Nephrectomy indications US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Nephrectomy indications. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Nephrectomy indications US Medical PG Question 1: A 61-year-old man presents with back pain and hematuria. The patient says his back pain gradually onset 6 months ago and has progressively worsened. He describes the pain as moderate, dull and aching, and localized to the lower back and right flank. Also, he says that, for the past 2 weeks, he has been having intermittent episodes of hematuria. The patient denies any recent history of fever, chills, syncope, night sweats, dysuria or pain on urination. His past medical history is significant for a myocardial infarction (MI) 3 years ago status post percutaneous transluminal coronary angioplasty and peripheral vascular disease of the lower extremities, worst in the popliteal arteries, with an ankle:brachial index of 1.4. Also, he has had 2 episodes of obstructive nephrolithiasis in the past year caused by calcium oxalate stones, for which he takes potassium citrate. His family history is significant for his father who died of renovascular hypertension at age 55. The patient reports a 20-pack-year smoking history and moderates to heavy daily alcohol use. A review of systems is significant for an unintentional 6.8 kg (15 lb) weight loss over the last 2 months. The vital signs include: blood pressure 145/95 mm Hg, pulse 71/min, temperature 37.2℃ (98.9℉), and respiratory rate 18/min. On physical examination, the patient has moderate right costovertebral angle tenderness (CVAT). A contrast computed tomography (CT) scan of the abdomen and pelvis reveals an enhancing mass in the upper pole of the right kidney. A percutaneous renal biopsy of the mass confirms renal cell carcinoma. Which of the following was the most significant risk factor for the development of renal cell carcinoma (RCC) in this patient?
- A. History of obstructive nephrolithiasis
- B. Moderate to heavy daily alcohol use
- C. 20-pack-year smoking history (Correct Answer)
- D. Family history of renovascular hypertension
- E. Peripheral vascular disease
Nephrectomy indications Explanation: ***20-pack-year smoking history***
- **Smoking** is the single most important modifiable risk factor for **renal cell carcinoma (RCC)**, increasing the risk by 50-100% in a dose-dependent manner.
- The duration and intensity of smoking, as indicated by a **20-pack-year history**, significantly contribute to the cumulative risk of developing RCC.
*History of obstructive nephrolithiasis*
- While **kidney stones** (nephrolithiasis) can cause symptoms similar to RCC (e.g., pain, hematuria), they are generally **not considered a direct risk factor** for RCC.
- The presence of calcium oxalate stones does not predispose an individual to kidney cancer directly.
*Moderate to heavy daily alcohol use*
- The relationship between **alcohol consumption** and RCC risk is not as clear or as strong as with smoking.
- Some studies suggest a potential link, but it is generally considered a **minor or inconsistent risk factor** compared to smoking.
*Family history of renovascular hypertension*
- **Renovascular hypertension** is hypertension caused by kidney artery stenosis, and while it might indicate underlying vascular issues, it is **not a direct risk factor for RCC**.
- A family history of hypertension in general may be weakly associated with RCC, but specifically renovascular hypertension is not.
*Peripheral vascular disease*
- **Peripheral vascular disease (PVD)** is a manifestation of systemic atherosclerosis and shares common risk factors with RCC (e.g., smoking, hypertension), but it is **not an independent risk factor for RCC**.
- PVD itself does not directly cause renal cell carcinoma.
Nephrectomy indications US Medical PG Question 2: A 53-year-old male presents to your office for abdominal discomfort. The patient states he first noticed pain on his right flank several months ago, and it has been gradually getting worse. For the past week, he has also noticed blood in his urine. Prior to this episode, he has been healthy and does not take any medications. The patient denies fever, chills, and dysuria. He has a 40 pack-year smoking history. Vital signs are T 37 C, BP 140/90 mmHg, HR 84/min, RR 14/min, O2 98%. Physical exam is unremarkable. CBC reveals a hemoglobin of 17 and hematocrit of 51%, and urinalysis is positive for red blood cells, negative for leukocytes. Which of the following is the most likely diagnosis?
