PANCE Exam: Genitourinary Review Questions & Answers

BENIGN CONDITIONS OF THE GU TRACT

Question: What is the most common tumor found in men?
Benign prostatic hyperplasia (BPH).

Question: A 56-year-old man who reports that his urinary stream has weakened. He also complains of nocturia, decreased force of stream, and hesitancy. He also states he is having postvoid dribbling. On the basis of patient’s history, what do you expect to find on his physical examination?
In most cases of suspected BPH, the prostate will have a smooth symmetric and firm elastic consistency. If you detect an irregular, harder nodule or lesion, cancer must be suspected.

Question: What percentage of men with BPH are afflicted with occult prostate cancer?
10% to 30%.

Question: How well does the size of the prostate in BPH correlate with the symptoms?
Not well. Symptoms can arise because of a small fibrous prostate as well as a large one. Additional symptoms can also develop as a result of median bar hypertrophy of the posterior vesicle neck, detrusor muscle decompensation, or instability.

Question: Name three tests that can be used to determine the presence of BPH:
1. Intravenous urography (IVU)
2. CT scan
3. Ultrasound.

Question: What class of drugs is used as a first-line treatment of BPH?
α-Blockers.

Question: Name the most common surgical procedure for the treatment of BPH:
Transurethral resection of the prostate (TURP).

Why is surgical correction of cryptorchism important?
Surgical correction is required to preserve fertility, but the procedure has no bearing on the future development of testicular cancer. Surgery must be performed before age 5 to preserve fertility.

Question: Which children are at higher risk for having cryptorchism?
Premature births have up to 20% prevalence.

Question: What is the most common systemic cause of erectile dysfunction?
Diabetes.

Question: Name some systemic conditions that can cause erectile dysfunction:
Diabetes, hypercholesterolemia, heart disease, depression, renal failure, adrenal and thyroid dysfunction.

Question: Name treatments for improving erectile dysfunction:
Hormonal replacement, vacuum constriction device, vascular surgery, vasoactive therapy, and penile prosthesis.

Question: A 4-year-old boy presents with a painless mass in his scrotum that fluctuates in size with palpation. The mass transilluminates. What is the probable diagnosis?
A communicating hydrocele. An inguinal scrotal ultrasound should distinguish hydrocele from bowel and a testicular nuclear scan should rule out testicular torsion.

Question: When do communicating hydroceles need repair?
If after 1 year to 18 months they do not reduce in size or become larger, surgery is indicated.

Question: Varicoceles are most common in which side of the scrotum?
The left. Varicoceles are a collection of veins in the scrotum. These patients have a higher incidence of infertility, presumably because of the increased temperature of the testes surrounded by the warm blood of the varicocele. Incidentally, the left testis is the first to descend and also hangs lower than the right in the majority of men. Hernias are also more common on the left side, too.

Question: Are varicoceles commonly treated surgically?
No, most are left alone. Treatment is reserved for cases of suspicion of infertility.

Question: Name the two common types of causes of urinary incontinence:
Stress and urge incontinence.

Question: What is a third type?
Overflow incontinence.

What is the mnemonic that refers to the correctable causes of urinary incontinence?
DIAPPERS
Delirium
Infection
Atrophic urethritis and atrophic vaginitis
Pharmaceuticals: sedatives, hypnotics, alcohol, diuretics, and anticholinergics
Psychologic disorders: depression, psychosis
Endocrine disorders: hyperglycemia, hypercalcemia
Restricted mobility
Stool impaction

Question: What is the most common form of urge incontinence?
Detrusor instability.

Question: What is the most common form of stress incontinence?
Urethral incompetence.

Question: What are some examples of stress incontinence?
Incontinence after laughing, coughing, sneezing, or lifting heavy objects.

Question: What are Kegel exercises?
Kegel exercises are pelvic floor muscle exercises. If properly performed, they can help improve the symptoms of urinary incontinence.

Question: What is the most effective treatment for stress incontinence?
Surgery, which has a 75% to 80% cure rate. This is used as a last resort.

Question: A 33-year-old male patient presents with a history of sudden onset of right flank pain that was sharp and doubled the patient over. This was also associated with nausea and vomiting and radiation of pain around the flank to the lower quadrant of the abdomen and scrotum. Based on this history, what is the likely diagnosis?
Kidney stone.

Question: Which gender has more kidney stones?
Men (a 3:1 male-to female ratio).

Question: Which t is the test of choice for ruling out a kidney stone?
Spiral CT scan.

Question: What is the one greatest factor in the prevention of kidney stones?
The amount of fluid intake by the patient. The more a patient is able to take in fluid, the less likely he or she will develop a stone. If a patient has a history of a stone, the recommendation is to try to double the amount of fluids.

What percentage of urinary calculi are radiopaque?
85%.

Question: What are the admission criteria for patients with renal calculi?
Infection with concurrent obstruction, a solitary kidney and complete obstruction, uncontrolled pain, intractable emesis, or large stones. Only 10% of stones >6 mm pass spontaneously. Other indications include renal insufficiency and complete obstruction or urinary extravasation, as demonstrated by the IVP.

Question: What percentage of patients with urinary calculi do not have hematuria?
10%.

Question: A urinary pH of 7.3 is conducive to the formation of what kind of stones?
Struvite and phosphate stones. Alkalotic urine actually inhibits the formation of uric acid and cystine stones. Conversely, struvite and phosphate stones are inhibited by a more acidic urine.

Question: Which type of stone formation is caused by a genetic error?
Cysteine stones. These stones are produced because there is an error in the transport of amino acids that results in cystinuria.

Question: Where is kidney stone formation most likely to occur?
In the proximal portion of the collecting system.

Question: Differentiate between radiolucent and radiopaque renal calculi:
90% of all stones are radiopaque and are composed of calcium oxalate, cysteine, calcium phosphate, or magnesium ammonium phosphate. Radiolucent obstruction consists of uric acid stones and blood clots.

Question: What is the 5-year recurrence rate for kidney stones?
50%. The 10-year recurrence rate is 70%.

Question: What percentage of patients spontaneously pass kidney stones?
80%. This is largely dependent on size. 75% of stones <4 mm pass spontaneously, while only 10% of those >6 mm pass spontaneously. Analgesics and increased fluid intake aid in outpatient management of kidney stones.

