Renal and GU presentations

Question 1

A 65-year-old male smoker with diabetes mellitus, hypertension, dyslipidaemia, and chronic kidney disease presents with chest pain. ECG changes suggest an acute myocardial infarction. He is taken for an urgent coronary angiogram. Three days later, he is noticed to have developed an elevated serum creatinine, oliguria, and hyperkalaemia.

Answer 1

Acute Kidney Injury

Question 2

A 45-year-old man presents to the emergency department with a 1-hour history of sudden onset of left-sided flank pain radiating down towards his groin. The patient is writhing in pain, which is unrelieved by position. He is nauseous and has been vomiting.

Answer 2

Nephrolithiasis

Question 3

A 54-year-old man with a 10-year history of diabetes and hypertension, with complications of diabetic retinopathy and peripheral neuropathy, presents to his primary care physician with complaints of fatigue and weight gain of 4.5 kg over the past 3 months. He denies any changes in his diet or glycaemic control but does state that he has some intermittent nausea and anorexia. He states that he has noticed that his legs are more swollen at the end of the day but improve with elevation and rest. Physical examination reveals an obese man with a sitting blood pressure of 158/92 mmHg.

Answer 3

Chronic Kidney Disease

Question 4

A 60-year-old man presents to his primary care physician with a 3-month history of increasing urinary frequency without burning and nocturia 3 times each evening. He has limited his fluid consumption and caffeine intake in the evening without much benefit. Examination demonstrates no suprapubic mass or tenderness. A rectal examination demonstrates normal rectal tone and a moderately enlarged prostate without nodules or tenderness.

Answer 4

Benign Prostatic Hyperplasia

Question 5

A 72-year-old man presents with a 6-month history of weak stream, straining, and hesitancy. There is no history of prostate cancer. The physical examination demonstrates a severely enlarged prostate without nodules. There is moderate suprapubic fullness prior to voiding

Answer 5

Benign prostatic hyperplasia

Question 6

A 34-year-old woman who is otherwise healthy has had a fever, nausea, and right-sided back pain for 2 days. The physical examination shows a temperature of 39.0ºC, blood pressure of 120/60 mm Hg, pulse of 110, respiratory rate of 18, and right-sided costovertebral angle tenderness to percussion. Dipstick urinalysis is positive for leukocytes, nitrites, and blood.

Answer 6

Acute pyelonephritis

Question 7

A 60-year-old woman presents with a long history of poorly controlled type 2 diabetes mellitus, musculoskeletal pains attributed to fibromyalgia, and depression. She has been seen several times with a variety of vague complaints; today, she states that she has lost her appetite and has been feeling feverish. Her lower back is bothering her more than ever, especially on the right, and her usual pain medication is not helping. Temperature is 38°C (100.5°F), weight is 3.6 kg (8 lb) lower than on her last visit, and physical examination is remarkable for right costovertebral angle tenderness.

Answer 7

Chronic pyelonephritis

History of poorly controlled T2DM - RF for UTI

Lower back pain localised to the right could be a sign of kidney involvement

Costovertebral angle tenderness –> Pyelonephritis

Question 8

A 76-year-old male with diabetes with known incomplete bladder emptying due to benign prostatic obstruction presents with haematuria, suprapubic pain, frequency, and urgency with associated fever.

Answer 8

Acute Cystitis (with urinary retention)

Question 9

A 24-year-old man presents with copious urethral discharge 4 days after having unprotected sex with a new partner. He is HIV-negative but has a history of prior STD treatments.

Answer 9

Urethritis

Question 10

A 20-year-old woman presents with vaginal discharge, dysuria, and dyspareunia. Her last sex partner got “a shot and some antibiotics”, but she is not sure for what. She “sometimes” uses condoms.

Answer 10

Urethritis

Question 11

A 21-year-old man presents with a 3-day history of worsening left-sided scrotal pain and swelling. He reports noticing a white urethral discharge over the last 24 hours. He is otherwise fit and well, and takes no regular medicine. He is heterosexual and has a single female partner, with whom he has unprotected intercourse.

