Urinary diversion procedures US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Urinary diversion procedures. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Urinary diversion procedures US Medical PG Question 1: Two hours after undergoing laparoscopic roux-en-Y gastric bypass surgery, a 44-year-old man complains of pain in the site of surgery and nausea. He has vomited twice in the past hour. He has hypertension, type 2 diabetes mellitus, and hypercholesterolemia. Current medications include insulin, atorvastatin, hydrochlorothiazide, acetaminophen, and prophylactic subcutaneous heparin. He drinks two to three beers daily and occasionally more on weekends. He is 177 cm (5 ft 10 in) tall and weighs 130 kg (286 lb); BMI is 41.5 kg/m2. His temperature is 37.3°C (99.1°F), pulse is 103/min, and blood pressure is 122/82 mm Hg. Examination shows five laparoscopic incisions with no erythema or discharge. The abdomen is soft and non-distended. There is slight diffuse tenderness to palpation. Bowel sounds are reduced. Laboratory studies show:
Hematocrit 45%
Serum
Na+ 136 mEq/L
K+ 3.5 mEq/L
Cl- 98 mEq/L
Urea nitrogen 31 mg/dL
Glucose 88 mg/dL
Creatinine 1.1 mg/dL
Arterial blood gas analysis on room air shows:
pH 7.28
pCO2 32 mm Hg
pO2 74 mm Hg
HCO3- 14.4 mEq/L
Which of the following is the most likely cause for the acid-base status of this patient?
- A. Hypoxia (Correct Answer)
- B. Uremia
- C. Late dumping syndrome
- D. Vomiting
- E. Early dumping syndrome
Urinary diversion procedures Explanation: ***Hypoxia***
- The patient exhibits **metabolic acidosis** (pH 7.28, HCO3- 14.4 mEq/L) with **appropriate respiratory compensation** (pCO2 32 mm Hg using Winter's formula: expected pCO2 = 1.5 × 14.4 + 8 ± 2 = 29.6 ± 2).
- The **pO2 of 74 mm Hg is significantly low** (normal range on room air: 80-100 mm Hg), indicating **hypoxemia** that leads to **tissue hypoxia** and **anaerobic metabolism**.
- In the setting of **obesity (BMI 41.5)** and **immediate post-operative status** after laparoscopic surgery, multiple factors contribute to hypoxemia including **atelectasis, reduced functional residual capacity, pain limiting deep breathing, residual anesthetic effects, and pneumoperitoneum effects**.
- Tissue hypoxia results in **lactic acidosis** (a high anion gap metabolic acidosis), which explains the acid-base disturbance. The **elevated BUN (31 mg/dL) with relatively normal creatinine** suggests prerenal azotemia from hypoperfusion, further supporting inadequate tissue oxygenation.
- The **tachycardia (103/min)** represents a compensatory response to improve oxygen delivery to hypoxic tissues.
*Vomiting*
- Vomiting causes loss of **gastric HCl**, resulting in **hypochloremic metabolic ALKALOSIS** (elevated pH and HCO3-), not acidosis.
- While this patient is vomiting, the acid-base status shows **acidosis**, which is the opposite of what vomiting typically causes.
- The low **Cl- (98 mEq/L)** is consistent with some gastric acid loss, but the dominant acid-base disorder is metabolic acidosis from another cause.
*Uremia*
- **Uremia** causes high anion gap metabolic acidosis due to retention of organic acids and phosphates in renal failure.
- While the **BUN is elevated (31 mg/dL)**, the **creatinine (1.1 mg/dL) is essentially normal**, especially for a patient with high muscle mass (130 kg).
- The BUN elevation is more consistent with **prerenal azotemia** (dehydration/hypoperfusion) rather than intrinsic renal failure causing uremic acidosis.
*Late dumping syndrome*
- **Late dumping syndrome** occurs **1-3 hours after eating** and results from rapid carbohydrate absorption causing hyperinsulinemia and subsequent **reactive hypoglycemia**.
- This patient's **glucose is normal (88 mg/dL)**, and symptoms began only **2 hours post-surgery** in the fasting state, not after a meal.
- Late dumping does not cause metabolic acidosis.