Question: Which bacterium is associated with magnesium ammonium phosphate uretero lithiasis?
Proteus, a bacterium that produces urease. These are infected stones and need to be removed. Antibiotics will help treat the UTI and will generally cease stone formation and urinary acidification. A urease inhibitor like acetohydroxamic acid will also prevent stone growth.

Question: Name the three most common anatomical sites where kidney stones are likely to get stuck:
1. Ureterovesicular junction (UVJ)
2. Crossing over the iliac vascular structures
3. Opening of the urethrovesicular junction

What is phimosis?
A condition in which the foreskin cannot be retracted posterior to the glans. The preliminary treatment is a dorsal slit.

Question: What is paraphimosis?
A condition in which the foreskin is retracted posterior to the glands and cannot be advanced over the glans.

Question: What is a nonsurgical method to attempt to reduce a paraphimosis?
Firmly squeeze the inflamed tissue for 5 to 10 minutes to reduce the size, then retract the paraphimosis distally while pushing the glans penis proximally.

Question: How is testicular torsion distinguished from epididymitis?
By the rate of the pain onset. Torsional pain typically begins instantaneously at maximum intensity, whereas epididymal pain grows steadily over hours or days. In torsion, you classically have a loss of the cremasteric reflex and a swollen firm high riding testicle. Clinically, elevation of the scrotum may relieve pain related to epididymitis but is not effective with torsional pain (Prehn sign). This test is not, however, considered diagnostic.

Question: How is testicular torsion diagnosed?
By emergency surgical exploration. A Doppler examination is also very sensitive but should not delay treatment.

Question: What is the testicular viability after 6, 10, and 24 hours of ischemia?
After 6 hours: 6% to 80%
After 10 hours: 10% to 20%
After 24 hours: 24% to near 0%

Question: What does a blue dot sign suggest?
Torsion of the epididymis or appendix testis. With transillumination of the testis, a blue reflection occurs. When detected early, a patient with torsion of the appendix testis will experience intense pain near the head of the epididymis or testis, which is frequently associated with a palpable tender nodule. If normal flow to the affected testis can be confirmed by a testicular ultrasound, immediate surgery can be avoided. Most appendages will calcify or degenerate within 10 to 14 days without harm to the patient.

Question: What is the postvoid residual volume that suggests urinary retention?
A volume greater than 60 mL.

Question: Testicular torsion is most common in which age group?
14-year-olds. Two-thirds of the cases occur in the second decade. The next most common group is newborns.

Question: A baby is brought to the emergency department because of vomiting and persistent crying. On examination, a testicle is tender and enlarged. What is the diagnosis?
Testicular torsion.

True/False: Testicular torsion frequently follows a history of strenuous physical activity or occurs during sleep:
True.

Question: True/False: 40% of patients with testicular torsion have a history of similar pain in the past that resolved spontaneously:
True.

Question: How do you manually attempt to reduce a testicular torsion?
Standing in front of the patient, you manually twist simultaneously the right testicle counterclockwise and the left testicle clockwise. Remember; open the book to reduce the testicles.

Question: What is the definitive treatment for testicular torsion?
Bilateral orchiopexy in which the testes are surgically attached to the scrotum.


INFECTIOUS/INFLAMMATORY CONDITIONS

Question: What is the most common pathogen of urinary tract infections (UTIs)?
Escherichia coli (80%). E. coli is also the most common cause of pyelonephritis and pyelitis because of its ascension from the lower urinary tract. Staphylococcus saprophyticus accounts for 5% to 15% of UTIs.

Question: What are some clinical complaints of patients with cystitis?
Urinary frequency, dysuria, urgency, suprapubic pain, and hematuria.

Question: Name three commonly used antibiotics for the treatment of uncomplicated cystitis:
1. Trimethoprim-sulfamethoxazole
2. Cephalexin
3. Nitrofurantoin

Question: What is the drug of choice for treating urinary tract infection due to Proteus mirabilis?
Ampicillin. This condition is common in young boys.

Question: What is the most common cause of epididymitis in the following age groups: prepubertal boys, men younger than 35 years, and men older than 35 years?
Prepubertal boys: Coliform bacteria
Men younger than 35: Chlamydia or Neisseria gonorrhoeae
Men older than 35: Coliform bacteria
Epididymitis is also frequently caused by urinary reflux, prostatitis, or urethral instrumentation.

Question: What does epididymitis in childhood suggest?
Obstructive or fistulous urinary defects. Epididymitis is rare in children.

How does the pain associated with epididymitis differ from that produced by prostatitis?
Epididymitis: Pain begins in the scrotum or groin and radiates along the spermatic cord. It intensifies rapidly, is associated with dysuria, and is relieved with scrotal elevation (Prehn sign).
Prostatitis: Patients have frequency, dysuria, urgency, bladder outlet obstruction, and retention. They may have low back pain and perineal pain associated with fever, chills, arthralgias, and myalgias.

Question: What percentage of patients with epididymitis will also have pyuria?
25%.

Question: What is the most common cause of epididymitis?
Chlamydia trachomatis in men younger than 35 years. E. coli in prepubertal and older patients.

Question: Acute testicular pain and relief of pain with elevation of the scrotum (Prehn sign) is classically associated with:
Epididymitis.

Question: Aside from antibiotics, what other instructions do you give a patient with acute epididymitis?
Rest with scrotal elevation. For a sexually transmitted bacterium, the sexual partner must also be treated.

Question: Name etiologies for acute orchitis:
Infectious etiologies (viral, bacterial, mycobacterial), mumps, and epididymitis.

Question: What is the basic treatment for uncomplicated orchitis?
Supportive care, rest, analgesia, and a recumbency position.

Question: A 35-year-old male patient has a 4-day history of dysuria, with perineal pain, and subjective fevers. On examination, you note a tender, boggy prostate. What is the likely diagnosis?
Acute prostatitis.

Question: What are the causative organisms of prostatitis?
E. coli (80%), Klebsiella, Enterobacter, Proteus, and Pseudomonas.

