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PAeasy Genitourinary

Terms in this set (148)

A 12-year-old boy presents with a 3-hour history of extreme, severe pain in the right testis. It started suddenly, is 8/10 in intensity, and does not radiate. It is associated with nausea and scrotal swelling. He never had such pain in his lifetime, and he denies any problem in urination. He has never been operated on, and he denies any history of trauma. He is allergic to penicillin.

On physical exam, the child is in visible distress. Temperature is 37.0°C, heart rate is 95, blood pressure is 120/70 mm Hg, and respiratory rate is 20 per minute. Genital examination reveals enlargement and edema of the entire scrotum. The right testicle is erythematous and tender to palpation; it appears to sit higher and lies horizontally in the scrotal sac relative to the left side. The cremasteric reflex is absent ipsilaterally, and there is no relief of pain upon elevation of the scrotum (Prehn's sign). Abdomen is non-tender and tympanic to percussion in all 4 quadrants. Bowel sounds are audible. Chest auscultation shows normal vesicular breathing with mild crepitations over the lower lung fields. Cardiac exam reveals normal S1 and S2, without rubs, murmurs, or gallop.

His initial labs show a hemoglobin of 14.5 g/dL, WBC of 13,000/mm³, platelets of 210,000/mm3, sodium of 140 mmol/dL, potassium of 3.8 mmol/dL, chloride of 95 mmol/dL, urea of 25 mg/dL, and creatinine of 0.9 mg/dL.



Question
What sign or symptom is the most sensitive for the diagnosis of this condition?

Answer Choices
1 Tenderness
2 Edema
3 Horizontal lie
4 Prehn sign
5 Loss of cremasteric reflex
Sodium Pentosanpolysulfate (Elmiron) 100mg TID
Explanation
The scenario is describing a patient with interstitial cystitis (IC). Patients with IC have a 10:1 female to male ratio and are typically in the third decade of life. Symptoms usually include urinary frequency, nocturia, urgency, and bladder or pelvic pain. Physical examination is usually unremarkable and helpful at ruling out other causes of the patient's symptoms. The urinalysis and urine culture are usually unremarkable, which also rules out other differential diagnoses. Cystoscopy with hydrodistention under sedation is often used to diagnose IC by both the appearance of the bladder and the bladder capacity (not usually over 350cc). Hunner's ulcers seen during cystoscopy with hydrodistention are pathognomonic for interstitial cystitis, although they do not have to be present for a patient to have this diagnosis (only present in 5-10% of cases). The hydrodistention can also help to relieve symptoms, and can be an effective treatment for many patients with IC. However, if symptoms persist, then other treatment options are warranted. Altering diet and avoiding foods and beverages that are bladder irritants can be helpful in improving symptoms in patients with IC. Beyond these measures, there are various medications that can offer relief.

Elmiron stands alone in its class of medications, but is similar to a class of medications called low molecular weight heparins. It prevents the irritation of the bladder wall that is the cause behind the patient's symptoms. This medication is prescribed 100mg TID and is a first-line treatment. It is the best choice of those listed as potential answers.

Ciprofloxacin (Cipro) is an antibiotic commonly used to treat urinary tract infections (UTI). While UTI would have been high on the list of differential diagnoses for this patient, it was ruled out by the negative urinalysis and urine culture.

Bisacodyl (Dulcolax) is a medication commonly used to treat constipation and would therefore not be an appropriate treatment for this patient.

Hydrocodone (Vicodin) and acetaminophen/aspirin/caffeine (Excedrin) are both commonly used to treat pain. Hydrocodone is often prescribed to patients with IC, as chronic opioid use is not uncommon due to the occasional extreme nature of the pelvic pain. However, it would not be the next best treatment and is essentially masking symptoms and not treating the IC. Excedrin is a pain reliever, but it contains caffeine. Caffeine is a bladder irritant and should be avoided by patients with IC, as it can potentiate the symptoms.
Explanation The correct answer is diabetes mellitus since the presence of polyuria would indicate hyperglycemia and the associated erectile dysfunction and/or balanitis may be the only other presenting symptom or sign of diabetes mellitus in a male patient. Erectile dysfunction is a common vascular and neurological complication of diabetes and occurs in up to 75% of male diabetics. Elevated blood sugars result in autonomic neuropathy of the cavernous nerve of the penis so that erectile dysfunction serves as one of the earliest indications of neuropathy. Likewise, hyperglycemia results in microvascular damage to the dorsal and cavernous arteries, in the same way retinopathy, nephropathy, and neuropathy develop, further contributing to poor perfusion and erectile dysfunction. Hyperglycemia also results in the colonization of skin organisms, commonly Candida, resulting in typical superficial yeast infections seen in diabetics such as balanitis in men and vulvovaginitis in women.
Benign prostatic hypertrophy (BPH) typically occurs in the periurethral zone of the prostate and usually presents with lower urinary symptoms (LUTS) that suggest obstruction (i.e. hesitancy, weak stream, straining, post-void leaking) or irritation (i.e. nocturia, frequency, urgency). Digital rectal examination of prostatic hyperplasia typically reveals a smooth, firm enlargement of the gland which may be asymmetrical or indurated. Early BPH is not typically associated with erectile dysfunction or Candidaskin infections.

Prostate cancer most often develops in the peripheral zone of the prostate and is usually asymptomatic. Locally advanced prostate cancer may encroach on the central transition zone of the prostate and present with irritative urinary symptoms. Prostate cancer that extends outside the prostate capsule may result in erectile dysfunction. Carcinomas in the peripheral zone are often palpable and typically a hard, irregular nodule or induration. Prostate cancer is not typically associated with Candidaskin infections.

Hypogonadism may present with fatigue, decreased libido, diminished erections, gynecomastia, or decreased testicular size, muscle mass, or hair growth associated with secondary sexual characteristics. It is typically not associated with an enlargement of the prostate, urinary complaints, or Candidaskin infections.

The characteristic presentation of diabetes insipidus (DI) is abnormally large amounts of dilute urine - insipidus means tasteless. Polyuria is massive, often associated with nocturia and enuresis, and results in dehydration, which is often not evident due to a compensatory increase in thirst and polydipsia. DI is the result of the posterior pituitary's failure to secrete antidiuretic hormone (ADH) resulting in central diabetes insipidus (DI) or the kidney's resistance to ADH resulting in nephrogenic DI. DI is not typically associated with Candidaskin infections.
A 56-year-old African-American man presents with urinary hesitancy, frequency, and nocturia. He has to get up and urinate 3 to 4 times per night, and he is not sure if he empties his bladder completely. He states that his symptoms have been getting worse over the past 2 years. His urinary stream is weaker than it was a 1 year ago. He denies blood in his urine, and there is no history of urinary tract infections, dysuria, or pain. He is otherwise in a good state of health, and he has no significant past medical or surgical history. Currently, he takes no medications, and he has no known drug allergies. On review of systems, you discover that his father and brother died of prostate cancer in their 50's. The remainder of the history and ROS is non-contributory.

Physical Examination:

Vital signs are stable and he is afebrile. General physical exam is unremarkable. Genital exam reveals a circumcised penis with no lesions or discharge. There is no inguinal adenopathy. Testicles are descended bilaterally with no lesions, masses, or hernias. Rectal exam reveals a smooth prostate with no nodules or tenderness.

Diagnostic investigations: Urinalysis is normal and Prostate-Specific Antigen (PSA) test is within normal range for age. (For men aged 50 to 59 years, the normal reference range is 0 to 3.5 ng/mL) After emptying 250 mL of urine, the post-void residual urine volume is 50 mL.



Question
What is the most appropriate intervention?

Answer Choices
1 Finasteride
2 Surgical therapy
3 Terazosin
4 Transrectal ultrasound with prostate biopsy
5 Urine culture and sensitivity
Explanation
Terazosin is the correct response.

Given the history, physical exam, and negative PSA, you have enough information to make the diagnosis of symptomatic benign prostatic hyperplasia (BPH). No further diagnostic studies are necessary. Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a histologic diagnosis characterized by proliferation of the cellular elements of the prostate. A classic history is usually sufficient to make the diagnosis. Clinical manifestations include urinary hesitancy, urinary frequency, urgency, nocturia (awakening at night to urinate), decreased or intermittent force of stream, and/or a sensation of incomplete bladder emptying.

Treatment:
Depending on the patient's preferences, the next step is to begin treatment; in most cases, medical therapy is initiated first. If the symptoms do not significantly interfere with the patient's life, he may choose to wait and refuse treatment once he is reassured that he does not have a life-threatening illness. This decision would be medically acceptable in this case. If he selects treatment, management begins with a selective α1-receptor blocker, such as doxazosin or terazosin. A medication specific for α 1A-receptor subtype, such as tamsulosin (Flomax®), may be used in patients who cannot tolerate traditional α1-receptor blockers. If medical therapy fails or if a patient has severe BPH with ongoing obstruction, retention of large volumes of urine, or recurrent urinary tract infections, surgical therapy should then be considered. The most commonly performed surgery is transurethral resection of the prostate.

Because of his family history, the patient in this case has an increased risk of prostate cancer; however, transrectal ultrasound with prostate biopsy is not indicated. This diagnostic procedure should be reserved for suspicion of prostate cancer. Based on this patient's family history and because he is African-American (African-Americans have a 50% higher incidence of and mortality from prostate cancer in comparison with Caucasians) a healthy index of suspicion is astute nonetheless. Given this patient's classic BPH presentation and the normal PSA, prostate cancer is low probability at this time. That being said, caution must be exercise when using PSA as a diagnostic tool to rule in or rule out prostate cancer. The USPSTF recommends against PSA-based screening for prostate cancer.

In addition, the negative prostate exam on rectal probing, while classically taught to be important, adds no additional information in most cases; currently, it is not recommended by the U.S. Preventive Services Task Force.

No evidence in the case points towards the need for urine culture and sensitivity.

Finasteride is a 5 α-reductase inhibitor. If the patient does not receive sufficient relief from maximum doses of a α1-receptor blocker, it may be added. However, it may take up to 6 months for a 5 α-reductase inhibitor to result in a noticeable difference in symptoms. Thus, finasteride is not a first-line treatment. The full therapeutic benefit of a α1-receptor blocker, on the other hand, will be apparent within 4-6 weeks.

Post-void residual is a diagnostic tool used to determine if a patient with BPH will benefit from scheduled bladder catheterizations. A post-void residual >200 mL is associated with an increased risk of urinary tract infections. Scheduled catheterizations are usually reserved for cases in which medical or surgical interventions do not correct the problem; they are also used when medical and surgical interventions are contraindicated.
gram negative bacteremia
Explanation
The correct response is Gram-negative bacteremia.

Some degree of enlargement of the prostate is extremely common from the age of 50 onwards, but this type of enlargement often produces either minor symptoms, or no symptoms at all. However, benign hypertrophy of the gland results in elongation and tortuosity of the prostatic urethra, and the median lobe may become a large, rounded, swelling overlying the posterior aspect of the internal urinary meatus. Here, it can act like a ball valve, producing urinary obstruction. The deranged anatomy in the region of the internal meatus, may allow urine into the prostatic urethra. The urine in this situation sets up a desire to micturate and this produces one of the most common symptoms of prostatism, namely, frequency. This is particularly worrisome to the patient at night, as it interferes with his sleep. The obstruction, and instrumentation to relieve it, predisposes to urinary infection. The obstruction to the outflow of the bladder may result in renal failure and uremia. Gram-negative enteropathogens are the most common cause of urinary tract infections and intra-abdominal sepsis, especially post-operatively, in the acute abdomen. Septicemia causes high fever, shivering, headache, and rapid breathing; it may progress to delirium, coma, and death.

Myocardial infection gives rise to chest pain, which is usually of greater severity and duration than in angina, and is associated with nausea, vomiting, sweating, and extreme distress. The patient may be cold and clammy with tachycardia, hypotension, cyanosis, and mild pyrexia (Postoperative bleeding may lead to hypotension and hypovolemic shock, unless fluid volume is rapidly replenished.

Arrhythmias may give rise to tachy- and bradycardias, which are sometimes felt as palpitations. They may also present with their hemodynamic consequences: dyspnea, angina, collapse, or 'funny turns'. Corresponding EKG changes are diagnostic.

Pneumonia is relatively slow in onset, with symptoms of systemic upset, fever, pleuritic pain, cough, and green sputum (may be scanty at first, or, 'rusty' in color, if due to pneumococcal). On examination, there will be signs of consolidation, or just localized crepitations. Tachypnea is a valuable sign, especially in the elderly, in whom there is high index of suspicion.
ACEI
Explanation
The pediatric patient described is apparently suffering from nephrotic syndrome. Glomerular disease induced proteinuria is the most common cause of nephrotic syndrome in children due to damage to the glomerular filtration barrier resulting in leakage of plasma proteins into the glomerular ultrafiltrate. Signs and symptoms in children include edema, urine protein: creatinine ratio > 0.2/gm creatinine; heavy proteinuria (urine protein >40 mg/m2/hr), hypoalbuminemia, and hyperlipidemia. The nephrotic range of proteinuria in children is higher than in adults (> 40 mg/m2/hr). Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers not only lower blood pressure but have that additional benefit of slowing the progression of kidney disease even in patients with normal blood pressure. Although this child is normotensive and is already receiving steroid treatment, the next best additional treatment, therefore, is an ACE inhibitor or an angiotensin receptor blocker (ARB) to decrease the proteinuria and GFR decline in order to reduce the risk of chronic kidney disease.

Diuretic is incorrect. Although a diuretic would provide symptomatic relief for the edema, it would not prevent the development of chronic kidney disease in this patient.

Spironolactone is incorrect. Spironolactone is an inhibitor of renal aldosterone effects such as sodium and water retention and would help combat the edema in this patient but would not decrease the risk of chronic kidney disease.

Beta blocker is incorrect. Beta blockers can be useful in the treatment of hypertension but this patient has not yet developed hypertension.

Mixed alpha and beta antagonist is incorrect. The use of a mixed alpha and beta antagonist drug is not indicated in this normotensive patient and would likely not reduce the risk of chronic kidney disease.
HSP
Explanation
The most likely diagnosis is Henoch-Scholein purpura, which is also known as anaphylactoid purpura. It is the most common cause of non-thrombocytopenic purpura in children. Boys are affected twice as frequently as girls. It is a common vasculitis of small vessels, with cutaneous and systemic manifestations. The systems primarily involved are the skin, gastrointestinal tract (GIT), and kidneys.

