Renal Question Set 2

A 70-years-old man presents with a history of painful micturition for 2 weeks. He is afebrile. On cystoscopy, a slightly erythematous area of 1.5 cm in diameter is seen on the mucosa of the bladder. The biopsy of this area has been sent and microscopic examination shows cells with increased nuclear/cytoplasmic ratio and marked hyperchromatism, involving the full thickness of the epithelium, but above the basement membrane. Which of the following best describes the biopsy findings mentioned above?

A 53-year-old female presents with acute respiratory distress. Physical examination reveals bilateral crepitations. Her vitals include blood pressure of 70/40 mm Hg, pulse 92/min, and SpO2 is 92%. Her urine output was found to be 400 ml for the past 24 Hrs. Urinalysis reveals oliguria and muddy brown granular casts. The fractional excretion of sodium is found to be < 20. Her past medical history includes myocardial infarction 2 years ago for which she underwent coronary bypass. The most likely cause for the present condition is?

A 47-year-old female presents with complaints of fever, with chills and rigors. She further complains of left side costovertebral tenderness. Vitals include a temperature of 103°F, BP of 125/ 84 mmHg, and pulse of 84/min. She is a diabetic for which she is taking metformin. Dipstick analysis is positive of leucocytes, nitrites, and blood. The most likely cause for the present condition is?

A 36-year-old female presents with increased tiredness and lethargy for the past 4 weeks. Investigations show her hemoglobin level to be 8.6 gm%, and serum creatinine of 4.6 mg/dL. Serum is negative for ANA and positive for C3 nephritis factor. Urinalysis shows a 3+ proteinuria. Renal biopsy shows hypercellular glomerulus with electron dense deposits along the glomerular basement membrane. What is the most likely cause?

A 53-year-old female presents with severe headache, nausea and vomiting for the past 48 hrs. Vitals show a BP of 220/ 134mm Hg, pulse of 88/ min. Urinanalysis shows a 2+ proteinuria and RBC casts. Which of the following renal lesions is most likely seen?

A 68-year-old male presents to his primary care physician with the complaints of increased fatigue and back pain for the past one year that has been progressively getting worse over the past few months despite adequate rest and trial of over the counter analgesics. His back pain is constant and present throughout the day. There is no radiation. He denies any trauma to his back. His past medical history is insignificant. On examination, there is mild tenderness over lumber region in the midline with an absence of paraspinal muscle tenderness. Straight leg raise test is negative. His skin and conjunctiva appear pale. The physician orders basic blood work. Reports are given below. Complete blood count: Hemoglobin: 9.8 g/dL Red blood cell: 4.9 million cells/µL Hematocrit: 41 % Total leukocyte count: 6800 cells/µL Neutrophils: 70 % Lymphocyte: 26 % Monocytes: 3 % Eosinophil: 1% Basophils: 0% Platelets: 230000 cells/µL Basic Metabolic Panel: Sodium: 136 mEq/L Potassium: 5.1 mEq/L Chloride: 101 mEq/L Bicarbonate: 24 mEq/L Albumin: 3.6 mg/ dL Urea nitrogen: 31 mg/dL Creatinine: 2.7 mg/dL Uric Acid: 6.7 mg/dL Calcium: 10.1 mg/dL Glucose: 105 mg/dL Urinalysis shows proteinuria without any RBCs or pus cells. The patient’s proteinuria best fits in which of the following category?

A 49-year-old female presents to the office for a follow-up visit. She was diagnosed with cirrhosis of liver a year ago and currently is under symptomatic treatment with complete abstinence from alcohol. She does not have any complaints at the moment. She has a past history of gout for 4 years which has been asymptomatic under medication. She is currently taking Spironolactone and Probenecid. She takes a diet rich in protein. Physical examination shows mild ascites with no palpable organs in the abdomen. A complete blood examination reveals normal findings while a basic metabolic panel with renal function shows: Sodium: 141 mEq/L Potassium: 5.1 mEq/L Chloride: 101 mEq/L Bicarbonate: 22 mEq/L Albumin: 3.4 mg/dL Urea nitrogen: 4 mg/dL Creatinine: 1.2 mg/dL Uric Acid: 6.8 mg/dL Calcium: 8.9 mg/dL Glucose: 111 mg/dL Which of the following explains here blood urea nitrogen value?

A 39-year-old female is brought to the emergency department in a semi-unconscious state by her neighbor who saw her passing out. There is no apparent injury on a primary survey. She isn’t taking any medications currently and was recently having loose stools for the past 3 days. She also mentions decreased frequency of urination. No further history is attainable. Her vital signs are blood pressure: 94/62 mmHg, temperature: 98 °F, pulse: 105/min and respiratory rate: 10/min. Her skin appears dry. Blood investigation is sent which comes out normal. Basic Metabolic Panel shows: Sodium: 138 mEq/L Potassium: 5.1 mEq/L Chloride: 103 mEq/L Bicarbonate: 24 mEq/L Albumin: 3.6 mg/ dL Urea nitrogen: 41 mg/dL Creatinine: 2.5 mg/dL Uric Acid: 6.8 mg/dL Calcium: 12.1 mg/dL Glucose: 108 mg/dL Routine urine analysis, renal function test, urine osmolality and urine electrolytes are sent for and reports are pending. Which of the following lab abnormalities would be expected in in this patient?

