Quiz 3

A 72-year-old male presents to the clinic complaining of hematuria for 2 days. He denies any pain but complains of frequency and urgency. The patient states that the blood seems to come near the end of his void, but he isn't 100% positive. He denies nausea, vomiting, or abdominal pain. On exam, the patient denies abdominal or suprapubic tenderness. You order a urinalysis with microscopy, which is positive for red blood cells but not casts. Cystoscopy is performed, and a tumor that invades into the muscularis propria is found. What is the appropriate form of treatment? a. Transurethral resection of the bladder tumor and intravesicular chemo. b. Radical cystectomy, pelvic lymphadenectomy, and ileal conduit. c. Intravesicular chemo and radiation therapy. d. Radiation therapy and Bacillus Calmette-Guerin.

B

A 9 year old male comes to your clinic with a known history of Wilms tumor. During your history and physical exam, you find that the patient has no iris in both eyes and has an intellectual disability. Which of the following would also be associated with his congenital syndrome? A. Macrosomia B. Genitourinary anomalies C. Pseudohermaphroditism D. Prominent eyes

B

A G1P0 25-year-old female that is 11 weeks pregnant presents to your clinic for her annual physical exam. Her vital signs were as follows: BP 116/72, HR 78bpm, O2 99% on room air, T 97.5 °F. She has no complaints today. After obtaining routine lab work, you find that her urinalysis was positive for leukocyte esterase and decide to send a urine culture. The urine culture comes back with >100,000 CFU/mL. What is the best treatment option for this patient? A) No antibiotic therapy indicated unless she becomes symptomatic B) Nitrofurantoin 100mg PO q6h x 5 days C) Trimethoprim/sulfamethoxazole160/800mg PO q12h x 10 days D) Bacteria in the urine is normal during pregnancy

B

A 32-year-old G0P0 diabetic female presents to the Emergency Department complaining of dysuria and back pain x 5 days. Patient also complains of nausea, persistent vomiting, stating she hasn't kept anything down in 3 days, and urinary urgency. Vital signs are as follows: HR 110, RR 22, BP 132/84, Temp 40.5℃, BMI 35 and O2 98% on room air. Physical exam reveals positive costovertebral angle tenderness on the left and decreased skin turgor. You order a UA and urine culture which return with a positive leukocyte esterase, positive nitrites and culture of 100,000 CFU/mL. What is the most appropriate management of this patient? A. Send home on ciprofloxacin x 14 days B. Admit to hospital on IV ampicillin and gentamicin C. Admit to hospital on IV Bactrim and fluids D. Send home and instruct patient to hydrate well

B

A 35-year-old Caucasian male with a history of diabetes mellitus presents to the emergency department with left sided flank pain. He reports the pain is a 9/10 and he appears uncomfortable on the exam table. He also states he noticed scant hematuria when he last used the restroom about an hour ago. He feels very nauseated secondary to the pain. Vital signs are as follows: Temperature: 98.6, BP: 138/85, HR: 107, RR: 15. As you perform your physical exam, he has positive costovertebral angle tenderness on the left side, but the rest of the exam is unremarkable. In addition to ordering labs, you want to order imaging on this patient. What is the imaging study of choice for this patient? A. Ultrasound B. Noncontrast CT scan of abdomen and pelvis C. Abdominal radiography D. CT scan of abdomen and pelvis with contrast

B

A 68 year old Caucasian male presents to your clinic following up with a painless ulcer on his penis that he noticed a month ago that did not resolve with a 4 week course of antibiotics. The ulcer has now started bleeding and he has also noticed swollen lymph nodes in his groin area. He has a medical history that is positive for genital warts He also reports that he drinks a 12 pack of beer a day and has a 100 pack year history. On physical exam, you find an ulcer on the glans of the penis is both palpable and painless. You also note that the right inguinal nodes are non-tender and enlarged. You decide to get a biopsy of the ulcer which is positive for penile squamous cell carcinoma. Which of the following was NOT a risk factor for this cancer. A: Age B: Alcohol C: Tobacco D: Condyloma Acuminatum

B

A 70-year-old Caucasian male presents today with intermittent hematuria. He reports no pain associated and that the blood is continuous throughout voiding. He started smoking when he was 30 years old, but quit 10 years ago. You perform a physical exam and everything is normal so you decide to order a urinalysis with microscopy as well as urine cytology. The urinalysis comes back with positive gross hematuria and cytology confirms the presence of cancer cells. A cystourethroscopy and biopsy is performed days later and the results describe a tumor that has invaded into the muscularis propria. What is the staging for this patient's bladder cancer? A. Tis B. T2 C. T1 D. T4

B

A 15-year-old male presents to clinic for his well-child visit. He has no abnormal vital signs and his height and weight are appropriate for his age, with no deviations from his typical growth patterns. He has a history of cryptorchidism that was corrected with a orchiopexy at 8 months old, but otherwise presents with no complaints or concerns. What is the best way to address his risk of testicular cancer in clinic today? A. Educate the patient on the importance of performing testicular self-exams monthly without performing a testicular exam in clinic B. Check an AFP and LDH and perform a scrotal US in clinic C. Perform a testicular exam during his visit and emphasize the importance of monthly testicular self-exams D. Perform a transcutaneous biopsy

C

A 22-year-old male presents to the clinic because of painless swelling of his scrotum for 1 month. He states that he first noticed the swelling in the shower after a flag football game. During the game, he was accidentally struck in the testicles but believed the swelling would go down on its own. Physical examination reveals a hard, non-tender, fixed mass of the right testicle. A scrotal ultrasound is performed and reveals irregular calcifications and a hypoechoic mass. You suspect testicular cancer. What is not a risk factor for testicular cancer? a. Family history b. Cryptorchidism c. Testicular trauma d. HIV infection

C

A 3 year old male presents to the clinic with a palpable mass on the lower left portion of his abdomen and mild, painless hematuria. His parents state that they first noticed the mass around 6 months ago but only decided to come to the clinic after their son began passing what appeared to be blood with his urine. They also state that their son has been having poor feeding lately and has appeared to be losing weight along with his other symptoms. Based on this patient's age and his urological symptoms, you conclude that this patients most likely diagnosis is which of the following? A. Wilm's Tumor B. Hydronephrosis C. Transitional Cell Carcinoma D. Prostate Cancer

A

A 30-year-old male presents to the clinic with a 5-day history of dysuria and urinary frequency. He is ill-appearing and reports malaise, chills, and some lower back pain. He denies any possibility of a sexually transmitted disease (STD). He denies having any abdominal pain, discharge, hematuria, nausea, or vomiting. On examination, he is febrile with a temperature of 101.7°F. No abdominal or costovertebral angle tenderness. Digital rectal examination reveals a tender, boggy, and slightly enlarged prostate. Gonorrhea and chlamydia infections are ruled out with a urine culture. Based on your findings and the most likely diagnosis, what would be the most appropriate treatment for this patient? A. Ciprofloxacin x 6 weeks B. Bactrim x 10 days C. Azithromycin 1 g x 1 day D. IV Ampicillin plus Gentamicin

