Urinary diversion procedures — MCQs

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 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 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 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?

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 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?

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?

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 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 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?