GU REVIEW

Q 22.2: Which of the following types of renal calculi is associated with an infectious cause? A struvite B uric acid C calcium oxalate D cystine E calcium phosphate

A

A 9-year-old boy presents with headache and dark cola colored urine that appeared 2 days after a respiratory tract infection, for which he was given amoxicillin. He has microscopic hematuria and proteinuria. The rest of his past medical history and family history are non-contributing. Physical examination reveals elevated blood pressure (120/80), and the rest of the examination is normal. Urinalysis shows hematuria (the presence of erythrocytes and erythrocytes casts) and protein loss of 2.8 grams. Question What is the most probable diagnosis? Answer Choices 1 IgA nephropathy 2 Alport Syndrome 3 Amoxicillin side effect 4 Acute poststreptococcal glomerulonephritis 5 Hemolytic-uremic syndrome (HUS)

Both gross and microscopic hematuria a couple of days after nonspecific upper respiratory tract infection and hypertension in male patients are highly suggestive on IgA nephropathy (Bergers disease). IgA nephropathy is the most common chronic glomerular disease worldwide. It may also be associated with gastroenteritis, acute or chronic renal failure, or may be asymptomatic when erythrocytes (RBCs), RBC casts, and proteinuria are discovered on urinalysis. Some patients also have hypertension. Pathophysiological mechanisms are subendothelial deposits of amorphous material that lead to vascular occlusions, mechanical RBC, and platelet damage, resulting in prothrombotic state. Alport syndrome is hereditary X-linked dominant hereditary nephritis that will also present with hematuria (asymptomatic or gross) 1-2 days after upper respiratory infection. This progressive hereditary nephritis will, however, be accompanied with bilateral sensorineural deafness and visual problems (patognomonical extrusion of central part of lenses into anterior ocular chamber). Amoxicillin side effects are not probable. Amoxicillin side effects include nausea, vomiting, rashes, antibiotic-associated colitis, and diarrhea, in addition to more rare side effects such as mental changes, lightheadedness, insomnia, confusion, anxiety, sensitivity to lights and sounds, and unclear thinking. Even allergy to amoxicillin presents with a change in mental state initially, followed by itching skin rash, fever, nausea, and vomiting any time during the treatment up to a week after treatment has stopped. Acute overdose of amoxicillin may manifest with renal dysfunction, lethargy, and vomiting, but this usually happens in very young children. Acute poststreptococcal glomerulonephritis can present with the same clinical picture: sudden hematuria, edema, and hypertension, usually together with non-specific constitutional symptoms. However, there is always a latent period between the streptococcal infection and the onset of signs and symptoms of acute glomerulonephritis. Latent period is 1-2 weeks after a throat infection and 3-6 weeks after a skin infection. Hemolytic-uremic syndrome (HUS) is acute renal failure associated with non-immune (Coombs-negative) microangiopathic hemolytic anemia and thrombocytopenia. It is the most common cause of acute renal failure in children (though it may occur in adults as well). In HUS, there is usually a prodromal gastroenteritis, fever, or bloody diarrhea for 2-7 days before the onset of renal failure, sometimes with central nervous system signs (irritability, lethargy, even seizures). Acute renal failure with anuria follows. Physical findings may reveal hypertension, edema, fluid overload, and severe pallor.

22.15: Your patient returns to your office for a follow up for non-insulin-dependent diabetes mellitus (NIDDM). Her HgA1c in the office is 6.4%. She is concerned about developing kidney disease from her diabetes and requests that you test her for this. What initial screening test should you order that would provide clues to potential diabetic nephropathy allowing for treatment to slow the disease progression? A 24-hour urine for protein B serum BUN/CR C urine microscopic D urine microalbumin E serum protein

D The correct answer is (D). An easy office dipstick or laboratory test for urine microalbumin should be done initially and periodically on diabetic patients who are at risk for diabetic nephropathy. Treatment should be initiated if microalbuminuria is found to slow disease progression. A urine microscopic for renal casts may be helpful if the patient has symptoms of kidney disease, but is not an initial screening test. Serum BUN/CR and GFR are useful tests for patients with known diabetic nephropathy to indicate the stage of chronic renal failure but is not elevated early in the disease progression, before urine microalbumin. A 24-hour protein is not indicated in this case as an initial screening test.

22.5: You are evaluating a urinalysis on a 44-year-old female due to complaints of recurrent urinary tract infections (UTIs). Which of the following microscopic findings would be most suggestive of chronic kidney disease? A red blood cell (RBC) casts B hyaline casts C white blood cell (WBC) casts D broad waxy casts E granular casts

D The correct answer is (D). Broad waxy casts are suggestive of chronic kidney disease. RBC casts suggest glomerulonephritis. Hyaline casts may occur with heavy exercise or febrile illness. WBC casts suggest infection or inflammation such as in pyelonephritis. Granular casts, although nonspecific, may suggest acute tubular necrosis.

22.24: A 39-year-old male complains of intermittent episodes of hematuria over the past 6 months, which resolved spontaneously without treatment. He also has noted some dull bilateral flank discomfort recently that he attributed to a strain after moving. He denies any dysuria or penile discharge. He further denies any history of kidney stones. His mother died in her 60s of kidney disease that required dialysis. On examination his BP is 148/92, P = 68, T = 98.2˚F. His examination is unremarkable except for bilateral palpable enlarged kidneys. Urine dip is positive for +1protein. What diagnostic test would be most helpful to confirm your suspected diagnosis? A complete blood count (CBC) with diff B acute abdominal series C 24-hour urine protein D renal ultrasound E kidney-ureter-bladder (KUB)

D The correct answer is (D). This patient's history and physical examination findings are suggestive of polycystic kidney disease. His family history also suggests the potential for polycystic kidney disease, which is a common hereditary disease that may lead to end-stage renal disease (ESRD). A renal ultrasound is the preferred test to confirm the diagnosis revealing multiple renal cysts. Radiographs and labs, choices (A) and (C), can help in your differential diagnosis but are not diagnostic of polycystic kidney disease

22.49: You are doing your usual morning rounds with your supervising physician when you are called to the emergency department with a new admission. In room 7 of the emergency department you note an ill-appearing 72-year-old male with a diagnosis of acute renal failure due to postrenal azotemia. Which of the following would be the most likely cause of his postrenal azotemia? A renal artery stenosis B nonsteroidal anti-inflammatory drug (NSAID) use C massive bleeding D dehydration E bladder outlet obstruction

E The correct answer is (E). Postrenal azotemia is caused by an obstructive process of the bladder, urethra, or ureters. In this case the patient is likely to have bladder outlet obstruction as a cause of his postrenal azotemia. In older med with benign prostatic hypertrophy (BPH), the patient may present with n/v, abdominal pain, and bladder distension. Relief of the obstruction should relieve the patient's symptoms and potentially the acute renal failure. All other choices are suggestive of prerenal azotemia.

A 35-year-old woman presents with a 24-hour history of fever, right flank pain, vomiting, dysuria, and hematuria. A urinalysis reveals large amounts of red and white blood cells, as well as leukocyte esterase, and a subsequent urine culture was positive for >100,000 Escherichia coli. The patient denies having a history of renal calculi, and a bedside renal ultrasound does not show any stones or hydronephrosis bilaterally. She is diagnosed with a right-sided pyelonephritis and admitted for pain control, hydration, and IV antibiotic therapy. Her symptoms, including her fever, abate quickly, and she is discharged after 48 hours of being afebrile. Question Which prescription would she most likely receive upon discharge? Answer Choices 1 Motrin 800 mg PO q 8 hours prn pain 2 Nitrofurantoin 100 mg PO BID x 7 days 3 Ciprofloxacin 500 mg PO BID x 14 days 4 Levofloxacin 500 mg PO daily x 7 days 5 Amoxicillin 500 mg PO BID x 14 days

Explanation Ciprofloxacin 500 mg PO BID x 14 days is the correct answer. Patients with pyelonephritis who are sick enough to be treated as an inpatient receive IV antibiotics until they have been afebrile for 24 - 48 hours. They also need to be able to tolerate oral hydration and oral medications before being discharged. Upon discharge, they will be given a prescription for antibiotics that will complete at least 2 weeks of antibiotic treatment. Ciprofloxacin has good coverage for E. coli urinary tract infections, and given at 500 mg PO BID x 14 days would be an appropriate choice as long as sensitivities from her culture showed Ciprofloxacin to have sensitivity. Motrin 800 mg PO q 8 hours prn pain is not the correct answer. While motrin is a good choice for patients who may still have some discomfort related to the pyelonephritis, it is not the most likely prescription for this patient to receive. She had become asymptomatic prior to discharge, so there would not be any reason to prescribe anything to help with pain or discomfort at that time. In addition, she is more likely to receive treatment for her infection than for pain. Nitrofurantoin 100 mg PO BID x 7 days is not the correct answer for several reasons. While nitrofurantoin is often an appropriate antibiotic for E. coli urinary tract infections, it does not achieve tissue levels reliable enough for pyelonephritis treatment. In addition, only 7 days of treatment does not add up to at least 2 weeks total of antibiotics. Levofloxacin 500 mg PO daily x 7 days is not the correct answer. While levofloxacin is an appropriate antibiotic to treat E. coli pyelonephritis, 7 days of treatment is not long enough in this situation. Amoxicillin 500 mg PO BID x 14 days is not the correct answer. While 14 days of antibiotics is a good length of time, amoxicillin does not have good coverage for E. coli, so it would not be a good choice to treat an E. coli related pyelonephritis.

Your patient is a 65-year-old man presenting with a 3-week history of progressive leg swelling, dyspnea on exertion, and increased thirst. A couple days ago, he started having nausea, headache, vomiting, and his gait became unsteady. He does not have chest pain or shortness of breath at rest. His medical history is significant for hypertension, type II diabetes, and chronic kidney failure. His medications include a beta blocker/alpha-1 blocker (carvedilol), aspirin, angiotensin-converting enzyme (ACE) inhibitor (lisinopril), biguanide (metformin), and a loop diuretic (furosemide). Physical examination reveals bilateral pitting edema up to his knees, swelling in the face, peripheral pulses 2+ in all extremities, and an unsteadiness during Romberg testing with both eyes open and closed. Auscultation reveals bilateral crackles at the lung bases, and the rest of his physical examination is not contributing. Laboratory findings are: Test Results Reference Range (males) Sodium 125 mEq/L 135-145 mEq/L Potassium 3.1 mEq/L 3.5-5.0 mEq/L Chloride 97 mEq/L 95-108 mEq/L CO2 22 mmol/L 20-32 mmol/L Creatinine 2.6 mg/dL 0.7-1.4 mg/dL Blood urea nitrogen 40 mg/dL 7-30 mg/dL Fasting Glucose 189 mg/dL <110 mg/dL Serum osmolality 270 mOsm/kg H2O 280-295 mOsm/kg H2O Total protein 6.0 g/dL 6.0-8.5 g/dL Albumin 2.9 g/dL 3.5-5 g/dL Total bilirubin 1.1 mg/dL 0.1-1.3 mg/dl Alkaline phosphatase 90 IU/L 40-120 U/L Alanine aminotransferase 34 IU/L 0-35 U/L Aspartate aminotransferase 37 IU/L 0-37 U/L Urine Sodium <10 mEq/L Variable (depending on volume status) Red blood cell count 4 000 000/uL 4,7 000 000- 6,1 000 000/uL White blood cell 6.8 000 /mm 3.8000-10.8000/mm3 Hemoglobin 11.0 g/dL 13.8-17.2 g/dL Platelets 300 000/mm3 150 000-450 000/mm3 Question What is the most probable cause of his neurological symptoms and signs? Answer Choices 1 Hyponatremia 2 Hypokalemia 3 Hypervolemia 4 Hyperglycemia 5 Anemia

Explanation Nausea, headache, vomiting, unsteady gait, and Romberg showing vestibular disfunction are most probably caused by hyponatremia, the most common electrolyte abnormality in clinical practice.

