B4E2 - Practice Exam
A 70-year-old widower in a new relationship complains of sudden loss of erectile function. He reports no previous erectile difficulty, but ever since a recent and disappointing encounter, he has been unable to achieve satisfactory erections. Morning erections do seem better than those occurring during intercourse. He denies starting any new medications or prior urologic problems. He is saddened by his problem and appears visibly depressed. He has no known cardiovascular disease. Which element of his history most supports a psychogenic cause for his ED? A. Sudden onset B. Depressed affect C. Persistence of morning erections D. Absence of cardiovascular symptoms
A
A second-year PA student is researching the role of HPV in causing cancer. Which of the following types of cancer is HPV most commonly associated with? A. Anogenital B. Breast C. Lung D. Oral E. Prostate
A
A weight lifter seeks help from his physician after he has been disqualified for chronic anabolic steroid use. The physician decides to have lab work done in order to evaluate his current reproductive hormone levels. What abnormalities of GnRH, FSH, and LH would you expect to find? A. Decreased FSH, decreased LH, decreased GnRH B. Decreased FSH, decreased LH, increased GnRH C. Increased FSH, decreased LH, increased GnRH D. Increased FSH, increased LH, decreased GnRH
A
In which of the following cases would treatment with corticosteroids for biopsy-proven interstitial nephritis be most likely to impact long-term renal recovery? A. A 37-year-old woman with sarcoidosis B. A 48-year-old man with slowly progressing interstitial nephritis over 2 months with fibrosis found on biopsy C. A 54-year-old man with diabetes mellitus and recent Salmonella infection D. A 63-year-old man with allergic interstitial nephritis after cephalosporin antibiotic use E. None of the above
A
It is hospital day 5 for a 65-year-old patient with prerenal azotemia secondary to dehydration. His creatinine was initially 3.6 mg/dL on admission, but it has improved today to 2.1 mg/dL. He complains of mild lower back pain, and you prescribe naproxen to be taken intermittently. By what mechanism might this drug further impair his renal function? A. Afferent arteriolar vasoconstriction B. Afferent arteriolar vasodilatation C. Efferent arteriolar vasoconstriction D. Proximal tubular toxicity E. Ureteral obstruction
A
Neonatal circumcision is indicated for: A. Congenital phimosis B. Micropenis C. Hypospadias D. Ambiguous genitalia
A
On examination, you find a mildly disoriented female in no acute distress. She has lower extremity and sacral edema. You obtain urine studies, showing a specific gravity of 1.020, pH 6, 3 RBCs/hpf, 2 WBCs/hpf, and muddy brown granular casts. The urine creatinine is 6.5 mg/dL and the urine sodium is 45 mEq/L. You calculate the FENa at 10.65%. Given the clinical course and urine findings, which of the following is the best diagnosis? A. Acute tubular necrosis (ATN) B. Acute interstitial nephritis (AIN) C. Vasculitis D. Heart failure (HF) E. Lactic acidosis
A
The parents of a healthy 12-year-old girl bring her to you for a physical examination required for school sports participation. She was recently treated with antibiotics for a throat infection. Vital signs are significant for a blood pressure of 135/85 mm Hg. Urine dipstick testing is positive for blood. Microscopic examination of the urine reveals red cell casts. Family history is negative for renal disease. Which of the following is the most likely diagnosis? A. APSGN B. IgA nephropathy C. Benign familial hematuria D. Goodpasture syndrome E. Henoch-Schönlein purpura (HSP) nephritis
A
The results of a urinalysis include the following: markedly positive for leukocyte esterase. On microscopic examination of the urine, white blood cell casts are present in the urine. In addition, the nitrite test on the urine dipstick is positive. Which of the following clinical scenarios is most compatible with this set of results? A. Infection in the kidney B. Trauma from an auto accident with no apparent damage to the kidney C. Advanced bladder cancer D. Severe liver disease
A
What is the most appropriate next step in the evaluation and management of your patient with DM2, good glucose control (A1C 6.4), retinopathy and now moderately increased albuminuria? A. Start an angiotensin-converting enzyme (ACE) inhibitor B. Start an angiotensin receptor blocker (ARB) C. Order renal ultrasound with Doppler of the renal arteries D. Start insulin E. Order a 24-hour urine collection for total protein
A
Which of the following patients has the greatest risk of progression to chronic kidney disease? A. A 30-year-old man with an estimated glomerular filtration rate (GFR) of 50 mL/min/1.73 m2 and 350 mg/g of persistent albuminuria B. A 45-year-old man with an estimated GFR of 90 mL/ min/1.73 m2 and <30 mg/g of persistent albuminuria C. A 55-year-old man with an estimated GFR of 70 mL/ min/1.73 m2 and 100 mg/g of persistent albuminuria D. A 65-year-old woman with an estimated GFR of 65 mL/ min/1.73 m2 and <30 mg/g of persistent albuminuria E. A 75-year-old man with an estimated GFR of 35 mL/ min/1.73 m2 and <30 mg/g of persistent albuminuria
A
Your patient is a 55-year-old woman recently diagnosed with diabetes mellitus type 2. You would like to screen for microvascular complications related to her DM. What test is most appropriate to screen for diabetic nephropathy? A. Urine microalbumin excretion measurement B. Urine dipstick C. Serum creatinine D. Kidney ultrasound
A
Your patients albumin/creatinine ratio is 42 mg/g. The next step to confirm moderately increased albuminuria is: A. Repeat urine albumin/creatinine ratio B. Urine dipstick for protein C. 24-hour urine collection for total protein excretion D. Serum creatinine E. Referral to a nephrologist
A
A 55-year-old male presents to your office for evaluation of blood in his urine discovered incidentally during a life insurance physical. The urinalysis showed 2+ blood on urine dipstick and 2 RBC/hpf. The remainder of the urinalysis and microscopic examination was normal. After an appropriate history and physical examination, your first step in the evaluation of this urine abnormality is to: A. Repeat the urinalysis and microscopic examination B. Obtain urine for culture C. Order a renal ultrasound D. Order a CT scan of the abdomen E. Order an intravenous pyelogram (IVP)
A
A 57-year-old man presents with nausea, vomiting, and fevers for 1 day. He also complains of dark urine. He had burning micturition for 1 day a few days ago, along with colicky abdominal pain radiating to the groin. He had a similar episode 2 weeks ago that improved with levofloxacin 500 mg PO daily for 7 days. Urine culture was done at that time, but the results are not available. Physical examination is significant for a temperature of 102.6°F, heart rate of 116 bpm, BP 112/70 mm Hg, saturating 98% on room air, and respiratory rate of 20/min. There is costovertebral angle tenderness on the right. CBC is significant for elevated WBCs at 15,000 cells/mm3 with a left shift. Urine is dark with increased specific gravity, otherwise unremarkable. Urine and blood cultures are sent. What is the best next step of action? A. Admit to medicine floor, start fluids and IV meropenem, and obtain a CT of the abdomen and pelvis with renal protocol. B. Switch to PO ciprofloxacin and discharge home. C. Do a rectal examination, and if the prostate examination is unremarkable, discharge with PO Bactrim. D. Admit; call Urology and Infectious Disease consults for the management of pyelonephritis.
