Urogenital complaints and Opthomology (320-331) (431-451) Flashcards
Under what 3 situations are UTIs most common?
Sexually active young women, elderly and posturethral catheter
Whats the most common causative bacteria
E.coli and gram negatives
main sx of uti?
dysuria
Main sx of pyelonephritis
back/flank pain
How to dx a UTI?
UA and reflex to culture - pyuria and + bacteria Gram stain
What follow up must be done on adolescents and men with pyelonephritis or recurrent infection?
Renal US and IVP to r/o anatomic etiology
How long does a pt with bacterial prostatitis need to be on antibiotics?
6-12 weeks for chronic
2 weeks for acute
What is the definition of asx bacteriuria
Urine culture >100,000 colony forming units
What patient populations should you treat asx bacteriuria?
- pregnant women
- pts with renal transplant
- about to undergo genitourinary procedure
- severe vesicouretral reflux
- struvite calculi
What is most common mode of transmission of AIDS worldwide?in USA?
heterosexual worldwide
homosexual USA
What genetic mutation makes pts highly resistant to HIV transmission?
CCR5 homozygous deletion
At what CD4 copunt do opportunic infections usually arise?
What should pts be put on when CD4
TMP-SMX to prophylax against PCP and toxoplasma encephalitis
Pt with painful vesicular and ulcerated lesions that resolve over 7 days. How to confirm dx?
direct flourescent antigen (DFA) staining. Tzank prep, serology, HSV, PCR, or culture
Risk of _____ increases 7-10x in women with hx of salpingitis
ectopic pregnancy
What antibiotics should be used on pts with PID?
azithromycin
flouroquinilone + metronidazole
cephalosporin + doxy
Pt presents with painless papule that erodes into a painless ulcer accompanied by tender, swollen lymph nodes causing groove in the inguinal ligament (groove sign) Dx? Etiology?
Lymphogranuloma venereum (serovars L1-L3) Chlamidya trachomatis
Pt from underdeveloped country presents w painful ulcer accompanied by painful swollen lymph nodes which suppurate and cause destructive changes in the groin. Dx? Etiology? Tx?
Chancroid
Haemophilus ducreyi
Macrolide, doxycycline and cephalosporin
Pt from underdeveloped country presents with painless nodules which over time slough off exposing large ulcers which spread and cause extensive destructive changes in the groin.
Biopsy shows purple oval forms inside macrophages which strain purple with Wright stain. Dx? Tx?
Granuloma inguinale (Donovaniasis)
Tx: Macrolide or doxy
What prophylaxis should pts receive if CD4
azithromycin for Mycobacterium avium intracellulare complex (MAC)
When should HAART therapy be started? (3 active antiviral agents)
If pt’s have symptoms related to HIV infection or if pt’s CD4
Painless hematuria DDx?
Primary renal disease (tumor, glomerulonephritis)
bladder tumor
prostatic dz
Painful hematuria DDx?
nephrolithiasis, renal infarction, UTI
What is the term when hemoglobin is detected in UA but theres no RBCs on microanalysis?
myoglobinuria or hemoglobinuria
When should you do cystoscopy?
only after UA and IVP
After what age is BPH common
> 45, 90% men older than 70 have BPH
What are the 3 criteria of BPH?
prostate size > 30mL
maximmum urinary flow rate 50
When is TURP indicated?
Refractory disease
For prostate glands >75g, what is the reccomendation?
Open prostatectomy
Pt presents with fevers, chills, low back pain, urinary frequency, and urgency, tender possible fluctuant and swollen prostate,.
Labs show leukocytosis, pyruia and bacteriuria.
Dx? Tx?