A 41-year-old male comes to the office for a regular health check-up. He doesn’t have any complaints during this visit. He doesn't have a history of any significant illness in the past. He currently takes Omeprazole for his Acid-Peptic disease. He is an occasional smoker and drinker. His family history is not significant. Vital signs include a blood pressure of 133/67 mmHg, pulse of 67/min, respiratory rate of 15/min and a temperature of 98 °F. His physical examination is within normal limits. A complete blood count reveals normal lab values. A urinalysis was ordered which shows: pH: 6.7 Color: light yellow RBC: none WBC: none Protein: absent Cast: hyaline casts Glucose: absent Crystal: none Ketone: absent Nitrite: absent Which of the following is the likely etiology for hyaline cast in this case?

A 34-year-old man presents to the clinic with the complaint of abdominal discomfort and blood in urine for 2 days. He has had a similar complaint of recurrent abdominal discomfort in the past for 5 years though, he doesn't remember passing any blood in urine. He has hypertension for the past 2 years and is under medication for the same duration. There is no history of weight loss, skin rashes, joint pain, vomiting, change in bowel habit, smoking. On examination, there are bilateral ballotable flank masses. Bowel sounds are normal. Renal function report shows: Urea: 50 mg/dL Creatinine: 1.4 mg/dL Protein: negative RBC: plenty The patient undergoes a ultrasonography of his abdomen which reveals multiple anechoic cysts with well defined walls and both kidneys are enlarged. Computed tomography scan confirms the presence of multiple cysts in the kidney. What is this patient most likely to be suffering from?

A 46-year-old male presents to the clinic with the complaint of intermittent flank pain on both sides for 5 days. The pain is colicky in nature and radiates to the groin. The patient took a medication from his old prescription labeled Hyoscyamine and got some relief. He has nausea but hasn't vomited until now. Although he has a history of renal stones in the past he denies any blood in his urine or stool and gives no history of fever or changes in his bowel habit and abdominal distension. He doesn't have joint pain. On examination of the abdomen, the is no organomegaly and bowel sounds are normal. His blood test report reveals: Serum Calcium: 8.9 mg/dL Serum uric acid: 4.5 mg/dL Serum creatinine: 1.1 mg /dL Urinalysis shows: pH: 6.0 Pus cells: none Red blood cells: 1-2/HPF Epithelial cell: 1/HPF Protein: negative Ketones: negative Crystals: oxalate (plenty) An ultrasonography shows echogenic medullary pyramid with multiple dense echogenic foci, in both kidneys,casting posterior acoustic shadow. Which of the following best describes the pathogenesis of the disease process?

A 31-year-old male presents to the office with the complaints of multiple episodes of blood in his urine and coughing of blood for the past 3 days. He also gives a history of decreased frequency of urination. He denies pain with urination or waking up frequently at night to go to the washroom. No previous similar symptoms or significant past medical history is noted. There is no history of bleeding disorders in his family. His vitals are blood pressure: 142/88 mmHg, pulse: 87/min, temperature: 98.2 °F and respiratory rate: 11/min. On examination, chest auscultation reveals normal vesicular breath sounds with no added sounds. Abdominal exam is normal. Complete blood count shows: Hemoglobin: 12 g/dL Red blood cell: 4.9 million cells/µL Hematocrit: 48 % Total leukocyte count: 6800 cells/µL Neutrophils: 70 % Lymphocyte: 25 % Monocytes: 4 % Eosinophil: 1 % Basophils: 0 % Platelets: 200000 cells/µL A routine urine examination is sent which shows: pH: 6.2 Color: dark brown RBC: 18-20/HPF WBC: 3-4/HPF Protein: 1+ Cast: RBC casts Glucose: absent Crystal: none Ketone: absent Nitrite: absent 24 hr Urine Protein excretion: 1.3 g A renal biopsy under light microscopy shows crescent formation composed of fibrin and macrophages. Which of the following best describes the indirect immunofluorescence finding in this condition?

A 45-year-old Caucasian male presents to the office with the complaints of facial puffiness and mild swelling in his back. He gives no history of chest pain, blood in urine or fever. He was recently diagnosed with colon cancer. His vitals are blood pressure: 122/78 mmHg, pulse: 76/min, temperature: 98.4 °F and respiratory rate: 10/min. On examination, there is mild facial puffiness pitting in nature and presacral edema. His other systemic findings are within normal limits. Urinalysis shows: pH: 6.2 Color: light yellow RBC: none WBC: 3-4/HPF Protein: 4+ Cast: oval fat bodies Glucose: absent Crystal: none Ketone: absent Nitrite: absent 24 hr Urine Protein excretion: 4.8 g A renal biopsy is ordered and diffuse capillary and basement membrane thickening is noted. Which of the following findings is expected to be present if an electron microscopy of the biopsy sample is performed?