A 42-year-old man presents with lower extremity swelling. His past medical history and review of symptoms is otherwise negative. The patient looks comfortable, with vitals showing the following: BP 142/91 mm Hg, HR 90 beats/min, RR 16 breaths/min, T 98°F, height 5'9'', and weight 158 lb. His examination is only remarkable for 2+ pitting edema in the lower extremities. The patient is counseled on a low-salt diet. The abnormal laboratory values are as follows: Lab Result Urinalysis 3+ protein, coarse granular casts, 2 - 5 WBCs, 0 - 2 RBCs Serum albumin 2.1 gm/dL Serum creatinine 2.0 mg/dL Serum BUN 18 mg/dL Hemoglobin 12.1 gm/dL Question What should be the next step in the management of this patient? Answer Choices 1 Obtain a urine culture and start ciprofloxacin empirically 2 Order an intravenous pyelogram to rule out a kidney stone 3 Repeat the urinalysis and observe patient 4 Order a 24-hour urine to quantitate urine protein 5 Order a renal biopsy

Explanation The clinical picture is most consistent with nephrotic syndrome. This syndrome is characterized by proteinuria in excess of 3.5 grams a day per 1.73 m3 body surface area. Other symptoms commonly seen include edema, hypoalbuminemia, and hyperlipidemia. Patients may also exhibit anemia. Usually there is not an active urine sediment. The correct diagnostic test to confirm nephrotic syndrome is a 24-hour urine to quantitate the protein loss.

A 27-year-old woman presents with a change in her urine color; the change occurred a few days ago and has persisted. Her vital signs are: blood pressure 145/90 mm Hg, pulse 82 bpm, respirations 16/min, and temperature 98.6° F. On physical examination, you note lower extremity edema. Urinalysis: Appearance: Pink and Cloudy Glucose: Negative Bilirubin: Negative Ketones: Negative Spec. Gravity: 1.035 Blood: 2+ pH: 6.5 Protein: Trace Urobilinogen: Normal Nitrite: Negative Leuk. Esterase: Negative Microscopic Examination: RBCs: 10 - 20 cells/hpf WBCs: 0 - 2 cells/hpf Question What is the initial diagnosis? Answer Choices 1 Nephrotic syndrome 2 Cystitis 3 Pyelonephritis 4 Nephrolithiasis 5 Nephritic syndrome

Explanation The clinical picture is suggestive of nephritic syndrome. Nephritic syndrome is classified as a glomerular disease; clinical findings include edema, hypertension, and hematuria. Clinical findings for nephrotic syndrome include large urine protein, peripheral edema, and low serum albumin. Large urinary protein is not present in this patient. Clinical findings in cystitis include the patient being afebrile, irritative voiding symptoms, and positive urine cultures. On urinalysis, leukocyte esterase is usually present with positive or negative nitrites; it has a cloudy appearance and may have a noxious smell. Microscopic exam may reveal WBCs and bacteria. These symptoms are not present in this patient. Findings with pyelonephritis include fever, flank pain, and symptoms similar to cystitis. These findings are not present in this patient. Patients with nephrolithiasis (kidney stones) present with flank pain that may be severe and occur suddenly; the pain may radiate to the anterior abdomen. Nausea and vomiting are also present. Patients tend to move constantly. These symptoms are not present in this patient.

A 75-year-old African-American woman presents for follow up of osteoarthritis, diet-controlled type II diabetes, and hypertension. She has taken ibuprofen PRN x 10 (osteoarthritis) and lisinopril (hypertension) for 15 years. Her last urine albumin to creatinine ratio was 180 mg/g. Her osteoarthritis is currently asymptomatic, and she has not taken ibuprofen for 2 months. In review of her laboratory results from earlier this week, you note that her most recent serum potassium was 5.8 mEqdl. Her blood pressure is 140/88. How should you treat her hyperkalemia? Answer Choices t 1 Sodium polystyrene sulfonate sorbitol, 30 g QD, for lisinopril and follow potassium 2 Sodium polystyrene sulfonate sorbitol, 60 g BID, for lisinopril and follow potassium 3 Substitute acetaminophen for prn ibuprofen and follow potassium 4 Advise patient to take 1 tsp of baking soda p.o.qd and follow potassium 5 Addition of diuretic to lisinopril and follow potassium

Explanation The correct response is addition of diuretic to lisinopril and potassium. This patient has not recently taken ibuprofen, making it an unlikely cause of her hyperkalemia. Ibuprofen and other non-steroidals can cause hyperkalemia by decreasing glomerular filtration rate, decreasing distal delivery of sodium (Na), thereby decreasing Na for potassium (K) exchange and flow for K excretion via flow-activated K channels. Sodium polystyrene sulfonate sorbitol is an exchange resin combined with a laxative. It exchanges potassium and sodium; it can be removed from the body in 4 - 24 hours if it produces a bowel movement. Many patients find it unpleasant tasting and do not like the laxative effect. It is possible that some patients would not want to take it daily. It is uncertain if bicarbonate administration would lower the potassium level. Lisinopril can elevate potassium by disrupting the renin-aldosterone-angiotensin system and inhibiting aldosterone-mediated potassium secretion. Presumably, this patient had a compelling indication (i.e., diabetes, albuminuria) to use lisinopril as a first-line blood pressure medication; African Americans without diabetes and or proteinuria might use diuretics or calcium channel blockers as first line antihypertensives. Goal blood pressures for patients >60 are generally less than 150/90 mm hg; the presence of proteinuria tightens this goal to less than 140/90 mm hg. The addition of a diuretic should increase distal delivery of sodium and assist with potassium excretion.

24-year-old man presents with gradual onset of scrotal pain. The pain is constant, and it lessens with elevation of the testicles. The patient developed a fever this morning. He has been voiding small amounts frequently, and he is also experiencing dysuria. The patient has a negative past medical history and past surgical history. He does not smoke, drink alcohol, or abuse illicit drugs. He is currently sexually active with a new partner. Examination reveals edema of the left testicle; there is tenderness to palpation. Cremasteric reflex is positive. Question What is the most appropriate intervention at this time? Answer Choices 1 Biopsy of the testicle 2 Testicular ultrasound 3 Insertion of foley catheter 4 Ciprofloxacin and doxycycline 5 Ceftriaxone and doxycycline

Explanation The patient is most likely suffering from acute epididymitis, so he should be treated with a single dose of IM ceftriaxone along with a 10-day course of oral doxycycline. Epididymitis is inflammation of the epididymis, the tube that connects the testicle to the vas deferens. Epididymitis is typically the result of infection. In younger, sexually active man, it is usually caused by Chlamydia trachomatis or Neisseria gonorrhoeae. In older man, epididymitis is associated with Gram-negative rods. Given the patient's age and sexual history, he should be treated with ceftriaxone, which will cover gonorrhea, as well as doxycycline, which is active against chlamydia.

hypevolemic hypotonic hyponatremic i couldn't paste the case study

Explanation This patient is in a hypervolemic hypotonic hyponatremic state. The hypervolemia can be identified primarily by history (edema and dyspnea) and physical exam (jugular venous distention, edema, and pulmonary effusion). The hypotonia (low serum osmolality) and hyponatremia most likely are due to a "dilution" effect, in which this patient's overall fluid status is high, but the sodium levels are normal or even elevated. This patient has hypoalbuminemia (common with chronic liver disease) and increased extracellular fluid, which is causing his mild pulmonary effusions and dyspnea. The most appropriate treatment for this patient is to begin intravenous or oral diuresis. Diuretics should be used with caution in patients with cirrhosis, but his pulmonary edema must be addressed. It would be potentially harmful to this patient to administer intravenous hypertonic saline solution, especially as his overall sodium level is likely normal to high. Hypertonic saline should only be used in acutely ill patients, with careful monitoring. Without prior records, it is difficult to assess any potential worsening in this patient's chronic cirrhosis. While it would be acceptable to advise the patient to contact his gastroenterologist for an appointment in addition to other interventions, it would not address his current hypervolemic hyponatremia or his pulmonary edema. With a complaint of shortness of breath, especially in a smoker, it could be rationalized to evaluate for a possible pulmonary embolus. However, he does not meet the Wells criteria for a PE (no suspected DVT, no tachycardia, no immobilization, no history of DVT/PE or malignancy, no hemoptysis, and alternative diagnoses are more likely than PE). Further evaluation for PE is not indicated. With severe electrolyte abnormalities, or those that do not respond to diuresis, it would be reasonable to initiate hemodialysis. This patient's abnormalities are not severe, and he is mildly symptomatic. A trial of diuresis is indicated before considering hemodialysis.

A 28-year-old man with no significant past medical history is rushed to the local trauma center following a stab wound to his chest. Paramedics report that there was significant blood loss. The patient has lost consciousness, is oliguric, and extremities are cool and moist to touch. His physical exam is also remarkable for tachycardia, tachypnea, a depressed systolic pressure, an immeasurable diastolic blood pressure. Question What is the preferred initial pharmacologic agent of choice for this patient? Answer Choices 1 Epinephrine 2 Hypertonic saline and dextran 3 Normal saline 4 Somatostatin 5 Vasopressin

Explanation This patient is presenting with signs and symptoms consistent with hypovolemic shock due to acute traumatic blood loss. 3 goals exist in the emergency department treatment of the patient with hypovolemic shock as follows: (1) maximize oxygen delivery - completed by ensuring adequacy of ventilation, increasing oxygen saturation of the blood, and restoring blood flow, (2) control further blood loss, and (3) fluid resuscitation. Current recommendations are for aggressive fluid resuscitation with lactated Ringer solution or normal saline in all patients with signs and symptoms of shock, regardless of underlying cause.

