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PAeasy Genitourinary, All Questions and answers, 100% proven pass rate. Graded A+ A 62-year-old male presents with complaints of numbness in his hands and feet, with occasional foot drop, memory di... sturbance, fatigue, paleness, anorexia, 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 supplementation could cause a hyperkalemic state: it should be avoided in chronic renal failure unless otherwise indicated. Phosphorus and magnesium should be restricted as indicated above. A 17-year-old high school basketball player had been hospitalized with a throat infection, fever, and a question of pneumonia. She had been taking a number of antibiotics and her physician noted edema and an elevated blood pressure. Ten days after being discharged, she began to note blood in her urine. You order an urinalysis and red blood cells and protein are noted in her urine. What is the most likely diagnosis? Answer Choices 1 Chronic Renal Failure 2 Nephrolithiasis 3 Cystitis 4 Glomerulonephritis 5 Nephrotic Syndrome - ✔✔Explanation The clinical picture is suggestive of glomerulonephritis. Signs and symptoms of glomerulonephritis include hematuria, proteinuria, edema, and hypertension usually occurring 7 to 10 days after the onset of acute pharyngitis. Chronic renal failure is most commonly caused by untreated or poorly-controlled diabetes mellitus and untreated or poorly-controlled hypertension. This is no indication of untreated or poorly-controlled diabetes mellitus and untreated or poorly-controlled hypertension in this patient. Nephrolithiasis, or kidney stones, would present with flank pain, ± fever, hematuria, and oliguria. There is no indication of flank pain or oliguria in this patient. Cystitis or bladder infection or inflammation would present with suprapubic pain, dysuria, nocturia, odd or foul smelling urine, an increase in urinary frequency, and no fever. On urinalysis, a cloudy appearance and white blood cells would be seen on microscopic examination. These symptoms are not present in this patient. Nephrotic syndrome presents with massive proteinuria, > 3.5g per 24 hour urine, hypoalbumenemia, edema, and hyperlipidemia. Oval fat bodies may be seen on urinalysis. These symptoms, with the exception of edema, are not present in this patient. At a yearly history and physical examination of a male patient, digital rectal exam reveals an enlarged prostate. You would more likely suspect benign prostatic hypertrophy, rather than prostate cancer, if the patient's history also included what presentation? Answer Choices 1 68-year-old with a free prostate specific antigen of 5% 2 48-year-old African American who is asymptomatic 3 52-year-old with a prostate specific antigen of 10 ng/mL 4 62-year-old with a brother treated for prostate cancer 5 72-year-old Caucasian who complains of a poor urinary stream - ✔✔72-year-old Caucasian who complains of a poor urinary stream Explanation The male patient most likely to have benign prostatic hypertrophy (BPH) is the 72-year-old Caucasian who complains of a poor urinary stream. BPH occurs in 90% of men >70 years old. It occurs in the periurethral zone of the prostate and usually presents with lower urinary symptoms (LUTS) that suggest obstruction (i.e. hesitancy, weak stream, intermittent stream, straining, incomplete emptying, post-void leaking) or irritation (i.e. nocturia, frequency, urgency). Risk factors for prostate cancer include men >50 years old or African American men >45 years old or a first-degree relative with prostate cancer. Prostate cancer most often develops in the peripheral zone of the prostate. Early prostate cancer is usually asymptomatic, but locally advanced prostate cancer may encroach on the central transition zone of the prostate and present with irritative urinary symptoms (i.e. nocturia, frequency, urgency). Laboratory findings suggestive of prostate cancer/BPH include: An elevated prostate specific antigen (PSA) >4 ng/mL: sensitivity of this value for prostate cancer is 57-79% In BPH, level of PSA is generally below 10 ng/dl, A rise in PSA >0.75 ng/mL per year would suggest prostate cancer A 17-year-old high school basketball player had been hospitalized with a throat infection, fever, and a question of pneumonia. She had been taking a number of antibiotics and her physician noted edema and an elevated blood pressure. Ten days after being discharged, she began to note blood in her urine. You order an urinalysis and red blood cells and protein are noted in her urine. What is the most likely diagnosis? Answer Choices 1 Chronic Renal Failure 2 Nephrolithiasis 3 Cystitis 4 Glomerulonephritis 5 Nephrotic Syndrome - ✔✔Explanation The clinical picture is suggestive of glomerulonephritis. Signs and symptoms of glomerulonephritis include hematuria, proteinuria, edema, and hypertension usually occurring 7 to 10 days after the onset of acute pharyngitis. Chronic renal failure is most commonly caused by untreated or poorly-controlled diabetes mellitus and untreated or poorly-controlled hypertension. This is no indication of untreated or poorly-controlled diabetes mellitus and untreated or poorly-controlled hypertension in this patient. Nephrolithiasis, or kidney stones, would present with flank pain, ± fever, hematuria, and oliguria. There is no indication of flank pain or oliguria in this patient. Cystitis or bladder infection or inflammation would present with suprapubic pain, dysuria, nocturia, odd or foul smelling urine, an increase in urinary frequency, and no fever. On urinalysis, a cloudy appearance and white blood cells would be seen on microscopic examination. These symptoms are not present in this patient. Nephrotic syndrome presents with massive proteinuria, > 3.5g per 24 hour urine, hypoalbumenemia, edema, and hyperlipidemia. Oval fat bodies may be seen on urinalysis. These symptoms, with the exception of edema, are not present in this patient. A 56-year-old African-American man presents with urinary hesitancy, frequency, and nocturia. He has to get up and urinate 3 to 4 times per night, and he is not sure if he empties his bladder completely. He states that his symptoms have been getting worse over the past 2 years. His urinary stream is weaker than it was a 1 year ago. He denies blood in his urine, and there is no history of urinary tract infections, dysuria, or pain. He is otherwise in a good state of health, and he has no significant past medical or surgical history. Currently, he takes no medications, and he has no known drug allergies. On review of systems, you discover that his father and brother died of prostate cancer in their 50's. The remainder of the history and ROS is non-contributory. Physical Examination: Vital signs are stable and he is afebrile. General physical exam is unremarkable. Genital exam reveals a circumcised penis with no lesions or discharge. There is no inguinal adenopathy. Testicles are descended bilaterally with no lesions, masses, or hernias. Rectal exam reveals a smooth prostate with no nodules or tenderness. Diagnostic investigations: Urinalysis is normal and Prostate-Specific Antigen (PSA) test is within normal range for age. (For men aged 50 to 59 years, the normal reference range is 0 to 3.5 ng/mL) After emptying 250 mL of urine, the post-void residual urine volume is 50 mL. Question What is the most appropriate intervention? Answer Choices 1 Finasteride 2 Surgical therapy 3 Terazosin 4 Transrectal ultrasound with prostate biopsy 5 Urine culture and sensitivity - ✔✔Explanation Terazosin is the correct response. Given the history, physical exam, and negative PSA, you have enough information to make the diagnosis of symptomatic benign prostatic hyperplasia (BPH). No further diagnostic studies are necessary. Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a histologic diagnosis characterized by proliferation of the cellular elements of the prostate. A classic history is usually sufficient to make the diagnosis. Clinical manifestations include urinary hesitancy, urinary frequency, urgency, nocturia (awakening at night to urinate), decreased or intermittent force of stream, and/or a sensation of incomplete bladder emptying. Treatment: Depending on the patient's preferences, the next step is to begin treatment; in most cases, medical therapy is initiated first. If the symptoms do not significantly interfere with the patient's life, he may choose to wait and refuse treatment once he is reassured that he does not have a life-threatening illness. This decision would be medically acceptable in this case. If he selects treatment, management begins with a selective α1-receptor blocker, such as doxazosin or terazosin. A medication specific for α 1A-receptor subtype, such as tamsulosin (Flomax®), may be used in patients who cannot tolerate traditional α1-receptor blockers. If medical therapy fails or if a patient has severe BPH with ongoing obstruction, retention of large volumes of urine, or recurrent urinary tract infections, surgical therapy should then be considered. The most commonly performed surgery is transurethral resection of the prostate. Because of his family history, the patient in this case has an increased risk of prostate cancer; however, transrectal ultrasound with prostate biopsy is not indicated. This diagnostic procedure should be reserved for suspicion of prostate cancer. Based on this patient's family history and because he is African-American (African-Americans have a 50% higher incidence of and mortality from prostate cancer in comparison with Caucasians) a healthy index of suspicion is astute nonetheless. Given this patient's classic BPH presentation and the normal PSA, prostate cancer is low probability at this time. That being said, caution must be exercise when using PSA as a diagnostic tool to rule in or rule out prostate cancer. The USPSTF recommends against PSA-based screening for prostate cancer. In addition, the negative prostate exam on rectal probing, while classically taught to be important, adds no additional information in most cases; currently, it is not recommended by the U.S. Preventive Services Task Force. No evidence in the case points towards the need for urine culture and sensitivity. Finasteride is a 5 α-reductase inhibitor. If the patient does not receive sufficient relief from maximum doses of a α1-receptor blocker, it may be added. However, it may take up to 6 months for a 5 α-reductase inhibitor to result in a noticeable difference in symptoms. Thus, finasteride is not a first-line treatment. The full therapeutic benefit of a α1-receptor blocker, on the other hand, will be apparent within 4-6 weeks. Post-void residual is a diagnostic tool used to determine if a patient with BPH will benefit from scheduled bladder catheterizations. A post-void residual >200 mL is associated with an increased risk of urinary tract infections. Scheduled catheterizations are usually reserved for cases in which medical or surgical interventions do not correct the problem; they are also used when medical and surgical interventions are contraindicated. A 63-year-old man presents with a 6-month history of symptoms of urinary frequency, hesitancy, and nocturia. In addition, burning dysuria has occurred on 2 occasions, requiring treatment with antibiotics. He has a 1-year history of angina pectoris, for which he takes occasional nitroglycerin. On physical examination, the blood pressure is 130/90; heart rate is 90/min and regular, and an enlarged prostate is palpable per rectum. Laboratory data, including EKG, yields no contraindication to surgery; he is operated upon for a transurethral resection of the prostate. Anesthesia and surgery are uneventful, and blood loss is minimal. 6 hours postoperatively, he experiences a shaking chill, a temperature of 40 degrees C, and his blood pressure is 90/60 mm Hg. What is the most likely diagnosis? Answer Choices 1 Gram-negative bacteremia 2 Myocardial infarction 3 Postoperative bleeding 4 Arrhythmia 5 Lobar pneumonia - ✔✔gram negative bacteremia Explanation The correct response is Gram-negative bacteremia. Some degree of enlargement of the prostate is extremely common from the age of 50 onwards, but this type of enlargement often produces either minor symptoms, or no symptoms at all. However, benign hypertrophy of the gland results in elongation and tortuosity of the prostatic urethra, and the median lobe may become a large, rounded, swelling overlying the posterior aspect of the internal urinary meatus. Here, it can act like a ball valve, producing urinary obstruction. The deranged anatomy in the region of the internal meatus, may allow urine into the prostatic urethra. The urine in this situation sets up a desire to micturate and this produces one of the most common symptoms of prostatism, namely, frequency. This is particularly worrisome to the patient at night, as it interferes with his sleep. The obstruction, and instrumentation to relieve it, predisposes to urinary infection. The obstruction to the outflow of the bladder may result in renal failure and uremia. Gram-negative enteropathogens are the most common cause of urinary tract infections and intra-abdominal sepsis, especially post-operatively, in the acute abdomen. Septicemia causes high fever, shivering, headache, and rapid breathing; it may progress to delirium, coma, and death. Myocardial infection gives rise to chest pain, which is usually of greater severity and duration than in angina, and is associated with nausea, vomiting, sweating, and extreme distress. The patient may be cold and clammy with tachycardia, hypotension, cyanosis, and mild pyrexia (Postoperative bleeding may lead to hypotension and hypovolemic shock, unless fluid volume is rapidly replenished. Arrhythmias may give rise to tachy- and bradycardias, which are sometimes felt as palpitations. They may also present with their hemodynamic consequences: dyspnea, angina, collapse, or 'funny turns'. Corresponding EKG changes are diagnostic. Pneumonia is relatively slow in onset, with symptoms of systemic upset, fever, pleuritic pain, cough, and green sputum (may be scanty at first, or, 'rusty' in color, if due to pneumococcal). On examination, there will be signs of consolidation, or just localized crepitations. Tachypnea is a valuable sign, especially in the elderly, in whom there is high index of suspicion. The effect of steroid therapy is evaluated in an 8 year-old African-American boy being treated for fatigue and generalized edema following a "bad cold". His vitals are T 37 C, pulse 90/min, RR 20/min and BP 110/70. Physical exam reveals presence of mild periorbital edema and marked peripheral edema in hands and feet with the remainder of exam within normal limits. Lab values include dipstick urine protein 3+; urine protein 50 mg/m2/hr (<40 mg/m2/hr) Specific gravity 1030 (1008-1020) Urine protein/creatinine ratio 2.0/gm creatinine (< 0.2/gm creatinine) Serum albumin 3.9 (5.9-8.0 gm/dl) Cholesterol 250 (112-247 mg/dl) Remainder of laboratory values including BUN and plasma creatinine are within normal limits. Question What additional treatment should be initiated in this patient to decrease the risk of chronic kidney disease? Answer Choices 1 Diuretics 2 Spironolactone 3 ACE inhibitor 4 Beta blocker 5 Mixed alpha + beta antagonist - ✔✔ACEI Explanation The pediatric patient described is apparently suffering from nephrotic syndrome. Glomerular disease induced proteinuria is the most common cause of nephrotic syndrome in children due to damage to the glomerular filtration barrier resulting in leakage of plasma proteins into the glomerular ultrafiltrate. Signs and symptoms in children include edema, urine protein: creatinine ratio > 0.2/gm creatinine; heavy proteinuria (urine protein >40 mg/m2/hr), hypoalbuminemia, and hyperlipidemia. The nephrotic range of proteinuria in children is higher than in adults (> 40 mg/m2/hr). Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers not only lower blood pressure but have that additional benefit of slowing the progression of kidney disease even in patients with normal blood pressure. Although this child is normotensive and is already receiving steroid treatment, the next best additional treatment, therefore, is an ACE inhibitor or an angiotensin receptor blocker (ARB) to decrease the proteinuria and GFR decline in order to reduce the risk of chronic kidney disease. Diuretic is incorrect. Although a diuretic would provide symptomatic relief for the edema, it would not prevent the development of chronic kidney disease in this patient. Spironolactone is incorrect. Spironolactone is an inhibitor of renal aldosterone effects such as sodium and water retention and would help combat the edema in this patient but would not decrease the risk of chronic kidney disease. Beta blocker is incorrect. Beta blockers can be useful in the treatment of hypertension but this patient has not yet developed hypertension. Mixed alpha and beta antagonist is incorrect. The use of a mixed alpha and beta antagonist drug is not indicated in this normotensive patient and would likely not reduce the risk of chronic kidney disease. A 5-year-old boy presents with history of low-grade fever, headache, and intermittent colicky pain in the abdomen, which has been localized mainly around the umbilicus since yesterday. The child has vomited once. In between the episodes of pain, the child is playful. His symptoms are also accompanied by a maculopapular rash that is more confluent over the lower extremities and the buttocks. There is no itching. Some areas of the rash are turning purple and red, which is suggestive of a hemorrhagic rash. Both knees and ankles are swollen and tender, and there is edema of the hands and feet mainly in the dependent areas. Examination of the cardiovascular, respiratory system, and abdominal examination are essentially normal. Laboratory investigations show: Hb. - 10gm%, WBC. 11,000/cm Platelet count - 550,000/cmm. Serum IGA - 500 mg /dL (normal 14-159 mg/dLfor 2-5 years age group) Urine - Proteinuria++, RBCs++ Stool - RBC+ Question What is the most likely diagnosis? Answer Choices 1 Kawasaki disease 2 Systemic onset Juvenile rheumatoid arthritis 3 Systemic lupus erythematosis 4 Henoch-Scholein purpura 5 Polyarteritis nodosa - ✔✔HSP Explanation The most likely diagnosis is Henoch-Scholein purpura, which is also known as anaphylactoid purpura. It is the most common cause of non-thrombocytopenic purpura in children. Boys are affected twice as frequently as girls. It is a common vasculitis of small vessels, with cutaneous and systemic manifestations. The systems primarily involved are the skin, gastrointestinal tract (GIT), and kidneys. The characteristic manifestation of the disease is the rash, which presents initially as a pink maculopapular rash, but progresses to petechiae and purpura, which typically is characterized clinically as palpable purpura. The rash may continue to appear intermittently for 3 or 4 months, or even up to 1 year. Edema and vasculitis of the GIT may lead to GI hemorrhage, manifesting with colicky pain in abdomen, vomiting, and hematemesis. There may be enlargement of mesenteric lymph nodes. Stool is positive for occult blood. Swelling of knee and ankle joints is frequently seen due to serous effusion. There may be edema of the dependent areas. Renal involvement, which is the most important cause of morbidity and mortality, manifests as hematuria, proteinuria, and hypertension. CNS and cardiac involvement may rarely occur. Laboratory findings include thrombocytosis, leukocytosis, and elevated ESR. Serum IgA levels are elevated. Urine examination shows albuminuria, hematuria, and presence of white blood cells and casts in the urine. Renal biopsy may show mesangial deposition of IgA. Diagnostic criteria of Kawasaki disease are fever of more than 5 days duration and presence of at least 4 of the following conditions: (1) Strawberry tongue (protuberance of tongue papillae) suggestive of streptococcal infection (2) Diffuse reddening of the oral and pharyngeal mucosa, dry and cracking lips. (3) Conjunctivitis without any discharge. (4) Edema/erythema of the hands and feet and later desquamation of the skin of the fingers and toes. (5) Polymorphous rash. (6) Cervical lymphadenopathy (at least one lymph node >1.5 cm). These features are not present in the above child. Systemic lupus erythematosis (SLE) is a multisystem disease involving nearly all the organs. It is an autoimmune disorder that causes inflammation of the blood vessels and connective tissue, resulting in multisystem involvement. It is seen more commonly in girls in contrast to HSP, which is more common in boys. Joints may be merely stiff or there may be active inflammation. Cutaneous manifestations include malar, or butterfly, rash involving the cheeks and nasal bridge. Rash may be photosensitive and may involve all sun exposed areas. This rash is quite different from the rash of Henoch-Schonlein purpura. Hepatosplenomegaly and lymphadenopathy are often present. Cardiac involvement may include pericarditis, valvular thickening, myocarditis, conduction abnormalities, and congestive cardiac failure. Pulmonary involvement includes pulmonary hemorrhage and fibrosis. This is in contrast to the index case. Renal involvement may manifest as hypertension, edema, electrolyte abnormalities, nephrosis, or acute renal failure. Systemic onset juvenile rheumatoid arthritis (JRA) may be characterized by spiking fevers, arthritis, hepatosplenomegaly, lymphadenopathy, and serositis leading to pericardial effusion. Fever is accompanied by a faint transient, evanescent salmon-colored macular rash more commonly over the trunk and proximal limbs. It is non-pruritic and may last for a few hours. Heat, even that of a warm bath, may cause reappearance of the rash. Lab investigation includes raised ESR, leukocytosis, thrombocytosis, and C-reactive proteins (CRP) and anemia of chronic disease. JRA is the most common chronic rheumatologic disease in children, with a minimum duration of 6 weeks. The new nomenclature juvenile idiopathic arthritis (JIA) is being increasingly used to better define various subgroups. Clinical manifestations of Polyarteritis nodosa (PAN) is a necrotizing vasculitis involving small and medium sized arteries. Boys and girls are equally affected. It is believed to be a post-infective autoimmune response in susceptible individuals commonly occurring after upper respiratory infection by group A streptococcal infection, chronic hepatitis B infection, infectious mononucleosis, and tuberculosis. Common features include fever, weight loss, and abdominal pain. Skin manifestations include purpura, edema, and painful nodules along the course of arteries. Cardiac involvement occurs as myocarditis, pericarditis, and arrhythmias. Angiography may show aneurismal dilatation and segmental stenosis. A 42-year-old woman presents for an evaluation of back pain. She states that she has a history of recurrent UTIs and that on occasion, she has noted that her urine appears red. Upon physical examination, she demonstrates CVA tenderness and a palpable abdominal mass. Her vital signs include blood pressure of 145/90 mmHg, respiratory rate of 16 breaths/min, and heart rate of 72 bpm. You order a urinalysis which has the following abnormal results: leukocyte esterase 1+, protein trace, and blood 3+. The microscopic examination reveals 5-10 WBCs/hpf and 20-30 RBCs/hpf. An abdominal ultrasound demonstrates multiple, bilateral fluid collections within the kidneys. Question What, if any, is the most likely underlying renal pathology? Answer Choices 1 Normal kidneys 2 Renal cell carcinoma 3 Goodpasture's syndrome 4 Polycystic kidney disease 5 Medullary sponge kidneys - ✔✔Polycystic Kidney Disease The clinical picture is suggestive of acute pyelonephritis in the setting of polycystic kidney disease. Abdominal or flank pain, blood in the urine, recurrent UTIs, and hypertension are common symptoms of polycystic kidney disease. Cystic lesions