A

A 38-year-old female presents to your clinic complaining of ongoing suprapubic pain and pressure over the past two months accompanied by increased urinary frequency during the day and nocturia. Her pain is relieved by urination and "gets really bad when I have to hold it." She denies incontinence, discharge, non-suprapubic pain, history of similar symptoms, other prior medical history, allergies, or medication use. Her social history includes no previous tobacco use, 1-2 glasses of wine a few nights per week, and 2-3 cups of coffee on most days. On physical exam, you note exquisite tenderness in the suprapubic region, without masses or lymphadenopathy. Urinalysis shows trace protein, negative leukocyte esterase and nitrite, and 1-2 red blood cells (RBCs) per high-powered field on microscopy, but is otherwise unremarkable. Urine culture and cytology are negative. Based on your most likely diagnosis, what is the best next step to address her symptoms? a. Amitriptyline in conjunction with education and diet modification b. Bethanechol (Urecholine) with education and diet modification c. Refer to GU for cystoscopy to rule out bladder cancer d. Ibuprofen in conjunction with education and diet modification

A

A 45-year-old Caucasion male smoker presents to your office with a complaint of urinary frequency and increased pain with urination. He informs you that he has been waking up more frequently during the night to urinate. He states that his diet consists of eating spicy foods, drinking sodas and coffee. He denies fever, changes in bowel movements, rashes, ulcers, penile discharge and hematuria. His vital signs are as follows: BP: 118/75mmHg, HR: 80 bpm, RR: 18, T: 98.6F. Physical exam was unremarkable. Lab results results are as follows: WBC 4500 uL, Na 145 mEq/L, Cl 105 mEq/L, serum creatinine 0.9 mg/dL, BUN 12 mg/dL, urine microscopy is negative for bacteria. UA was negative for nitrite and leukoesterase. Urine cultures were <50,000 CFU/ml of staphylococcus epidermidis. Cystoscopy with biopsy was ordered to rule out cancer. The biopsy results stated, "no malignant cells identified." The cystoscopy report findings stated "reduced capacity, scarring and cracking of the mucosa with distention and appearance of glomerulation after distention." What is the most likely diagnosis? A. Interstitial Cystitis B. Pyelonephritis C. Asymptomatic bacteriuria D. Balanitis

A

A 63-year-old man presents to your clinic with hypertension. His past medical history is significant only for nephrolithiasis. Analysis of his prior kidney stones revealed a calcium oxalate composition. When considering what antihypertensive medication to start him on, which class of drugs should be considered to treat his hypertension while also reducing the risk of future stone recurrence? A. Thiazide Diuretics B. Beta-Blockers C. Calcium Channel Blockers D. ACE Inhibitors

A

A 69-year-old Caucasian male by the name of Donald Trump presents to the ED complaining of "blood in his pee for awhile now". Mr. Trumps states that the blood in his urine is typically at the end of the urinary stream, comes and goes and does not cause him any pain. He reported coming to the ER solely because his wife Melania Trump insisted he come. Associated symptoms include urinary frequency. He denies abdominal pain, bone, flank or pelvic pain, anorexia, pallor, lower extremity edema, rectal fullness or weight loss. PMHx includes chronic cystitis, and leukemia at the age of 50, treated with cyclophosphamide. SHx includes a 30-pack-year smoking history. Suspecting bladder cancer, cytology was performed which detected non-muscle invasive disease of the bladder, staged at Tis (i.e. carcinoma in situ, high-grade dysplasia, confined to the epithelium). What is the best treatment choice for non-muscle invasive disease of the bladder, staged at Tis (i.e. carcinoma in situ) ? A. TURBT +/- intravesicular chemo B. Radical cystectomy and pelvic lymphadenectomy and ileal conduit +/- chemo, +/- radiation C. Chemotherapy alone D. Chemo and Radiation

A

A 70-year-old African-American male presents for an abdominal ultrasound as screening for an abdominal aortic aneurysm. The ultrasound reveals no aneurysm, however a solid 25mm mass is found incidentally on the lower lobe of the right kidney. The mass was found to be irregular in shape, hyperechoic within the mass, and without a strong posterior wall echo. He is asymptomatic and reports a 30-pack year history of smoking and drinks one to two beers a night. Past medical history includes type 2 diabetes, hypertension, and obesity. He is a retired petroleum engineer. What is your next best step for this patient? A. CT scan of abdomen and pelvis with and without IV contrast to rule out renal cell carcinoma. B. Reassure the patient that he likely has a simple benign renal cyst. C. Renal biopsy for tissue analysis of the mass. D. Chest x-ray to determine if there has been metastasis to the lungs.

A

A 72-year-old female presents to your clinic from her nursing home with a certified nursing assistant who states the patient has an altered state of consciousness and fever. After taking the patient's history and physical, you order a full fever workup. Her chest radiograph reveals consolidation, and the urine culture reveals 105 colony-forming units (CFU)/mL. All other diagnostic tests were negative. After confirming her diagnosis of pneumonia, what treatment do you give the patient for her bacteriuria? a. No treatment b. Bactrim c. Clindamycin d. Cranberry pills

A

Chad Michael is a 27-year-old male who presents to the clinic with a possible persistent UTI. 14 days ago, he was seen at this clinic and given Ciprofloxacin for 10 days which he completed. Looking at his previous culture and sensitivity, ciprofloxacin appeared to be the appropriate antibiotic to give. Initially Chad reports he had some improvements with his symptoms, but today he presents with a fever, rectal pain and dysuria. He denies any recent sexual activity given his recent diagnosis. His past medical history is unremarkable. His vitals show the following: T 102F, BP 140/78, P 89, RR 18, SpO2 98% Room Air. Based on this information, what is your next best step? A. Complete a physical exam and include a digital rectal exam to rule out prostatitis B. Order a CT abdomen/pelvis C. Admit to the Emergency Room (ER) D. Complete an ultrasound Answer:

A

Randall Pearson, a 48 year old male, presents to your primary care clinic in rural Philadelphia with complaints of severe back pain and weight loss. Upon taking a proper history you note he underwent extensive chemo and radiation for prostate cancer as well as a diagnosis of sickle cell disease at age 4. He reports a history of smoking, but he quit 2 months ago because "he was told he should" denies illicit drug use, but drinks 1 shot of whisky a night "to unwind after a long day." He worked at a coal mine from 15 years old up until last year when he got a promotion and now works onsite, but in an office. His new job is stressful and he thinks "all those years in the mine are catching up with him past few months" due to all that back pain he's been having, but is still surprised by how much weight he has been losing as well. He was adopted and knows nothing about his biological family history. As you listen to Mr. Pearson, you think back to your GU lecture in PA school and a lightbulb goes off for your top differential and you know for certain what diagnostic tool to use next before referring to GU, which is... A. Ultrasound B. CT scan C. MRI D. No imaging, lab work only

A

You are the genitourinary PA who is called to evaluate a 2-hour old male, who on newborn exam had what appeared to be "two urethra openings" and chordee, according to the labor and delivery nurse. Prior to seeing the patient, you are concerned he may have hypospadias from that description. Upon exam, the patient has a true urethra on the ventral side of the distal penile shaft and what appears to be another urethra in the normal position at the end of the glans. However, when you place a probe inside what appears to be a urethra at the end of the glans, you discover it is a blind-ending urethral pit. You do a pelvic ultrasound to rule out any other organ anomalies. You also note that both testicles are descended into their respective scrotal sacs. The penis has an abnormal curvature downwards. You enter the mother's room on the post-partum floor and discuss her son's diagnosis of hypospadias with her and her husband. They ask how this condition is treated, and if their son will still be able to be circumcised tomorrow. What is your response? A. The treatment of choice for this condition is a urethroplasty, which is an elective procedure. We often advise against circumcising the neonate until after the hypospadias repair, as the foreskin can be used for the reconstructive urethroplasty. B. The treatment of choice for this condition is a urethroplasty, which is an urgent and required procedure. It is necessary we do the procedure immediately because, with hypospadias, the patient does not have a functional urethra, and therefore is unable to empty his bladder. We often advise against circumcising the neonate until after the repair, as the foreskin can be used for the reconstructive urethroplasty. C. The treatment of choice for this condition is a urethroplasty, which is an elective procedure. We often encourage circumcision prior to the procedure, as it makes the urethroplasty much easier to do and lessens the risk of post-operative infection. D. The treatment of choice for this condition is a dilation, which is an elective procedure. We often advise against circumcising the neonate until after the hypospadias repair, as the foreskin can be used for the reconstructive procedure.