*Early dumping syndrome*
- **Early dumping syndrome** occurs **10-30 minutes after eating** due to rapid gastric emptying of hyperosmolar contents into the small intestine, causing fluid shifts.
- Symptoms include **cramping, diarrhea, vasomotor symptoms (flushing, palpitations, dizziness)**, not metabolic acidosis.
- This patient has not yet eaten post-operatively, making dumping syndrome impossible.
Urinary diversion procedures US Medical PG Question 2: A 31-year-old obese Caucasian female presents to the Emergency Department late in the evening for left lower quadrant pain that has progressively worsened over the last several hours. She describes the pain as sharp and shooting, coming and going. Her last bowel movement was this morning. She has also had dysuria and urgency. Her surgical history is notable for gastric bypass surgery 2 years prior and an appendectomy at age 9. She is sexually active with her boyfriend and uses condoms. Her temperature is 99.5 deg F (37.5 deg C), blood pressure is 151/83 mmHg, pulse is 86/min, respirations are 14/minute, BMI 32. On physical exam, she has left lower quadrant tenderness to palpation with pain radiating to the left groin and left flank tenderness on palpation. Her urinalysis shows 324 red blood cells/high power field. Her pregnancy test is negative. What is the next best step in management?
- A. A KUB (kidneys, ureters and bladder) plain film
- B. Noncontrast CT scan (Correct Answer)
- C. Exploratory laparoscopy
- D. Transvaginal ultrasound
- E. Intravenous pyelogram
Urinary diversion procedures Explanation: ***Noncontrast CT scan***
- The patient presents with classic symptoms of **renal colic**, including acute onset, radiating flank and groin pain, dysuria, urgency, and significant hematuria (324 RBCs/HPF) on urinalysis, indicating a likely kidney stone. A **noncontrast CT scan** of the abdomen and pelvis is the most sensitive and specific imaging modality for detecting urinary tract calculi.
- A noncontrast CT scan can readily identify the size, location, and number of stones, as well as detect complications such as **hydronephrosis**, which is crucial for determining the appropriate management strategy.
*A KUB (kidneys, ureters and bladder) plain film*
- While a KUB plain film can identify some radiopaque stones, it has **limited sensitivity and specificity** compared to CT, especially for radiolucent stones, small stones, or stones obscured by bowel gas.
- **It does not provide information about hydronephrosis** or other renal pathologies, making it less useful for comprehensive evaluation of suspected kidney stones.
*Exploratory laparoscopy*
- This is an **invasive surgical procedure** that is not indicated as a primary diagnostic step for suspected kidney stones.
- Exploratory laparoscopy would only be considered if imaging studies reveal an **acute abdominal emergency** requiring surgical intervention or if the diagnosis remained elusive after less invasive methods.
*Transvaginal ultrasound*
- A transvaginal ultrasound is primarily used to evaluate **pelvic reproductive organs** in females, such as the uterus and ovaries.
- While it can sometimes visualize the distal ureters, it has **poor sensitivity for detecting ureteral stones** and is not the preferred imaging modality for kidney stone diagnosis.
*Intravenous pyelogram*
- An intravenous pyelogram (IVP) involves contrast administration and X-rays and was historically used for kidney stone diagnosis. However, it has been **largely replaced by noncontrast CT** due to its lower sensitivity, slower procedure time, and exposure to intravenous contrast and associated risks.
- CT offers superior anatomical detail and can identify stones more accurately without the need for contrast in the setting of suspected renal colic.
Urinary diversion procedures US Medical PG Question 3: A 79-year-old man with a history of prostate cancer is brought to the emergency department because of lower abdominal pain for 1 hour. He has not urinated for 24 hours. Abdominal examination shows a palpable bladder that is tender to palpation. A pelvic ultrasound performed by the emergency department resident confirms the diagnosis of acute urinary retention. An attempt to perform transurethral catheterization is unsuccessful. A urology consultation is ordered and the urologist plans to attempt suprapubic catheterization. As the urologist is called to see a different emergency patient, she asks the emergency department resident to obtain informed consent for the procedure. The resident recalls a lecture about the different modes of catheterization, but he has never seen or performed a suprapubic catheterization himself. Which of the following statements by the emergency department resident is the most appropriate?
- A. “I would prefer that you obtain informed consent when you become available again.” (Correct Answer)
- B. “Suprapubic catheterization is not the treatment of choice for this patient.”
