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 hydronephrosis
a) Ultrasonography
b) Kidneys, ureters, and bladder (KUB)
plain radiograph
c) Helical CT without intravenous contrast
d) 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
contrast
b) Retrograde urethrogram
c) Focused assessment with sonography in trauma
(FAST) scan
d) 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 obstruction
b) A 30-year-old man with a single kidney and
signs of obstruction
c) A 40-year-old man with a 4-mm stone in the
distal ureter
d) 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 4
A 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 pyelogram
b) CBC with differential and peripheral smear
c) Complete urinalysis with microscopic examination
d) Blood cultures
e) 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 teacolored 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/dL
b) A serum creatinine of 8.4 mg/dL
c) An oxygen requirement of 4 L by nasal cannula
d) An arterial pH of 7.02
e) 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 formation
b) This injury is typically managed conservatively and rarely
requires operative repair
c) A stat ultrasound should be obtained to evaluate the penile
compartments
d) A foley catheter should be immediately placed to prevent acute
urinary retention
e) 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 patients 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) Thrombocytopenia
b) Reactive arthritis syndrome
c) Kawasaki disease
d) Subarachnoid hemorrhage
e) 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 boys 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 mellitus
b) Lymphoma
c) Asymptomatic chlamydial urethrtis
d) Tuberculosis
e) 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 betahemolytic 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 transplant
b) 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)