Question: What is the outpatient treatment for prostatitis?
TMP-SMX, double strength po bid for 30 days; or ciprofloxacin, 500 mg po bid for 30 days; or norfloxacin, 400 mg po bid for 30 days.

Question: A 23-year-old female patient presents with 5 days of fever, right flank pain, along with dysuria and nausea with vomiting. On examination, there is right-sided CVA tenderness and the abdomen and pelvic examinations are benign. What is the likely diagnosis?
Acute pyelonephritis.

What are the likely pathogens for an acute, uncomplicated pyelonephritis?
Gram-negative rods such as E. coli, Proteus, Klebsiella, Enterobacter, and Pseudomonas. S. aureus can also cause, but this is usually spread hematogenously.

Question: In making a correct diagnosis of pyelonephritis, what are some differentials to consider?
Acute cholecystitis, appendicitis, diverticulitis, and pancreatitis. Also consider a patient with a history of kidney stones to have an infected stone in the renal pelvis.

Question: What is the treatment for an uncomplicated case of pyelonephritis?
Intravenous ampicillin or an aminoglycoside prior to obtaining culture results. As an outpatient treatment, quinolones or nitrofurantoin are used. Aggressive fluid intake is also done along with analgesia for pain.

Question: What is the course for a pregnant patient with pyelonephritis?
This requires inpatient care with aggressive fluids and IV antibiotics. In some early cases of pregnancy, outpatient therapy can be done with very close follow-up.

Question: Outpatient management of pyelonephritis should be reserved for what patients?
Young, otherwise healthy patients who are not vomiting, are hemodynamically stable, are defervescing with antipyretics, and are able to drink fluids. These patients should be treated with IV fluids, antipyretics, and a dose of IV antibiotics, such as gentamicin, a third-generation cephalosporin, or TMP-SMX.

Question: What are the risk factors for subclinical pyelonephritis?
Multiple prior UTIs, longer duration of symptoms, recent pyelonephritis, diabetes, anatomic abnormalities, immunocompromised patients, and indigents.

Question: What is the most common cause of urethritis in men?
Neisseria gonorrheae (gonococcal urethritis) or Chlamydia trachomatis (nongonococcal urethritis). Gonorrhea presents with a purulent discharge from the urethra, whereas chlamydia is generally associated with a thinner, white mucous discharge. Treatment should cover both gonorrhea and chlamydia because there is a high incidence of coinfection. Ceftriaxone for gonorrhea and doxycycline or tetracycline for chlamydia are the drugs of choice.

Question: What are the most common causes of nongonococcal urethritis?
Chlamydia trachomatis. Ureaplasma urealyticum is another common cause.

Question: What is the most common clinical manifestation of disseminated gonococcal infection?
Gonococcal arthritis–dermatitis syndrome. Arthritis, a pustular or papular rash, and tenosynovitis are exhibited with this syndrome.

A 75-year-old diabetic man presents with a fever, appearing toxic, complaining of acute onset of pain and swelling in his scrotum. He denies urinary symptoms and has a painful, erythematous, edematous scrotum with crepitus. What is the diagnosis and treatment?
Fournier gangrene. This usually presents in immunocompromised elderly patients and is due to infection or trauma of the perianal area. Bacteroides fragilis and E. coli predominate. Treatment is supportive plus broad-spectrum parenteral antibiotics against anaerobes and gram-negative enteric organisms. Urological consult for surgical debridement is necessary.

Question: What is the inflammation of the foreskin called?
Balanitis or balanoposthitis.


NEOPLASTIC DISEASES

Question: A 66-year-old male patient presents with a 3-day history of painless hematuria. There are no other complaints and his examination is normal with exception of mild bloody discharge from the urethral meatus. There is no history of trauma. What is the most likely etiology?
Bladder cancer.

Question: What is the number one risk factor for bladder cancer?
Smoking, which accounts for 60% of all cases.

Question: How is bladder cancer confirmed as a diagnosis?
By cystoscope and biopsy.

Question: Which is the most common type of bladder cancer?
Transitional cell carcinoma. Schistosomiasis infection, aniline dyes, smoking, and the male gender are all risk factors.

Question: What is the most common physical examination finding in men with prostate cancer?
They will have a normal examination with a normal palpated prostate.

Question: Do prostate cancers present with voiding problems?
No, they normally are asymptomatic and are found by the PSA. Larger growths can cause voiding issues, but these are usually later stage cancers.

Question: What percentage of men with PSAs greater than 10 ng/mL will have prostate cancer?
Between 50% and 70%.

Question: What is the standard method for diagnosing prostate cancer?
Transrectal ultrasound guided biopsy.

Which is the most common type of prostate cancer?
Acinar adenocarcinoma (95%).

Question: Where is prostate cancer most commonly found?
In the peripheral regions of the prostate.

Question: What is the biggest risk factor for prostate cancer?
Age. The median age for diagnosis of prostate cancer is 72 years.

Question: Where is the most common site for prostate cancer to metastasize?
Bone. Most typical area is the axial skeleton.

Question: What are the six Whitmore-Jewett stages of prostatic cancer?
1. A1–A2: No palpable tumor confined to capsule with a positive random biopsy.
2. B2–B3: Palpable tumor confined to 1 gland or a nodule confined to 1 lobe. Both are contained within the capsule.
3. C1: Extension beyond the capsule.
4. C2: Involvement of the seminal vesicles.
5. D1: Metastasis to regional lymph nodes.
6. D2: Metastasis beyond regional lymph nodes.

Question: What is the best screening method for prostate cancer?
A combination of a digital rectal examination (DRE) and PSA test.

Question: What is the definitive surgical treatment for prostate cancer?
Radical prostatectomy. In some localized tumors, radiation therapy may be indicated as an alternative.

Question: What types of radiation therapy are available for treating prostate cancer?
Directed beam radiation and transperineal radioactive seed implantation.

Question: A 64-year-old male patient presents to the emergency department with a 1-month history of mild hematuria, flank pain, weight loss, and subjective fever. On examination, you palpate a firm small mass on trapping the right kidney. What is the likely diagnosis in this patient?
Renal cell carcinoma.

Question: What percentage of patients with renal cell carcinoma present with hematuria (gross or microscopic)?
60%.

