Clin Med - Nephro/GU
causes of ATN
1. Ischemic (prerenal AKI, surgery, dehydration, shock) 2. Nephrotoxic (aminoglycosdies, contrast, post crush injury(rhabdo), uric acid, hemolysis
Lab results for a post-operative oliguric patient reveals an increased BUN to creatinine ratio. The patient has a low fractional excretion of sodium (less than 1%). Which of the following is the most likely diagnosis? A. prerenal azotemia B. acute tubular necrosis C. acute glomerulonephritis D. obstructive uropathy
A
Which of the following agents can be used as a urinary analgesic? A. Phenazopyridine (Pyridium) B. Oxybutynin (Ditropan) C. Finasteride (Proscar) D. Imipramine (Tofranil)
A
In order to prevent the progression of diabetic nephropathy which of the following medications should be instituted? A. Lisinopril (Prinivil) B. Propranolol (Inderal) C. Verapamil (Calan) D. Hydrochlorothiazide (Diuril)
A (ACE slow progression of CKD)
Which of the following is a cause of acute kidney failure due to prerenal azotemia? A. Excessive diuresis B. Urinary tract obstruction C. Radiologic contrast media D. Aminoglycosides
A (B is postrenal, C/D are intrinsic)
An elderly appearing adult male patient is transported to the emergency room with unconsciousness for an underdetermined amount of time. There is no family and the only history is provided by the paramedics. The patient arouses to verbal and painful stimuli. VS: T-97.0 degrees F rectally, P-52 bpm, R-10, BP-95/60 mmHg. Physical examination is unremarkable except for ecchymosis across his extremities. A Foley catheter is inserted draining a small amount of dark brown urine. Urine dipstick reveals 4+ positive hemoglobin and protein. Microscopic urinalysis reveals no RBCs but many renal tubular epithelial cells and renal tubular casts. Drug screen is negative, blood alcohol is 2.5 mg/dL, and creatinine is 4.9 mg/dL. What is the most likely diagnosis? A. Rhabdomyolysis causing acute renal failure B. Obstructive uropathy causing acute renal failure C. Ethanol ingestion causing acute renal failure D. Methanol ingestion causing acute renal failure
A (blood in urine but no RBCs, granular casts/epithelial cells (ATN))
A 38-year-old male presents with fever, perineal pain, and dysuria. On physical examination, the patient is toxic- appearing, febrile, and his prostate is very tender to palpation. Laboratory testing reveals leukocytosis, pyuria, and bacteriuria. Which of the following is the treatment of choice for this patient? A. Ciprofloxacin B. Ceftriaxone and doxycycline C. Azithromycin + Ceftriaxone D. Nitrofurantoin
A (fluoroquinolone)
TX of choice to slow progression of CKD
ACE
A 30-year-old man comes to the emergency department because of blood in his urine for 2 days. He has also been feeling unwell, with a sore throat, running nose, cough, and fever. Medical history includes 3 episodes of hematuria in the past that have spontaneously resolved. His temperature is 36.7°C (97.9°F); pulse is 80/min; respirations are 18/min, and blood pressure is 145/90 mm Hg. Examination is non-contributory. Urinalysis shows moderate numbers erythrocytes, a few leukocytes, red cell casts, and a large amount of protein. No bacteria are cultured. Renal biopsy demonstrates large dark mesangial deposits. What is most appropriate initial treatment?
ACE inhibitor (pt has IgA nephropathy)
AKI that presents with hematuria, dysmorphic RBC, proteinuria
AGN
what two disorders present with crescents on biopsy? How do you distinguish them?
ANCA associated GN, good pasture's ANCA has NO immune deposits good pastures has IgG deposits
Muddy brown granular casts + epithelial cells
ATN
A 15 year-old male patient presents with oliguria, hematuria, proteinuria, and fatigue following streptococcal pharyngitis 2 weeks ago. What is the most likely diagnosis?
