Internal Medicine Summer Board Review General Internal Medicine Session 2

1. Internal Medicine Summer Board Review General Internal Medicine Session 2 Mashkur Husain

2. Question 11 • A 28-year-old woman is evaluated for headache, purulent nasal discharge, and left unilateral facial and maxillary tooth pain present for 4 days. • On physical examination, temperature is 37.3 °C (99.1 °F); vital signs are otherwise normal. There is mild tenderness to palpation over the maxillary sinus on the left. Nasal examination shows inflamed turbinates bilaterally with a small amount of purulent discharge. Maxillary transillumination is darker on the left than on the right. Otoscopic examination is normal bilaterally. There is no lymphadenopathy in the head or neck.

3. Answer Choice Which of the following is the most appropriate next step in management? A Amoxicillin B Chlorpheniramine C Nasal culture D Sinus CT E Systemic corticosteroids

4. Answer Choice Which of the following is the most appropriate next step in management? A Amoxicillin B Chlorpheniramine C Nasal culture D Sinus CT E Systemic corticosteroids

5. Explanation • This patient with clinical findings typical of acute sinusitis should be observed and given symptomatic treatment, such as chlorpheniramine. Most cases of acute sinusitis are caused by viruses and typically resolve in 7 to 10 days without directed therapy. The clinical presentation is not helpful in determining whether the cause of symptoms is viral or bacterial. However, because most cases of viral or bacterial sinusitis resolve spontaneously within 10 days, observation and treatment of the associated symptoms with analgesics and decongestants is appropriate. • Antibiotics are generally reserved for sinusitis accompanied by high or continued fever or worsening symptoms, and even in this setting, their efficacy is not well documented. When used, an antibiotic focused on common respiratory organisms is reasonable. • Nasal cultures have not been shown to be helpful in diagnosing a bacterial etiology for sinusitis or in guiding antibiotic therapy. • Sinus imaging is not part of the initial management of acute sinusitis because imaging results are frequently abnormal in symptomatic patients with either a viral or bacterial sinusitis, and also in a high percentage of asymptomatic patients. Imaging is generally indicated in patients with a complicated presentation, such as those with visual changes or severe headache. • Inhaled nasal corticosteroids are frequently prescribed for acute symptom relief for sinusitis and have some efficacy in this setting; however, the role of systemic corticosteroids in acute sinusitis is not clear, and they are not recommended.

6. Key Point and Education Objective • Manage acute sinusitis. • Most cases of viral or bacterial sinusitis resolve spontaneously within 10 days, and observation and treatment of the associated symptoms with analgesics and decongestants is appropriate.

7. Sinusitis Diagnosis Acute bacterial sinusitis is defined as lasting 7 or more days and involving any one of the following factors: • purulent nasal discharge • maxillary tooth or facial pain, especially unilateral • unilateral maxillary sinus tenderness • worsening symptoms after initial improvement • Imaging, including CT, should be considered in patients with AIDS or in other immunocompromised patients to evaluate for fungal infection or other atypical infections but is not otherwise indicated. • Complications of acute sinusitis are unusual but deadly. Patients with cavernous sinus thrombosis have fever, nausea, vomiting, headache, orbital edema, or cranial nerve involvement. Other complications include brain abscess, bacterial meningitis, and osteomyelitis. Don't Be Tricked • Do not select any imaging tests for immunocompetent patients with acute sinusitis. • Do not treat sinusitis with antibiotics unless high fever or symptoms suggesting complicated illness have lasted ≥7 days. Drug Therapy • The first-line choice for suspected bacterial sinusitis is amoxicillin-clavulanate. Doxycycline is recommended for patients allergic to penicillin.

8. Question 12 • A 32-year-old woman is evaluated following a diagnosis of chronic fatigue syndrome. She has a several-year history of chronic disabling fatigue, unrefreshing sleep, muscle and joint pain, and headache. A comprehensive evaluation has not identified any other medical condition, and a screen for depression is normal. Her only medications are multiple vitamins and dietary supplements. Physical examination is normal.

