Question 1

A 26-year-old woman comes to the office for an annual examination. The patient has regular menses with no intermenstrual spotting or abnormal vaginal discharge. Review of systems is negative. The patient is sexually active with her boyfriend of 1 year and uses combined oral contraceptives. She has no chronic medical conditions or previous surgeries. The patient's menstrual periods are regular, every 28 days with 3-4 days of light vaginal bleeding. Her last menstrual period ended 2 weeks ago. The patient's last Pap test, 3 years ago, was normal; the human papillomavirus vaccination series was completed at age 17. She has never had a sexually transmitted infection and has had 4 lifetime sexual partners. Family history is noncontributory. The patient does not use tobacco, alcohol, or illicit drugs. She has no known allergies. Temperature is 36.7 C (98.1 F), blood pressure is 134/88 mm Hg, and pulse is 76/min. BMI is 32 kg/m². Pelvic examination reveals normal external genitalia with no areas of inflammation. On speculum examination, the cervix has no lesions, is nonfriable, and has no discharge. The uterus is small and mobile and has no cervical motion tenderness. There are no adnexal masses. Pap testing is negative for intraepithelial lesions; however, multiple motile, flagellated organisms are visualized. Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bfcd_d1ef_8f63_c7ea0ba1d927_MD0005_00 Motile, flagellated organisms identified on a Pap test or wet mount are consistent with Trichomonas vaginalis, a protozoan parasite that is transmitted sexually. Clinical features in women include dysuria, urinary frequency, dyspareunia, vaginal pruritus, and a green, frothy discharge. Vaginal and cervical punctate hemorrhages ("strawberry cervix") are sometimes seen. However, vaginal trichomoniasis can also be asymptomatic in women and identified incidentally on routine cervical cytology, as in this patient. trichomoniasis Irritation and exposed bleeding areas in the vagina, as well as the presence of Trichomonas, can increase rates of HIV transmission. As a result, screening is recommended in HIV-positive patients and in women with a history of multiple sexually transmitted infections. Therefore, regardless of symptoms, both partners are treated with oral metronidazole to reduce the risk of reinfection and of HIV transmission (Choice C). Sexual partners should undergo clinical evaluation and testing for other sexually transmitted infections; however, expedited partner therapy (eg, prior to evaluation) is an appropriate initial step. (Choice A) Azithromycin is used to treat Chlamydia trachomatis, a bacterium causing a sexually transmitted infection that typically presents as asymptomatic cervicitis. Chlamydia is diagnosed via nucleic acid amplification testing and is not evident on microscopy or Pap test. (Choice D) Trichomoniasis should always be treated as symptoms may eventually develop and the presence of Trichomonas organisms can facilitate HIV transmission. (Choice E) Oral metronidazole has a significantly higher cure rate than vaginal metronidazole. It achieves higher therapeutic levels that eradicate reservoirs in the urethra and periurethral glands and thereby prevents recurrence. Educational objective: Trichomonas vaginalis, a flagellated, motile protozoan, causes trichomoniasis, a common sexually transmitted infection. Infected patients and their sexual partners are treated with oral metronidazole regardless of symptoms (or lack thereof) as untreated Trichomonas infection can increase the rates of HIV transmission. References: Trichomoniasis - are we giving the deserved attention to the most common non-viral sexually transmitted disease worldwide? (http://www.ncbi.nlm.nih.gov/pubmed/28357378) Challenges and persistent questions in the treatment of trichomoniasis. (http://www.ncbi.nlm.nih.gov/pubmed/27697044)

Question 2

A 46-year-old man comes to the office due to dysuria and a dull, aching pain in the penis and perineal region.  The symptoms began 6 months ago and prompted the patient to visit an urgent care center twice.  Both times, he received a short course of antibiotics, which improved symptoms temporarily, but they returned within days.  The patient has also had pain during ejaculation but no urethral discharge, back pain, abdominal pain, weakness, or incomplete voiding.  He is married and monogamous with his wife and has 2 children.  He does not use tobacco or illicit drugs but occasionally drinks 1 or 2 beers on weekends.  He has no medication allergies and no family history of cancer.  Temperature is 37.1 C (98.8 F), blood pressure is 126/84 mm Hg, pulse is 72/min, and respirations are 14/min.  Physical examination shows no abdominal or costovertebral angle tenderness.  Digital rectal examination reveals a mildly tender prostate that is symmetric and not enlarged.  The external genitalia are normal in size and appearance and are nontender to palpation. The most likely diagnosis is discussed with the patient, and he asks what can be done to relieve his symptoms.  Which of the following is the most appropriate response to this patient?

Accepted Answer

Explanation: The underlying cause of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) remains unclear. As a result, there is much uncertainty about the ideal approach to treatment. Most patients receive a combination of therapies including medications for prostate enlargement (eg, alpha blockers), antibiotics, anti-inflammatories, and/or psychotherapy. (Choice A) Antispasmodic medications are occasionally prescribed to patients with CP/CPPS who have prominent manifestations of bladder overactivity. However, these medications are not considered first-line for CP/CPPS and are used far more rarely than medications for prostate enlargement. (Choice B) The surgical treatment of CP/CPPS is generally not considered first-line due to inconsistent and limited improvement of symptoms. (Choice D) Patients who develop CP/CPPS often have a history of other pain disorders such as fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome, leading some researchers to speculate that CP/CPPS might have a psychologic component. Although evidence now shows that cognitive behavior therapy may be a potentially useful therapeutic intervention, antipsychotic medications are not currently recommended as part of first-line care. (Choice E) A wide-range of treatment options are available for CP/CPPS and often improve symptoms when used in combination. Educational objective: The underlying cause of chronic prostatitis/chronic pelvic pain syndrome is unknown. Patients are generally treated with a combination of therapies including medications for prostate enlargement (eg, alpha blockers), antibiotics, anti-inflammatories, and/or psychotherapy.

Question 3

A 3-year-old girl is brought to the emergency department due to pain and fever.  Two days ago, she developed mild abdominal and back pain.  Her fever began yesterday morning and reached a maximum of 40.1 C (104.2 F) last night.  Over the last 8 hours, she had 6 episodes of emesis but has since tolerated a few sips of water.  The girl has a history of constipation since the start of toilet training at age 2 and has "pellet-like" stools once a week.  She has frequent urinary accidents during the day and night.  She takes no medications and has no other medical problems.  Immunizations are up to date.  Temperature is 40 C (104 F), blood pressure is 90/60 mm Hg, pulse is 110/min, and respirations are 20/min.  Physical examination shows a tired-appearing girl with dry mucous membranes.  She has right costovertebral tenderness.  The abdomen is soft, nontender, and nondistended.  The remainder of the examination is unremarkable.  Laboratory results are as follows:  A 20-mL/kg normal saline bolus is administered.  The patient has another episode of emesis and an additional void in the emergency department. The patient is admitted to the hospital, and intravenous antibiotics are started.  Urine culture is positive for pansensitive Escherichia coli.  Blood culture is negative.  After 48 hours, the patient is tolerating oral fluids and is afebrile.  The patient is discharged from the hospital on oral antibiotics.  Which of the following should be recommended to prevent recurrence of this patient's infection?