on abdominal ultrasound are a hallmark of the disorder. These lesions would not be present in a patient with normal kidneys. A solid renal mass is most often seen in the context of renal cell carcinoma. Goodpasture's syndrome is defined as a combination of glomerulonephritis and pulmonary hemorrhages. The disease is usually preceded by an upper respiratory tract infection. Patients usually present with dyspnea and hemoptysis. This is not seen in this patient. Medullary sponge kidney is a common and benign disorder presenting at birth and is not usually diagnosed until the 4th of 5th decade. Common findings include gross hematuria, recurrent UTIs, and renal stones. The kidneys will have irregular enlargements of the medullary and interpapillary collecting ducts giving a "Swiss cheese" appearance. This is not the finding present on this patient's abdominal ultrasound. A 2-year-old boy presents with a firm, painless mass in his right testicle. It is determined that he has an endodermal sinus tumor. What tumor marker is most likely to be elevated? Answer Choices 1 Alpha-fetoprotein 2 5 hydroxytryptamine 3 Gastrin 4 Vasoactive intestinal peptide (VIP) 5 Acid phosphatase - ✔✔AFP Explanation An endodermal sinus tumor is also called a yolk sac tumor, infantile embryonal carcinoma, embryonal adenocarcinoma of the prepubertal testis, or orchioblastoma. The presence of alpha-fetoprotein is very typical. Alpha-fetoprotein is seen with a variety of tumors, such as hepatocellular carcinoma, pancreatic carcinoma, testicular tumors, and others. 5-hydroxytryptamine is serotonin. Serotonin is an indolamine. The precursor for serotonin is tryptophan. Serotonin is a neurotransmitter. Serotonin is also the precursor to melatonin. As a tumor marker, 5-hydroxytryptamine (serotonin) is the major product seen with carcinoid tumors. Gastrin is a hormone that is ordinarily secreted by cells within the stomach. Specifically, gastrin is secreted by G cells, which are in the stomach antrum. Gastrin stimulates acid secretion of the stomach. Pathologically, gastrin can be produced by pancreatic islet cells tumors. Vasoactive intestinal peptide is sometimes abbreviated as VIP. Vasoactive intestinal peptide can be seen with islet cell tumors and pheochromocytoma. The prostate has the enzyme acid phosphatase. Acid phosphatase is actually a group of enzymes, which can be found in a few other tissues as well. With the development of prostate cancer, elevated serum acid phosphatase can be seen. A 55-year-old woman presents with a 2-month history of gross hematuria. She states she has no pain with urination, but the hematuria is persistent. On questioning, she states that she has had a 1-month history of some progressively worsening left flank pain and persistent back pain. The pains are not debilitating, but they are nagging. She has no chronic medical problems. She admits to a 50-pack/year smoking history, and she states she is currently retired from her job as a teacher. Vital signs are within normal limits, and physical exam reveals a left side abdominal mass. Urine dipstick only shows too numerous to count RBCs, and urine cultures are negative. CT scan of the abdomen and pelvis with and without contrast reveals a 4.2 cm solid enhancing lesion in the left renal parenchyma. Question What is the most effective treatment for this patient? Answer Choices 1 Radiation of the kidney 2 Chemotherapy 3 Left nephrectomy 4 Hormonal therapy 5 Observation - ✔✔Left Nephrectomy Explanation This patient likely has renal cell carcinoma of the left kidney. Surgery is most effective treatment for primary RCC. Partial nephrectomies are common in peripheral tumors that are less than 4 cm in size, but total nephrectomies are the treatment of choice in larger or more centrally located tumors. Radiation preoperatively and/or postoperatively has not been shown to change overall survival with RCC. Chemotherapy currently available is not beneficial in RCC. Hormone therapy, including progesterone therapy, has not been shown to be effective in treatment of RCC. Observation is a viable option in elderly patients and poor surgical candidates if the tumor is less than 3 cm in size. These patients are often followed with CT scans every 6 months. Your patient is a 55-year-old man presenting with a strong, sudden need to urinate. He feels his bladder spasms and sometimes has involuntary loss of urine. The problem started several months ago and seems to be worsening. He is very upset because it sometimes happens during his business meetings. His urinalyses were always normal. He takes no medications. Careful examination shows that he has urge incontinence. Bladder training and behavioral techniques were unsuccessful, and you decided to introduce medication. Before suggesting a medication for this condition, you will tell him that this drug may have some side effects: dry mouth, difficulty in urination, constipation, blurred vision, tachycardia, drowsiness, and dizziness. Question This may happen because you will be prescribing what type of drug? Answer Choices 1 Cholinergic 2 Anticholinergic 3 Epinephrine 4 Antibiotic 5 Botulinum toxin - ✔✔Anticholinergic Urge incontinence is defined as involuntary loss of urine occurring for no apparent reason together with a feeling of urinary urgency (a sudden need or urge to urinate) that represents a hygienic or social problem to the individual. The most common cause of urge incontinence is involuntary and inappropriate detrusor muscle contractions. The drug you will suggest is anticholinergic (like Oxybutynin). It will relieve urinary and bladder difficulties, including frequent urination and urge incontinence by decreasing muscle spasms of the bladder, increasing the capacity of the bladder, and delaying the initial urge to void. It is a competitive antagonist of M1, M2, and M3 muscarinic acetylcholine receptors and in higher doses can act as spasmolytic on bladder smooth muscle. Anticholinergic side effects are dry mouth, difficulty in urination, constipation, blurred vision, tachycardia, drowsiness, and dizziness. Cholinergic drug will cause slowing of the heartbeat and increases in normal secretions. For this reason, patients who already have a problem with incontinence should not be advised to use these drugs. Epinephrine is not indicated in this patient. Epinephrine stimulates the ends of the sympathetic or inhibitory nerves of the bladder, with the effect of relaxation of the bladder muscles and the increase in tone and rate of contraction of the ureter. The secretion of urine is increased synchronously with the rise in arterial pressure. It will also cause overacting heart, palpitation, and vomiting. There is no need for antibiotics in a patient with normal urine analysis for a problem that lasts several months. Botulinum toxin is given as intradetrusor injection in patients who have failed pharmacological therapy. It has been shown to decrease episodes of urinary leakage by preventing the release of acetyl choline from presynaptic membrane. It is also indicated for urinary incontinence in patients with neurologic conditions (e.g., spinal cord injury, multiple sclerosis). It sometimes can cause urinary retention given as intradetrusor injections and occasionally headache, light-headedness, fever, abdominal pain, and diarrhea (not necessarily a direct result of Botox). A 2-month-old infant is being seen for a routine examination by his pediatrician. However, his mother admits to not following recommendations and has not had him seen by the pediatrician since hospital discharge. During the genitourinary examination, the pediatrician cannot palpate the testis on either side of the scrotum. The pediatrician is concerned that the infant has bilateral cryptorchidism (or undescended testes), but needs to make sure testes are present somewhere above the scrotum. Question What laboratory testing and imaging study combination would the pediatrician order? Answer Choices 1 Luteinizing hormone, follicle stimulating