the inservice exam

1. the inservice exam • Feb 25, 2009 • Short term  $$$ (moonlighting, Mets) • Long term  $$$$$$ (licensure, career in EM) • But also: intro to EM practice • Similar questions to ABEM • Last year: 207 questions counted • Physician’s Evaluation and Educational Review VII • Las Vegas Board Review Course MP3s (2003?) • EMEDS Review sinaiem.org/files/articles/BR-emeds/ … jar files

2. This lecture series • Board review: Five months, 20 lectures… • Different than Dr. Cherkas sessions • This year: • More engagement than 2005-6 • More questions, buzzwords than last year • More repetition • More candy

3. OB+GYN+GU • About 19 questions in PEER VII (out of 410) • Some overlap in ID, S+S, Procedures + Skills • Last year’s inservice: it was 8+7 out of 207 • CV, GI, Pulm, Trauma each ~20 • Likely emphasis: details that make or break ED diagnosis or management

4. OB+GYN+GU • Today: Pregnancy, UTI, PID • Select Male Concerns: scrotal and penile • No renal / stones / HD / PD complications • You already got some STDs from Jim Hinchey

5. Warning: Graphic Photos of our Holiday Parties

8. Question 1 A 32 year old man presents with a painful erection that has lasted for more than 10 hours. Which of the following medications is the most likely cause of this condition? • Olanzapine Not the psych drug (Zyprexa) you should be thinking of… • Pseudoephedrine No – this is a therapy (only if given early) • Terbutaline No – this is a therapy (0.25 mg subQ q30 min … in the deltoid) • Trazodone Most causes of priapism are iatrogenic, from anti-HTN or psych meds • Venlafaxine Also linked to priapism but much less common than trazodone

9. Priapism Low flow (90%, ischemia), venous obstruction • Meds (psychotropics, antihistamines, anti-HTN, viagra, cocaine) • Hematologic (sickle cell, leukemia, thalassemia) • Intra-cavernosalinjections (pre-1998) • Spinal cord injuries • Painful • 12+ hours  to thrombosis and ischemia  impotence High flow (10%), arterial source • Secondary to groin or straddle injury • Arterial cavernosal shunt • Less pain, no fibrosis • Treat with embolization

10. Priapism Rx • General Treatment: • Focus on pain control, urinary obstruction, hydration, O2 (sicklers) • Alpha-adrenergic antagonists: terbutalineIM, intracorporalphenylephrine • Corporal aspiration • Shunt surgery • Sickle cell: PRBCs, hyperbaric oxygen • Iatrogenic (due to penile injections for impotence) • Leukemia: terbutaline, chemo • Non-reversible causes: idiopathic, high spinal cord injury, meds

11. Question 2 A 47 year old uncircumcised, obese man presents with painful “tip of the penis.” Exam shows a swollen and tender glans and foreskin. On retraction, the foreskin appears excoriated and has a foul-smelling, purulent discharge. No other findings are present. What is the diagnosis? • Balanoposthitis Balanitis (glans) + foreskin! Usually skin flora. Treat with sitz, cleaning, keflex. If it’s cheesy, it’s candida. May be the presenting sign for diabetes – check a FSBS! • Fournier’s gangrene Patient not immunocompromised, no systemic signs or spreading beyond tip. • Herpes simplex Vesicles… not discharge. • Paraphimosis Can’t extend. Vicious cycle; true emergency. Give ice, sugar, puncture… slit? • Phimosis Can’t retract. Can lead to pain, UTI. Dilate, plus 4-6 weeks of steroid cream.

12. Balanoposthitis • Balanitis = inflammation of the glans penis • Posthitis = inflammation of the foreskin • Cause: • Usually Staph/Strep, can be fungal • Poor hygiene, undiagnosed DM, seborrheic dermatitis • Rx: • Local measures: soap, drying • Antifungal cream, possible broad spectrum antibiotics (cephalosporin)

13. Phimosis / Paraphimosis • Phimosis = inability to retract foreskin • Uncommon cause of urinary retention • Congenitial or bc of chronic balanoposthitis • Paraphimosis = retracted skin that cannot be reduced • A true urologic emergency • Can lead to gangrene of glansbc of arterial compromise • Leave foley in place if present • Rx: If unable to reduce manually • Use Local anesthetic at constricting band, make superficial vertical incision to decompress

14. Question 3 A 13 year old boy is brought in for sudden onset of groin pain. On exam, the patient’s right testis is swollen, tender, and slightly elevated in the scrotum. Which of the following statements regarding this condition is correct? • CT is the imaging study of choice CT gives great anatomy… but who wants IV, radiation on a kid’s nads? • Duplex ultrasonography provides little data about testicular anatomy US is 100% specific for torsion, good anatomy. Manual detorsion shouldn’t wait. • Positive cremasteric reflex confirms the diagnosis Reflex should be absent in torsion • Relief of pain with elevation reliably differentiates this condition from epididymitis Relief of pain with elevation (Prehn’s sign) suggests epididymitis… not reliable… • The “bell-clapper” deformity predisposes patients to this condition Tunica vaginalis (a fold of peritoneum) should just cover superior pole of testis and attach to posterior scrotum. If it covers entire testicle and attaches to spermatic cord, testis can rotate more freely.

