Q 1:
A 3-year-old boy develops edema, and his general pediatrician obtains laboratory results revealing hypoalbuminemia, proteinuria, and hypercholesterolemia that are consistent with nephrotic syndrome. He sends the patient to the emergency department because the boy has not voided for 12 hours. On physical examination, he has anasarca and abdominal distention. His mucous membranes are dry, and his skin turgor is decreased. He is less active than normal but arousable. His heart rate is 145 beats/min and blood pressure is 70/40 mm Hg.
Of the following, the MOST appropriate initial therapy for this child is intravenous
A. albumin
B. albumin and furosemide
C. furosemide
D. lactated Ringer solution
E. 0.9% sodium chloride solution
The Answer :
A
Explanation:
The child described in the vignette is showing obvious signs of hypovolemia, indicating the need for albumin infusion (1 mg/kg of body weight of 25% albumin) to help restore volume in the intravascular space and reduce the edema.
This may be repeated up to four times per day, as needed.
Furosemide therapy will result in loss of intravascular volume, which would exacerbate his hypovolemia.
Normal saline alone may restore some intravascular volume temporarily, but the infusion will leak out into the interstitium rapidly and worsen the edema.
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Q 2:
A mother brings in her 3-year-old daughter because of daytime urinary incontinence and abdominal pain. The mother explained that the girl was toilet trained at 2 years of age. On physical examination, growth parameters and vital signs are normal, although the girl has mild suprapubic tenderness without associated costovertebral angle tenderness or sacral dimples.
Urinalysis shows a urine specific gravity of 1.025, pH of 6.5, 2+ blood, 1+ protein, 3+ leukocyte esterase, and positive nitrite. Urine microscopy demonstrates 5 to 10 red blood cells/high-power field, 20 to 50 white blood cells/high-power field, and 3+ bacteria. Of the following, the MOST likely etiologic agent is
A. Enterococcus faecalis
B. Escherichia coli
C. Klebsiella pneumoniae
D. Proteus mirabilis
E. Staphylococcus saprophyticus
Answer :
B
Escherichia coli is the causative organism in 80% to 90% of first-time urinary tract infections (UTIs) in children.
Other pathogens include Klebsiella pneumonia, Proteus sp, Enterococcus sp, and Staphyloccus saprophyticus.
Pseudomonas also can be a pathogen in immunocompromised patients or those who have received repeated courses of antibiotics for recurrent infections.
Organisms such as E coli, K pneumoniae, and Proteus sp can reduce dietary nitrate to nitrite, so a positive urine dipstick test for nitrite, as reported for the girl in the vignette, is virtually diagnostic of gram-negative bacteruria.
Of note, the nitrite test is much less helpful in infants.
Conversion of nitrate to nitrite may take up to 4 hours. Because infants and young children have small bladder volumes and urinate frequently, there may be insufficient time for nitrites to be formed and, therefore, the nitrite test may be negative even in the presence of a UTI caused by a gram-negative organism.
Urine pH also may be useful in diagnosing UTIs.
Urease-producing organisms (eg, Proteus mirabilis, some strains of S saprophyticus) degrade urea into ammonia, resulting in an elevated urine pH (8.0 to 8.5).
The girl described in the vignette has symptoms of a lower UTI.