- A. Pyelonephritis
- B. Renal oncocytoma
- C. Renal cell carcinoma (Correct Answer)
- D. Abdominal aortic aneurysm
- E. Polycystic kidney disease
Nephrectomy indications Explanation: ***Renal cell carcinoma***
- The classic triad of **flank pain**, **hematuria**, and a palpable abdominal mass (which may not always be present or detected on physical exam)
- **Erythrocytosis** (high hemoglobin and hematocrit) due to increased **erythropoietin** production by the tumor, and a significant **smoking history** are strong indicators.
*Pyelonephritis*
- This is an infection of the kidney, typically presenting with **fever**, **chills**, **dysuria**, and flank pain.
- The patient denies fever and chills, and the urinalysis is negative for leukocytes, making pyelonephritis unlikely.
*Renal oncocytoma*
- While it is a **renal tumor** that can cause flank pain or hematuria, it is typically **benign** and does not usually cause paraneoplastic syndromes like erythrocytosis.
- In the presence of erythrocytosis and a strong smoking history, a malignant cause like RCC is more probable.
*Abdominal aortic aneurysm*
- An AAA can cause abdominal or flank pain, but it would not typically cause **hematuria** or **erythrocytosis**.
- Rupture or dissection of an AAA presents as severe, acute pain and hemodynamic instability, which is not described.
*Polycystic kidney disease*
- This genetic disorder is characterized by multiple cysts in the kidneys, leading to pain, hematuria, and **renal failure over time**.
- While it can cause hematuria, it is less likely to present with new-onset erythrocytosis and in a patient with no previous medical history.
Nephrectomy indications US Medical PG Question 3: A 40-year-old man comes to the physician for a follow-up examination. He feels well. He has no urinary urgency, increased frequency, dysuria, or gross hematuria. He has a history of recurrent urinary tract infections. His last urinary tract infection was 3 months ago and was treated with ciprofloxacin. Current medications include a multivitamin. He has smoked one pack of cigarettes daily for 18 years. Vital signs are within normal limits. The abdomen is soft and nontender. There is no costovertebral angle tenderness. Laboratory studies show:
Hemoglobin 11.2 g/dL
Leukocyte count 9,500/mm3
Platelet count 170,000/mm3
Serum
Na+ 135 mEq/L
K+ 4.9 mEq/L
Cl- 101 mEq/L
Urea nitrogen 18 mg/dL
Creatinine 0.6 mg/dL
Urine
Blood 2+
Protein negative
RBC 5–7/hpf, normal shape and size
RBC casts negative
WBC 0–2/hpf
Bacteria negative
Urine cultures are negative. Urine analysis is repeated and shows similar results. A cystoscopy shows no abnormalities. Which of the following is the most appropriate next step in management?
- A. Annual urinalysis
- B. Reassurance
- C. CT urography (Correct Answer)
- D. Voided urine cytology
- E. Transrectal ultrasound
Nephrectomy indications Explanation: ***CT urography***
- The patient has **microscopic hematuria** with **2+ blood on urinalysis** and **5-7 RBCs/hpf**, in the absence of infection or other identifiable causes, which warrants further investigation for potential malignancy.
- Given the patient's **smoking history** (18 pack-years) and age, which are significant risk factors for **urothelial carcinoma** (bladder, renal pelvis, ureters), imaging with CT urography is crucial to visualize the entire urinary tract for tumors or other structural abnormalities.
*Annual urinalysis*
- This option represents a passive approach to monitoring, which is inadequate given the presence of **unexplained microscopic hematuria** and risk factors for malignancy.
- Delaying definitive investigation could lead to a missed or delayed diagnosis of a potentially treatable condition like **urothelial cancer**.
*Reassurance*
- Reassurance is inappropriate when **microscopic hematuria** is present without a clear benign cause, especially in a patient with risk factors like **smoking history**.
- This could lead to a false sense of security and delay the diagnosis and treatment of a serious underlying condition.
*Voided urine cytology*
- **Urine cytology** has a low sensitivity for detecting low-grade bladder cancers, though it can be useful for high-grade cancers and carcinoma in situ.