Prostatitis, dx made clinically
Tx: fluoroquinolone or TMP-SMX
What is the most common ca in males and second most common cause of ca death?
prostate cancer. First MCC death is lung ca
PSA sensitive or specific?
sensitive. PSA is elevated in 90% of prostate adeno CA but, controversy over screening tool
Where does prostate ca often metastasize?
via lymph/ blood causing osteoblastic lesions
What is the primary cause of impotence
erectile dysfunction due to... psychological decreaased testosterone hypo/hyperthyroid Cushings syndrome Increased prolactin
What are some causes for secondary erectile dysfunction
vascular dz
Drugs
Neurologic dz
**How can you differentiate psychogenic from organic causes of erectile dysfunction
nocturnal penile tumescence
What is the mechanism of action of Sildenafil, tadalafil, Vardenafil etc?
Cyclic GMP-specific PDE5 inhibitor which improves relaxation of smooth muscles in corpora cavernosum
What is an absolute contraindication to PDE5 inhibitors?
Use of nitrates
Decreased vision secondary to fafilure of development of the pathway between the retina and visual cortex before ages 7-11
ambylopia
What sx might a person with ambylopia have
Esotropia (inward rotation of eyes)
exotropia ( outwardly rotated walled eyes)
Refractive error not correctable with lenses
Unable to see in bilateral temporal fields usually caused by a pituitary tumor
bitemporal hemianopsia
Lesion of the medial longitudinnal fasciculus classically found in multiple sclerosis
internuclear opthalmoplegia
What is the defecit caused by internuclear opthalmoplegia?Why?
inability to adduct the ipsilateral eye past midline on lateral conjugate gaze
lack of communication between the contralateral cn Vi nucleus and ipsilateral CNIII nucleus
Midbrain tectum lesion that results in paralysis of upward gaze and is associated with pineal tumor
Parinaud’s syndrome
Afferent defect of cn ii causing pupil not to react to direct light, but will react consensually when light is shined into contralateral eye
Marcus Gunn Pupil
How to test marcus gun pupil?
swinging flashlight test - denervated eye will appear to dilate when light is shone in because it is dilating back to baseline when consensual light is removed from other eye
pathognomonic for tertiary syphilis (neurosyphilis
Argyll Robertson pupil (pupils constrict with accomodation but do not constrict to direct light stimulation)
upward lens dislocation
Marfans
downward lens dislocation
homocystinuria
variable lens dislocation
Alport’s syndrome
Ring of golden pigment around the iris
Kayser Fleisher Ring
Fleshy growth from conjunctiva onto nasal side of cornea associated with exposure to wind, sand, sun, dust etc
Pteryguim
Benign yellowish nodules on either side of the cornea seen in pts >35, may have foreign body sensation in eye
Pinguecula
Spontaneous onset of a painless right red patch on the sclera - benign self limited condition usually seen after over exertion
Subconjunctivial hemorrhage
If you see subconjunctival hemorrhage in setting of trauma, what must be done?
r/o ruptured globe
Rapid loss of vision and pain upon mocing the eye, spontaneously remitting in 2-8 weeks, but each relapse damages more of the eye. Caused by inflammation of the optic nerve, usually unilateral.+APD. Dx? Tx? What is the first sign of?
Retrobulbar neuritis
tx - corticcosteroids
1st sign of multiple sclerosis
Inflammation of the optic nerve within the eye, can be caused by infection, meningitis, syphillis, tumor. variable vision loss and decreased pupillary light reflex. +Affarent pupillary defect if unilateral. Dx? Tx?
optic neuritis
Tx corticosteroids
What does the fundoscopic exam look like in pt with optic neuritis?
disk hyperemia
Inflammation of the internal meiobomian sebaceous gland that presents with swelling on conjunctival surface of eyelid. Dx? Tx?
Chalazion
tx: warm compress/steroid ointment
Infection of the external sebaceous glands of Zeiss or Mol that presents with tender red swelling at lid margin. Dx? tx?
Hordeolum (stye)
Tx: hot compress add antibiotics
Inflammation of the eyelids and eyelashes resulting from infection ususally S. aureus, or secondary to seborrhea. Presents as red, swollen eyelid margins with dry flakes noted on eyelashes. Dx? Tx?
Blepharitis.