Accepted Answer

Explanation: 11ec2b69_bfcc_996d_8f63_a7fe4ba22e1d_MD0005_00 Dysfunction of the bowel and bladder is an important risk factor for urinary tract infection (UTI) in toddlers who are toilet training. Children may develop abnormal elimination habits, such as stool withholding and incomplete defecation, which lead to functional constipation. Fecal retention causes rectal distension, which can obstruct bladder emptying. Incomplete, dysfunctional voiding results in stagnant urine, which promotes microbial growth, increasing the risk for UTI. rectal distension obstruct bladder emptying A thorough history should include assessment of dietary intake, precipitating factors (eg, toilet training), and stool consistency and frequency. Management includes increasing dietary fiber and water intake as well as titrating laxative use (eg, polyethylene glycol) to produce soft, regular bowel movements. (Choice A) Primary nocturnal enuresis is defined by the inability to achieve nighttime dryness in children age >5, and a common first step in management is enuresis alarm therapy. However, this patient is only age 3, and the first step in improving her continence is to treat her constipation. (Choice C) Evaluation and treatment of constipation is necessary to prevent dysfunctional voiding and recurrent UTIs. (Choice D) Prophylactic antibiotics are often indicated in patients with vesicoureteral reflux, which is diagnosed by voiding cystourethrogram in patients with recurrent, febrile UTIs. Prophylactic antibiotics are not indicated for a patient with a single, uncomplicated UTI. (Choice E) Repeat urine culture may be indicated in patients with continued symptoms while on antibiotic therapy to ensure adequate treatment of infection. However, it is not indicated in patients with clinical resolution of a treated UTI and does not change management. Educational objective: Chronic constipation can prevent complete bladder emptying and promote urinary stasis, a risk factor for development of urinary tract infections. References: The association of constipation with childhood urinary tract infections. (http://www.ncbi.nlm.nih.gov/pubmed/18947551) Bladder and bowel dysfunction in children: an update on the diagnosis and treatment of a common, but underdiagnosed pediatric problem. (http://www.ncbi.nlm.nih.gov/pubmed/28265323)

Question 4

A 58-year-old man comes to the office for follow-up 2 months after a non-ST elevation myocardial infarction.  During the hospitalization, he underwent cardiac catheterization with a percutaneous coronary intervention to the left anterior descending artery.  The patient's subsequent hospital course was uncomplicated, and he has not had any recurrent chest pain, dyspnea, or dizziness.  However, since hospitalization he has not been able to achieve an erection sufficient for sexual intercourse, which has never happened previously.  The patient says, "I am still interested in sex, but maybe my heart is just not able to work as well as it used to."  He continues to have spontaneous nocturnal erections, and reports a satisfying marriage with no significant marital discord.  The patient has returned to work as an insurance agent and has experienced no difficulty climbing 2 flights of stairs at his workplace.  Medical history is notable for type 2 diabetes mellitus, hypertension, and hyperlipidemia.  Current medications include aspirin, clopidogrel, metformin, atorvastatin, isosorbide mononitrate, lisinopril, and carvedilol.  He does not use alcohol or illicit drugs; he has a 40-pack-year smoking history but quit 8 weeks ago.  Vital signs are within normal limits, and physical examination shows no abnormalities.  Laboratory testing shows normal blood counts and serum chemistry studies, and hemoglobin A1c is 7.1%.  Which of the following is the best next step in management of this patient's erectile dysfunction?

Accepted Answer

Explanation: 11ec2b69_bfd1_0646_8f63_09d71659af3d_MD0005_00 Sexual activity can increase the risk of myocardial infarction due to the associated tachycardia and acute rise in blood pressure. However, most patients with uncomplicated myocardial infarction (ie, no recurrent angina, no arrhythmias, normal ventricular function) and successful revascularization are at low risk of cardiac complications and may resume normal sexual activity ~2 weeks following the initial cardiac event. Erectile dysfunction (ED) is common in patients with cardiovascular disease due to decreased penile blood flow, endothelial dysfunction, and vasoactive medications. However, this patient expresses significant apprehension regarding sexual activity following his cardiac event, and the sudden onset of ED and normal nonsexual nocturnal erections suggest a likely psychogenic etiology. Therefore, the initial management should include a more detailed psychological assessment and counseling, possibly with the assistance of a clinical psychologist. (Choice A) Routine sexual activity is associated with physical exertion of approximately 3-4 metabolic equivalents (METS), which is comparable to brisk walking or ascending 2 flights of stairs. This patient is asymptomatic with moderate exertion, and stress testing is not indicated. (Choice B) Chronic diabetes increases the risk for ED. However, tight glycemic control has not been shown to reverse established ED. Furthermore, this patient's control is near target, his ED has a likely psychogenic basis, and more aggressive diabetic management is unlikely to have a significant benefit. (Choice C) Phosphodiesterase-5 inhibitors (eg, sildenafil) are the first-line treatment for most patients with ED, including those with cardiovascular disease. However, these medications are contraindicated in patients taking nitrates (eg, isosorbide mononitrate) as concomitant use can cause a precipitous drop in blood pressure leading to syncope. (Choice E) Beta blockers (eg, carvedilol) are associated with an increased risk of ED. However, they are strongly recommended for patients with symptomatic atherosclerotic cardiac disease and should not be discontinued so soon after a myocardial infarction. Educational objective: Sudden onset of erectile dysfunction with normal nonsexual nocturnal erections suggests a likely psychogenic etiology. Initial management should include a detailed psychological assessment and counseling. References: Erectile dysfunction. (http://www.ncbi.nlm.nih.gov/pubmed/27929275)

Question 5

A 9-month-old boy is brought to the office for follow-up of an undescended testis.  Developmentally, the infant sits without support, babbles, and can pick up objects with his pointer finger and thumb.  He is fed formula and eats table foods 3 times a day.  He was born at 38 weeks gestation without complications during pregnancy or labor and delivery.  The patient takes no medications and has no allergies.  He is up to date with vaccinations.  Length, weight, and head circumference are at the 50th percentile.  On physical examination, the infant is nondysmorphic, alert, and active, and is crawling on the floor.  The abdomen is soft, nontender, and nondistended.  Genital examination shows absent rugae on the left hemiscrotum with a palpable testicle in the left inguinal canal; the right testicle is palpable in the right hemiscrotum.  The penis appears normal with a centrally located urethral meatus, and urinary stream is normal.  The anus is patent with no lesions.  Which of the following statements regarding this patient's genitourinary condition is most accurate?

Accepted Answer

Explanation: 11ec2b69_bfcf_7fa2_8f63_2bb3ed156376_MD0005_00 This patient with a palpable testicle in the left inguinal canal and a left empty hemiscrotum has cryptorchidism, or an undescended testicle. Normal testicular descent from the intra-abdominal space through the inguinal canal occurs at 28 weeks gestation. Any interruption of this process results in an undescended testis. Although cryptorchidism is common in newborns, the spontaneous descent typically occurs during the first few months of life. However, those with an undescended testis at age 6 months are referred for orchiopexy, as spontaneous descent is unlikely to occur after this age (Choice A). Without surgery, patients are at increased risk for numerous complications, including inguinal hernias, testicular torsion, subfertility, and testicular cancer. If an undescended testis is bilateral or intra-abdominal, the risk of developing testicular cancer is even greater. Although orchiopexy decreases the rate of malignant transformation, the risk remains higher than that of the general population. However, surgical fixation of the testis in the scrotum enables detection of testicular masses on examination. (Choice B) Parental consent is sufficient to proceed with surgical intervention in a minor. Deferring surgery until the patient is age 18 increases the risk for complications related to cryptorchidism. (Choices C and E) The risk of infertility and testicular torsion decreases after orchiopexy. Early orchiopexy, ideally by age 1, is recommended to maximize fertility potential. Educational objective: Infants age >6 months with an undescended testis should be referred for orchiopexy. Although the risk of testicular malignancy is decreased after orchiopexy, it remains higher than in patients without a history of cryptorchidism. References: Management of undescended testes: European Associated of Urology/European Society for Paediatric Urology Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/27687532) Evaluation and treatment of cryptorchidism: AUA guideline. (http://www.ncbi.nlm.nih.gov/pubmed/24857650)

