UNIVERSITY OF THE PHILIPPINES MANILA

PHILIPPINE GENERAL HOSPITAL

DEPARTMENT OF MEDICINE

RESIDENTS EXAM
GASTROENTEROLOGY AND NEPHROLOGY

July 25, 2007

MULTIPLE TRUE OR FALSE. There are 5 statements after each question.

Determine whether each statement is true or false. On the answer sheet, place an
x in the box corresponding to your answer.

GASTROENTEROLOGY

1. In the evaluation of a patient with gastrointestinal disease, which of the following are
TRUE with respect to the clinical history? (HPIM p. 1727)
a. Symptoms from mechanical obstruction, ischemia, inflammatory bowel
disease, and functional bowel disorders are worsened by meal ingestion.
b. Long-standing symptoms commonly result from acute infection, toxin exposure, or
abrupt inflammation or ischemia; while symptoms of short duration point to an underlying
chronic inflammatory or neoplastic condition or a functional bowel disorder.
c. Ulcer pain occurs at intermittent intervals lasting weeks to months, whereas
biliary colic has a sudden onset and lasts up to several hours.
d. Sudden awakening from sleep suggests functional bowel disorder rather than an
organic disease.
e. Secretory diarrhea usually improves with fasting, while diarrhea from malabsorption
persists without oral intake.

2. Which of the following are complications of endoscopic retrograde

cholangiopancreatography? (HPIM p. 1732)
a. pancreatitis
b. bleeding
c. ascending cholangitis
d. pseudocyst infections
e. retroperitoneal perforation

3. TRUE statements regarding acute gastrointestinal hemorrhage: (HPIM p. 1732-33)

a. Decreases in hematocrit and hemoglobin are reliable gauges of the magnitude of
acute bleeding.
b. The magnitude of the initial hemorrhage is probably the most important
indication for urgent endoscopy, since a large initial bleed increases the likelihood
of ongoing or recurrent bleeding.
c. Less than half of patients with melena actually have GI bleeding coming from
proximal the ligament of Treitz, while 90% of patients with melena are bleeding from the
colon.
d. Marked coagulopathy or thrombocytopenia is usually treated before endscopy,
since correction of these abnormalities may lead to resolution of the bleeding, and
techniques for endoscopic hemostasis are limited in such patients.
e. Tracheal intubation for airway protection should be considered before upper
endoscopy for patients with repeated hematemesis and suspected variceal
hemorrhage.

4. Which of the following endoscopic findings in peptic ulcer is/are associated with a low
risk of rebleeding? (HPIM p. 1733)
a. a platelet plug is seen from a vessel wall in the base of an ulcer
b. clean-based ulcer
c. flat red or purple spots in the ulcer base
d. large adherent clots covering the ulcer base
e. active spurting from an ulcer

5. Which of the following increase the likelihood of reflux of gastric contents, as seen in
gastroesophageal reflux disease (GERD)? (HPIM p. 1742-44)
a. pyloric obstruction
b. acid-hypersecretion states
c. upright position
d. pregnancy
e. tight clothes

6. TRUE of GERD: (HPIM p. 1743)

a. The characteristic symptoms are the regurgitation of sour material in the mouth and
hematemesis.
b. Hematemesis suggests the development of a peptic stricture.
c. Recurrent pulmonary aspiration of gastric contents may cause aspiration
pneumonia, pulmonary fibrosis or chronic asthma.
d. Mucosal biopsies to detect Barrets esophagus must be taken nearest the lower
esophageal sphincter, as the esophageal mucosal changes are specifically seen in this
area.
e. Patients should be advised to reduce weight, sleep with the head of the bed
elevated 4-6 inches, and stop smoking.

7. TRUE statements regarding the different types of esophagitis: (HPIM p. 1745)

a. Radiation esophagitis, a common occurrence for treatment of thoracic cancers,
is enhanced by the administration of radiosensitizing drugs such as doxorubicin,
bleomycin, cyclophosphamide and cisplatin.
b. Viscous lidocaine and indomethacin are treatment options for radiation
esophagitis.
c. Pill esophagits can be prevented by taking pills in the upright position and
washing them down with copious amounts of fluids.
d. Glucocorticoids have been proven beneficial in the treatment of patients with acute
corrosive esophagitis.
e. Ulcerative colitis may cause inflammatory strictures, sinus tracts and fistulas in the
esophagus.

8. TRUE statements regarding peptic ulcer disease: (HPIM p. 1748-49)

a. Most duodenal ulcers are found in the terminal portion of the duodenum.
b. Biopsy of gastric and duodenal ulcers should be considered because of the possibility
of malignancy.
c. It is now clear that H. pylori and NSAID-induced injury account for the majority
of duodenal ulcers; gastric acid contributes to injury but does not play a primary
role.
d. Serious gastrointestinal ulceration does not occur with aspirin doses taken <300
mg/day.
e. Smoking appears to decrease ulcer healing rates, impair response to therapy,
and increase ulcer-related complications, but acid secretion is not abnormal in
smokers.

9. TRUE statements regarding Helicobacter pylori: (HPIM p. 1749-50)

a. Infection by this organism is dependent on the ability to produce urease which
produced ammonia from urea, an essential step in alkalinizing the surrounding
pH.
b. The prevalence of H. pylori does not differ significantly among the various countries
of the world.
c. Transmission occurs from person to person, following an oral-oral or fecal-oral
route.
d. H. pylori is also associated with the development of gastric mucosal-associated
lymphoid tissue (MALT) lymphoma and gastric squamous cell carcinoma.
e. H. pylori lipopolysaccharide (LPS) has low immunologic activity compared to
that of other organisms.

