A 62-year-old male presents with complaints of numbness in his hands and feet, with occasional foot drop, memory disturbance, fatigue, paleness, anorexia,
... [Show More] nausea, and weight loss. He has a known history of diabetes and hypertension. Which of the following conditions is most likely responsible for these symptoms?
Chronic Renal Failure
Explanation: Chronic renal disease is associated with functional disturbances in all organ systems, including the central nervous system. Renal disease promotes CNS complications including neuropathies and neuromuscular irritability, along with systemic symptoms. The symptoms are typically progressive if the underlying renal disease is not addressed. Although other conditions promote similar neuropathies, such as diabetes, they are differentiated by the level of involvement, progression, and associated symptoms. With Guillain Barre, an acute polyradiculoneuropathy would be expected to progress, and have associated weakness. Cerebrovascular accidents are not typically accompanied by generalized systemic symptoms, and a middle cerebral artery occlusion would be expected to have contralateral hemiparesis and hemisensory deficit.
Which condition is suggested by urethritis, arthritis, and conjunctivitis?
A chlamydial infection
B gonococcal infection
C reactive arthritis
D tertiary syphilis
Reactive arthritis
Both chlamydia and gonorrhea infections can result in urethritis. Gonococci can disseminate to the joints and cause septic arthritis. Chlamydia is typically asymptomatic but can cause chronic conjunctivitis in adolescents and young adults. Reactive arthritis (also known as Reiter syndrome) is a result of an untreated chlamydia infection, and although typically characterized, in texts, by the triad of urethritis, arthritis, and conjunctivitis, all of the symptoms may not be present or not identified at the time of presentation. Tertiary syphilis is characterized by neurologic and cardiovascular disease, gumma, auditory and ophthalmic involvement, and cutaneous lesions.
A 51-year-old male patient presents to your family practice office complaining of genital discomfort with dysuria. His digital rectal exam reveals an enlarged, tender prostate. His prostate-specific antigen (PSA) returns elevated with a value of 11.1 mg/mL, which you fractionate, and this reveals approximately 75% free PSA. His urinalysis reveals moderate white cells and trace blood. What would be your next step in treating this patient?
A Begin him on 6 weeks of doxycycline to treat his prostatitis and when resolved, repeat his PSA level.
B Immediately refer him to a urologist for prostate biopsy to rule out prostate cancer.
C Immediately refer him to a urologist for cystoscopy to rule out bladder cancer and perform a computed tomography (CT) scan of the abdomen and pelvis in the interim.
D Order a stat testicular sonogram to rule out torsion.
E Order a CT scan of the abdomen and pelvis.
Begin him on 6 weeks of doxycycline to treat his prostatitis and when resolved, repeat his PSA level.
This patient has signs and symptoms consistent with prostatitis. Additionally, while his PSA is elevated, this is common in prostatits as well as prostate cancer, and his free PSA is of a percentage that prostate cancer is unlikely. However, it would be prudent to recheck his PSA after treatment and resolution of his symptoms to confirm that an underlying cancer is not smoldering.
A 12-year-old boy presents with a 3-hour history of extreme, severe pain in the right testis. It started suddenly, is 8/10 in intensity, and does not radiate. It is associated with nausea and scrotal swelling. He never had such pain in his lifetime, and he denies any problem in urination. He has never been operated on, and he denies any history of trauma. He is allergic to penicillin.
On physical exam, the child is in visible distress. Temperature is 37.0°C, heart rate is 95, blood pressure is 120/70 mm Hg, and respiratory rate is 20 per minute. Genital examination reveals enlargement and edema of the entire scrotum. The right testicle is erythematous and tender to palpation; it appears to sit higher and lies horizontally in the scrotal sac relative to the left side. The cremasteric reflex is absent ipsilaterally, and there is no relief of pain upon elevation of the scrotum (Prehn's sign). Abdomen is non-tender and tympanic to percussion in all 4 quadrants. Bowel sounds are audible. Chest auscultation shows normal vesicular breathing with mild crepitations over the lower lung fields. Cardiac exam reveals normal S1 and S2, without rubs, murmurs, or gallop.