-------------------------------------------
Q3
-------------------------------------------
Q3
A 4-year-old boy presents with periorbital edema. He is receiving no medications, and his family history is negative for renal disease. On physical examination, he is afebrile; his heart rate is 88 beats/min, respiratory rate is 18 breaths/min, and blood pressure is 106/62 mm Hg; and he has periorbital and pitting pretibial edema. Laboratory evaluation shows normal electrolyte values, blood urea nitrogen of 14.0 mg/dL (5.0 mmol/L), creatinine of 0.3 mg/dL (26.5 mcmol/L), and albumin of 1.6 g/dL (16.0 g/L). Urinalysis demonstrates a specific gravity of 1.020; pH of 6.5; 3+ protein; and negative blood, leukocyte esterase, and nitrite. Microscopy results are normal. Additionally, complement component (C3 and C4) values are normal, and results of serologic testing for antinuclear antibody, hepatitis B and C, and human immunodeficiency virus are negative. Of the following, you are MOST likely to advise the parents that
A. a renal biopsy is warranted to determine the optimal treatment
B. disease relapse can be expected in fewer than 25% of those achieving remission
C. patients who relapse have a similar prognosis as those who do not respond to steroids
D. remission is expected in more than 75% of patients who receive corticosteroid treatment
E. tacrolimus is the preferred treatment for patients who do not respond to corticosteroids
Answer :
D
The boy described in the vignette has signs and symptoms of nephrotic syndrome.
Causes of nephrotic syndrome can be subdivided into
A- Primary glomerulopathies (eg, minimal change disease, focal segmental glomerulosclerosis, mesangial
proliferative glomerulonephritis).
B- Secondary glomerulopathies (eg, lupus nephritis, membranoproliferative glomerulonephritis due to
hepatitis C, and human immunodeficiency virus nephropathy).
The initial evaluation of new-onset nephrotic syndrome centers on establishing whether it is due to a primary glomerulopathy and warrants an empiric trial of corticosteroids.
Clinical features that suggest secondary glomerulopathy include :
- Moderate-to-severe hypertension.
- Gross hematuria.
- Laboratory markers suggestive of a secondary glomerulopathy include :
- Azotemia,
- Hypocomplementemia.
- Positive antinuclear antibody finding.
- Positive serologic test for human immunodeficiency virus or hepatitis B or C.
The normal blood pressure and renal function as well as the absence of hematuria, hypocomplementemia, or a positive serologic test for lupus or viral infection described for the boy in the vignette are consistent with primary glomerulopathy. Accordingly, this child should receive a 4- to 6-week trial of daily corticosteroids because nearly 90% of childhood nephrotic syndrome cases are sensitive to steroids.
Although 90% of pediatric patients achieve a state of remission with corticosteroids, 50% to 70% experience at least one relapse during their disease course.
Unless clinical or serologic findings raise the possibility of an underlying glomerulonephritis, renal biopsy is not warranted.
The steroid response, not renal biopsy findings, is the best predictor of the prognosis for childhood nephrotic syndrome.
Steroid-sensitive patients, even those who have a relapsing course, have a better prognosis than steroid-resistant patients.
The approximately 10% of patients who are steroid-resistant have a guarded prognosis, with a risk
of developing chronic renal failure.
Steroid-resistant patients require a renal biopsy to establish histologic information.
------
Q 4:
D
The boy described in the vignette has signs and symptoms of nephrotic syndrome.
Causes of nephrotic syndrome can be subdivided into
A- Primary glomerulopathies (eg, minimal change disease, focal segmental glomerulosclerosis, mesangial
proliferative glomerulonephritis).
B- Secondary glomerulopathies (eg, lupus nephritis, membranoproliferative glomerulonephritis due to
hepatitis C, and human immunodeficiency virus nephropathy).
The initial evaluation of new-onset nephrotic syndrome centers on establishing whether it is due to a primary glomerulopathy and warrants an empiric trial of corticosteroids.
Clinical features that suggest secondary glomerulopathy include :
- Moderate-to-severe hypertension.
- Gross hematuria.
- Laboratory markers suggestive of a secondary glomerulopathy include :
- Azotemia,
- Hypocomplementemia.
- Positive antinuclear antibody finding.
- Positive serologic test for human immunodeficiency virus or hepatitis B or C.
The normal blood pressure and renal function as well as the absence of hematuria, hypocomplementemia, or a positive serologic test for lupus or viral infection described for the boy in the vignette are consistent with primary glomerulopathy. Accordingly, this child should receive a 4- to 6-week trial of daily corticosteroids because nearly 90% of childhood nephrotic syndrome cases are sensitive to steroids.
