KFP – Kidney and urinary health (Renal Urology)

Thomas Nguyen, aged 42, presents to your general practice clinic with a 3-month history of intermittent left flank pain and a recent episode of visible haematuria. He reports the pain as colicky in nature, sometimes radiating to the groin. He denies dysuria, urgency or frequency. He has no significant past medical history and takes no regular medications.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Works as a warehouse manager. Smokes 10 cigarettes per day. Drinks alcohol socially. No recent travel. Lives with partner and two children.

Family history: His father had renal cell carcinoma diagnosed in his 70s.

Examination findings: Afebrile, BP 132/84 mmHg, HR 74 bpm. Abdominal examination reveals mild tenderness in the left flank, no palpable masses. No costovertebral angle tenderness. Testicular examination is normal.

Investigations: Urine dipstick: Blood +++, Protein +, Nitrites -, Leukocytes -. Midstream urine (MSU) sent for MCS. FBC and UEC normal. Non-contrast CT KUB is arranged.

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What is the most likely diagnosis and appropriate next steps in management? Select three (3) from the following list:

Angela Robertson, a 65-year-old woman, presents for review after experiencing increased urinary frequency and nocturia over the past month. She reports a dull ache in her suprapubic region and describes her stream as slow with difficulty initiating urination. She denies haematuria or incontinence. There is no fever or flank pain.

Medications: Metformin 500 mg BD, Atorvastatin 20 mg daily

Past history: Type 2 diabetes mellitus (10 years), hypertension

Social history: Retired school teacher. Lives alone. Non-smoker. No alcohol. No recent travel.

Examination findings: Abdomen soft, mild suprapubic tenderness without guarding. No palpable bladder. No costovertebral angle tenderness.

Investigations: Urine dipstick: Glucose +, Blood -, Protein +. Midstream urine (MSU) pending. FBC and UEC normal. HbA1c 7.4%. Bladder scan: post-void residual (PVR) volume 250 mL.

What are the most likely diagnosis and appropriate management steps? Select three (3) from the following list:

David Halim, a 72-year-old man, presents with a 3-month history of progressive fatigue, anorexia, and unintentional weight loss of 5 kg. He reports occasional dull right-sided abdominal discomfort and recent onset of microscopic haematuria. He denies dysuria or fever. He has a 40-pack-year smoking history and drinks 1–2 beers daily.

Medications: Ramipril 5 mg daily, aspirin 100 mg daily

Past history: Hypertension, hyperlipidaemia

Family history: Non-contributory

Examination findings: Pale conjunctivae, BP 138/82 mmHg, HR 78 bpm. Abdomen soft, non-tender with a palpable right-sided mass on deep palpation. No lymphadenopathy. Digital rectal examination is normal.

Investigations: Urinalysis: Blood ++, Protein +. Urine MCS: sterile. FBC: Hb 102 g/L (130–180), MCV 85 fL (80–100), WBC and platelets normal. UEC: eGFR 68, creatinine 98 µmol/L (60–110). LFTs: mild elevation in ALP. CT abdomen with contrast is pending.

What are the most likely diagnosis and next appropriate steps? Select three (3) from the following list:

Emily West, a 26-year-old teacher, presents with a 2-day history of dysuria, urinary frequency, and suprapubic discomfort. She denies fever, back pain, or vaginal discharge. This is her second similar episode in the past six months. She is sexually active with a male partner and uses a diaphragm for contraception.

Medications: None

Allergies: Nil known

Past history: Nil significant

Social history: Non-smoker, moderate alcohol intake, no recent travel

Examination findings: Afebrile. Mild suprapubic tenderness. No flank or costovertebral angle tenderness. No vaginal discharge or cervical motion tenderness on speculum examination.

Investigations: Urine dipstick: Nitrites +, Leukocytes +++, Blood +. Midstream urine (MSU) sent for culture and sensitivity. No abnormalities on urine beta-hCG.

What is the most likely diagnosis and the most appropriate next steps in management? Select two (2) from the following list:

Michael Yorke, a 58-year-old truck driver, presents with new-onset nocturia, reduced urine stream, and difficulty initiating urination over the past two months. He denies haematuria, fever, or dysuria. He has no significant past medical history.

Medications: Nil

Allergies: Nil known

Past history: Nil

Family history: Father had benign prostatic hyperplasia (BPH)

Social history: Smokes 5 cigarettes/day, drinks 3–4 beers on weekends

Examination findings: Abdomen soft and non-tender. Bladder not palpable. Digital rectal examination: Prostate mildly enlarged, smooth, non-tender, no nodules.

Investigations: Urine dipstick: Negative for blood, nitrites, and leukocytes. PSA: 2.1 µg/L (age-adjusted normal range <4.0 µg/L). Renal function normal. Bladder scan shows post-void residual of 140 mL.

What are the most likely diagnosis and appropriate initial management steps? Select three (3) from the following list:

Sara Molyneux, a 32-year-old woman, presents with sudden onset of right-sided flank pain radiating to the groin, associated with nausea and vomiting. She reports passing a small amount of blood in her urine but denies fever, dysuria, or frequency. She has had two similar episodes in the past year, which resolved spontaneously. She is otherwise healthy and not on regular medications.

Medications: Nil

Allergies: Nil known

Past history: Recurrent nephrolithiasis (not formally investigated)

Social history: Works as a personal trainer, drinks 3L water/day, low dairy intake. No family history of kidney disease.