A
You decide to start finasteride for your patient with BPH. You see him again 2 months later when he presents with a febrile illness. He thinks that he might have the flu, but his BPH symptoms worsened at the same time. For the last 2 days, he has felt feverish with back pain, perineal pain, and generalized malaise. He complains of dysuria and worsening urinary frequency and urgency. During your examination, you make sure NOT to: A. Perform a rectal examination B. Massage the prostate C. Swab the urethra for chlamydia D. Perform urinalysis and microscopic examination of the urinary sediment
B
You get the patient through her episode of hypercalcemia and advise her to lay off the calcium-based antacids, favoring an H2-antagonist instead. As your patient's renal disease progresses over the years, you find that she has become anemic with a hemoglobin of 9.9 g/dL. She takes a multivitamin. Her iron studies are consistent with anemia of chronic disease and her screening colonoscopy last year was normal. The anemia is normocytic and normochromic. If you were to treat her with an erythropoietic agent (e.g., erythropoietin or darbepoetin), her target hemoglobin would be: A. 8 to 9 g/dL B. 10 to 11 g/dL C. 13 to 14 g/dL D. >15 g/dL
B
A 49-year-old female with a 5-year history of type 2 diabetes mellitus presents for an initial visit. She has no known complications of diabetes. She takes metformin, glyburide, and aspirin. On examination, you find a pleasant, obese female in no distress. Her blood pressure is 136/86 mm Hg. As you discuss monitoring her diabetes, you recommend screening for early kidney disease. Which of the following approaches is the recommended way to screen for diabetic kidney disease? A. Obtain a 24-hour urine collection for albumin now and again in 3 years B. Obtain a spot urine albumin every year C. Obtain a spot urine albumin/creatinine ratio every year D. Obtain a urinalysis every year E. Obtain a serum creatinine every year
C
A 55-year-old man complains of ED but also reports frontal headaches, trouble with peripheral vision, and occasional breast discharge. Which of the following conditions is the most serious possible cause of his complaints? A. Primary testicular failure B. Drug effect C. Pituitary tumor D. Migraine
C
A 60-year-old diabetic man is noted to have chronic kidney disease (CKD) based on a calculated glomerular filtration rate (GFR) of 8 mL/min/1.73 m2. His serum creatinine is 9.1 mg/dL and blood urea nitrogen (BUN) is 93 mg/dL. The provider recommends hemodialysis for this patient's condition to address the numerous complications associated with CKD. Which of the following complications would not be improved with hemodialysis? A. Hyperkalemia B. Fluid overload C. Infection risks D. Uremic state E. Hyperphosphatemia
C
Your 55yo patient comes in with incidental hematuria finding. Further history reveals that he smokes one to two packs of cigarettes per day. He has a normal blood pressure and the remainder of the physical examination is unrevealing. Two urine samples reveal microscopic hematuria, with 5 RBC/hpf on each sample. The rest of the urinalysis is normal, and there are no red cell casts. In your evaluation of this patient, you include all of the following tests EXCEPT: A. Urine cytology B. CBC C. Serum creatinine D. CT scan of the abdomen and pelvis with particular note of the kidneys E. Renal biopsy
E
Your patient with moderately increased albuminuria has a full urinalysis to rule out renal inflammation (e.g., nephritis) and overt proteinuria (nephrotic syndrome). The urinalysis is entirely negative. What further investigations must your patient undergo to eliminate other potential causes of proteinuria? A. Renal biopsy B. Renal ultrasound with Doppler of the renal arteries C. ANA, ESR, CRP D. All of the above E. None of the above
E
A 45-year-old woman with type 2 diabetes presents to the clinic for follow-up. She states that over the past year, she has decreased vision in the left eye. She also has had some occasional chest pain for the past 2 months. On examination, the blood pressure is 145/92 mm Hg. The cardiac and lung examinations are normal. Laboratory tests show the urinalysis reveals 1+ proteinuria. Serum laboratory tests reveal a baseline Cr of 1.6 mg/dL, a low-density lipoprotein (LDL) cholesterol level of 135 mg/dL. Which of the following is the best medication to start the patient on at this time? A. ACE inhibitor B. Hydralazine C. Oral nitrate D. Thiazide diuretica
A
A 21-year-old college student and self-described as a "ladies' man" (interpret: jerk) presents because of a concerning spot that developed on his penis. He complains of pain at the spot but denies itching. He reports no fever. When asked further about his sexual practices, he reports no condom use because his partners are all "on the pill." He had chlamydia in high school but is otherwise healthy. His review of systems is negative. On examination of the penis, you find a 1-cm tender, erythematous papule with a deep central ulceration at the glans penis. There is some mild, tender lymphadenopathy in the inguinal area. The rest of the examination is unremarkable. This lesion is most likely caused by: A. Haemophilus ducreyi B. Neisseria gonorrhoeae C. Staphylococcus aureus D. Treponema pallidum
A
A 22-year-old male presents complaining of a painless lump on his left testicle. He denies penile discharge, dysuria, or other urinary complaints. He underwent a left orchidopexy for an undescended testicle at age 6. Otherwise, his past medical history is unremarkable. On examination, the penis is circumcised with no lesion or discharge. There is adenopathy in the left inguinal area. His testicles are descended bilaterally with a 1-cm palpable, irregular mass on the mid-lateral portion of the left testicle. His examination is otherwise unremarkable. Your patient is worried about testicular cancer and wants to know if he is at risk. All of the following are associated with an increased risk of testicular cancer EXCEPT: A. Vasectomy B. HIV infection C. Cryptorchidism D. Klinefelter syndrome E. Family history
