GenitourinaryttEXAMttMASTER
Att62-year-
oldttwomanttisttbeingtttreatedttforttchronicttcongestivettheartttfailure.ttShetthastt
beenttputttontthydrochlorothiazidetttherapy.ttHerttserumttelectrolytettlevelsttar
ettbeingttmonitoredttandttshowttattpersistenttthypokalemia.
Question
Thettadditionttofttwhattttotthertttherapeuticttregimenttwouldttbettmostttappropri
ate?tt-ttcorrectttanswer✔✔Correctttanswer:
Amiloride
Explanation
Amiloridettisttattpotassium-
sparingttdiuretic.ttItsttdiuretictteffectttisttnotttveryttpotent;tttherefore,ttitttisttgoodt
ttottusettinttcombinationttwithttotherttdiuretics.
Acetazolamidettisttattcarbonicttanhydrasettinhibitor.ttItttcausesttattmildttdiuresi
s,ttattmarkedttelevationttoftturinaryttpH,ttandttattsignificantttlossttofttpotassium.
Furosemidettisttattloopttdiuretic.ttIttthasttattrapidttonsetttofttactionttandttisttattpoten
tttdiuretic.ttHowever,ttitttalsottcausesttpotassiumttdepletionttandttwouldttonlyttw
orsenttthetthypokalemia.
,Indapamidettisttattthiazidettanalogttwithttattlongttdurationttofttaction.ttIfttanythin
g,ttitttwouldttexacerbatettthetthypokalemia.
Mannitolttisttanttosmoticttdiureticttandttwouldttnotttbettrecommendedttinttthisttp
atient.ttFurthermore,ttitttwouldttnottthavettattpotassium-sparingtteffect.
Case
Att42-year-
oldttmanttpresentsttwithttlowerttextremityttswelling.ttHisttpastttmedicaltthistory
ttandttreviewttofttsymptomsttisttotherwisettnegative.ttThettpatientttlooksttcomfo
rtable,ttwithttvitalsttshowingttthettfollowing:ttBPtt142/91ttmmttHg,ttHRtt90ttbeat
s/min,ttRRtt16ttbreaths/min,ttTtt98°F,ttheighttt5'9'',ttandttweighttt158ttlb.ttHisttex
aminationttisttonlyttremarkablettfortt2+ttpittingttedemattinttthettlowerttextremiti
es.ttThettpatientttisttcounseledttonttattlow-
saltttdiet.ttThettabnormalttlaboratoryttvaluesttarettasttfollows:
LabttResult
Urinalysistt3+ttprotein,ttcoarsettgranularttcasts,tt2tt-tt5ttWBCs,tt0tt-tt2ttRBCs
Serumttalbumintt2.1ttgm/dL
Serumttcreatininett2.0ttmg/dL
SerumttBUNtt18ttmg/dL
Hemoglobintt12.1ttgm/dL
,Question
Whatttshouldttbettthettnextttstepttinttthettmanagementttofttthisttpatient?tt-
ttcorrectttanswer✔✔Correctttanswer:
Orderttatt24-hourtturinetttottquantitatetturinettprotein
Explanation
Thettclinicalttpicturettisttmostttconsistentttwithttnephroticttsyndrome.ttThisttsyn
dromettisttcharacterizedttbyttproteinuriattinttexcessttoftt3.5ttgramsttattdayttpertt1.
73ttm3ttbodyttsurfacettarea.ttOtherttsymptomsttcommonlyttseenttincludettedem
a,tthypoalbuminemia,ttandtthyperlipidemia.ttPatientsttmayttalsottexhibitttane
mia.ttUsuallytttherettisttnotttanttactivetturinettsediment.ttThettcorrectttdiagnostic
tttesttttottconfirmttnephroticttsyndromettisttatt24-
hourtturinetttottquantitatettthettproteinttloss.
Ifttthettdiagnosisttisttconfirmed,ttattrenalttbiopsyttmayttbettconsideredtttottaidttintt
determiningttthettcausettofttnephroticttsyndrome.ttHowever,ttbecausettitttisttantti
nvasivetttest,ttitttshouldttnotttbettperformedttuntilttthettdiagnosisttisttestablished.