10. TRUE statements regarding the treatment of peptic ulcer disease: (HPIM p. 1753-
54)
a. Aluminum hydroxide can cause phosphate depletion by causing diarrhea, while
magnesium hydroxide can cause constipation.
b. The magnesium-containing antacids should not be used in chronic renal
failure patients because of possible hypermagnesemia, and aluminum may cause
chronic neurotoxicity in these patients.
c. Cimetidine can bind to hepatic cytochrome P450 causing drug-drug interaction,
while famotidine and nizatidine do not.
d. Proton pump inhibitors are substituted benzimidazole derivatives that reversibly
inhibit H+,K+-ATPase.
e. Misoprostol is insoluble in water and becomes a viscous paste within the stomach
and duodenum, binding primarily to sites of active ulceration.

11. A patient with gastric ulcer was positive for the urease test. What doses will you
order for the omeprazole-amoxicillin-clarithromycin (OAC) regimen for H. pylori
eradication? (HPIM p. 1754)
a. Omeprazole 40 mg BID, Amoxicillin 500 mg TID, Clarithromycin 250 mg TID
b. Omeprazole 20 mg OD, Amoxicillin 250 mg BID, Clarithromycin 500 mg BID
c. Omeprazole 20 mg BID, Amoxicillin 1000 mg BID, Clarithromycin 500 mg BID
d. Omeprazole 20 mg BID, Amoxicillin 500 mg BID, Clarithromycin 500 mg OD
e. Omeprazole 40 mg OD, Amoxicillin 1000 mg OD, Clarithromycin 250 mg BID

12. Absorption of which of which of the following substances is impaired in ileal

dysfunction? (HPIM p. 1765)
a. folate
b. iron
c. bile acids
d. calcium
e. cobalamin

13. Which of the following statements are TRUE regarding celiac sprue? (HPIM p.
1770-1772)
a. It is characterized by the presence of periodic acid-Schiff (PAS)-positive
macrophages in the lamina propria.
b. The diagnosis is established by clinical, histologic, and immunologic response to the
administration of glucocorticoids.
c. The histopathologic changes have a proximal to distal intestinal distribution of
severity, which probably reflects the exposure of the intestinal mucosa to varied
amounts of dietary gluten.
d. Use of rice in place of wheat flour is very helpful for affected patients.
e. The most important complication is malnutrition.

14. TRUE statements regarding the inflammatory bowel diseases (IBDs) ulcerative
colitis and Crohns disease: (HPIM p. 1776-89)
a. The prevalence for IBDs is higher in rural areas and in the lower socioeconomic
classes, reflecting a possible relationship with an infectious process.
b. In ulcerative colitis, the lesions occur in continuity without areas of uninvolved
mucosa, whereas the lesions are skipped in Crohns disease.
c. Ulcerative colitis can affect any part of the gastrointestinal tract from the mouth to the
anus.
d. The non-caseating granulomas of Crohns disease can also be seen in the
lymph nodes, peritoneum, mesentery, liver and pancreas.
e. Crohns disease usually involves all layers of the affected segments, while only
the mucosa and superficial submucosa are affected in ulcerative colitis, except in
fulminant disease.

15. TRUE statements regarding irritable bowel syndrome (IBS): (HPIM p. 1789-90)
a. Alteration in bowel habits is the most consistent clinical feature.
b. Malnutrition due to inadequate caloric intake is common in IBS.
c. Sleep deprivation is unusual because abdominal pain is almost uniformly
present only during waking hours.
d. Appearance of the disorder for the first time in old age, a progressive course from
time of onset, persistent diarrhea after 48-hour fast, and presence of nocturnal diarrhea
or steatorrhea support the diagnosis of irritable bowel syndrome.
e. Stool may be accompanied by passage of large amounts of mucus, but
bleeding is not a feature of IBS.

16. TRUE statements regarding colonic diverticular disease: (HPIM p. 1795-96)

a. Diverticulosis commonly affects the ascending colon and this may be a result of the
relative high-pressure zone within this segment.
b. Patients with presumed bleeding from diverticular disease requiring emergent surgery
should undergo sigmoidectomy since most of the bleeding diverticula are localized in the
sigmoid.
c. The diagnosis of diverticulitis is best made by colonoscopy.
d. The most common type of diverticulum affecting the colon is a
pseudodiverticulum, which is a herniation of the mucosa through the muscularis
propria.
e. The current recommended antimicrobial coverage for those with symptomatic
diverticular disease is trimethoprim/sulfamethoxazole or ciprofloxacin and
metronidazole.

17. TRUE statements regarding acute intestinal obstruction: (HPIM p. 1803-04)

a. Adhesions and external hernias are the most common causes of small intestinal and
colonic obstruction.
b. Spastic or dynamic ileus results from prolonged contraction of the intestine and is
common after any abdominal operation.
c. Vomiting, accumulation of fluids within the lumen, and sequestration of fluid
into the edematous intestinal wall as a result of impaired venous return from the
intestine contribute to massive loss of fluids and electrolytes, especially
potassium.
d. In small-intestinal obstruction, vomiting is almost invariable, and it is earlier and more
profuse with a more distal site of obstruction.
e. Procrastination of operation because of improvement in well-being of the
patient during resuscitation and gastric decompression usually leads to
unnecessary and hazardous delay in proper treatment.

18. Which of the following are parameters included in the Child-Pugh classification of
cirrhosis? (HPIM p. 1813)
a. serum bilirubin
b. alanine aminotransferase (ALT)
c. serum albumin
d. serum creatinine
e. ascites

19. TRUE of the laboratory evaluation of liver disease: (HPIM p.1813-16)

a. Aminotransferases and alkaline phosphatase do not measure liver function at
all.
b. Conjugated bilirubin always binds to albumin in the serum and is not filtered by the
kidneys; therefore, any bilirubin found in the urine is unconjugated bilirubin.
c. There is a direct correlation between the degree of liver cell damage and the level of
the aminotransferases.
d. Elevation of liver-derived alkaline phosphatase is not totally specific for
cholestasis; a less than threefold elevation from normal can be seen in almost any
type of liver disease.
e. Significant changes in the serum albumin is seen in viral hepatitis, drug-related
hepatotoxicity, and obstructive jaundice.