A 15-year-old boy is brought to the office by his mother with the complaints of facial puffiness and smoky urine.The mother noticed puffiness of her son’s face a week ago and since then it has been progressive. She adds by saying that her son’s urine is smoky and looks abnormal. She denies any change in his urinary frequency or abdominal discomfort but mentions that her son had a sore throat 3 weeks ago. She gives no history of her son having fever. On examination, facial edema is apparent. His vital signs are blood pressure 145/85 mmHg, pulse: 96/min, temperature: 98.4 °F and respiratory rate: 20/min. Complete blood count report shows: Hemoglobin: 10.1 g/dL Red blood cell: 4.9 million cells/µL Hematocrit: 46 % Total leukocyte count: 6800 cells/µL Neutrophils: 70 % Lymphocyte: 26 % Monocytes: 3 % Eosinophil: 1 % Basophils: 0 % Platelets: 210000 cells/µL ESR: 18 mm (1st hour) Urine analysis shows: pH: 6.4 Color: dark brown RBC: plenty WBC: 3-4/HPF Protein: absent Cast: RBC and granular casts Glucose: absent Crystal: none Ketone: absent Nitrite: absent Which of the following lab findings can be expected in this patient?

A 12-year-old girl is brought to the office by her mother with the complaints of cola-colored urine and mild facial puffiness for that began 5 days ago. According to her mother, she had a sore throat 3 weeks back. Her immunization records are up to date. The mother denies fever and any change in bowel habit. Vitals are: blood pressure: 138/78 mmHg, pulse: 88/min, temperature: 98.2 °F and respiratory rate: 11/min. On examination, there is pitting edema of the extremities. An oropharyngeal examination is normal. Urinalysis done at the office shows: pH: 6.2 Color: dark brown RBC: 18-20/HPF WBC: 3-4/HPF Protein: 1+ Cast: RBC casts Glucose: absent Crystal: none Ketone: absent Nitrite: absent 24 hr urine protein excretion: 0.6 g Which of the following would best describe the light microscopy finding in this case?

A 36-year-old female comes to the office with the complaint of facial swelling and decreased urination that she first noticed 2 weeks ago. It has been gradually progressive since then. She was diagnosed with Systemic Lupus Erythematosus (SLE) 2 years back and is on azathioprine and corticosteroid. Her vitals include blood pressure: 142/90 mm Hg, pulse: 89/min, temperature: 98.7 °F, respiratory rate: 11/min. On examination, there is a minimal erythematous rash on her face exhibiting a butterfly pattern. There is swelling of the face and lower extremities which are pitting in nature. Her blood investigation shows: RBC: 4.9 x 106/mm^3 Hemoglobin: 13 g/dL Hematocrit: 4 % Total leukocyte count: 7100 cells/mm^3 Neutrophils: 68 % Lymphocyte: 25 % Eosinophil: 1 % Monocytes: 4 % Basophils: 0 % Platelet count: 210000/mm^3 Urine analysis shows: pH: 6.2 Color: dark brown RBC: 10-12/HPF WBC: 3-4/HPF Protein: 1+ Cast: RBC casts Glucose: absent Crystal: none Ketone: absent Nitrite: absent 24 hr urine protein excretion: 1.3 g Her renal function test showed: Sodium: 141 mEq/L Potassium: 5.7 mEq/L Chloride: 101 mEq/L Bicarbonate: 22 mEq/L Albumin: 3.4 mg/ dL Urea nitrogen: 31 mg/dL Creatinine: 2.9 mg/dL Uric Acid: 6.8 mg/dL Calcium: 8.1 mg/dL Glucose: 111 mg/dL What changes would be expected under light microscopy in this case?

A 25-year-old male visits his primary care physician with the complaints of coughing up blood in his sputum and dark colored urine for 1 week. There are streaks of blood intermixed with phlegm. He also expresses concerns about his urine being grossly dark brown. He has never had such symptoms in the past. He is currently not taking any medication nor has had any major bleeding from minor injuries. Family history is negative for bleeding disorders. His vital signs are blood pressure: 160/100 mm Hg, pulse: 88/min, temperature: 98.3 °F and respiratory rate: 11/min. On examination, there are no significant clinical findings. Urine analysis shows: pH: 6.7 Color: dark brown RBC: 12-14/HPF WBC: 3-4/HPF Protein: absent Cast: RBC and granular casts Glucose: absent Crystal: none Ketone: absent Nitrite: absent 24 hr urine protein excretion: 1 g/24 hr Her renal function test showed: Sodium: 136 mEq/L Potassium: 5.1 mEq/L Chloride: 101 mEq/L Bicarbonate: 22 mEq/L Albumin: 3.5 mg/ dL Urea nitrogen: 28 mg/dL Creatinine: 2.5 mg/dL Uric Acid: 6.8 mg/ dL Calcium: 8.7 mg/ dL Glucose: 111 mg/dL A kidney biopsy is obtained, and immunofluorescence shows linear IgG deposition in the glomeruli. Which of the following antibodies is most likely responsible for this patient’s condition?

A 51-year-old male presents to the office with the complaints of gradual swelling of his face and frothy urine which was first noticed by his wife 4 days ago. He says that now his limbs also appear to be swollen. He does not have any significant past medical history except for diabetes mellitus for the past 10 years. He currently is on metformin and has well controlled blood sugar and HbA1c levels. He does not smoke and drinks alcohol occasionally. His labs during his last visit, 6 months back, were normal. On examination, there is pitting edema in the lower extremities and on his face. His vitals are blood pressure: 121/78 mmHg, pulse: 77/min, temperature 98 °F and respiratory rate: 10/ min. A urinalysis shows: pH: 6.2 Color: light yellow RBC: none WBC: 3-4/HPF Protein: 4+ Cast: fat globules Glucose: absent Crystal: none Ketone: absent Nitrite: absent 24 hr urine protein excretion: 5.1 g Which of the following is the most probable underlying cause generalized edema in this patient?

