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RenalMain91-100Q1A57-year-oldmartcomestothephysicianfor2episodesofbloodinhisurine.Healsocomplainsoffatigueandfeverforthelast4weeks.Hehasnoothermedicalproblemsandtakesnomedications.Thepatienthasa50-pack-yearsmokinghistorybutdoesnotusealcoholorillicitdrugs.Hisfatherdiedfromablooddisorder,butthepatientisunsureofthespecificname.Vitalsignsarewithinnormallimits.Examinationshowsaleft-sidedvaricocelethatfailstoemptywhenthepatientisrecumbent.Theremainderoftheexaminationshowsnoabnormalities.Laboratoryresultsareasfollows:Whichofthefollowingisthemostappropriatediagnosticprocedure?A.Chestx-rayB.AbdominalCTscanC.UrinecytologyD.Serumalpha-fetoproteinlevelsE.UltrasoundofthetesticlesF.BonemarrowbiopsyA1Correctanswer:BThispatientmostlikelyhasrenaicellcarcinoma(RCC).MostRCCpatientsareasymptomaticuntilthediseaseisadvanced.TheclassictriadofRCC(flankpain,hematuria,andapalpableabdominalrenalmass)isfoundinonly10%ofpatients;whenpresent,itstronglysuggestsadvanced/metastaticdisease.Hematuriaisseeninabout40%ofpatientsandsignifiestumorinvasionofthecollectingsystem.Scrotalvaricoceles(mostareleft-sided)areobservedinabout10%ofpatients.VaricocelestypicallyfailtoemptywhenthepatientisrecumbentduetotumorobstructionofthegonadalveinwhereItenterstherenalvein.Presenceofthisfindingshouldalwaysraisesuspicionformassobstructiontovenousflow,as3sseeninRCC.Twentypercentofpatientsmayalsohaveconstitutionalsymptomssuchasfever,nightsweats,anorexia,weightloss,oreasyfatigability.Ectopicproductionoferythropoietinbythetumorcanproducepolycythemia,althoughmostadvancedtumorsareassociatedwithanemia.CTscanoftheabdomenisthemostsensitiveandspecifictestfordiagnosingRCCandshouldbeobtainedwhentheindexofsuspicionishigh.(ChoiceA)Chestx-rayisimportanttocheckformetastasisbutwillnotindicatethediagnosisinthispatient(ChoiceC)Thecombinationoffever,scrotalvaricocele,andpolycythemiawouldvirtuallyexcludebladdercancer,althoughthispatientisatriskduetohissmokinghistoryandpresenceofhematuria.UrinecytologyisnothelpfulindiagnosingRCC.(ChoicesD&E)Thispatientsfindingsareunlikelytoindicatetesticularcarcinoma;therefore,anultrasoundofthetesticlesorserumalpha-fetoproteinmeasurementswouldnotbehelpful.(ChoiceF)ErythrocytosisandthrombocytosisareseenasparaneoplasticmanifestationsofRCC.BonemarrowbiopsyisnotIndicatedatthistime.Educationalobjective:Unilateralvaricocelesthatfailtoemptywhenapatientisrecumbentraisesuspicionforanunderlyingmasspathology,suchasrenalcellcarcinoma(RCC),thatobstructsvenousflow.CTscanoftheabdomenisthemostsensitiveandspecifictestfordiagnosingRCC.Q2A54-year-oldmancomestotheemergencydepartmentwithcrampinglowerabdominalpain;mildnausea,and2episodesofwaterydiarrhea.Hehasnofevervomiting,orurinarysymptoms.Hispastmedicalhistoryisunremarkable.Thepatient'sfatherdiedatage60fromabdominalaorticaneurysmrupture.HeIsalifetimenonsmoker.Hisvitalsignsarenormal.CTscanoftheabdomenwithcontrastisshownIntheimagebelow.Theabdominalpainresolvesin2hourswithoutanyinterventionandthepatientwantstogohome.WhichofthefollowingisthemostappropriatemanagementfortherenalfindingsontheCTscan?A.AntibioticsB.PercutaneousaspirationC.ReassuranceonlyD.SurgicalexcisionE.UreteralstentplacementA2Correctanswer:CThispatient'sabdominalCTscanshowsasimplerenalcyst.Suchcystsaremostcommonlyseeninpatientsage50.Theyarebenignandoftendiscoveredincidentallybyradiologicalexamination.Mostofthetime,cystsdonotcausehypertension,flankpain,hematuria,orproteinuria;infectionoccursrarely.Whenarenalcystisfoundonimaging,itisoftenpossibletodifferentiatebetweenasimplecystandamalignantcysticmassbasedontheradiologicalfeatures.Featuressuggestingmalignancyincludeirregularormultiiocuiarstructurewithmultipleseptations,heterogeneouscontent,andcontrastenhancementonCTorMRI.incidentallydiscoveredcystswithbenignfeaturesrequirenoadditionalfollow-upevaluationorimaging,andthepatientmaybereassured.(ChoiceA)AntibioticsarenotindicatedasthereIsnoevidenceofbacterialinfection(eithergastrointestinalorgenitourinary).(ChoiceB)Percutaneousaspirationofthecystisnotindicatedasthepatienthasnosymptomsfromit.Percutaneousaspirationmaybeconsideredifthecystislargeandpainfulorinfectedwithpurulentmaterial,(ChoiceD)Surgicalexcisionornephrectomyisnotindicatedasthispatienthasasimplebenigncystwithgoodprognosis.(ChoiceE)UreteralstentplacementIsIndicatedwhenthereisurinaryobstructionattheureterorrenalpelvis.Dilationoftherenalpelvis(hydronephrosis)orureter(hydroureter)isatypicalsignofurinaryobstruction.ThispatienthasnosymptomsofurinaryobstructionorradiologicalsignsofobstructiononCTscan.Educationalobjective:Simplerenalcystsarealmostalwaysbenignanddonotrequirefurtherevaluation.FeaturesconcerningformalignantrenalmassIncludeamultiiocuiarmass,Irregularwalls,thickenedseptae,andcontrastenhancement.Q3A66-year-oldmanwithahistoryofpoorlycontrolledtype2diabetesandhypertensioncomestothephysicianforaroutinevisit.Hehasnocurrentcomplaints.Hisbloodworkfrom2monthsagoshowedhyperkalemia,andhisphysiciandiscontinuedlisinoprilatthattime.Thepatient'scurrentmedicationsincludeglipizide,furosemide,nifedipine,andaspiri