A

69 year-old G0P0 Caucasian female Reeta skeeter presents to your GU clinic complaining of a "prolonged period". She is upset because she was told that once she went through menopause, which she did at age 54 years, she would no longer have her period. She hadn't had her period for the last 15 years, but for the past 2-3 weeks she has occasionally noticed blood in the toilet and on her toilet paper after she urinates. After you ask, she does say that she has been urinating more frequently than usual. After doing a UA w/ microscopy, urine culture, cytology, cystourethroscopy with biopsy, and an MRI w/ IV contrast. You diagnose the patient with bladder cancer. You found tumor invasion into the muscularis propia of the bladder, but did not notice tumor growth in surrounding tissues. What stage of bladder cancer does this patient most likely have? A. T1 B. T2 C. T3 D. T4

B

A 2-year-old Caucasian male presents to your pediatric clinic with abnormal urination. His mother states ever since he started toilet training, he is unable to urinate properly. She claims his urine stream is deflected upward and he is unable to direct the stream into the toilet. He has no other symptoms associated with this condition. Upon physical exam, you note he is circumcised and there is scarring on the ventral aspect of the meatus on the glans penis . The rest of the exam was unremarkable. Based on the symptoms and physical exam, what is the most likely diagnosis for this patient? A. Urethral Stricture B. Meatal Stenosis C. Hypospadias D. Epispadias

B

A 23-year-old female presents to your clinic complaining of pain with urination. She states that it began two days ago and describes a burning pain and urgency with urination. She denies any history of sexually transmitted infections and is sexually active with her boyfriend of two months, but uses condoms. Her vitals are as follows: BP: 110/62 mmHg, P: 68 beats per minute, T: 99.0°F, R: 14 breaths per minute, O2: 99% on room air. Physical exam is unremarkable and urinary analysis is positive for nitrites and leukocyte esterase. Which of the following is the best treatment combination for this patient? A. Cranberry juice, probiotics, and Gatorade B. Increased water intake, ciprofloxacin, and proper hygiene C. Amoxicillin, Gatorade, and avoid urination D. Increased water intake, pro-biotics, and Bactrim

B

A 23-year-old male truck driver comes to your clinic complaining of a "spraying" when he urinates. He has had some pain with urination for the past 3 months but thought it was related to sitting in a truck all day. He noticed the spraying about a week ago and was able to come into the clinic after he completed his trip. When asked, he tells you he only urinates about twice a day, and "not much comes out." While this does cause bladder discomfort, the patient has found it more productive at work to urinate less frequently so he can drive more miles in a day. Physical exam is normal, though he has discomfort when you push on the lower abdomen, which feels like he has a full bladder. After ordering a urinalysis and culture and a BMP, you return to the exam room to let the patient know you are referring him to GU. He feels like this is "no big deal," but you tell him that although these symptoms may seem relatively harmless, this condition can have serious complications. What are potential complications of his most likely condition? A. Chronic prostatitis, gallbladder stones, urine reflux B. Hydronephrosis, bladder stones, hypertrophy of the detrusor muscle C. Bladder stones, infection risk, atrophy of the detrusor muscle D. Prostatitis, hypertrophy of detrusor muscle, decrease residual urine in the bladder after voiding

B

A 27 year old Caucasian male comes into your emergency department with complaints of excruciating left scrotal pain and swelling. He states pain began 4 hours ago and has gradually worsened, with current pain level at a 9/10. He notes that he is sexually active with his boyfriend of 2 years and engages in rectal intercourse. Patient denies any known history of trauma. You order an ultrasound with doppler, which is negative for signs of testicular torsion. How do you treat your patient? A) Bactrim and Fluoroquinolone B) Rocephin and Fluoroquinolone C) Rocephin and Azithromycin D) Bed rest, scrotal elevation, and anti-inflammatories.

B

A 28 year-old woman presents with severe intermittent right flank pain. She has never had this happen to her and is otherwise healthy with no significant past medical history. She also says she feels very nauseous from the pain but has not yet vomited. The pain is described as 10/10 and occasionally radiates down to her pubic area. When obtaining your history you note that she admits to being sexually active and has a history of a recurrent Proteus urease-producing upper urinary tract infection which has not improved after proper antibiotic therapy. After performing your physical exam you note that she has no CVA tenderness. Her pelvic and abdominal exam are unremarkable including a negative obturator and iliopsoas sign. You order a quick beta hCG test to rule out pregnancy which comes back negative. Lastly, you order a urinalysis, urine culture, and a non-contrast CT of the abdomen and pelvis upon your suspicion of nephrolithiasis. CT comes back positive with evidence of a renal staghorn stone and her urine analysis showed that her urine pH=7.25. Which of following stones would you most likely expect to find upon removal based on her presentation and workup results? A. Calcium Oxalate B. Struvite C. Uric Acid D. Cannot determine

B

A 29 year old male was referred to your GU clinic with painless, solid testicular swelling. He said that his wife had found the mass and urged him to come in. He denies nausea, vomiting, coughing, bone pain, or back pain. His past medical history is significant for cryptorchidism, but is otherwise healthy. You decide to run labs and find elevated alpha-fetoprotein (AFP), elevated lactate dehydrogenase (LDH), and an elevated beta subunit of human chorionic gonadotropin (beta-hCG). Scrotal ultrasound revealed a hyperechoic mass of the patient's right testicle. You diagnose the patient with testicular cancer. You stage the cancer and find that it is confined only to the testicle. Which stage of testicular cancer does this patient have? A. Stage 0 B. Stage 1 C. Stage 2 D. Stage 3

B

A 32 year old male presents to the clinic stating that he has had increased urinary frequency, urgency, and bladder pain for the past two months. His pain is worse when the bladder is full and in the morning. He drinks three cups of coffee each morning and occasionally drinks green tea throughout the day. His vitals are as follows: BP 122/86 mmHg, HR 94 bpm, RR 16 breaths/min, T 99.7ºF, O2 98% RA. Initially, a urinalysis is performed and reveals microscopic hematuria and is negative for leukocyte esterase, nitrites, and has more than 8 white blood cells per HPF. The urine culture is negative. The PA is concerned about bladder cancer, so urine cytology is performed and shows no evidence of dysplasia. The next day, a cystoscopy with hydrodistention reveals glomerulation and biopsy shows no evidence of dysplasia. What is the best initial treatment for this patient? A. Bactrim B. Modify diet, anticholinergic medication, and ibuprofen C. Cystectomy D. Anticholinergic medication and ibuprofen