A
A 30-year-old man complains of recurrent, self-limited episodes of "bloody" urine and abdominal pain. He has a 10-year history of smoking one-half pack of cigarettes per day. His grandfather died of kidney disease, and his paternal aunt and father are currently treated on the "kidney machine." What is the most likely diagnosis? A. Polycystic kidney disease B. Bladder cancer C. Ureteral calculus D. IgA nephropathy E. Urinary tract infection
A
A 35-year-old woman has undergone four vaginal deliveries. She notes urinary loss six to seven times a day concurrently with coughing or sneezing. She denies dysuria or an urge to void. Her urine culture is negative. What is the treatment of choice? A. Suburethral sling procedure (with or without preceding pessary trial) B. Oxybutynin (Ditropan) C. Placement of ureteral stents D. Surgical repair of the fistulous tract E. Intermittent self-catheterization
A
A 39-year-old woman wets her underpants two to three times each day. She feels as though she needs to void but cannot make it to the restroom in time. What is the treatment of choice? A. Oxybutynin (Ditropan) B. Placement of ureteral stents C. Propranolol (Inderal) D. Placement of an artificial urethral sphincter E. Intermittent self-catheterization
A
A 45-year-old man is prescribed 5-alpha-reductase inhibitor, finasteride, for benign prostatic hypertrophy. His physician mentions potential side effects of the drug that include A. gynecomastia. B. increases in prostatic serum antigen (PSA). C. eunuchism. D. impotence.
A
Which of the following cell types are specific to a latent genital infection with HSV-2? A. Trigeminal ganglia B. Sacral ganglia C. Vagal nerve ganglia D. Neural sensory ganglia
B
Which of the following is the most likely cause of fever in a patient who had a successful cadaveric renal transplantation 8 months ago? A. Methicillin-resistant Staphylococcus urinary tract infection B. Cytomegalovirus (CMV) infection C. Chronic allograft nephropathy D. Cyclosporin-associated fever E. Graft-versus-host disease
B
Which of the following pairs regarding the consequences of untreated renal failure is an incorrect match? A. Hyperkalemia from potassium retention/Cardiac arrhythmias B. Decreased production of erythropoietin/Thrombocytopenia C. Decreased synthesis of 1,25-dihydroxyvitamin D/Hypocalcemia with hyperparathyroidism D. Salt and water retention/Hypertension
B
A 10-year-old male presents with his mother, who appears very anxious. She reports several episodes of red-brown urine this morning. The patient reports feeling a bit tired, but otherwise has no complaints. His past medical history is unremarkable and he takes no medications. On review of systems, he reports about 10 days of a sore throat that completely resolved a few days ago. On examination, you find a pleasant young male in no acute distress. He is afebrile. His blood pressure is 140/94 mm Hg, and he has trace pretibial edema. The remainder of the examination is unrevealing. All of the following tests are likely to be helpful in the workup of this patient EXCEPT: A. Urinalysis B. Abdominal X-ray C. CBC D. Plasma electrolytes E. BUN and creatinine
B
A 15-year-old boy presents for his routine annual checkup with his pediatrician. He reluctantly admits to 2 recent episodes of pain in his left testicle. The pain was quite intense but subsided in 15 minutes and 60 minutes, respectively. Which of the following is the most likely cause of recurrent episodes of testicular pain that resolve spontaneously? A. Acute appendicitis B. Testicular torsion C. Epididymitis D. Torsion of the testicular appendage
B
A 32-year-old male presents to discuss permanent sterilization. He clearly states that he wants a vasectomy, and sooner is better than later. He is married and has three children at home. His wife just gave birth to twins. He is healthy and takes no medications. He looks tired and anxious. You examine him and find no abnormalities. The vas deferens is easily isolated bilaterally. What is your next step? A. Refer him for psychological counseling as he is clearly under a great deal of stress B. Provide him with detailed counseling on vasectomy, give him written material on the procedure, and ask him to discuss it with his wife C. Do the vasectomy right now; the next patient can wait D. Tell him that he is not an appropriate candidate for vasectomy because of his history of hypertension
B
A 33-year-old woman with recently treated acute myelogenous leukemia now in remission is admitted to the hospital with lethargy, fever, and tachycardia. Blood cultures grow Pseudomonas that is resistant to cefepime. She is started on IV gentamicin. Five days after starting gentamicin, her serum creatinine rises from her baseline of 1.0 mg/dL to 2.4 mg/dL. No red or white cell casts are seen on her urinalysis. Her magnesium level is decreased at 1.5 mg/dL. Renal ultrasound is unremarkable with no hydronephrosis. Which of the following is the most likely mechanism of her acute kidney injury? A. Acute interstitial nephritis B. Acute tubular necrosis C. Glomerulonephritis D. Ischemic injury E. Obstruction
B
A 56-year-old man with known CKD presents to the emergency center with a 3-day history of shortness of breath and rapid weight gain. On examination of the heart, you are able to auscultate an S3 heart sound and hear crackles at the lung bases. You also see moderate JVD. The oxygen saturation is 90% on room air. Which of the following is your next step in evaluation? A. Order an echocardiogram. B. Order a chest x-ray. C. Measure a Cr to calculate GFR. D. Order a computed tomographic (CT) angiograph of the chest.
