Surgery Renal

Item: 1 of 16 ~ 1 • Mark -<] C> Jill ~· ~J
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• 1
A 60-year-old man presents to the urologist complaining of difficulty urinating . He states he frequently gets out of bed in ~~AI
the m iddle of the night to go to the bathroom . Once he gets to the bathroom he can't urinate easily and must "bear down"
to do so . He denies any history of sexually transmitted disease, trauma to the genitourinary tract, or prior genitourinary
•4 instrumentation. On rectal examination the patient has an enlarged prostate and one 1-cm area of induration located on the
•5
middle posterior aspect of the prostate. He has a prostate-specific antigen level of 6 ng/mL (normal : 0-4 ng/mL), blood urea
nitrogen of 20 mg/L, and creatinine of 1.6 mg/L. The patient undergoes a transrectal prostate biopsy, and no dysplasia or atypia
•6 is present.
•7
•8 Which of the following is the most appropriate treatment?
•9
• 10 A. Brachytherapy
• 11
B. Radical retropubic prostatectomy
• 12
• 13 C. Terazosin
• 14 D. Transurethral resection of the prostate
• 15
E. Watchful wait ing
• 16
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The correct answer is C. 740/o chose this .
•2
The patient has benign prostatic hyperplasia (BPH), which may produce obstructive (hesitancy, weakened and intermittent
•3 urinary stream, and urinary r etention) or irritat ive (urge incontinence and nocturia) symptoms. Wh ile biopsy is not usua lly
•4 warranted in cases of BPH, a digital rectal exam (DRE) in this patient revea led a suspicious nodule requiring further
•5 eva luation . In most cases of BPH, DRE reveals a uniformly enlarged, rubbery prostate w ithout areas of induration . The patient
in this case had an area of induration, suggestive of cancer. Add it ional ly, wh ile BPH may cause mildly elevated levels of
•6
prostate-specific antigen ( PSA), prostate cancer can also result in elevated PSA levels. Therefore, biopsy is warranted to
•7 distinguish between benign and ma lignant disease . This patient's biopsy r evealed a benign process . Most patients w ith BPH
•8 warrant a tria l of medical management. Terazosin is an a 1 -adrenergic antagonist and is usually the first-line treatment for
•9
patients w ith symptomatic BPH .
Prostate-specific antigen Benign prostatic hyperplasia Nocturia Urinary retention Rectal examination Prostate cancer Biopsy Hyperplasia Urinary incontinence Nodule (medicine)
• 10
Prostate Antigen Malignancy Benign tumor Fecal incontinence Cutaneous condition Cancer Receptor antagonist Rectum Benignity Therapy
• 11
• 12 A is not correct. 2% chose this.

• 13
Brachytherapy might be indicated if the biopsy had shown more dysplasia and irregula rity consistent with carcinoma .
Brachytherapy involves placing radioactive seeds with in the tumor, allowing for localized radiation therapy.
• 14 Brachytherapy Radiation therapy Biopsy Neoplasm Dysplasia Radioactive decay Carcinoma Radiation
• 15
B is not correct. 20/o chose this .
• 16
Radical r etropubic prostatectomy (RRP) m ight be ind icated if the biopsy had shown prostatic carcinoma. RRP is much too
aggressive an approach for ben ign prostatic hyperplasia .
Benign prostatic hyperplasia Prostatectomy Radical retrooubic prostatectomy Prostate cancer Biopsy Hyperplasia Carcinoma Benign tumor Benignity
D is not correct. 160/o chose this.

Transurethral resection of the prostate wou ld be indicated if med ical management fa iled to improve the patient's symptoms or
if he had signs of severe obstruction, such as an elevated post-void residual or evidence of hydronephrosis on renal
ultrasound .
Hydronephrosis Transurethral resection of the prostate Medical ultrasound Ultrasound Prostate Segmental resection Prostate cancer Kidney
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1 Brachytherapy Radiation therapy Biopsy Neoplasm Dysplasia Radioactive decay Carcinoma Radiation
•2 B is not correct. 2 0/o chos e this .

•3 Radical retropubic prostatectomy (RRP) might be indicated if the biopsy had shown prostatic carcinoma. RRP is much too
•4 aggressive an approach for benign prostatic hyperplasia .
Benign prostatic hyperplasia Prostatectomy Radical retropubic prostatectomy Prostate cancer Biopsy Hyperplasia Carcinoma Benign tumor Benignity
•5
•6 D is not correct. 160/o chose this .
•7 Transurethral resection of the prostate wou ld be indicated if medica l management failed to improve the patient's symptoms or
•8 if he had signs of severe obstruction, such as an elevated post-void residual or evidence of hydronephrosis on renal
ultrasound .
•9
Hydronephrosis Transurethral resection of the prostate Medical ultrasound Ultrasound Prostate Segmental resection Prostate cancer Kidney
• 10
E is n ot correct. 6 0/o c hose th is.
• 11
Watchful wait ing wou ld be acceptable if the man were less symptomatic .
• 12
Watchful waiting
• 13
• 14
• 15 Bottom line :
• 16 BPH may produce obstructive (hesitancy, weakened and interm ittent urinary stream, and urinary retention) or irritative
(urge incontinence and nocturia) symptoms . Initial therapy typically includes trial of medica l management. Agents include
a-blockers (tamsu losin and terazosin) and anti-androgens (finasteride). Indications for more aggressive management
include severe obstruction, such as an elevated post-vo id residual of evidence of hydronephrosis on renal ultrasound.
Finasteride Tamsulosin Hydronephrosis Nocturia Urinary retention Terazosin Ultrasound Medical ultrasound Urinary incontinence Benign prostatic hyperplasia Kidney Antiandrogen
References:
FA Step 2 CK 9th ed pp 488-489
FA Step 2 CK 8th ed p 459
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A 65-year-old man presents to the clin ic for follow-up . Th,e man was diagnosed with non-insulin-dependent diabetes
•2
mellitus last year. He retired from his work in a textile factory 2 years ago, drinks socially, and has smoked a pack of
•3 cigarettes per day for 30 years. Recently, he was evaluated by a urologist for hematuria and flank pa in. The evaluation
•4 eventually led to a CT scan with intravenous contrast, whi ch showed a solid, contrast-enhancing, 6 x 8 em rena l mass .
•5
Resection shows an exophytic lesion .
•6
What genetic disease is most commonly associated with this type of rena l tumor?
•7
•8
•9
A. Charcot- Marie-Tooth disease
• 10 B. Multiple endocrine neoplasia type I

• 11
C. Multiple endocrine neoplasia type IIB
• 12
D. Shy-Drager syndrome
• 13
• 14 E. von Hippei-Li ndau syndrome
• 15
• 16
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•3
The correct answer is E. 76% chose this.
•4
von Hippei-Lindau (VHL) syndrome results from a mutation in the gene encod ing VH L tumor suppressor protein, leading to
•5 cerebellar hemangioblastomas, retinal hemangioblastomas, pancreatic cysts, pancreatic carcinomas, and
•6 pheochromocytomas. Forty percent of patients with VH L develop renal cell ca rcinoma (RCC; most commonly clea r cel l), and
•7 75% develop rena l cysts . RCC is responsible for 30% of deaths in patients with VHL. The classic triad of RCC is hematu ria,
flank pain, and a palpable flank mass. RCC is also known to cause polycythemia, and classica lly enhances on CT. Smoking is a
•8
risk factor.
•9 Hematuria Renal cell carcinoma Gene Polycythemia Protein Mutation Abdominal pain Neoplasm Pancreas Carcinoma Tumor suppressor gene Cyst Cerebellum Pheochromocytoma
• 10 Risk factor Kidney Von Hippei-Lindau disease
• 11
A is not correct. 6% chose this .
• 12
Cha rcot-Ma rie-Tooth disease is a hered itary motor and sensory neuropathy cha racterized by loss of muscle and touch
• 13 sensation . Patients classically have pes cavus (high arched feet), foot drop, and hammer toes (permanently bent) . It is not
• 14 associated w ith renal ma lignancies .
Charcot-Marie-Tooth disease Pes cavus Hereditary motor and sensory neuropathy Foot drop Peripheral neuropathy Muscle
• 15
• 16 B is not correct. 40/o chose this .
Multiple endocrine neoplasia type I is characterized by pa rathyroid hyperplasia, pancreatic islet cell tumors (insulinoma),
gastrinoma, and pituitary tumors.
Gastrinoma Insulinoma Multiple endocrine neoplasia Parathyroid hormone Endocrine system Hyperplasia Parathyroid gland Pituitary adenoma Pancreatic islets Pituitary gland
Neoplasm
C is not correct. SO/o chose this.

The neoplasms associated w ith multiple endocrine neoplasia type liB are classically mucosal neuromas, medullary thyroid
carcinoma and pheochromocytoma . Marfanoid body habitus is another associated finding .
Pheochromocytoma Medullary thyroid cancer Multiple endocrine neoplasia Multiple endocrine neoplasia type 2b Neoplasm Endocrine system Thyroid Marfanoid Morphology (biology)
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1 Charcot-Marie-Tooth disease Pes cavus Hereditary motor and sensory neuropathy Foot drop Peripheral neuropathy Muscle
2
B is not correct. 4 0/o chose this .
•3
Mult iple endocrine neoplasia type I is characterized by parathyroid hyperplasia, pancreatic islet cell tumors (insulinoma),
•4
gastrinoma, and pitu itary tumors.
•5 Gastrinoma Insulinoma Multiple endocrine neoplasia Parathyroid hormone Endocrine system Hyperplasia Parathyroid gland Pituitary adenoma Pancreatic islets Pituitary gland
•6 Neoplasm
•7
C is not correct. SOfo chose this .
•8
The neoplasms associated w ith mult iple endocrine neoplasia type liB are classically mucosal neuromas, medullary thyr oid
•9 carcinoma and pheochromocytoma . Marfanoid body habitus is another associated finding .
• 10 Pheochromocytoma Medullary thyroid cancer Multiple endocrine neoplasia Multiple endocrine neoplasia type 2b Neoplasm Endocrine system Thyroid ~1arfanoid Morphology (biology)
• 11 Thyroid cancer Marfan syndrome Thyroid neoplasm Neuroma Carcinoma
• 12 D is not correct. 9 % chos e this .