Thettpatienttthasttnottsymptomsttofttatturinarytttractttinfectionttandttonlyttattsmall
ttnumberttofttWBCsttintthertturinalysis,ttsottatturinettculturettandttempirictttreatm
entttwouldttnotttbettindicated.
Sincettthettpatientttdoesttnottthavetthematuriattorttpain,ttattkidneyttstonettisttunlik
ely;tttherefore,ttanttintravenousttpyelogramttwouldttnotttbettindicated.
, Case
Att54-year-
oldttmanttpresentsttwithttattlumpttintthisttscrotumttrecently.ttAfterttansweringttm
anyttquestionsttaboutttpossiblettsymptomsttandttundergoingttattthoroughttgenit
ourinaryttexamination,ttthettpatientttistttoldttthattthettmostttlikelytthasttatthydroc
ele.
Question
Whatttfindingsttmostttcloselyttsupportttthisttdiagnosis?tt-
ttcorrectttanswer✔✔orrectttanswer:
Non-tender,ttfluid-filledttlesionttthattttransilluminates
ExplanationttThettcorrectttanswerttisttattnon-tender,ttfluid-
filledttlesionttthattttransilluminates.ttAtthydrocelettisttattcollectionttofttfluidttwit
hinttthetttunicattvaginalis.ttItttisttnon-
tender,ttusuallyttdevelopsttslowlyttovertttime,ttandttwilltttransilluminatettwhentt
attlightttisttheldttuptttottthettscrotalttwall.ttPatientsttcanttexperiencettfluctuatingtts
izettofttthetthydrocele,ttswellingttofttthettscrotumttorttinguinalttcanal,ttheavyttsen
sationttwithinttthettscrotum,ttandttdottnottttypicallyttexperiencettanyttpain.
Solidttmassttwithinttthetttesticlettthatttdoesttnottttransilluminatettisttnotttthettcorr
ectttanswer.ttSolidttmassesttthatttarettactuallyttinttthetttesticlettitselfttarettmaligna
nciesttuntilttproventtotherwise.ttPatientsttmaytthavettattreactivetthydrocelettintta
dditiontttottthettmalignancy,ttbuttthydrocelesttdottnotttactuallyttpresentttasttsolidt
Att62-year-
oldttwomanttisttbeingtttreatedttforttchronicttcongestivettheartttfailure.ttShetthastt
beenttputttontthydrochlorothiazidetttherapy.ttHerttserumttelectrolytettlevelsttar
ettbeingttmonitoredttandttshowttattpersistenttthypokalemia.
Question
Thettadditionttofttwhattttotthertttherapeuticttregimenttwouldttbettmostttappropri
ate?tt-ttcorrectttanswer✔✔Correctttanswer:
Amiloride
Explanation
Amiloridettisttattpotassium-
sparingttdiuretic.ttItsttdiuretictteffectttisttnotttveryttpotent;tttherefore,ttitttisttgoodt
ttottusettinttcombinationttwithttotherttdiuretics.
Acetazolamidettisttattcarbonicttanhydrasettinhibitor.ttItttcausesttattmildttdiuresi
s,ttattmarkedttelevationttoftturinaryttpH,ttandttattsignificantttlossttofttpotassium.
Furosemidettisttattloopttdiuretic.ttIttthasttattrapidttonsetttofttactionttandttisttattpoten
tttdiuretic.ttHowever,ttitttalsottcausesttpotassiumttdepletionttandttwouldttonlyttw
orsenttthetthypokalemia.
,Indapamidettisttattthiazidettanalogttwithttattlongttdurationttofttaction.ttIfttanythin
g,ttitttwouldttexacerbatettthetthypokalemia.
Mannitolttisttanttosmoticttdiureticttandttwouldttnotttbettrecommendedttinttthisttp
atient.ttFurthermore,ttitttwouldttnottthavettattpotassium-sparingtteffect.