Acute glomerulonephritis (post infectious GN)
A urinalysis performed during a routine physical examination on a 43 year-old male reveals 1-2 hyaline casts/HPF. The remainder of the UA is normal. Based upon these results, the physician assistant should A. collect a urine for culture and sensitivity B. do nothing, since these casts are considered normal C. refer the patient to a nephrologist D. schedule the patient for a CT scan
B (Hyaline casts are not indicative of renal disease. They can be found following strenuous exercise and with concentrated urine or during a febrile illness.)
A 20-year-old Japanese man presents with gross hematuria, hypertension, and edema. He has had nasal congestion, runny nose, cough, and painful swallowing for the past two days. His past medical history is significant for diabetes mellitus type 1. Urine analysis shows severe proteinuria (2 g/day) and hematuria. Renal biopsy reveals immunoglobulin A and C3 deposition on the mesangium. Administration of which of the following medications is the most appropriate next step? A. Azathioprine B. Lisinopril C. Methylprednisolone D. Mycophenolate mofetil
B (IgA nephropathy)
A 15 year old boy comes to your clinic after having a sore throat, he wasn't treated. He now has hematuria, pretibial edema and hypertension. What antibody do expect on lab findings? A. ANCA B. ASO C. ANA D. Anti GBM
B (post streptococcal glomerulonephritis)
A 28-year-old female comes to the office with fever, flank pain, and dysuria for the past two days. Which of the following urinalysis results are suggestive of acute pyelonephritis? A. Hyaline casts B. Red cell casts C. White cell casts D. Granular casts
C
A 28-year-old man is reviewed on the surgical ward because of oliguria for 12 hours. The patient had an emergency splenectomy 1 day ago for a ruptured spleen after being involved in a motor vehicle accident. Temperature is 36.8°C (98°F), pulse is 87/min, respirations are 18/min, and blood pressure is 102/64 mm Hg. Examination shows a midline laparotomy scar and marked abdominal hematoma. Laboratory tests show low haemoglobin and elevated serum creatinine. Which of the following is the most likely diagnosis? A. Acute glomerulonephritis B. Bladder calculi C. Acute tubular necrosis D. Renal vasculitis E. Acute tubulointerstitial nephritis
C (ATN can occur post surgery)
A 14-year-old girl comes to the emergency department because of worsening fatigue, nausea and vomiting for the past day. For the past week she has been receiving outpatient treatment of intravenous gentamicin for an infectious exacerbation of her longstanding bronchiectasis. She has type 1 diabetes and self-manages her insulin administration. She is afebrile, pulse is 92/min, respirations are 16/min, saturation is 96% on room air, and blood pressure is 142/86. An arterial blood gas shows pH 7.1, PaCO2 22 mmHg, PaO2 85 mmHg, and HCO3 14 mEq/L. Further blood results show an elevated serum blood urea nitrogen (BUN), creatinine and urea. Which of the following is the most likely diagnosis? A. Acute pyelonephritis B. Chronic kidney disease C. Intrinsic acute kidney injury D. Pre-renal acute kidney injury E. Post-renal acute kidney injury
C (ATN due to aminoglycoside)
A 26 year-old woman comes to the office for her first prenatal visit at 9 weeks gestation. During evaluation, her urinalysis reveals asymptomatic bacteriuria. Which of the following antibiotics is the preferred treatment in this patient? A. Doxycycline B. Trimethoprim (Monotrim) C. Nitrofurantoin (Macrobid) D. Erythromycin
C (other options are PCN or keflex)
A 15-year-old girl comes to her pediatrician because she has had blood in her urine. She is otherwise healthy, with the exception of a sore throat approximately 2 weeks before. Review of systems is notable only for swollen ankles, which she denies having experienced before. On physical exam, her blood pressure is 145/85 mm Hg and she has 1+ lower leg edema bilaterally. Which of the following serum studies is most likely to be elevated? A. Amyloid B. Anti-glomerular basement membrane antibodies C. Anti-streptolysin O D. C3 Complement E. Immunoglobulin A
C (post infectious GM: complements would be low)
Which antibodies are seen in patients with granulomatosis with polyangiitis?