• 13 Shy-Drager syndr ome, or mult iple system atrophy, is unrelated to r enal cell carcinoma . It is usually associated with
• 14 hypotension and autonomic nervous system dysfunction .
Multiple system atrophy Autonomic nervous system Hypotension Renal cell carcinoma Nervous system Atrophy
• 15
• 16
Bottom line :
Forty percent of patients with von Hippei-Li ndau disease develop renal cell ca rcinoma .
Von Hippel-lindau disease Renal cell carcinoma Carcinoma
References:
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A 68-year-old man who is otherwise healthy presents to his physician for evaluation for prostate cancer staged T2NOMO .
2 He wants help understanding what that means and what t reatment option is best for him .
•3
•4
Which of the following is the best description of a T2NOMO cancer of the prostate, and what treatment should be used'
•5
•6
•7
•8 A. The tumor extends through the prostate capsule and is best treated w ith hormonal therapy
•9 B. The tumor is confined to the prostate and best treated w ith rad ical prostatectomy
• 10
C. The tumor is confined to the urethra and best treated with a transuretheral resection of the prostate
• 11
• 12
D. The tumor is fixed next to seminal vesicles and the pelv ic wa ll, and best treated with chemotherapy
• 13 E. The tumor is not clinically apparent, and the patient is to be followed by annual prostate-specific antigen screening
• 14
• 15
• 16
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QID: 22574
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•4 The correct answer is B. 680/o chose this .
•5 Patients with disease staged T2 means it is confined with in the prostate. With the goa l of a long-term cure 1 the best ava ilable
•6 option is a radical prostatectomy. Risk factors for prostate cancer include age >45 years 1 African-American ethnicity1 genetics 1
and diet high in animal fats. Before the advent of prostate-specific antigen (PSA) screening/ prostate cancer was normally
•7
diagnosed by digital rectal examination or urinary obstructive symptoms. When symptomatic1 patients present with urgency/
•8 noct uria1 frequency1 and hesitancy. Prostate cancer is now commonly diagnosed while the patient is asymptomatic via an
•9 elevated serum PSA level. Prostate biopsy is the gold standard for diagnosis. Early-stage disease is t reated with radical
• 10 prostatectomy/ external beam rad iation therapy/ or brachytherapy and watchfu l waiting . Metastatic disease is treated with
androgen deprivation therapy or chemotherapy.
• 11 Prostate-specific antigen Rectal examination Brachytherapy Nocturia Androgen deprivation therapy Prostate cancer Prostatectomy Watchful waiting Radiation therapy Androgen
• 12
Metastasis External beam radiotherapy Biopsy Chemotherapy Prostate Prostate biopsy Antigen Cancer Gold standard (test) Asymptomatic African Americans
• 13
• 14
A is not correct. 140/o chose this .
Tumor that extends th rough the prostate capsu le is staged T3 . Hormonal therapy is usua lly used for clinica lly advanced
• 15
tumors with metastasis1 because reducing the testosterone may reduce symptoms and prevent tumor growth .
• 16 Testosterone Metastasis Hormonal therapy (oncology) Hormone therapy Neoplasm Prostate Prostate cancer Hormone
C is not correct. 9% chose this.

Prostate cancer usually grows from peripherally to with in and is not usually confined to the urethra . A transurethral resection
of the prostate is main ly used to treat obstructive symptoms associated with prostate hyperplasia.
Urethra Prostate cancer Transurethral resection of the prostate Cancer Hyperplasia Prostate Segmental resection
D is not correct. 3% chose this.

Tumor that is fixed to adjacent structures or muscle is staged T4. Chemotherapy is reserved for patients with advanced
prostate cancer that is no longer responsive to hormonal therapy.
Chemotherapy Prostate cancer Hormone therapy Neoplasm Hormonal therapy (oncoloQy) Hormone Prostate Cancer Muscle
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1 Tumor that extends through the prostate capsu le is staged T3 . Hormonal therapy is usua lly used for clinica lly advanced
2
tumors with metastasis, because reducing the testosterone may reduce symptoms and prevent tumor growth .
Testosterone Metastasis Hormonal therapy (oncology) Hormone therapy Neoplasm Prostate Prostate cancer Hormone
3
•4 C is not correct. 9% chose this.
•5 Prostate cancer usually grows from peripherally to withi n and is not usually confined to the urethra. A transurethral resection
of the prostate is mainly used to treat obstructive symptoms associated with prostate hyperplasia .
•6
Urethra Prostate cancer Transurethral resection of the orostate Cancer Hyperplasia Prostate Segmental resection
•7
D is not correct. JO/o chose this.
•8
Tumor that is fixed to adjacent structures or muscle is staged T4. Chemotherapy is reserved for patients with advanced
•9
prostate cancer that is no longer responsive to hormonal therapy.
• 10 Chemotherapy Prostate cancer Hormone therapy Neoplasm Hormonal therapy (oncology) Hormone Prostate Cancer Muscle
• 11
E is not correct. 60/o chose this .
• 12
Tumor that is not apparent on biopsy is staged TO . Annual prostate-specific antigen levels and digital rectal examinations
• 13 should be offered to men >50 years old.
• 14 Prostate-specific antigen Biopsy Antigen Neoplasm
• 15
• 16
Bottom line:
Patients with prostate cancer at stage T2 means it is confined w ithin the prostate and best treated with rad ica l
prostatectomy.
Prostatectomy Prostate cancer Cancer Prostate
Ref er en ces:
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A 62-year-old woman with hypertension, diabetes, and rh eumatoid arthritis presents to an outpatient clinic for follow-up. A ~~AI
2 recent abdominal CT obtained during a work-up for abdominal pain and bloody diarrhea revealed diverticulitis and a cystic
3 renal lesion . The cyst was described as contrast-enhancing and 4 em in diameter, with a 1-cm solid component visible in
•4 the center of the lesion . The cyst wall was 3-4 mm thick .
•5
•6 What is the proper management of this r enal cyst?
•7
•8 A. Cisplatin-based chemotherapy
•9 B. Follow-up CT scan in 6 months
• 10
C. Renal biopsy
• 11
• 12 D. Renal MRI
• 13 E. Su rgical excision
• 14
• 15
• 16
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The correct answer i s E. 41 % chose this.
3
The mass in question is likely a cystic renal cell carcinoma (RCC) . The Bosniak classification separates lesions based on their
4
radiographic findings. Contrast-enhancement suggests a Bosniak III -IV lesion, and such lesions are highly correlated w ith
•5 malignancy (85%-100%) . Bosniak I-II lesions, wh ich are non-contrast-enhancing, are less likely to represent malignancy
•6 (40%-50%) . This patient has a Bosniak IV lesion . Appropriate management of Bosniak III-IV lesions is surgical excision .
•7 Nephrectomy and nephron-sparing partial nephrectomy are the preferred procedures .
Renal cell carcinoma Kidney Nephrectomy Cancer
•8
•9 A i s not correct. 3% ch ose this .
• 10 Chemotherapy has no role in the treatment of renal cell carcinoma . Cisplatin-based combination chemotherapy has been used
postorch iectomy for men with low stage non-seminoma germ cell tumors w ith much success.
• 11 Renal cell carcinoma Chemotherapy Genm cell Nonseminoma Carcinoma Germ cell tumor Combination chemotherapy Kidney Neoplasm
• 12
B is not correct. 21% chose th is .
• 13
Watchful wait ing is appropriate for simple renal cysts . The lesion described has a solid component to it, and thus it is not a
• 14
simple cyst .
• 15 watchful waiting Cyst Lesion Kidney
• 16
C i s not correct. 2 8 0/o chose this.
Renal mass biopsy has a high false-negative rate, and thus is not routinely performed . Renal cell carcinoma may coexist with
benign components, making a negative biopsy result unreliable. In add it ion, there is a risk of seeding the biopsy tract with
malignant cells.
Renal cell carcinoma Biopsy Type I and type II errors Malignancy Carcinoma Cancer Kidney Benign tumor
D i s not correct. 7 0/o chose this.

CT is the most accurate and cost-effective diagnostic modality for renal cell carcinoma . MRI is useful for preoperative work- up
for metastases includ ing renal vein or vena caval involvement, but has no role in disease management. MRI is also usefu l
when ult rasonog raphy and CT are nondiagnostic and/or rad iograph ic contrast cannot be administered because of allergy or in •
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1 Renal cell carcinoma Chemotherapy Germ cell Nonseminoma Carcinoma Germ cell tumor Combination chemotherapy Kidney Neoplasm
2 B is not correct. 210/o chose th is.

3 Watchful wait ing is appropriate for simple renal cysts . The lesion described has a solid component to it, and thus it is not a
4 simple cyst.
Watchful waiting Cyst lesion Kidney
•5
•6 C is not correct. 2 8 0/o chose this .
•7 Renal mass biopsy has a high false-negative rate, and thus is not routinely performed . Renal cell carcinoma may coexist with
•8 benign components, making a negative biopsy result unreliable. In addit ion, ther e is a risk of seeding the biopsy tract with
malignant cells.
•9
Renal cell carcinoma Biopsy Type I and type II errors Malignancy Carcinoma Cancer Kidney Benign tumor
• 10
D is not correct. 7 % chose this .
• 11
CT is the most accurate and cost-effective diagnostic modality for renal cell carcinoma . MRI is useful for preoperative work- up
• 12
for metastases including r enal vein or vena caval involvement, but has no role in disease management. MRI is also usefu l
• 13 when ultrasonography and CT are nondiagnostic and/ or rad iograph ic contrast cannot be administered because of allergy or in
• 14 the setting of poor renal function .
Renal cell carcinoma Renal vein Magnetic resonance imaging Metastasis Medical ultrasound Renal function carcinoma Allergy Kidney Medical imaging CT scan
• 15
• 16
Botto m line :
In suspected cystic renal cell carcinoma, treatment of choice is either nephr ectomy or nephron-sparing partial nephrectomy.
Renal cell carcinoma Nephrectomy Carcinoma Kidney
References:
FA Step 2 CK 9th ed pp 491-492; 540
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A 23-year-old construction worker is admitted after his right leg became t rapped under a concrete block at a construction ~~AI
2 site . After r emoval of the block, there were visible signs of crush inju ry to his thigh, and he was airlifted to a local hospital.
3 In t ransit he received several bags of intravenous fluids and analgesics . He is alert and oriented on arrival at the hospital.
4 His blood pressur e is 140/ 80 mm Hg , pulse is 70/ min, and respiratory rate is 12/ m in. Physical examination is significant for
•5
mu lt iple contusions and abrasions on the anterior portion of his right thigh . Distal pulses are palpable, and sensation in the
affected extremity is normal. Laboratory studies show a potassium level of 6 .1 mEq/ L, phosphate of 8 .2 mg/ dL, calcium of 6 .3
•6
mg/ dL, and uric acid of 20 mg/ dL.
•7
•8 What additional laboratory finding is most consistent with his most likely diagnosis?
•9
• 10 A. Creatine kinase levels < 1000 I U/ L
• 11
B. Decreased serum lactic acid dehydrogenase
• 12
• 13 C. Elevated homocysteine levels
• 14 D. Elevated t roponin I levels
• 15
E. Positive urine dipstick for blood
• 16
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The correct a nswer i s E. 6 1% ch ose this.
2
This patient has suffered rhabdomyolysis secondary to a crush injury and is at risk for pigment (myoglobin)-induced renal
3 failure. Even w ithout overt renal fail ure, myoglobinuria is common after crush injuries and is manifested by the finding of
4 blood on urine dipstick but the absence of RBCs on microscopic examination. The dipstick assay reacts w ith both hemoglobin
5
and myoglobin, and thus will ind icate the presence of blood in either case . But because the glomeru li are intact, no blood
passes into the urine. Intracellular contents of muscle cells leak out as circulation returns to the damaged tissue. Lactate
•6
dehydrogenase, uric acid, phosphate, and potassium levels can increase rapidly, and patients must be mon itored for signs of
•7 card iac and system ic irregularities, such as peaked T waves and/or muscle weakness . In severe cases, dialysis is used to
•8 manage severe hyperkalem ia .
Rhabdomyolysis Hyperkalemia Myoglobin Uric acid Myoglobinuria Lactate dehydrogenase Hemoglobin Glomerulus (kidney) Urine Glomerulus Dialysis Lactic acid Crush syndrome
•9
~1uscle weakness Phosphate Urine test strip Pigment Potassium Muscle
• 10
• 11 A i s not correct. 1 30/o chose this .
• 12 A hallmark of rhabdomyolysis is the elevation of creatine kinase (CK) levels, wh ich can climb > 100,000 IU/L. In the case of
• 13
severe crush injuries, high levels are all the more likely. Treatment strategies for acute rhabdomyolysis usually involve
following plasma CK levels, aggressive hydration, and urine alkalinization .
• 14 Rhabdomyolysis Creatine kinase Creatine Urine Crush syndrome Blood plasma
• 15
B is not correct. ] Ofo chose t h is .
• 16
Serum lactate dehydrogenase levels increase during rhabdomyolysis.
Rhabdomyolysis Lactate dehydrogenase Lactic acid Blood plasma Serum (blood)
C i s not correct. 9% ch ose this.