20. Which of the following are TRUE regarding acute viral hepatitis? (HPIM p. 1828)
a. The typical morphologic lesions of all types of viral hepatitis are similar.
b. Anti-HAV-positivity increases in prevalence as a function of increasing age and
increasing socioeconomic status.
c. Pegylated interferon plus ribavirin is the preferred treatment regimen for Hepatitis B.
d. The highest rates of fulminant disease is seen in acute infection with Hepatitis
D virus.
e. An epidemiologic feature that distinguishes Hepatitis E virus infection is the
rarity of secondary person-to-person spread from infected persons to their close
contacts.
21. Which of the following clinical and laboratory features suggest progression of acute
hepatitis to chronic hepatitis due to Hepatitis B virus? (HPIM p. 1834)
a. lack of complete resolution of clinical symptoms of anorexia, weight loss, and
fatigue and the persistence of hepatomegaly
b. presence of bridging necrosis on liver biopsy
c. persistence of anti-HBe beyond 3 months after acute hepatitis
d. persistence of HBsAg beyond 6 months after acute hepatitis
e. persistence of HBeAg beyond 1 month after acute hepatitis

22. TRUE statements regarding the treatment of an acute attack of viral hepatitis:
(HPIM p. 1835-36)
a. In hepatitis B, antiviral therapy with lamivudine has been shown to improve the rate of
recovery; thus, it is recommended to prevent progression to chronic hepatitis B.
b. In hepatitis C, progression to chronic hepatitis is the rule; thus antiviral treatment is of
no use.
c. Most patients do not require hospitalization for acute hepatitis.
d. If severe pruritus is present, glucocorticoids can be helpful.
e. Physical isolation of patients with hepatitis to a single room and bathroom is
unnecessary except in the case of fecal incontinence for hepatitis A or D, or uncontrolled
voluminous bleeding in hepatitis B or C

23. TRUE statements regarding portal hypertension: (HPIM p. 1863)

a. The absence of valves in the portal veins facilitates retrograde blood flow from
the high-pressure portal system to the lower-pressure systemic venous
circulation.
b. A frequent marker of the presence of cirrhosis in a patient being followed for chronic
liver disease is a progressive decrease in hemoglobin.
c. Beta adrenergic blockade has been shown to prevent decrease the incidence of a
subsequent variceal bleed after an initial episode, but does not prevent the occurrence
of the initial bleed.
d. If the pretreatment resting pulse of the patient is 100 bpm, the target resting pulse
rate after beta adrenergic blockade for portal hypertension is 80 bpm.
e. Portal systemic shunt surgery does not result in improves survival rates in
patients with cirrhosis.

24. TRUE statements regarding the various complications of cirrhosis: (HPIM p. 1864-
69)
a. Variceal banding and sclerotherapy are generally effective in esophageal
varices, but not in fundal varices.
b. Transjugular intrahepatic portosystemic shunt (TIPS) is an alternative for those who
are poor surgical candidates for liver transplantation.
c. For patients with ascites, the goal is the loss of no more than 2.0 kg/day if both
ascites and peripheral edema are present, and no more than 1.0 kg/day in patients with
ascites alone.
d. Fluid restriction is the cornerstone of therapy for ascites due to cirrhosis.
e. In hepatorenal syndrome, the kidneys are grossly structurally normal, as well as the
results of urinalysis amd pyelography; however, biopsy reveals acute tubular necrosis
and interstitial nephritis.

25. TRUE statements regarding acute pancreatitis: (HPIM p. 1896-1900)

a. Acute pancreatitis is excluded in a 30 year old male presenting with 5-day history of
abdominal pain if his serum amylase is normal.
b. Hematocrit values >50% may represent more severe disease because of loss of
plasma into the retroperitoneal space and peritoneal cavity.
c. Alcoholism continues to be the most common cause.
d. It is organ failure, in which acute renal failure predominates, that determines the
outcome in the majority of difficult to manage cases.
e. Nasogastric suction is advantageous for mild to moderately severe cases, and its use
should be considered mandatory rather than elective.

NEPHROLOGY

26. TRUE statements regarding the pathophysiology of prerenal acute renal failure:
(HPIM p. 1644-45)
a. Prerenal and postrenal acute renal failure due to ischemia are part of a spectrum of
manifestations of renal hypoperfusion.
b. In hypovolemia, norepinephrine, angiotensin II and AVP act in concert in an attempt
to preserve cardiac and cerebral perfusion by stimulating vasodilation in relatively
nonessential vascular beds.
c. In renal hypoperfusion, biosynthesis of vasoconstricting prostaglandins is enhanced,
and these compounds preferentially constrict the efferent arterioles.
d. Angiotensin II induces preferential dilation of afferent arterioles.
e. Pharmacologic inhibitors of either renal prostaglandin synthesis and
angiotensin II activity and angiotensin II receptor blockers are the drugs that
interfere with the adaptive responses in the renal microcirculation.