A 70-year-old man presents with a 3-month history of urinary leaking. He notes that he suddenly feels the need to urinate. He notes symptoms when at rest and when asleep; he has not had any symptoms when coughing or bearing down. He has not experienced urinary dribbling, dysuria, foul smelling urine, or fever. He has daily bowel movements. He has no other known medical problems, and he takes no medications. His temperature is 98 degrees Fahrenheit. His bladder is not distended, and he walks without difficulty. His post void residual is 30 ml. His rectal examination is normal, and his urinalysis is unremarkable. Question What is the most likely diagnosis? Answer Choices 1 Stress incontinence 2 Urge incontinence 3 Overflow incontinence 4 Mixed incontinence 5 Fecal impaction

Explanation This patient most likely has urge incontinence. In urge incontinence, patients typically have involuntary leaks, increased urinary frequency, and nocturnal incontinence either during or just after the sensation of needing to void. Symptoms are not exacerbated by increased abdominal pressure or the stress of coughing/sneezing. Bladder detrusor muscles may be overactive, leading to the unexpected release of urine. Treatments include scheduled voiding and anticholinergic medications (oxybutynin, etc.). Stress incontinence is characterized by the involuntary leaking of urine during stress or increases in abdominal and bladder pressure, such as coughing and sneezing. Bladder pressure at these times exceeds urethral pressure, allowing urine to leak through the urethra. Urinary tract deficits are found commonly in older patients; both men and women have decreased bladder sensation, decreased contractility, and involuntary bladder contractions, which predispose them to incontinence. Obesity, pregnancy, and vaginal births may increase the risk for stress incontinence. In such cases, the pelvic floor muscles may be insufficiently strong to support the urethra and overcome pressure of urine flowing from the bladder. Mixed incontinence refers to the presence of symptoms of both stress and urge incontinence. It may be seen in 1/3 of patients. Overflow incontinence refers to urinary leaks that occur due to an obstruction of urine flow. In the absence of urinary retention, post void residuals are typically elevated; normal post-void residuals in the absence of retention are less than 200 ml. His 30 ml post-void urine volume is not consistent with urinary retention. Initially, patients with urinary retention may experience dribbling after voids, straining, the sensation of a full bladder, and a constant urge to void. Prostatic hypertrophy, atonic bladders, etc. can impede urine flow. Once urine volume exceeds bladder capacity, it may spill out, causing a leak. Overflow incontinence may be distinguished from urge incontinence by urodynamic testing, and it may be treated with terazosin and finasteride. Many medical problems and medications can contribute to incontinence. Delirium, restricted mobility, urinary infection, fecal impaction, polyuria, and medications that decrease urethral pressure (e.g., alpha blockers, neuroleptics, and benzodiazepines) or increased bladder pressure (e.g. anticholinergics, beta blockers, anti-Parkinson's medications, and bethanechol) may contribute to incontinence. The normal rectal examination and the history of regular bowel movements make fecal impaction a less likely diagnosis in this case.

Question Ico-delete Highlights Your 52-year-old male patient has chronic renal failure on dialysis for 1 year. He is suffering from anemia and hypoproteinemia. He complains of bone pains, which have developed recently. Renal osteodystrophy is diagnosed after appropriate tests and you plan vitamin D therapy. What is the role of the kidneys in the synthesis of vitamin D? Answer Choices 1 Hydroxylation of 25-hydroxy vitamin D3 at the number 1 position 2 Hydroxylation of 1,-hydroxy vitamin D3 at the number 25 position 3 Activiation of cholesterol to cholecalciferol 4 Conversion of calcitriol to cholecalciferol 5 Providing the cholesterol for synthesis of vitamin D

Explanation Activation of Vitamin D is completed by the kidneys when they hydroxylate it at the number 1 position. The 25-hydroxy cholecalciferol is converted to 1, 25 dihydroxycholecalciferol (calcitriol) by the kidneys by 1-alpha-hydroxylase. This activates vitamin D for use in calcium and phosphorus uptake from the intestinal lumen. Hydroxylation of vitamin D3 at the number 25 position is accomplished by the liver. Cholesterol is activated to cholecalciferol by sunlight (UV light) in the skin. Once active, vitamin D3 is placed in the intestinal epithelial cells. Excess can be lost through the lumen. Cholecalciferol cannot be converted to calcitriol without the intermediate hepatic step. Calcitriol is not converted to cholecalciferol. Cholesterol is synthesized by the liver or from dietary sources.

Which one of the following organisms is the cause of epididymitis in young men under 35 years Answer Choices 1 N. gonorrhea 2 P. aeruginosa 3 C. acuminata 4 T. pallidum 5 H. ducreyi

Explanation The cause of epididymitis in young men under 35 years is usually sexually transmitted organisms such as N. gonorrhea and C. trachomatis. T. pallidum causes syphilis and H. ducreyi causes chancroid.

A 22-year-old man presents with fever and a transient maculopapular rash of 1 week duration. His serum creatinine and blood urea nitrogen (BUN) are elevated. The urinalysis is significant for hematuria, pyuria, white blood cell casts, and eosinophiluria. What is the most likely diagnosis? Answer Choices 1 Acute tubular necrosis 2 Diabetic nephropathy 3 Hypertensive nephrosclerosis 4 Interstitial nephritis 5 Lupus nephritis

Explanation The clinical picture of fever, recent etiological exposure (e.g., drugs, infection), maculopapular rash with serum and urinalysis findings of elevated creatine, elevated BUN, hematuria, pyuria, white blood cells casts and eosinopiluria is suggestive of interstitial nephritis. Interstitial nephritis typically occurs following medication administration, but can also occur in response to viruses or bacterial infections. It is an allergic reaction of the kidney that results in fevers, rash, arthralgias, hematuria, and eosinophilia. The eosinophils in the urine are pathognomonic for this disease. In acute tubular necrosis, the BUN and creatinine are elevated but the urinalysis may show a brown color. On microscopic examination, muddy brown casts (pigmented granular casts), epithelial cell casts, and renal tubular cells would be seen, which is not the case in this patient. There is no history of diabetes or hypertension in this patient; therefore, diabetic nephropathy and hypertensive nephrosclerosis are ruled out. Lupus nephritis is a complication of systemic lupus erythematosus. It is an autoimmune inflammatory disorder that affects many organs. 85% of patients are women. On urinalysis, hematuria and proteinuria are common findings.

A 69-year-old woman presents with a 3-month history of intermittent urinary incontinence. After further questioning, she reveals that she experiences leakage after having an intense need to void. Question This is an example of which of the following types of incontinence? Answer Choices 1 Stress 2 Urge 3 Overflow 4 Functional 5 Detrusor muscle underactivity

Explanation The correct answer is urge incontinence. It is defined as the inability to delay voiding when the urge to void is present. It is the most common type of incontinence and is due to detrusor muscle hyperactivity. Stress incontinence is leakage of urine with increased abdominal pressure that typically occurs with coughing, sneezing, etc. Overflow incontinence is due to detrusor muscle inactivity and it may be idiopathic or related to a nerve dysfunction causing neurogenic bladder. When the detrusor muscle does not contract effectively, the bladder becomes overfull and is at risk for leakage. The post-void residual urine is elevated in these cases as well.

Case Ico-delete Highlights A 13-year-old boy presents for an annual examination; he has no complaints about his health. Upon physical examination, his body temperature is 98.3°F, his blood pressure is 150/100 mm Hg, and he shows a slight periorbital puffiness. He explains that recently he has been staying up late to read and has noticed 'puffy eyes' in the morning. Urinalysis indicates light-brown urine, low-level proteinuria, and no bacteriuria. Question What is the most likely diagnosis? Answer Choices 1 IgA nephritis 2 Nephritic glomerular disease 3 Nephrotic glomerular disease 4 Orthostatic proteinuria 5 Urinary tract infection

Nephritic syndrome is characterized by low-level proteinuria and edema of the face. The syndrome is caused by lesions within the glomeruli that allow the escape of red cells into urine; the glomerular filtration rate decreases and fluid retention might cause hypertension. IgA nephritis is incorrect because there is no indication of prolonged or repeated urinary bleeding or sudden swelling of the hands and feet, which are symptoms of this more serious condition. Nephrotic glomerular disease is incorrect; the symptoms for nephrotic disease are similar to the ones for the nephritic syndrome, but there is massive proteinuria which leads to hypoalbuminemia, a condition in which large amounts of albumin are released in the patient's urine. Orthostatic proteinuria is incorrect because this condition occurs when the total protein in the urine is higher when a patient stands than when laying down or sleeping. There are no other symptoms, and it is not associated with any risk for renal disease. Urinary tract infection is incorrect because there is no evidence of bacteriuria or blood in the urine and the patient does not have any fever.

Case Ico-delete Highlights A 22-year-old woman develops fever, rash, arthralgias, and decreasing urine output 2 weeks after completing a course of penicillin to treat streptococcal pharyngitis. Her physical exam is normal. She takes no other medications or supplements and has no other past history or symptoms. Her laboratory work results are as follows: Total white blood cell count 7.0x103/cmm Eosinophils elevated Serum creatinine 1.5 mg/dl Serum potassium 4.0 meq/l Serum bicarbonate 23 meq/l Fasting Blood glucose 80 mg/dl Urinalysis no casts, no bacterial growth, 2 red cells per high powered field, numerous white cells, trace protein Erythrocytes sedimentation rate elevated Question What diagnostic study will confirm her diagnosis? Answer Choices Ico-marker Ico-abct 1 Renal ultrasound Ico-marker Ico-abct 2 Renal biopsy Ico-marker Ico-abct 3 Renal gallium scan Ico-marker Ico-abct 4 Urine eosinophil count Ico-marker Ico-abct 5 24 hour urine for creatinine clearance

Renal biopsy

22.20: A 20-year-old college football player presents with a chief complaint of a dull ache in his scrotum after prolonged standing on the sideline. It seems to get worse with vigorous activity and is relieved by lying down. Dilated veins in the left scrotum are observed on inspection, and both testicles are palpable and without masses. What is the most likely diagnosis? A varicocele B spermatocele C hydrocele D testicular mass

The Correct Answer is: A A varicocele can be recognized by the presence of scrotal enlargement caused by dilation of the pampiniform venous plexus. Varicoceles present as a "bag of worms" in the spermatic cord and are more prominent when the patient stands. More than 80% of the time, varicoceles occur on the left side. Hydroceles and spermatoceles are caused by fluid collection and are usually asymptomatic. Testicular masses must always be included in the differential diagnosis of scrotal masses, as they generally present as painless.

22.47: A 43-year-old female patient presents with back pain and hematuria. The patient reports having this problem earlier this year and recalls her previous clinician telling her, "they're just cysts." Denying any history of urinary tract infections, the patient reports her mother was on dialysis before passing away. The patient is afebrile and her physical examination is positive for diffuse back tenderness and bilateral flank masses with palpation. Urine dipstick is positive for 3+ blood and is negative for leukocytes and nitrites. What is this patient's most likely diagnosis? A adult polycystic kidney disease B renal cyst C horseshoe kidney D renal cell carcinoma

The Correct Answer is: A Adult polycystic kidney disease is a hereditary condition that almost always has a bilateral presentation (95% of the cases). It does not appear until after the age of 40, and dialysis or kidney transplantation is necessary for survival. Renal cysts and renal cell carcinoma generally present unilaterally. A horseshoe kidney (fusion of the renal tissue) may be palpated bilaterally; otherwise, the patient is asymptomatic.