Question: What is the only significant risk factor for developing renal cell carcinoma?
Smoking.

What is the best method for detecting renal cell carcinoma?
CT scan is the preferred test. Most tumors are found incidentally.

Question: While considering the work-up for a patient with a suspected renal cell carcinoma, what other tests should be ordered?
The CT scan will also evaluate the contralateral kidney. In addition, chest X-ray to rule out pulmonary metastasis as well as a bone scan should be performed. Alkaline phosphatase may be elevated in these patients.

Question: What is the definitive treatment for a patient with renal cell carcinoma?
Radical nephrectomy. In some cases where the tumor is isolated, a partial nephrectomy can be performed.

Question: Is chemotherapy an effective treatment option for renal cell carcinoma?
No, there are no drugs that are effective in treating this disease.

Question: A 27-year-old male patient presents with a painless nodular growth on his right testicle that has been present for the last 3 months. There is no history of pain, urinary symptoms, or difficulty with ejaculate. What is the most likely problem that this patient has?
Testicular cancer until proven otherwise.

Question: Which testicle is more likely to have a cancer, the right or the left?
The right. This parallels with the higher amount of cryptorchidism on that side.

Question: What imaging technique is used to confirm a testicular mass?
Testicular ultrasound.

Question: How is the diagnosis of testicular cancer made?
By orchiectomy.

Question: What are the treatments for testicular cancer?
Orchiectomy and retroperitoneal radiation.

Question: What is the most common cancer in young adult males?
Testicular cancer is one of the leading cancers in incidence in young adult men with an average age of about 32 years. There is a significantly increased incidence of carcinoma developing in cryptorchid testes.

Question: What is the best tumor marker for testicular cancer?
Placental alkaline phosphatase (PLAP). 70% to 90% of patients with testicular cancer have elevated PLAP. Other tumor markers are a-fetoprotein and β-hCG.

Question: What is an important difference between testicular teratomas in children and adults?
In children, teratomas are benign lesions. In adults, they may metastasize.

What is the most common neoplasm in men younger than 30 years?
Seminomas. This is also the most common type of testicular neoplasm. Peak incidence is between ages 20 and 40 years, with a smaller peak occurring below age 10. 90% to 95% are germinal tumors. However, only 60% to 70% are germinal in children. Cryptorchidism is a significant risk factor for this cancer.

Question: A mother brings in her 3-year-old son because she has noticed that his abdomen has increased in size. In addition, the child has been having subjective fever. On examination, the child is found to be hypertensive and has a palpable mass on the left side of the abdomen. There is also microscopic hematuria and mild anemia on laboratory reports. Given this history, what is the likely diagnosis of the child?
Wilms tumor

Question: What is the most common malignant renal tumor in children?
Wilms tumor is a highly malignant tumor of mixed histology. A suspected hereditary form of Wilms tumor that is transmitted as an autosomal dominant disorder accounts for about 40% of all tumors. An abdominal mass is the presenting complaint in these children with peak ages at diagnosis of 1 to 3 years.

Question: One to two percent of the affected patients will have a recurrence of the Wilms tumor. Where is this recurrence most likely to be?
The chest.

Question: What is the treatment for a patient with a Wilms tumor?
Surgical exploration of the abdomen to view the contralateral kidney as well as the liver and lymph nodes. Surgical resection of the tumor is attempted with effort to not spill and seed the abdomen.

Question: What is the prognosis for a Wilms tumor?
The overall cure rate is 90%.


RENAL DISEASES

Question: What are some common physical examination findings in patients with chronic renal disease?
In general, the patients appear ill and complain of fatigue, weakness, and malaise. They may have a fishy odor on breath. Hypertension is frequently seen. Skin may be yellow and easy to bruise. Cardiovascular examination may have cardiomegaly with a displaced PMI, rales, and edema.

Question: What is the most common cause of acute renal failure?
Acute tubular necrosis. This occurs after toxic or ischemic renal injuries caused by shock, surgery, or rhabdomyolysis.

Question: What is the most common cause of chronic renal failure?
NIDDM.

When are renal insufficiency symptoms displayed?
When 90% of the nephrons have been destroyed. Hypertension, diabetes mellitus, glomerulonephritis, polycystic kidney disease, tubulointerstitial disease, and obstructive uropathy are all causes of chronic renal failure.

Question: What is the most common cause of cardiac arrest in a uremic patient?
Hyperkalemia.

Question: What is the most common cause of intrinsic renal failure?
Acute tubular necrosis (80%–90%), resulting from an ischemic injury (the most common cause of ATN) or from a nephrotoxic agent. Less frequent causes of intrinsic renal failure (10%–20%) include vasculitis, malignant hypertension, acute GN, or allergic interstitial nephritis.

Question: What type of anemia is characteristic of chronic renal failure?
Normochromic, normocytic.

Question: Name an abnormal ultrasound finding that suggests chronic renal failure:
Kidneys <9 cm in length are abnormal. A difference of >1.5 cm in length between the two kidneys suggests unilateral kidney disease. Kidneys with a small or absent renal cortex are also indicative of chronic renal failure.

Question: What is the life expectancy of chronic renal patients after the disease has progressed to dialysis?
Patients between the ages of 55 and 64 years have an average 22-year life expectancy. Patients older than 60 and with end-stage renal disease have a 5-year life expectancy.

Question: What is the most common cause of death in patients with renal failure?
Cardiac dysfunction (45%), followed by infection (14%), and then cerebrovascular disease (6%).

Question: What are the causes of advanced chronic renal failure and large kidneys?
Amyloidosis, polycystic kidney disease, diabetic nephropathy, HIV-ATN (AIDS nephropathy), and multiple myeloma.

Question: What does acute renal failure in a patient with alcoholic cirrhosis and a urine sodium of less than 10 suggest?
Prerenal azotemia or hepatorenal syndrome.

Question: Acute renal failure caused by Wegener granulomatosis may respond best to what treatments?
This is usually rapidly progressive GN and responds to high-dose steroids and cyclophosphamide.

Question: Total and persistent anuria with renal failure should prompt a work-up for what?
These patients are presumed to be obstructed until proven otherwise.

