B4U2 Practice Questions

RBC casts

glomerulonephritis

Patient will present as → a 68-year-old woman who presents to your office with leakage of urine when she sneezes, laughs, or coughs. She reports that these symptoms strictly occur during the day and never at night. She denies any subjective fever, dysuria, or hematuria. Pelvic examination is notable for a protrusion from the anterior vagina.

stress incontinence

waxy casts

chronic renal disease

Which of the following is the portion of the nephron responsible for the absorption of 90% of the ultrafiltrate? A. Proximal convoluted tubule B. Loop of Henle C. Distal convoluted tubule D. Collecting duct

A. Proximal convoluted tubule

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. do nothing, since these casts are considered normal Hyaline casts are not indicative of renal disease. They can be found following strenuous exercise and with concentrated urine or during a febrile illness.

Which surgical technique is most appropriate for correcting cystocele? A. Posterior repair B. Manchester repair C. Anterior repair D. Sacrocolpopexy

C. Anterior repair

Which of the following diagnostic findings in the urinary sediment is specific for a diagnosis of chronic renal failure? A. Hematuria B. Proteinuria C. Broad waxy casts D. Hyaline casts

C. Broad waxy casts

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. White cell casts

A 42-year-old male accountant with a significant past medical history of obesity presents to his primary care physician after one week of lower back pain. After moving into a new home three days ago, he woke up the next morning with bilateral lower back pain without any radiation. He reports no recent trauma, fever, chills, numbness, tingling, or incontinence. He has not had any urinary frequency or dysuria. He takes no medications and has no significant past medical history. Which additional findings in his history or physical exam would make the diagnosis of lumbosacral sprain/strain more likely? A. Abnormal gait B. Increased pain with coughing C. Loss of ankle jerk D. Point tenderness on spinous processes E. Spasm of paraspinal muscles

E. Spasm of paraspinal muscles Spasm of the paraspinous muscles (E) suggests lumbosacral sprain/strain. Increased pain with coughing (B), abnormal gait (A), and loss of ankle jerk (C) point to conditions that compress a regional nerve root, while point tenderness on the spinous processes (D) often indicates an origin in the vertebra (osteoporotic fracture, malignancy, etc.).

Patient will present as → a 33-year-old man who comes to the ED 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 three episodes of hematuria in the past that have spontaneously resolved. His temperature is 98.9°F; pulse is 82/min; respirations are 18/min, and blood pressure is 145/90 mm Hg. PE is normal. Urinalysis shows moderate numbers of erythrocytes, a few leukocytes, red cell casts, and a large amount of protein. No bacteria are cultured. A renal biopsy demonstrates large dark mesangial deposits.

IgA nephropathy

Patient will present as → a 15-month-old male who is brought into your office for his routine exam. On exam, you notice that he has no irises, consistent with aniridia. He is also found with a palpable, non-tender mass on the left side of his abdomen. On further questioning, his mother reveals that her cousin had a similar abdominal mass at a young age.

Wilms tumor

Patient will present as → a 48-year-old woman who presents to the emergency department due to severe back pain and difficulty urinating. Her symptoms began approximately 3 hours ago and reports the pain is in her left mid-back. She describes the pain as sharp and 9/10. The pain radiates to her left groin. On physical exam, there is left-sided costovertebral angle tenderness. A non-contrast computerized tomography (CT) scan of the abdomen is ordered. She is started on a nonsteroidal anti-inflammatory drug (NSAID) and intravenous normal saline.

hydronephrosis

Patient will present as → 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

hyaline casts

normal

Patient will present as → a 60-year-old multiparous woman presents to your office complaining of the sudden need to urinate followed by the occasional loss of urine. She denies leaking urine with coughing or sneezing.

overactive bladder

Patient will present as → a 34-year-old male with hematuria and flank/abdominal pain. He denies any recent trauma. He reports a history of recurrent urinary tract infections and his family history is significant for his mother who died of a "brain bleed" at age 42. Vital signs are significant for a blood pressure of 158/105 mmHg. On physical exam, there a late systolic crescendo murmur with a midsystolic click and tenderness upon palpation of the abdominal flanks. An ultrasound of the abdomen shows bilateral anechoic renal cysts with posterior enhancement.

polycystic kidney disease

Patient will present as → a 10 y/o is brought to the clinic with her mother for dark urine. The mother mentions that the child was complaining of sore throat and cough/cold symptoms two weeks ago. The urine shows gross hematuria without nitrites or leukocytes.

postinfectious glomerulonephritis

Patient will present as → a 32-year-old female presents with fever, chills, nausea, and flank pain for 24 hours. She developed dysuria and urinary frequency 3 days prior and states that both have worsened. On physical exam, you note suprapubic abdominal pain and CVA tenderness. The urinalysis reveals white blood cell casts.

pyelonephritis

WBC casts

pyelonephritis

White blood cell casts in urine are pathognomonic for ?

pyelonephritis

Patient will present as → a 27-year-old male presents to the clinic complaining of coughing up small amounts of blood daily for the past week. He denies smoking, sick contacts, or recent travel. Chest radiographs demonstrate interstitial pneumonia with patchy alveolar infiltrates suggestive of multiple bleeding sites. Urinalysis is positive for blood and protein. A positive result is returned for anti-glomerular basement membrane antibody (anti-GBM Ab)

rapidly progressive glomerulonephritis

Patient will present as → a 69-year-old man with a 55-pack-year smoking history, diabetes type II, and hyperlipidemia presents to his primary care clinic for an annual exam. He has no complaints. He reports that his blood glucose has been under tight control and that he has not smoked a cigarette for the past 5 months. Vital signs are HR 69 bpm, BP 180/100 mmHg, RR 12/min, and O2 saturation 99% on room air. Physical examination is notable for bruits bilaterally just lateral of midline near his umbilicus. You initiate an anti-hypertensive medication, but his blood pressure continues to be suboptimal. Creatinine is 3.5

renal artery stenosis

A patient with the following ABG has what type of acid-base disorder? ph 7.52, PCO2 40, Bicarb 38 PH (7.35-7.45 normal) CO2 (35-45 normal) HCO3 (20-26 normal) A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

D. Metabolic alkalosis

Horseshoe kidney is associated with which of the following conditions? A. Diabetes mellitus B. Down's syndrome C. Hypertension D. Renal carcinoma

D. Renal carcinoma

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. Gentamicin In hospitalized patients up to 25% of patients receiving aminoglycosides sustain some degree of acute tubular necrosis. Gentamicin is one of the most toxic aminoglycosides, streptomycin is the least nephrotoxic of the aminoglycosides

Patient will present as → a 69-year-old man with a 55-pack-year smoking history, diabetes type II, and hyperlipidemia presents to his primary care clinic for an annual exam. He has no complaints. He reports that his blood glucose has been under tight control and that he has not smoked a cigarette for the past 5 months. Vital signs are HR 69 bpm, BP 180/100 mmHg, RR 12/min, and O2 saturation 99% on room air. Physical examination is notable for bruits bilaterally just lateral of midline near his umbilicus. You initiate an anti-hypertensive medication, but his blood pressure continues to be suboptimal. Creatinine is 3.5.

renal vascular disease

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, which of the following disorders is most likely to be responsible for this clinical picture? A. chronic renal failure B. middle cerebral artery occlusion C. Guillain-Barre syndrome D. Raynaud's phenomena

A. chronic renal failure Patients with chronic renal failure will have accelerated atherosclerosis, hypertension, anemia due to lack of erythropoietin production, a tendency toward GI symptoms of anorexia, nausea, and weight loss, and neurological symptoms of peripheral neuropathy that occurs in a stocking and glove distribution along with peripheral motor impairment such as foot drop and restless legs syndrome. Diabetes and hypertension are risk factors for the development of chronic renal disease.