27. Ischemic injury is most prominent in these segments of the nephron: (HPIM p.
1645)
a. cortical portion of the proximal tubule
b. terminal medullary portion of the proximal tubule
c. descending limb of the loop of Henle
d. thick ascending limb of the loop of Henle
e. thin ascending limb of the loop of Henle

28. What is the proper sequence of events that occur during prerenal acute renal
failure? (HPIM p. 1646)
S Activation of central baroreceptors
A Tubule epithelial cell injury
N Decreased effective circulating volume
D Vasoconstriction and mesangial cell contraction
Y Regeneration of tubule epithelium

a. A-Y-N-D-S
b. S-N-A-Y-D
c. Y-A-N-S-D
d. S-A-N-D-Y
e. N-S-D-A-Y

29. TRUE statements regarding nephrotoxic intrinsic acute renal failure: (HPIM p.
1646-47)
a. The incidence is increased in the elderly and in those with true or effective
hypovolemia.
b. Contrast-nephropathy is characterized by an acute but reversible rise in BUN
and creatinine, and is dose-related.
c. Acute renal failure does not occur when the aminoglycoside doses are maintained in
the therapeutic range.
d. Hypercalcemia compromises GFR predominantly by tubular obstruction of calcium
phosphate crystals.
e. Common causes of hemoglobinuria-induced ARF include traumatic crush injury,
seizures, and excessive exercise.

30. Evaluation of urine output and urinalysis are important tool in assessing the function
of the urinary tract. Which of the following are TRUE? (HPIM p. 1647-48)
a. Wide fluctuations in urine output raise the possibility of intermittent
obstruction.
b. In prerenal ARF, the urinalysis is characteristically cellular and contains transparent
hyaline casts.
c. Pigmented muddy brown casts are characteristic of chronic kidney disease.
d. Eosinophiluria is a characteristic of allergic interstitial nephritis and
atheroembolic ARF.
e. Dipsticks for urinary proteins satisfactorily detect proteinuria due to multiple myeloma
and those with injury to the glomerular ultrafiltration barrier.

31. TRUE of the laboratory findings in ARF: (HPIM p. 1649)

a. Serum BUN / creatinine ratio is the best index in distinguishing prerenal ARF from
ischemic or nephrotoxic ARF.
b. Sodium is reabsorbed avidly from glomerular filtrate in patients with intrinsic ARF, but
not in patients with prerenal ARF.
c. Fractional excretion of Na (FENa) from prerenal ARF is typically <1.0% but can
be >1.0% if the patient is receiving diuretics, has bicorbonaturia, or adrenal
insufficiency.
d. The initial rise in creatinine is seen within 24 to 48 hours of therapy with many tubule
epithelial toxins such as aminoglycosides and cisplatin, reflecting their direct toxic effect.
e. In general, red cell casts indicate postrenal lesions such as tumors or lithiasis.

32. ARF impairs renal excretion of sodium, potassium, water, and perturbs divalent
cation metabolism. Which of the following are TRUE of the complications of ARF?
(HPIM p. 1650)
a. Expansion of extracellular fluid volume can manifest as weight gain, bibasilar
lung rales, raised JVP and dependent edema.
b. Serum potassium typically rises by 0.5 mmol/L per day in oliguric and anuric
patients due to impaired excretion of ingested or infused potassium and
potassium released from injured tissues.
c. Unexcreted fixed nonvolatile acids produced from dietary protein metabolism
contribute to metabolic alkalosis.
d. Mild hypophosphatemia is an invariable complication of ARF.
e. Hyperkalemia may be particularly severe in patients with rhabdomyolysis,
hemolysis or tumor lysis syndrome.

33. TRUE statement regarding treatment of acute renal failure: (HPIM p. 1650-52)
a. Adminsitration of allopurinol and urine acidification are useful prophylactic measures
in patients at high risk for acute urate nephropathy.
b. Ethanol is an important adjunct to hemodialysis in the emergency treatment of
ethylene glycol intoxication.
c. Management of prerenal ARF should focus on elimination of the causative
hemodynamic abnormality or toxin, avoidance of additional insults, and
prevention and treatment of complications.
d. Absolute indications for dialysis include the uremic syndrome and refractory
hypovolemia, hypernatremia and metabolic acidosis.
e. Hyperphosphatemia is usually controlled by oral aluminum hydroxide or calcium
carbonate, which promote renal excretion of phosphorus.

34. TRUE statements regarding the etiology and pathophysiology of chronic renal
disease: (HPIM p. 1653-54)
a. By the time plasma creatinine concentration is even mildly elevated,
substantial chronic nephron injury has already occurred.
b. Proteinuria, abnormal urinary sediment and urinary tract structural
abnormalities are already evidence of kidney damage even in the face of normal or
increased GFR.
c. Hypertensive nephropathy and chronic glomerulonephritis are the leading underlying
etiologies of both CRD and end-stage renal disease (ESRD).
d. Azotemia refers to the clinical and laboratory syndrome, reflecting dysfunction of all
organ systems as a result of untreated or undertreated acute or chronic renal failure.
e. Uremia refers to the retention of nitrogenous waste products as renal insufficiency
develops.

35. TRUE of the clinical and laboratory manifestations of uremia: (HPIM p. 1655-1660)
a. Hypokalemia is uncommon in CRD and usually reflects markedly reduced
dietary K intake, in association with excessive diuretic therapy or GI losses.
b. Osteitis fibrosa cystica, the hallmark lesion of secondary hyperparathyroidism
is characterized by irregularly woven abnormal ostoeid, fibrosis and cyst
formation.
c. A microcytic, hypochromic anemia attributable to CRD is observed beginning at stage
3 CRD and is almost universal at stage 4.
d. Uremic fetor is a uniriferous odor to the breath and is derived from the
breakdown of ammonia in saliva.
e. Asterixis, myoclonus and chorea are common in terminal uremia, which may
also be associated with seizures and coma.