- While it may be considered in conjunction with imaging, it is not the most appropriate *initial* next step to identify the source of hematuria throughout the entire urinary tract, especially when imaging can detect other pathologies.
*Transrectal ultrasound*
- A **transrectal ultrasound** is primarily used to evaluate the **prostate gland**, typically in the context of prostate-specific antigen elevation or prostatic symptoms.
- It would not effectively visualize the bladder, ureters, or kidneys, which are the primary concerns for microscopic hematuria in this patient's demographic and risk factors.
Nephrectomy indications US Medical PG Question 4: A 59-year-old Caucasian man presents with a one-month history of left flank fullness and pain. The patient has stable angina, which is controlled with medications including atorvastatin, metoprolol, and aspirin. His vital signs are within normal limits. BMI is 32 kg/m2. Clinical examination reveals a 10 x 10-cm palpable mass in the left flank. Testicular examination indicates left varicocele. Laboratory parameters are as follows:
Urine
Blood 3+
WBC none
RBC 65/hpf without dysmorphic features
Abdominal CT scan confirms the presence of a large solid mass originating in the left kidney with impingement on the left renal vein. Based on the most likely diagnosis, which of the following is considered a risk factor in this patient?
- A. Obesity (Correct Answer)
- B. Varicocele
- C. Atorvastatin
- D. Lynch syndrome
- E. Caucasian race
Nephrectomy indications Explanation: ***Obesity***
- This patient's **BMI of 32 kg/m2** indicates **obesity**, which is a well-established risk factor for **renal cell carcinoma (RCC)**, the most likely diagnosis given the clinical presentation (flank mass, hematuria, varicocele, and CT findings).
- Obesity is thought to increase RCC risk due to associated hormonal changes, such as increased **estrogen** and **insulin-like growth factor 1 (IGF-1)**, and chronic inflammation.
*Varicocele*
- While a **left varicocele** is a clinical finding often associated with **renal cell carcinoma**, particularly on the left side due to impingement on the left renal vein, it is a **symptom/sign** of the disease, not a risk factor for its development.
- The varicocele develops because the tumor obstructs the **left renal vein**, leading to retrograde flow and dilation of the **gonadal vein**.
*Atorvastatin*
- **Atorvastatin**, a statin used to treat hyperlipidemia and prevent cardiovascular disease, has **no known association** with an increased risk of renal cell carcinoma.
- Some studies even suggest a potential **protective effect** of statins against certain cancers, but this is not definitively established for RCC, and certainly not a risk factor.
*Lynch syndrome*
- **Lynch syndrome** (hereditary nonpolyposis colorectal cancer) is primarily associated with an increased risk of **colorectal cancer**, **endometrial cancer**, and other gastrointestinal/genitourinary cancers, but **not renal cell carcinoma**.
- Renal cell carcinoma is more commonly linked to other genetic syndromes like **Von Hippel-Lindau disease** or **hereditary papillary renal carcinoma**.
*Caucasian race*
- While there are some **racial disparities** in certain cancer incidences, the **Caucasian race itself is not considered a primary modifiable risk factor** for renal cell carcinoma.
- **African Americans** may have a slightly higher risk for RCC, but this is often attributed to socioeconomic factors and comorbidities rather than race as an independent biological risk factor.
Nephrectomy indications US Medical PG Question 5: A 42-year-old woman comes to the physician because of right flank pain that started 3 days following a procedure. Her vital signs are within normal limits. Physical examination shows right costovertebral angle tenderness. An intravenous pyelogram shows a dilated renal pelvis and ureter on the right with a lack of contrast proximal to the ureterovesical junction. This patient most likely recently underwent which of the following procedures?
- A. Hysterectomy (Correct Answer)
- B. Foley catheter insertion
- C. Cesarean delivery
- D. Appendectomy
- E. Inguinal hernia repair
Nephrectomy indications Explanation: ***Hysterectomy***
- **Ureteral injury** is a known complication of hysterectomy due to the ureter's close proximity to the uterine arteries and adnexa, especially near the **ureterovesical junction**.