22.32: A 53 year-old female is diagnosed with bladder cancer after an extensive work-up. Which pathology would be expected on her results, considering the most common cause of bladder cancer? A Urothelial (transitional) cell carcinoma B Squamous cell carcinoma C Adenocarcinoma D Clear cell carcinoma E Basal cell carcinoma

The Correct Answer is: A Baldder carcinoma pathology is transitional (urothelial) cell carcinoma (~90% of cases) (A); squamous cell carcinoma (B), (~7% of cases); adenocarcinoma (C), (~2% of cases). Clear cell carcinoma (D) and basal cell carcinoma (E) are not common findings in bladder cancer.

22.16: Which of the following is a potential complication of acute pyelonephritis? A perinephric abscess B renal vein thrombosis C allergic interstitial nephritis D struvite stones E hepatic failure

The Correct Answer is: A Because pyelonephritis is an infectious disease, the most likely complication is a perinephric abscess, which occurs as the result of inadequate therapy. Since it is not vascular in origin, renal vein thrombosis would not occur. Allergic interstitial nephritis is caused by an antigen-antibody reaction, which does not occur with acute pyelonephritis. Struvite stones are due to chronic infection with urease-producing organisms, such as Proteus and Pseudomonas, not to an acute infection. Hepatic failure can be a complication of acute renal failure, but not acute pyelonephritis.

22.39: Assuming that a patient has maintained a normal baseline creatinine of 1.0 mg/dL with a normal glomerular filtration rate (GFR) of 100 mL/min, which of the following indicates a more significant change in the GFR? A increase in creatinine from 1.0 to 2.0 mg/dL B increase in creatinine from 2.0 to 4.0 mg/dL C increase in creatinine from 4.0 to 8.0 mg/dL D increase in creatinine from 8.0 to 16.0 mg/dL

The Correct Answer is: A GFR describes the amount of blood passing through the kidneys per minute. There is an inverse relationship between GFR and serum creatinine. In a patient with normal renal function, doubling of the serum creatinine represents a loss of approximately 50% of GFR. Using this information, the loss of GFR can be estimated from changes in the serum creatinine. For example, assume normal creatinine levels of 1.0 mg/dL and normal GFR of 100 mL/min. A doubling of the serum creatinine from 1.0 mg/dL to 2.0 mg/dL represents an approximate reduction in GFR from 100 mL/min to 50 mL/min (50% of GFR has been lost). Each additional doubling of the creatinine decreases the remaining GFR by approximately one half. When renal function is severely impaired, large increases in the creatinine (ie, from 8.0 to 16.0 mg/dL) represent only small decreases in GFR (from about 12 to 6 mL/min). This example emphasizes the importance of detecting increases in serum creatinine early. However, serum creatinine level does not become abnormal until ˜25% of renal function is lost. Therefore, other methods of estimating GFR are more useful in detecting early decreases in GFR.

22.36: A 32-year-old man presents to the urgent care center with a concern of scrotal tenderness that began 3 days ago and has now worsened. Physical examination reveals a temperature of 100.7°F, positive tenderness in the posterolateral aspect of the right testis with swelling, spermatic cord tenderness with palpation, and no transillumination. What is this patient's most likely diagnosis? A epididymitis B orchitis C epididymo-orchitis D testicular torsion

The Correct Answer is: A Pain and swelling are prominent features of epididymitis; fever and abdominal pain may also be present. Epididymitis is caused by an ascending infection that without treatment will continue to the testicles, causing a significant swelling that will make it difficult for the clinician to distinguish between the epididymis and the testicles (epididymo-orchitis). Orchitis alone is most commonly viral (mumps) and observed in prepubertal boys. In men younger than 30 years, epididymitis can be confused with torsion

22.19: Which of the following are common adverse effects associated with aminoglycosides? A diarrhea and bone marrow depression B ototoxicity and nephrotoxicity C blurred vision and hyperglycemia D headache and hypoglycemia E rash and dyspepsia

The Correct Answer is: B All aminoglycosides are ototoxic and nephrotoxic. The likelihood of experiencing these toxicities occurs when treatment lasts beyond 5 days, at higher doses, in elderly patients, and those suffering from renal insufficiency. Other agents that produce either of these toxicities should not be used concurrently

22.33: A 57-year old male with hypovolemia and decreased cardiac output is diagnosed with acute kidney injury (acute renal failure). What is the most likely cause of acute kidney injury? A Prerenal azotemia B Ischemia-associated injury C Glomerulonephritis D Antibiotics E Postrenal acute kidney injury

The Correct Answer is: A Prerenal azotemia (A) is the most common form of acute kidney injury (AKI). Azotemia is a buildup of nitrogen waste products in the body, resulting in a rise in serum Cr or BUN concentration, due to inadequate renal plasma flow and intraglomerular hydrostatic pressure to support normal glomerular filtration. The most common clinical conditions associated with prerenal azotemia are hypovolemia, decreased cardiac output, and medications that interfere with renal autoregulatory responses such as nonsteroidal anti-inflammatory drugs (NSAIDs) and inhibitors of angiotensin II. Intrinsic AKI includes glomerulonephritis, ischemia (B), sepsis/infection, vascular injury, and nephrotoxins including antibiotics (D)/(C). Postrenal AKI (E) occurs when the normally unidirectional flow of urine is acutely blocked either partially or totally, leading to increased retrograde hydrostatic pressure and interference with glomerular filtration. Postrenal AKI includes bladder outlet obstruction.

22.45: Which of the following radiographic studies is indicated for the initial evaluation of a questionable palpable mass in the area of the kidney, with no other complaints by the patient? A renal ultrasound B intravenous pyelogram (IVP) C abdominal computed tomography D magnetic resonance imaging

The Correct Answer is: A Renal masses are initially identified by ultrasound. Ultrasound will be able to distinguish between a solid mass and a cyst. It is not uncommon to find some texts state that an intravenous pyelogram is noted as the initial test. Intravenous pyelograms have limited value, especially in differentiating small tumors. Whether a mass or a cyst, these findings are usually referred to a urologist who will follow-up with their own IVP and CT.

22.14: A 7-year-old male is suspected to have a Wilms' tumor (nephroblastoma). What is the most common symptom at presentation? A Abdominal mass B Hypertension C Hematuria D Coagulopathy E Fever

The Correct Answer is: A The diagnosis of a Wilms' tumor is most commonly made after the discovery of an asymptomatic mass, by a family member or a physician, during a routine physical examination. The most common sign is an abdominal mass (A). Other symptoms at presentation include abdominal pain and distention, anorexia, nausea and vomiting, fever (E) and hematuria. Hypertension (B) is seen in 25-60% of cases and is caused by elevated renin levels. As many as 30% of patients demonstrate hematuria (C) and coagulopathy (D) can occur in up to 10%.

22.40: A 32 year-old male presents to the emergency department in Acute Renal Insufficiency (AKI). Which of the following conditions would be most likely observed in intrinsic AKI? A Septic shock B Congestive heart failure C Benign prostatic hypertrophy D NSAID overdose E Chronic liver failure

The Correct Answer is: A The most common causes of intrinsic AKI are sepsis, ischemia, and nephrotoxins, both endogenous and exogenous. Prerenal acute kidney injury can be caused from hypovolemia, decreased cardiac output, decreased circulation of blood volume (CHF, liver failure), and impaired renal autoregulation (NSAIDs, ACE-I/ARB, cyclosporine)---(E), (D), and (B). Postrenal causes include bladder outlet obstruction including bladder stones and BPH (C).

22.34: A 56-year-old male patient is diagnosed with prostatitis. Which of the following is the least appropriate antibiotic to prescribe in the family practice setting? A ceftriaxone B doxycycline C levofloxacin D trimethoprim-sulfamethoxazole (TMP-SMX) E All are appropriate antibiotics for this patient in this setting.

The Correct Answer is: A The response to antibiotics in acute bacterial prostatis is usually prompt, perhaps because drugs penetrate readily into the acutely inflamed prostate Antibiotic selection should be guided by results of urine cultures and susceptibility results. Appropriate empiric antibiotics include a fluroquinolone (i.e.levofloxacin 500 mg once daily) or TMP/SMX (one double-strength tablet every 12 hours). Patients who are too ill for oral therapy or are septic on presentation should be hospitalized for initial parenteral treatment (intravenous quinolones with or without an aminoglycoside). Ceftriaxone would not be recommended as first-line.

22.60: A 51-year-old male patient presents to your family practice office complaining of genital discomfort with dysuria. His digital rectal exam reveals an enlarged, tender prostate. His prostate-specific antigen (PSA) returns elevated with a value of 11.1 mg/mL, which you fractionate, and this reveals approximately 75% free PSA. His urinalysis reveals moderate white cells and trace blood. What would be your next step in treating this patient? A Begin him on 6 weeks of doxycycline to treat his prostatitis and when resolved, repeat his PSA level. B Immediately refer him to a urologist for prostate biopsy to rule out prostate cancer. C Immediately refer him to a urologist for cystoscopy to rule out bladder cancer and perform a computed tomography (CT) scan of the abdomen and pelvis in the interim. D Order a stat testicular sonogram to rule out torsion. E Order a CT scan of the abdomen and pelvis.

The Correct Answer is: A This patient has signs and symptoms consistent with prostatitis. Additionally, while his PSA is elevated, this is common in prostatits as well as prostate cancer, and his free PSA is of a percentage that prostate cancer is unlikely. However, it would be prudent to recheck his PSA after treatment and resolution of his symptoms to confirm that an underlying cancer is not smoldering.