Question: A renal biopsy in a patient with acute renal failure, hematuria, and red cell casts will most likely reveal what lesion?
A proliferative glomerulonephritis, usually with crescents.

What continuous modes of renal replacement therapy used in ARF?
CVVH and peritoneal dialysis. Hemodialysis is an intermittent therapy.

Question: What are the first-line oral phosphate binders used in CRF?
Calcium carbonate and calcium acetate. Aluminum-containing agents are best avoided.

Question: What are the causes of high levels of PTH in CRF?
Hyperphosphatemia, hypocalcemia due to deficiency of vitamin D, and parathyroid receptor resistance.

Question: What is the etiology of CRF associated with cerebral berry aneurysms?
Adult polycystic kidney disease is associated with cerebral berry aneurysms.

Question: What are the indications for emergent dialysis in ARF?
Intractable acidosis, intractable hyperkalemia, intractable volume overload, BUN over 80 to 100, encephalopathy, pericarditis, uremic bleeding, and certain intoxications.

Question: At what GFR will patients with CRF due to diabetes need to start dialysis?
Dialysis usually begun at GFR of 10 to 15 mL/min.

Question: Sudden ARF, seen after initiation of ACE inhibitors, should prompt a work-up for what diseases?
ACE inhibitors are likely to cause ARF in patients with bilateral renal artery stenosis or renal artery stenosis in a solitary kidney.

Question: What type of ARF is usually seen with rhabdomyolysis?
Acute tubular necrosis.

Question: What pathology is usually seen in patients with CRF, nephrotic syndrome, and AIDS?
Usually focal segmental glomerulosclerosis is seen at biopsy.

Question: What type of acute renal failure is seen in a patient with systemic lupus erythematosus (SLE)?
SLE with diffuse proliferative GN is likely to cause renal failure, nephrotic syndrome, hematuria, and cylindruria. This may be treated with steroids and pulse IV cyclophosphamide.

Question: What is the most common cause of intrinsic renal failure?
Acute tubular necrosis.

Question: What four clinical findings are indicative of acute glomerulonephritis (GM)?
1. Oliguria
2. Hypertension
3. Pulmonary edema
4. Urine sediment containing RBCs, WBCs, protein, and RBC casts

What is the most common cause of postinfectious glomerulonephritis?
Poststreptococcal group A β-hemolytic. However, other infections may also produce GN-related infections. GN is caused by an immune complex deposition in glomeruli. Most patients recover renal function spontaneously within a few weeks.

Question: What syndrome is characterized by a rapidly progressive, antiglomerular basement membrane antibody-induced GN that is preceded by pulmonary hemorrhage and hemoptysis?
Goodpasture syndrome.

Question: A urinalysis reveals RBC casts and dysmorphic RBCs. What is the probable origin of hematuria?
Glomerulus.

Question: What is the most common cause of proteinuria?
Pathology of the glomerulus. Other causes include tubular pathology or overproduction of protein.

Question: What is the classic presentation of poststreptococcal glomerulonephritis (PSGN)?
Sudden development of gross hematuria, hypertension, edema, and renal insufficiency following a throat or skin infection with group A β-hemolytic streptococcus. Patients frequently also have generalized complaints of fever, malaise, lethargy, abdominal pain, etc.

Question: What signs and symptoms are prevalent with poststreptococcal glomerulonephritis?
Facial edema and decreased urinary output. Urine may be dark. Other laboratory results include normochromic anemia because of hemodilution, increased sedimentation rate, numerous RBCs and WBCs in the urine with casts, and hyperkalemia. Hospitalization is advised.

Question: How early in the development of “strep throat” will antibiotic therapy decrease the risk for PSGN?
Antibiotics have not been found to decrease the risk for PSGN.

Question: What laboratory test best confirms PSGN as the diagnosis?
Anti-DNAse B antibody titer.

Question: What is the most common form of lupus nephritis?
Diffuse proliferative nephritis (WHO class IV). Unfortunately, this is also the most severe form.

Question: The biopsy of the kidney from a 24-year-old male patient with nephrotic syndrome shows increased mesangial cells and, on immunofluorescence, C3 deposits in the mesangium. What is the man’s diagnosis and prognosis?
This man has membranoproliferative glomerulonephritis (a type of chronic glomerulonephritis). Prognosis is poor, with many patients progressing to end-stage renal failure.

Question: What findings mark the presentation of a patient with rapidly progressive glomerulonephritis?
Hematuria (most common), edema (periorbital), HTN, ascites, pleural effusion, rales, and anuria.

The laboratory reports from a patient with hematuria show depressed levels of C3. What etiologies should you suspect?
Chronic infection, lupus, poststreptococcal glomerulonephritis, or membranoproliferative glomerulonephritis.

Question: What is the most common cause of nephrotic syndrome in children? In adults?
Children: Minimal change disease.
Adults: Idiopathic glomerulonephritis.

Question: What is the diagnostic triad of the nephrotic syndrome?
Edema, hyperlipidemia, and proteinuria with hypoproteinemia.

Question: What is the main goal of treatment in nephrotic syndrome?
Treat the underlying cause of the syndrome. In most cases, treating hypertension and fluid overload is paramount. Some patients may require strict sodium and fluid restrictions as well as diuretics, and some patients may require dialysis.

Question: Name some risk factors for developing polycystic kidney disease:
Younger age of onset for kidney disease, black race, male gender, hypertension, and a presence of polycystin-1 gene.

Question: What is the best testing method to detect polycystic kidney disease?
Renal ultrasound for patients older than 30 years, and CT or MRI for patients younger than 30 years.

Question: What are some extrarenal manifestations of polycystic renal disease?
Cerebral hemorrhages, including subarachnoid, saccular aneurysms, aortic and root dilatation, as well as mitral valve prolapse and aortic regurgitation. These are mainly due to the abnormalities of collagen.


ELECTROLYTE AND ACID/BASE DISORDERS

Question: What are the two main reasons for hyponatremia?
Either an increase in intracellular volume and water gain, or due to a primary sodium loss.

Question: What is the most common drug that can induce hyponatremia?
Thiazide diuretics.

