100 original questions · single best answer · A–E choices
Andrew Bland, MD, FACP, FAAP
Blueprint reviewed October 24, 2026
Prepare for the exam decision
Recognize the presentation, interpret the findings, and select the single best answer to the question asked. Standard entry-level diagnosis and management determine the key. Additional clinical nuance appears only after the answer.
This bank focuses on the NCCPA renal (5%) and genitourinary (4%) blueprint domains. It is not a complete all-system PANCE exam. Items are original educational material, not NCCPA questions or an endorsed product; scores do not predict passing.
How this compares with PANCE
PANCE has 300 questions in five 60-question, 60-minute blocks. Responses can be reviewed and changed within a block until it ends. This site offers one 60-question renal/GU block at that pace, selected across task categories. It does not reproduce the full exam’s organ-system distribution, interface, or psychometric validation.
These items follow the single-best-answer clinical format illustrated by NCCPA public sample questions and critiques, with five choices and a reason for each option. Study mode adds feedback after each checked answer; exam mode withholds it until submission or time expiry.
Choose your session
Check each answer when ready, then read the explanation and continue at your own pace.
The key is the expected answer for the stated item. The discussion explains when additional patient information or changing evidence could alter real care. These labels do not claim knowledge of NCCPA’s unpublished answer keys.
Answers are held in this page until reset or reload. Keep the page open to preserve your attempt.
Study session
Question navigator — answered ✓ · flagged ★
Review your results
Question
Bank item 1
A 45-year-old man has a 3-mm distal ureteral stone on CT. He is afebrile, has two functioning kidneys, a normal creatinine, no pyuria, and pain controlled with oral medication. He can drink and has reliable follow-up. Which initial plan is most appropriate?
Answer and explanation
Correct answer: D. Outpatient observation, analgesia, and scheduled reassessment
Immediate ureteroscopic extraction — Extraction can be needed if observation fails or complications develop; it is not required immediately here.
Empiric antibiotics until the stone passes — There is no evidence of infection in this presentation.
Urgent nephrostomy drainage — Urgent drainage is needed for infected obstruction or other threatened kidney function, neither of which is present.
Outpatient observation, analgesia, and scheduled reassessment — Correct. A small uncomplicated distal stone can be observed with return precautions and confirmation of passage or resolution of obstruction.
Admission for forced intravenous hydration — Forced hydration does not push a stone through and can worsen pain.
Topic: GU · Ureteral stone · Task: Clinical intervention
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: A small uncomplicated distal stone can be observed with return precautions and confirmation of passage or resolution of obstruction.
Clinical interpretation: Observation is correct only because infection, uncontrolled symptoms, and threatened kidney function are excluded. A solitary kidney, AKI, fever, or failed observation can make intervention appropriate even for a small stone.
Further teaching detail
Passage varies with measured width and location. A high passage probability is not a guarantee. Fever, uncontrolled pain, vomiting, anuria, or worsening kidney function changes the plan. Tamsulosin offers its clearest benefit for larger distal stones, especially >5 mm; expulsive use is off-label.
A 28-year-old woman has dysuria, fever of 39°C, nausea, and right costovertebral-angle tenderness. Urinalysis shows pyuria and nitrites; urine culture grows E. coli. Which diagnosis best accounts for these findings?
Answer and explanation
Correct answer: B. Acute pyelonephritis
Acute cystitis — Bladder infection alone does not explain the systemic illness and flank tenderness.
Acute pyelonephritis — Correct. Fever and flank tenderness with urinary infection support kidney involvement.
Drug-induced interstitial nephritis — No culprit medication or sterile inflammatory pattern is described.
Bladder pain syndrome — This is usually chronic and does not cause a febrile E. coli infection.
Urethritis — Urethritis can cause dysuria but is less consistent with this culture and upper-tract presentation.
Topic: GU · Pyelonephritis · Task: Most likely diagnosis
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Fever and flank tenderness with urinary infection support kidney involvement.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 62-year-old woman has eGFR values of 52 and 50 mL/min/1.73 m² four months apart. First-morning UACR values are 120 and 140 mg/g. Which GFR–albuminuria category describes her CKD?
Answer and explanation
Correct answer: D. G3a A2
G3a A1 — A1 requires UACR <30 mg/g.
G3b A2 — G3b requires eGFR 30–44.
G3a A3 — A3 requires UACR >300 mg/g.
G3a A2 — Correct. Persistent eGFR 45–59 is G3a; UACR 30–300 mg/g is A2.
A 68-year-old man with BPH has been unable to urinate for 10 hours and has a painful, distended bladder. Bladder scan shows 850 mL. There is no trauma, blood at the urethral meatus, or known urethral stricture. What should be done first?
Answer and explanation
Correct answer: B. Prompt urethral catheterization
Start tamsulosin and reassess tomorrow — An alpha blocker can support a later voiding trial but does not promptly decompress this bladder.
Prompt urethral catheterization — Correct. Acute retention requires bladder decompression; monitor for complications and address the cause.
Give a loop diuretic — Increasing urine production does not relieve the outlet obstruction.
Schedule elective prostate resection without drainage — Definitive treatment planning should not delay decompression.
Begin finasteride and reassess in a month — Finasteride acts too slowly to manage acute retention.
Why this is the keyed exam answer: Acute retention requires bladder decompression; monitor for complications and address the cause.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 24-year-old man has muscle pain and dark urine after prolonged exertion. Creatine kinase is 38,000 U/L. Which laboratory result requires the most urgent cardiac evaluation and treatment?
Answer and explanation
Correct answer: A. Potassium 6.8 mmol/L
Potassium 6.8 mmol/L — Correct. Severe hyperkalemia can cause fatal arrhythmia and warrants urgent ECG assessment and treatment.
Calcium 8.0 mg/dL without symptoms — Mild asymptomatic hypocalcemia can occur early in rhabdomyolysis and is not the immediate priority here.
Sodium 136 mmol/L — This sodium is within the usual reference range.
Phosphate 5.2 mg/dL — Phosphate can rise with muscle breakdown, but this result is less immediately dangerous than severe hyperkalemia.
Magnesium 2.0 mg/dL — This magnesium is within the usual reference range.
Why this is the keyed exam answer: Severe hyperkalemia can cause fatal arrhythmia and warrants urgent ECG assessment and treatment.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 16-year-old boy develops abrupt severe unilateral scrotal pain and vomiting. The affected testis is high-riding and horizontal, and the ipsilateral cremasteric reflex is absent. He has no dysuria or fever. What is the most likely diagnosis?
Answer and explanation
Correct answer: B. Testicular torsion
Epididymitis — Infection more often produces a gradual inflammatory presentation; these findings prioritize torsion.
Testicular torsion — Correct. Abrupt pain with an abnormal testicular lie and absent reflex strongly suggests torsion.
Varicocele — A varicocele usually causes a chronic, positional ache or painless swelling.
Torsion of the appendix testis — This more often causes focal upper-pole tenderness with a normal testicular lie.
Hydrocele — An uncomplicated hydrocele does not cause this acute ischemic pattern.
Topic: GU · Acute scrotum · Task: Most likely diagnosis
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Abrupt pain with an abnormal testicular lie and absent reflex strongly suggests torsion.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 43-year-old woman has three days of vomiting and diarrhea, orthostatic dizziness, dry mucous membranes, and creatinine 1.8 mg/dL from a baseline of 0.8. Urine sediment is bland and renal ultrasound shows no obstruction. Which mechanism is most likely?
Answer and explanation
Correct answer: E. Reduced kidney perfusion from extracellular volume depletion
Immune-mediated glomerular inflammation — There is no hematuria, proteinuria, or active sediment to support this.
Renal arterial embolism — Abrupt focal pain or an embolic context would be more suggestive.
Bilateral ureteral obstruction — Ultrasound and the clinical history do not support obstruction.
Drug-induced interstitial inflammation — There is no medication trigger or inflammatory sediment.
Reduced kidney perfusion from extracellular volume depletion — Correct. The history and examination support hemodynamic AKI from fluid losses.
Topic: Renal · Hemodynamic AKI · Task: Most likely diagnosis
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: The history and examination support hemodynamic AKI from fluid losses.
Clinical interpretation: Volume loss supports fluid replacement here. Heart failure can also reduce effective kidney perfusion; a congested patient may need decongestion rather than a fluid bolus.
Further teaching detail
Low effective renal perfusion also occurs in heart failure. A low-perfusion label does not automatically justify fluid administration; assess congestion and the cause.
A woman with diabetes has 2+ protein on a random urine dipstick obtained during a routine visit. She is well, without fever, urinary symptoms, menstruation, or recent vigorous exercise. Which test best quantifies albuminuria for CKD risk classification?
Answer and explanation
Correct answer: B. First-morning urine albumin-to-creatinine ratio
Repeat dipstick reported only as plus signs — Dipstick grading is semiquantitative and affected by urine concentration.
First-morning urine albumin-to-creatinine ratio — Correct. UACR quantifies albumin relative to creatinine and is preferred for albuminuria risk classification; confirm persistence.
Spot urine albumin concentration without creatinine — Concentration alone is affected by urine dilution.
Twenty-four-hour creatinine clearance — This estimates clearance and does not quantify albuminuria.
Spot total protein-to-creatinine ratio — PCR measures total protein and can be useful, but it does not directly provide the albumin category requested.
Why this is the keyed exam answer: UACR quantifies albumin relative to creatinine and is preferred for albuminuria risk classification; confirm persistence.
Clinical interpretation: UACR is the requested albuminuria test. PCR is useful for total/nonalbumin protein; selected timed collections remain useful, especially metabolic stone evaluation.
A 66-year-old man taking metformin has stable CKD with repeat eGFR values of 27 mL/min/1.73 m². There is no acute illness. Under FDA kidney-function labeling, which medication should be discontinued because this eGFR is below its labeled threshold?
Answer and explanation
Correct answer: D. Metformin
Losartan with stable potassium and blood pressure — An eGFR of 27 alone is not a reason to stop a tolerated ARB.
Amlodipine — Amlodipine is not contraindicated solely by this eGFR.
Atorvastatin — Atorvastatin is not contraindicated solely by this eGFR.
Metformin — Correct. FDA labeling contraindicates metformin below eGFR 30 because accumulation can increase lactic-acidosis risk.
Dapagliflozin used for CKD protection — This eGFR does not require stopping dapagliflozin used for kidney protection.
Why this is the keyed exam answer: FDA labeling contraindicates metformin below eGFR 30 because accumulation can increase lactic-acidosis risk.
Clinical interpretation: The stem explicitly asks for FDA labeling, so stopping below eGFR 30 is the keyed answer. Selected observational studies of continuing metformin challenge the net benefit of routine discontinuation. They do not establish absence of severe or fatal lactic-acidosis risk. A specialist may document a monitored off-label plan; clarify the rationale rather than independently changing it. This is a label–evidence discussion, not evidence that NCCPA accepts an off-label answer.
Further teaching detail
Metformin is not directly nephrotoxic. Observational target-trial emulations challenge routine discontinuation in selected CKD G4 patients, but do not establish randomized safety or exclude severe/fatal lactic-acidosis risk. If a nephrologist documents an individualized off-label plan, clarify monitoring and sick-day instructions with that clinician; do not casually overrule it or treat it as the FDA recommendation.
After a crush injury, a patient has creatinine 3.1 mg/dL, creatine kinase 45,000 U/L, and urine dipstick 3+ blood with 0–2 RBCs per high-power field. FENa is 0.6%. Which interpretation is most appropriate?
Answer and explanation
Correct answer: A. Pigment-associated tubular injury remains possible despite the low FENa
Pigment-associated tubular injury remains possible despite the low FENa — Correct. Myoglobin-related injury can occur with FENa <1%; the injury context and sediment matter.
The FENa proves volume depletion — A sodium-handling index alone cannot establish volume status.
The FENa excludes urinary obstruction — FENa can be low or high in obstruction and cannot exclude it.
The dipstick proves glomerular hematuria — Heme positivity with few RBCs suggests pigment rather than intact red cells.
The FENa excludes intrinsic kidney injury — Low FENa is not exclusive to hemodynamic AKI.
Why this is the keyed exam answer: Myoglobin-related injury can occur with FENa <1%; the injury context and sediment matter.
Clinical interpretation: A low FENa is a clue to sodium handling, not proof of simple volume depletion. Pigment injury, GN, early obstruction, CKD, and diuretics can change its interpretation.