9. Answer Choice Which of the following is the most appropriate management for this patient's symptoms? A Acyclovir B Evening primrose oil C Graded exercise program D Growth hormone E Sertraline

10. Answer Choice Which of the following is the most appropriate management for this patient's symptoms? A Acyclovir B Evening primrose oil C Graded exercise program D Growth hormone E Sertraline

11. Explanation • The most appropriate management for this patient is to begin a graded exercise program. Chronic fatigue syndrome (CFS) is defined as medically unexplained fatigue that persists for 6 months or more and is accompanied by at least four of the following symptoms: subjective memory impairment, sore throat, tender lymph nodes, muscle or joint pain, headache, unrefreshing sleep, and postexertional malaise lasting longer than 24 hours. Management of CFS is challenging and is geared toward managing symptoms and maintaining function, rather than seeking cure. A comprehensive, individually tailored approach is required, typically based on nonpharmacologic therapy, such as lifestyle modification and sleep hygiene. Specific treatment options that have been demonstrated to improve symptoms include graded exercise programs and cognitive-behavioral therapy (CBT). CBT in this setting is targeted in part at breaking the cycle of effort avoidance, decline in physical conditioning, and increase in fatigue, and can work well in combination with graded exercise in this regard. CBT reduces fatigue and improves functional status. • Although Epstein-Barr virus and a host of other infectious agents have been considered in the pathogenesis of CFS, none have been borne out by careful study; therefore, antiviral therapy, including acyclovir, has no role in the treatment of CFS. A variety of other medications have been tried, including corticosteroids, mineralocorticoids, growth hormone, and melatonin, but with no clear evidence of benefit, and are not indicated for this patient. • Current evidence is not sufficiently robust to recommend dietary supplements, herbal preparations (evening primrose oil), homeopathy, or even pharmacotherapy. Patients with concomitant depression should be treated with antidepressants. Although no specific class of antidepressant is recommended in this setting, tricyclic antidepressants are often utilized in patients with CFS and depression owing to their adjunct effectiveness in treating muscle pain.

12. Key Point and Education Objective • Manage chronic fatigue syndrome • Effective treatment options for chronic fatigue syndrome include graded exercise programs and cognitive-behavioral therapy.

13. Chronic Fatigue Diagnosis • Chronic fatigue is disabling and lasts more than 6 months. The core clinical features of this syndrome are physical and mental fatigue exacerbated by physical and mental effort. These are subjective phenomena and are often less evident on objective testing. The common medical diagnoses characterized by chronic fatigue can be established though a standard history, physical examination, and basic laboratory studies. Specialized studies are not needed. • Chronic fatigue is defined as fatigue lasting more than a month that impairs the ability to perform desired activities; it may be caused by a number of medical conditions and generally improves with treatment of the underlying cause. • Chronic fatigue syndrome (CFS) is a distinct entity defined as persistent or relapsing fatigue for at least 6 months that is disabling and medically unexplained. Associated symptoms may include memory impairment, sore throat, myalgia, arthralgia, headaches, unrefreshing sleep, and postexertional malaise lasting >24 hours. Extensive diagnostic evaluation is not needed in patients with typical symptoms and with normal physical examination and basic laboratory study results. Therapy • Chronic fatigue typically improves with treatment of the underlying medical cause. • Establishing goals of therapy and managing patient expectations are key treatment components of CFS. Focus treatment on minimizing the impact of fatigue through nonpharmacological interventions (cognitive-behavioral therapy and graded exercise), which are beneficial in improving, but not curing, symptoms. No specific class of medication has been shown to be effective in CFS.

14. Question 13 • A 19-year-old woman is evaluated for a 1-week history of left ear canal pruritus, redness, and pain. She swims 1 mile each day and has recently started wearing plastic ear plugs to keep water out of her ears while swimming. • On physical examination, she is afebrile, blood pressure is 98/66 mm Hg, pulse rate is 62/min, and respiration rate is 16/min. She appears healthy and in no distress. There is pain with tugging on the pinna and compression or movement of the tragus. The left ear canal is shown. With irrigation, the left tympanic membrane appears normal. There is no preauricular or cervical lymphadenopathy.

