Questions 08/23/2012

Renal Urogenital

Question 1

Which of the following imaging modalities used in evaluating renal colic is the MOST sensitive and specific for identifying renal calculi or hydronephrosisa) Ultrasonographyb) Kidneys, ureters, and bladder (KUB)

plain radiographc) Helical CT without intravenous contrastd) Intravenous pyelography (IVP)

Answer 1

• Helical CT without intravenous contrast

• 95-98% sensitive • 95% specific• IVP 80-85% sensitive, 95% specific• Ultrasonography 65-93% sensitive,

90-95% specific• KUB 45-60% sensitive

Question 2

During the initial trauma evaluation of a 24-year-old male involved in a motor vehicle accident, blood is discovered at the urethral meatus, and there is concern for a pelvic fracture. Which of the following diagnostic modalities should be used to evaluate a possible urethral injury?a) Helical abdominal CT scan with intravenous and

oral contrastb) Retrograde urethrogramc) Focused assessment with sonography in trauma

(FAST) scand) Intravenous pyelogram (IVP)

Answer 2

• Intravenous pyelogram• Can be performed in the

resuscutation bay• 50-60 cc of radiocontrast solution

injected into urethral meatus

Question 3

Which of the following patients with nephrolithiasis can be safely discharged home?a) A 50-year-old diabetic man with associated

urinary tract infection and signs of obstructionb) A 30-year-old man with a single kidney and

signs of obstructionc) A 40-year-old man with a 4-mm stone in the

distal ureterd) A 25-year-old woman with uncontrolled pain

and persistent vomiting

Answer 3

• Consider admission for patients with large stones (>5 mm), irregular stones, or proximal stones

• Use a lower threshold for patients with severe concurrent underlying disease (angina, COPD) or the eldergly

• Examples that may require urgent decompression include solitary kidney and complete obstruction, ureterolithiasis, hydronephrosis and fever, urosepsis with obstruction

• Discussion with urology with follow up in 1 week should be obtained for patients with 1) renal insufficiency, 2) severe underlying disease, 3) IV urogram showing extravasation or complete obstruction, 4) multiple ED visits, 5) stone > 6 mm, 6) sloughed renal papillae, 7) associated UTI without sepsis

Question 4A 37-year-old woman has a 2-week history of intermittent headache and general malaise. Over the last 24 hours, she has developed back pain, hematuria, vomiting, fever, and confusion. She denies recent travel or insect bites. There is no history of dysuria, urgency, frequency, or kidney stones. Her oral temperature is 38 C and her heart rate is 100/min. Physical findings include pale conjunctiva, borderline tachycardia, bilateral costovertebral tenderness, and several purpuric skin lesions. Her urine dipstick is strongly positive for hemoglobin, but negative for nitrites and leukocyte esterase. The test that will most likely reveal the correct diagnosis is:a) Intravenous pyelogramb) CBC with differential and peripheral smearc) Complete urinalysis with microscopic examinationd) Blood culturese) Liver function tests

Answer 4

• Thrombotic thrombocytopenic purpura• Pentad: central nervous system

abnormalities, renal pathology, fever, microangiopathic hemolytic anemia, and thombocytopenia

• Treatment of choice plasma exchange (plasmapheresis)

• Avoid platelet transfusion as it may cause thrombi in microcirculation

Question 5

Fire rescue brings you a 55-year-old man with no known medical history for evaluation. His neighbor, who last saw him 4 days ago, found him on the floor. On arrival, he is somnolent but arousable. Examination shows an afebrile, ill-appearing man with a heart rate of 130/min and a blood pressure of 90/60 mm Hg. His urine is tea-colored and shows a large amount of blood on urine dipstick but the microscopy is negative for blood. Although his laboratory results are still pending, you suspect rhabdomyolysis and are concerned about acute renal failure. Which of the following is an indication to begin emergent hemodialysis?a) A BUN of 76 mg/dLb) A serum creatinine of 8.4 mg/dLc) An oxygen requirement of 4 L by nasal cannulad) An arterial pH of 7.02e) A potassium level of 7.2 with hyperacute T waves on EKG

Answer 5

• Indications for emergent dialysis– Uncontrolled hyperkalemia (K+ >6.5 mmol/L or rising)– Intractable fluid overload in association with persistent hypoxia, or

lack of response to conservative measures– Uremic pericarditis– Progressive uremic/metabolic encephalopathy; asterixis, seizures– Serum sodium level < 115 or > 165 mEq/L– Severe metabolic acidosis resistant to sodium bicarbonate, or

cases in which repeat dosing of sodium bicarbonate is contraindicated

– Life-threatening poisoning with a dialyzable drug such as lithium, aspirin, methanol, ethylene glycol, or theophylline