The characteristic manifestation of the disease is the rash, which presents initially as a pink maculopapular rash, but progresses to petechiae and purpura, which typically is characterized clinically as palpable purpura. The rash may continue to appear intermittently for 3 or 4 months, or even up to 1 year.

Edema and vasculitis of the GIT may lead to GI hemorrhage, manifesting with colicky pain in abdomen, vomiting, and hematemesis. There may be enlargement of mesenteric lymph nodes. Stool is positive for occult blood.

Swelling of knee and ankle joints is frequently seen due to serous effusion. There may be edema of the dependent areas. Renal involvement, which is the most important cause of morbidity and mortality, manifests as hematuria, proteinuria, and hypertension. CNS and cardiac involvement may rarely occur.

Laboratory findings include thrombocytosis, leukocytosis, and elevated ESR. Serum IgA levels are elevated. Urine examination shows albuminuria, hematuria, and presence of white blood cells and casts in the urine. Renal biopsy may show mesangial deposition of IgA.

Diagnostic criteria of Kawasaki disease are fever of more than 5 days duration and presence of at least 4 of the following conditions:

(1) Strawberry tongue (protuberance of tongue papillae) suggestive of streptococcal infection
(2) Diffuse reddening of the oral and pharyngeal mucosa, dry and cracking lips.
(3) Conjunctivitis without any discharge.
(4) Edema/erythema of the hands and feet and later desquamation of the skin of the fingers and toes.
(5) Polymorphous rash.
(6) Cervical lymphadenopathy (at least one lymph node >1.5 cm).
These features are not present in the above child.

Systemic lupus erythematosis (SLE) is a multisystem disease involving nearly all the organs. It is an autoimmune disorder that causes inflammation of the blood vessels and connective tissue, resulting in multisystem involvement. It is seen more commonly in girls in contrast to HSP, which is more common in boys. Joints may be merely stiff or there may be active inflammation.

Cutaneous manifestations include malar, or butterfly, rash involving the cheeks and nasal bridge. Rash may be photosensitive and may involve all sun exposed areas. This rash is quite different from the rash of Henoch-Schonlein purpura. Hepatosplenomegaly and lymphadenopathy are often present.

Cardiac involvement may include pericarditis, valvular thickening, myocarditis, conduction abnormalities, and congestive cardiac failure. Pulmonary involvement includes pulmonary hemorrhage and fibrosis. This is in contrast to the index case. Renal involvement may manifest as hypertension, edema, electrolyte abnormalities, nephrosis, or acute renal failure.

Systemic onset juvenile rheumatoid arthritis (JRA) may be characterized by spiking fevers, arthritis, hepatosplenomegaly, lymphadenopathy, and serositis leading to pericardial effusion. Fever is accompanied by a faint transient, evanescent salmon-colored macular rash more commonly over the trunk and proximal limbs. It is non-pruritic and may last for a few hours. Heat, even that of a warm bath, may cause reappearance of the rash. Lab investigation includes raised ESR, leukocytosis, thrombocytosis, and C-reactive proteins (CRP) and anemia of chronic disease. JRA is the most common chronic rheumatologic disease in children, with a minimum duration of 6 weeks. The new nomenclature juvenile idiopathic arthritis (JIA) is being increasingly used to better define various subgroups.

Clinical manifestations of Polyarteritis nodosa (PAN) is a necrotizing vasculitis involving small and medium sized arteries. Boys and girls are equally affected. It is believed to be a post-infective autoimmune response in susceptible individuals commonly occurring after upper respiratory infection by group A streptococcal infection, chronic hepatitis B infection, infectious mononucleosis, and tuberculosis. Common features include fever, weight loss, and abdominal pain. Skin manifestations include purpura, edema, and painful nodules along the course of arteries. Cardiac involvement occurs as myocarditis, pericarditis, and arrhythmias. Angiography may show aneurismal dilatation and segmental stenosis.
Anticholinergic
Urge incontinence is defined as involuntary loss of urine occurring for no apparent reason together with a feeling of urinary urgency (a sudden need or urge to urinate) that represents a hygienic or social problem to the individual. The most common cause of urge incontinence is involuntary and inappropriate detrusor muscle contractions. The drug you will suggest is anticholinergic (like Oxybutynin). It will relieve urinary and bladder difficulties, including frequent urination and urge incontinence by decreasing muscle spasms of the bladder, increasing the capacity of the bladder, and delaying the initial urge to void. It is a competitive antagonist of M1, M2, and M3 muscarinic acetylcholine receptors and in higher doses can act as spasmolytic on bladder smooth muscle. Anticholinergic side effects are dry mouth, difficulty in urination, constipation, blurred vision, tachycardia, drowsiness, and dizziness.

Cholinergic drug will cause slowing of the heartbeat and increases in normal secretions. For this reason, patients who already have a problem with incontinence should not be advised to use these drugs.

Epinephrine is not indicated in this patient. Epinephrine stimulates the ends of the sympathetic or inhibitory nerves of the bladder, with the effect of relaxation of the bladder muscles and the increase in tone and rate of contraction of the ureter. The secretion of urine is increased synchronously with the rise in arterial pressure. It will also cause overacting heart, palpitation, and vomiting.

There is no need for antibiotics in a patient with normal urine analysis for a problem that lasts several months.

Botulinum toxin is given as intradetrusor injection in patients who have failed pharmacological therapy. It has been shown to decrease episodes of urinary leakage by preventing the release of acetyl choline from presynaptic membrane. It is also indicated for urinary incontinence in patients with neurologic conditions (e.g., spinal cord injury, multiple sclerosis). It sometimes can cause urinary retention given as intradetrusor injections and occasionally headache, light-headedness, fever, abdominal pain, and diarrhea (not necessarily a direct result of Botox).
Explanation
Luteinizing hormone (LH), follicle stimulating hormone (FSH), and testosterone levels followed by ultrasonography is the correct answer. In male infants under the age of 3 months, LH, FSH, and testosterone levels are helpful in determining whether there are testes present. Ultrasonography has a sensitivity of 76%, a specificity of 100%, and an overall accuracy of 84% when diagnosing undescended testes that are nonpalpable on examination. MRI would have also been a good imaging choice, as it has a sensitivity of 86%, a specificity of 79%, and an overall accuracy of 85%. However, ultrasonography is both easier and a lower risk to perform on infants and children, making it the more popular choice in many cases.

Luteinizing hormone, follicle stimulating hormone, and testosterone levels followed by CT scan is not the correct answer. CT scan findings in children when used in the diagnosis of nonpalpable undescended testes are historically not reliable. Therefore, the imaging study of CT scan makes this answer incorrect.

Human chorionic gonadotropin (HCG) stimulation test and testosterone levels followed by ultrasonography is not the correct answer. The HCG stimulation test is done by administering 2000IU of HCG daily for 3 days and checking testosterone levels pre- and post-stimulation. This helps to determine the presence or absence of testicular tissue. However, this test is reserved for infants over 3 months of age. Ultrasonography is the correct imaging study, but the answer is incorrect due to the laboratory test being incorrect.

Human chorionic gonadotropin stimulation test and testosterone levels followed by x-ray is not the correct answer. The HCG stimulation test is done by administering 2000IU of HCG daily for 3 days and checking testosterone levels pre- and post-stimulation. This helps to determine the presence or absence of testicular tissue. However, this test is reserved for infants over 3 months of age. X-ray is not used at all in the diagnosis of cryptorchidism. Both facets of this answer choice are incorrect.

Human chorionic gonadotropin stimulation test and testosterone levels followed by CT scan is not the correct answer. The HCG stimulation test is done by administering 2000IU of HCG daily for 3 days and checking testosterone levels pre- and post-stimulation. This helps to determine the presence or absence of testicular tissue. However, this test is reserved for infants over 3 months of age. CT scan findings in children when used in the diagnosis of nonpalpable undescended testes are historically not reliable. Both facets of this answer choice are incorrect.
Explanation
Streptococcus pyogenes (group A beta-hemolytic) cause 3 types of diseases: 1) pyogenic diseases, such as pharyngitis and cellulitis, 2) toxigenic diseases, such as scarlet fever and toxic shock syndrome, and 3) immunologic diseases, such as rheumatic fever and acute glomerulonephritis. Glomerulonephritis occurs especially following skin infections.

Streptococcus pneumoniae are Gram-positive lancet-shaped cocci arranged in pairs (diplococci) or short chains. On blood agar, they produce alpha-hemolysis. Virulence factors of Pneumococci are polysaccharide capsules. Pneumococci cause pneumonia, bacteremia, meningitis, and infections of the upper respiratory tract, such as otitis and sinusitis. Mortality rate is high in elderly, immunocompromised (especially splenectomized), and/or debilitated patients. They should be immunized with the polyvalent polysaccharide vaccine.

Peptostreptococci grow under anaerobic or microaerophilic conditions and produce variable hemolysis. Peptostreptococci are members of the normal flora of the gut and female genital tract and participate in mixed anaerobic infections of the abdomen, pelvis, lungs, and brain.

Streptococcus agalactiae (group B streptococcus) colonize the genital tract of some women and can cause neonatal meningitis and sepsis. They are usually bacitracin-resistant.

Enterococcus faecalis (group D streptococcus), formerly known as Streptococcus faecalis, are part of the normal flora in the gut. They can cause urinary, biliary, and cardiovascular infections.
Inability to retract the foreskin over the glans penis in an uncircumcised male patient
Explanation
Inability to retract the foreskin over the glans penis in an uncircumcised male patient is the correct answer. Phimosis can be the result of recurrent infections or irritation, advanced age, diabetes, and poor hygiene. Patients can experience painful erections, recurrent balanitis, and voiding difficulties. Treatment can be with topical steroids followed by gradual retraction of the foreskin or circumcision.

Entrapment of the foreskin behind the glans penis in an uncircumcised male patient is not the correct answer. This is a description of a patient with paraphimosis. Typically, this results in retraction of the foreskin for medical or hygiene purposes that is not followed by properly pulling the foreskin back in place over the glans penis. This can be very painful, and needs to be manually reduced as soon as possible to prevent necrosis of the glans penis. A dorsal slit or circumcision may be necessary if manual reduction is not possible.

Erythema and edema of the glans penis in an uncircumcised male patient is not the correct answer. This description most closely describes balanitis and does not address the placement or status of the foreskin, which is the main concern with phimosis.

Erythema and edema of the phallus in a circumcised male patient is not the correct answer, as patients who are circumcised cannot experience phimosis due to their lack of foreskin.

Erythema and edema of the glans penis in a circumcised male patient is not the correct answer, as patients who are circumcised cannot experience phimosis due to their lack of foreskin.
Anti DNAase B serology
Explanation
The correct answer is anti-DNAase B serology to identify post-streptococcal glomerulonephritis. Group A β-hemolytic streptococci pharyngitis may result in the delayed complication of post-streptococcal glomerulonephritis 10-14 days after the infection. Patient presentations may range from subclinical symptoms to acute nephritic syndrome as streptococci may produce streptolysin, DNAase, and hyaluronidase that lead to tissue destruction and disseminate infection. Serology testing to identify antibodies to these exoenzymes can aid in the diagnosis by demonstrating indirect evidence of infection. Confirmation may require serial antibody draws that reveal a rise in titer levels above baseline.

Urine culture and sensitivity would be appropriate if the clinical picture only entailed fever and flank tenderness in the presence of pyuria and hematuria suggesting a urinary tract infection. That diagnosis does not explain the presence of proteinuria with renal tubular epithelial cells and casts. These indicate intrinsic kidney damage, which is not seen in urinary tract infections. Further serology testing is indicated in the post pharyngitis period.

Urine cytology is ordered in the presence of gross or microscopic hematuria, which is often painless, to identify malignant cells in the urinary tract. This patient does not fit the epidemiologic profile or clinical presentation of malignancy to warrant cytology testing.

Erythrocyte sedimentation rate can aid in detecting an inflammatory response, such as nephritis, but it lacks specificity to identify the infectious process.

Urine protein electrophoresis is indicated to identify abnormal levels of free monoclonal light chains (Bence Jones protein) from immunoglobins in cases of myeloma.
Chronic renal disease
Explanation
The correct response is chronic renal disease. Casts are cylindrical structures, consisting of clumps or clusters of cells or material that can form in the renal distal and collecting tubules of the kidney. Casts form when the pH of the urine is acidic and when the urine is very concentrated. Casts dislodge from the kidney and can be seen in the urine. In order to see casts, urine must be visualized under low power on a microscope. There are various types of casts that can be characterized into acellular versus cellular casts; each category can be further characterized, and the various casts can be associated with various disease processes. Granular casts are the 2nd most common type of cast and result from the breakdown of cellular material. They are most often indicative of chronic renal disease, but can also be seen if a patient has just vigorously exercised. Waxy casts are also indicative of advanced renal disease, specifically indicating a more chronic issue.

Fatty casts are the result of the breakdown of lipid-rich epithelial cells; they are pathognomonic for high urinary protein nephrotic syndrome. High urinary protein nephrotic syndrome does not lead to the formation of granular casts.

Nephritic syndromes, urinary tract injury, glomerulonephritis, and vasculitis can all result in red blood cell casts. Whenever there are red blood cells within a cast, there is a strong indication for glomerular damage from a number of different disease processes. Glomerulonephritis does not lead to the formation of granular casts.

If white blood cells are seen within a cast, this is an indication that there is an inflammation or infection of the kidney known as pyelonephritis. Various other inflammatory states can also result in white blood cell casts. Pyelonephritis does not lead to the formation of granular casts.

Acute tubular necrosis, cytomegalovirus, hepatitis, and toxic ingestion can all result in epithelial cell casts. These casts are the result of desquamation of the renal tubule cells into the collecting system. Acute tubular necrosis does not lead to the formation of granular casts.
Explanation
Acute prostatitis is defined as an inflammation of the prostate gland that develops suddenly and is common in men, likely due to reflux of infected urine into intraprostatic ducts. This can happen after instrumentation, catheterization, or trauma, like horseback riding, biking, etc., and worsened by dehydration, as in this patient. The National Institutes of Health classification of inflammatory conditions of the prostate is as follows:
I Acute prostatitis
II Chronic bacterial prostatitis
III A Chronic prostatitis/pelvic pain syndrome, inflammatory
III B Chronic prostatitis/pelvic pain syndrome, noninflammatory
IV Asymptomatic inflammatory prostatitis

Gram negative organisms are the main culprit, including E.coli, proteus, klebsiella, enterobacter, and pseudomonas. Symptoms of dysuria, fever, perineal pain, and tender prostate are typical. Treatment is with trimethoprim-sulfamethoxazole or quinolones for 4 weeks. In sicker patients, hospitalization may be needed, in which case IV antibiotics with aminoglycoside and ampicillin should be given until the patient is afebrile for 24-48 hours, then oral antibiotics continued for total of 4-6 weeks to avoid complications such as abscess formation or chronic prostatitis.
Acute pyelonephritis presents with fever, flank pain, tender renal angle, and normal rectal exam. Treatment includes oral fluoroquinolone or trimethoprim-sulfamethoxazole for mild to moderate disease and IV ceftriaxone or a fluoroquinolone for hospitalized patients, to be substituted with oral antibiotics after improvement in symptoms. Total duration of antibiotics should be 10-14 days.