- C. “I would be happy to obtain informed consent on your behalf, but I'm not legally allowed to do so during my residency.”
- D. “I will make sure the patient reads and signs the informed consent form.”
- E. “I will ask the patient to waive informed consent because this is an urgent procedure.”
Urinary diversion procedures Explanation: ***"I would prefer that you obtain informed consent when you become available again."***
- Informed consent requires that the person obtaining consent be **knowledgeable about the procedure**, its risks, benefits, and alternatives, and be able to answer the patient's questions thoroughly. The resident, having never performed or seen the procedure, cannot fulfill this requirement.
- The urologist, as the attending physician performing the procedure and the expert in suprapubic catheterization, is the most appropriate person to **educate the patient and obtain consent**.
*"Suprapubic catheterization is not the treatment of choice for this patient."*
- **Urethral catheterization is the first-line treatment for acute urinary retention**; however, it was unsuccessful.
- **Suprapubic catheterization is the appropriate next step** when transurethral catheterization fails or is contraindicated.
*"I would be happy to obtain informed consent on your behalf, but I'm not legally allowed to do so during my residency."*
- There is **no legal prohibition** for a resident to obtain informed consent, provided they are competent to do so and have adequate knowledge of the procedure.
- The issue here is the resident's **lack of knowledge and experience** with the particular procedure, not their legal status as a resident.
*"I will make sure the patient reads and signs the informed consent form."*
- Simply having the patient read and sign a form is **insufficient for valid informed consent**.
- Informed consent is a **process of communication** that ensures the patient understands the procedure, not just a signature on a document.
*"I will ask the patient to waive informed consent because this is an urgent procedure."*
- While this is an urgent situation, it is **not an emergency that precludes obtaining informed consent**.
- **Waiving informed consent** is generally reserved for life-threatening emergencies where immediate intervention is required to save a patient's life and there is no time to obtain consent, which is not the case here.
Urinary diversion procedures US Medical PG Question 4: A 38-year-old woman presents to the primary care physician with a complaint of painless hematuria over the last 5 days. History reveals that she has a 20 pack-year smoking history, and her last menses was 10 days ago. Her blood pressure is 130/80 mm Hg, heart rate is 86/min, respiratory rate is 19/min, and temperature is 36.6°C (98.0°F). Physical examination is within normal limits. Laboratory studies show:
Creatinine 0.9 mg/dL
Blood urea nitrogen 15 mg/dL
Prothrombin time 12.0 sec
Partial thromboplastin time 28.1 sec
Platelet count 250,000/mm3
Urine microscopy reveals 15 RBC/HPF and no leukocytes, casts, or bacteria. Which of the following is the best next step for this patient?
- A. Cystoscopy (Correct Answer)
- B. Digital rectal examination
- C. Reassurance
- D. Renal biopsy
- E. Check urine for NMP22 and BTA
Urinary diversion procedures Explanation: ***Cystoscopy***
- The patient presents with **painless gross hematuria** and a significant **smoking history**, which are strong risk factors for **bladder cancer**.
- **Cystoscopy** is the definitive diagnostic procedure to visualize the bladder and perform biopsies if suspicious lesions are found.
*Digital rectal examination*
- This examination is primarily used to assess the prostate in men or for colorectal concerns.
- It would not provide diagnostic information for the source of hematuria in a female patient, especially when a urological malignancy is suspected.
*Reassurance*
- While some cases of hematuria are benign, the presence of **painless gross hematuria** and a significant **smoking history** in this patient makes watchful waiting or reassurance inappropriate.
- There is a high index of suspicion for a serious underlying condition like **urothelial carcinoma** that requires urgent investigation.
*Renal biopsy*
- **Renal biopsy** is indicated when there is evidence of glomerular disease (e.g., dysmorphic red blood cells, red blood cell casts, proteinuria, renal insufficiency).
- The patient's urine microscopy shows **eumorphic RBCs** and **no casts or proteinuria**, making glomerular disease less likely, and her renal function is normal.
*Check urine for NMP22 and BTA*
- While **NMP22** and **BTA** are urine markers for bladder cancer, they have **limited sensitivity and specificity** and are not definitive diagnostic tests.