Question 6

A 55-year-old man comes to the emergency department due to a painful, persistent erection. Earlier in the evening, the patient used an intracavernosal injection of alprostadil to achieve an erection for sexual intercourse. His erection persisted afterward but he was able to fall asleep. He was then awakened 4 hours later due to pain in his penis. The patient placed an ice pack over the region, but the painful erection remained. He does not have a history of genitourinary trauma or similar episodes in the past. Medical history is notable for type 2 diabetes mellitus and peripheral vascular disease. Current medications include lisinopril, metformin, rosuvastatin, and low-dose aspirin. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 37 C (98.6 F), blood pressure is 120/78 mm Hg, pulse is 88/min, and respirations are 14/min. The corpora cavernosa of the penis are engorged and tender to palpation. The glans and the corpus spongiosum are softly distended without rigidity. There are no genital lesions, urethral discharge, or evidence of trauma. Cavernosal blood gas analysis shows pH of 7.2, pCO₂ of 65 mm Hg, and pO₂ of 30 mm Hg, consistent with ischemic priapism. Corporeal aspiration is attempted but fails to relieve the patient's symptoms. Which of the following is the best next step in the management of this patient's condition?

Accepted Answer

Explanation: Priapism is a persistent (eg, >4 hr), painful erection. It is characterized by impaired outflow from the corpora cavernosa, leading to acidosis, anoxia, and tissue ischemia. Priapism is a medical emergency that can lead to irreversible ischemic injury if not corrected promptly. Common risk factors for ischemic (low-flow) priapism include phosphodiesterase-5 inhibitors (eg, sildenafil), intracavernosal injections (eg, alprostadil), certain medications (eg, trazodone), and sickle cell disease. The diagnosis of ischemic priapism can be confirmed by blood gas analysis of a corporeal aspirate. At the onset of symptoms, priapism may be terminated with simple interventions (eg, urination, cold compresses), but symptoms lasting >4 hours require invasive treatment (Choice E). Aspiration of the corpora cavernosa (often followed by irrigation with cold saline) is advised, with intracavernosal injection of an alpha agonist (eg, phenylephrine) if aspiration does not rapidly relieve the symptoms. (Choice A) Angiographic embolization is the treatment of choice for nonischemic (high-flow) priapism, which is significantly less common than ischemic priapism and is often due to a traumatic fistula from the cavernosal artery. (Choice B) Doppler ultrasonography can help distinguish between ischemic and nonischemic priapism. This patient's cavernosal blood gas analysis confirms ischemic priapism, and care should not be delayed for additional testing. (Choice D) Ischemic priapism is a common complication of sickle cell disease. Intravenous fluids and supplemental oxygen are often administered as adjunctive therapy but are unlikely to be adequate treatment for this patient. Educational objective: Priapism is a persistent, painful erection that can lead to irreversible ischemic injury if not corrected promptly. At the onset of symptoms, priapism may be terminated with simple interventions (eg, urination, cold compresses), but symptoms lasting >4 hours require invasive treatment. Management includes aspiration of the corpora cavernosa and intracavernosal injection of an alpha agonist (eg, phenylephrine). References: Ischemic priapism: a clinical review. (http://www.ncbi.nlm.nih.gov/pubmed/28270944)

Question 7

A 7-month-old boy is brought to the office for a routine visit.  The parents' only concern is that their son's "private area looks abnormal," which his primary care provider has been monitoring.  He breastfeeds on demand and recently started eating pureed fruits and vegetables.  The infant urinates frequently and stools once a day.  He rolls in both directions, responds to his name, and transfers objects from one hand to the other.  The patient was born by cesarean delivery at 36 weeks gestation for maternal preeclampsia.  He was small for gestational age but has gained weight appropriately since birth.  Weight, length, and head circumference track along the 30th percentile.  Physical examination shows an interactive and alert infant.  The abdomen is soft, nontender, and nondistended.  Genital examination reveals a hypoplastic, hypopigmented, empty left scrotum (shown in the image below).  A small mobile mass is palpable in the left inguinal canal.  The right testicle is palpated in the right hemiscrotum, which has normal cremasteric reflex and normal rugae.  The penis is uncircumcised, and the urethral meatus is at the tip of the glans.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bfcf_f4d4_8f63_f1c2b119ba7c_MD0005_00 This patient with a hypoplastic, hypopigmented, poorly rugated, and empty scrotum has an undescended left testis, or cryptorchidism. A history of being premature and small for gestational age increases the risk of undescended testes. The diagnosis is typically based on physical examination, and imaging is not routinely recommended. Ultrasonography is not sensitive in detecting nonpalpable testes (compared to exploratory surgery) and does not alter the treatment course if the testes are palpable (Choice B). The treatment for cryptorchidism is an orchiopexy, or surgical fixation of the testis to the scrotal wall. Referral for surgery is indicated by age 6 months (corrected for gestation), as spontaneous testicular descent rarely occurs after this age. Early orchiopexy before age 1 year optimizes fertility potential and testicular growth. Surgical fixation of the testis also decreases the risk of testicular torsion. However, families should be educated that testicular cancer risk is decreased, but not eliminated, after an orchiopexy, and close surveillance with testicular examinations is warranted. (Choice A) A karyotype can identify a disorder of sex development in a patient with bilateral nonpalpable testes or unilateral cryptorchidism in combination with hypospadias or micropenis. This patient with unilateral palpable cryptorchidism does not require a karyotype. (Choice C) Reassurance and continued observation are no longer appropriate in this patient as the testis is unlikely to descend after age 6 months and spermatogonia degeneration begins as early as this age. (Choice E) Surgical excision of the testis is performed if testicular cancer is suspected. This is rare in infants, and a small, mobile mass in the inguinal canal is more likely to be an undescended testicle. Educational objective: Spontaneous descent of undescended testes is rare after age 6 months, and an orchiopexy is performed during infancy to optimize fertility and testicular growth. References: Evaluation and treatment of cryptorchidism: AUA guideline. (http://www.ncbi.nlm.nih.gov/pubmed/24857650) Cryptorchidism: a practical review for all community healthcare providers. (http://www.ncbi.nlm.nih.gov/pubmed/28265313) Management of undescended testes: European Association of Urology/European Society for Paediatric Urology Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/27687532)

Question 8

A 42-year-old man comes to the office with concerns about his sexual function. The patient reports an abrupt inability to participate in sexual intercourse for the past 2 months. He is variably able to achieve an erection during foreplay but is unable to maintain an erection sufficient to engage in intercourse. The patient reports normal sexual desire. He has been married for 4 years and says, "I am ready to start a family, but my wife is focused on her job right now and is not as excited as I am." Medical history is notable for hypertension, migraine headaches, and irritable bowel syndrome. Current medications include lisinopril and as-needed polyethylene glycol and ibuprofen. The patient does not use tobacco or illicit drugs and drinks 1 or 2 cans of beer on weekends. He exercises several times per week. Family history is notable for hypertension in his parents. Blood pressure is 124/68 mm Hg, pulse is 70/min, and BMI is 23 kg/m². Physical examination shows normal heart sounds. Extremities are warm and peripheral pulses are normal. The patient's genitalia and body hair distribution are normal. Visual fields are intact. Blood cell counts and serum chemistry are within normal limits. Which of the following is the best response and next step concerning this patient's symptoms?

