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NBME 24 Answers

nbme24/Block 1/Question#13 (reveal difficulty score)
A 4-year-old boy is brought to the emergency ...
Proliferative glomerulonephritis ๐Ÿ” / ๐Ÿ“บ / ๐ŸŒณ / ๐Ÿ“–
tags: renal nephropathy Renal

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 +6  upvote downvote
submitted by โˆ—usmile1(154)

Membranous nephropathy and minimal change disease can be easily ruled out as they are nephrotic syndromes. Tubulointerstitial nephritis (aka acute interstitial nephritis) can be ruled out as it causes WBC casts not RBC as seen in this question. Papillary necrosis - either has no casts or it might show WBC casts but not RBC because the problem is not in the glomeruli.

table of nomenclature on page 582 explains that proliferative just means hyper cellular glomeruli. Given the patients history of sore throat two weeks ago, now presenting with Nephritic Syndrome with RBC casts, proliferative glomerulonephritis is the only reasonable answer.

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medguru2295  This was my precise login. I wound up getting it by elimination. But, didn't like that answer as its uncommon in small children and the child seemingly had no risk factors. +1
thotcandy  @medguru2295 FA says it's most commonly seen in children and it's selflimited vs adults is rare and can lead to renal insuff +2
peqmd  They're using the broad category for PSGN, Pathoma pg 130 IIC. PSGN = Hypercellular, inflammed glomeruli on H&E stain and cross referencing the FA table mentioned hypercellular => Proliferative. +6
unknown001  that was the reason why i chose this answer. to nbme : thats not cool bro +

 +5  upvote downvote
submitted by โˆ—nbmehelp(49)

This is BS bc PSGN is like the only nephrotic/nephritic syndrome I thought I had down cold

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 +1  upvote downvote
submitted by โˆ—diabetes(31)

RBC casts===> glomerulonephritis the only option there.

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thotcandy  I saw BUN/cr > 20 and instantly though prerenal --> ischemic pap necrosis due to analgesics. Are nephritic syndromes just excluded from that whole thing? FA says BUN and Cr are increased for nephritic syndromes but does the ratio just not matter? +2
fatboyslim  Ischemic pap necrosis wouldn't have RBC casts +1

 +0  upvote downvote
submitted by failingnbme(3)

can nephritic syndrome be without HTN?

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yiqi  I got wrong for the same reason!!! +

 +0  upvote downvote
submitted by โˆ—mousie(272)

is this subacute endocarditis associated Membrano-proliferative GN?

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jus2234  The question describes how he had a strep infection 15 days ago, and now this is poststreptococcal glomeruloneprhitis, which can also be described as proliferative glomerulonephritis +13
seagull  The question would be too fair if it just said PSGN. Instead we need to smell our own farts first. +73
yotsubato  And they used terminology NOT found in FA +8
water  who said they were limited to FA? +5
nbmehelp  FA uses the common nomenclature and the fact most of our other resources use the same nomenclature for this, I think we can agree that is is the accepted terms. If they're gonna decide not to use the nomenclature that most medical students are taught then they should provide their own study materials at that point for us to use. The test shouldn't be this convoluted for no reason. +11
alimd  Ok. They can use terminology whatever they want. But BUN-CR>20 is CLEARLY prerenal right? +2
an_improved_me  I think you're talking passed each other. The fact of the matter is that NBME doesn't really care how we prepare. It cares to stratify students using whatever stupid metrics it deems necessary. It's not limited to first-aid, and that doesn't mean that it shouldn't be. +3
utap2001  Not only RBC cast, but the BUN/Cr ratio>20 can help rule out other possibility. BUN/Cr>20 -> pre-renal-> PSGN. AIN or ATN are renal or post-renal. +1

 -1  upvote downvote
submitted by โˆ—azibird(279)

Why are there lots of RBCs but few RBC casts? That made me think about a post tubule process.

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boostcap23  Any amount of RBC casts is an abnormality and indicates tubular pathology. Normally should have none. Just like how even a single neutrophil in CSF is abnormal. +2

 -6  upvote downvote
submitted by โˆ—nwinkelmann(366)

So actually.... Medscape says that PSGN can progressive to a proliferative glomerulonephritis mechanism and so proliferative glomerulonephritis should be considered as a differential diagnosis for PSGN. "The presence of acute kidney injury may suggest an alternate diagnosis (eg, membranoproliferative glomerulonephritis [MPGN], Henoch-Schรถnlein purpura [HSP], systemic lupus erythematosus [SLE]) or a severe or worsening APSGN, such as observed in those with crescentic glomerulonephritis or rapidly progressive glomerulonephritis... Differential Diagnosis: This includes most other types of childhood glomerulonephritides. These include IgA nephropathy, membranoproliferative glomerulonephritis, hereditary nephritis, and other forms of postinfectious glomerulonephritis."

Ironically enough, this must be what they were asking, i.e. complications of PSGN, because AMBOSS (another Step resource) directly linked the above article I found before looking farther and coming across the AMBOSS section.

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