Genitourinary
System Exam
Master:
Questions &
Answers for
Nursing &
Medical Review
,Question 1:
Question
Glomerular damage inflicted in a patient with Goodpasture's disease is best described by which of
the following?
Correct Answer:
Correct answer:
Auto-antibodies are produced against glomerular basement membrane
Explanation
In Goodpasture's disease, autoantibodies (IgG) are produced against basement membrane antigen (type IV
collagen). Simultaneous pulmonary hemorrhage and glomerulonephritis due to autoantibody deposition in pulmonary
and glomerular basement membrane is known as Goodpasture's syndrome.
Question 2:
Case Ico-delete Highlights
A 55-year-old woman presents with a 2-month history of gross hematuria. She states she has no
pain with urination, but the hematuria is persistent. Upon questioning, she states that she does have
some progressively worsening left flank pain. The pains are not debilitating, but they are nagging.
She has no chronic medical problems. She admits to a 50 pack-year smoking history, and she states
she is currently retired from her job as a teacher. Vital signs are within normal limits, and physical
exam reveals a left side abdominal mass. Urine dipstick only shows too numerous to count RBCs,
and urine cultures are negative.
Question
What test would best confirm your diagnosis?
Correct Answer:
Correct answer:
CT scan with and without contrast kidney protocol
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. So the clinical picture points to cancer, with renal
cell carcinoma as the most likely diagnosis. The study of choice to evaluate the kidneys for masses is a CT scan with
and without contrast kidney protocol. Any mass that enhances with IV contrast should be considered RCC until
proven otherwise.
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 second most common urologic cancer, and the mean age at
diagnosis is 65. It is more common in men than women (2.7:1), and 98% of primary bladder cancers are epithelial
malignancies (majority urothelial cell carcinomas). A cystoscopy is the diagnostic study of choice for suspected
bladder cancer.
An MRI can help differentiate between a cyst and a solid lesion, but it is not the best study for suspected RCC.
A KUB can often miss some smaller solid lesions in the kidney, as can an IVP, especially if the lesion is not located in
the renal collecting system. These are both useful in imaging stones.
The correct workup for hematuria includes both upper and lower urinary tract studies. Ideally, a patient would get
both a CT scan with and without contrast kidney protocol and a cystoscopy, but you are looking for different things
with each of these studies; in this patient, a CT scan is more likely to confirm your diagnosis.
Question 3:
Case
A 5-year-old boy presents with history of low-grade fever, headache, and intermittent colicky pain in
the abdomen, which has been localized mainly around the umbilicus since yesterday. The child has
,vomited once. His symptoms are also accompanied by a maculopapular rash that is more confluent
over the lower extremities and the buttocks. There is no itching. The rash is a purplish-red color.
Both knees and ankles are swollen and tender, and there is edema of the hands and feet mainly in
the dependent areas. Examination of the cardiovascular, respiratory system, and abdominal
examination are essentially normal.
Laboratory investigations show:
Hb. - 10gm%, WBC. 11,000/cmm
Platelet count - 550,000/cmm
Serum IGA - 500 mg /dL (normal 14-159 mg/dLfor 2-5 years age group)
Urine - Proteinuria++, RBCs++
Stool - RBC+
Question
What is the most likely diagnosis?
Correct Answer:
Correct answer:
Henoch-Scholein purpura
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, often referred to 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. Central nervous system 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 the 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 the 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 Henoch-Schonlein purpura, 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.
Question 4:
Case
A 47-year-old Caucasian woman presents for evaluation of acute abdominal pain. She was brought
in by her son, who reports the patient had not been eating or drinking well for several days. Further
history, exam, and imaging studies were performed. The patient was pre-hydrated with sodium
bicarbonate, had an abdominal CT with IV contrast, and was later admitted to the medical floor with
a provisional diagnosis of diverticulitis.
Her past medical history is significant for diabetes mellitus, which was diagnosed 12 years ago, and
hypertension. Both conditions were reported to have been under good control. Her medications
include regular and long-acting insulin and hydrochlorothiazide/lisinopril 25/20 mg QD. She has
recently been taking 800mg ibuprofen BID-TID for her abdominal pain during the last week. She has
no known allergies.
While in the hospital, the patient's laboratory results are followed daily. 2 days after the CT with
contrast, it is noted that her serum creatinine has risen to a level of 3.5 mg/dL. Records from 1
month ago at her family physician showed her labs to include a hemoglobin A1C of 6.8%, creatinine
of 1.2 mg/dL, GFR of > 60 mL/min/1.73 m2, and blood pressure of 127/78 mm Hg.
Question
Which of the following is a major risk factor for this patient's sudden decline in renal function?
Correct Answer:
Correct answer:
Diabetes mellitus
Explanation
Diabetes mellitus is a major risk factor for renal impairment after administration of IV contrast. In one study, DM had
an odds ratio of 5.47 for development of contrast nephropathy.
A baseline GFR > 60 mL/min/m2 estimates nearly normal creatinine clearance. Individuals with significantly reduced
GFRs are at high risk for contrast nephropathy. Because creatinine clearance is inversely related to the creatinine
level, this patient's lower creatinine level also supports less risk for the contrast nephropathy. However, it was not
enough to offset the risk from her diabetes.
Caucasian race is not considered a major risk factor in developing contrast nephropathy. Race is not a major factor in
the development of contrast nephropathy. However, if any race is implicated for higher risk, it would be African
Americans.
Pre-hydration with sodium bicarbonate is a means of reducing risk, rather than a major risk factor, for contrast
nephropathy. Pre-hydration seems to confer a protective effect, preventing hypotension and decreased renal blood
flow. The sodium bicarbonate has been suggested in many studies to be more effective than traditional saline
System Exam
Master:
Questions &
Answers for
Nursing &
Medical Review
,Question 1:
Question
Glomerular damage inflicted in a patient with Goodpasture's disease is best described by which of
the following?
