ROSH REVIEW Genitourinary

One Step Further Question: When should serum potassium be measured after beginning treatment for hyperkalemia?

Answer: 1-2 hours after initiating therapy.

One Step Further Question: At what age should discussion about prostate cancer screening occur in African-American men or those with a family history of prostate cancer?

Answer: 45 years.

One Step Further Question: When considering scrotal pain, which signs favor a diagnosis of testicular torsion over epididymitis?

Answer: Acute severe pain, high-riding testicle, pain worsens with testicle elevation, absent cremasteric reflex, normal testicle but decreased blood flow on color Doppler ultrasonography.

One Step Further Question: Which serum component, if low, may cause a spuriously low total serum calcium reading?

Answer: Albumin concentrations lower than 4 g/dL will reduce the total serum calcium level

One Step Further Question: Where are propylene glycol and ethylene glycol commonly found?

Answer: Antifreeze.

One Step Further Question: What is the most common cause of renal artery stenosis?

Answer: Atherosclerosis.

One Step Further Question: What is the treatment for primary syphilis?

Answer: Benzathine penicillin G 2.4 million units IM, single dose, is nearly universally curative. Doxycycline for 2 weeks is an alternative for penicillin-allergic patients.

One Step Further Question: What is the most common cause for secondary hyperparathyroidism?

Answer: Chronic Kidney disease causing decreased levels of 1,25-dihydroxyvitamin D.

One Step Further Question: There is a choice between which 2 antibiotics (and what are their durations of therapy) for the treatment of uncomplicated, outpatient acute bacterial prostatitis?

Answer: Ciprofloxacin or trimethoprim/sulfamethoxazole for a minimum of 14 days, but typically 4-6 weeks.

One Step Further Question: When urine is collected by catheterization, what colony count is considered diagnostic for infection?

Answer: Colony count >50,000 cfu/mL.

One Step Further Question: What is the difference between condyloma acuminatum and condyloma lata?

Answer: Condyloma acuminatum are broad-based, pedunculated, cauliflower-like warts caused by human papillomavirus. Condyloma lata are broad-based, flat, moist papules due to Treponema pallidum.

One Step Further Question: Women with autosomal dominant polycystic kidney disease have an increased risk of what pregnancy complication?

Answer: Ectopic pregnancy.

One Step Further Question: Which organism is the most common cause of urinary tract infections?

Answer: Escherichia coli.

One Step Further Question: Which disease, caused by lymphatic obstruction, commonly results in chronic hydrocele (elephantiasis)?

Answer: Filariasis, a parasitic disease caused by nematodes (commonly Wuchereria and Brugia species) and transmitted by black flies and mosquitoes.

One Step Further Question: What are congenital abnormalities commonly associated with Wilms tumor?

Answer: Horseshoe kidney, duplicate collecting system, hypospadia and cryptorchidism.

One Step Further Question: What is the recommended treatment protocol for acute pyelonephritis/cyst infection in those with polycystic kidney disease?

Answer: Hospital admission, blood and urine cultures and intravenous fluoroquinolones.

One Step Further Question: What is the most common complication of chronic kidney disease?

Answer: Hypertension.

One Step Further Question: What is the most common complication of post-streptococcal glomerulonephritis?

Answer: Hypertension.

One Step Further Question: What electrolyte abnormality results in U-waves on an ECG?

Answer: Hypokalemia.

One Step Further Question: How does iron ingestion lead to metabolic acidosis?

Answer: Iron, at toxic levels, poisons the cellular mitochondria leading to lactic acidosis

One Step Further Question: What effect does finasteride have on the PSA level?

Answer: It lowers PSA levels by about 50% after 6 months of use.

One Step Further Question: Patients with Fragile X syndrome are predisposed to which cardiac abnormality?

Answer: Mitral valve prolapse.

One Step Further Question: In cases of hyperglycemia, should the sodium level be corrected prior to calculating the anion gap?

Answer: No, because the chloride level is similarly diluted.

One Step Further Question: Is the ototoxicity commonly seen in salicylate toxicity permanent?

Answer: No. The tinnitus, seen at salicylates levels > 20 mg/dL, is reversible.

One Step Further Question: Which medications commonly cause urinary retention?

Answer: Opioid analgesics, anticholinergics, antidepressants, antipsychotics and calcium channel blockers.

One Step Further Question: What urinalysis finding is present in patients with marked hyperlipidemia from nephrotic syndrome?

Answer: Oval fat bodies, lipid deposits in sloughed renal tubular epithelial cells, occur with marked hyperlipidemia

One Step Further Question: What is the name of the inability to retract foreskin?

Answer: Phimosis.

One Step Further Question: Which artery most commonly used to perform an arterial puncture of a blood gas?

Answer: Radial artery.

One Step Further Question: What is the most common risk factor for bacterial vaginosis?

Answer: Sexual activity.

One Step Further Question: What is the treatment of choice for Chlamydial urethritis?

Answer: Single dose azithromycin.

One Step Further Question: What is the treatment for hyperkalemia resulting in metabolic acidosis?

Answer: Sodium bicarbonate.

One Step Further Question: What medication is used to ion trap aspirin in the urine thus enhancing elimination?

Answer: Sodium bicarbonate.

One Step Further Question: What theoretical complication can infusion of intravenous calcium cause in a patient taking digitalis?

Answer: Stone heart, an irreversible, non-contractile state of impaired diastolic relaxation.

One Step Further Question: What is the third most common cause of genital ulcers in addition to chancroid and herpes?

Answer: Syphilis.

One Step Further Question: What is the most common cause of hyperkalemia found on blood work?

Answer: The most common cause is spurious elevation from extravascular hemolysis.

One Step Further Question: What is the peak age for presentation with a Wilms tumor?

Answer: The third year of life.

One Step Further Question: What is the approximate duration of action of calcium on cardiac membrane stabilization?

Answer: The time is 30 to 60 minutes.

One Step Further Question: What disease, caused by a chlamydial infection, is one of the leading causes of preventable blindness worldwide?

Answer: Trachoma.

One Step Further Question: What test is used to diagnose a hydrocele?

Answer: Transillumination.

One Step Further Question: True or false: A prostate specific antigen level of zero guarantees the absence of prostate cancer?

Answer: True.

One Step Further Question: With any complaint of urinary incontinence, it is important to first rule out which condition?

Answer: Urinary tract infection.

One Step Further Question: What is the treatment for acute interstitial nephritis?

Answer: Withdrawal of offending medication.

One Step Further Question: Can an angiotensin II receptor blocker be used in patients with ACE inhibitor intolerance?

Answer: Yes.

One Step Further Question: Can testicular torsion occur during sleep?

Answer: Yes. Up to 50% of all cases are reported to occur during sleep.

Which one of the following is the most likely cause of acute kidney injury in a patient with eosinophiluria? Acute interstitial nephritis Ethylene glycol poisoning Poststreptococcal glomerulonephritis Rhabdomyolysis

Correct Answer ( A ) Explanation: Acute interstitial nephritis is an important cause of acute renal failure resulting from immune-mediated tubulointerstitial injury. The presence of eosinophiluria in a patient with acute kidney injury suggests acute interstitial nephritis, which is typically an allergic reaction to medications such as penicillins, sulfa-containing antibiotics and diuretics, NSAIDs and proton pump inhibitors. Patients with acute interstitial nephritis may also present with a rash, fever, eosinophilia, and other constitutional symptoms.

In which biochemical abnormality can you see Chvostek sign (contraction of the facial muscles after tapping on the facial nerve anterior to the ear)? Hypercalcemia Hyperkalemia Hypocalcemia Hypokalemia

Correct Answer ( C ) Explanation: Signs of hypocalcemia include the Chvostek sign (evoked facial nerve irritability), Trousseau sign, and a prolonged QT interval. Severe hypocalcemia is associated with impaired cardiac contractility. In some individuals, hypoparathyroidism is detected only by an asymptomatic reduction in the serum calcium concentration. Hypocalcemia and an elevated serum phosphorus concentration in association with absent PTH levels confirm the diagnosis of hypoparathyroidism. In pseudohypoparathyroidism, parathyroid hormone (PTH) levels are elevated, reflecting the PTH-resistant state, but otherwise the biochemical findings of hypocalcemia and hyperphosphatemia are similar to those of hypoparathyroidism.

A 57-year-old woman with a long history of poorly-controlled diabetes mellitus presents with worsening edema in her legs and an occasional "wet-sounding" cough. Physical exam shows 2+ pitting edema extending to mid-calf bilaterally and trace periorbital edema. Blood tests show hypoalbuminemia and hyperlipidemia and urinary protein excretion is 3.5 grams/24 hours. Which of these complications may occur as a direct result of her new condition? Deep vein thrombosis Gouty arthritis Peripheral neuropathy Struvite calculi

Correct Answer ( A ) Explanation: Deep vein thrombi secondary to a hypercoagulable state may occur in patients with nephrotic syndrome due to excessive urinary protein losses. As serum albumin levels drop below 2 grams/dL, patients typically become deficient in antithrombin, protein C, and protein S, which causes an increased propensity to clotting. Patients with nephrotic syndrome who develops a thrombosis in any location should be anticoagulated for 3-6 months; recurrent thrombi may warrant anticoagulation indefinitely. Nephrotic syndrome is characterized by the triad of hypoalbuminemia, hyperlipidemia, and proteinuria greater than 3 grams/24 hours. Symptoms include dependent edema that can become generalized, ascites, and pulmonary edema. One third of adults with nephrotic syndrome have an underlying systemic disease such as diabetes mellitus, systemic lupus erythematous, or amyloidosis, as opposed to one of many primary renal diseases. Nephrotic syndrome is diagnosed based on the above blood and urinalysis findings. Renal biopsy is typically needed to determine the etiology unless there is a known likely secondary cause. Treatment requires increasing the patient's daily protein intake and using an ACE-inhibitor or angiotensin receptor-blocker to reduce protein loss. Salt restriction and thiazide or loop diuretics aid in edema management. Statins and diet changes may help manage the hyperlipidemia.