In the emergency department, you are evaluating a 64 year old previously healthy male presenting with fever, altered mental status and shortness of breath. At admission, his temperature is 103 degrees Fahrenheit, pulse is 128 beats per minute, respiratory rate is 27 breaths per minute, oxygen saturation 94% on 15L non-rebreather. On exam, he is hypotensive and appears acutely ill, with somnolence and respiratory distress with diffuse crackles. While your attending prepares to intubate the patient, bloodwork is collected. Labs show the following: Na 134 mEq/L Cl 100 mmol/L HCO3 14 mmol/L Lactic acid 4.9 mmol/L ABG: pH 7.33 / PaO2 61 mm Hg / PaCO2 31 mm Hg How do you interpret his acid/base status? A. Anion gap metabolic acidosis B. Anion gap metabolic alkalosis C. Anion gap respiratory alkalosis D. Non-anion gap metabolic acidosis E. Non-anion gap metabolic alkalosis

A. Anion gap metabolic acidosis The patient's bicarbonate is low, which indicates a likely primary metabolic acidosis, which is more common than metabolic compensation for a respiratory alkalosis. In addition, based on the ABG collected, the patient does not have a respiratory alkalosis. Once a metabolic acidosis has been determined, the next step is to calculate the anion gap (Na - [Cl + HCO3]); for this patient it is 20 mEq/L, which is above the normal range of 8-16, indicating an anion gap metabolic acidosis. A couple of helpful mnemonics for etiologies of anion gap metabolic acidosis are MUDPILES or GOLD MARK (see case for description). For this patient, his acidosis is likely due to severe sepsis from his acute illness with an elevated lactic acid.

A 40-year-old female presents for follow-up 1 year after surgery. She is complaining of fatigue and occasional nausea. She had often become dehydrated, but this has improved in the last few months. She has had significant weight loss in the past year. Her recent lab work reveals a macrocytic anemia. What is the most likely type of surgery that she underwent? A. Bariatric surgery B. Cholecystectomy C. Appendectomy D. Colectomy E. Inguinal surgery repair

A. Bariatric surgery Due to the small size of the gastric pouch, patients who have undergone bariatric surgery may become dehydrated because they cannot take in large amounts of water and need to become accustomed to drinking water more frequently. Bariatric surgery also often results in B12 deficiency and related anemia, typically months to a year after surgery, due to removal or shortening of the ilium where intrinsic factor-cobalamin complex is absorbed.

Which of the following is most frequently associated with renal cell carcinoma? A. Hematuria B. Inguinal pain C. Hypocalcemia D. Fever

A. hematuria Gross or microscopic hematuria, flank pain, or mass is common in renal cell carcinoma.

A 51 year-old male with renal artery stenosis and an elevated BUN and creatinine, is newly diagnosed as hypertensive. Which of the following agents should be avoided? A. hydrochlorothiazide-triamterene B. prazosin C. nifedipine D. verapamil E. furosemide

A. hydrochlorothiazide-triamterene This is a potassium sparing diuretic and should be avoided in anyone with renal disease. ACEI should be avoided as well (but none of these are ACEI's).

A 75-year-old male comes to the clinic for a review of the workup of his chronic kidney disease (CKD). His past medical history is significant for hypertension, diet-controlled diabetes mellitus type II, coronary artery disease, and benign prostatic hyperplasia (BPH). His blood pressure and diabetes have been well-controlled by antihypertensive medications and following a diabetic diet. Urinalysis and urine microscopy are normal. His creatinine is 1.5 mg/dL with a GFR of 55mL/min. Renal ultrasound shows normal-sized kidneys with good corticomedullary differentiation, mild hydronephrosis, and normal blood flow per dopplers. What is the most likely cause of his chronic kidney disease? A. Benign prostatic hyperplasia B. Diabetes mellitus C. Glomerulonephritis D. Hypertension E. Renal artery stenosis

A. Benign prostatic hyperplasia This patient has multiple risk factors for CKD, including diabetes mellitus, hypertension, and BPH. In addition, he has coronary artery disease, which increases his risk for renal artery stenosis. However, his urine is bland, and his kidneys appear normal on an ultrasound except for the hydronephrosis. These findings support BPH as the cause for his CKD. Diabetic nephropathy tends to cause larger-than-normal kidneys with poor corticomedullary differentiation and proteinuria. Glomerulonephritis would present with an abnormal urinalysis and urine microscopy. Hypertension should not have evidence of hydronephrosis on the renal ultrasound and may demonstrate small kidneys. Renal artery stenosis often presents with uncontrolled hypertension, asymmetric kidneys on ultrasound and decreased renal blood flow by doppler to the affected kidney.

A 26 year-old sexually active woman has a 3-day history of dysuria, frequency, and urgency. She has a fever of 102 degrees F orally with shaking chills and right-sided costovertebral angle tenderness. Urinalysis reveals 10-20 RBCs/HPF, 30 WBCs in clumps/HPF, 3-4 WBC casts and 3+ bacteria. Which of the following is the treatment of choice for outpatient management? A. Ciprofloxacin B. Erythromycin C. Doxycycline D. Amoxicillin

A. Ciprofloxacin Treatment with a quinolone is first line treatment of pyelonephritis on an outpatient basis. If the patient were admitted then empiric treatment with Ampicillin and an aminoglycoside IV would be initiated until culture and sensitivity results were obtained.

A 48-year old married Caucasian presents to you with a 6-month history of 'feeling a lump down below' and backache. The lump is bigger when she has been on her feet all day. She also complains of poor urinary stream and a feeling of incomplete emptying of her bladder. She admits to no urinary incontinence or bowel symptoms. She had a total abdominal hysterectomy (TAH) 4 years ago for menorrhagia. She has two children who were delivered vaginally. The most likely diagnosis is A. Cystocele B. Rectocele C. Uterine prolapse D. Cervical polyp

A. Cystocele

A 7-year-old boy wets the bed on most nights. He does not experience daytime symptoms. Which of the following is the preferred pharmacological agent to decrease the incidence of bedwetting? A. Desmopressin B. Phenytoin C. Pramipexole D. Hyoscyamine E. Oxybutynin

A. Desmopressin When the parents and child are interested and motivated to work toward long-term management, initial management of enuresis involves the treatment of coexisting conditions, clarification of goals and expectations, provision of education/advice, and motivational therapy. It is reasonable to recommend active therapy to children with monosymptomatic nocturnal enuresis who have no improvement after three to six months of initial management if enuresis continues to be a problem for the child and family (eg, is associated with diminished self-esteem, prevents the child from attending sleepovers). Initial active therapies include enuresis alarms and desmopressin (a synthetic vasopressin analog).

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. Excessive diuresis Prerenal azotemia is due to renal hypoperfusion which can occur with intravascular volume depletion such as excessive diuresis, hemorrhage, and gastrointestinal losses.

You are working at a skilled nursing facility, rounding on your patients. The nurse tells you that Mrs. Viera, an 83-year-old resident with a history of heart failure, has been having vomiting, diarrhea, and fever since the previous afternoon. The nurse also reports a decrease in urine output since early that morning. On your assessment, you notice that Mrs. Viera is slightly more confused than baseline, with dry mucous membranes. On chart review, you see that her baseline creatinine is 1.6 mg/dL, and that her medication list includes furosemide. You order stat labs which return with the following results: Serum sodium: 134 mEq/L Serum blood urea nitrogen (BUN): 17 mg/dL Serum creatinine: 2.1 mg/dL Urinary sodium: 200 mEq/L Urinary blood urea nitrogen (BUN): 385 mg/dL Urinary creatinine: 220 mg/dL How does the fractional excretion of sodium (FENa) help you identify the etiology of the patient's acute kidney injury (AKI)? A. FENa cannot be reliably interpreted in this patient B. FENa is < 1%, indicating a prerenal etiology C. FENa is < 1%, indicating likely acute tubular necrosis (ATN) D. FENa is > 1%, indicating a prerenal etiology E. FENa is > 1%, indicating likely acute tubular necrosis (ATN)

A. FENa cannot be reliably interpreted in this patient This patient's calculated FENa is 1.4%. FENa < 1 has a 96% sensitivity and 95% specificity for distinguishing prerenal causes from acute tubular necrosis (ATN). However, since the equation uses the urinary sodium, this calculation cannot be reliably interpreted in patients taking loop diuretics, which cause an increase in urinary sodium excretion. Therefore, in patients taking loop diuretics presenting with AKI, the fractional excretion of urea (FEUrea) is the preferred equation: FEUrea ≤ 35% indicates prerenal etiology with 78% sensitivity and 88% specificity, whereas FEUrea > 50% indicates a diagnosis of ATN. This patient's calculated FEUrea is 21.6%, which supports the presumptive diagnosis of prerenal AKI based on the patient's history and exam.