– Bleeding dyscrasia secondary to uremia– Excessive BUN and creatinine levels: trigger levels are arbiitrary; it

is generally advisable to keep BUN level < 100 milligrams/dL, but each patient should be evaluated individually

Question 6

A 22-year-old college student complains of penile pain and deformity. He states that 2 hours ago he was having intercourse when he noted a “snapping” sensation in his penis followed by localized pain and asymmetric swelling. You suspect a penile fracture. Which of the following statements is true?a) The injury is due to a traumatic fracture of the corpus

spongiosum and resulting hematoma formationb) This injury is typically managed conservatively and rarely

requires operative repairc) A stat ultrasound should be obtained to evaluate the penile

compartmentsd) A foley catheter should be immediately placed to prevent

acute urinary retentione) Of patients with this injury, a minority will experience a

permanent deformity

Answer 6

• Penile fracture• Three compartments, 2 corpora cavernosa,

1 corpus spongiosum• Corpus spongiosum contains the urethra• Fracture involves the tunica albuginea and

corpus cavernosa• Typically managed by operative hematoma

evacuation and repair of tunica albuginea• Up to 10% experience permanent deformity,

sexual dysfunction, and impaired erections

Question 7

Choose the correct statement about contrast-induced nephropathy:a) Pretreatment with intravenous steroids and

diphenydramine (Benadryl) may reduce the risk of developing nephropathy

b) Pretreatment with furosemide (Lasix) may reduce the risk of developing nephropathy

c) Pretreatment with intravenous fluids may reduce the risk of developing nephropathy

d) There is no association between the patient’s age and the risk of developing contrast-induced nephropathy

e) Following contrast administration, serum creatinine levels typically peak at 14 days and resolve in 60-90 days

Answer 7

• Contrast induced nephropathy• Transient elevation peaking at day 3,

resolving within 10 days• Risk factors include increased

baseline creatinine, heart failure, diabetes, volume depletion, hypertension, NSAID use, liver failure, and age > 75 years

Question 8

In children, priapism is most commonly associated with of the following:a) Thrombocytopeniab) Reactive arthritis syndromec) Kawasaki diseased) Subarachnoid hemorrhagee) Leukemia

Answer 8

• Priapism• Common causes in adults include sickle cell anemia,

spinal cord lesions, medications, drugs of abuse, intercavernosal injections for impotence.

• Common causes in children include leukemia and sickle cell anemia

• Two types: low flow (painful, decreased venous outflow) and high flow (painless, increased arterial inflow associated with penile laceration)

• Initial management includes terbutaline 0.25 mg SQ, penile nerve block for pain control, urology consultation

Question 9

A woman brings her 19-month-old uncircumcised son to be evaluated for swelling and irritation of his penis. You see that the boy’s penis and glans are edematous, erythematous, and excoriated. Retraction of the foreskin is painful and there is white cheesy material between the foreskin and glans. No erosive lesions are present. There is no urethral discharge, pain with urination, or other urinary problems. He has had three prior similar episodes, all of which grew Candida albicans. The entity most common associated with this condition is:a) Diabetes mellitusb) Lymphomac) Asymptomatic chlamydial urethrtisd) Tuberculosise) Peyronie disease

Answer 9

• Balanoposthitis• Refers to inflammation of glans penis and

foreskin (balanitis is inflammation of glans only)• Primarily caused by infection (group A beta-

hemolytic strep, Neiserria gonorrhoeae, Chlamydia)

• Management includes addressing hygiene (sitz baths to reduce inflammation), topical antibacterial or antifungal cream.

• Topical steroids can be helpful for extensive inflammation

Question 10

Concerning the evaluation of a fever in a renal transplant patient:a) Opportunistic infections are most common within the first

month following transplantb) Although a wide variety of bacterial, mycobacterial, viral, and

parasitic opportunistic infections are frequently seen within the first year following transplant, patients rarely develop fungal infections until more than 3 years post transplant

c) In contrast to HIV, cytomegalovirus infection is rare and typically follows a benign course

d) Noninfectious causes of fever include atelectasis, acute rejection, and post-transplant lymphoma

e) Rectal temperatures should never be obtained due to the risk of infection

Answer 10• Solid organ transplant• Complications can be classified into one of four categories: anatomy,

infection, rejection, and drug toxicity• Infection is the primary cause of mortality after transplantation• Timing of infection can be separated into three periods: first month,

between 1 and 6 months, and more than 6 months post-transplant• First month infections are related to transplant procedures,

catheters, and intubation• 1 to 6 month infections are immunomodulating viral infections (CMV,

hepatitis B and C, EBV, etc.) or opportunistic infections (pneumocystis, listeria, fungal)

• Greater than 6 months are divided according to infection susceptibility: healthy transplant (normal community acquired infections such as influenza, UTI, pneumonia), chronic viral infection (varicella zoster virus, hperpes simplex virus) and chronic rejection (opportunistic infections and parasites)