Although 90% of pediatric patients achieve a state of remission with corticosteroids, 50% to 70% experience at least one relapse during their disease course.
Unless clinical or serologic findings raise the possibility of an underlying glomerulonephritis, renal biopsy is not warranted.
The steroid response, not renal biopsy findings, is the best predictor of the prognosis for childhood nephrotic syndrome.
Steroid-sensitive patients, even those who have a relapsing course, have a better prognosis than steroid-resistant patients.
The approximately 10% of patients who are steroid-resistant have a guarded prognosis, with a risk
of developing chronic renal failure.
Steroid-resistant patients require a renal biopsy to establish histologic information.
------
Q 4:
A
4-year-old girl who has presumed minimal change nephrotic syndrome presents at
your office because of a recent rapid weight gain. The mother reports that the
urine protein determinations have been 4+ for 2 weeks. Physical examination
reveals generalized edema, blood pressure of 115/74 mm Hg, and heart rate of 85
beats/ min. Findings on the remainder of the examination are normal. The urine
protein is 4+. You prescribe oral prednisone. Two days later the mother reports
that the girl's urine is dark, she has not voided for 12 hours, and she has
abdominal pain.
Of
the following, the most likely cause of this girl's hematuria and decreased
urine output is:
A. acute
glomerulonephritis
B. hemorrhagic
cystitis
C. pyelonephritis
D. renal
vein thrombosis
E. tubulointerstitial
nephritis due to steroid therapy
Answer :
D
The development of RVT is usually heralded by the sudden onset of gross
hematuria and unilateral or bilateral flank masses. Patients can also present
with microscopic hematuria, flank pain, hypertension, or oliguria. RVT is
usually unilateral. Bilateral RVT results in acute kidney
failure.
Renal vein thrombosis (RVT) occurs in 2 distinct clinical situations:
- In newborns and infants, RVT is commonly associated with asphyxia, dehydration, shock, sepsis,
congenital hypercoagulable states, and maternal diabetes.
- In older children, RVT is seen in patients with nephrotic syndrome, cyanotic heart disease, inherited
hypercoagulable states, and sepsis and following kidney transplantation and following exposure to
angiographic contrast agents.
RVT begins in the intrarenal venous circulation and can spread to the main renal vein and inferior vena cava. Thrombus formation is mediated by endothelial cell injury resulting from hypoxia, endotoxin, or contrast media.
Other contributing factors include hypercoagulability from either nephrotic syndrome or mutations in genes that encode clotting factors (i.e., factor V Leiden deficiency); hypovolemia and diminished vascular blood flow associated with septic shock, dehydration, or nephrotic syndrome; and intravascular sludging caused by polycythemia.
---------------------------
Q 5:
Renal vein thrombosis (RVT) occurs in 2 distinct clinical situations:
- In newborns and infants, RVT is commonly associated with asphyxia, dehydration, shock, sepsis,
congenital hypercoagulable states, and maternal diabetes.
- In older children, RVT is seen in patients with nephrotic syndrome, cyanotic heart disease, inherited
hypercoagulable states, and sepsis and following kidney transplantation and following exposure to
angiographic contrast agents.
RVT begins in the intrarenal venous circulation and can spread to the main renal vein and inferior vena cava. Thrombus formation is mediated by endothelial cell injury resulting from hypoxia, endotoxin, or contrast media.
Other contributing factors include hypercoagulability from either nephrotic syndrome or mutations in genes that encode clotting factors (i.e., factor V Leiden deficiency); hypovolemia and diminished vascular blood flow associated with septic shock, dehydration, or nephrotic syndrome; and intravascular sludging caused by polycythemia.
---------------------------
Q 5:
Urinalysis
obtained during a health supervision visit of a 10-year-old boy reveals 2+
protein. The remainder of the urinalysis is normal. Results of family and
personal medical histories as well as physical examination of the boy are
negative.