Examination findings: BP 124/80 mmHg, HR 88 bpm, afebrile. Tenderness in right flank. Abdomen soft, no guarding or rebound. No costovertebral angle tenderness. Normal bowel sounds.

Investigations: Urine dipstick: Blood +++, Nitrites -, Leukocytes -. Midstream urine sent. FBC and UEC normal. Non-contrast CT KUB: 5 mm obstructing calculus in right mid-ureter, with mild hydronephrosis.

What are the appropriate next management steps? Select three (3) from the following list:

James Carroll, a 19-year-old university student, presents with bilateral testicular discomfort and dysuria for the past 3 days. He describes a dull ache in his scrotum and perineal area, worse after urination. He also reports urinary frequency and urgency, but no fever or vomiting. He is sexually active with male partners and does not consistently use protection.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Smokes cannabis occasionally. Lives in university housing.

Examination findings: Afebrile. Mild bilateral testicular tenderness with associated epididymal swelling. No scrotal erythema. Cremasteric reflex intact bilaterally. No inguinal hernias or masses. Digital rectal examination: mild tenderness of the prostate, no nodules.

Investigations: Urine dipstick: Blood +, Leukocytes ++, Nitrites -. First void urine sent for NAAT. Midstream urine sent for MCS.

What is the most likely diagnosis and appropriate management? Select three (3) from the following list:

Linda Fraser, a 48-year-old woman, presents with a 4-week history of foamy urine and bilateral ankle swelling, especially in the evenings. She denies dysuria, frequency, haematuria, or flank pain. Her blood pressure has been high at home, but she has not seen a GP in several years.

Medications: Nil

Allergies: Nil known

Past history: Gestational hypertension with her last pregnancy 10 years ago

Social history: Works full-time in retail. No smoking, drinks wine socially. No recent travel.

Examination findings: BP 162/94 mmHg, HR 82 bpm. Bilateral pitting oedema to mid-shin. No rash. JVP not elevated. Chest clear. Abdomen soft, non-tender.

Investigations:
Urine dipstick: Protein +++, Blood –
Spot urine ACR: 320 mg/mmol (<3)
UEC: Creatinine 102 µmol/L (60–110), eGFR 78 mL/min/1.73 m²
Albumin: 28 g/L (35–50)
Cholesterol: Total 7.2 mmol/L (despite fasting)

What are the most likely diagnosis and appropriate next steps? Select three (3) from the following list:

Daniel Pope, a 62-year-old man, presents with painless visible haematuria for the past 3 days. He denies any dysuria, fever, frequency or urgency. He has never had haematuria before and has no previous urological history. He smokes one pack of cigarettes daily and has done so for 40 years. He has no known occupational exposures and no family history of urological cancers.

Medications: Amlodipine 5 mg daily

Allergies: Nil known

Past history: Hypertension

Social history: Retired carpenter, lives alone. No recent travel.

Examination findings: BP 134/78 mmHg, HR 76 bpm. Abdomen soft, no palpable masses or tenderness. DRE: Prostate smooth, non-tender, normal in size. No suprapubic fullness.

Investigations:
Urinalysis: Blood +++, Nitrites -, Leukocytes –
MSU: No growth
UEC: Normal
FBC: Hb 142 g/L (130–180), Platelets and WBC normal
PSA: 2.5 µg/L
Renal tract ultrasound: Normal kidneys, normal bladder wall, no hydronephrosis

What are the most appropriate next steps in management? Select three (3) from the following list:

Jacob El-Khoury, a 5-year-old boy, is brought in by his mother with a history of facial puffiness and swollen legs for the past week. He has also had reduced urine output and his urine appears frothy. He has no fever, rash, joint pain, or recent infections. He attends kindergarten and has been well otherwise.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Nil known renal disease

Examination findings: BP 102/62 mmHg, HR 88 bpm. Puffy eyelids, periorbital oedema, and bilateral pitting oedema to knees. No respiratory distress. Normal heart and lung sounds. Abdomen soft, non-tender with shifting dullness. No skin rash or arthropathy.

Investigations:
Urinalysis: Protein +++, Blood –
UEC: Na 135 mmol/L, K 4.1 mmol/L, Creatinine 42 µmol/L
Albumin: 18 g/L
Cholesterol: Total 7.5 mmol/L
FBC: Hb 127 g/L, WCC 6.4 x10⁹/L, Platelets 384 x10⁹/L

What is the most likely diagnosis and appropriate initial management? Select three (3) from the following list:

Gavin Rogers, a 74-year-old man, presents with increasing fatigue, anorexia, and back pain over the past 3 months. He reports mild constipation and has lost 6 kg unintentionally. He also describes nocturia and occasional difficulty with urination. He has a 50-pack-year smoking history and drinks 1–2 standard drinks per day.

Medications: Paracetamol PRN for osteoarthritis

Allergies: Nil known

Past history: Osteoarthritis, hypertension (not on treatment)

Family history: Brother with prostate cancer at age 68

Examination findings: Pale. BP 142/78 mmHg. Mild tenderness in the lower lumbar spine. Digital rectal examination: firm, nodular prostate with asymmetry. No neurological deficits. No lymphadenopathy or hepatosplenomegaly.

Investigations:
FBC: Hb 105 g/L (130–180), MCV 88 fL, WCC and platelets normal
UEC: Creatinine 132 µmol/L (60–110), eGFR 48 mL/min
Corrected Calcium: 2.85 mmol/L (2.15–2.65)
PSA: 94 µg/L (normal <4.0)
ALP: 360 U/L (30–110)

What is the most likely diagnosis and the appropriate next steps? Select three (3) from the following list:

Alison Ng, a 38-year-old woman, presents with sudden onset of gross haematuria and loin pain on the left side. She also reports a mild headache and dizziness. She has no history of trauma, fever, or infection. Her blood pressure has been consistently elevated over the last 6 months but she has not yet started treatment.

