1.

A 65-year-old male is hospitalized for debridement of diabetic leg ulcer, with

associated cellulitis. He has a history of hypertension, diabetes, and
hyperlipidemia. His home medication regimen consists of metformin and
glipizide, as well as lovastatin, atenolol, and lisinopril. His creatinine was
measured on admission, and was 1.1. On admission to the hospital, metformin and
glipizide are discontinued, and scheduled insulin injections are used to control his
blood sugars. His pain is controlled with acetaminophen and ibuprofen. In
addition, he is started on gentamicin and piperacillin/tazobactam to cover his
lower extremity cellulitis in preparation for debridement. Operative debridement
of the ulcer occurs on hospital day two, with an uneventful perioperative course.
He is afebrile and his vital signs are normal. His laboratory survey on hospital day
three is shown below.

WBC 9,000
Hgb 12.5
Platelets 220,000

Sodium 135
Potassium 4.1
Chloride 101
Bicarbonate 18
BUN 50
Creatinine 3.1
Glucose 89
AST 22
ALT 23
Total Protein 7.1
Albumin 3.8

INR 0.9
aPTT 35

Urinalysis: pH 5.0, specific gravity 1.010, negative for blood, no red blood cells,
no white blood cells, no bacteria, LE negative, Nitrite negative, epithelial cell
casts present

Urine sodium 50
Urine creatinine 50

What is the most likely cause of this patient’s renal failure?

a. Tazobactam/piperacillin
b. Gentamicin
c. Uncontrolled infection
d. Rhabdomyolysis due to compartment syndrome
e. NSAID use
2. A 65-year-old male is hospitalized for debridement of diabetic leg ulcer, with
associated cellulitis. He has a history of hypertension, diabetes, and
hyperlipidemia. His home medication regimen consists of metformin and
glipizide, as well as lovastatin, atenolol, and lisinopril. His creatinine was
measured on admission, and was 1.1. On admission to the hospital, metformin and
glipizide are discontinued, and scheduled insulin injections are used to control his
blood sugars. His pain is controlled with scheduled acetaminophen and ibuprofen.
In addition, he is started on gentamicin and piperacillin/tazobactam to cover his
lower extremity cellulitis in preparation for debridement. Operative debridement
of the ulcer occurs on hospital day two, with an uneventful perioperative course.
He is afebrile and his vital signs are normal. His laboratory survey on hospital day
three is shown below.

WBC 9,000
Hgb 12.5
Platelets 220,000

Sodium 135
Potassium 4.1
Chloride 101
Bicarbonate 18
BUN 60
Creatinine 2.5
Glucose 89
AST 22
ALT 23
Total Protein 7.1
Albumin 3.8

INR 0.9
aPTT 35

Urinalysis: pH 5.0, specific gravity 1.030, negative for blood, no red blood cells,
no white blood cells, no bacteria, LE negative, Nitrite negative, no casts

Urine sodium 5
Urine creatinine 50

What is the most likely cause of this patient’s renal failure?

a. Tazobactam/piperacillin
b. Gentamicin
c. Uncontrolled infection
d. Rhabdomyolysis due to compartment syndrome
e. NSAID use
3. A 65-year-old male is hospitalized for debridement of diabetic leg ulcer, with
associated cellulitis. He has a history of hypertension, diabetes, and
hyperlipidemia. His home medication regimen consists of metformin and
glipizide, as well as lovastatin, atenolol, and lisinopril. His creatinine was
measured on admission, and was 1.1. On admission to the hospital, metformin and
glipizide are discontinued, and scheduled insulin injections are used to control his
blood sugars. His pain is controlled with scheduled acetaminophen and ibuprofen.
In addition, he is started on gentamicin and piperacillin/tazobactam to cover his
lower extremity cellulitis in preparation for debridement. Operative debridement
of the ulcer occurs on hospital day two, with an uneventful perioperative course.
On hospital day three, he complains of fatigue and a rash. He is febrile and
tachycardic, and his previously well controlled blood pressure is 140/90. His
exam is remarkable for a maculopapular rash over the chest and back. His
laboratory survey on hospital day three is shown below.

WBC 13,000
Hgb 12.5
Platelets 220,000
Differential 60% neutrophils
25% eosinophils
10% lympocytes
5% monocytes
Sodium 135
Potassium 4.1
Chloride 101
Bicarbonate 18
BUN 50
Creatinine 3.1
Glucose 89
AST 22
ALT 23
Total Protein 7.1
Albumin 3.8

INR 0.9
aPTT 35

Urinalysis: pH 5.0, specific gravity 1.030, negative for blood, no red blood cells,
10-15 white blood cells per high power field, no bacteria, LE negative, Nitrite
negative, WBC casts are present. Eosinophil smear of the urine is positive.