Answer 11

Examination reveals a tender, erythematous, swollen left hemiscrotum with a palpably thickened epididymis

Epididymo-orchitis -

As there is urethal discharge - most likely due to N.gonnorhoea/C.trachomatis

Question 12

A 30-year-old man presents with a 3-day history of a progressively diminishing urinary stream, dysuria, and urinary frequency. He considers there is no possibility of a sexually transmitted infection. He is sufficiently ill with malaise and chills to require hospital admission. On examination, he is febrile with a temperature of 38.5°C (101.3°F).

Answer 12

Digital rectal examination reveals a tender, boggy, and slightly enlarged prostate.

Prostatitis

Question 13

A 40-year-old man presents with a recent history of dysuria and genital and perineal pain. He has felt feverish and unwell intermittently but has not previously sought medical attention.

Answer 13

Digital rectal examination reveals an enlarged, soft-feeling, and tender prostate.

Prostatitis
(Should kind of know from genital and perineal pain with dysuria?) - but otherwise add above)

Question 14

An otherwise healthy 22-year-old Japanese-American man presents with visible haematuria accompanied by flank pain. He has a 2-day history of sore throat, fever, chills, malaise, and headache. Physical examination reveals erythema and inflammation of the uvula and pharynx, enlarged tonsils with patchy greyish-white exudates, and tender anterior cervical lymphadenopathy. The rest of the examination is normal. Urinalysis shows cola-coloured urine with haematuria and 3+ protein.

Answer 14

IgA Nephropathy - 2 day history of sore throat

(Post strep glomerulonephritis - 2-4 weeks)

Question 15

A 35-year-old man with no past medical history presents to the emergency department after he noted cola-coloured urine. He denies pain or fever associated with the blood in the urine, but has had a sore throat for the past 3 days, which is getting better. He has not had a similar episode previously. Examination reveals a non-blanching purpuric rash over both his legs. There are no other abnormalities.

Answer 15

Glomerulonephritis

Non blanching purpuric rash suggests - henoch schnolein purpura which can cause inflammation of the blood vessels of the kidneys

As a result it could be leaning to IgA nephropathy more than other nephritic diseases

Question 16

A 52-year-old man presents to his physician complaining of one week of progressively worsening weakness, anorexia, malaise, cough, and dark urine. He reports feeling bad for the past few weeks and thought that he was simply recovering slowly from an upper respiratory tract infection. Over the past two days he has been alarmed to notice small amounts of blood in his sputum. He has been having some shortness of breath. He has no prior personal or family history of renal disease. He has been a smoker for 30 years and he smokes a packet of cigarettes a day. He works as a car mechanic.

Answer 16

Good pasture’s disease

Haemoptysis + Dark urine (haematuria)

Renal + lung pathology = good pasture’s

Question 17

A 5-year-old boy presents with a short history of facial oedema that has now progressed to total body swelling involving the face, abdomen, scrotum, and feet. Other symptoms include nausea, vomiting, and abdominal pain. The parents report that the child had a viral illness with fever a few days before the development of the swelling

Answer 17

Minimal change disease (nephrotic syndrome)

Age
- Progressive oedema
- Nausea, vomiting - due to fluid overload

Question 18

A 42-year-old white man with no previous medical history presents to his primary care physician with progressively increasing oedema of both lower extremities. The patient has pitting pedal oedema rated as 3+ (5 mm oedema, pit formed on palpation is deep and lasts >1 minute). Urinalysis reveals marked proteinuria (3+).

Answer 18

Nephrotic syndrome

Difficult to tell apart between focal segmental glomerulosclerosis and membranous nephropathy

(BMJ - Focal segmental glomerulosclerosis)

Question 19

A 48-year-old man presents to his family doctor with a recent lower-extremity swelling that is gradually worsening. Over the last few weeks, he has also noticed puffiness under his eyes. A urinalysis demonstrates significant proteinuria, and a 24-hour urine collection confirms proteinuria of 12 g. He has no history of diabetes mellitus, macroscopic haematuria, or hypertension.