Medications: Nil

Allergies: Nil known

Past history: Nil surgical; occasional migraines

Family history: Her father died from a ruptured brain aneurysm at age 49. Her older sister is on dialysis for polycystic kidney disease.

Examination findings: BP 168/98 mmHg, HR 88 bpm. Abdomen: left flank fullness, ballotable mass. No costovertebral angle tenderness. Fundoscopy: mild arteriovenous nipping.

Investigations:
Urinalysis: Blood +++, Protein ++
FBC: Hb 128 g/L, WCC and platelets normal
UEC: Creatinine 92 µmol/L, eGFR 86 mL/min
Renal ultrasound: Bilaterally enlarged kidneys with multiple cortical cysts of varying size

What is the most likely diagnosis and next appropriate steps? Select three (3) from the following list:

Nina Qureshi, a 29-year-old woman, presents with frequency, urgency, dysuria, and left flank pain for the past 2 days. She also reports fevers and chills. She has no known history of urinary tract infections. She is sexually active, using an intrauterine device (IUD) for contraception.

Medications: IUD in situ, no regular medications

Allergies: Nil known

Past history: Nil significant

Examination findings: Temperature 38.7 °C, BP 110/70 mmHg, HR 102 bpm. Left costovertebral angle tenderness. Mild suprapubic tenderness. Otherwise normal examination.

Investigations:
Urine dipstick: Blood +, Nitrites +, Leukocytes +++
MSU: Pending
UEC: Normal
FBC: WCC 14.2 × 10⁹/L, Neutrophils 11.8 × 10⁹/L
CRP: 86 mg/L

What is the most likely diagnosis and the appropriate next steps? Select three (3) from the following list:

Oscar Murdoch, a 67-year-old man, presents with worsening fatigue and peripheral oedema over the past 3 months. He reports poor appetite and pruritus. His urine is described as foamy but he has no dysuria, urgency, or haematuria. He has a history of type 2 diabetes mellitus and hypertension, both diagnosed 12 years ago.

Medications: Metformin 1g BD, Perindopril 5mg daily, Atorvastatin 20mg daily

Allergies: Nil known

Past history: Type 2 diabetes, hypertension, dyslipidaemia

Examination findings: BP 148/88 mmHg, HR 80 bpm. Bilateral pitting oedema to knees. No rash. Retinopathy present on fundoscopy. Abdomen soft, no organomegaly.

Investigations:
UEC: Creatinine 162 µmol/L, eGFR 36 mL/min
Urinalysis: Protein ++, Glucose +, Blood –
Urine ACR: 216 mg/mmol
HbA1c: 7.2%
Albumin: 29 g/L
FBC: Hb 115 g/L (normocytic, normochromic)

What is the most likely diagnosis and the next best steps in management? Select three (3) from the following list:

Samira Patel, a 45-year-old woman, presents with persistent urinary urgency and suprapubic discomfort for the past 4 months. She reports urinating up to 12 times per day, including waking twice at night. Her urine cultures have been consistently negative despite antibiotic trials. She denies fever, flank pain, haematuria, or vaginal discharge. Symptoms worsen with stress and during menstruation.

Medications: Occasional ibuprofen for menstrual cramps

Allergies: Nil known

Past history: Irritable bowel syndrome (IBS)

Examination findings: Abdomen soft with mild suprapubic tenderness. No CVA tenderness. No pelvic organ prolapse on vaginal examination. Neurological examination normal.

Investigations:
Urinalysis: Trace protein, no blood, no leukocytes, no nitrites
Urine cultures (x3): No growth
Renal tract ultrasound: Normal kidneys and bladder
UEC: Normal
FBC: Normal

What are the most likely diagnosis and appropriate next steps? Select three (3) from the following list:

Henry Wallace, a 52-year-old man, presents with a 2-month history of worsening lower urinary tract symptoms including frequency, urgency, nocturia, and a weak stream. He also reports perineal discomfort and a sensation of incomplete bladder emptying. He denies haematuria or fever but reports mild testicular heaviness. He had a similar episode 6 months ago that resolved with antibiotics.

Medications: Nil

Allergies: Nil known

Past history: One prior episode of presumed prostatitis

Social history: Office worker, sexually active with wife, non-smoker, no alcohol

Examination findings: Afebrile, normal vital signs. Abdomen soft. DRE: Prostate mildly tender, slightly boggy but not nodular. No perineal or testicular masses.

Investigations:
Urinalysis: Negative for nitrites, leukocytes, or blood
MSU: No growth
PSA: 1.6 µg/L
UEC: Normal
STI screen: Negative

What is the most likely diagnosis and appropriate management? Select three (3) from the following list:

Eliza Hampton, a 31-year-old woman, presents with sudden onset severe left loin pain radiating to the groin. The pain began 3 hours ago and is associated with nausea and one episode of vomiting. She denies any urinary symptoms, fever, or vaginal discharge. She is not sexually active and has no prior urological history. Her last menstrual period was 2 weeks ago.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Works as a vet nurse, lives with housemates

Examination findings: BP 126/74 mmHg, HR 92 bpm, afebrile. Left flank tenderness, no rebound or guarding. Abdomen soft. Normal bowel sounds. No costovertebral angle tenderness. Bimanual pelvic exam unremarkable.