A 25-year-old woman visiting from India presents to the Emergency Department with a complaint of a painless ulcer on her vulva. She states it started as a nodule a week prior, but then erupted as a large red ulcer that bleeds easily, even after light contact. She denies fevers, chills, dysuria, or vaginal discharge. On examination, a "beefy-red" ulcer is noted on her vulva. No lymphadenopathy is appreciated. No other vesicles, lesions, or rashes are visualized. Which of the following is the most likely diagnosis? Granuloma inguinale Herpes simplex virus Lymphogranuloma venereum Syphilis

Correct Answer ( A ) Explanation: Donovanosis, or granuloma inguinale, is caused by Klebsiella granulomatis, a gram negative intracellular bacterium. The disease is most prevalent in India, southern Africa, and central Australia. It is rare in the United States. The incubation period lasts for 2 weeks to 6 months, after which time a painless subcutaneous nodule forms on the penis or vulva. The nodule progresses to a painless ulcer with rolled borders that is highly vascular, giving it the classic "beefy-red" appearance. Due to the vascularity, the lesions bleed easily with contact. Lymphadenopathy is not present. Diagnosis is made by visualization of Donovan bodies (safety-pin shaped intracellular organisms) in monocytes on tissue biopsy. Treatment is with doxycycline for at least 3 weeks. Alternative medications include azithromycin, ciprofloxacin, erythromycin, and trimethoprim-sulfamethoxazole. Lymphogranuloma venereum (C) (LGV) is a sexually transmitted disease more prevalent in tropical countries and is typically more prevalent in the homosexual population. It is caused by Chlamydia trachomatis, a gram negative intracellular bacteria. Incubation lasts for 3 to 21 days when a small, painless genital ulcer appears and spontaneously resolves after 2 to 3 days. The secondary stage begins 7 to 30 days after the resolution of the primary lesion and is characterized by buboes which are painful, firm fluctuant lymph nodes which form a "groove sign" (adenopathy that extends above and below the iinguinal ligament).

26-year old sexually active man presents with a 3-day history of unilateral, painful testicular swelling. He reports subjective fevers and dysuria and denies nausea and vomiting. Urinalysis shows leukocyte esterase and greater than 10 white blood cells. What is the next step in management for this patient? ADoxycycline and ceftriaxone therapy BLevofloxacin CTesticular ultrasound DUrethral swab and Gram stain

Correct Answer ( A ) Explanation: Epididymitis is the most common cause of scrotal pain in adults and is characterized by acute unilateral pain and swelling. The pain usually begins at the epididymis and can spread to the entire testicle (epididymo-orchitis). Other symptoms include fever, erythema of the scrotal skin, and dysuria. It is associated with a C-reactive protein level greater than 24 mg per L and increased blood flow on ultrasonography. Chlamydia trachomatis and Neisseria gonorrhoeae are the most common organisms responsible for bacterial epididymitis in males younger than 35 years. Guidelines recommend ceftriaxone (250 mg IM x 1) and doxycycline (100 mg PO BID x 10 days) for treatment of suspected epididymitis in males younger than 35 years. Levofloxacin (B) is the treatment of choice for epididymitis-orchitis in males older than 35 years of age. The most common pathogens in this population are the enteric bacteria (e.g. E. coli).

A 19-year-old boy presents with scrotal pain and fever. Examination reveals a tender, swollen testicle. Scrotal Doppler ultrasonography shows increased blood flow to the testicle. Elevation of the scrotum lessens the patient's pain. Which of the following organisms is the most common cause of this condition in this patient? Chlamydia trachomatis Escherichia coli Group A Streptococcus Staphylococcus epidermidis

Correct Answer ( A ) Explanation: Epididymitis occurs most commonly in men between the ages of 14 and 35 years. Epididymitis is characterized by a gradual onset of scrotal pain, fever and urinary urgency, frequency, dysuria, pyuria or hematuria. Examination usually reveals localized epididymal edema and tenderness (posterior aspect of scrotum), possible testicular tenderness, and a normal cremasteric reflex. Pain may be relieved with testicular elevation (positive Prehn sign). Scrotal pain should be initially evaluated with a color Doppler ultrasound test, and in the case of epididymitis, the typical findings are an enlarged, thickened epididymis with increased blood flow. The most common organism responsible for epididymitis in those 14 to 35 years-of-age are Neisseria gonorrhoeae and Chlamydia trachomatis. In older individuals (traditionally > 35 years of age), the gram-negative rod bacteria (Escherichia, Klebsiella, Enterobacter and Citrobacter species) are most common.

A 68-year-old woman with no significant medical history presents to the clinic with her daughter for cognitive changes. The daughter says that her mother gets "lost" in conversations, and that she would "sleep all day" if permitted. Further questioning reveals a recent history of constipation, as well as passing two kidney stones within the past 12 months. Which of the following electrolyte imbalances is most consistent with these symptoms? Hypercalcemia Hyperkalemia Hypocalcemia Hypokalemia

Correct Answer ( A ) Explanation: Hypercalcemia is associated with cognitive changes, malaise and fatigue, constipation, and renal calculi. Other symptoms may include polyuria, polydipsia, and bone pain. This can be remembered by the phrase "stones, bones, abdominal groans, psychic moans, and fatigued overtones." Hypercalcemia has many possible etiologies, though primary hyperparathyroidism remains the most common. Others include hypercalcemia of malignancy, multiple myeloma, sarcoidosis, prolonged immobilization, or excessive intake of calcium/vitamin D supplements. The most accurate measurement of serum calcium is the ionized calcium concentration and should be ordered whenever the total serum calcium abnormal. Until the primary cause is identified, hypercalcemia is initially managed with fluids and forced calciuresis. Intravenous saline is needed in severe cases. Intravenous bisphosphonates may be used in hypercalcemia that is due to hyperparathyroidism or a malignancy. Calcitonin can be given to manage hypercalcemia while the bisphosphonates reach therapeutic levels. Unmanaged hypercalcemia may lead to serious complications including neuromuscular manifestations such as weakness or paresthesia, or cardiac arrhythmias secondary to QT interval shortening or heart block.

A 61-year-old man with a history of diabetes mellitus presents to the emergency department with complaints of weakness, fatigue, chest pain and shortness of breath. His pulse is 58/min, respirations are 14/min and blood pressure is 110/78 mm Hg. Physical exam findings include absent deep tendon reflexes. An ECG shows peaked T-waves, shortened QT interval and ST-segment depression. Which of the following is the most appropriate initial therapy? Calcium Epinephrine Potassium Sodium bicarbonate

Correct Answer ( A ) Explanation: Hyperkalemia is a common clinical finding that occurs when the serum potassium concentration is above 3.5-5.5 mEq/L in adults. The most common cause of hyperkalemia is decreased potassium excretion. This can occur in patients with renal impairment, diabetes mellitus and those taking certain medications such as potassium-sparing diuretics, nonsteroidal anti-inflammatory agents and ACE inhibitors. It can also be the result of increased potassium intake or a shift of potassium from the intracellular to the extracellular space. Many patients with hyperkalemia are asymptomatic. When clinical manifestations occur, patients generally present with symptoms related to cardiac and muscular function. The most common patient complaints are fatigue and weakness. Other symptoms may include chest pain, shortness of breath, nausea, vomiting, and paresthesias. Diagnosis is made when elevated serum potassium is determined through blood testing. The blood test should be repeated before any action is taken to reduce the potassium level in a patient without a previous history of hyperkalemia. Rapid acting therapy should be initiated in patients with hyperkalemia and ECG changes, serum potassium greater than 6.5-7 mEq/L, or in which the serum potassium level is rapidly increasing. Initial therapy is with calcium. Calcium helps to stabilize cardiac membranes but does not actually lower serum potassium levels. Therefore, after calcium is administered, other agents such as insulin with dextrose, should be administered to shift potassium intracellular.

Which organism is the principle cause of epididymitis in men under the age of 35? Chlamydia trachomatis Haemophilus ducreyi Mycoplasma genitalium Neisseria meningitidis

Correct Answer ( A ) Explanation: In men younger than 35 years, Chlamydia trachomatis (along with Neisseria gonorrhoeae) is the principal cause of epididymitis, whereas in men older than 35 years, complicated urinary tract infection with uropathogens is a more common cause, especially in those with prostate disorders. Up to 15% of epididymitis cases are complicated by chronic pain that is usually idiopathic and often unresponsive to antibiotics. Other complications include decreased fertility and, rarely, testicular abscess. Chlamydia can spread from the urethra to the epididymis, causing epididymitis in up to 1 to 3% of infected men. Symptoms include testicular pain and scrotal erythema and swelling that are typically unilateral. On examination, there is palpable swelling and tenderness of the epididymis; accompanying findings may include testicular tenderness, scrotal erythema and swelling, urethral discharge, or hydrocele.

A 17-year-old woman with a history of type 1 diabetes presents to the emergency room. She states that she was in her usual state of health yesterday, but today developed nausea, vomiting, and severe abdominal pain. She states that she ran out of her insulin yesterday. On exam, you notice her to be tachypneic. Laboratory results reveal the following: Na: 140 Cl:100 Bicarb:12 Glucose: 650 Ketones: 2+ pH: 2.9 PaCO2:30 What primary acid/base disorder does this patient exhibit?