C-ANCA, PR3-ANCA
A 52 year-old patient presents with fatigue, complaints of paleness, anorexia, nausea, and weight loss. The patient also complains of numbness in his hands and feet and a recent occurrence of foot drop. He has a past history of diabetes and hypertension. Based on his clinical presentation, what disorders is most likely to be responsible for this clinical picture?
CKD (commonly due to HTN/DM, presents with anemia (pallor), n/v/anorexia due to uremia)
A 73-year-old woman comes to the emergency department due to fever and chest pain that worsens when she lies down. She also reports fatigue and anorexia for the past five weeks, though she has remained thirsty. She has had hypertension for the past 20 years. Her temperature is 37.7°C (99.9°F), pulse is 84/min, respirations are 18/min, and blood pressure is 167/98 mm Hg. Physical examination shows a pale, frail, ill-appearing lady. She has flaking skin on her arms and legs that look like they have been scratched extensively. On auscultation, heart sounds are muffled.
CKD (uremic pericarditis, anemia, HTN, bone disease)
When the diagnosis of gonococcal urethritis is confirmed, what is the treatment of choice?
Ceftriaxone
•59 y old man presents with hematuria and edema. Past history significant for recurrent palpable lesions on her legs associated with arthralgias. Exam reveals crops of palpable purpura. UA reveals proteinuria 4+. •Labs: +ANA, Anti DsDNA negative. •Hep Bs Ag and Ab negative. Hep C Ab positive. C3 normal, C4 low
Cryoglobulinemia
A 4-year-old boy is brought into the pediatrician's office by his mother because she says that his eyes have started to "look puffy" over the past week. She also feels like picking him up has been more difficult recently because he's been feeling "heavier" than usual. In general, the boy has been healthy, with only occasional upper respiratory tract illnesses, and the most recent one resolved a couple weeks ago. Physical examination shows periorbital edema and 2+ ankle edema, with a small fluid wave on the abdominal exam. A urine dipstick reveals no leukocytes, no erythrocytes, and no epithelial cells; no nitrates, no ketones, no glucose; however, the protein is 4+. Given his presentation, which of the following would you most likely expect to see on laboratory analysis? A. Hyperalbuminemia and elevated calcium concentrations B. Hyperalbuminemia with hyponatremia C. Hyperalbuminemia with low serum complement concentrations D. Hypoalbuminemia and hyperlipidemia E. Hypoalbuminemia with decreased IgM and IgG concentrations
D
Of the following, which is more commonly recognized as a secondary cause of nephrotic syndrome? A. Sjögren syndrome B. Cushing disease C. Hemolytic anemia D. Amyloidosis
D
Which of the following diagnostic findings is most likely to be found on urinalysis in a patient diagnosed with glomerulonephritis? A. Muddy brown casts B. Oval fat bodies C. Protein excretion of 3.2 g/day D. Red blood cell casts
D
Which of the following signs and symptoms is typically noted in patients with acute cystitis? A. Fever and chills B. CVA tenderness C. Flank pain D. Frequency and dysuria
D
A 65 year-old patient presents with hypertension and peripheral edema. Urinalysis reveals pale urine, with a specific gravity of 1.002, 2+ protein, trace glucose, and is negative for red blood cells and leukocytes. Serum electrolytes include BUN of 58 mg/dl and creatinine of 4.5 mg/dl. These are unchanged from previous results obtained 3 months and 6 months ago. Of the following, what other laboratory abnormalities would you expect? A. Hypercalcemia B. Metabolic alkalosis C. Hypophosphatemia D. Anemia
D (CKD: hyperphosphatemia, metabolic acidosis, hypocalcemia)
Which of the following medications is most likely to cause acute tubular necrosis? A. Trimethoprim-sulfamethoxazole (Bactrim) B. Acetaminophen C. Cephalothin (Kefzol) D. Gentamicin
D (aminoglycoside or radioconstrast)
Which of the following can be used to treat chronic bacterial prostatitis? A. Penicillin B. Cephalexin (Keflex) C. Nitrofurantoin (Macrobid) D. Levofloxacin (Levaquin)
D (fluoroquinolones or bactrim)
MC cause of prostatitis
E. coli (>35), think chlamydia or gonorrhea if <35
associated with APO1 gene in African Americans, HTN, obesity, and heroin abuse
FSGS
kidney biopsy will show sclerosis
FSGS
A 64-year-old woman comes to the emergency department because of sinusitis, a runny nose, and hemoptysis for the past 3 months. The nasal drainage is often purulent and occasionally contains blood. The patient has also experienced new joint pains and fatigue during the same time-period. Examination shows tenderness to percussion over the maxillary sinuses; however, is otherwise non-contributory. Urinalysis shows 3+ microscopic hematuria and 2+ proteinuria. What is the diagnosis?