A 32-year-old African-American female presents to the office with the complaints of frothy urine and swelling of her body that started 4 days ago. She noticed the swelling first in the face then gradually involved other parts of her body. The frequency of urination is same with no noticeable change in its appearance. She is HIV positive and is under treatment with abacavir, dolutegravir, and lamivudine. Vitals include blood pressure of 122/89 mmHg, pulse of 55/min, temperature of 98F and respiratory rate of 14/min. On examination, there is generalized pitting edema. A urinalysis is sent which shows the following: pH: 6.6 Color: light yellow RBC: none WBC: 1-2/HPF Protein: 4+ Cast: fat globules Glucose: absent Crystal: none Ketone: absent Nitrite: absent 24 hr urine protein excretion: 5.2 g A renal biopsy is performed which shows the following (see image). What is this patient most likely suffering from? (Image: by Nephron, https://commons.wikimedia.org/wiki/File:Focal_segmental_glomerulosclerosis_-_high_mag.jpg, Licence: CC BY-SA 3.0, https://creativecommons.org/licenses/by-sa/3.0/)

A 32-year-old Caucasian female presents to the office with the complaints of frothy urine swelling of her body that started 6 days ago. She says that she first noticed swelling in her face that gradually involved other parts of her body. On further questioning, she gives a history of Rheumatoid arthritis for two year. She is taking Penicillamine and Methotrexate for the past six months. Vitals include blood pressure of 122/89 mmHg, pulse of 55/min, temperature of 98F and respiratory rate of 14/min. On examination, there is generalized pitting edema along with some subcutaneous nodules on the dorsal aspect of the forearm. Urinalysis shows: pH: 6.6 Color: light yellow RBC: none WBC: 1-2/HPF Protein: 4+ Cast: fat globules Glucose: absent Crystal: none Ketone: absent Nitrite: absent 24 hr urine protein excretion: 4.8 g Her basic metabolic panel reveals: Sodium: 141 mEq/L Potassium: 5.1 mEq/L Chloride: 101 mEq/L Bicarbonate: 22 mEq/L Albumin: 3.2 mg/dL Urea nitrogen: 17 mg/dL Creatinine: 1.3 mg/dL Uric Acid: 6.8 mg/ dL Calcium: 8.9 mg/ dL Glucose: 111 mg/dL A renal biopsy is ordered which shows diffuse capillary and glomerular basement membrane thickening. Which of the following is the most likely cause for her impaired renal function?

A 5-year-old boy is brought to the office by his mother with the complaints of facial puffiness and frothy urine. His mother doesn’t give any history of similar symptoms in the past. There is no known major illness in past or any hospitalization history. The birth history is uneventful and all his vaccinations are up to date. Vitals are blood pressure 100/62 mm Hg, Pulse: 110/min, temperature: 98 °F and respiratory rate: 16/min. On examination, there is generalized swelling of the body which is pitting in nature. A urinalysis is sent which shows: pH: 6.2; Color: light yellow; RBC: none; WBC: 3-4/HPF; Protein: 4+; Cast: Fat globules Glucose: absent Crystal: none; Ketone: absent; Nitrite: absent; 24 hr urine protein excretion: 4.1 g. A renal biopsy is sent which shows normal glomeruli in light microscopy. Which of the following is the most likely diagnosis?

A 34-year-old lady visits the physician’s office with the complaints of facial swelling with dark colored urine. She remembers her swelling first being mentioned by a colleague 4 days ago. The facial swelling has been progressive and spread to her lower limbs. She gives a history of intravenous drug abuse but denies any such use for the past 5 years. On examination, there is pitting edema over lower limbs. Her vitals are blood pressure: 140/88 mmHg, pulse: 78/min temperature: 97.7 °F and respiratory rate: 9/min. A complete blood examination shows: Hemoglobin: 12 g/dL; Red blood cell: 4.9 million cells/ µL; Hematocrit: 48 %; Total leukocyte count: 6800 cells/ µL; Neutrophils: 61 %; Lymphocyte: 34 %; Monocytes: 4 %; Eosinophil: 1 %; Basophils: 0 %; Platelets: 200,000 cells/ µL. An urinalysis is sent which shows: pH: 6.2; Color: light brown; RBC: 8-10/HPF; WBC: 3-4/HPF; Protein: 4+; Cast: RBC casts; Glucose: absent; Crystal: none Ketone: absent Nitrite: absent 24 hr Urine Protein excretion: 3.7 g. Serology test is sent which shows: HIV: negative; IgM Hep A: negative; IgM Hep C: negative; Hepatitis B: - HBsAg: positive - HBeAg: negative - Anti HBs: negative - Anti-HBe: positive - IgG Anti HBc: positive Which of the following is the most likely light microscopic finding if a renal biopsy is done in this case?