Homocysteine levels can increase with end-stage renal d isease (ESRD), most likely secondary to decreased glomerular
filtration. This poses a potential risk to ESRD patients w ho are already at increased risk for cardiovascular events because
elevated homocysteine levels are associated with increased risk of coronary events. Although this patient may have some
renal impairment, no evidence is provided that he suffers from ESRD.
Kidney disease Glomerulus Circulatory system Kidney Chronic kidney disease
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B is not correct. ]Ofo chose this.
2
Serum lactate dehydrogenase levels increase du ring rhabdomyolysis.
3 Rhabdomyolysis Lactate dehydrogenase Lactic acid Blood plasma Serum (blood)
4
5
Homocysteine levels can increase with end-stage renal disease (ESRD ), most likely secondary to decreased glomerula r
•6 filtration . This poses a potential risk to ESRD patients w ho are already at increased risk for cardiovascular events because
•7 elevated homocysteine levels ar e associated with increased risk of coronary events. Although th is patient may have some
•8 renal impairment, no evidence is provided that he suffers f rom ESRD .
Kidney disease Glomerulus Circulatory system Kidney Chronic kidney disease
•9
• 10 D is not correct. 100/o chose this .
• 11 Troponin I is specific to ca rdiac tissue and levels ar e unlikely to be elevated in a crush injury that does not involve dir ect
damage to the myocardium .
• 12
Troponin I TNNI3 Cardiac muscle Troponin
• 13
• 14
• 15 Bottom line:
• 16 Myog lobinuria is common after crush injuries and is manifested by the finding of blood on urine dipstick but the absence of
RBCs on microscopic examination . Lactate dehydrogenase, uric acid, phosphate, and potassium levels can increase rapi dly,
and patients must be monitored for signs of cardiac and systemic irregularities such as peaked T waves and/or muscle
weakness.
Myoglobinuria Uric acid Lactate dehydrogenase Crush syndrome Urine Lactic acid Urine test strip ~1uscle weakness Phosphate ~1uscle Potassium
References:
FA Step 2 CK 9th ed pp 470; 488
FA Step 2 CK 8th ed pp 442; 446
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A 75-year-old man presents to his primary care physician complain ing of difficu lty urinating . He also complains of having ~~AI
2 to awaken multiple times during the night, difficulty maintaining a urine stream, and occasional incontinence. Urinalysis is
3 normal. Digital rectal examination reveals a spongy, uniformly enlarged prostate without distinct masses . His prostate-
4 specific antigen level is 5 ng/ml, unchanged since a year ago.
5
•6 What is the mechan ism of action of the most appropriate first-line therapy?
•7
•8 A. Act as a gonadotropin-releasing hormone agonist and suppresses testosterone production in the testes
•9 B. Act as an agonist on a 1 -receptors in smooth muscle of the prostate and bladder neck
• 10
C. Act as an antagon ist on a 1 -receptors in smooth muscle of the prostate and bladder neck
• 11
• 12 D. Increases the metabolism of testosterone to dihydrotestosterone

• 13 E. Radioactive ablation of prostate t issue
• 14
• 15
• 16
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4 The correct answer is C. 740/o chose this.
5 This patient has classic symptoms of benign prostatic hyperplasia (BPH) . This condition is caused by hyperplasia in the
6 transition zone of the prostate, with subsequent enlargement leading to ureth ral obstruction, as well as reactive detrusor
•7 muscle hypertrophy, which causes irritative symptoms . a 1 -ad renoreceptors in the prostate and bladder neck stimu late smooth
muscle contraction; a-antagon ists such as terazosin, doxazosin, and tamsulosin promote relaxation of these muscles and
•8
improve symptoms .
•9 Doxazosin Benign prostatic hyperplasia Tamsulosin Terazosin Detrusor urinae muscle Smooth muscle tissue Urinary bladder Prostate Hypertrophy Hyperplasia
• 10
A is not correct. 3% chose this.
• 11
Prostatic enlargement is a testosterone-dependent phenomenon, specifica lly related to dihydrotestosterone, a metabolite of
• 12 testosterone produced in the periphery. While castration and gonadotropin-releasing hormone agon ists can be used to treat
• 13 benign prostatic hyperplasia, the adverse effects (impotence) make them unsu itable for first-line therapy.
Benign prostatic hyperplasia Gonadotropin-releasing hormone Dihydrotestosterone Testosterone Hyperplasia Metabolite Castration Hormone Erectile dysfunction Benign tumor
• 14
• 15 B is not correct. 200/o chose this .

• 16 Stimulation of the a 1 - receptors in the prostatic smooth muscle and bladder neck leads to increased contractility, causing
symptoms of obstruction and irritation . First- line medications like terazosin, doxazosin, and tamsulosin antagonize these
receptors.
Doxazosin Tamsulosin Terazosin Smooth muscle tissue Urinary bladder

Prostatic epithelial tissue responds to dihydrotestosteron,e (DHT), and blocking its metabolism from testosterone is an
effective treatment strategy for ben ign prostatic hyperplasia . Finasteride is a Sa-reductase inhibitor that decreases, rather
than increases, the production of DHT.
Benign prostatic hyperplasia Finasteride Dihydrotestosterone Testosterone Epithelium Hyperplasia ~1etabolism Benign tumor Enzyme inhibitor Benignity
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receptors.
2 Doxazosin Tamsulosin Terazosin Smooth musde tissue Urinary bladder
3
4
Prostatic epithelial t issue responds to dihydrotestosteron,e ( DHT), and blocking its metabolism from testosterone is an
5 effective treatment strategy for ben ign prostatic hyperplasia. Finasteride is a Sa-reductase inhibitor that decreases, rather
6 than increases, the production of DHT.
Benign prostatic hyperplasia Finasteride Dihydrotestosterone Testosterone Epithelium Hyperplasia ~1etabolism Benign tumor Enzyme inhibitor Benignity
•7
•8 E is not correct. 10/o chose this .
•9 Prostatic ablation w ith rad ioactive implants is a first-line treatment for prostate cancer. Clues that this patient has benign
• 10 prostatic hyperplasia and not cancer are his digital rectal examination findings ( no hard nodu les) and his prostate-specific
antigen (PSA) level. It is important to know that PSA levels increase with benign prostatic hyperplasia , but a stable level of 5
• 11
ng/ mL is normal for a man 75 years old .
• 12 Prostate-specific antigen Benign prostatic hyperplasia Rectal examination Prostate cancer Ablation Prostate Hyperplasia Antigen Benign tumor Cancer Therapy Benignity
• 13 Nodule (medicine) Rectum

• 14
• 15
Bottom Line:
• 16
a 1 -Adrenoreceptors in the prostate and bladder neck stimulate smooth muscle contraction . Therefore, a-antagon ists such as
terazosin, doxazosin, and tamsulosin are good first-line treatment for ben ign prostatic hyperplasia and act to promote
relaxation of these muscles and improve symptoms.
Doxazosin Benign prostatic hyperplasia Tamsulosin Terazosin Prostate Smooth musde tissue Urinary bladder Hyperplasia
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QID: 21877 ..1 Previous Next 'V!I!ues
Lab Notes Calculator
1
A 52-year-old man is recovering in the surgical intensive care unit from a total colectomy for colorectal adenocarcinoma 1 ~~AI
2 day earli er. He has one peripheral intravenous li ne that is being used to run a patient-controlled analgesia pump, 0 . 5
3 normal saline at 86 m L/hr, and cefazolin . He has no complaints, appears well, and is conversational. Relevant laboratory
4 findings are a serum sodium level of 110 mEq/L; his sodium level was 137 m Eq/L 1 day earlier.
5
6 What is the best next step in the management of th is patient?
•7
•8 A. Discontinue cefazolin
•9 B. Discontinue patient-controlled analgesia pump
• 10
C. Draw blood for testing from the other arm
• 11
• 12 D. Restrict fluid intake

• 13 E. Switch to hypertonic sali ne infusion
• 14
• 15
• 16
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The correct answer is C. 420/o chose this.
3
This patient has a dangerously low serum sodium value but no apparent symptoms of hyponatremia ( confusion, st upor,
4
seizu re s) . Therefore, it is li kely t hat this value is spu rious . This is a common occu r rence in pat ient s who are phlebot omized in
5 t he sam e ar m as the intravenous infusion, proximal to the catheter site.
6 Hyponatremia Sodium Intravenous therapy Catheter Epileptic seizure Stupor Blood plasma Infusion Serum (blood)
7 A is not correct. 4% chose this.

•8 There is no associat ion between int ravenous cefazoli n and hyponat remia .
•9 Hyponatremia Cefazolin Intravenous therapy
• 10 B is not correct. 60/o chose this.

• 11 Patient-controlled analgesia pumps are not a significant source of free water and are unlikely to contribute t o hyponatremia .
• 12 Hyponatremia Patient-controlled analgesia Analgesic
• 13
D is not correct. 290/o chose this .
• 14
Flu id restriction is the appropr iate treatm ent for m ild, asympt om at ic hyponat remia (sodium 130-135 mEq/ L) . However, it is
• 15 important t o ensure t he hyponatrem ia is real prior t o initiating t reatment .
Hyponatremia Sodium Fluid restriction Asymptomatic Equivalent (chemistry)
• 16
E is not corr ect. 19% chose this.

Hypertonic sali ne can be used for t he treatm ent of severe, symptomat ic hyponatremia . I n severe cases (seizures), correct ion
should not exceed 1.5- 2 m Eq/h r, especially if hyponat rem ia has been long standing . Too-rap id correct ion of the hyponat rem ia
can re sult in central pontine myelinolysis. Prior t o initiati rng t reatment , t he diagnosis must be confirmed . Consider ing t his
pati ent is asymptomatic, th is is not an appropriate pr im ary int ervention.
Central pontine myelinolysis Hyponatremia Tonicity Saline (medicine) Saline water Epileptic seizure Pons
Bottom Line:
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1 There is no association between intravenous cefazolin and hyponatremia .