GPA
A 38-year-old woman comes to the emergency department because of shortness of breath and cough, productive of blood-tinged sputum for 3 days. She has been unresponsive to antibiotic therapy from her family doctor. Her temperature is 38.0°C (100.4°F), pulse is 92/min, respirations are 18/min, and blood pressure is 110/68 mm Hg. Laboratory studies show an elevated erythrocyte sedimentation rate (ESR) and circulating cytoplasmic anti-neutrophil cytoplasmic antibodies (c-ANCA). Urinalysis shows dysmorphic red cells and red blood cell casts. What is the diagnosis? What antibodies are most likely to be found in the patient's serum?
GPA (+ CANCA, upper and lower resp sx, constitutional sx, hemoptysis) Anti-proteinase-3 antibodies (PR3)
RBC casts suggest
Glomerulonephritis
MC causes of CKD
HTN, DM
A 4-year-old boy is brought to the emergency department by his mother because of a 1 day history of rash. She says that he had Streptococcal pharyngitis several weeks ago, but was in his normal state of health until 5 days ago when he began complaining of right hip pain. This subsided and was replaced by right knee and ankle pain one day ago. At the same time, he developed a rash of dark red spots scattered on his legs, buttocks, and forearms. He also began complaining of nausea and stomach pains 2 hours ago. Physical examination shows a purpuric rash located in dependent areas, and a swollen right knee without effusion, erythema, or warmth. Urinalysis shows microscopic hematuria with proteinuria. Serum electrolytes, including creatinine, are within normal limits. What is the most likely diagnosis?
Henoch Schonlein Purpura (MC in children following an infection : presents with joint pain, abd pain, palpable purpura)
A 7-year-old boy comes to the clinic because his mother has noticed "bumps on his bottom" since last week. He has no major past medical history. He is unvaccinated due to his parents' personal preferences. He says that both of his knees hurt him. His mother reports that he has had a stomach ache that has come and gone a few times since yesterday. Physical examinations shows diffuse tenderness of the abdomen to palpation, but no distention or masses. A dermatologic survey reveals palpable purpura over the buttocks and upper thighs. Complement levels are normal. What is the diagnosis and tx?
Henoch Schonlein Purpura (MC in children: presents with joint pain, abd pain, palpable purpura) tx is supportive
What condition presents with nephritic disease and characteristic skin manifestations on the lower extremities and buttocks?
Henoch-Schönlein purpura.