B
A 62-year-old diabetic man underwent an abdominal aortic aneurysm repair 2 days ago. He is being treated with gentamicin for a urinary tract infection. His urine output has fallen to 300 mL over 24 hours, and his serum creatinine has risen from 1.1 mg/dL on admission to 1.9 mg/dL. Which of the following laboratory values would be most consistent with a prerenal etiology of his renal insufficiency? A. FENa of 3% B. Urinary sodium level of 10 mEq/L C. Central venous pressure reading of 10 mm Hg D. Gentamicin trough level of 4 µg/mL
B
A 63-year-old woman with a history of cervical cancer treated with a hysterectomy and pelvic irradiation now presents with acute oliguric renal failure. On physical examination, she has normal jugular venous pressure, is normotensive without orthostasis, and has a benign abdominal examination. Her urinalysis shows a specific gravity of 1.010, with no cells or casts on microscopy. Urinary FENa is 2%, and the Na level is 35 mEq/L. Which of the following is the best next step? A. Bolus of intravenous fluids B. Renal ultrasound C. Computed tomographic scan of the abdomen with intravenous contrast D. Administration of furosemide to increase her urine output
B
A 67-year-old man with coronary artery disease, dyslipidemia, and eczema comes to you complaining of lower back pain and left leg pain. The pain is worse when he stands for long periods of time but improves when he bends forward to push his shopping cart around the grocery store. He indicates that his feet "burn" and "ache" after walking different distances every day. His lower extremity neuromuscular examination is unremarkable. Which of the following is the most appropriate treatment for this patient? A. Emergent spinal cord decompression B. Epidural corticosteroid injection C. Kyphoplasty D. Bed rest for 4 days E. Tramadol
B
After an appropriate history and physical examination, which of the following tests is the initial diagnostic study of choice in your patient with a scrotal mass? A. CT scan B. Ultrasound C. Complete blood count (CBC) D. Alpha fetoprotein (AFP) E. Pelvic x-ray
B
An 80-year-old female with a history of advanced CHF is admitted to the hospital with acute on chronic systolic heart failure. The patient was started on a high dose of intravenous furosemide twice a day. The next day, she made a good amount of urine and her shortness of breath improved slightly. Her creatinine increased to 2.1 (baseline is 1.5). On hospital day 3, the patient's creatinine increased to 2.4. Her respiratory rate is 24/min and her saturation is 92% on 6 L by nasal cannula. On examination, her estimated jugular venous pressure is 15 and she has bilateral fine crackles heard diffusely in both lung fields. Her input in the last 24 hours was 1500 cm3, and her UOP was 2700 cm3. What would you do next? A. Hold furosemide and repeat BMP the next day. B. Continue IV furosemide. C. Switch to oral furosemide. D. Hold furosemide, give 250 cm3 of normal saline, and repeat BMP. E. Call nephrology for hemodialysis.
B
Before you tear up the prescription for terazosin you accidentally wrote, you review its side effects. Potential side effects of alpha-blockers include all the following EXCEPT: A. Retrograde ejaculation B. Hypertension C. Intraoperative floppy iris syndrome D. Priapism
B
Consequences of circumcision include which of the following? A. Overall reduction in mortality of circumcised infants compared with uncircumcised infants B. Reduction in UTIs in the first year of life C. Reduction in the number of sexual partners D .All of the above
B
On examination, you find an uncomfortable appearing male in no distress. His temperature is 38.4°C, and the rest of his vital signs are normal. The prostate on digital rectal examination is tender, enlarged, warm, and boggy. The remainder of the examination is unremarkable. Urinalysis is consistent with an infection. He has a sulfa allergy. Which of the following is the most appropriate treatment plan for this patient? A. Prescribe trimethoprim-sulfamethoxazole 160 mg-800 mg BID for 42 days B. Prescribe ciprofloxacin 500 mg orally BID for 21 days C. Admit for IV levofloxacin 500 mg daily for 14 days D. Admit for IV levofloxacin 500 mg daily, followed by completion of therapy with oral levofloxacin 500 mg daily for 14 days when the patient is stable E. Perform transrectal ultrasound to rule out prostatic abscess
B
The primary mechanism by which renal failure occurs in rhabdomyolysis is: A. Glomerular destruction B. Acute tubular necrosis (ATN) C. Interstitial nephritis D. None of the above
B
Which of the following asymptomatic patients would most benefit from treatment of the finding of more than 105 CFU/mL of Escherichia coli on urine culture? A. A 23-year-old sexually active woman B. A 33-year-old pregnant woman C. A 53-year-old diabetic woman D. A 73-year-old woman in a nursing home
B
Your patient with hx of DM2, CKD, coronary artery bypass grafting presents with gradually increasing dyspnea and cough. Her urine output is reported to be normal. Her vitals show temperature 37°C, pulse 76 bpm, respiratory rate 24, and blood pressure 92/46 mm Hg. You note crackles at both lung bases. Her heart rhythm is regular and an S4 is audible. She has JVD of 9 cm and 2+ pitting pretibial edema. The ECG shows sinus tachycardia but no evidence of potassium toxicity (peaked T-waves, prolonged QT). Laboratory results: troponin-T and CK normal, BUN 70 mg/dL, Cr 2.0 mg/dL (her baseline was 1.5 mg/dL), Na 128 mEq/L (reference range 135-145), K 5.5 mEq/L (reference range 3.5-5.0), HCO3 19 mEq/L, WBC 14,500 per mm3, remainder of the CBC is normal. Urinalysis shows protein and glucose with a specific gravity >1.030, but there are few cells and no casts. Cultures and a chest x-ray are pending. You suspect that her elevated creatinine is primarily due to which of the following processes? A. Adverse toxic effects of drugs on the kidney B. Heart failure or other prerenal cause of renal failure such as dehydration C. Sudden progression of diabetic nephropathy D. Urinary obstruction E. Urinary tract infection
B
Which one of the following statements about the clinical utility of prostate-specific antigen (PSA) is controversial? A. It is useful to determine success of treatment. B. It is useful as an indicator of the extent of disease, particularly bone metastases. C. It is useful for monitoring recurrence of prostate cancer. D. It is useful as a screening test for prostate cancer in men older than 50 years.