15. Testicular Torsion • Cause: twisting of the spermatic cord • Maldeveloped testes (at baseline tend to lie more horizontal than vertical = bell clapper deformity) • Findings: Young male with abdominal pain • Peak incidence in puberty but can occur at any age • Sudden onset of pain, not changed by scrotal elevation • Absence of cremasteric reflex (normal: stroking proximal medial thigh causes testicle to elevate) • Tests: Ultrasound Doppler, Nuclear Scan • Rx: Emergent urology consult for surgical repair • May try Manual Derotation while waiting (rotate testicle in lateral direction, “open book.” Relief of pain indicates success.)

16. Testicular AppendageTorsion • Cause: twisting of pedunculated structures on the epididymis or testis • More common than testicular torsion in prepubertal boys • Findings: • “Blue Dot Sign:” pathognomonic, represents hemorrhage of appendage visualized through thin scrotal skin. • Tests: Doppler ultrasound • Rx: Possible surgery. May not be necessary if doppler of testicle is normal.

17. Epididymitis • Cause: Inflammatory process (gradual) • Can be infectious or due to reflux of sterile urine • Young boys: think of congenital abnormalities • Gram neg. Secondary to structural, neurologic, functional abnormalities of lower tract • Sexually active: usually STD-related • If Gram neg, give erythromcin • Elderly: think of obstruction (prostate, stricture) • Usually E.coli and Klebsiella • 5-25% of testicular cancers are initially misdiagnosed as epididymitis • S/Sxs: gradual onset of pain • Prehn’s sign = relief of pain with elevation of scrotum • Rx: Abx as indicated by age, NSAIDs, bed rest, scrotal support, intermittent ice packs

20. Acute Prostatitis • Cause: • Sexually Active: consider STD (GC) • Elderly: consider E.coli • S/Sxs: • Perineal pain, dysuria, frequency, fever/chills, urinary retention • “Boggy” enlarged, tender prostate • Prostate massage is contraindicated • May lead to bacteremia

21. Question 4 A 56 year old man with DM II presents with 3-4 days of fever and groin pain. There is no hx of recent illness, but glucose levels have been difficult to control for over a week. His exam is in the next figure. What is the most appropriate initial treatment? Can we do this, Cherkas-style? • High-dose intravenous penicillin • Hyperbaric oxygen therapy • Intravenous piperacillin/tazobactam • Suprapubic catheterization • Surgical debridement

23. Question 4, continued A 56 year old man with DM II presents with 3-4 days of fever and groin pain. There is no hx of recent illness, but glucose levels have been difficult to control for over a week. His exam is in the next figure. What is the most appropriate initial treatment? • High-dose intravenous penicillin Not enough coverage (most common Cx is E. coli, Bacteroides, and staph…) • Hyperbaric oxygen therapy An adjunct, and a controversial one. Certainly not initial therapy. • Intravenous piperacillin / tazobactam Could go for pen (for G+ and C. perfringes) plus aminoglycoside or 3g cephalo for gram negs, plus anaerobe coverage with metronidazole or clinda. • Suprapubic catheterization May become necessary, depending on extent. But not initial therapy for this pt. • Surgical debridement Almost certainly necessary, but not the initial treatment.

24. Scrotal Abscess • Must differentiate between abscess of the skin (hair follicle carbuncle/furuncle) vs. Abscess of scrotal contents • Skin abscess Rx: I&D, no abx • Intra-scrotal abscess can be a complication of epididymitis • Ultrasound can help to distinguish • Must differentiate from Fournier’s • Low threshhold for Urologic Consultation

25. Fournier’s Gangrene • Surgical Emergency • Extensive tissue loss and increased mortality with delayed diagnosis • Cause: • Polymicrobialinfxn of subcutaneous tissue that originates either in the skin, urethra, rectum • Immunocompromised at risk (DM,EtOH, IVDA, chronic steroids) • Findings: • Can start as a benign infection or abscess • Quickly becomes “virulent” with crepitus • Always consider this in any pt with scrotal, rectal or genital pain or tachycardia out of proportion to clinical findings