Hyponatremia Cefazolin Intravenous therapy
2
3 B is not correct. 60/o chose this.
4 Patient-controlled ana lgesia pumps are not a significant source of free water and are unlikely to contribute to hyponatremia .
Hyponatremia Patient-controlled analgesia Analgesic
5
6 D is not correct. 290/o chose this.
7 Flu id restriction is the appropriate treatment for m ild, asymptomatic hyponatremia (sodium 130-135 mEq/L) . However, it is
•8 important to ensure the hyponatrem ia is rea l prior to initiating treatment .
Hyponatremia Sodium Fluid restriction Asymptomatic Equivalent (chemistry)
•9
• 10 E is not correct. 19% chose this.
• 11 Hypertonic saline can be used for the treatment of severe, symptomatic hyponatremia . I n severe cases (seizures), correction
should not exceed 1.5-2 mEq/hr, especially if hyponatrem ia has been long stand ing . Too-rapid correction of the hyponatremia
• 12
can result in centra l pontine myelinolysis . Prior to initiating treatment, the diagnosis must be confirmed . Considering this
• 13 patient is asymptomatic, this is not an appropriate primary intervention .
• 14 Central pontine myelinolysis Hyponatremia Tonicity Saline (medicine) Saline water Epileptic seizure Pons
• 15
• 16
Bottom line:
This patient has a dangerously low serum sodium level but no apparent symptoms of hyponatremia (confusion, stupor,
seizures) . Draw blood from the arm opposite to the intravenous infusion to confirm .
Hyponatremia Sodium Intravenous therapy Blood plasma Serum (blood) Epileptic seizure Sodium in biology Stupor
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1
A 60-year-old man presents to his primary care physician with the chief complaints of fatigue and unintentional weight
2 loss over the past few months . He has noted blood in his urine, but never brought it to a physician's attention because it
3 was never painful. Over the past 2 weeks, he has also developed a nonproductive cough. On physical examination the man
4 is cachectic with temporal wasting . He has a palpable, irregula rly shaped mass that is located just above the pubic symphysis to
the left of the midline. Digital rectal examination reveals a normal prostate and guaiac-negative stool. Urinalysis is positive for
5
blood . CT scans of the chest, abdomen, and pelvis show a la rge tumor in the bladder and several suspicious-looking pelvic and
6 cervical lymph nodes. X-ray of the chest reveals four 1-cm lesions in the man's left lung . He undergoes a cystoscopy and a 4-cm
7 mass is seen on the left superior aspect of the bladder. A biopsy reveals transitional cell carcinoma .
•8
•9 Which treatment is most appropriate for this man's disease?
• 10
• 11 A. Hospice
• 12
B. Intravesicular 6acille Calmette-Guerin and systemic chemotherapy
• 13
• 14
C. Pelvic exenteration and systemic chemotherapy
• 15 D. Systemic chemotherapy
• 16
E. Transu reth ra l resection of the bladder tumor, pelvi c radiat ion, and systemic chemotherapy
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3
4 The correct answer is D. 350/o chose t his.
5
This patients has metastatic transitional cell carcinoma (TCC) of the bladder, and TCC is the predominant histologic type seen
in the United States, represent about 90% of all bladder cancers . Fatigue and weight loss, as seen in this patient, are
6
suspicious for metastatic disease or a metabolically activ,e tumor. The treatment of metastatic TCC of the bladder is systemic
7 chemotherapy. With today's therapies, patients with metastatic TCC have a median survival of about 12 months and a 3-year
8 survival rate of about 15%-20%. For patients with good performance status, adequate renal function, and metastatic
•9
urothelia l cancer, a cisplatin-based combination chemotherapy is recommended. The utility of surgery in patients with
metastatic disease is not well defined . Although there is some suggestion that surgery may be warranted in some patients,
• 10 given the extent of spread ( includ ing lung metasteses), this man would probably not stand to benefit.
• 11 Transitional cell carcinoma Chemotherapy Metastasis Histology Urinary bladder Neoplasm Performance status Carcinoma Combination chemotherapy Fatigue (medical) Renal function
• 12 Urothelium Weight loss Lung Cancer Metabolism Epithelium Kidney
• 13
A is not correct. 100/o chose this.
• 14
Supportive or palliative care is indeed warranted in some cases if the patient is competent, informed about options, and does
• 15 not desire treatment. At this point the patient has not voiced any objection to treatment. Therefore, the standard of care
• 16 should be offered first .
Palliative care Standard of care
B is not correct. 110/o chose t his.

This combination is not regularly used in the management of bladder cancer. Intravesicular Bacille Calmette-Guerin (BCG) is
one of the agents used to treat superficial transitional ce ll carcinoma without the use of systemic chemotherapy.
Transitional cell carcinoma Bladder cancer Chemotherapy Urinary bladder Cancer Carcinoma
C is not correct. 100/o chose this.

Extensive pelvic exenteration (en bloc resection of all pel vic organs) and systemic chemotherapy would not be the standard
treatment for a patient with metastatic disease . There is some evidence that a metastectomy and chemotherapy in addition
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• I I • • I I ..
1
This combination is not regularly used in the management of bladder cancer. Intravesicular Bacille Ca lmette-Guerin { BCG ) is
2
one of the agents used to treat superficial transit iona l cell car cinoma without the use of systemic chemotherapy.
3 Transitional cell carcinoma Bladder cancer Chemotherapy Urinary bladder Cancer Carcinoma
4
5
Extensive pelv ic exenteration ( en bloc r esection of all pelvic organs) and systemic chemotherapy would not be the standard
6 treatment for a patient with metastatic disease . There is some evidence that a metastectomy and chemotherapy in addition
7 to local bladder and pelvic dissection may improve survival; however, this is not the standar d of car e, and given the
8 numerous lung lesions, such an aggressive approach is of limited benefit.
Pelvic exenteration Chemotherapy Metastasis Segmental resection lung Urinary bladder Pelvis Evisceration (ophthalmology) Dissection Standard of care
•9
• 10 E is not correct. 34% chose this.
• 11 Transurethral resection of bladder tumor, pelvic radiation, and systemic chemotherapy is not warranted for metastatic bladder
cancer. This combination does have a role in invasive ca ncer w ithout evidence of metastases, but this patient has metastatic
• 12
disease includ ing four lung lesions . In cases of non-muscle invasive bladder cancer, complete transurethral resection with
• 13 intravesical chemotherapy or immunotherapies can be employed .
• 14 Bladder cancer Chemotherapy Urinary bladder Metastasis Immunotherapy Neoplasm Segmental resection Radiation Cancer Lung Transurethral resection of the prostate Pelvis
• 15
• 16
Bottom line:
The preferred treatment for patients with metastatic transit ional cell carcinoma {TCC) of the bladder and urinary t ract is a
cisplatin-based combination chemotherapy.
Transitional cell carcinoma Chemotherapy Metastasis Urinary system Carcinoma Combination chemotherapy Urinary bladder Epithelium
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1
A 29-year-old man with no past medical history presents to a urologist after 2 years of unsuccessful attempts at ~~AI
2 conceiving a child . The man states that his wife is 24 year s old and has no med ica l problems. She was evaluated for
3 infertility by a gynecologist, and no abnorma lities were found. The man has no history of sexually transm itted disease or
4 urologic diseases. Physical examination reveals a tall ma n with long legs who appears younger than his stated age. He has
min imal facia l hair and a slight ful lness to his breasts bilateral ly. The patient's testicles are 2 .2 em long and firm. A semen
5
sample is obtained, wh ich shows no sperm .
6
7
For what disease is th is man at increased risk'
8
•9
A. Germ cell tumor
• 10
• 11
B. Paraphimosis
• 12 C. Peyron ie's disease
• 13
D. Renal cell carcinoma
• 14
• 15
E. Transitional cell carcinoma
• 16
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3
4 The correct answer is A. 760/o chose this.
5 The man described has Klinefelter's syndrome. The classic triad is small, firm testes, azoospermia, and gynecomastia. The
6 syndrome (47, XXY) is associat ed with an increased likelihood of germ cell t umors in extragonada l sites. Breast cancer is also
7
much more likely in these patients .
Klinefelter syndrome Gynecomastia Germ cell Azoospermia Testicle Breast cancer Germ cell tumor Cancer Non-Kiinefelter X'XY Neoplasm
8
9 B is not correct. 6 0/o chose this .
• 10 Paraph imosis describes a retracted foreskin that cannot be replaced to its normal position .
Paraphimosis Foreskin
• 11
• 12 C i s not correct. 60/o chose this .

• 13 Peyronie's disease is a disease in which a ha rd plaque develops on the penis result ing in painful erection, curvature of t he
penis, and poor erection quality. It is not associated with Kli nefelter's syndrome .
• 14
Klinefelter syndrome Peyronie's disease Penis Human penis
• 15
D is not correct. 9 % chose this .
• 16
Renal cell carcinoma is not associated with Kli nefelter's syndrome.
Klinefelter syndrome Renal cell carcinoma Carcinoma Kidney
E i s not corr ect. 30/o c hose t his.

The risk factors for transitional cell carcinoma include exposure to dyes and smoking . There is no known relationsh ip to
Klinefelter's syndrome .
Klinefelter syndrome Transitional cell carcinoma Carcinoma Tobacco smoking
Bottom Line :
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1
B is not correct. 60/o chose this.
2
Paraphimosis describes a retracted foreskin that cannot be replaced to its normal posit ion .
3 Paraphimosis Foreskin
4
5
Peyron ie's disease is a disease in which a hard plaque develops on the penis resulting in painfu l erection, curvatu re of the
6
penis, and poor erection quality. It is not associated w ith Klinefelter's synd rome.
7 Klinefelter syndrome Peyronie's disease Penis Human penis
8
9
Renal cell ca rcinoma is not associated w ith Klinefelter's synd rome .
• 10 Klinefelter syndrome Renal cell carcinoma Carcinoma Kidney
• 11
E is not correct. 30/o chose this .
• 12
The risk factors for t ransit iona l cell carcinoma include exposure to dyes and smoking . There is no known relationship to
• 13 Klinefelter's syndrome .
• 14 Klinefelter syndrome Transitional cell carcinoma Carcinoma Tobacco smoking
• 15
• 16
Bottom line:
Klinefelter's syndrome presents with a classic triad of sma ll, firm testes, azoospermia, and gynecomastia. The syndrome
( 47,XXY) is associated with an increased likelihood of germ cel l tumors in extragonadal sites .
Klinefelter syndrome Gynecomastia Germ cell Azoospermia Testicle Non-Klinefelter XXY Genm cell tumor Neoplasm
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Item: 10 of 16 ~ 1 • Mark <:] (:>- Jill ~· ~J
1
A 55-year-old caucasian male presents to his primary care physician with complaints of left flank pain, hematuria, and a
2 palpable abdominal mass for the past 3 weeks. He admits to a 9 .1-kg ( 20-lb) un intentional weight loss in the past 3
3 months and some m ild fatigue, but otherwise feels healthy. He has no significant past medical history and denies any
4 allergies or medication use. His heart rate is 90/ min, blood pressur e is 150/ 95 mm Hg, r espiratory rate is 26/ min, and
temperature is 36 .7°C (98°F) . Abdominal CT with contrast confirms the diagnosis and shows unilateral disease and metastasis
5
to ipsilateral renal hilar lymph nodes. Staging CT did not any other metastases . A gross pathology specimen is seen in the
6 image .
7
8
9
• 10
• 11
• 12
• 13
• 14
• 15
• 16
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3
4
5
6
7
8
9
• 10
• 11
• 12
• 13
• 14
Which of t he following is the best surgica l treatment for this condition?
• 15
• 16
A. Left adrenalectomy with ipsilateral nephrect omy
B . Left laparoscopic nephrectomy
C. Left nephron-sparing surgery
D . Left radical nephrectomy
E. Left radical nephrectomy and adjuvant sorafenib
a
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2 The correct a nswer is D. 430/o chose t his.