A 22-year-old woman comes to the office because her urine is cola-colored and she has not urinated since yesterday morning. Her past medical history is significant for pharyngitis two weeks ago. Her mother and grandmother have type 2 diabetes. Her blood pressure is 146/92 mmHG. On physical examination, she has edema of her face and hands. Which of the following is the most likely diagnosis? A. Glomerulonephritis B. Acute tubular necrosis C. Nephrolithiasis D. Diabetic nephropathy

A. Glomerulonephritis Glomerulonephritis presents with hematuria, cola-colored urine, oliguria, and edema of the face and eyes in the morning. Urinalysis reveals red blood cells, mild proteinuria and red blood cell casts. Glomerulonephritis can occur 1-3 weeks after a strep infection.

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. Which of the following is the most appropriate intervention at this time? A. Hemodialysis B. Continue to observe C. Administration of high dose steroids D. Bilateral nephrectomy

A. Hemodialysis

A 58-year-old female with chronic kidney disease stage 3, secondary to type 2 diabetes mellitus, presents to the clinic to establish care. Her blood pressure is 154/86 mmHg. Her body mass index (BMI) is 30 kg/m2. Her hemoglobin A1C is 9.8 mg/dL, and urine microalbumin/creatinine ratio is 1.5 mg/dL. She takes long-acting insulin. In addition to tighter glucose management, which of the following would be the best treatment for diabetic nephropathy? A. Lisinopril B. Pentoxifylline C. Protein restriction D. Simvastatin E. Spironolactone

A. Lisinopril Treatment of diabetic nephropathy focuses on glycemic and blood pressure control. Intensive glycemic control can delay the development of proteinuria and decrease in glomerular filtration rate (GFR). Treatment of hypertension, particularly with blockers of renin-angiotensin, slows loss of renal function. Both angiotensin receptor blockers (ARBs) and angiotensin-converting-enzyme (ACE) inhibitors (such as lisinopril) decrease the development and worsening of proteinuria and slow the loss of GFR. However, using an ACE inhibitor and ARB together does not slow loss of renal function further and is associated with hyperkalemia and increased incidence of acute kidney injury. Some studies have shown that adding spironolactone (mineralocorticoid receptor agonist) to lisinopril decreases proteinuria, but there is no long-term data regarding the slowing loss of GFR. Pentoxifylline has been shown to decrease proteinuria and slow loss of GFR in small non-randomized studies. Additional studies are needed to verify the effect of pentoxifylline. Lipid lowering is important in the overall management of diabetes, as diabetes is considered a coronary heart disease equivalent, but it has not been shown to prevent diabetic nephropathy. Low-protein diets have been studied in diabetic nephropathy and it is uncertain if protein restriction slows decline in GFR. Additionally, diabetics are at increased risk for protein malnutrition, so protein restriction should not be recommended to the patient.

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. Lisinopril (Prinivil) All patients should be started on an ACE inhibitor to prevent the progression of proteinuria. ACE inhibitors appear to improve glomerular hemodynamics by decreasing glomerular pressure.

Which of the following treatments of constipation should be used with extreme caution in patients who have chronic renal insufficiency? A. Magnesium hydroxide (Milk Of Magnesia) B. Psyllium (Metamucil) C. Docusate sodium (Colace) D. Lactulose (Chronulac)

A. Magnesium hydroxide (Milk Of Magnesia) Question 4 Explanation: Patients with chronic renal insufficiency have difficulty excreting magnesium and hypermagnesemia almost always occurs in a patient with chronic renal insufficiency.

A 38-year-old female with a past medical history of sarcoidosis and recent completion of a six-month steroid taper presents to her primary care physician after two weeks of lower lumbar back pain. She does not recall any trauma but began to feel a sharp pain after bending over to pick up laundry. The pain radiates bilaterally into her anterior abdomen. She has found no relief with over-the-counter NSAIDs. On physical exam, she has point tenderness along her vertebrae in the L1-L2 region. There are no neurologic deficits and reflexes are intact. Which of the following is the most appropriate next step in management? A. Order a plain x-ray B. Order complete blood count (CBC) C. Reassess in four weeks D. Recommend conservative management E. Refer to spine specialist

A. Order a plain x-ray The "red flag" in this history is that of chronic steroid use, and the concomitant risk of osteoporotic vertebral fracture; therefore, imaging is indicated. A vertebral fracture is best diagnosed with a plain x-ray (A). A CBC will not help with the diagnosis and would be indicated only if neoplasm or spinal infection was suspected (B). Referral to a spine specialist is unnecessary (E) unless a compression fracture is found on imaging and the patient is deemed a candidate for surgical management, but would not be the appropriate next step at this time until imaging is done. Conservative management (D) and/or reassessment in four weeks (C) demonstrate a failure to recognize the "red flag."

A patient with the following ABG has what type of acid-base disorder? ph 7.30, PCO2 60, Bicarb 22 PH (7.35-7.45 normal) CO2 (35-45 normal) HCO3 (20-26 normal) A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A. Respiratory acidosis

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. Rhabdomyolysis causing acute renal failure Since the patient was found unconscious for an undetermined amount of time and the blood alcohol is elevated the patient has been in a state of prolonged immobilization resulting in muscle ischemia resulting in myoglobinuria. This is responsible for turning the dipstick positive without the RBCs seen on the urinary microscopy. The myoglobin causes an acute tubular necrosis resulting in the sloughing of the renal tubular epithelium. Obstructive uropathy does not cause acute tubular necrosis and occurs over time. Methanol ingestion causes visual symptoms, ethylene glycol causes renal failure.

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

A. adult polycystic kidney disease

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. prerenal azotemia Patients who have prerenal azotemia with otherwise normal kidneys will have severe sodium retention in order to help to save fluid. The amount of sodium in the urine is therefore very low.

What type of antihypertensive medication is contraindicated in patients with renal artery stenosis?

ACE inhibitors (result in renal insufficiency)

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. ASO This patient has classic symptoms of hematuria, pretibial edema and hypertension indicative of nephritic syndrome. The history of an untreated sore throat is key to the diagnosis of post streptococcal glomerulonephritis. He would have a positive ASO titer.

A 15 year-old male patient presents with oliguria, hematuria, proteinuria, and fatigue following streptococcal pharyngitis 2 weeks ago. Which of the following is the most likely diagnosis? A. Acute pyelonephritis B. Acute glomerulonephritis C. Systemic lupus erythematosus D. Initial onset of type 1 diabetes mellitus

B. Acute glomerulonephritis Acute glomerulonephritis is a complication that can follow a streptococcal infection after 1 to 3 weeks.

