B4E2 - Study Cases
Focal Segmental Glomerulosclerosis (FSGS)
A 50-year-old obese female with a 5-year history of mild hypertension controlled by a thiazide diuretic is being evaluated because proteinuria was noted on a urine dipstick during her routine yearly medical visit. Physical examination discloses a BP of 130/80, elevated jugular venous pressure, a fourth heart sound, and trace pedal edema. Laboratory values are as follows: serum Cr 1.2 mg/dL, BUN 18 mg/dL, and CrCl 87 mL/min. Urinalysis shows pH 5.0, specific gravity 1.018, protein 3+, no glucose, and occasional coarse granular cast. Urine protein excretion is 5.9 g/dL. A renal biopsy demonstrates that 60% of the glomeruli, mostly in the corticomedullary junction, have segmental scarring by light microscopy, with the remainder of the glomeruli appearing unremarkable. What is the most likely diagnosis?
Nephrolithiasis
A 48-year-old white man presents to the emergency department with unremitting right flank pain. He denies dysuria and fever. He reports significant nausea without vomiting. He has never experienced anything like this before. On examination, he is afebrile, and his blood pressure is 160/80 mm Hg with a pulse rate of 110/min. He is writhing on the gurney, unable to find a comfortable position. His right flank is mildly tender to palpation, and abdominal examination is benign. Urinalysis is significant for 1+ blood, and microscopy reveals 10-20 red blood cells per high-power field. What is the most likely diagnosis?
Stage 3 CKD
A 49-year-old African-American female with type 2 diabetes mellitus, hypertension, and hyperlipidemia returns for a follow-up visit. She's had diabetes for 15 years, and her control has been variable over that time. Now, her glycosylated hemoglobin is 8%. She has developed moderately increased albuminuria and diabetic retinopathy. You tell her that her renal function has progressively declined, which alarms her since her mother is on hemodialysis. Her creatinine was 1.2 mg/dL 3 years ago, and now it is 1.9 mg/dL. Her GFR is 36 mL/min/1.73 m2. She weighs 100 kg, and her blood pressure is 120/76 mm Hg. What is the most appropriate description of her renal function?
Overflow incontinence
A 50-year-old healthy woman with a history of 4 vaginal deliveries presents for evaluation of urinary incontinence. She feels like she can never empty her bladder completely. With intentional voiding and with unintentional urinary leakage, she typically passes small amounts of urine. She has no dysuria. On initial exam, you notice a large cystocele obvious by inspection even prior to your speculum examination. Her post-void residual testing demonstrates 250 cc of urine in her bladder. What is the most likely diagnosis?
Complement Levels + ASO titers
JG is an 8-year-old boy with no past medical history who presented to primary care clinic with facial edema for two days. He also complained of rhinorrhea, epistaxis, and a frontal headache. He was diagnosed with sinusitis and started on antibiotic therapy. The following day he developed abdominal swelling. He was again evaluated in the office where he was found to be hypertensive to 142/90 mm Hg. His exam was significant for mild periorbital edema, but he did not have pharyngitis, lymphadenopathy, swollen joints, or a rash. His urinalysis showed 2+ protein, numerous red blood cells (RBCs), and RBC casts What further diagnostic tests should be ordered?
No imaging indicated
A 45-year-old man with no significant past medical history presents with severe back pain after lifting heavy boxes at work 2 days ago. Other than his back pain, his review of symptoms is negative. His pain is exacerbated by coughing and sneezing. The pain radiates from his lower back down his right posterior thigh to his great toe when you perform both a straight leg raise and the contralateral leg raise tests. His strength, sensation, and reflexes are intact and symmetrical. Which imaging modality would be indicated?
CKD Stage 3a; Anemia, Metabolic Acidosis, Vit D Deficiency, Hyperparathyroidism, and Metabolic bone disease
65-year-old man with a history of DM2, HTN, and obesity comes to your clinic for a 3m FU visit. He was diagnosed with DM 15 years ago and HTN 20 years ago. He has no complaints and no episodes of hypoglycemia. He is eating better and has lost 10 lb in the last 1 year. On physical examination his BMI is 32, and BP 130/75. He has a normal heart examination. His foot examination demonstrates peripheral neuropathy with abnormal monofilament testing. His blood sugars have been better controlled in the last 6m and his last HbA1C is 7.0%, which is an improvement from a previous 9.2%. Other test results include CBC with hemoglobin 11.0, normal WBC and platelets, creatinine 1.2, and GFR 55. He has normal Na, K+, and Ca. Urine dipstick shows negative protein and urine microalbumin with 60 mg/g creatinine that has persisted for 6 months despite blood pressure control with a thiazide diuretic. His LDL is at goal. His last dilated eye examination showed nonproliferative retinopathy What's the diagnosis and what complications is this pt most at risk for?
Acute Kidney Injury (AKI)
80yo patient with a history of CKD Stage III, CHF, BPH, DM2 who is presenting with weakness and difficulty passing urine x3days. He had poor oral intake for a week prior to admission. On examination, he has hypogastric tenderness and dullness to percussion over that area, dry mucosa, +1 b/l pitting edema. His heart rate is 100 and his blood pressure is 100/60. Labs showed Na 130, K+ 5.1, Cl 103, Bicarb 16, BUN 95, Cr 8.5 (baseline 1.8)m Gluc 220. CXR shows mild b/l interstitial infilt and cardiomegaly. ECG shows sinus tach and peaked T waves. What is the most likely diagnosis?
