KC GU Flashcards
*Dialysis question; first time the patient has had dialysis. The patient became altered and felt nauseated. Comes in resolved with normal vitals. Normal labs and Normal CT Head.
What is the diagnosis?
Disequilibrium syndrome
*6 indications of dialysis in a ESRD patient
- Hyperkalemia
- Acidosis
- Pulmonary edema/respiratory failure
- Pericarditis
- Encephalopathy
- Toxic ingestion (e.g. ASA, methanol, ethylene glycol)
- Hyperphosphatemia
*What are the three most common electrolyte abnormalities in a patient with end stage renal disease?
Hyperkalemia
Hypocalcemia
Hyperphosphatemia
Hypermagnesemia
*Old lady on lithium, metformin, diclofenac. Had a CT scan with contrast a few days ago and was put on cipro for UTI and now comes in lethargic and febrile. Cr elevated 280, HCO3 20, lithium 2.6, K 3.6.
4 contributing factors to her renal failure.
Hypovolemia
Sepsis
Nephrotoxins: cipro, contrast, NSAIDs, lithium
Diabetic nephropathy
*Old lady on lithium, metformin, diclofenac. Had a CT scan with contrast a few days ago and was put on cipro for UTI and now comes in lethargic and febrile. Cr elevated 280, HCO3 20, lithium 2.6, K 3.6.
3 indications this patient has for possible emergent hemodialysis
Lithium
Acidosis
Altered mental status (uremic encephalopathy)
*Old lady on lithium, metformin, diclofenac. Had a CT scan with contrast a few days ago and was put on cipro for UTI and now comes in lethargic and febrile. Cr elevated 280, HCO3 20, lithium 2.6, K 3.6. 4 Interventions that might have prevented contrast-induced nephropathy.
- IVF
- Stop metformin diclofenac
- Lithium level
- Avoid cipro
*What does the evidence say is the definition of contrast induced nephropathy?
Acute renal dysfunction as measured by an increase by 25% in creatinine with temporal relation of receiving IV contrast and no other cause identified
*What are risk factors exist for CIN?
- Age >60yo,
- DM,
- CKD,
- dehydration,
- multiple myeloma,
- high contrast load
*What can you do to the patient that will reduce the risk of CIN that will help appease this nervous resident?
- Do a non-contrast scan if feasible,
- IV fluids,
- hold nephrotoxic drugs
lower dose of contrast and limit repeat scans
NAC
*What are 4 laboratory indicators that an AKI is pre-renal?
- Increased urine specific gravity
- Cr:Urea ratio < 10:1 (SI units)
- Urine sodium concentration <20 mEq/L
- Fractional excretion of sodium <1%
*What are medications that can cause intrinsic renal failure?
- NSAIDs
- Vancomycin
- HCTZ
- Ramipril
- Cisplatin
- Radiocontrast media
- Anti-virals (e.g. tenofovir)
*A 12 year old presents with a 2 week history of URI symptoms. She is here today because she thinks her GFR is down for some reason. She has RBC casts. What is the cause of these casts and what does that make the patients source of AKI likely to be?
Glomerular damage – likely post-streptococcal glomerulonephritis in this case
*What is the outpatient management of PID? (Dose, duration)
- Ceftriaxone 500 mg IM x 1
plus - Doxycycline 100 mg PO BID x 14 days
+/- Metronidazole 500 mg PO BID x 14 days
*32 year promiscuous women with RLQ pain that has now migrated and is also RUQ . She has a purulent OS and tender adnexal mass. What are two complications of PID that she has?
Fitz Hugh curtis
Tubo-ovarian abscess
*Three findings of PID that evidence would suggest we should treat empirically
The diagnosis of PID should be considered and presumptive treatment initiated in any sexually active woman at risk for sexually transmitted infections with lower abdominal pain or pelvic pain if no alternative diagnosis is identified
and if one or more of the following findings are present:
Minimal criteria
- Cervical motion tenderness
- Uterine tenderness
- Adnexal tenderness
*2 supporting lab features of PID
- Elevated ESR
- Elevated CRP
- White blood cells on microscopy of vaginal secretions
- Laboratory confirmation of endocervical gonorrhea or chlamydia
*List two tests to diagnose syphilis
- Dark field microscopy (direct visualization, good for active infection, exmaple of trepomonal test)
- Serologic testing (VDRL) - looks for host antibodies from destroyed host cells (non trepomonal test less specific)
- Treponemal antibody test - looks for antibodies specific to syphillis, can be positive after treatment
Two types of testing - trepomonal and non trepomonal. The first detects antibodies produced by the bacteria (more specific). The second looks for antibodies based on the host response (more sensitive)
*List three other infectious causes of genital ulcers
- Genital herpes
- Chancroid
- Lymphogranuloma venereum
- Donovanosis
- Abscess (draining)
*How do you treat his condition (no dose)?