Which of these is most accurate regarding hyperkalemia? A. Excessive potassium intake alone is more commonly responsible for hyperkalemia than decreased renal potassium excretion B. Drugs responsible for hyperkalemia include angiotensin-receptor blockers (ARBs) and nonsteroidal anti-inflammatory drugs (NSAIDs) C. Transtubular potassium gradient (TTKG) measurement is required in all patients with suspected hyperkalemia D. Hemodialysis is required, even in mild cases of hyperkalemia without ECG abnormalities

B. Drugs responsible for hyperkalemia include angiotensin-receptor blockers (ARBs) and nonsteroidal anti-inflammatory drugs (NSAIDs) ACE inhibitors lower the levels of aldosterone, thereby promoting potassium retention in the kidneys and bloodstream. People with diabetes and kidney disease are at increased risk of hyperkalemia so ACE inhibitors must be used with caution in these patients. The hypothesized mechanism for hyperkalemia associated with NSAIDs is related to the inhibition of prostacyclin. In contrast to COX-1, COX-2 mediates prostacyclin synthesis, which increases potassium secretion at the distal tubule. Medications that impair renal potassium excretion, as follows: Potassium-sparing diuretics, which are especially used in the treatment of cirrhosis and chronic heart failure NSAIDs ACE inhibitors The combination of spironolactone and ACE inhibitors ARBs Direct renin inhibitors (eg, aliskiren) Calcineurin inhibitors (eg, cyclosporine, tacrolimus) Antibiotics (eg, pentamidine and trimethoprim-sulfamethoxazole) Epsilon-aminocaproic acid Oral contraceptive agents, such as drospirenone

You are working in the emergency department, and your attending asks you to see a 65-year-old male presenting with abdominal pain. In gathering the history, the patient tells you that he has had two to three days of progressive generalized "achy" abdominal pain, along with decreased appetite and decreased urine output. On further clarification, he reports not urinating in the past two days. On examination, vital signs are normal. He is alert, oriented, and in no acute distress. His exam is benign with the exception of mild abdominal distention, a palpable bladder, and an enlarged prostate on digital rectal exam. Which of the following is the next best step? A. Computed tomography (CT) of his abdomen and pelvis B. Foley catheter placement C. Intravenous (IV) diuretics D. IV fluids E. Renal ultrasound

B. Foley catheter placement This patient is presenting with symptoms of postrenal obstruction. The urgent next step is foley catheter placement to relieve the obstruction, which can be both diagnostic and therapeutic. Alternatively, a bedside bladder scan can be performed to confirm the enlarged bladder (many bedside nurses can do this technique), prior to catheter placement. The patient's enlarged prostate increases the likelihood of bladder outlet obstruction. Post-obstructive renal failure is a "can't miss" diagnosis, as longer obstruction time leads to an increased incidence of acute kidney injury, infection, and urosepsis. Prompt relief of the obstruction is important. A urologic CT scan (without contrast) can be utilized to evaluate patients with presumed obstruction. Additionally, magnetic resonance imaging (MRI) has very high sensitivity and specificity for identifying the obstruction and may also be able to differentiate acute versus chronic renal failure. Its main limitations are cost and accessibility. However, these modalities would be reserved for cases in which the cause of obstruction may be unclear, which is not the case in this patient. This patient is presenting with signs and symptoms of a urinary obstruction. IV fluids are indicated in prerenal acute kidney injury, but would not treat this patient's most-likely underlying pathology. In addition, diuretics (to promote urine output) would be contraindicated in a complete obstruction, and would not be recommended in this setting without any additional information about the underlying etiology of his symptoms. Renal ultrasound is a quick, safe, and relatively inexpensive way to evaluate for hydronephrosis; however, in this patient with a palpable bladder and high degree of suspicion of obstruction below the bladder outlet, the first step should be Foley insertion.

A 48-year-old male with a history of chronic alcoholism presents to the emergency department with complaints of fatigue, muscle cramps and weakness, and constipation. He reports that these symptoms have developed over the past several weeks, and he admits to currently drinking 750 ml of whiskey daily. Physical examination is significant for 1+ reflexes at the bilateral patellar tendons and absent reflexes distally at the bilateral Achilles tendons. A complete blood count, complete metabolic panel, and EKG are ordered. The patient's EKG shows U waves. The results of the complete blood count and metabolic panel are pending. Which of the following is the best management for the most likely cause of this patient's condition? A. IV potassium replacement alone B. IV magnesium and potassium replacement C. Calcium gluconate followed by sodium bicarbonate, albuterol, insulin, and glucose D. Kayexalate and furosemide E. Hemodialysis

B. IV magnesium and potassium replacement A chronic alcoholic presenting with hypokalemia is likely also hypomagnesemic. In order to achieve effective correction of potassium levels, both potassium and magnesium must be replaced.

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 A. Post streptococcal glomerulonephritis (PSGN) B. IgA nephropathy C. Minimal change disease (MCD) D. Membranous nephropathy

B. IgA nephropathy IgA nephropathy presents after an upper respiratory illness with deposition of IgA within the mesangium of the glomerulus.

A 45-year-old female with stage 3 chronic kidney disease, secondary to lupus nephritis, presents to the emergency department with confusion. Her husband reports that she has been complaining of nausea and itching for several weeks. Diphenhydramine has not alleviated the itching. Her physical exam is significant for lethargy, orientation to person only, excoriations on all of her extremities, a pericardial friction rub, asterixis, crackles at the lower lung fields, and pitting edema of the lower extremities to the knees. Her labs are significant for sodium 135 mEq/L, potassium 5.5 mEq/L, creatinine 5 mg/dL [creatinine was 2.5 mg/dL six months ago], HCO3 20 mEq/L, and an anion gap of 14. What is the pathophysiological mechanism of her acute state? A. Decreased cardiac output from non-ischemic cardiomyopathy B. Inability of the kidneys to excrete organic waste products C. Inability of the liver to excrete nitrogenous waste products D. Ingestion of ethanol, leading to accumulation of ketones E. Poor oral intake, leading to accumulation of ketones

B. Inability of the kidneys to excrete organic waste products This patient is presenting with a constellation of symptoms and findings consistent with uremia. Given the chronicity of her nausea and itching, her kidneys have been declining over several months. Uremia is caused by the kidneys' inability to excrete organic waste products. While poor oral intake could result in a starvation ketosis, which would worsen her anion gap metabolic acidosis, it would not explain her other symptoms of itching, friction rub, or asterixis. Hepatic encephalopathy, which occurs with liver failure, is caused by the liver's inability to excrete nitrogenous waste products; however, she has no signs of advanced liver disease (jaundice, ascites, spider angiomata). Ingestion of too much ethanol can cause a ketosis, which would worsen her anion gap metabolic acidosis, but would not explain her other symptoms. Non-ischemic cardiomyopathy would explain the volume overload; however, it would not explain her neurological symptoms.

What is the most common cause of nephritic syndrome in a 4-year-old? A. Trauma B. Recent strep infection C. Dehydration D. Nonsteroidal anti-inflammatory drugs (NSAIDs) E. Varicella infection

B. Recent strep infection Poststreptococcal glomerulonephritis is the leading cause of acute nephritic syndrome. The condition is most frequently encountered in children between 2 and 6 years of age with a recent history of pharyngitis. It is rare in children younger than 2 and adults older than 40. The incidence of poststreptococcal glomerulonephritis appears to be decreasing. The condition typically develops approximately 10 days after pharyngitis or 2 weeks after a skin infection with a nephritogenic strain of group A hemolytic Streptococcus. It has not been determined whether antibiotic treatment of the primary skin infection affords protection from the development of poststreptococcal glomerulonephritis. The classic presentation of poststreptococcal glomerulonephritis is a nephritic syndrome with oliguric acute renal failure. Most patients have milder disease, and subclinical cases are common. Patients with severe disease experience gross hematuria characterized by red or smoky urine, headache, and generalized symptoms such as anorexia, nausea, vomiting, and malaise. Inflammation of the renal capsule can lead to flank or back pain. Physical examination may show hypervolemia, edema, or hypertension. Acute poststreptococcal glomerulonephritis is usually diagnosed on clinical and serologic grounds without the need for biopsy, especially in children with a typical history. The overall prognosis in classic poststreptococcal acute proliferative glomerulonephritis is good. Most patients recover spontaneously and return to baseline renal function within 3 to 4 weeks with no long-term complications.