A 57-year-old male with diabetes mellitus type II presents for a routine follow-up. His blood glucose levels have been inconsistently controlled with Metformin and diet since his diagnosis 3 years ago. He is currently is on Metformin and diet control with exercise. His vitals are blood pressure: 122/82 mm Hg, pulse: 83/ min, temperature: 97.4 °F and respiratory rate: 10/min. At this current visit, urinalysis demonstrates : pH: 6.2; Color: light yellow; RBC: none; WBC: none; Protein: 4+; Cast: RBC casts; Glucose: absent; Crystal: none; Ketone: absent; Nitrite:absent; 24 hr Urine Protein excretion: 3.7 g His urine albumin loss mapping shows: Urine Albumin Loss/24hr - Current: 215 mg; Urine Albumin Loss/24hr - 3 Months ago: 28 mg. His blood sugar analysis shows: Fasting blood sugar: 153 mg/dl Post-Prandial blood sugar: 225 mg/dl HbA1c: 7.4 % Which of the following best describes the expected microscopic finding on renal biopsy in this case?

A 43-year-old male presents to the office with an episode of fever and right flank pain for 2 days. He recorded his temperature at home and it was 101 °F. He also complains of burning sensation while urinating with increased frequency of urination for past 2 weeks along with an increased urge to urinate. He is diabetic for past 10 years and under medication. There is tenderness over the right loin area- positive renal angle tenderness. His vitals are: Blood pressure: 122/82 mm Hg, pulse: 104/min, temperature: 100 °F and respiratory rate: 11/ min. Blood investigation reports show: Hemoglobin: 14 g/dL; Red blood cell: 5.1 million cells/ µL; Hematocrit: 45 %; Total leukocyte count: 11500 cells/ µL; Neutrophils: 81 %; Lymphocyte: 14 %; Monocytes: 4 %; Eosinophil: 1 %; Basophils: 0 %; Platelets: 240,000 cells/ µL. A urinalysis is sent which shows: pH: 6.2; Color: turbid yellow; RBC: none; WBC: 12-14/HPF; Protein: trace; Cast: WBC casts; Glucose: absent; Crystal: none; Ketone: absent; Nitrite: positive. His Blood sugar analysis shows: Random blood sugar: 189 mg/ dL; HbA1C: 5.9 %. A Contrast CT scan is ordered which shows focal wedge-like regions which appear swollen and demonstrate reduced enhancement compared with the normal portions of the kidney. No additional finding is noted. Which of the following is the most likely predisposing factor in this case?

A 9-year-old boy is brought to the hospital by his mother with the complaint of fever and loin pain for past 3 days. She mentions that he has had such symptoms recurrently for past 4 years for which he was treated with antibiotics and got better but eventually recurred. On examination, he is warm to touch and there is tenderness over right costovertebral angle. His vital signs are blood pressure: 100/64 mm Hg, pulse: 100/min, temperature: 100.4 °F, respiratory rate: 14/min. Blood work shows: Hemoglobin: 12 g/dL; Red blood cell: 5.1 million cells/ µL; Hematocrit: 45 %; Total leukocyte count: 8500 cells/ µL; Neutrophils: 71 %; Lymphocyte: 24 %; Monocytes: 4 %; Eosinophil: 1 % Basophils: 0 %; Platelets: 240,000 cells/ µL. Urinalysis shows: pH: 6.2; Color: turbid yellow; RBC: none; WBC: 8-10/HPF; Protein: trace; Cast: WBC casts; Glucose: absent; Crystal: none; Ketone: absent; Nitrite: positive. A Computed-Tomography scan shows renal scarring, multiple atrophy sites with compensatory hypertrophy of residual normal tissue. There is additional renal cortical thinning. Which of the following would be the most likely microscopic finding if a renal biopsy were to be done?

А 26-уеаr-old male, сurrеntlу undеrgoіng ѕtаndаrd thеrару for а rесеntlу dіаgnoѕеd асtіvе tubеrсuloѕіѕ іnfесtіon, dеvеloрѕ ѕuddеn onѕеt of fеvеr аnd dесrеаѕеd frеquеnсу of urіnаtіon. Не іѕ on аntі-tubеrсulаr therapy for the last 2 monthѕ. Оn ехаmіnаtіon, thеrе іѕ mіld ріttіng еdеmа ovеr hіѕ lowеr lіmbѕ. Ніѕ vіtаl ѕіgnѕ аrе blood рrеѕѕurе: 110/76 mm Нg, рulѕе: 78/mіn, tеmреrаturе: 97.6 °F, rеѕріrаtorу rаtе: 8/ mіn. Hemoglobin: 14 g/dL; Red blood cell: 5.1 million cells/ µL; Hematocrit: 45 %; Total leukocyte count: 5500 cells/ µL; Neutrophils: 71 %; Lymphocyte: 14 %; Monocytes: 4 %; Eosinophil: 11 %; Basophils: 0 %; Platelets: 240,000 cells/ µL. His urine analysis shows: pH: 6.2; Color: light yellow; RBC: none; WBC: Eosinophils plenty; Protein: 1+; Cast: none; Glucose: absent; Crystal: none; Ketone: absent; Nitrate: negative; 24 hr Urine Protein excretion: 0.6 g. A renal function test shows: Sodium: 141 mEq/L; Potassium: 5.1 mEq/L; Chloride: 101 mEq/L; Bicarbonate: 24 mEq/L; Albumin: 4.3 mg/ dL; Urea nitrogen: 11 mg/dL; Creatinine: 2.2 mg/dL; Uric Acid: 6.8 mg/ dL; Calcium: 8.9 mg/ dL; Glucose: 111 mg/ dL. A renal biopsy shows eosinophilic infiltration and diffuse parenchymal inflammation. Which of the following is the most likely diagnosis in this case?