B

A 39-year-old woman presents to the emergency room and says she is in labor. She says that she has not had any prenatal care since her first visit a little over 7 months ago, when they told her she was a month along. She said that she refused their request for her to stop smoking. She felt judged, so she didn't go back. After a further interview, you are able to estimate that she is 35 weeks along. She is admitted and is stable. Vital signs are: temperature 98.8°F, oral; Heart rate: 90 beats per minute, regular; Blood pressure 143/86 mmHg, right arm; Respiratory rate: 17, unlabored; Height: 5'4"; Weight: 180 lbs; Body mass index: 30.9; SpO2: 99% on room air. A vaginal delivery is completed 4 hours later without complication. The baby boy has an APGAR score of 7 and is in good health, despite being born premature. Physical exam is all normal, except that the PA notices excess foreskin on the boy's penis and an abnormal penile curvature. She examines closer and notices an extra opening on the ventral side. Which of the following is FALSE regarding the most likely diagnosis? A) The majority of cases for this condition are distal penile or coronal B) It is recommended that these newborns be circumcised so that the excess skin does not obstruct the extra urethral opening and cause a blockage C) Risk factors for this condition include parental family history, exposure to pesticides, advanced maternal age, and maternal diabetes D) 6 months is the minimum time needed between procedures to allow for complete healing in order to treat this condition

B

A 42 year-old Caucasian male patient with HIV presents to the ER with dysuria x 7 days and severe right lower back pain and nausea x 1 day. He tells you he took an over-the-counter medication which didn't help much and turned his urine a weird color. His vitals today are: BP 118/78, HR 92bpm, O2 98% on room air, T 39 degrees Celsius. Upon physical exam, the patient has tenderness at the right costovertebral angle, but the remainder of the exam is unremarkable. You order a urinalysis which has white blood cell casts and is cloudy in appearance, CBC which results with WBC count >22,000/mm3, and urine culture which results as >100,000 CFU/mL. You suspect pyelonephritis and order a CT scan to rule out other sources, and it is consistent with pyelonephritis. Based on his history, physical exam, and CT findings, you diagnose him with pyelonephritis. What is the treatment of choice for this patient? A. oral ciprofloxacin x 10-14 days B. hospitalization with IV Ampicillin plus Gentamicin C. IV azithromycin D. oral TMP-SMX (Bactrim) x 10-14 days

B

A 48-year-old Caucasian male with a history of Gonorrhea, Chlamydia, and Trichomonas presents to his genitourinary (GU) provider with complaints of increased urine frequency, mild clear discharge, and a weak stream of urine. He first noticed these symptoms five days ago. The patient states that the last time he was treated for a sexually transmitted infection was 6 months ago. The infection was eradicated for him and for his girlfriend, and he has not had any new sexual partners since. He denies any genital ulcerations, hematuria, fever, or abdominal pain. Physical GU exam reveals a circumcised male without any lesions or ulcerations, a patent urethral meatus with scant clear discharge present, and no edema or tenderness. Based on the patient's history and physical exam findings, in addition to a urethral stricture, what differential diagnosis should his provider have highest on his list when determining how to work up the patient? A) Trichomonas infection B) Prostatitis C) Urinary Tract Infection D) Interstitial Cystitis

B

A 55-year old male with a history of hypertension and gout presents with sudden, colicky right flank pain that radiates anteriorly toward the groin. His vital signs follow: BP 120/82 mmHg right arm, HR 86 bpm, RR 20 breaths/min, T 98.5ºF axillary, O2 98% on room air. Physical exam is unremarkable except for right flank tenderness. Urinalysis reveals microscopic hematuria. Which of the following dietary recommendations can decrease the recurrence of this patient's most likely diagnosis? A. Increase sodium intake B. Increase fluid intake C. Decrease calcium intake D. Increase animal protein intake

B

A 64 y/o Caucasian male presents to your clinic for an annual check up. When inquiring about any changes since his last visit, he states that he has started swimming more frequently for exercise, and plans to take part in a 6 mile open water race in Mexico early next year. His medical history includes hypertension which is well controlled on hydrochlorothiazide. He was also diagnosed with benign prostate hypertrophy 2 years ago, and he is currently taking finasteride for that. He denies any surgical history other than an appendectomy when he was 16 y/o. He drinks two beers a night on the weekends, and does not use tobacco or any recreational drugs. Which of the following parts of his history puts your patient at risk for prostate cancer? A. Hypertension B. Finasteride C. Increase in exercise D. Beer consumption

B

A 64-year-old male patient and his wife present to the office today to discuss his recent diagnosis of renal cell cancer (RCC). Understandably, they both have a lot of questions. The patient asks, "what put me at risk for this?" The patient has a 20-year-pack history and drinks 1-2 beers each weekend. He also has hypertension and diabetes mellitus. Which part of this patient's medical history is not a risk factor for RCC? A) Smoking B) Light to moderate alcohol consumption C) Hypertension D) Diabetes mellitus

B

A 67 Caucasian male presents to the clinic because he noticed blood in his urine for the last 5 months. He describes it as intermittent and painless. When it is present, it usually appears bloody throughout the voiding process, especially towards the end. He has a 30 pack-year smoking history. He denies fever, unintentional weight loss, and changes in bowel movements. Physical exam including a digital rectal exam (DRE) come back normal. A urinalysis shows > 100 RBCs per high power field (HPF). Because of your high suspicion for cancer, you refer. A cystourethroscopy and biopsy of the bladder is done. Results show that it is in fact bladder cancer, and it has invaded through the epithelium but not into the muscle. What stage is this? A. Ta B. T1 C. T2 D. T3

B

A 67 year old Caucasian man presents to your clinic complaining of painless blood in his urine for the past month. He tells you that the episodes have been on and off, happening every few days. He did not come in until just now because he said it is not painful and happens every once in a while. He notices the blood in his urine is thought his urination. The patient has a history of nephrolithiasis that was treated 15 years ago. He has been a smoker for 30 years and smokes a pack per day. His chest, lung, and abdominal exams were unremarkable and his urinalysis was positive for hematuria confirmed with microscopy. You are highly suspicious that he has bladder cancer. Which of the following is most likely the cause? A . Adenocarcinoma B. Transitional cell carcinoma C. Squamous cell carcinoma D. Clear Cell Carcinoma

B

Lance Armstrong, a 48-year-old male, presents to your primary care office for a routine annual exam. Today his vital signs are as follows: BP: 128/80, HR: 56, SpO2: 98%, temp: 37.0 C, height: 5'10", weight: 165 lbs, BMI: 23.7. His past medical history is significant for testicular cancer (in remission), chronic mild low back pain (controlled with NSAIDs), and polycythemia vera. His family history is significant for lung cancer (paternal grandmother, deceased) and prostate cancer (father, diagnosed at age 66). While taking a social history, you learn that your patient is retired, has been married to his wife for 10 years, does not smoke, drinks wine after dinner once or twice a week, and enjoys running, swimming, and biking several times a week. Because of his family history of prostate cancer, your patient is interested in being screened at this time. What should you tell him about PSA screening? A. He does not need to be screened at this time; routine screening is not indicated until age 50. B. If PSA screening is ordered today, the results may not be accurate. C. DRE screening is preferable to PSA screening for detection of prostate cancer. D. Certain medications such as finasteride and NSAIDs could artificially increase his PSA.