A 9 year-old boy who has had cold-like symptoms for the past few days is brought to the clinic by his mother who states that her son had gross hematuria this morning. Prior to the cold-like symptoms the boy has been in excellent health. He is up-to-date on all of his immunizations. The patient does not have any edema, hypertension or purpura. Urinalysis reveals the urine to be cola-colored with a 2+ positive protein and 2+ hemoglobin. Microscopic analysis reveals 50-100 RBCs/HPF, no WBCs, bacteria, casts or crystals. What is the most likely diagnosis
IgA nephropathy (24-48 hrs post URI)
A 23-year-old woman comes to the office because of bloody urine for 2 days. She has no dysuria nor abdominal pain, and her last menstrual period was 2 weeks ago. She had an upper respiratory tract infection a few days previous to the start of these new urinary symptoms, and remembers having similar episodes of hematuria in the past, but she never previously sought medical attention for them. Urinalysis is positive for moderate levels of blood and mild levels of protein. What is the diagnosis? What diagnostic test has the highest sensitivity and specificity for this condition? What will it show?
IgA nephropathy (gross hematuria 24-48 hrs after URI/GI inf) Renal biopsy: IgA depositis in mesangium
A 15-year-old boy comes to the office because of blood in his urine for 2 days. He has had this symptom twice before with previous respiratory infections and there is no recent history of trauma. There is no urinary frequency, urgency, dysuria, or penile discharge. Medical history includes an upper respiratory tract infection which he is currently recovering from. Physical examination shows that the external genitalia appear normal, and there is no abdominal or scrotal tenderness. Urinalysis shows moderate hematuria. What is the most likely diagnosis?
IgA nephropathy (hematuria 24-48 hrs post URI)
BUN: Cr < 10:1.
Intrinsic failure
A 3-year-old boy is brought in by his parents to the clinic complaining of foamy urine. The parents deny tea-colored or foul-smelling urine. Physical examination shows a boy with swelling around the periorbital region and ankles. Renal biopsy shows no discernible abnormalities on light microscopy but electron microscopy shows a blunting of the foot processes of the podocytes. What is the most likely diagnosis?
MCD
A 5-year-old girl comes to the pediatrician's office because of edema in her lower legs, ankles, and feet. The edema is less apparent in the morning and worsens throughout the day. The patient's mother states that the patient had suffered from an upper respiratory infection the previous week. Her temperature is 36.8°C (98.3°F), pulse is 102/min, respirations are 26/min, and blood pressure is 84/60 mm Hg. Examination shows pale lower extremities that exhibit 2+ pitting edema. Urinalysis was positive for fatty casts and negative for hematuria. Urine protein was 4.9 g/24 h. What is the dx and tx?
MCD (children post viral infection, nephrotic - edema+ proteinuria > 3.5) steroids
what meds do you want to avoid in ckd?
NSAIDS/contrast
cause of prerenal AKI vs. intrinsic AKI vs. postrenal AKI
PRE: reduced renal perfusion (hypovolemia, CHF, liver failure, NSAID/ACE) INTR: direct kidney damage (ATN, AGN, AIN) POST: obstruction (BPH, stone, cancer)
A 23 year old male comes to the office because of shortness of breath and cough, as well as occasional hemoptysis. He has peripheral edema. Urinalysis shows proteinuria(< 3.5 g) and a sediment with dysmorphic red cells, white cells, and red cell and granular casts. Blood serology test shows antibodies to the glomerular basement membrane. What is the appropriate treatment for this disease?
Plasmapheresis combined with prednisone and cyclophosphamide (good pasture's syndrome: sn of GN and pulmonary hemorrhage)
BUN:Cr > 20:1
Pre-renal
FENa < 1
Pre-renal
diagnostic of choice for urethral stricture
RUG + VCUG
A 54 year-old woman with history of lupus comes to the office with increasing significant peripheral edema over the past four days. Laboratory findings include marked proteinuria, hypoalbuminemia and hyperlipidemia. What diagnostic study is the best for determining the cause of the proteinuria?