Acute urethritis is associated with dysuria and urethral discharge with pruritus at urethral meatus. Fever, chills, frequency, urgency, and hematuria are uncommon. It may be gonococcal, which is the most common cause of urethritis in men or nongonococcal urethritis (NGU). Although most cases of NGU are due to chlamydia trachomatis, other etiologies include T. vaginalis, Mycoplasma genitalium, and Ureaplasma urealyticum. Gram stain and culture or the urethral discharge should be done. Treatment is with ceftriaxone 125mg IM, cefixime 400mg PO, ciprofloxacin 500mg PO, or ofloxacin 400mg PO, all in a single dose in gonococcal urethritis and azithromycin 1gm PO or doxycycline 100mg BID for 7 days or ofloxacin 400mg PO BID for 7 days for NGU.

Rectal abscess is a distant possibility in this patient. It presents with constant pain in the rectal area and perhaps fever and malaise but no dysuria or cloudy urine. Rectal exam will be tender and reveal a fluctuant mass. UA, however, will not be abnormal. Treatment is with incision, drainage, and perhaps antibiotics for anaerobic coverage.

Anal fissure presents with excruciating pain with the passage of bowel movements and is associated with constipation. The passage of stool may be accompanied by bright rectal bleeding usually limited to a small amount on the toilet paper but sometimes more profuse bleeding. Treatment aims at relaxing the sphincter, keeping bowel movements soft and smooth, and pain control.
testicular torsion
Explanation
Testicular torsion in the adolescent boy is a urologic emergency, the most common cause of acute scrotal swelling and pain, and the most common cause of testicular loss. Torsion occurs in 1:4000 and occurs most commonly on the left side in the United States. The cause is a congenital anomaly that occurs in approximately 12% of boys/men, in which the tunica vaginalis is attached too high, allowing the testicle to rotate freely on the spermatic cord and vascular pedicle in the tunica vaginalis. Approximately 40% of boys/men have the anomaly bilaterally. Testicular torsion usually occurs between 12 and 18 years of age with the peak age of 14. It may occur up to 30 years of age, and it is found in infants and occasionally neonates at the time of birth. Up to 50% of patients may have had prior episodes of mild intermittent testicular pain that has resolved spontaneously, due to intermittent torsion and spontaneous derotation. Associated symptoms may include nausea and vomiting (20%), fever (16%), abdominal pain (20 - 30%), and urinary frequency (4%). Physical examination may demonstrate a horizontal position of the testis, and it may be elevated compared to the uninvolved side. The cremasteric reflex is usually absent, but its presence does not rule out testicular torsion. Elevation of the scrotum does not relieve the pain. The diagnosis is a clinical diagnosis. Because it consumes precious time, ultrasound examination of the testis with color flow Doppler should only be ordered when the diagnosis is uncertain and can determine if there is blood flow to the testis. The studies are 86% sensitive and 100% specific in making the diagnosis if the only criterion is decreased blood flow. Radionuclide scans are 90 - 100% accurate in identifying decreased blood flow. Rapid diagnosis is critical; if surgical intervention is provided within 6 hours of onset, the salvage rate for the testis is 80 - 100%; after 6 hours, the salvage rate is approximately 0%.

Acute idiopathic scrotal edema is uncommon, but presents acutely with the average age of presentation 6 years. 90% of patients have a unilateral presentation. The scrotal skin is red and tender, but the testis appears to be normal. The redness tends to extend off the scrotum onto the perineum or onto the penis. This tends to resolve spontaneously in 48-72 hours and leaves no sequelae. Doppler ultrasound, if done, demonstrates good blood flow to the testis with peritesticular edema and fluid in the scrotal wall. Laboratory examination is normal except for occasional eosinophilia.

Acute epididymitis and/or orchitis is not a common pediatric diagnosis. It was first described in 1956. The onset tends to be more gradual, generally over a few days, with fever and dysuria. Elevation of the scrotum may reduce discomfort. The cause may be viral, such as adenovirus, mumps, or Epstein-Barr virus, or bacterial. Bacterial infection is often associated with structural changes in the urinary tract. Urinalysis and urine culture may be helpful in establishing the diagnosis. Typical treatment is with rest, analgesia, and antibiotics if there is concern about a bacterial etiology. If a bacterial cause is identified, urinary tract imaging should be performed. There have been rare reports of acute epididymitis progressing to testicular infarction.

Torsion of the appendix testis may present similarly to testicular torsion. Tenderness is usually localized to the upper portion of the testis and, typically, a blue dot is seen on the scrotal skin resulting from the venous congestion in the appendix testis. This is a self-limited condition and does not require surgical intervention. There are 5 appendages to the testis, all of which serve no function. If one twists or infarcts, symptoms result. Pain is less intense than with testicular torsion, and the cremasteric reflex is usually present.

Varicocele occurs in 10 - 15% of males, 16% of adolescents, and 20 - 40% of men evaluated for infertility. First described in adolescents in 1885, the most common age of presentation is adolescence and early adulthood. They are caused by incompetent or absent valves of the spermatic veins, resulting in dilatation of the veins of the pampiniform plexus. Rarely are they caused by compression of the renal vein by a tumor, an aberrant renal artery, an obstructed renal vein. Doppler ultrasonography can demonstrate retrograde blood flow. They are most common on the left side, are usually asymptomatic, but may present with vague scrotal discomfort and swelling. Of those with symptoms, 2% have intratesticular Varicocele and these are more common on the right side. The typical physical finding is the bag of worms within the scrotal sac. They may be missed on physical examination if the supine position, so the patient should be examined in a standing position. Patients should be referred to urologists for further evaluation and to discuss options for treatment which sometimes, but not always, requires surgery.
Nephrogenic diabetes insipidus
This patient's symptoms of excessive production of urine (polyuria) is most likely caused by nephrogenic diabetes insipidus secondary to lithium use. Lithium impairs the distal water reabsorption in the collecting ducts, mediated by vasopressin (ADH), leading to the production of large quantities of dilute urine. Unfortunately, lithium use, even for as short a period as 1 year, can lead to irreversible damage of the renal tubules (via down-regulation and production of receptors and channels responsible for water reabsorption).

Treatments for lithium-induced nephrogenic diabetes insipidus include A) amiloride, a distal-tubule acting diuretic which competes with lithium for access to ion channels and thus prevents the lithium-induced polyuria, and B) hydrochlorothiazide with a low-salt diet, in order to effectively decrease the quantity of urine produced. Depakote can be substituted for lithium,but as mentioned above, lithium may cause irreversible tubular damage.

In central diabetes insipidus, decreased levels of ADH are produced by the posterior pituitary. Nephrogenic, not central diabetes insipidus is the expected complication of lithium use. ADH is usually released in response to increases in serum osmolality, and/or decreases in arterial volume. Non-osmotic causes such as nausea in post-opertive setting can also elicit ADH release. Head injury, granulomas, and other central nervous system abnormalities can lead to impaired ADH production and release. Central and nephrogenic diabetes are distinguished by a water deprivation test as described in the following table:



Disorder Response to ADH Treatment
Central DI >50% increase in urine osmoles Vasopressin, DDAVP, Decreased salt intake

Nephrogenic DI <10% increase in urine osmol. Diuretics, Removal of offending medications, Decreased salt intake

Primary polydipsia <10% increase in urine osmol. Fluid restriction

Central diabetes insipidus is treated by the administration of vasopressin (DDAVP), intra-nasally, orally, or intravenously.

The differential diagnosis for polyuria also includes the presence of excess serum solutes, ie: glucose and mannitol than can be reabsorbed by the kidney tubules. Hyperglycemia is an unexpected cause of this patient's polyuria since no glucose was found in this urinalysis.

Following acute kidney injury (previously termed acute renal failure), damaged renal tubules may temporarily have difficulty concentrating and diluting urine. The benign urine (lack of blood, protein, cells and casts), makes this cause of polyuria unlikely.

Polyuria secondary to polydipsia is intuitive. Unlike patients with diabetes insipidus, patients with primary polydipsia (also termed psychogenic polydipsia) will have decreased urine production when they decrease their fluid intake, will increase their plasma ADH levels, and concentrate their urine appropriately in response to decreased fluid intake. Primary polydipsic patients are also less prone to abnormalities of sodium.

Note that polyuria is not equivalent to urinary urge, the sudden need to void, or to urinary frequency, voiding in the order of 7-15 times/day.
The correct response is intravenous calcium replacement.

The patient described in the above scenario is having signs and symptoms consistent with hypocalcemia. This electrolyte deficiency is most likely due to the fact that she had a total thyroidectomy 3 weeks ago; this has led to what is termed acquired hypoparathyroidism. The parathyroid glands are primarily responsible for secreting parathyroid hormone (PTH). PTH's primary actions include increasing osteoclastic activity, renal tubular reabsorption of calcium, stimulation of the synthesis of 1,25-dihydroxycholecaldiferal by the kidneys. PTH also inhibits the absorption of phosphate and bicarbonate by the renal tubules; all of these actions lead to the increase of serum calcium. Removal of the thyroid and inadvertently the removal of the parathyroid glands (and PTH) has led to hypocalcemia. Acquired hypoparathyroidism is most commonly seen following surgical thyroidectomies and could be a transient or permanent condition.

Signs and symptoms of hypocalcemia typically are not seen until serum levels fall below 7.5 mg/dL or lower. Patients may experience paresthesias, hyperreflexia, tetany, muscle spasms, muscle cramps, or even seizures. Physical examination may reveal a positive Chvostek sign (facial spasms following percussion on the facial nerve) and a positive Trousseau sign (carpopedal spasms of the hand by inflammation of a sphygmomanometer above systolic BP for several minutes.) Refractory hypotension may also be found. Severe cases of hypocalcemia may also lead to prolonged QT intervals on ECG, which potentially can lead to torsades de pointes. Oral supplementation of calcium is utilized in patients who are asymptomatic; however, our patient is displaying significant signs and symptoms. For this reason, the answer choice of intravenous calcium replacement is suitable at this point in time.

Oral magnesium, oral potassium, and intravenous sodium supplementation are all inappropriate treatments at this time; these electrolytes are still in acceptable ranges.
Urinalysis
Enuresis means any involuntary loss of urine. If it is used to denote incontinence during sleep, it should always be qualified with the adjective "nocturnal." Nocturnal enuresis is defined as involuntary urination in sleep without urological or neurological causes after the age of 5 years, at which time bladder control would normally be expected. The classification of enuresis is based on whether the child has ever achieved bladder control. Primary enuresis refers to a child who has never been dry; whereas, secondary enuresis means the child has been dry for a period but becomes enuretic later.

Another useful classification is based on a period when the child does not have bladder control:

• Nocturnal enuresis: Enuresis at night only.

• Diurnal enuresis: Enuresis during the day only.

• Nocturnal and diurnal enuresis: Enuresis during both day and night.

The pathophysiology of enuresis is not completely clear; however, immaturity on the part of the autonomic nervous system that controls the bladder is present in the vast majority of cases. Only 20% of children with enuresis have a psychodevelopmental disorder (lower intelligence quotient or behavioral disorder). Secondary enuresis is often associated with a stressful environmental event. Urinalysis is the only mandatory investigation for nocturnal enuresis.

Treatment: the therapeutic approach is still based on empirical data. Therapy is aimed at alleviating the symptoms of nocturnal enuresis rather than at curing the condition.

A behavior-modification program is the treatment of choice, including buzzer/bell and pad, positive reinforcement, charting progress to increase confidence and self-esteem, urinating before bedtime, avoiding liquids after the evening meal, and avoiding psychological trauma through blame or belittling the child.

Complete cystometric evaluation is incorrect. Cystometric analysis is used to evaluate the bladder's capacity to contract and expel urine.

Intravenous pyelography (IVP) is incorrect. IVP refers to a series of X-rays taken of the kidneys, their collecting or drainage system (the ureters), and the bladder. It is done to locate a suspected obstruction to the flow of urine through the collecting system.

Renal ultrasound is incorrect. If enuresis also occurs in the daytime or if urinary flow is small or interrupted, a renal ultrasound and a careful neurologic examination are indicated.

Urine culture is incorrect. Urine culture may be appropriate, but is not most important. Urine culture is useful mainly when history, physical examination, or both suggests infection.
A 61-year-old man with known cirrhosis presents with a 1-week history of "puffy" ankles and increased shortness of breath. A week prior to symptom onset, he had traveled on vacation, where he engaged in walking, sightseeing, and eating out. He admits more dyspnea with lying down and with increased exertion. His shoes feel snug, and he notes a definite line from wearing socks. The patient denies chest pain, leg pain, fevers, claudication, nausea, headache, lethargy, and hemoptysis.

His past medical history is remarkable for cirrhosis and a history of alcoholism. He is awaiting a liver transplant. He had a liver biopsy, but no other surgeries. He takes no medications, has no allergies, and has been abstinent of alcohol for 9 months. He lives with his wife, works as an electrician, and smokes cigarettes at 1 pack-per-day.

Vitals are normal, including oxygen saturation. On physical exam, the patient appears in no acute distress and with normal mental status. His physical exam is remarkable for mild jugular venous distention, 2-3+ edema in lower extremities, and mild dullness to lung percussion. No hepatomegaly or ascites is noted.

This patient's laboratory results are shown in the chart.