Accepted Answer

Explanation: 11ec2b69_bfd2_3ec7_8f63_3be61da3c685_MD0005_00 Normal male erectile function requires interplay between psychological and physical stimulation, and vascular, neurological, and hormonal systems. Causes of erectile dysfunction (ED) can be categorized as organic (eg, hypogonadism, arterial insufficiency, neurological impairment) or psychogenic. Psychogenic ED is typically due to interpersonal conflict, performance anxiety, or an underlying emotional disorder. Clinical factors suggesting a psychogenic etiology include sudden onset, situational ED (eg, ED with a certain partner but normal erectile function during masturbation), and persistence of nonsexual nocturnal erections. This patient's abrupt onset and underlying interpersonal conflict with his wife suggest a psychogenic cause, which should be pursued with a more detailed psychological assessment. (Choice A) Organic ED is often initially intermittent or slowly progressive and is more common with advancing age. Phosphodiesterase-5 inhibitors (eg, sildenafil) are first-line treatment for organic ED and are effective in most patients. However, this patient's symptoms are more consistent with a psychogenic cause, and a more detailed psychological assessment should be performed first. (Choice B) ED due to hypogonadism typically has a gradual rather than an abrupt onset. Libido is usually suppressed, and additional features (eg, testicular atrophy, loss of body hair) may also be present. (Choice C) Spinal MRI is useful for evaluating ED due to lumbosacral nerve root compression (eg, cauda equina syndrome, spinal stenosis). However, these patients typically have additional symptoms, such as back pain, leg weakness, or bowel and bladder dysfunction. (Choice D) Vascular imaging with duplex ultrasound or penile angiography is occasionally useful for evaluating organic ED due to impaired blood flow. However, this would be unlikely in a young nonsmoker with a normal vascular examination. Educational objective: Psychogenic erectile dysfunction is typically due to interpersonal conflict, performance anxiety, or an underlying emotional disorder. Clinical factors suggesting a psychogenic etiology include abrupt onset, situational symptoms, and persistence of nonsexual nocturnal erections. References: Erectile dysfunction. (http://www.ncbi.nlm.nih.gov/pubmed/27929275)

Question 9

A 15-year-old boy is brought to the office by his parents due to concerns about his pubertal development. The patient says, "I am the only one of my friends whose voice has not changed and who does not have any body hair. I'm tired of being called 'weak' in gym class." The patient has been fatigued lately, which he attributes to staying up late talking with friends; he otherwise feels well. He has had no recent headaches, vomiting, or vision changes. The patient has a good appetite and eats a well-varied diet. His father is 178 cm (5 ft 10 in) and his mother is 160 cm (5 ft 3 in). Blood pressure is 116/70 mm Hg and pulse is 78/min. Weight and height are at the 15th and 3rd percentiles, respectively, unchanged from his last visit 12 months ago. The patient's height has increased 4.5 cm (1.8 in) since then. Physical examination shows a well-appearing, quiet adolescent with no dysmorphic features. The thyroid is palpable and not enlarged. There is no gynecomastia. Cardiopulmonary examination is normal. The testes are soft and measure 2 mL (Tanner stage I). The phallus is normal in length. There is no axillary or pubic hair. The rest of the physical examination is normal. Bone age x-ray is consistent with age 13. Item 1 of 2 Which of the following is the most likely diagnosis in this patient?

Accepted Answer

Explanation: 11ec2b69_bfd0_9115_8f63_074fc782dcd3_MD0005_00 Puberty is considered delayed if no secondary sexual characteristics (typically testicular enlargement [>4 mL] or breast development) are present by age 14 in boys or age 12 in girls. This patient with short stature but normal growth velocity (4-6 cm/yr) most likely has constitutional delay of puberty. A family history of "late bloomers" would support this diagnosis; however, this history is not present in every case. In contrast to familial short stature, in which short stature and normal growth velocity are accompanied by a normal bone age, constitutional delay is associated with a delayed bone age on x-ray of the wrist, as seen in this patient (Choice C). Height and pubertal development typically correlate more closely with bone age than with chronological age. On follow-up, patients with constitutional delay of puberty often demonstrate an onset of puberty similar to that of family members, and reaching the midparental adult height is expected following the pubertal growth spurt. (Choice B) Although a pituitary tumor (eg, craniopharyngioma) can interrupt normal hormonal regulation required for pubertal development, patients frequently have headache and loss of peripheral vision due to the mass. This patient has no features of an intracranial mass. (Choice D) Hypothyroidism may cause pubertal delay, short stature, and fatigue; however, decreased growth velocity would be expected. In addition, fatigue is more commonly related to poor sleep habits in adolescents without other findings of metabolic slowing (eg, weight gain, bradycardia, constipation) or thyromegaly. (Choice E) Kallmann syndrome is characterized by anosmia and hypogonadotropic hypogonadism. Affected males often have cryptorchidism and a micropenis. It is far less common than constitutional delay and is unlikely in this patient without anosmia. Educational objective: Constitutional delay is characterized by delayed development of secondary sexual characteristics in conjunction with delayed bone age, short stature but normal growth velocity, and a family history of "late bloomers." References: Normal and abnormal puberty. (http://www.ncbi.nlm.nih.gov/pubmed/25905253)

Question 10

A 49-year-old man comes to the physician to discuss poor sexual performance. He has been unable to sustain erections for the past year. In the last 2 months, he has not had any erections at all, including at night or when he wakes up in the morning. Past medical history is significant for type 2 diabetes mellitus, hyperlipidemia, and chronic exertional buttock and thigh pain. His medications include insulin detemir and atorvastatin. The patient works as a truck driver and leads a sedentary lifestyle. He has smoked 1½ packs of cigarettes daily for the past 30 years. His blood pressure is 134/68 mm Hg and pulse is 78/min. His BMI is 32 kg/m². Heart sounds are normal. There is no evidence of sensory loss over the lower extremities. Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: The most likely cause of erectile dysfunction in this patient is peripheral artery disease (PAD). He has multiple risk factors (diabetes mellitus, hyperlipidemia, and cigarette smoking) for atherosclerosis, and his buttock and thigh pain would be typical for intermittent claudication due to aortoiliac PAD. The pain maybe accompanied by weakness of the hip or thigh while walking. Bilateral aortoiliac disease can also lead to erectile dysfunction (ED). Leriche syndrome is the triad of lower-extremity claudication, absent or diminished femoral pulses, and ED. The next step in management is an ankle-brachial index (ABI) measurement to screen for PAD. ABI <0.9 is considered abnormal and has a high sensitivity and specificity for PAD. ED is also a strong predictor for coronary artery disease. Therefore, patients with ED who have 3 or more atherosclerotic risk factors or symptomatic PAD should be screened for cardiovascular disease (eg, exercise or pharmacologic stress test) prior to initiating specific therapy for sexual dysfunction. ankle-brachial index (ABI) (Choice B) Cystoscopy and pelvic ultrasound are typically used for the evaluation of prostate and bladder dysfunction, which are unlikely to be the source of this patient's symptoms. (Choice C) Testosterone deficiency can lead to a decrease in libido and erectile dysfunction; however, patients with testosterone deficiency can usually still achieve nocturnal penile erections. (Choice D) Phosphodiesterase-5 (PDE-5) inhibitors (eg, sildenafil, vardenafil, tadalafil) are the first-line therapy for patients with ED. However, a detailed evaluation for the underlying cause of sexual dysfunction should be performed prior to initiating treatment with PDE-5 inhibitors. (Choice E) Psychosocial factors, including depression and stress, can lead to erectile dysfunction. Furthermore, many medications used to treat depression can cause decreased libido and ED, which can worsen the existing problem. However, this patient's presentation is most suggestive of PAD as the underlying cause of ED. Educational objective: Erectile dysfunction (ED) is often caused by peripheral artery disease (PAD), and is also a strong predictor of coronary artery disease. Patients with ED and atherosclerotic risk factors should receive appropriate diagnostic testing (eg, ankle-brachial index, cardiac stress testing) prior to initiating specific therapy for sexual dysfunction. References: Is erectile dysfunction predictive of peripheral vascular disease? (http://www.ncbi.nlm.nih.gov/pubmed/15006259) Linking erectile dysfunction and coronary artery disease. (http://www.ncbi.nlm.nih.gov/pubmed/16391538) Erectile dysfunction. (http://www.ncbi.nlm.nih.gov/pubmed/23040455)