Slipped Capital Femoral Epiphysis (SCFE)
A 13-year-old male presents to the clinic with his mother for difficulty walking. He is unsure of when the problem first began, but has noticed it getting worse over the last week. It has forced him to stop playing sports. He reports a dull pain in the left hip but denies trauma. On examination, you find an obese male in no distress. There is loss of internal rotation, abduction, and flexion at the left hip joint. When his hip is flexed to 90 degrees, this loss of ROM is more pronounced. What is the most likely diagnosis?
Interstitial Cystitis
A 45-year-old female presents to your clinic complaining of urinary frequency, "bladder" pain, and urinary urgency. There is no dysuria, however. She has had hematuria on dipstick several times with urinalysis showing microscopic hematuria on more than three occasions. This has been going on for several months and other practitioners (less skilled than yourself) have treated with a number of antibiotics without any relief. On questioning, she also notes bladder pain during intercourse and some chronic, vague, lower pelvic pain distinct from the bladder pain. At this visit, urinalysis and pelvic examination are unremarkable except for tenderness over the bladder area. What is the most likely diagnosis?
Acute poststreptococcal glomerulonephritis (APSGN)
A 14-year-old boy presents with a 3-day complaint of "brown urine." He has been your patient since birth and has experienced no major illnesses or injuries. He is active in band and cross-country, and denies drug use or sexual activity. Two weeks ago, he had 2 days of fever and a sore throat, but he improved spontaneously and has been well since. His review of systems is remarkable only for his slightly puffy eyes, which he attributes to late-night studying for final examinations. On physical examination, he is afebrile, his blood pressure is 135/90 mm Hg, he is active and nontoxic in appearance, and he has some periorbital edema. The urine dipstick has a specific gravity of 1.035 and contains 2+ blood and 2+ protein. You spin the urine, resuspend the sediment, and identify red blood cell casts under the microscope. What is the most likely cause of this patient's hematuria?
Yes, he is cleared. But he will need to wear an eye shield on the helmet to protect his seeing eye from bilateral vison loss.
A 14-year-old young man comes to see you for a PPE for freshman football. His past medical history is significant for retinoblastoma as a child. He has a right artificial eye, otherwise he has no medical problems or sequelae of his cancer. Is he cleared to play? Does he need special precautions?
Patellofemoral pain syndrome (PFPS)
A 15-year-old female cross-country runner presents to your clinic with the chief complaint of bilateral knee pain. She describes a gradual increase in her symptoms during the first 3 weeks of the season. She wants to run varsity this year and has done extra running and hill training after practice each day. She describes anterior knee pain in the patellar region with little or no swelling, but complains of crepitus and pain exacerbated by running, squatting, stair climbing, and prolonged sitting with the knee bent. What is the most likely diagnosis?
Doxycycline 100mg BID x7d
A 16-year-old girl presents to clinic with a complaint of vaginal discharge. She has only one sexual partner but is unsure if her partner may have had other sexual contacts. On physical examination, there is ectopy and some mucoid discharge. The cervix bled easily while obtaining discharge and cells for a wet mount and genetic probe test. The wet mount showed many white blood cells (WBCs) but no visible pathogens. What is the treatment for this diagnosis?
Clarify if she feels them at rest; if so, get EKG for further work up. Ask more FHx questions, obviously.
A 17-year-old athlete with no medical problems comes to see you for his senior cross country PPE. His history form is negative except he admits that last season, after running an intense workout in the heat, he passed out while walking to get water. He had no symptoms of seizure and was "out only a couple of seconds." He has no history of syncope in the past, and his exam, including evaluating for murmurs in the supine and prone position, is normal. What do you want to do next?
Metronidazole 500mg BID x7d
A 17-year-old teen presents with vaginal itching, odor, and discharge for several weeks. She has one partner who is asymptomatic. Speculum examination shows a cervix with inflammation and punctate hemorrhages on the cervix(attached) and with a copious foamy white discharge with a fishy odor. What is the treatment for this diagnosis?
Acute cystitis (UTI)
A 2-year-old female comes into clinic with complaint of painful urination. You order a UA which shows moderate LE and negative nitrites. Her urine culture grew to greater than 100 000 CFU Escherichia coli. What is the most likely diagnosis?
Chancroid
A 21-year-old college student and self-described as a "ladies' man" (interpret: jerk) presents because of a concerning spot that developed on his penis. He complains of pain at the spot but denies itching. He reports no fever. When asked further about his sexual practices, he reports no condom use because his partners are all "on the pill." He had chlamydia in high school but is otherwise healthy. His review of systems is negative. On examination of the penis, you find a 1-cm tender, erythematous papule with a deep central ulceration at the glans penis. There is some mild, tender lymphadenopathy in the inguinal area. The rest of the examination is unremarkable. What is the most likely diagnosis?
Ceftriaxone 500mg IM, once + Doxy 100mg BID x7d
A 21-year-old male college student presents to primary care clinic with a chief complaint of penile discharge. He has a 1-week history of burning when urinating and thick discharge at other times. He is sexually active with both men and women, including receptive and insertive anal sex and oral sex with men in addition to vaginal intercourse with women. He uses condoms inconsistently with both male and female partners. He denies previous history of sexually transmitted infection (STI). His past medical history and family history are negative. His exam reveals a thick white discharge at the urethral meatus. He has a normal testicular and rectal exam with no evidence of lesions or lymph nodes How will you treat the suspected diagnosis?