3 This patient presents with the classic triad for renal cell carcinoma (RCC): flank pain, hematuria, and palpable mass.
4
However, these findings are present in on ly 10% of patient presentations. Both flank pain and a palpable mass indicate
advanced disease, as well as the CT evidence of nodal disease. The image provided shows the resected kidney that has been
5 bisected by the pathology team to further study the tumor. The tissue of origin for RCC is the proximal renal tubular
6 epitheli um. Renal cancer occurs in both a sporadic (nonhered itary) and a hereditary form, and both forms are associated with
7 structural alterations of the short arm of chromosome 3. Staging is crucial for determining the treatment of RCC. Patients
w ith disease li mited to Gerota fascia (renal fascia) are best treated with a partial or radical nephrectomy. Radical
8
nephrectomy is the en bloc resection of the kidney, Gerota fascia, the adrena l gland (may be spared depending on tumor
9 location), the lymph nodes at the renal hil um, and the proximal half of the ureter. Patients with a larger, centrally-located
10 tumor and a normal contralateral kidney should undergo a radical nephrectomy, but a partial nephrectomy should be
• 11
attempted in cases with less advanced disease . Stage IV (metastatic) RCC may sometimes be treated with nephrectomy (if
they have limited metastatic lesions) with the possibility of postoperative immunotherapy.
• 12 Adrenal gland Renal fascia Ureter Renal cell carcinoma Hematuria Hilum (anatomy) Nephrectomy Kidney cancer Metastasis Epithelium Abdominal pain lymph node Kidney
• 13
Immunotherapy Cancer staging Renal hilum Segmental resection Neoplasm Carcinoma Pathology Fascia Contralateral cancer Proximal convoluted tubule Anatomical terms of location
• 14
CT scan Gland lymph
• 15
• 16
A is not correct. 1 20/o chose t his.
Adrenalectomy with ipsilateral nephrectomy is the surgery of choice for treating neuroblastoma, not renal cell carcinoma .
Neuroblastoma is an embryonal tumor of neural crest origin due to a defect in the N-myc oncogene . More than 50% occur in
the adrenal medulla and present as asymptomatic abdom inal masses by the age of 8 years. Treatment depends on staging,
although surgical resection is the mainstay of therapy, wijth or without chemotherapy and/or radiation therapy.
Embryoma Adrenal medulla Neuroblastoma Renal cell carcinoma Radiation therapy Neural crest Chemotherapy Nephrectomy Oncogene Neoplasm Asymptomatic
Anatomical terms of location Carcinoma Segmental resection Embryo Adrenalectomy Adrenal gland Ipsilateral N-Myc Kidney
6 is not correct. ] Ofo chose t his.

Laparoscopic nephrectomy wou ld be less invasive, incur less morbidity, and possibly provide a shorter recovery time, a need
fnr II'>~~ n;;i n ml'>rlir:;;tinn . ;;nrl II'>~~ hlnnrl In~~ . I ;; n;; rn~r:nnir: n;;rti;;l nl'>nhrl'>r:tnmv i~ tl'>r:h nir:;;llv rliffir:1 1It ;;nrl ~hn11 lrl nn lv hi'>
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1 B is not correct. ]Ofo chose this.

2 Laparoscopic nephrectomy would be less invasive, incur less morbidity, and possibly provide a shorter recovery time, a need
3 for less pain medication, and less blood loss . Laparoscopic partial nephrectomy is technically difficu lt and should on ly be
4 performed by experienced clin icians. An open partia l neph rectomy may be preferable in select patients ( eg, those with a
solitary kidney) because open laparotomy requires a relatively shorter warm ischemia time, which may lower the risk of
5
subsequent rena l dysfunction . However, disadvantages include increased operating room time and higher cost in addition to
6 concerns about tumor spillage and the technical difficulties in defining surgical ma rgins. The patient in this case already has
7 nodal involvement as reported on CT scan, so laparoscopic nephrectomy is not indicated .
laparotomy cr scan Nephrectomy laparoscopic surgery laparoscopy Ischemia Morbidity Kidney Analgesic Neoplasm Bleeding
8
9 C is not correct. 4% chose this.
10 Neph ron-sparing su rgery, otherwise known as a partial nephrectomy, may be a viable treatment option for rena l cell
• 11
carcinoma in early stage disease when the tumor is < 7 em and if it is technically feasible ( eg, on ly one pole involved), and if
there are no obvious signs of metastatic spread . Howeve·r, the surgery is contraindicated when there is evidence of obvious
• 12
nodal metastasis. Therefore, in this case, partial nephrectomy is not the preferred t reatment.
• 13 Renal cell carcinoma Metastasis Nephrectomy carcinoma Neoplasm Kidney
• 14
E is not correct. 34% chose this.
• 15
This patient has loca lized rena l cell carcinoma, due to presence of unilatera l kidney mass and ipsilateral involvement of hila r
• 16 lymph nodes. There is not a role for adjuvant chemotherapy, including tyrosine kinase inh ibitors {TKI) such as sorafenib. The
best treatment is radical nephrectomy along for a patient that has loca lized rena l cell carcinoma . In contrast, chemotherapy
agents such as TKI, IL-2, and nivolumab are suitable for treating advanced renal cell carcinoma, making this answer choice
less li kely.
Renal cell carcinoma Sorafenib Nivolumab Chemotherapy Inter1eukin 2 Nephrectomy lymph node Tyrosine kinase Adjuvant Adjuvant therapy Protein kinase inhibitor Carcinoma
Kidney Tyrosine lymph Hilum (anatomy) Immunologic adjuvant Kinase Anatomical terms of location
Bottom Line:
Rr~rlir:;;l nAnhn~r:tomv i~ ;;nnrnnri r~tA for lr~rnA Rl.l. hJmor~ w ith othAr inrlir:r~tion~ of ;;rlvr~nr:Arl rli~F'!i'I~F'! ~llr:h ;;~ rAnr~l hil;; r
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. .. . . .. . .. .. . .. . .. .. .. .. . . .. . .. .. .. . .. .. . . - .. .. . . . .
1
2 C is not correct. 4 % chose this.

3 Nephron-sparing surgery, otherwise known as a partial nephrectomy, may be a viable treatment option for renal cell
carcinoma in early stage disease when the tumor is < 7 em and if it is technically feasible ( eg, only one pole involved), and if
4
there are no obvious signs of metastatic spread . Howeve·r, the surgery is contraind icated when there is evidence of obvious
5 nodal metastasis. Therefore, in th is case, partial nephrectomy is not the preferred treatment.
6 Renal cell carcinoma Metastasis Nephrectomy carcinoma Neoplasm Kidney
7 E is not correct. 34 % chose this.

8 This patient has localized rena l cell carcinoma, due to presence of un ilateral kidney mass and ipsilateral involvement of hilar
9 lymph nodes. There is not a role for adjuvant chemotherapy, including tyrosine kinase inhibitors (TKI) such as sorafenib. The
10 best treatment is radical nephrectomy along for a patient that has localized renal cell carcinoma . In contrast, chemotherapy
agents such as TKI, I L- 2, and nivolumab are su itable for treating advanced renal cell carcinoma, making th is answer choice
• 11
less likely.
• 12 Renal cell carcinoma Sorafenib Nivolumab Chemotherapy Inter1eukin 2 Nephrectomy lymph node Tyrosine kinase Adjuvant Adjuvant therapy Protein kinase inhibitor Carcinoma
• 13 Kidney Tyrosine lymph Hilum (anatomy) Immunologic adjuvant Kinase Anatomical terms of location
• 14
• 15
Bottom Line :
• 16
Radical nephrectomy is appropriate for large RCC tumors w ith other indications of advanced disease such as renal hilar
nodal involvement. A partial nephrectomy should be considered for sma ller tumors. The classic triad for RCC includes flank
pain, hematuria, and a palpable mass, but th is triad is only present in 10% of patient presentations.
Hematuria Nephrectomy Abdominal pain Hilum (anatomy) Kidney Neoplasm
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1
A 38-year-old man was thrown from his motorcycle and brought to the emergency department by emergency medical ~~AI
2 services. The paramedics report his in it ial blood pressure was 74/52 mm Hg, pu lse was 128/min, and respiratory rate was
3 33/min . He was given 2 L of lactated Ringer's solution en route, and medical antishock trousers were applied. On arrival to
4 the trauma bay his blood pressure is 78/56 mm Hg, pulse is 125/min, and respiratory rate is 28/min . On examination pelv ic
compression elicits severe pain, and blood is noted at the urethral meatus.
5
6
Which of the following is the most appropriate next step in management?
7
8
A. Abdominal ultrasound
9
10 B. Administration of blood products
· 11 C. Foley catheter insertion and urinalysis
• 12
D. Intravenous pyelogram
• 13
• 14 E. Retrograde urethrogram
• 15
• 16
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3
The correct answer is B. 310/o chose this.
4
Blood at the urethral meatus suggests urethral injury and significant active internal hemorrhage, most likely due to a
5 fractured pelvis. However, addressing the urethral injury must wait until the patient is appropriately stabilized . Init ial
6 management of this patient involved fluid resuscitation; !however, his vital signs and shock index (heart rate divided by
7
systolic blood pressure) have been m inimally responsive to the 2-L intravenous fluid bolus already administered by the
paramed ics. Furthermore, the evidence for hemorrhage as the source of the hemodynam ic instability implies a high likelihood
8 of need ing replacement blood products. Therefore, the best next step is the adm inistration of blood products as the operating
9 room is being prepared .
Intravenous therapy Bleeding Vital signs Blood pressure Urethra Heart rate Pelvis Fluid replacement Internal bleeding Systole Bolus (medicine) Operating theater
10
11 A is not correct. 210/o chose this.
• 12 Although an abdominal ultrasound may be used in the initial eva luation of trauma, it will not provide any information that is
• 13 not already known : the patient is bleeding internally. The blood at the urethral meatus and the pain on pelvic compression
• 14
suggests that the pelvis is the source of hemodynamic instability.
Medical ultrasound Ultrasound Pelvis Abdominal ultrasonography Urinary meatus
• 15
• 16 C is not correct. 5% chose this.
A Foley catheter should never be placed in a patient with suspected urethral damage because the catheter could increase the
urethral injury.
Foley catheter Catheter Urethra

An intravenous pyelogram does not adequately assess urethral injury in the setting of trauma . In add it ion, the patient's
kidneys have most likely suffered during the period of hypotension, and may not be able to handle the iodine load associated
with this procedure.
Intravenous pyelogram Hypotension Intravenous therapy Iodine Kidney Urethra
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C is not correct. SO/o chose this.
2
A Foley catheter should never be placed in a patient with suspected urethral damage because the catheter could increase the
3 urethral injury.
4 Foley catheter Catheter Urethra
5 D is not correct. 9% chose this.