hormone, and testosterone levels followed by CT scan 2 Luteinizing hormone, follicle stimulating hormone, and testosterone levels followed by ultrasonography 3 Human chorionic gonadotropin stimulation test and testosterone levels followed by ultrasonography 4 Human chorionic gonadotropin stimulation test and testosterone levels followed by X-ray 5 Human chorionic gonadotropin stimulation test and testosterone levels followed by CT scan - ✔✔Explanation Luteinizing hormone (LH), follicle stimulating hormone (FSH), and testosterone levels followed by ultrasonography is the correct answer. In male infants under the age of 3 months, LH, FSH, and testosterone levels are helpful in determining whether there are testes present. Ultrasonography has a sensitivity of 76%, a specificity of 100%, and an overall accuracy of 84% when diagnosing undescended testes that are nonpalpable on examination. MRI would have also been a good imaging choice, as it has a sensitivity of 86%, a specificity of 79%, and an overall accuracy of 85%. However, ultrasonography is both easier and a lower risk to perform on infants and children, making it the more popular choice in many cases. Luteinizing hormone, follicle stimulating hormone, and testosterone levels followed by CT scan is not the correct answer. CT scan findings in children when used in the diagnosis of nonpalpable undescended testes are historically not reliable. Therefore, the imaging study of CT scan makes this answer incorrect. Human chorionic gonadotropin (HCG) stimulation test and testosterone levels followed by ultrasonography is not the correct answer. The HCG stimulation test is done by administering 2000IU of HCG daily for 3 days and checking testosterone levels pre- and post-stimulation. This helps to determine the presence or absence of testicular tissue. However, this test is reserved for infants over 3 months of age. Ultrasonography is the correct imaging study, but the answer is incorrect due to the laboratory test being incorrect. Human chorionic gonadotropin stimulation test and testosterone levels followed by x-ray is not the correct answer. The HCG stimulation test is done by administering 2000IU of HCG daily for 3 days and checking testosterone levels pre- and post-stimulation. This helps to determine the presence or absence of testicular tissue. However, this test is reserved for infants over 3 months of age. X-ray is not used at all in the diagnosis of cryptorchidism. Both facets of this answer choice are incorrect. Human chorionic gonadotropin stimulation test and testosterone levels followed by CT scan is not the correct answer. The HCG stimulation test is done by administering 2000IU of HCG daily for 3 days and checking testosterone levels pre- and post-stimulation. This helps to determine the presence or absence of testicular tissue. However, this test is reserved for infants over 3 months of age. CT scan findings in children when used in the diagnosis of nonpalpable undescended testes are historically not reliable. Both facets of this answer choice are incorrect. A 65-year-old Caucasian man presents for a routine physical. He states that he is concerned about the development of prostate cancer. His history is significant for benign prostatic hyperplasia (BPH), for which he underwent a transurethral resection of the prostate (TURP) 3 years ago. His social history is significant for a 50 pack-year history of smoking, and he worked for 40 years as a coal miner. His father died of prostate cancer at age 76. What factor would most likely contribute to his risk of developing prostate cancer? Answer Choices 1 Race 2 History of BPH 3 Smoking history 4 Family history 5 Occupational history - ✔✔The correct response is family history. Several risk factors have been identified for prostate cancer, including race and nationality. African-Americans are twice as likely to develop prostate cancer as are Caucasian Americans, and the incidence is higher in North America and western Europe than in other areas of the world. Age is the single largest risk factor, with rates of prostate cancer increasing rapidly after the age of 50. High fat diets and a sedentary lifestyle have also been linked to prostate cancer. Men with first-degree relatives with prostate cancer are twice as likely to develop prostate cancer as are other men, and the risk is even higher if multiple relatives are affected. Other factors, such as a history of smoking and occupational exposures, have not been conclusively linked to prostate cancer. Benign prostatic hypertrophy arises in cells in a different area of the prostate gland, and a history of BPH does not increase the risk of developing prostate cancer. A 10-year-old boy is brought to the clinic by his mother. She noted that his face is swollen, and he told her that his urine was cloudy and reddish. He has a history of falling and abrading the skin of his right thigh 2 weeks ago. The next day, the skin became red, hot, and tender; the infection was treated with a topical antibiotic ointment. The cellulitis gradually healed. You suspect acute glomerulonephritis. What organism is the most likely cause of the disease? Answer Choices 1 Streptococcus pyogenes (group A beta-hemolytic) 2 Streptococcus agalactiae (group B) 3 Enterococcus faecalis 4 Peptostreptococcus 5 Streptococcus pneumoniae - ✔✔Explanation Streptococcus pyogenes (group A beta-hemolytic) cause 3 types of diseases: 1) pyogenic diseases, such as pharyngitis and cellulitis, 2) toxigenic diseases, such as scarlet fever and toxic shock syndrome, and 3) immunologic diseases, such as rheumatic fever and acute glomerulonephritis. Glomerulonephritis occurs especially following skin infections. Streptococcus pneumoniae are Gram-positive lancet-shaped cocci arranged in pairs (diplococci) or short chains. On blood agar, they produce alpha-hemolysis. Virulence factors of Pneumococci are polysaccharide capsules. Pneumococci cause pneumonia, bacteremia, meningitis, and infections of the upper respiratory tract, such as otitis and sinusitis. Mortality rate is high in elderly, immunocompromised (especially splenectomized), and/or debilitated patients. They should be immunized with the polyvalent polysaccharide vaccine. Peptostreptococci grow under anaerobic or microaerophilic conditions and produce variable hemolysis. Peptostreptococci are members of the normal flora of the gut and female genital tract and participate in mixed anaerobic infections of the abdomen, pelvis, lungs, and brain. Streptococcus agalactiae (group B streptococcus) colonize the genital tract of some women and can cause neonatal meningitis and sepsis. They are usually bacitracin-resistant. Enterococcus faecalis (group D streptococcus), formerly known as Streptococcus faecalis, are part of the normal flora in the gut. They can cause urinary, biliary, and cardiovascular infections. Which one of the following organisms is the cause of epididymitis in young men under 35 years Answer Choices 1 N. gonorrhea 2 P. aeruginosa 3 C. acuminata 4 T. pallidum 5 H. ducreyi - ✔✔N gonorrhea Explanation The cause of epididymitis in young men under 35 years is usually sexually transmitted organisms such as N. gonorrhea and C. trachomatis. T. pallidum causes syphilis and H. ducreyi causes chancroid. An 83-year-old man presents to his urologist's office with "problems down there." He is a poor historian, but his wife accompanies him and helps with his review of systems. She does not report that he has any voiding issues and reports that he has never had to see a urologist before now. Genitourinary examination is suggestive of phimosis. Question What physical examination finding would support this diagnosis? Answer Choices 1 Entrapment of the foreskin behind the glans penis in an uncircumcised male patient 2 Erythema and edema of the glans penis in an uncircumcised male patient 3 Erythema and edema of the phallus in a circumcised male patient 4 Erythema and edema of the glans penis in a circumcised male patient 5 Inability to