36. TRUE statements regarding the treatment of CRD: (HPIM p. 1656-61)

a. It is recommended to increase phosphate levels to 1.4 mmol/L to suppress
parathyroid hyperplasia, preventing osteitis cystica, osteomalacia and myopathy.
b. For the management of hypertension, the choice of antihypertensive is similar to that
in the general population with added consideration of cardioprotective benefit provided
by beta adrenergic blockade.
c. Uremic pericarditis is an absolute indication for initiation if dialysis.
d. Iron supplementation is unnecessary and superfluous for CRD-associated anemia
since the cause of the anemia is erythropoietin deficiency.
e. The first lines of management for uremic pruritus are to rule out unrelated skin
disorders and to control phosphate concentration with avoidance of an elevated
calcium-phosphate product.
37. Which of the following etiologies may lead to chronic kidney disease with normal
kidney size? (HPIM p. 1660)
a. hypertension
b. systemic lupus erythematosus
c. HIV
d. polycystic kidney disease
e. diabetes

38. TRUE statements regarding the evaluation and diagnosis of CKD: (HPIM 1660-61)
a. The presence or absence of broad casts on examination of the urinary sediment can
help in aiding the clinician in determining the underlying etiology of the CKD.
b. Having bilateral small kidneys in a patient should not preclude a clinician to perform a
renal biopsy since the etiology can still be determined this way in about half of cases.
c. The most useful imaging test is a CT scan without the use of a radiocontrast dye in
order to prevent nephrotoxicity.
d. The most important initial step in the evaluation of a patient presenting de
novo with evidence of renal failure us to distinguish newly diagnosed CRD from
acute renal failure.
e. Dietary protein restriction has been shown to slow down the progression of diabetic
nephropathy but not for other causes of CRD.

39. Which of the following antihypertensive agents also have antiproteinuric and renal
protective effects? (HPIM p. 1661)
a. losartan
b. verapamil
c. captopril
d. diltiazem
e. carvedilol

40. Important considerations in the management of CRD include the following

statements: (HPIM p. 1662)
a. The decline in GFR precedes microalbuminuria in diabetic patients and heralds renal
as well as cardiovascular complications.
b. Temporary relief of symptoms and signs of uremia such as anorexia, nausea and
vomiting may be achieved with administration of sodium bicarbonate.
c. The loading dose of most drugs need to be adjusted in patients with CRD.
d. Renal replacement therapy should not be initiated when the patient is totally
asymptomatic.
e. Only kidney transplantation offers the potential for nearly complete
rehabilitation since dialysis replaces only 10-15% of normal kidney function at the
level of small-solute removal.

41. Lives of patients with ESRD have been prolonged because of dialysis. Which of
the following are TRUE regarding this modality of treatment for renal failure? (HPIM p.
1663-67)
a. Mortality of patients on dialysis are mostly from infections.
b. Hemodialysis is favored in younger patients because of their better manual dexterity
and greater visual acuity, and because they prefer the independence and flexibility of
home-based hemodialysis.
 c. The use of bicarbonate instead of acetate in dialysate solutions has decreased
the incidence of hypotension during dialysis, since acetate has vasodilatory and
cardiodepressive effects.
d. Double-lumen catheters permit blood flow comparable to permanent
arteriovenous access, but the latter are prone to infection and to occlusion
because of thrombosis.
e. Anaphylactoid reactions are the most common acute complication of hemodialysis
and treatment consists of discontinuing ultrafiltration, administration of 100-250 mL
isotonic saline, and administration of salt-poor albumin.

42. TRUE statements regarding kidney transplantation: (HPIM p. 1668-73)

a. Virtually all ESRD patients who receive a transplant have a higher life
expectancy than risk-matched patients who remain in dialysis.
b. A positive cross match of recipient serum with donor T lymphocytes representing anti-
HLA class I is predictive of chronic rejection.
c. Clinical evidence of rejection is usually characterized by fever, swelling and
tenderness over the allograft, and rarely does it present with a rising serum creatinine
level alone.
d. Surveillance for skin and cervical cancer is necessary for patients on
immunosuppressants since the incidence of tumors is approximately 100 times
greater than that in the general population.
e. The first rejection period is usually treated with IV methylprednisolone 500 to
1000 mg daily for 3 days.

43. Virtually all glomerular injury results in impairment of glomerular filtration and/or the
inappropriate appearance of plasma proteins and blood cells in the urine. Which of the
following are TRUE regarding glomerular disease? (HPIM p. 1674-76)
a. Lesions are classified as segmental or global when they involve the minority (<50%)
or the majority (>50%) of glomeruli, respectively.
b. Lesions are termed focal or diffuse when they involve part or almost all of the
glomerular tuft, respectively.
c. The clinical term rapidly progressive GN and the pathologic term crescentic
GN are often used interchangeably.
d. Nephrotic syndrome is associated with a prothrombotic state as a
consequence of the heavy proteinuria.
e. Membranoprolierative glomerulonephritis is a hybrid lesion that presents with
a combination of nephritic and nephrotic features.

44. A 30 year old female presents with a 1 month history of facial edema and hematuria.
Work-ups showed serum creatinine of 500 umol/L, normal-sized kidneys on ultrasound,
dysmorphic red cells and red cell casts on urinalysis, and 1 gram 24-hour urine protein
excretion. Which of the following histologic patterns do you expect to find? (HPIM p.
1674)
a. minimal change disease
b. diffuse proliferative glomerulonephritis
c. membranous glomerulopathy
d. crescentic glomerulonephritis
e. focal and segmental glomerulosclerosis

45. An SLE patient with active nephritis will present with which of the following serologic
or immunofluorescence results? (HPIM p. 1680)
a. negative for anti-glomerular basement (GBM) antibodies
b. positive for anti-neutrophil cytoplasmic antibiodies (ANCA)
c. low C3 levels
d. linear IgG and C3 deposits on immunofluorescence
e. granular IgG and C3 deposits on immunofluorescence

46. TRUE statements regarding SLE nephritis: (HPIM p. 1681-82)

a. Most glomerular injury is triggered by the formation of autoantibodoes directed
against the glomerular basement membrane.
b. ANA titers tend to fall with treatment and may not be detected during
remissions.
c. Anti-dsDNA antibodies are highly specific for SLE and changes in their titers
correlate with activity of lupus nephritis.
d. Treatment is not indicated for proliferative nephritis as this histologic pattern portends
an excellent prognosis (90-100% 5-year survival rates).
e. Glucocorticoids and cyclophosphamide are the mainstays of therapy for patients
whose renal biopsy reveal mesangial deposits of immunoglobulins.