Correct Answer ( A ) Explanation: Metabolic acidosis with elevated anion gap is seen in diabetic ketoacidosis (DKA). The pH in this example is below 7.35, which is consistent with acidemia. Once the acid/base is classified, look at the bicarbonate and note that it is also low. This scenario, low pH and low bicarbonate, is consistent with a metabolic acidosis. The anion gap is calculated by subtracting the serum anions from the serum cations. The common calculation for the anion gap is [sodium - (chloride + bicarbonate)]. In this scenario, the anion gap is 140 - (100 + 12) = 28. Therefore, this patient has an anion gap metabolic acidosis. A normal anion gap is between 3 to 10 mEq/L. Anything above 10 is considered an elevated anion gap. Patients with diabetic ketoacidosis have an elevated anion gap acidosis, hyperglycemia, and ketonemia. The most common precipitant of DKA is infection and missed insulin doses. Symptoms at presentation include nausea, vomiting, and abdominal pain. Compensatory deep and labored breathing (Kussmaul respirations) occurs, as the patient works to remove excess carbon dioxide through increased respirations. Some other conditions that cause an elevated anion gap are lactic acidosis, ketoacidosis, and ingestion of methanol, ethylene glycol, salicylates, and propylene glycol

A 70-year-old woman with multiple myeloma presents with confusion, lethargy, abdominal cramping, nausea and generalized weakness. Her vital signs are normal. What electrolyte abnormality is likely responsible for this presentation? Hypercalcemia Hyperkalemia Hypocalcemia Hypokalemia

Correct Answer ( A ) Explanation: Patients with multiple myeloma are at an increased risk for hypercalcemia secondary to increased breakdown of bone. In a patient with multiple non-specific symptoms, electrolyte disturbances should be suspected. Hypercalcemia can present with a number of symptoms including altered mental status, abdominal pain, nausea, vomiting, weakness, lethargy, muscle aches and depression. The most common cause of hypercalcemia is primary hyperparathyroidism. Malignancy is also a common cause. About 30% of patients with multiple myeloma will experience hypercalcemia at some point in their clinical course. Severe hypercalcemia (>14 mg/dl) can lead to both high degree AV blocks and ventricular dysrhythmias. Treatment of hypercalcemia focuses first on restoring intravascular volume with intravenous fluids (IVF). Patients at risk for hypercalcemia are often volume depleted secondary to chronic illness and decreased oral intake. Restoring circulating volume allows for increased perfusion to the kidneys and elimination of calcium through urine. Once intravascular volume has been repleted, the clinician can attempt to enhance renal elimination (i.e. forced diuresis) by administering a loop diuretic (i.e. furosemide). Although not typically started in the ED, bisphosphonates can be given to inhibit osteoclast activity thus reducing the amount of calcium entering the blood stream.

A 67-year-old man presents to his primary care provider with dyspnea and fatigue. He has a past medical history of hypertension, diabetes mellitus, and stage 3 chronic kidney disease. A CBC shows a hemoglobin of 9 g/dL, hematocrit of 28%, total iron-binding capacity of 220 mcg/dL, mean corpuscular volume of 80 fL, mean corpuscular hemoglobin concentration of 31 g/dL, and ferritin of 310 ng/dL. A peripheral blood smear shows normocytic, normochromic red blood cells with few reticulocytes. Which of the following is the most appropriate management? Cyanocobalamin Darbepoetin Ferrous gluconate and darbepoetin Red blood cell transfusion

Correct Answer ( B ) Explanation: The man in this case has anemia of chronic disease and should be managed with darbepoetin. Anemia in chronic kidney disease (CKD) is primarily due to decreased production of erythropoietin by the diseased kidney. Almost all of patients with glomerular filtration rate less than 30 mL/min have some degree of anemia. Erythropoietin is produced by the kidney in response to decreased blood oxygen levels. Erythropoietin stimulates red blood cell production by the bone marrow. Anemia in CKD should be differentiated from iron deficiency anemia. In anemia of CKD, total iron binding capacity is usually normal to decreased; mean corpuscular volume and mean corpuscular hemoglobin are slightly decreased. Serum ferritin levels are usually increased. The anemia in CKD is usually normocytic and normochromic, in contrast to iron deficiency anemia which is a microcytic and hypochromic anemia. Symptoms of CKD anemia include fatigue, dyspnea, depression, palpitations, and reduced exercise capacity. Recombinant human erythropoietin and other erythropoiesis-stimulating agents are the standard of care for anemia in CKD. Treatment is usually recommended when hemoglobin (Hgb) levels fall below 10 g/dL. The goal of treatment should be to maintain Hgb levels between 10.5 and 11.5 g/dL. Hgb levels greater than 13 g/dL are associated with increased morbidity and mortality. Epoetin alpha and darbepoetin are two erythropoiesis-stimulating agents commonly used. Both drugs have a black box warning for increased risk of thromboembolism, myocardial infarction, and stroke when used to target Hgb levels > 11 g/dL. Because CKD alone is an independent risk factor for development of cardiovascular disease, risks versus benefits should be weighed before initiated an erythropoiesis-stimulating agents. Patients with CKD require close prevention and management of cardiovascular disease. At this point, this man does not require a red blood cell transfusion (D). A red blood cell transfusion threshold of 7 to 8 g/dL is generally accepted in hemodynamically stable patients except those with acute coronary syndrome.

A 24-year old woman presents with URI symptoms. She is 32 weeks pregnant. As part of her work-up, you order a urinalysis, which shows 2+ bacteria with no WBCs. Two days later, the lab calls you and informs you that the urine culture is positive. You call the patient back and she denies symptoms of urinary tract infection. With regards to the urine culture results, what treatment is indicated? Cephalexin 500 mg QID for 7 days Ciprofloxacin 500 mg QID for 7 days No treatment is necessary Trimethoprim-sulfamethoxazole 1 DS tablet BID for 3 days

Correct Answer ( A ) Explanation: The patient has asymptomatic bacteriuria of pregnancy confirmed by a positive urine culture and should be treated with an oral antibiotic that is known to be safe in pregnancy, such as cephalexin 500 mg QID for 7 days. Asymptomatic bacteriuria is common in the general population and in most scenarios does not require therapy. However due to the high risk of complication seen during pregnancy, it should be treated with antibiotics. It is seen in 2-10% of pregnant women and is commonly due to E. coli. Pregnant women have an increased risk of developing urinary tract infections due to the pressure that the enlarged uterus exerts on the ureters and bladder, incomplete emptying during voiding and impaired ureteral peristalsis from progesterone-induced relaxation of the ureteral smooth muscle. Complications of untreated asymptomatic bacteriuria include development of a lower urinary tract infection, pyelonephritis, renal abscess, renal failure, bacteremia, sepsis, intrauterine growth retardation, premature labor and neonatal death. Treatment options generally include cephalosporins, such as cephalexin, amoxicillin (or amoxicillin-clavulanate) and nitrofurantoin. All of which are recognized as Category B by the Food and Drug Administration; meaning that animal studies have failed to show a risk to the fetus. Treatment duration should be for 7-10 days.

A 67-year-old man with hypertension and end-stage renal disease presents after an incomplete dialysis session secondary to shortness of breath. His vital signs are BP 110/95, HR 65, RR 22, T 37.3°C, and oxygen saturation 99% on 2L NC. You obtain the ECG above. Which of the following is the most appropriate next step in this patient's management? Calcium gluconate Cardiology consultation Defibrillation Transcutaneous pacing

Correct Answer ( A ) Explanation: This ECG is indicative of hyperkalemia, one of the most lethal complications of chronic kidney disease encountered in the ED. A potassium level of 6 mEq/L should be considered potentially dangerous, even though many patients with ESRD chronically tolerate serum levels above this and do not manifest ECG changes. The most rapid treatment for hyperkalemia is intravenous calcium (gluconate with peripheral access, chloride with central access), which transiently reverses cardiac effects of hyperkalemia by antagonism of potassium at the cardiac membrane. Calcium is indicated in all patients with suspected hyperkalemia who have widening of the QRS, an unstable dysrhythmia, bradycardia, or hypotension.

A 19-year-old man presents to the ED with pain along his penile shaft for the past 7 days. He reports a low-grade fever and myalgias and was sexually active with a new partner 10 days ago. He denies any penile discharge or dysuria. There is no inguinal adenopathy palpated on exam, but he has tender penile lesions, revealed in the image seen above. Which of the following is most likely to be an effective treatment? Acyclovir PO Ceftriaxone IM Doxycycline PO Penicillin G IM

Correct Answer ( A ) Explanation: This is a patient with a primary herpes infection, characterized by a low-grade fever; myalgias; and multiple painful, shallow, tender, genital lesions. These typically follow a 2-7-day incubation period. Patients often do not have adenopathy until the 2nd or 3rd week of illness. Lesions last for 2-4 weeks. Treatment is acyclovir to reduce the duration of symptoms and viral shedding.

A 59-year-old man presents with 2 days of dysuria, frequency, lower abdominal pain, and chills. He has been eating and drinking normally and is able to urinate, though he has general malaise. He denies penile discharge, testicular pain, sexual activity, a history of sexually transmitted infections, prior urinary symptoms, or weight loss. The patient's abdomen is soft and nontender; his genitourinary exam is normal except that on a gentle rectal exam, he has a boggy, tender prostate. A urinalysis, urine culture, and Gram stain are sent and pending. Which of the following is the most likely cause of this patient's symptoms? Escherichia coli Neisseria gonorrhoeae Peptostreptococcus magnus Pseudomonas aeruginosa

Correct Answer ( A ) Explanation: This is a patient with acute bacterial prostatitis, as evidenced by the development of acute urinary symptoms, malaise, chills, and a boggy, tender prostate. Most of the causative organisms are the same as those that cause urinary tract infections, and E. coli is responsible for more than 80% of cases.

