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Old 11-17-2012
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Arrow Billy Step 1 Questions # 83

A 48-year-old man is hospitalized for shock after massive blood loss in a motor vehicle accident. On the patient’s second day in the hospital, his blood urea nitrogen (BUN) and creatinine levels begin to rise and he develops pitting edema to his knees. A subsequent urinalysis shows numerous granular casts. Which of the following is the most appropriate treatment?


(A) Angioplasty
(B) Broad-spectrum antibiotics
(C) Corticosteroids
(D) Fluids and dialysis
(E) Use of ultrasound to remove blockage
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Old 11-17-2012
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Default my answer :)

(D) Fluids and dialysis - acute tubular necrosis 2ndary to hypotension
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Old 11-17-2012
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Default Was missing you billy ;-) I mean your questions. hehe

(D) Fluids and dialysis
Acute tubular necrosis
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d) fluid and dialysis...hypovolemic shock-ATN
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Old 11-18-2012
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Thumbs Up D is correct (Thankyou KOOLKILLER)

This man’s history indicates that he is suffering from acute tubular necrosis secondary to ischemia of the epithelial cells of the proximal convoluted tubule. Granular casts on urinalysis is also a significant sign that this is acute tubular necrosis. These cells, given their high metabolic rate, are particularly sensitive to a drop in blood pressure such as that experienced in hemorrhagic shock. In this patient, the immediate therapeutic plan is to correct the fluid and electrolyte imbalance. The fluid replacement should include both crystalloid (eg, normal saline, lactated Ringer’s) and blood products due to the severity of blood loss. If recovery of renal function is delayed or if the kidneys never fully recover, dialysis is indicated. The epithelium will usually regenerate in a few weeks.


Answer A is incorrect. Angioplasty is a minimally invasive procedure that involves eliminating the renal artery occlusion by placing intravascular stents in the renal artery and thereby restoring proper blood fl ow to the kidney. This patient is not suffering from acute renal failure due to stenosis/occlusion of the renal artery, so angioplasty is not indicated as an appropriate treatment.

Answer B is incorrect. Broad-spectrum antibiotics are indicated in cases of shock due to sepsis or in pyelonephritis. This patient is in hemodynamic shock caused by massive blood loss. Since there is no infection, antibiotics will not be beneficial. Additionally, because the patient is experiencing renal failure, any drug that is metabolized by the kidney should be used with caution.

Answer C is incorrect. Immune-mediated disease can also cause acute renal failure. Corticosteroids are indicated in immune-mediated disease. Since that is not the mechanism of this patient’s renal failure, it is not indicated.

Answer E is incorrect. This treatment is reserved primarily for renal stones obstructing the outflow of urine and causing postrenal acute renal failure.
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