Calcium phosphate — Calcium phosphate can form wedges or rosettes, rather than the classic envelope pattern.
Cystine — Cystine crystals are typically flat hexagons.
Calcium oxalate — Correct. Calcium oxalate dihydrate crystals classically have an envelope appearance.
Topic: GU · Stone composition · Task: Diagnostic studies
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Calcium oxalate dihydrate crystals classically have an envelope appearance.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 25-year-old woman has three culture-confirmed cystitis episodes in six months. She wants to identify a modifiable exposure. Which additional history is most relevant?
Answer and explanation
Correct answer: B. Use of a spermicide-containing contraceptive
Usual direction of wiping after urination — Routine hygiene assumptions should not replace evidence-based risk assessment.
Use of a spermicide-containing contraceptive — Correct. Spermicides are an established modifiable risk factor for recurrent cystitis.
Whether she always urinates immediately after intercourse — Postcoital voiding has not been established as reliable prevention.
Whether she wears cotton underwear — Underwear material is not an established explanation for recurrent infections.
Preference for showers rather than baths — This is not a comparably established recurrent-UTI risk factor.
Topic: GU · Recurrent UTI risk · Task: History and examination
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Spermicides are an established modifiable risk factor for recurrent cystitis.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A patient with rising creatinine and hypertension has dysmorphic RBCs, RBC casts, and proteinuria on urine microscopy. Which disease process is most strongly suggested?
Answer and explanation
Correct answer: E. Glomerular inflammation
Uncomplicated ureteral colic — Stones may cause hematuria but not this typical glomerular sediment.
Isolated bladder outlet obstruction — Obstruction alone does not explain the active glomerular sediment.
Lower urinary tract infection — Cystitis does not usually generate glomerular red-cell morphology or RBC casts.
Pure hemodynamic reduction in GFR — Uncomplicated hemodynamic AKI generally has a bland sediment.
Glomerular inflammation — Correct. The combination of dysmorphic RBCs, RBC casts, and proteinuria strongly favors glomerular bleeding.
Why this is the keyed exam answer: The combination of dysmorphic RBCs, RBC casts, and proteinuria strongly favors glomerular bleeding.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
Why this is the keyed exam answer: Nitrates and PDE5 inhibitors can cause dangerous hypotension when combined.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 59-year-old woman has had type 2 diabetes for 18 years and has diabetic retinopathy. Over four years, UACR has gradually increased from 80 to 1,100 mg/g and eGFR has declined from 70 to 44 mL/min/1.73 m². Urine sediment is bland. Which cause of CKD is most likely?
Answer and explanation
Correct answer: B. Diabetic kidney disease
Acute renal infarction — An infarction causes an abrupt event rather than this gradual course.
Diabetic kidney disease — Correct. Longstanding diabetes, retinopathy, gradual albuminuria, and a bland sediment fit diabetic kidney disease.
Acute interstitial nephritis — The slow course without a drug trigger or inflammatory urine is less consistent.
Poststreptococcal glomerulonephritis — An acute nephritic syndrome after infection would be more typical.
Autosomal dominant polycystic kidney disease — No cystic imaging pattern or suggestive family history is described.
Why this is the keyed exam answer: Longstanding diabetes, retinopathy, gradual albuminuria, and a bland sediment fit diabetic kidney disease.
Clinical interpretation: This pattern supports diabetic kidney disease without proving it. Abrupt decline, active sediment, systemic features, or an atypical course warrant evaluation for another cause.
An adult patient’s creatinine rises from 1.0 to 1.5 mg/dL in 48 hours. Urine output remains 0.8 mL/kg/hour and kidney replacement therapy is not required. Under KDIGO criteria, which classification applies?
Answer and explanation
Correct answer: E. AKI stage 1
AKI stage 2 — Stage 2 requires a 2.0–2.9-fold creatinine rise or qualifying oliguria.
CKD G3a established by this change — CKD requires chronicity; these two acute creatinine values cannot establish it.
No AKI — The absolute and relative creatinine changes both meet AKI criteria.
AKI stage 3 — No stage 3 creatinine, urine-output, or replacement-therapy criterion is present.
AKI stage 1 — Correct. A 1.5-fold creatinine rise within seven days, or a rise ≥0.3 mg/dL within 48 hours, meets stage 1.
Topic: Renal · AKI staging · Task: Diagnostic studies
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: A 1.5-fold creatinine rise within seven days, or a rise ≥0.3 mg/dL within 48 hours, meets stage 1.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 74-year-old man has new AKI, weak urinary stream, and frequent small voids with dribbling. Which examination finding most directly supports lower urinary tract obstruction with retention?
Answer and explanation
Correct answer: C. A distended, dull-to-percussion suprapubic bladder
Bilateral ankle edema — Edema is nonspecific and does not localize an obstruction.
A systolic heart murmur — A murmur does not directly identify urinary obstruction.
A distended, dull-to-percussion suprapubic bladder — Correct. A palpable or percussible bladder supports retained urine; confirm volume with bladder scan.
Costovertebral-angle tenderness — This can accompany infection or stones and does not establish bladder retention.
Dry mucous membranes — This suggests possible volume depletion rather than directly demonstrating retention.
Topic: GU · Postrenal AKI · Task: History and examination
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: A palpable or percussible bladder supports retained urine; confirm volume with bladder scan.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A woman with CKD has a clinic BP of 148/84 mm Hg measured immediately after walking in, while talking, with her arm unsupported. Before comparing this value with an intensive standardized-office BP target, which step is most appropriate?
Answer and explanation
Correct answer: E. Repeat BP after seated rest using correct cuff size and supported arm
Measure over a thick sleeve to improve comfort — The cuff should be placed on the bare arm.
Ask her to keep talking during measurement — Talking can distort the reading.
Use a smaller cuff to improve contact — An undersized cuff can falsely elevate BP.
Use the first reading without repeating it — An unstandardized value may overestimate resting BP.
Repeat BP after seated rest using correct cuff size and supported arm — Correct. Standardized measurement is necessary before applying a target derived from standardized readings.
Topic: Renal · BP measurement · Task: History and examination
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: Standardized measurement is necessary before applying a target derived from standardized readings.
Clinical interpretation: The exam decision is to obtain a valid measurement. KDIGO’s intensive target refers to standardized readings and tolerability; a casual reading, frailty, or symptomatic orthostasis can change treatment decisions.
Further teaching detail
KDIGO suggests standardized-office systolic BP <120 mm Hg when tolerated in many adults with nondialysis CKD. This is not interchangeable with a casual clinic reading. Frailty, orthostasis, comorbidity, and other guidelines affect individual goals.
A 27-year-old man notices a firm, painless nodule within one testis. It does not transilluminate. Which study is the best initial imaging test?
Answer and explanation
Correct answer: D. Scrotal ultrasound
PET scan — PET is not routine initial diagnostic imaging for a testicular mass.
CT of the chest — Chest imaging may be part of staging after a suspected tumor is evaluated, not the initial local test.
Retrograde urethrogram — This examines the urethra rather than the testis.
Scrotal ultrasound — Correct. Ultrasound establishes whether a lesion is intratesticular and characterizes both testes.
Abdominal radiograph — A plain radiograph does not characterize a testicular mass.
Topic: GU · Testicular mass · Task: Diagnostic studies
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Ultrasound establishes whether a lesion is intratesticular and characterizes both testes.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 64-year-old man has bothersome voiding symptoms attributed to BPH despite lifestyle measures. Urinalysis is normal, postvoid residual is 45 mL, and there is no orthostatic hypotension. He wants medication that relaxes outlet smooth muscle and usually improves symptoms within days to weeks. Which drug fits this goal?
Answer and explanation
Correct answer: C. Tamsulosin
Finasteride — This reduces prostate volume over months and is most useful with demonstrable enlargement.
Oxybutynin — This targets bladder storage symptoms and is not the requested outlet-relaxing treatment.
Tamsulosin — Correct. An alpha-1 blocker relaxes prostate/bladder-neck smooth muscle and acts relatively quickly.
Dutasteride — This is another slower-acting 5-alpha-reductase inhibitor.
Desmopressin — This can target selected nocturnal polyuria, with sodium precautions, rather than outlet resistance.
Why this is the keyed exam answer: An alpha-1 blocker relaxes prostate/bladder-neck smooth muscle and acts relatively quickly.
Clinical interpretation: Tamsulosin fits the stated rapid-relief mechanism. Prostate size, retention risk, storage symptoms, erectile dysfunction, orthostasis, and preferences can favor other or combined treatments.
A 38-year-old woman with ADPKD asks whether she should discuss screening for an intracranial aneurysm. She has no acute symptoms and would be eligible for preventive treatment. Which family-history detail most strongly supports screening?
Answer and explanation
Correct answer: E. Her mother had an aneurysmal subarachnoid hemorrhage
Her father has essential hypertension — Hypertension matters clinically but is not this specific familial screening trigger.
Her sister has calcium oxalate stones — Stones do not create the same aneurysm risk history.
Her grandmother had cataract surgery — This does not support ADPKD-associated aneurysm screening.
Her brother has uncomplicated diverticulosis — Diverticular disease is a possible extrarenal association, not this aneurysm-screening trigger.
Her mother had an aneurysmal subarachnoid hemorrhage — Correct. A family history of intracranial aneurysm or subarachnoid hemorrhage is a key screening indication in ADPKD.
Topic: Renal · ADPKD risk · Task: History and examination
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: A family history of intracranial aneurysm or subarachnoid hemorrhage is a key screening indication in ADPKD.
Clinical interpretation: The family history supports aneurysm screening. A thunderclap headache requires emergency evaluation, not an elective screening MRA; a nonspecific headache alone does not establish an aneurysm.
Further teaching detail
Noncontrast time-of-flight MRA is generally preferred for screening. Sudden thunderclap headache is an emergency, not a routine screening visit. Other symptoms and patient preferences may also warrant specialist discussion.
A 55-year-old woman has fever of 39.4°C, tachycardia, pyuria, and a 7-mm ureteral stone with hydronephrosis. After initial sepsis resuscitation and IV antibiotics, what is the essential next intervention?
Answer and explanation
Correct answer: A. Urgent urinary drainage with a ureteral stent or nephrostomy
Urgent urinary drainage with a ureteral stent or nephrostomy — Correct. An infected obstructed collecting system needs prompt source control.
Observation until the stone passes — Observation leaves the infected system obstructed.
Tamsulosin alone — Medical expulsive therapy does not provide urgent drainage.
Outpatient oral antibiotics without drainage — Antibiotics alone are insufficient source control for infected obstruction.
Immediate definitive lithotripsy before infection control — Definitive stone treatment is generally delayed until infection is controlled; drainage comes first.
Why this is the keyed exam answer: An infected obstructed collecting system needs prompt source control.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A patient taking naproxen has BUN 54 mg/dL and creatinine 1.0 mg/dL. He is not hypotensive. Which additional history most directly suggests a nonrenal contribution to the high BUN-to-creatinine ratio?
Answer and explanation
Correct answer: B. Black, tarry stools
Painful red urine with clots — This suggests a urinary bleeding source, not digestion of blood in the upper GI tract.
Black, tarry stools — Correct. Digestion of blood from an upper GI bleed can increase urea generation; bleeding may also cause volume loss.
A new rash after an antibiotic — This can suggest a drug reaction or interstitial nephritis, not excess urea generation from digested blood.
Colicky flank pain radiating to the groin — This suggests a ureteral stone rather than an upper GI source of urea.
Hesitancy with incomplete bladder emptying — This suggests retention, which requires assessment but does not specifically identify a nonrenal urea source.
Topic: Renal · BUN/creatinine limitations · Task: History and examination
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: Digestion of blood from an upper GI bleed can increase urea generation; bleeding may also cause volume loss.
Clinical interpretation: Upper GI bleeding can raise urea without a primary fall in GFR, but bleeding and volume depletion may coexist. The ratio should not determine fluid treatment by itself.
Further teaching detail
Catabolism, corticosteroids, protein intake, liver function, and muscle mass also affect this ratio. Interpret it with the history, examination, creatinine trend, and urine findings.
A 35-year-old woman had microscopic hematuria during culture-confirmed cystitis. Her urinary symptoms resolve after appropriate treatment. What follow-up is most appropriate to confirm that the hematuria was transient?