Complete blood count (CBC)- Normal
Chest x-ray- Mild bilateral effusions
Urinalysis- Normal
Beta-natriuretic peptide (BNP)- Normal
Complete Metabolic Panel (CMP)- Abnormal as indicated below:
Test Result Normal range Units
Sodium 126 134-144 mmol/L
Potassium 3.4 3.4-4.9 mmol/L
Chloride 100 100-109 mmol/L
HCO3 26 20-31 mmol/L
Glucose 98 70-99 mg/dL
Bun 18 7-18 mg/dL
Creatinine 1.1 0.6-1.2 mg/dL
Calcium 8.8 8.8-10.5 mg/dL
Albumin 2.6 3.5-5.0 g/dL
Total Protein 5.9 6.4-8.2 g/dL
AST (SGOT) 112 15-37 U/L
ALT (SGPT) 108 5-43 U/L
Alk Phosphatase 158 50-136 U/L
Total Bilirubin 1.9 0.1-1.2 mg/dL
eGFR >60 >60 mL/min/1.73m2
Osmolality 265 285-293 Mmol/kg H2O

Question
What is the most appropriate intervention for this patient's fluid and sodium status?

Answer Choices
1 Administer intravenous hypertonic saline solution
2 Advise the patient to contact his gastroenterologist for an appointment
3 Begin intravenous or oral diuresis
4 Evaluate for possible pulmonary embolus
5 Initiate hemodialysis
Begin intravenous or oral diuresis
This patient is in a hypervolemic hypotonic hyponatremic state. The hypervolemia can be identified primarily by history (edema and dyspnea) and physical exam (jugular venous distention, edema, and pulmonary effusion). The hypotonia (low serum osmolality) and hyponatremia most likely are due to a "dilution" effect, in which this patient's overall fluid status is high, but the sodium levels are normal or even elevated. This patient has hypoalbuminemia (common with chronic liver disease) and increased extracellular fluid, which is causing his mild pulmonary effusions and dyspnea. The most appropriate treatment for this patient is to begin intravenous or oral diuresis. Diuretics should be used with caution in patients with cirrhosis, but his pulmonary edema must be addressed.

It would be potentially harmful to this patient to administer intravenous hypertonic saline solution, especially as his overall sodium level is likely normal to high. Hypertonic saline should only be used in acutely ill patients, with careful monitoring.

Without prior records, it is difficult to assess any potential worsening in this patient's chronic cirrhosis. While it would be acceptable to advise the patient to contact his gastroenterologist for an appointment in addition to other interventions, it would not address his current hypervolemic hyponatremia or his pulmonary edema.

With a complaint of shortness of breath, especially in a smoker, it could be rationalized to evaluate for a possible pulmonary embolus. However, he does not meet the Wells criteria for a PE (no suspected DVT, no tachycardia, no immobilization, no history of DVT/PE or malignancy, no hemoptysis, and alternative diagnoses are more likely than PE). Further evaluation for PE is not indicated.

With severe electrolyte abnormalities, or those that do not respond to diuresis, it would be reasonable to initiate hemodialysis. This patient's abnormalities are not severe, and he is mildly symptomatic. A trial of diuresis is indicated before considering hemodialysis.
Klinefelter syndrome
Explanation Fragile X syndrome results from a mutation in the FMR1 gene, located on the long arm of the X chromosome (Xq27). It is characterized by moderate mental retardation. The phenotypic manifestations of fragile X syndrome vary, but often include developmental delay, hyperactivity, abnormal craniofacials, and macro-orchidism (in post-pubertal males). Greater than 99% of affected individuals have what is known as a "full mutation" in the FMR1 gene. This mutation is caused by an increased number of CGG trinucleotide repeats in the 5' end of the gene (> 230 CGG repeats), which causes aberrant methylation of the gene, and aberrant expression of the gene product. Mothers of affected children that have this full mutation are obligate carriers of a "premutation" in the FMR1 gene. This premutation or "intermediate" allele has between 55 and 230 CGG repeats, and can expand upon transmission to offspring. (The normal allele has between 6 and 54 CGG repeats). These women, and their family members, are at an increased risk to have children affected with fragile X syndrome. Molecular genetic testing is available on a clinical basis to determine the status of the FMR1 gene allele(s).
Klinefelter syndrome affects males. It is diagnosed by an abnormal karyotype. Individuals with this syndrome have an extra X chromosome, with the karyotype being 47, XXY (Variations occur, but this karyotype is the most common). The extra X chromosome seems to affect the functioning of the testes and testosterone production. Adolescent boys with this disorder may undergo gynecomastia. Most are tall, but not particularly coordinated. The penis is of normal length; however the testes are small. Treatment with male sex hormones can be helpful.

X-linked adrenoleukodystrophy is caused by a mutation in the ALD gene, located on the long arm of the X chromosome (Xq28). The childhood form most commonly presents between the ages of four and eight years. It begins with symptoms of attention deficit and hyperactivity disorder, but gets progressively worse, with symptoms including difficulty with previously mastered subjects such as speech and reading. The affected individual also becomes clumsy and has visual disturbances. Brain MRI is often abnormal, even while symptoms are still mild. The rate of progression of the disorder varies, but leads to death in a matter of years. Along with the childhood form of the disease, there are several other types. Type two usually presents during middle age (possibly as early as in the twenties), and includes leg stiffness and weakness and sexual dysfunction. This, too, is progressive, usually over decades. Type three, which is found in approximately 10% of cases, is characterized by adrenal insufficiency. Presentation can be anywhere between two years of age to adulthood.

X-linked mental retardation hypotonic facies syndrome is caused by a mutation in the XNP gene, also located on the X chromosome (Xq13.3). Affected individuals have a distinct phenotype that includes genital abnormalities, a common set of facial features, and severe developmental delays with mental retardation. All patients have a normal 46, XY karyotype; however their appearance at birth can range anywhere from a male with hypospadius to a normal appearing female. Common craniofacial features include a small head circumference, small triangular nose, tented upper lip, prominent lower lip and open mouth. Short stature is common. Developmentally, milestones are delayed to a marked degree. Hypotonia is commonly present. Interestingly, the mutated gene appears to down regulate expression of the alpha-globin gene, leading to a microcytic and hypochromic anemia in some affected individuals.

Individuals with XYY syndrome have an abnormal karyotype - 47, XYY. Physical development is normal, although these individuals have an increased likelihood for learning problems and tend to be tall.
Increased fluid intake
Explanation
This patient has passed calcium oxalate stones in his urine. Increasing his intake of fluids will help prevent future episodes of nephrolithiasis. At least 2 liters/day of fluid intake is suggested to prevent recurrent nephrolithiasis. Increased intake of water, coffee, and beer will all lead to decreased urine concentration of stone-forming solutes; alcoholic beverages inhibit the action and secretion of anti-diuretic hormone, leading to decreased urine solute concentration. In addition, reducing the intake of oxalate-rich foods, such as rhubarb, green leafy vegetables, chocolate, tea, liver, nuts, and seeds, is recommended.

Crystals form in urine when the urine is supersaturated with crystal-forming solutes such as calcium, phosphate, and uric acid. Some patients overexcrete solutes, while others drink inadequate amounts of fluids to keep solutes dissolved. Stones also occur when the urine is infected with urea-splitting bacterium (Proteus). Here, urea is broken down into ammonia and bicarbonate, which then forms ammonium hydroxide and bicarbonate, the components of struvite stones. Struvite stones consist of a triple phosphate of calcium, magnesium, and ammonium

Certain stone inhibitors, such as pyrophosphate, citrate, and magnesium, prevent crystal growth. In patients who have low levels of these inhibitors, stones are more likely to form. We do not know if this patient is deficient in urinary stone inhibitors, only that he passed calcium oxalate stones.

24-hour urine collections, preferably 2 samples drawn 6 weeks apart, are recommended to assess urinary citrate excretion. Decreased intake of oranges (being a type of citrus fruit) will likely decrease urinary citrate levels. This modification will be of little benefit if his urine citrate levels are normal and may be detrimental if his levels are low.

Increased intake of liver is not recommended; liver is an oxalate-rich food.

Increased sodium is not advised in a patient who is prone to developing urinary calcium stones. Increased sodium intake leads to increased calcium excretion, which may promote further calcium stone formation. Increased protein intake is not recommended for patients with risk or recurrent renal stones and should be limited to less than 80/g day.

Nephrolithiasis is a common problem, affecting some ~ 2 - 9% of the population. Without preventative treatment, 50% of patients having an episode of nephrolithiasis will likely have recurrent episodes over the next 10 years.

Because of its likely recurrence, measures to prevent recurrent nephrolithiasis (such as increasing water intake, decreasing sodium intake, and moderating calcium intake) are all important in a patient such as this one who has documented calcium phosphate stones.
Explanation
The correct response is that you should perform kidney function tests.

Your patient has galactorrhea, amenorrhea, and signs and symptoms that suggest a renal insufficiency (fatigue, somnolence, easy bruising, peripheral edema); the insufficiency was probably caused by long-standing diabetes (diabetic retinopathy develops after a long history of diabetes). Chronic renal failure elevates prolactin by decreasing peripheral clearance of the hormone. Evaluation of hyperprolactinemia should include a review of medications, including estrogen therapy, and history of fertility or gonadal dysfunction. Elevated prolactin levels can result in secondary hypogonadism.

In general, signs and symptoms of hyperprolactinemia are due to either the excess hormone secretion (i.e., galactorrhea and amenorrhea) or local compression (e.g., new-onset or persistent headache, dizziness, visual changes, and vision loss). Since your patient has no signs of any of them, biochemical tests should be ordered before the imaging. Laboratory evaluation should include a repeat serum prolactin test, measurements of TSH and free T4, and a pregnancy test. If the results come back normal and if other diagnoses are excluded, the most likely diagnosis is a prolactinoma. A pituitary MRI should only be obtained in such cases.

Elevated prolactin levels can result in secondary hypogonadism. Serum testosterone levels should be checked in men with galactorrhea.

Visual field testing can be performed in individuals with specific visual complaints, especially loss or impairment of peripheral vision.
Normal Saline
Explanation
This patient is presenting with signs and symptoms consistent with hypovolemic shock due to acute traumatic blood loss.

3 goals exist in the emergency department treatment of the patient with hypovolemic shock as follows: (1) maximize oxygen delivery - completed by ensuring adequacy of ventilation, increasing oxygen saturation of the blood, and restoring blood flow, (2) control further blood loss, and (3) fluid resuscitation.

Current recommendations are for aggressive fluid resuscitation with lactated Ringer solution or normal saline in all patients with signs and symptoms of shock, regardless of underlying cause.

If a patient is moribund and markedly hypotensive (class IV shock), both crystalloid and type O blood should be started initially. These guidelines for crystalloid and blood infusion are not rules; therapy should be based on the condition of the patient.

Epinephrine is indicated as initial resuscitation management in cardiac arrest, anaphylactic shock, symptomatic bradycardia, and hypotension refractory to volume replacement. Epinephrine is associated with a host of adverse effects such as induction of pulmonary hypertension, tachyarrhythmia, myocardial ischemia, lactic acidosis, hyperglycemia and compromise hepatosplanchnic perfusion, oxygen exchange, and lactate clearance.

The combination of hypertonic saline and dextran also has been studied because of previous evidence that it may improve cardiac contractility and circulation. Studies in the US and Japan have failed to show any difference when this combination was compared with isotonic sodium chloride solution or lactated Ringer solution.

Somatostatin and octreotide infusions have been shown to reduce gastrointestinal bleeding from varices and peptic ulcer disease. These agents possess the advantages of vasopressin without the significant side effects.

In the patient with GI bleeding, intravenous vasopressin and H2 blockers have been used. Vasopressin commonly is associated with adverse reactions, such as hypertension, arrhythmias, gangrene, and myocardial or splanchnic ischemia. Therefore, it should be considered secondary to more definitive measures. H2 blockers are relatively safe but have no proven benefit.
IgA nephropathy
Both gross and microscopic hematuria a couple of days after nonspecific upper respiratory tract infection and hypertension in male patients are highly suggestive on IgA nephropathy (Bergers disease). IgA nephropathy is the most common chronic glomerular disease worldwide. It may also be associated with gastroenteritis, acute or chronic renal failure, or may be asymptomatic when erythrocytes (RBCs), RBC casts, and proteinuria are discovered on urinalysis. Some patients also have hypertension. Pathophysiological mechanisms are subendothelial deposits of amorphous material that lead to vascular occlusions, mechanical RBC, and platelet damage, resulting in prothrombotic state.

Alport syndrome is hereditary X-linked dominant hereditary nephritis that will also present with hematuria (asymptomatic or gross) 1-2 days after upper respiratory infection. This progressive hereditary nephritis will, however, be accompanied with bilateral sensorineural deafness and visual problems (patognomonical extrusion of central part of lenses into anterior ocular chamber).

Amoxicillin side effects are not probable. Amoxicillin side effects include nausea, vomiting, rashes, antibiotic-associated colitis, and diarrhea, in addition to more rare side effects such as mental changes, lightheadedness, insomnia, confusion, anxiety, sensitivity to lights and sounds, and unclear thinking. Even allergy to amoxicillin presents with a change in mental state initially, followed by itching skin rash, fever, nausea, and vomiting any time during the treatment up to a week after treatment has stopped. Acute overdose of amoxicillin may manifest with renal dysfunction, lethargy, and vomiting, but this usually happens in very young children.

Acute poststreptococcal glomerulonephritis can present with the same clinical picture: sudden hematuria, edema, and hypertension, usually together with non-specific constitutional symptoms. However, there is always a latent period between the streptococcal infection and the onset of signs and symptoms of acute glomerulonephritis. Latent period is 1-2 weeks after a throat infection and 3-6 weeks after a skin infection.
Hemolytic-uremic syndrome (HUS) is acute renal failure associated with non-immune (Coombs-negative) microangiopathic hemolytic anemia and thrombocytopenia. It is the most common cause of acute renal failure in children (though it may occur in adults as well). In HUS, there is usually a prodromal gastroenteritis, fever, or bloody diarrhea for 2-7 days before the onset of renal failure, sometimes with central nervous system signs (irritability, lethargy, even seizures). Acute renal failure with anuria follows. Physical findings may reveal hypertension, edema, fluid overload, and severe pallor.
Renal tubular obstruction
Explanation
Acyclovir precipitates in renal tubules because it is poorly soluble in urine. In that way, it causes the obstruction of renal tubules and acute renal failure.

Endothelial injury is characterized by reduced vasodilation, a proinflammatory state, and prothrombic properties; it may be associated with hypertension and diabetes, particularly in type II diabetes with insulin resistance. However, in a patient with acute kidney failure who has been exposed to the high dose of parenteral therapy with a poorly soluble nephrotoxic drug, endothelial injury should not be your initial choice.

Renal tubular cells dysfunction due to hypersensitivity reaction to drugs or by infection will cause acute interstitial nephritis. It is often associated with obstruction or reflux, so that you can include this in your list of differential diagnoses. However, the development of acute renal failure during the therapy with acyclovir makes renal tubular obstruction more likely.