Investigations:
Urinalysis: Blood ++, Nitrites -, Leukocytes –
Serum beta-hCG: Negative
UEC: Normal
FBC: Normal
Non-contrast CT KUB: 3 mm calculus in the left distal ureter, no hydronephrosis

What are the most appropriate next steps in management? Select three (3) from the following list:

Christopher Lin, a 34-year-old man, presents with dark urine and mild lower limb swelling over the past 5 days. He reports having a sore throat 2 weeks ago but did not seek medical attention. He denies dysuria, flank pain, or fever. He has no known chronic illnesses and takes no medications.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Father has hypertension

Examination findings: BP 152/96 mmHg, HR 82 bpm. Mild bilateral pedal oedema. No rash. Lungs clear. Abdomen soft, no organomegaly. No joint swelling.

Investigations:
Urinalysis: Blood +++, Protein ++
UEC: Creatinine 128 µmol/L, eGFR 68 mL/min
FBC: Hb 134 g/L, WCC and platelets normal
ASOT: Elevated
Complement C3: Low
Anti-dsDNA and ANA: Negative

What is the most likely diagnosis and next best steps? Select three (3) from the following list:

Michelle Thomson, a 63-year-old woman, presents for evaluation of recurrent urinary tract infections. She has had four episodes in the past year, each treated with antibiotics with temporary resolution. She reports urgency, frequency, and dysuria during each episode but is currently asymptomatic. She is sexually active with her long-term partner and has no history of incontinence or haematuria.

Medications: Calcium/vitamin D, bisphosphonate weekly

Allergies: Nil known

Past history: Osteoporosis, menopause at 51

Social history: Retired nurse, non-smoker, drinks wine socially

Examination findings: Unremarkable. No suprapubic tenderness or pelvic organ prolapse. Post-void residual volume by bladder scan is 30 mL.

Investigations:
Most recent MSU: E. coli, sensitive to nitrofurantoin
Urinalysis today: Negative
Renal tract ultrasound: Normal kidneys and bladder
FBC, UEC: Normal

What are the most appropriate next steps in management? Select three (3) from the following list:

Declan Moore, a 21-year-old university student, presents with right-sided scrotal pain and swelling that began suddenly 3 hours ago. He describes the pain as severe and constant, with some associated nausea. He denies dysuria, fever, or recent trauma. He is sexually active with one female partner. He has no history of similar symptoms.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives in student accommodation, drinks alcohol occasionally

Examination findings: HR 102 bpm, BP 128/78 mmHg, afebrile. Right testis swollen, tender, high-riding with horizontal lie. Absent cremasteric reflex on the right. No inguinal hernia or discharge. Left testis normal.

Investigations: [Insert Image Here]

What is the most likely diagnosis and appropriate management? Select three (3) from the following list:

Hannah James, a 57-year-old woman, presents for evaluation of worsening fatigue, pruritus, and muscle cramps over the last 3 months. She also reports occasional nausea and poor appetite. Her past medical history includes long-standing poorly controlled type 2 diabetes mellitus and hypertension. She has a history of diabetic retinopathy and peripheral neuropathy.

Medications: Metformin 500 mg BD, gliclazide MR 60 mg daily, perindopril 10 mg daily, amlodipine 5 mg daily

Allergies: Nil known

Examination findings: BP 152/88 mmHg, HR 76 bpm. Pale conjunctivae. Mild bilateral ankle oedema. No focal neurological deficits. No abdominal masses or renal bruit.

Investigations:
UEC: Creatinine 328 µmol/L, eGFR 16 mL/min
Urine ACR: 284 mg/mmol
HbA1c: 8.4%
Serum phosphate: 1.9 mmol/L (0.8–1.5)
Calcium: 2.10 mmol/L (2.15–2.65)
Haemoglobin: 94 g/L
PTH: Elevated

What are the most appropriate next steps in management? Select three (3) from the following list:

Isaac Hall, a 10-year-old boy, is brought in by his mother due to facial puffiness and reduced urine output over the last 3 days. He has been otherwise well, with no fever, rash, joint pain, or recent illness. His mother notes that his urine appears ‘frothy’ and he’s been more tired than usual.

Medications: Nil

Allergies: Nil known

Past history: Mild eczema

Family history: Nil renal disease

Examination findings: BP 102/68 mmHg. Puffy eyelids and mild bilateral lower limb oedema. Abdomen soft. Chest clear. No lymphadenopathy or rash.

Investigations:
Urinalysis: Protein +++, Blood –
UEC: Creatinine 38 µmol/L (normal), eGFR normal
Albumin: 21 g/L (35–50)
Cholesterol: 6.9 mmol/L
FBC: Normal
Urine protein/creatinine ratio: 280 mg/mmol

What is the most likely diagnosis and appropriate management? Select three (3) from the following list:

Vincent Andrews, a 68-year-old man, presents with generalised malaise, new-onset confusion, and reduced urine output over the last 2 days. He has also had poor oral intake due to nausea and diarrhoea for 3 days. His past history includes heart failure with reduced ejection fraction and chronic kidney disease stage 3.

Medications: Frusemide 40 mg daily, ramipril 10 mg daily, spironolactone 25 mg daily

Allergies: Nil known

Examination findings: BP 96/62 mmHg, HR 88 bpm, afebrile. Dry mucous membranes. Mild peripheral oedema. JVP not elevated. Chest clear. No focal neurological findings.