A 40 year-old female G5P5 complains of small quantities of urine leaking when she coughs, sneezes, or laughs. Her genitourinary examination is unremarkable and her urinalysis is normal. At this time, which of the following is the most appropriate management plan? A. Refer for a cystoscopy B. Recommend Kegel exercises C. Refer for surgical correction D. Recommend hormone replacement therapy

B. Recommend Kegel exercises

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. Which of the following diagnostic studies is the best for determining the cause of the proteinuria? A. Renal ultrasound B. Renal biopsy C. Cystoscopy D. Computed tomography scan

B. Renal biopsy

A patient with the following ABG has what type of acid-base disorder? ph 7.52, PCO2 25, Bicarb 22 PH (7.35-7.45 normal) CO2 (35-45 normal) HCO3 (20-26 normal) A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

B. Respiratory alkalosis

Which of the following statements is accurate regarding the presentation of nephrotic syndrome? A. Hematuria is among the most common presenting symptoms in adults with nephrotic syndrome B. The first sign of nephrotic syndrome in children is usually swelling of the face C. The presence of deep venous thrombosis or pulmonary embolism suggests a diagnosis other than nephrotic syndrome D. Weight loss and hypotension are frequently present in adults with nephrotic syndrome

B. The first sign of nephrotic syndrome in children is usually swelling of the face The first sign of nephrotic syndrome in children is usually swelling of the face; this is followed by swelling of the entire body. Adults can present with dependent edema. Foamy urine may be a presenting feature. A thrombotic complication, such as deep venous thrombosis of the calf veins or even a pulmonary embolus, may be the first clue to nephrotic syndrome. Additional historical features can be related to the cause of nephrotic syndrome. Thus, the recent start of a nonsteroidal anti-inflammatory drug (NSAID) suggests such drugs as the cause, and a greater-than-10-year history of diabetes with symptomatic neuropathy indicates diabetic nephropathy. Edema is the salient feature of nephrotic syndrome and initially develops around the eyes and legs. With time, the edema becomes generalized and may be associated with an increase in weight, the development of ascites, or pleural effusions. Hematuria and hypertension manifest in a minority of patients; this condition is sometimes referred to as "nephritic-nephrotic." Additional features on examination vary according to cause and as a result of whether renal function impairment is present. Thus, in the case of longstanding diabetes, the patient may have diabetic retinopathy, which correlates closely with diabetic nephropathy. If the kidney function is reduced, the patient may have hypertension, anemia, or both.

A 78-year-old male with a significant past medical history of chronic kidney disease stage II, coronary artery disease, and hypertension presents with lumbar back pain. He has also been feeling general malaise and chills over the past few days. On review of systems, he reports having some difficulty urinating with hesitancy and pain on urination. Currently, his chronic conditions are well managed with metoprolol, lisinopril, and aspirin. He has never smoked. Vital signs: temperature is 38 °C (100.4 °F), blood pressure is 135/75 mmHg, pulse is 76 beats/minute, and respiratory rate is 15 breaths/minute. Given this history, which of the following physical exam maneuvers would be the most helpful in making the diagnosis? A. Abdominal palpation B. Auscultation for an abdominal bruit C. Digital rectal exam D. Pinprick sensation of the legs E. Straight leg test

C. Digital rectal exam This patient is presenting with symptoms of a genitourinary infection. In an older male patient, prostatitis may present with low back pain. This patient's symptoms—general malaise, chills, hesitancy and pain on urination—and vital signs (fever) suggest acute bacterial prostatitis. Patients with acute bacterial prostatitis will often have exquisite tenderness over the prostate on rectal exam (C). This patient could also have pyelonephritis, so assessing for costovertebral angle tenderness and collecting a urinalysis would also be appropriate in this setting. A straight leg test (E) can be performed to evaluate for radiculopathy; however, this patient does not have back pain radiating to the leg below the knee, which is a hallmark sign of radiculopathy. Abdominal palpation (A) can help determine if the patient may have an abdominal mass. Assessing for an abdominal bruit (B) is appropriate in older patients with back pain, however, aortic pathology is less likely in this patient, who does not smoke and who has a fever. Patients with neuropathy will often have decreased pinprick sensation of the lower extremities (D), but he does not have any numbness or burning sensation in the lower extremities which would be symptoms associated with this diagnosis.

On a pelvic computed tomography, a patient is found to have incidental bilateral hydronephrosis. Which of the following urinary symptoms would point to a urethral stricture as the cause of his findings? A. Dysuria B. Frequency C. Hesitancy D. Nocturia E. Urgency

C. Hesitancy Hydronephrosis is an indication of an obstructive process that is causing changes in the renal pelvis or calyces. Urethral stricture, a cause of lower urinary tract obstruction, shares symptoms such as hesitancy with other obstructive processes like benign prostatic enlargement or tumor of the bladder or urethra. Urinary urgency, dysuria, and frequency are irritative voiding symptoms. Nocturia can be caused by several processes and is not specific to obstructive disease.

A 27 year-old patient presents with crush injuries to both lower extremities after being involved in an automobile accident. Within six hours of the accident, urine output has decreased to less than 10 cc per hour. Within 24 hours the serum creatinine increased from 0.9 mg/dl to 2.9 mg/dl and serum CPK is now 12,000 U/L. In addition to a fluid challenge with normal saline, which of the following is the most appropriate treatment as this time? A. IV calcium chloride B. Oral captopril (Capoten) C. IV sodium bicarbonate D. Oral sevelamer (Renagel)

C. IV sodium bicarbonate Treatment of acute renal failure due to rhabdomyolysis is best accomplished with IV fluids and forced alkaline diuresis.

A patient with the following ABG has what type of acid-base disorder? ph 7.30, PCO2 40, Bicarb 16 PH (7.35-7.45 normal) CO2 (35-45 normal) HCO3 (20-26 normal) A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

C. Metabolic acidosis

A 78-year-old female is diagnosed with overactive bladder and given a trial of oxybutin (Ditropan). She is suffering from mild dementia and, in addition to her complaints of dry mouth, the oxybutin seemed to worsen her confusion. What is the next appropriate medication of choice for her condition? A. Darifenacin (Enablex) B. Fesoterodine (Toviaz) C. Mirabegron (Myrbetriq) D. Oxybutin extended release (Ditropan XL) E. Tolterodine (Detrol)

C. Mirabegron (Myrbetriq) Although the side effect of dry mouth could decrease with extended release formulation of oxybutin or by switching to tolterodine that is better tolerated by the elderly patients, the effects of the antimuscarinic agents (oxybutin, tolterodine, trospium, solifenacin, darifenacin, fesoterodine) on this patient's dementia are a concern. Therefore, the use mirabegron, a β3-adrenergic agonist, is indicated. This class of medications works by increasing bladder capacity by smooth-muscle relaxation allowing the bladder to store more urine.

Which of these is most accurate regarding hyponatremia? A. Loop diuretics are the most common cause of medication-related hyponatremia B. Hypervolemic hypotonic hyponatremia is the most common form of hyponatremia C. Most patients with hyponatremia are asymptomatic, and the condition is incidentally noted on laboratory findings D. The rate of correction for patients with chronic, severe symptomatic hyponatremia should be 2 mEq/L/h, with a total increase > 10 mEq/L in a 24-hour period

C. Most patients with hyponatremia are asymptomatic, and the condition is incidentally noted on laboratory findings

A 68 year-old woman comes to the office for evaluation of urinary incontinence. For the past few months, she has had an intense urgency to urinate, followed by leakage of urine. Which of the following is the most appropriate intervention for this patient? A. Intravaginal estrogen cream (Premarin cream) B. Terazosin (Hytrin) C. Oxybutynin (Ditropan) D. Intravaginal miconazole cream (Monistat cream)

C. Oxybutynin (Ditropan) Urge incontinence is caused by detrusor overactivity that causes urinary leakage. Antimuscarinics, such as oxybutynin, are prescribed to relax the pelvic muscles.