B

Mr. Jones, a 65 year old African American male, presented two weeks ago to your urology clinic with new-onset increased frequency and nocturia. At his initial appointment you performed a digital rectal exam and found the prostate to be hard and nodular. There have been two prostate-specific antigen (PSA) tests performed, both of which were positive. Additionally, Mr. Jones had a transrectal ultrasound with prostate biopsy performed this morning. According the Gleason Score criteria, which score on the pathology report would most concern you about Mr. Jones' prognosis. A: 3+3 =6 B: 4+3 =7 C: 3+4 =7 D: 1+2 =3

B

Sally, a 9 year old African American female, presents to clinic with stomach pains for the past week. Her mom states that she has not been hungry recently and has had a fever the past couple nights. On physical exam, Sally's temperature is 100.9F, pulse is 110 bpm, blood pressure is 125/80mmHg, and her respiratory rate is 20 bpm. On physical exam, Sally has a firm, 3cm abdominal mass that is not tender. You send Sally to get an abdominal ultrasound, but while waiting on results, you want to ask her mother about any potential congenital syndromes Sally may have been screened for at birth. Which of the following is not one of the congenital syndromes associated with Sally's likely tumor? A) WAGR Syndrome B) Au-Kline Syndrome C) Denys-Drash Syndrome D) Beckwith-Wiedemann Syndrome

B

Stevie Wonder is a 69-year-old African American male who comes into your primary care clinic complaining of right flank pain and blood in his urine. He notes that this has been going on for the past 2 weeks, however, he has been on tour and hasn't had the chance to come in until now. On exam you note a palpable abdominal mass on the right side. His vital signs show BP 128/82, HR 90, T 98.7°F, RR 18, O2 99% on room air. You suspect he may have renal cell carcinoma. Which of the following is NOT a risk factor for renal cell carcinoma? A. Smoking B. Alcohol consumption C. Hypertension D. Obesity

B

Your patient is a 21 year old male that reports to the clinic after finding "a painless bump" on his testicles. He states that he recently learned about self testicular exams in his college Pathophysiology class and was concerned about what he possibly found on his exam. On physical exam the patient has a hard, non-tender, fixed mass on the right inferolateral testicle. He denies any other symptoms currently. The patient is referred to GU where it is found that he has an elevated alpha feta protein, lactate dehydrogenase, and beta-hCG. Ultrasound was positive for microlithiasis and a hypoechoic mass. A CT was performed and was negative for any node involvement. The patient was told that he had testicular cancer, and more specifically a seminoma. Based on the provided information, what is the most likely testicular cancer stage and what is the most appropriate treatment? A: Seminoma Stage I: No treatment necessary B: Seminoma Stage I: Orchiectomy C: Seminoma Stage II: Orchiectomy, +/- XRT, +/- chemotherapy D: Staging cannot be determined until a transcutaneous biopsy is performed

B

A 24 year old male patient presents to your primary care clinic complaining of burning with urination for the last three days. He states he does not notice any blood in his urine, and the frequency of his urination has not changed over this time period. However, he does report a mild mucoid discharge from the tip of his penis that appears to be worse in the morning. Upon questioning, he admits to unprotected intercourse with a new sexual partner approximately 5 days ago. He is unsure of her current STI status. His vitals are as follows: Temp 98.8 degrees F, RR of 16 breaths/min, HR of 72 bpm, O2sat of 98% on room air and BP of 118/78. Nucleic acid amplification testing (NAAT) was conducted and was shown to be positive for C. trachomatis and negative for N. gonorrhoeae. According to his clinical picture, what is the best treatment and follow up plan for this patient? A: Ceftriaxone 250mg IM x1 plus Azithromycin 1g PO x1. Follow up in three weeks for test of cure. B: Azithromycin 1g PO x 1. Follow up in three weeks for test of cure. C: Azithromycin 1 g PO x 1. No test of cure necessary. D: Ceftriaxone 250mg IM x1 plus Azithromycin 1g PO x1. No test of cure necessary.

C

A 28-year-old G0P0 sexually active female presents in the emergency department with progressively worsening right sided back pain for the past 4 days. She reports dysuria, urinary frequency, urinary urgency, nausea, vomiting (x2), and chills. She reports having intercourse 5 days ago with her boyfriend of 6 months and denies voiding after coitus. Vital signs are: BP 112/78, HR 99 bpm, RR 18 bpm, and temperature 101.8 °F. Physical exam reveals costovertebral tenderness of the right flank. A urine sample and CBC were obtained. The urinalysis showed (+) leukocyte esterases, (+) nitries, and white blood cell casts. Urine pregnancy test was (-), and urine culture is still pending. The CBC revealed a leukocyte count of 12.8 K/uL. The patient has no comorbidities and does not appear toxic. Based on the most likely diagnosis, what is the best treatment option for this patient? A. Amoxicillin B. Doxycycline C. Ciprofloxacin D. Erythromycin

C

A 29 year old man presents to your primary care clinic complaining of difficulty urinating for the past two weeks. On further questioning, he describes the flow of urine as "weak" when he is trying to go, but "dribbles" when he is not trying to go. His past medical history includes gonorrhea and chlamydia three times in the past 4 years. The patient is sitting comfortably on the exam table and denies pain, nausea, vomiting or hematuria. Genital exam reveals normal penis and testes without masses, edema, tenderness or lesions. Urethral meatus is fully patent and without discharge. A urine dipstick is unremarkable. Digital rectal exam (DRE) reveals a normal sized prostate without nodules or masses. You plan to send off a urinalysis and culture, and refer to GU for a cystourethroscopy. Based on the information you already have, which of the following do you expect the urologist to find on the scope? A) A stone in the prostatic urethra B) An enlarged prostate gland C) Narrowing of the urethra D) A tumor in the bladder

C

A 3-year-old male is brought by his mother to your clinic to establish care. His mother states that he was diagnosed with a "genetic thing" by his previous pediatrician but can't remember the name. She tells you that he was born at 38 weeks, weighed 9lbs 2oz, and was 22 inches long. While speaking with the mother, you notice the child has prominent eyes, ear creases, and macroglossia. Later that day, when reviewing the medical documents from his last pediatrician, your suspicion of Beckwith-Wiedemann Syndrome is confirmed. Due to his increased risk of Wilms tumor, which of the following screenings is appropriate? A. Screening with ultrasound every 3 months until age 5 B. Screening with CT abdomen and pelvis with contrast until age 8 C. Screening with ultrasound every 3 months until age 8 D. Screening with UA with microscopy annually until age 8

C

A 34-year-old woman presents to your clinic complaining of 1 day of dysuria, increased urinary frequency and urgency, and a feeling of incomplete voiding. She is otherwise healthy and takes no medications. She is sexually active with no history of sexually transmitted disease. She denies any vaginal discharge, nausea, or chills. She is afebrile. On physical exam you note tenderness to palpation in the suprapubic region, but no costovertebral angle tenderness. You order a urinalysis and the dipstick is positive for leukocyte esterase and nitrites. Her hCG level came back as less than 5 mIU/mL. Given the most likely diagnosis, what is the most common pathogen that causes this infection? A. Group B streptococcus B. Staphylococcus epidermidis C. Escherichia coli D. Pseudomonas aeruginosa

C

A 37 year old African American female presents to the emergency department with a 2 day history of sudden onset urinary frequency, urgency, and burning with urination. She denies back pain, flank pain, urethral discharge, nausea, vomiting, abdominal pain, fever, and chills. She admits to being sexually active with her husband (only partner), denies any history of STD's, and is not using any contraceptives. Her last menstrual period was 6 weeks ago. Her physical exam is unremarkable including negative CVA tenderness. Her vitals include BP:117/75, HR: 88bpm, Temperature: 97.6F, RR: 17 breaths/minute, SPO2: 99% on room air. Urinalysis with microscopy is positive for leukocyte esterase, nitrite, and pyuria. Serum hCG is 50,000 mIU/mL. Urine culture reveals 130,000 CFU/ml colonies. Which of the following is the best treatment option? A. Treat with oral Ciprofloxacin and encourage hydration B. Treat with IV Rocephin and encourage hydration C. Treat with oral Nitrofurantoin and encourage hydration D. Treat with oral Azithromycin and encourage hydration