16. Answer Choice Which of the following is the most likely diagnosis? A Acute otitis externa B Delayed-type hypersensitivity reaction to ear plugs C Malignant otitis externa D Otitis media

17. Answer Choice Which of the following is the most likely diagnosis? A Acute otitis externa B Delayed-type hypersensitivity reaction to ear plugs C Malignant otitis externa D Otitis media

18. Explanation • This patient most likely has uncomplicated acute otitis externa. Her swimming puts her at risk for otitis externa owing to moist conditions created by daily water immersion. Symptoms include otalgia, itching or fullness with or without hearing loss, and pain intensified by jaw motion. Signs include internal tenderness when the tragus or pinna is pushed or pulled and diffuse ear canal edema, purulent debris, and erythema, with or without otorrhea. Otitis externa can cause erythema of the tympanic membrane and mimic otitis media. In otitis externa, however, pneumatic otoscopy shows good tympanic membrane mobility. Management consists of clearing the canal of as much debris as possible to optimize penetration of ototopical agents as well as to visualize the tympanic membrane to ensure it is intact before initiating treatment. Topical agents have been the mainstay of therapy for uncomplicated otitis, although there is a paucity of data regarding the effectiveness of one topical treatment compared with another. An ototopical agent containing neomycin, polymyxin B, and hydrocortisone is frequently used and is effective when given for 7 to 10 days. Mild otitis externa can be treated with a dilute acetic acid solution. • Whereas an allergic reaction to plastic ear plugs should be considered, the purulent discharge and the much higher likelihood of this being bacterial acute otitis externa make a delayed type (type IV) hypersensitivity reaction unlikely. Delayed hypersensitivity reactions (contact dermatitis) are typically characterized by erythema and edema with vesicles or bullae that often rupture, leaving a crust. Allergic reactions to the plastic in hearing aids, metal in earrings, or even to otic suspension drops used to treat otitis externa should always be considered in the differential diagnosis of an inflamed external auditory canal. • Malignant otitis externa is a much more serious entity in which the infection in the ear canal spreads to the cartilage and bones nearby. It is frequently accompanied by fever, significant pain, and otorrhea, and patients usually appear much more ill than this healthy-appearing woman with localized ear discomfort. On physical examination, granulation tissue is often visible along the inferior margin of the external canal. • Pain with tugging on the pinna and movement of the tragus and an inflamed external auditory canal make otitis media highly unlikely as a diagnostic possibility. In addition, acute otitis media is associated with signs of middle ear effusion and middle ear inflammation (erythema of the tympanic membrane), which are not present in this patient.

19. Key Point and Education Objective • Diagnose acute otitis externa. • Symptoms of otitis externa include otalgia, itching or fullness, and pain intensified by jaw motion; signs include internal tenderness when the tragus or pinna is pushed or pulled and diffuse ear canal edema, purulent debris, and erythema.

20. External Otitis Diagnosis • Patients with typical external otitis present with otalgia, ear discharge, pruritus, and conductive hearing loss. Be aware of the several other varieties of external otitis: • Malignant external otitis is characterized by systemic toxicity and evidence of infection spread beyond the ear canal (mastoid bone, cellulitis) and is typically found in patients with diabetes or who are immunocompromised. Most commonly caused by Pseudomonas aeruginosa. • Ramsay Hunt syndrome is caused by varicella-zoster viral infection and characterized by facial nerve paralysis, sensorineural hearing loss, and vesicular lesions on and in the ear canal. • Acute myringitis is characterized by hemorrhagic bullae on the lateral surface of the tympanic membrane secondary to viral or Mycoplasma infection. Drug Therapy • Select combination antibiotic and corticosteroid drops for typical external otitis, systemic antipseudomonal antibiotics for malignant external otitis, and antiviral agents for Ramsay Hunt syndrome. Test Yourself • A 70-year-old man with type 2 diabetes mellitus has had a severe left earache since yesterday. He has a fever and tachycardia, and his left external ear canal is swollen. Moist white debris and granulation tissue are visible. ANSWER: Diagnose malignant external otitis and select IV ciprofloxacin

21. Ramsay Hunt Syndrome:

22. Question 14 A 72-year-old woman is evaluated for sudden hearing loss in the left ear with moderate ringing that started yesterday. She has no vertigo or dizziness. On physical examination, vital signs are normal. Otoscopic examination is initially obscured by cerumen bilaterally. Once cerumen is removed, the tympanic membranes appear normal and there is some redness in the canals bilaterally. When a 512 Hz tuning fork is placed on top of the head, it is louder in the right ear. When placed adjacent to the left ear, it is heard better when outside the ear canal than when touching the mastoid bone. Neurologic examination is normal other than left-sided hearing loss.

