1 / 58

GU Board Review

GU Board Review. Aric Bakshy, MD. Question 1 .

bryar-skinner
Download Presentation

GU Board Review

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. GU Board Review Aric Bakshy, MD

  2. Question 1 • A 24 year old woman presents complaining of dysuria, urgency, and frequency. She denies fever, vomiting, or back pain. She has no significant past medical history or medication allergies. She is ICON neg. UA shows +3 blood, + Nitrite, + Leukocyte esterase. What is the most appropriate course of action? A. Urine culture and treat with abx 3 days B. Urine culture and treat with abx 7 days C. Treat with abx 3 days D. Treat with abx 7 days E. Wait for microscopic analysis of UA before next step

  3. Answer 1: C • Treat with abx for 3 days! • UTI most commonly dx bacterial infection • Nitrite sensitivity 50%, specificity 90% • Leukocyte Esterase sensitivity 48% and specificity 85% • Official UA has sensitivity of 60% • If either test positive with clinical sx dx is likely • Negative UA does not r/o infection • Pts without risk factors for complicated UTI do NOT need cultures

  4. The burning bean • Risk factors for complicated UTI -Pregnancy -DM recurrent UTI -Recent indwelling catheter or instrumentation -Structural abnormalities -Male sex -Extremes of age

  5. The burning bean • Treatment of Uncomplicated UTI: 3 days tx; Bactrim, Fluoroquinalones • Pregnancy: Nitrofuantoin, Keflex • Complicated UTI: 7 days tx, culture

  6. Question 2 • A 56 year old man with DM 2 p/w fever for 3-4 days and groin pain. His exam appears as the image. What is the most appropriate initial management?

  7. Question 2 A. High-Dose penicillin B. Hyperbaric oxygen therapy C. Pipercillin/Tazobactam D. Suprapubic catheterization E. Surgical Debreidment

  8. Answer 2: C Pipercillin/Tazobatam • Fournier's Gangrene • Necrotizing Fasciitis of penis and scrotum • Treatment is Abx and debridement • Risk factors include DM, EtOHism, and immunocompromised • Usually combination of aerobic and anaerobic bacteria • Ecoli, Bacteroides, Staph; Clostridium possible if starting in colorectal region

  9. Fourniers Gangrene • PEN- covers Gram + and Clostridium • Aminoglycoside or 3rd Gen Cephalosporin- covers Gram Negative • Clindamycin or Metronidazole- Covers anaerobes • Suprapubic cath may be needed, hyperbaric oxygen is an adjunct tx in some cases

  10. Question 3 • Which of the following statements regarding radiographic contrast-induced acute tubular necrosis is correct? A. ACE-I, given orally pre-contrast can be protective B. Metformin can be protective C. N-Acetyl-L-cysteine given IV prior to contrast can be protective D. Patients with DM are naturally protected from contrast induced-nephropathy. E. Volume infusion at the time of contrast administration increases the risk of renal injury.

  11. Answer 3: Mucomyst! Contrast Induced Nephropathy • ATN is typically a reversible cause of renal insufficiency • Unk cause of contrast induced nephropathy, thought to be due to obstruction by cases, cellular debris, and injury to peri-tubular capillaries • CIN defined as rise in Cr of 25% or incr by .5; may progress to oliguric ARF • Rise in Cr over 3 days; resolution within 2 weeks • Most important risk factor is preexisting renal Insufficiency (Cr > 1.4mg/dl) • Risk Factors: DM, Multiple Myeloma, Age > 60, Large vol contrast, volume depletion

  12. To serve and protect the Bean! • N-Acetyl-L-Cysteine • Clinical studies on 2 days pre-treatment orally prior to contrast load • Statistical yet clinically unknown benefit to NAC given in ED • Prevention of Contrast-Induced Nephropathy With Sodium Bicarbonate. Shavit et al.JAMA.2004; 292: 1428 • (13.6%) infused with sodiumchloride but in only 1 (1.7%) of those receiving sodium bicarbonate(meandifference, 11.9%; 95% confidence interval [CI], 2.6%-21.2%;P = .02). • Cheaper and more efficacious than ED provided NAC!