Renal biopsy (new onset of nephrotic syndrome, determines the cause of the proteinuria and to guide management decisions.)
tx for patients with metabolic acidosis due to CKD
Sodium bicarb
70-year-old man presents to his family physician complaining of back pain and frequent urination. The patient's medical history is unremarkable. Upon rectal examination a firm nodule in the patient's prostate is noted. What is diagnostic of choice and appropriate treatment?
TRUS w/ biopsy radical prostatectomy or radiation therapy depending on METS
tx of post infectious GM
abx + supportive care
When performing a rectal examination, prostatic massage is contraindicated in
acute bacterial prostatitis
MC type of prostate cancer
adenocarcinoma
What diagnostic findings in the urinary sediment is specific for a diagnosis of chronic renal failure?
broad waxy casts
A 66-year-old man comes to the primary care office because of fatigue and polyuria for the past month, as well as hematuria for the past day. After some laboratory results and a renal biopsy, he is diagnosed with chronic kidney disease. What would be most likely in this patient's lab findings?
broad waxy casts elevated BUN:CR low GFR (<60) proteinuria low EPO
patient will present with cyanosis of the nose, ears and digits, and Raynaud phenomenon. Hx of Hep C. low complement (LOWER C4 than C3). What is the dx and tx?
cryoglobulinemia treat underlying disorder (Hep), immunosupression
A 50-year-old man comes to the office because of foamy urine for 6 weeks. He states that he used to get a little foam in the past when rapidly emptying a full bladder, however recently he has been getting foam whenever he urinates, regardless of amount or time of day. His medical history includes osteoarthritis, gout, and type II diabetes mellitus. His temperature is 36.8°C (98°F), pulse is 87/min, respirations are 18/min, and blood pressure is 152/89 mm Hg. Examination shows decreased fine sensation on both feet bilaterally. There is also a skin ulcer on the left hallux which appears to have been there for some time. Laboratory investigations show there are no erythrocytes on urinalysis, and that the albumin/creatinine ratio is 42 mg/mmol. What is the most likely diagnosis? Tx?
diabetic nephropathy glycemic control + ACE
A patient has been followed for 3 years with a continual decline in glomerular filtration rate (GFR). Currently the GFR is 10 ml/min and examination of the patient reveals a pericardial friction rub. What is the most appropriate intervention at this time?
dialysis (in ESRD + uremic pericarditis)
causes interstital nephritis
drugs (nsaid, pcn, sulfa, phenytoin), infection/autoimmune (SLE, strep, CMV, sjogrens, sarcoidosis)
5 major signs of nephritic syndrome
dysmorphic RBC RBC casts proteinuria HTN progressive renal dysfunction (rising Cr)
Tx of prerenal AKI
fluids
A 24-year-old man comes to the clinic because of recent-onset hemoptysis. He felt well until three days ago, when he developed an upper respiratory tract infection with cough, nasal congestion, and rhinorrhea. His temperature is 37°C (98.6°F), pulse is 104/min, respirations are 18/min, and blood pressure is 170/100 mm Hg. Physical examination shows no other abnormalities. Laboratory studies show: normal complement and high BUN:Cr. Urinalysis shows dysmorphic RBC and RBC casts. Chest radiograph shows bilateral fluffy pulmonary infiltrates. Biopsy shows IgG deposits. What is the most likely diagnosis?
good pasture's syndrome
common complications fo CKD
hyperkalemia metabolic acidosis hyperphosphatemia hypocalcemia bone disease uremic encephalopathy uremic pericarditis anema/coagulopathy
a 63-year-old man with shortness of breath and confusion. Over the past week he has had to sleep in his recliner due to feeling short of breath while supine. Medical history is significant for chronic obstructive pulmonary disease and a prior myocardial infarction requiring coronary artery bypass grafting. On physical exam, the patient is altered but able to follow commands. There is jugular venous distension, an S3 heart sound, and 2+ lower extremity pitting edema. Laboratory testing is significant for a brain natriuretic peptide 950 pg/mL and serum sodium of 130 mmol/L.