А 60-уеаr-old Ніѕраnіс mаn, wіth а hіѕtorу of oѕtеoаrthrіtіѕ, рrеѕеntѕ to thе offісе for а rеgulаr hеаlth сhесk-uр. Не hаѕ bееn аwаіtіng hір rерlасеmеnt ѕurgеrу for hіѕ oѕtеoаrthrіtіѕ whісh hаѕ bееn thеrе for 5 уеаrѕ. Не adds that he took high doses of painkillers for the hip pain all these years but now they don't provide any relief . Оn ехаmіnаtіon, thеrе іѕ а lіmіtеd rаngе of motіon of hіѕ rіght hір. No аddіtіonаl fіndіngs are notеd. Ніѕ vіtаlѕ аrе blood рrеѕѕurе: 110/70 mm Нg, рulѕе: 78/mіn, tеmреrаturе: 98.1 °F, rеѕріrаtorу rаtе: 10/mіn. Laboratory results reveal: Hemoglobin: 12 g/dL; Red blood cell: 5.1 million cells/ µL; Hematocrit: 45 %; Total leukocyte count: 6500 cells/ µL; Neutrophils: 71 %; Lymphocyte: 14 %; Monocytes: 4 %; Eosinophil: 11 %; Basophils: 0 %; Platelets: 240,000 cells/ µL. Urinalysis shows: pH: 6.2; Color: light yellow; RBC: 7-8/ HPF; WBC: 10-12 /HPF; Protein: 1+; Cast: none; Glucose: absent; Crystal: none; Ketone: absent; Nitrite: negative; 24 hr Urine Protein excretion: 0.9 g. Urine for Culture : No growth noted after 48 hours of inoculation at 37 °C. Which of the following is most likely diagnosis in this case?

А 55-уеаr-old mаn рrеѕеntѕ to thе offісе wіth the сomрlаіnt of bonе раіn. Тhе раіn іѕ gеnеrаlіzеd іn аrеаѕ lіkе knееs, еlbows, bасk and ѕhouldеrs. Не has stage IV Сhronіс Kіdnеу Dіѕеаѕе and is wаіtіng for a renal trаnѕрlаnt аnd currently is undеr wееklу hеmodіаlуѕіѕ. Оn ехаmіnаtіon, thеrе іѕ реrірhеrаl ріttіng еdеmа аnd ѕсrаtсh mаrkѕ ovеr thе forеаrm and trunk. Ніѕ vіtаl ѕіgnѕ аrе blood рrеѕѕurе: 146/88 mm Нg, рulѕе: 84/mіn, tеmреrаturе: 97.9 °F аnd rеѕріrаtorу rаtе: 9/mіn. A blood investigation reports are given below: Laboratory results reveal: Hemoglobin: 11 g/dL; Red blood cell: 4.5 million cells/ µL; Hematocrit: 40 %; Total leukocyte count: 6500 cells/ µL; Neutrophils: 71 %; Lymphocyte: 34 %; Monocytes: 4 %; Eosinophil: 1 %; Basophils: 0 %; Platelets: 240,000 cells/ µL. Renal function test shows: Sodium: 136 mEq/L; Potassium: 5.9 mEq/L; Chloride: 101 mEq/L; Bicarbonate: 21 mEq/L; Albumin: 2.8 mg/ dL; Urea nitrogen: 31 mg/dL; Creatinine: 2.9 mg/dL; Uric Acid: 6.8 mg/ dL; Glucose: 111 mg/ dL. Which of the following set of findings would be expected in this patient in his current visit?

А 55-уеаr-old mаn рrеѕеntѕ to hіѕ рrіmаrу саrе рhуѕісіаn wіth the сomрlаіnt of еаѕу fаtіguаbіlіtу for a couple of months. He was feeling well during his last visit 6 months back. Не hаѕ а hіѕtorу of Нуреrtеnѕіon and is taking amlodіріnе аnd enаlарrіl for last 8 уеаrѕ аnd Dіаbеtеѕ Меllіtuѕ for 5 уеаrѕ. His Metformin was switched to Insulin last year. He also has Сhronіс Kіdnеу Dіѕеаѕе(СKD) for a уеаr now. Ніѕ vіtаl ѕіgnѕ аrе blood рrеѕѕurе: 138/84 mm Нg, рulѕе: 81/mіn, tеmреrаturе: 98.2 °F аnd rеѕріrаtorу rаtе:9/ mіn. Оn ехаmіnаtіon, а modеrаtе аmount of раllor іѕ notісеd on thе раlреbrаl сonјunсtіvа аnd nаіl bеd. Remaining of the examination is normal. Blood tests show: Hemoglobin: 8.5 g/dL; Red blood cell: 4.2 million cells/ µL; Hematocrit: 39 %; Total leukocyte count: 6500 cells/ µL; Neutrophils: 61 %; Lymphocyte: 34 %; Monocytes: 4 %; Eosinophil: 1 %; Basophils: 0 %; Platelets: 240,000 cells/ µL. A basic metabolic panel shows: Sodium: 133 mEq/L; Potassium: 5.8 mEq/L; Chloride: 101 mEq/L; Bicarbonate: 21 mEq/L; Albumin: 3.1 mg/ dL; Urea nitrogen: 31 mg/dL; Creatinine: 2.8 mg/dL; Uric Acid: 6.4 mg/ dL; Calcium: 8.1 mg/ dL; Glucose: 111 mg/ dL. Which of the following explanation best explains the mechanism for her decreased hemoglobin?

