An 18-year-old female gymnast is admitted to the hospital with pelvic pain. Physical examination reveals that the patient has a history of primary amenorrhea and an imperforate hymen. Which of the following is the most likely explanation for this condition?

A 2-week-old boy presented with persistent swelling of his left scrotum, but there has been no noticeable
discomfort. Physical examination shows bilateral descended
testicles with an enlarged, fluctuant left hemi-scrotum that transilluminates brightly.
No inguinal or abdominal masses are present. The most likely cause of this patient's
condition is a swelling in which of the following locations?

A 31-year-old man comes to the emergency department complaining of right-sided scrotal pain and swelling that has gradually worsened over the last 3 days. His temperature is 38.3 C (101 F). On physical examination, his right hemiscrotum is warm, tender, and erythematous. The cremasteric reflex is present. A scrotal ultrasound reveals a fluid collection consistent with a superficial scrotal abscess.
Which of the following lymph node groups is most likely to be tender and swollen?

A 24-year-old woman is admitted to the hospital with lower abdominal pain. A CT examination reveals an abnormal mass occupying the left adnexa in the pelvis. During the surgical procedure the ureter and the structures immediately medial to the ureter are identified. Which of the following vascular structures crosses the ureter just lateral to the cervix of the uterus?

A 21-year-old man comes to the emergency department due to 2 days of gross
hematuria. He reports passage of small blood clots in urine but has had no pain,
dysuria, or similar symptoms in the past. The patient has no prior medical problems
and does not take any medications. He does not use tobacco, alcohol, or illicit
drugs. His younger sister has sickle cell disease. His temperature is 36.7 C (98 F).
blood pressure is 120/70 mm Hg, and pulse is 100/min. Abdominal and
genitourinary examination is unremarkable. Which of the following is the most likely
cause of this patient's hematuria?
A. Acute pyelonephritis
B. Amyloidosis
C. Hemolytic-uremic syndrome
D. Hypersensitivity interstitial nephritis
E . Ischemic tubular necrosis
F. Papillary necrosis

Renal papillary necrosis classically presents with gross hematuria, acute flank pain,
and passage of tissue fragments in urine. It is most commonly seen in patients with
sickle cell disease or trait, diabetes mellitus, analgesic nephropathy, or severe
obstructive pyelonephritis.

A 17-year-old female presents to your office with urinary frequency, urgency, and
burning during urination. She has also noticed a scant vaginal discharge. The
symptoms started two days ago. Which of the following additional findings would be
most suggestive of pyelonephritis in this patient?
• A. Abdominal pain
• B. Fever
• C. Microscopic hematuria
• D. Bacteriuria
• E. White blood cell casts
F. Sterile pyuria

A 17-year-old female presents to your office with urinary frequency, urgency, and
burning during urination. She has also noticed a scant vaginal discharge. The
symptoms started two days ago. Which of the following additional findings would be
most suggestive of pyelonephritis in this patient?
• A. Abdominal pain
• B. Fever
• C. Microscopic hematuria
• D. Bacteriuria
• E. White blood cell casts

🔹(Choice A) Abdominal pain is a non-specific symptom. It can be seen in acute
pyelonephritis and in a large number of other conditions, like pelvic inflammatory
disease.
🔹(Choice B) Fever is a sign of any systemic infection. In acute pyelonephritis, it may
also be accompanied by shaking chills, nausea, vomiting, diarrhea, muscle aches,
and anorexia.
🔹(Choices C and D) Bacteriuria and microscopic hematuria are found in both upper
(acute pyelonephritis) and lower (cystitis, urethritis) UTIs.


🔺
WBC casts are formed in tubules, and are pathognomonic for acute pyelonephritis
when accompanied by systemic manifestations of febrile illness. WBC casts are
also seen with acute interstitial nephritis, but clinical presentation is different in that
patients have only a low-grade fever and do not experience painful urination.

A 47-year-old male treated for sinusitis with ampicillin later develops fever,
maculopapular skin rash, and oliguria. His serum creatinine level is 2.4 mg/dL. Urine
sediment microscopy reveals red blood cells, neutrophils, and eosinophils. The
pathologic process in this patient's kidney most likely involves which of the following?
A. Small renal arterioles
B. Glomeruli
C. Renal interstitium
D. Renal papillae
E. Calyces and ureters
F. Bladder

Fever, maculopapular rash and symptoms of acute renal failure one to three weeks
after beginning treatment with a ß-lactam antibiotic or a number of other drugs are
highly suggestive of acute interstitial nephritis. Peripheral eosinophilia and
eosinophiluria are important clinical clues. Symptoms resolve completely after
cessation of the medication.

A 65-year-old man comes to the emergency department due to severe lower abdominal pain and nausea. He also has not been able to urinate for the past 24 hours. The patient has a history of hypertension and benign prostatic hyperplasia. On examination, a large mass is palpable in the suprapubic area. Multiple attempts at urethral catheterization are unsuccessful, and an ultrasound-guided midline
suprapubic cystostomy is planned. Which of the following is the most likely sequence of structures traversed by the trocar and cannula during the procedure?
A. Skin, superficial fascia, aponeurosis, transversalis fascia, bladder wal
B. Skin, superficial fascia, aponeurosis, transversalis fascia, peritoneum,
bladder wall
C. Skin, superficial fascia, transversalis fascia, aponeurosis, bladder wall
D. Skin, superficial fascia, transversalis fascia, aponeurosis, peritoneum,
bladder wall
E. Skin, superficial fascia, transversalis fascia, bladder wall