A 32-year-old woman presents six hours after ingesting 40 tablets of regular-strength (325 mg) aspirin in a suicide attempt. She is lethargic with a heart rate of 106 beats/minute, blood pressure of 142/84 mm Hg, respiratory rate of 30 breaths/minute, and a temperature 38.5 0C. What abnormality would be expected on her arterial blood gas? Mixed respiratory acidosis with a metabolic alkalosis Mixed respiratory alkalosis with a metabolic acidosis Pure metabolic acidosis Pure respiratory alkalosis

Correct Answer ( B ) Explanation: Aspirin toxicity results in a complex acid-base disturbance. Salicylates stimulate the respiratory center resulting in tachypnea, with a subsequent decrease in pCO2 and respiratory alkalosis. Cell metabolism is also interrupted, leading to the production of lactic acid and ketoacids and an elevated anion gap metabolic acidosis. The mixed respiratory alkalosis with the elevated anion gap metabolic acidosis can result in a near-normal pH. In the late stages of toxicity, as the patient becomes progressively more fatigued with associated electrolyte abnormalities and dehydration, a respiratory acidosis can occur which signals impending cardiovascular collapse.

Which of the following is the most appropriate treatment for urge incontinence? Estrogen replacement therapy Oxybutynin Pseudoephedrine Sildenafil

Correct Answer ( B ) Explanation: Urinary incontinence is characterized by the unintentional loss of urine. Urge incontinence is the most common type of incontinence in geriatric patients and is due to detrusor overactivity. Patients may feel an abrupt urge to urinate, but cannot get to the toilet in time. It is also associated with nocturia. The workup begins with a bladder-voiding diary, urinalysis and urine culture. Examination should begin with determining post void residual (PVR) by having the patient completely void, then checking for residual urine volume via catheterization or ultrasonography. PVR > 200 indicates urinary retention. Nonpharmacologic therapy should be tried first. These include frequently scheduled voids, bladder training such as urge suppression, and behavior modifications such as reducing caffeine and alcohol and late night fluid intake. Pharmacologic therapy includes anticholinergics such as oxybutynin and tolterodine. These agents antagonize acetylcholine at muscarinic receptors, leading to bladder smooth muscle relaxation. Tolterodine may cause less dry mouth than oxybutynin.

A 26-year-old woman is found to have a blood pressure of 160/90 mm Hg. Similar values are obtained on two subsequent visits. She denies episodic headaches, palpitations, and diaphoresis. She is not obese. On abdominal exam, she is found to have a renal bruit. No abdominal masses are palpated. Her serum creatinine is 1.5 mg/dL. What is the most likely diagnosis? Autosomal dominant polycystic kidney disease Fibromuscular dysplasia Minimal change disease Pheochromocytoma

Correct Answer ( B ) Explanation: Fibromuscular dysplasia should be suspected in women younger than 35 years with unexplained hypertension. Fibromuscular dysplasia (FMD) is most commonly seen in women. The mean age of diagnosis is 52 years. The renal arteries and extracranial cerebrovascular arteries are most commonly affected and most patients have involvement of multiple arteries. FMD is a noninflammatory, nonatherosclerotic disease that results in arterial occlusion, stenosis, and dissection. The etiology of FMD is unknown, however, there are reported autosomal inheritance in some families. Hormones have also been implicated given the predominance of middle-aged women affected. Hypertension is the most common finding in renal FMD. Flank pain or abdominal pain can result from renal or mesenteric artery ischemia, aneurysm, or dissection. Typical findings of extracranial cerebrovascular FMD include headache, pulsatile tinnitus, and neck pain. These symptoms are indicative of stenosis, dissection, aneurysmal rupture, or thromboembolism. FMD should be suspected in women with hypertension before 35 years of age, women with severe or resistant hypertension, women with an epigastric bruit, in any woman less than 60 years of age with a transient ischemic attack or stroke. Non-invasive diagnostic imaging, like computed tomography angiography (CTA), magnetic resonance angiography (MRA), or duplex ultrasonography, are usually sufficient to diagnose FMD. Treatment of FMD depends on severity of disease and the arteries involved. Patients presenting with acute stroke symptoms should be managed as an ischemic stroke regardless of FMD. Angioplasty with or without stenting for renal FMD has a good prognosis. Medical management involves blood pressure management and secondary prevention of strokes with antiplatelet agents. Minimal change disease (D) is in the nephrotic spectrum of renal disease. Typical symptoms include periorbital and dependent edema, hyperlipidemia, and hypoalbuminemia. Minimal change disease is most commonly seen in children.

You are evaluating a mentally challenged 45-year-old man for groin pain. On examination you notice that he has large ears, a prominent jaw, and large symmetric testicles. These findings are consistent with which one of the following? Asperger's syndrome Fragile X syndrome Klinefelter's syndrome Variant form of Down syndrome

Correct Answer ( B ) Explanation: Fragile X syndrome accounts for more cases of mental retardation in males than any other genetic disorder except Down syndrome. Fragile X syndrome is caused by an expansion mutation in the Fragile X mental retardation 1 (FMR1) gene located on the X chromosome. It characteristically leads to some degree of mental retardation. The phenotype is subtle, with minor dysmorphic features and developmental delay during childhood. Characteristic features during adolescence are an elongated face, prominent jaw, large ears, macro-orchidism, and a range of behavioral anomalies and cognitive deficits. Behavior is characterized by attention deficits, hand flapping, hand biting, and gaze aversion. The diagnosis of fragile X syndrome is confirmed by molecular genetic testing of the FMR1 gene. Down syndrome (D) is a chromosomal abnormality known as trisomy 21 and has a collection of clinical features which include micrognathia, macroglossia, epicanthal folds, flattened facial appearance, single transverse palmar crease as well as many other distinguishing features. This patient does not have any features of Down syndrome. Klinefelter syndrome (C) is caused by an additional X chromosome in males (47, XXY). Clinical findings are nonspecific during childhood; thus, the diagnosis commonly is made during adolescence or adulthood in males who have small testes with hypergonadotropic hypogonadism and gynecomastia. Virtually all men with Klinefelter syndrome are infertile.

A 67-year old woman is admitted to the hospital with a change in mental status. The initial workup includes a chemistry profile that reveals a plasma potassium level of 6.4 mEq/L (N 3.7 - 5.2). An ECG is performed that reveals peaked T waves. Which of the following is the most appropriate to administer to this patient? Albuterol Calcium gluconate Furosemide Sodium polystyrene sulfonate

Correct Answer ( B ) Explanation: Hyperkalemia is defined as a serum potassium concentration greater than 5.5 mEq/L in adults. As the potassium concentration increases, the patient is at increased risk of a lethal dysrhythmia. In patients with severe hyperkalemia, treatment focuses on immediate stabilization of the myocardial cell membrane. Although calcium gluconate has no effect on the plasma potassium level, it should be given when there are electrophysiologic changes in the setting of hyperkalemia in order to stabilize the cardiac membrane and reduce the risk of dysrhythmias. Calcium has no effect on the serum level of potassium. For that reason, administration of calcium should be accompanied by the use of other therapies that actually help lower serum potassium levels. Definitive therapy is hemodialysis in patients with renal failure or when pharmacologic therapy is not sufficient.

A 67-year old woman is admitted to the hospital with a change in mental status. The initial workup includes a chemistry profile that reveals a plasma potassium level of 6.4 mEq/L (N3.7-5.2). An ECG is performed that reveals peaked T waves. Which of the following is the most appropriate to administer to this patient? Albuterol Calcium gluconate Furosemide Sodium polystyrene sulfonate

Correct Answer ( B ) Explanation: Hyperkalemia is defined as a serum potassium concentration greater than 5.5 mEq/L in adults. As the potassium concentration increases, the patient is at increased risk of a lethal dysrhythmia. In patients with severe hyperkalemia, treatment focuses on immediate stabilization of the myocardial cell membrane. Although calcium gluconate has no effect on the plasma potassium level, it should be given when there are electrophysiologic changes in the setting of hyperkalemia in order to stabilize the cardiac membrane and reduce the risk of dysrhythmias. Calcium has no effect on the serum level of potassium. For that reason, administration of calcium should be accompanied by the use of other therapies that actually help lower serum potassium levels. Definitive therapy is hemodialysis in patients with renal failure or when pharmacologic therapy is not sufficient.

You have made a new diagnosis of polycystic kidney disease in one of your primary care patients. Proper maintenance of normal blood pressure should be obtained with which of the following medications? Furosemide Losartan Metoprolol Verapamil

Correct Answer ( B ) Explanation: In a patient with polycystic kidney disease, the development of hypertension signifies disease progression. Therefore, it is clinically necessary to maintain proper blood pressure in these patients. Target levels for adults are 140/90 mmHg or below the seventy-fifth percentile for children. Angiotensin-converting-enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) are the preferred therapeutics. Studies have shown that treatment with these drugs, as compared to other antihypertensives, is associated with preservation of normal renal function in those with PKD. Common ARBs are medications ending in -sartan, such as losartan, irbesartan and valsartan.