A 45-year-old Caucasian man visits the office with the complaints of severe pain with urination for 5 days. He further adds saying that it’s itchy with a burning discomfort at the tip of his penis. He is also concerned about a yellow coloured urethral discharge which he noticed a week back. Before his symptoms began, he was enjoying a break from work vacationing in Ibiza, where he had sexual intercourse with multiple partners at different parties organized by the hotel he was staying at. Physical examination shows edema and erythema concentrated around the urethral meatus, accompanied by a mucopurulent expressed discharge. Which of the following tools will best aid in the identification of the causative agent for his symptoms?

A 13 year old Caucasian female is brought to the ER by her parents for 5 days of abdominal pain, fever, vomiting, and mild diarrhea. Her parents have been giving her paracetamol in the past 3 days, which they stopped 24 hours ago when they noted blood in her daughter's urine. Upon admission, the patient has a fever of 39.6°C and is hemodynamically stable. While waiting for results of laboratory tests, the patient develops intense left flank pain, and nausea and vomiting intensifies. Her condition rapidly deteriorates with an abnormally high blood pressure of 180/100 mmHg, a heart rate of 120 beats per minute, and laboured breathing leading to ventilatory failure. Under these conditions, the ER team immediately transfers the patient to the pediatric ICU, however the patient dies shortly after. The pathologist shares with you some excerpts from her complete blood count and peripheral smear report: Hemoglobin: 7 mg/dL; Mean: 14.0 g/dL (-2SD: 13.0 g/dL). MCV: 85 fL; 80 - 96 fL. Platelets: 60,000; 150,000 - 450,000. Peripheral smear: Schistocytes (+); Schistocytes (-). White blood cells: 12,900; 4,500 - 11,000. What is the most likely diagnosis?

A 62 year old Caucasian male goes to the emergency room (ER) for intense lower abdominal pain associated with the impossibility to urinate. Physical examination shows intense lower abdominal pain. Rectal examination reveals an enlarged, smooth and symmetrical prostate. The ER team fails to pass a Foley catheter through the urethra and the urology team decides to place a suprapubic catheter to drain the urine and relief the patient’s symptoms. An ultrasound shows dilation of the collecting system in both kidneys. Laboratory test show an elevated serum creatinine of 1.6 mg/dL, for an estimated glomerular filtration rate (eGFR) of 50 ml/min/1.73m². Three weeks after the acute event, the patient visits the urology team for in a follow up visit, in which he claims having close to normal urination, however his serum creatinine persist elevated at 1.5 mg/dL. What renal gross findings correlates with this patient’s condition?

A 40 year old woman of Asian descent is admitted to the ER for severe right flank pain, fever, chills and decreased urine output. On admission her vital signs are: body temperature of 39°C (102.2 F), heart rate of 120 beats per minute, a regular breathing pattern, and blood pressure of 128/70 mmHg. Cardiopulmonary auscultation is normal, and the abdominal exam shows exquisite pain elicited by right lumbar percussion. After initiating intravenous antibiotics empirically, the patient's condition improves significantly, however a low urine output persists. Results from tests ordered on admission show: Urine culture: Proteus mirabilis, > 150,000 CFU/mL; < 100,000 CFU/mL to no bacterial growth in asymptomatic patients (normal range). Urinalysis: Density: 1.030; Leukocyte esterase (+); Nitrites (+); pH: 7.8; Density: 1.030 - 1.060; Leukocyte esterase (-), Nitrites (-), pH: 4.5 - 8.0 (normal range). C- reactive protein: 60 mg/dL; 0 - 10 mg/dL (normal range). Serum creatinine: 1.8 mg/dL; 0.6 - 1.2 mg/dL (normal range). BUN: 40 mg/dL; 7 - 20 mg/dL(normal range). Plain abdominal film: Complex renal calculus in the right kidney; None. With the above in mind, which of the following is the most likely type stone?

A 56 year old Caucasian female presents to the ER for 12 hours of right colic pain that travels her groin down her inner thigh. The pain increased minutes before urinating some blood and passing what she describes as “gravel”. She was diagnosed with gout and hypertension 5 years ago. Physical examination is unremarkable. The ER team orders a CT scan which shows a mild dilation of the right ureter associated with multiple small stones of low Hounsfield unit values (HU) and a urinalysis. Which of the following findings is most likely to appear in this patient’s urinalysis?