22.56: A 75-year-old woman, mother of four, presents to your office to establish care. Appearing healthy, she reports a past medical history positive for hypertension and denies any additional problems. However, when specifically asked she admits to having urinary incontinence for "a couple of years" and now describes symptoms that have recently worsened, with the patient experiencing the need to void almost hourly. These desires to urinate are so severe that she is now using four to five adult incontinence pads per day to manage the urine she leaks. What is the most likely diagnosis? A urge incontinence B stress incontinence C overflow incontinence D functional incontinence

The Correct Answer is: A Urinary incontinence is defined as involuntary urine loss. Urge incontinence is the result of uninhibited urge sensations that are so strong that the patient experiences an involuntary urine loss. Women particularly experience this problem with the changes associated with aging (weakened pelvic muscles secondary to childbirth as well as estrogen depletion causing weakening of the detrusor muscle). The problem may be worsened by the use of diuretics to treat hypertension. Stress incontinence is associated with increases in intra-abdominal pressure (laughing, sneezing, coughing, etc.). Overflow incontinence is associated with leaking small amounts of urine from mechanical factors that affect an already distended bladder. Functional incontinence is associated with patients who exhibit cognitive impairment (

22.18: A 14-year-old boy presents to the emergency department with acute scrotal pain and vomiting for the past 2 hours. His left testicle is in extreme pain and he states the pain started while playing basketball in gym class. Which diagnostic test would help confirm your suspected diagnosis? A Transillumination B Doppler ultrasound C Urine cultures and sensitivity D Radionuclide imaging E Serum human chorionic gonadotropin levels

The Correct Answer is: B Doppler ultrasound (B) is the diagnostic imaging of choice to confirm testicular torsion, with radionuclide imaging (D) a distant second. Testicular torsion is time sensitive and MRI or more invasive imaging may lead to the delay of surgical intervention. Time is critical (< 6 hours) for the salvage of the affected testicle. Transillumination (A) is seen in hydrocele fluid. Urine cultures and sensitivity (C) can confirm urinary tract infections or sexually transmitted diseases causing epididymitis. If an intrascrotal tumor is suspected, serum tumor beta-human chorionic gonadotropin levels (E) should be obtained.

22.50: A 65-year-old woman presents with a complaint of blood in her urine, intermittently for the last month. The patient denies any fever, chills, flank pain, or dysuria. Social history is positive for tobacco use (45 pack years), but patient reports stopping her tobacco use last year. What is the most likely cause of her hematuria? A urinary tract infection (UTI) B bladder cancer C renal calculi D pyelonephritis

The Correct Answer is: B Hematuria in women older than 60 years is consistent with a bladder malignancy. Bladder cancer causes episodic, gross hematuria that is usually painless. Cigarette smoking is a risk factor that also increases the incidence of bladder cancer. Painful hematuria associated with suprapubic discomfort or dysuria (or both) is more indicative of cystitis or calculi. Pyelonephritis is associated with chills, fever, and flank pain.

22.57: A 72-year-old man is transported via ambulance to the emergency department with severe chest pain and shortness of breath. Electrocardiogram (ECG) reveals ST-segment elevation in leads II, III, and aVF. While in the emergency department, he loses consciousness and is found to be in ventricular fibrillation. Resuscitation is successful, and a pulse is restored within 3 minutes. He is taken to the cardiac catheterization laboratory, where he undergoes two-vessel stenting. Two days later, his creatinine has increased from a baseline of 1.1 to 2.2 mg/dL. The next day, the creatinine is 3.9 mg/dL. Fractional excretion of sodium is ordered. You would expect this to be A <1 B >1 C unchanged from baseline D undetectable E equal to the serum creatinine level

The Correct Answer is: B Intrinsic ARF results in alterations in the kidneys' ability to respond to changes in hemostasis. When the integrity of the kidneys remains intact, sodium is conserved when GFR declines in an attempt to reestablish volume and perfusion, resulting in a fractional excretion of sodium (FENa) of <1. However, when the glomeruli are injured, the kidneys lose the ability to reabsorb sodium as the GFR decreases, and the FENa will be >1. The etiology of this patient's renal failure is most likely contrast-induced acute tubular necrosis following an ischemic episode, which is intrinsic ARF.

22.9: A 66-year-old man with a medical history of aortic stenosis is admitted to the hospital with increasing shortness of breath. Physical examination reveals a regular pulse of 120 beats/min, blood pressure of 95/50 mm Hg, and a respiratory rate of 32 breaths/min. The estimated jugular venous pressure (JVP) is greater than 15 cm, rales are heard halfway up the lung fields bilaterally, and a holosystolic murmur is heard at the apex. There is a tender enlarged liver with hepatojugular reflux and 2+ pretibial and pedal edema. Plain film of the chest reveals cardiomegaly and pulmonary edema. ECG is suggestive of left ventricular hypertrophy. Admission laboratory studies include the following: What type of hyponatremia does this patient most likely have? A hypovolemic hypotonic B hypervolemic hypotonic C hypovolemic isotonic D hypervolemic hypertonic E hypovolemic hypertonic

The Correct Answer is: B Most often, hyponatremia is due to excessive water retention rather than a true sodium deficiency. The first step in evaluating hyponatremia is to determine serum osmolality. Knowing whether the serum is isotonic (normal osmolality), hypotonic (low osmolality), or hypertonic (high osmolality) can help determine the etiology of the hyponatremia, and therefore, treatment. The most common causes of isotonic hyponatremia are hyperproteinemia and hyperlipidemia. The most common causes of hypertonic hyponatremia are hyperglycemia, presence of radiocontrast agents, and the presence of inactive metabolites, that is, mannitol, sorbitol, glycerol, and maltose.

: A 63-year-old male with type 2 diabetes mellitus and hyperlipidemia is being seen for routine blood work to assess his renal function. Blood pressure is 130/90 and pulse is 75. His blood chemistries show hypoalbuminemia and hypoproteinemia. His urinalysis shows urine protein excretion of 3.5 grams per 24 hours, microscopically shows oval fat bodies in the urine, and Maltese crosses under polarized light. Which of the following findings would support the suspected diagnosis? A Maculopapular rash B Peripheral edema C Jaundice D Hematuria E Costovertebral angle tenderness

The Correct Answer is: B Nephrotic syndrome is diagnosed with bland urine sedimentation, urine protein excretion > 3 g per 24 hours, hypoalbuminemia of < 3g/dl, peripheral edema, hyperlipidemia and oval fat bodies in the urine. Peripheral edema (B) is a hallmark sign of nephrotic syndrome, which occurs when the serum albumin concentration is < 3 g/dL (30 g/L). Edema is most likely due to sodium retention. Initially, this presents in the dependent areas of the body subject to gravity (lower extremities); such edema can become generalized as in periorbital edema. Patients can experience dyspnea due to pulmonary edema, pleural effusions and diaphragmatic compromise with ascites. In adults, roughly one-third of patients diagnosed with nephrotic syndrome also have a concurrent systemic disease such as diabetes mellitus, amyloidosis or systemic lupus erythematosus. Serum creatinine may or may not be abnormal at the time of presentation, depending on the severity, acuity and chronicity of the disease. Only nephrotic syndrome would show oval fat bodies in his urine. Maculopapular rash (A) is seen with scarlet fever, measles, and syphilis. Jaundice (C) is usually seen with liver abnormalities. Hematuria (D) is seen with glomerulonephritis. CVA tenderness (E) is seen with pyelonephritis

22.48: A renal ultrasound would be most beneficial for diagnosing which of the following? A nephrotic syndrome B polycystic kidney disease C glomerulonephritis D acute tubular necrosis E lupus nephritis

The Correct Answer is: B Renal ultrasound is useful for assessing kidney size and thickness of the cortex, and for the presence of masses, cysts, obstruction, and hydronephrosis. Intrinsic disease is best assessed by establishing the clinical context, analyzing the urine for protein, cells, and casts, and possibly by doing a biopsy. Loss of cortical thickness is a nonspecific finding, and ultrasound does not establish an etiology

22.17: When initially screening for CKD, which of the following would be ordered? A 24-hour urine collection B blood pressure measurement, serum creatinine level, spot urine protein measurement C renal ultrasound D abdominal CT scan E renal angiogram

The Correct Answer is: B Screening for the presence of chronic kidney disease involves checking a serum creatinine level, checking blood pressure for the presence of hypertension, checking urinary protein for evidence of glomerular injury, and obtaining a history to check for the presence of risk factors, such as hypertension, diabetes mellitus, autoimmune disease, infection, or family history. Initial screening would not include a 24-hour urine collection. This is a cumbersome, inconvenient, more expensive test than the spot urinary protein reading and would not provide additional information. Renal ultrasound and abdominal CT scan would not be indicated in the initial stages of the work-up. These would be done only after laboratory studies were done and only if indicated

22.28: The most common cause of nephrotic syndrome in children is A post-streptococcal glomerulonephritis B minimal change disease C diabetes mellitus D NSAIDs E polycystic kidney disease

The Correct Answer is: B The most common cause of nephrotic syndrome in children is minimal change disease. Diffuse injury to the capillaries is the underlying cause, resulting in significant proteinuria, edema, hypoalbuminemia, and hyperlipidemia. It accounts for 65% of cases of nephrotic syndrome in children; however, 10% of adults with nephrotic syndrome have minimal change disease. Treatment is with corticosteroids for 2 to 4 weeks, dietary sodium restriction, and sometimes diuretics to reduce the edema. Relapse and lack of response to corticosteroids can occur. If the latter occurs, renal biopsy is indicated to rule out other causes of the nephrotic syndrome, such as focal glomerulosclerosis and membranoproliferative glomerulonephritis

22.30: What is the chief complaint associated with bladder cancer? A pyuria B hematuria C dysuria D urinary frequency

The Correct Answer is: B The most common complaint of bladder cancer is painless hematuria, which occurs in 85% to 90% of patients. Additional symptoms of bladder irritability, and urinary frequency, urgency, and dysuria are the second most common presentation and are usually associated with invasive bladder cancer.

22.51: Which of the following best describes the mechanism of action of angiotensin-converting enzyme (ACE) inhibitors in controlling blood pressure and preventing or slowing kidney damage? A They result in systemic vasodilation. B They increase renal tubular excretion of sodium. C They result in dilation of the efferent arteriole, reducing glomerular pressure. D They block the angiotensin II receptor on the cell membrane. E They reduce production of angiotensinogen, the precursor to angiotensin I.

The Correct Answer is: C ACE inhibitors prevent the conversion of angiotensin I to angiotensin II, thereby interrupting the renin-angiotensin-aldosterone system, which regulates blood pressure. The glomerular efferent arteriole dilates, given the decreased stimulus from angiotensin II to constrict. This lowers pressure in the glomerulus by lowering resistance to outflow. This effectively results in a decrease in GFR, resulting in increased serum creatinine and potassium levels. However, these changes are not necessarily indications to discontinue the ACE inhibitor. Usually, the creatinine increases 0.2 to 0.4 mg/dL and then levels out. Monitoring serum creatinine and potassium levels is indicated. If only mild increases occur and stabilize, or if there are no changes, the ACE inhibitor can, and should, be continued so that the patient derives the beneficial effect of the decline in pressure within the glomerulus, which will slow down the progression of CKD.