In acute interstitial nephritis, renal tubular cells dysfunction is caused primarily by a hypersensitivity reaction. When caused by an allergic reaction, the symptoms of acute tubulointerstitial nephritis are fever, rash, and enlarged kidneys. Besides, acyclovir-induced crystalluria that causes mechanical tubular obstruction is the better option in this case.

Kidney infection with acute renal failure is not a probable diagnosis in a patient that has no back pain and no signs of a urinary tract infection.
Chlamydia trachomatis
Chlamydia are bacteria. Chlamydia was once thought to be protozoa as well as viruses, but it is neither; they are bacteria in the order Chlamydiales. Chlamydia is obligate intracellular organisms. Characteristic of chlamydia infections is the development of inclusion bodies. Chlamydia trachomatis cause approximately 50% of all cases of nongonococcal urethritis in males. Chlamydia trachomatis causes more nongonococcal urethritis in boys/men than Trichomonas vaginalis does.

Urethritis is an inflammation of the urethra. It is classified as either gonococcal urethritis (caused by Neisseria gonorrhoeae) or nongonococcal urethritis (caused by something other than Neisseria gonorrhoeae). Common causes of nongonococcal urethritis are Chlamydia trachomatis, Trichomonas vaginalis, and Ureaplasma urealyticum.

Chlamydophila psittaci does not cause nongonococcal urethritis. Chlamydophila psittaci causes a systemic illness called psittacosis, parrot fever, or ornithosis. Psittacosis is acquired from birds.

Trichomonas vaginalis is a protozoan. Trichomonas vaginalis can cause nongonococcal urethritisin males.It also causes trichomoniasis vaginitis, sometimes called trichomoniasis.

Ureaplasma urealyticum is considered a mycoplasma. Ureaplasma urealyticum is in the family Mycoplasmataceae and the genus Ureaplasma. Bacteria in the genus Ureaplasma require urea; therefore, Ureaplasma urealyticum is found primarily in genitourinary tract. Ureaplasma urealyticum is a common cause of nongonococcal urethritis.

Pneumocystis jiroveci (formerly called Pneumocystis carinii) is a fungus, not a protozoan. In an immunosuppressed host, Pneumocystis jiroveci can cause pneumonia. Pneumocystis jiroveci does not cause nongonococcal urethritis.
A 7-year-old girl presents for a 1-day history of bloody urine. The grossly bloody urine scared both the girl and her parents, but she denies dysuria and frequency. No trauma or sexual abuse has occurred. The parents deny recent fever in the patient, but note that she had a fever for a few days accompanying a sore throat. She was given acetaminophen at an appropriate dosage for her weight, and about 3 days of some leftover amoxicillin; both the fever and pharyngitis then resolved. Her past medical history is unremarkable for any chronic illnesses. Her only medication is a multivitamin, and she has NKDA. She has had no surgeries, and family history is unremarkable for urinary tract disorders or any bleeding disorders.

On physical exam, she appears interactive and in no apparent distress; she is well-nourished, non-obese, and perhaps mildly edematous. Vitals are a temperature of 99.0° F and a BP of 138/85 mm Hg; P is 98, and RR is 20. No rashes are found. Cardiac exam reveals normal rate and rhythm; there are no murmurs or rubs. On abdominal exam, her abdomen is non-distended, non-tender, and without masses or hepatosplenomegaly. She has no CVA tenderness.

A urinalysis is performed; the significant findings are as follows:

Protein 2+
Glucose Negative
Ketones Negative
Blood 4+
Nitrites Negative
Leukocyte esterase 1+

Microscopic analysis is performed, which confirms the presence of red blood cells (RBCs) that are dysmorphic and indicate RBC casts.

Blood tests are ordered, which reveal a complete blood count within normal limits and a complete metabolic panel with elevated creatinine. The patient's antistreptolysin O level is elevated, and her serum complement level is low.



Question
What is the most likely diagnosis for this patient?

Answer Choices
1 Acute cystitis
2 Analgesic abuse nephropathy
3 Diabetic nephropathy
4 Postinfectious glomerulonephritis
5 Renal cell carcinoma
Postinfectious glomerulonephritis
Explanation
Of the listed choices, this pediatric patient most likely has postinfectious glomerulonephritis (PIGN), or poststreptococcal glomerulonephritis. The diagnosis is supported by both her history and the test results. "An estimated 5 to 10% of patients with streptococcal pharyngitis" may develop this condition.1 Though the test is not specific, the antistreptolysin O, along with the history of pharyngitis, help establish a recent streptococcal infection for this patient. PIGN falls under the broader category of nephritic syndromes characterized by hematuria and RBC casts, with possible proteinuria, edema, hypertension, and elevated serum creatinine. Treatment for PIGN is supportive, and normal renal function returns for the vast majority of patients.

While the hematuria and presence of leukocyte esterase are consistent with acute cystitis, the rest of the history and findings are not. The classic presentation of acute cystitis includes dysuria and frequency. The remainder of the patient's presentation (i.e., edema, elevated BP, RBC casts, and serum tests) is inconsistent with acute cystitis. The leukocyte esterase is not specific for infection; in this case, it indicates inflammation in the urinary tract.

Analgesic abuse nephropathy is a chronic tubulointerstitial nephritis "caused by cumulative lifetime use of large amounts (i.e., ≥ 2 kg) of certain analgesics."1 Though this patient was dosed with acetaminophen, her use was in small amounts and only for a few days. The history can rule out this diagnosis.

Diabetic nephropathy is an important diagnosis to keep in mind when evaluating renal dysfunction, as it is the most common cause of nephrotic syndrome. The diagnosis includes a history of diabetes and demonstrated proteinuria, which can be confirmed by various methods. This patient has no history of diabetes, and even if she presented with elevated glucose, diabetic nephropathy would not be expected to develop for many years.

Renal cell carcinoma (RCC) is suggested by persistent hematuria, especially in individuals over age 50 or in those at high risk. The serum findings in this patient are not consistent with the diagnosis of RCC. CT, MRI, and sometimes renal biopsy help confirm the diagnosis for RCC.
Explanation
Ciprofloxacin 500 mg PO BID x 14 days is the correct answer. Patients with pyelonephritis who are sick enough to be treated as an inpatient receive IV antibiotics until they have been afebrile for 24 - 48 hours. They also need to be able to tolerate oral hydration and oral medications before being discharged. Upon discharge, they will be given a prescription for antibiotics that will complete at least 2 weeks of antibiotic treatment. Ciprofloxacin has good coverage for E. coli urinary tract infections, and given at 500 mg PO BID x 14 days would be an appropriate choice as long as sensitivities from her culture showed Ciprofloxacin to have sensitivity.

Motrin 800 mg PO q 8 hours prn pain is not the correct answer. While motrin is a good choice for patients who may still have some discomfort related to the pyelonephritis, it is not the most likely prescription for this patient to receive. She had become asymptomatic prior to discharge, so there would not be any reason to prescribe anything to help with pain or discomfort at that time. In addition, she is more likely to receive treatment for her infection than for pain.

Nitrofurantoin 100 mg PO BID x 7 days is not the correct answer for several reasons. While nitrofurantoin is often an appropriate antibiotic for E. coli urinary tract infections, it does not achieve tissue levels reliable enough for pyelonephritis treatment. In addition, only 7 days of treatment does not add up to at least 2 weeks total of antibiotics.

Levofloxacin 500 mg PO daily x 7 days is not the correct answer. While levofloxacin is an appropriate antibiotic to treat E. coli pyelonephritis, 7 days of treatment is not long enough in this situation.

Amoxicillin 500 mg PO BID x 14 days is not the correct answer. While 14 days of antibiotics is a good length of time, amoxicillin does not have good coverage for E. coli, so it would not be a good choice to treat an E. coli related pyelonephritis.
kidney
A known side effect of lithium is nephrogenic diabetes insipidus. Nephrogenic diabetes insipidus can be seen in a significant minority of the patients taking lithium. Nephrogenic diabetes insipidus results when the collecting duct of the kidney does not respond to antidiuretic hormone (ADH).

In complete nephrogenic diabetes insipidus, the kidney is unresponsive to ADH. Therefore, exogenous vasopressin (ADH) will not increase the urine osmolality.

The pituitary gland secretes numerous hormones. The posterior lobe of the pituitary is the neurohypophysis. One of the hormones secreted by the posterior pituitary is antidiuretic hormone (ADH). The production of the posterior pituitary hormones actually occurs in the hypothalamus. Antiduiretic hormone (ADH) is also known as arginine vasopressin. It works on the collecting tubules of the kidney to conserve water. When the pituitary does not secrete ADH, the condition is called central diabetes insipidus.

The urinary bladder is a muscular sac. The bladder stores urine and it is not responsible for concentration or production of urine. Pathology of the bladder does not result in nephrogenic diabetes insipidus.

The ureter is a tube that transmits urine from the kidney to the bladder. The ureter is not responsible for concentration or production of urine. Pathology of the ureter does not result in nephrogenic diabetes insipidus.

The urethra is a tube that transmits urine from the bladder out of the body. The urethra is not responsible for concentration or production of urine. Pathology of the urethra does not result in nephrogenic diabetes insipidus.
Plan voiding ureterocystogram
Explanation
Urinary tract infections (UTIs) are common in children and may cause permanent kidney damage. Urinary tract anomalies are risk factors for UTIs, and you should search for them in a boy of this age. While voiding cystourethrography (VCUG) is not recommended routinely after the first UTI, it should be performed if there is a recurrence, particularly a recurrence of febrile UTIs. Kidneys and bladder ultrasound are performed in younger children (3 - 5 years of age) as the initial step to evaluate anatomy, but they cannot relieve vesicoureteral reflux (VUR).

Recommendations regarding antimicrobial prophylaxis still lack evidence, both for and against regardless, in this case, your approach should be based on the diagnosis of the presence of eventual urinary tract anomalies.

You should tell the patient's mother that circumcision reduces UTIs, especially in high-risk boys; however, it is more important to exclude the presence of anatomical abnormalities, which put this boy at an even bigger risk.

Voiding dysfunction is defined as daytime voiding disorders in children who do not have neurologic, anatomic, obstructive, or infectious abnormalities of the urinary tract. It is recommended that toilet training begin when a child is 18 months old and shows the interest. A child's interest usually appears around 24 - 25 months. Daytime dryness is usually achieved by 3 years of age. Dysfunctional voiding can lead to VUR, accidental urinary leakage, and UTIs; however, it is too early to think about the presence of dysfunctional voiding in this child.

Both radionuclide cystography and voiding cystourethrography are used in detecting and grading vesicoureteral reflux. While VCUG is suggested for both girls and boys, radionuclide cystography is suggested only for girls because voiding cystourethrography is needed for adequate anatomic imaging of the urethra and bladder in boys.
nephrogenic diabetic insipidus
Explanation
A known side effect of lithium is nephrogenic diabetes insipidus. This side effect is very common. Nephrogenic diabetes insipidus results when the collecting duct of the kidney does not respond to the antidiuretic hormone (ADH).

Antiduiretic hormone (ADH) is also known as arginine vasopressin. It is secreted from the pituitary. It works on the collecting tubules of the kidney to conserve water.

Nephrogenic diabetes insipidus is characterized by renal resistance to ADH. This results in a large output of dilute urine. There will be polyuria and polydipsia. Hypernatremia would be present. In contrast to central diabetes insipidus, plasma ADH level would be elevated and there is no response to the administration of vasopressin. Nocturia can be present.

In complete nephrogenic diabetes insipidus, the kidney is unresponsive to ADH. Therefore, exogenous vasopressin (ADH) will not increase the urine osmolality.

The syndrome of inappropriate ADH secretion (SIADH) is due to excess ADH (antidiuretic hormone) or an ADH like substance. The syndrome of inappropriate ADH secretion is characterized by concentrated urine. There will be an accompanying serum hyponatremia. Hyponatremia can cause central nervous system symptoms (obtundation, seizure, and coma).

Central diabetes insipidus is characterized by a lack of antidiuretic hormone (ADH) secretion from the pituitary. Because of the deficiency of ADH, there is an inability of the kidney to concentrate the urine. This results in a large urine output of dilute urine. There will be polydipsia and polyuria. Nocturia can be present. Hypernatremia would be present. In contrast to nephrogenic diabetes insipidus, there is an increase in urine osmolality in response to the administration of vasopressin.

Diabetes mellitus is due to an absolute or relative insulin deficiency. Untreated, it is characterized by polyuria, polydipsia, and polyphagia, and there will be an elevated blood glucose and glucosuria. Glucosuria is the presence of glucose in the urine.

Psychogenic polydipsia is a psychological condition. A patient with psychogenic polydipsia drinks an enormous amount of water. Because of this large water intake, there is polyuria. However, with psychogenic polydipsia nocturia is usually absent. There will also be hyponatremia.
Your patient is a 65-year-old man presenting with a 3-week history of progressive leg swelling, dyspnea on exertion, and increased thirst. A couple days ago, he started having nausea, headache, vomiting, and his gait became unsteady. He does not have chest pain or shortness of breath at rest. His medical history is significant for hypertension, type II diabetes, and chronic kidney failure. His medications include a beta blocker/alpha-1 blocker (carvedilol), aspirin, angiotensin-converting enzyme (ACE) inhibitor (lisinopril), biguanide (metformin), and a loop diuretic (furosemide). Physical examination reveals bilateral pitting edema up to his knees, swelling in the face, peripheral pulses 2+ in all extremities, and an unsteadiness during Romberg testing with both eyes open and closed. Auscultation reveals bilateral crackles at the lung bases, and the rest of his physical examination is not contributing. Laboratory findings are:

Test

Results

Reference Range (males)

Sodium
Potassium
Chloride
CO2
Creatinine
Blood urea nitrogen
Fasting Glucose
Serum osmolality

125 mEq/L
3.1 mEq/L
97 mEq/L
22 mmol/L
2.6 mg/dL
40 mg/dL
189 mg/dL
270 mOsm/kg H2O

135-145 mEq/L
3.5-5.0 mEq/L
95-108 mEq/L
20-32 mmol/L
0.7-1.4 mg/dL
7-30 mg/dL
<110 mg/dL
280-295 mOsm/kg H2O

Total protein
Albumin
Total bilirubin
Alkaline phosphatase
Alanine aminotransferase
Aspartate aminotransferase

6.0 g/dL
2.9 g/dL
1.1 mg/dL
90 IU/L
34 IU/L
37 IU/L

6.0-8.5 g/dL
3.5-5 g/dL
0.1-1.3 mg/dl
40-120 U/L
0-35 U/L
0-37 U/L

Urine Sodium

<10 mEq/L

Variable (depending on volume status)

Red blood cell count

White blood cell
Hemoglobin
Platelets

4 000 000/uL

6.8 000 /mm
11.0 g/dL
300 000/mm3

4,7 000 000- 6,1 000 000/uL

3.8000-10.8000/mm3
13.8-17.2 g/dL
150 000-450 000/mm3



Question
What is the most probable cause of his neurological symptoms and signs?