- The presented symptoms of flank pain, CVA tenderness, and hydronephrosis (dilated renal pelvis and ureter with lack of contrast flow) occurring post-procedure strongly indicate **ureteral obstruction** or injury during the surgery.
*Foley catheter insertion*
- While catheterization can cause trauma, it would typically lead to **urethral or bladder injury**, not a ureteral obstruction at the ureterovesical junction causing hydronephrosis.
- The symptoms are more consistent with an injury higher up in the urinary tract that is not usually associated with a Foley catheter.
*Cesarean delivery*
- A C-section involves opening the abdomen to deliver a baby, but it generally does not involve dissection near the ureters to the extent that a hysterectomy does, making ureteral injury less common.
- The primary surgical field during a C-section is the uterus, while ureteral injury is more characteristic of procedures involving extensive pelvic dissection, such as hysterectomy.
*Appendectomy*
- An appendectomy is a procedure to remove the appendix and typically involves the right lower quadrant of the abdomen, away from the course of the ureter and ureterovesical junction.
- Injury to the ureter is a very rare complication of appendectomy and would not typically manifest as this type of obstruction.
*Inguinal hernia repair*
- Inguinal hernia repair involves structures in the groin region, anterior to the peritoneal cavity, and is far removed from the ureters and bladder.
- Ureteral injury is not a recognized complication of inguinal hernia repair.
Nephrectomy indications US Medical PG Question 6: A 61-year-old man comes to the physician because of several episodes of dark urine over the past 2 weeks. He does not have dysuria or flank pain. He works in a factory that produces dyes. Since an accident at work 5 years ago, he has had moderate hearing loss bilaterally. He takes no medications. He has smoked a pack of cigarettes daily for 29 years and drinks one alcoholic beverage daily. Vital signs are within normal limits. Physical examination shows no abnormalities. His urine is pink; urinalysis shows 80 RBC/hpf but no WBCs. Cystoscopy shows a 3-cm mass in the bladder mucosa. The mass is resected. Pathologic examination shows an urothelial carcinoma with penetration into the muscular layer. An x-ray of the chest and a CT scan of the abdomen and pelvis with contrast show a normal upper urinary tract and normal lymph nodes. Which of the following is the most appropriate next step in management?
- A. Palliative polychemotherapy
- B. Transurethral resection of tumor with intravesical BCG instillation
- C. Radical cystectomy (Correct Answer)
- D. Transurethral resection of tumor with intravesical chemotherapy
- E. Radiation therapy
Nephrectomy indications Explanation: ***Radical cystectomy***
- The patient has an **urothelial carcinoma** that has **penetrated the muscular layer**. This indicates an **invasive bladder cancer (T2 or greater)**, for which radical cystectomy is the standard of care to achieve cure.
- While imaging showed no distant metastasis, the deep invasion into the muscle requires aggressive surgical removal of the bladder, prostate (in men), and seminal vesicles, along with pelvic lymph node dissection.
*Palliative polychemotherapy*
- This option is typically reserved for patients with widespread **metastatic disease** or those who are not surgical candidates, which is not the case here.
- The patient's initial workup shows no evidence of distant metastasis, making a curative approach like surgery more appropriate.
*Transurethral resection of tumor with intravesical BCG instillation*
- This approach, often used for **high-grade non-muscle invasive bladder cancer**, is insufficient for muscle-invasive disease.
- **BCG instillation** aims to prevent recurrence and progression in superficial disease but cannot eradicate cancer that has invaded the muscularis propria.
*Transurethral resection of tumor with intravesical chemotherapy*
- Similar to BCG, **intravesical chemotherapy** is primarily effective for **non-muscle invasive bladder cancer** to prevent recurrence or treat carcinoma in situ.
- It does not provide adequate treatment for cancer that has invaded the detrusor muscle, as systemic or deeper treatments are required.