C

A 4 y/o female, Amy Abdomen, was brought into the clinic today by her mother with abdominal pain. The mother informs you that Amy's belly looks swollen and she has vomited a couple of times. You note that she is holding her right upper quadrant on the exam table. Her vital signs are: BP: 135/87, T: 99 F, RR: 26 breaths/min, HR: 110 bpm. On exam, Rovsing's, Obturator, and Psoas signs are negative. Upon palpation, you note a large, firm, smooth mass in the right upper quadrant. Based on your current differential, you order a urinalysis and it comes back positive for microscopic hematuria. Based on these findings, what is the most likely cause of her abdominal pain? A. Renal Cell Carcinoma B. Appendicitis C. Wilms Tumor D. Cholecystitis

C

A 4-year-old African American male patient presents to your clinic with a progressive abdominal mass. His mother mentions that he has always been relatively healthy and then one day she noticed a distention on the side of his abdomen. You inquire about any past medical history. His mother mentions that he had an issue with one of his testes not descending properly, but no other issues apart from that. You palpate the mass and note that it is smooth, firm, non-tender, and located in the left, upper quadrant. Which of the following is the best initial diagnostic study for the most likely diagnosis in this patient? A. CT abdomen and pelvis with contrast B. Biopsy C. Abdominal ultrasound D. MRI with and without contrast

C

A 4-year-old male presents to your primary care clinic with his parents. His mother complains that he has had abdominal pain and swelling for the past 8 weeks that will not go away. She is very persistent that this is more than just a mild tummy ache, as she reports that her son has seemed more tired lately, has a reduced appetite, and has had a low-grade fever intermittently for 2 weeks. Birth history includes a spontaneous vaginal delivery with no complications, and he has no known medical conditions. Vital signs are as follows: T 100.4F, P 105 bpm, BP 122/80, RR 22, Ht 41 in, Wt 40 lbs. On physical exam, you palpate a firm, smooth mass in the right upper quadrant that does not cross the midline. What is the most appropriate initial diagnostic study for your suspected diagnosis? A. CT abdomen and pelvis with contrast B. Chest X-ray C. Abdominal ultrasound with doppler D. Renal biopsy

C

A 4-year-old male presents to your primary care office with the chief complaint of abdominal distension. The mother states that the patient has not been eating much, but his stomach keeps "pooching out." The patient had a normal exam a year ago at his well child visit. The mother states that the child's paternal grandfather has hypertension, but all other family members are healthy. Review of systems is unremarkable except complaints of mild abdominal pain and fullness. Vital signs are as follows: BP: 125/85, HR: 120, T: 99.0, RR: 20. On exam, there is a palpable hard mass in the left upper quadrant that is non-tender and does not cross the midline. Urinalysis is positive for hematuria on microscopy. What is the most likely diagnosis?A. Renal cell carcinoma B. Polycystic kidney disease C. Wilms tumor D. Pheochromocytoma

C

A 40-year-old man presents with a 4-day history of oliguria, dysuria, and urinary frequency. He appears very ill with malaise, and has pain in his lower back. On examination, his vital signs are as follows: BP: 121/82, HR: 110, T 101.3°F (38.5°C), R: 22, O2: 98%. He denies any history of sexually transmitted diseases. When a digital rectal examination is performed, it reveals a tender, boggy, and slightly enlarged prostate. When should PSA screening be done based on his assumed diagnosis? A. Perform in the clinic now B. Defer it because a DRE was performed C. Defer it for 6-8 weeks after symptoms resolved D. Defer for 48 hours and abstain from certain activities

C

A 44-year-old female presents to the ED complaining of severe left flank pain, nausea and vomiting for the last 2 hours. Her vitals are HR 98bpm, RR 18 breaths/min, T 98.8°F, BP 132/84mmHg, O2 99% RA. Physical exam is remarkable for left costovertebral angle tenderness and urinalysis reveals microscopic hematuria but is otherwise unremarkable. A CT scan of the abdomen and pelvis without contrast reveals one 2mm stone in the distal left ureter. Which of the following is an appropriate management strategy? A) IM ceftriaxone and IV fluids B) Bed rest and placement of foley catheter C) Oral NSAIDs, encourage ambulation and fluids D) Immediate GU consult for emergent stone decompression

C

A 45 y/o male with a past medical history of type 2 diabetes and a BMI of 32 comes to your office today complaining of "something weird's going on down there". After taking a more encompassing history, you do a physical exam (including a very thorough genitourinary exam) and notice that the penis is tender to palpation and erythematous with a curd like exudate coming from the meatus. In addition, this patient is uncircumcised. You order a urinalysis, nucleic acid amplification test (NAAT) and a urine culture. The NAAT and urinalysis come back unremarkable for any sexually transmitted diseases and you are still waiting on the urine culture. What do you expect is the most common pathogen for this likely diagnosis? A) Neisseria gonorrhoeae B) Pseudomonas C) Candida albicans D) Klebsiella

C

A 60 year-old African American male walks into the clinic complaining of a lesion on his penis that has been present for 2 months. He said he was given penicillin for it previously, but it didn't get better. He also stated that there is some bleeding and denies any pain associated with the lesion. Upon examination you also notice that there is also some balanitis. He has a 40 pack year history and is a diabetic controlled on Metformin. A sexual transmitted disease (STD) panel was ran that all came back negative. What is the next best step for this patient? A. Prescribe him more penicillin B. Watch and wait for the lesion to resolve C. Perform a biopsy of the tissue D. Immediately send him for radiation therapy

C

A 61-year-old Caucasian male presents to the clinic with painless, gross hematuria for the past four months. Patient is a construction worker who denies alcohol intake but notes a 20 pack-year history of smoking. He also complains of dysuria and urinary incontinence but denies fever, flank pain, or chronic illnesses. Microscopic urinalysis reveals red blood cells with no nitrite, leukocyte esterase, or casts. In addition, he denies taking any prescribed or over-the-counter medications. Which of the following is the most likely diagnosis? A. Urinary tract infection B. Pyelonephritis C. Bladder cancer D. Nephrolithiasis

C

A 62 year old Caucasian male with a 40 pack year history presented to your clinic for a colon cancer screening 3 weeks ago when he stated that was his first time at a doctor's office in years and that he came because his wife made him. He denied any symptoms, however his wife said she was worried because he had been "dropping weight like crazy". At the last exam, a digital rectal exam (DRE) was performed and the prostate was found to be indurated. Along with a DRE, a prostate specific antigen (PSA) was measured at 6.0 ng/mL. He returned to the office last week for a follow-up PSA that was measured at 6.1 ng/mL. Based on the indurated prostate and his PSA levels, the patient reported days later for his transrectal ultrasound with prostate biopsy. The completed pathology report was sent to your office today and it states that the primary differentiation pattern seen on biopsy was that the specimen had irregular masses of neoplastic cells with few glands. The secondary differentiation pattern was that the specimen had distinct infiltration of cells from glands at margins. What Gleason Score would you expect to see for this patient and is it indicative of cancer? A. 6 (4+2); indicative for prostate cancer B. 4 (3+1); indicative for prostate cancer C. 7 (4+3); indicative for prostate cancer D. 8 (5+3); not indicative for cancer