Answer Choices
1 Hyponatremia
2 Hypokalemia
3 Hypervolemia
4 Hyperglycemia
5 Anemia
Hyponatremia
Explanation
Nausea, headache, vomiting, unsteady gait, and Romberg showing vestibular disfunction are most probably caused by hyponatremia, the most common electrolyte abnormality in clinical practice. Hyponatremia is defined as a serum sodium concentration less than 135 mEq/L and is severe when the serum sodium level falls below 125 mEq/L. It is often relatively asymptomatic. Hyponatremia manifests mostly by neurological symptoms secondary to cerebral edema. When the serum sodium level drops, water moves from the extracellular space into cells and causes cellular swelling. Brain swelling is probably the first to manifest, given the fact that the brain contains around 80% water and has no space within a skull to accommodate swelling. Early symptoms of cerebral edema are nausea, headache, and vomiting. In the acute cases (those that happen over several hours), hyponatremia may cause acute cerebral edema, with seizures, brain herniation, respiratory failure, coma, and death. However, hyponatremia that develops over several days gives a chance for the brain to adapt to the excess water by extruding osmolytes (potassium, chloride, and small organic molecules), thus equalizing the osmolality between the intra- and extracellular fluid. Therefore, the symptoms of chronic hyponatremia are less severe, even when laboratory shows severe hyponatremia, slightly decreased cognitive functions, mild nausea, and mild gait and balance disturbances. Physical examination in patients with hyponatremia is generally not specific and usually relates to the underlying condition - in this case, probably renal failure.

Hypokalemia will not present with neurological symptoms. Mild hypokalemia is often without symptoms, and severe hypokalemia, with serum potassium concentrations of 2.5-3 mEq/L, causes mostly muscle symptoms, such as weakness, pain, cramps, constipation (disturbance in the smooth muscles function), and, when severe, can cause flaccid muscle paralysis.

Volume overload, primarily salt and water, will manifest as subcutaneous edema, ascites, and/or pulmonary edema, presenting with the symptoms of the failure of those organs. Your patient has volume overload, but neurological symptoms in hypervolemia with hyponatremia are also caused by sodium disbalance. Hypervolemia with hyponatremia is most commonly caused by chronic heart failure, liver, or kidney disease.

Hyperglycemia of 189 mg/dL is unlikely the cause of progressive leg swelling, dyspnea on exertion, increased thirst, nausea, headache, vomiting, unstaeady gait, and balance disturbances.

Severe anemia may present with dypnea, thirst, and dizziness, but anemia in this case is very unlikely to be the cause and is not the cause of progressive leg swelling and neurological symptoms and signs.
Urge Incontinence
Explanation
This patient most likely has urge incontinence.

In urge incontinence, patients typically have involuntary leaks, increased urinary frequency, and nocturnal incontinence either during or just after the sensation of needing to void. Symptoms are not exacerbated by increased abdominal pressure or the stress of coughing/sneezing. Bladder detrusor muscles may be overactive, leading to the unexpected release of urine. Treatments include scheduled voiding and anticholinergic medications (oxybutynin, etc.).

Stress incontinence is characterized by the involuntary leaking of urine during stress or increases in abdominal and bladder pressure, such as coughing and sneezing. Bladder pressure at these times exceeds urethral pressure, allowing urine to leak through the urethra. Urinary tract deficits are found commonly in older patients; both men and women have decreased bladder sensation, decreased contractility, and involuntary bladder contractions, which predispose them to incontinence.

Obesity, pregnancy, and vaginal births may increase the risk for stress incontinence. In such cases, the pelvic floor muscles may be insufficiently strong to support the urethra and overcome pressure of urine flowing from the bladder.

Mixed incontinence refers to the presence of symptoms of both stress and urge incontinence. It may be seen in 1/3 of patients.

Overflow incontinence refers to urinary leaks that occur due to an obstruction of urine flow. In the absence of urinary retention, post void residuals are typically elevated; normal post-void residuals in the absence of retention are less than 200 ml. His 30 ml post-void urine volume is not consistent with urinary retention. Initially, patients with urinary retention may experience dribbling after voids, straining, the sensation of a full bladder, and a constant urge to void. Prostatic hypertrophy, atonic bladders, etc. can impede urine flow. Once urine volume exceeds bladder capacity, it may spill out, causing a leak. Overflow incontinence may be distinguished from urge incontinence by urodynamic testing, and it may be treated with terazosin and finasteride.

Many medical problems and medications can contribute to incontinence. Delirium, restricted mobility, urinary infection, fecal impaction, polyuria, and medications that decrease urethral pressure (e.g., alpha blockers, neuroleptics, and benzodiazepines) or increased bladder pressure (e.g. anticholinergics, beta blockers, anti-Parkinson's medications, and bethanechol) may contribute to incontinence.

The normal rectal examination and the history of regular bowel movements make fecal impaction a less likely diagnosis in this case.
Urologic surgeon for radical nephrectomy
Explanation
The most appropriate intervention for this patient is referral to a urologic surgeon for radical nephrectomy, which is the "standard treatment for localized RCC and provides a reasonable chance for cure."1 The nephrectomy serves to diagnose, stage, and treat the cancer. "Surgical removal of the kidney is the most accurate method to definitively diagnose and to stage RCC."2

A referral to a medical oncologist for traditional cytotoxic chemotherapy is not recommended, as "none of the cytotoxic chemotherapy agents have been shown to improve survival in renal cell carcinoma."2 Immunotherapy (interleukon or interferon) is considered a reasonable addition to nephrectomy in patients with metastatic RCC, but there is no current evidence suggesting this patient has metastatic disease.

RCC is considered a radiation-resistant tumor, so external beam radiation is rarely used as a primary treatment. Radiation may have a role in palliative treatment in special circumstances.

Referral to a urologist for a retrograde pyelogram would not address the RCC. This type of imaging allows visualization of the bladder, ureters, and pelvicaliceal collecting system by administering contrast through a catheter to flow up toward the kidneys. This type of imaging may be helpful in the diagnosis of urethral strictures, trauma, and reflux, but adds no additional information and certainly no treatment value for this patient with RCC.

A referral to hospice for palliative care only suggests there are no reasonable treatments for this patient and that he is expected to die within 6 months. However, 5-year survival rates are around 66% for stage I RCC, and this patient should be offered the referral for treatment.
Bacillus Calmette-Guérin
Explanation
The correct answer is bacillus Calmette-Guérin (BCG), as this is a common intravesical treatment for patients who have either recurrent bladder cancer or multiple tumors at one time. BCG is administered to patients with bladder cancer on an outpatient basis, typically weekly for 6 weeks, but can also be given as maintenance monthly or every 6 months after initial treatment at the urologist's discretion. After treatment, bladder surveillance is extremely important, as bladder cancer recurrence rates can be as high as 50% over 5 years. Bladder cancer surveillance consists of outpatient cystoscopy and urinary cytology every 3 months for 18-24 months, every 6 months for 2 years, and then annually.

Ciprofloxacin is not the correct answer, as this is an antibiotic that is typically used to treat urinary tract, upper respiratory, and skin infections. Ciprofloxacin is available in oral and intravenous forms, but not intravesical.

Potassium chloride (KCL) is also not the correct answer. While KCL could, in fact, be administered intravesically, it is not used to treat bladder cancer. It is sometimes administered intravesically as a "potassium sensitivity test" to help with the diagnosis of interstitial cystitis. 40ml KCL solution is administered through a catheter, and then the patient's pain and urgency are rated compared to administration of plain water.

Sulfamethoxazole-trimethoprim is also not the correct answer, as this is an antibiotic that is typically used to treat urinary tract, upper respiratory, and skin infections. Sulfamethoxazole-trimethoprim is available in oral and intravenous forms, but not intravesical.

Pentosan polysulfate sodium is also not the correct answer. This medication is available in an oral form and can also be administered intravesically as a bladder instillation. It is used in both forms for the treatment of interstitial cystitis, not bladder cancer.
Prostate Cancer
Explanation
This patient's presentation is most consistent with prostate cancer. Risks associated with prostate cancer include a high-fat diet, family history, and African American ethnicity. Upon digital rectal exam (DRE), it may manifest as focal nodules or areas of induration within the prostate. Obstructive voiding symptoms can occur with prostate cancer or benign prostatic hypertrophy; however, the prostate is more likely to demonstrate the absence of the median sulcus in BPH, not nodularity, as is observed in cancer. Manifestations of metastatic and advanced prostate cancer may also include weight loss and loss of appetite, anemia, bone pain (with or without pathologic fracture, most likely of the lumbar spine), neurologic deficits from spinal cord compression, and lower extremity lymphedema secondary to lymph node metastasis.

Acute bacterial prostatitis typically presents with fever, chills, malaise, arthralgias, myalgias, perineal or prostatic pain, dysuria, and obstructive and irritative urinary tract symptoms, including frequency, urgency, dysuria, nocturia, hesitancy, weak stream, and incomplete voiding. There may also be lower abdominal or back pain and spontaneous urethral discharge. The prostate will be tender, nodular, hot, boggy, or normal-feeling on digital rectal examination in acute prostatitis. Suprapubic abdominal tenderness and an enlarged tender bladder due to urinary retention may also be present. Absence of systemic symptoms and persistence of pain for at least 3 months indicates chronic prostatitis.

Risk factors that favor the development of bladder cancer include cigarette smoking and exposure to industrial dyes or solvents. Common presenting findings include gross or microscopic hematuria and irritative voiding symptoms such as frequency and urgency. Metastasis may cause hepatomegaly, lymphadenopathy, and lymphedema associated with involvement of pelvic lymph nodes.

A form of nephrolithiasis, ureterolithiasis is caused by calculi in the ureters. It presents as abrupt, severe, colicky pain in the flank and ipsilateral lower abdomen. There is often radiation to testicles or vulvar area with intense nausea with or without vomiting. There is significant costovertebral angle tenderness; pain can move to the upper/lower abdominal quadrant coinciding with the migration of the ureteral stone. Patients typically are constantly changing body positions, such as writhing and pacing about. Tachycardia, hypertension, and microscopic hematuria are common.
Renal cell carcinoma
Explanation
Hematuria is the most common presenting sign of urinary tract cancer. Silent or painless hematuria suggests tumor or renal parenchymal disease. Renal cell carcinoma can present with flank pain, hematuria, persistent back pain, and an abdominal mass; also, it can be found incidentally on CT scan; therefore, the clinical picture points to cancer with renal cell carcinoma as the most likely diagnosis. Smoking is a risk factor for renal cell cancer. RCC is more common in men than women (2:1), and it has a peak incidence in the 6th decade of life.

Bladder cancer often presents with gross hematuria, but it is most typically painless. The left flank pain and back pain are more characteristic of RCC. Bladder cancer is the 2nd most common urologic cancer, and the mean age at diagnosis is 65 years. It is more common in men than women (2.7:1), and 98% of primary bladder cancers are epithelial malignancies (majority urothelial cell carcinomas).

Acute cystitis typically presents with irritative voiding symptoms (frequency, urgency, dysuria) and suprapubic discomfort in addition to possible hematuria. Urinalysis will show pyuria, bacteriuria, and varying degrees of hematuria. Urine cultures will show specific organisms.

Urethritis is inflammation of the urethra that presents with urethral discharge, dysuria, and itching. Urethritis is most often caused by a STD. This patient does not have a history of unprotected sexual intercourse or any other symptoms that would indicate this diagnosis.

Ureteral calculi can present with hematuria, but it also typically presents with flank or abdominal pain as well, but no abdominal mass. If the stone is in the ureter, it often causes some hydroureter with or without hydronephrosis, both of which cause some pain or discomfort. The patient has no past history of forming stones.
Renal biopsy
Explanation
This patient most likely has acute interstitial nephritis (AIN) secondary to her penicillin exposure. Of the listed choices, only renal biopsies yield information specific to acute interstitial nephritis.

Renal biopsy is the criterion standard for diagnosing AIN. Lymphocytic and plasma cell infiltrates in the peritubular areas of the interstitium are noted. However, being an invasive procedure, it is not used in all patients, especially if the condition is mild or if the patient improves rapidly after removing the offending cause.

Renal ultrasound may show slight increases in renal size and cortical echogenicity in AIN, but this may also occur with other renal conditions. A clinician may order this test to evaluate for other forms of injury (such as acute renal obstruction) in the evaluation of acute kidney injury.

24-hour urine samples are used to assess urine output, daily protein, electrolyte excretion, and creatinine clearance, a measure of renal filtering ability. Currently, calculations of creatinine clearance are made using the modification of diet in renal disease (MDRD) equation. Here, a 24-hour urine collection will tell us how well her kidneys are working, but it will not show the cause of their decline in function.

Elevated Urinary eosinophils may be found in a variety of other diseases, including pyelonephritis and prostatitis. The positive predictive value of urine eosinophils for diagnosing AIN is low (Kodner).

Gallium scans have limited predictive value for diagnosing AIN (Markowitz). Cortical necrosis (i.e., secondary to ischemia) unrelated to AIN and other diseases may cause similar patterns of uptake as AIN.

If the patient was still on the medication suspected to cause the problem, it should be discontinued and never again used. This alone may cause resolution of her illness in a couple of weeks. Her symptoms, urine output, volume status, serum creatinine, and electrolytes should be monitored to evaluate for the need for dialysis. She can be started on prednisone therapy for 2 weeks, to be tapered thereafter.
Bladder cancer
Explanation
Hematuria is the most common presenting sign of urinary tract cancer, and bright red gross hematuria is usually of lower urinary tract origin. Silent or painless hematuria suggests tumor or renal parenchymal disease; therefore, the clinical picture points to cancer, with bladder cancer as the most likely diagnosis. Smoking and exposure to industrial dyes or solvents (like in a rubber plant) are risk factors for bladder cancer. Bladder cancer is the 2nd most common urologic cancer, and the mean age at diagnosis is 65 years. It is more common in men than women (2.7:1), and 98% of primary bladder cancers are epithelial malignancies (majority urothelial cell carcinomas). Ordering cytology of the urine sample is often helpful with higher grade and stage bladder cancers. Patients can become anemic with chronic blood loss, so a CBC is justified. Diagnosis is made by cystoscopy with biopsy.