D
45-year-old female presents to your clinic complaining of urinary frequency, "bladder" pain, and urinary urgency. There is no dysuria, however. She has had hematuria on dipstick several times with urinalysis showing microscopic hematuria on more than three occasions. This has been going on for several months and other practitioners (less skilled than yourself) have treated with a number of antibiotics without any relief. On questioning, she also notes bladder pain during intercourse and some chronic, vague, lower pelvic pain distinct from the bladder pain. At this visit, urinalysis and pelvic examination are unremarkable except for tenderness over the bladder area. The MOST IMPORTANT next step is: A. Urine culture B. Trial of 4 weeks of antichlamydial therapy C. Pelvic ultrasound D. Psychiatry consult and/or SSRI therapy for somatization disorder (now called somatic symptom disorder)
C
A 21-year-old man is diagnosed with poststreptococcal glomerulonephritis. Which of the following is likely to be found in his urine? A. >3 g per 24-hour proteinuria without hematuria B. Macroscopic hematuria and 24-hour urinary albumin of 227 mg C. Microscopic hematuria with leukocytes and 24-hour urinary albumin of 227 mg D. Positive urine culture for Streptococcus E. Sterile pyuria without proteinuria
C
A 23-year-old pregnant woman presents with the signs and symptoms of a urinary tract infection. She is 3 months pregnant. The choice of a trimethoprim-sulfisoxazole drug over a fluoroquinolone drug might be recommended because A. the likely bacteria involved in a UTI during pregnancy are not sensitive to fluoroquinolones. B. in pregnancy, the fluoroquinolone drugs are not absorbed after oral administration. C. the fluoroquinolones are contraindicated in pregnancy. D. trimethoprim-sulfisoxazole achieves much higher plasma concentrations than fluoroquinolone drugs in pregnancy. E. trimethoprim-sulfamethoxazole also has urinary analgesic effects
C
A 35-year-old woman presents with complaints of bilateral lower extremity edema, polyuria, and moderate left-sided flank pain that began approximately 2 weeks ago. There is no past medical history. She is taking no medications and denies tobacco, alcohol, or illicit drug use. Examination shows normal vital signs, including normal blood pressure. There is 2+ edema in bilateral lower extremities. The 24-hour urine collection is significant for 3.5 g of protein. Urinalysis is bland except for the proteinuria. Serum creatinine is 0.7 mg/dL, and ultrasound examination shows the left kidney measuring 13 cm and the right kidney measuring 11.5 cm. You are concerned about renal vein thrombosis. What test do you choose for the evaluation? A. CT of the renal veins B. Contrast venography C. Magnetic resonance venography D. 99Tc-labeled diethylene-triamine-pentaacetate acid (DTPA) imaging E. Ultrasound with Doppler evaluation of the renal veins
C
A 39-year-old woman with hypertension and type 2 diabetes has been noted to have progressively worsening renal insufficiency. Which of the following measures is most important in the prevention of ESRD? A. Tobacco cessation B. Triglyceride control C. Glycemic control D. Weight control E. Dietary sodium restriction
C
A 45-year-old woman begins hemodialysis for end-stage renal disease associated with diabetes mellitus. Which of the following is her most likely eventual cause of death? A. Dementia B. Major bleeding episode C. Myocardial infarction D. Progressive uremia E. Sepsis
C
A 46-year-old obese man visits his primary care provider for his yearly checkup. While there, the physician asks about his sex life and mentions that he is having trouble getting and maintaining an erection. What drug will the physician prescribe for the man? A. Nitric synthase inhibitors B. Tamoxifen C. Phosphodiesterase-5 inhibitors D. 5-alpha-reductase inhibitors
C
You have now determined that your patient, with increased Cr and BUN:Cr ratio of <20, has become oliguric. Which of the following is most likely to help you narrow the differential diagnosis of renal failure? A. Calculation of creatinine clearance B. Arterial blood gases C. CT scan of the abdomen D. Fractional excretion of sodium (FENa) E. Furosemide challenge
D
A 75-year-old female presents to the emergency department with vomiting, high-grade fever, and left flank pain of 2 days duration. Prior to that, the patient started having dysuria a week ago and her primary care doctor started her on ciprofloxacin. The dysuria did not improve. Pt has a hx of CHF, CAD s/p bypass 5y ago. The patient mentioned a CT of the chest was done 10 days prior to this presentation for follow-up of a pulmonary nodule found incidentally on CXR 6 months ago. On examination, the patient is lying on the bed and sweating. Vital signs: temperature 39°C, blood pressure 100/60, heart rate 110 bpm, respiratory rate 22/min, and oxygen saturation 97% on room air. Positive findings on clinical examination include: bilateral fine crackles in both lung bases, a systolic ejection murmur at the heart base rated 3/6 with radiation to the carotids, and left costophrenic tenderness. nitial labs—WBC: 18,000 with 15% bands, Hg: 12, HCT: 36, platelets: 250,000, Na: 131, K: 3.7, Cl: 99, HCO3: 28, BUN: 80, Cr: 2.8 (last Cr was 0.7 ten days ago), glucose: 95, Ca: 8.0, BNP: 300, and lactic acid: 3.0 (normal is up to 2.0). Urinalysis showed elevated white blood cells, trace protein and blood, bacteriuria, and many hyaline casts. Urine sodium was 8 mmol/L. FeNa was <1%. What is the most likely cause of the patient's AKI? A. Contrast nephropathy B. AIN C. AKI secondary to volume depletion D. AKI secondary to CHF E. ATN