*Radiation therapy*
- While radiation therapy can be considered for bladder cancer, it is typically used in specific situations, such as for patients who are **not surgical candidates** or as part of a **bladder-sparing trimodality therapy** (TURBT, chemotherapy, and radiation) for highly selected patients.
- For muscle-invasive disease without clear contraindications for surgery, **radical cystectomy** offers better long-term survival rates.
Nephrectomy indications US Medical PG Question 7: A 63-year-old man undergoes uncomplicated laparoscopic cholecystectomy for acute cholecystitis and is admitted to the surgical ward for postoperative management. On postoperative day 1, routine laboratory studies reveal an increase in serum creatinine to 1.46 mg/dL from 0.98 mg/dL before the operation; BUN is 37 mg/dL, increased from 18 mg/dL on prior measurement; K is 4.8 mEq/L and CO2 is 19 mEq/L. The patient has an indwelling urinary catheter in place, draining minimal urine over the last few hours. Which of the following is the most appropriate next step in management?
- A. Initiate emergent hemodialysis
- B. Obtain bilateral renal ultrasonography
- C. Obtain urinalysis
- D. Evaluate urinary catheter for obstruction (Correct Answer)
- E. Administer IV fluid bolus
Nephrectomy indications Explanation: ***Evaluate urinary catheter for obstruction***
- The patient presents with **acute kidney injury (AKI)** evidenced by elevated BUN and creatinine, along with minimal urine output, raising suspicion for a **post-renal obstruction**.
- Given the presence of an indwelling urinary catheter, a **mechanical obstruction** (e.g., kink, clot) is the most immediate and easily reversible cause to investigate.
*Initiate emergent hemodialysis*
- While the patient has AKI, there are no immediate life-threatening indications for **emergent hemodialysis** such as severe hyperkalemia, refractory acidosis, or pulmonary edema.
- Furthermore, investigating and potentially reversing the cause of AKI should precede considering dialysis.
*Obtain bilateral renal ultrasonography*
- **Renal ultrasonography** is appropriate for evaluating post-renal causes after simpler causes of obstruction, such as a catheter issue, have been ruled out.
- It would be used to assess for hydronephrosis, which indicates **ureteral or bladder outlet obstruction**.
*Obtain urinalysis*
- A **urinalysis** can help characterize intrinsic renal causes of AKI (e.g., ATN, interstitial nephritis) but is less helpful in initial assessment of a suspected acute obstruction related to a catheter.
- The immediate priority is to rule out a mechanical issue with the indwelling catheter.
*Administer IV fluid bolus*
- The patient's BUN/creatinine ratio (approximately 25:1) suggests a potential **pre-renal etiology** (volume depletion), but the minimal urine output with an indwelling catheter warrants ruling out obstruction first.
- Administering fluids without addressing a potential obstruction could worsen patient outcome if the obstruction is present.
Nephrectomy indications US Medical PG Question 8: Three hours after undergoing open proctocolectomy for ulcerative colitis, a 42-year-old male complains of abdominal pain. The pain is localized to the periumbilical and hypogastric regions. A total of 20 mL of urine has drained from his urinary catheter since the end of the procedure. Temperature is 37.2°C (98.9°F), pulse is 92/min, respirations are 12/min, and blood pressure is 110/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Physical examination shows a 20 cm vertical midline incision and an ileostomy in the right lower quadrant. There is no fluid drainage from the surgical wounds. The urinary catheter flushes easily and is without obstruction. Cardiopulmonary examination shows no abnormalities. Serum studies show a blood urea nitrogen of 30 mg/dL and a creatinine of 1.3 mg/dL. Which of the following is the most appropriate next step in management?
- A. Administer tamsulosin
- B. Administer intravenous furosemide
- C. Obtain an abdominal CT
- D. Start ciprofloxacin
- E. Administer intravenous fluids (Correct Answer)
Nephrectomy indications Explanation: ***Administer intravenous fluids***
- The patient's **oliguria** (20 mL urine over 3 hours, ~7 mL/hour) post-surgery, elevated **BUN (30 mg/dL)**, and **creatinine (1.3 mg/dL)** with a **BUN:Cr ratio >20:1** suggest **prerenal acute kidney injury** due to **hypovolemia**.
