A 45-year-old man presents with a long history of ulcers on the bottom of his feet. He recalls having a similar looking ulcer on the side of his penis when he was 19 years old for which he never sought treatment. The patient denies any fever, chills, or constitutional symptoms. He reports multiple sexual partners and a very promiscuous sexual history. He has also traveled extensively as a writer since he was 19. The patient is afebrile, and his vital signs are within normal limits. A rapid plasma reagin (RPR) test is positive, and the result of a Treponema pallidum particle agglutination (TP-PA) is pending. Which of the following findings would most likely be present in this patient?

Wide-based gait with a low step

A 17-year-old male, accompanied by his uncle, presents to a doctor with his arm in a sling. There is blood dripping down his shirt. He pleads with the physician to not report this injury to authorities, offering to pay extra for his visit, as he is afraid of retaliation from his rival gang. The physician examines the wound, which appears to be a stabbing injury to his left anterior deltoid. This case study in medical ethics asks: How should the physician best handle this patient's request?

Breach confidentiality and report the stab wound to the police

Maintain confidentiality, as reporting stab wounds is not required

Breach confidentiality and discuss the injury with the uncle

Maintain confidentiality and schedule a follow-up visit with the patient

Maintain confidentiality, as retaliation may result in greater harm to the patient

A previously healthy 25-year-old male comes to his primary care physician with a painless solitary lesion on his penis that developed 4 days ago. He has not experienced anything like this before. He is currently sexually active with multiple partners and uses condoms inconsistently. His temperature is 37.0°C (98.7°F), pulse is 67/min, respirations are 17/min, and blood pressure is 110/70 mm Hg. Genitourinary examination shows a shallow, nontender, firm ulcer with a smooth base along the shaft of the penis. There is nontender inguinal adenopathy bilaterally. Which of the following is the most appropriate next step to confirm the diagnosis?

Urine polymerase chain reaction

Fluorescent treponemal antibody absorption test

A 54-year-old male carpenter accidentally amputated his right thumb while working in his workshop 30 minutes ago. He reports that he was cutting a piece of wood, and his hand became caught up in the machinery. He is calling the emergency physician for advice on how to transport his thumb and if it is necessary. Which of the following is the best information for this patient?

Wrap thumb in saline-moistened, sterile gauze and place in sterile bag

Place thumb in cup of cold milk

Wrap thumb in sterile gauze and submerge in a cup of saline

There is no need to save the thumb

Place thumb directly into cooler of ice

A 40-year-old sailor is brought to a military treatment facility 20 minutes after being involved in a navy ship collision. He appears ill. He reports a sensation that he needs to urinate but is unable to void. His pulse is 140/min, respirations are 28/min, and blood pressure is 104/70 mm Hg. Pelvic examination shows ecchymoses over the scrotum and perineum. There is tenderness over the suprapubic region and blood at the urethral meatus. Digital rectal examination shows a high-riding prostate. Abdominal ultrasound shows a moderately distended bladder. X-rays of the pelvis show fractures of all four pubic rami. Which of the following is the most likely cause of this patient's symptoms?

Tearing of the posterior urethra

Tearing of the anterior urethra

Rupture of the corpus cavernosum

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

"Can you tell me more about the symptoms you have been experiencing?"

"Does the diarrhea typically precede the constipation, or vice-versa?"

"Is the diarrhea foul-smelling?"

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

"Are the symptoms worse in the morning or at night?"

Three hours later, the patient is reassessed. Her right arm is put in an elevated position and physical examination of the extremity is performed. The examination reveals reduced capillary return and peripheral pallor. Pulse oximetry of her right index finger on room air shows an oxygen saturation of 84%. Which of the following is the most appropriate next step in management?

Obtain split-thickness skin graft

Perform right upper extremity amputation

A 70-year-old man with metastatic castration-resistant prostate cancer presents to the emergency department with severe back pain, bilateral lower extremity weakness (3/5 strength), and urinary retention that started 8 hours ago. He has known bone metastases and his PSA has been rising despite androgen deprivation therapy. MRI spine shows an epidural mass at T10 with severe spinal cord compression and near-complete canal obliteration. He is neurologically intact above T10. Radiation oncology, neurosurgery, and medical oncology are consulted. Evaluate the optimal management approach.

Emergent surgical decompression followed by radiation therapy

Corticosteroids, radiation therapy, and switch to next-line systemic therapy

Stereotactic radiosurgery as single-modality treatment

Palliative care consultation and comfort measures only given metastatic disease

High-dose corticosteroids and emergent radiation therapy alone

Paraphimosis and phimosis — USMLE Lesson

🔒 Foreskin Fixations

Phimosis: Inability to retract the foreskin over the glans.
- Physiologic in infants.
- Tx: Topical steroids, stretching; circumcision if refractory.
Paraphimosis: ⚠️ Urologic Emergency!
- Retracted foreskin trapped proximal to the glans.
- Causes venous congestion, edema, arterial compromise.
- Tx: Manual reduction, dorsal slit.

⭐ > Paraphimosis is often iatrogenic; always reduce the foreskin after catheterization or examination.

Phimosis and Paraphimosis Comparison Diagram

⭕ Pathophysiology - The Constriction Crisis

Phimosis: A tight, non-retractile preputial ring (foreskin) prevents glans exposure.
- Pathologic: Scarring from inflammation (balanitis) or lichen sclerosus (BXO) creates a fibrotic ring.
Paraphimosis (Emergency): Retracted foreskin gets trapped behind the glans corona.
- Acts as a tourniquet → venous congestion & edema.
- ↑ Edema worsens constriction → arterial compromise → ischemia & necrosis.

⭐ Paraphimosis is a vicious cycle: constriction causes edema, which in turn worsens the constriction, leading to arterial compromise.

🤏 Clinical Manifestations - Signs of the Squeeze

Paraphimosis (Urologic Emergency)

Acutely painful, swollen, erythematous glans.
Constricting band of foreskin trapped behind the corona.
Progresses from venous congestion (dusky glans) to arterial compromise (necrosis).
May cause urinary retention.

Phimosis and Paraphimosis: Normal vs. Abnormal Foreskin

Phimosis

Inability to retract the foreskin.
Often asymptomatic.
Can present with ballooning of prepuce during urination, weak stream, or recurrent infections (balanitis).

⭐ Paraphimosis is a urologic emergency requiring immediate reduction to prevent glandular necrosis. Phimosis is typically a non-urgent condition.

🩺 Diagnosis - Spotting the Strangulation

Paraphimosis (Urologic Emergency):
- Clinical diagnosis: Painful, swollen glans with a constricting band of foreskin trapped behind it.
- Foreskin is retracted & cannot be reduced (pulled forward).
- ⚠️ Risk: Arterial compromise → necrosis.
Phimosis (Typically Non-emergent):
- Clinical diagnosis: Inability to retract the foreskin over the glans.

⭐ Key differentiator: Paraphimosis = foreskin trapped behind the glans (strangulation). Phimosis = foreskin trapped over the glans.

Management - The Un-Ringing

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⚡ Biggest Takeaways

Paraphimosis is a urologic emergency: a retracted foreskin is trapped behind the glans, causing vascular compromise and necrosis.

Phimosis is the inability to retract the foreskin. It is physiologic in infants but pathologic if due to scarring.

Differentiate: Paraphimosis = stuck back (emergency). Phimosis = stuck forward (less urgent).

Immediate manual reduction is the first-line treatment for paraphimosis; failure may require a dorsal slit.

Pathologic phimosis is managed with topical steroids or elective circumcision.

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