Of
the following, the BEST next step is to:
A. arrange
consultation with a nephrologist
B. examine
the urine of family members
C. obtain
a 24-hour urine sample for protein quantification
D. obtain
renal ultrasonography
E. perform
a urinalysis on the first morning void
Answer :
E
If
urinalysis reveals protein in the urine of any child, an evaluation is
mandatory. The urine also should be assessed for the presence of red blood
cells (RBCs), white blood cells, nitrites, and bacteria. RBCs in conjunction
with protein on urinalysis suggest renal parenchymal disease or urinary tract
infection. Nitrites or bacteria in a clean-catch or catheterized specimen
strongly indicate urinary tract infection. Most patients who have proteinuria do
not have edema due to a reduction of oncotic pressure.
In
the absence of symptoms such as edema, abdominal or flank pain, dysuria, or
fever, evaluation of proteinuria can proceed in a stepwise manner. The most
prudent initial step is to obtain a first-morning specimen and repeat the
urinalysis. If the specimen is negative for protein, the diagnosis of
orthostatic proteinuria (OP) can be made. If there is protein in the urine on a
first-morning specimen, protein and creatinine in the urine should be quantitated.
If the protein/creatinine (P/C) ratio is less than 0.25, observation and repeat
measurement of the ratio within the next month are appropriate. A P/C greater
than 0.25 on the first-morning specimen warrants further evaluation.
OP
is diagnosed in a patient who has a finding of proteinuria by dipstick on a
random (mid-day) sample and a completely negative finding by dipstick on the
first-morning sample. This benign condition does not portend long-term risk for
subsequent renal disease. Its cause remains obscure, but it may be related to
compression of the renal vein from the kidney. Regardless of the mechanism,
affected patients do not require periodic evaluation. It is worth mentioning
that OP cannot be the ultimate diagnosis in a patient who has RBCs in the urine.
A
false-positive result for protein in the urine may be seen in a sample that is
extremely alkaline (urine pH, >8.0). Proteinuria may be masked with a very
dilute urine (specific gravity, <1.005). Protein also may be transiently
present in the urine of patients who have fever or acute illness. It is prudent
to re-examine the urine at a later date in these patients.
Renal
ultrasonography eventually may be necessary in a patient who has proteinuria
that does not disappear on the first-morning specimen. A 24-hour urine
collection for protein determination also is reserved for patients who have
proof of protein in the urine on the first-morning specimen. A family history
always is essential in the evaluation of any patient, although there is no evidence
that OP is a familial disease. The benign nature of OP obviates the need for a
consultation with a nephrologist.
---------------
Q6 :
Q 7 :
---------------
Q6 :
A
12-year-old boy presents to the emergency department with a 3-day history of
tea-colored urine that began 2 days following an upper respiratory tract
infection. There is no history of dysuria, and findings on physical examination
are normal. The family history is negative for any kidney disease. His blood
pressure is 115/70 mm Hg. Urinalysis reveals: specific gravity, 1.025; pH, 6.0;
red blood cells, too numerous to count; 1+ protein; and 0 to 2 white blood
cells. Electrolyte levels are normal.
Of
the following, the MOST likely diagnosis is:
A. Alport
syndrome
B. focal
segmental glomerulosclerosis
C. hypercalciuria
D. immunoglobulin
A nephropathy
E. postinfectious
glomerulonephritis
Answer :
D
---------Answer :
D
Immunoglobulin
A nephropathy (IgAN), or Berger diseas.
The most common
presenting symptom is gross hematuria following an upper respiratory tract infection.
There is generally no pain associated with the gross hematuria, although some
patients report “loin” pain.
Any child who has gross hematuria, defined as
pink, red, or brown-colored urine, must be evaluated. The first step is to
analyze the urine for the presence of red blood cells (RBCs).
The absence of
RBCs in urine that is discolored indicates the presence of hemoglobin,
myoglobin, or porphyrins. If RBCs are present, as in the patient described in
the vignette, IgAN must be considered in the differential diagnosis.