His initial labs show a hemoglobin of 14.5 g/dL, WBC of 13,000/mm³, platelets of 210,000/mm3, sodium of 140 mmol/dL, potassium of 3.8 mmol/dL, chloride of 95 mmol/dL, urea of 25 mg/dL, and creatinine of 0.9 mg/dL.
Question
What sign or symptom is the most sensitive for the diagnosis of this condition?
Answer Choices
1 Tenderness
2 Edema
3 Horizontal lie
4 Prehn sign
5 Loss of cremasteric reflex
Explanation
Testicular torsion is a true urologic emergency and needs to be differentiated from other causes of testicular pain (e.g., trauma, epididymitis/orchitis, incarcerated hernia, varicocele, idiopathic scrotal edema, and torsion of the appendix testis). The finding of an ipsilateral absent cremasteric reflex is the most accurate and sensitive sign of testicular torsion. This reflex is elicited by stroking or pinching the medial thigh, causing contraction of the cremaster muscle which elevates the testis. The cremasteric reflex is considered positive if the testicle moves at least 0.5 cm.
The patient is a 35-year-old woman who presents as a new patient with urinary frequency, urgency, dysuria, and suprapubic discomfort for several months. Repeated urinalysis and clean catch urine cultures ordered by her primary care physician have been unremarkable. The urologist does not find any significant physical exam findings and decides to perform a cystoscopy under IV sedation. Findings include velvety red patches known as Hunner's ulcers, and a bladder biopsy is negative for cancer. Passive hydrodistention of the bladder is performed at the time of the cystoscopy and is found to provide the patient with minimal relief from her symptoms following the procedure.
Question
What medication would be an appropriate next step in this patient's treatment?
Answer Choices
1 Ciprofloxacin (Cipro) 500mg BID x 7 days
2 Sodium Pentosanpolysulfate (Elmiron) 100mg TID
3 Bisacodyl (Dulcolax) 5mg once daily
4 Hydrocodone (Vicodin) 5/500 q 4-6 hours prn
5 Acetaminophen/Aspirin/Caffeine (Excedrin) 1-2 tablets daily
Sodium Pentosanpolysulfate (Elmiron) 100mg TID
Explanation
The scenario is describing a patient with interstitial cystitis (IC). Patients with IC have a 10:1 female to male ratio and are typically in the third decade of life. Symptoms usually include urinary frequency, nocturia, urgency, and bladder or pelvic pain. Physical examination is usually unremarkable and helpful at ruling out other causes of the patient's symptoms. The urinalysis and urine culture are usually unremarkable, which also rules out other differential diagnoses. Cystoscopy with hydrodistention under sedation is often used to diagnose IC by both the appearance of the bladder and the bladder capacity (not usually over 350cc). Hunner's ulcers seen during cystoscopy with hydrodistention are pathognomonic for interstitial cystitis, although they do not have to be present for a patient to have this diagnosis (only present in 5-10% of cases). The hydrodistention can also help to relieve symptoms, and can be an effective treatment for many patients with IC. However, if symptoms persist, then other treatment options are warranted. Altering diet and avoiding foods and beverages that are bladder irritants can be helpful in improving symptoms in patients with IC. Beyond these measures, there are various medications that can offer relief.
Elmiron stands alone in its class of medications, but is similar to a class of medications called low molecular weight heparins. It prevents the irritation of the bladder wall that is the cause behind the patient's symptoms. This medication is prescribed 100mg TID and is a first-line treatment. It is the best choice of those listed as potential answers.
Ciprofloxacin (Cipro) is an antibiotic commonly used to treat urinary tract infections (UTI). While UTI would have been high on the list of differential diagnoses for this patient, it was ruled out by the negative urinalysis and urine culture.
Bisacodyl (Dulcolax) is a medication commonly used to treat constipation and would therefore not be an appropriate treatment for this patient.
Hydrocodone (Vicodin) and acetaminophen/aspirin/caffeine (Excedrin) are both commonly used to treat pain. Hydrocodone is often prescribed to patients with IC, as chronic opioid use is not uncommon due to the occasional extreme nature of the pelvic pain. However, it would not be the next best treatment and is essentially masking symptoms and not treating the IC. Excedrin is a pain reliever, but it contains caffeine. Caffeine is a bladder irritant and should be avoided by patients with IC, as it can potentiate the symptoms.