6 An intravenous pyelogram does not adequately assess urethral injury in the setting of trauma . In add it ion, the patient's
7 kidneys have most likely suffered du ring the period of hypotension, and may not be able to handle the iodine load associated
8 w ith this procedure.
Intravenous pyelogram Hypotension Intravenous therapy Iodine Kidney Urethra
9
10 E is not correct. 34% chose this.
11 A urethrog ram is the definit ive study for suspected urethra l injury. A recta l exam ination performed as part of the rapid
trauma survey to assess rectal tone and determ ine the presence of gross blood wil l most likely have revealed a high-riding,
• 12
boggy prostate, increasing the suspicion for ureth ral injury. However, assessment of the urethral injury needs to wa it until the
• 13 patient is appropriately stabil ized, especially in the context of a likely pelvic fracture causing hemodynam ic instability.
• 14 Pelvic fracture Urethra Rectal examination Pelvis Rectum Retrograde urethrogram Prostate cancer Prostate Bone fracture
• 15
• 16
Bottom line:
Blood at the ureth ral meatus suggests ureth ral injury. However, specific injuries such as broken bones, severed limbs, and
injured soft tissues are only addressed once the patient's circu lation, airway, and breathing have been eva luated .
Internal urethral orifice Urinary meatus Urethra Meatus
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A 28-year-old man presents to the clin ic complain ing of heaviness in his testicle for 2 weeks . He says he feels as though
2
his testicle is enlarged . The man has a temperature of 37 .2°C (98 .9°F), heart rate of 60/min, and blood pressure of
3 115/70 mm Hg. He has an unremarkable abdominal examination with no palpable masses. The right testicle is noticeably
4 larger than the left testicle. There are no discrete nodu les . Testicu lar ultrasound reveals a homogenous intratesticu lar mass and
an orch iectomy is subsequently performed. On pathology, seminomatous elements are seen. A stag ing CT scan is performed
5
and reveals an enlarged 1.8 em retroperitoneal lymph node. He is diagnosed with stage IIA testicular sem inoma (T2N1MO) .
6
7
What additiona l treatment is needed?
8
9
A. Contralatera l orchiectomy
10
11
B. Platinum-based chemotherapy and bilatera l orchiectomy
• 12 C. Prophylactic mediastinal radiation
• 13
D. Retroperitoneal lymph node dissection
• 14
• 15
E. Retroperitoneal radiation
• 16
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3
4 The correct answer i s E. 3 5 % chose this .
5 Seminoma is a tumor type that is extremely sensit ive to radiation. Stages I or IIA disease can be successfully treated w ith
6 orchiectomy and radiation of the r etro peritoneum . The low dose of rad iation t hat is required is usually well-tolerated wit h
7
minimal gastrointestinal side effects . Chemotherapy can be used as salvage therapy for patients who relapse following
radiation . The staging of seminomas is as follows: stage I: disease confined to the testis; stage II: r etroperitoneal nodal
8 involvement (IIA if <2 em and liB if >2 em ); stage III: supradiaphragmatic nodal involvement or involvement of the viscera.
9 Seminoma Orchiectomy Retroperitoneal space Salvage therapy Chemotherapy Neoplasm Organ (anatomy) Testicle Radiation Gastrointestinal tract Human gastrointestinal tract
10
A i s not correct. 7 % ch ose this.
11
At this point there is no need to r emove the man's other testicle . Removal of the contralateral testicle may be warranted if
12 there is ma lignant involvement of the left testicle. The case presented here is a seminoma in the right testicle and does not
• 13 warrant this surgical procedure .
Seminoma Testicle Contralateral Cancer Malignancy Surgery Anatomical terms of location
• 14
• 15 B is not correct. 2 30/o chose th is .

• 16 Platinum-based chemotherapy is used to treat patients t hat have metastatic nonseminomatous germ cell tumors after
treatment by or ch iectomy or with bulky retroperitoneal d isease . In the case of unilateral testicular cancer, a bilateral
orchiectomy is not warranted.
Orchiectomy Germ cell Testicular cancer Chemotherapy Retroperitoneal space Metastasis Germ cell tumor Cancer Cisplatin Neoplasm
C i s not correct. 6 % chose this.

Prophylactic mediastinal radiation had been practiced in the past, but it is no longer used . The myelosuppression that may
result can compr omise the patient's ability to r eceive chemotherapy at a later date.
Bone marrow suppression Chemotherapy Mediastinum Preventive healthcare
D is not correct. 2 9 0/o chose this.
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1
2 B is not correct. 2 30/o chose th is.

3 Platinum-based chemotherapy is used to treat patients that have metastatic nonseminomatous germ cell tumors after
4
treatment by orch iectomy or with bulky retroperitoneal d isease . In the case of unilateral testicular cancer, a bilateral
orchiectomy is not warranted .
5 Orchiectomy Germ cell Testicular cancer Chemotherapy Retroperitoneal space Metastasis Germ cell tumor Cancer Cisplatin Neoplasm
6
C is not correct. 60/o chos e this .
7
Prophylactic mediastinal rad iation had been practiced in the past, but it is no longer used . The myelosuppression that may
8
result can compromise the patient's ability to receive chemotherapy at a later date.
9 Bone marrow suppression Chemotherapy Mediastinum Preventive healthcare
10
D is not correct. 2 9 0/o chose this .
11
Retroperitoneal lymph node dissection {RPLND) is used in treating low-stage nonseminomatous germ cell tumors and has
12 sign ificant morbidity. RPLND often damages the sympathetic innervation of the sem inal vesicle, wh ich can lead to retrograde
• 13 ej aculation and infertility. The case presented here is a seminoma and does not warrant this surgical procedure .
Seminal vesicle Seminoma Lymph node Retrograde ejaculation Germ cell Retroperitoneal space Retroperitoneal lymph node dissection Lymphadenectomy Surgery Lymph Infertility
• 14
Ejaculation Germ cell tumor Neoplasm Sympathetic nervous system Morbidity Dissection Nerve
• 15
• 16
Bottom line :
Seminomas in stages I or IIA can be successfully treated with orchiectomy and radiation of the retroperitoneum .
Orchiectomy Retroperitoneal space
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A 35-year-old female restrained driver of a midsize sport utility vehicle is brought to the emergency department ( ED) after 1•AI
being involved in a high-velocity, head-on collision. Her init ial v itals in the ED are a blood pr essure of 100/ 62 mm Hg, A
3 heart rate of 110/ m in, respiratory rate of 18/ min, temperatur e of 37.6°C ( 99.7°F), and 94% oxygen saturation on room
4 air. She had a Glasgow Coma Scale score of 4 in the field, which improved to 6 at arriva l in the ED. In it ial laboratory tests show
patient has a hemoglobin of 10 g/ dl, hematocrit 38%, and WBC of 12, 000 cells/ mel . No blood is observed at the urethral
5
meatus, nor is there any evidence of pelvic fracture on trauma radiographs . A FAST exam performed bedside in the ED is
6 negative. A Foley catheter is placed without difficulty, but there is noticeable hematuria in the collecting bag.
7
8 What is the next step in management?
9
10 A. CT scan of abdomen and pelvis
11
B. Packed red blood cells
12
• 13 C. Pelvic angiography
• 14 D. Renal ultrasonography
• 15
E. Retrograde ur ethrography
• 16
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The correct answer is A. 490/o chose this.
2
ACT scan of the abdomen and pelvis would be appropriate to look for bladder and renal injury. A negative FAST examination
3 does not exclude the presence of internal bleeding. The presence of blood in the urine after a Foley catheter insertion could
4 be from the insertion of the catheter. However, because she had significant trauma from a high-speed motor vehicle collison,
5
even in the light of negative radiographs of the pelvis for fracture or trauma, the hematuria must be worked-up further for
bladder and/or renal injury. Because the patient is hemodynamically stable, the best next step would be to work-up the
6 bleed ing with a CT of the abdomen and pelvis .
7 Foley catheter Hematuria CT scan Catheter Pelvis Urinary bladder Abdomen Urine Radiography Kidney Major trauma Bone fracture
8
B is not correct. ]Ofo chose this.
9
The patient is hemodynamically stable at this t ime. She needs a CT scan immediately to help establish the source of the
10 bleed ing . If the patient becomes hemodynamically unstable then it would be v ita l to start blood products.
11 CT scan Hemodynamics
12 C is not correct. 6% chose this.

13 ACT scan wou ld be performed before pelvic angiography. The CT scan can be done immediately and is a better in itial
• 14 diagnostic test due to the multiple potential etiologies for hematuria . If CT scan helps determine that the bleeding is most
• 15
likely coming from pelvic vessels, and the patient is stabl e, pelvic angiography can be used next as a diagnostic and
therapeutic test. However, in the setting of t rauma, most commonly pelvic vessel bleeds w il l be initially treated with packing
• 16
in order for the vessels to tamponade and stop bleeding.
Hematuria CT scan Angiography Etiology (medicine) Etiology Pelvis

Renal ultrasonography would not be helpful in this scenar io as it was essentia lly done during the FAST exam . Plus, the more
sensitive test would be the CT scan .
CT scan Medical ultrasound Kidney
E is not correct. 23% chose this.