Answer and explanation
Correct answer: E. Repeat urinalysis with microscopy after the infection has resolved
Immediate kidney biopsy in every case — Biopsy is not indicated solely by infection-associated hematuria without a renal pattern.
No further testing because infection permanently explains hematuria — Hematuria should be shown to resolve rather than indefinitely attributed to infection.
Annual CT urography regardless of repeat urinalysis — Routine serial CT is not the next step for this presentation.
Urine cytology alone — Cytology does not replace repeat microscopy in this setting.
Repeat urinalysis with microscopy after the infection has resolved — Correct. Document resolution; persistent hematuria requires risk-based evaluation.
Topic: GU · Hematuria follow-up · Task: Health maintenance and prevention
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Document resolution; persistent hematuria requires risk-based evaluation.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A patient with advanced CKD has elevated PTH, a normal 25-hydroxyvitamin D concentration, and low calcitriol. Which kidney process is impaired?
Answer and explanation
Correct answer: D. Conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D
Skin synthesis of cholecalciferol — This is a cutaneous process and does not explain normal substrate with reduced renal activation.
Renal degradation of calcitriol by 24-hydroxylation — Reduced degradation would tend to preserve calcitriol, not explain reduced synthesis.
Hepatic conversion of vitamin D to 25-hydroxyvitamin D — The normal 25-hydroxyvitamin D value argues against this as the stated defect.
Conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D — Correct. Reduced renal activation of vitamin D contributes to secondary hyperparathyroidism.
Hepatic synthesis of vitamin D-binding protein — This is not the impaired renal activation step described.
Why this is the keyed exam answer: Reduced renal activation of vitamin D contributes to secondary hyperparathyroidism.
Clinical interpretation: Reduced renal vitamin-D activation explains the laboratory pattern. It does not mean every elevated PTH requires calcitriol; assess trends, calcium, phosphate, vitamin D, and severity.
Further teaching detail
An elevated PTH alone does not automatically require activated vitamin D in nondialysis CKD. Assess trends and modifiable factors; treatment is individualized for severe, progressive hyperparathyroidism.
A nonpregnant 24-year-old woman has two days of dysuria and urinary frequency, positive nitrites, and pyuria. She has no fever, flank pain, or vaginal symptoms. eGFR is 95 mL/min/1.73 m² and she has no drug allergies. Which regimen is a recommended option for acute uncomplicated cystitis?
Answer and explanation
Correct answer: D. Nitrofurantoin 100 mg orally twice daily for 5 days
Nitrofurantoin 100 mg once as a single dose — A single nitrofurantoin dose is not an adequate treatment course.
IV vancomycin for 14 days — This is unnecessarily broad parenteral treatment and does not appropriately target typical gram-negative cystitis.
Fluconazole orally for 3 days — There is no evidence of a fungal infection.
Nitrofurantoin 100 mg orally twice daily for 5 days — Correct. This is a recommended bladder-infection regimen when kidney function is adequate.
Amoxicillin empirically without regard to susceptibility — Resistance makes empiric plain amoxicillin an unreliable choice in many settings.
Why this is the keyed exam answer: This is a recommended bladder-infection regimen when kidney function is adequate.
Clinical interpretation: Nitrofurantoin fits bladder-confined infection with adequate renal function. Fever, flank pain, pregnancy, resistance, allergy, or reduced function can change the antibiotic choice.
A 49-year-old woman is newly diagnosed with type 2 diabetes. She has no urinary symptoms and her serum creatinine is within the laboratory reference interval. Which kidney assessment should be included now?
Answer and explanation
Correct answer: E. Calculate eGFR and obtain a spot UACR
Defer all kidney testing until edema appears — Kidney disease may be asymptomatic for years.
Measure BUN alone — BUN is affected by many nonfiltration factors and does not assess albuminuria.
Obtain a screening CT of the kidneys — Imaging is not the routine initial diabetes kidney-screening test.
Obtain a urine culture as the only kidney test — Culture assesses infection, not CKD risk.
Calculate eGFR and obtain a spot UACR — Correct. Creatinine alone can miss reduced filtration or albuminuric kidney disease.
Topic: Renal · Diabetes screening · Task: Health maintenance and prevention
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Creatinine alone can miss reduced filtration or albuminuric kidney disease.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 67-year-old man reports progressive hesitancy, weak stream, and nocturia without fever or dysuria. Which prostate examination finding most supports BPH as a contributor?
Answer and explanation
Correct answer: D. Smooth, symmetric, nontender enlargement
A normal-sized gland with exquisite focal fluctuance — Fluctuance raises concern for an abscess, not uncomplicated benign enlargement.
Marked tenderness with a boggy gland — This suggests acute prostatitis in an appropriate clinical context.
A hard irregular nodule — This raises concern for malignancy rather than uncomplicated BPH.
Smooth, symmetric, nontender enlargement — Correct. This is compatible with benign enlargement in a patient with voiding symptoms.
A fixed asymmetric induration — This is concerning for malignancy.
Topic: GU · Lower urinary tract symptoms · Task: History and examination
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: This is compatible with benign enlargement in a patient with voiding symptoms.
Clinical interpretation: A smooth enlarged prostate supports BPH but does not exclude cancer or other causes of LUTS. Neither examination nor one PSA cutoff is definitive.
Further teaching detail
Neither a benign examination nor a PSA below a single cutoff excludes prostate cancer. LUTS also has bladder, neurologic, and medication-related causes.
A patient has creatinine 2.4 mg/dL with no prior laboratory records available. Which ultrasound finding most strongly supports longstanding parenchymal kidney disease?
Answer and explanation
Correct answer: D. Bilaterally small kidneys with cortical thinning
A normally distended bladder — Bladder filling alone does not establish chronic kidney disease.
Mild isolated unilateral pelviectasis — This may reflect collecting-system dilation and does not establish diffuse chronic parenchymal loss.
Normal-sized kidneys with preserved cortex — Normal size does not exclude CKD but is less supportive of established atrophy.
Bilaterally small kidneys with cortical thinning — Correct. Reduced size and thin cortex support chronic parenchymal loss.
A single simple cortical cyst — A solitary simple cyst does not establish diffuse chronic disease.
Why this is the keyed exam answer: Reduced size and thin cortex support chronic parenchymal loss.
Clinical interpretation: Small kidneys and cortical thinning support chronicity. Diabetes, amyloid, infiltrative disorders, and ADPKD may produce CKD with normal or enlarged kidneys.
A 26-year-old man has a solid intratesticular mass. In this setting, substantial elevation of which serum marker most strongly indicates a nonseminomatous component rather than pure seminoma?
Answer and explanation
Correct answer: B. Alpha-fetoprotein
Carcinoembryonic antigen — CEA is not a standard marker for distinguishing these testicular tumors.
Alpha-fetoprotein — Correct. Pure seminoma does not produce AFP; a significant elevation suggests a nonseminomatous component after other causes are considered.
Prostate-specific antigen — PSA is not a germ-cell-tumor marker.
Beta-human chorionic gonadotropin — Beta-hCG can be elevated in seminoma as well as nonseminomatous tumors.
Lactate dehydrogenase — LDH is nonspecific and does not distinguish these tumor categories.
Why this is the keyed exam answer: Pure seminoma does not produce AFP; a significant elevation suggests a nonseminomatous component after other causes are considered.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 61-year-old woman with type 2 diabetes has eGFR 42 mL/min/1.73 m² and persistent UACR 1,000 mg/g despite a maximally tolerated ARB. Potassium is 4.5 mmol/L. BP is 128/76 mm Hg and HbA1c is 6.9%. She has no prior ketoacidosis or recurrent genital infections. Which addition best provides further kidney and heart-failure protection?
Answer and explanation
Correct answer: B. Dapagliflozin
Furosemide solely to lower UACR — A loop diuretic treats congestion but is not a substitute for disease-modifying therapy.
Dapagliflozin — Correct. An SGLT2 inhibitor provides organ protection in eligible CKD even when HbA1c is near target.
Ibuprofen — An NSAID does not provide kidney protection and can precipitate AKI.
Glyburide solely to lower HbA1c further — Additional glucose lowering with this agent is not the requested organ-protective strategy and increases hypoglycemia risk in CKD.
Lisinopril added to the ARB — Dual ACE inhibitor–ARB treatment increases adverse effects without a favorable net benefit.
Why this is the keyed exam answer: An SGLT2 inhibitor provides organ protection in eligible CKD even when HbA1c is near target.
Clinical interpretation: An SGLT2 inhibitor fits the kidney-protection decision despite near-target HbA1c. Finerenone and other therapy may also be appropriate; sequencing, potassium, comorbid heart failure, tolerability, and cost matter.
Further teaching detail
Persistent albuminuria may also support finerenone when kidney function and potassium permit. ACE inhibitors and ARBs are alternatives, not a combination; ARNI has a distinct role in eligible heart failure.
A 15-year-old boy has abrupt severe testicular pain, a high-riding transverse testis, and an absent cremasteric reflex. The emergency clinician has high suspicion for torsion, and obtaining ultrasound would substantially delay treatment. What is the best next step?
Answer and explanation
Correct answer: A. Immediate urologic surgical assessment and exploration
Immediate urologic surgical assessment and exploration — Correct. High clinical suspicion warrants urgent exploration without an imaging delay.
Wait for routine outpatient ultrasound — Delay threatens testicular viability.
Obtain a CT pelvis before contacting urology — CT is not the appropriate test and delays definitive care.
Discharge with scrotal support and analgesia — Supportive treatment alone leaves possible ischemia untreated.
Give oral antibiotics and reassess in 48 hours — This does not treat torsion.
Why this is the keyed exam answer: High clinical suspicion warrants urgent exploration without an imaging delay.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A patient with AKI has potassium 7.1 mmol/L and new QRS widening. Cardiac monitoring and IV access are established. Which treatment should be given immediately to stabilize the myocardium while potassium-shifting and removal therapies are arranged?
Answer and explanation
Correct answer: E. Intravenous calcium
Intravenous furosemide alone — Urinary potassium removal depends on kidney response and does not provide immediate membrane stabilization.
Oral sodium zirconium cyclosilicate alone — A binder does not replace immediate membrane stabilization in this ECG emergency.
Oral sodium bicarbonate alone — This does not rapidly protect the myocardium in this setting.
Oral potassium restriction alone — Dietary restriction is far too slow for the current threat.
Intravenous calcium — Correct. Calcium rapidly reduces cardiac membrane excitability; it does not lower serum potassium.
Why this is the keyed exam answer: Calcium rapidly reduces cardiac membrane excitability; it does not lower serum potassium.
Clinical interpretation: IV calcium is the immediate answer because ECG toxicity is present. It must be followed by potassium shifting and removal. A binder-based outpatient plan applies to a different severity and setting.
A 64-year-old postmenopausal woman has three culture-confirmed cystitis episodes in a year and bothersome vaginal dryness with atrophic changes. She has no current infection, unexplained vaginal bleeding, or contraindication to local estrogen. Which preventive option best addresses this contributing condition?
Answer and explanation
Correct answer: C. Low-dose vaginal estrogen
Systemic oral estrogen solely for UTI prevention — Systemic estrogen is not recommended solely for recurrent-UTI prevention.
Fluconazole prophylaxis — The history documents bacterial cystitis, not recurrent candidiasis.
Low-dose vaginal estrogen — Correct. Local estrogen is recommended for eligible peri/postmenopausal women with recurrent UTI and hypoestrogenic changes.
Postcoital voiding as the sole proven preventive treatment — Postcoital voiding has not been established as reliable prevention.
Daily vaginal antiseptic douching — Douching is not an evidence-based preventive strategy and may cause irritation.
Topic: GU · Recurrent UTI prevention · Task: Health maintenance and prevention
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: Local estrogen is recommended for eligible peri/postmenopausal women with recurrent UTI and hypoestrogenic changes.
Clinical interpretation: The answer concerns low-dose vaginal estrogen for recurrent UTI in an eligible postmenopausal patient. It is not an endorsement of systemic estrogen for UTI prevention, and the evidence for one formulation should not be generalized to all hormone regimens.
An asymptomatic 56-year-old man at average prostate-cancer risk asks whether he should have a PSA test. He is healthy and has no prior PSA result. Which approach is most appropriate?
Answer and explanation
Correct answer: C. Discuss potential benefits and harms and make a shared screening decision
Use digital rectal examination alone as a definitive screening test — DRE alone is not an adequate substitute for a shared PSA-screening decision.
