NMS Q&A Family Medicine

122 NMS Q&A Family MedicineExamination Answers1. The answer is C. 50 years of age in the absence of familyhistory or African race is the time that routine screeningof asymptomatic males should begin. In cases ofAfrican-American race and family history of prostatecancer in the first degree relatives, screening should beginat the age of 40 years. Screening should be repeated annuallyonce initiated. Screening is recommended by theAmerican Cancer Society, consisting of prostate-specificantigen To be sure the USPSTF does not advocate forscreening.2. The answer is C. Lowering the PSA cut-off to increasespecificity is an incorrect statement. Lowering a cut-offfor a test whose abnormality is defined as above the cutoffincreases sensitivity but decreases specificity. All theother statements are true and for the reasons given. Thegreater the proportion of free PSA to total PSA the lesslikely the chances of malignancy for a given level of totalPSA. Increasing the intervals between PSA drawingswould reduce cost and inconvenience (at the expense ofsensitivity). Defining a cut-off for the rate of increase ofPSA addresses aggressiveness of the tumor and generallythat cut-off is 1 ng/mL/year – above which is considered acriterion for the diagnosis of and a measure of aggressivenessof the cancer. Lowering PSA cut-offs for youngerblacks to improve sensitivity makes sense in that AfricanAmericans have a higher incidence of carcinoma of theprostate and the cancer appears at younger age. Conversely,increasing the cut-off point defining abnormalityin older blacks (as well as older people of all races)improves specificity in the latter groups (reduces chancesof false-positive results).3. The answer is D. Positive test for blood in all threeglasses indicates that hematuria emanates from bladder,ureter, or kidney; bladder is the focus because of thesmoking history and its risk of bladder cancer. Blood inthe first glass indicates a urethral source; in the third glassonly, a prostate source. The three glass test is virtuallynever positive for the second glass.4. The answer is E. Taking nitrates strictly contraindicatedto be taken concomitantly with a nitrate. althoughnitrates are usually given for coronary insufficiency, thatcondition per se is not such a contraindication. Studieshave ruled out serious side effects by taking any of thephosphodiesterase 5 inhibitors in the face of all the otherconditions listed and others. The latter include statuspost TURP, coronary artery by-pass, depression, prostatecancer, and renal insufficiency, including patients ondialysis.5. The answer is D. A varicocele is the one choice listedthat is not painful. Epididymitis is a well-known cause ofacute testicular pain that typically has a slower onset thanthat portrayed in the vignette. Epididymitis virtuallyalways is associated with pyuria. Trauma should be obviousin the history unless it was associated with head traumaand amnesia for the event. Cancer is typically painless butmay be acutely painful and acutely swollen if there occurshemorrhage into the tumor. The story fits that of testiculartorsion in that it occurred in an intra-adolescent boy, andnone of the other possibilities has as rapid an onset astorsion. Abdominal pain, nausea, and vomiting are oftenfound in torsion. Thus, although varicocele is ruled out byhistory and the other choices figure in the differential diagnosis,the most likely diagnosis is torsion of the testicle.6. The answer is C. A Doppler stethoscope test may be themost readily available test. In torsion, it will demonstratethe audible bruit of arterial blood in the uninvolved sidebut not on the affected side, except in rare cases. The technetiumscan is helpful in confirming the diagnosis andshould be the next test to be performed. Complete bloodcell count and urinalysis are unremarkable in torsion. Theintravenous pyelogram has no application in the diagnosisof any of the choices in the differential diagnosis.7. The answer is C. Torsion of the testicle must be relievedto restore arterial circulation to the testicle within 6 hours.Otherwise, the testicle is functionally (and cosmetically)lost. Doxycycline is indicated for expectant treatment ofinfection by Neisseria gonorrhoeae and Chlamydia organisms,both of which are frequently implicated in epididymitis.Elective exploration is appropriate for cancer andelective repair for varicocele. Sulfamethoxazole/trimethoprim(Bactrim) is a typical regimen for cystitis and somecases of prostatitis.8. The answer is A. Epididymitis is well described in thevignette. Although the testicular anatomy may be difficultto differentiate, careful examination usually allows thephysician to identify the epididymis and the testicleproper as ovoid and not deformed. Torsion was describedand is best identified by the methods alluded to in Questions5 and 6. However, in torsion, despite confoundingedema, one should appreciate that the testicle itself is thesource of tenderness and that the epididymis is normalin size and not tender. Orchitis manifests tenderness ofthe testicle and, in most cases, enlargement but no changein the basic shape of the organ. The signs of ischemia andlack of evidence of obstructed arterial flow usually allowtorsion to be ruled out. Testicular cancer manifests an