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Comments ...

 +4  (nbme21#27)

FA 2018 p. 609. Suspect urethral injury if blood is seen at the urethral meatus. Mechanism of posterior urethral injury = pelvic fracture, which we see in this patient. Urethral catheterization is relatively contraindicated.

hyperfukus  thank you!

 +3  (nbme21#2)

Uworld Qid 1543 has a good explanation as to how pulmonary fibrosis increases the radial traction on the airway walls.

cienfuegos  I think this is it -pulmonary fibrosis increases elastic recoiland widens airway 2/2 increased outward force (radial traction) by fibrotic tissue thus decreasing airflow resistance thus supernormal expiratory flow rates (higher than nl following correction for lung volume)

Subcomments ...

submitted by brolycow(15),

He has heart failure which leads to a decrease in renal blood flow and prerenal azotemia. In prerenal azotemia, BUN:Cr ratio is >= 20; Activation of the RAAS system due to the prerenal azotemia means that the spec grav is high at 1.025 and he is holding onto sodium so urinary sodium will be low (<20, FENa <1%).

figprincess  did you figure out the the ratio by actually divding out the numbers since the q didn't give it as a ratio? also what resource tells us what prerenal spec gravity should be? +  
brolycow  I just usually remember from class that spec grav 1.001-1.010 is considered dilute urine, and anything 1.025 and above is concentrated. For this question specifically, I think I remember there only being one option that even had the ratio >=20, all of the others were like 15 or less, so just have to rule them out. +2  
benzjonez  Very helpful video for acute kidney injury: https://www.youtube.com/watch?v=bMp6IxDKK2Q +2  
notadoctor  Another explanation that helped me is that inability to concentrate the urine means something is wrong with the kidneys. If you have dilute urine, or the spec gravity is between 1.001-1.010 in someone with low urine output it suggests something is wrong with the concentration mechanisms of the kidney. Because this person had congestive heart failure we were already looking for something that matched up with prerenal azotemia so we can pretty much get rid of all the answer choices that suggest other azotemias. Then finally to get the precise answer I looked at the BUN/Cr ratio which you would expect to be high(>= 20). +  
mikay92  Would fully recommend the OnlineMedEd video on AKI. Goes through the differential, lab results, treatment, etc in a very clear and concise manner. +  
drdoom  repost via @benzjonez -> https://www.youtube.com/watch?v=bMp6IxDKK2Q +  
drdoom  @mikay92 is this the OnlineMedEd video you're referring to? -> https://youtu.be/EWFgzVtMN50 +1  
drdoom  aha! there is an updated AKI video but you need an OnlineMedEd (free) account to view it: https://onlinemeded.org/spa/nephrology/acute-kidney-injury/acquire +  

submitted by aesalmon(40),

Can anyone explain why this is not a pituitary adenoma? Is it just a lack of other symptoms?

benzjonez  I think that they just wanted you to notice the **calcifications**. Per FA, "calcifications are common in craniopharyngiomas," whereas I don't think you'd expect to see calcifications in a prolactinoma. +7  
epr94  also the option is prolactinoma not broad pituitary calcifications and he doesnt show any specific signs of high prolactin +