A 66-year-old man presents to the office with polyuria and erectile dysfunction. He denies any other symptoms or significant past medical history. Physical examination reveals Tanner stage 5 of the external genitalia, balanitis of an uncircumcised penis, and slightly enlarged, symmetrical and smooth prostate. His condition is most likely the result of:
Answer Choices
1 Benign prostatic hypertrophy
2 Diabetes insipidus
3 Diabetes mellitus
4 Hypogonadism
5 Prostate cancer
Explanation The correct answer is diabetes mellitus since the presence of polyuria would indicate hyperglycemia and the associated erectile dysfunction and/or balanitis may be the only other presenting symptom or sign of diabetes mellitus in a male patient. Erectile dysfunction is a common vascular and neurological complication of diabetes and occurs in up to 75% of male diabetics. Elevated blood sugars result in autonomic neuropathy of the cavernous nerve of the penis so that erectile dysfunction serves as one of the earliest indications of neuropathy. Likewise, hyperglycemia results in microvascular damage to the dorsal and cavernous arteries, in the same way retinopathy, nephropathy, and neuropathy develop, further contributing to poor perfusion and erectile dysfunction. Hyperglycemia also results in the colonization of skin organisms, commonly Candida, resulting in typical superficial yeast infections seen in diabetics such as balanitis in men and vulvovaginitis in women.
Benign prostatic hypertrophy (BPH) typically occurs in the periurethral zone of the prostate and usually presents with lower urinary symptoms (LUTS) that suggest obstruction (i.e. hesitancy, weak stream, straining, post-void leaking) or irritation (i.e. nocturia, frequency, urgency). Digital rectal examination of prostatic hyperplasia typically reveals a smooth, firm enlargement of the gland which may be asymmetrical or indurated. Early BPH is not typically associated with erectile dysfunction or Candidaskin infections.
Prostate cancer most often develops in the peripheral zone of the prostate and is usually asymptomatic. Locally advanced prostate cancer may encroach on the central transition zone of the prostate and present with irritative urinary symptoms. Prostate cancer that extends outside the prostate capsule may result in erectile dysfunction. Carcinomas in the peripheral zone are often palpable and typically a hard, irregular nodule or induration. Prostate cancer is not typically associated with Candidaskin infections.
Hypogonadism may present with fatigue, decreased libido, diminished erections, gynecomastia, or decreased testicular size, muscle mass, or hair growth associated with secondary sexual characteristics. It is typically not associated with an enlargement of the prostate, urinary complaints, or Candidaskin infections.
The characteristic presentation of diabetes insipidus (DI) is abnormally large amounts of dilute urine - insipidus means tasteless. Polyuria is massive, often associated with nocturia and enuresis, and results in dehydration, which is often not evident due to a compensatory increase in thirst and polydipsia. DI is the result of the posterior pituitary's failure to secrete antidiuretic hormone (ADH) resulting in central diabetes insipidus (DI) or the kidney's resistance to ADH resulting in nephrogenic DI. DI is not typically associated with Candidaskin infections.
A 63-year-old woman presents to you with a 5-year history of stage-3 chronic kidney disease. She states that she has not been very good about following her provider's orders, and wants to know what things she can do to help her condition.
Question
What is the appropriate dietary management for this patient?
Answer Choices
1 Salt, water, and protein restriction, potassium supplementation, and magnesium restriction
2 Salt, water, and protein restriction, with phosphorus, potassium, and magnesium restriction
3 Salt and water restriction, with magnesium supplementation, and potassium restriction
4 Salt, water, and protein restriction, with phosphorus and magnesium supplementation
5 Salt, water, and protein restriction, with magnesium and phosphorus restriction
Salt, water, and protein restriction, with phosphorus, potassium, and magnesium restriction
Explanation
The correct answer is restriction of salt, water, protein, phosphorus, and magnesium, as well as potassium. Some studies have shown that protein restriction will slow the progression to end-stage renal disease. Overload of sodium and water can lead to congestive heart failure and edema. Phosphorus and magnesium restriction is needed, as hyperphosphatemia and hypermagnesemia can be seen in chronic renal failure; this is due to decreased excretion of phosphate and magnesium.
The other answers are not correct, as potassium [Show Less]