retract the foreskin over the glans penis in an uncircumcised male patient - ✔✔Inability to retract the foreskin over the glans penis in an uncircumcised male patient Explanation Inability to retract the foreskin over the glans penis in an uncircumcised male patient is the correct answer. Phimosis can be the result of recurrent infections or irritation, advanced age, diabetes, and poor hygiene. Patients can experience painful erections, recurrent balanitis, and voiding difficulties. Treatment can be with topical steroids followed by gradual retraction of the foreskin or circumcision. Entrapment of the foreskin behind the glans penis in an uncircumcised male patient is not the correct answer. This is a description of a patient with paraphimosis. Typically, this results in retraction of the foreskin for medical or hygiene purposes that is not followed by properly pulling the foreskin back in place over the glans penis. This can be very painful, and needs to be manually reduced as soon as possible to prevent necrosis of the glans penis. A dorsal slit or circumcision may be necessary if manual reduction is not possible. Erythema and edema of the glans penis in an uncircumcised male patient is not the correct answer. This description most closely describes balanitis and does not address the placement or status of the foreskin, which is the main concern with phimosis. Erythema and edema of the phallus in a circumcised male patient is not the correct answer, as patients who are circumcised cannot experience phimosis due to their lack of foreskin. Erythema and edema of the glans penis in a circumcised male patient is not the correct answer, as patients who are circumcised cannot experience phimosis due to their lack of foreskin. A 65-year-old man presents with flank pain, blood in his urine, and an unexplained weight loss. His past medical history is significant for numerous infections, kidney stones, cigarette use, and alcohol use. On physical exam, there is a palpable abdominal mass, as well as a low-grade fever. Diagnostic tests determine that he has cancer. Question What puts this patient at risk for the development of his particular type of cancer? Answer Choices 1 Eschericia coli infection 2 Urolithiasis 3 Smoking 4 Interstitial nephritis 5 Schistosoma haematobium infection - ✔✔Smoking Explanation This patient has renal cell carcinoma. Smoking is a risk factor for many neoplasms, including renal cell carcinoma. There is a classic triad associated with renal cell carcinoma: hematuria, flank pain, and a palpable abdominal mass; however, the classic triad is not seen in most patients. Other presenting symptoms include a fever and weight loss. Cells from the proximal convoluted tubule are the most common cells that renal carcinoma arises from. There is an increased incidence of renal cell carcinoma with von Hippel-Lindau disease. Escherichia coli infection, urolithiasis, and interstitial nephritis are not known risk factors. Schistosoma haematobium infection is associated with bladder tumors. A 1-month-old infant boy presents with a 101.5 fever. He was a full term baby born via vaginal delivery. His mother was GBS (group B strep) positive and treated adequately. Since birth he has been exclusively breastfed and has been gaining weight slowly. He has no URI symptoms and is active and feeding well. He receives a sepsis workup and is admitted for 48-hour sepsis rule out. At 24 hours, his urine culture grows e. coli. His other cultures are negative, and he is sent home on antibiotics. Question What further testing should be done as an outpatient when he has recovered? Answer Choices 1 Monthly urine cultures 2 No testing required until he has a second UTI 3 CT of the pelvis 4 MRI of the abdomen 5 Voiding cystourethrogram - ✔✔Voiding Cystourethrogram Explanation Any boy who has a urinary tract infection should undergo an initial urethral catheterization to collect a urine sample as the infant or child is unable to void upon request. A sensitivity test could also be ordered, so that the health care provider can test the bacteria to confirm which medication is best for treating the UTI infection. Immediately following the clearing of infection, additional testing may be recommended to rule out abnormalities in the urinary tract. Kidneys can be damaged with repeated infections. The age of the child and the type of urinary infection will determine the types of tests that will be ordered. As this child is less than 2 months, a voiding cystourethrogram should be ordered to confirm that hydronephrosis, scarring, obstructive uropathy, or masses are not associated with the urinary tract infection. As an individual test cannot detect all that needs to be known about the urinary tract that could prove useful, multiple tests might be necessary. Such tests could include: Kidney and bladder ultrasound, computerized tomography scan, magnetic resonance imaging, radionuclide scan, or urodynamics. A 6-year-old boy presents to the office with a fever, malaise, and dark urine. His mother states he missed school earlier this month with a sore throat. On examination blood pressure is 120/88 mm Hg, pulse is 82/min, temperature 100.6°F, and respirations 16/minute. On physical assessment, the patient appears ill with only mild costovertebral angle tenderness noted. Urinalysis reveals the following: Urinalysis Result Specific gravity 1.00 pH 5.2 protein + 1 blood + 2 glucose negative ketones negative bilirubin negative urobilinogen negative nitrates negative leukocyte esterase + 1 Microscopic examination reveals: RBCs, renal tubular epithelial cells, RBC casts, and granular casts. Question What test will determine the most likely etiology? Answer Choices 1 Urine for culture and sensitivity 2 Urine cytology 3 Erythrocyte sedimentation rate 4 Anti DNAase B serology 5 Urine protein electrophoresis - ✔✔Anti DNAase B serology Explanation The correct answer is anti-DNAase B serology to identify post-streptococcal glomerulonephritis. Group A β-hemolytic streptococci pharyngitis may result in the delayed complication of post-streptococcal glomerulonephritis 10-14 days after the infection. Patient presentations may range from subclinical symptoms to acute nephritic syndrome as streptococci may produce streptolysin, DNAase, and hyaluronidase that lead to tissue destruction and disseminate infection. Serology testing to identify antibodies to these exoenzymes can aid in the diagnosis by demonstrating indirect evidence of infection. Confirmation may require serial antibody draws that reveal a rise in titer levels above baseline. Urine culture and sensitivity would be appropriate if the clinical picture only entailed fever and flank tenderness in the presence of pyuria and hematuria suggesting a urinary tract infection. That diagnosis does not explain the presence of proteinuria with renal tubular epithelial cells and casts. These indicate intrinsic kidney damage, which is not seen in urinary tract infections. Further serology testing is indicated in the post pharyngitis period. Urine cytology is ordered in the presence of gross or microscopic hematuria, which is often painless, to identify malignant cells in the urinary tract. This patient does not fit the epidemiologic profile or clinical presentation of malignancy to warrant cytology testing. Erythrocyte sedimentation rate can aid in detecting an inflammatory response, such as nephritis, but it lacks specificity to identify the infectious process. Urine protein electrophoresis is indicated to identify abnormal levels of free monoclonal light chains (Bence Jones protein) from immunoglobins in cases of myeloma. A 47-year-old Caucasian woman presents for evaluation of acute abdominal pain. She was brought in by her son, who reports the patient had not been eating or drinking well for several days. Further history, exam, and imaging studies were performed. The patient was pre-hydrated with sodium bicarbonate, had an abdominal CT with IV contrast, and was later admitted to the medical floor with a provisional diagnosis of diverticulitis. Her past medical history is significant for diabetes mellitus diagnosed 12 years ago and hypertension. Both conditions were reported to have been under good control. Her medications include regular and long-acting insulin and hydrochlorothiazide/lisinopril 25/20 mg QD. She has recently been taking 800mg ibuprofen BID-TID for her abdominal pain during the last week. She has no known allergies. While in the hospital, the patient's laboratory results are followed daily. 