Investigations:
UEC: Creatinine 268 µmol/L (baseline 135), eGFR 21 mL/min
K+: 6.1 mmol/L (3.5–5.0)
Na+: 131 mmol/L (135–145)
HCO₃: 17 mmol/L (22–32)
ECG: Tall peaked T-waves

What are the most appropriate next steps in management? Select three (3) from the following list:

Lisa Armstrong, a 44-year-old woman, presents with fatigue, haematuria, and joint pain. She also reports a recent 2-week history of sinus congestion and cough with blood-streaked sputum. She denies urinary frequency, dysuria, or flank pain. There is no known recent infection.

Medications: Occasional ibuprofen for joint aches

Allergies: Nil known

Past history: Seasonal allergic rhinitis

Examination findings: BP 148/92 mmHg, HR 84 bpm, no fever. Pale. Mild tenderness in small finger joints, no effusions. Lung auscultation reveals faint crackles bilaterally.

Investigations:
Urinalysis: Blood +++, Protein ++
UEC: Creatinine 176 µmol/L (baseline unknown), eGFR 35 mL/min
CRP: 86 mg/L
FBC: Hb 102 g/L, WCC 8.3 x10⁹/L, Platelets 410 x10⁹/L
Anti-neutrophil cytoplasmic antibody (ANCA): Positive (c-ANCA pattern)

What are the most appropriate next steps in management? Select three (3) from the following list:

Trevor Nash, a 73-year-old man, presents for a routine check-up. He is asymptomatic but had a recent urinalysis at a pre-operative clinic that showed trace blood. He denies dysuria, haematuria, weight loss, or urinary frequency. He has no past urological history.

Medications: Aspirin 100 mg daily, perindopril 5 mg daily

Allergies: Nil known

Past history: Hypertension, osteoarthritis

Social history: Retired mechanic, smoked 20 cigarettes per day for 35 years (quit 10 years ago), moderate alcohol intake

Examination findings: Normal abdominal and genitourinary exam. No flank tenderness. DRE: smooth, mildly enlarged prostate

Investigations:
Urinalysis (x2): Microscopic haematuria confirmed on repeat
Urine MCS: No growth
PSA: 2.2 µg/L
Renal function: Normal
Renal tract ultrasound: Normal kidneys and bladder, prostate mildly enlarged

What are the most appropriate next steps? Select three (3) from the following list:

Felicity Morgan, a 36-year-old woman, presents with sudden onset of left-sided loin pain and visible haematuria. She has no fever, dysuria, or urinary frequency. Her pain is severe, colicky, and radiates to the groin. She reports a similar episode two years ago but did not follow up. She drinks little water and follows a high-protein, low-carb diet for weight loss.

Medications: Oral contraceptive pill

Allergies: Nil known

Past history: One prior renal colic episode, not investigated

Examination findings: HR 94 bpm, BP 132/76 mmHg, afebrile. Left flank tenderness. Abdomen otherwise soft and non-tender. No CVA tenderness or signs of peritonism.

Investigations:
Urinalysis: Blood +++, Nitrites -, Leukocytes –
Beta-hCG: Negative
UEC: Normal
CT KUB: 6 mm calculus at left ureterovesical junction with mild hydronephrosis

What are the most appropriate next steps in management? Select three (3) from the following list:

Edward Chalmers, a 66-year-old man, presents with a 2-month history of worsening nocturia, weak urinary stream, and sensation of incomplete emptying. He denies haematuria, pain, or systemic symptoms. He has no significant past urological history but reports getting up 3–4 times a night to void.

Medications: Atorvastatin 20 mg daily

Allergies: Nil known

Past history: Hypercholesterolaemia, diet-controlled type 2 diabetes

Examination findings: DRE: Prostate mildly enlarged, smooth, non-tender. Bladder not palpable. Abdomen soft and non-tender.

Investigations:
Urinalysis: Normal
PSA: 1.8 µg/L
UEC: Normal
Bladder scan: Post-void residual 60 mL
International Prostate Symptom Score (IPSS): 17 (moderate)

What are the most appropriate next steps in management? Select three (3) from the following list:

Aliyah Rahman, a 7-year-old girl, is brought in by her parents due to increased frequency of urination and new-onset daytime urinary incontinence over the past month. She denies dysuria, urgency, fever, or flank pain. Her parents report that she was previously toilet trained with no issues. There is no nocturnal enuresis.

Medications: Nil

Allergies: Nil known

Past history: Unremarkable birth and developmental history

Family history: Mother had similar symptoms as a child

Examination findings: Normal growth parameters. Abdomen soft, non-tender. No spinal or neurological abnormalities. External genitalia normal.

Investigations:
Urinalysis: Normal
Bladder scan post-void residual: 75 mL (elevated for age)
UEC: Normal
MSU: No growth
Renal tract ultrasound: Normal kidneys and bladder

What is the most appropriate diagnosis and next steps in management? Select three (3) from the following list:

George Faulkner, a 75-year-old man, presents with worsening lower limb oedema and breathlessness on exertion over the past month. He reports no chest pain or orthopnoea but notes reduced appetite and foamy urine. He has no history of heart disease. He takes medications for hypertension and gout.

Medications: Allopurinol, amlodipine

Allergies: Nil known

Past history: Hypertension, hyperuricaemia

Examination findings: BP 142/88 mmHg, HR 84 bpm. Bilateral pitting oedema to knees, JVP not elevated. Chest clear. No hepatosplenomegaly. No rash.