26. Question 5 In the treatment of a 3 year-old boy with UTI, which of the following additional signs is the strongest indication for hospital admission? • Localized myalgias whatever • Maculopapular rash not really associated with UTI at any age • Marked fever no – this is often the presenting symptom • Mucoid diarrhea may help distinguish UTI from AGE at this age, shouldn’t affect dispo • Persistent vomiting Vomicking unable to take ABx, mandates IV therapy and admission

28. Question 6 A 24 year old woman complains of dysuria, urgency, and frequency. She denies f/c, no n/v, no back pain. She has no known drug allergies and a urine pregnancy test is negative. Bedside urine dip shows 3+ blood, 1+ nitrites, and 1+ leukocyte esterase. What is the most appropriate course? • Order a urine culture and treat with an appropriate ABx for 3 days Rosen’s and Tintinalli say no culture is necessary, only 10-20% will fail empiric tx • Order a urine culture and treat with an appropriate ABx for 7 days Not pregnant, not a male, not elderly, not diabetic, no hx of prior UTI’s… • Treat with an appropriate ABx for 3 days Empiric therapy without UCx is appropriate if no risk factors for complications • Treat with an appropriate ABx for 7 days 3d is enough. Use local abiogram to guide ABx choice. • Wait for microscopic analysis of the urine before deciding whether to order a urine culture. Wait for FEW ORG SEEN ??? A UTI patient should be your fastest dispo of the day.

29. Urinary Tract Infection • Cause: • E.coli (90%), Klebsiella, Proteus, Enterobacter (5-20% combined) • Males usually secondary to urologic disease • Dx: • Sxs + 100 CFUs of single pathogen • Relapse = same organism & serotype, < 1 month since initial infection • Reinfection = recurrence of sxs 1-6 months after initial infection, usually different organism

30. UTIs: Deeper Thoughts • Complicated UTIs • Underlying urologic pathology, pregnancy, immunocompromised, usually not E.coli • Asymptomatic bacteriuria: • Can progress to symptomatic infection, especially in pregnancy • Acute Urethral Syndrome • +Dysuria, but with low (or no) bacterial count in urine cultures. UA often positive. • Generally indicates infection & should be treated • DysuriaDdx: chlamydia, herpes, GC, vaginitis

31. UTIs: Lab Tests • Nitrite: specific (90%) but not sensitive (50%) • Based on bacteria-induced change of nitrate to nitrite (varies by bug, urine incubation) • Leukocyte Esterase: similar (80% sp, 48% sn) • Based on presence of WBCs in urine • Pyuria = 2-5 WBC in females, 1-2 WBC in males • Bacteriuria = any bacteria in an uncentrifuged gram stain smear, or > 15/HPF in centrifuged specimen • Chlamydia infection can be associated with low WBC and low bacterial counts

32. UTIs: When to Culture? • Pyelonephritis, recent hxpyelonephritis • Underlying urologic pathology • Children, Males • Diabetics, Immunocompromised • Recent Instrumentation, Indwelling catheter • Prolonged Sxs prior to Rx • 3 or more UTIs in the past year DO NOT need to culture young, healthy women with uncomplicated UTIs DO need to r/o other sources of pyuria/dysuria: STDs, prostatitis, pyelonephritis, epididymitis

33. Female, lower tract, nonrecurrent, simple TMP/SMZ BID x 3d Quinolone x 3d Female, lower tract, complicated / or Male, upper tract TMP/SMZ x 10d Macrobid x 10d Cefadroxil x 10d Amox/Augmentin x 10d Quinolone x 10d Female, lower tract, suspected STD Doxycycline x 10d TMP/SMZ x 10d Erythromycin x 10d (E.coli not covered) culture for chlamydia, GC Think Pseudomonas in high-risk patients Cover with broad spectrum Abx Adult UTI Treatment

34. High-Risk Pyelonephritis • Pregnancy: • Incidence of pyelonephritis increases in the 3rd trimester and may precipitate preeclampsia, sepsis & miscarriage • DM, Sickle Cell Anemia • Renal Calculi / obstruction • Elderly / Debilitated • Carcinoma, Chemotherapy • Recent hospitalization • Recent instrumentation of UT Pyelonephritis = leading cause of perinephric abscess

35. Question 7 A 17 year old woman complains of dysuria x3 days. She denies f/c, no n/v/d, no abd pain. Pelvic exam reveals a homogenous white discharge that coats the vaginal walls. Pregnancy test is negative. Wet mount shows clue cells. The best treatment is: • azithromycin this is not chlamydialurethritis or PID! (chlamydiais #1 reported STI) • ceftriaxone this is not gonococcalurethritis or PID! • fluconazole if it were fungal, they would have said cottage cheese.. • levofloxacin this is not a UTI! and levaquin has poor anaerobe coverage… • metronidazole therapy of choice in both pregnant and nonpregnant patients. A seven-day course of clinda cream or pills is also acceptable. Metronidazole also works on trichomonas, which can present similarly to vaginosis (but is described with dyspareunia, dysuria, and a wet mount that shows flagellates).