- Post-operative fluid losses from **third-spacing**, blood loss, and insensible losses commonly cause hypovolemia after major abdominal surgery.
- **Intravenous fluids** are the most appropriate initial step to restore intravascular volume and improve renal perfusion.
*Administer tamsulosin*
- **Tamsulosin** is an alpha-blocker used to relax smooth muscle in the prostate and bladder neck, primarily for **urinary retention** due to benign prostatic hyperplasia.
- This patient's oliguria is due to **prerenal azotemia** from hypovolemia, not prostatic obstruction, and the catheter flushes easily without obstruction.
*Administer intravenous furosemide*
- **Furosemide** is a loop diuretic that increases urine output, but administering it in the context of **prerenal acute kidney injury** can worsen hypovolemia and further compromise renal function.
- Diuretics are generally contraindicated in oliguria due to hypovolemia and should only be considered after volume resuscitation.
*Obtain an abdominal CT*
- While an abdominal CT can diagnose surgical complications, there are no immediate signs of a surgical emergency like **anastomotic leak** or **bowel obstruction**.
- Addressing the likely **hypovolemia** is more urgent and should precede further imaging in this scenario.
*Start ciprofloxacin*
- The patient does not show signs of infection, such as fever or localized signs of bacterial peritonitis, making **antibiotics** like ciprofloxacin inappropriate as the initial management step.
- The elevated BUN and creatinine are more indicative of volume depletion than infection.
Nephrectomy indications US Medical PG Question 9: A 24-year-old male is brought in by fire rescue after being the restrained driver in a motor vehicle accident. There was a prolonged extraction. At the scene, the patient was GCS 13. The patient was boarded and transported. In the trauma bay, vitals are T 97.2°F, HR 132 bpm, BP 145/90 mmHg, RR 22/min, and O2 Sat 100%. ABCs are intact with a GCS of 15, and on secondary survey you note the following (Figure F). FAST exam is positive at Morrison's pouch. Abdominal exam shows exquisite tenderness to palpation with rebound and guarding. Which of the following radiographs is most likely to be present in this patient?
- A. Radiograph C (Correct Answer)
- B. Radiograph B
- C. Radiograph D
- D. Radiograph A
- E. Radiograph E
Nephrectomy indications Explanation: ***Radiograph C***
- This radiograph displays a **ruptured spleen** with significant intrasplenic and perisplenic hemorrhage, depicted by contrast extravasation and fluid collection. The patient's presentation with a positive **FAST exam at Morrison's pouch**, exquisite abdominal tenderness, rebound, and guarding strongly indicates significant **intra-abdominal bleeding**, which is consistent with active hemorrhage from a ruptured organ like the spleen.
- The patient's **tachycardia (HR 132 bpm)** despite stable blood pressure suggests compensated shock due to blood loss, further supporting the presence of a severe hemorrhagic injury.
- Splenic injury is one of the most common solid organ injuries in blunt abdominal trauma from motor vehicle accidents.
*Radiograph B*
- This radiograph depicts a **pelvic fracture**, which can cause significant blood loss but does not directly explain the positive FAST exam at **Morrison's pouch**, which specifically indicates fluid in the hepatorenal recess of the peritoneal cavity.
- While pelvic fractures are common in motor vehicle accidents, the abdominal findings of exquisite tenderness, rebound, and guarding point more towards an **intra-abdominal organ injury** with peritoneal irritation rather than solely a pelvic injury.
- Pelvic hematomas are typically **retroperitoneal** and would not cause peritoneal signs.
*Radiograph D*
- This radiograph shows a **renal injury** with hemorrhage, which accounts for retroperitoneal bleeding. However, renal injuries typically do not result in a positive FAST exam at **Morrison's pouch** because the fluid tends to collect in the retroperitoneum rather than the peritoneal cavity.
- While significant, renal hemorrhage would not fully explain the diffuse **peritoneal signs** like rebound and guarding across the abdomen.