- They are primarily used for surveillance in patients with a history of bladder cancer or in conjunction with cystoscopy, not as a standalone initial diagnostic step.
Urinary diversion procedures US Medical PG Question 5: Please refer to the summary above to answer this question
Which of the following is the most likely diagnosis?
Patient Information
Age: 66 years
Gender: M, self-identified
Ethnicity: African-American
Site of Care: office
History
Reason for Visit/Chief Concern: "I need to go to the bathroom all the time."
History of Present Illness:
1-year history of frequent urination
urinates every 2–3 hours during the day and wakes up at least 3 times at night to urinate
has had 2 episodes of cystitis treated with antibiotics in the past 4 months
has a weak urinary stream
has not noticed any blood in the urine
does not have any pain with urination or ejaculatory dysfunction
Past Medical History:
type 2 diabetes mellitus
nephrolithiasis, treated with percutaneous nephrolithotomy
essential tremor
Medications:
metformin, canagliflozin, propranolol
Allergies:
sulfa drugs
Social History:
sexually active with his wife; does not use condoms consistently
has smoked one pack of cigarettes daily for 50 years
drinks one to two glasses of beer weekly
Physical Examination
Temp Pulse Resp BP O2 Sat Ht Wt BMI
37°C
(98.6°F)
72/min 16/min 134/81 mm Hg –
183 cm
(6 ft)
105 kg
(231 lb)
31 kg/m2
Appearance: no acute distress
Pulmonary: clear to auscultation
Cardiac: regular rate and rhythm; normal S1, S2; S4 gallop
Abdominal: overweight; no tenderness, guarding, masses, bruits, or hepatosplenomegaly
Extremities: no joint erythema, edema, or warmth; dorsalis pedis, radial, and femoral pulses intact
Genitourinary: no lesions or discharge
Rectal: slightly enlarged, smooth, nontender prostate
Neurologic: alert and oriented; cranial nerves grossly intact; no focal neurologic deficits
- A. Urethral stricture
- B. Prostate cancer
- C. Neurogenic bladder
- D. Acute prostatitis
- E. Benign prostatic hyperplasia (Correct Answer)
Urinary diversion procedures Explanation: ***Benign prostatic hyperplasia***
- The patient's symptoms of **frequent urination**, **nocturia**, **weak urinary stream**, and a **slightly enlarged, smooth, nontender prostate** on rectal exam are classic for BPH.
- Recurrent **cystitis** can be a complication of BPH due to incomplete bladder emptying.
*Urethral stricture*
- While a urethral stricture can cause a **weak urinary stream** and incomplete emptying, it would typically present with more significant difficulty voiding, possibly **pain** during urination, or a history of instrumentation/trauma.
- The rectal exam finding of an **enlarged prostate** points away from a primary stricture.
*Prostate cancer*
- Although prostate cancer can cause similar urinary symptoms, an enlarged prostate due to cancer is often described as **nodular, firm, or asymmetric** on rectal exam, not smooth.
- The absence of **hematuria** or significant pain also makes cancer less likely as the primary driver of these symptoms.
*Neurogenic bladder*
- A neurogenic bladder would involve neurological deficits affecting bladder control, such as spinal cord injury, stroke, or severe neuropathy, which are not described in this patient beyond an **essential tremor** unlikely to cause these specific lower urinary tract symptoms.
- The patient has no other neurological symptoms like **focal weakness** or sensory loss.
*Acute prostatitis*
- Acute prostatitis typically presents with **fever, chills, perineal pain, dysuria**, and a **tender, swollen prostate** on examination, none of which are present in this patient.
- The symptoms here are **chronic** (1 year history) rather than acute.
Urinary diversion procedures 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
Urinary diversion procedures 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.
Urinary diversion procedures US Medical PG Question 7: 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)
Urinary diversion procedures 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.
Urinary diversion procedures US Medical PG Question 8: Six hours after near-total thyroidectomy for Graves disease, a 58-year-old man has not had any urine output. The surgery was successful and the patient feels well except for slight neck pain. He has type 2 diabetes mellitus and hypertension. His father had autosomal dominant polycystic kidney disease. Prior to the surgery, the patient was taking metformin and lisinopril regularly and ibuprofen as needed for headaches. His current medications include acetaminophen and codeine. His temperature is 36.2°C (97.2°F), pulse is 82/min, and blood pressure is 122/66 mm Hg. Physical examination shows a 7-cm surgical wound on the anterior neck with mild swelling, but no reddening or warmth. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?