36. Gardnerella (BV) • New term: AnerobicVaginosis • Gram negative rod, faculatative anaerobe • “fishy” order, rather than maldorous • Clue cells: anaerobes sticking to squamous epithelial cells. Looks like a fried egg with salt and pepper under microscope. • Rx: Flagyl. • Truly, flagylin first trimester is controversial.

38. Trichomonas Women: Frothy, grey, malodorous Men: asymptomatic, urethritis Drop it on slide: see swimming things Word STRAWBERRY: GOES WITH TRICH Other strawberries: tongue A protozoan. Rx: Flagyl (not intuitive) Think Flagyl if you have no idea what to use! (giardia, anaerboes, ameobas, other parasites) What else should you be doing after you treat the patient: treat partner Single dose therapy In Pictures: look like fat sperm

40. Candida • Yeast • Risk factors: • diabetes (common presentation of new onset DM) • contraception • antibiotics • Cottage cheese, no smell • Drop on slide: KOH dissolves other elements, leaves behind hyphae (spaghetti) and spores (meatballs) • RX: single treatment of fluconazole, or lotrimin suppository

43. Question 8 A 23 year old woman presents complaining of lower abdominal pain. Pelvic exam reveals yellow vaginal discharge, as well as moderate CMT. Adnexa are tender, but no masses are present. Outpatient management may be considered if the patient has: • A physician who can provide followup care It’s hard to discharge PID: Poor followup, adolescence, HIV, N/V, ambiguity… • Pelvic abscess Um, no. This would be a reason for IV ABx, admission • Positive urine pregnancy test No. Pregnancy should actually protect against PID – this presentation is ominous. • Already taken antibiotics for similar complaints So they’ve failed outpatient therapy and need IV ABx and admission • Temperature greater than 38.8C Fever is not uncommon but I guess the PEER folks found this concerning

44. PID/Salpyngitis Causes: Neisseriagonorrhoeae, chlamydiatrachomatis (#1), Gardnerellavaginalis, anerobes • Ascending disease: starts in cervix, goes through tubes • Risk Factors: anything that mucks up the tubes. Previous PID, IUD, adolescent w/multiple partners

45. PID, continued • Can’t be ruled on physical exam. FORGET CMT • CMT, adnexal tenderness, elevated temperature, discharge • DON’T NEED TO ADMIT ALL PATIENTS Consider for: • Pregnancy—this is very uncommon • Immunosuppressed • IUD • Clinically ill • Outpatient compliance issues • Fertility issues • TOA • peritonitis

46. More on PID • Cervical culture not correlates with actually causative organism. Treatment always empiric • Complicatons: • Chronic pain/dyspareunia • TOA • infertility (most common cause of infertility) • Fitz-Hugh-Curtis: RUQ pain w/o biliary disease • Watch out in RUQ pain questions on boards. What is the next thing you do? answer is pelvic exam • F-H-C catch phrase: violin strings (adhesions between capsule of liver and abdominal wall)

48. PID • Rx: treat Gonorrhea and chlamydia. • Gonococci: ceftriaxone/cefuroxime or quinolone (single dose) • Chlamydia/anaerobes: doxy 10 days (slower turnover rate) If recurrent/chronic/fails treatment, think anaerobes. FLAGYL

50. Question 9 The side effects of emergency contraception meds can be reduced by: • Avoiding their use in smokers Risk of VTE goes up with OCP use and age over 35, obesity, and smoking • Peri- or post-ovulatory administration Actually there’s theoretical risk of ectopic here – the P might cause ciliarydysfxn. • Taking the pill before a meal Symptoms of n/v, headache, fatigue are benign. Abd pain must get ectopic w/u • Using a progestin-only regimen WHO ‘98 says P dosing within 72 hours is more effective than Yuzpe, fewer AE • Using combination pills with both estrogen and progestin Yuzpe ‘74 method is two E+P doses, twelve hours apart, within 72 hours of sex.