A 25 year-old female presents with right lower quadrant pain, right flank pain, nausea, and vomiting. Her temperature is 39.6 degrees C. There is right CVA tenderness and RLQ tenderness. Pelvic exam is unremarkable. Urinalysis reveals pH 7.0, trace protein, negative glucose, negative ketones, positive blood, and positive nitrates. Specific gravity is 1.022. Microscopic shows 102 RBCs/HPF, 50-75 WBCs/HPF, rare epithelial cells, and WBC casts. The most likely diagnosis is A. acute salpingitis B. nephrolithiasis C. acute pyelonephritis D. appendicitis

C. acute pyelonephritis Acute pyelonephritis presents with flank pain, fever, and generalized muscle tenderness. Urinalysis shows pyuria with leukocyte casts.

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 A. congestive heart failure B. end-stage liver disease C. nephrotic syndrome D. malnutrition

C. nephrotic syndrome

Your new admission is a 60-year-old male with a massive retroperitoneal hemorrhage which required embolization in interventional radiology. His only past medical history is atrial fibrillation, for which he takes rivaroxaban. His blood pressure was 70/30 mmHg upon arrival in the emergency department (ED) and has since stabilized. His admission labs show his blood urea nitrogen (BUN) is 45 mg/dL and creatinine (Cr) is 3.2 mg/dL. His urine microscopy shows muddy brown casts. What is the most-likely diagnosis? A. Acute glomerulonephritis (Acute GN) B. Acute interstitial nephritis (AIN) C. Acute pyelonephritis D. Acute tubular necrosis (ATN) E. Chronic kidney disease (CKD)

D. Acute tubular necrosis (ATN) Acute tubular necrosis (ATN) is the most-common cause of intrinsic renal injury, and results from ischemic or toxic insult to the tubules. For this patient, it was his hypovolemia from massive acute blood loss that led to tubular ischemia. Muddy brown casts, as depicted in the image, can be seen in ATN, but are absent in 20-30% of cases. Management of ATN includes correcting the underlying condition (i.e. improving renal perfusion, stopping offending medication) and close monitoring and management of fluid and electrolytes. Acute GN results from an autoimmune response that leads to inflammation and damage to the glomeruli. The urinalysis (UA) in Acute GN shows hematuria, proteinuria, and red blood cell (RBC) casts AIN is most-commonly caused by infections and medications (i.e. antibiotics, proton pump inhibitors, non-steroidal anti-inflammatory drugs (NSAIDs), etc.) and the UA often shows sterile pyuria. Urine eosinophils can be seen, but this test lacks both sensitivity and specificity. Acute pyelonephritis is an infection of the kidney, and patients generally present with signs and symptoms of an active infection. In addition, the UA should support the diagnosis of an active urinary tract infection (UTI), such as the presence of white blood cells (WBCs) CKD is defined as either kidney damage or a decreased glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m2 for at least three months. This patient's kidney damage is likely acute.

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. Amyloidosis Nephrotic syndrome can be primary (a disease specific to the kidneys) or secondary (a renal manifestation of a systemic general illness). In all cases, injury to glomeruli is an essential feature. Kidney diseases that affect tubules and interstitium, such as interstitial nephritis, do not cause nephrotic syndrome. Primary causes of nephrotic syndrome include the following, in approximate order of frequency: Minimal-change nephropathy Focal glomerulosclerosis Membranous nephropathy Hereditary nephropathies Secondary causes include the following, again in order of approximate frequency: Diabetes mellitus Lupus erythematosus Viral infections (eg, hepatitis B, hepatitis C, HIV) Amyloidosis and paraproteinemias Preeclampsia Alloantibodies from enzyme replacement therapy

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. Anemia

A 58-year-old woman is followed in the nephrology clinic for long standing chronic kidney disease (CKD) secondary to uncontrolled hypertension. Her glomerular filtration rate (GFR) continues to decline, and she is approaching initiation of hemodialysis. Plans are made to obtain vascular access at the appropriate time, and the patient undergoes the requisite screening to be enrolled as an end stage renal disease (ESRD) patient. Among patients on chronic hemodialysis, which of the following is the most common cause of death? A. Stroke B. Hyperkalemia C. Infection D. Cardiovascular disease E. Cancer

D. Cardiovascular disease This patient will soon initiate hemodialysis for ESRD; the most common cause of death among dialysis patients is cardiovascular disease, which includes sudden cardiac death, acute myocardial infarction, heart failure, and other etiologies. All other choices are common causes of death among patients on HD, however, cardiovascular disease is the most common cause.

A 37-year-old male who drives a delivery truck presents to your clinic after acute onset of severe lower back pain that began after lifting a large package while at work. When you enter the room, you find him standing, unable to sit comfortably. On physical exam, he has limited lumbar flexion, reduced to 45 degrees, positive straight leg test at 45 degrees on the left, normal gait, but difficulty with heel walk. He has 4/5 strength on the left with ankle plantar flexion. Strength is preserved on the right. Which additional physical exam finding would be consistent with this man's level of disc herniation? A. 2/5 strength on hip flexion B. Decreased range of motion on lumbar extension C. Decreased rectal tone D. Hypoactive ankle tendon reflex E. Positive Stoop test

D. Hypoactive ankle tendon reflex The clinical signs presented by this patient—difficulty with heel walk and the abnormal strength of ankle plantar flexion—is consistent with nerve root impingement at the level of L5-S1. Of the answers listed, a hypoactive ankle tendon reflex (D) is also consistent with a nerve root impingement at this level. Pain with lumbar extension (B) suggests degenerative disease or spinal stenosis, and spinal stenosis is similarly suggested by a positive stoop test (E). Diminished hip flexor strength (A) suggests a lesion at the L2, L3, or L4 level, and decreased rectal tone (C) suggests a cauda equina lesion.

A 35 year-old pregnant patient presents with fever, chills, and left-sided flank pain. On physical examination left-sided CVA tenderness is noted. Urinalysis reveals numerous white blood cells and white blood cell casts. Which of the following is the most appropriate treatment? A. Oral ciprofloxacin (Cipro) B. Oral trimethoprim-sulfamethoxazole (Bactrim) C. IV gentamicin (Garamycin) D. IV ceftriaxone (Rocephin)

D. IV ceftriaxone (Rocephin)

Working at your clinic, you receive a call from a patient of yours, a 45-year-old male who was seen three days ago complaining of lower back pain. At that time he had no history of trauma, pain that improved while lying down, and no neurologic deficits. He works as a truck driver. He was treated conservatively along with pharmacologic intervention with NSAIDs and muscle relaxants. He calls your office now due to only minimal improvement. And although his symptoms have not changed, he is frustrated with the slow progress, needs to get back to work as soon as possible, and is concerned this might be "something serious." Which of the following is the most appropriate next step in management? A. Ask him to double the dosage of his muscle relaxants B. Obtain a plain film x-ray C. Order an MRI D. Reassure him and schedule a follow-up appointment in a few days E. Schedule him for an appointment immediately

D. Reassure him and schedule a follow-up appointment in a few days Given this clinical presentation, the likelihood of this being an episode of lumbar sprain/strain is high, and the odds of this being "something serious" (nerve root compression, malignancy, infection) is still low. The original plan is a good one and he should be reassured to continue this course and follow up in a few days (D). No new medications (A) or imaging studies (B, C) would help, and an urgent appointment will not change the anticipated course (E). Some physicians might choose to involve a physical therapist at this time, but this option is not available for this question.