C

A 62 year old male comes to your clinic with painless hematuria that "comes and goes" x8 months. He has noticed that lately he's had increased frequency and urgency. When asked about the timing of hematuria, the patient tells you that it occurs throughout his urination. Physical exam is only significant for a suprapubic palpable mass. He admits to some weight loss, but tells you he recently started a new diet so he's not surprised. The patient denies tobacco use, past medical or family history of cancer, recent sexual activity, fever, and nausea/vomiting. UA with microscopy reveals 26-50 RBC/HPF, but is otherwise unremarkable and urine culture is negative. You decide to order a cystourethroscopy with biopsy and the results reveal T2N0M0 bladder cancer. Based on your knowledge of tumor staging, how do you interpret these results? A. Papillary tumor confined to the epithelium, no nodal disease, no distant metastases B. Tumor invasion into the lamina propria, no nodal disease, no distant metastases C. Tumor invasion into the muscularis propria, no nodal disease, no distant metastases D. Tumor involvement of the perivesical fat, no nodal disease, no distant metastases

C

A 65-year old man, whom is accompanied by his wife, presents to the clinic complaining about "wetting his undergarments". He seems quite embarrassed, explaining how this has never happened to him before and it recently started about 2 weeks ago. He says it tends to take place right after he comes out of the bathroom. His wife chimed in and mentioned how he seems to be going to the bathroom more frequently, to which the husband responds "I feel as if only a little bit of urine comes out at a time, so I end up going to the bathroom more frequently.'' The patient informs you that about a month ago he had artificial disk surgery and he had a catheter placed. He angrily says the experience was awful and the techs must have hurt him putting in the catheter because it has become painful to urinate since then. On physical exam, just as you suspected, you are able to palpate a full bladder. The rest of the exam is unremarkable. Based on the patient's history and significant physical exam finding, what diagnostic test will help you narrow down your differential and properly diagnose your patient? A. Urinalysis B. Urine Culture C. Retrograde Urethrography D. Cystourethroscopy

C

A 70 year old Caucasian male with a 30 pack year history presents to your clinic after noticing blood in his urine. The hematuria is painless and seems to come and go, so he did not think it was a big deal. He decided to come to the clinic after experiencing pelvic pain, loss of appetite, and unintentional weight loss. During the physical exam, you note lower extremity edema and palpable suprapubic mass. His vitals are as follows: BP: 130/88, HR: 86, T 99.3°F, R: 16, O2: 97%. You suspect bladder cancer, so you order UA microscopy, urine culture, and urine cytology for confirmation. The diagnostic tests show a tumor that has invaded the muscularis propria of the bladder. There is no regional nodal involvement or metastases. What is the most appropriate TNM staging for this patient? A. Ta N0 M0 B. T1 N0 M1 C. T2 N0 M0 D. T3 N0 M0

C

Billy Bob is 35-year-old Caucasian male with no significant past medical history complaining of fever, chills, dysuria, increased urinary frequency, and perineal pain onset x2 days ago. He mentions having 3 female sexual partners in the last month. He admits to not consistently using condoms and recently noticed white discharge on his penis. His vitals are noted to be: 120/84 mmHg, 105 beats per minute, 16 breaths per minute, 101.8 F. On physical exam, he has no abdominal tenderness, rebound, or guarding and he has no costovertebral angle tenderness. His penis does not have any lesions but is notable for white to yellow discharge. On digital rectal exam, the patient has a tender, enlarged prostate that is irregular and warm. You order a complete blood count (CBC), urinalysis, and urine culture. CBC was notable for a white blood cell count of 15,000/mm3. Urinalysis reveals positive leukocyte esterase and positive nitrite. Urine culture is positive for E. Coli, Gonorrhea, and Chlamydia. Based on the patient's history, physical exam, and lab results, how do you treat him? A. PO Bactrim x4-6 weeks B. Ceftriaxone 250 mg IM plus Azithromycin 1 g PO x1 dose C. Ceftriaxone 250 mg IM plus Azithromycin 1 g PO x1 dose and PO Bactrim x4-6 weeks D. Miconazole 1% cream x7-14 days

C

Ian Pennington a 2 year old male presents with his mother to your primary care clinic. The mom states that her son is having trouble with potty training explaining that he has difficulty directing the urine stream into the toilet and has a small stream with increased voiding time. The mom doesn't believe he is having any pain with urination as he is not fussy or agitated. There has been no gross hematuria or fever according to the mom. His vitals signs are normal in office and he has been meeting his developmental milestones accordingly. On inspection you notice scarring on the ventral aspect of the meatus, the rest of the physical exam is normal. As a primary care PA, what is your next step? A: Reassure the mom that difficulty with potty training is normal. B: Diagnosis the patient with meatal stenosis and prescribe Bactrim x 7-10 days. C: Refer the patient to pediatric GU D: Perform a cystoscopy in office to confirm a suspected mental stenosis

C

A 55-year-old female presents to clinic with extreme back pain near the right flank. She mentions she likely had a urinary tract infection (UTI) two weeks ago due to having cloudy urine and a low-grade fever, but she drank some cranberry juice and felt better. Two days ago she woke up with a 101.7°F fever and noticed her urine was much darker than normal. She drank more cranberry juice but said severe pain began this morning. You run a urinalysis and urine culture, which are positive for bacteria. She has no other ongoing issues. She is currently on no medications and has no known drug allergies. You decide to treat based on your diagnosis. What is the best treatment? a. IV Ampicillin + Gentamicin b. IV Ciprofloxacin c. Oral Bacitracin d. Oral Ciprofloxacin

D

A 37-year-old male presents to your clinic with pain of the glans penis. He reports the pain began 5 days ago and have continued to worsen. His past medical history is significant for type 2 diabetes mellitus, cirrhosis, and chronic back pain. Significant physical exam findings are as follows: Vital signs: temperature 98.6°F, oral; Heart rate: 89 beats per minute, regular; Blood pressure 145/87 mmHg, right arm; Respiratory Rate: 16, unlabored; Height : 5'11" Weight: 220 lbs; Body mass index: 30.7; SpO2: 99% on room air. Genitourinary exam demonstrates an uncircumcised penis that is erythematous and inflamed. There is curd-like purulent exudate present on the glans penis. You diagnose the patient with balanitis, educate the patient on proper hygiene, and prescribe Clotrimazole 1% cream. What part of the patient's history and physical exam was not a predisposing factor for his diagnosis? A) Type 2 diabetes mellitus B) Cirrhosis C) Obese body mass index D) Hypertensive blood pressure

D

A 53 year old African American male presents to your primary care clinic complaining of flank pain and hematuria that has been getting progressively worse for the past 3 weeks. He reports anorexia and weight loss. In addition, he notes that his scrotum "looks like it has worms or something in it". Upon physical exam, you note that he appears cachectic and a small mass can be palpated on the lower pole of his right kidney. You order an abdominal ultrasound while the patient is in your office. Which of the following findings would be a strong indication that a CT or further imaging needs to be ordered for this patient? A) The mass is round with sharply demarcated smooth walls. B) The mass is anechoic. C) There is a strong posterior wall echo. D) The mass measures 5 cm and has thickened irregular walls.