47. TRUE of the nephrotic syndrome: (HPIM p. 1684-85)

a. Tubular proteinuria which results from failure of tubular resorption of low molecular-
weight plasma proteins, may be a cause of nephrotic syndrome.
b. The key component of nephrotic syndrome is edema, and the other components and
complications are all secondary to this.
c. Hypercoagulability is caused, at least in part, by increased urinary loss of
antihrombin III, and altered levels or activity of proteins C and S.
d. There may be microcytic hypochromic anemia from urinary loss of transferrin that is
readily responsive to the administration of iron.
e. Nonspecific measures that may reduce proteinuria include ACE inhibitors,
angiotensin receptor blockers and NSAIDs.

48. Which of the following are TRUE for the various tubular disorders? (HPIM p. 1694-
98)
a. In autosomal dominant polycystic kidney disease (ADPKD), renal failure
progresses slowly but in cases of sudden decrement in kidney function, ureteral
obstruction from stone, clot or compression by a cyst are likely causes.
b. At least 3 to 5 cysts per kidney demonstrated by ultrasound is the standard
diagnostic criteria for ADPKD.
c. Liddles syndrome has a clinical presentation of hypokalemia, metabolic alkalosis and
normal to low blood pressure.
d. Type 1 (distal) renal tubular acidosis (RTA) is characterized by a normal anion gap
metabolic acidosis, urine pH<5.5, hypokalemia, and the absence of nephrocalcinosis.
e. With the stress of an intercurrent illness, acidosis and hypokalemia may be life-
threatening in Type 1 (distal) RTA.

49. Which of the following are TRUE regarding acute uric acid nephropathy? (HPIM p.
1704)
a. This tubulointerstitial disease is usually seen as part of the tumor lysis
syndrome.
b. Pathologic changes are usually the result of crystalline deposits of uric acid and
monosodium urate salts in the parenchyma, inciting an inflammatory response with
lymphocytic infliltration, foreign body-giant cell reaction and fibrosis.
c. Hyperuricemia can be a consequence of renal failure of any etiology and is
distinguished from the other causes by a urine uric acid/creatinine ratio greater
than 1 mg/mg.
d. Increasing urine volume with diuretics lowers intratubular uric acid
concentration.
e. Acidification of the urine to pH 5 or less enhances uric acid solubility.

50. TRUE statements regarding nephrolithiasis: (HPIM p. 1710)

a. Uric acid stones are usually radiolucent.
b. Struvite crystals are rectangular prisms said to resemble coffin lids.
c. The vast majority of stones less than 0.5 cm in diameter will pass out of the
urinary tract spontaneously.
d. Ultrasound is now the preferred procedure for the detection of nephrolithiasis.
e. Increasing urine volume to 2.5 liters per day has been shown to decrease stone
recurrence, as seen in a study comparing patients who had increased fluid intake
and those in the control group.

51. TRUE statements regarding the epidemiology and pathogenesis of urinary tract
infections: (HPIM p. 1715-16)
a. The vast majority of acute symptomatic infections involve old women.
b. Isolation of Staphylococcus aureus from the urine should arouse suspicion of
bacteremic infection of the kidney.
c. Sexually transmitted infections such as Chlamydia trachomatis, Neiserria
goneorhea and herpes simplex virus should be suspected in patients with sterile
urine but have acute urinary symptoms and pyuria.
d. In the vast majority of cases, bacteria gain entry into the bladder by downward
migration of bacteria from the kidneys.
e. Infection superimposed on urinary obstruction may lead to rapid destruction of
renal tissue and this requires identification and repair of the obstructive lesion.

52. TRUE statements regarding the conditions affecting the pathogenesis of UTI:
(HPIM p. 1716-17)
a. In males <50 years old and who have no history of rectal intercourse, UTI is
exceedingly uncommon and this diagnosis should be questioned in the absence
of proper documentation.
b. An anatomically impaired vesicoureteral junction facilitates reflux of bacteria
and thus upper tract infection.
c. Infections in patients with structural or functional abnormalities of the urinary
tract are generally caused by bacterial strains that lack uropathogenic properties.
d. Secretors of blood group antigens are at increased risk of recurrent UTI.
e. Voiding after intercourse reduces the risk of cystitis probably because it
promotes the clearance of bacteria introduced during intercourse.

53. Which of the following are TRUE with regards to the principles that underlie the
treatment of UTIs? (HPIM p. 1718)
a. When the involvement of enterococci is suspected in complicated UTIs, the empiric
regimen should be either ceftriaxone or ceftazidime.
b. Neither ampicillin or cotrimoxazole should be used as initial therapy for acute
uncomplicated pyelonephritis because of high prevalence of antibiotic resistance.
c. Relief of clinical symptoms does not always indicate bacteriologic cure.
d. In general, infections confined to the lower urinary tract and those also involving the
upper tract are treated with antibiotics for the same duration.
e. Treatment of asymptomatic catheter-associated bacteriuria may be of greatest
benefit to elderly women who most often develop symptoms if left untreated.

MULTIPLE CHOICE: Choose the BEST answer.