23. Answer Choice Which of the following is the most appropriate management of this patient? A Acyclovir B Neomycin, polymyxin B, and hydrocortisone ear drops C Triethanolamine ear drops D Urgent audiometry and referral

24. Answer Choice Which of the following is the most appropriate management of this patient? A Acyclovir B Neomycin, polymyxin B, and hydrocortisone ear drops C Triethanolamine ear drops D Urgent audiometry and referral

25. Explanation • This woman with sudden-onset unilateral sensorineural hearing loss requires urgent audiometry and otorhinolaryngology referral because early diagnosis and treatment may be associated with improved outcomes. Based on the initial examination, this patient does not have conductive hearing loss because she hears better when sound is transmitted via air (through the external ear canal and middle ear) than when it is transmitted via bone vibration. Sudden sensorineural hearing loss (SSNHL) is an alarming problem that is defined as sensorineural hearing loss occurring in 3 days or less. Patients often report immediate or rapid hearing loss or loss of hearing upon awakening. Ninety percent have unilateral hearing loss, and some have tinnitus, ear fullness, and vertigo. SSNHL constitutes a considerable diagnostic challenge because it may be caused by many conditions, including infection, neoplasm, trauma, autoimmune disease, vascular events, and ototoxic drugs. Immediate otorhinolaryngologic referral is required. Improvement occurs in about two thirds of patients. Oral or intratympanic corticosteroids are usually given, although randomized trials differ in their conclusions regarding efficacy. • Otic herpes zoster (Ramsay Hunt syndrome) is characterized by herpetic lesions in the external canal and ipsilateral facial palsy neither of which is seen in this patient. Acyclovir may be considered in a clear case of Ramsay Hunt syndrome but has been shown to be unhelpful in idiopathic SSNHL. • Neomycin, polymyxin B, and hydrocortisone ear drops are a possible treatment for acute otitis externa. This patient is unlikely to have otitis externa because she does not have otalgia, otorrhea, itching, or pain intensified by jaw motion. She does not have internal tenderness when the tragus or pinna is pushed or pulled. Her ear canal erythema is most likely secondary to the trauma of recent cerumen removal than otitis externa. • Triethanolamine ear drops may help to treat or prevent cerumen impaction, but cerumen impaction causes conductive hearing loss, not sudden sensorineural hearing loss. After her cerumen was successfully removed, the patient's conductive hearing was intact, making this an unlikely cause of her sudden hearing loss in her left ear. Cerumen impaction is also unlikely to cause tinnitus.

26. Key Point and Education Objective • Manage sudden sensorineural hearing loss. • Patients with sudden sensorineural hearing loss should be urgently evaluated by audiometry and considered for oral or intratympanic corticosteroid treatment by an otorhinolaryngologist.

27. Hearing Loss Diagnosis • The Weber and Rinne tests help distinguish conductive from sensorineural hearing loss. • In patients with a conductive hearing loss, a nonmobile tympanic membrane may indicate fluid or a mass in the middle ear or retraction from negative middle ear pressure. • Select audiography for all patients with unexplained hearing loss. For patients with progressive asymmetric sensorineural hearing loss, select MRI or CT to evaluate for acoustic neuroma. • Sudden sensorineural hearing loss occurs acutely, usually within 12 hours of onset, and is unilateral in 90% of cases. It has many etiologies, including viral, vascular, autoimmune, and most commonly idiopathic. Therapy • Treat otitis or cerumen impaction if present. Select urgent referral to ENT specialist for sudden, unexplained hearing loss. Treatment with corticosteroids is controversial but frequently provided. Test Yourself • A 35-year-old previously healthy man has had difficulty hearing in his right ear since last night. He has rhinorrhea and nasal congestion. His external auditory canals and tympanic membranes are normal; a 512-Hz tuning fork is placed on his forehead, and he hears the tone louder in his left ear than in his right ear. • ANSWER: Choose sudden sensorineural hearing loss and emergent ENT referral.

28. Webber and Rinne Tests Summary

29. Question 15 • A 23-year-old man is evaluated for a 3-day history of redness and itchiness of the right eye. He had an upper respiratory tract infection 3 days before the eye symptoms began. Each morning he has awoken with crusting over the lids. He is otherwise healthy, with no ocular trauma or recent medical problems. • On physical examination, he is afebrile, blood pressure is 122/72 mm Hg, pulse rate is 66/min, and respiration rate is 16/min. Right eye conjunctival injection is present, with some crusting at the lids. Bilateral vision is 20/20. Pupils are equally round and reactive to light.