  13. Question 4 • 66 y/o F on renal transplant list is rushed to the ER from HD because she is bleeding from her shunt when the catheter was removed. HR is 113, BP 98/54; in addition to direct pressure and calling vascular surgery, what is the most appropriate management? • Administer dexamethasone to stimulate platelet function • Administer enoxaparin to minimize clot aggregation • Administer protamine sulfate to reverse heparin used during HD • Avoid IVF to preserve pts renal function • Give whole blood to match her volume loss

  14. Answer 4: C Protamine Sulfate Shunt Complications -Arterial venous fistula most often with radial artery and cephalic forearm vein -Arterialization of venous side in 3-5 weeks after surgery -Tunnel catheters (Quintin, Hickman) used to bridge -Most common complication is thrombosis of AVF- loss of thrill -Infection occurs in 2-5% of pts; Staph Aureus most common

  15. Shunt Complications • ”Steal Syndrome”; vascular insufficiency distal to shunt p/w cold painful fingertips, dx w/ u/s • Shunt Bleeding: Usually controlled with direct pressure; when severe Protamine (.01mg/unit of heparin) • Platelet dysfunction can be augmented with Desmopressin(DDAVP) .3mg/kg- more important in massive GIB in renal failure • Blood transfusions may be necessary in pre-transplant pts- give wither CMV negative or leukocyte reduced blood

  16. Question 5 • A 27 y/o F on peritoneal dialysis p/w abd pain and fever X 2 days. She noticed cloudy dialysate and she gave a sample of fluid to the nurse at triage. Her abdomen is normal on inspection but is tender diffusely with rebound. What is the most appropriate tx? • CT scan of abdomen with contrast • Intraperitoneal first-gen cephalosporin or vancomycin • Intravenous first-gen cephalosporin of vancomycin • Laparotomy for removal of Tenckhoff catheter • Placement of a Hickman catheter and emergent HD

  17. Answer 5: B Intraperitoneal Peritoneal Dialysis • PD is most common form of dialysis outside the USA • Peritoneal membrane is the blood-dialysate interface • 8L of dialysate per day given, 10 L removed • Peritonitis is most common complication • Dx based on >100 WBC, 50% pms, or a positive gram stain

  18. Peritoneal Dialysis • Most common bacteria are Staph-aureus, Staph-epi, Strep spp, and gram negatives • Tx is intraperitoneal loading dose of Cefazolin, vancomycin, or ceftazidime and outpt abx for 10-14 days • Abdominal wall hernia occurs in 10-20% of pts due to increased abd pressure

  19. Question 6 • Which of the following statements regarding phosphorous metabolism is pts with ESRD is correct? • A low calcium-phosphate product indicates a high risk for systemic calcification • Prevention of systemic calcification includes oral calcium-binding gels and high phosphate dialysate • Symptoms of systemic calcification includes painful, swollen joints due to pseudogout • Systemic calcification affects only the small vessels of the extremities • These patients have reduced phosphate absorption and lower serum phosphate levels

  20. Answer 6: C painful everything Systemic Calcification in ESRD • Decrease in phosphate excretion->increased serum PO4 • Phosphate binds serum calcium • Kidney fails to activate Vit D • Low serum calcium stimulates PTH release (secondary Hyperparathyroidism) • Calcium released from bone causes renal osteodystropthy and increased serum calcium-phophate binding

  21. Systemic Calcification • Calcium-Phosphate Product (Ca X PO4)> 72 • Swollen painful joints due to pseudogout (positive birefringent rhomboid crystals) • Small vessel calcification causing distal necrosis, esp finger tips, toes • Calcification of cardiac and pulm vasculature • Tx with phosphate binding medications, low calcium dialysate

  22. Question 7 • A 47 year old uncircumcised, obese male p/w painful tip of his penis. Physical exam reveals a swollen and tender glans and foreskin. On retraction the foreskin is excoriated, purulent, and there is a foul smelling discharge. This is limited to the glans. What is the diagnosis Dr? • Balanoposthitis • Fourniers Gangrene • HSV infection • Paraphimosis • Phymosis

  23. Question 7: A Balanopothitis • Inflamed Glans of Penis! • Usually inf; can be dermatitis • Skin flora, candida, rarely G/C • Tx with sitz bath, gentle cleansing, first-gen cephalosporin • White cheesy typical of candida- use oral fluconazole or topical

  24. Phimosis • Constriction of foreskin • Inability to retract over glans of penis • Leads to pain, inability to urinate • Steroid cream 4-6 weeks • Dilation, circumcision

  25. Paraphimosis • Inability to pull foreskin (A)nterioly • EMERGENCY • Vascular compromise and necrosis • Flaccid penis with distal engorgement • Analgesia, ICE, constant gentle traction • Puncture glans to allow edema out • Dorsal Slit