Urinalysis
in any child who has gross hematuria also should assess the presence of protein
(indicating renal parenchymal disease), white blood cells (suggesting either
renal parenchymal disease or infection), and nitrites (suggesting urinary tract
infection).
It is important to note that nephrolithiasis and urolithiasis are
extremely uncommon in the absence of abdominal or urethral pain. Serum
electrolyte levels must be evaluated to assess renal function. Finally, renal
ultrasonography should be performed to ascertain the presence of a structural
malformation such as cystic disease, hydronephrosis, tumor, or obstruction.
Alport
syndrome, or familial nephritis, is a kidney disease caused by abnormal
collagen deposition in the basement membrane of the glomerulus. This slowly
progressive disease generally affects males. Alport syndrome may present with
either gross or microscopic hematuria, but it is much less common than IgAN.
Associated features include deafness and ocular abnormalities.
Focal segmental
glomerulosclerosis is a glomerular disease that typically presents with
proteinuria. Hematuria may be present, but it is not the predominant feature.
Hypercalciuria typically presents with hematuria, but the hematuria is usually
microscopic, unless accompanied by lithiasis. Lithiasis almost always is
associated with excruciating flank, abdominal, or urethral pain.
Finally,
postinfectious glomerulonephritis usually presents with gross hematuria, but
generally at least 2 weeks after an upper respiratory tract infection and often
is associated with a sore throat.
Q 7 :
You
are evaluating a 2-month-old infant for microscopic hematuria. He has a history
of respiratory distress syndrome and bronchopulmonary dysplasia and currently
is receiving caffeine and furosemide. Urinalysis reveals: specific gravity,
1.010; pH, 6.5; 15 to 20 red blood cells; no protein; and 0 to 2 white blood
cells. Electrolyte levels are normal.
Of
the following, the MOST likely cause of the hematuria is:
A. benign
familial hematuria
B. hypercalciuria
C. multicystic
kidney dysplasia
D. tumor
E. urinary
tract infection
Answer :
B
Answer :
B
Furosemide
therapy has been associated with the development of hypercalciuria, most
commonly among infants who receive the drug for treatment of bronchopulmonary
dysplasia. The first sign of hypercalciuria is usually microscopic hematuria
with red blood cells (RBCs) in the urine. Hypercalciuria usually is
asymptomatic, but occasionally may be severe enough to result in calcium stone
formation and abdominal pain. Any patient who is receiving chronic furosemide
or loop diuretic therapy, such as the infant described in the vignette, should
be screened routinely for RBCs in the urine.
----------------------------------
Q 8:
An
11-year-old girl who has chronic renal failure of unknown cause is found to
have a hemoglobin of 6.5 g/dL (65 g/L) on an incidental blood count. She does
not report increasing fatigue. She is being maintained on chronic ambulatory
peritoneal dialysis. Results of other laboratory studies include: reticulocyte
count, 0.3% (3 x 10-3); white blood cell count, 7,900/cu mm (7.9 x 109/L);
platelet count, 399 x 103/cu mm (399 x 109/L); mean corpuscular volume, 84 fL;
and creatinine, 2.5 mg/L (221 mcmol/dL).
Of
the following, the MOST appropriate therapy for this girl's anemia is:
A. ferrous
sulfate orally
B. ferrous
sulfate parenterally
C. multivitamins
that include copper
D. recombinant
erythropoietin subcutaneously
E. red
blood cell transfusion
Answer :
D
--------
Q 9
Answer
C
Q 11
Answer :
D
Erythropoietin is a glycoprotein synthesized
predominantly in the kidney. Its production is induced by hypoxia, and its
primary effect is to stimulate erythroid progenitor cell proliferation.
Administration of rhEPO parenterally three
times a week allows most patients on dialysis to become
transfusion-independent. Dosages have varied, but many centers start
dialysis-dependent patients at 50 to 100 U/kg of body weight subcutaneously or
intravenously three times a week. Subcutaneous administration may be more
efficacious.
