Question of the week # 291

291) A 66 year old man with past medical history of hypertension and  type-2 diabetes mellitus is evaluated in your office during a regular follow up visit for his diabetes. During this visit, he reports problem getting and maintaining an erection.  On the times that he does have an erection, they are very soft.  He says this problem began approximately 10 months ago and has slowly worsened but he was too embarrassed to disclose this during his previous visits. He still has a strong sexual desire and this problem has caused strain in his current relationship.  He is physically very active walking two to three miles per day. His medications include glipizide and hydrocholrthiazide. He says his home blood sugars have been “perfect”. A Hemoglobin A1C 2 weeks ago was 6.0gm% .  He currently does not smoke after having quit smoking 15 years ago. Physical examination shows blood pressure 140/90 mmHg, pulse 86, respiratory rate 20 bpm. Genitilia and testicles are normal in size . Peripheral pulses are normal. Rest of the physical examination is normal. Which of the following is the most appropriate next step in managing this patient?

A) Obtain Serum Total Testosterone

B) Obtain Nocturnal Penile Tumescence

C) Start Sildenafil

D) Prescribe Vacuum assisted erection device

E) Switch Hydrochlorthiazide to ACE inhibitor

 

Question of the week # 290

290) A 72 year old man with history of Diabetes Mellitus and peripheral vascular disease is evaluated in your office for impotence. He denies any premature ejaculation and states that he can not even attain an erection. Further studies confirm erectlie dysfunction secondary to organic causes. The patient denies any history of angina in the past. His medications include Aspirin, Clopidogrel, Glargine insulin and Lispro. His most recent HGBA1C was 6.5%. You offer him sildenafil for erectlie dysfunction. He is now concerned about the possible side effects. Which of the following is the most common side effect of sildenafil?

A) Headache

B) Nasal congestion

C) Diarrhea

D) Blurred vision

E) Flu like symptoms

Question of the week # 289

289) A 32 year old male athlete is evaluated in the office for bilateral breast enlargement. He is a state champion in running and is scheduled to participate in the national level running championship in few weeks. He is very concerned about his appearance.   He denies using any illicit drugs or exogenous androgens or aromatase inhibitors  is seen in the office during a routine follow up visit.  His past medical history is unremarkable. Physical examination reveals gynecomastia bilaterally. His laboratory investigations reveal:

WBC 8.8k/µl

Hemoglobin 18.5 g/dL ( Normal = 13.0 to 16.5 gm%),

Mean cell volume (MCV)  84  fL

Platelet count 310k/µl

Which of the following is most useful in establishing the diagnosis?

A) Erythropoetin level

B) Urine Drug Screen

C) Serum Total Testosterone

D) Urine Testosterone/ Epitestosterone ratio

E) Serum Free Testosterone

Question of the week # 288

288) A 38 year old caucasian man  is seen in the office during a routine follow up visit.  His past medical history is significant for testicular non-seminomatous germ cell tumor diagnosed 9 months ago and was treated with radical orchiectomy of left testicle and chemotherapy.  He completed chemotherapy 6 months ago and achieved a complete response. His tumor markers and imaging studies 3 months after completion of therapy were normal. He complains of decreased sexual drive and energy.  He denies smoking tobacco or alcohol. He  uses Marijuana on a daily basis but quit 2 months ago. His family history is unremarkable.  Physical examination shows absent left testicle. Rest of the physical is normal. Serum alpha-fetoprotein is normal. Beta HCG is elevated at 15U/L ( Normal < 5 U/L) . A chest X-ray , CT scan of the abdomen and pelvis are normal.  His routine laboratory investigations including complete blood count are within normal limits. Which of the following is most likely reason for his elevated Beta-HCG?