Answer 19

Nephrotic syndrome

Difficult to tell apart between focal segmental glomerulosclerosis and membranous nephropathy

(BMJ - membranous nephropathy)

Question 20

A thin 65-year-old man with no significant past medical history presents with a 5-month history of right-sided flank discomfort and abdominal fullness. He finally seeks medical attention because of 2 weeks of lower extremity oedema, and 4 days of gross haematuria with clots. On examination, his blood pressure is 160/90 mmHg, heart rate is 120 bpm and regular, and he is afebrile. He is found to have a palpable right-sided lower abdominal mass, and pitting oedema to the mid-shins bilaterally, which is worse on the right.

Answer 20

Renal cell carcinoma

5 month history (Chronic) - flank discomfort and abdominal fullness - can indicate renal mass

Lower extremity oedema - could be due to IVC compression or obstruction due to a tumour or thrombus formation (complication of RCC)

Gross haematuria with clots - visible blood in urine –> RCC

Hypertension - due to increased renin

Palpable right sided mass.

Question 21

A 64-year-old retired painter presents with painless haematuria. He had a similar episode 1 year ago and was given antibiotics for a presumed urinary infection and his bleeding resolved. He has a decreased urinary stream and nocturia twice a night. He has smoked a pack of cigarettes daily for 45 years.

Answer 21

Bladder cancer

Question 22

0-year-old black man presents to his general practitioner with complaints of difficulty with urination. He describes a weak stream and a sense of incomplete voiding. He describes nocturia (5 episodes per night) and has been taking an alpha-blocker for this with minimal improvement. He says he can last about 60-90 minutes without urinating. He denies any suprapubic tenderness, dysuria, or haematuria. He further denies any back pain or gastrointestinal complaints. Rectal examination reveals his prostate to be approximately 60 mL, asymmetrical, with a large 2-cm nodule at the right base.

Answer 22

Prostate cancer

Question 23

A 35-year-old man presents with non-specific testicular discomfort and the feeling of a mass in the testis. On examination, a 2 cm by 1 cm smooth, painless mass is palpated in the right testis. The mass does not transilluminate with light. There is no lymphadenopathy.

Answer 23

Testicular cancer- mass

Varicocele usually described as a bag of worms (also usually on the left side)

Question 24

A 30-year-old healthy man presents with primary infertility. He has been unable to establish a pregnancy for the last 12 months with his partner. On physical examination, a scrotal mass that feels like a bag of worms is easily palpable when the patient is standing and is non-palpable when supine. The testicles are symmetrical and normal in size.

Answer 24

Varicocele

Question 25

A 12-month-old boy presents to his primary care physician with a right scrotal mass. The mass is smaller in the morning than in the evening and increases significantly in size during crying. It gets smaller again when he is lying down. He has no gastrointestinal or urinary symptoms. Physical examination demonstrates normal findings on the left side of the scrotum and a non-tender soft swelling on the right side. The mass is transilluminated when a light is shone on the scrotum.

Answer 25

Hydrocele

Question 26

A 13-year-old boy developed sudden-onset unilateral scrotal pain that woke him from sleep. He presents with left scrotal pain, nausea and vomiting, and left lower abdominal pain. On examination, he has a tender, enlarged, high-riding left testicle with a transverse lie. There is an absent cremasteric reflex on the left.

Answer 26

Testicular torsion

Question 27

A 40-year-old multiparous female presents to her primary care physician with a 10-year history of urinary leakage associated with coughing or sneezing. Urinary leakage began shortly after her third vaginal delivery and has gradually become more frequent. It also occurs during physical exertion and during intercourse. She is greatly embarrassed by this problem and has limited her social activities as a result

Answer 27

Urinary incontinence (Stress incontinence)

Question 28

A 68-year-old man presents to the emergency department complaining of an inability to urinate during the previous 12 hours. He has severe lower abdominal pain. Prior to this, he noted a weaker force of urinary stream, difficulty in starting his urinary stream, and frequent episodes of waking at night to pass urine. On examination, he has lower abdominal distention, which is dull to percussion.

Answer 28

Obstructive uropathy/urinary retention –> loss of ability/weaker ability to pass urine even when bladder is full

Dullness to percussion - fluid filled bladder