22.61: A 68-year-old male patient presents to your office complaining of difficulty urinating, nocturia that is interfering with his sleep to the point where he is fatigued, along with lower back pain. On physical examination, his prostate is enlarged, irregular, and slightly tender. His U/A is normal. Of the following items that may be in your differential diagnosis must you pursue fully? A benign prostatic hypertrophy B prostatitis C prostate cancer D testicular torsion E urinary retention

The Correct Answer is: C Incidental or stage A (T1) carcinoma of the prostate presents no physical signs (it is nonpalpable) and is only diagnosed by the pathologist when prostate tissue is removed as treatment for symptomatic bladder outlet obstruction presumed to be caused by benign prostatic hyperplasia or is found by an elevated PSA (T1c). Patients with stage B (T2) or higher disease have a hard nodule on the prostate that can be felt during rectal examination. Previously, 50% of patients presented with evidence of metastases, including weight loss, anemia, bone pain (commonly in the lumbosacral area), or acute neurologic deficit in the lower limbs. Today, however, fewer than 20% of patients present in this way because of earlier diagnosis due to wide use of PSA screening (stage migration).

22.27: A patient presents to your family practice office with classic renal colic with his pain being a 6 on a 1 to 10 scale, with 10 being the worst pain imaginable. You refer your patient for a stat computed tomography (CT) scan of the kidneys. Your radiologist calls and advises that the CT reveals that your patient has a 4 mm stone at the ureterovesical junction (UVJ) on the left side without evidence of hydronephrosis. What should you advise your patient? A Go directly to the emergency department for admission. B Go directly to the emergency department for hydration and pain management. C Return to the office, administer ketorolac IM, give a prescription for an opioid, increase fluids, strain their urine, go to the emergency department if the pain worsens, and return in 48 hours for a reevaluation. D Go home, take four Motrin IB tablets every eight hours for pain, and go to the emergency department if the pain worsens. E Refer the patient for immediate lithotripsy.

The Correct Answer is: C Nonsteroidal anti-inflammatory drugs (NSAIDs) in general, and ketoralac specifically more so than other, causes constriction of the renal afferent arteriole, reducing pressure on a kidney stone and providing significant pain relief. Generally speaking a stone of less than 5 mm, especially at the UVJ, will pass relatively rapidly (within 48 hours) and the patient only needs to strain their urine to collect the stone and receive analgesia.

22.46: A 61-year old female patient who is a smoker is undergoing a routine physical examination in your family practice. She is otherwise asymptomatic but her urinalysis reveals microscopic hematuria. Your next definitive step would include which of the following? A Refer her for a spiral CT scan of the kidneys to ascertain where her renal calculi may be and to rule out hydronephrosis. B Repeat her urinalysis in the morning after asking the patient to hydrate with at least eight glasses of water in the interim. C Send her urine for cytology and refer her to a urologist to rule out bladder cancer. D Send her urine for a C&S and depending upon the result, start her on antibiotics E Start a course of levofloxacin to resolve her occult urinary tract infection.

The Correct Answer is: C Painless hematuria must always include bladder cancer in the differential diagnosis. Without another reasonable explanation—something that is not the case in this patient—bladder cancer must be ruled out, beginning with cytology and subsequent referral to an urologist.

22.38: A 17-year-old boy high school wrestler is brought into the emergency department after he collapsed at a wrestling match. He spent time fully clothed in a hot sauna prior to the match to try to "make weight." Labs are ordered, and results come back as follows: Which IV fluid regimen would most effectively treat this patient's hypernatremia? A quarter normal (hypotonic) saline B half-normal saline C isotonic (normal) saline D dextrose 5% in water E lactated Ringer's

The Correct Answer is: C The patient presents with a combination of inadequate fluid intake and excessive losses due to perspiration, resulting in hypovolemia and hypernatremia. The most common causes of hypernatremia are inadequate fluid intake resulting in hemoconcentration and diabetes insipidus (DI), resulting in excessive renal fluid losses. Normal urine osmolality is 500 to 850 mOsm/kg but can range from 50 to 1,200 mOsm/kg depending on the patient's fluid intake. Urine osmolality >400 mOsm/kg indicates that the renal fluid-conserving mechanism is intact, as the kidneys are working to preserve volume. A lower urine osmolality would be consistent with DI, characterized by a lack of response to anti-diuretic hormone (ADH), resulting in excessive urinary losses of water with worsening hypernatremia. Treatment is directed at the cause. If the patient is dehydrated, restoring fluid volume is the goal. If the patient has DI, treating the underlying disease will lower the serum sodium level. For this dehydrated patient, the treatment would be to administer isotonic (normal) saline, which contains 0.9% sodium, because of the large free water deficit. Quarter-normal saline contains 0.25% sodium, half-normal saline contains 0.45% sodium, and lactated Ringer's solution is similar to half-normal saline in its sodium content. Dextrose 5% in water (D5W) contains no electrolytes. Isotonic saline is the appropriate choice because it treats not only the volume deficit but the serum osmolality as well. Its osmolality (308 mOsm/kg) is often lower than the plasma osmolality because of the hypovolemic state and, therefore, helps restore normal serum osmolality. Once serum osmolality becomes more normal, the isotonic saline can be replaced by D5W to replace the remaining free water deficit. If the free water deficit were less dramatic, initial IV fluid treatment could be half-normal saline, followed by D5W

22.12: A 59-year-old female with history of non-insulin-dependent diabetes mellitus (NIDDM), hypertension, and chronic kidney disease (CKD) returns for follow-up of her labs. You note that she her GFR has decreased from 40 to 36 ml/min/1.73m 2 . What stage of chronic kidney disease is she currently? A 1 B 2 C 3 D 4 E 5

The Correct Answer is: C There are five stages of CKD. Stage 3 Chronic kidney disease is referred to as a moderately decreased GRF between 30-59 ml/min/1.73m 2 . All other choices reflect different ranges of GRF above or below

22.54: A 42-year-old woman, with a history of struvite renal calculus, calls the office with a complaint of a urinary tract infection. As part of the interview, she reports intermittent, mild right flank pain for 4 days. Her urine dipstick is positive for microscopic hematuria, and the urine pH is 7.5. The KUB film is positive with two visible stones in the right kidney. Which of the following organisms is most likely to be cultured from the urine specimen? A Escherichia coli B Klebsiella C Proteus D Chlamydia trachomatis

The Correct Answer is: C This patient has struvite stones. They are frequently associated with recurrent urinary tract infections, visible stones, and high urine pH. These stones are formed by urease-producing organisms including Proteus and Pseudomonas while being caused less commonly by Klebsiella. Struvite stones are not typically caused by E. coli and C. trachomatis.

22.29: A 66-year-old female patient presents to your family practice clinic for a complete physical exam. She is a smoker and you counsel her at length regarding smoking cessation. She is a well- controlled hypertensive taking lisinopril, along with an 81 mg enteric aspirin. You review her testing which reveals the following: • Comprehensive metabolic panel is normal. • Complete blood count is normal. • Urinalysis is normal, except for trace blood. • Fasting lipids are to goal. • Immunochemical fecal occult blood testing (IFOBT) is negative for occult blood. Of the following, what is a next appropriate step to take? A Schedule a colonoscopy to rule out colon cancer. B Refer her to pulmonary medicine for pulmonary function testing. C Refer her to a urologist to rule out bladder and renal cell carcinoma. D Stop her aspirin. E Send out her urine for culture and sensitivity, and in the interim start her on an empiric antibiotic.

The Correct Answer is: C Unless the patient has another reason to have hematuria, consideration should be made of the possibility of bladder or renal cell cancers, especially in a smoker. After ruling out other causes, the standard of care is to refer this patient to a urologist to rule out these potentially life threatening cancers.

22.10: Which of the following statements about anemia associated with CKD is TRUE? A Iron and folic acid by mouth are the most effective treatments. B Transfusion of packed red blood cells monthly is the most effective treatment. C IM erythropoietin given monthly is the most effective treatment. D It is due to the inability of the kidney to transform erythropoietin into its physiologically active form. E It occurs early in the course of CKD.

The Correct Answer is: D Anemia associated with CKD is the result of inadequate erythropoietin synthesis by the kidneys. This hormone signals the bone marrow to synthesize red blood cells. A deficiency will result in anemia. In the absence of erythropoietin, iron would not be of use since red blood cell synthesis is inadequate. Folic acid would also not be of use and does not play a role in the etiology of this type of anemia. Transfusion is a tempering measure only, used to increase oxygen-carrying capacity in the case of symptomatic ischemia. Anemia due to erythropoietin deficiency generally does not occur until the GFR decreases to <60 mL/min, or approximately 50% of normal. Intramuscular administration of erythropoietin is the only effective treatment to induce red blood cell production. Depending on the formulation used, this can be given once a week or once every 2 weeks. Oral iron supplementation is needed to produce adequate hemoglobin for the increased de novo red cell production

22.53: A 63-year-old male with type 2 diabetes mellitus and hyperlipidemia is being seen for routine blood work to assess his renal function. Blood pressure is 130/90 and pulse is 75. His blood chemistries show hypoalbuminemia and hypoproteinemia. His urinalysis shows urine protein excretion of 3.5 grams per 24 hours and microscopically shows oval fat bodies in the urine. The following lab results are within normal range: WBC, BUN, and creatinine. What is the suspected diagnosis? A Pyelonephritis B Glomerulonephritis C Acute renal failure D Nephrotic syndrome E Wilms tumor

The Correct Answer is: D Nephrotic syndrome (D) is diagnosed with bland urine sedimentation, urine protein excretion > 3 g per 24 hours, hypoalbuminemia of < 3g/dl, peripheral edema, hyperlipidemia, and oval fat bodies in the urine. In adults, roughly one-third of patients diagnosed with nephrotic syndrome also have a concurrent systemic disease such as diabetes mellitus, amyloidosis, or systemic lupus erythematosus. Serum creatinine may or may not be abnormal at the time of presentation, depending on the severity, acuity, and chronicity of the disease. Only nephrotic syndrome would show oval fat bodies in his urine. Glomerulonephritis (B) would should hypertension. Pyelonephritis (A) would show an increased WBC count. Acute renal failure (C) would show a change in BUN/creatinine. Wilms' tumor (E) is seen in children and does not have this presentation.

22.52: Which of the following is diagnostic of nephrotic syndrome? A hypoalbuminemia, hypolipidemia, proteinuria >10 g/24 h B hypoalbuminemia, hyperlipidemia, proteinuria >1 g/24 h C hypoalbuminemia, hyperlipidemia, proteinuria >2 g/24 h D hypoalbuminemia, hyperlipidemia, proteinuria >3.5 g/24 h E normal albumin, hyperlipidemia, proteinuria >10 g/24 h

The Correct Answer is: D Nephrotic syndrome is defined as proteinuria >3.5 g/24 h resulting in hypoalbuminemia (<3.0 g/dL), hyperlipidemia (total cholesterol >250 mg/dL), and edema, probably due to increased renal tubule permeability. Causes include diabetic nephropathy, HIV nephropathy, chronic hepatitis B and C, amyloidosis, systemic lupus erythematosus, constrictive pericarditis, Hodgkin's disease, minimal change disease, and many medications, including phenytoin and NSAIDs.