Order annual PSA testing without discussing tradeoffs — Screening is not a mandatory annual test for every adult man.
Discuss potential benefits and harms and make a shared screening decision — Correct. Screening should reflect informed preferences, risk, and life expectancy.
Explain that a PSA below 4 ng/mL rules out cancer — No single PSA threshold excludes cancer.
Recommend immediate prostate biopsy before any screening test — Biopsy is not the first step for an average-risk asymptomatic patient.
Topic: GU · Prostate screening · Task: Professional practice
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: Screening should reflect informed preferences, risk, and life expectancy.
Clinical interpretation: Shared decision-making is the correct approach. Age, family/genetic risk, prior PSA, health, and life expectancy can change when testing begins, its interval, or whether it continues.
A 57-year-old woman develops AKI six weeks after starting omeprazole. Urinalysis shows sterile pyuria and occasional WBC casts. Ultrasound shows no obstruction. She has no rash or fever. Which diagnosis should be strongly considered?
Answer and explanation
Correct answer: B. Drug-induced acute interstitial nephritis
Renal colic from a ureteral stone — There is no colic or obstruction.
Drug-induced acute interstitial nephritis — Correct. A new implicated drug plus inflammatory urine findings supports AIN; the classic hypersensitivity triad is often absent.
Chronic diabetic kidney disease alone — The acute medication-associated change and pyuria need another explanation.
Uncomplicated cystitis — A sterile culture and kidney dysfunction after a drug exposure favor another process.
Minimal change disease alone — Heavy proteinuria and nephrotic features would be expected rather than this interstitial pattern.
Topic: Renal · Drug-associated AKI · Task: Most likely diagnosis
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: A new implicated drug plus inflammatory urine findings supports AIN; the classic hypersensitivity triad is often absent.
Clinical interpretation: AIN is a working diagnosis supported by exposure and urine findings. WBC casts and the absence of fever/rash are not definitive; assess competing causes and whether biopsy is needed.
Further teaching detail
WBC casts indicate renal inflammation, not one unique diagnosis. Review medications, stop the suspected trigger when appropriate, and obtain nephrology assessment; biopsy may be needed.
An 8-year-old boy develops periorbital edema, hypertension, and cola-colored urine two weeks after streptococcal pharyngitis. Urine contains RBC casts and serum C3 is low. What is the most likely diagnosis?
Answer and explanation
Correct answer: D. Poststreptococcal glomerulonephritis
Hypercalciuria — Hypercalciuria may cause hematuria but does not fit the low-C3 nephritic syndrome.
IgA nephropathy — Hematuria often occurs during or shortly after a respiratory infection, typically with normal complement.
Minimal change disease — This more typically causes nephrotic proteinuria without this nephritic sediment.
Poststreptococcal glomerulonephritis — Correct. The latent interval, nephritic sediment, and low C3 support poststreptococcal GN.
Acute cystitis — Cystitis does not explain low complement, RBC casts, and edema.
Topic: Renal · Postinfectious GN · Task: Most likely diagnosis
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: The latent interval, nephritic sediment, and low C3 support poststreptococcal GN.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A healthy 58-year-old man has an incidental 3-cm solid enhancing renal cortical mass on a contrast CT obtained for another reason. There is no metastatic disease described. What is the most appropriate next step?
Answer and explanation
Correct answer: D. Refer to urology for renal-mass assessment and shared treatment planning
Reassure him that all incidental renal lesions are simple cysts — Solid enhancement is not the appearance of a simple cyst.
Start systemic chemotherapy without tissue or staging review — This is not appropriate initial management of a localized renal mass.
Perform immediate radical nephrectomy without specialist evaluation — Management may include nephron-sparing treatment or selected surveillance; a radical operation is not automatic.
Refer to urology for renal-mass assessment and shared treatment planning — Correct. An enhancing solid mass requires evaluation; management depends on tumor and patient factors.
Treat empirically with antibiotics and assume resolution — There is no evidence of infection.
Topic: GU · Renal mass · Task: Clinical intervention
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: An enhancing solid mass requires evaluation; management depends on tumor and patient factors.
Clinical interpretation: Urologic assessment is the exam answer; it does not commit the patient to radical nephrectomy. Size, anatomy, comorbidity, biopsy results when useful, and preferences guide surveillance or intervention.
A hospitalized adult develops a generalized seizure. Serum sodium is 112 mmol/L and measured serum osmolality is low; glucose is normal. Airway support and seizure management are underway. Which sodium-directed treatment is indicated immediately?
Answer and explanation
Correct answer: A. Carefully monitored intravenous 3% saline bolus therapy
Carefully monitored intravenous 3% saline bolus therapy — Correct. Severe neurologic symptoms from hypotonic hyponatremia require prompt hypertonic saline with frequent reassessment.
Oral salt tablets alone — Oral treatment is inadequate for this emergency.
Rapid infusion of dextrose water — Electrolyte-free water can worsen hyponatremia.
Tolvaptan as the initial rescue treatment — A vaptan is not emergency seizure rescue and can cause uncontrolled correction.
Fluid restriction alone — Restriction alone is too slow during a seizure.
Topic: Renal · Severe hyponatremia · Task: Clinical intervention
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: Severe neurologic symptoms from hypotonic hyponatremia require prompt hypertonic saline with frequent reassessment.
Clinical interpretation: Seizure makes hypertonic saline urgent. After initial symptom control, the safe correction plan depends on chronicity, urine output, potassium, and osmotic-demyelination risk.
Further teaching detail
The immediate goal is a small controlled sodium rise sufficient to improve symptoms, not normalization. Monitor sodium and urine output closely and prevent overcorrection; chronicity and ODS risk guide correction limits.
A 4-year-old child has edema, urine protein 4+, serum albumin 1.8 g/dL, normal blood pressure and kidney function, and normal C3. Urine has no RBC casts. Which underlying disorder is most likely?
Answer and explanation
Correct answer: A. Minimal change disease
Minimal change disease — Correct. This is the typical presentation of childhood idiopathic nephrotic syndrome.
IgA nephropathy — Hematuria is a more typical presenting clue.
Diabetic kidney disease — The age and history do not support longstanding diabetic injury.
Acute pyelonephritis — There is no fever, pyuria, or infectious syndrome.
Poststreptococcal glomerulonephritis — Low C3 and a nephritic sediment would be more typical.
Why this is the keyed exam answer: This is the typical presentation of childhood idiopathic nephrotic syndrome.
Clinical interpretation: The classic childhood presentation makes minimal change disease likely. Atypical features or steroid resistance change the diagnostic workup and biopsy decision.
A recurrent calcium-stone former has 24-hour urine volume 1.1 L/day. Urine calcium and citrate are within the laboratory reference ranges. He has no heart failure or fluid restriction. Which initial counseling target is most appropriate?
Answer and explanation
Correct answer: A. Increase fluid intake enough to produce at least 2.5 L of urine daily
Increase fluid intake enough to produce at least 2.5 L of urine daily — Correct. A urine-output target accounts for variable fluid losses better than one fixed intake amount.
Start a thiazide solely because he has had any calcium stone — Medication should reflect recurrence risk, evaluation, expected benefit, and adverse effects rather than an automatic rule.
Limit all fluids after breakfast — This would worsen low urine volume.
Eliminate all dietary calcium — Normal dietary calcium is generally preferred; extreme restriction can increase oxalate absorption.
Increase sodium intake substantially — High sodium can increase urinary calcium excretion.
Topic: GU · Stone prevention · Task: Health maintenance and prevention
Exam answer and clinical care
Guidance–evidence tension
Why this is the keyed exam answer: A urine-output target accounts for variable fluid losses better than one fixed intake amount.
Clinical interpretation: Higher urine volume remains a guideline-based prevention target, but implementing advice is not the same as proving fewer clinical recurrences in every trial. Recent prevention studies have mixed or limited results. Individualize feasible measures and medications, review adverse effects, and retain metabolic 24-hour urine evaluation for appropriate stone formers.
Further teaching detail
A 24-hour metabolic urine collection remains useful in selected stone formers; it is a different use from routine CKD albuminuria quantification. Recent prevention trials leave uncertainty about the size of clinical benefit. Favor feasible low-risk measures and reassess medication benefit and adverse effects.
Three days after starting trimethoprim, a patient’s creatinine rises from 0.9 to 1.2 mg/dL. Urine output, potassium, urinalysis, and cystatin-C-based eGFR are unchanged. Which mechanism best explains this isolated change?
Answer and explanation
Correct answer: A. Inhibition of tubular creatinine secretion
Inhibition of tubular creatinine secretion — Correct. Trimethoprim can raise measured serum creatinine without a corresponding fall in filtration.
Increased creatinine removal by the liver — This would not explain a rise.
Obligatory irreversible glomerular destruction — This pattern does not establish structural kidney damage.
Increased glomerular creatinine filtration — Increased filtration would tend to lower serum creatinine.
Direct interference with every creatinine laboratory assay — The classic effect is altered renal secretion, not universal analytic interference.
Why this is the keyed exam answer: Trimethoprim can raise measured serum creatinine without a corresponding fall in filtration.
Clinical interpretation: The stable cystatin-C estimate and other findings support a secretion effect in this stem. Trimethoprim can also cause hyperkalemia and true AKI; the same creatinine rise without those reassuring data needs assessment.
Further teaching detail
Trimethoprim can also cause hyperkalemia, and trimethoprim–sulfamethoxazole can be associated with true AKI. Do not dismiss every creatinine rise as a secretion effect.
A 29-year-old woman at 22 weeks of pregnancy has colicky flank pain and microscopic hematuria. She is afebrile and hemodynamically stable. Which imaging study is preferred first for suspected urinary stones?
Answer and explanation
Correct answer: B. Renal and bladder ultrasound
Routine-dose noncontrast CT as the first test — CT may be justified if needed after assessment, but it is not the preferred first study here.
Renal and bladder ultrasound — Correct. Ultrasound is the preferred initial imaging approach in pregnancy.
Intravenous pyelography — This involves radiation and is not preferred first-line imaging.
PET/CT — This is not an appropriate stone evaluation.
Abdominal radiography alone — This has limited diagnostic value and uses ionizing radiation.
Topic: GU · Imaging in pregnancy · Task: Diagnostic studies
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: Ultrasound is the preferred initial imaging approach in pregnancy.
Clinical interpretation: Pregnancy makes ultrasound the first choice. A nondiagnostic study with ongoing concern may require additional imaging, including carefully justified CT; imaging is not categorically forbidden.
A patient receiving maintenance hemodialysis has persistently elevated phosphate despite dietary counseling and adequate dialysis. A phosphate binder is prescribed. When should it generally be taken to work as intended?
Answer and explanation
Correct answer: C. With meals containing phosphate
Only immediately after each dialysis session — Binding is linked to food intake, not solely the dialysis schedule.
Only when bone pain occurs — Treatment is guided by serial biochemical assessment, not intermittent pain.
With meals containing phosphate — Correct. Binders act in the gut on ingested phosphate.
Only at bedtime on an empty stomach — This misses much of the dietary phosphate load.
Several hours before every meal — Separating the binder widely from food reduces its opportunity to bind meal phosphate.
Topic: Renal · CKD mineral management · Task: Pharmaceutical therapeutics
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: Binders act in the gut on ingested phosphate.
Clinical interpretation: A binder with meals fits persistent hyperphosphatemia on dialysis. Normal phosphate in nondialysis CKD is not an automatic indication for a binder or activated vitamin D.
Further teaching detail
Do not prescribe a binder merely because CKD or elevated PTH is present when phosphate is normal. Consider calcium, phosphate, and PTH together over time.
A patient is found to have eGFR 28 mL/min/1.73 m² today. Which additional finding most directly establishes that reduced GFR was already present for more than three months?
Answer and explanation
Correct answer: C. Documented eGFR 29 mL/min/1.73 m² five months earlier
BUN 60 mg/dL today — A single BUN cannot establish chronicity.
Fatigue during the past week — Fatigue is nonspecific and short in duration.
Documented eGFR 29 mL/min/1.73 m² five months earlier — Correct. Prior reduced eGFR establishes the required time dimension, while still allowing superimposed AKI.
Mild ankle edema today — Edema does not establish the duration of reduced GFR.
Hemoglobin 9.8 g/dL today — Anemia has multiple causes and does not date the kidney dysfunction.