Question 11

A 4-year-old girl is brought to the office due to a cat bite.  Her parents say that the girl and her friend were attempting to dress up the family's cat when it bit the patient on the right thumb.  The bite occurred approximately an hour ago.  The parents washed the girl's thumb with soap and water before bringing her to the office.  The cat has been with the family since it was a kitten and is fully vaccinated.  The girl has a history of anaphylaxis following peanut and soy exposure, and her parents carry injectable epinephrine.  Vital signs are within normal limits.  The patient has minimal pain.  Examination reveals a single puncture wound on the pad of the right thumb.  There is no erythema, drainage, or tenderness to palpation.  Range of motion is normal.  The remainder of the examination is unremarkable.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bfce_6e30_8f63_a93f06cb2b85_MD0005_00 Mammalian bites can lead to infection from either oral flora of the animal (eg, Pasteurella, oral anaerobes) or skin flora of the patient (eg, Streptococcus pyogenes, Staphylococcus aureus). Cat bites are considered particularly high-risk as feline teeth are thin and sharp, resulting in puncture wounds that inoculate bacteria deep into tissue. Bites also carry a higher risk of infection if they are on the hands/feet, >12 hours old, and in immunocompromised patients. For patients with any of these historical features, wounds should be left open to heal by secondary intention and antibiotic prophylaxis should be provided. Amoxicillin-clavulanate is the first-line agent for prophylaxis following mammalian bites as it provides coverage against both gram-negative (eg, Pasteurella) and gram-positive (eg, S pyogenes) organisms as well as oral anaerobes. (Choice A) Despite this patient's benign physical examination, cat bites are highly likely to result in infection without antibiotic prophylaxis. Observation alone would not be appropriate management. (Choice C) Azithromycin can be used for the treatment of cat-scratch disease due to Bartonella henselae. However, azithromycin prophylaxis neither prevents the development of cat-scratch disease nor provides coverage against more common organisms such as Pasteurella. (Choices D and E) Clindamycin has activity against oral anaerobes and gram-positive organisms (eg, Streptococcus, Staphylococcus) but is not active against gram-negative organisms (eg, Pasteurella). Similarly, trimethoprim-sulfamethoxazole has activity against Pasteurella but lacks activity against oral anaerobes or Streptococcus. These agents can be used in combination for bites in penicillin-allergic patients, but neither is sufficient as monotherapy. Educational objective: Mammalian bites can cause infection from gram-negative, gram-positive, and anaerobic organisms from the animal's oral flora or the patient's skin flora. For high-risk bites (eg, cat bites, bites on hand/foot), first-line management is prophylaxis with amoxicillin-clavulanate. References: Dog and cat bites. (http://www.ncbi.nlm.nih.gov/pubmed/25250997)

Question 12

A 7-year-old boy is brought to the emergency department by paramedics after being attacked by a dog.  Approximately an hour ago, the boy was playing in a park near his house when he tried to separate 2 stray dogs that were fighting.  The dogs assaulted the patient, dragged him to the ground, and bit him multiple times on the upper extremities and face.  His parents were able to drive the dogs away.  The boy is otherwise healthy and up to date on immunizations.  Temperature is 37.1 C (98.8 F) and pulse is 138/min.  The child is inconsolable; intravenous morphine and midazolam are administered to allow examination of his wounds.  Multiple, deep bite wounds are found on the dorsal forearms bilaterally.  There is also a 6-cm, macerated wound overlying the left mandible extending to the left ear.  The upper extremity wounds are actively bleeding and contain specks of dirt and grass.  Pressure is applied, and hemostasis of all wounds is achieved.  The wounds are copiously irrigated and cleaned, and rabies prophylaxis is initiated.  The mother asks about tetanus and says, "Please do everything you can for him!  My husband was bitten by a dog last year and received several shots for tetanus."  Which of the following is the most appropriate response?

Accepted Answer

Explanation: 11ec2b69_bfce_e361_8f63_0f84f854d8b4_MD0005_00 Following a mammalian bite, the decision to administer tetanus prophylaxis (ie, tetanus toxoid-containing vaccine ± tetanus immune globulin) is based on the severity of the wound and the immunization status of the patient. For patients who have received ≥3 tetanus toxoid doses, a booster dose of tetanus toxoid is indicated only if their last tetanus dose was ≥10 years ago (for clean or minor wounds) or ≥5 years ago (for dirty or severe wounds). Patients who have received <3 tetanus toxoid doses (ie, incompletely immunized) or whose vaccine status is uncertain should receive a tetanus toxoid booster. If such patients have dirty or severe wounds, they should also receive tetanus immune globulin. This child has severe wounds with evidence of contamination (eg, bite wound, specks of dirt, plant matter). However, the child is up to date on immunizations, which means he has received at least 4 tetanus toxoid-containing vaccines (ie, diphtheria, tetanus toxoid, and acellular pertussis [DTaP] at age 2, 4, and 6 months and an additional DTaP at 4 years). His last dose was <5 years ago. Therefore, there is no need for either a tetanus toxoid booster or tetanus immune globulin (Choices C and D). (Choice B) Prompt cleansing of bite wounds is critical in infection prevention but does not preclude the need for tetanus prophylaxis for at-risk patients. This patient does not require a tetanus toxoid booster only because he is completely immunized and his last dose was <5 years ago. (Choice E) The availability of the animals can impact the decision to administer rabies post-exposure prophylaxis but does not factor into the decision to give tetanus prophylaxis. Tetanus prophylaxis decisions are based on the severity of the wound and immunization status. Educational objective: Fully immunized patients with dirty (eg, mammalian bite) or severe wounds should receive a tetanus toxoid booster only if their last dose was ≥5 years ago. Unimmunized or incompletely immunized patients with such wounds should receive both tetanus toxoid booster and tetanus immune globulin. References: Dog and cat bite-associated infections in children. (http://www.ncbi.nlm.nih.gov/pubmed/23404346)

Question 13

A 15-year-old boy is brought to the office by his parents due to concerns about his pubertal development.  The patient says, "I am the only one of my friends whose voice has not changed and who does not have any body hair.  I'm tired of being called 'weak' in gym class."  The patient has been fatigued lately, which he attributes to staying up late talking with friends; he otherwise feels well.  He has had no recent headaches, vomiting, or vision changes.  The patient has a good appetite and eats a well-varied diet.  His father is 178 cm (5 ft 10 in) and his mother is 160 cm (5 ft 3 in).  Blood pressure is 116/70 mm Hg and pulse is 78/min.  Weight and height are at the 15th and 3rd percentiles, respectively, unchanged from his last visit 12 months ago.  The patient's height has increased 4.5 cm (1.8 in) since then.  Physical examination shows a well-appearing, quiet adolescent with no dysmorphic features.  The thyroid is palpable and not enlarged.  There is no gynecomastia.  Cardiopulmonary examination is normal.  The testes are soft and measure 2 mL (Tanner stage I).  The phallus is normal in length.  There is no axillary or pubic hair.  The rest of the physical examination is normal.  Bone age x-ray is consistent with age 13. When the family is asked if there are any concerns, the patient answers, "I'm worried that my body will never change and I'll be this way for the rest of my life.  I'm stressed about changing in the locker room in front of my soccer teammates because I don't think I look like I should at my age.  It makes me want to quit the soccer team."  Which of the following statements would be the best response to this patient's concerns?