C
A 75-year-old man with a negative past medical history comes to your office complaining of a 3-day history of painless "bloody urine," which has now resolved. He is frightened because he has never experienced bloody urine. Which of the following would be considered an alarm symptom or feature in this patient? A. Deafness B. Burning upon urination C. Smoking history D. Recent travel to the Ukraine E. History of ureteral calculus
C
A couple you have known for a few years comes to your office to announce that they are expecting and that they want you to be the baby's doctor (strange that they didn't ask you to be the mother's doctor, but you let it slide). According to an ultrasound, the fetus is male. The couple is ambivalent about neonatal circumcision and wants your advice. You start the conversation by saying: A. "Circumcision is a relic of history and should be illegal" B. "All major medical organizations (e.g., AAFP, AAP, AMA) recommend routine neonatal circumcision" C. "The decision to perform circumcision is a personal one, influenced by a number of factors—but primarily by cultural, religious, and familial issues" D. "Do whatever you want. I don't really care what you do with a tiny piece of skin"
C
A surgical colleague asks you to consult on a patient because of increasing creatinine (yes, we know this will never happen with a surgeon—just consider this a thought experiment). A 63-year-old woman was admitted for an elective cholecystectomy. She is on postoperative day 3 and has fever with delirium. Her current medications are morphine, cefotetan, and acetaminophen as needed. She takes nothing by mouth, but has intravenous fluids (5% dextrose/0.45% saline) running at 100 cc/hr ... continuously ... since surgery. Plasma studies from the day of surgery and this morning are available: Laboratory Test Day Before Surgery Sodium (mEq/L)- 138 Potassium (mEq/L)- 4.5 Chloride (mEq/L)- 103 HCO3 (mEq/L)- 24 BUN (mg/dL)- 15 Creatinine (mg/dL)- 1.1 Day of Consultation Sodium (mEq/L)- 130 Potassium (mEq/L) 5.8 Chloride (mEq/L) 105 HCO3 (mEq/L) 18 BUN (mg/dL) 30 Creatinine (mg/dL) 2.0 The BUN/Cr ratio on the day of consultation suggests that: A. She is hypovolemic B. She has a prerenal cause of her increased creatinine, such as heart failure C. Intrinsic kidney disease is more likely than a prerenal cause of her increased creatinine D. Pyelonephritis is the most likely cause of her increased creatinine
C
In a patient with severe right-sided flank pain, which of the following lowers your suspicion for nephrolithiasis? A. Stabbing, severe pain B. Intermittent nature of pain C. Onset approximately 2 months ago D. Hematuria E. History of nephrolithiasis
C
In addition to holding a patients metformin, which of the following interventions would be most likely to reduce their risk of developing contrast-induced nephropathy? A. N-acetylcysteine and IV saline B. N-acetylcysteine and mannitol C. IV saline D. Sodium bicarbonate and mannitol E. Mannitol and IV saline
C
In taking your patient's history, if he had described apainfullump in his scrotum, the LEAST likely cause would be: A. Chlamydia B. Inguinal hernia C. Hydrocele D. Testicular torsion
C
The results of a urinalysis include the following: a positive test for urine protein by dipstick; a positive dipstick test for urine glucose; and a positive dipstick test for urinary ketones. Which of the following clinical scenarios is most compatible with this set of results? A. Infection in the kidney B. Trauma from an auto accident with no apparent damage to the kidney C. Poorly controlled diabetes mellitus D. Severe liver disease
C
Which of the following findings in urine sediment is associated with nephrotic syndrome? A. Red cell casts B. White cell casts C. Oval fat bodies D. Uric acid crystals E. Granular casts
C
Which of the following is the leading cause of chronic kidney disease in North America? A. Autosomal dominant polycystic kidney disease B. Contrast nephropathy C. Diabetic nephropathy D. Focal segmental glomerulosclerosis E. Recurrent renal calculi
C
Which of the following is the most appropriate first step in determining the nature of a patient's elevated creatinine? A. Give a trial bolus of normal saline B. CT scan of the abdomen C. Determine volume of urine output D. Obtain urine for culture E. Give a trial dose of furosemide
C
Which of the following laboratory abnormalities typically can be seen accompanying acute kidney injury? A. Hypercalcemia B. Hypokalemia C. Hyponatremia D. Hypophosphatemia E. Metabolic alkalosis
C
Which of the following statements best describes the usual course of post-streptococcal glomerulonephritis? A. Most patients progress to renal failure B. After resolution of the initial episode, recurrent episodes of gross hematuria are common C. In most cases, hypertension and uremia subside within 1 to 2 weeks after onset. D. In most cases, hypertension is persistent and requires treatment E. Adults tend to recover more quickly than children
C
Which of the following statements most accurately describes HSV infections? A. HSV establishes lytic infection in neural ganglion cells. B. Latent HSV infections can be prevented in persons with functional cell-mediated immunity. C. Primary and recurrent HSV infections are treated with drugs that inhibit the viral DNA polymerase. D. HSV infection is transmitted via direct contact with symptomatic shedding of viral particles in active lesions. E. Severe neonatal herpes infections are commonly associated with in utero transmission.