D

A 55-year-old Caucasian male comes into your clinic with concerns of "a red bump on my privates" for the past six weeks. He admits to a 10 pack year history of smoking and a diet primarily composed of fast food since he travels a lot for work. His past medical history shows he was diagnosed with HPV 8 years prior but is unsure the last time he was tested for other sexually transmitted infections. Upon physical exam, you notice a bleeding, erythematous lesion on the prepuce that is approximately 1 cm in diameter and palpable. You also note mild balanitis. He adds that he is surprised that it is painless for how bad it looks. In addition to a tissue biopsy, what should you also include in your initial workup for this patient? A) Duplex ultrasonography with doppler B) Initiate oral steroids to decrease inflammation C) Perform transillumination D) Obtain STI testing

D

A 25-year-old male presents to your clinic complaining of a painless lump in his scrotal area for the past few months that has recently been getting bigger. He denies any pain or recent trauma. He states he has never been sexually active. He has no current medical conditions. His vitals are as follows: BP 120/82 mmHg, RR 14 breaths per minute, HR 64 beats per minute, T 98.5F, and O2 is 99% on room air. On physical exam, he is well-appearing and in no apparent distress. Lungs are clear to auscultation bilaterally and the heart has a regular rate and rhythm with no murmurs, rubs, or gallops. Upon physical exam, you notice a firm, painless 3.4 cm mass in the right testis without transillumination. The rest of the genital exam is unremarkable. You suspect testicular cancer. Which of the following is NOT a risk factor for testicular cancer? A. Cryptorchidism B. Klinefelter syndrome C. High cholesterol D. Acromegaly

D

A 29 year old mother, Janet, presents with her 3 year old son, Peter, concerned that during potty training she noticed her son had an abnormal stream of urine. She states that when working on standing to urinate, he consistently manages to get urine all over the toilet seat, and has trouble getting the urine into the bowl. She states that they have worked together on aim, but his urine stream seems to go up and not down. She says that she does not want to resort to teaching him to sit to urinate only, but does not know what else to do. When asking the mother about surgical history, she states that he hasn't had any surgeries except for his circumcision done at two days of age. She also denies any history of penile trauma, catheterization, or ever being told that her son had any penile abnormalities. When asked, she states that she has observed that his stream of urine does come from a urethral meatus at the center, tip of the glans. The patient Peter is afebrile, well developed and well nourished, and in no apparent distress. Before you even begin your genitourinary physical exam of the patient, which of these differential diagnoses are you leaning toward? A) Urethral stricture B) Hypospadias C) Epispadias D) Meatal stenosis

D

A 29 year old white male, Andy Arytenoid, presents to urgent care with severe flank pain that radiates to the stomach and groin. The pain began very abruptly, waking him up in the middle of the night, and "comes and goes in waves". The patient did not have any urinary symptoms before this began. He rates the pain as a 9/10, with the worst pain of his life being a shattered patella. The patient states that he had a tournament yesterday, so he has been eating more animal protein such as chicken to bulk up, which he loves to eat heavily salted. He was very dehydrated and had darker urine after the tournament. The patient has never had pain like this before. As you are taking his history, the patient begins to vomit. He does not take any medications and has no chronic conditions. Costovertebral angle tenderness (CVAT) is positive. Rovsing's sign, the obturator sign, the psoas sign and McBurney's point are negative. Which positive diagnostic test would you expect with this condition? A) Urinalysis with positive leukocyte esterase, positive nitrites B) Urine culture with >100,000 CFU/mL colonies of E. Coli C) Non-contrast CT with inflamed appendix D) Non-contrast CT with radiopaque 2mm stone

D

A 57-year old African American male presents to the clinic for a 7-day history of painless hematuria. He also states that he has some pain in his lower back that is worse on the right side. While taking his history, he states to have benign prostatic hyperplasia and claims to have always had difficulty urinating, despite therapy with oral finasteride 5mg once daily. However, he denies any prior episodes of hematuria. He denies dysuria or urgency but states to have a decreased urine stream and increased frequency that has been present for the last 4 years. He also has hypertension that is well controlled on lisinopril 20mg once daily. He has a 10 pack-year smoking history and states to drink 5-6 drinks per week, mostly beer. He works part-time as a car mechanic, as he also takes care of his elderly mother. He is not married and denies any sexual intercourse in the last 6 months, however he states that is he heterosexual. On physical exam, you note an obese African American male that appears his stated age. He is not in acute distress, but is shifting on the exam table and rubbing his lower back. Cardiac, pulmonary, and abdominal exams are unremarkable. There is right flank pain and positive right costovertebral angle tenderness on musculoskeletal exam. Vital signs are below:T: 99.9 P: 86 R: 18 BP: 162/96 SpO2: 99% on RAA dipstick urinalysis done in clinic showed the following:Blood-tinged, non-turbid appearing urine, 3+ protein, 2+ red blood cells, negative nitrites, negative leukocyte esteraseA urine microscopy showed the following:Red blood cells >5 per high power field, white blood cells 0-2 per high power field, no bacteria, few hyaline castsBased on his exam and urinalysis, what is the next best test to order for this patient? A. Prostate specific antigen level B. 24 hour urine collection C. Kidney ureter bladder x-ray D. CT

D

A 60-year-old African American male presents to your office for his annual check-up. He has a family history of prostate cancer and would like to continue to be screened regularly. His last PSA (prostate specific antigen) was taken two years ago. In which of the following scenarios is it not necessary to defer screening of his PSA? A) He has pelvic pain and dysuria and you suspect bacterial prostatitis B) He has urinary retention and is unable to completely empty his bladder C) He went on a long bike ride for 50km yesterday afternoon D) He had a digital rectal exam performed at the beginning of your visit

D

A 68 year old male presents to clinic with a painless lump on his penis. He also has bleeding, a rash on his penis and balanitis. He has a past medical history including melanoma, lymphoma, phimosis, and HPV. He is a chronic smoker with a 40 PPD. He states he has also lost 10 pounds this month and feels more tired than usual. After evaluation via STD testing, MRI, CT, and Fine Needle Aspiration, you diagnose him with penile cancer. Which of the following would be performed when assessing extent of penile cancer? A. Gleason Score B. Cystourethroscopy C. Bosniak D. Sentinel Node Biopsy

D

Jane Sanderson is a 55 year old female presents to the ED with "a little" low back pain and a "blood tinge" to her urine. She denies fever or chills. Her temperature is 98.7 degrees Fahrenheit. She denies any significant past medical history and is not taking any medications currently. After reviewing her chart you see that she has been treated for multiple urinary tract infections in the last year by different providers in the ED. Her past urine cultures were all positive for Proteus mirabilis and she received the appropriate antibiotic treatment for this organism at previous visits. The pH of her urine ranged from 7.20-7.22 at these visits. You order another urinalysis with culture today and see Proteus mirabilisagain, a pH of 7.22, and positive hematuria. You also order a noncontrast CT of the abdomen and pelvis and see a 11 mm branched stone occupying the renal pelvis. After careful consideration you refer to urology and they perform an extracorporeal shock wave lithotripsy (ESWL) and treat her with Cefdinir for the Proteus mirabilis. Based on this information, what type of stone will urology most likely find? A. Uric acid B. Amorphous phosphate crystals C. Calcium Oxalate D. Struvite

D

Mr. Blancher is a 55-year-old African American male that comes into the clinic today complaining of difficulty voiding for the past couple of weeks. He has no other associated symptoms, but confesses that he has been using a medication called Propecia to help him with his hair loss that comes from aging. In addition, he is an avid smoker and has been on the keto diet for the past couple of years. Physical exam was mostly normal, except on digital rectal exam the posterior lobe of the prostate felt more enlarged on the right side compared to the left. Which of the following is true in regards to the next steps that need to be taken for Mr. Blancher? A. If a PSA were to be ordered, it is important to know that Mr. Blancher's results could be falsely elevated because he is currently taking Propecia. B. A PSA, CBC, and CMP should be ordered for Mr. Blancher immediately and wait for results to decide if he needs to be referred to GU. C. If a PSA were to be ordered and the results came back as 6 ng/mL, Mr. Blancher needs to be immediately referred to GU because abnormal DRE and elevated PSA indicate he has prostate cancer. He needs treatment right away. D. A PSA, CBC, and CMP should be ordered for Mr. Blancher and he needs a referral for GU.

D