Penicillin G 2.4 million U IM single dose
*What is the treatment for Initial HSV outbreak
Acyclovir 400 mg PO TID for 7 to 10 days or Valacyclovir 1000 mg PO BID for 7 to 10 days
*What is the treatment for Gonococcal pharyngitis
Ceftriaxone 500 mg IM single dose, azithromycin 1 g PO single dose
*What is the treatment for Disseminated gonorrhea
Ceftriaxone 1 g IV daily until clinical improvement, azithromycin 1 g PO single dose iv)
*What is the treatment for Lymphogranuloma venerum
Doxycycline 100 mg PO BID for 21 days (UpToDate)
*What is the treatment for Trichomonas
Metronidazole 500g BID x 7 days
*What are 3 risk factors for PID?
ID: young age <25, smoking/EtOH/drug use
Sexual: Hx/partner Hx of STI, new partner w/i 3m, multiple partners, unprotected intercourse, sex worker
Recent procedure: instrumentation of uterus, interruption of cervical barrier, IUD insertion
*3 Diagnostic Criteria for PID
Minimum criteria
- Cervical motion tenderness
- Adnexal tenderness
- Uterine tenderness
*4 other clinical or biochemical findings for PID
Cervical friability
Mucopurulent discharge
Oral temperature >101° F
Elevated erythrocyte sedimentation rate
Elevated C-reactive protein
White blood cells (WBCs) on microscopy of vaginal secretions
Laboratory confirmation of endocervical gonorrhea or chlamydia
*4 Reasons to Admit in PID
• Surgical emergencies cannot be excluded (ie, appendicitis)
• Pregnancy
• Tubo-ovarian abscess
• Severe illness, nausea and vomiting, or high fever
• Inability to follow or tolerate outpatient oral regimens
• Failure to respond to oral antibiotic therapy
*What is the organism that causes syphilis?
Treponema pallidum
*Ddx syphilis: 5 other diseases that cause lesions on the palms and soles
- Secondary syphilis
- Rocky mountain spotted fever
- Coxsackie/Hand foot and mouth disease
- Janeway lesions of bacterial endocarditis
- Kawasaki disease
- Measles
- Toxic shock syndrome
- Meningococcemia
- Rat bite fever
*4 ultrasound findings of torsion
Diffusely hypoechoic
Asymmetric testicles
Normal or decreased flow
Spermatic cord twist
*5 physical exam findings of torsion
High-riding testicle
Transverse alignment
Entire testicular tenderness/pain
No cremasteric reflex
Very swollen
*2 immediate management things to do (torsion)
Uro consult
Manual detortion
*Patient with colicky RLQ pain. (renal colic question) give 5 DDX other than PID and ovarian torsion
Appendicitis
Intestinal obstruction
AAA
Tumour
Pyelonephritis
Referred pain from testicle
*What are indications for admission of renal colic? (absolute)
- Obstruction + infection
- Intractable nausea or vomiting
- Severe pain requiring parenteral analgesics
- Urinary extravasation
- Hypercalcemic crisis
*Medical expulsion therapy drug dose
tamsulosin, 0.4 mg PO daily
Nifedipine XR 30 mg PO daily
*Indication for tamsulosin
Both the European Urological Association (EAU) and American Urological Association (AUA) recommend alpha blockers for the expulsion of distal ureteral stones when there is no indication for immediate surgical stone removal.
*17 year old male with L scrotal swelling and pain. Atraumatic. He is sexually active.
What are 2 physical exam findings that suggest torsion instead of epididymitis?
Absent cremasteric reflex
Horizontal/transverse lie
*What are 6 things on your differential causing this presentation?
Testicular torsion
Apendix testes torsion
Orchitis/epidydimitis
Inguinal hernia
Hydrocele
*What are 2 LABORATORY tests you want to order?
Urinalysis/culture
PCR Gon/chlam
*If this was due to an infectious etiology, what 2 drugs would you use to treat it (name, route, dose, duration)?
Ceftriaxone 250mg IM x1
Doxycycline 100mg PO BID x10d
*What is the most serious non-suppurative complication of this condition? (?epididymitis)
?Testicular infarction
*What are 5 pharmacologic causes of priapism (drugs/drug classes)
o Phosphodiesterase (PDE5) inhibitors: sildenafil
o Nitrates
o Antihypertensives (alpha-antagonist): Prazosin
o Antidepressants: Trazodone, fluoxetine
o Antipsychotics: Chlorpromazine
o Drugs of abuse: Cocaine, MJ
o Anticoagulants
*Differentiate high and low flow priapism: their pathophysiology and features
Ischemic (veno-occlusive, low flow) priapism is a nonsexual, persistent erection characterized by little or no cavernous blood flow and abnormal cavernous blood gases (hypoxic, hypercarbic, and acidotic). The corpora cavernosa are rigid and tender to palpation. Patients typically report pain. A variety of etiologic factors may contribute to the failure of the detumescence mechanism in this condition. Ischemic priapism is an emergency. The more common of the two.