C
While covering the ED, a 62-year-old female you have known for several years presents with her husband. She appears lethargic and is unable to give a coherent history. Her husband tells you that she began having stomach pain, nausea, and diarrhea 2 days ago. Although she has not been vomiting, she has been unable to drink or eat much due to nausea. She takes furosemide for edema and albuterol/ipratropium (Combivent) for chronic obstructive pulmonary disease (COPD). She smokes a pack of cigarettes per day. On physical examination, her respiratory rate is 30, pulse 104 bpm, blood pressure 112/64 mm Hg, and temperature 37.9°C. She is somnolent and disoriented. Oral mucosa is dry. Lung examination demonstrates diminished air movement bilaterally. Her abdomen is diffusely tender, but there is no rebound. Rectal examination is negative for occult blood. The first laboratory test you have available is a room air arterial blood gas (although venous would have been fine, right?): pH 7.12, PaCO2 33 mm Hg, PaO2 80 mm Hg, HCO3 10 mEq/L, and oxygen saturation 92%. This blood gas is most consistent with which of the following processes? A. Compensated metabolic acidosis B. Compensated respiratory acidosis C. Poorly compensated metabolic acidosis D. Poorly compensated respiratory acidosis E. Pure respiratory alkalosis
C
You are asked to consult on a patient who is hospitalized by an orthopedic surgeon (consulted by a surgeon twice in a chapter—congratulations!). The patient is a 25-year-old female who has a history of osteomyelitis from an open fracture sustained in a skiing accident. She has recently begun to spike a fever to 38.5°C and have a rapid increase in her creatinine. Medications: nafcillin, ibuprofen, morphine, lactated Ringer solution IV 100 cc/hr. Labs: Cr 3.5 mg/dL, BUN 25 mg/dL. CBC shows mild WBC count of 12,500/mm3 and differential shows eosinophilia. Considering prerenal versus renal causes, you calculate the FENa, and what would you expect to find? A. FENa >2%, urine sodium <20 mg/dL B. FENa <1%, urine sodium <20 mg/dL C. FENa >2%, urine sodium >40 mg/dL D. FENa <1%, urine sodium >40 mg/dL
C
You are seeing a 67-year-old man who reports mild dysuria for the past 3 months. Which of the following symptoms would be least concerning for bladder cancer? A. One episode of bloody urine last week B. An 18 pack-year smoking history C. Associated symptoms of difficulty initiating urination and a weak urinary stream D. Associated symptoms of urinary frequency and urgency
C
You start tamsulosin. Unfortunately, the patient is not able to tolerate it due to dizziness. His symptoms are bothersome enough that he wishes to try something else. You consider finasteride. Which of the following is true of finasteride? A. It permanently reduces prostate volume, even after the drug is stopped B. It is approved by the Food and Drug Administration (FDA) for abnormal hair growth in women C. It may reduce the overall risk of developing prostate cancer, but increases the risk of developing high-grade prostate cancers D. It improves symptoms within 1 week of starting the drug E. None of the above
C
Your patient decides to "get snipped" (as he puts it). You perform the vasectomy using a no-scalpel technique. The procedure was fairly easy, and the patient tolerated it well. One month after the procedure, the patient calls to complain about a painful swelling that has developed superior and slightly posterior to the left testis. He has no other symptoms. Which of the following is the most likely diagnosis? A. Hematoma B. Varicocele C. Congestive epididymitis D. Abscess
C
Your powers of deduction lead you to the conclusion that the patient's urinary symptoms are due to BPH. He has always been proud of his bladder capacity (men can be proud of just about anything) and is embarrassed that he is taking frequent bathroom stops when driving with his wife on their road trips; your patient desires treatment. To give him the most immediate relief, you prescribe which of the following? A. Finasteride B. Oxybutynin C. Tamsulosin D. Imipramine E. Furosemide
C
While counseling your patient on vasectomy, you discuss which of the following issues? A. Partner's desire for permanent sterility B. Effect of the procedure on sexual function C. Reversibility of the procedure D. Complications E. All of the above
E
A 72-year-old man with a long history of hypertension presents to the emergency department complaining of not being able to urinate for the last 36 hours. He also has a 1-day history of nausea, vomiting, and abdominal pain. He states that his urinary stream has been decreasing over the past 2 years. On examination, the abdomen is firm and tender, and the prostate is enlarged. His serum Cr level is 3.4 mg/dL. Which of the following is the best next step? A. Give intravenous fluids and see if he begins to make urine. B. Perform a renal ultrasound in the emergency department. C. Maintain tight control of his blood pressure. D. Place an indwelling Foley catheter.
D
All of the following laboratory abnormalities are consistent with the diagnosis of acute prostatitis EXCEPT: A. Leukocytosis B. Hematuria C. Bacteriuria D. Elevated creatinine E. Elevated PSA
D
Which of the following interventions has been shown to decrease the recurrence of calcium oxalate renal stones? A. A diet with abundant spinach and rhubarb B. Aspirin C. Low-calcium diet (400 mg/day) D. Thiazide diuretics E. Vitamin C supplements
D
Which of the following is the most common acute complication of hemodialysis? A. Anaphylactoid reactions to dialyzer B. Bleeding from access site C. Hypertension D. Hypotension E. Muscle cramps
D
Which of the following statements about male gonadal dysfunction is not true? A. Partial androgen deficiency is common in men with advancing age. B. Not all men develop low levels of testosterone, while gonadal failure in women is inevitable. C. The reference range for testosterone in men is based on the values found in healthy young men. D. Routine use of testosterone for hormone replacement, especially in men over the age of 65, is widely accepted.
D
A 19-year-old female presents to your office concerned about protein in her urine. As a college student, she has a part-time job in a medical laboratory. She "repurposed" a few urine dipsticks from the laboratory—you know, "just checking her urine"—and found that she had 2+ protein on urine dipstick. She has no urinary symptoms and denies fever, weight changes, and edema. She is afebrile with a blood pressure of 118/68 mm Hg. Examination is otherwise unremarkable. Repeat urinalysis in the office confirms 2+ protein, specific gravity 1.020, pH 6.5, and no blood. The urine microscopic examination is normal. Which of the following is the most appropriate next action in evaluating this patient? A. Repeat urinalysis and urine culture B. Ultrasound of the kidneys C. 24-hour urine collection for protein and creatinine D. Random urine protein/creatinine ratio
D
A 40-year-old woman is diagnosed with cervical intraepithelial disease. Biopsy is suspicious for HPV related disease. What histologic features support the role of HPV? A. Central, basophilic intranuclear cellular inclusions B. Cowdry type A intranuclear cellular inclusions C. Enlarged multinucleated cells D. Cytoplasmic vacuolization and nuclear enlargement of cells E. Numerous atypical lymphocytes
D
