AKT – Renal Urology

Joseph Tran, aged 45, presents with two weeks of right-sided flank pain and intermittent macroscopic haematuria. He has not had any recent trauma and denies fever or urinary frequency. He is a non-smoker with no significant past medical history. There is no family history of renal disease. He has no recent overseas travel.

Examination reveals a soft, non-tender abdomen. His blood pressure is 135/82 mmHg and temperature is 36.7°C. Urinalysis reveals haematuria but no proteinuria or leucocytes.

An ultrasound shows mild right-sided hydronephrosis without visible calculi. A CT IVP is pending.

What is the most appropriate next step in management?

Margaret Collins, aged 72, presents with urinary incontinence. She reports urgency, frequency, and occasional nocturia, with several episodes of leakage before reaching the toilet. This has worsened over the past 6 months and is now impacting her social life. She takes ramipril and atorvastatin and has no allergies.

She has a BMI of 31. Pelvic examination is normal. A bladder diary shows frequent small voids and urgency episodes. Urinalysis is normal and MSU is negative.

What is the most appropriate initial management?

Hamish Butler, aged 18, presents with left testicular pain that began suddenly 3 hours ago. The pain is severe and associated with nausea. He denies trauma or urinary symptoms. No previous similar episodes.

Examination reveals a high-riding left testicle with transverse lie and marked tenderness. The cremasteric reflex is absent on the affected side.

What is the most appropriate next step?

Sabrina Nasser, aged 34, presents with dysuria and suprapubic discomfort. She has had 2 similar episodes in the last 12 months. She is sexually active with one partner, uses condoms regularly, and has no significant past medical history.

Urinalysis shows leucocytes and nitrites. MSU is sent. She is not febrile and has no flank pain or nausea.

What is the most appropriate management?

George Wilkins, aged 64, presents with fatigue, nocturia and frothy urine. He has a history of hypertension and type 2 diabetes for 10 years. Medications include metformin, perindopril, and amlodipine. BP is 138/84 mmHg. There is bilateral pitting oedema to the mid-shins.

Urinalysis shows 3+ protein and trace blood. An ACR is 320 mg/mmol. eGFR is 48 mL/min/1.73m².

What is the most appropriate next step in management?

Annette Halliday, aged 57, presents with persistent urinary leakage despite voiding regularly. She describes continuous dribbling of urine and reports a prior hysterectomy for fibroids 12 years ago. She denies urgency or dysuria.

On examination, there is no pelvic organ prolapse. Post-void residual is minimal. Urinalysis is normal.

What is the most likely diagnosis?

Michael Barry, aged 64, presents for routine check-up. He is asymptomatic but routine blood tests show a creatinine of 135 μmol/L (previously 102 μmol/L 1 year ago). eGFR is 52 mL/min/1.73m². Repeat urinalysis shows 2+ protein and trace blood. BP is 128/76 mmHg.

He takes perindopril and simvastatin.

What is the most appropriate next investigation?

Timothy Reid, aged 82, presents with difficulty initiating urination and post-void dribbling. He wakes 3–4 times per night to void. He denies haematuria or pain. He takes aspirin and metoprolol.

On DRE, the prostate is smooth, enlarged, and non-tender. Urinalysis is normal. PVR is 180 mL.

What is the most appropriate initial treatment?

Nathaniel James, aged 40, presents with sudden onset severe right loin pain radiating to the groin. He is restless and unable to get comfortable. He has vomited twice. No fever or dysuria.

On examination, he is afebrile, HR 98 bpm, BP 142/86 mmHg. Abdomen is soft but tender in the right flank. Urinalysis shows haematuria.

What is the most appropriate next investigation?

Debbie Reynolds, aged 67, presents with fatigue and pruritus. Routine blood tests reveal eGFR of 24 mL/min/1.73m², Hb 102 g/L, phosphate 1.7 mmol/L, and calcium 2.02 mmol/L. Her PTH is 18 pmol/L (high). She is on perindopril, rosuvastatin, and calcium carbonate.

What is the most appropriate management for her mineral bone disorder?

Leonard Maclean, aged 61, presents with lethargy and decreased appetite. He has type 2 diabetes and hypertension. Routine pathology shows eGFR 28 mL/min/1.73m² and HbA1c of 6.7%. He is taking metformin, perindopril and amlodipine.

What is the most appropriate management regarding his metformin?

Emily Foster, aged 25, presents with dysuria, urgency and suprapubic discomfort. This is her third UTI in the last 4 months. She is otherwise well and takes no regular medications. She is sexually active with a regular partner.

Urinalysis confirms leucocytes and nitrites. MSU sent.

What is the most appropriate next step?

Markus Petrovic, aged 49, presents with left scrotal swelling noticed over the last 3 months. It is painless and gradually increasing in size. No trauma or infection history.