Accepted Answer

Explanation: If a specific underlying disorder is identified in patients with delayed puberty, treatment should be targeted toward that disorder. The most likely diagnosis in this patient is constitutional delay of puberty, and it is likely that he will begin puberty soon. However, associated psychological issues caused by delayed puberty should be addressed, and a confidential interview with this patient is indicated to screen for possible depression and anxiety. The health care provider should also evaluate for bullying, as the patient mentioned that he is repeatedly called "weak" by his peers. If psychosocial concerns are severe, or if puberty is significantly delayed, short-term testosterone therapy in boys, or estrogen therapy in girls, may be considered. Pharmacotherapy, however, should be used only in boys age >14 or girls age >12. (Choice A) A psychiatric referral may be necessary, but not before a more in-depth assessment of this patient's current mental state. (Choice B) Although regular follow-up to assess for puberty onset and to monitor psychosocial issues is required, it is not appropriate to defer discussion of possibly serious psychological concerns for another 3 months. (Choice D) Recommending a change of sports may provide a temporary solution to this patient's stress about changing in the locker room, but it does not address his concerns about being criticized in gym class, his peer interactions, or his future physical development. (Choice E) It is not appropriate to provide reassurance without first understanding the severity of the patient's concerns. Educational objective: Pubertal delay can cause significant embarrassment and stress for adolescents. When psychosocial concerns are expressed, a confidential interview should be conducted to screen for depression and anxiety. References: Screening for major depressive disorder in children and adolescents: a systemic review for the U.S. Preventive Services Task Force. (http://www.ncbi.nlm.nih.gov/pubmed/26857836)

Question 14

A 46-year-old man comes to the office due to dysuria and a dull, aching pain in the penis and perineal region. The symptoms began 6 months ago and prompted the patient to visit an urgent care center twice. Both times, he received a short course of antibiotics, which improved symptoms temporarily, but they returned within days. The patient has also had pain during ejaculation but no urethral discharge, back pain, abdominal pain, weakness, or incomplete voiding. He is married and monogamous with his wife and has 2 children. He does not use tobacco or illicit drugs but occasionally drinks 1 or 2 beers on weekends. He has no medication allergies and no family history of cancer. Temperature is 37.1 C (98.8 F), blood pressure is 126/84 mm Hg, pulse is 72/min, and respirations are 14/min. Physical examination shows no abdominal or costovertebral angle tenderness. Digital rectal examination reveals a mildly tender prostate that is symmetric and not enlarged. The external genitalia are normal in size and appearance and are nontender to palpation. Item 1 of 3 Which of the following is the best next step in the diagnosis of this condition?

Accepted Answer

Explanation: Chronic prostatitis is a common condition that affects 2%-10% of men. Manifestations include >3 months of dysuria, pain in the genitourinary region, and/or pain during ejaculation. Prostate examination is usually normal but may show hypertrophy, tenderness, or edema. Because some symptoms of chronic prostatitis resemble a urinary tract infection, patients often inappropriately receive short courses of antibiotic therapy. Although this may transiently improve symptoms, manifestations generally recur within days of antibiotic cessation. The diagnosis of chronic prostatitis typically requires urinalysis and urine culture before and after prostate massage. (Choice B) CT scan of the abdomen and pelvis is not typically indicated for patients with symptoms of chronic prostatitis unless abdominal pain is also present. Urinalysis and urine culture are easy to perform, low-cost, and not associated with radiation; they would almost always be done prior to consideration of CT scan. (Choice C) This patient has a normal genital examination and no testicular pain. Ultrasound of the scrotum would not be indicated at this time. (Choice D) Patients with urinalysis evidence of hematuria usually require urine cytology and referral for cystoscopy to evaluate for bladder cancer. This patient should receive a urinalysis prior to any other testing. (Choice E) This patient with a nonenlarged, symmetric prostate does not require prostatic biopsy at this time. Biopsy is not typically part of the diagnostic workup for chronic prostatitis. Educational objective: Chronic prostatitis is a common condition that usually presents with >3 months of dysuria, pelvic pain, and/or pain during ejaculation. Patients with suspected chronic prostatitis should receive a urinalysis and urine culture before and after prostate massage.

Question 15

A 64-year-old man comes to the physician for follow-up of an abnormal test.  He was hospitalized a week earlier for an episode of acute urinary retention provoked by amitriptyline.  His other medical problems include post-herpetic neuralgia, hypertension, hyperlipidemia, and a stable abdominal aortic aneurysm.  He is a former smoker and his father had prostate cancer.  Physical examination during the admission showed a moderately enlarged, nontender prostate with no nodularity.  The obstruction was relieved by a Foley catheter, and amitriptyline was stopped.  The patient has had no voiding difficulties or other urinary symptoms since being discharged.  Blood tests at the time of hospital admission showed a white blood cell count of 12,000/µL, creatinine of 1.4 mg/dL, and serum prostate-specific antigen of 7.5 ng/mL (normal <4 ng/mL).  No prior prostate-specific antigen levels are available for comparison.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bfd3_c568_8f63_6374a08cd143_MD0005_00 Prostate-specific antigen (PSA) is a glycoprotein expressed by both normal prostate tissue and prostate cancer. Persistently elevated PSA can be due to benign prostatic hyperplasia (BPH), prostate cancer, and prostatic inflammation or infection (prostatitis). BPH is highly prevalent in healthy men age >50, and PSA can be mildly elevated (up to 6.5 ng/mL) without any associated malignancy. In addition, mild-to-moderate PSA elevation can occur transiently due to urine retention, subclinical inflammation, cystoscopy, or ejaculation. This patient's elevated PSA is most likely due to recent hospitalization for amitriptyline-induced urinary retention. Acute urinary retention can lead to prostatic inflammation and swelling and transiently elevate serum PSA. However, the elevation is generally mild and normalizes over the following 2-6 weeks. In addition, a digital rectal examination during inpatient admission can also mildly elevate PSA. This patient's urinary symptoms have resolved, and he needs no further intervention except a repeat PSA test to document improvement. A persistently elevated or rising PSA level may warrant further investigation. Recent guidelines have questioned the validity of PSA for prostate cancer screening. However, PSA can be very useful as a diagnostic test in ill patients with symptoms of possible prostatic disease (eg, hematuria, urine retention, unexplained pelvic pain). It can also be used to follow the course of established prostate cancer. (Choice A) Transurethral resection of the prostate (TURP) and related procedures (eg, microwave thermotherapy, laser prostatectomy) may relieve symptoms of bladder outlet obstruction but are indicated only for chronically persistent obstructive symptoms. TURP is usually considered only if the patient first fails a trial of medication to relieve the symptoms. (Choice B) Computed tomography scan of the genitourinary system is useful in evaluating disease of the upper tract (eg, kidney stones, renal cell carcinoma). However, it has poor sensitivity for diagnosing prostate cancer. (Choice C) Cystoscopy is indicated for evaluating symptoms related to the bladder and urethra (eg, hematuria to rule out bladder cancer). It is also performed during TURP and similar procedures in patients with symptomatic BPH. However, it is not necessary in this patient whose symptoms have resolved. (Choice E) Transrectal biopsy of the prostate is indicated for patients with evidence of prostate malignancy (eg, prostate nodules, asymmetric prostate enlargement) or persistently elevated PSA. This patient had a benign prostate examination, and transrectal biopsy is not recommended at this time unless the PSA remains elevated or rises further. Educational objective: Transient elevations of prostate-specific antigen (PSA) can occur due to a variety of benign causes (eg, urinary retention) and usually decrease within 4-6 weeks. Further investigation is needed if the PSA level remains elevated or prostate examination shows suspicious findings. References: A systematic review of the diagnostic accuracy of prostate specific antigen. (http://www.ncbi.nlm.nih.gov/pubmed/19744336) Management of elevated prostate-specific antigen in men with nonbacterial chronic prostatitis. (http://www.ncbi.nlm.nih.gov/pubmed/19570492)

