose "---" if you don't want to tell. AMG for US & Canadian medical schools. IMG for all other medical schools.
USMLE Steps History
What steps finished! Example: 1+CK+CS+3 = Passed Step 1, Step 2 CK, Step 2 CS, and Step 3.

Choose "---" if you don't want to tell.

Favorite USMLE Books
What USMLE books you really think are useful. Leave blank if you don't want to tell.
Location
Where you live. Leave blank if you don't want to tell.

Log-in

Human Verification

In order to verify that you are a human and not a spam bot, please enter the answer into the following box below based on the instructions contained in the graphic.



Thread Tools Search this Thread
Search this Thread:

Advanced Search
Display Modes


Similar Threads
Thread Thread Starter Forum Replies Last Post
Immunology is very hard for me ... aungawa USMLE Step 1 Forum 6 07-31-2016 04:21 AM
Another Hard Question TheOneTheOnly USMLE Step 1 Forum 18 09-03-2010 10:18 AM
Hard Question TheOneTheOnly USMLE Step 1 Forum 21 09-01-2010 12:14 PM
Fa 2010 your gift for working hard MDCRUZ USMLE Step 1 Forum 1 05-24-2010 03:06 PM

RSS Feed
Find Us on Facebook
vBulletin Security provided by vBSecurity v2.2.2 (Pro) - vBulletin Mods & Addons Copyright © 2017 DragonByte Technologies Ltd.

USMLE® & other trade marks belong to their respective owners, read full disclaimer
USMLE Forums created under Creative Commons 3.0 License. (2009-2014)