Why this is the keyed exam answer: Prior reduced eGFR establishes the required time dimension, while still allowing superimposed AKI.
Clinical interpretation: Prior values establish CKD but do not exclude superimposed AKI. Compare the current change with baseline rather than treating every new symptom as chronic.
A woman with several days of vomiting has arterial pH 7.50, bicarbonate 36 mmol/L, and PaCO₂ 48 mm Hg. Which primary acid–base disorder is present?
Answer and explanation
Correct answer: A. Metabolic alkalosis
Metabolic alkalosis — Correct. Alkalemia with increased bicarbonate indicates primary metabolic alkalosis; the higher PaCO₂ is compatible with compensation.
Normal acid–base status — The pH is above the usual 7.35–7.45 range.
Metabolic acidosis — The bicarbonate is elevated rather than reduced.
Respiratory alkalosis — A primary respiratory alkalosis would have a low PaCO₂.
Respiratory acidosis — Primary respiratory acidosis causes acidemia, with compensation assessed in context.
Why this is the keyed exam answer: Alkalemia with increased bicarbonate indicates primary metabolic alkalosis; the higher PaCO₂ is compatible with compensation.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A patient’s creatinine increases from 1.2 to 2.0 mg/dL within a week of starting an ACE inhibitor. He has known severe bilateral renal artery stenosis. Which action is most appropriate?
Answer and explanation
Correct answer: C. Hold the ACE inhibitor and promptly assess kidney perfusion, volume status, potassium, and other AKI contributors
Add an NSAID to reverse the creatinine increase — NSAIDs can further reduce renal perfusion.
Ignore the change because every creatinine rise is beneficial — A substantial rise is not an expected benign dip to ignore.
Hold the ACE inhibitor and promptly assess kidney perfusion, volume status, potassium, and other AKI contributors — Correct. A large acute rise in this setting needs evaluation and temporary medication adjustment.
Conclude that all patients with CKD must permanently avoid RAAS blockers — This specific high-risk situation does not invalidate their benefits in appropriately selected CKD.
Add an ARB to restore filtration — Dual RAAS blockade can worsen harm.
Topic: Renal · RAAS therapy and AKI · Task: Pharmaceutical therapeutics
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: A large acute rise in this setting needs evaluation and temporary medication adjustment.
Clinical interpretation: This large acute rise with bilateral renal artery stenosis merits holding and assessing treatment. A small stable hemodynamic dip in a different patient may be acceptable; RAAS blockers have substantial benefits when appropriately used.
A 30-year-old man is hemodynamically stable after a motor-vehicle collision. He has flank ecchymosis and gross hematuria. What is the most appropriate study to assess suspected renal injury?
Answer and explanation
Correct answer: D. Contrast-enhanced CT of the abdomen and pelvis with appropriate delayed images
Noncontrast stone-protocol CT alone — This does not adequately assess vascular enhancement or urinary extravasation.
Urine culture alone — Culture does not assess traumatic anatomy.
Contrast-enhanced CT of the abdomen and pelvis with appropriate delayed images — Correct. CT characterizes parenchymal, vascular, and collecting-system injury in a stable trauma patient.
Elective outpatient ultrasound in one month — This delays needed evaluation of significant trauma.
Why this is the keyed exam answer: CT characterizes parenchymal, vascular, and collecting-system injury in a stable trauma patient.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 71-year-old woman has a sudden compelling need to void followed by leakage before she reaches the toilet. She has no leakage with coughing, dysuria, mobility limitation, or continuous dribbling. Urinalysis is normal and postvoid residual is 25 mL. Which type of incontinence is most likely?
Answer and explanation
Correct answer: E. Urgency urinary incontinence
Overflow incontinence — Overflow is associated with incomplete emptying and a higher residual.
Continuous leakage from a urinary fistula — A fistula typically causes continuous leakage rather than urgency-linked episodes.
Functional incontinence — The history does not indicate an inability to reach or use the toilet from mobility or cognitive limitations.
Stress urinary incontinence — Stress leakage occurs with increased abdominal pressure, such as coughing.
Urgency urinary incontinence — Correct. Urgency immediately preceding leakage with a low residual fits urgency incontinence.
Topic: GU · Incontinence · Task: Most likely diagnosis
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Urgency immediately preceding leakage with a low residual fits urgency incontinence.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A patient with profuse diarrhea has sodium 140, chloride 114, and bicarbonate 16 mmol/L. Albumin is 4.0 g/dL. Arterial pH is 7.29 and PaCO₂ is 34 mm Hg. Which primary disorder best fits these results? Use an anion-gap reference range of 8–12 mmol/L without potassium.
Answer and explanation
Correct answer: C. Normal-anion-gap metabolic acidosis
Primary respiratory alkalosis — The patient is acidemic with a primary fall in bicarbonate.
Primary respiratory acidosis — PaCO₂ is reduced and appropriate for compensation, not the cause of acidemia.
Normal-anion-gap metabolic acidosis — Correct. The anion gap is 140 − (114 + 16) = 10. GI bicarbonate loss produces a hyperchloremic metabolic acidosis.
High-anion-gap metabolic acidosis — The calculated gap is within the supplied reference range.
Metabolic alkalosis — Bicarbonate and pH are reduced, not elevated.
Why this is the keyed exam answer: The anion gap is 140 − (114 + 16) = 10. GI bicarbonate loss produces a hyperchloremic metabolic acidosis.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A patient taking a loop diuretic has potassium 2.9 mmol/L that remains low despite replacement. Magnesium is 1.0 mg/dL (reference 1.7–2.4). Which additional treatment most directly helps correct the persistent potassium loss?
Answer and explanation
Correct answer: E. Magnesium replacement
Insulin without dextrose — Insulin shifts potassium into cells and can worsen hypokalemia.
Increased loop-diuretic dosing — This can increase urinary potassium and magnesium losses.
Sodium zirconium cyclosilicate — This removes potassium and would worsen the deficit.
Albuterol — Beta-2 stimulation shifts potassium into cells.
Magnesium replacement — Correct. Magnesium deficiency promotes renal potassium wasting and can make hypokalemia refractory.
Why this is the keyed exam answer: Magnesium deficiency promotes renal potassium wasting and can make hypokalemia refractory.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A patient taking lithium has persistent polyuria, sodium 151 mmol/L, high serum osmolality, and very dilute urine. Urine concentration changes minimally after supervised desmopressin administration. Which diagnosis is most likely?
Answer and explanation
Correct answer: A. Nephrogenic diabetes insipidus
Nephrogenic diabetes insipidus — Correct. Lithium can impair renal response to vasopressin; desmopressin produces little improvement.
SIADH — SIADH causes water retention and usually hyponatremia, not this dilute polyuria.
Hyperglycemic osmotic diuresis — No hyperglycemia or glucosuria is given, and the pattern indicates impaired water conservation.
Central diabetes insipidus — Urine usually concentrates substantially after desmopressin when vasopressin deficiency is the primary problem.
Primary polydipsia — Primary water excess usually produces low or normal sodium.
Topic: Renal · Hypernatremia · Task: Most likely diagnosis
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: Lithium can impair renal response to vasopressin; desmopressin produces little improvement.
Clinical interpretation: Lithium and minimal desmopressin response support nephrogenic DI. Partial defects, mixed causes, and water-intake limitations can complicate real cases; desmopressin testing requires supervision.
After thyroid surgery, a patient develops carpopedal spasm and perioral tingling. Ionized calcium is markedly low and the QT interval is prolonged. Which immediate treatment is most appropriate?
Answer and explanation
Correct answer: D. Monitored intravenous calcium gluconate
Oral calcium alone with review next week — This is too slow for symptomatic hypocalcemia with ECG changes.
Oral cinacalcet — Cinacalcet can further lower calcium.
Why this is the keyed exam answer: Symptomatic acute hypocalcemia requires prompt IV calcium and cardiac monitoring.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A patient with a newly discovered lung mass has calcium 13.5 mg/dL and suppressed intact PTH. Which interpretation of the calcium–PTH relationship is most appropriate?
Answer and explanation
Correct answer: C. The hypercalcemia is PTH-independent
The results establish primary hyperparathyroidism — Primary hyperparathyroidism generally has elevated or inappropriately nonsuppressed PTH.
The results establish secondary hyperparathyroidism — Secondary hyperparathyroidism has elevated PTH and does not fit this pattern.
The hypercalcemia is PTH-independent — Correct. Suppressed PTH is an appropriate response to elevated calcium and suggests another driver, including malignancy.
The results establish tertiary hyperparathyroidism — Tertiary hyperparathyroidism has autonomous elevated PTH.
The suppressed PTH is causing the hypercalcemia — Reduced PTH does not raise calcium.
Why this is the keyed exam answer: Suppressed PTH is an appropriate response to elevated calcium and suggests another driver, including malignancy.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A patient has recurrent episodes of torsades de pointes with a prolonged QT interval. Between episodes she has a pulse and stable blood pressure. In addition to removing QT-prolonging drugs and correcting electrolytes, which IV drug is indicated?
Answer and explanation
Correct answer: B. Magnesium sulfate
Procainamide — Procainamide can prolong QT and is unsuitable for torsades.
Magnesium sulfate — Correct. IV magnesium is used for recurrent polymorphic ventricular tachycardia associated with long QT.
Potassium chloride as a rapid undiluted IV push — Potassium must never be administered as an undiluted IV push.
Sotalol — Sotalol can further prolong QT.
Dofetilide — Dofetilide prolongs repolarization and can cause torsades.
Topic: Renal · Magnesium and arrhythmia · Task: Pharmaceutical therapeutics
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: IV magnesium is used for recurrent polymorphic ventricular tachycardia associated with long QT.
Clinical interpretation: Magnesium applies to recurrent torsades with long QT. Sustained unstable polymorphic VT requires immediate electrical treatment; do not delay resuscitation for a drug infusion.
A severely malnourished patient is about to restart nutrition. Which electrolyte should be monitored closely because an insulin-mediated intracellular shift can cause profound depletion during refeeding?
Answer and explanation
Correct answer: A. Phosphate
Phosphate — Correct. A rapid phosphate fall is characteristic of refeeding syndrome; potassium and magnesium also require monitoring.
Ionized calcium — Calcium abnormalities are not the hallmark insulin-mediated shift in this syndrome.
Bicarbonate — Bicarbonate is not the characteristic depleted substrate.
Sodium — Fluid and sodium balance matter, but phosphate depletion is the characteristic risk being tested.
Chloride — Chloride is not the characteristic depleted intracellular substrate in refeeding.
Topic: Renal · Phosphate depletion · Task: Health maintenance and prevention
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: A rapid phosphate fall is characteristic of refeeding syndrome; potassium and magnesium also require monitoring.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A patient with an opioid overdose is breathing six times per minute. Arterial pH is 7.21, PaCO₂ 70 mm Hg, and bicarbonate 27 mmol/L. What is the primary acid–base disorder?
Answer and explanation
Correct answer: D. Acute respiratory acidosis
Metabolic acidosis — The primary abnormality is increased PaCO₂, not low bicarbonate.
Chronic compensated respiratory acidosis — A chronic process would generally have a greater bicarbonate increase.
Respiratory alkalosis — PaCO₂ is elevated, not reduced.
Acute respiratory acidosis — Correct. Hypoventilation raises PaCO₂; the small bicarbonate increase fits an acute response.
Metabolic alkalosis — The patient is acidemic, not alkalemic.
Why this is the keyed exam answer: Hypoventilation raises PaCO₂; the small bicarbonate increase fits an acute response.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A patient with an acute pulmonary embolism is tachypneic. Arterial pH is 7.49, PaCO₂ 29 mm Hg, and bicarbonate 22 mmol/L. Which primary disorder is present?
Answer and explanation
Correct answer: B. Acute respiratory alkalosis
Acute respiratory acidosis — PaCO₂ is low, not high.
Why this is the keyed exam answer: Hyperventilation lowers PaCO₂ and raises pH.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A patient with DKA has received initial isotonic fluid. Potassium is 4.4 mmol/L. Which treatment most directly stops ongoing ketone production?
Answer and explanation
Correct answer: C. Insulin with protocol-based glucose and potassium monitoring
Sodium bicarbonate alone — Bicarbonate does not correct the underlying insulin deficiency.
An oral SGLT2 inhibitor — SGLT2 inhibitors are not DKA treatment and can contribute to ketoacidosis.
