Exam Section 2: Item 22 of 50 National Board of Medical Examiners®

Comprehensive Clinical Science Self-Assessment

)( 22. A 57-year-old man with a history of chronic kidney disease is admitted to the hospital because of a 1-day history of blood in his
urine and severe pain in his right side. He has type 2 diabetes mellitus. During the past 5 years, he has passed renal calculi
twice. Medications are lisinopril, metoprolol, glyburide, and furosemide. His pulse is 100/min; other vital signs are within normal
limits. Abdominal examination shows right flank tenderness. There is trace swelling of the ankles. Laboratory studies show:
Serum
Urea nitrogen 45 mg/dl
Creatinine 4.3 mg/dl
Urine
Blood 4+
Protein 4+
too numerous to
RBC
count

Serum urea nitrogen and creatinine concentrations are unchanged from 1 month ago. Which of the following is the most
appropriate next step in diagnosis?

A) X-ray of the abdomen

, B) Intravenous pyelography
C) Renal ultrasonography
D) CT scan of the abdomen without contrast
E) MRI of the kidneys
Correct Answer: D.

This patient's presenting findings of acute flank pain, hematuria, and proteinuria, as well as his history of renal calculi, are consistent
with nephrolithiasis. The majority of renal calculi are radioopaque and can be visualized on CT scan . CT scan of the abdomen
without contrast is a sensitive modality for the detection of renal calculi. Most radiolucent calculi, including struvite or cystine calculi,
but excluding pure matrix and protease inhibitor calculi, are nonetheless visible on CT scan. Renal ultrasonography, while less
sensitive, may be useful for the detection of radiolucent calculi. Most patients with small renal calculi (if based on calcium oxalate,
which is the most common type) can be treated with thiazide diuretics, a low-sodium diet, and supplementation with potassium
citrate. Patients with large calculi may require extracorporeal shock wave lithotripsy or surgical removal with percutaneous
nephrolithotomy or ureteroscopic lithotripsy. This patient's baseline increased creatinine puts him at high risk for post-renal azotemia;
threats to kidney function should be addressed urgently in such patients.

Incorrect Answers: A, B, C, and E.

X-ray of the abdomen (Choice A) is an inexpensive and widely available modality that is useful for the detection of large, radioopaque
calculi. However, x-ray images are vulnerable to attenuation by adipose tissue surrounding the kidney in the retroperitoneal space
and may fail to detect small calculi.

Intravenous pyelography (Choice B) provides good sensitivity for the detection of renal calculi but is time-consuming and less
sensitive in comparison to a non-contrast CT scan.

Renal ultrasonography (Choice C) is useful for the detection of radiolucent calculi but has poor sensitivity for the detection of small
renal calculi. Additionally, if a calculus has migrated to the mid-ureter, ultrasonography sensitivity for detection may decrease.

MRI of the kidneys (Choice E) is less sensitive for the detection of renal calculi in comparison with CT scan, and is time consuming
and costly.

Educational Objective: Nephrolithiasis presents with acute onset flank pain and often with hematuria. CT scan of the abdomen
without contrast has superior sensitivity for the detection of nephrolithiasis in comparison to plain film x-ray, intravenous pyelography,
ultrasonography, and MRI.

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