The
primary side effects of rhEPO in chronic renal failure are the development of
iron deficiency (related to increased iron utilization), hypertension, and seizures.
The administration of iron helps to prevent iron deficiency. The hypertension
probably is due to reversal of the vasodilatory effects of the anemia and
occurs in only a minority of patients. The etiology of the seizures is not
clear and may not differ from that seen in patients who have chronic renal
failure and are not receiving rhEPO.
--------
Q 9
Of
the following, the MOST accurate statement regarding ureteroceles is that they:
A. are
classically diagnosed by computed tomography
B. are
more common in males than in females
C. are
the most common cause of urinary retention in females
D.
E. usually
do not present with a urinary tract infection
Answer
C
Ureteroceles
are cystic dilatations of the distal submucosal or intravesical portion of a
ureter. They are seen in about 1% to 2% of children who undergo cystoscopy,
although the incidence in the general pediatric population is unknown.
Ureteroceles frequently are associated with duplicated ureters (two ureters
intersecting with the kidney). They may be located entirely within
(intravesical) or outside the bladder (ectopic), at the bladder neck or
urethra. The etiology of ureteroceles remains elusive. The current theory
suggests that they derive from an intrinsic defect in the ureteral bud and from
abnormal incorporation of the ureteral bud into the urethra and bladder.
Various
anomalies are associated with ureteroceles, including duplicated ureters.
Because of the potential association with duplicated ureters, renal
ultrasonography should be undertaken in affected children to assess for
hydronephrosis. In addition, contralateral vesicoureteral reflux or obstruction
may occur. Finally, about 10% of ureteroceles may be bilateral.
Ureteroceles
are the most common cause of urinary retention in females. They usually
manifest in early childhood with symptoms suggesting infection of the urinary
tract: fever, dysuria, foul-smelling urine, hematuria, and abdominal pain. If
the ureterocele is located near or in the urethra, prolapse into the urethra
may occur, resulting in urinary retention.
-----
Q 10
-----
Q 10
A
5-year-old girl visited her doctor 2 weeks ago to treat a sore throat. He
prescribed an antibiotic that she took, but the parents cannot recall its name.
She presents at the emergency department today with gross hematuria and
periorbital edema. She has a blood pressure of 150/95 mm Hg. The attending
physician suspects she has acute postinfectious glomerulonephritis (PIAGN).
Urinalysis reveals too numerous-to-count red blood cells and 2+ protein. To
confirm the diagnosis, you measure serum complement levels; the C3 is 57 mg/dL
(5.7 g/L) (low) and the C4 is 24 mg/dL (2.4 g/L) (normal). Within 3 days, the
gross hematuria and hypertension resolve spontaneously. Six weeks later you see
her in your office.
Of
the following, the laboratory results that would be consistent with resolving
PIAGN are:
C3 Hematuria Protein
A. Low Microscopic Negative
B. Low Microscopic Positive
C. Normal Microscopic Negative
D. Normal Microscopic Positive
E. Low None Negative
Answer
C
Acute
postinfectious glomerulonephritis (PIAGN) is the current term used to describe
any acute inflammation of the kidney caused by an infectious agent that results
in gross hematuria, edema, and hypertension. Historically, the most common
pathogen causing PIAGN was group A beta-hemolytic Streptococcus. It is the most
common cause of PIAGN in children. Other infectious agents include
Staphylococcus aureus, S epidermidis, echovirus, human immunodeficiency virus,
adenovirus, influenza A virus, and Epstein-Barr virus.
PIAGN
can occur in children of any age, but most typically affects those younger than
12 years. Pharyngitis and pyoderma are the most likely antecedent infections
associated with PIAGN. Throat infection usually precedes the onset of
hematuria, edema, and hypertension by about 2 weeks; pyoderma may precede the
renal manifestations by as many as 6 weeks.