What is the most likely cause of this patient’s renal failure?

a. Tazobactam/piperacillin
b. Gentamicin
c. Pyelonephritis
 d. Rhabdomyolysis due to compartment syndrome
e. NSAID use

4. A 65-year-old male is hospitalized for prostate surgery. He has a history of

hypertension, diabetes, benign prostatic hypertrophy, and hyperlipidemia. His
home medication regimen consists of metformin and glipizide, as well as
lovastatin, terazosin, atenolol, and lisinopril. His creatinine was measured on
admission, and was 1.1. On admission to the hospital, metformin and glipizide are
discontinued, and scheduled insulin injections are used to control his blood
sugars. His pain is controlled with scheduled acetaminophen and ibuprofen. In
addition, he is given perioperative antibiotics per the usual operating room
protocol to prevent perioperative infection. His prostatectomy occurs on hospital
day one, and takes four hours with the patient placed in the dorsal lithotomy
position and with generous amounts of bladder irrigation. No adverse events
occurred before, during, or after the procedure, and the patient’s postoperative
course was uneventful. Pain is controlled with scheduled ibuprofen and morphine.
On hospital day three, he complained of fatigue and he has made very little urine
according to the nurse’s notes, despite having a bladder catheter in place that
functions well with flushing. His laboratory survey on hospital day three is shown
below.

WBC 13,000
Hgb 12.5
Platelets 220,000
Differential 60% neutrophils
35% lympocytes
5% monocytes
Peripheral smear: normal

Sodium 135
Potassium 4.1
Chloride 101
Bicarbonate 18
BUN 50
Creatinine 3.1
Glucose 89
AST 900
ALT 300
Total Protein 7.1
Albumin 3.8

INR 0.9
aPTT 35

Urinalysis: pH 5.0, specific gravity 1.010, 4+ blood, no red blood cells, no white
blood cells, no bacteria, LE negative, Nitrite negative, muddy brown casts noted
 Urine sodium 50
Urine creatinine 50

What is the most likely cause of this patient’s renal failure?

a. Tazobactam/piperacillin
b. Gentamicin
c. Hemorrhage
d. Rhabdomyolysis
e. NSAID use
f. Bladder outlet obstruction

5. A 65-year-old male is hospitalized for prostate surgery. He has a history of

hypertension, diabetes, benign prostatic hypertrophy, and hyperlipidemia. His
home medication regimen consists of metformin and glipizide, as well as
lovastatin, terazosin, atenolol, and lisinopril. His creatinine was measured on
admission, and was 1.1. On admission to the hospital, metformin and glipizide are
discontinued, and scheduled insulin injections are used to control his blood
sugars. His pain is controlled with scheduled acetaminophen and ibuprofen. In
addition, he is given perioperative antibiotics per the usual operating room
protocol to prevent infection. His prostatectomy occurs on hospital day one, and
takes four hours with the patient placed in the dorsal lithotomy position and with
generous amounts of bladder irrigation. No adverse events occurred before,
during, or after the procedure, and the patient’s postoperative course was
uneventful. Pain is controlled with scheduled ibuprofen and morphine. On
hospital day two, his catheter is removed. The next morning he complains of
abdominal pain and he has voided very little urine according to the nurse’s notes.
His vital signs are: T 99.1, HR 100, RR 16, BP 150/90. What is the next correct
course of action?

a. Replace the indwelling urinary catheter

b. Order an abdominal ultrasound
c. Measure urine and serum electrolytes
d. Discontinue ibuprofen and give high volume resuscitation IV fluids
e. Type and cross in preparation for a blood transfusion

6. A 45-year-old female is in the surgical ICU following multiorgansystem trauma

in a motor vehicle accident. She has been in the ICU for two weeks, and has
developed ventilator-associated pneumonia in the last three days. In the last few
days, she has also had gradually decreasing urine output and worsening azotemia
despite aggressive fluid resuscitation and concomitant high-dose diuretic use. She
has a urinary catheter in place that flushes and aspirates adequately. Current
medications include sodium bicarbonate, sodium polystyrene sulfonate, calcium
gluconate, vancomycin, gentamycin, insulin, and omeprazole. She has become
progressively edematous, and has worsening pulmonary edema on her chest xray,
 as well as higher mechanical ventilator settings. Vitals are: T 99.1 HR 100, BP
100/60, RR 20. Her labs are shown below:

