Answer :USMLE step 2 Mcq 248:a 25 year old male complains of intensifying pain in his left flank radiating to his left groin



Correct Answer: B

Antibiotics should be utilized in all cases of epididymitis, regardless of a negative urinalysis or the urethral Gram stain result. Nonsteroidal anti-inflammatory agents or narcotic analgesics also generally are prescribed to patients with epididymitis. Empiric coverage varies with patient's age. Males younger than 35 years need empiric coverage for C trachomatis and N gonorrhoeae, usually with ceftriaxone and doxycycline or azithromycin. Prepubertal patients and males older than 35 years require empiric coverage for coliform bacteria (enteric gram-negative bacilli or Pseudomonas). For his age group, sexually transmitted pathogens are the organisms most responsible for epididymitis. Ceftriaxone will treat Neisseria gonorrhoeae; it will not cover the most common organism, Chlamydia trachomatis. In addition to ceftriaxone, the patient needs doxycycline or azithromycin. Most cases of epididymitis can be managed on an outpatient basis with urology follow-up scheduled within 3-7 days. Pain most often begins gradually in the scrotum or groin, radiating along the spermatic cord, and will often intensify over the next few hours. The degree of epididymal swelling is variable, but it often reaches twice normal size over 3 to 4 hours. Fever and generalized toxicity may be seen. A urethral discharge or associated irritative voiding symptoms may accompany the swelling and pain.There may be tenderness over the groin, lower abdomen, and scrotum. The scrotal skin is usually erythematous and warm. There will often be a leukocytosis in the range of 10,000 to 30,000/mm3 . Urine analysis may or may not reveal evidence of bacterial infection. Only 24% will have pyuria. Chlamydia will not be identified in a routine examination of the sediment, whereas E. coli will be. If a urethral discharge is present, it must be examined for gram-negative intracellular diplococci and other bacteria. The most common cause of epididymitis in men over age 35 is infection with coliforms or species of Pseudomonas. Gram-positive cocci are also important pathogens. This age group distinction is important not only from the standpoint of therapy but because bacterial epididymitis in men over age 35 is commonly associated with underlying urologic pathology. The older patient (over age 35) with epididymitis may give a history of recent genitourinary tract manipulation


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