Question 16

A 60-year-old man comes to the emergency department due to fever, burning on urination, generalized body aches, and lower abdominal discomfort. The dysuria began 3 days ago, and the remainder of the symptoms developed within the last 24 hours. The patient also has been unable to urinate for the past 18 hours. He has a history of hypertension, hyperlipidemia, coronary artery disease, and benign prostatic hyperplasia. Medications include aspirin, metoprolol, atorvastatin, lisinopril, and tamsulosin. He is not sexually active. The patient does not use tobacco, alcohol, or illicit drugs and has no medication allergies. Temperature is 38.3 C (100.9 F), blood pressure is 130/75 mm Hg, pulse is 105/min, and respirations are 16/min. Abdominal examination reveals mild lower abdominal tenderness with no costovertebral angle tenderness. The urinary bladder is palpable in the hypogastric area. Rectal examination reveals a swollen, tender, and enlarged prostate with no palpable nodules. The genitals are normal in appearance and nontender to palpation. Laboratory testing shows a leukocyte count of 12,500/mm³ with 85% neutrophils and an elevated serum creatinine at 1.3 mg/dL (last known value: 0.9 mg/dL). Microscopic urinalysis results are as follows: Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: This patient with fever, dysuria, leukocytosis, and lower abdominal pain has urinalysis evidence of pyuria and bacteriuria. Although this constellation of findings is consistent with a urinary tract infection, the presence of a tender, swollen prostate makes acute bacterial prostatitis more likely. One of the most common complications of acute bacterial prostatitis is acute urinary retention, which is due to urethral impingement from prostate swelling. Manifestations typically include an inability to void, suprapubic fullness/discomfort, and renal insufficiency. A bladder scan can confirm the diagnosis (>300 mL residual volume). Treatment involves urgent bladder decompression with suprapubic catheterization (urethral catheterization is occasionally attempted by urologists who are experienced with this procedure but may increase the risk of septic shock) and empiric antibiotics (eg, trimethoprim-sulfamethoxazole, ciprofloxacin). (Choice A) 5-alpha-reductase inhibitors are useful in chronic bladder outlet obstruction secondary to benign prostatic hyperplasia. This patient has pyuria and bacteruria with a tender, swollen prostate indicating his bladder outlet obstruction is due to an acute prostate infection; urgent bladder decompression and antibiotics are required. (Choices C and E) Patients with signs and symptoms of acute bacterial prostatitis do not generally require imaging. CT scan of the abdomen and pelvis and transrectal ultrasound of the prostate are usually reserved for those who have persistent symptoms and laboratory abnormalities despite appropriate antimicrobial therapy. (Choice D) Prostatic massage with prostatic fluid analysis is often used to diagnose chronic bacterial prostatitis. This test should be avoided in patients with acute bacterial prostatitis as it offers no additional diagnostic benefit, is quite uncomfortable, and increases the risk of bacteremia. Educational objective: Patients with acute bacterial prostatitis usually have fever, dysuria, urinary frequency, and cloudy urine. Rectal examination typically reveals a warm, edematous, and very tender prostate (unlike urinary tract infection). Prostatic swelling can lead to bladder outlet obstruction with acute urinary retention; treatment with urgent bladder decompression (eg, suprapubic catheter) and antibiotics is required. References: Ultrasound-guided transrectal placement of a drainage tube as therapeutic management of patients with prostatic abscess. (http://www.ncbi.nlm.nih.gov/pubmed/18673079) Urinary retention in adults: diagnosis and initial management. (http://www.ncbi.nlm.nih.gov/pubmed/18350762)

Question 17

A 63-year-old African-American male presents for the evaluation of urinary urgency, hesitancy, nocturia, and a weak urinary stream.  These symptoms have progressively worsened over the past year, despite being on doxazosin.  He denies any fever, abdominal pain, hematuria, malaise, or weight loss.  He is a non-smoker and non-alcoholic.  Rectal examination reveals a smooth, firm enlargement of the prostate without any induration or asymmetry.  Neurological examination is normal.  His PSA level is elevated, and you explain the option of transurethral resection of the prostate.  He is concerned about the complications of the procedure.  Which of the following is the most likely expected complication of this procedure?

Accepted Answer

Explanation: Retrograde ejaculation is the most frequent complication of transurethral resection of the prostate (TURP), which is an invasive procedure used in the management of benign prostatic hyperplasia (BPH). (Choices B and C)Urinary tract infections and urethral strictures are also complications of TURP, but are less common. (Choices D and E) Urinary incontinence and erectile dysfunction have been described with TURP but are relatively uncommon. Educational Objective: Retrograde ejaculation is the most frequent complication of transurethral resection of the prostate, and all patients should be made aware of this. References: Sexual functions in patients with benign prostatic hyperplasia before and after transurethral resection of the prostate. (http://www.ncbi.nlm.nih.gov/pubmed/9537689)

Question 18

A 55-year-old man comes to the office after a friend was diagnosed with prostate cancer.  He has no urinary symptoms and has never had prostate cancer screening.  The patient has a history of hyperlipidemia, which is being managed with lifestyle modification.  He takes no medications, exercises regularly, and does not use tobacco, alcohol, or illicit drugs.  Screening colonoscopy at age 50 was normal, and the patient has no significant family history of cancer.  Which of the following is a true statement that should be taken into consideration when counseling the patient regarding prostate cancer screening?