30. Answer Choice Which of the following is the most appropriate management of this patient? A Cool compresses to the affected eye B Oral antihistamine C Topical antibiotics D Topical corticosteroids

31. Answer Choice Which of the following is the most appropriate management of this patient? A Cool compresses to the affected eye B Oral antihistamine C Topical antibiotics D Topical corticosteroids

32. Explanation • The most appropriate management is the application of cool compresses to the affected eye. This patient has symptoms and signs most consistent with viral conjunctivitis. Onset is usually acute, with unilateral redness, watery discharge, itching, crusting, a diffuse foreign body sensation, and mild photophobia. This patient's preceding upper respiratory tract infection, normal vision, and unilateral eye involvement are supportive of this diagnosis. Viral conjunctivitis is managed conservatively with cool compresses. The patient should be told not to share towels or other personal items with family members and should wash his hands frequently throughout the day. He should also be warned that the infection may spread to the other eye before resolving. • Allergic conjunctivitis may be recurrent and seasonal and presents with itching, conjunctival edema, and cobblestoning under the upper lid. It usually responds to topical antihistamines, short-course topical NSAIDs (3 days maximum), and compresses. Oral antihistamines have no role in the treatment of viral conjunctivitis. • Bacterial conjunctivitis usually has a mucopurulent discharge, in contrast to the clear, watery discharge seen in viral conjunctivitis. Topical antibiotics are not efficacious for viral conjunctivitis and can be associated with adverse effects, including the development of contact dermatitis and antibiotic resistance. If a lubricant is required, non-antibacterial lubricating agents may be used. • Topical corticosteroids are not indicated despite the patient's discomfort and should rarely, if ever, be used by physicians other than ophthalmologists. If used inappropriately for herpes simplex, fungal, or bacterial conjunctivitis, topical corticosteroids can lead to corneal scarring, melting, and perforation.

33. Key Point and Education Objective • Manage viral conjunctivitis. • Viral conjunctivitis, characterized by acute onset and unilateral redness, watery discharge, itching, crusting, a diffuse foreign body sensation, and mild photophobia, is managed conservatively with cool compresses.

34. Red Eye Diagnosis • The primary causes of red eye include viral and bacterial conjunctivitis, subconjunctival hemorrhage, allergic conjunctivitis, eyelid abnormalities, episcleritis and scleritis, acute angle-closure glaucoma, uveitis, and keratitis. Of these, the most common is conjunctivitis, primarily viral. Red eye consists of categories of entities with or without ocular pain and/or visual loss. The combination of red eye, ocular pain, and visual loss warrants emergent referral to an ophthalmologist. Select Snellen visual acuity testing for all patients. Don't Be Tricked • Do not treat a red eye with topical corticosteroids. Test Yourself • A 39-year-old man has bilateral red eyes and pain for 2 days. He has arthritis and chronic low-back pain. Visual acuity is 20/40 bilaterally. Eyes are intensely injected, with prominent circumcorneal erythema. • ANSWER: Diagnose acute iritis associated with ankylosing spondylitis and select emergent referral to an ophthalmologist.

36. Bacterial

37. Herpes

38. Viral

39. Allergic

40. Episcleritis

41. Irisitis

42. Question 16 A 68-year-old man is evaluated for continuing urinary frequency and nocturia. His symptoms have been slowly progressive over the past 1 to 2 years with a weak urinary stream and hesitancy. He was started on doxazosin 6 months ago, which he tolerates well and initially provided some improvement. However, his symptoms have continued and are beginning to interfere with his quality of life, particularly the urinary frequency and nocturia. His only other medical problem is hypertension, for which he takes lisinopril and metoprolol. On physical examination, he is afebrile, blood pressure is 140/85 mm Hg, pulse rate is 70/min, and respiration rate is 14/min. BMI is 25. He has a symmetric moderately enlarged prostate gland with no prostate nodules or areas of tenderness. A urinalysis is normal.

43. Answer Choice Which of the following is most appropriate next step in treatment of this patient's benign prostatic hyperplasia? A Add finasteride B Change doxazosin to finasteride C Change doxazosin to tamsulosin D Prescribe a fluoroquinolone antibiotic for 4 weeks

44. Answer Choice Which of the following is most appropriate next step in treatment of this patient's benign prostatic hyperplasia? A Add finasteride B Change doxazosin to finasteride C Change doxazosin to tamsulosin D Prescribe a fluoroquinolone antibiotic for 4 weeks