Investigations:
Urinalysis: Protein +++
Urine ACR: 322 mg/mmol
Albumin: 24 g/L
Cholesterol: Total 6.8 mmol/L
UEC: Creatinine 96 µmol/L, eGFR 76 mL/min
ANA: Negative, Hep B/C negative
Serum protein electrophoresis: Monoclonal spike (IgG)

What are the most appropriate next steps in management? Select three (3) from the following list:

Natalie Tran, a 24-year-old woman, presents with dysuria and urinary frequency that began two days ago. She has no fever, loin pain, or vaginal discharge. This is her third episode of similar symptoms in the past 12 months. She is sexually active with a new partner and uses condoms inconsistently. She is otherwise well.

Medications: Nil

Allergies: Nil known

Past history: Recurrent urinary tract infections

Examination findings: Afebrile. Mild suprapubic tenderness. No costovertebral angle tenderness. No vaginal discharge. Abdomen soft, no masses.

Investigations:
Urinalysis: Leukocytes ++, Nitrites +
Midstream urine: Pending culture
Pregnancy test: Negative

What are the most appropriate next steps in management? Select three (3) from the following list:

Harvey Quinn, a 62-year-old man, presents with progressive bilateral lower limb swelling and fatigue. He denies chest pain, dyspnoea, or orthopnoea. His urine has appeared frothy for several months. He has a long-standing history of poorly controlled type 2 diabetes and hypertension.

Medications: Metformin 1g BD, gliclazide MR 60mg daily, perindopril 10mg daily

Allergies: Nil known

Past history: Type 2 diabetes, hypertension, diabetic retinopathy

Examination findings: BP 154/92 mmHg, HR 84 bpm. Bilateral pitting oedema to mid-shin. No raised JVP. Chest clear. Fundoscopy shows background retinopathy.

Investigations:
Urinalysis: Protein +++, Blood –
Urine ACR: 410 mg/mmol
Albumin: 26 g/L
Cholesterol: 7.4 mmol/L
UEC: Creatinine 118 µmol/L, eGFR 58 mL/min
HbA1c: 8.3%

What are the most appropriate next steps in management? Select three (3) from the following list:

Lucas Bentley, a 41-year-old man, presents with a 6-month history of intermittent bilateral flank pain and haematuria. He denies dysuria, fever, or urinary frequency. He has a strong family history of kidney disease, with his mother starting dialysis in her late 50s. He is otherwise well and takes no regular medications.

Allergies: Nil known

Past history: Nil significant

Family history: Mother on dialysis (cause unknown), maternal uncle died of a ruptured intracranial aneurysm

Examination findings: BP 158/94 mmHg, HR 78 bpm. Abdomen: Bilateral palpable kidneys. No tenderness, rash, or peripheral oedema.

Investigations:
UEC: Creatinine 104 µmol/L, eGFR 84 mL/min
Urinalysis: Blood ++, Protein +
Renal ultrasound: Bilaterally enlarged kidneys with multiple cortical cysts

What are the most appropriate next steps in management? Select three (3) from the following list:

Sarah Delaney, a 58-year-old woman, presents with generalised fatigue and persistent microscopic haematuria found on two separate urine tests over the past 6 months. She is asymptomatic, with no dysuria, urinary frequency, or flank pain. She has no history of kidney disease or urinary tract infections.

Medications: None

Allergies: Nil known

Past history: Nil significant

Family history: Father had a kidney transplant for ‘unknown kidney problem’ in his 60s

Examination findings: BP 128/76 mmHg, HR 74 bpm. Abdomen soft, non-tender. No oedema or flank masses. No rash or joint swelling.

Investigations:
Urinalysis: Blood ++, Protein trace
MSU: No growth
UEC: Creatinine 82 µmol/L, eGFR 76 mL/min
Urine microscopy: Dysmorphic red cells
Urine ACR: 6 mg/mmol

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Malcolm Rowe, a 79-year-old man, presents with lethargy, poor appetite, and recent onset of constipation. He also mentions mild back pain and has unintentionally lost 4 kg in the past 2 months. He has a history of hypertension and osteoarthritis. He denies urinary symptoms or abdominal pain.

Medications: Paracetamol, amlodipine 5 mg daily

Allergies: Nil known

Past history: Hypertension, osteoarthritis

Examination findings: BP 140/86 mmHg, HR 82 bpm. Mild pallor. No lymphadenopathy. Abdomen soft, non-tender. No spinal tenderness.

Investigations:
UEC: Creatinine 221 µmol/L (eGFR 28 mL/min)
Corrected calcium: 3.1 mmol/L (2.15–2.65)
Urinalysis: Protein +++, Blood –
Serum protein electrophoresis: Monoclonal IgG band
FBC: Hb 104 g/L, normal WCC and platelets

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Jasmine Wells, a 31-year-old woman, presents with sudden-onset left-sided flank pain and visible haematuria. She denies any recent trauma, fever, dysuria, or previous similar episodes. She has a known diagnosis of systemic lupus erythematosus (SLE) diagnosed two years ago, and is on regular follow-up with a rheumatologist.

Medications: Hydroxychloroquine 200 mg daily, prednisolone 5 mg daily

Allergies: Nil known

Past history: SLE, no renal involvement previously documented

Examination findings: BP 142/88 mmHg, HR 88 bpm. Mild left flank tenderness. No rash. Abdomen soft, no palpable masses.

Investigations:
Urinalysis: Blood +++, Protein ++
UEC: Creatinine 142 µmol/L, eGFR 52 mL/min
Urine ACR: 78 mg/mmol
ANA: Positive
Anti-dsDNA: Elevated
Complement C3 and C4: Low

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Thomas Leung, a 54-year-old man, presents with persistent fatigue and swelling of his ankles over several weeks. He denies chest pain, breathlessness, or urinary symptoms. He has a past history of hepatitis B infection and is not on any regular medications.