Correct Answer:
Correct answer:
Auto-antibodies are produced against glomerular basement membrane
Explanation
In Goodpasture's disease, autoantibodies (IgG) are produced against basement membrane antigen (type IV
collagen). Simultaneous pulmonary hemorrhage and glomerulonephritis due to autoantibody deposition in pulmonary
and glomerular basement membrane is known as Goodpasture's syndrome.
Question 2:
Case Ico-delete Highlights
A 55-year-old woman presents with a 2-month history of gross hematuria. She states she has no
pain with urination, but the hematuria is persistent. Upon questioning, she states that she does have
some progressively worsening left flank pain. The pains are not debilitating, but they are nagging.
She has no chronic medical problems. She admits to a 50 pack-year smoking history, and she states
she is currently retired from her job as a teacher. Vital signs are within normal limits, and physical
exam reveals a left side abdominal mass. Urine dipstick only shows too numerous to count RBCs,
and urine cultures are negative.
Question
What test would best confirm your diagnosis?
Correct Answer:
Correct answer:
CT scan with and without contrast kidney protocol
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. So the clinical picture points to cancer, with renal
cell carcinoma as the most likely diagnosis. The study of choice to evaluate the kidneys for masses is a CT scan with
and without contrast kidney protocol. Any mass that enhances with IV contrast should be considered RCC until
proven otherwise.
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 second most common urologic cancer, and the mean age at
diagnosis is 65. It is more common in men than women (2.7:1), and 98% of primary bladder cancers are epithelial
malignancies (majority urothelial cell carcinomas). A cystoscopy is the diagnostic study of choice for suspected
bladder cancer.
An MRI can help differentiate between a cyst and a solid lesion, but it is not the best study for suspected RCC.
A KUB can often miss some smaller solid lesions in the kidney, as can an IVP, especially if the lesion is not located in
the renal collecting system. These are both useful in imaging stones.
The correct workup for hematuria includes both upper and lower urinary tract studies. Ideally, a patient would get
both a CT scan with and without contrast kidney protocol and a cystoscopy, but you are looking for different things
with each of these studies; in this patient, a CT scan is more likely to confirm your diagnosis.
Question 3:
Case
A 5-year-old boy presents with history of low-grade fever, headache, and intermittent colicky pain in
the abdomen, which has been localized mainly around the umbilicus since yesterday. The child has
,vomited once. His symptoms are also accompanied by a maculopapular rash that is more confluent
over the lower extremities and the buttocks. There is no itching. The rash is a purplish-red color.
Both knees and ankles are swollen and tender, and there is edema of the hands and feet mainly in
the dependent areas. Examination of the cardiovascular, respiratory system, and abdominal
examination are essentially normal.
Laboratory investigations show:
Hb. - 10gm%, WBC. 11,000/cmm
Platelet count - 550,000/cmm
Serum IGA - 500 mg /dL (normal 14-159 mg/dLfor 2-5 years age group)
Urine - Proteinuria++, RBCs++
Stool - RBC+
Question
What is the most likely diagnosis?
Correct Answer:
Correct answer:
Henoch-Scholein purpura
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, often referred to 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. Central nervous system 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 the 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 the 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 Henoch-Schonlein purpura, 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.
Question 4:
Case
A 47-year-old Caucasian woman presents for evaluation of acute abdominal pain. She was brought
in by her son, who reports the patient had not been eating or drinking well for several days. Further
history, exam, and imaging studies were performed. The patient was pre-hydrated with sodium
bicarbonate, had an abdominal CT with IV contrast, and was later admitted to the medical floor with
a provisional diagnosis of diverticulitis.
Her past medical history is significant for diabetes mellitus, which was diagnosed 12 years ago, and
hypertension. Both conditions were reported to have been under good control. Her medications
include regular and long-acting insulin and hydrochlorothiazide/lisinopril 25/20 mg QD. She has
recently been taking 800mg ibuprofen BID-TID for her abdominal pain during the last week. She has
no known allergies.
While in the hospital, the patient's laboratory results are followed daily. 2 days after the CT with
contrast, it is noted that her serum creatinine has risen to a level of 3.5 mg/dL. Records from 1
month ago at her family physician showed her labs to include a hemoglobin A1C of 6.8%, creatinine
of 1.2 mg/dL, GFR of > 60 mL/min/1.73 m2, and blood pressure of 127/78 mm Hg.
Question
Which of the following is a major risk factor for this patient's sudden decline in renal function?
Correct Answer:
Correct answer:
Diabetes mellitus
Explanation
Diabetes mellitus is a major risk factor for renal impairment after administration of IV contrast. In one study, DM had
an odds ratio of 5.47 for development of contrast nephropathy.
A baseline GFR > 60 mL/min/m2 estimates nearly normal creatinine clearance. Individuals with significantly reduced
GFRs are at high risk for contrast nephropathy. Because creatinine clearance is inversely related to the creatinine
level, this patient's lower creatinine level also supports less risk for the contrast nephropathy. However, it was not
enough to offset the risk from her diabetes.
Caucasian race is not considered a major risk factor in developing contrast nephropathy. Race is not a major factor in
the development of contrast nephropathy. However, if any race is implicated for higher risk, it would be African
Americans.
Pre-hydration with sodium bicarbonate is a means of reducing risk, rather than a major risk factor, for contrast
nephropathy. Pre-hydration seems to confer a protective effect, preventing hypotension and decreased renal blood
flow. The sodium bicarbonate has been suggested in many studies to be more effective than traditional saline
