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1. Which one of the following is NOT a major risk factor for the development of contrast dye

   A. Large Dye Load (eg. >125cc)
   B. Diabetes Mellitus
   C. Congetive Heart Failure
   D. Cerebrovascular Disease
   E. Renal Insufficiency

2. A 32 year old black woman presents to the emergency room with chest pain, shortness of breath, peripheral edema, peripheral arthritis (hands, wrists, ankles), and bloody urine. She has had increased fatigue and malaise over the past several months. The arthritis began 3 months ago and is worse in the morning and then at the end of the day. She denies rash, Raynaud's, sore throat, alcohol or drug abuse, smoking, recent urinary tract infection, or other symptoms. Her menses have been irregular over the past 4 months but she has 2 children (normal gestation and delivery). She has had an appendectomy and a cholecystectomy. On exam, she is an ill-appearing young woman with a pulse of 135 bpm, blood pressure (sitting up) 150/95 mmHg, repirations 22/minute, and oral temperature of 99.8°F. Pulse oximetry on room air shows an oxygen saturation of 92%. She has normal skin and HEENT exam, mild diffuse anterior cervical lymphadenopathy, clear lungs, a soft two-part pericardial friction rub, right flank pain, normal abdominal examination except for mildly decreased bowel sounds, normal rectal exam, negative stool occult blood, and bilateral diffuse hand swelling. There is 2+ pitting edema to the mid- calf bilaterally. Neurological examination is grossly normal. A urinalysis done in the emergency room reveals a specific gravity of 1.030gm/mL, pH 7.3, 3+ blood, 2+ leukocytes, 3+ albumin, no glucose, trace urobilinogen, trace nitrite. Microscopic examination of the urine shows red blood cell casts, 20-50 RBC/hpf, 5-10 WBC/hpf, no bacteria. An arterial blood gas drawn on room air reveals an oxygen of 68mmHg, carbon dioxide 25mmHg, pH 7.30, and a calculated bicarbonate of 20mM.
3. Which of the following is LEAST likely to account for the above presentation [2] ?

   A. Goodpasture's Syndrome
   B. Acute Bacterial Endocarditis
   C. IgA Nephropathy
   D. Wegener's Granulomatosis (ANCA positive)
   E. Lupus Nephritis

4. The patient is given furosemide, 40mg intravenously, and oxygen by nasal cannula. An ECG reveals changes consistent with pericarditis (PR depressions with diffuse ST elevations) along with diffusely low voltage. A full battery of laboratory tests are drawn, two sets of blood cultures obtained, the urine is sent for culture and eosinophil examination, and an emergency cardiac echo is obtained which shows a moderate pericardial effusion without evidence for tamponade. A chest radiograph is completely normal.

• Which of the following is the MOST appropriate next step [3]:

  A. Administer low ("renal range") dose dopamine to improve urine output
  B. Administer an intravenous bolus of methylprednisolone
  C. Arrange an emergent renal biopsy to evaluate the cause of the renal failure
  D. Perform a diagnostic and therapeutic pericardial tap
  E. Wait for results of ANA, ANCA, and RF tests and blood cultures (available in 48 hours)

• The MOST likely diagnosis is [4]:

  A. Goodpasture's Syndrome
  B. Acute Bacterial Endocarditis
  C. IgA Nephropathy
  D. Wegener's Granulomatosis (ANCA positive)
  E. Lupus Nephritis

• The acid-base disorder described for this patient is an example of [5]:

  A. Mixed metabolic acidosis and respiratory alkalosis
  B. Mixed metabolic acidosis and respiratory acidosis
  C. Metabolic acidosis with respiratory compensation
  D. Respiratory alkalosis with metabolic compensation
  E. Metabolic alkalosis and respiratory acidosis

• Which of the following is NOT true concerning hepatorenal syndrome [6] ?

  A. The urine sodium is typically >15mM
  B. The condition develops in the setting of portal hypertension
  C. Liver transplantation is currently the only effective therapy
  D. Ascites, often massive, is typically present
  E. Albumin infusions, furosemide, and spironolactone rarely reverses the condition

• A 56 year old man is brought to the emergency room by his wife due to increased lethargy and confusion. The patient was treated for mild hypertension with a ß-adrenergic blocker and with lovastatin for elevevated cholesterol. He had been well until three months earlier, when increasing fatigue developed. He and his wife attributed this to working longer hours and "needing a vacation." Two weeks ago he had been particularly tired and took two days off from work, feeling like he had the flu. He had a couple of night sweats over the past week but they went away with acetaminophen (Tylenol®). Early in the day, the patient's wife found him asleep in a chair and had a bit of trouble waking him. When the patient tried to walk, he was very unsteady but denied a dizzy sensation, saying that his muscles did not "feel right." Vital signs showed a pulse of 80 bpm, blood pressure 105/65 mmHg, respirations 16/minute, and a temperature of 97.2°F orally. Physical examination was unrevealing except that the patient appeared to be dilerious; asterixus was not present.

• A serum protein electrophoresis on the patient above reveals a monoclonal IgG kappa band. The total serum immunoglobulin level is 5.2gm/dL (normal <3.3gm/dL). The most likely electrolyte abnormality to explain the patient's delirium is [8]:

  A. Hypocalcemia
  B. Hyponatremia
  C. Hypercalcemia
  D. Hyperkalemia
  E. Hypernatremia

• The electrolyte abnormality in Question [8] is felt to be responsible for much of the patient's delirium. The most appropriate inital treatment in this patient is [9]:

  A. Calcitonin, then Pamidronate
  B. Bicarbonate and Furosemide
  C. Hypertonic Saline
  D. Fluid Restriction and Normal Saline with Furosemide
  E. Normal Saline

• Hypoperfusion of the kidney leading to a "pre-renal" state is found in all of the following EXCEPT [10]:
A. Congestive Heart Failure
B. Renal Vein Thrombosis
C. Cyclosporine Toxicity
D. Cirrhosis with Ascites
E. Nephrotic Syndrome

Answers

1. D
2. C
3. B
4. E
5. A
6. A
7. D
8. C
9. E
10. B