A 67-year-old man presents to your office six months after prostatectomy for follow up on his previously diagnosed prostate cancer. Labwork reveals an elevated serum prostate specific antigen. After discussing options with the patient, a decision is made to use pharmacologic treatment. Which of the following is the most appropriate initial agent? Doxazosin Leuprolide Tadalafil Terazosin

Correct Answer ( B ) Explanation: In the United States, prostate cancer is the most frequently diagnosed type of cancer in men after skin cancer. Prostate cancer is seen more commonly in African-American men and the likelihood of developing this type of cancer increases with age. Risk factors include a family history of prostate cancer, cigarette smoking and a diet high in animal fat. Most patients diagnosed with prostate cancer are asymptomatic and the cancer is found on digital rectal exam (DRE) or because of an elevated serum prostate specific antigen (PSA). Diagnosis is made with biopsy. Treatment is based on severity of disease and after discussion with patient since options may significantly impact quality of life. Initial treatment discussion should focus on the patient's life expectancy and the characteristics of the tumor. Treatment options for localized prostate cancer include active surveillance, prostatectomy, radiation therapy and hormonal therapy. When systemic therapy is indicated, androgen deprivation therapy is initiated using gonadotropin releasing hormone (GnRH) agonists such as leuprolide. Doxazosin (A) and Terazosin (D) are alpha-1-adrenergic antagonists used in the treatment of benign prostatic hypertrophy. Tadalafil (C) is a phosphodiesterase-5 inhibitor used to treat both erectile dysfunction and benign prostatic hypertrophy.

An 18-year-old woman, who was just fired from her job, admits to ingesting 50 tablets of 325 mg strength aspirin three hours prior to arrival in the ED. She complains of dyspnea and tinnitus but denies any nausea and vomiting. On physical examination, you find a moderately distressed diaphoretic woman with tachycardia and tachypnea but clear lungs bilaterally and an oxygen saturation of 98%. You ask the nurse to initiate intravenous access, draw labs, and continuous cardiac monitoring. The arterial blood gas results are called back to you by the lab. What is the classic early blood gas seen in adults with acute aspirin ingestion? Metabolic acidosis Metabolic acidosis and respiratory alkalosis Metabolic and respiratory acidosis Triple acid/base disorder (respiratory alkalosis, high anion gap metabolic acidosis, and metabolic alkalosis)

Correct Answer ( B ) Explanation: Salicylates (aspirin) directly stimulate the respiratory center of the brain to cause hyperventilation and a subsequent respiratory alkalosis. A concurrent metabolic acidosis also develops, primarily from the uncoupling of oxidative phosphorylation, which leads to anaerobic metabolism, lactate production (with development of an anion gap), and hyperthermia. There is increased fatty acid metabolism as well, which results in excess ketone production and superimposed ketoacidosis. The respiratory alkalosis is not compensation for the metabolic acidosis.

A previously healthy, asymptomatic 21-year-old woman presents to your office with questions about screening for sexually transmitted infections. She is sexually active and would like to know what screening tests she should have done. Which of the following is the next best step in management? Annual testing for human papillomavirus Annual testing for Neisseria gonorrheae and Chlamydia trachomatis One time screening for hepatitis B One time screening for herpes simplex virus

Correct Answer ( B ) Explanation: Sexually transmitted infections (STIs) are a serious public health problem in the United States and worldwide. Sequelae of untreated STIs include infertility, cervical cancer, infections, and transmission to uninfected individuals. Many patients with STIs are asymptomatic, and assessment of risk factors is an important aspect of determining who and when to screen. STI counseling and an assessment of risk factors begins with a thorough sexual history including questions about new partners, frequency of condom use, history of multiple sexual partners, intercourse with trauma, and types of sexual exposures. Risk factors for STIs include new and multiple sexual partners, age younger than 25 years, previous STIs, illegal drug use, incarceration at a correctional facility or juvenile detention facility, intercourse with sex workers, and meeting sexual partners on the internet. The United States Preventive Services Task Force (USPSTF) recommends annual screening for Neisseria gonorrheae and Chlamydia trachomatis infection in sexually active women under the age of 25 years.

A 55-year-old man presents to the office interested in obtaining medication for his erectile dysfunction. He states he has trouble maintaining and keeping erections 75% of the time and has no other medical problems. His main concern is that he is single and sometimes not sure when the opportunity will present to have sex, so he wants the medication with the longest duration. Which of the following medications should you recommend? ASildenafil (Viagra®) BTadalafil (Cialis®) CVardenafil (Levitra®) DYocon (Yohimbine®)

Correct Answer ( B ) Explanation: Tadalafil has a duration of 24-72 hours. Phosphodiesterase-5 inhibitors are first-line therapy for erectile dysfunction (ED) and are effective in most cases, including antidepressant-induced ED and diabetes related. In 1998, sildenafil was the first PDE-5 inhibitor to become FDA approved, followed by vardenafil and tadalafil in 2003. The medications differ in absorption, potential effective time interval, and side effects.

In the patient with an enlarged prostate, which of the following drugs causes involution of benign prostatic tissue and prostate shrinkage? Doxazosin (Cardura®) Finasteride (Proscar®) Tadalafil (Cialis®) Vardenafil (Levitra®)

Correct Answer ( B ) Explanation: The 5 alpha-reductase inhibitors have been available since the early 1990s and finasteride was the first agent in this class. Finasteride prevents the conversion of testosterone to the more active metabolite dihydrotestosterone in the prostate. This inhibition results in involution of BPH tissue and prostate shrinkage. On average, most men achieve 20% to 40% reduction in prostate size after at least 6 months of use. In general, these agents are most effective in men with prostate glands more than 30 g. Urologists also use 5 alpha-reductase inhibitors to treat chronic hematuria due to an enlarged prostate and sometimes prescribe these agents before transurethral resection of the prostate (TURP) to lessen surgical bleeding. Finasteride is also indicated for hair-regrowth of the scalp. Doxazosin (A) is an alpha-adrenergic blocking oral agents to treat BPH has been commonplace since the 1980s. These agents are directed at the dynamic component of BPH and LUTS by relaxing the smooth muscle tissue in the bladder neck and prostate. In simple terms, they relax the bladder outlet, resulting in better urinary flow.

You are in the clinic with a medical student who saw a 17-year-old girl for vaginal discharge. The medical student informs you that the patient complains of yellow discharge that is accompanied by pruritus. The patient has been sexually active for the past six months with one partner. The patient also has an intrauterine device placed six months ago. On examination, there is white vaginal discharge with strong odor. The vaginal pH is 5 with clue cells on wet mount. You diagnose bacterial vaginosis. The medical student asks you what causes it. Which of the following statements would best describe the cause of bacterial vaginosis? Acquisition of Trichomonas vaginalis Decrease in concentration of Lactobacillus sp. Increase in concentration of Gardnerella vaginalis Overgrowth of Candida albicans

Correct Answer ( B ) Explanation: The patient has vaginal discharge due to bacterial vaginosis. It represents a complex change in the vaginal flora brought about by the reduction in concentration of the dominant lactobacilli. These lactobacilli produce hydrogen peroxide that is important in preventing overgrowth of anaerobes that are normally present in the vaginal flora. The loss of lactobacilli results in the increase of vaginal pH and massive overgrowth of anaerobes. These anaerobes produce large amounts of proteolytic carboxylase enzymes that break down vaginal peptides into amines. Common anaerobes include Gardnerella vaginalis, Ureaplasma sp., and Mycoplasma sp. Clinical features include off-white, thin, and homogeneous vaginal discharge with "fishy" odor. Diagnosis is based on the presence of at least three of Amsel criteria: characteristic vaginal discharge, pH ˃ 4.5, positive whiff test, and clue cells on wet mount. Treatment is indicated for relief of symptoms using metronidazole or clindamycin administered either orally or intravaginally.

A patient's arterial blood gas is noted to have a pH 7.32, pCO2 32 mm Hg, HCO3 16 mmol/L. Which of the following is the correct interpretation of this arterial blood gas? Metabolic acidosis with respiratory alkalosis Pure metabolic acidosis Pure respiratory acidosis Respiratory acidosis with metabolic alkalosis

Correct Answer ( B ) Explanation: This patient has a pH 7.32 with a decreased serum bicarbonate and therefore has a metabolic acidosis. Physiologic compensation for a metabolic acidosis involves stimulation of the respiratory center, thereby increasing minute ventilation in an attempt to decrease the pCO2 and bring the pH back near 7.4. With normal respiratory compensation, for every 1 mmol/L decrease in HCO3, there should be a 1 mm Hg decrease in pCO2. If the measured value of pCO2 in higher than expected, there is a concomitant respiratory acidosis. Likewise, if the measured value of pCO2 is lower than expected, there is a concomitant respiratory alkalosis. The anticipated pCO2 can also be calculated using the formula pCO2 = (1.5 * [HCO3] + 8) +/- 2. In this case, with a HCO3 16 mmol/L, the expected pCO2 is 32 mm Hg (1.5 * 16 + 8). Because the calculated pCO2 and the measured pCO2 are the same, this patient has a pure metabolic acidosis.

A 23-year-old man presents with burning and itching of the penis. On physical examination, the patient is uncircumcised. There is erythema and inflammation of the distal foreskin and superficial layer of the glans. With retraction of the foreskin there is scant white discharge. What is the appropriate treatment? Ceftriaxone IM Clotrimazole cream Doxycycline Mupirocin ointment

Correct Answer ( B ) Explanation: This patient has balanoposthitis, inflammation of the glans penis (balanitis) as well as the distal foreskin (posthitis). There are multiple causes of balanoposthitis. In younger patients, local irritation from bubble baths is a common cause as well as from soaps and detergents. These cases are treated with topical steroids like hydrocortisone. The etiology may also be infectious with candida as the most common organism. With Candidal infections, a whitish discharge with some eroded plaques may be present. This patient's presentation is suggestive of a Candida infection which is treated with topical antifungal agents such as clotrimazole. Other infectious organisms include anaerobic organisms (treated with topical metronidazole) as well as streptococcal infections. It is uncommon for sexually transmitted infections to cause balanoposthitis. By far the most common contributing factor is poor hygiene.