WBC 15,000
Hgb 10.5
Platelets 220,000

Sodium 132
Potassium 6.1
Chloride 101
Bicarbonate 15
BUN 70
Creatinine 3.5
Glucose 89
AST 22
ALT 23
Total Protein 7.1
Albumin 3.0

INR 1.5
aPTT 65

Urinalysis: pH 5.0, specific gravity 1.010, negative for blood, no red blood cells,
no white blood cells, no bacteria, LE negative, Nitrite negative, epithelial cell
casts present

Urine sodium 50
Urine creatinine 50

What is the most correct next step?

a. Begin hemodialysis
b. Sodium restriction
c. Free water restriction
d. Potassium restriction
e. Give albumin infusion
f. Start total parenteral nutrition with maximal amounts of protein

7. A 51-year-old patient with hypertension, hyperlipidemia, diabetes, and chronic

kidney disease is seen by his primary care doctor for routine care. His health
maintenance, including PSA, immunizations, and colonoscopy, are up to date. He
is maintained on insulin injections, atenolol, lisinopril, atorvastatin, oral sodium
bicarbonate, and HCTZ. He has no complaints, and is well appearing on general
survey. Vitals: T 98.5, HR 75, RR 16, BP 115/65. He weighs 75 kg, and his exam
is normal. Routine lab work is shown below, with unchanged renal function from
his previous baseline:
 WBC 9,000
Hgb 10.1
Platelets 220,000
MCV 89
Iron 60

Sodium 132
Potassium 5.1
Chloride 101
Bicarbonate 18
BUN 30
Creatinine 1.9
Glucose 89
Calcium 8.5
Phosphate 4.2
AST 22
ALT 23
Total Protein 7.1
Albumin 3.9
Hgb A1C 6.5

What is the next correct step in this patient’s management?

a. Start erythropoietin therapy

b. Start hemodialysis therapy
c. Prescribe calcitriol therapy
d. Refer patient for parathyroidectomy
e. Prescribe a low protein diet
f. Increase dose of lisinopril

8. A 51-year-old patient with hypertension, hyperlipidemia, diabetes, and chronic

kidney disease is seen by his primary care doctor for routine care. His health
maintenance, including PSA, immunizations, and colonoscopy, are up to date. He
is maintained on insulin injections, atenolol, lisinopril, atorvastatin, oral sodium
bicarbonate, and furosemide. He has no complaints, and is well appearing on
general survey. Vitals: T 98.5, HR 75, RR 16, BP 135/85. He weighs 75 kg, and
his exam is normal. Routine lab work is shown below, with unchanged renal
function from his previous baseline:

WBC 9,000
Hgb 12.7
Platelets 220,000
MCV 89
Iron 60

Sodium 132
 Potassium 5.1
Chloride 101
Bicarbonate 18
BUN 30
Creatinine 1.9
Glucose 89
Calcium 8.5
Phosphate 4.2
AST 22
ALT 23
Total Protein 7.1
Albumin 3.9
Hgb A1C 6.5

Urine microalbumin/creatinine is 200mg/g

What is the correct next step in this patient’s management?

a. Prescribe amlodipine
b. Increase insulin dose
c. Start hemodialysis therapy
d. Prescribe calcitriol therapy
e. Prescribe a low protein diet

9. A 59-year-old patient with hypertension, hyperlipidemia, diabetes, and chronic

kidney disease is seen in the ER for chest pain and fatigue. His pain started 12
hours prior to seeking care, and is relieved somewhat by leaning forward. His
health maintenance, including PSA, immunizations, and colonoscopy, are up to
date. He is maintained on insulin injections, atenolol, lisinopril, atorvastatin, oral
sodium bicarbonate, and HCTZ. He looks uncomfortable. Vitals: T 98.5, HR 115,
RR 16, BP 185/95. He weighs 60 kg, and his exam is remarkable for JVD to the
angle of the jaw when sitting upright, tachycardia, and a friction rub heard over
the precordial area. Labs:

WBC 9,000
Hgb 9.7
Platelets 220,000
MCV 89
Iron 60

Sodium 132
Potassium 7.1
Chloride 101
Bicarbonate 13
BUN 85
Creatinine 5.5
 Glucose 89
Calcium 7.5

Troponin-I 0.22 (normal 0.04-0.10)

EKG is pictured below.

EKG with peaked T waves and diffuse ST elevations as seen in uremic pericarditis with
hyperkalemia

What is the correct next step in this patient’s management?

a. Hemodialysis
b. Emergent cardiac catheterization
c. Thrombolytic medication
d. Aspirin, metoprolol, sublingual nitroglycerin, and morphine
e. Oral naproxen sodium