- A. Obtain renal scintigraphy
- B. Perform bedside bladder scan (Correct Answer)
- C. Administer furosemide
- D. Obtain urinalysis
- E. Obtain renal biopsy
Urinary diversion procedures Explanation: **Perform bedside bladder scan**
- The absence of urine output post-surgery is concerning for **urinary retention**, especially given the recent surgery and pain medication use. A bedside bladder scan is the quickest and least invasive way to confirm significant bladder distension.
- Postoperative urinary retention can be caused by various factors, including the effects of anesthesia, pain, immobility, and certain medications like opioids, which the patient is currently receiving (codeine).
*Obtain renal scintigraphy*
- **Renal scintigraphy** is used to assess kidney function and blood flow, but it is not the initial test for acute anuria or oligoanuria in the immediate postoperative period.
- This test would be more appropriate if there was suspicion of a vascular compromise to the kidneys or an intrinsic kidney problem, which is not the most likely cause of acute anuria in this clinical context.
*Administer furosemide*
- Administering a loop diuretic like **furosemide** without knowing if the patient has obstructive uropathy or hypovolemia could be harmful.
- If the patient has urinary retention, furosemide would be ineffective and could potentially worsen dehydration if the anuria is due to severe hypovolemia.
*Obtain urinalysis*
- A **urinalysis** evaluates urine sediment and chemical properties, which would be useful for diagnosing intrinsic kidney disease, infection, or nephrolithiasis.
- However, with complete anuria (no urine output), there is no urine to analyze, making this step impractical and unhelpful in determining the immediate cause of no urine output.
*Obtain renal biopsy*
- A **renal biopsy** is an invasive procedure used to diagnose intrinsic kidney diseases. It carries risks and is not an appropriate initial step for acute anuria after surgery.
- It would only be considered if less invasive tests pinpointed a specific intrinsic renal pathology requiring tissue diagnosis, which is far down the diagnostic algorithm for acute anuria.
Urinary diversion procedures US Medical PG Question 9: A 50-year-old man is brought to the emergency department because of a 3-day history of left flank pain. The patient has had two episodes of urolithiasis during the last year. He initially had pain with urination that improved with oxycodone. Over the past day, the pain has worsened and he has additionally developed fever and chills. He has hypertension and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 20 years. He does not drink alcohol. His current medications include metformin and lisinopril. The patient appears ill and uncomfortable. His temperature is 39.1°C (102.3°F), pulse is 108/min, respirations are 22/min, and blood pressure is 90/62 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. Examination of the back shows left costovertebral angle tenderness. Physical and neurologic examinations show no other abnormalities. Laboratory studies show:
Hemoglobin 14.2 g/dL
Leukocyte count 13,900/mm3
Hemoglobin A1c 8.2%
Serum
Na+ 138 mEq/L
K+ 3.8 mEq/L
Cl-
98 mEq/L
Calcium 9.3 mg/dL
Glucose 190 mg/dL
Creatinine 2.1 mg/dL
Urine pH 8.3
Urine microscopy
Bacteria moderate
RBC 6–10/hpf
WBC 10–15/hpf
WBC casts numerous
Ultrasound shows enlargement of the left kidney with a dilated pelvis and echogenic debris. CT scan shows a 16-mm stone at the left ureteropelvic junction, dilation of the collecting system, thickening of the wall of the renal pelvis, and signs of perirenal inflammation. Intravenous fluid resuscitation and intravenous ampicillin, gentamicin, and morphine are begun. Which of the following is the most appropriate next step in the management of this patient?
- A. Intravenous pyelography
- B. Tamsulosin therapy
- C. Percutaneous nephrostomy (Correct Answer)
- D. Shock wave lithotripsy
- E. Ureteroscopy and stent placement
Urinary diversion procedures Explanation: ***Percutaneous nephrostomy***
- The patient presents with **obstructive pyelonephritis** due to a large **ureteral stone** (16 mm) and signs of **urosepsis** (fever, chills, hypotension, leukocytosis, elevated creatinine).