Question: Name three medical conditions that can commonly cause hyponatremia to occur:
1. Congestive heart failure
2. Cirrhosis of the liver
3. Nephrotic syndrome

What disorder causes hyponatremia, normovolemia, and has a large release of arginine vasopressin (AVP) in the setting of increased water intake?
Syndrome of inappropriate antidiuretic hormone (SIADH). Some of the causes for this are neuropsychiatric, malignant tumors, surgery, and some medications.

Question: What is
beer potomania?
These are patients who drink excessive amounts of beer and have poor protein intake in their diet, which results in an overload of volume, thus causing hyponatremia.

Question: What are the two main goals in the treatment of hyponatremia?
1. Water restriction to lower the overall water volume.
2. Treatment of the underlying cause of the hyponatremia.

Question: A 93-year-old female patient is admitted for severe malnutrition and hyponatremia with a serum level of 121 mmol/L. She has mental status changes that are related to the hyponatremic state. What is the main therapy for this severely ill patient?
Patients with severe hyponatremia and neurological symptoms on examination require hypertonic solution to be infused so that the serum concentration is raised to 1 to 2 mmol/L for the first 3 to 4 hours and then to 12 mmol/L for the first 24 hours total.

Question: What is the risk of treating hyponatremia too fast?
You can create osmotic demyelination syndrome, which will cause paralysis, dysarthria, and dysphagia.

Question: What is the single biggest factor for a patient with hypernatremia?
Loss of overall water in the body.

Question: What are some causes for hypernatremia?
Varying degrees of hyperosmolality with a mild thirst response. In other situations, deprivation of water, infants, physically handicapped, and mentally impaired patients are at risk of not getting adequate water intake.
Nonrenal etiologies for hypernatremia include diarrhea, insensible losses through the skin and respiratory tract (fevers, burns, infections).

Question: What is the most common reason for hypernatremia?
Drug-induced osmotic diuresis, or diabetes insipidus.

Question: Name physical examination features that can be present in a patient with hypernatremia:
Contracted volume with hypotension, dry mucous membranes, and neurological symptoms of altered mental status, weakness, irritability, focal deficits, coma, and seizures.

Question: What is the main goal of treatment of hypernatremia?
First determine the cause of the reason behind the electrolyte imbalance, and then prevent further damage.

What is the safest and most effective corrective treatment of hypernatremia?
Water by mouth or nasogastric (NG) tube placement.

Question: How would geophagia (eating clay) affect an individual’s electrolyte?
It will cause hypokalemia because the clay will bind the potassium. This was a common finding in the African American population in the south, and can still be seen in some populations.

Question: What effect does diabetic ketoacidosis have on potassium?
It will cause a depletion of potassium by way of the Na+ K+-ATPase pump stimulation.

Question: What are some gastrointestinal problems, which can cause hypokalemia?
Vomiting, diarrhea, excessive loss of laxatives, and volume depletion.

Question: What is the main cause in a patient who suffers from chronic potassium loss?
Renal-induced potassium wasting.

Question: A 46-year-old female patient is evaluated for hypokalemia and a value of 2.9 mg/dL. She is given potassium supplements and is rechecked a week later only to find that she is still at a low level of 3.0 mg/dL despite taking 40 mEq daily. She is not on any medications. What could be this patient’s disorder causing the hypokalemia?
Primary hyperaldosteronism, which is sometimes caused by a primary tumor of the adrenal gland resulting in hypokalemia. Other possibilities include renal cell carcinoma, ovarian carcinoma, and Wilms tumors in children. These other possibilities are a result of hyperreninemia, which will draw off potassium.

Question: Can Cushing disease present with hypokalemia?
Yes, and is a result of the elevated glucocorticoid levels, which cause an inactivation of cortisol.

Question: Name some physical examination features in patients with hypokalemia:
Muscle fatigue, weakness, myalgias, and in more serious cases hypoventilation and paralysis can occur.

Question: What electrophysiological effects can be seen on an EKG in a patient with hypokalemia?
Flattening of the T-wave, prominent U-wave, and in some cases a prolonged PR interval.

Question: Name some causes of hyperkalemia:
Renal failure, decreased arterial volume circulation, decreased secretion of potassium by either hypoaldosteronism or enhanced chloride absorption, and drugs such as ACE inhibitors and NSAIDs.

Question: What are some physical symptoms of patients with hyperkalemia?
Muscle weakness, which can progress to paralysis and respiratory depression (hypoventilation).

What electrophysiological effects can be seen on an EKG in a patient with hyperkalemia?
Peaked T-wave, prolonged PR interval, and QRS duration. This can eventually lead to ventricular fibrillation or asystole.

Question: A 66-year-old male patient presents to the emergency department with an arrhythmia, which is determined to be a widened QRS complex that has resulted in the patient going in and out of ventricular fibrillation. His potassium on initial evaluation is 7.6 mg/dL and the patient’s renal function is intact. What would be the treatment of choice for this life-threatening illness?
Calcium gluconate.

Question: What is the other treatment for hyperkalemia in a non–life-threatening illness?
Regular insulin and glucose to draw the potassium into the cells. Another alternative is administration of a thiazide loop diuretic to waste potassium.

Question: What is the fastest and most reliable treatment for hyperkalemia?
Hemodialysis.

Question: What are some presenting symptoms in patients with mild hypercalcemia? Severe cases?
In general, most patients are asymptomatic. Some will experience trouble concentrating, depression, and personality changes. Some other symptoms will be nausea, constipation, pancreatitis, and anorexia.
In severe hypercalcemia, the symptoms will be lethargy, coma, and stupor.

Question: What are some primary disorders that can cause hypercalcemia?
Parathyroid adenomas and hyperplasia of the parathyroid.

Question: What is one factor that could mislead you in a correct diagnosis of hyper- or hypocalcemia?
Serum albumin levels, which bind to calcium. If this level is either high or low, it can impact the serum levels of calcium.

Question: What is the most common cause of hypercalcemia?
Primary hyperparathyroidism followed by malignancy.

Question: What is the treatment of choice for hypercalcemia?
Bisphosphonates.

Question: What are the most common reasons for hypocalcemia?
Impaired vitamin D production and impaired parathyroid hormone production.