  26. Question 8 • A 32 year old man presents with a painful erection that has lasted 10 hours. Which of the following medications would most likely cause this condition? • Olanzapine • Pseudoephedrine • Terbutaline • Trazodone • Venlafaxine

  27. Answer 8: D Priapus -Greek minor God of fertility, protector of gardens, livestock, and male genitalia -Son of aphrodite by dionysis, hermes, or adonis -Punished for rape by having genitals replaced by large wooden ones -Pompeii, House ofVettii

  28. Priapism- Pathophysiology Priapism • Painful prolonged erection • High Flow- rare, due to traumatic fistula between cavernosal artery and corpus cavernosum, non-painful, less risk ischemia, tx with embolisation • Low Flow- common, impaired venous outflow from corpus cavernosum

  29. Priapism, etiology • Children- Sickle cell anemia, leukemia; vascular occlusion • Adults-Iatrogenic; hydralazine, prazosin, ccb, trazadone, chlorpromazine, other SSRI • Occasionally with sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis)

  30. Priapism- Treatment • Dorsal penile nerve block, analgesia • Hydration for sickle cell • Tertbutaline .25-.5mg SC to deltoid q30 min • Pseudoephedrine 60-120mg po if given early (low evidence) • Cavernosal aspiration of blood with instillation of saline + alpha-antagonist • Urology consult

  31. Question 9 • A 13 year old boy is brought to the ER for sudden onset of groin pain. On examination his right testicle is swollen, raised, and tender. Which of the following statements regarding this pts condition is correct? • CT of the affected are is the imaging study of choice • Duplex ultrasonography provides little useful anatomic information • Positive creamasteric reflex confirms the diagnosis • Relief of pain with elevation reliably differentiates this condition from epididymitis • The bell clapper deformity predisposes pts to this condition

  32. Answer E: Bell Clapper Testicular Torsion • Peak incidence age 13 • Time is Testis- 96% salvage in <4 hrs, <10% if delayed 24 hours • Testis descends through inguinal canal taking with is peritoneal lining (Tunica Vaginalis)and fixes to posterior scrotum • Bell Clapper deformity results from Tunica Vaginalis connects to spermatic cord instead and allows testis to rotate freely.

  33. Testicular Torsion • Presentation: Pain, swelling, loss of cremasteric reflex, no relief with elevation • Manual Detorsion- Open Book • Color flow doppler U/S is 100% specific and 80% sensitive for testicular torsion • Radionucleotide scintigraphy • Urology consult

  34. Epidiymitis • Gradual onset testicular/lower abdominal pain • Bacteria most common cause; >40 yrs G/C, >40 Ecoli • Viral infections (mumps) • Prehns sign: elevation of scrotum relieves pain a bit • Tx: Outpt for <40 y/o is 10 days of doxycycline or ofloxacin • Tx: Outpt for >40 yrs is floroquinolone or Bactrim

  35. Question 10 • Which of the following statements regarding imaging techniques for evaluation of suspected kidney stones is correct? • CT scanning poses risk of nephrotoxic contrast • CT scanning provides little data about the adjacent intrabdominal structures • Intravenous pyelogram is highly sensitive but does not provide information on renal function • Plain radiography is highly specific • Ultrasonography is the preferred modality for pregnant pts but might not identify stones smaller than 5mm

  36. Answer 10: E Ultrasound Nephrolithiasis/Urolithiasis • 7% of men and 3% woman age 20-50 • RF: Dehydration, hot climates, fam hx, male, gout, laxatives, HPTH, Crohns, Type 1 RTA • Renal function, infectious • Imaging required only for suspicion of high grade obstruction, toxic appearance, first episode, questionable dx • CT Scan sensitive (97%) and specific (96%) for stones >1mm • Ultrasound less sensitive for stone <5mm but can assess for hydronephrosis (sensitive 85-95%, specific 100%)

  37. Urolithiasis • IV pyelogram can assess renal function and and nearly as sensitive as CT • 90% Stones are radiopaque • 90% of stones <5mm will pass within 4wks, 15% stones 5-8mm will pass • Most common site of impaction is ureterovesicular junction; the lower the stone the more likely to pass • Treatment: Toradol + Morphine

  38. Urolithiasis • Efficacy of alpha-blockers for the treatment of ureteral stones. Journal of Urology, 2007 • Meta-analysis of 11 randomized studies, n=911 • Alpha-blockers associated with 44% greater chance of spontaneous stone expulsion