45. Explanation • This patient has classic findings of symptomatic benign prostatic hyperplasia (BPH), and combination therapy with both an α-blocker and a 5α-reductase inhibitor is indicated. The American Urological Association (AUA) guideline on treatment of BPH recommends that patients with an AUA symptom score greater than 7 or who are bothered by their symptoms receive treatment for BPH. 5α-Reductase inhibitors (5-ARIs), such as finasteride and dutasteride, may be suitable in patients who have failed to respond to or do not tolerate α-antagonists and those with severe symptoms. The Medical Therapy of Prostate Symptoms Study demonstrated that in the long term, among men with larger prostates, combination therapy is superior to either α-blocker or 5-ARI therapy in preventing progression and improving symptoms. Similarly, the ComBAT trial demonstrated that combination therapy resulted in significantly greater improvements than single-agent therapy. Combination therapy was associated with a higher incidence of adverse effects than monotherapy. • 5-ARIs decrease the production of dihydrotestosterone, thereby arresting prostatic hyperplasia. Because shrinkage is slow, symptoms often do not improve until after 6 months of therapy. Therefore, these agents are not typically used as initial monotherapy for BPH, and switching this patient from an α-antagonist to a 5-ARI would not be indicated. Side effects include erectile and ejaculatory dysfunction, reduced libido, gynecomastia, and breast tenderness.

46. α-Antagonists (terazosin, doxazosin, alfuzosin, tamsulosin, silodosin) relax the prostatic smooth muscle in the bladder outflow tract, act rapidly (usually within 48 hours), and are considered first-line treatment, producing a clinical response in 70% of men. All drugs in this class have similar efficacy and tend to improve symptoms by 30% to 40%. Although some agents are more selective for prostate-specific α-receptors and therefore have less effect on systemic blood pressure, there is not a significant difference in effectiveness in treating BPH. Therefore, there is no benefit in switching between α-antagonists in this patient, as he has tolerated his current treatment well. Abnormal ejaculation is a side effect and appears similar for all α-antagonists. Elderly patients are less likely to discontinue treatment because of ejaculatory dysfunction than because of cardiovascular side effects, such as postural hypotension, dizziness, and headaches. A 4-week course of a fluoroquinolone antibiotic would be appropriate therapy for chronic bacterial prostatitis. However, this patient has no symptoms or signs of prostatitis on examination and a normal urinalysis, making this diagnosis unlikely.

47. Key Point and Education Objective • Treat benign prostatic hyperplasia. • In patients with symptomatic benign prostatic hyperplasia, the combination of an α-blocker and a 5α-reductase inhibitor is associated with greater improvement in symptoms and more side effects than treatment with either agent alone.

48. Benign Prostatic Hyperplasia Diagnosis • BPH leads to irritative symptoms (urinary urgency, frequency, and nocturia) and obstructive symptoms (decreased urinary stream, intermittency, incomplete emptying, and straining). BPH is diagnosed primarily by medical history and digital rectal examination. Urinalysis is recommended to identify other causes of lower urinary tract symptoms. When a diagnosis of BPH has been established, the American Urological Association Symptom Index quantifies symptom severity and guides treatment decisions Therapy • For most patients, conservative treatment is sufficient (reduce fluid intake, stop contributing medications [diuretics, anticholinergics]). The two major BPH drug classes include: • α-adrenergic blockers (terazosin, tamsulosin, doxazosin, alfuzosin, and prazosin) • 5-α reductase inhibitors (finasteride, dutasteride) • α-Adrenergic blockers are superior to 5-α reductase inhibitors. α-Adrenergic blockers plus finasteride are more effective than either drug alone but are associated with increased adverse effects. Transurethral resection of the prostate (TURP) is indicated in patients with severe urinary symptoms, urinary retention, persistent hematuria, recurrent urinary tract infections, or renal insufficiency clearly attributable to BPH.

49. Question 18 • A 28-year-old man is evaluated for a 6-month history of pelvic pain, urinary frequency, and painful ejaculation. He has been treated with antibiotics for urinary tract infections three times in the past 6 months, each time with temporary relief of symptoms but recurrence shortly after completion of antibiotics. • On physical examination, vital signs are normal. There is minimal suprapubic tenderness with palpation. The prostate is of normal size with minimal tenderness and no nodules. Urinalysis shows multiple leukocytes, bacteria, and no erythrocytes.

50. Answer Choice Which of the following is the most appropriate treatment of this patient? A 1-week course of trimethoprim-sulfamethoxazole B 1-month course of ciprofloxacin C Cognitive-behavioral therapy D Finasteride