Because
the symptoms of PIAGN may mimic any acute glomerulonephritis, it is essential to
obtain appropriate laboratory tests to confirm the diagnosis. Urinalysis
typically reveals red blood cells and red blood cell casts. Serum electrolyte
concentrations are generally normal in PIAGN, although some patients may
experience a decline in renal function. Those who have elevated serum
creatinine levels should have the creatinine measurement repeated. In patients
in whom the creatinine levels continue to rise after several days, one must
entertain the possibility that the patient may have rapidly progressive
glomerulonephritis, requiring immediate consultation with a nephrologist.
Because
the complement system is involved in the pathogenesis of PIAGN, serum
complement 3 (C3) levels are reduced. Low C3 and C4 levels must raise the
suspicion of other causes of AGN, such as membranoproliferative GN or lupus
nephritis. One additional test that can be performed is evaluation of
anti-DNAse B, which is almost uniformly abnormal in PIAGN.
Q 11
You
are seeing an 11-year-old girl who had a previous history of urinary tract
infection at age 2. Previous radiographic studies have included renal
ultrasonography and voiding cystourethrography, both of which yielded normal
results. She has no complaints at this time. Urinalysis reveals 1+ nitrites,
but is otherwise negative. Results of a urine culture from a clean catch
specimen reveal greater than 100,000 cfu/mL Escherichia coli.
Of
the following, the MOST appropriate treatment for this patient is:
A. intramuscular
ceftriaxone
B. observation
C. oral
ciprofloxacin
D. oral
nitrofurantoin
E. oral
trimethoprim-sulfamethoxazole
Answer
B
Several prospective studies have shown that there is no value to identifying or treating asymptomatic children who have bacteriuria, such as the girl in the vignette. Unnecessary treatment only leads to the emergence of resistant strains of bacteria; many patients clear the bacteriuria uneventfully
-------
Q 12
Answer
D
Immunoglobulin A nephropathy (IgAN), or Berger disease, is a glomerular disease that occurs most often during the second decade of life and in adults. The most common presenting symptom is gross hematuria following an upper respiratory tract infection. There is generally no pain associated with the gross hematuria, although some patients report “loin” pain.
-------
Q 13
Answer
B
Several prospective studies have shown that there is no value to identifying or treating asymptomatic children who have bacteriuria, such as the girl in the vignette. Unnecessary treatment only leads to the emergence of resistant strains of bacteria; many patients clear the bacteriuria uneventfully
-------
Q 12
A
12-year-old boy presents to the emergency department with a 3-day history of
tea-colored urine that began 2 days following an upper respiratory tract
infection. There is no history of dysuria, and findings on physical examination
are normal. The family history is negative for any kidney disease. His blood
pressure is 115/70 mm Hg. Urinalysis reveals: specific gravity, 1.025; pH, 6.0;
red blood cells, too numerous to count; 1+ protein; and 0 to 2 white blood
cells. Electrolyte levels are normal.
Of
the following, the MOST likely diagnosis is:
A. Alport
syndrome
B. focal
segmental glomerulosclerosis
C. hypercalciuria
D. immunoglobulin
A nephropathy
E. postinfectious glomerulonephritisAnswer
D
Immunoglobulin A nephropathy (IgAN), or Berger disease, is a glomerular disease that occurs most often during the second decade of life and in adults. The most common presenting symptom is gross hematuria following an upper respiratory tract infection. There is generally no pain associated with the gross hematuria, although some patients report “loin” pain.
-------
Q 13
One
month ago, a 10-year-old boy presented to you with edema of the face, hands,
and feet. Urinalysis revealed 20 to 25 red blood cells and 4+ protein. You
diagnosed nephrotic syndrome and placed him on a recommended regimen of oral
steroids. His face now exhibits cushingoid features, but his edema has not
subsided. Urinalysis today reveals 4+ protein and moderate blood.
Of
the following, the MOST likely diagnosis at this time is:
A. focal
segmental glomerulosclerosis
B. Henoch-Schönlein
purpura
C. immunoglobulin
A nephropathy
D. minimal-change
nephrotic syndrome
E. postinfectious
acute glomerulonephritis
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