A 32 year old Caucasian male visits his family physician for 10 months of persistent left flank pain, weight loss, and fatigue. He further adds that in the last month he has had hematuria a couple of times. His mother was diagnosed and treated for a pheochromocytoma when she was 36 years old, and his father died at 45 years after a myocardial infarction. His personal medical history is not relevant, he does not smoke, and used to be a varsity athlete at high school and university level. Physical examination shows temporal wasting, pale mucous membranes and palms, a palpable mass in the left flank and a left that varicocele that does not reduce upon recumbency. His family physician sends the patient to the ER for a priority abdominal CT scan which reports back a complex left renal mass and an as an additional finding a hemangioblastoma in T10. The case is consulted with the oncology team , who orders a biopsy that reports compact cells with prominent nucleoli, with eosinophilic cytoplasm within a network of small, thin walled vasculature. What is the most likely type of tumour in this patient?

A 4 year old African-American girl is being followed by the pediatric oncology team after her pediatrician found a palpable abdominal mass towards the right flank 2 weeks ago. Abdominal ultrasonography detected a solid mass in the right kidney, without infiltration of the renal vein and inferior vena cava, followed by a contrast enhanced computed tomography (CT) that confirmed the presence of a solitary mass in the right kidney surrounded by a pseudocapsule consisting of a rim of normal tissue, displacing it medially, and distorting the collecting system. No nodal involvement was detected. In which of the following chromosomes you would expect a genetic abnormality?

An amish pregnant young lady gives birth to her first child at the family farm. After delivery, the assisting midwife notices a triangular defect in the lower anterior abdominal wall; she clamps the umbilical cord with a cloth and urge the family to seek immediate medical care at the nearest hospital. Upon admission to the pediatric emergency room, the attending pediatrician further notices an open bladder plate with an exposed urethra, a low set umbilicus, an anteriorly displaced anus, and an inguinal hernia; no omphalocele is noted. The external genitalia is also affected, with a shortened penis with a pronounced upward curvature and the urethral opening along the dorsal surface. What is the most likely diagnosis in this case?

A 31 year old Caucasian female visits her local walk-in clinic for 2 days of dysuria, increased voiding frequency, urgency and intense suprapubic pain. She just came back a day ago from a short honeymoon trip to Prague. Upon examination the patient is found with exquisite suprapubic pain. Costovertebral tenderness is absent and pelvic examination is normal. Body temperature is 36.5 °C, heart rate is 78 beats per minute, and the respiratory rate is 15 cycles per minutes. Which of the following organisms would be most likely isolated in this patient?

A 42 year old patient approaches your office complaining about of 1 year long of persistent dysuria, increasingly discomfort with bladder filling and voiding, and suprapubic pain. She further comments she has been presenting abdominal cramps and alternating periods of diarrhea and constipation for the past 4 months. Her family medical history is negative for malignancies and hereditary disorders. Her personal history is relevant for various visits to the general practitioners for similar complains that resulted in multiple antimicrobial regimes for urinary tract infection, with the last prescription containing ciprofloxacin. At the moment she is not taking any medication. Physical examination shows variable suprapubic tenderness, as well as tender areas in the pelvic floor. Body temperature is 37C, heart rate 68 beats per minute, blood pressure is 120/58 mmHg, and the respiratory rate is 13 cycles per minute. Vaginal examination is normal, no adnexal masses are detected and no secretions are noticed. She brings an urinalysis and an urine culture from 1 week ago that show the following: Urine culture: Negative; < 100,000 CFU/mL to no bacterial growth in asymptomatic patients (normal range). Urianalysis: Density: 1.030; Leukocyte esterase (-); Nitrites (-); pH: 6.0, Presence of 4 RBCs per high power field; Density: 1.030 - 1.060; Leukocyte esterase (-), Nitrites (-), pH: 4.5 - 8.0 (normal range).

A 63 year old patient visits her family physician because in the past 8 months she has been experiencing difficulty to get the urine stream started, with many occasions needing extra effort pass the urine. She describes the stream as intermittent and slow, and comments that she needs to go to the restroom immediately after urinating as she feels there is some more to void. Her personal medical history is negative for malignancies, and all of her cytologies have been reported as normal. The only medication she takes is an angiotensin receptor blocker to treat essential hypertension diagnosed 5 years ago. Physical examination is unremarkable, except for herniation of anterior wall of the vagina that goes beyond the hymen. Which of the following types of incontinence is affecting the patient?

During your obstetric clerkship, you are observing a third-year resident assist a delivery. The patient only had one prenatal ultrasound, that reported a male fetus. The delivery progresses without complications and the pediatrician-in-charge of the newborn notices a short, broad, upturned penis, with an orifice in its dorsal aspect; both testicles are present in the scrotum. Both the attending and PGY-3 resident immediately recognize the condition. Which of the following female anatomical structures is derived from the embryonic structure affected in this patient?

A 66 years old male has been on haemodialysis for past ten years – 3 days a week, suffering from chronic renal failure. The patient who has a medical history of hypertension, diabetes mellitus and gout starts experiencing fatigue with the. The patient is punctual in his medication and dialysis but the fatigue is there for couple of weeks without any apparent reasoning. The attending doctor wants to investigate his blood. Which medical state among the following is not related to chronic renal failure?