2 days after the CT with contrast, it is noted that her serum creatinine has risen to a level of 3.5 mg/dL. Records from 1 month ago at her family physician showed her labs to include a hemoglobin A1C of 6.8%, creatinine of 1.2 mg/dL, GFR of > 60 mL/min/1.73 m2, and blood pressure of 127/78. Question Which of the following is a major risk factor for this patient's sudden decline in renal function? Answer Choices 1 Baseline GFR > 60 mL/min/m2 2 Caucasian race 3 Diabetes mellitus 4 Pre-hydration with sodium bicarbonate 5 Younger age - ✔✔DM Explanation Diabetes mellitus is a major risk factor for renal impairment after administration of IV contrast. In one study, DM had an odds ratio of 5.47 for development of contrast nephropathy. A baseline GFR > 60 mL/min/m2 estimates nearly normal creatinine clearance. Individuals with significantly reduced GFRs are at high risk for contrast nephropathy. Because creatinine clearance is inversely related to the creatinine level, this patient's lower creatinine level also supports less risk for the contrast nephropathy. However, it was not enough to offset the risk from her diabetes. Caucasian race is not considered a major risk factor in developing contrast nephropathy. Race is not a major factor in the development of contrast nephropathy. However, if any race is implicated for higher risk, it would be African Americans. Pre-hydration with sodium bicarbonate is a means of reducing risk, rather than a major risk factor, for contrast nephropathy. Pre-hydration seems to confer a protective effect, preventing hypotension and decreased renal blood flow. The sodium bicarbonate has been suggested in many studies to be more effective than traditional saline (sodium chloride). Younger age is not a risk factor for contrast nephropathy. Elderly age is a risk factor, with particular concern arising in patients 75 years of age and older. A 67-year-old man presents with a subacute onset of lower urinary tract symptoms. He is unable to discuss his past medical history or current medications. An initial genitourinary workup is started, and a microscopic urinalysis reveals granular and waxy casts. Question With what disease process are his results closely associated? Answer Choices 1 Chronic renal disease 2 High urinary protein nephrotic syndrome 3 Glomerulonephritis 4 Pyelonephritis 5 Acute tubular necrosis - ✔✔Chronic renal disease Explanation The correct response is chronic renal disease. Casts are cylindrical structures, consisting of clumps or clusters of cells or material that can form in the renal distal and collecting tubules of the kidney. Casts form when the pH of the urine is acidic and when the urine is very concentrated. Casts dislodge from the kidney and can be seen in the urine. In order to see casts, urine must be visualized under low power on a microscope. There are various types of casts that can be characterized into acellular versus cellular casts; each category can be further characterized, and the various casts can be associated with various disease processes. Granular casts are the 2nd most common type of cast and result from the breakdown of cellular material. They are most often indicative of chronic renal disease, but can also be seen if a patient has just vigorously exercised. Waxy casts are also indicative of advanced renal disease, specifically indicating a more chronic issue. Fatty casts are the result of the breakdown of lipid-rich epithelial cells; they are pathognomonic for high urinary protein nephrotic syndrome. High urinary protein nephrotic syndrome does not lead to the formation of granular casts. Nephritic syndromes, urinary tract injury, glomerulonephritis, and vasculitis can all result in red blood cell casts. Whenever there are red blood cells within a cast, there is a strong indication for glomerular damage from a number of different disease processes. Glomerulonephritis does not lead to the formation of granular casts. If white blood cells are seen within a cast, this is an indication that there is an inflammation or infection of the kidney known as pyelonephritis. Various other inflammatory states can also result in white blood cell casts. Pyelonephritis does not lead to the formation of granular casts. Acute tubular necrosis, cytomegalovirus, hepatitis, and toxic ingestion can all result in epithelial cell casts. These casts are the result of desquamation of the renal tubule cells into the collecting system. Acute tubular necrosis does not lead to the formation of granular casts. A 39-year-old male was out on a ranch with his friends for the weekend. He indulged in horseback riding daily, stretched out over several hours in the afternoon. On his return home, he experienced high fever with chills and malaise, myalgias, dysuria, perineal pain, and cloudy urine. Examination in the ER revealed a temperature of 101.5°F, pulse 110/min, BP 120/80 mmHg, and respiratory rate of 16/min. There was no pallor, jaundice, or lymphadenopathy. Lungs were clear and no murmurs appreciated. Abdominal exam showed no tenderness, masses, ascites, or hepatosplenomegaly. Bowel sounds were active, and rectal exam showed exquisite tenderness. Significant labs included WBC 13,400/uL and urinalysis with 15 WBC and 4 RBC. Question What would be a provisional diagnosis with blood and urine cultures pending? Answer Choices 1 Acute pyelonephritis 2 Acute urethritis 3 Rectal abscess 4 Anal fissure 5 Acute prostatitis - ✔✔Explanation Acute prostatitis is defined as an inflammation of the prostate gland that develops suddenly and is common in men, likely due to reflux of infected urine into intraprostatic ducts. This can happen after instrumentation, catheterization, or trauma, like horseback riding, biking, etc., and worsened by dehydration, as in this patient. The National Institutes of Health classification of inflammatory conditions of the prostate is as follows: I Acute prostatitis II Chronic bacterial prostatitis III A Chronic prostatitis/pelvic pain syndrome, inflammatory III B Chronic prostatitis/pelvic pain syndrome, noninflammatory IV Asymptomatic inflammatory prostatitis Gram negative organisms are the main culprit, including E.coli, proteus, klebsiella, enterobacter, and pseudomonas. Symptoms of dysuria, fever, perineal pain, and tender prostate are typical. Treatment is with trimethoprim-sulfamethoxazole or quinolones for 4 weeks. In sicker patients, hospitalization may be needed, in which case IV antibiotics with aminoglycoside and ampicillin should be given until the patient is afebrile for 24-48 hours, then oral antibiotics continued for total of 4-6 weeks to avoid complications such as abscess formation or chronic prostatitis. Acute pyelonephritis presents with fever, flank pain, tender renal angle, and normal rectal exam. Treatment includes oral fluoroquinolone or trimethoprim-sulfamethoxazole for mild to moderate disease and IV ceftriaxone or a fluoroquinolone for hospitalized patients, to be substituted with oral antibiotics after improvement in symptoms. Total duration of antibiotics should be 10-14 days. Acute urethritis is associated with dysuria and urethral discharge with pruritus at urethral meatus. Fever, chills, frequency, urgency, and hematuria are uncommon. It may be gonococcal, which is the most common cause of urethritis in men or nongonococcal urethritis (NGU). Although most cases of NGU are due to chlamydia trachomatis, other etiologies include T. vaginalis, Mycoplasma genitalium, and Ureaplasma