A 49-year-old man with a long-standing history of chronic renal failure as a consequence of diabetic nephropathy is brought to the emergency room for nausea, lethargy, and confusion. His physical examination is significant for an elevated jugular venous pressure, clear lung fields, and harsh systolic and diastolic sounds heard over the precordium. Serum chemistries reveal K 5.1 mEq/L, CO2 17 mEq/L, BUN 145 mg/dL, and creatinine 9.8 mg/dL. Which of the following is the most appropriate next step in therapy? A. Administer intravenous insulin and glucose B. Administer intravenous sodium bicarbonate C. Administer intravenous furosemide D. Begin hemodialysis urgently
D
A 54-year-old woman with a history of colon cancer treated with resection and chemotherapy 2 years earlier is admitted to the hospital after routine lab work at her primary care physician's office showed a blood urea nitrogen of 65 mg/dL and a creatinine of 4.5 mg/dL. She reports mild fatigue and recent lower back pain, but otherwise feels well. She does admit to recent nonsteroidal anti-inflammatory drug (NSAID) use but has not taken more than the recommended quantity. Aside from stopping the NSAID and avoidance of nephrotoxins, which of the following studies should be the next step? A. CT of the abdomen/pelvis with oral contrast B. Postvoid residual volume of bladder C. Retrograde urography D. Ultrasound of the abdomen/kidney E. Urinary fractional excretion of sodium
D
A 60-year-old man comes to see his physician for his yearly checkup. His physician measures his serum prostatic antigen levels and finds that they are elevated. What is the potential diagnosis for this man? A. Breast cancer B. Skin cancer C. Benign prostatic hypertrophy D. Prostate cancer
D
A 65-year-old man with hypertension, diabetes, and recently diagnosed CKD stage 3 comes to your office asking about medications that could delay the progression of his kidney disease. Which of the following medications would you recommend? A. Loop diuretics B. Thiazide diuretics C. Calcium channel blockers D. ACE inhibitors E. Aldosterone antagonists
D
A 70-year-old man with a long-standing history of hypertension and coronary artery disease is found to have abnormal laboratory test results including an elevated creatinine and a GFR of 45 mL/min. His electrolytes are normal. Urinalysis is negative for protein and blood. His hypertension is well controlled. His GFR 6 months ago was 55 mL/min. Which statement best describes his kidney function? A. He has acute kidney failure given the rapid deterioration of his GFR. B. He has a normal kidney function as evidenced by his normal urinalysis but he is at risk to develop CKD given his declining GFR. C. He has CKD stage 4 and should be referred to a nephrologist for further evaluation. D. He has CKD given his abnormal GFR that has persisted for longer than 3 months.
D
A 42-year-old woman with long-standing diabetes mellitus complains of small amounts of constant dribbling of urine with a larger amount of urine loss with coughing or lifting. What is the treatment of choice? A. Oxybutynin (Ditropan) B. Surgical repair of the fistulous tract C. Propranolol (Inderal) D. Placement of an artificial urethral sphincter E. Intermittent self-catheterization
E
A 57-year-old man with a history of diabetes mellitus and chronic kidney disease with a baseline creatinine of 1.8 mg/dL underwent cardiac catheterization for acute myocardial infarction. He is subsequently diagnosed with acute kidney injury related to iodinated contrast. All of the following statements are true regarding his acute kidney injury EXCEPT: A. Fractional excretion of sodium will be low. B. His creatinine is likely to peak within 3-5 days. C. His diabetes mellitus predisposed him to develop contrast nephropathy. D. Transient tubule obstruction with precipitated iodinated contrast contributed to development of his acute kidney injury. E. White blood cell casts are likely on microscopic examination of urinary sediment.
E
A 65-year-old man with a history of hypertension, diabetes, and chronic low back pain presents to the clinic for follow-up. His physical examination is unremarkable with no edema or jugular venous distension. Recent laboratory testing shows a decreased glomerular filtration rate of 55 mL/min/1.73 m2. His hemoglobin A1c is 5.4%. He is currently on metformin, naproxen, and hydrochlorothiazide. What medication change could help slow his progression of chronic kidney disease? A. Add furosemide B. Discontinue metformin C. Discontinue naproxen D. Substitute lisinopril for hydrochlorothiazide E. C and D
E
A 78-year-old man presents to your clinic with gradual onset of perineal and scrotal pain and fever over the past 36 hours. He was recently hospitalized with pneumonia and discharged 7 days ago. With further questioning, he reports dysuria since hospital discharge, which he relates to the removal of a bladder catheter he had in place while in the hospital. Which of the following is the most likely cause of his pain? A. Urolithiasis B. Abdominal aortic aneurysm C. Testicular torsion D. Inguinal hernia E. Prostatitis
E
At a routine follow-up appointment, Mr. S, a 64-year-old attorney, complains of having to urinate frequently, prompting him to interrupt meetings, court proceedings, and social activities to go to the bathroom. Despite feeling a strong need to urinate, the amount of urine he produces is small—"just a few ounces." Despite an urge to void, it takes several seconds to start the stream, which is weak. Over the past 2 months, he has noticed that the urge to void can come on suddenly and intensely, sometimes accompanied by leakage of a small amount of urine that visibly wets his pants (which he finds extremely embarrassing). If he zips up his trousers promptly after emptying his bladder, he often finds a small wet mark on the front of his pants when he leaves the washroom. Because of his long work hours, Mr. S admits to a long-standing habit of drinking an espresso in the morning and 2 to 3 cups of regular coffee over the course of the day. What is the most likely etiology of his incontinence? A. Idiopathic overactive bladder B. Incompetent urethral sphincter C. Bladder outlet obstruction with overflow D. Excessive caffeine intake E. Detrusor hyperactivity due to prostatic hyperplasia
E
If your patient had not had an orchidopexy to repair the undescended testicle, he would be at risk for developing all of the following problems EXCEPT: A. Infertility B. Inguinal hernia C. Testicular torsion D. Testicular malignancy E. Impotence
E
When considering benign prostatic hyperplasia (BPH), you reflect on the common symptoms of this syndrome, which include all of the following EXCEPT: A. Urinary retention B. Post-void dribbling C. Frequency D. Nocturia E. Hematuria
E
Which of the following can cause a false-negative albumin/creatinine ratio? A. Vigorous exercise B. Fever C. Cachexia D. Poor glycemic control E. Large muscle mass
E
Which of the following fluid or electrolyte abnormalities can be seen in some patients after the relief of bilateral renal obstruction? A. Hyperkalemia B. Hypermagnesemia C. Hypernatremia D. Hypovolemia E. C and D
E
Which of the following is/are associated with autosomal-dominant polycystic kidney disease (ADPKD)? A. Liver cysts B. Cerebral aneurysms C. Colonic diverticula D. Cardiac valvular disease E. All of the above
E