Medications: Nil

Allergies: Nil known

Past history: Chronic hepatitis B (untreated)

Social history: Works in IT, non-smoker, minimal alcohol intake

Examination findings: BP 138/84 mmHg, HR 78 bpm. Mild bilateral ankle oedema. No jaundice or hepatosplenomegaly. Lungs and heart sounds normal.

Investigations:
UEC: Creatinine 106 µmol/L, eGFR 74 mL/min
Urinalysis: Protein ++, Blood –
Urine ACR: 290 mg/mmol
Albumin: 27 g/L
Hepatitis B viral load: Detectable
ANA/anti-dsDNA: Negative

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Leah Morton, a 22-year-old woman, presents with dysuria and increased urinary frequency over the past 24 hours. She also reports suprapubic discomfort. She is sexually active and uses the oral contraceptive pill. She has had one similar episode 6 months ago. She denies fever, flank pain, or vaginal discharge.

Medications: Ethinylestradiol/levonorgestrel

Allergies: Nil known

Past history: One previous UTI, treated successfully

Examination findings: Afebrile, HR 76 bpm, BP 118/72 mmHg. Mild suprapubic tenderness. No costovertebral angle tenderness. No vaginal discharge.

Investigations:
Urinalysis: Leukocytes ++, Nitrites +
Urine culture: Pending
Pregnancy test: Negative

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Matilda Brooks, a 47-year-old woman, presents with sudden-onset right flank pain and visible haematuria. She has no fever or urinary frequency. She denies trauma or recent illness. She has no personal history of renal disease but reports her brother had a ‘kidney tumour’ removed at age 50. She is a non-smoker and otherwise well.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Brother with renal cell carcinoma at age 50

Examination findings: BP 136/82 mmHg, HR 78 bpm, afebrile. Right flank tenderness on deep palpation, no masses felt. No oedema.

Investigations:
Urinalysis: Blood +++, Protein +
UEC: Normal
Renal ultrasound: 4.2 cm solid mass in right kidney, suspicious for malignancy

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Brendan Lewis, a 60-year-old man, presents for review of blood tests ordered as part of a cardiovascular risk assessment. He is asymptomatic. However, his blood tests show new-onset proteinuria and reduced kidney function. He has a history of hypertension and is overweight. He does not have diabetes.

Medications: Amlodipine 10 mg daily

Allergies: Nil known

Past history: Hypertension for 10 years

Examination findings: BP 146/88 mmHg, HR 76 bpm. No oedema. Fundoscopy: mild hypertensive retinopathy. No rash, joint abnormalities, or features of systemic illness.

Investigations:
UEC: Creatinine 126 µmol/L, eGFR 55 mL/min
Urinalysis: Protein ++, Blood –
Urine ACR: 128 mg/mmol
FBC: Normal
HbA1c: 5.6%

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Peter Zahran, a 33-year-old man, presents with bilateral flank discomfort and dark-coloured urine noticed over the last two days. He also reports mild ankle swelling and a general sense of fatigue. He recently recovered from a sore throat about two weeks ago. He has no known medical conditions.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: BP 148/92 mmHg, HR 82 bpm. Mild pedal oedema. No rash or joint swelling. Cardiopulmonary and abdominal exams unremarkable.

Investigations:
Urinalysis: Blood ++, Protein ++
UEC: Creatinine 138 µmol/L, eGFR 62 mL/min
FBC: Normal
ASOT: Elevated
Complement C3: Low
Urine microscopy: Red cell casts

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Andrew Cormack, a 70-year-old man, presents for routine review. He is asymptomatic but a recent urinalysis done during a pre-operative check showed microscopic haematuria. Repeat testing confirmed persistent non-visible haematuria. He denies dysuria, frequency, urgency, or abdominal pain. He has a 45-pack-year smoking history and drinks moderately.

Medications: Aspirin 100 mg daily, atorvastatin 20 mg daily

Allergies: Nil known

Past history: Hypertension, osteoarthritis

Examination findings: Normal abdominal, prostate, and testicular examination. No flank tenderness. No palpable masses.

Investigations:
Urinalysis (x2): Blood ++, no protein, nitrites, or leukocytes
Urine culture: No growth
PSA: 1.7 µg/L
eGFR: 76 mL/min
Renal tract ultrasound: Normal kidneys, bladder, and prostate

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Emily Zhao, a 5-year-old girl, is brought in by her parents due to new-onset facial puffiness and reduced urine output over the past few days. She has no fever, rash, or joint pain. Her appetite is reduced. There is no recent illness or medication use. Her immunisations are up to date.

Medications: Nil

Allergies: Nil known

Past history: Unremarkable

Family history: Nil relevant

Examination findings: BP 102/64 mmHg, HR 90 bpm. Puffy eyelids, mild lower limb oedema. No rash, no organomegaly, chest clear.

Investigations:
Urinalysis: Protein +++, Blood –
UEC: Creatinine 36 µmol/L, eGFR >90 mL/min
Albumin: 18 g/L
Cholesterol: 6.3 mmol/L
Urine protein/creatinine ratio: 260 mg/mmol

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Martin Geary, a 48-year-old man, presents with persistent urinary hesitancy, weak stream, and a feeling of incomplete emptying for the past 6 months. He denies haematuria, dysuria, or constitutional symptoms. He is concerned about his urinary symptoms affecting work and sleep.