- **Urgent decompression** of the obstructed kidney is critical to relieve pressure, improve renal function, and control infection. A percutaneous nephrostomy provides immediate drainage, which is life-saving in this severe context.
*Intravenous pyelography*
- This is an imaging study used to visualize the urinary tract and is **contraindicated** in patients with **renal insufficiency** (creatinine 2.1 mg/dL) due to the risk of contrast-induced nephropathy.
- Furthermore, it would only provide diagnostic information and **would not address the urgent need for renal decompression** in a patient with urosepsis.
*Tamsulosin therapy*
- **Alpha-blockers** like tamsulosin can facilitate the passage of **smaller ureteral stones** (typically <10 mm) by relaxing ureteral smooth muscle.
- However, this patient has a **large stone (16 mm)**, signs of **sepsis**, and **renal obstruction**, making medical expulsive therapy ineffective and dangerous as a primary intervention.
*Shock wave lithotripsy*
- **Extracorporeal shock wave lithotripsy (ESWL)** is a non-invasive procedure for breaking up kidney stones into smaller fragments.
- It is **contraindicated** in patients with active **urinary tract infections** or **sepsis** because of the risk of disseminating the infection.
*Ureteroscopy and stent placement*
- While ureteroscopy with stent placement can relieve obstruction, it is an **invasive procedure** that may be challenging in a patient with severe sepsis and inflammation.
- **Percutaneous nephrostomy** offers a less invasive and more immediate way to achieve **decompression** in an unstable patient, with definitive stone management to follow once the infection is controlled.
Urinary diversion procedures US Medical PG Question 10: A 22-year-old man is rushed to the emergency department after a motor vehicle accident. The patient states that he feels weakness and numbness in both of his legs. He also reports pain in his lower back. His airway, breathing, and circulation is intact, and he is conversational. Neurologic exam is significant for bilateral lower extremity flaccid paralysis and impaired pain and temperature sensation up to T10-T11 with normal vibration sense. A computerized tomography scan of the spine is performed which shows a vertebral burst fracture of the vertebral body at the level of T11. Which of the following findings is most likely present in this patient?
- A. Intact vibration sense
- B. Bowel incontinence (Correct Answer)
- C. Flaccid paralysis at the level of the lesion
- D. Spasticity below the lesion
- E. Impaired proprioception sense
Urinary diversion procedures Explanation: ***Bowel incontinence***
- The presented symptoms of acute **bilateral lower extremity flaccid paralysis**, **impaired pain and temperature sensation**, and a T11 **vertebral burst fracture** are highly indicative of **anterior cord syndrome**.
- **Anterior cord syndrome** characteristically involves damage to the **anterior two-thirds of the spinal cord**, affecting the **corticospinal tracts** (motor control), **spinothalamic tracts** (pain and temperature sensation), and the **autonomic fibers** that control bladder and bowel function, leading to **bowel and bladder dysfunction**.
*Intact vibration sense*
- The sensation of **vibration** and **proprioception** is carried by the **dorsal columns** (posterior part of the spinal cord), which are typically **spared** in **anterior cord syndrome**.
- Therefore, **intact vibration sense** is an expected finding, but the question asks for the **most likely finding** that represents a significant complication of the syndrome.
*Flaccid paralysis at the level of the lesion*
- While **flaccid paralysis** is present in the lower extremities, it occurs **below the level of the lesion** due to damage to the descending motor tracts (corticospinal tracts).
- Flaccid paralysis *at* the level of the lesion would typically involve damage to the **lower motor neurons** at that specific segment, which is not the primary feature described for a burst fracture causing **anterior cord syndrome**.
*Spasticity below the lesion*
- **Spasticity** typically develops much **later** in spinal cord injuries, after the initial phase of **spinal shock** resolves (usually weeks to months).
- In the acute phase following a significant spinal cord injury, **flaccid paralysis** is the more common finding below the lesion, reflecting spinal shock.
*Impaired proprioception sense*
- Similar to vibration sense, **proprioception** is primarily mediated by the **dorsal columns**, which are generally **spared** in **anterior cord syndrome**.
- Therefore, **proprioception** would likely be **intact**, not impaired, in this specific type of spinal cord injury.
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