Nonischemic (arterial, high flow) priapism is a nonsexual, persistent erection caused by unregulated cavernous arterial inflow. Cavernous blood gases are not hypoxic or acidotic. Typically the penis is neither fully rigid nor painful. Antecedent trauma is the most commonly described etiology. Nonischemic priapism does not require emergent treatment.
*What are 3 treatments for priapism?
o Compression (hands or adhesive wrap)
o Corpora cavernosum aspiration
o Phenylephrine injection
o Ice pack
o Analgesia
o Dorsal nerve block
o Cavernoglanular (corporoglanular) shunt
*What are 5 non-pharmacologic causes of priapism
o SCD
o Leukemia
o Kawasaki
o Trauma
o Infection
o FB
*Three complications of priapism
o Penile fibrosis
o Urinary retention
o Impotence
Necrosis of cavernous smooth muscles
*Most sensitive exam finding for torsion
Absent cremasteric reflex
*Viral causes of orchitis (4)
Mumps
Rubella
Coxsackie
Echovirus
Parvovirus
MRCP - thinks peds
*4 bacteria for epididymitis
N. gonorrhoeae,
C. trachomatis,
E. coli,
Klebsiella, and
P. aeruginosa
*Pathognomonic sign for testicular appendage torsion
Blue dot sign 25%
*4 causes of painless scrotal swelling
• Varicocele
• Hydrocele
• Inguinal hernia
• Testicular carcinoma
• Epididymal cyst/spermatocele
• Idiopathic scrotal edema
*What are 5 obstructive causes of urinary retention
Benign prostatic hypertrophy
Prostatitis
Phimosis
Paraphimosis
Meatal stenosis
Tumor
Foreign body
Calculus
Stricture
Hematoma
Carcinoma
*What are 5 medication causes of urinary retention
Antihistamines
Anticholinergic agents
Antispasmodic agents
Tricyclic antidepressants
α-Adrenergic stimulators
Cold tablets
Ephedrine derivatives
Amphetamines
*What are 4 neurogenic causes of urinary retention
Motor Paralytic
Spinal shock
Spinal cord syndromes
Sensory Paralytic
Tabes dorsalis
Diabetes
Multiple sclerosis
Syringomyelia
Spinal cord syndromes
Herpes zoster
*What is 1 “other” cause of urinary retention
Psychodynamic stressors (eg, lazy bladder syndrome)
Infectious ex. Urethritis, urinary tract infection, prostatitis\
*RN can’t pass foley, what are 3 methods to decompress bladder
- Suprapubic cath
- Urology consult : for other instrumentation
- Coude cath
*Three things you must ensure before ptis discharged with a leg bag
- appropriate follow-up
- begin alpha-blocker
- ensure urine draining
- Education of catheter management
- ensure no infection
- ensure no post-obstructive diuresis
*What are risk factors for renal colic?
DRY ROCKS
Dehydration / hot climates / acidosis
Recurrent UTI
Y chromosome
Relatives with stones
Odd habits (milk-alkali, laxative abuse, calcium ingestion)
Calcium diseases (primary hyperparathyroidism, malignancy, sarcoid)
Kidney stones
Small bowel diseases (Crohns)
*Pain is controlled. What meds will you send the patient home on?
Pain Rx and Tamsulosin
*Ddx acute testicular pain (5)
- testicular torsion,
- epididymitis,
- torsion of the appendix of the testis,
- testicular tumor or
- hernia
- orchitis,
- testicular rupture
*Name 2 laboratory tests you would send for suspected epididymitis
• Urinalysis/Urine culture
• Urine nucleic acid amplification test (NAAT) for N. gonorrhoeae and C. trachomatis
*2 most common organisms in epididymitis
• Neisseria gonorrhoea
• Chlamydia trachomatis
*A treatment regimen including dose and duration for epididymitis
Ceftriaxone 250mg IM x 1 + Doxy 100mg BID x 10 days
*List 4 immediate/short term complications of foley catheter placement (for AUR)
- Post-obstruction diuresis
- Hypotension
- Hematuria
- False passage
- Urinary tract infection
*Prostatits: 4 organisms
E. coli,
Klebsiella,
Enterobacter,
Proteus, or
Pseudomonas spp.
chlamydia and gonorrhea
*Prostatits: 3 treatments
NSAIDs
Tamsulosin
Ciprofloxacin 500 mg every 12 hours (PO) x 14 days
OR
Trimethoprim-sulfamethoxazole 160/800 mg bid (PO)
*What is the definitive treatment for testicular torsion?
Bilateral orchipexy
*4 Ddx RLQ pain in 32F (not PID or torsion)
Appy
Ectopic
Nephrolithiasis
Endometriosis
*What is the MOST sensitive test to diagnose ovarian torsion (gold standard)
Diagnostic laparoscopy
*2 main causes of ovarian torsion
Most cases of torsion in this population are associated with an enlarged ovary (>5.0 cm), either secondary to benign neoplasm or cysts, as seen in ovulation induction, hyperstimulation syndrome, or polycystic ovarian syndrome.
*What is the most common ultrasound abnornmality of ovarian torsion?
Asymmetric enlargement of the ovary is the most common finding
*List 5 differential diagnoses for non-pregnant PVB
PALM—Structural Causes
P olyp
A denomyosis
L eiomyoma
M alignancy and hyperplasia
COEIN—Nonstructural Causes
C oagulopathy: vWF
O vulatory Dysfunction: (anything that disrupts the HPA axis: prolactiinoma, hypothyroid, PCOS, adrenal hyperplasia, anorexia, stress, weight loss
E ndometrial: regular ovulatory bleeding that is especially heavy
I atrogenic
N ot yet classified: infection (STI/PID), post-coital, trauma, forigen bodies, atrophic vaginitos
*5 management steps for heavy vaginal bleeding with hgb 55
Uterine packing
TXA
PRBC/massive transfusion
Correct coagulopathy
IV estrogen (25mg unconjugated estrogen)
Remove all the clots from cervix
HYsterectomy
Angiography / embolization in IR
*Who could you consult, other than gyne for management of heavy PVB?
IR Angiography / embolization
*Which ovary torts more, left or right?
Slight predominance on the right side
Right utero-ovarian ligament is longer and the sigmoid bowel on the L is protective
*Describe the pathophysiology of OHSS
- “OHSS is an iatrogenic syndrome characterized by ovarian enlargement (from multiple ovarian cysts) and fluid shifts to the extravascular space, causing:
- Ascites
- Hypovolemia
- Electrolyte abnormalities”
- Increase the thrombotic risk.
*Describe 3 clinical features of OHSS that you can see/diagnose at the bedside
Taken from UpToDate:
- Mild: Abdominal distension/discomfort, nausea/vomiting, diarrhea, enlarged ovaries
- Moderate: Mild features plus ultrasonographic evidence of ascites
- Severe: Mild plus moderate features, plus clinical evidence of ascites, severe abdominal pain, intractable nausea/vomiting, rapid weight gain, pleural effusion, severe dyspnea, oliguria/anuria, hypotension, syncope, venous thrombosis
*List 4 differential diagnoses for a patient with pelvic pain who is undergoing fertility treatment
- Ectopic pregnancy
- Ovarian hyperstimulation syndrome
- Ovarian torsion
- Ovarian cyst
- Pelvic inflammatory disease/infection (e.g. post egg retrieval)
- Uterine perforation
Think drugs, retrival and then ectopic
*Acute heavy PVB on chronic with hgb 55. 4 Tx in ED.
- Blood transfusion
- IV TXA
- IV estrogen (Premarin)
- IV ketorolac
*What are secondary options for treatment refractory AUB?
Intrauterine balloon cath
Gyne for dilation and curettage, uterine artery embolization, or hysterectomy
List 10 gyne causes of pelvic pain in the non pregnant patient
Ovarian: torsion, cyst, tubo-ovarian abscess, ovarian hyperstimulation syndrome
Infectious: PID, salpingitis
Uterine: endometritis, endometriosis, fibroids, uterine perforation, dysmenorrhea, cancer
List 7 causes of pelvic pain in the pregnant patient
First trimester: ectopic, threatened abortion, non viable pregnancy, ovarian hyperstimulation syndrome
Second and third trimester: placenta previa, placental abruption, labour, Braxton-hicks, round ligament pain, uterine rupture
List 10 non-gyne causes of pelvic pain
GI: appendicitis, diverticulitis, ischemic bowel, perforated viscus, bowel obstruction, incarcerated/strangulated hernia, fecal impaction, IBD, IBS, gastro
GU: pyelonephritis, cystitis, kidney stone
Vascular: septic pelvic thrombosis, ovarian venous thrombosis, sickle cell, pelvic congestion
MSK: muscular strain, hernia, hematoma, pelvic fracture
Neuro: depression, sexual abuse, herpes zoster, abdominal migraine
What is an AKI
Increase in serum creatinine >1.5x baseline within the last 7 days or
UO <0.5 ml/kg/hr x 6 hours
List 10 clinical features of AKI
Cardiovascular: pulmonary edema, hypertension, arrhythmia, pericarditis, pericardial effusion, myocardial effusion, pulmonary embolism
Metabolic: hyponatremia, hyperkalemia, hypermagnesemia, hypocalcemia, hyperphosphatemia, hyperuricemia
Neurologic: asterixis, mental status changes, somnolence, coma, seizures
GI: nausea, vomiting, gastritis, pancreatitis, GI bleeding
Hematologic: anemia, bleeding disorders
Infections
List 5 etiologies of pre-renal failure
Low volume: GI losses, blood losses, insensible losses, third spacing (pancreatitis, burns)
Decreased cardiac output: MI, valvular disease, cardiomyopathy
Disordered regulation of pre-renal blood flow: NSAIDs, ACE/ARBs, cyclosporine, tacrolimus
List 4 lab findings that suggest pre-renal failure
High BUN: creatinine ratio (10:1-20:1)
Increased urine osmolarity >500 and increased specific gravity >1.020
Decreased urine sodium <20 mEq with decreased FENA <1%
List 5 etiologies of post-renal failure
Intrarenal and ureteral: kidney stones, malignancy, crystal precipitation (uric acid, oxalic acid), drug precipitation (methotrexate, acyclovir)
Bladder: kidney stones, blood clots, prostatic hypertrophy, bladder carcinoma, neurogenic bladder
Urethra: phimosis, stricture
Neurogenic
List 4 main types of intrarenal failure
Vascular, glomerular, interstitial, tubular
Describe 5 etiologies and 3 clinical findings of glomerulonephritis
Post infectious (strep, HIV, hepatitis), autoimmune (HSP, HUS, Lupus, Berger’s, Goodpasture’s)
Hematuria, proteinuria, red cell cast
Describe 5 etiologies of vascular renal failure
Large vessel: renal artery thrombosis, embolism, sickle cell
Small vessel: vasculitis, scleroderma, malignant hypertension, HUS, TTP, HIV
Describe 5 etiologies and 3 clinical findings of acute interstitial nephritis
Immune/allergic mediated kidney injury. Etiologies:
Drugs: antibiotics esp penicillins, NSAIDs (this is different than being nephrotoxic)
Infection
Systemic disease: sarcoidosis, lupus
Presents with fever, rash, eosinophilia (generally no oliguria; not a volume problem)
Describe 5 etiologies and 3 clinical findings of ATN
Injury to the renal tubules, generally a diagnosis of exclusion. Etiologies:
Ischemia: pre-renal shock, sepsis, heat stroke, post op
Nephrotoxins: contrast, antibiotics (esp aminoglycosides), rhabdomyolysis
Hypotension, FENA >1%, Urine sodium high (unlike in pre-renal), granular cast
Patient presents with AKI and hypovolemia. How would you distinguish prerenal from ATN
Prerenal: decreased urine sodium, FENA <1%
ATN: increased urine sodium, FENA >1%
Identify the pathology associated with each of the following:
1. +ve dipstick for blood but no RBCs
2. Red cell casts
3. White cell casts
4. Granular casts
5. Hyaline casts
6. Fatty casts
7. Eosinophil casts
- Pigment ex. myoglobin
- Glomerulonephritis, vasculitis
- AIN, renal parenchymal inflammation
- ATN
- Pre-renal (dehydration)
- Nephrotic syndrome
- AIN
List 5 complications of uremia
Uremic encephalopathy, pericarditis +/- pericardial effusion, pulmonary edema, rash (uremic frost, pruritus), decreased immune response, nausea/vomiting
Patient with chronic kidney disease on dialysis develops confusion. List 4 etiologies
Uremic encephalopathy, dialysis dementia, disequilibrium syndrome, electrolyte abnormalities, stroke, SDH (X10 more frequent)
Patient with chronic kidney disease on dialysis develops hypotension. List 4 etiologies
Hypovolemia, excessive fluid removal, hemorrhage, cardiogenic shock, dysrhythmia, pericardial tamponade, MI, anaphylactoid reaction, air embolism
Patient with chronic kidney disease on dialysis develops SOB. List 4 etiologies
Pulmonary edema, MI, CHF, PE
Patient with chronic kidney disease on dialysis pain at their fistula site. List 4 etiologies
Thrombosis, infection, rupture, steal syndrome (vascular insufficiency), bleeding, aneurysm/pseudoaneurysm
List 4 metabolic abnormalities associated with kidney disease
Hyperkalemia, hypermagnesemia, hypocalcemia, hyponatremia, hyperphosphatemia, hyperuricemia, acidosis
List 5 indications for dialysis
AEIOU: acidosis, electrolytes (hyperkalemia), intoxications, volume overload (ex. pulmonary edema or malignant hypertension), uremia
What are the diagnostic criteria for peritonitis in a patient who receives peritoneal dialysis
WBC >100 with 50% neutrophils
How would you treat a patient with peritonitis from peritoneal dialysis
Vancomycin 30 mg/kg IP + Ceftazidime 1g IP or Cefepime 1g IP
List 2 bacteria associated with peritonitis in peritoneal dialysis
Coagulase negative staph, streptococcus
List 6 treatable causes of acute on chronic kidney disease
Hypovolemia, CHF, hypertension, nephrotoxic agents, obstructive disease, renal artery stenosis, reflux nephropathy
Compare nephrotic vs. nephritic syndrome
Nephrotic: Loss of protein through glomerular filtration. Presents with proteinuria, low serum protein, volume overload (low oncotic pressure), high cholesterol (liver compensates for low protein by releasing cholesterol). Treated with salt restriction. Nephritic: Inflammation at the glomeruli with antibody complexes. No proteinuria, but RBCs/hematuria on urine dip ‘coca-cola’ urine (Tamm-Horsfall protein), and oliguria
List 7 differential diagnosis for genital ulcers
(Box 88.1)
Genital herpes, primary syphilis, chancroid, lymphogranuloma venereum, granuloma inguinale, trauma, neoplasm, behcet’s disease, abscess
List 7 differential diagnosis for genital discharge
(Box 88.1)
Gonorrhea, chlamydia, nongonococcal urethritis, PID, trichomoniasis, bacterial vaginosis, candida, foreign body, irritants/allergens
List 5 non GU features that suggest gonorrhea
Arthritis, tenosynovitis, pustular skin lesions, conjunctivitis, pharyngitis
What is the treatment for isolated gonorrheal infection
Ceftriaxone 500mg IM
List 1 focal complication of chlamydia
Lymphogranuloma venereum LGV
What is the treatment for isolated chlamydia
Azithromycin 1g or Doxycycline 100mg PO BID x 7 days
Describe the clinical features of a yeast infection
Thick, white, clumpy discharge with pruritus and irritation. Not an STI. Usually candida albicans. May occur after antibiotic use, estrogen use, diabetes, pregnancy, immunocompromised states
List 1 treatment option for a yeast infection
Fluconazole 150 mg PO
Describe the clinical features of trichomonas
Green, foul smelling discharge with petechiae on the cervix (strawberry cervix).
Think green on top of red strawberry but its rotten - gross
List the treatment for trichomonas
Metronidazole 500mg PO BID x 7 days
Describe the clinical features of bacterial vaginosis
Thin, gray, malodorous discharge with a “fishy” smell. Not an STI. Due to a change in lactobacillus with other polymicrobial groups
List the treatment for bacterial vaginosis and two indications for treatment
Metronidazole 500mg PO BID x 7 days; only needed before instrumentation or pregnancy
What is the bacterial responsible for syphilis
Treponema pallidum
Describe the stages of syphilis
Primary (3 weeks): painless chancre with a clean base, seronegative (only dx is by swab of the lesion)
Secondary (2-12 weeks): systemic symptoms: LAD, rash (palms and soles), flu-like illness, lymphadenopathy, alopecia, hepatitis, ocular changes. Seropositive
Tertiary: 10+ years can present with cardiac or neurological symptoms
List 10 non GU clinical manifestations of syphilis
Systemic: fever, flu-like illness, LAD
GI: hepatitis, hepatosplenomegaly
Cardiac: aortic aneurysms, aortic regurg, aoritis
Neuro: headaches, vertigo, personality changes, dementia, ataxia
Cutaneous: mucocutaneous lesions, keratitis, rash, alopecia
What is the treatment of syphilis
Benzathine penicillin 2.4 million units IM
What is the Jarisch-Herxheimer reaction
Sx worsening 24-48 hours after treatment for syphilis
What organisms is responsible for chancroid
Haemophilus Ducreyi
List 3 causes of painful genital lesions
Chancroid, HSV, Allergy, Behcet’s ulcers
List 5 causes of painless genital lesions
Syphilis, HPV, LGV, granuloma inguinale, molluscum, folliculitis
List 5 complications of pID
Sepsis, death, tubo-ovarian abscess, perihepatitis (Fitz-Hugh-Curtis)
Tubal infertility, ectopic
Chronic pain
List an inpatient treatment regime for PID
Cefoxitin 2G IV Q6h + Doxycycline 100mg PO or 12 q 12 hours + Flagyl or aminoglycoside (gentamicin) if moderate or severe
What are the 5 STDs that require mandatory reporting in Canada
Gonorrhea, chlamydia, syphilis, HIV, Hep B
List 6 consequences of HSV infection
- Vertical transmission from pregnant woman to her fetus after delivery has a high morbidity and mortality risk for the new born
- Pneumonitis
- Meningoencephalitis
- Hepatitis
- Disseminated infection
- Transverse Myelitis
Patient presents with dysuria. List 2 non UTI causes
vaginitis, non- gonococcal urethritis, STI, trauma, allergy/irritants
List 10 risk factors for the development of UTI
Female, previous UTI
Intercourse, spermicides
Anything that prolongs urinary retention: diabetes, pregnancy, older adults, incomplete emptying (ex. neurogenic bladder), prostate enlargement, obstruction
Chronic indwelling catheters
Immunosuppression
Define uncomplicated UTI
Non pregnant female with a structurally and functionally normal urinary tract
List 5 possible definitions of complicated UTI
Male, pregnant, children, elderly, anatomic abnormalities, immunocompromised, recent instrumentation, indwelling Foley, kidney stones
List 2 indications to treat asymptomatic bacteriuria
Pregnant, undering urologic procedure
List 6 possible microorganisms responsible for UTI. Which one is the most common?
KEEPPS- Klebsiella, E Coli (most common), Enterococcus, Proteus, Pseudomonas, Staph Aureus
List 2 microorganisms that present with -ve nitrates
Enterococcus, pseudomonas
List 10 indications for urine culture
Box 89.1
Patient: children, adult men, immunocompromised, pregnant women, older patients, toxic looking
PmHx: hx of chronic or recurrent UTIs, anatomic abnormalities, comorbid medical disease (diabetes, alcoholism, cancer)
Hx: treatment failure, long duration of sx, recently hospitalized, already on antibiotics, recent instrumentation
Suspicion of kidney stones
List 3 possible antibiotic treatments that can be used in uncomplicated UTI
[Hamilton ID handbook]
Septra 1 DS PO BID x 3 days
Macrobid 100mg PO BID x 5 days
Cephalexin 500mg PO QID x 5-7 DAYS
Fosfomycin 3g PO x1. Also effective for ESBL and VRE
Amox-Clav 875/125 mg PO BID x 5 days
Ciprofloxacin 500mg PO BID x 3 days
List 3 possible antibiotic treatments that can be used in complicated UTIs
“[Hamilton ID handbook]
Duration 7 days, 14 if catheter associated
Septra 1DS PO q12h 7-14 days
Cephalexin 500mg QID or Amox-Clav 875/135 mg BID 7-14 days
Ciprofloxacin 500mg BID x 7-14 days or 400 mg IV BID. First line in HIV; >40% local resistance in Hamilton”
What antibiotics would you use for suspicion of UTI + STI
Levofloxacin 500 daily x 7d (covers uropathogens, chlamydia) + ceftriaxone 500 mg IM x1 (gonorrhea)
List 3 possible antibiotic treatments in pregnancy
Amox-clav 875 mg BID for 5-7 days
Nitrofurantoin 100mg BID for 5-7 days (avoid in first trimester - risk of fetal malformations; and late pregnancy >36 weeks - risk of hemolytic anemia)
Fosfomycin 3g as a signal dose
Septra 160/800 mg PO BID for 3 days (avoid in first trimester - risk of teratogenic effects ;and late pregnancy - risk of kernicterus)
Avoid fluoroquinolones during all of pregnancy
List 2 possible antibiotic treatments for pyelonephritis; for inpatient and outpatient
[Hamilton ID handbook]
Ceftriaxone 1g IV q24h or Tobramycin 5-7 mg IV daily or Pip Tazo 3.375g q6H
Oral treatment similar to complication UTIs
List 3 complications or prostatitis
Chronic pelvic pain syndrome, prostatic abscess, urinary retention
List 10 mimics of renal colic
Serious: AAA, PE, ectopic, bowel obstruction, incarcerated hernia, renal mass, renal vein thrombosis
Most common: biliary, appendicitis, pyelonephritis, ovarian cyst, renal mass, AAA
List 4 types of kidney stones
Calcium (75%): occurs in patients w risk factors for hypersecretion
Struvite (15%): occurs in patients with UTI; bacteria precipitates urea ex. proteus. Radiolucent
Uric acid (10%): occurs in patients with gout
Cystine (1%): occurs in children due to a genetic defect that causes renal tubular absorption of amino acids
List 10 risk factors for the development of kidney stones
Box 89.2
Based on stone type
- Calcium oxalate: hyperparathyroidism, milk-alkali, hypercalcemia of malignancy, sarcoidosis, IBD, hyperuricosuria
- Struvite/magnesium: UTI, laxative abuse
- Uric: gout, hyperuricosuria, renal tubular acidosis (precipitation or uric acid is unlikely at a higher pH)
Patient: Obesity, male, white, previous kidney stones
Family history
Dehydration, hot/arid climates
Memory aid: DRY ROCKS - dehydration/hot climate/acidosis, recurrent UTI, Y chromosome, relatives with stones, odd habits (milk-alkali, laxative abuse, calcium ingestion), calcium disease (primary hyperparathyroidism, malignancy, sarcoid), kidney stones, small bowel disease (Crohns)
List 5 common site for stone obstruction
Renal calyx, ureteropelvic junction (UPJ), pelvic brim, ureterovesicular junction, vesical orifice
List 3 predictors of stone passage
Size, location, pain
List indications for hospitalization with a patient in kidney stones
Box 89.4
Absolute: obstructing septic stone, intractable N/V, severe pain requiring IV analgesia, urinary extravasation, hypercalcemic crisis
Relative: significant comorbidities, high grade obstruction leukocytosis, solitary kidney or renal disease, psycho social factors affecting home management
List 4 indications for imaging a patient with renal colic
Atypical signs/symptoms, hx of solitary or transplanted kidney, toxic, high grade obstruction [Rosens]
Generally image first time presenters, sepsis, searching for alternative diagnosis, no improvement with initial treatment
List 5 differentials for painful scrotal swelling
Torsion, appendage torsion, epididymitis, orchitis, trauma (rupture), strangulated hernia
List 5 differentials for painless scrotal swelling
Tumor, hydrocele, varicocele, spermatocele, cyst, hernia, scrotal edema (CHF, cirrhosis)
List 2 differentials for scrotal swelling in each of the following age groups: infant, child, adolescent, adult
Infant: hernia, hydrocele
Child: torsion, epididymitis, hernia
Adolescent: epididymitis, torsion, trauma
Adult: epididymitis, hernia, tumor, trauma, torsion, Fournier’s gangrene
List 2 possible treatment strategies for epididymitis
If STI suspected: CTX 500 mg IM, doxycycline 100mg PO BID x 10 days
if UTI suspected: levofloxacin 500 mg PO OD x 10 days
List 3 viral causes of orchitis and associated treatment
Mumps, coxsackie, varicella
Treated with supportive care; NSAIDs, elevation with ice
What is a hydrocele
Collection of fluid in the tunica vaginalism. Transilluminates. May be reactive or congenital. May be communicating (generally needs surgery) or non communicating (most regress spontaneously)
What is a varicocele
Dilated veins in the pampiniform plexus due to incomplete drainage. “Bag of worms” texture
List two false negatives and one false positive of ultrasound for torsion
False negative: early in disease course (blood flow is present), intermittent torsion, partial torsion (venous but not arterial occlusion)
False positive: young boys with physiologically low flow
List 10 etiologies for hematuria
Cancer: bladder cancer, renal cell carcinoma, Wilms tumor (pediatric)
Glomerulonephritis: IgA nephropathy, post infectious, vasculitis (Berger’s), lupus nephritis, HUS, HSP
Trauma: exercise induced, Foley, stricture
Heme: coagulopathy, sickle cell disease
Kidney Stones
Infection: UTI, STI, diverticulosis, or post-strep infection
Structural abnormalities: polycystic kidney disease, AVM, thromboembolism, polyps, BPH, AAA
List 3 etiologies of hematuria suspected in children
GN disease, infection, obstruction, malignancy
List 10 causes of non RBC red urine
Hemoglobinuria, myoglobinuria (rhabdo)
- Dipstick positive but UA negative
Beets, berries, rhubarb, food colour
Drugs: sulfa drugs, nitrofurantoin, rifampin, chloroquine, hydroxychloroquine, iodine, bromide
List 7 risk factors for urologic cancer
age, male sex, smoking, family history of bladder cancer, occupational exposures to the chemical industry (chemicals or dyes), chronic urinary infection, chronic indwelling foreign body, pelvic irradiation
Which type of ovarian cyst is more often hemorrhagic
Corpus luteal
List 5 types of ovarian cysts
Follicular, corpus luteal, dermoid, fibroma, endometrioma
List 5 risk factors for ovarian torsion
Presence of ovarian mass/cyst, Infertility treatment (ovulation induction , hyperstimulation syndrome ), Benign Ovarian tumor, Enlarged ovary >0.5 cm in size, PCOS
List 5 ultrasound findings in ovarian torsion
Box 90.1 - Large ovary (most common), associated ovarian mass, loss of enhancement, edema, pelvic free fluid, loss of venous waveforms, loss of arterial waveforms
Not in [Box 90.1] but listed in text of Rosens: heterogenous stroma (due to edema), peripherally displaced follicles, twisting of the pedicle (whirlpool sign)
List 5 CT findings in ovarian torsion
Box 901. - Enlargement of the ovary, associated ovarian mass, edema, pelvic free fluid, thickening of the fallopian tube, deviation of the uterus to the affected side, associated hemorrhage
List 4 causes of pre-menstrual vaginal bleeding
Assault, infection (STI), foreign body, coagulopathy, trauma (straddle injury), perimenarchal, precocious puberty, PCOS
List 5 risk factors associated with endometrial cancer
Anything that causes more menstrual cycles: early menarche, late menopause, anovulatory cycles, nulliparity. Age >55, obesity, DM, metabolic syndrome
What endometrial thickening is considered abnormal
> 4.5mm; needs referral
List 3 medications that can be prescribed for abnormal uterine bleeding
NSAIDs, TXA, OCP
List 4 types of emergency contraception
Levonorgestrel (Plan B) 1.5mg PO: effective up to 72 hours, over the counter
Ulipristal acetate (Ella) 30mg PO: effective up to 120 hours, needs prescription
Copper IUD
Combined OCP: no longer commonly used