  39. Question 11 • A 56 year old man reports intermittent, painless hematuria X 2 weeks. He is on coumadin for DVT tx, smokes. Physical exam is wnl. US shows TNTC RBC and 5 WBC/ HPF. Cr is 0.9 and Hgb is 14 and INR is 2.9. A CT scan of abdomen and pelvis is normal. What is the next step? • Administer 10mg Vit K • Order U/S of l/e for DVT • Rx 7 days cipro and d/c home • Reassure pt that he prob passed a stone and just chill • Refer pt to a urologist for cystoscopy

  40. Answer 11: E Urologist • Hematuria • 1ml of blood can make urine grossly bloody and >5rbc/hpf warrants further w/u • Age <20: Infections, glomerulonephritis • Age 20-40: Kidney stone, UTI • Age >40: Men= Bladder Ca, Women=UTI • Blood only at beginning of stream likely urethral source • Blood at end bladder neck/prostate • Blood throughout entire stream bladder, ureter, kidney

  41. Hematuria • Presence of casts, protein indicate likely renal pathology • 80% of pts on anticoagulants who have hematuria have identifiable source • CT scan of the abdomen may show renal mass/ stone but is otherwise not necessary • Referral to urologist as outpt

  42. Question 12 • In the treatment of a 3 year old boy with a UTI, which of the following additional signs is the strongest indication for admission? • Localized myalgias • Maculopapular rash • Marked fever • Mucoid Diarrhea • Persistent Vomiting

  43. Answer 12: E, Vomiter UTI in pediatric pts • Neonates- fever, irritable, poor feeding, part of “r/o sepsis” w/u • Infants/Toddler- Abdominal pain, vomiting, enuresis • School Kids- Typical adult sx • Only vomiting leading to inability to take medication would result in hospitalization

  44. Question 13 • A 54 year old man presents with decreasing urine output for over the past week. He has a h/o ESRD and underwent living donor transplant 3 months ago. Physical exam reveals BP of 150/100, minimal tenderness over transplant site. UA shows no infection. Current meds are Diltiazem, cyclosporine, azathioprine, prednisone. Normal cyclosporin levels would make this pts presentation c/w what? • Acute Rejection • Cyclosporin-Induced Nephropathy • Development of post-surgical lymphocele • Renal Artery Stenosis • Tissue-invasive CMV infection

  45. Answer 13: A- Acute Rejection Renal Transplant Pt • Renal transplant failure 15-25% incidence in first year • Acute renal failure presents with decrease urine output, worsening of HTN, and rise in Cr at 20% over baseline • Severe cases with tenderness over allograph, fever, leukocytosis • Renal Bx often needed for acute rejection v.s iatrogenic • Medications that inhibit C-P450 increase levels of cyclosporin, tacrolimius, sirolimus which are nephrotoxic- always call team!

  46. Renal Transplant Patient • ER w/u includes UA, Culture, Drug Levels, CBC • Ultrasound of kidneys to r/o obstructive uropathy and compression from lymphocele or hematoma • Doppler study to assess for renal vein or artery (1st week) thrombosis • Renal artery stenosis occurs slowly and cause pre-renal azotemia

  47. Renal Transplant Patient • Post-Surgical lymphocele • occurs in 1st 3 months in 5-15% pts • Sx: pain over allograft, acute RF due to compression of ureter, or iliac vein thrombosis/compression causing lower extremity swelling • CMV Infection • 10-15% of renal transplant pts • 1st-6 months • Fever, elevated LFTs, pancytopenia • May be tissue invasive with GI, Pulm, CNS involvement

  48. Question 14 • A 45 year old man presents to the ER with low back pain X 2 weeks. He was seen in the ER one week ago and d/c'd with Motrin. On questioning he admits that he also has rectal pain. On exam he has a fever of 101.2 with a normal rectal vault but tender and boggy prostate. His urine shows >10 wbc/hpf but is Nitrite Neg. What is the best course of action? • Continue the motrin and d/c home • Urine culture, 28 day course of cipro , f/u urology • Urine culture, 14 day course of cipro, f/u urology • CT scan pelvis to r/o proctitis • Urine culture, call back for results

  49. Answer 14: B Culture and 28 days abx • Prostatitis Subtypes • Acute Bacterial • Non-bacterial • Chronic Bacterial • Proctodynia • Many presentations; fevers, chills, dysuria, rectal pain, low back pain • In infectious types >10wbc/hpf

  50. Prostatitis Acute Bacterial • 80% Aerobic G- Bact (ecoli, enterobacter, serratia, pseudomonas) • Age <35 consider C/G • Boggy Tender prostate • No prostate massage- bacteremia! • Tx 14 days with fluoroquinolone

More Related