Insulin with protocol-based glucose and potassium monitoring — Correct. Insulin suppresses lipolysis and ketogenesis; potassium and glucose must be monitored and managed.
A potassium binder — A binder does not suppress ketone production.
A loop diuretic — Diuresis does not stop ketogenesis and may worsen volume loss.
Why this is the keyed exam answer: Insulin suppresses lipolysis and ketogenesis; potassium and glucose must be monitored and managed.
Clinical interpretation: Insulin stops ketogenesis, but severe hypokalemia changes the sequence: potassium must be corrected before insulin when below the protocol threshold. Fluids, electrolytes, and the precipitating cause also need treatment.
A patient with small-cell lung cancer has sodium 124 mmol/L, serum osmolality 260 mOsm/kg, urine osmolality 480 mOsm/kg, and urine sodium 55 mmol/L. He is clinically euvolemic; thyroid, adrenal, and kidney function are adequate, and he takes no diuretic. What is the most likely diagnosis?
Answer and explanation
Correct answer: D. Syndrome of inappropriate antidiuresis
Extrarenal sodium loss with hypovolemia — The examination and relatively high urine sodium without diuretics do not support this as the best explanation.
Nephrogenic diabetes insipidus — This causes dilute polyuria and often hypernatremia.
Primary polydipsia — The urine would generally be appropriately dilute.
Syndrome of inappropriate antidiuresis — Correct. Hypotonic hyponatremia with inappropriate urine concentration and exclusion of major mimics supports SIADH.
Hyperglycemic translocational hyponatremia — Measured serum osmolality would usually be elevated in marked hyperglycemia.
Topic: Renal · SIADH · Task: Most likely diagnosis
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: Hypotonic hyponatremia with inappropriate urine concentration and exclusion of major mimics supports SIADH.
Clinical interpretation: The stem deliberately excludes thyroid, adrenal, renal, and diuretic mimics. Real patients require those exclusions before assigning SIADH.
After prolonged septic shock, a patient has persistent AKI despite restoration of perfusion. Urine microscopy shows numerous muddy brown granular casts and renal tubular epithelial cells. What is the most likely diagnosis?
Answer and explanation
Correct answer: A. Acute tubular injury
Acute tubular injury — Correct. This sediment strongly supports tubular injury in the ischemic/septic context.
Uncomplicated cystitis — Cystitis does not explain tubular casts and persistent AKI.
Urethral stricture alone — A stricture does not directly account for this tubular sediment.
Minimal change disease — The sediment and shock history favor tubular injury rather than isolated nephrotic disease.
Pure hemodynamic AKI without tubular injury — A bland sediment would be more typical.
Why this is the keyed exam answer: This sediment strongly supports tubular injury in the ischemic/septic context.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A young adult has hemoptysis, rapidly rising creatinine, and RBC casts. Kidney biopsy shows crescentic glomerulonephritis with linear IgG staining along the glomerular basement membrane. Which diagnosis is most likely?
Answer and explanation
Correct answer: C. Anti-glomerular basement membrane disease
Minimal change disease — This does not produce crescentic GN or linear IgG.
IgA nephropathy — IgA nephropathy has predominantly mesangial IgA deposits.
Anti-glomerular basement membrane disease — Correct. Linear IgG in a pulmonary–renal syndrome supports anti-GBM disease.
Poststreptococcal GN — Immune deposits are granular rather than a characteristic linear pattern.
ANCA-associated pauci-immune vasculitis — Pauci-immune GN lacks the prominent linear immunoglobulin staining.
Topic: Renal · Pulmonary–renal syndrome · Task: Most likely diagnosis
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Linear IgG in a pulmonary–renal syndrome supports anti-GBM disease.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A patient with nephrotic syndrome asks which new symptom should prompt urgent evaluation for a thrombotic complication. Which symptom is most concerning?
Answer and explanation
Correct answer: B. New unilateral painful leg swelling
Chronic fatigue without new symptoms — Fatigue is nonspecific.
New unilateral painful leg swelling — Correct. Nephrotic syndrome increases thrombosis risk; this symptom can indicate DVT.
Unchanged morning eyelid puffiness — This is a common edema pattern, not a specific thrombotic signal.
Foamy urine without a recent change — This can accompany proteinuria but is not a thrombotic warning sign.
Stable symmetric ankle swelling — This may reflect existing edema but does not specifically suggest a new unilateral thrombus.
Topic: Renal · Nephrotic complications · Task: Health maintenance and prevention
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: Nephrotic syndrome increases thrombosis risk; this symptom can indicate DVT.
Clinical interpretation: New unilateral swelling requires DVT assessment. This is different from deciding whether every nephrotic patient should receive preventive anticoagulation, which requires individualized thrombosis and bleeding assessment.
A patient with advanced kidney failure develops pleuritic chest pain and a pericardial friction rub. ECG and assessment do not suggest acute coronary occlusion; the team diagnoses uremic pericarditis. What is the most appropriate treatment direction?
Answer and explanation
Correct answer: A. Urgent initiation or intensification of dialysis
Urgent initiation or intensification of dialysis — Correct. Uremic pericarditis is a clinical indication for kidney replacement therapy.
Schedule reassessment in six months — This complication requires urgent action.
Treat only with oral iron — Iron does not treat uremic pericarditis.
Wait for eGFR to fall below a fixed threshold — A symptomatic uremic complication takes priority over a numeric threshold.
Treat only with increased oral fluids — Fluids do not clear the uremic burden and may worsen overload.
Why this is the keyed exam answer: Uremic pericarditis is a clinical indication for kidney replacement therapy.
Clinical interpretation: Uremic pericarditis is a clinical dialysis indication. An eGFR or creatinine alone does not establish when an otherwise stable patient must start dialysis.
A patient with CKD has normocytic anemia, a low reticulocyte count, adequate iron stores, and no evidence of bleeding or hemolysis. Which mechanism best explains the reduced red-cell production?
Answer and explanation
Correct answer: D. Reduced renal erythropoietin production
Increased erythropoietin secretion — This would stimulate rather than suppress red-cell production.
Increased red-cell fragmentation — Hemolysis is not supported and would usually stimulate reticulocytosis if marrow response is intact.
Excess thyroid hormone production — This is not the characteristic CKD anemia mechanism.
Reduced renal erythropoietin production — Correct. Loss of adequate erythropoietin signaling contributes to hypoproliferative anemia in CKD.
Isolated loss of intrinsic factor — This more typically causes B12-related macrocytic anemia.
Why this is the keyed exam answer: Loss of adequate erythropoietin signaling contributes to hypoproliferative anemia in CKD.
Clinical interpretation: Reduced erythropoietin is the mechanism after other causes are excluded. In practice, check iron availability, inflammation, bleeding, nutrition, and other causes before choosing anemia therapy.
Imaging in a young adult with recurrent urinary infections shows low-positioned kidneys joined across the midline by a band of renal tissue connecting their lower poles. Which congenital anomaly is present?
Answer and explanation
Correct answer: A. Horseshoe kidney
Horseshoe kidney — Correct. Fusion of the lower poles produces the characteristic horseshoe configuration.
Unilateral renal agenesis — Agenesis means one kidney failed to form.
Duplex collecting system — A duplicated collecting system does not imply lower-pole fusion across the midline.
Autosomal dominant polycystic kidney disease — ADPKD produces multiple cysts rather than lower-pole fusion.
Multicystic dysplastic kidney — This is a dysplastic cystic kidney rather than fused lower poles.
Topic: Renal · Horseshoe kidney · Task: Most likely diagnosis
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Fusion of the lower poles produces the characteristic horseshoe configuration.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 3-year-old child has a painless abdominal mass, microscopic hematuria, and hypertension. Ultrasound shows a solid mass arising within one kidney. Which diagnosis is most likely?
Answer and explanation
Correct answer: D. Wilms tumor
Renal cell carcinoma — RCC is much less typical at this age.
Simple renal cyst — A simple cyst is fluid-filled, not a solid tumor.
Acute pyelonephritis — Infection does not typically produce this painless solid renal mass.
Wilms tumor — Correct. A renal mass in a preschool child with these findings is characteristic of Wilms tumor.
Neuroblastoma — Neuroblastoma usually arises from adrenal or sympathetic tissue rather than within the kidney.
Topic: Renal · Wilms tumor · Task: Most likely diagnosis
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: A renal mass in a preschool child with these findings is characteristic of Wilms tumor.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 29-year-old woman has difficult-to-control hypertension and an abdominal bruit. CT angiography shows alternating narrowing and dilation of a renal artery, without ostial atherosclerotic plaque. What is the most likely cause?
Answer and explanation
Correct answer: A. Fibromuscular dysplasia
Fibromuscular dysplasia — Correct. A beaded renal artery in a younger patient is characteristic of fibromuscular dysplasia.
Acute renal vein thrombosis — This involves the vein rather than a beaded artery.
Atherosclerotic renal artery stenosis — This more often affects the ostium/proximal artery in an older atherosclerotic population.
Polycystic kidney disease — This produces renal cysts, not the arterial pattern described.
Acute interstitial nephritis — AIN does not cause this angiographic finding.
Topic: Renal · Renovascular disease · Task: Most likely diagnosis
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: A beaded renal artery in a younger patient is characteristic of fibromuscular dysplasia.
Clinical interpretation: The beaded artery suggests fibromuscular dysplasia. That diagnosis does not mean every patient needs an intervention; anatomy, hypertension, and procedural assessment guide treatment.
A patient with heart failure has dyspnea and bilateral leg edema. Which bedside finding most strongly supports elevated central venous pressure rather than isolated dependent venous insufficiency?
Answer and explanation
Correct answer: B. Elevated jugular venous pressure
Visible superficial varicose veins alone — Varicosities support local venous disease without necessarily elevated central venous pressure.
Chronic ankle hyperpigmentation alone — This can result from chronic venous insufficiency.
A healed ankle venous ulcer alone — This supports chronic peripheral venous disease rather than necessarily central congestion.
Edema that worsens after standing alone — This pattern can occur with local venous insufficiency.
Topic: Renal · Volume assessment · Task: History and examination
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: JVP reflects right-sided filling pressure and supports systemic congestion.
Clinical interpretation: JVP helps identify central congestion. Leg edema can also arise from venous insufficiency, DVT, medications, or lymphatic disease; indiscriminate diuresis can cause AKI.
A previously healthy adult has profuse diarrhea, tachycardia, hypotension, cool extremities, and no evidence of pulmonary congestion. After immediate assessment, which fluid is appropriate for initial intravascular volume resuscitation?
Answer and explanation
Correct answer: B. An isotonic crystalloid with reassessment of response
Sterile water intravenously — IV sterile water without solute is unsafe and can cause hemolysis.
An isotonic crystalloid with reassessment of response — Correct. Isotonic crystalloid restores extracellular and intravascular volume; reassess rather than giving unlimited fluid.
A hypotonic saline solution as the primary resuscitation fluid — Hypotonic fluid is less appropriate for initial shock resuscitation.
A loop diuretic instead of fluid — Diuresis would worsen the volume deficit.
Dextrose 5% in water alone — After glucose metabolism this distributes as free water and is not an effective initial resuscitation fluid.
Why this is the keyed exam answer: Isotonic crystalloid restores extracellular and intravascular volume; reassess rather than giving unlimited fluid.
Clinical interpretation: The stem describes hypovolemic shock without congestion. Reassess after fluid; heart failure, kidney failure, and ongoing losses change volume and rate.
A patient has a confirmed heterozygous pathogenic variant causing autosomal dominant polycystic kidney disease. Her partner is unaffected. What is the chance that each child inherits the variant?
Answer and explanation
Correct answer: C. 50%
25% — This is not the expected probability for a heterozygous dominant parent and an unaffected partner.
100% — A heterozygous parent passes one of two alleles to each child.
50% — Correct. A heterozygous autosomal dominant variant has a one-in-two transmission probability in each pregnancy.
0% — Autosomal dominant variants can be transmitted to either sex.
75% — This overstates the transmission probability.
Topic: Renal · ADPKD inheritance · Task: Health maintenance and prevention
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: A heterozygous autosomal dominant variant has a one-in-two transmission probability in each pregnancy.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
Ultrasound in a patient with an obstructing ureteral stone shows dilation of the renal pelvis and calyces upstream from the stone. What is the term for this finding?