Accepted Answer

Explanation: 11ec2b69_bfd4_61a9_8f63_1183162fd107_MD0005_00 Prostate cancer is common, with a lifetime incidence of up to 16% of men. However, it is often relatively indolent and has a long preclinical phase in which patients do not experience symptoms. Most men who develop prostate cancer die from other causes. Prostate-specific antigen (PSA) tests can be used for early detection of prostate cancer. However, because PSA commonly detects slow-growing tumors, up to half of all screening-detected cancers are overdiagnosed (ie, cancer that would not have become clinically significant during a patient's lifetime). Different professional societies have different screening guidelines, most of which emphasize the importance of counseling and individualization of recommendations. Prostate cancer is rare in men age <55, and routine screening in this age group is not recommended. Screening is also not recommended for men age ≥70 or for those with a life expectancy <10 years because the risks likely outweigh any mortality benefits for these patients (Choice D). For men age 55-69, PSA screening likely confers reduced prostate cancer mortality, but the absolute benefit is small and is at least partially offset by harms, including false-positive tests and adverse effects of treatment (eg, sexual dysfunction, urinary incontinence) (Choice E). Screening in average-risk men age 55-69 can be considered but should be performed only after appropriate patient education and shared decision-making. However, these screening recommendations do not apply to patients with increased prostate cancer risk (eg, African Americans, positive family history) or to diagnostic testing in symptomatic men. (Choice A) Digital rectal examination (DRE) is helpful in evaluating for possible prostate cancer in men with an elevated PSA. However, it has low sensitivity and specificity for screening and is generally not recommended for prostate cancer screening. (Choice C) Screen-detected prostate cancer is often localized and indolent. A "watchful waiting" approach may be preferable to aggressive treatment for these tumors and may reduce the harms resulting from screening. Educational objective: Prostate cancer is often indolent, and most men with prostate cancer die from other causes. Screening for prostate cancer with prostate-specific antigen can be considered for men age 55-69, but the absolute benefit is small. Screening is not recommended for those age <55 or ≥70 or with a life expectancy <10 years. References: Screening for prostate cancer: recommendation statement. (http://www.ncbi.nlm.nih.gov/pubmed/30277733)

Question 19

A 46-year-old man comes to the office due to dysuria and a dull, aching pain in the penis and perineal region.  The symptoms began 6 months ago and prompted the patient to visit an urgent care center twice.  Both times, he received a short course of antibiotics, which improved symptoms temporarily, but they returned within days.  The patient has also had pain during ejaculation but no urethral discharge, back pain, abdominal pain, weakness, or incomplete voiding.  He is married and monogamous with his wife and has 2 children.  He does not use tobacco or illicit drugs but occasionally drinks 1 or 2 beers on weekends.  He has no medication allergies and no family history of cancer.  Temperature is 37.1 C (98.8 F), blood pressure is 126/84 mm Hg, pulse is 72/min, and respirations are 14/min.  Physical examination shows no abdominal or costovertebral angle tenderness.  Digital rectal examination reveals a mildly tender prostate that is symmetric and not enlarged.  The external genitalia are normal in size and appearance and are nontender to palpation. Urine microscopy after prostate massage reveals 30 leukocytes/hpf, and subsequent culture is negative.  What is the most likely diagnosis?

Accepted Answer

Explanation: The diagnosis of chronic prostatitis is generally made when urinalysis after prostate massage reveals >20 leukocytes/hpf. Urine culture results then differentiate patients as having either: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) - urine culture results are aseptic Chronic bacterial prostatitis - urine culture results show bacteriuria (>10 fold increase after prostate massage) CP/CPPS occurs far more commonly than chronic bacterial prostatitis. (Choice A) Patients with acute prostatitis are typically ill with high fever, dysuria, pelvic/perineal pain, and cloudy urine. Rectal examination usually reveals a warm, edematous, and very tender prostate. Urine culture usually reveals a gram-negative organism such as Escherichia coli or Proteus. (Choice B) Chronic bacterial prostatitis is diagnosed when urine culture after prostate massage shows bacteriuria at a >10-fold concentration compared with urinalysis prior to prostate massage. This patient with an aseptic urine culture has CP/CPPS. (Choice D) Interstitial cystitis can also be associated with long-standing dysuria and aseptic pyuria but is usually characterized by discomfort that is worse when the bladder is full and improved with voiding. In addition, most cases occur in women. (Choice E) Overactive bladder is usually characterized by urinary frequency and urgency. Pelvic pain, dysuria, and pyuria would be atypical. Educational objective: Chronic prostatitis/chronic pelvic pain syndrome is characterized by >3 months of dysuria and pelvic pain. Urine studies following prostate massage usually show pyuria (>20 leukocytes/hpf) with no microorganisms.

Question 20

A 26-year-old woman comes to the office due to greenish vaginal discharge and vulvar pruritus that started several days ago. The patient had an uncomplicated vaginal delivery 2 months ago and is breastfeeding her infant exclusively. She completed a course of antibiotics for lactational mastitis 2 weeks ago. The patient has no chronic medical conditions and has had no surgeries. She was treated for a Chlamydia trachomatis cervicitis during high school. Sexually transmitted infection screening performed at the initial prenatal visit was negative. The patient is in a monogamous relationship with her boyfriend of 3 years. She is taking a daily prenatal vitamin and does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98 F) and blood pressure is 100/60 mm Hg. BMI is 30 kg/m². Vulvar edema and erythema are present. Pelvic examination reveals a nontender, anteverted uterus and no adnexal masses. Speculum examination shows punctate hemorrhages on the cervix. Which of the following is the most appropriate treatment for this patient?

Accepted Answer

Explanation: 11ec2b69_bfcd_35ae_8f63_e3abc6a30f1f_MD0005_00 This patient's presentation is consistent with trichomoniasis, a sexually transmitted infection caused by the protozoa Trichomonas vaginalis. The infection may be asymptomatic or present with a malodorous, frothy, yellow-green vaginal discharge; vulvovaginal pruritus and erythema; dyspareunia from vaginal inflammation; and postcoital bleeding. Punctate hemorrhages can be seen in the vagina and/or on the cervix. Examination of the vaginal fluid typically shows an elevated pH (>4.5) and motile flagellated organisms on wet mount microscopy. motile flagellated organisms The first-line antibiotic regimen is single-dose oral metronidazole 2 g. However, metronidazole enters breast milk and may cause loose stools and candidiasis in exposed infants. Although 1 dose of metronidazole is not an indication for complete cessation of breastfeeding, breast milk produced immediately after treatment has a significant concentration of metronidazole (Choice D). To minimize infant exposure, breastfeeding should be discontinued; breast milk should be expressed and discarded for 24 hours after dose administration. (Choice A) Doxycycline is indicated for the treatment of Chlamydia trachomatis cervicitis, which presents with a mucopurulent cervical discharge and a friable cervix. There is no associated vulvar pruritus. In addition, doxycycline is not recommended during breastfeeding as it is excreted in breast milk and may cause tooth discoloration and enamel hypoplasia in the infant. (Choice B) Oral fluconazole treats Candida vulvovaginitis, a sequela of antibiotic use, which presents with vulvovaginal pruritus and erythema. However, Candida vulvovaginitis typically presents with a thick, white, clumpy discharge and a nonfriable cervix. Fluconazole is excreted in breast milk; however, breastfeeding can continue as there are no known adverse effects. (Choice E) When treating trichomoniasis vaginal metronidazole therapy has lower cure rates (<50%) than oral therapy. Vaginal therapy does not treat concomitant urethral and periurethral gland infections, leading to inadequate treatment.Educational objective: Trichomoniasis is characterized by vulvovaginal pruritus and erythema; a frothy, yellow-green discharge; and punctate hemorrhages in the vagina or on the cervix. Single-dose oral metronidazole is the preferred treatment. To avoid infant exposure, breast milk should be expressed and discarded for 24 hours after dose administration. References: Trichomoniasis - are we giving the deserved attention to the most common non-viral sexually transmitted disease worldwide? (http://www.ncbi.nlm.nih.gov/pubmed/28357378) Trichomonas vaginalis: a review of epidemiologic, clinical and treatment issues. (http://www.ncbi.nlm.nih.gov/pubmed/26242185) Sexually transmitted diseases treatment guidelines, 2015. (http://www.ncbi.nlm.nih.gov/pubmed/26042815)

Exam 1: Advanced Clinical Medicine