GASTROENTEROLOGY

1. Which of the following diagnostic procedures provides the most accurate

preoperative local staging of esophageal, pancreatic, and rectal malignancies, although
it does not detect most distant metastases? (HPIM p. 1730)
a. small-bowel enteroscopy
b. endoscopic retrograde cholangiopancreatography
c. endoscopic ultrasound
d. manometry

2. The gold standard for the diagnosis of colonic mucosal disease: (HPIM p. 1730)
a. barium enema
b. Abdominal CT scan with triple contrast
c. Colonoscopy
d. Capsule endoscopy

3. Which of the following defines a Dieulafoys lesion? (HPIM p. 1734)

a. A linear mucosal rent near or across the gastroesophageal junction that is often
associated with retching or vomiting.
b. Flat mucosal vascular abnormalities which cause slow intestinal blood loss.
c. A large-caliber arteriole that runs immediately beneath the gastrointestinal
mucosa and bleeds through a pinpont mucosal erosion.
d. Abnormal nutrient arteries that penetrate the muscular wall of the colon en route to
the colonic mucosa.

4. The second most common complication of peptic ulcer disease: (HPIM p. 1752-53)
a. gastrointestinal bleeding
b. gastric outlet obstruction
c. pernicious anemia
d. perforation

5. Test of choice for documenting eradication of H. pylori: (HPIM p. 1755)

a. repeat biopsy and culture
b. urea breath test
c. serology
d. stool antigen detection

6. A patient has undergone bowel resection a decade ago. Presently, he manifests

with deficiencies in calcium, folate, and iron but without evidence of cobalamin
deficiency. What segment of the GI tract is most probably removed during the previous
operation? (HPIM p. 1768)
a. stomach
b. duodenum
c. jejunum
d. ileum
e. ascending colon

7. The mainstay in the treatment of mild to moderate inflammatory bowel disease is:
(HPIM p. 1785)
a. azathioprine
b. 6-mercaptopurine
c. prednisone
d. sulfasalazine
e. metronidazole and/or ciprofloxacin

8. The gold standard in the diagnosis of acute arterial occlusive disease is: (HPIM p.
1798)
a. angiography
b. spiral CT scan
c. colonoscopy
d. early laparotomy
e. duplex ultrasound

9. A 65 year old male with chronic intake of aspirin for a previous myocardial infarct
suddenly complains of severe abdominal pain. You see the patient in severe abdominal
pain. On PE, the BP is 110/80, HR 110 with irregularly irregular rhythm, (+) bipedal
edema. Your abdominal PE, however, does not show any abnormal findings. What is
the most probable diagnosis? (HPIM p. 1798)
a. perforated NSAID-induced peptic ulcer
b. acute intestinal obstruction
c. torsion of the small intestines
d. acute mesenteric arterial occlusion
e. mesenteric venous thrombosis
f. acute ovarian torsion

For Nos. 10-13, choose the best answer from the choices below:
A. Acute Hepatitis B
B. Treat with lamivudine
C. Vaccinated with hepatitis B
D. Observe for rise in ALT then treat as necessary
E. Natural immunity to hepatitis B

(B) 10. HBV DNA titer of 100,000 copies/mL, HBsAg (+) for >6 months, Child-Pugh
Class A liver cirrhosis, ALT elevated 2.5x
(A) 11. HBsAg (-), anti-HBc IgM (+), ALT 10 x elevated
(C) 12. anti-HBs (+), anti-HBc IgG (-)
(E) 13. anti-HBs (+), anti-HBc IgG (+)

14. Which is TRUE regarding spontaneous bacterial peritonitis? (HPIM Chap. 112)
a. etiologic agents are usually gram (+) organisms and anaerobes
b. may be due to a ruptured viscus
c. usually occurs in the presence of minimal ascites
d. Cefotaxime is a good empiric antibiotic pending culture studies
15. Which of the following is TRUE regarding pyogenic liver abscesses?
a. usually a result of biliary tract disease
b. often solitary
c. patients are asymptomatic
d. 1/3 of patients have concomitant bloody diarrhea

16. The most common intestinal malabsorption syndrome: (HPIM p. 1725)

a. celiac disease
b. lactase deficiency
c. Zollinger-Ellison syndrome
d. Crohns ileitis
e. chronic pancreatitis

17. Hyperpigmented macules in the lips is suggestive of:

a. Familial adenomatous polyposis
b. Neurofibromatosis
c. Peutz-Jehgers syndrome
d. Hereditary Non-polyposis Colon Cancer

18. A 64 year old female was diagnosed with pancreatic head cancer 5 months ago and
now consults your clinic for severe pruritus. Which of the following will you expect to find
on physical examination?
a. acholic stools on rectal examination
b. spider angiomata
c. friction rub at the right subcostal margin
d. obliterated Traubes space

19. Wilsons disease is associated with this physical examination finding? (HPIM p.
1871)
a. Dark line in gums
b. Colonic ulceration
c. Kayser-Fleischer rings
d. Colonic polyposis

20. Which of the following has a serum ascites-albumin gradient (SAAG) > 1.1 mg/dL?
(HPIM p. 1866)
a. nephrotic syndrome
b. Pancreatic cancer
c. Hepatic Schistosomiasis
d. TB peritonitis

21. Gastric ulcers usually penetrate into the: (HPIM p. 1752)

a. ascending colon
b. descending colon
c. right hepatic lobe
d. left hepatic lobe
e. pancreas

22. What type of liver injury does right-sided heart failure cause? (HPIM p. 1862)
a. pre-sinusoidal fibrosis
b. post-sinusoidal fibrosis
c. extrahepatic biliary tract obstruction
d. nutmeg liver
e. Budd-Chiari Syndrome

23. Antibody detected in 90% of patients with Primary Biliary Cirrhosis (HPIM p. 1860)
a. Anti-LKM
b. Anti-Sm
c. Anti-mitochondrial antibody
d. anti-centromere

For numbers 24 to 26, match the diagnosis labeled A to D with the clinical or laboratory
feature: (HPIM p. 1739-46)
A. Achalasia
B. Diffuse Esophageal Spasm
C. Zenkers diverticulum
D. Esophageal candidiasis