A 52-year-old female with stage 4 chronic kidney disease, secondary to hypertensive nephropathy, presents to establish care. Her blood pressure is 154/86 mmHg on 12.5mg of hydrochlorothiazide. Her urine microalbumin/creatinine ratio is 1. What is the best treatment for her hypertension? A. Increase the dose of the hydrochlorothiazide and add lisinopril B. Increase the dose of the hydrochlorothiazide and add losartan C. Stop the hydrochlorothiazide and start chlorthalidone D. Stop the hydrochlorothiazide and start lisinopril E. Stop the hydrochlorothiazide and start losartan

D. Stop the hydrochlorothiazide and start lisinopril This patient is spilling protein in her urine, so an angiotensin converting enzyme inhibitor (ACE-I), such as lisinopril, or angiotensin receptor blocker (ARB), such as losartan, is required. ACE-Is are less expensive than ARBs, so should be tried first. ARBs are appropriate for use in patients who cannot tolerate ACEIs because of side effects, such as cough, or allergic reactions, such as angioedema. Thiazide diuretics such as hydrochlorothiazide and chlorthalidone are not effective with stage 4 and stage 5 chronic kidney disease (CKD).

When neither volume overload nor volume contraction is the probable cause of hyponatremia, which of the following should be considered? A. An adrenal disorder B. A pituitary disorder C. A liver disorder D. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

D. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

The most definitive treatment for primary enuresis is A. oxybutynin chloride (Ditropan) B. imipramine (Tofranil) C. trimethoprim-sulfamethoxazole (Bactrim) D. desmopressin (DDAVP)

D. desmopressin (DDAVP)

A 13-year-old boy presents with fever and blood in his urine. Examination shows an asymptomatic mass in the left lower quadrant. Urinalysis shows hematuria and small leukocytes. Which of the following is the most likely diagnosis? A. renal cell carcinoma B. intussusception C. volvulus D. nephroblastoma

D. nephroblastoma Nephroblastoma also known as Wilms tumor typically presents with an asymptomatic abdominal mass noticed by the parent or an increasing size of the abdomen. On examination, the mass feels smooth and firm, is well defined, and usually does not cross the midline. Gross hematuria may be present, but rare, and some patients have microscopic hematuria when tested. Wilms tumor accounts for approximately 5% of cancers in children younger than 15 years. Wilms tumor arises from the kidney and the average age at diagnosis is 4 years. Ultrasound and CT of the abdomen can be used to confirm the presence of an intra-abdominal mass. Treatment includes exploratory abdominal surgery for removal and staging with a mixture of chemotherapy. Intussusception (telescoping of the small intestine) typically presents in an infant with paroxysmal paroxysmal abdominal pain, vomiting, and diarrhea that may progress into bloody stools. Volvulus is normally the result of intestinal malrotation that causes occlusion of the superior mesenteric artery and eventual bowel necrosis. Infants typically present within 3 weeks of life with bile-stained vomiting and bowel obstruction.

A 63-year-old male with stage 3 chronic kidney disease (CKD), secondary to hypertension, presents for a routine follow-up. His blood pressure is 134/72 mmHg. His physical exam is within normal limits. His labs are significant for a potassium of 5.3 mEq/L and phosphorus of 5 mg/dL. What is the explanation for his hyperkalemia and hyperphosphatemia? A. Excess dietary potassium and phosphorus B. Excess intestinal absorption of potassium and phosphorus C. Impaired intestinal absorption of potassium and phosphorus D. Impaired renal absorption of potassium and phosphorus E. Impaired renal excretion of potassium and phosphorus

E. Impaired renal excretion of potassium and phosphorus Patients with CKD have a decrease in nephron mass and impaired renal potassium excretion. This can lead to hyperkalemia. Hyperphosphatemia can occur with CKD due to an inability of the kidney to excrete excess dietary phosphorus. The intestinal tract functions normally in patients with CKD. CKD patients have to limit their dietary intake of potassium and phosphorus, however, hyperkalemia and hyperphosphatemia are secondary to impaired excretion and can occur even when patients are eating a "normal" amount of these electrolytes.

It is the Monday after a major national holiday, and you are seeing a 58-year-old male in the emergency department with progressive shortness of breath and generalized weakness over the previous two days. He has a history of end-stage renal disease (ESRD) due to diabetes and hypertension. He is chronically anuric and undergoes hemodialysis (HD) every Tuesday, Thursday, and Saturday. He says, "You know, Doc, I definitely indulged a bit too much at the holiday dinner." On exam, he appears short of breath, sitting upright on the gurney and speaking in 2- to 3-word sentences. His temperature is 36.1 C (97 F), pulse is 75 beats/minute, respiratory rate is 20 breaths/minute, blood pressure is 180/60 mmHg, and oxygen saturation is 94% on 10 liters/minute face mask. His exam is notable for diffuse crackles bilaterally, jugular venous pulse and pressure (JVP) of 12 cm while upright, lower extremity pitting edema to above his knees bilaterally, and a left arteriovenous (AV) fistula with a strong thrill. His labs are notable for the following: Sodium (Na): 132 mEq/L Potassium (K): 5.5 mEq/L Chloride (Cl): 111 mEq/L Bicarbonate (HCO3): 19 mEq/L Blood urea nitrogen (BUN): 48 mg/dL Creatinine (Cr): 5.9 mg/dL Phosphorus: 5.1 mg/dL Albumin: 3.4 g/dL Troponin: 0.04 ng/mL pH: 7.35 Chest x-ray shows pulmonary vascular congestion and pulmonary edema. Electrocardiogram (ECG) is normal. What is the next-best step in evaluation and/or management of this patient? A. Blood cultures and intravenous (IV) antibiotics B. Calcium gluconate IV C. Computed tomography angiography (CTA) of the chest D. Furosemide 40 mg IV push and reevaluation in four hours E. Nephrology consult for urgent hemodialysis

E. Nephrology consult for urgent hemodialysis This patient has ESRD and volume overload with pulmonary edema due to dietary indiscretion, which is an indication for urgent hemodialysis. While he has ESRD rather than AKI, the indications for urgent dialysis apply to both ESRD and AKI patients. A helpful mnemonic for remembering indications for urgent hemodialysis is "AEIOU" (see case): Acidosis - mild acidosis can sometimes be managed with bicarbonate replacement, but more severe or refractory acidosis requires hemodialysis for correction. Electrolytes - particularly hyperkalemia refractory to conservative measures. Ingestion - of toxins or medications that can be removed with hemodialysis. This includes toxic alcohols, salicylates, phenobarbital, and lithium. Overload - volume overload that is either refractory or cannot be managed with conservative measures. This patient is significantly volume overloaded, manifested by respiratory distress from acute hypoxia, crackles on lung exam, elevated JVP, and leg edema. Uremia - based on clinical assessment. Findings of symptomatic uremia include altered mental status, nausea, generalized pruritus, asterixis, and uremic pericardial friction rub. Calcium gluconate can be given acutely in hyperkalemia to stabilize the cardiac membrane, but does not lower the total body potassium level and is therefore a temporizing measure. This patient's potassium was within the upper limit of normal with a normal ECG. Additionally, his hypoxia should be addressed more urgently. The history, exam, and imaging are all supportive of pulmonary edema from volume overload; this is much more likely than a pulmonary embolism (PE), and therefore delaying treatment for a CTA would not be appropriate. The patient is anuric (does not make urine), so treatment with furosemide and re-evaluating four hours later is not correct and would result in a delay of more-appropriate treatment. There is no evidence of an active infection currently that would prompt the need for blood cultures and antibiotics.