hypervolemia
a previously healthy 11-year-old boy presents to the emergency department with a 3-day history of nausea, anorexia, weakness, abdominal pain, and an episode of vomiting. He has no history of fever, diarrhea, constipation, respiratory or urinary symptoms, or use of laxatives or diuretics. Physical examination reveals a thinly built boy with signs of sunken eyes, slightly dry mucous membranes, and generalized skin hyperpigmentation. He is afebrile, with a capillary refill time of less than 2 seconds, blood pressure of 94/68 mm Hg, and a heart rate of 116 beats/min. His weight is 32 kg (70.5 lb) (weight loss of 6% in the previous 3 days).
hypovolemia
AKI that presents with fever + maculopapular rash
interstitial nephritis
wbc casts + eosinophils suggests
interstitial nephritis
FENa > 1
intrinsic (ATN)
urine Na >20 suggests
intrinsic AKI (ATN)
A 27-year-old woman comes to the office because of fatigue, joint pains, and a facial rash for 3 weeks. She states that pain and swelling in her knees makes it difficult to walk normally in the morning, however it seems to improve a little over the day. Her medical history is noncontributory. Her temperature is 37.8°C (100°F), pulse is 87/min, respirations are 18/min, and blood pressure is 152/88 mm Hg. Examination shows erythema affecting the cheeks and bridge of the nose. There are also bilateral knee effusions, and pitting peripheral edema to the ankles. Urinalysis shows abnormal levels of protein and erythrocytes.
lupus nephritis (class III/IV nephritic due to hematuria)
A 36-year-old man comes to the clinic because of progressive swelling in all of his limbs for the past month. He initially thought that he had been consuming too many salty foods, but the swelling has worsened despite restricting sodium in his diet. His current medications include ibuprofen for chronic back pain. His temperature is 37.0°C (98.6°F), pulse is 83/min, respirations are 16/min, and blood pressure is 138/86 mm Hg. Physical examination shows a palpable liver edge 2cm below the right costal margin and anasarca. Laboratory blood studies are positive for the presence HBsAg and negative for Anti-HBsAg. Urinalysis shows 4+ protein and a follow-up 24-hour urine collection shows a loss of 4.1g of protein. A kidney biopsy is performed and shows thickened capillaries and glomerular basement membrane on light microscopy with subepithelial deposits seen on electron microscopy. What is the most likely diagnosis? Tx?
membranous nephropathy (assoc with Hep B, biopsy will show GBM thickening and subepithelial deposits steroids + cyclophosphamide
A 55-year-old man comes to the emergency department because of dyspnea, a productive cough with scarce mucoid sputum and blood. A year ago, he developed a fever, fatigue, and muscle pain. More recently, he experienced some hematuria and edema in his legs. He has a history of diabetes and hypertension. His temperature is 39.2°C (102.5°F), pulse is 118/min, respirations are 21/min, and blood pressure is 139/98 mm Hg. Bilateral diffuse wheezes are heard on auscultation. Chest radiographs shows diffuse infiltrates with an interstitial and alveolar pattern. Computerized tomography of the chest shows areas of bilateral ground glass appearance with micro-nodules. A biopsy of the kidney shows advanced sclerosis with formation of crescents. An anti-neutrophil cytoplasmic antibody (ANCA) investigation using indirect immunofluorescence was positive and disclosed a perinuclear pattern (p-ANCA). What is likely the cause of the patient's symptoms? What is the tx?
microscopic polyangitis (+P ANCA, dyspnea, hemoptysis, constiutional sx, crescents on biopsy) steroids+cyclophosphamide
orchitis is associated with what disorder?