Case
Att42-year-
oldttmanttpresentsttwithttlowerttextremityttswelling.ttHisttpastttmedicaltthistory
ttandttreviewttofttsymptomsttisttotherwisettnegative.ttThettpatientttlooksttcomfo
rtable,ttwithttvitalsttshowingttthettfollowing:ttBPtt142/91ttmmttHg,ttHRtt90ttbeat
s/min,ttRRtt16ttbreaths/min,ttTtt98°F,ttheighttt5'9'',ttandttweighttt158ttlb.ttHisttex
aminationttisttonlyttremarkablettfortt2+ttpittingttedemattinttthettlowerttextremiti
es.ttThettpatientttisttcounseledttonttattlow-
saltttdiet.ttThettabnormalttlaboratoryttvaluesttarettasttfollows:
LabttResult
Urinalysistt3+ttprotein,ttcoarsettgranularttcasts,tt2tt-tt5ttWBCs,tt0tt-tt2ttRBCs
Serumttalbumintt2.1ttgm/dL
Serumttcreatininett2.0ttmg/dL
SerumttBUNtt18ttmg/dL
Hemoglobintt12.1ttgm/dL
,Question
Whatttshouldttbettthettnextttstepttinttthettmanagementttofttthisttpatient?tt-
ttcorrectttanswer✔✔Correctttanswer:
Orderttatt24-hourtturinetttottquantitatetturinettprotein
Explanation
Thettclinicalttpicturettisttmostttconsistentttwithttnephroticttsyndrome.ttThisttsyn
dromettisttcharacterizedttbyttproteinuriattinttexcessttoftt3.5ttgramsttattdayttpertt1.
73ttm3ttbodyttsurfacettarea.ttOtherttsymptomsttcommonlyttseenttincludettedem
a,tthypoalbuminemia,ttandtthyperlipidemia.ttPatientsttmayttalsottexhibitttane
mia.ttUsuallytttherettisttnotttanttactivetturinettsediment.ttThettcorrectttdiagnostic
tttesttttottconfirmttnephroticttsyndromettisttatt24-
hourtturinetttottquantitatettthettproteinttloss.
Ifttthettdiagnosisttisttconfirmed,ttattrenalttbiopsyttmayttbettconsideredtttottaidttintt
determiningttthettcausettofttnephroticttsyndrome.ttHowever,ttbecausettitttisttantti
nvasivetttest,ttitttshouldttnotttbettperformedttuntilttthettdiagnosisttisttestablished.
Thettpatienttthasttnottsymptomsttofttatturinarytttractttinfectionttandttonlyttattsmall
ttnumberttofttWBCsttintthertturinalysis,ttsottatturinettculturettandttempirictttreatm
entttwouldttnotttbettindicated.
Sincettthettpatientttdoesttnottthavetthematuriattorttpain,ttattkidneyttstonettisttunlik
ely;tttherefore,ttanttintravenousttpyelogramttwouldttnotttbettindicated.
, Case
Att54-year-
oldttmanttpresentsttwithttattlumpttintthisttscrotumttrecently.ttAfterttansweringttm
anyttquestionsttaboutttpossiblettsymptomsttandttundergoingttattthoroughttgenit
ourinaryttexamination,ttthettpatientttistttoldttthattthettmostttlikelytthasttatthydroc
ele.
Question
Whatttfindingsttmostttcloselyttsupportttthisttdiagnosis?tt-
ttcorrectttanswer✔✔orrectttanswer:
Non-tender,ttfluid-filledttlesionttthattttransilluminates
ExplanationttThettcorrectttanswerttisttattnon-tender,ttfluid-
filledttlesionttthattttransilluminates.ttAtthydrocelettisttattcollectionttofttfluidttwit
hinttthetttunicattvaginalis.ttItttisttnon-
tender,ttusuallyttdevelopsttslowlyttovertttime,ttandttwilltttransilluminatettwhentt
attlightttisttheldttuptttottthettscrotalttwall.ttPatientsttcanttexperiencettfluctuatingtts
izettofttthetthydrocele,ttswellingttofttthettscrotumttorttinguinalttcanal,ttheavyttsen
sationttwithinttthettscrotum,ttandttdottnottttypicallyttexperiencettanyttpain.
Solidttmassttwithinttthetttesticlettthatttdoesttnottttransilluminatettisttnotttthettcorr
ectttanswer.ttSolidttmassesttthatttarettactuallyttinttthetttesticlettitselfttarettmaligna
nciesttuntilttproventtotherwise.ttPatientsttmaytthavettattreactivetthydrocelettintta
dditiontttottthettmalignancy,ttbuttthydrocelesttdottnotttactuallyttpresentttasttsolidt