Acute cystitis typically presents with irritative voiding symptoms (frequency, urgency, dysuria) and suprapubic discomfort in addition to possible hematuria. Urinalysis will show pyuria, bacteriuria, and varying degrees of hematuria. Urine cultures will show specific organisms.

Renal cell carcinoma can present with flank pain, hematuria, persistent back pain, and an abdominal mass; also, it can be found incidentally on CT scan. RCC is more common in men than women (2:1), and it has a peak incidence in the 6th decade of life. This could be a possible option for diagnosis, but the significant history of smoking and previous work history points more toward bladder cancer.

Urethritis is inflammation of the urethra that presents with urethral discharge, dysuria, and itching. Urethritis is most often caused by a STD. This patient does not have a history of unprotected sexual intercourse or any other symptoms that would indicate this diagnosis.

Ureteral calculi can present with hematuria, but it also typically presents with flank or abdominal pain as well. If the stone is in the ureter, it often causes some hydroureter with or without hydronephrosis, both of which cause some pain or discomfort. The patient has no past history of forming stones.
Blockade of the enzymatic conversion of testosterone to dihydrotestosterone
Explanation
Benign prostatic hypertrophy (BPH) is a condition that arises as a result of proliferation of stromal cells in the periurethral glands of the prostate. Consequently, whereas cancer most commonly arises in the outer layer of the prostate, BPH is a condition associated with the inner portion or transition zone. BPH is a condition that accompanies aging. By age 60, approximately 50% of men have microscopic evidence of BPH and by age 85, about 85% of men will have BPH.

The exact cause of BPH remains unclear; however, it is most likely the result of changes in the local hormonal milieu of the prostate. Dihydrotestosterone (DHT) is produced in the prostate via conversion of testosterone by the 5-alpha reductase enzyme. DHT is known to promote stromal proliferation. It is hypothesized that elevated estrogen levels that accompany aging increase the density of DHT receptors in the prostate, leading to hyperplasia. In addition, the density of alpha-1 adrenergic receptors, which contract smooth muscle cells in the prostate, also appears to increase with age, contributing to the obstructive urinary symptoms that typically bring patients with BPH to clinical attention.

Microscopic prostatic hyperplasia in and of itself is not dangerous; there is no known association between BPH and prostate cancer. However, prostatic enlargement around the urethral canal can cause urinary outflow obstruction. Clinically, patients report urinary hesitancy, decreased force of urination, interrupted urinary stream, and a feeling of incomplete bladder emptying. Recurrent urinary tract infections may also occur because of residual urine pooling. In severe cases, hydronephrosis may result.

In patients with BPH, digital rectal examination reveals lateral and/or median lobe prostatic enlargement. However, prostate size correlates poorly with obstructive symptoms and urodynamic studies are the most useful means of quantifying the severity of BPH. Peak flow rates under 10 ml/sec and residual urine volumes of greater than 150 ml are indicators of significant obstruction.

There are 2 main categories of pharmacological agents used to treat BPH: alpha-1 adrenergic antagonists and 5-alpha reductase inhibitors. Alpha-1 adrenergic antagonists (e.g., terazosin, doxazosin, tamsulosin) relax prostatic smooth muscle by blocking the action of alpha-1 adrenergic agonists, reducing obstructive symptoms. By contrast, 5-alpha reductase inhibitors (e.g., finasteride) reduce DHT levels by blocking enzymatic conversion of testosterone. It should be noted that finasteride also lowers prostate specific antigen (PSA) levels, which may complicate the use of PSA as a screening test for prostate cancer.
Calcium
Explanation
The correct answer is calcium. Calcium stones are the most common type of renal calculi and can be further characterized as either calcium oxalate or calcium phosphate stones. Calcium oxalate stones make up about 60% and calcium phosphate stones make up about 20%, which results in calcium stones being about 80% of stones overall. Geography, fluid intake, and diet can all influence stone formation, but metabolism and genetics can also play a role. Absorptive hypercalciuria, renal hypercalciuria, and resorptive hypercalciuria can all result in calcium stone formation. Hyperuricosuria, gout, hyperoxaluria, and hypocitraturia are all other causes of calcium calculi.

Uric acid is the not the correct answer, as this is not the most common type of renal calculus. Uric acid stones make up about 10% of stones in the United States. Hyperuricosuira and/or a urinary pH less than 5.5 are the 2 most common causes of uric acid stones. Gout, increased turnover of nucleic acids (such as in polycythemia or psoriasis), increased purine intake, and alcohol consumption are all causes of hyperuricosuria and can therefore put a patient at risk for uric acid stones.

Struvite is not the correct answer, as this is not the most common type of renal calculus. Struvite stones make up about 7% of total renal calculi. Urinary tract infections secondary to the presence of urea splitting organisms can result in the formation of struvite stones. Klebsiella, Proteus, Staphylococcus, and Pseudomonoas produce urease. Urease breaks down urea and aids in the formation of ammonia. The ammonia then undergoes hydrolysis, which results in alkaline urine and reduced solubility of struvite, as well as urine that is supersaturated in struvite.

Cystine is not the correct answer, as this is not the most common form of renal calculi. Cystine stones make up about 3% of total renal calculi. Cystine stones form due to an autosomal recessive disorder in the metabolism of cystine, which leads to cystinuria. Once the urinary saturation of cystine is more than 250 mg/L, cystine stones can start to form.

Magnesium is not the correct answer, as this is not a type of renal calculi. In fact, magnesium has been known to be preventative of stone formation and is, therefore, a component in a lot of renal calculi prevention measures. Hypomagnesuria, usually dietary in nature, is a known risk factor for renal calculi formation. Maintaining urine magnesium about 50 mg/day is preventative.
Normalize weight
Explanation
This patient will benefit from lifestyle modification to normalize her body weight post-pregnancy. Dietary modifications, exercise, breastfeeding, and nutritional counseling may be helpful. She was overweight pre-pregnancy, with a BMI > 30 kg/m2. Obesity is a known risk factor for incontinence. It is also a risk factor for insulin resistance and diabetes, which may also contribute to various forms of incontinence. None of the other options listed below will help prevent incontinence; in fact, they may be risks for incontinence.

Incontinence is common in pregnancy. Fetal compression of the bladder plus large volumes of urine due to suggested volume intake and increased glomerular filtration rates may contribute to this. Postpartum, vaginal birth, and changes in the laxity/strength of the pelvic floor may contribute to stress incontinence. Stress incontinence is characterized by the involuntary leaking of urine during stress or increases in abdominal and bladder pressure, such as coughing and sneezing. Bladder pressure at these times exceeds urethral pressure, allowing urine to leak through the urethra.

Treatments for stress incontinence include pelvic floor exercises. By repeatedly contracting and relaxing the vagina and pelvic floor, leaking may decrease. In this patient's case, treating her cough with cough suppressants may additionally help with the urine leaks. In obese patients, 5 - 10% weight loss may also improve symptoms. Pessaries may be inserted into the vagina to increase urethral support. Urethral support can also be increased surgically by inserting a fascial sling or vaginal tape to support the urethra.

Smoking cessation is laudable on many accounts. It may contribute to low birth weight in the baby and is risk factor for a variety of cardiovascular diseases in the mother. It is not currently considered a risk factor for incontinence.

Episiotomy may be a risk factor for fecal incontinence, but it is not a known risk for urinary incontinence.

Oxybutynin is an anticholinergic amine used in the treatment of neurogenic bladder and overactive bladder/urge incontinence. Reports of its use during pregnancy and lactation are not available (Micromedex).

Duloxetine is used in the management of stress incontinence. It is a reuptake inhibitor of serotonin and noradrenaline. Its use is not suggested in pregnancy because it is category C and may have teratogenic effects.
Alpha-1 adrenergic antagonists
Explanation
The correct response is alpha-1 adrenergic antagonists.

Benign prostatic hypertrophy (BPH) is a condition that arises as a result of proliferation of stromal cells in the periurethral glands of the prostate. Consequently, whereas cancer most commonly arises in the outer layer of the prostate, BPH is a condition associated with the inner portion or transition zone. BPH is a condition that accompanies aging. By age 60, approximately 50% of men have microscopic evidence of BPH; by age 85, about 85% of men will have BPH.

The exact cause of BPH remains unclear; however, it is most likely the result of changes in the local hormonal milieu of the prostate. Dihydrotestosterone (DHT) is produced in the prostate via conversion of testosterone by the 5-á reductase enzyme. DHT is known to promote stromal proliferation. It is hypothesized that elevated estrogen levels that accompany aging increase the density of DHT receptors in the prostate, leading to hyperplasia. In addition, the density of alpha-1 adrenergic receptors, which contract smooth muscle cells in the prostate, also appears to increase with age, contributing to the obstructive urinary symptoms that typically bring patients with BPH to clinical attention.

Microscopic prostatic hyperplasia in and of itself is not dangerous; there is no known association between BPH and prostate cancer. However, prostatic enlargement around the urethral canal can cause urinary outflow obstruction. Clinically, patients report urinary hesitancy, decreased force of urination, interrupted urinary stream, and a feeling of incomplete bladder emptying. Recurrent urinary tract infections may also occur because of residual urine pooling. In severe cases, hydronephrosis may result.

In patients with BPH, digital rectal examination reveals lateral and/or median lobe prostatic enlargement. However, prostate size correlates poorly with obstructive symptoms and urodynamic studies are the most useful means of quantifying the severity of BPH. Peak flow rates under 10 ml/sec and residual urine volumes of greater than 150 ml are indicators of significant obstruction.

There are 2 main categories of pharmacological agents used to treat BPH: alpha-1 adrenergic antagonists and 5-alpha reductase inhibitors. Alpha-1 adrenergic antagonists (e.g., terazosin, doxazosin, tamsulosin) relax prostatic smooth muscle by blocking the action of alpha-1 adrenergic agonists, reducing obstructive symptoms. By contrast, 5-alpha reductase inhibitors (e.g., finasteride) reduce DHT levels by blocking enzymatic conversion of testosterone. It should be noted that finasteride also lowers prostate specific antigen (PSA) levels, which may complicate the use of PSA as a screening test for prostate cancer.
Wilm's tumor
Explanation The clinical picture is suggestive of Wilm's Tumor. It accounts for most renal tumors in childhood during the first 5 years of life. It affects both sexes equally. It is a solitary growth that affects either part of the kidneys. There are congenital anomalies associated with it, most commonly the GUT anomalies, hemihypertrophy, sporadic aniridia, and mental retardation. It is commonly manifested by an abdominal mass that is described as generally smooth, firm and rarely crosses the midline, and it causes abdominal pain and vomiting. Hypertension is seen in 60% of the patients either due to elaboration of renin by the tumor cells or due to compression of the renal vasculature by the tumor. Hematuria is also uncommon and mostly microscopic. CT scan confirms the diagnosis which will show an intrarenal tumor, therefore ruling out Neuroblastoma. Treatment is by surgical removal. Chemotherapy is indicated post-operatively for the residual tumor.
Neuroblastoma is a malignancy of the neural crest. It is the most common solid tumor in children outside the CNS. It is slightly more common in males and whites and median age of diagnosis is 2 years old. It arises mostly in the abdomen either in the adrenal gland or retroperitoneal sympathetic ganglia followed by the thoracic area mostly seen in the posterior mediastinum. Other sites are the head, neck, and epidural area. Tumors in the head and neck region are sometimes associated with Horner's Syndrome (Mioisis, Ptosis, Anhidrosis, and Enophthalmos). Diagnosis is by CT scan or MRI but pathologic diagnosis is made by biopsy. Tumor markers such as VMA and HVA (Homovanillic Acid) help confirm the diagnosis. Treatment is surgery, chemotherapy, and radiation depending on the stage of the tumor.

Nephroblastomatosis are immature renal elements called Nephrogenic rest. It is a Wilm's tumor precursor lesion that is both unifocal and deep within the Renal parenchyma (intralobar rest) or multi-focal (perilobar rest). Subsequent development of Wilm's tumor in the other kidney is more likely in patients with this feature; therefore prompt inspection of the contralateral kidney is necessary during surgery of the neprhogenic rest. CT scan follow-up should also be done.

Renal Cell Carcinoma is rare during the first decade of life but can occur occasionally in teenagers. Initial presentations are abdominal mass and hematuria. Surgical resection may offer cure, but prognosis is poor with post-operative residual disease.

Mesoblastic Nephroma is a massive, firm, solitary renal mass and is generally thought to be benign. It resembles Leiomyoma or low-grade leiomyosarcoma grossly and microscopically. It also accounts for the majority of congenital renal tumors. It is more often seen in males and noted to produce renin. Treatment is surgical resection.
Bed-wetting alarm system
Explanation
Bedwetting, or enuresis, is a common problem in the pediatric age group. Prevalence at the age of 5 years is 7% in males and 3% in females. At the age of 10 years the prevalence is 3% for males and 2% in females. Enuresis is divided into primary enuresis, where the child has never been dry at night, and secondary enuresis, where the child who has been continent for at least 6 months starts to wet the bed again. Primary nocturnal enuresis is associated with a smaller bladder capacity, abnormal arousal patterns during sleep, and inappropriate or inadequate toilet training. Secondary enuresis is generally precipitated by situations of psychological stress, such as a recent move, marital conflict, or a new sibling in the household. Only rarely does enuresis have an organic component and usually urological procedures are not warranted.

General treatment guidelines that patients and especially the parents should be educated on include voiding before retiring, limiting fluids prior to bedtime, and expecting older children to clean their own bedding.

More often than not the first line intervention is considered bed-wetting alarms. These have been found in multiple studies to be extremely effective in producing a long-term cure. The bed-wetting alarms are moisture-sensing devices that are placed near the child's genitals, and are activated to trigger an alarm when the child voids in bed. These alarms go off at the initial first few drops of voiding; thus awakening the child to get out of bed and finish voiding in the toilet or hold urine until later. This evokes a conditioned response of waking and inhibiting urination. They are generally recommended in children older than seven years. Therapy is recommend for at least 3 months and used every night. Parents must get up with the child to ensure the child does not just turn off the alarm and go back to sleep. If used appropriately, bed-wetting alarms are successful in 2/3 of the patients that utilize them.