mumps
nephritic or nephrotic: hematuria, proteinuira (<2.5) HBP, raised JVP, RBC casts, abrupt onset, edema, cola colored urine, oliguira
nephritic
nephritic or nephrotic: heavy edema, severe proteinuria > 3.5, low serum albumin
nephrotic
A patient presents with edema, which is most noticeable in the hands and face. Laboratory findings include proteinuria, hypoalbuminemia, and hyperlipidemia. The most likely diagnosis is
nephrotic syndrome
a 6-year-old boy who is brought to the emergency department by his mother due to swelling around his eyes and legs. The mother reports that the patient recently recovered from an upper respiratory tract infection. Physical exam is significant for periorbital and lower extremity edema. Laboratory testing is significant for hypoalbuminemia and normal complement levels. Urinalysis demonstrates 4+ protein and fatty casts with "maltese cross" sign.
nephrotic syndrome (most likely MCD: child following viral infection)
Hyaline casts in urine
non specific, can be normal
A 9-year-old boy is brought to the office because of "tea-colored" urine and puffiness around his eyes for 2 days. His father states that two weeks ago, his son had a rash for five days on his face. The rash started as a cluster of "pimples" that popped and dried into a yellow crust. His temperature is 37.5°C (99°F), pulse is 72/min, respirations are 14/min, and blood pressure is 134/86 mm Hg. Urinalysis shows dark colored urine, many red blood cells, and protein. Serum testing shows low levels of complement factor C3. What is the most likely diagnosis?
post infectious GM (1-3 weeks following impetigo, low complement, dark urine)
A 5-year-old female is brought to the office by her mother because of "coke colored" urine for a day. Three weeks ago, she was given antibiotics for impetigo. Past medical history is non-contributory. Her temperature is 36.5°C (97.7°F), pulse is 72/min, respirations are 14/min, and blood pressure is 134/86 mm Hg. Urine microscopy demonstrates dysmorphic erythrocytes and red blood cell casts. The result of a 24-hour urine collection is 2.6 g of protein/24 hr. Which of the following is the most likely diagnosis?
post infectious GN (impetigo 3 weeks ago, nephritic sx)
AKI that may present with abdominal pain + urinary symptoms (change in frequency/flow)
postrenal
urine Na < 20 indicates what type of AKI
pre renal AKI
A male patient complains of chronic dysuria, frequency, and urgency with associated perineal pain. The most likely diagnosis is
prostatitis
urethritis is associated with what disorder?
reactive arthritis
A 21 year-old female presents with dysuria. On examination of the urine, many squamous epithelial cells are noted. What is the next best step in the evaluation or treatment of this patient?
recollect sample, many squamous epithelial cells indicates poor collection/contamination
A 59-year-old man with a history of hypertension presents to his primary care physician for blood pressure management. He has tried lisinopril, hydrochlorothiazide, and losartan, and had minimal effect. He has a strong family history of cardiovascular disease. Physical examination is notable for a bruit in the right flank. Routine bloodwork shows an elevated creatinine. Preparations are made for a doppler ultrasound of the renal arteries.
renal artery stenosis
blood in UA but NO RBCs indicates
rhabdo or hemolysis
blood in urine, but no RBCs on microscopy points to
rhabdomyolysis or hemolysis
A 7-year-old male presents to the clinic because of generalized swelling. The patient was recently diagnosed with a respiratory infection and is currently taking antibiotics to treat it. Otherwise, his history is unremarkable. Physical examination shows edema, but is otherwise normal. Urinalysis shows proteinuria, no red blood cells, no red cell casts, no white blood cells, and no white blood cell casts. What is the most likely course of action at this point?
steroids (MCD common in children after viral infection, biopsy not necessary unless atypical)
a 56-year-old male with pain during urination, decreased urinary stream and incomplete bladder emptying. Uroflometry demonstrate poor bladder emptying and low peak rate of urine flow. What is the dx and tx?
urethral stricture urethral dilation/stent
diagnostic criteria for AKI
↑ serum creatinine of ≥ 0.3 mg/dL within 48 hours ↑ serum creatinine of 1.5 fold from baseline, Urine output is below 0.5cc/kg/hr for > 6 consecutive hours .