(C) 24. halitosis

(D) 25. white plaques
(B) 26. corkscrew appearance

NEPHROLOGY

27. Which is typically a feature of intrinsic acute renal failure, in contrast to prerenal
ARF? (HPIM p. 1649)
a. urine Na concentration <10 mmol/L
b. urine specific gravity > 1.020
c. Fractional excretion of Na >1
d. plasma BUN/creatinine ratio>20

28. Metabolic acidosis with serum Na 141 mmol/L, Cl 98 mmol/L and HCO3 8 mEq/L is
NOT consistent with:
a. Methanol ingestion
b. Chronic kidney disease
c. Diabetic ketoacidosis
d. Renal tubular acidosis

29. Which is NOT a cause of postrenal acute renal failure? (HPIM p. 1647)
a. A large myoma uteri
b. Prostate carcinoma
c. Staghorn calculus on the left
d. Neurogenic bladder

30. A finding consistent with nephrotic syndrome: (HPIM p. 1674)

a. BP 150/100
b. Frothy urine
c. 90% dysmorphic RBCs in urine
d. serum Crea 400 umol/L
31. Which urinalysis finding indicates chronic tubulointerstitial scarring and tubular
atrophy with widened tubule diameter? (HPIM p. 1660)
a. WBC casts
b. (+) eosinophils
c. broad casts
d. hematuria with 85% dysmorphic RBCs

32. A 45 year old female with diabetic nephropathy was operated on for calculous
cholecystitis. To prevent further renal insult, which of the following pain medications
can be safely administered to her:
a. Mefenamic acid
b. Celecoxib
c. Tramadol
d. Ibuprofen

33. Target blood pressure value in proteinuric CRD patients (in mmHg): (HPIM p. 1661)
a. 140/90
b. 135/85
c. 130/80
d. 125/75
e. 120/80

34. The most common cause of morbidity and mortality among CKD patients in all
stages: (HPIM p. 1657)
a. diabetic emergencies
b. cardiovascular disease
c. pneumonia
d. urinary tract infection
e. catheter-related infection

35. Which of the following conditions should be suspected in a patient with a

discrepancy between proteinuria detected by dipstick and the sulfosalicylic acid
precipitation method? (HPIM p. 1684)
a. minimal change disease
b. focal segmental glomerulosclerosis
c. acute tubular necrosis
d. multiple myeloma
e. Alport syndrome

36. The most common glomerulopathy worldwide is: (HPIM p. 1690)

a. IgA nephropathy
b. Alport syndrome
c. Acute post-infectious glomerulonephritis
d. minimal change disease
e. Henoch-Schonlein purpura

37. What drug or toxin can cause papillary necrosis which is demonstrated on
pyelography by the ring sign? (HPIM p. 1703)
a. lithium
b. heroin
c. acetaminophen
d. lead
e. aristolochic acid in Chinese herb-containing slimming pills

38. INCORRECTLY paired intervention for hyperkalemia and mechanism of action:

a. Calcium gluconate forms complexes with ionized potassium
b. Salbutamol intracellular shift of potassium
c. Glucose-insulin infusion intracellular shift of potassium
d.Furosemide decreases total body potassium by kaliuresis

39. Which is TRUE regarding struvite stones? (HPIM p. 1714)

a. They are a result of urinary infection with bacteria, usually Pseudomonas.
b. Struvite is composed of ammonium, phosphate and calcium.
c. Complete removal of the stone with subsequent sterilization is the urinary tract
is the treatment of choice.
d. Irrigation of the renal pelvis with the antiseptic hemiacidrin kills the bacteria.

40. Most common etiology of emphysematous pyelonephritis: (HPIM p. 1720)

a. E. coli
b. Proteus
c. Staph. Aureus
d. Pseudomonas aeruginosa
e. Enterococci

41. Which antibiotic should NOT be given to pregnant patients with UTI: (HPIM p. 1719)
a. cotrimoxazole
b. nitrofurantoin
c. amoxicillin
d. cefuroxime
e. norfloxacin

42. A 60 year old male came in for a general check up. You found out that he has a
blood pressure of 150/100, an enlarged but smooth prostate on rectal examination, an
FBS of 150 mg/dL, and a serum Creatinine of 300 umol/L. Which of the following is
NOT consistent with diabetic nephropathy?
a. Normal sized kidneys by ultrasound
b. Albuminuria of +++
c. Negative urine glucose
d. Hematuria

43. A patient was worked up gross hematuria. Urinalysis showed abundant RBCs and
all are of normal morphology. The following are possible causes EXCEPT:
a. Cyclophosphamide administration
b. GUTB
c. Renal cell carcinoma
d. Invasive cervical cancer
e. Proliferative GN

44. A 45 year old smoker underwent contrast-enhanced chest CT scan for an incidental
finding of a mass on the lower lobe of the left lung. Knowing that contrast-induced
nephropathy is a possible complication, which of the following will best detect such:
(HPIM p. 1646)
a. urine output monitoring
b. Urinalysis
c. Serum creatinine
d. Urine creatinine
e. renal ultrasound

45. Goodpasture syndrome would manifest with which serologic marker?(HPIM p. 1680)
a. ANA
b. anti-GBM
c. perinuclear ANCA
d. cytoplasmic ANCA
e. antistreptolysin O

46. Which of the following features is present when the cause of urinary obstruction is
released? (HPIM p. 1723)
a. potential for volume depletion
b. hypertension
c. oliguria
d. hyperkalemic, hyperchloremic acidosis
e. azotemia

47. Which simple intervention will readily determine whether the cause of urinary tract
obstruction is below or above the bladder neck? (HPIM p. 1723)
a. anterograde urogram
b. retrograde urogram
c. insertion of bladder catheter
d. CT scan
e. renal ultrasound