Alarm therapy requires a cooperative, motivated child and family. Parental involvement plays an essential role when using alarm devices due to the consistency that is necessary. Treatment must involve education and avoidance of being judgmental and even shaming the child due to most children feeling ashamed; the goal of treatment is to help the child establish their continence and at the same time maintain or gain self-esteem.

It is recommended that children use these alarm devices until they experience three weeks of complete dryness. For complete resolution of nocturnal enuresis, the bed-wetting alarm may be needed to be used for up to 15 weeks. Relapse rates are higher when the alarm system is discontinued after shorter dry periods. Studies have shown that compared with other skill-based or pharmacologic treatments, the bed-wetting alarm has a higher success rate (75%) and a lower relapse rate.

Desmopressin and imipramine are the primary drugs used in the treatment of nocturnal enuresis but should not be considered first line interventions. Imipramine administration is only slightly less effective than the alarm systems in bringing about dryness, usually within 2 weeks. Long-term results are less promising as the enuresis tends to return while off the medication.

Desmopressin acetate typically has an excellent response over the short-term, but again, the enuresis tends to recur when the child is taken off the medication.

Fluid restriction and wearing diapers at night may resolve the consequences of the issue but will not create the behavior which will lead to the actual bedwetting from stopping; behavioral modification/training is a main key to treatment.
CT scan of abdomen and pelvis without contrast
Explanation
This patient most likely suffers from urolithiasis. These patients typically present with unilateral renal colic that often radiates to the ipsilateral groin or testis and hematuria. These patients generally cannot sit still secondary to the pain and discomfort. They can also exhibit guarding, nausea, and vomiting in some cases. A stone protocol (non-contrast) CT scan has become the standard initial workup of patients with suspected stone. This study is especially useful in the emergency department, since it can quickly and effectively diagnose urolithiasis. A CT scan gives the most information (location and size of stone, hydronephrosis, any anatomical variations, etc.) to the urologist who will likely see the patient. Stones are more common in men than women (3:1), and initial presentation is typically in the 3rd of 4th decade of life.

MRIs are used more often in assessing soft tissues; they are not typically useful in urolithiasis cases.

Ultrasound of the kidneys can reveal hydronephrosis and cystic or solid lesions. Stones can sometimes be assessed as well, but small stones are occasionally not visible.

A kidney, ureter, bladder X-ray will show approximately 90% of stones. Uric acid stones are not visible on plain film, and some stones are difficult to see because of size or location. A KUB is a viable option, but not the best study to order.

Intraveneous urogram is most useful after a thorough bowel preparation, so a non-emergent study will typically yield more information than an emergent study. However, if high-grade obstruction is suspected, emergent intervention with intraveneous urogram may be warranted. These patients can have an elevated temperature and a CT scan can show high-grade obstruction, so that is still the best initial study.
Testicular malignancy
Explanation
This patient's physical exam findings suggest testicular malignancy. In the United States, the incidence of testicular cancer in African-Americans is approximately 1/4 of that in Caucasians. Within a given race, individuals in the higher socioeconomic classes have approximately twice the incidence of those in the lower classes. Testicular cancer is slightly more common on the right side than on the left, coinciding with higher rates of right cryptorchidism. Of all acquired and congenital risk factors, cryptorchidism is the strongest associated risk factor associated with testicular cancer. Placement of the cryptorchid testis into the scrotum (orchiopexy) does not alter the malignant potential of the cryptorchid testis; however, it does facilitate examination and tumor detection.

The most common symptom of testicular cancer is a painless enlargement of the testis. Enlargement is usually gradual, and a sensation of testicular heaviness is not unusual. Acute testicular pain is seen in approximately 10% of cases, and may be the result of intratesticular hemorrhage or infarction.

Approximately 10% of patients are asymptomatic at presentation, and the tumor may be detected incidentally following trauma or by the patient's sexual partner. On physical exam, a testicular mass or diffuse enlargement is found in most cases. The mass is typically firm and nontender, and the epididymis should be easily separable from it. A hydrocele may accompany the testicular tumor and help to camouflage it. Transillumination of the scrotum can help to distinguish between these entities.

Palpation of the abdomen may reveal bulky retroperitoneal disease; assessment of supraclavicular, scalene, and inguinal nodes should be performed. Gynecomastia is present in 5% of all germ cell tumors, but may be present in 30 - 50% of Sertoli and Leydig cell tumors. Its cause seems to be related to multiple complex hormonal interactions involving testosterone, estrone, estradiol, prolactin, and hCG. Hemoptysis may be seen in advanced pulmonary disease.

Findings consistent with epididymitis are an enlarged, tender epididymis associated with fever, urethral discharge, and irritative voiding symptoms.

A translucent, fluid-filled hydrocele should be visualized by transillumination of the scrotum.

Orchitis presents with inflamed, painful, tender, and swollen testes.

A varicocele, which is an engorgement of the pampiniform plexus of veins in the spermatic cord, should disappear when the patient is in the supine position. It is frequently described as a 'bag of worms' that is separate from the testes.
bladder cancer
Hematuria is the most common presenting sign of urinary tract cancer, and bright red gross hematuria is usually of lower urinary tract origin. Silent or painless hematuria suggests tumor or renal parenchymal disease; therefore, the clinical picture points to cancer, with bladder cancer as the most likely diagnosis. Smoking and exposure to industrial dyes or solvents (like in a rubber plant) are risk factors for bladder cancer. Bladder cancer is the 2nd most common urologic cancer, and the mean age at diagnosis is 65 years. It is more common in men than women (2.7:1), and 98% of primary bladder cancers are epithelial malignancies (majority urothelial cell carcinomas). Ordering cytology of the urine sample is often helpful with higher grade and stage bladder cancers. Patients can become anemic with chronic blood loss, so a CBC is justified. Diagnosis is made by cystoscopy with biopsy.

Acute cystitis typically presents with irritative voiding symptoms (frequency, urgency, dysuria) and suprapubic discomfort in addition to possible hematuria. Urinalysis will show pyuria, bacteriuria, and varying degrees of hematuria. Urine cultures will show specific organisms.

Renal cell carcinoma can present with flank pain, hematuria, persistent back pain, and an abdominal mass; also, it can be found incidentally on CT scan. RCC is more common in men than women (2:1), and it has a peak incidence in the 6th decade of life. This could be a possible option for diagnosis, but the significant history of smoking and previous work history points more toward bladder cancer.

Urethritis is inflammation of the urethra that presents with urethral discharge, dysuria, and itching. Urethritis is most often caused by a STD. This patient does not have a history of unprotected sexual intercourse or any other symptoms that would indicate this diagnosis.

Ureteral calculi can present with hematuria, but it also typically presents with flank or abdominal pain as well. If the stone is in the ureter, it often causes some hydroureter with or without hydronephrosis, both of which cause some pain or discomfort. The patient has no past history of forming stones.
Begin volume expansion prior to the contrast study
Explanation
Mild volume expansion prior to the CT with IV contrast is recommended to prevent contrast nephropathy in higher-risk patients.1 Hydration should begin an hour or more before the procedure and continue several hours after the CT. There is evidence showing better results with NaHCO3 over regular saline (NaCl).2 This patient had several indicators of volume depletion - she was taking a diuretic and had decreased oral intake, along with potentially some fluid/blood loss with the diverticulitis, and her BP was hypotensive.

A change to metformin is not recommended for this patient. Metformin, while not nephrotoxic directly, can increase the likelihood of lactic acidosis.3 She likely has some pre-existing renal disease (diabetic nephropathy) and metformin is relatively contraindicated in this patient. Some experts recommend cessation of metformin when patients undergo contrast studies in order to decrease likelihood of contrast nephropathy.

Loop diuretics are also not recommended. These drugs can increase risk of contrast nephropathy and should be discontinued, preferably a few days prior to any contrast studies.4

Though mannitol has a role in treatment and prevention of oliguria, it is an osmotic diuretic and can increase risk of renal damage after exposure to contrast.3,5

Traditional high-osmolar iodinated contrast material carries a higher risk of contrast nephropathy than the newer low osmolar contrast materials. Risk is also dose-dependent, so a single study with a shorter exposure to a lower dose has less chance of inducing contrast nephropathy compared to repeat/multiple studies, with longer administration of high-dose.2,3,4
Explanation
Testicular cancer is the most common cancer of young men between 15 and 34 years of age and is 4.5 times more common among Caucasian men then African Americans. 12% will have a history of cryptorchidism. Tumor presents commonly as a circumscribed, nontender area of induration within the testes that does not transilluminate. However, sometimes pain may be associated with torsion of the tumor, infarction, or bleeding into the tumor. The most common complaint is a feeling of fullness or heaviness in the scrotum. In most cases the epididymis and spermatic cord feel normal. Advanced tumors are diffusely enlarged and can be rock hard. Ultrasound is a sensitive and specific test that can discriminate between testicular neoplasm and other nonmalignant disorders. Additional tests for tumor markers and staging are indicated. All patients undergo orchiectomy with close observation for early stage tumors and chemotherapy and radiation for others. Either way, the prognosis is generally excellent.

Testicular torsion will usually present with abrupt onset of acute testicular pain, swelling, and erythema. Torsion occurs because the attachments between the epididymis and the tunica vaginalis are loose, allowing the testis to twist on its vascular pedicle compromising blood flow. This is also known as the bell-clapper deformity. The cremasteric reflex is absent and lack of pain relief with gentle elevation of the affected testis is suggestive. Treatment consists of rapid surgical detorsion and fixation of the testis to the scrotal wall (orchiopexy) before irreversible testicular necrosis occurs.

Varicocele is a dilatation of the venous plexus of the spermatic cord and affects about 20% of adolescents and male young adults. A palpable mass, which feels like a 'bag of worms', can be felt above the testis. Varicoceles rarely cause pain. It is most evident in a standing position; it collapses while supine. If there is progressive discomfort or a discrepancy in testicular volume with possible effects on fertility, a urological referral for surgical repair is indicated.

Epididymitis is usually associated with a urinary tract anomaly; however, it can be caused by a virus or bacteria, it is commonly caused by Chlamydia trachomatis.

Acute epididymitis is characterized by severe pain, tenderness, and swelling of the testes. Urinalysis and culture will typically be abnormal.

Trauma may cause an overlying hematocele, swelling of the scrotum, and poor transillumination; in general, it will cause ecchymosis. Although this patient experienced precipitating trauma, there is no evidence of swelling or ecchymosis to indicate traumatic hematocele alone. Testicular trauma is usually an event that is indelibly inscribed in the memory of the victim, and it can be recited with much precision. Traumatic hematoceles are best managed with surgical exploration, evacuation, and repair of the testis.
calcium
The correct answer is calcium. Calcium stones are the most common type of renal calculi and can be further characterized as either calcium oxalate or calcium phosphate stones. Calcium oxalate stones make up about 60% and calcium phosphate stones make up about 20%, which results in calcium stones being about 80% of stones overall. Geography, fluid intake, and diet can all influence stone formation, but metabolism and genetics can also play a role. Absorptive hypercalciuria, renal hypercalciuria, and resorptive hypercalciuria can all result in calcium stone formation. Hyperuricosuria, gout, hyperoxaluria, and hypocitraturia are all other causes of calcium calculi.

Uric acid is the not the correct answer, as this is not the most common type of renal calculus. Uric acid stones make up about 10% of stones in the United States. Hyperuricosuira and/or a urinary pH less than 5.5 are the 2 most common causes of uric acid stones. Gout, increased turnover of nucleic acids (such as in polycythemia or psoriasis), increased purine intake, and alcohol consumption are all causes of hyperuricosuria and can therefore put a patient at risk for uric acid stones.

Struvite is not the correct answer, as this is not the most common type of renal calculus. Struvite stones make up about 7% of total renal calculi. Urinary tract infections secondary to the presence of urea splitting organisms can result in the formation of struvite stones. Klebsiella, Proteus, Staphylococcus, and Pseudomonoas produce urease. Urease breaks down urea and aids in the formation of ammonia. The ammonia then undergoes hydrolysis, which results in alkaline urine and reduced solubility of struvite, as well as urine that is supersaturated in struvite.

Cystine is not the correct answer, as this is not the most common form of renal calculi. Cystine stones make up about 3% of total renal calculi. Cystine stones form due to an autosomal recessive disorder in the metabolism of cystine, which leads to cystinuria. Once the urinary saturation of cystine is more than 250 mg/L, cystine stones can start to form.

Magnesium is not the correct answer, as this is not a type of renal calculi. In fact, magnesium has been known to be preventative of stone formation and is, therefore, a component in a lot of renal calculi prevention measures. Hypomagnesuria, usually dietary in nature, is a known risk factor for renal calculi formation. Maintaining urine magnesium about 50 mg/day is preventative.
Most often, hyponatremia is due to excessive water retention rather than a true sodium deficiency.
The first step in evaluating hyponatremia is to determine serum osmolality. Knowing whether the serum is isotonic (normal osmolality), hypotonic (low osmolality), or hypertonic (high osmolality) can help determine the etiology of the hyponatremia, and therefore, treatment.

The most common causes of isotonic hyponatremia are hyperproteinemia and hyperlipidemia.

The most common causes of hypertonic hyponatremia are hyperglycemia, presence of radiocontrast agents, and the presence of inactive metabolites, that is, mannitol, sorbitol, glycerol, and maltose. Treatment is aimed at correcting the underlying disorder.

Most commonly, hyponatremia occurs in the setting of low osmolality (hypotonic). To further evaluate the etiology of the hyponatremia, it must be determined if the patient is hypovolemic, euvolemic, or hypervolemic.
Hypovolemic hyponatremia is usually due either to extrarenal or intrarenal sodium losses. Extrarenal losses occur from dehydration, diarrhea, and vomiting. Urinary sodium measures <10 mEq/L (normal, >20 mEq/L), as the kidneys are avidly retaining sodium in an attempt to restore volume.
Treatment is directed at restoring volume.

Intrarenal sodium losses occur from the use of diuretics and ACE inhibitors, nephropathies, and mineralocorticoid deficiency. Urinary sodium measures >20 mEq/L. Treatment is directed at reversing the underlying cause.

The most common causes of euvolemic hyponatremia are SIADH, postoperative hyponatremia, hypothyroidism, psychogenic polydipsia, and endurance exercise. In these cases, electrolyte-free water is retained, which results in a true physiologic hyponatremia. Treatment is directed at correcting the underlying abnormality and replacing sodium losses.

Hypervolemic hyponatremia is caused by congestive heart failure, liver disease, nephrotic syndrome, and advanced CKD in general, anything that causes fluid retention. Treatment is directed at treating the underlying disease, restricting water intake, and facilitating excretion of water.