Penicillin G 2.4mu IM, once; Report to health department
A 21-year-old woman comes in for a routine well-woman exam. She began sexual activity about 1 month ago with a new partner and uses condoms most of the time. She denies any other symptoms today. She has been sexually active for many years, and you prepare her for a pelvic exam with Pap smear. During the external genital exam you notice a 3 cm-vulvar ulcer. It is nontender and feels indurated. You are also able to palpate a few small inguinal lymph nodes during external exam. Upon close further inspection of vulva and perianal region, no other lesions are identified. The rest of her pelvic exam is normal including wet prep and KOH examination. How will you treat this and what else must you do?
UTI; Nitrofurantoin/Bactrim/Fosfomycin
A 22-year-old female presents to the ED with 3 days of increased urinary frequency and suprapubic pain after micturition. She has no fevers, chills, or flank pain, nausea or vomiting, and urethral discharge. There have been no similar complaints in the past. She is sexually active and uses a barrier mode of contraception. She has no history of sexually transmitted diseases. She has no allergies to medications or food. Physical examination is unremarkable. Spot urinary pregnancy test is negative. Urinalysis is significant for 12 white blood cells (WBCs) and 3 red blood cells (RBCs), and the urine is nitrite positive. She has no primary care physician. What is the most likely diagnosis and treatment?
Varicocele
A 46-year-old man presents complaining of dull, left-sided scrotal pain and swelling. The swelling goes away when he lays down. The patient reports that he isn't really sure when his symptoms started, but they have been present and slowly progressive for several years. With further questioning, he admits to infertility. What is the most likely diagnosis?
Urge incontinence
A 24-year-old nulliparous woman is being seen in the office for problems with "losing urine at inconvenient times." She states that has had difficulty with feeling like she needs to void all the time. She reports that at least 10 times a day, she has such an intense feeling of needing to void that she has to run to the bathroom within 10 to 15 seconds or she will lose her urine in her clothes. The patient states that she avoids drinking a lot of liquids during the day due to this problem. "My life is ruined because of this bladder problem," she explains. Physical examination reveals a well-supported bladder and no hypermobility of the urethra. The neurologic examination of the perineal and perianal area is normal. Multiple cultures and assays for urinary tract infections and urethritis have been performed over the years, and the culture results have been negative. What is the most likely diagnosis?
Orchiectomy
A 25-year-old man presents with a complaint of testicular enlargement. Examination reveals a hard nodule on the left testicle, 2 cm in diameter. What test is both diagnostic and therapeutic for this disease?
Poststreptococcal/Post-infectious Glomerulonephritis
A 28-year-old nursery school teacher developed a marked change in the color of her urine ("cola-colored") 1 week after she contracted impetigo from one of her students. She also complained of a new onset of global headaches and fluid retention in her legs. Examination revealed a blood pressure of 158/92 mm Hg, resolving honey-crusted pustules over her right face and neck, 1+ pitting edema of her ankles, and no cardiac murmur. Urinalysis revealed 2+ protein and numerous red cells and red cell casts. Her serum creatinine was elevated at 1.9 mg/dL. Serum complement levels (CH50, C3, and C4) were low. What is the most likely diagnosis?
Bactrim/Nitrofurantoin
A 30-year-old female comes into clinic with several days of burning with urination and complaint of urinary urgency. She has had several prior UTIs but is otherwise healthy. She is currently on no medications, and she has taken TMP-SMX in the past for UTIs. Assuming UA is notable for UTI, how will you treat this patient?
IgA Nephropathy
A 30-year-old woman has recurrent episodes of "smoky" brownish urine and dysuria, usually preceded by a cough, nasal congestion, and feverishness. These episodes spontaneously resolve without treatment and then she feels well. She has smoked one-half pack of cigarettes per day for 5 years. What is the most likely diagnosis?
Metronidazole 500mg BID x7d
A 31-year-old woman presents with a malodorous vaginal discharge for 3 weeks. There is no associated vaginal itching or pain. She is married and monogamous. She admits to douching about once per month to prevent odor but it is not working this time. On examination, her discharge is visible. It is thin and off-white. Wet prep examination shows that more than 50% of the epithelial cells are clue cells What is your treatment for this patient?
Acyclovir 400mg TID x1-5d Valacyclovir 1g BID x1-5d Famciclovir 250mg BID x1-5d
A 32-year-old man presents with complaints of a 1-week history of multiple painful vesicles on the shaft of his penis associated with tender groin adenopathy. The vesicles broke 2 days ago and the pain has increased. He had similar lesions 1 year ago but never went for a healthcare examination at that time. He has had 3 different female sexual partners in the past 2 years but has no knowledge of them having any sores or diseases. What are the treatment options for this patient?
Absolutely. Start low dose, and check his potassium and creatinine in 1 to 2 weeks.
A 33-year-old male with type 1 diabetes and with a long history of nonadherence is your next patient in clinic. He has turned over a new leaf, and is keeping all his appointments and taking his meds. Unfortunately, his Cr is 2.7 mg/dL (GFR 34 mL/min/1.73 m2). Blood pressure is 129/82 mm Hg, and potassium 4.7 mEq/L today. Should you start him on an ACEi/ARB?
ACL tear
A 33-year-old woman felt a pop in her knee while skiing around a tree. She felt immediate pain and had difficulty walking when paramedics removed her from the slopes. Within a couple of hours, her knee was swollen. On examination the next day, she was able to walk 4 steps with pain. She had a moderate effusion without gross deformity and full range of motion. She had no tenderness at the joint line, the head of the fibula, over the patella, or over the medial or lateral collateral ligaments. She had a positive Lachman test, a negative McMurray test, and no increased laxity with valgus or varus stress. What is the most likely diagnosis?