On examination, there is a soft fluctuant swelling superior to the left testicle, which transilluminates. No inguinal hernia palpable.

What is the most likely diagnosis?

Patricia Yuen, aged 76, presents after a fall. Bloods show Na 132 mmol/L, K 4.2 mmol/L, urea 8.4 mmol/L, creatinine 104 µmol/L. She takes sertraline, metoprolol, and aspirin. She appears euvolaemic, and urinalysis shows normal sodium excretion.

Serum osmolality is low and urine osmolality is high.

What is the most likely cause of her hyponatraemia?

Geraldine O’Neill, aged 70, presents with sudden onset painless visible haematuria. She has a 40 pack-year smoking history but stopped 10 years ago. No trauma or anticoagulant use.

Urinalysis confirms gross haematuria. No infection signs.

What is the most appropriate next investigation?

Thomas Fairbanks, aged 48, presents with sudden onset anuria and nausea. He has recently started NSAIDs for a back injury. On examination, he is hypertensive at 158/96 mmHg and mildly oedematous. Bloods show creatinine 460 µmol/L, urea 22 mmol/L, K 5.6 mmol/L.

What is the most likely diagnosis?

Monique Delacroix, aged 33, presents with loin pain, haematuria and a family history of “kidney problems”. Her BP is 146/92 mmHg. Urinalysis confirms microscopic haematuria and proteinuria. Ultrasound reveals multiple bilateral renal cysts.

What is the most likely diagnosis?

Kyle Thompson, aged 29, presents with scrotal pain and swelling for 2 days. He has dysuria and frequency. On examination, the scrotum is tender, erythematous and swollen. Lifting the testicle relieves the pain.

What is the most likely diagnosis?

Helen Gough, aged 74, presents with increasing fatigue and bone pain. She has a known history of chronic kidney disease. Labs show eGFR 22 mL/min/1.73m², calcium 2.0 mmol/L, phosphate 1.6 mmol/L, and PTH 21 pmol/L.

What is the most appropriate long-term treatment?

Jacob Styles, aged 52, presents with painless scrotal swelling. He first noticed it several months ago, and it is gradually increasing in size. On examination, the mass is non-tender, separate from the testis, and transilluminates.

What is the most appropriate next step in management?

Angela Samuels, aged 68, presents with a 3-month history of fatigue and vague abdominal discomfort. She has a 40-pack-year smoking history. On examination, she has mild right flank tenderness. Urinalysis reveals microscopic haematuria. CT abdomen shows a 4 cm solid mass in the right kidney.

What is the most likely diagnosis?

Brendan Tuohy, aged 55, presents with difficulty voiding and lower abdominal discomfort. He has a history of diabetes and has recently started amitriptyline for neuropathic pain. On bladder scan, a post-void residual volume of 600 mL is found.

What is the most appropriate next step?

Jasmine Yilmaz, aged 29, presents with cloudy, malodorous urine and suprapubic discomfort. She is sexually active, uses the OCP and has no allergies. This is her first UTI. Urinalysis shows nitrites and leukocytes.

What is the most appropriate antibiotic therapy?

Samira Alvi, aged 59, presents with persistent oedema and frothy urine. BP is 148/94 mmHg. Urinalysis shows 4+ protein, no blood. Serum albumin is 22 g/L and cholesterol is elevated.

What is the most likely diagnosis?

Jordan Wylie, aged 36, presents with 3 episodes of kidney stones in the past 4 years. He wants to know how to reduce his risk. His most recent stone was calcium oxalate.

What is the most appropriate dietary advice?

Isobel Darby, aged 62, presents with recurrent UTIs. She is postmenopausal and sexually active. Vaginal examination shows atrophic changes. Urinalysis shows pyuria and bacteriuria.

What is the most appropriate long-term management strategy?

Daniel Mahoney, aged 45, presents for review of hypertension. He has been stable on ramipril. Routine bloods show an eGFR drop from 88 to 64 over 6 months, and ACR has increased to 45 mg/mmol.

What is the most appropriate next step?

Caroline Flynn, aged 7, presents with facial puffiness and tea-coloured urine. BP is 132/84 mmHg. She had a sore throat 2 weeks ago. Urinalysis shows haematuria and proteinuria.

What is the most likely diagnosis?

Steven Ah Kee, aged 58, presents with gross haematuria and left flank pain. He has a history of smoking. A CT urogram shows a filling defect in the left renal pelvis.

What is the most likely diagnosis?

Naomi Bennett, aged 73, presents with nocturia and daytime urinary frequency. She denies incontinence or haematuria. She has a history of diabetes and mild cognitive impairment. Urinalysis is negative.

What is the most appropriate initial management?