22.22: Which of the following U.S. Preventive Services Task Force (USPSTF) recommendations for prostate cancer is correct? A All African-American men over 40 years old should have a digital rectal examination (DRE) and a prostate-specific antigen (PSA) screening annually. B All patients should receive a DRE and PSA screening at 50 years of age. C All high-risk patients should receive a PSA screening annually starting at 50 years of age. D DREs are not recommended and PSA screening is recommended based upon patient risk, but only after discussing the benefits and risks with the patient and the patient expressing the desire to have the examination performed.

The Correct Answer is: D Prostate cancer screening in older men is a particularly challenging topic because significantly more older men die with prostate cancer than from it. Nonetheless, 92% of prostate cancer deaths occur in men who are older than 65 years. Although prostate cancer can be detected earlier via PSA testing, mortality from prostate cancer has not been reduced as a result of screening. The USPSTF has concluded that evidence to recommend for or against screening is lacking. Other organizations such as the American Cancer Society and American Urological Society recommend screening among those with at least a ten-year life expectancy. The matter is complicated by the fact that techniques to treat prostate cancer often greatly affect quality of life. Furthermore, we are not able to reliably predict whether a particular prostate cancer is life-threatening. Given the uncertainties, PSA screening should be reserved for the most robust of older men and only after a thorough discussion of the arguments for and against screening.

Which of the following laboratory findings will be observed in a patient with noninflammatory nonbacterial prostatitis? A positive bacterial culture from postmassage urine (chronic) B positive bacterial culture with expressed prostatic secretions (chronic) C negative bacterial culture with elevated leukocytes D negative bacterial culture with normal leukocytes

The Correct Answer is: D Prostatitis includes a continuum of prostate characteristics ranging from acute episodes to prostatodynia, a noninflammatory disorder. Patients with acute bacterial prostatitis will have an exquisitely tender prostate gland, and prostatic massage is contraindicated in these patients. Chronic prostatitis patients may have no evidence of an acute infection but will have increased leukocytes. Nonbacterial prostatitis is broken into two subcategories with the noninflammatory classification having neither bacteria nor leukocytes.

22.59: A 73-year-old male presents to clinic with a history of blood in his urine for the past month. He has mild irritation with voiding but denies any other symptoms except an unintentional weight loss of 20 pounds in the past 6 months. His past medical history includes hyperlipidemia, seasonal allergies, and fibromyalgia. He denies alcohol use and has a 22 pack-year history of tobacco use. Which risk factor supports your diagnosis? A Fibromyalgia B Hyperlipidemia C Seasonal allergies D Cigarette smoking E Age

The Correct Answer is: D Risk factors for bladder cancer include cigarette smoking (D) and exposure to industrial dyes and solvents. Age (E) is not a risk factor but the mean age of diagnosis is 73 years old and is more common in men than women (3.1:1). Fibromyalgia (A), hyperlipidemia (B), and seasonal allergies (C) have not shown any correlation to predisposing a person to bladder carcinoma.

22.44: You are asked to see a diabetic patient with retinopathy and hypertension. On examination, the patient's blood pressure is noted to be 180/90 mm Hg. Urinalysis shows microalbumin of 300 mg/dL. Labs: blood urea nitrogen 22 mg/dL, creatinine 1.5 mg/dL. Which of the following classes of antihypertensive medications would be best to prescribe in this setting? A calcium channel blocker B loop diuretic C alpha blocker D thiazide diuretic E ACE inhibitor

The Correct Answer is: E ACE inhibitors are the drug of choice in this setting. Control of systemic blood pressure can reduce renal vascular damage. In diabetic patients, ACE inhibitors are especially beneficial because of the added effect of reducing intraglomerular pressure and decreasing proteinuria. Current target blood pressure in patients with diabetic nephropathy is <130/80 mm Hg. Calcium channel blockers and diuretics do not offer renoprotective benefits but may be used to control hypertension. (American Diabetes Association, 2009, p. S28; JNC 7 Report, 2003; NKF-K/DOQI Guidelines, 2002, pp. 79-80; Watnick and Morrison, 2009, p. 819) American Diabetes Association . Diabetes care .

22.37: A 73-year-old male presents to clinic with a history of blood in his urine for the past month. He denies irritation with voiding or any other symptoms. He does state an unintentional weight loss of 20 pounds in the past 6 months. His past medical history includes hyperlipidemia, seasonal allergies, and fibromyalgia. He denies alcohol use and has a 22 pack-year history of tobacco use. On physical examination you note bilateral inguinal lymphadenopathy. Which of the following is the most likely diagnosis? A Benign prostate hypertrophy B Urinary tract infection C Prostatitis D Syphilis E Bladder carcinoma

The Correct Answer is: E Bladder cancer's presenting symptom is hematuria in 85-90% of patients (E). Clinical findings include masses detected on bimanual exam, lymphedema of the lower extremities, or palpable lymphadenopathy with advanced cancers. Urinary tract infections (B) and prostatitis (C) commonly cause discomfort with voiding. BPH (A) does not correlate with a 20-pound weight loss, smoking history, or lymphadenopathy. This history and physical examination do not show any signs of syphilis (D

22.26: A 63-year-old male with chronic kidney disease is in the ICU with bradycardia, flaccid paralysis, and an ileus. A stat work-up includes an ECG showing peaked T waves. Which lab finding would you suspect? A Hypomagnesemia B Hypercalcemia C Hypokalemia D Hypocalcemia E Hyperkalemia

The Correct Answer is: E Hyperkalemia (E), >5.0 mEq/L, usually occurs in patients with advanced kidney disease and impairs neuromuscular transmission including muscle weakness, flaccid paralysis, and ileus. ECG includes bradycardia, prolonged PR interval, peaked T waves, and QRS widening. Hypokalemia (C) can also present with flaccid paralysis or ileus but ECG findings show decreased and broadening T waves with prominent U waves. Hypomagnesemia (A) and hypocalcemia (D) have common symptoms of weakness and muscle cramps and can show prolonged QT intervals of ECG. Hypercalcemia (B) is often asymptomatic until >12 mg/dL, which includes constipation, polyuria, and nausea/vomiting, with ECG showing a shortened QT interval.

A man with suspected acute renal failure provides a urine specimen that demonstrates high urine osmolality, low sodium urine, and high BUN-to-creatinine ratio. The urine microscopic examination reveals few red blood cells and white blood cells with no casts. What is the most likely explanation? Answer Choices 1 Postrenal cause 2 Prerenal cause 3 Glomerulonephritis 4 Acute tubular necrosis 5 Interstitial nephritis

The clinical picture is suggestive of a postrenal cause. Common etiology includes obstruction of the urinary tract. Initial urine findings include high urine osmolality, low sodium urine, and a high BUN-to-creatinine level. The microscopic examination may be normal, but it also may contain red blood cells, white blood cells, or crystals. A prerenal cause would have hyaline casts present. Glomerulonephritis would have dysmorphic red blood cells and red blood cell casts on microscopic examination. Acute tubular necrosis would have pigmented granular casts and renal tubular epithelial cells on microscopic examination. Interstitial nephritis would have pyuria (including eosinophiluria), white blood cell casts, and white blood cells on microscopic examination. Patients may also present with fever and a transient maculopapular rash.

A 44-year-old diabetic woman presents with a 2-week history of lower extremity edema. She has no other symptoms. Physical examination of her lower extremities reveals bilateral 2+ pitting edema. Answer Choices 1 Cirrhosis 2 Cystitis 3 Pyelonephritis 4 Nephrotic syndrome 5 Nephritic

The clinical picture is suggestive of nephrotic syndrome. Peripheral edema is the hallmark of nephrotic syndrome; this occurs when serum albumin levels drop below 3 g/dL. Other findings include positive urinary protein (large amounts); oval fat bodies ('Maltese crosses') may be seen on microscopic urine exam. Clinical findings associated with cirrhosis include symptoms of weakness, easily fatigability, disturbed sleep, muscle cramps, and weight loss. In 70% of cases the liver is palpable. Jaundice is not an early sign, but a later symptom occurring when the disease progresses. Urine findings include darkened urine color, positive bilirubin, variable urobilinogen, and negative protein. These findings are not present in this patient. Clinical findings in cystitis include irritative voiding symptoms and positive urine cultures. On urinalysis, leukocyte esterase is usually present with positive or negative nitrites and a cloudy appearance. Microscopic exam may reveal WBCs and bacteria. These symptoms are not present in this patient. Findings with pyelonephritis include fever, flank pain, and symptoms similar to cystitis. These findings are not present in this patient. Nephritic syndrome can present with proteinuria, hematuria, azotemia, RBC casts, oliguria, and hypertension. These findings are not present in this patient.

22.55: A generally healthy, 20-year-old male complains of malaise, mild flank discomfort, and cola-colored urine for the past 24 hours. He denies any history of kidney stones. He does admit to having a sore throat and fever about a week ago that has since resolved. His BP is 160/94 P-92 and T is 97.2˚F. His urinalysis is positive for protein, RBCs, leukocytes, and RBC casts. His BUN (blood urea nitrogen) and CR are also elevated. A post-streptococcus glomerulonephritis B infectious mononucleosis C urinary tract infection (UTI) caused by resistant e-coli D pyelonephritis E metabolic syndrome

The correct answer is (A). This patient's history of sore throat and acute nephritic presentation lead to the most likely diagnosis of post-streptococcus glomerulonephritis . Infectious mononucleosis can cause a sore throat, but is not typically associated with the nephritic presentation above. UTIs and pyelonephritis may present with pyuria and hematuria, but would unlikely cause hypertension and elevated BUN/CR. Pyelonephritis would likely present with fever. Metabolic syndrome is not associated with a sore throat or any of these renal symptoms.

22.58: Your patient is a 70-year-old female who has a history of non-insulin-dependent diabetes mellitus (NIDDM), hypertension, chronic kidney disease (CKD), and gastroesophageal reflux disease (GERD). You receive a call that her potassium is elevated at 5.8 mEq/L. Last week you treated her for potassium of 6 mEq/L. Her current medications are listed in the following choices. Which of the following medications should you consider discontinuing due to persistent hyperkalemia? A acetaminophen B lisinopril C amlodipine D glyburide E omeprazole

The correct answer is (B). A potential complication of CKD, usually in the later stages, is hyperkalemia. Hyperkalemia can also be induced by ACE inhibitors such as lisinopril or ARBs and may need to be discontinued. Another antihypertensive that does not cause hyperkalemia may be substituted. The remaining choices are unlikely to cause hyperkalemia.