Answer and explanation
Correct answer: C. Hydronephrosis
Polycystic kidney disease — This is a cystic disorder, not simply upstream collecting-system dilation.
Renal cortical atrophy — This describes loss of cortical tissue, not collecting-system dilation.
Hydronephrosis — Correct. Hydronephrosis describes dilation of the collecting system; interpretation depends on the obstruction context.
Renal agenesis — This means congenital absence of a kidney.
Nephrocalcinosis — This is calcium deposition within renal tissue.
Why this is the keyed exam answer: Hydronephrosis describes dilation of the collecting system; interpretation depends on the obstruction context.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 23-year-old man has gradually increasing epididymal tenderness, urethral discharge, and recent sexual exposure. Torsion has been excluded. Gonorrhea and chlamydia testing is pending, and there is no history suggesting enteric exposure. Which empiric regimen is appropriate?
Answer and explanation
Correct answer: C. Ceftriaxone plus doxycycline
Nitrofurantoin alone — This is a bladder-directed drug and is inadequate for this STI-associated infection.
Fluconazole alone — The presentation does not suggest fungal infection.
Ceftriaxone plus doxycycline — Correct. This covers likely gonococcal and chlamydial epididymitis.
Metronidazole alone — This does not cover the likely pathogens.
Doxycycline alone without gonococcal coverage — Doxycycline alone does not adequately cover gonorrhea.
Why this is the keyed exam answer: This covers likely gonococcal and chlamydial epididymitis.
Clinical interpretation: Ceftriaxone plus doxycycline fits likely STI-associated epididymitis. Enteric exposure, instrumentation, culture data, allergy, and local guidance can change the regimen.
An underimmunized 19-year-old man develops fever and painful testicular swelling several days after parotid swelling. Torsion is excluded. Which cause is most likely?
Answer and explanation
Correct answer: E. Mumps-associated orchitis
Simple hydrocele — A hydrocele does not explain the febrile illness after parotitis.
Testicular malignancy — Malignancy more often presents as a painless mass and does not explain parotitis.
Varicocele — This is a venous dilation rather than acute viral inflammation.
Peyronie disease — This causes penile plaque and curvature, not orchitis.
Mumps-associated orchitis — Correct. Mumps can cause orchitis, especially after puberty.
Topic: GU · Orchitis · Task: Most likely diagnosis
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Mumps can cause orchitis, especially after puberty.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A man has fever, dysuria, pelvic pain, and a very tender prostate on gentle rectal examination. Which examination maneuver should be avoided in suspected acute bacterial prostatitis?
Answer and explanation
Correct answer: C. Vigorous prostatic massage
Checking for costovertebral-angle tenderness — This can help evaluate upper urinary tract involvement.
Assessing blood pressure and pulse — These are important for identifying sepsis.
Vigorous prostatic massage — Correct. Massage can increase the risk of bacteremia in acute bacterial prostatitis.
Measuring temperature — Vital signs help assess severity.
Examining for suprapubic distention — This helps assess associated retention.
Topic: GU · Prostatitis · Task: History and examination
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Massage can increase the risk of bacteremia in acute bacterial prostatitis.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A man with diabetes has rapidly progressive perineal pain, fever, skin discoloration, and crepitus. What is the most appropriate management?
Answer and explanation
Correct answer: A. Emergency surgical evaluation and debridement with broad-spectrum IV antibiotics and resuscitation
Emergency surgical evaluation and debridement with broad-spectrum IV antibiotics and resuscitation — Correct. Fournier gangrene is a necrotizing infection requiring urgent source control.
Observation until imaging confirms every affected tissue plane — Imaging should not delay surgery when clinical suspicion is high.
Elective drainage after cultures finalize — Treatment must not wait for final cultures.
Oral antibiotics with review in one week — Outpatient treatment delays lifesaving source control.
Topical antifungal cream alone — A superficial antifungal does not treat necrotizing infection.
Why this is the keyed exam answer: Fournier gangrene is a necrotizing infection requiring urgent source control.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 22-year-old man has dysuria and purulent urethral discharge after a new sexual exposure. Which test is preferred to identify gonorrhea and chlamydia?
Answer and explanation
Correct answer: A. Nucleic acid amplification testing on first-catch urine
Nucleic acid amplification testing on first-catch urine — Correct. Urine NAAT is the preferred diagnostic method for these pathogens in men.
Routine urine cytology — Cytology evaluates abnormal cells rather than these infections.
Serum PSA — PSA does not identify urethral pathogens.
A standard midstream urine culture as the only test — Routine bacterial culture does not reliably diagnose both infections.
A renal ultrasound alone — Imaging does not identify gonorrhea or chlamydia.
Topic: GU · Urethritis · Task: Diagnostic studies
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Urine NAAT is the preferred diagnostic method for these pathogens in men.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 68-year-old man with a 45-pack-year smoking history has recurrent painless gross hematuria. Urine culture is negative. Which diagnosis must be prioritized in the evaluation?
Answer and explanation
Correct answer: D. Urothelial carcinoma of the bladder
Acute testicular torsion — This causes an acute scrotal syndrome, not isolated painless hematuria.
Acute pyelonephritis — There is no fever or flank tenderness.
Uncomplicated cystitis — There are no infectious symptoms and culture is negative.
Urothelial carcinoma of the bladder — Correct. Painless visible hematuria with tobacco exposure is a classic warning presentation.
Minimal change disease — This typically causes nephrotic proteinuria rather than painless gross hematuria.
Topic: GU · Bladder cancer · Task: Most likely diagnosis
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: Painless visible hematuria with tobacco exposure is a classic warning presentation.
Clinical interpretation: Bladder cancer is the concern, not a confirmed diagnosis. Painless hematuria still needs a complete risk-based urinary tract evaluation.
A 63-year-old man has a persistent ulcerated lesion on the glans that has not healed after several weeks. Which next step is most appropriate?
Answer and explanation
Correct answer: A. Prompt urologic assessment for biopsy
Prompt urologic assessment for biopsy — Correct. A persistent suspicious penile lesion requires tissue diagnosis to assess for malignancy.
Repeated empiric topical treatment indefinitely — Failure to heal should trigger diagnostic assessment rather than indefinite empiric therapy.
Observation for a year before reassessment — This risks delaying diagnosis.
PSA testing as the definitive diagnostic test — PSA does not diagnose a penile lesion.
Reassurance because penile cancer never involves the glans — The glans is a possible site of penile malignancy.
Topic: GU · Penile cancer · Task: Clinical intervention
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: A persistent suspicious penile lesion requires tissue diagnosis to assess for malignancy.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 72-year-old man has progressive weight loss and persistent back pain. Which additional finding most strongly supports advanced prostate cancer as a concern?
Answer and explanation
Correct answer: E. A hard irregular prostate with osteoblastic bone lesions
A retractile testis on examination — This does not explain the systemic and skeletal findings.
A tender boggy prostate during an acute fever — This suggests acute prostatitis.
A smooth nontender prostate and stable mechanical pain — This is less suggestive of metastatic malignancy.
A transilluminating scrotal swelling — This suggests hydrocele.
A hard irregular prostate with osteoblastic bone lesions — Correct. This combination raises strong concern for metastatic prostate cancer.
Topic: GU · Prostate cancer · Task: History and examination
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: This combination raises strong concern for metastatic prostate cancer.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A term infant’s testis remains undescended at six months of age and cannot be brought into the scrotum on examination. What is the most appropriate next step?
Answer and explanation
Correct answer: B. Refer for pediatric surgical/urologic evaluation
Attempt forceful repeated manipulation at home — This is not appropriate treatment.
Refer for pediatric surgical/urologic evaluation — Correct. Persistent cryptorchidism at six months warrants referral for timely orchiopexy planning.
Reassure that follow-up is unnecessary — Persistent undescended testes need evaluation.
Wait until puberty for spontaneous descent — Delaying through childhood increases avoidable risks.
Begin routine testosterone without specialist evaluation — Hormonal treatment is not the routine first approach for unilateral cryptorchidism.
Topic: GU · Cryptorchidism · Task: Health maintenance and prevention
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: Persistent cryptorchidism at six months warrants referral for timely orchiopexy planning.
Clinical interpretation: Persistent cryptorchidism at six months warrants referral. A truly retractile testis is a different finding and needs serial examination rather than automatic orchiopexy.
A 52-year-old man reports acquired penile curvature and pain during erection. Which finding best supports Peyronie disease?
Answer and explanation
Correct answer: E. A palpable fibrous plaque in the tunica albuginea
Purulent urethral discharge — This suggests urethritis.
A fluid-filled transilluminating scrotal swelling — This suggests hydrocele.
A foreskin trapped behind an edematous glans — This is paraphimosis.
A painless intratesticular mass — This suggests a testicular lesion.
A palpable fibrous plaque in the tunica albuginea — Correct. Plaque formation accounts for acquired curvature in Peyronie disease.
Topic: GU · Peyronie disease · Task: History and examination
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Plaque formation accounts for acquired curvature in Peyronie disease.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A child with recurrent febrile UTIs has a voiding cystourethrogram showing urine passing from the bladder into the ureter and renal collecting system. Which abnormality is demonstrated?
Answer and explanation
Correct answer: D. Vesicoureteral reflux
Renal agenesis — This means absence of a kidney.
Ureteropelvic junction obstruction — This obstructs drainage at the renal pelvis–ureter junction rather than demonstrating bladder-to-ureter reflux.
Bladder exstrophy — This is an exposed bladder wall, not the flow abnormality described.
Vesicoureteral reflux — Correct. VUR is retrograde urine flow from bladder toward the upper urinary tract.
Why this is the keyed exam answer: VUR is retrograde urine flow from bladder toward the upper urinary tract.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A newborn has a urethral opening on the ventral penis with a dorsal hooded foreskin. The family requests routine circumcision. What is the most appropriate advice?
Answer and explanation
Correct answer: E. Defer circumcision and refer to pediatric urology
Wait until adulthood to mention the finding — Timely specialist assessment is appropriate.
Use repeated forceful foreskin retraction — This does not relocate the urethral opening and risks injury.
Proceed because circumcision corrects the urethral location — Circumcision does not correct hypospadias.
Treat with antibiotics until the meatus moves — This is a structural anomaly, not an infection.
Defer circumcision and refer to pediatric urology — Correct. The child has hypospadias, and foreskin may be useful for reconstruction.
Topic: GU · Hypospadias · Task: Health maintenance and prevention
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: The child has hypospadias, and foreskin may be useful for reconstruction.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A newborn boy has a urethral opening on the dorsal surface of the penis. Which diagnosis describes this finding?
Answer and explanation
Correct answer: E. Epispadias
Paraphimosis — Paraphimosis is a retracted foreskin trapped behind the glans.
Phimosis — Phimosis describes inability to retract the foreskin.
Peyronie disease — This is acquired fibrous plaque-related curvature.
Hypospadias — Hypospadias places the opening ventrally.
Epispadias — Correct. Epispadias places the urethral opening dorsally.
Topic: GU · Epispadias · Task: Most likely diagnosis
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Epispadias places the urethral opening dorsally.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
After catheterization, a patient’s foreskin remains retracted behind the glans. The glans is painful and swollen, and the foreskin cannot be returned normally. What is the most appropriate action?
Answer and explanation
Correct answer: A. Urgent reduction with analgesia and urologic help if unsuccessful
Urgent reduction with analgesia and urologic help if unsuccessful — Correct. Paraphimosis can compromise perfusion and needs prompt reduction.
Apply an antifungal and discharge — This does not release the constricting foreskin.
Leave the foreskin retracted to reduce moisture — This perpetuates the constriction.
Treat with an oral diuretic alone — Diuresis does not correct the mechanical problem.
Wait several days for spontaneous improvement — Delay risks ischemic injury.
Why this is the keyed exam answer: Paraphimosis can compromise perfusion and needs prompt reduction.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A healthy 3-year-old boy has a nonretractile foreskin without scarring, infections, pain, or urinary obstruction. What is the most appropriate counseling?
Answer and explanation
Correct answer: D. Use gentle hygiene and avoid forced retraction
Insert a urinary catheter daily — There is no retention and catheterization would add harm.
Immediate circumcision is mandatory — Asymptomatic physiologic nonretractility does not mandate surgery.
Force the foreskin back daily until it separates — Forced retraction can cause injury and scarring.
Use gentle hygiene and avoid forced retraction — Correct. Physiologic nonretractility is common in young children and does not by itself require intervention.