Miconazole OTC 1-3d [Topical]
A 35-year-old woman presents with severe vaginal and vulvar itching. She also complains of a thick white discharge. Wet prep shows pseudohyphae. Shown is her cervix What is the typical treatment for this diagnosis?
Iliotibial band syndrome
A 37-year-old male presents to your office with complaints of lateral knee pain. He is in the process of training for a marathon and has noticed a worsening pain on his lateral knee that started about a month ago and has not resolved. On examination, he has no pain with terminal knee extension but during flexion his pain returns. What is the most likely diagnosis?
Human Papillomavirus (HPV)
A 42-year-old woman presents to the physician's office for a routine gynecologic examination. She is feeling well and has no specific complaints at this visit. While reviewing your records, you see that she has not come in for a Papanicolaou (Pap) smear in approximately 5 years. She admits that she has not come in because she has been feeling fine and did not think it was really necessary. She has a history of 3 pregnancies resulting in three full-term vaginal deliveries of healthy children. She was treated at 22 years of age for Chlamydia infection. She has never had an abnormal Pap smear. Her social history is notable for a 1-pack per day smoking history for the past 25 years. She is divorced from her first husband and is sexually active with a live-in boyfriend for the past 3 years. She has had 7 sexual partners in her lifetime. Her examination today is normal. You perform a Pap smear as part of the examination. The report arrives 10 days later with the diagnosis of high-grade squamous intraepithelial lesion. What is the most likely infectious etiology of this lesion?
Stress incontinence
A 45-year-old female is seen in primary care clinic. She has had 3 spontaneous vaginal deliveries and is having regular menses. After the birth of her last child, she has had some urine leakage associated with coughing. Over the course of several years, the amount of urinary leakage has worsened, and she reports that now she is losing a small amount of urine with minor cough, change in position, or minimal Valsalva maneuver. She has no nocturia What is the most likely diagnosis?
PDE5i (Sildenafil)
A 46-year-old man with benign essential hypertension (on hydrochlorothiazide) comes to see you in clinic for follow-up of his BP. His BP has been well controlled on this medicine. His only complaint is of intermittent problems with his ability to get and maintain an erection sufficient for sexual intercourse. This has been occurring off and on for the past 12 months. It is getting more frequent and happens 4 to 5 times a month. He has been happily married for 20 years, and his wife is his only sexual partner. His social history is notable for cigarette smoking (1ppd) and occasional alcohol use. He denies any illicit drug use. He is not aware of any chronic illnesses in his family. In addition to what he has already reported, his review of systems is notable for some nocturia (about twice a night). His PE is notable for a well-appearing man who is obese (BMI = 33 kg/m2), BP = 128/78 mm Hg. The rest of PE is unremarkable. His lab work results are normal. How will you treat this patient?
Chronic Kidney Disease (CKD)
A 46-year-old woman presents to the clinic for the first time, complaining of decreased urinary output with a foamy appearance for 5 months. She also complains of swelling in both legs and nonbloody, nonbilious emesis a few times a week. She was diagnosed with type 2 diabetes 10 years ago and has been taking insulin for 2 years. She does not check her sugar levels at home. When asked about her diet, she states that she eats the best she can for what she can afford but often has very little appetite and vomits sometimes. The patient last saw her health care provider 8 months ago, and insulin is her only medication. On examination, the patient is an obese woman. Her temperature is 99 °F (37.2 °C), heart rate is 108 beats/min, blood pressure is 198/105 mm Hg, respirations are 19 breaths/min, and oxygen saturation is 94% on room air. She has periorbital edema. Her skin is hyperpigmented on both lower extremities. Her heart is tachycardic with an S4 gallop auscultated and without murmurs or rubs. When palpating the heart's point of maximal impulse (PMI), it is lateral to the left midclavicular line. There are vesicular breath sounds throughout both lungs. Her neck reveals no jugular venous distension (JVD), and there are no carotid bruits. The lower extremities reveal pitting pretibial edema with a pit recovery time less than 40 seconds. Laboratory studies in your office include a urinalysis showing hyaline casts, 3+ proteinuria, and glucose, but negative for ketones. Her hemoglobin is 10.9 g/dL, and her hematocrit is 32% with a mean corpuscular volume (MCV) of 82.3 fL. What is the most likely diagnosis?
Greater trochanteric bursitis
A 47-year-old female with a past medical history of obesity and low back pain presents complaining of progressive pain in her right lateral hip that is worse with activity. She does not recall any trauma or inciting incident. On exam there is tenderness to palpation, and you notice associated swelling and redness. Plain radiographs are obtained and show no obvious abnormalities. What is the most likely diagnosis?
IV Fluids Alpha-Blockers NSAIDs
A 47-year-old woman presents to the office with severe right flank pain that does not radiate. Dipstick urinalysis shows hematuria, and microscopic examination confirms the presence of many red blood cells per high-power field. There is no pyuria or bacteriuria. The physician gives her some pain medication and sends her to get a non-contrast helical computed tomography (CT). The CT scan shows a 3mm stone in the right ureter and some mild hydronephrosis. What are the treatment options for this patient?
Stress Incontinence
A 48-year-old G3P3 woman is seen in the office with complaints of a 2-year history of loss of urine four to five times each day, typically occurring with coughing, sneezing, or lifting; she denies dysuria or the urge to void during these episodes. These events cause her embarrassment and interfere with her daily activities. The patient is otherwise in good health. A urine culture performed 1 month prior was negative. On examination, she is slightly obese. Her blood pressure is 130/80 mm Hg, her heart rate is 80 beats per minute, and her temperature is 99 °F (37.2 °C). The breast examination is normal without masses. Her heart has a regular rate and rhythm without murmurs. The abdominal examination reveals no masses or tenderness. A midstream voided urinalysis is unremarkable. What is the most likely diagnosis?
Chronic Kidney Disease (CKD)
A 48-year-old man presents to the outpatient clinic with several nonspecific complaints. Over the past 3 to 4 months, he has become easily fatigued and unable to concentrate at work. He also has poor appetite and pain in his thighs, knees, and legs. He is generally healthy and has not seen a medical provider in over 5 years. Eight years ago, when he visited an emergency center for the treatment of a laceration on his arm, he was informed that his blood pressure was elevated. Currently, the patient is afebrile, with a blood pressure of 173/92 mm Hg and a regular heart rate of 84 beats per minute. He has several areas of skin ecchymosis over his knees and thighs. Laboratory results include a white blood cell (WBC) count of 6500 cells/mm3, hemoglobin of 9 g/dL, hematocrit of 27%, blood urea nitrogen (BUN) of 80 mg/dL, serum creatinine of 7.7 mg/dL, and serum potassium of 5.3 mEq/L. What is the most likely diagnosis?
Noncontrast CT Scan
A 48-year-old man with diabetes mellitus, hyperlipidemia, and atrial fibrillation presents to the emergency department for evaluation of left flank pain and groin pain that has been severe and present for approximately 3 hours. His medications include metformin, atorvastatin, and warfarin. He is uncomfortable and has a temperature of 37°C (98.6°F), heart rate of 105 beats/min, blood pressure of 145/95, respiratory rate of 21 breaths/min, and room air oxygen saturation of 98%. His physical examination is notable for left flank pain but no abdominal organomegaly or focal tenderness. An electrocardiogram shows sinus tachycardia with nonspecific ST-T wave changes. International normalized ratio is 2.0. His renal function is normal, and urine analysis shows many red blood cells, few white blood cells, no bacteria, and no crystals. What is the preferred diagnostic study?
Fluconazole 150mg PO, Once
A 48-year-old perimenopausal female presents with a 3-day history of vulvar pruritus. A limited vulvar and vaginal examination reveals significant erythema with satellite lesions on the labia majora. Wet prep microscopy reveals abundant pseudohyphae and inflammatory cells. You somehow assemble all these clues into a diagnosis of candidal vulvovaginitis (and you can tell the patient is impressed when she says, "That's right, genius. I've got a yeast infection"). She enquires about use of oral therapy, as vaginal creams are "messy." What else can you give this patient that is not topical?
Acute Kidney Injury (AKI)
A 54-year-old man with a history of type 2 diabetes mellitus and coronary artery disease is admitted to the coronary care unit with worsening angina and hypertension. His pain is controlled with intravenous nitroglycerin, and he is treated with aspirin, beta-blockers to lower his heart rate, and angiotensin-converting enzyme (ACE) inhibitors to lower his blood pressure. Cardiac enzymes are normal. He undergoes coronary angiography, which reveals no significant stenosis. By the next day, his urine output has diminished to 200 mL over 24 hours. Examination at that time reveals that he is afebrile with heart rate of 56 beats per minute (bpm) and blood pressure 109/65 mm Hg. His neck veins are flat, chest is clear, and heart rhythm is normal with an S4 gallop and no murmur or friction rub. His abdomen is soft without masses or bruits. He has no peripheral edema or rashes, with normal pulses in all extremities. His fundoscopic examination reveals dot hemorrhages and hard exudates. Current laboratory studies include Na 140 mEq/L, K 5.3 mEq/L, Cl 104 mEq/L, CO2 19 mEq/L, and blood urea nitrogen (BUN) 69 mg/dL. His creatinine (Cr) level has risen to 2.9 mg/dL from 1.6 mg/dL on admission. What is the patient's new clinical problem?
Prostate biopsy
A 55-year-old Caucasian male presents to primary care clinic to establish care. He has DM2, which is well controlled on metformin, and HTN for which he takes 20 mg lisinopril daily. On review of systems, he reports urinary frequency, nocturia (waking up 2-3 times per night), and decreased urinary stream that are all new this year. He denies any dysuria, hematuria, urgency, and erectile dysfunction. He is concerned about the number of times he has to get up at night and would like to know if there is something that can help his symptoms. You perform a DRE, his prostate is asymmetric and you palpate a hard nodule in the left lobe. You order a PSA which is within the normal range at 2.1 ng/mL. What is the next step in management of this patient?
Prostate: Maybe get a PSA Testicular: NO! Heaven forbid a man should be one less testicle on a false-positive
A 55-year-old Caucasian man comes to your clinic for an annual examination. He has no pertinent medical history and feels well. His family history is positive for dyslipidemia in his father. His review of systems and physical examination is unremarkable. He is interested in having all the recommended cancer screening tests suggested for someone of his age. Is he eligible for Testicular or Prostate CA screening?
a-1 antagonist (Tamsulosin)
A 58-year-old black male presents to your clinic complaining of urinary hesitancy, frequency, and three to four episodes of nocturia per night, which have been worsening over the past few years. His urinary stream is weaker than it was a few years ago, and he feels he does not empty his bladder completely. He denies any history of urinary tract infections (UTIs) or painful urination. He is otherwise well with no significant past medical or surgical history. Currently, he takes no medications and has no allergies. On reviewing his family history, he notes his father and older brother died of prostate cancer in their fifties. His general physical examination is normal, and a genital examination is unremarkable. Digital rectal examination reveals a smooth prostate with no nodules or tenderness. Your patient's urinalysis and PSA are normal. After emptying 250 mL of urine, the postvoid residual urine volume is 50 mL. What medical therapy would you start this patient on?
Metabolic Bone disease/Osteoporosis
A 58-year-old obese woman with hypertension, type 2 diabetes, and chronic kidney disease is admitted to hospital after a right femoral neck fracture sustained in a fall. Recently, she had been complaining of fatigue and was started on epoetin alfa subcutaneous injections. Her other medications include an angiotensin-converting enzyme inhibitor, a β-blocker, a diuretic, calcium supplementation, and insulin. On review of systems, she reports mild tingling in her lower extremities. On examination, her blood pressure is 148/60 mm Hg. She is oriented and able to answer questions appropriately. There is no evidence of jugular venous distention or pericardial friction rub. Her lungs are clear, and her right lower extremity is in Buck traction in preparation for surgery. Asterixis is absent. What complication from CKD is the patient most likely suffering from?
Transcervical left femoral neck fracture
A 60-year-old woman comes to the emergency room for hip pain. She felt a pop in her hip accompanied by the immediate onset of pain that prohibited her from walking. She had fallen 2 days prior. Xray is shown: What is the most likely diagnosis from the XR?
Acute prostatitis
A 63-year-old male presents to the ED with a 2-day history of fever, urinary frequency, dysuria, and difficulty initiating the urinary stream. He also relates having some perineal pain. On examination, his vitals are stable except for a temperature of 38.5°C. His rectal examination is remarkable for a tender, warm, edematous prostate. There are no perirectal masses and the stool is heme negative. He has no penile lesions, discharge, scrotal masses, or tenderness. He does not exhibit any costovertebral angle tenderness. His UA is positive for 10 WBCs/HPF, 1+ nitrite, 1+ leukocyte esterase. What is the most likely diagnosis?
PDE-5i (Sildenafil)
A 63-year-old male with a history of insulin-dependent diabetes complains of decreased libido and difficulty maintaining an erection, worsening over the past few years. He does have occasional erections sufficient for penetration and awakens with an erection at times. His medical history is also significant for hypertension and an appendectomy. His medications include insulin, lisinopril, and hydrochlorothiazide. He has been married for 30 years and has two grown children, ages 24 and 26. On physical examination, you find normal genitalia, normal femoral and dorsalis pedis pulses, appropriate virilization, and slightly diminished sensation at the plantar aspects of the feet with an otherwise intact neurological examination. All lab testing has been normal. What is the initial treatment for this patient?
Vulvovaginal Candidiasis
A 65-year-old female presents for a health maintenance examination. She complains of a vulvar itching and describes it as "It feels like I'm baking baguettes in my vagina!," and her symptoms have worsened over the last few weeks. She is sexually active with her husband and has experienced dyspareunia with penetration lately. She always uses a water-based lubricant with intercourse. On examination, you find complete erythema of the labia minora and majora, and a thick white discharge from the vaginal opening. There is no other skin or mucosal involvement. What is the most likely diagnosis?
Benign Prostatic Hyperplasia (BPH)
A 68-year-old man presents to the physician with a complaint of urinary frequency. He states that he has noted increased urgency and frequency for approximately 1 year, but his symptoms have become progressively worse. He states that currently he seems to have to urinate "all the time" and often feels as if he has not completely emptied his bladder. He must get up to urinate three or four times each night. In addition, in the last month, he sometimes has postvoid dribbling. He denies fevers, weight loss, and bone pain. His medical history is notable only for hypertension. His medications include atenolol and aspirin. The family history is negative for malignancy. On examination, he appears healthy. His vital signs are notable for a blood pressure of 154/92 mm Hg. The prostate is diffusely enlarged, with no focal nodule or tenderness. Benign prostatic hyperplasia is suspected. What is the most likely diagnosis?
Refer her to Nephrology for cystoscopy w/ biopsy
A 78-year-old female presents to establish care after moving from another state to be closer to her adult children. She has a pmh of COPD, CAD, OA, and depression. She is on aspirin, citalopram, famotidine, lisinopril, simvastatin, and clopidogrel. You review her outside health records from her previous PCP and discover that a routine screening urine dipstick for bladder cancer performed within the past 6 months demonstrated moderate blood with trace protein. The patient informs you that she did not follow up with her PCP. She currently denies recent abdominal pain, chest pain, difficulty urinating, vaginal pain, vaginal discharge, or vaginal bleeding. She also denies pain with urination or frequency of urination. You examine the patient and find no signs of edema, flank pain, or abdominal mass. There is no external vaginal or rectal bleeding noted. Her blood pressure is 135/86 mm Hg. Microscopic examination of the urinary sediment shows 5 erythrocytes per HPF. Her lab work returned with no signs of infection. You inquire about previous urologic instrumentation and re-inquire about a history of gross hematuria. She denies ever seeing a urologist, but she does now recall an episode of frankly bloody urine that self-resolved after two days without associated symptoms. What is your next step in evaluation?
Intrarenal AKI; potentially prerenal
A healthy 26-year-old woman sustained a significant crush injury to her right upper extremity while on the job at a local construction site. She was brought to the emergency department and subsequently underwent pinning and reconstructive surgery and received perioperative broad-spectrum antibiotics. Her blood pressure remained normal throughout her hospital course. On the second hospital day, a medical consultant noted a marked increase in her creatinine, from 0.8 to 1.9 mg/dL. Her urine output dropped to 20 mL/h. Serum creatine kinase was ordered and reported as 3400 units/L. What category type does this patient fit into for her diagnosis?
Anticholinergic (Oxybutynin)
A healthy 65-year-old woman comes to primary care clinic for her annual physical. She takes no medications and has no complaints. However, when you ask a detailed review of systems, she tells you she wears a pad because she often has trouble making it to the bathroom. She does try to void on a regular and frequent basis and does not try to hold her urine. She leaks a moderate amount of urine several times a day. Her urinary leakage is not associated with coughing or laughing and also happens at nighttime. Her physical exam is normal. What is the first line treatment for this patient?
Order Semen analysis, Testosterone, LH, FSH
A married couple presents to a primary care physician with a complaint of infertility. They have been trying to get pregnant for approximately 1 year. During that time, they have had intercourse approximately three or four times a week without birth control. There is a 3-year-old child from the woman's prior marriage. The man has never had a child to his knowledge. He denies sexual dysfunction. He had both gonorrhea and chlamydial infection in his early 20s and one episode of prostatitis for which he was treated. His medical history is otherwise unremarkable. He takes no medications. He denies tobacco and drug use and drinks only rarely. On examination, his testes are approximately 4.5 × 3 × 2.5 cm bilaterally. The epididymis is irregular to palpation bilaterally. There are no varicoceles or hernias. The vas deferens is present and without abnormality. The prostate is of normal size, with no bogginess or tenderness. The penis has no fibrosis or angulation. The urethral meatus is appropriately situated. What would the next step in your evaluation be?
Meniscus Tear
A sports injury is sustained by a young male while playing basketball, resulting from twisting and squatting. The patient immediately noticed swelling and pain in his right knee, unable to bear full weight with a ballotable patella. Lachman and anterior drawer testing are unremarkable. When performing rotation of the flexed knee internally and externally while extending, there is an audible click and immediate pain in the right knee. What is the most likely diagnosis?
ACL Tear
An 18-year-old high school football player comes into your office on a Friday morning after injuring his left knee in last night's game. He walks in on crutches given to him by the school's trainer. He has significant left knee swelling. Your patient does not recall exactly what happened, but believes his foot was planted and the injury occurred when he tried to twist and turn toward midfield. He felt a pop in his knee and had to be helped off of the field. He had pretty significant swelling by halftime and was unable to return to the game. What is the most likely diagnosis?
Trichomoniasis
An 18-year-old woman comes in for a chief complaint of profusely thick vaginal discharge. She has had a 12-day history of new vaginal discharge that is thick and yellowish in color. She is sexually active with one male partner and is not using condoms. She is on intramuscular medroxyprogesterone (last shot 6 weeks ago) and is not taking any other medications or using feminine hygiene products. She does report scant vaginal bleeding intermittently over the last month. Past medical, family, and social history is otherwise negative. Abdominal exam is normal. External genital exam is normal with no lesions or lymphadenopathy. Speculum exam shows clear vaginal mucosa and discharge. She has erythema and friability of the cervix with mucopurulent discharge at the cervical os. You note she does not have cervical motion tenderness or adnexal tenderness. You obtain a nucleic acid amplification test for gonorrhea and chlamydia and prepare a wet prep slide with saline and potassium hydroxide (KOH) prep. Wet prep slide shows a large number of leukocytes with evidence of motile organisms, but no clue cells. KOH is negative for Candida infection. What is the most likely diagnosis?
Urinary Tract Infection
An 84-year-old woman is brought to the emergency department by ambulance from her long-term care facility for increased confusion, combativeness, and fever. Her medical history is significant for Alzheimer disease and well-controlled hypertension. The patient is "confused" and combative with the staff, which, per her family, is not her baseline mental status. Her temperature is 100.5 °F, heart rate is 130 beats per minute (bpm), blood pressure is 76/32 mm Hg, respiratory rate is 24 breaths per minute, and oxygen saturation is 95% on room air. On examination, she is lethargic but agitated when disturbed, her neck veins are flat, her lung fields are clear, and her heart rhythm is regular and tachycardic without murmur or gallops. Abdominal examination is unremarkable, and her extremities are warm and pink. After administration of 2 L of normal saline over 60 minutes, her blood pressure is 95/58 mm Hg. The initial laboratory work returns. Her white blood cell count (WBC) is 14,000/mm3, with 67% neutrophils, 3% bands, and 24% lymphocytes. Serum lactate is 3 mmol/L. No other abnormalities are noted. A chest x-ray obtained in the emergency department is normal. Urinalysis shows 2+ leukocyte esterase, negative nitrites, and trace blood. Microscopy shows 20 to 50 white blood cells per high-power field, 0 to 3 red blood cells, and many bacteria. What is the most likely diagnosis?
Renal Biopsy
CG is a 12-year-old girl with no past medical history who is referred to a pediatric nephrology clinic for microscopic hematuria detected at a sports physical examination. Her renal ultrasound was normal, but she has not had any additional evaluation. She has no history of urinary tract infections, and she has not had any epistaxis, hemoptysis, or sinus disease. She does recall two previous episodes of "brown urine," though she does not recall an association with upper respiratory tract infections (URIs) or other illnesses. Her family history is significant for a grandfather with recurrent nephrolithiasis and hypertension. Her physical exam is normal including a blood pressure of 90/70 mm Hg. Her UA however shows large blood, 3+ protein, numerous RBCs, and RBC casts. What diagnostic testing provides a definitive diagnosis for this condition?
Acute interstitial nephritis
The patient is a 25-year-old female who has a history of osteomyelitis from an open fracture sustained in a skiing accident. She has recently begun to spike a fever to 38.5°C and have a rapid increase in her creatinine. Medications: nafcillin, ibuprofen, morphine, lactated Ringer solution IV 100 cc/hr. Labs: Cr 3.5 mg/dL, BUN 25 mg/dL. CBC shows mild WBC count of 12,500/mm3 and differential shows eosinophilia. The patient's examination shows a diffuse rash and the urine contains white cell casts. There are no red cells in the urine. What is the most likely diagnosis?