22.42: A 56-year-old male, with history of hyperlipidemia and non-insulin-dependent diabetes mellitus (NIDDM) presents to the emergency department with a history of increasing peripheral edema over the past week. On examination he is noted to have periorbital, scrotal, and +2 pretibial edema. His lungs are CTAB. He denies any chest pain or shortness of breath. Urine dipstick reveals 4+ protein. Urine microscopic reveals Maltese crosses consistent with lipiduria. Labs include a decreased serum albumin of 2 g/dl, decreased total protein of 5.5 g/dl, and normal glomerular filtration rate (GFR). What is the most likely diagnosis? A pyelonephritis B congestive heart failure (CHF) C nephrotic syndrome D prostatitis E Deep venous thrombosis (DVT)

The correct answer is (C). This patient has typical symptoms of nephrotic syndrome, which includes significant proteinuria, hypoalbuminemia, and typical presentation of edema. He also has a history of hyperlipidemia and laboratory findings of lipiduria, which is also common in nephrotic syndrome. Furthermore, his history of diabetes mellitus is also a potential cause of nephrotic syndrome. Pyelonephritis and prostatitis would present with urine WBCs and is not consistent with the laboratory findings or edema. CHF would more likely present with dyspnea, rales on exam, and peripheral edema but would unlikely involve the periorbital area. DVT would likely present with unilateral swelling of the LE, and discomfort and is not consistent with the laboratory findings above.

t a yearly history and physical examination of a male patient, digital rectal exam reveals an enlarged prostate. You would more likely suspect benign prostatic hypertrophy, rather than prostate cancer, if the patient's history also included what presentation? Answer Choices 1 68-year-old with a free prostate specific antigen of 5% 2 48-year-old African American who is asymptomatic 3 52-year-old with a prostate specific antigen of 10 ng/mL 4 62-year-old with a brother treated for prostate cancer 5 72-year-old Caucasian who complains of a poor urinary stream

The male patient most likely to have benign prostatic hypertrophy (BPH) is the 72-year-old Caucasian who complains of a poor urinary stream. BPH occurs in 90% of men >70 years old. It occurs in the periurethral zone of the prostate and usually presents with lower urinary symptoms (LUTS) that suggest obstruction (i.e. hesitancy, weak stream, intermittent stream, straining, incomplete emptying, post-void leaking) or irritation (i.e. nocturia, frequency, urgency). Risk factors for prostate cancer include men >50 years old or African American men >45 years old or a first-degree relative with prostate cancer. Prostate cancer most often develops in the peripheral zone of the prostate. Early prostate cancer is usually asymptomatic, but locally advanced prostate cancer may encroach on the central transition zone of the prostate and present with irritative urinary symptoms (i.e. nocturia, frequency, urgency). Laboratory findings suggestive of prostate cancer/BPH include: An elevated prostate specific antigen (PSA) >4 ng/mL: sensitivity of this value for prostate cancer is 57-79% In BPH, level of PSA is generally below 10 ng/dl, A rise in PSA >0.75 ng/mL per year would suggest prostate cancer

Case Ico-delete Highlights The effect of steroid therapy is evaluated in an 8 year-old African-American boy being treated for fatigue and generalized edema following a "bad cold". His vitals are T 37 C, pulse 90/min, RR 20/min and BP 110/70. Physical exam reveals presence of mild periorbital edema and marked peripheral edema in hands and feet with the remainder of exam within normal limits. Lab values include dipstick urine protein 3+; urine protein 50 mg/m2/hr (<40 mg/m2/hr) Specific gravity 1030 (1008-1020) Urine protein/creatinine ratio 2.0/gm creatinine (< 0.2/gm creatinine) Serum albumin 3.9 (5.9-8.0 gm/dl) Cholesterol 250 (112-247 mg/dl) Remainder of laboratory values including BUN and plasma creatinine are within normal limits. Question Ico-delete Highlights What additional treatment should be initiated in this patient to decrease the risk of chronic kidney disease? Answer Choices 1 Diuretics 2 Spironolactone 3 ACE inhibitor 4 Beta blocker 5 Mixed alpha + beta antagonist

The pediatric patient described is apparently suffering from nephrotic syndrome. Glomerular disease induced proteinuria is the most common cause of nephrotic syndrome in children due to damage to the glomerular filtration barrier resulting in leakage of plasma proteins into the glomerular ultrafiltrate. Signs and symptoms in children include edema, urine protein: creatinine ratio > 0.2/gm creatinine; heavy proteinuria (urine protein >40 mg/m2/hr), hypoalbuminemia, and hyperlipidemia. The nephrotic range of proteinuria in children is higher than in adults (> 40 mg/m2/hr). Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers not only lower blood pressure but have that additional benefit of slowing the progression of kidney disease even in patients with normal blood pressure. Although this child is normotensive and is already receiving steroid treatment, the next best additional treatment, therefore, is an ACE inhibitor or an angiotensin receptor blocker (ARB) to decrease the proteinuria and GFR decline in order to reduce the risk of chronic kidney disease. Diuretic is incorrect. Although a diuretic would provide symptomatic relief for the edema, it would not prevent the development of chronic kidney disease in this patient. Spironolactone is incorrect. Spironolactone is an inhibitor of renal aldosterone effects such as sodium and water retention and would help combat the edema in this patient but would not decrease the risk of chronic kidney disease. Beta blocker is incorrect. Beta blockers can be useful in the treatment of hypertension but this patient has not yet developed hypertension. Mixed alpha and beta antagonist is incorrect. The use of a mixed alpha and beta antagonist drug is not indicated in this normotensive patient and would likely not reduce the risk of chronic kidney disease.

Case Ico-delete Highlights A 19-year-old man presents with a 2-day history of heaviness and a dull aching discomfort in his right hemiscrotum. Upon questioning, he admits to having unprotected sex with a new partner about a week ago. On physical exam, the patient is found to have a markedly swollen and extremely tender right epididymis that is warm to the touch. An ultrasound reveals normal blood flow to both testicles, with increased blood flow to the right epididymis. Question What is the appropriate treatment for this patient? Answer Choices 1 TMP-SMX, 160 mg/800 mg PO q 12 hours for 4 weeks 2 Doxycycline, 100 mg PO q 12 hours for 2-3 weeks 3 Ciprofloxin, 500 mg PO q 12 hours for 5 days 4 Fluconazole, 150 mg PO for 1 dose 5 Nitrofurantoin, 100 mg PO q 12 hours for 2 weeks

This patient has a classic presentation for epididymitis. In sexually active men younger than 35 years, C. trachomatis and N. gonorrhoeae are the most common organisms. In older men and children, E. coli is the most common organism. This patient recently had unprotected sex with a new partner, so he more likely has a sexually transmitted cause of epididymitis. The most appropriate treatments for sexually active men are either doxycycline 100 mg PO q 12 hrs for 10-21 days or ceftriaxone 250 mg IM for 1 dose. For suspected non-sexually acquired epididymitis, the treatment is TMP-SMX (160 mg/800 mg) PO q 12 hours for 21-28 days. Non-sexually acquired epididymitis infections are typically associated with urinary tract infections and prostatitis. Testicular torsion can be ruled out with an ultrasound.

A 25-year-old woman develops fever and malaise 3 weeks after starting trimethoprim/sulfamethoxazole for treatment of a urinary tract infection. Her plasma total white count is 7x10 3/cmm, with elevated eosinophils on the differential. Her urinalysis shows many white cells, 2 white cell casts/high powered field, no red cells or casts, trace protein, and no bacterial growth. Her serum creatinine is 1.3 mg/dl. Her erythrocyte sedimentation rate is elevated. The remainder of her laboratory work is normal. What findings are expected on renal biopsy? Answer Choices 1 Tubulitis, interstitial infiltrate 2 Red cell casts in tubules 3 Kimmelstiel-Wilson nodules 4 Normal renal biopsy findings 5 Necrosis of proximal tubules

This patient has findings suggestive of acute interstitial nephritis (AIN) and most likely will have tubulitis and interstitial infiltrates noted if she undergoes a renal biopsy. AIN is an immune-mediated form of acute kidney injury (acute renal failure). Patients develop varying degrees of renal failure, characterized by changes in urine output, electrolyte imbalances, acidemia, and azotemia (elevations in serum creatinine with or without nausea, sleep disturbances, shakiness, etc.) in response to viral, bacterial, immunological, or pharmaceutical insults. A variety of antibiotics, ACE inhibitors, proton pump inhibitors, seizure medications, etc. are known to cause AIN. The development of AIN is not dependent on the size of the dose of the medication given. Many infections, including HIV, EBV, and mumps, can also cause AIN. Additionally, immunological diseases, such as lupus and Wegener's granulomatosis, can cause AIN. Diagnosis is made by history of exposure, findings if noted of rash/fever/arthralgias, and the presence of pyuria, white cell urinary casts, and elevated erythrocyte sedimentation rate. Urinary eosinophils may be noted, but may also occur in the setting of other bladder or renal abnormalities, so they are not specific. Treatment involves removal of offending drugs, treatment of infections, monitoring urine volume, and laboratories for the need for dialysis support. Steroids have been used if patients do not respond to the above within a few days, but they may not hasten recovery (Clarkson). Immunomodulatory therapy (e.g., cyclophosphamide) has also been used. Red cell tubular casts are suggestive of glomerulonephritis. Glomerulonephritis occurs secondary to infectious, immunological, and neoplastic processes. Kimmelstiel-Wilson nodules are characteristic of diabetic nephropathy. Diabetic nephropathy is a complex disease found in many type I and II diabetics. It is the leading cause of end stage kidney disease in the United States. Necrosis of proximal tubules is characteristic of acute tubular necrosis (ATN). ATN is a form of acute tubular injury more common in the inpatient setting. Medications, infections, and renal hypoperfusion secondary to sepsis +- cardiac failure may lead to injury of the renal tubules.

A 32-year-old man reports anorexia, constipation, fatigue, thirst, weakness, drowsiness, nausea, and muscle pain that has developed over the last few days. He has been bedridden for the last 3 months after a traffic accident wherein his 3 cervical vertebras were fractured. A few weeks ago, a diagnosis of kidney stones and chronic renal insufficiency was established. The rest of his personal and family history is noncontributing. His physical examination today demonstrates quadriplegia, and the rest of examination is within normal limits. Question While waiting for the laboratory results, you order an EKG, which you expect will probably reveal what? Answer Choices 1 Ventricular fibrillation 2 QT prolongation 3 Fusion of QRS-T 4 Torsades de pointes 5 Short QRS complex

Your patient has nonspecific symptoms, but the history of spinal cord injury, immobilization, kidney stones, and renal insufficiency suggests the presence of hypercalcemia. Prolonged immobilization may result in hypercalcemia, hypercalciuria, and osteoporosis because of the suppression of parathyroid-1,25-dihydroxyvitamin D axis. Hypercalciuria develops within the first week after injury and continues for 6 - 18 months. Hypercalcemia will occur when the rate of calcium resorption exceeds the capacity of urinary excretion. It usually happens 4 - 8 weeks after spinal cord injury. Children, adolescents, and persons with impaired renal function are particularly prone to hypercalciemia. Elevated calcium in an immobilized patient increases osteoclastic bone resorption because of the lack of signals from active muscles through the osteocytes. The release of calcium suppresses production of parathyroid hormone, resulting in increased serum phosphate and reduced synthesis of 1,25-dihydroxyvitamin D.