An 18-year-old sexually active man presents with painful swelling in his groin. He developed painful lesions on his penis one week ago and now has right sided groin swelling. His examination demonstrates multiple penile ulcerations and a large, painful, fluctuant lymph node in the right groin. Which organism is responsible for this infection? Chlamydia trachomatis Haemophilus ducreyi Herpes simplex virus Klebsiella granulomatis

Correct Answer ( B ) Explanation: This patient has chancroid, caused by Haemophilus ducreyi. Patients develop multiple painful genital ulcers and the characteristic inguinal bubo. The ulcerations are sharply demarcated with purulent bases. Fifty percent of patients have lymph node involvement with a unilateral, large, painful and fluctuant node (bubo). H. ducreyi is difficult to culture and the diagnosis is often made clinically. Drainage of the bubo is not routinely recommended as it responds to antimicrobial therapy. Treatment options include: azithromycin 1 g PO, ceftriaxone 250 mg IM, ciprofloxacin 500 mg PO twice daily for three days, or erythromycin 500 mg PO three times daily for seven days.

A 44-year-old woman with multiple sclerosis presents with 3 weeks of urine leakage. She does not have a strong desire to urinate prior to her most distressing complaint of "dribbling". She has no history of pelvic surgery. She denies dribbling after coughing or sneezing. Which of the following best describes this patient's urinary incontinence? Deformity (lack-of-continuity) Overflow Stress Urge

Correct Answer ( B ) Explanation: Urinary incontinence is a common disorder in primary care. It is more common in women than men. The key to the diagnosis and successful treatment is understanding the different categories of incontinence. Overflow incontinence is characterized by unpredictable dribbling of urine or weak urine stream due to detrusor hyporeflexia (underactive bladder) or urinary outlet obstruction. Underactive bladder may be due to medications (e.g. calcium channel blockers, anticholinergics) or detrusor denervation or injury. Outlet obstruction may be due to enlarged prostate gland, tumors, urethral stricture, or chronic constipation. Treatment includes discontinuation of medications that promote urinary retention. Prazosin and terazosin are alpha-blockers that induce internal sphincter relaxation and may relieve retention associated with benign prostatic hyperplasia (BPH). 5-alpha-reductase inhibitors such as finasteride may partially relieve symptoms associated with BPH, but require months for onset of effect. Acute urinary retention and acontractile bladders require indwelling or intermittent catheterization.

Which of the following is the first line medical treatment for symptomatic hypercalcemia? Bisphosphonates Calcitonin Fluid rehydration Furosemide

Correct Answer ( C ) Explanation: Aggressive rehydration with intravenous fluids is the initial treatment for patients diagnosed with hypercalcemia. Patients with calcium levels greater than 14 mg/dL or symptomatic patients with calcium levels greater than 12 mg/dL should be immediately and aggressively treated with fluid resuscitation. Normal saline should be used to achieve a urine output of 200 mL/hour. Volume depletion leads to enhanced renal sodium loss, which tends to perpetuate the hypercalcemia by increasing sodium resorption in the kidneys. Common manifestations of hypercalcemia include nephrolithiasis, bone pain, QT interval shortening, gastrointestinal manifestations and psychiatric effects - remembered by the mnemonic Stones, Groans, Moans, and Psychiatric overtones). Primary hyperparathyroidism and malignancy account for more than 90% of hypercalcemia cases. Other causes include medications such as lithium and thiazide diuretics, Vitamin-D intoxication, granulomatous disease, immobilization, and other endocrine disorders. When evaluating for hyperparathyroidism, it is important to obtain a full history, exam and medication history as well as an intact parathyroid hormone (PTH) level. Calcitonin (B) and bisphosphonates (A) are both effective at lowering calcium levels by inhibiting osteoclastic bone resorption and are both used for hypercalcemia once hydration has been initiated. Bisphosphonates are only used in hypercalcemia of malignancy and will take 72 hours to act, whereas calcitonin is used in all causes of hypercalcemia and is rapid acting, however tachyphylaxis after 24 hours is a common side effect. In resistant, life-threatening hypercalcemia, hemodialysis should be instituted.

Which of the following disorders causes a normal anion gap metabolic acidosis? Cyanide exposure Diabetic ketoacidosis Diarrhea Salicylate ingestion

Correct Answer ( C ) Explanation: Diarrhea is a common cause of normal anion gap metabolic acidosis. Metabolic acidosis is defined as a reduced serum bicarbonate concentration. Normal anion gap metabolic acidosis is thought to be less immediately dangerous than anion gap metabolic acidosis. Normal anion gap metabolic acidosis can be caused by a variety of conditions including rapid infusion of 0.9% saline, renal tubular acidosis, ingestion of acetazolamide and calcium chloride and hypoaldosteronism.

Which of the following is the most common solid renal tumor of childhood? Adenocarcinoma Leiomyoma Nephroblastoma Renal lipoma

Correct Answer ( C ) Explanation: Nephroblastoma, or Wilms tumor, is the most common solid renal tumor of childhood. It accounts for approximately 5% of all childhood cancers and in 5% of those cases the cancer occurs bilaterally. There is a sporadic form that arises from two postzygotic mutations and a familial form that arises after one pre-zygotic mutation and one postzygotic mutation. Signs and symptoms range from the discovery of an asymptomatic abdominal mass to abdominal pain, anorexia, abdominal distention, vomiting, and hematuria. Urinalysis will demonstrate hematuria and a complete blood count (CBC) may show anemia. Diagnosis can be made by obtaining abdominal ultrasound or CT scans of the abdomen, although chest X-ray is used to evaluate for metastatic lung disease. Treatment includes surgical resection of the kidney and is usually accomplished through a radical nephrectomy through a transabdominal incision. Chemotherapy and radiation therapy are also used as adjuncts to surgical resection. If the histology of the tumor is favorable, the prognosis is good with a 4-year-survival rate around 90%.

Which of the following best describes phimosis? Dilatation of the pampiniform venous plexus Fluid collection in the scrotum Inability to retract the foreskin over the glans penis Inability to return the retracted foreskin to its normal position

Correct Answer ( C ) Explanation: Phimosis is the inability to retract the foreskin over the glans penis and occurs in uncircumcised males. There are two types of phimosis. Physiologic phimosis is a natural occurrence in newborn males and is caused by adhesions in the tissue between the glans and inner prepuce. Pathologic phimosis occurs in adolescence or adulthood after the foreskin was previously able to be retracted. It occurs because of scar tissue that may develop as a result of poor hygiene, infection or inflammation. Diagnosis is a clinical one and emergency treatment is generally not required. Circumcision is not always necessary in phimosis. Stretching of the foreskin, topical steroids or surgical release are all options in the treatment of phimosis and an outpatient urology consult should be ordered to help with management.

5-year-old boy has acute onset of hematuria, periorbital edema, and hypertension. He has no other complaints and review of systems is unremarkable. Recent medical history is significant for a "cold" last week. What is the most likely etiology of his hematuria? Coagulopathy IgA nephropathy Post-streptococcal glomerulonephritis Urinary tract infection

Correct Answer ( C ) Explanation: Post-streptococcal glomerulonephritis classically presents as hematuria that begins 1-2 weeks after an episode of streptococcal pharyngitis or 3-6 weeks after a streptococcal skin infection. Often the initial infection is mild and thus does not lead to medical evaluation or recognition. Affected children are typically 5 - 12 years old with a mean age of 7 years old. Treatment is supportive. Although > 60% of patients briefly develop hypertension, > 95% make a full recovery.

A 25-year old man presents to the Emergency Department after a motor vehicle accident. An endotracheal tube was placed at the scene and he was transported via helicopter to the local trauma center. In the Emergency Department he had multiple imaging studies and lab tests done. His vital signs are HR 120, BP 110/75, RR 14 (vented), and T 36°C. Upon exam you note multiple facial lacerations with abrasions to his scalp, a midline trachea, clear breath sounds bilaterally, a benign abdomen, a stable pelvis, and minor lacerations to his extremities. A computer topography scan of his head shows a non-displaced skull fracture without intracranial hemorrhage. The other imaging studies show no other injuries to his chest, abdomen, or pelvis. Labs are hemoglobin 15.0, WBC 9,000, and platelets 200,000. He has been admitted to the Intensive Care Unit. Shortly after arriving an arterial blood gas is drawn which shows pH 7.30, PCO2 79 mm Hg, PO2 100 mm Hg, HCO3 24 mEq/L. Which of the following best describes this patient's metabolic state? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Correct Answer ( C ) Explanation: Respiratory acidosis is the result of hypoventilation and the development of hypercapnia. Arterial blood gases (ABG) are used to monitor metabolic state. Acidemia is defined as a pH below 7.35 and a respiratory cause is identified if the PCO2 is greater than 40 mm Hg. Hypoventilation can be caused by a variety of reasons. The underlying cause is CO2 retention and accumulation in the blood. This can be caused by chronic retention from pulmonary disease such as chronic obstructive pulmonary disease (COPD) or acute retention when patients are breathing on a ventilator. After 6-12 hours, the kidneys begin to compensate by increasing excretion of acid and generating more bicarbonate (HCO3). Compensated respiratory acidosis is noted after HCO3 increases greater than 28. Identification of reversible causes or changes in ventilator settings are the most appropriate treatment or intervention.