Medications: None

Allergies: Nil known

Past history: Nil significant

Examination findings: DRE: Smooth, symmetrically enlarged prostate. No nodules. Abdomen: No masses. Bladder not palpable.

Investigations:
Urinalysis: Normal
Post-void residual: 90 mL
PSA: 1.3 µg/L
UEC: Normal
International Prostate Symptom Score (IPSS): 19 (moderate)

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Isobel Kennedy, a 29-year-old woman, presents with severe right-sided loin pain that started suddenly 4 hours ago. The pain radiates to her groin and is associated with nausea but no vomiting. She denies dysuria or urinary frequency. She is sexually active and not using contraception.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: HR 92 bpm, BP 122/78 mmHg, afebrile. Right costovertebral angle tenderness. Abdomen soft but tender on right side. No guarding or rebound. No vaginal discharge or adnexal tenderness.

Investigations:
Urinalysis: Blood ++, Nitrites -, Leukocytes –
Serum beta-hCG: Negative
UEC: Normal
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Hamish O’Donnell, a 67-year-old man, presents with fatigue and reduced exercise tolerance. He denies oedema, chest pain, or urinary symptoms. He has type 2 diabetes and hypertension, both moderately controlled. Routine blood tests reveal mild renal impairment. He is concerned about his kidney health.

Medications: Metformin 1g BD, perindopril 5 mg daily

Allergies: Nil known

Past history: Type 2 diabetes (diagnosed 10 years ago), hypertension

Examination findings: BP 138/84 mmHg, HR 80 bpm. No oedema. Fundoscopy shows diabetic retinopathy. Cardiovascular and respiratory exams normal.

Investigations:
UEC: Creatinine 118 µmol/L, eGFR 58 mL/min
Urine ACR: 43 mg/mmol
HbA1c: 7.4%
Urinalysis: Protein +, no blood
FBC: Normal

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Annabelle Simms, a 35-year-old woman, presents with dysuria, urinary frequency, and suprapubic discomfort for the past 2 days. She denies fever, flank pain, or vaginal discharge. She is sexually active with one partner and uses condoms. She has no relevant past medical history and is otherwise well.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Examination findings: Afebrile, HR 76 bpm, BP 118/70 mmHg. Mild suprapubic tenderness. Abdomen soft. No costovertebral angle tenderness.

Investigations:
Urinalysis: Leukocytes ++, Nitrites +
MSU: Sent for culture
Pregnancy test: Negative

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Timothy Reid, a 75-year-old man, presents with fatigue, anorexia, and unintentional weight loss of 6 kg over the last 3 months. He has a 50-pack-year smoking history. He denies haematuria, dysuria, or abdominal pain. Examination reveals a firm, non-tender mass in the left upper quadrant.

Medications: Irbesartan 150 mg daily, atorvastatin 20 mg daily

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Examination findings: BP 138/80 mmHg, HR 76 bpm. Left upper quadrant mass palpable. No oedema or lymphadenopathy. Chest clear.

Investigations:
UEC: Creatinine 112 µmol/L, eGFR 63 mL/min
FBC: Hb 110 g/L, WCC and platelets normal
Urinalysis: Blood ++, Protein +
Renal ultrasound: 6.5 cm solid mass in left kidney

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Grace Halim, a 42-year-old woman, presents with a 3-month history of urinary urgency, increased daytime frequency, and nocturia. She denies dysuria, haematuria, or incontinence. She has no fever or flank pain. She reports that the symptoms are affecting her quality of life and work concentration.

Medications: Nil

Allergies: Nil known

Past history: Irritable bowel syndrome

Examination findings: Abdomen soft, non-tender. No pelvic masses. No suprapubic tenderness. Neurological exam normal.

Investigations:
Urinalysis: Normal
MSU: No growth
Bladder diary: 12 voids/day, 3/night, small volumes each time
Bladder scan: Post-void residual <40 mL

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Yusuf Karim, a 62-year-old man, presents with fatigue and vague lower back discomfort. He has noticed his urine has become darker over the past week. He is on chronic NSAIDs for osteoarthritis. He denies fever, dysuria, or weight loss. He is a non-smoker and drinks socially.

Medications: Ibuprofen 400 mg TDS

Allergies: Nil known

Past history: Osteoarthritis of knees

Examination findings: BP 154/90 mmHg, HR 82 bpm. No flank tenderness. Abdomen soft, no palpable masses.

Investigations:
Urinalysis: Blood ++, Protein ++
UEC: Creatinine 162 µmol/L, eGFR 42 mL/min
Urine microscopy: Red cell casts
Urine ACR: 89 mg/mmol
ANA/ANCA: Negative
Serum albumin: 33 g/L

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Layla Thomas, a 58-year-old woman, presents with new-onset nocturia, frequency, and suprapubic discomfort. She has had three similar episodes in the last 12 months, each treated with antibiotics. She is postmenopausal, sexually active, and uses no hormone replacement therapy. She denies flank pain or systemic symptoms.

Medications: Rosuvastatin 10 mg daily

Allergies: Nil known

Past history: Hyperlipidaemia, recurrent urinary tract infections

Examination findings: Afebrile, abdomen soft with mild suprapubic tenderness. No CVA tenderness. No vaginal discharge or signs of atrophy.

Investigations:
Urinalysis: Leukocytes ++, Nitrites +
MSU: Sent for culture
UEC: Normal

What are the most appropriate next steps in management? Select three (3) from the following list: