gu board review aric bakshy, md. question 1 za 24 year old woman presents complaining of dysuria,...
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GU Board Review
Aric Bakshy, MD
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 daysB. Urine culture and treat with abx 7 daysC. Treat with abx 3 daysD. Treat with abx 7 daysE. Wait for microscopic analysis of UA before next
step
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
The burning bean
Risk factors for complicated UTI-Pregnancy-DMrecurrent UTI-Recent indwelling catheter or
instrumentation-Structural abnormalities-Male sex-Extremes of age
The burning bean
Treatment of Uncomplicated UTI: 3 days tx; Bactrim, Fluoroquinalones
Pregnancy: Nitrofuantoin, Keflex
Complicated UTI: 7 days tx, culture
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?
Question 2
A. High-Dose penicillinB. Hyperbaric oxygen therapyC. Pipercillin/TazobactamD. Suprapubic catheterizationE. Surgical Debreidment
Answer 2: C Pipercillin/TazobatamFournier's GangreneNecrotizing Fasciitis of penis and
scrotumTreatment is Abx and debridementRisk factors include DM, EtOHism, and
immunocompromisedUsually combination of aerobic and
anaerobic bacteriaEcoli, Bacteroides, Staph; Clostridium
possible if starting in colorectal region
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
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 protectiveB. Metformin can be protectiveC. N-Acetyl-L-cysteine given IV prior to contrast can
be protectiveD. 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.
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
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 sodium chloride but in only 1 (1.7%) of those receiving sodium bicarbonate(mean difference, 11.9%; 95% confidence interval [CI], 2.6%-21.2%; P = .02).
Cheaper and more efficacious than ED provided NAC!
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?
A. Administer dexamethasone to stimulate platelet function
B. Administer enoxaparin to minimize clot aggregationC. Administer protamine sulfate to reverse heparin used
during HDD. Avoid IVF to preserve pts renal functionE. Give whole blood to match her volume loss
Answer 4: C Protamine SulfateShunt 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
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
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?
A. CT scan of abdomen with contrastB. Intraperitoneal first-gen cephalosporin or
vancomycinC. Intravenous first-gen cephalosporin of
vancomycinD. Laparotomy for removal of Tenckhoff catheterE. Placement of a Hickman catheter and emergent
HD
Answer 5: B IntraperitonealPeritoneal DialysisPD is most common form of dialysis
outside the USAPeritoneal membrane is the blood-
dialysate interface8L of dialysate per day given, 10 L
removedPeritonitis is most common
complicationDx based on >100 WBC, 50% pms, or
a positive gram stain
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
Question 6 Which of the following statements regarding
phosphorous metabolism is pts with ESRD is correct?
A. A low calcium-phosphate product indicates a high risk for systemic calcification
B. Prevention of systemic calcification includes oral calcium-binding gels and high phosphate dialysate
C. Symptoms of systemic calcification includes painful, swollen joints due to pseudogout
D. Systemic calcification affects only the small vessels of the extremities
E. These patients have reduced phosphate absorption and lower serum phosphate levels
Answer 6: C painful everythingSystemic Calcification in ESRDDecrease in phosphate excretion-
>increased serum PO4Phosphate binds serum calciumKidney fails to activate Vit DLow serum calcium stimulates PTH
release (secondary Hyperparathyroidism)
Calcium released from bone causes renal osteodystropthy and increased serum calcium-phophate binding
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
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?
A. BalanoposthitisB. Fourniers GangreneC. HSV infectionD. ParaphimosisE. Phymosis
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
Phimosis
Constriction of foreskin
Inability to retract over glans of penis
Leads to pain, inability to urinate
Steroid cream 4-6 weeks
Dilation, circumcision
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
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?
A. OlanzapineB. PseudoephedrineC. TerbutalineD. TrazodoneE. Venlafaxine
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
Priapism- Pathophysiology
PriapismPainful prolonged erectionHigh 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
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)
Priapism- Treatment
Dorsal penile nerve block, analgesiaHydration for sickle cellTertbutaline .25-.5mg SC to deltoid
q30 minPseudoephedrine 60-120mg po if
given early (low evidence)Cavernosal aspiration of blood with
instillation of saline + alpha-antagonist
Urology consult
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?
A. CT of the affected are is the imaging study of choice
B. Duplex ultrasonography provides little useful anatomic information
C. Positive creamasteric reflex confirms the diagnosisD. Relief of pain with elevation reliably differentiates
this condition from epididymitisE. The bell clapper deformity predisposes pts to this
condition
Answer E: Bell Clapper
Testicular TorsionPeak incidence age 13Time 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.
Testicular Torsion
Presentation: Pain, swelling, loss of cremasteric reflex, no relief with elevation
Manual Detorsion- Open BookColor flow doppler U/S is 100%
specific and 80% sensitive for testicular torsion
Radionucleotide scintigraphy Urology consult
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 bitTx: Outpt for <40 y/o is 10 days of
doxycycline or ofloxacinTx: Outpt for >40 yrs is floroquinolone
or Bactrim
Question 10 Which of the following statements regarding
imaging techniques for evaluation of suspected kidney stones is correct?
A. CT scanning poses risk of nephrotoxic contrast
B. CT scanning provides little data about the adjacent intrabdominal structures
C. Intravenous pyelogram is highly sensitive but does not provide information on renal function
D. Plain radiography is highly specificE. Ultrasonography is the preferred modality for
pregnant pts but might not identify stones smaller than 5mm
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%)
Urolithiasis
IV pyelogram can assess renal function and and nearly as sensitive as CT
90% Stones are radiopaque90% of stones <5mm will pass within
4wks, 15% stones 5-8mm will passMost common site of impaction is
ureterovesicular junction; the lower the stone the more likely to pass
Treatment: Toradol + Morphine
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
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?
A. Administer 10mg Vit K B. Order U/S of l/e for DVTC. Rx 7 days cipro and d/c homeD. Reassure pt that he prob passed a stone
and just chillE. Refer pt to a urologist for cystoscopy
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
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
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?
A. Localized myalgiasB. Maculopapular rashC. Marked feverD. Mucoid DiarrheaE. Persistent Vomiting
Answer 12: E, Vomiter
UTI in pediatric ptsNeonates- fever, irritable, poor
feeding, part of “r/o sepsis” w/uInfants/Toddler- Abdominal pain,
vomiting, enuresisSchool Kids- Typical adult sxOnly vomiting leading to inability
to take medication would result in hospitalization
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?
A. Acute RejectionB. Cyclosporin-Induced NephropathyC. Development of post-surgical lymphoceleD. Renal Artery StenosisE. Tissue-invasive CMV infection
Answer 13: A- Acute RejectionRenal 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!
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
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
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?
A. Continue the motrin and d/c homeB. Urine culture, 28 day course of cipro , f/u urologyC. Urine culture, 14 day course of cipro, f/u urologyD. CT scan pelvis to r/o proctitisE. Urine culture, call back for results
Answer 14: B Culture and 28 days abx Prostatitis SubtypesAcute BacterialNon-bacterialChronic BacterialProctodynia
Many presentations; fevers, chills, dysuria, rectal pain, low back pain
In infectious types >10wbc/hpf
Prostatitis
Acute Bacterial80% Aerobic G- Bact (ecoli,
enterobacter, serratia, pseudomonas)
Age <35 consider C/GBoggy Tender prostateNo prostate massage-
bacteremia!Tx 14 days with fluoroquinolone
Prostatitis
Chronic Bacterial Ecoli (80%), Enterobacteriaceae,
enterococci, and P aeruginosa May have non-tender prostateCauses recurrent UTI’s in menMay present with obstructive sx;
hesitancy, incomplete voiding10-fold bacterial growth in the EPS;
100,000 CFU not needed28 day course Fluoroquinolone or Bactrim
Prostatitis
Prostodynia Not a true inflammation May be due to a primary voiding dysfunction May also have a psychological component Prazosin or diazepam with sitz baths. Tx: Consult urologyNon-bacterial Prostatitis C Trachomatis, Ureaplasma spp, M
tuberculosis, Coccidioides, Histoplasma, and Candida
Tx: Consult urology
Question 15 A 70 y/o unk male is BIBEMS for AMS. He is
lethargic, confused upon arousal, and has a pungent odor. Pt is afebrile. His BP is 70/60 and HR is 140, 100% on RA. He has JVD to his ear. Standard labs, EKG, and a cxr are ordered. His chemistry returns sig for a BUN of 120 and Cr of 10. He has a pun Hct of 38. He has no AVF or dialysis port. The nurse notes he just passed a large melanotic BM. Which of the following should not be considered in the initial w/u and management of the pt?
A. Airway managementB. Bedside cardiac ultrasoundC. DDAVP .3mg IV, Type and Cross 4 unitsD. Arrange for hemodialysisE. CT of the head
Answer 15- E CT head
Acute Renal Failure3 Major TypesPre-renal- Poor Cardiac Output,
HypotensionRenal- Renal parenchymal dzPost-renal- Obstruction past the
kidney・
Acute Renal Failure
DiagnosisFeNa = (urine Na/plasma Na)/(urine
creatinine/plasma creatinine) ・FeNa <1 % = Prerenal FeNa >1% = RenalDon’t forget the Foley!Creatinine 1.0 mg/dL - Normal GFR
Creatinine 2.0 mg/dL - 50% GFR Creatinine 4.0 mg/dL - 75% GFR
Creatinine 8.0 mg/dL - 95% GFR
Acute Renal Failure
ComplicationsCardiovascular: Hypotension/ Vol
OverloadUremia: Encephlopathy,
Pericardial Effusion/TamponadeHeme: Anemia, Platelet
DysfunctionElectrolytes: Hyperkalemia,
HypocalcemiaPulm: Pulmonary Edema
Acute Renal Failure
Indications for Emergent DialysisVolume overloadHyperkalemia (K+ >6.5 or rising)Acid-base imbalanceSymptomatic uremia (pericarditis,
encephalopathy, bleeding dyscrasia, nausea, vomiting, pruritus)
Uremia (BUN>100)Dialyzable intoxications: methanol, ethylene
glycol, theophylline, aspirin, lithium
THE END!