A) Recurrent tumor

B) Marijuana Use

C) Hypogonadism

D) Chemotherapy effect

E) Hyperthyroidism

Question of the week # 287

287) A 38 year old caucasian man  is seen in the office due to decreased libido and energy. His past medical history is significant for testicular cancer diagnosed 1 year ago and was treated with radical orchiectomy of left testicle and chemotherapy. He denies smoking tobacco but admits using Marijuana on a daily basis for the past few months. His family history is unremarkable.  Physical examination  reveals gynecomastia and absent left testicle. Body mass index is 24.  His routine laboratory investigations including complete blood count are within normal limits. Serum total testosterone level is reduced and Serum LH concentration is elevated. The patient is started on Testosterone replacement therapy with a testosterone skin gel. Which of the following is the most appropriate step in follow up care of  this patient after starting testosterone therapy?

A) Digital Rectal exam and Serum PSA level at one year

B) Hematocrit at 6 months and then, every year

C) DEXA scan at one year

D) Serum Testosterone level at 6 months

E) Serum LH at one month.

Question of the Week # 245

245 )  A 52-year-old man presents with acute onset of pain in his left testis which started abruptly after unprotected sexual intercourse. The pain started 3 hours ago, it is severe and constant. He denies any fever, chills, nausea or vomiting. On physical examination, the patient is afebrile and in severe distress. Testcular examination reveals a normal sized diffusely tender left testicle. Cremasteric reflex is absent on the left. A routine testicular ultrasound reveals normal testicles. A Complete Blood Count and Urinalysis are normal. What is the next step in management of this condition?

A)     Observation and Antibiotics

B)      Surgical exploration

C)      Repeat Testicular Doppler Ultrasound

D)     Laparotomy

E)      Observation alone

Question of the Week # 244

244 )  A 10-year-old Caucasian boy presents with right scrotal pain of 7 hours duration. The pain is acute in onset, constant and does not change with position. The patient denies any fever, chills, dysuria, nausea or vomiting. He denies any recent history of trauma. On physical examination, the patient is afebrile and is in moderate distress secondary to pain. There is no urethral discharge. Cremasteric reflex is present bilaterally. There is bluish discoloration and localized tenderness in the upper part of the testes. Labs reveal a normal Complete Blood Count and Urinalysis. What is the most likely clinical diagnosis in this patient?

A)     Testicular torsion

B)      Strangulated Hernia

C)      Congenital Hydrocele

D)     Torsion of Testicular appendix

E)      Acute Epidydimitis

 

 

 

 

Question of the Week # 220

220 )  A 32 year old woman presents to the office for evaluation of dysuria, frequency and urgency. She has had two episodes of urinary tract infection in the last 4 months. Her previous episodes were managed with 3 day course of trimethoprim-sulfamethoxazole.  She has been using cranberry juice but has not experienced any improvement in recurrences. At this time, she denies any flank pain or fever.  She is sexually active with one partner and uses diaphragms with spermicide for contraception. Physical examination is normal except for mild supra-pubic tenderness. There is no costo-vertebral angle tenderness. Urinalysis  reveals pyuria and 3+ leukoesterase. There are no WBC casts. Which of the following is the most appropriate recommendation to avoid recurrent urinary tract infections in this patient?

A) Post-coital voiding

B) Post-Coital Trimethoprim-sulfamethoxazole

C) Avoid vaginal spermicides

D) CT scan abdomen

E) Daily Trimethoprim-Sulfamethoxazole

Question of the Week # 219

219 )  A 32 year old woman presents to the office for evaluation of recurrent urinary tract infections. She has had two episodes of cystitis in the last 4 months. In the past she was managed with 3 day course of trimethoprim-sulfamethoxazole. Now, she presents with burning micturition, urgency and frequency. She denies flank pain or fever.  She uses diaphragms with spermicide for contraception. She is sexually active with one partner and her last sexual intercourse was 5 months ago since her partner is away on a business tour. Physical examination is normal except for mild supra-pubic tenderness. Which of the following is the most appropriate recommendation to avoid recurrent urinary tract infections in this patient?

A) Post-coital voiding

B) Post-Coital Trimethoprim-sulfamethoxazole

C) Avoid vaginal spermicides

D) CT urogram and Cystoscopy

E) Daily Trimethoprim-Sulfamethoxazole

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