- The kidneys are retroperitoneal organs, so isolated renal injuries do not typically cause hemoperitoneum.
*Radiograph A*
- This radiograph shows a **liver laceration**, which can cause a positive FAST exam and intra-abdominal hemorrhage. Liver injuries are also common in blunt abdominal trauma.
- However, in the context of this patient's presentation, **splenic rupture** is more likely given the specific clinical findings. Morrison's pouch (hepatorenal recess) can collect blood from either liver or splenic injuries due to gravitational flow.
- The degree of peritoneal irritation and hemodynamic changes suggest a more extensive hemorrhagic injury pattern consistent with splenic rupture.
*Radiograph E*
- This radiograph shows a **bowel injury** that might demonstrate free air or bowel wall thickening. While bowel injuries can occur in trauma, they typically present with **pneumoperitoneum** (free air) rather than the fluid collection seen on FAST exam.
- Primary hemorrhage from hollow viscus injury is less common and less severe than solid organ injuries.
- The combination of **hemodynamic instability markers** (tachycardia) and clear peritoneal signs with positive FAST for fluid points more definitively to a significant solid organ injury with active bleeding rather than hollow viscus injury.
Nephrectomy indications US Medical PG Question 10: A 33-year-old man is brought to the emergency department 20 minutes after losing control over his bicycle and colliding with a parked car. The handlebar of the bicycle hit his lower abdomen. On arrival, he is alert and oriented. His pulse is 90/min, respirations are 17/min and blood pressure is 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. The pupils are equal and reactive to light. There are multiple bruises over his chest and lower extremities. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. There is no pelvic instability. Rectal examination is unremarkable. A complete blood count, prothrombin time, and serum concentrations of glucose, creatinine, and electrolytes are within the reference range. Urine dipstick is mildly positive for blood. Microscopic examination of the urine shows 20 RBCs/hpf. Which of the following is the most appropriate next step in management?
- A. Intravenous pyelography
- B. Laparotomy
- C. Observation and follow-up
- D. Suprapubic catheterization
- E. CT scan of the abdomen and pelvis (Correct Answer)
Nephrectomy indications Explanation: ***CT scan of the abdomen and pelvis***
- This patient has suffered significant trauma to the lower abdomen, as indicated by colliding with a parked car and handlebar impact, along with **hematuria** (urine dipstick positive for blood, 20 RBCs/hpf).
- A CT scan of the abdomen and pelvis is crucial to assess for potential **intra-abdominal organ injury**, particularly to the kidneys, bladder, or bowel, given the mechanism of injury and the presence of hematuria.
*Intravenous pyelography*
- While IVP can visualize the urinary tract, it is generally **less sensitive and specific** than CT scanning for detecting trauma-related urinary tract injuries and concurrent injuries to other abdominal organs.
- Furthermore, modern trauma care primarily utilizes **CT scanning** due to its superior anatomical detail and ability to assess multiple organ systems simultaneously.
*Laparotomy*
- **Exploratory laparotomy** is a surgical procedure indicated for patients with signs of **hemodynamic instability**, peritonitis, or clear evidence of severe intra-abdominal injury, none of which are present in this hemodynamically stable patient.
- Performing a laparotomy without further diagnostic imaging in a stable patient is premature and carries unnecessary risks.
*Observation and follow-up*
- While the patient is currently hemodynamically stable and the abdomen is soft and non-tender, the **mechanism of injury** (handlebar impact to the lower abdomen) combined with **hematuria** suggests a high likelihood of significant internal injury that requires further evaluation.
- **Observation alone** without imaging could lead to delayed diagnosis and treatment of a potentially serious injury to the urinary tract or other abdominal organs.
*Suprapubic catheterization*
- **Suprapubic catheterization** is used to drain the bladder when urethral catheterization is not possible or contraindicated, for example in cases of suspected urethral injury.
- There is no indication of urethral injury here (**unremarkable rectal exam**, no gross blood at the meatus), and the primary concern is evaluation of the organs, not bladder drainage.
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