urealyticum. Gram stain and culture or the urethral discharge should be done. Treatment is with ceftriaxone 125mg IM, cefixime 400mg PO, ciprofloxacin 500mg PO, or ofloxacin 400mg PO, all in a single dose in gonococcal urethritis and azithromycin 1gm PO or doxycycline 100mg BID for 7 days or ofloxacin 400mg PO BID for 7 days for NGU. Rectal abscess is a distant possibility in this patient. It presents with constant pain in the rectal area and perhaps fever and malaise but no dysuria or cloudy urine. Rectal exam will be tender and reveal a fluctuant mass. UA, however, will not be abnormal. Treatment is with incision, drainage, and perhaps antibiotics for anaerobic coverage. Anal fissure presents with excruciating pain with the passage of bowel movements and is associated with constipation. The passage of stool may be accompanied by bright rectal bleeding usually limited to a small amount on the toilet paper but sometimes more profuse bleeding. Treatment aims at relaxing the sphincter, keeping bowel movements soft and smooth, and pain control. A 15-year-old adolescent boy is seen in your office at 11:30 A.M. with a complaint of left scrotal pain and swelling; it started at 7 A.M. that same day, which is when he woke up. He recalls no trauma; when questioned, he says that he has never had intercourse. He has been feeling nauseated, and he vomited once. Physical examination demonstrates a well-nourished, well-developed boy, appearing moderately uncomfortable. Vital signs are normal. with the exception of a temperature of 37.9 degrees centigrade orally. Pain assessment score (Wong-Baker scale) is 6/10. He is Tanner Stage III puberty. The remaining physical examination is normal, except for the following findings: The left testicle is approximately 1.5 times the size of the right testicle. The skin is diffusely erythematous. Due to tenderness when touched, it is difficult to palpate the scrotum. Cremasteric reflex is absent. There are small, soft, pea-sized lymph nodes in both inguinal areas. Penis is circumcised and appears normal. Scrotal ultrasonography with Doppler ultrasound demonstrates decreased blood flow to the testis. Question What is the most likely diagnosis? Answer Choices 1 Acute idiopathic scrotal edema 2 Epididymo-orchitis 3 Testicular torsion 4 Torsion of testicular appendage 5 Varicocele - ✔✔testicular torsion Explanation Testicular torsion in the adolescent boy is a urologic emergency, the most common cause of acute scrotal swelling and pain, and the most common cause of testicular loss. Torsion occurs in 1:4000 and occurs most commonly on the left side in the United States. The cause is a congenital anomaly that occurs in approximately 12% of boys/men, in which the tunica vaginalis is attached too high, allowing the testicle to rotate freely on the spermatic cord and vascular pedicle in the tunica vaginalis. Approximately 40% of boys/men have the anomaly bilaterally. Testicular torsion usually occurs between 12 and 18 years of age with the peak age of 14. It may occur up to 30 years of age, and it is found in infants and occasionally neonates at the time of birth. Up to 50% of patients may have had prior episodes of mild intermittent testicular pain that has resolved spontaneously, due to intermittent torsion and spontaneous derotation. Associated symptoms may include nausea and vomiting (20%), fever (16%), abdominal pain (20 - 30%), and urinary frequency (4%). Physical examination may demonstrate a horizontal position of the testis, and it may be elevated compared to the uninvolved side. The cremasteric reflex is usually absent, but its presence does not rule out testicular torsion. Elevation of the scrotum does not relieve the pain. The diagnosis is a clinical diagnosis. Because it consumes precious time, ultrasound examination of the testis with color flow Doppler should only be ordered when the diagnosis is uncertain and can determine if there is blood flow to the testis. The studies are 86% sensitive and 100% specific in making the diagnosis if the only criterion is decreased blood flow. Radionuclide scans are 90 - 100% accurate in identifying decreased blood flow. Rapid diagnosis is critical; if surgical intervention is provided within 6 hours of onset, the salvage rate for the testis is 80 - 100%; after 6 hours, the salvage rate is approximately 0%. Acute idiopathic scrotal edema is uncommon, but presents acutely with the average age of presentation 6 years. 90% of patients have a unilateral presentation. The scrotal skin is red and tender, but the testis appears to be normal. The redness tends to extend off the scrotum onto the perineum or onto the penis. This tends to resolve spontaneously in 48-72 hours and leaves no sequelae. Doppler ultrasound, if done, demonstrates good blood flow to the testis with peritesticular edema and fluid in the scrotal wall. Laboratory examination is normal except for occasional eosinophilia. Acute epididymitis and/or orchitis is not a common pediatric diagnosis. It was first described in 1956. The onset tends to be more gradual, generally over a few days, with fever and dysuria. Elevation of the scrotum may reduce discomfort. The cause may be viral, such as adenovirus, mumps, or Epstein-Barr virus, or bacterial. Bacterial infection is often associated with structural changes in the urinary tract. Urinalysis and urine culture may be helpful in establishing the diagnosis. Typical treatment is with rest, analgesia, and antibiotics if there is concern about a bacterial etiology. If a bacterial cause is identified, urinary tract imaging should be performed. There have been rare reports of acute epididymitis progressing to testicular infarction. Torsion of the appendix testis may present similarly to testicular torsion. Tenderness is usually localized to the upper portion of the testis and, typically, a blue dot is seen on the scrotal skin resulting from the venous congestion in the appendix testis. This is a self-limited condition and does not require surgical intervention. There are 5 appendages to the testis, all of which serve no function. If one twists or infarcts, symptoms result. Pain is less intense than with testicular torsion, and the cremasteric reflex is usually present. Varicocele occurs in 10 - 15% of males, 16% of adolescents, and 20 - 40% of men evaluated for infertility. First described in adolescents in 1885, the most common age of presentation is adolescence and early adulthood. They are caused by incompetent or absent valves of the spermatic veins, resulting in dilatation of the veins of the pampiniform plexus. Rarely are they caused by compression of the renal vein by a tumor, an aberrant renal artery, an obstructed renal vein. Doppler ultrasonography can demonstrate retrograde blood flow. They are most common on the left side, are usually asymptomatic, but may present with vague scrotal discomfort and swelling. Of those with symptoms, 2% have intratesticular Varicocele and these are more common on the right side. The typical physical finding is the bag of worms within the scrotal sac. They may be missed on physical examination if the supine position, so the patient should be examined in a standing position. Patients should be referred to urologists for further evaluation and to discuss options for treatment which sometimes, but not always, requires surgery. An 8-year-old boy is evaluated for persistent bed wetting. He has never been continent, averaging 2 - 3 episodes of bedwetting per week. His urological evaluation revealed a normal bladder and urethra, with no neurological problems. Lately, his problem has been a source of much embarrassment; he is unable to attend camp or sleepovers due to fear of wetting his bed. He has tried multiple interventions, including lifestyle changes, alarm systems, and reward systems. His physical exam shows no abnormalities. His parents are keen on a rapid resolution to his problems, and they insist treatment be initiated. [Show More]

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