Give long-term antibiotic prophylaxis — There is no infection indication.
Topic: GU · Physiologic phimosis · Task: Health maintenance and prevention
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: Physiologic nonretractility is common in young children and does not by itself require intervention.
A man has a painful rigid erection lasting six hours unrelated to sexual stimulation. Corporal blood is dark, hypoxic, and acidotic. What is the appropriate initial definitive treatment?
Answer and explanation
Correct answer: B. Corporal aspiration and intracavernosal phenylephrine with monitoring
Use oral analgesics alone — Pain treatment does not resolve the ischemia.
Corporal aspiration and intracavernosal phenylephrine with monitoring — Correct. Acute ischemic priapism requires urgent local treatment to restore outflow.
Observe at home until the next morning — Ischemia is time-sensitive.
Give sildenafil — A PDE5 inhibitor is not the immediate rescue treatment for this episode.
Delay local treatment for a prolonged hydration trial — Systemic measures must not delay definitive local treatment.
Why this is the keyed exam answer: Acute ischemic priapism requires urgent local treatment to restore outflow.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A patient has a painless, fluctuant scrotal swelling. Which bedside finding most supports a simple hydrocele?
Answer and explanation
Correct answer: B. Transillumination of the fluid-filled swelling
Tender epididymal swelling with fever — This suggests infection.
Transillumination of the fluid-filled swelling — Correct. Fluid around the testis can transmit light; ultrasound is used when the examination is uncertain or the testis cannot be assessed.
An absent cremasteric reflex with abrupt pain — This raises concern for torsion.
A hard irregular intratesticular nodule — This raises concern for a testicular tumor.
A bag-of-worms texture that increases with Valsalva — This suggests varicocele.
Topic: GU · Hydrocele · Task: History and examination
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: Fluid around the testis can transmit light; ultrasound is used when the examination is uncertain or the testis cannot be assessed.
Clinical interpretation: Transillumination supports a fluid collection but does not exclude an underlying testicular lesion. Obtain ultrasound when examination is incomplete or uncertain.
A 17-year-old boy has a soft bag-of-worms mass above the left testis. It becomes more prominent while standing and with Valsalva and decreases supine. Which diagnosis is most likely?
Answer and explanation
Correct answer: E. Varicocele
Testicular carcinoma — A tumor is a solid intratesticular lesion rather than a compressible positional venous mass.
Hydrocele — A hydrocele is a fluid collection rather than a cluster of dilated veins.
Acute orchitis — Orchitis causes inflammatory testicular tenderness and swelling.
Testicular torsion — Torsion is an acute painful ischemic process.
Varicocele — Correct. Dilated pampiniform veins produce this positional examination pattern.
Topic: GU · Varicocele · Task: History and examination
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: Dilated pampiniform veins produce this positional examination pattern.
Clinical interpretation: A typical positional left varicocele fits this answer. A new nonreducible lesion or other atypical findings warrant investigation for secondary obstruction.
A prepubertal girl has spotting on her underwear. Examination shows a circumferential doughnut-shaped rim of reddish tissue surrounding the urethral opening. Which finding best explains the bleeding?
Answer and explanation
Correct answer: C. Urethral mucosal prolapse
Imperforate hymen — This obstructs the vaginal opening and does not form this urethral lesion.
Rectal prolapse — This emerges from the anus, not the urethral meatus.
Urethral mucosal prolapse — Correct. Circumferential everted urethral mucosa has this characteristic appearance.
Cystocele — A cystocele bulges through the anterior vaginal wall rather than forming a urethral ring.
Urethral caruncle — A caruncle is a focal lesion rather than a circumferential ring.
Topic: GU · Urethral prolapse · Task: History and examination
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Circumferential everted urethral mucosa has this characteristic appearance.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A 40-year-old man has a progressively weak, spraying urinary stream after prior urethral instrumentation. The prostate is not enlarged. Which condition is most likely?
Answer and explanation
Correct answer: C. Urethral stricture
Acute pyelonephritis — This would more typically cause fever and flank symptoms.
Peyronie disease — Penile plaque affects curvature, not typically urethral caliber.
Urethral stricture — Correct. Scar-related urethral narrowing can follow instrumentation and cause obstructive symptoms.
Minimal change disease — This causes proteinuria rather than an obstructive stream.
Varicocele — A scrotal venous disorder does not narrow the urinary outlet.
Topic: GU · Urethral stricture · Task: Most likely diagnosis
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Scar-related urethral narrowing can follow instrumentation and cause obstructive symptoms.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A woman with prior vaginal deliveries reports pelvic pressure and a vaginal bulge. On straining, the anterior vaginal wall descends. Which structure is prolapsing?
Answer and explanation
Correct answer: E. Bladder
Urethral mucosa through the urethral meatus — This is urethral prolapse, not an anterior vaginal bulge.
Rectum — A rectocele typically affects the posterior vaginal wall.
Cervix as the leading apical structure — This describes uterine/apical rather than isolated anterior wall prolapse.
Small bowel through the upper posterior vagina — This describes an enterocele.
Topic: GU · Bladder prolapse · Task: History and examination
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Anterior vaginal wall prolapse commonly represents cystocele.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A woman leaks small amounts of urine when coughing or exercising. She has no urgency, infection, or elevated postvoid residual. Which conservative treatment is most appropriate first?
Answer and explanation
Correct answer: C. Supervised pelvic-floor muscle training
An indwelling urinary catheter — A chronic catheter is not appropriate initial treatment here.
Long-term antibiotic therapy — There is no infection.
Supervised pelvic-floor muscle training — Correct. Pelvic-floor strengthening is a first-line conservative treatment for stress incontinence.
A loop diuretic — Increasing urine production does not correct stress leakage.
Immediate sling surgery before conservative treatment — Surgery may be appropriate after evaluation and shared decisions, but conservative treatment is a suitable first step here.
Why this is the keyed exam answer: Pelvic-floor strengthening is a first-line conservative treatment for stress incontinence.
Clinical interpretation: Pelvic-floor therapy is a suitable initial conservative option. Severity, prior treatment, patient preferences, and specialist assessment may lead to devices or surgery.
A woman has urgency, frequency, and occasional urgency leakage. Urinalysis and postvoid residual are normal. She prefers to begin without medication. Which intervention is appropriate?
Answer and explanation
Correct answer: D. Bladder training with scheduled voiding and urgency-suppression techniques
Immediate urethral dilation without obstruction — No stricture or retention has been demonstrated.
Daily prophylactic antibiotics despite negative testing — There is no demonstrated infection.
Avoid all fluids throughout the day — Extreme restriction is not appropriate counseling.
Bladder training with scheduled voiding and urgency-suppression techniques — Correct. Behavioral bladder training is a recommended option for overactive bladder.
Continuous catheter drainage — This is not an appropriate routine first intervention.
Why this is the keyed exam answer: Behavioral bladder training is a recommended option for overactive bladder.
Clinical interpretation: Bladder training fits the patient’s preference. Drugs or procedures may also be chosen through shared decisions; there is not one mandatory treatment sequence for everyone.
A 20-year-old has recurrent episodes of visible hematuria beginning during upper respiratory infections. Complement is normal. Urine shows dysmorphic RBCs. Which diagnosis is most likely?
Answer and explanation
Correct answer: E. IgA nephropathy
Rhabdomyolysis — Pigment urine typically has heme positivity with few intact RBCs.
Acute cystitis — The glomerular red-cell pattern and recurrent respiratory association argue against isolated cystitis.
Minimal change disease — Nephrotic proteinuria, rather than recurrent glomerular hematuria, is more typical.
Poststreptococcal GN — This usually follows a latent interval and often has reduced C3.
IgA nephropathy — Correct. Hematuria concurrent with mucosal infection and normal complement is a typical pattern.
Topic: Renal · IgA nephropathy · Task: Most likely diagnosis
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Hematuria concurrent with mucosal infection and normal complement is a typical pattern.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
A volume-depleted patient develops AKI after taking high-dose ibuprofen. Which drug effect most directly contributes to reduced glomerular perfusion?
Answer and explanation
Correct answer: E. Reduced prostaglandin-mediated afferent arteriolar dilation
Direct blockade of glucose reabsorption in the proximal tubule — This describes SGLT2 inhibition, not ibuprofen.
Increased aldosterone synthesis as its primary action — This is not the mechanism being tested.
Increased renal prostaglandin synthesis — NSAIDs inhibit rather than increase this pathway.
Selective dilation of the afferent arteriole — This is opposite the relevant NSAID effect.
Reduced prostaglandin-mediated afferent arteriolar dilation — Correct. NSAID inhibition of prostaglandins can constrict the afferent circulation when perfusion is dependent on them.
Why this is the keyed exam answer: NSAID inhibition of prostaglandins can constrict the afferent circulation when perfusion is dependent on them.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
An adult has rhabdomyolysis after prolonged immobilization. He is volume depleted, has preserved urine output, and has no pulmonary edema. Potassium is 4.9 mmol/L. Which initial kidney-directed treatment is most appropriate?
Answer and explanation
Correct answer: C. Isotonic IV crystalloid with urine-output and volume monitoring
Routine mannitol for every patient — Routine mannitol has not established a kidney-outcome benefit.
Restrict all fluids despite volume depletion — This can worsen kidney hypoperfusion.
Isotonic IV crystalloid with urine-output and volume monitoring — Correct. Early goal-directed fluid replacement supports perfusion and limits pigment concentration while avoiding overload.
Start dialysis solely because CK is elevated — Dialysis is based on clinical complications, not CK alone.
Routine bicarbonate infusion regardless of acid–base status — Routine alkalinization is not required for every patient.
Why this is the keyed exam answer: Early goal-directed fluid replacement supports perfusion and limits pigment concentration while avoiding overload.
Clinical interpretation: Fluids fit a volume-depleted patient making urine. With anuria, pulmonary edema, or severe heart failure, unrestricted fluid can cause harm; kidney replacement therapy depends on complications.
A patient with decision-making capacity declines recommended dialysis after discussing the likely benefits, burdens, alternatives, and consequences. There is no misunderstanding or coercion. What is the most appropriate response?
Answer and explanation
Correct answer: C. Respect the informed refusal, document the discussion, and arrange ongoing care
End all medical care immediately — Refusal of one treatment does not justify abandonment.
Begin dialysis without consent because it is recommended — A capable patient’s informed refusal cannot be disregarded merely because clinicians disagree.
Respect the informed refusal, document the discussion, and arrange ongoing care — Correct. A capable patient may decline treatment; continued care and symptom support remain important.
Ask family to override the patient’s decision — A surrogate does not replace the decision of a capable patient.
Withhold information about alternatives to increase acceptance — Informed decisions require honest information.
Topic: Renal · Informed refusal · Task: Professional practice
Exam answer and clinical care
Clinical context can change the decision
Why this is the keyed exam answer: A capable patient may decline treatment; continued care and symptom support remain important.
Clinical interpretation: Respecting refusal depends on decision-making capacity and adequate information. Delirium, coercion, or an inability to understand requires assessment, not an automatic assumption of valid refusal.
A PA discovers that a potassium supplement was given to the wrong patient. The patient is currently asymptomatic. What is the most appropriate response?
Answer and explanation
Correct answer: A. Promptly assess the patient, notify the responsible team, disclose the error, and follow the safety-reporting process
Promptly assess the patient, notify the responsible team, disclose the error, and follow the safety-reporting process — Correct. Patient assessment, transparent communication, and system reporting address immediate and future harm.
Tell only a coworker and omit documentation — Informal discussion is not adequate assessment, disclosure, or reporting.
Alter the record to match the intended order — Falsifying documentation is unacceptable.
Assume the dose was harmless and take no action — Potential harm requires assessment rather than assumption.
Wait for symptoms before telling anyone — Delay may miss preventable harm.
Topic: Renal · Patient safety · Task: Professional practice
Exam answer and clinical care
Exam and clinical care align
Why this is the keyed exam answer: Patient assessment, transparent communication, and system reporting address immediate and future harm.
Clinical interpretation: The central principle tested here also guides clinical care. Apply it after confirming the findings in the stem and checking for additional patient-specific factors; the question does not provide a complete care plan.
Each row links to questions that directly test that topic. Use the map to find gaps in your knowledge after a session. One or two questions can introduce a topic; they cannot exhaust everything that may be tested.
The topic map is hidden during an exam block to avoid giving clues.