In a diabetic patient with new microalbuminuria, which of the following is the recommended first line treatment for the prevention of kidney disease? Amlodipine Blood pressure control to less than 120/70 Hemoglobin A1c less than 8.0 Low protein diet

Correct Answer ( D ) Explanation: A low protein diet has been shown to decrease urine albumin excretion and improve glomerular filtration rate (GFR). This may lower the rate of progression to end-stage renal disease and death compared with a normal-protein diet.

A 55-year-old man with stage III chronic kidney disease presents to the emergency department after a syncopal episode. He complains of cramping and weakness in his arms and legs for two days. A 12-lead ECG obtained in triage is shown above. Which of the following is the most likely cause of this patient's ECG changes? AAccessory pathway conduction BCoronary artery vasospasm CDecreased membrane excitability DSubendocardial ischemia

Correct Answer ( C ) Explanation: Symptomatic hyperkalemia is a life-threatening electrolyte abnormality typically seen in patients with underlying acute or chronic kidney disease. It can also be seen in conditions that cause increased tissue breakdown. Cardiac conduction abnormalities are the most serious manifestations of hyperkalemia. Symmetrical peaked T waves are the earliest ECG changes seen. Later changes include lengthening of the PR interval and QRS duration, disappearance of the P wave, and ultimately widening of the QRS complex into a sinusoidal pattern. The muscle and cardiac manifestations of hyperkalemia are a result of impaired neuromuscular transmission due to the persistent depolarization caused by elevated extracellular potassium levels. This leads to inactivation of the sodium channels, causing decreased membrane excitability that manifests as muscle weakness and cardiac conduction abnormalities.

A previously healthy 13-year-old boy presents to the emergency department with a complaint of severe groin pain that started two hours after he got home from soccer practice. His mother tells you that he's vomited twice since the onset of symptoms and is complaining of nausea. Physical exam findings include left-sided scrotal swelling and erythema, with tenderness to palpation of the left testicle which is sitting higher than the right. Cremasteric reflex is absent. Which of the following is the most likely diagnosis? Epididymitis Hydrocele Testicular torsion Testis tumor

Correct Answer ( C ) Explanation: Testicular torsion is a urological emergency that occurs when the spermatic cord structures twist, resulting in blood loss to the testicle. Early diagnosis and intervention is critical to saving the viability of the testicle and future fertility of the patient. Testicular torsion generally occurs in neonates and adolescents, and rarely occurs in adult men. In neonates it occurs when the testes rotate prior to the development of the tunica vaginalis, which is the structure that holds the testes in place within the scrotum. In adolescents it may be related to sports, physical activity or trauma. Clinical manifestations include sudden onset of unilateral pain in the scrotum, scrotal swelling, fever, nausea and vomiting. Once there is a high suspicion of testicular torsion, the recommended intervention is immediate surgical exploration. In order to be able to save the testicle, surgery must occur within six hours of symptom onset. Treatment delay may result in the need for orchiectomy or future decreased fertility.

A febrile infant with first urinary tract infection should be referred to undergo what other evaluation? Intravenous pyelogram Nuclear scanning with technetium-labeled dimercaptosuccinic acid (tc-99m DMSA scan) Renal and bladder ultrasonography Voiding cystourethrography

Correct Answer ( C ) Explanation: The 2011 AAP UTI Clinical Practice Guideline, Action Statement 5, states that febrile infants with 1st UTI should undergo renal and bladder ultrasonography (RBUS) to detect anatomic abnormalities that may require further evaluation and intervention. The RBUS should be done during the first 2 days of treatment to identify serious complications such as renal or perirenal abscesses or pylonephrosis if the patient's clinical illness is unusually severe or is not clinically improving. However, if the patient demonstrates significant improvement, then the RBUS should be performed after resolution of the acute illness.

34-year-old woman presents to the Emergency Department five days after total thyroidectomy with tingling in her hands. On physical examination, she has twitching at the corner of her mouth upon tapping the side of her face. Which of the following laboratory abnormalities is most likely? Hyperkalemia Hypervitaminosis D Hypocalcemia Hypophosphatemia

Correct Answer ( C ) Explanation: This patient is exhibiting signs and symptoms of hypocalcemia, most commonly caused by hypoparathyroidism. Signs and symptoms are exclusively related to hypocalcemia, and include reduced myocardial contractility, perioral and distal extremity paresthesias, and tetany. There are two hallmark physical exam findings with significant hypocalcemia: Chvostek's sign and Trousseau's sign. Chvostek's sign consists of facial twitching caused by tapping the facial nerve anterior to the ear. Trousseau's sign consists of carpal spasm when a blood pressure cuff is inflated on the upper arm above the systolic pressure for greater than three minutes. Partial or total thyroidectomy is the most common etiology of hypoparathyroidism as the parathyroid is located immediately behind and is often partially or totally attached to the thyroid gland. Other causes of hypoparathyroidism include a congenital deficiency or infiltrate of the parathyroid glands from metastatic carcinoma, hemochromatosis, or Wilson disease. Diagnosis of hypocalcemia is often made on physical exam; however, laboratory testing should be obtained including both a total and ionized calcium level, serum 25-(OH) and 1,25-(OH) vitamin D, and parathyroid hormone levels. An ECG should also be performed to evaluate for prolongation of the QT interval. Management includes calcium and vitamin D supplementation. In severe, symptomatic hypocalcemia, calcium gluconate or calcium chloride should be administered intravenously, depending on the severity of symptoms. Calcium chloride has three times more calcium per equal volume, but has the risk of tissue ischemia and necrosis if infused peripherally. Thus, calcium gluconate is preferred.

A 40-year-old woman presents to her primary care provider with abdominal pain that has slowly worsened over the past year. She admits to having intermittent hematuria. She has a history of recurrent urinary tract infections. Her blood pressure is 145/92 mm Hg, pulse 72 beats/min, respiratory rate of 18 breaths/min, and temperature 98.6°F. On exam, palpable masses are noted in the bilateral flanks and an enlarged, nodular liver is noted. Which of the following is the most likely diagnosis? Hydronephrosis Nephrolithiasis Polycystic kidney disease Pyelonephritis

Correct Answer ( C ) Explanation: This woman most likely has polycystic kidney disease. Autosomal dominant polycystic kidney (ADPKD) disease is the most common form of polycystic kidney disease and is one of the most common hereditary disorders in the United States. Family history for kidney disease is positive in 75% of patients. ADPKD is characterized by cyst formation and enlargement in the kidney and other organs (e.g. liver, pancreas). Cerebral aneurysm is the most serious complication. Half of ADPKD patients develop end-stage renal disease by age 60. Risk factors for progressive renal dysfunction includes genetic factors, hypertension, male sex, early-onset of symptoms, increased kidney size, low birth weight, and increased urinary sodium excretion. Patients usually start developing symptoms by the third to fourth decade of life. Hypertension is one of the earliest signs of renal disease. Patients typically present with a history of recurrent urinary tracts infections or nephrolithiasis. Abdominal and flank pain are the most common presenting complaint. A polycystic liver may produce a dull, aching pain and sense of fullness. Pain can be exacerbated by enlargement or rupture of a cyst. In adults, ultrasonography is the most common screening method because it is safe and inexpensive. However, computed tomography and magnetic resonance imaging are more sensitive. Definitive diagnosis requires genetic testing. Screening for cerebral aneurysm is only recommended for patients with a positive family history of intracerebral bleed. Patients should be monitored for worsening renal function. Rigorous control of blood pressure helps decrease cardiovascular mortality and slows the progression of renal failure. Eventually patients may require dialysis or renal transplant. Nephrectomy may be considered in the presence of recurrent infection, impaired activities of daily living, or suspected malignancy.

A previously healthy 23-year-old woman presents to your office complaining of burning with urination. She indicates that two days ago she started experiencing symptoms which also included frequent urination, suprapubic tenderness and dark-colored urine. She is afebrile and denies flank pain. Which of the following is the most appropriate therapy? Ampicillin Gentamicin Levofloxacin Nitrofurantoin

Correct Answer ( D ) Explanation: Acute cystitis is a urinary tract infection (UTI) that affects the bladder. Non-pregnant women who are otherwise healthy generally have uncomplicated cases of acute cystitis that may be treated in the outpatient setting. Cystitis is very common and risk factors include a history of cystitis, recent sexual intercourse and spermicide use. Patients present with symptoms including dysuria, urgency, frequency, hematuria and suprapubic pain. Diagnosis is made with the presence of clinical symptoms and laboratory evidence of bacteriuria or pyuria on urinalysis. Treatment is with antibiotics, with nitrofurantoin and trimethoprim-sulfamethoxazole being good choices, regardless of age. Nitrofurantoin concentrates in bladder and is therefore effective for cystitis. However, it is less effective and not recommended for upper tract infections such as pyelonephritis. Antimicrobial resistant organisms are increasingly being found in UTIs and community resistance prevalence should be considered when choosing an agent.