Retrog rade urethrography would be appropriate to determine urethra integrity. However, there is no blood seen at the
1trcthr;::~~l n"\.o;:.ti iC: ;::.nrl t lr""ino rll"\oe rlr;::~~ in \M hon ;::. I=I"\ IC:n/ ie nl;:a,rori ll r"otrl"\l"lr"'.::l rfo 1""\/~tl"\t"u";:::u.,.., t""f"\ 1drl he h.olnf• d h a1t \At;:ae nt"\t 1"\fforcri in
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2
ACT scan wou ld be performed before pelvic angiography. The CT scan can be done immediately and is a better in itial
3 diagnostic test due to the multiple potential etiologies for hematuria . If CT scan helps determine that the bleeding is most
4 li kely coming from pelvic vessels, and the patient is stabl e, pelvic angiography can be used next as a diagnostic and
5
therapeutic test. However, in the setting of trauma, most commonly pelvic vessel bleeds w il l be initially treated with packing
in order for the vessels to tamponade and stop bleeding .
6 Hematuria CT scan Angiography Etiology (medicine) Etiology Pelvis
7
D is not correct. 1 50/o chose t his .
8
Renal ultrasonography would not be helpful in this scenar io as it was essentially done during the FAST exam . Plus, the more
9
sensitive test would be the CT scan .
10 CT scan Medical ultrasound Kidney
11
E is n ot correct. 23% ch ose this .
12
Retrograde urethrography wou ld be appropriate to determine urethra integrity. However, there is no blood seen at the
13 urethral meatus, and urine does drain when a Foley is placed . A retrograde cystogram could be helpful but was not offered in
• 14 this scenario .
Retrograde urethrogram Cystography Urethra Urine Internal urethral orifice Urinary meatus
• 15
• 16
Botto m line :
CT scanning of the abdomen and pelv is or retrograde cystography are appropriate diagnostic tests if gross blood is found
after Foley catheter placement in the setting of blunt injury.
Foley catheter Cystography CT scan Pelvis Catheter Abdomen
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A 78-year-old man presents to his physician compla ining of a bulge in his groin that has gradually enla rged over the past
2 year. It is less prominent when he lies on his back. He also has type 2 diabetes mellitus. He notes that he has had to get
3 up three times each night to urinate for the past severa l years . During the day he feels the need to urinate every hour,
4 though he often strains and experiences dribbling of urine . Otherwise, he has felt well, and den ies any fevers, weight loss,
abdom ina l pain, nausea, vomiting, or change in bowel habits. Physica l exam ination shows a slightly distended abdomen w ith
5
pain on palpation below the umbilicus. There is a bu lging mass on the patient's left lower abdomen immed iately above the leg
6 crease that is 4-5 em in diameter. The mass easily reduces and is not visible when the patient is lying down . A digital rectal
7 exam ination reveals an enlarged prostate; stool is guaiac negative .
8
9 Which of the following will alleviate this patient's symptoms?
10
11 A. Bladder augmentation
12
B. High-fiber diet and stool softeners
13
• 14
C. Pyeloplasty
• 15 D. These findings are an unavoidable consequence of aging

• 16
E. Transureth ra l prostate resection
F. Ureteral reimplantation
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3
The correct answer i s E. 54 % ch ose this.
4
The man has sequelae of a chronic lower urinary tract obstruction . The man's history and physica l examination results are
5 consistent w ith ben ign prostatic hyperplasia, which is the cause of urinary freq uency, urgency, and nocturia . The mass that he
6 complains of is an inguina l hernia that likely is secondary to the enormous amount of straining required to urinate past th is
7 obstruction . Transurethral resection of the prostate (TURP) is the on ly procedure listed that could reli eve the obstruction .
During TURP, a resectoscope is inserted through the tip of the pen is and into the urethra; this resectoscope is used to ligate
8
and remove the prostatic tissue surrounding the urethra, thereby relieving obstruction and restoring normal urinary flow.
9 Benign prostatic hyperplasia Inguinal hernia Nocturia Urethra Transurethral resection of the prostate Urinary system Urinary retention Prostate Physical examination Hyperplasia
10 Prostate cancer Urination Sequela Hernia Human penis Penis Benignity Frequent urination
11
A i s not correct. 9 % ch ose this.
12
Bladder augmentation wou ld not relieve the obstruction. The procedure reduces the pressure in the bladder and would only
13 increase the man's capacity to hold urine . Bladder augmentation is useful in patients with neurogenic bladders . The increased
14 bladder capacity may help prevent overflow incontinence, and protect the kidneys from damage secondary to the effects of
• 15 high bladder pressure .
Bladder augmentation Urinary incontinence Urine Urinary bladder Kidney Overflow incontinence Fecal incontinence
• 16
B is not correct. 110/o chose th is.
Strain ing secondary to constipation could cause a femoral hernia, but would not explain the chronic lower urinary tract
obstruction supported by symptoms of hesitancy, frequency, urinary retention, and post-void dribbli ng . A high-fiber diet and
stool softeners would treat constipation, but would not address this man's urinary obstruction.
Constipation Urinary retention Urinary system Hernia
C i s not correct. 9% chose this.

Pyeloplasty is a surgical reconstruction of the renal pelvis. It may be used to relieve upper urinary tract obstruction.
Pyeloplasty would not have prevented femoral hernia or chronic lower urinary tract obstruction supported by symptoms of
~.o.--=~---·· & ..... - • • - - - · · . . ..: - - - · ... _ . __ .. ; __ --...1 - - - - ., ... ;...,1 ........ ;; L..L-.1:--
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2
Pyeloplasty is a surgical reconstruction of the renal pelvis. It may be used to relieve upper urinary tract obstruction .
3 Pyeloplasty would not have prevented femoral hernia or chronic lower urinary tract obstruction supported by symptoms of
4 hesitancy, frequency, urinary r etention, and post-void drit bbling.
Renal pelvis Urinary retention Hernia Pelvis Pyeloplasty Kidney Urinary system
5
7 Chronic lower urinary obstruction is not an unavoidable consequence of aging . In fact, long-stand ing obstruction can cause
8 irr eversible r enal failure if the partial obstruction is present long enough, and the patient does not void every few hours.
Frequent voiding or catheterization of a partially obstructed system may decompress the distended bladder enough to keep
9
filling pressu res low .
10 Urinary retention Catheter Urinary bladder Urinary catheterization Kidney
11
F is not correct. 50/o chose this.
12
Ureteral reimplants are not used in the treatment of benign prostatic hyperplasia . The reimplant has a role in vesicoureteral
13 reflux. It may also be used if there is an obstruction at the ureters' junction with the bladder.
14 Benign prostatic hyperplasia Vesicoureteral reflux Ureter Hyperplasia Urinary bladder Reflux Gastroesophageal reflux disease
• 15
• 16
Bottom line:
Straining secondary to chronic lower urinary tract obstruction can precipitate a direct inguinal hernia in patients with benign
prostatic hyperplasia . Transurethral prostate r esection can relieve the obstruction .
Benign prostatic hyperplasia Inguinal hernia Urinary system Hyperplasia Hernia Urinary retention Prostate Benignity Prostate cancer
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A previously healthy 14-year-old boy presents to the emergency department after a high school football game because of
2 the sudden onset of intense left-sided scrotal pain for the past 1.5 hours. He feels nauseous and has had one bout of
3 nonbloody, nonbilious emesis. He had a normal bowel movement th is morning and has had no trouble passing gas during
4 this episode of pain. The patient reports that his scrotum is enlarged, and he also has diffuse abdom inal pain. On genitourinary
examination, there is gross scrotal edema with left testicular enlargement and elevation in position when compared with the
5
right side . There is no pain reli ef on elevation of the scrotum , and there is no cremasteric reflex on the left side . Laboratory
6 studies and urinalysis show :
7
8 WBC count : 12,000/ mm3
Hematocrit: 43 %
9
Hemoglobin : 15 g/ dL
10 Platelet count: 400,000/ mm 3
11 Color of urine: amber
12
Specific gravity: 1.015
pH: 6.5
13 Glucose: negative
14 Ketones: negative
• 15 Protein : trace
RBCs: negative
• 16
Hemoglobin : negative
Bilirubin: negative
Nitrites : negative
WBCs: 4/ hpf
Which of the following is the most likely diagnosis?
A. Epididym it is
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Item: 15 of 16 ~ 1 • Mark <::::J t::> iii 9' ~:·11
QIO: 23656 ~ PreVIOUS Next Lab 'i?.llues Notes Calculator
U::;, I I I
1
Hematocrit: 43%
2
Hemoglobin: 15 g/dL
3 Platelet count: 400,000/mm3
4 Color of urine: amber
5
Specific gravity: 1.015
pH: 6.5
6
Glucose: negative
7 Ketones: negative
8 Protein: trace
RBCs: negative
9
Hemoglobin: negative
10 Bilirubin: negative
11 Nitrites: negative
12 WBCs: 4/hpf
13
14
Which of the following is the most likely diagnosis?
• 15
• 16
A. Epididym it is
B. Hydrocele
C. Orchitis
D. Strangulated inguinal hernia
E. Testicular torsion
a
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2 The correct answer is E. 78% chose this.

3 Testicular torsion is a surgical emergency occurring in male patients most often between 12 and 18 years of age. The
4
congenita l anomaly known as "the bell clapper deformity" results in an inappropriately high attachment of the tun ica
vaginalis, leaving the testicle to freely rotate on the spermatic cord with in the tunica vag ina lis . When the testicle twists on the
5 cord, there can be venous occlusion and engorgement, with subsequent arterial ischemia causing infarct of the testicle .
6 Patients present with sudden, intense, usua lly unilateral :scrota l pain with associated scrotal swelling, abdominal pain, and
7 nausea and vomit ing . The involved testicle is exquisitely tender to palpation, may have a horizontal lie, and may be elevated
in position compa red to the other side. There can be ipsil ateral loss of the cremasteric reflex, and treatment is immed iate
8
su rgery for de-torsion and orchiopexy within the first 6 hours of onset of pain to avoid loss of a testicle .
9 Cremasteric reflex Orchiopexy Testicular torsion Tunica vaginalis Spermatic cord Suroical emergency Ischemia Palpation Congenital disorder Infarction Testicle
10 Anatomical terms of location Abdominal pain Testicular cancer Vomiting Nausea Reflex Vascular occlusion Ipsilateral
11
A is not correct. 6% chose this.
12
Epididymitis is an inflammation or infection of the epididym is most often due to the retrograde extension of sexua lly
13 transmitted organisms from the vas deferens . It is seen most often in sexually active men 19-40 years of age . Progression is
14 gradua l in nature; common complaints include nausea, fever, dysuria, and scrotal pain and edema . Physical exam
15 demonstrates an exquisitely tender and edematous epidi dym is. In SO% of cases, urinalysis results will be abnormal. In
addition, a positive Prehn's sign, described as decreased pain w ith scrota l elevation or support, may be present. Epididymit is
• 16
is treated with antibiotics .
Epididymitis Dysuria Prehn's sign Epididymis Vas deferens Urinalysis Inflammation Antibiotics Edema Physical examination Infection Fever