Question: Name some physical examination characteristics in patients with hypocalcemia:
Paresthesias of the fingers and toes and circumoral regions are some symptoms. Chvostek sign as well as carpal spasm can be present. Severe hypocalcemia can present with seizures, bronchospasm, laryngospasm, and prolonged QT interval on EKG.

What is the treatment for a patient with severe hypocalcemia?
Calcium gluconate.

Question: For patients with chronic hypocalcemia, what is the long-term management treatment?
Elemental calcium supplements, 1 to 1.5 g/day.

Question: What are some physical examination characteristics in patients with hypomagnesemia?
Tetany, weakness, seizures, muscle weakness, ataxia, nystagmus, vertigo, depression, irritability, delirium, and psychosis.

Question: What are some EKG findings in patients with hypomagnesemia?
Prolonged PR or QT intervals and flattening of T waves. Digitalis toxicity may be enhanced with low magnesium levels.

Question: What is the most common cause of hypermagnesemia in a patient with renal failure?
Patient use of compounds high in magnesium, such as antacids. This can result in neuromuscular paralysis.
Consider IV calcium. Saline and furosemide-assisted diuresis may not help a patient with renal failure, so consider dialysis as well.

Question: What are some common causes of increased anion gap?
Aspirin, methanol, uremia, diabetes, idiopathic (lactic), ethylene glycol, and alcohol are all reasonably common.
Numerous etiologies may produce the entity above-listed demurely as “lactic.” Lactic acidosis may be the result of shock, seizures, acute hypoxemia, INH, cyanide, ritodrine, inhaled acetylene and carbon monoxide, and ethanol. Sodium nitroprusside, povidone-iodine ointment, sorbitol, and xylitol can induce an anion gap acidosis.
Other causes of anion gap acidosis include toluene intoxication, iron intoxication, sulfuric acidosis, short bowel syndrome (D-lactic acidosis), formaldehyde, nalidixic acid, methenamine, and rhubarb (oxalic acid). Inborn errors of metabolism, such as methylmalonic acidemia and isovaleric acidemia, may also elicit a gap acidosis response.
Recall some pearls for sorting out the differential diagnosis:

1. Methanol—Visual disturbances and headache are common. May produce wide gaps because each 2.6 mg/dL of methanol contributes 1 mOsm/L to gap. Compare this with alcohol: each 4.3 mg/dL adds 1 mOsm/L to gap.
2. Uremia—Must be quite advanced before it causes an anion gap.
3. Diabetic ketoacidosis—Both hyperglycemia and glucosuria typically occur. Alcoholic ketoacidosis (AKA) is often associated with low blood sugar and mild or absent glucosuria.
4. Salicylates—High levels contribute to gap.
5. Lactic acidosis—Check serum level. This condition also has broad differential, as cited above.
6. Ethylene glycol—Also causes calcium oxalate or hippurate crystals in urine. Each 5.0 mg/dL contributes 1 mOsm/L to gap.

Question: What are the major physiologic causes of metabolic acidosis?
Increases in endogenous acids (lactate and ketoacids), loss of bicarbonate, and accumulation of endogenous acids (renal failure).

What is the treatment of metabolic acidosis with a pH < 7.20?
Sodium bicarbonate IV.

Question: What are the three major conditions of metabolic acidosis?
1. Lactic acidosis
2. Diabetic ketoacidosis (DKA)
3. Alcoholic ketoacidosis

Question: Name some drugs and toxins that can cause metabolic acidosis:
- Salicylates
- Alcohols
- Ethylene glycol
- Methanol
- Isopropyl alcohol.

Question: Name some causes for a patient to have metabolic alkalosis:
Exogenous bicarbonate loads such as alkali ingestion, extracellular volume contraction, and potassium deficiency such as GI (vomiting, aspiration), renal disorders (diuretics, lactic acidosis recovery), hypercalcemia, drugs (PCNs), magnesium deficiency, potassium deficiency, and high and low renin volume expansion disorders (renal artery stenosis, accelerated hypertension, licorice ingestion).

Question: What is the expected change in serum bicarbonate in chronic respiratory acidosis or alkalosis?
Bicarbonate increases by approximately 3 mEq/L for each 10 mm Hg increase in Paco2 in chronic respiratory acidosis. Bicarbonate decreases by 4 to 5 mEq/L for each 10 mm Hg decrease in Paco2 in chronic respiratory alkalosis.

Question: A 45-year-old obese man presents with dyspnea, peripheral edema, snoring, and excessive daytime sleepiness. A room air arterial blood gas in drawn and the pH is 7.34, PaCO2 60 mm Hg, the PaO2 is 58 mm Hg, and the calculated HCO3− is 28 mEq/L. What is the acid–base disturbance?
Chronic, compensated respiratory acidosis. If this was acute respiratory acidosis, the pH would be 7.24 with a normal HCO3−.

Question: What are some common causes of respiratory alkalosis?
Respiratory alkalosis is defined as a pH above 7.45 and a Pco2 less than 35. Common causes of respiratory alkalosis include any process that may induce hyperventilation: shock, sepsis, trauma, asthma, CVA, PE, anemia, hepatic failure, heat stroke, exhaustion, emotion, pregnancy, salicylate poisoning, hypoxemia, pregnancy, and inadequate mechanical ventilation.

Question: What is respiratory alkalosis?
A pH above 7.45 and a Pco2 less than 35. Alkalosis shifts the O2 disassociation curve to the left. It also causes cerebrovascular constriction. The kidneys compensate for respiratory alkalosis by excreting HCO3−.

What are some causes of respiratory acidosis?
Respiratory acidosis is defined as a pH of 7.35 or less and a Pco2 of 35. Common causes of respiratory acidosis include drugs, CVA, infection, asthma, lung disease such as emphysema, bronchitis, ARDS, neurologic disorders such as poliomyelitis, myasthenia, and muscular dystrophy. Obesity, kyphoscoliosis, and hypoventilation are other etiologies.

Question: What are some reasons for volume contraction?
Vomiting, diarrhea, nasogastric suctioning, diuretics, hyperaldosteronism, and diabetes insipidus.