A 32-year-old woman presents for a routine physical examination. She feels well with no specific complaints. On physical examination, her blood pressure is noted to be 154/92 mm Hg. You note slight fullness to the abdomen on palpation without tenderness or obvious mass. Routine labs are ordered, including a UA, with the following results: UA and sediment analysis: 2+ blood, trace protein, negative leukocyte esterase, negative nitrite; 10 to 20 red blood cells (RBCs) per high power field (HPF), no leukocytes, bacteria, or other cells; rare granular casts. BUN 12, Creatinine 0.8. What is the most likely cause of the hematuria? A. urinary tract infection B. glomerulonephritis C. renal calculi D. urinary sample contamination E. polycystic kidney disease

E. polycystic kidney disease Polycystic kidney disease (PKD) is an autosomal dominant disorder that affects approximately 500,000 patients in the United States, occurring in about 1 in 800 live births. Fifty percent of patients will reach ESRD by age 60, and PKD accounts for approximately 10% of hemodialysis patients. It is the most common hereditary disorder to result in ESRD. Family history is positive in 75% of cases, but genetic mutations can occur spontaneously, and patients can present without a family history. Signs and symptoms of PKD include abdominal fullness due to enlarged kidneys, abdominal pain due to bleeding into cysts, microscopic or gross hematuria, depending on the extent of the disease, and hypertension. Patients are often asymptomatic, and the first signs of the disease may be hypertension, microscopic hematuria, and mild proteinuria. Abdominal fullness and pain occur later in the disease, as the number and size of cysts increase. Ultrasound is the diagnostic test of choice to detect PKD: three or more cysts in patients younger than 30, three or more cysts in each kidney in patients 30 to 59 years of age, and five or more cysts in each kidney in patients older than 60 are the diagnostic criteria. Complications include pain, gross hematuria from a ruptured cyst, infected cysts, nephrolithiasis, HTN, and cerebral aneurysms (10% to 15% of patients have arterial aneurysms in the Circle of Willis). There is no effective treatment. Good control of blood pressure and a low protein diet may slow disease progression. There are two distinct genotypes of PKD—PKD1 and PKD2. The disease progresses more slowly in the latter. Urinary tract infection would not fit this patient scenario, as she has no dysuria, and UA is negative for leukocytes, leukocyte esterase, nitrites, and bacteria. Renal calculi would not cause abdominal fullness and hypertension and would be symptomatic on presentation. The urine sample is not contaminated as there are no squamous epithelial cells reported. In the absence of RBC casts and clinical signs and symptoms, this would not be glomerulonephritis

Patient will present as → a 26-year-old man who presents with hematuria, periorbital edema, and jaundice. He has a medical history of opioid use disorder with prior hospitalizations for a heroin overdose. He is on Suboxone but is non-adherent. His blood pressure is 162/102 mmHg. Physical examination is significant for scleral icterus, hepatomegaly, and palpable purpura. Serology shows decreased C3 and C4 levels and elevated anti-hepatitis C antibodies. Urinalysis demonstrates dysmorphic red blood cells and red blood cell casts

Membranoproliferative glomerulonephritis

Patient will present as → a 35-year-old African American, HIV-positive male presents to your office after a routine urinalysis showed proteinuria 2 days ago. Social history includes intravenous drug use 15 years ago. Current medications include prophylactic antibiotics but no antiretroviral therapy. Examination shows a thin appearing male. You note a considerable amount of ankle edema. Urinalysis reveals 3+ proteinuria without hematuria or red cell casts. Serum albumin is 2.3 g/dL (3.5-5.5 g/dl).

focal segmental glomerulosclerosis

Patient will present as → an 18-year-old female presents to the gynecologist for the first time. She reports that she has not started to menstruate. The OB/GYN notes that the patient is short-statured and has notably delayed breast development with webbing skin between the neck and shoulders. With a review of the patient's history, you note she has experienced recurrent urinary tract infections. An investigational abdominal/pelvic US is ordered for suspicion of ?

a horseshoe kidney

eosinophil casts

acute interstitial nephritis

Patient will present as → a 52-year-old male with a past medical history of diabetes mellitus who presents with fever, and acute onset left lower quadrant abdominal pain. CT scan with contrast shows acute diverticulitis. He is started on broad-spectrum antibiotics. The next day, labs reveal a rise in creatinine from 0.7 mg/dL to 2.0 mg/dL. Urinalysis is obtained and a significant amount of muddy brown casts is found.

acute kidney injury

low urine osmolality, FENa >2%

acute tubular necrosis

muddy casts

acute tubular necrosis

Patient will present as → a 65-year-old male with shortness of breath, loss of appetite, and fatigue. He denies any chest pain but states that his wife noticed his legs appear swollen. Medical history is significant for diabetes, hypertension, and obesity. On physical exam, there is decreased tactile fremitus and dullness to percussion of the chest wall. There is pitting edema in the lower extremities. His blood pressure is 160/98 and temperature is 99.9°F. On laboratory testing, his glomerular filtration rate (GFR) is 45 mL/minute/1.73 m2. His urinalysis reveals broad waxy casts.

chronic kidney disease

Patient will present as → a 45-year-old female complaining of pressure in the pelvis and vagina along with discomfort when straining. She also feels that her bladder hasn't fully emptied after urinating.

cystocele

Patient will present as → 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 70 lbs (weight loss of 6% in the previous 3 days).

dehydration

Patient will present as → a 41-year-old male who has a longstanding history of hypertension and diabetes presents with a complaint of pruritus, lethargy, lower extremity edema, nausea, and emesis. He denies any other medical illnesses. On physical exam, the patient is a well-developed, well-nourished male in moderate distress. Blood pressure 180/110, pulse 80, respirations 24 and he is afebrile. Body weight 76.5 kg. HEENT is remarkable for fundoscopic findings of A-V nicking and copper wire changes consistent with hypertensive injury. Cardiac exam reveals an S1, S2, and S4. The remainder of the exam is remarkable for 2+ lower extremity edema and superficial excoriations of his skin from scratching. His GFR is calculated at 6.6 ml/min.

end stage renal disease

Patient will present as → a 75-year-old male who is brought to the emergency room by his daughter for mental status changes. His primary care provider started him on oxycodone and duloxetine (Cymbalta) for diabetic neuropathy. Past medical history (PMH) includes chronic kidney disease (CKD) with eGFR = 26 mL/min/1.73 m2, peripheral vascular disease, gout, congestive heart failure, and coronary artery disease. He has been unable to eat due to nausea but has been able to take fluids.

hyponatremia

Patient will present as → a 35-year-old man who comes to the clinic because of increasing swelling in all of his limbs for the past month. His medications include ibuprofen for chronic low back and knee pain. His temperature is 97.6°F, pulse is 88/min, respirations are 14/min, and blood pressure is 142/86 mm Hg. Physical examination reveals a palpable liver edge 2cm below the right costal margin. Labs are positive for 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.

membranous nephropathy

Patient will present as → a 56-year-old male two days post-bilateral ureterosigmoidostomy for bladder resection due to cancer. He complains of increasing shortness of breath. The patient denies cough, chest pain, or fever. Physical examination is unremarkable except for an increased respiratory rate of 30 breaths/min. Arterial blood gas reveals pH of 7.28, pCO2 22 mmHg, and HCO3 13 mEq/L

metabolic acidosis

Patient will present as → a 12-year-old boy who presents to your office for a yearly physical examination. His mother reports that she has noticed he has gained about 16 lb over the past two months and his face is swollen upon awakening in the morning which improves throughout the day. The patient tells you his urine is bubbly. On examination, he has 2+ bilateral lower extremity edema with normal blood pressure for his age. Your preliminary testing shows creatinine 0.7 mg/dL (0.6-1.2 mg/dL), ↓ albumin 1.07 g/dL (3.5-5.5 g/dl), urine protein 5.4 grams per day, and ↑ total cholesterol of 321.

minimal change disease

Patient will present as → 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 a "Maltese cross" sign.

nephrotic syndrome

Patient will present as → a 65-year-old man who noticed blood in his urine earlier this morning. This has never happened before and he denies any new medications or prior infection. He also reports having flank pain for the past few weeks. Medical history is significant for hypertension. He has a 40-pack-year smoking history. On physical examination, there is a firm, nontender, and homogeneous mass in the right flank.

renal cell carcinoma