Renal Cell Carcinoma
This patient is a 53-year-old man who presents with hematuria, night sweats, and left flank pain. He is noted to be anemic. What is the most likely diagnosis?
Osteoarthritis of the knee
This is the radiograph of an obese 68-year-old woman who complains of chronic knee pain. She has tried acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) but continues to have difficulty walking because of pain. There is no erythema and only minimal effusion on examination. It is not inflamed. What is the most likely diagnosis?
Displaced Femoral Neck Fracture
What diagnosis is show in the image?
Degenerative Disc Disease (L4-L5)
What diagnosis is shown in the MRI?
Herniated Nucleus Pulposus (HNP)
What diagnosis is shown in the image?
Gotcha! Normal XR of Right Hip Joint
What is shown in the image?
Lumbar Spinal Stenosis
What is the diagnosis in the Image?
Avascular Necrosis
What is the diagnosis in the image?
Left Posterior Hip Dislocation
What is the diagnosis in the image?
Spondylolisthesis
What is the diagnosis in the image?
Nephrolithiasis
What is the most likely diagnosis in the non-contrasted abdominal CT?
Order EKG and refer to Cardio. Restrict play until workup complete.
You are a new primary care provider in your town, and you volunteer to help with PPEs at your neighborhood high school. The first patient you see is a male junior soccer player. There is nothing concerning on his history form. His exam is normal except he has a 2/6 systolic murmur. He doesn't recall ever being told he had a murmur in the past. His parents aren't with him and you have no medical records. You confirm that he has no symptoms of chest pain or syncope. He does have a murmur that increases mildly when he stands. What do you want to do next?
Ceftriaxone 500mg IM, once + Doxycycline 100mg BID x14d + Metronidazole 500mg BID x14d
You are called to the emergency department to evaluate a patient with a 2-day history of abdominal pain. She is a 24-year-old G1 P1 female whose LMP was 1 week ago. On the "1-10" scale, her pain is a "12." She is on oral contraceptives for birth control. She has "never missed a pill" and "could not possibly be pregnant." Her pain is across her lower abdomen and a little more on the right side than the left. She has felt feverish. She has had some nausea but no vomiting. She denies bowel or bladder problems. Her pain improves with acetaminophen and worsens with activity. On examination, she appears uncomfortable but not toxic. Her temperature is 38°C, but the rest of her vitals are normal. Her abdominal examination reveals decreased bowel sounds, with tenderness to palpation primarily across the lower quadrants. She has minimal guarding and no rebound tenderness. Her pelvic examination is remarkable for cervical motion tenderness. The uterus is of normal size and consistency with no masses. You obtain cultures/PCR for chlamydia and gonorrhea. The urine pregnancy test is negative ("I told you not to waste healthcare dollars—especially in this economy," your patient complains). The urinalysis is negative for nitrites and leukocytes, and the WBC is 15,600/mm3with an increase in bands. She reports that she's had an appendectomy. How will you treat this patient?
Acute bacterial prostatitis
You are seeing an 80-year-old man with a 2-day history of dysuria and increased urinary frequency. These symptoms have worsened over the last day, and this morning, he was unable to urinate. He also developed fever, shaking chills, and lower abdominal pain. He underwent bladder catheterization during a hospitalization 1 week ago. He denies back pain, hematuria, and scrotal swelling or pain. What is the most likely diagnosis?
No, he's on nitrates.
You see a 66-year-old man in clinic who has a history of coronary artery disease (CAD) with a myocardial infarction (MI), type 2 diabetes mellitus, hypertension, and hypercholesterolemia. His MI was 6 months ago. He was treated with a coronary artery bypass graft (CABG) because of his history of diabetes and the severity and distribution of his CAD. His cardiologist has already given him clearance to resume sexual activity. However, he complains of ED and wants to know about treatment options. He did have some mild depression after his MI, but this has improved. He denies any loss in libido. He is on a beta blocker, aspirin, a statin, and nitrates for his angina, which is well controlled. His last hemoglobin (Hb) A1c was 6.5%. His last LDL was 69 mg/dL. BP is 124/74 mm Hg. Cardiac exam is notable for 1+ femoral and peripheral pulses. Other than this, his exam is only notable for his sternotomy scar. Is this patient a candidate for PDE5i treatment?
Gonorrhea
Your patient is 17 years old. He told his mother that he was having abdominal pain, but really he is worried that he may have contracted an STI. He has become fairly promiscuous and does not use condoms (after the gynecomastia disappeared, his mojo returned). In the last week he has developed dysuria and a yellowish urethral discharge. He has no other symptoms. What is the most likely diagnosis?
Hyperacute allograft rejection
Your patient is a 50 year old man with 2 year hx of CKD. He is undergoing hemodialysis treatment and is on antihypertensive medications. He has been on the renal transplant list for 2 years. An acceptable match with a cadaveric kidney is found, and the patient is taken to the operating room. The kidney is placed in the right lower abdomen. Blood supply is established with the iliac vessels. As the surgeons are performing anastomosis of the donor ureter to the bladder, the anesthesiologist informs the team that the blood pressure has dropped to 70/40 mm Hg, heart rate has increased to 130 beats per minute, and the temperature is now 101 °F. The transplanted kidney appears mottled and cyanotic. What is the most likely complication?