Question: Name some etiologies that have hypovolemia with normal extracellular or expanded volume:
Decreased cardiac output by myocardial or valvular disease, low albumin (cirrhosis, nephrotic syndrome), acute pancreatitis, ischemic bowel, rhabdomyolysis, and sepsis.

Question: How is renal tubular acidosis (RTA) classified?
RTA is classified into one of three types: type 1 (distal RTA), type II (proximal RTA), or type IV (mineralocorticoid deficiency). There is no type III.

Question: What are the mechanisms for the different types of RTA?
In type I, there is a deficiency in the secretion of the hydrogen ion by the distal tubule and collecting duct. In type II, there is a decrease in the bicarbonate reabsorption in the proximal tubule. For type IV (most common type), there is aldosterone deficiency, which leads to impairment of sodium reabsorption as well as potassium and hydrogen excretion.

Question: Which isolated form of RTA will be most likely to lead to renal failure?
Distal (type I), though most cases of type I RTA have an excellent prognosis.

Question: What type of RTA usually presents as an isolated condition?
Type I (distal RTA).

Question: What are the characteristic acid–base electrolyte abnormalities associated with type I and type II RTA?
Hypokalemic, hyperchloremic metabolic acidosis.

Question: What are the characteristic acid–base/electrolyte abnormalities associated with type IV RTA?
Hyperkalemic, hyperchloremic metabolic acidosis.

Question: What is the underlying cause of type IV RTA?
Decreased sodium reabsorption secondary to lack of aldosterone effect.

Question: What diseases are associated with type IV RTA?
Diseases of the adrenal gland; most commonly Addison disease and congenital adrenal hyperplasia.

What treatments are used to ameliorate bleeding in a uremic patient?
Dialysis may lessen bleeding as may DDAVP, cryoprecipitate, or even platelet transfusions. Estrogens may lessen bleeding from angiodysplasia.

Question: What medications are likely to cause acute renal failure with interstitial nephritis?
Beta-lactam antibiotics, cimetidine, NSAIDs, Dilantin, rifampin are but a few.

Question: What medications may be associated with hemolytic uremic syndrome?
Mitomycin, estrogens, and cyclosporin are known culprits.

Question: What comorbid factors are likely to increase the risk of contrast-induced ATN?
Azotemia, diabetic nephropathy, CHF, multiple myeloma, and dehydration.

Question: What are some common causes of prerenal acute renal failure?
Volume depletion and decreased effective volume (CHF, sepsis, cirrhosis).

Question: What are the causes of postrenal failure?
Ureteral and urethral obstruction.

Question: What arrhythmia is frequently encountered during renal dialysis?
Hypokalemia-induced ventricular fibrillation.

Question: What are some causes of false-positive hematuria?
Food coloring, beets, paprika, rifampin, phenothiazine, Dilantin, myoglobin, or menstruation.

Question: Name some common nephrotoxic agents:
Aminoglycosides, NSAIDs, contrast dye, and myoglobin.

Question: What is the definition of oliguria? Of anuria?
Oliguria: Urine output < 500 mL/day
Anuria: Urine output < 100 mL/day

Question: What is the initial treatment for priapism?
Terbutaline, 0.25 to 0.5 mg subcutaneously.

Question: If a urine dipstick is positive for blood, but a urine analysis is negative for RBCs, what is the probable disease?
Rhabdomyolysis. Severe muscle damage can result in free myoglobin in the blood. Very high levels can lead to acute renal failure.

Question: What is the most common manifestation of Goodpasture disease?
Hemoptysis. These patients usually develop pulmonary hemorrhage before any signs of renal failure develop.

What two common medications can induce nephrogenic diabetes insipidus?
Lithium and amphotericin B.

Question: A patient with nephrogenic diabetes insipidus has a serum sodium level of 117 mEq/L. How do you determine how much NaCl to administer to keep the risk of cerebral edema at a minimum?
Amount of NaCl to add in mEq/L = 0.6 × wt (in kg) × (140 – serum sodium).

Question: What percentage of kidney transplants donated from a relative (usually a parent) are still functional after 3 years?
75% to 80%.

Question: Patients born with what disease are more likely to have horseshoe kidneys?
Turner syndrome.

Question: What is the antihypertensive of choice in patient with chronic diabetic nephropathy?
Angiotensin-converting enzyme inhibitors are preferred.

Question: What is the major therapy used to treat allergic interstitial nephritis not responding to discontinuation of the culprit medication?
Corticosteroids.

Question: Chronic renal failure with hypertension, small shrunken kidneys, and gout at an early age should suggest what?
Lead nephropathy should be considered.

Question: What is the most common anatomical abnormality associated with chronic urinary tract infections?
Vesicoureteral reflux.

Question: What factors predispose one to acute papillary necrosis?
Analgesic abuse, sickle cell disease, diabetes mellitus, and alcoholism are usual predisposing factors.

Question: What major renal toxicity is seen with amphotericin B?
Tubulointerstitial disease with a distal hypokalemic renal tubular acidosis and hypomagnesemia.

Question: Acute renal failure seen after use of cocaine may be due to what?
Rhabdomyolysis leading to ATN.

Question: What causes priapism?
Prolonged sex, leukemia, sickle cell trait and disease, blood dyscrasias, pelvic hematoma or neoplasm, syphilis, urethritis, and drugs including phenothiazine, prazosin, tolbutamide, anticoagulants, and corticosteroids.

What medication is the best treatment for preventing nephropathy in diabetic patients?
ACE inhibitors. They are found to reduce endpoint renal disease, dialysis, and transplantation by 50%.


REFERENCES
Brunicardi FC, Anderson DK, Billiar TR, et al. Schwartz’s Principles of Surgery. 8th ed. New York, NY: McGraw-Hill; 2005.
Fauci Anthony S., B. E. (2008, 7 1). Harrisons Online. New York, NY.
McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis and Treatment 2009. New York, NY: McGraw-Hill; 2009.
McPhee SJ, Ganong WF. Pathophysiology of Disease: An Introduction to Clinical Medicine. 5th ed. New York, NY: McGraw-Hill; 2006.
Tanagho E, McAninch JW Smith’s General Urology. 17th ed. New York, NY: McGraw-Hill; 2008.