A patient presents with scrotal swelling suspicious of hydrocele. Which of the following is the most appropriate intervention at this time? Complete metabolic panel and urinalysis Computed tomography scan Surgical consultation Ultrasonography

Correct Answer ( D ) Explanation: As the testicle descends during fetal development, an out-pocketing of the peritoneum follows. This is known as the processus vaginalis testis, which normally pinches off after complete descent to form the tunica vaginalis testis. Any fluid accumulation in the tunic vaginalis testis, or in a persistent processus vaginalis testis, is called hydrocele. Hydroceles, although commonly self-limited in newborns, can occur at any age, and almost always present as painless, unilateral scrotal swelling of acute or insidious onset. Typical examination findings include a fluctuant, ovoid, nontender mass about the testicle, making direct palpation of the testicle difficult. A hydrocele transilluminates on exam. What widens the differential in hydrocele is the possibility of having swelling about the testicle or swelling about the spermatic cord. If the swelling extends proximally to the inguinal ring, one must consider an indirect inguinal hernia. In any case of scrotal swelling, color Doppler ultrasonography is the first diagnostic test recommended.

A 17-year-old boy presents with dysuria and urethral discharge. He reports multiple female partners, but none of them are experiencing similar symptoms. Which of the following tests results are most likely to be present? Flagellated, motile protozoans on smear of a urethral swab Gram negative intracellular diplococci on smear of a urethral swab Positive HSV-2 IgG titer Positive urine Chlamydia PCR

Correct Answer ( D ) Explanation: Chlamydia trachomatis is the second most common sexually transmitted infection in both males and females in the United States (HPV is the first). The most common manifestation of chlamydial infection in males is urethritis, or the infection may be asymptomatic. However, infection may also lead to epididymitis, prostatitis, proctitis, and reactive arthritis. Nucleic acid amplification tests (NAAT)'s, such as polymerase chain reactions (PCR's) are sensitive and specific tests to establish a diagnosis of C.trachomatis. In the above case, a positive urine Chlamydia PCR is likely to be present.

A 45-year-old Caucasian man presents to your office with questions about prostate cancer screening. He does not have a family history of prostate cancer and wants to know at what age he should begin screening. According to the U.S. Preventive Services Task Force, which of the following is the most appropriate next step in management? Begin screening at age 50 Order serum prostate specific antigen now, then begin screening at age 50 Perform an initial digital rectal exam now, then begin screening at age 50 Screening is not recommended

Correct Answer ( D ) Explanation: In the United States, prostate cancer is the most frequently diagnosed type of cancer in men after skin cancer. Prostate cancer is seen more commonly in African-American men and the likelihood of developing this type of cancer increases with age. Risk factors include a family history of prostate cancer, cigarette smoking and a diet high in animal fat. Routine screening for prostate cancer has been a controversial subject. Current United States Preventive Services Task Force guidelines recommend against prostate specific antigen (PSA) screening for prostate cancer. Some men will request screening and a discussion about the risks and benefits of screening should occur prior to initiating PSA testing or digital rectal exam (DRE). Most patients diagnosed with prostate cancer are asymptomatic and the cancer is found on DRE or because of an elevated serum PSA. Diagnosis is made with biopsy. Treatment decisions are determined after discussion with the patient about the severity of disease and quality of life related to treatment side effects. Options include active surveillance, prostatectomy, radiation therapy and hormonal therapy.

A 19-year-old man who is a college student presents to the ED with concern for a lesion on his penis for the past two days. He began a relationship with a new sexual partner three weeks ago. On exam, there is a non-tender 2-cm ulcer on the dorsum of his glans. There is no inguinal adenopathy. An HIV ELISA and RPR are negative. What is the most likely diagnosis? Chancroid Granuloma inguinale Lymphogranuloma venereum Primary syphilis

Correct Answer ( D ) Explanation: Primary syphilis is characterized by a small papule that develops at the site of inoculation (usually genital) that becomes a painless, indurated ulcer, often described as the classic chancre. The chancre develops after an incubation period of 10-90 days, is present for 3-6 weeks, and resolves spontaneously. Serologic tests (VDRL and RPR) can be falsely negative for up to four weeks after the chancre appears and should not be relied upon to rule out primary syphilis. They are, however, quite sensitive for ruling out the diagnosis in later stages.

Which of the following is associated with an increased likelihood of testicular torsion? Age greater than 50 years Epididymitis Fixed testis Undescended testis

Correct Answer ( D ) Explanation: Testicular torsion can occur at any age, but it has bimodal peaks: the first year of life and at puberty (ages 12 to 18). Torsion results from maldevelopment of fixation between the enveloping tunica vaginalis and the posterior scrotal wall, as seen with an undescended testicle (cryptorchidism). Characteristically, the involved testis is aligned along a horizontal rather than a vertical axis. Frequently there is a history of an athletic event, strenuous physical activity, or trauma just before the onset of scrotal pain. The pain usually occurs suddenly, is severe, and is usually felt in the lower abdominal quadrant, the inguinal canal, or the testis. On physical exam, there is loss of the cremasteric reflex. This is observed in nearly 100% of patients with torsion. The cremasteric reflex is a superficial reflex observed in men. This reflex is elicited by lightly stroking the superior and medial part of the thigh. The normal response is an immediate contraction of the cremaster muscle that pulls up the testis on the side stroked. In the setting of testicular torsion, this reflex is absent. The testicle is usually tender and firm and the scrotum is swollen and tender. In cases with a high suspicion of torsion, the patient should be taken to the OR immediately by a urologist. If the diagnosis is equivocal, color Doppler and ultrasound is the best diagnostic modality.

Which of the following medications can cause hyperkalemia? Furosemide Hydrochlorothiazide Regular insulin Trimethoprim-sulfamethoxazole (TMP-SMX)

Correct Answer ( D ) Explanation: The trimethoprim component of TMP-SMX can cause reversible elevations of both creatinine and potassium. TMP-SMX is a sulfonamide antibiotic that is frequently used in the treatment of a variety of bacterial infections. A decade ago, it was the most commonly prescribed antibiotic for urinary tract infections. However, the increased rate of Escherichia coli resistance to the drug has limited it's use for this indication. TMP-SMX is widely used in outpatient treatment of skin and soft-tissue infections because of its activity against methicillin resistant Staphylococcus aureus (MRSA). Among its many side effects, it can cause elevations in creatinine and hyperkalemia. It should be used cautiously in patients with renal impairment or in pairing it with other drugs that can cause hyperkalemia. Furosemide (A) is a loop diuretic agent that can cause hypokalemia and is often used in the treatment of hyperkalemia with preserved renal function. Hydrochlorothiazide (B) is a diuretic, antihypertensive agent that can lead to hypokalemia. Insulin (C) can cause transient hypokalemia by shifting potassium into cells and it is a mainstay of hyperkalemia treatment.

Rapid Review Epididymitis

Epididymitis Patient will be complaining of gradual onset unilateral scrotal pain PE will show increased color flow on doppler, relief with testicular elevation (Prehn's sign) Most commonly caused by < 35 yo: C. trachomatis, N. gonorrhea > 35 yo: E. coli, Pseudomonas Treatment is < 35 y/o ceftriaxone/doxycycline, > 35 y/o ciprofloxacin

A seven-year-old boy, with a history of hypospadia, presents with abdominal pain. Examination reveals normal temperature, stable weight, and a nontender left abdominal mass. Further abdominopelvic, cranial nerve and neuromuscular examination is unremarkable. Urinalysis reveals scant red blood cells. Which of the following is the most likely diagnosis? Ewing sarcoma Hodgkin lymphoma von Hippel-Lindau syndrome Wilms tumor

Nephroblastoma, or Wilms tumor, is the most common abdominal malignancy in children, affecting 1 out of 100,000 children under the age of 15 years. It accounts for 7% of all childhood cancers. It is caused by alterations in the genes responsible for genitourinary development. The most common presenting symptom is an asymptomatic abdominal mass (80% of cases) and abdominal pain (25% of cases). Hematuria, hypertension and fever affect 5-30% of cases. Examination usually reveals a palpable abdominal mass. Work-up includes CBC, BMP, UA, coagulation studies and cytogenetic studies for 1p and 16q chromosomal deletions. Imaging begins with renal ultrasound, but may eventually include chest radiographs, abdominal CT or abdominal MRI. Treatment usually consists of nephrectomy followed by chemotherapy, with or without post-operative radiotherapy. von Hippel-Lindau syndrome (C) is a rare, autosomal dominant genetic disorder characterized by several tumors: retinal and central nervous system hemangioblastomas, renal cell carcinoma, pheochromocytoma, pancreatic islet cell tumors and epididymal cystadenomas. Presenting symptoms include headache, balance problems, dizziness, weakness and vision problems, none of which are present in this patient.

One Step Further Question: What is a bell clapper deformity?

One Step Further Question: What is a bell clapper deformity?

A 68-year-old African-American man presents to your office with complaints of urinary frequency, hesitancy and nocturia. Digital rectal exam reveals asymmetric areas of induration and nodules. Which lab finding is most consistent with the diagnosis? Elevated blood urea nitrogen Elevated serum prostate specific antigen Presence of protein on urinalysis Presence of white blood cells on urinalysis

orrect Answer ( B ) Explanation: In the United States, prostate cancer is the most frequently diagnosed type of cancer in men after skin cancer. Prostate cancer is seen more commonly in African-American men and the likelihood of developing this type of cancer increases with age. It is uncommon in men younger than fifty. Risk factors include a family history of prostate cancer, cigarette smoking and a diet high in animal fat. Most patients diagnosed with prostate cancer are asymptomatic and the cancer is found on digital rectal exam (DRE) or because of an elevated serum prostate specific antigen (PSA). Men with risk factors or suspicious physical exam findings on DRE should have a workup initiated that includes evaluation of serum PSA. Diagnosis is made with biopsy. Treatment decisions are determined after discussion with the patient about the severity of disease and quality of life related to treatment side effects. Options include active surveillance, prostatectomy, radiation therapy and hormonal therapy.