Ravi Patel, aged 50, presents with loin pain and fever. He has a history of nephrolithiasis. He appears unwell and is febrile at 38.9°C. Urinalysis shows pyuria and haematuria. Imaging reveals a 6 mm obstructing ureteric stone with proximal hydronephrosis.

What is the most appropriate next step?

Sylvia Watkins, aged 81, presents with new-onset confusion and lethargy. Her medications include frusemide, sertraline, and omeprazole. Her sodium is 122 mmol/L. She is euvolaemic on examination.

What is the most likely cause of her hyponatraemia?

Aliya Hussain, aged 39, is found to have microscopic haematuria on pre-employment screening. She is asymptomatic, and her BP is 122/78 mmHg. Repeat urinalysis confirms haematuria with no proteinuria.

What is the most appropriate next step?

Trevor Lawton, aged 61, presents with progressive bilateral lower limb oedema and weight gain. He has a history of hypertension. Labs show albumin 24 g/L, cholesterol 6.9 mmol/L, and urinalysis with 4+ protein.

What is the most appropriate initial investigation?

Kathryn Lu, aged 46, presents with a history of passing stones and wants to know how to prevent recurrence. She asks about the best initial test for determining stone risk.

What is the most appropriate investigation?

Harriet Jones, aged 83, presents with confusion and a recent fall. She lives alone. Bloods show Na 129 mmol/L, K 4.0 mmol/L, creatinine 85 µmol/L. She is euvolaemic. Current medications include indapamide, perindopril and sertraline.

What is the most likely contributor to her hyponatraemia?

Zane McLeod, aged 20, presents with sudden-onset left testicular pain while at the gym. Pain is severe and associated with nausea. On examination, the testicle is tender, high-riding and swollen. Cremasteric reflex is absent.

What is the most appropriate next step?

Louise Tan, aged 72, presents with urgency and frequency without dysuria. She has been previously treated for UTIs without clear benefit. MSU culture is negative.

What is the most appropriate management step?

Damien Forrest, aged 38, presents with loin pain and visible haematuria. He reports a similar episode two years ago. His father had a history of kidney stones. A non-contrast CT KUB confirms a 7 mm mid-ureteric stone.

What is the most appropriate next step?

Nina Waugh, aged 42, presents with lower abdominal pain and dysuria. Urinalysis is positive for nitrites and leukocytes. She has a penicillin allergy (anaphylaxis).

What is the most appropriate empiric antibiotic?

Phillip Wong, aged 60, presents for review of stable chronic kidney disease. His eGFR has been around 42 for the past year. He takes perindopril, atorvastatin, and aspirin. BP today is 128/76 mmHg.

Which intervention is most likely to slow further progression of his CKD?

Georgia Maxwell, aged 70, presents with new-onset gross haematuria. She is a smoker. Urine dip shows blood, no nitrites or leukocytes. She denies pain or systemic symptoms.

What is the most appropriate next step?

James Arman, aged 33, presents with infertility. Semen analysis shows azoospermia. On examination, there is a soft mass in the left hemiscrotum that feels like a ‘bag of worms’ and increases with Valsalva.

What is the most likely diagnosis?

Helen Mowbray, aged 29, presents with dysuria and increased frequency. She has had multiple UTIs in the past and recently completed a 5-day course of trimethoprim. She is now febrile and has left flank pain.

What is the most likely diagnosis?

Gary Rudd, aged 66, presents with lower urinary tract symptoms. His PSA is 6.4 ng/mL. Digital rectal examination reveals a smooth, mildly enlarged prostate.

What is the most appropriate next step?

Melissa Han, aged 36, presents with a single episode of macroscopic haematuria. She is otherwise well and has no past medical history. Urinalysis confirms blood, no protein or infection. Renal function is normal.

What is the most appropriate next step in investigation?

Jonathan Doyle, aged 52, has newly diagnosed hypertension and proteinuria on dipstick. His BP is 158/94 mmHg. Bloods reveal eGFR 65, creatinine 104 µmol/L.

What is the most appropriate first-line antihypertensive?

Sandra Drew, aged 78, presents with general malaise. She has stage 4 chronic kidney disease. Her medications include perindopril, metformin, atorvastatin and aspirin. Recent pathology shows K 5.9 mmol/L and eGFR 18 mL/min/1.73m².

What is the most appropriate medication change?

Abdul Rahman, aged 26, presents with painless, persistent scrotal swelling. On examination, there is a firm, non-transilluminating mass arising from the testicle.

What is the most appropriate next investigation?

Felicity James, aged 58, presents with fatigue and normocytic anaemia. Her eGFR is 28 mL/min/1.73m² and creatinine is 165 µmol/L. Iron studies are normal, CRP is not elevated.

What is the most appropriate next step in management?