Hydrocele is a collection of serous fluid caused by a defect or irritation in the tunica vaginalis. When uncompl icated, patients
tend to be asymptomatic and may present with a painless enlarged scrotum . However, hydroceles may be reactive as a result
of infection or torsion . Care must be taken to differentiat:e between a hydrocele and an acute scrotum via ultrasound
anatomic imag ing with Doppler eva luation of testicular blood flow.
Hydrocele Tunica vagina lis Serous fluid Scrotum Testicular pain Ultrasound Medical ultrasound Asymptomatic Testicular cancer Testicle Infection
C. i~ nnt r.nrn~c:t _ 40/n r.hn~A thi~.
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1 • • • y• • •
anatomic imag ing with Doppler eva luation of testicular blood flow.
2
Hydrocele Tunica vagina lis Serous fluid Scrotum Testicular pain Ultrasound Medical ultrasound Asymptomatic Testicular cancer Testicle Infection
3
4
Orchitis is an acute inflammatory reaction of the testes secondary to infection, most commonly mumps. Bacterial orchitis is
5
rare and usually is a complication of a preexisting case of epididym it is in sexua lly active ma les > 15 years old, or in men >50
6 years of age w ith ben ign prostatic hyperplasia . Because this patient has no signs of previous viral infection or epididym it is,
7 orchitis is not likely.
Benign prostatic hyperplasia Epididymitis Orchitis Mumps Testicle Hyperplasia Inflammation Infection Viral disease
8
9 D is not correct. SOfo chose this.
10 Strangulated inguina l hernia may present w ith scrota l pain and edema due to ischemia of the entrapped hernia sac. However,
11 the patient would also have signs and symptoms of a small bowel obstruction, such as abdom inal distention, bilious vomiting,
and the inability to pass gas or stool. Strangulated hernias are also su rgica l emergencies and require immediate reduction to
12
preserve the viability of entrapped structures.
13 Inguinal hernia Bowel obstruction Hernia Ischemia Small intestine Vomiting Edema Flatulence Abdominal distension Surgical emergency Groin Inguinal canal Feces Scrotum
14
15
Bottom Line:
• 16
Patients with testicu lar torsion present with sudden, intense, usua lly unilateral scrotal pain with associated scrotal swelling,
abdom ina l pain, and nausea and vomiting . Treatment is immediate surgery for de-torsion and orchiopexy with in the first 6
hou rs of onset of pain to avoid loss of the testicle .
Orchiopexy Testicular torsion Testicle Testicular cancer Abdominal pain Nausea Vomiting Scrotum
References:
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A 65-year-old caucasian male with a history of hypertensit on and diabetes, controlled with med ications, presents to his
2 physician for a physical examination . Although, he has no issuses w ith his urination and has excellent erectile function, he
3 is concerned about recently measured prostate-specific antigen level of 9 ng/mL. There is no abnormality detectble on
4 =
digital rectal examination . He is found to have a Gleason 3 + 3 6 prostate cancer that is confined in the prostatic capsu le on
biopsy. He is reluctant to undergo treatment due to the side effects he has read about.
5
6
Which of the following approach shou ld be considered in this patient?
7
8
A. Androgen deprivation therapy
9
10 B. Brachytherapy
11 C. Externa l beam radiation therapy
12
D. Radical prostatectomy
13
14 E. Surveillance
15
• 16
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3
The correct answer is E. 41% chose this.
4
Patients with low-risk clin ically local ized prostte cancer have diasease dectected with prostate biopsy only (life expectancy
5 > 10 years), w ith normal digital rectal examination . To be classified as very low risk, such patients must have a histologic
6 grade group 1 (Gleason scor e 6 or lower on biopsy) and serum PSA < 10 ng/ml as in this patient. His only comorbidities ar e
7
hypertension and diabetes, well controlled with medications. Thus, at this point, defin itive therapy like radica l prostatectomy,
brachytherapy or external beam radiation therapy (RT) or active surveillance may all be appropriate options . Among the
8 approaches mentioned, benefit and risk associated w ith each approach, indiv id ual preference and comorbid it ies should be
9 considered. Since, the patient in the vignette is reluctant to undergo defenitive thera py at this time, active surveillance of
10 prostate cancer w ith prostate-specific antigen levels and dig ital rectal examination (DRE) shou ld be offerr ed . Definitive
therapy may be offerred on a later date if the disease progresses.
11
Prostate-specific antigen Rectal examination Brachytherapy Gleason grading system Prostatectomy Prostate cancer Radiation therapy Biopsy Grading (tumors) Diabetes mellitus
12
External beam radiotherapy Hypertension Ufe expectancy Prostate biopsy Antigen Prostate Histology Cancer Therapy Comorbidity Watchful waiting Rectum
13
Active surveillance of prostate cancer
14
15 A is not correct. 170/o chose this.

16
Androgen deprivation therapy is used primarily for metastatic disease . This type of therapy is usual ly achieved through the
use of a gonadotropin-releasing hormone antagonist and nonsteroidal antiandrogens, although luteinizing hormone-releasing
hormone agonists have also been employed . The patient in the vignette has a loca lized diasese and this therapy should not
be considered .
Gonadotropin-releasing hormone Androgen deprivation therapy Androgen Receptor antagonist Hormone Gonadotropin-releasing hormone antagonist Hormone antagonist Metastasis
Antiandrogen Androgen suppression Antagonist

Brachytherapy is a type of radiation therapy in which ra dioactive seeds are planted directly in prostatic tissue . Although,
brachytherapy can be considered defin itive in this patient , because it not only has a potential for cure, but it is also well
tolerated comoared to suraerv. Since, the patient is rel uctant to underao anv intervention at this time, active surveil lance can •
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1 Gonadotropin-releasing hormone Androgen deprivation therapy Androgen Receptor antagonist Hormone Gonadotropin-releasing hormone antagonist Hormone antagonist Metastasis
2 Antiandrogen Androgen suppression Antagonist
3
B is not correct. 9 0/o chose this.
4
Brachytherapy is a type of radiation therapy in which rad ioactive seeds are planted directly in pr ostatic t issue . Although,
5 brachytherapy can be considered definitive in this patient, because it not only has a potential for cure, but it is also well
6 tolerated compared to surgery. Since, the patient is reluctant to under go any intervention at this t ime, active surveil lance can
be considered init ially, instead of brachytherapy.
7
Brachytherapy Radiation therapy Active surveillance of prostate cancer Radioactive decay Watchful waiting Radiation
8
9
10
External beam rad iation therapy can be an effective treatment for locally confined prostate cancer. Although well tolerated
compared to surgery, potential complications may include erectile dysfunction, diarrhea, and r ectal irritation . Since, the
11 patient is reluctant to undergo any intervention at this time, active surveillance can be considered init ially, instead of external
12 beam radiation therapy( RT) .
Erectile dysfunction Radiation therapy Prostate cancer Diarrhea External beam radiotherapy Prostate Cancer Watchful waiting Radiation Active surveillance of prostate cancer
13
14 Dis not correct. 170/o chose this.
15 Radical prostatectomy is the gold standard in the treatment of locally confined prostate cancer. The patient most li kely to
16 benefit from rad ical pr ostatectomy wou ld have a relative long life expectancy, no significant surgical risk factor s, and a
preference to undergo surgery. Although , the patient will benefit with this approach, he is not w illing to under go treatment at
this t ime.
Prostate cancer Prostatectomy Prostate Life expectancy Cancer Gold standard
Bottom line :
Radical prostatectomy, brachytherapy or external beam radiation therapy ( RT) or active surveillance may all be appropriate
options for low-risk prostate cancer. Benefit and ri sk associated with each approach, individual preference and comorbidit ies
should be considered .
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1 • • • y, • • y py
Brachytherapy Radiation therapy Active surveillance of prostate cancer Radioactive decay Watchful waiting Radiation
2
3 C is not correct. 160/o chose this.
4 External beam rad iation therapy can be an effective treatment for locally confined prostate cancer. Although well tolerated
compared to surgery, potential complications may include erectile dysfunction, diarrhea, and rectal irritation . Since, the
5
patient is reluctant to undergo any intervention at this time, active surveillance can be considered initially, instead of external
6 beam radiation therapy( RT) .
7 Erectile dysfunction Radiation therapy Prostate cancer Diarrhea External beam radiotherapy Prostate Cancer Watchful waiting Radiation Active surveillance of prostate cancer

9 Radical prostatectomy is the gold standard in the treatment of locally confined prostate cancer. The patient most li kely to
10 benefit from radical prostatectomy wou ld have a relative long life expectancy, no significant surgical risk factors, and a
11 preference to undergo surgery. Although, the patient will benefit with this approach, he is not w illing to undergo treatment at
this time.
12
Prostate cancer Prostatectomy Prostate Life expectancy Cancer Gold standard
13
14
15 Bottom line :
16 Radical prostatectomy, brachytherapy or external beam radiation therapy ( RT) or active surveillance may all be appropriate
options for low-risk prostate cancer. Benefit and risk associated with each approach, individual preference and comorbidities
should be considered .
Brachytherapy Prostatectomy Radiation therapy Prostate cancer External beam radiotherapy Radiation Watchful waiting Active surveillance of prostate cancer Prostate Cancer
Comorbidity
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Item: 1 of 16 ~ 1 • Mark -<] C> Jill ~· ~J

QID: 2163 5 ..1 Previous Next Lab'V!I!ues Notes Calculator

• 12 A is not correct. 2% chose this.

D is not correct. 160/o chose this.

•2 B is not correct. 2 0/o chos e this .

• 10 B. Multiple endocrine neoplasia type I

• 10 Risk factor Kidney Von Hippei-Lindau disease

C is not correct. SO/o chose this.

• 11 Thyroid cancer Marfan syndrome Thyroid neoplasm Neuroma Carcinoma

• 12 D is not correct. 9 % chos e this .

C is not correct. 9% chose this.

D is not correct. 3% chose this.

D i s not correct. 7 0/o chose this.

2 B is not correct. 210/o chose th is.

C i s not correct. 9% ch ose this.

• 12 D. Increases the metabolism of testosterone to dihydrotestosterone

i. Mark -<l I>

• 15 B is not correct. 200/o chose this .

D is not correct. 20/o chose this.

• 13 Nodule (medicine) Rectum

• 12 D. Restrict fluid intake

7 A is not correct. 4% chose this.

• 10 B is not correct. 60/o chose this.

E is not corr ect. 19% chose this.

1 There is no association between intravenous cefazolin and hyponatremia .

• 12 Urothelium Weight loss Lung Cancer Metabolism Epithelium Kidney

B is not correct. 110/o chose t his.

C is not correct. 100/o chose this.

• 12 C i s not correct. 60/o chose this .

E i s not corr ect. 30/o c hose t his.

B . Left laparoscopic nephrectomy

C. Left nephron-sparing surgery

D . Left radical nephrectomy

E. Left radical nephrectomy and adjuvant sorafenib

2 The correct a nswer is D. 430/o chose t his.

6 is not correct. ] Ofo chose t his.

1 B is not correct. ]Ofo chose this.

2 C is not correct. 4 % chose this.

7 E is not correct. 34 % chose this.

D is not correct. 9% chose this.

5 D is not correct. 9% chose this.

• 15 B is not correct. 2 30/o chose th is .

C i s not correct. 6 % chose this.

D is not correct. 2 9 0/o chose this.

2 B is not correct. 2 30/o chose th is.

12 C is not correct. 6% chose this.

D is not correct. 150/o chose this.

E is not correct. 23% chose this.

• 15 D. These findings are an unavoidable consequence of aging

C i s not correct. 9% chose this.

Which of the following is the most likely diagnosis?

D. Strangulated inguinal hernia

2 The correct answer is E. 78% chose this.

B is not correct. 40/o chose this.

C. i~ nnt r.nrn~c:t _ 40/n r.hn~A thi~.

15 A is not correct. 170/o chose this.

Antiandrogen Androgen suppression Antagonist

B is not correct. 90/o chose this.

2 Antiandrogen Androgen suppression Antagonist

8 D is not correct. 170/o chose this.

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