Tx: Wash lid margins daily with baby shampoo control scalp seborrhea with shampoo
Marked swelling and erythema of the eye often with proptosis, decreased vision, limited eye movement. Can spread to cavernous sinus leading to thrombosis and meningitis. Dx? Tx?
Oribital cellulitis
Tx emergently with IV vancomycin, + 3rd gen cephalosporin, CT scan to r/o abscess
How do you differentiate pre septal and oribital cellulitis?
Pre-septal cellulitis will not have changes in vision or limited eye moment.
Infection of the lacrimal sac, usually caused by S.aureus, s. pneumo, h. influe, or s. pyogenes
Dacryocystitis
What is the differential Dx for Red eye?
Bacterial conjunctivitis Viral conjunctivitis Allergic conjunctivitis Hyphema Xerophthalmia Corneal abrasion Keratitis Uveitis Angle closure glaucoma Subconjunctival hemorrhage
Pt with minimal pain, no vision changes, has red eye
PURULENT discharge, no pupillary changes
RaRELY pre-auricular adenopathy (only N.gono)Dx? Tx?
Bacterial conjunctivitis
Topical flouroquinolone or erythromycin
Pt with minimal pain, no vision changes, red eye WATERY discharge, no pupillary changes Often pre-auricular adenopathy Often pharyngitis Dx? causes? Tx?
viral conjunctivitis
Causes: adnovirus, HSV, EBC, influenza, echovirus, coxsackie
Tx: None required,self-limited
No pain, vision, or pupil changes. red eye
marked pruritis
Bilaterla WaTERY eyes
dx? Tx?
Allergic conjunctivitis
Antihistamine or steroid drops
Blood in anterior chamber of the eye, fluid level noted. Pain, no vision changes, red eye noted,
No discharge, no pupil changes Dx? Cause? Tx?
Hyphema
caused by blunt ocular trauma
Tx: check intraocular pressure
Minimal pain, vision blurry, no pupillary changes no discharge. Bitot’s spots and keratoconjunctivitis sicca seen. dx? causes? tx?
Xerophthalmia
Causes: Sjogren’s dz or vitamin a defeciency
Tx artificial tears, vitamin A
What are bitot spots?
desquamated conjunctival cells seen in Xerophthalmia
How do you diagnose Keratoconjunctivitis sicca seen in Sjrogen’s?
Schirmer test - place filter paper over eyelid and if not wet in 15 mins, Dx.
Painful, with photophobia red eye.
No puil changes, watery discharge. flourescein stain shows corneal defect…dx? Tx?
Corneal abrasion
Caused by direct trauma to eye
Tx: antibiotics, eye back, examine daily
Pain, photophobia, tearing DeCREASED VIsiOn.
Flourescein stain shows dendritic branching. Pus in anterior chamber (hypopyon - grave sign). Dx? Cause? Tx
Keratitis
caused by Herpes simplex , but can be caused by adenovirus, HsV, pseudomonas, s. pneumo, staph, moraxella.
Tx: emergency immediate opthalmology consult and topical vidarabine
Inflammation of the iris, ciliary body, and/or choroid
Pain, miosis, photophobia
Flare and cells seen on aqueous humor on slit lamp examination. Dx? Causes? Tx?
Uveitis
Seen in seronegative spondyloarthropathy, IBD, sarcoidosis or infection (cmv, syphillis, TB)
Tx: underlying disease
Severe eye pain, red eye, decreased vision, halos around lights, fixed mid-dilated pupil, eyeball firm to pressure and vomiting. Dx? Cause? Tx?
Acute closure glaucoma
decreased aqueous humor outflow via canal of Schlemm - mydriatics can also cause
Tx: EMERGENCY - IV mannitol and glaucoma acetazolamide, laser iridotomy, timolol bromonidine
Spontaneous onset of painless bright red patch caused by rupture of episcleral vessel. Dx? Cause? Tx?
Subconjunctival hemorrhage
overexertion, valsalva, or trauma Can also be seen in pts with uncontrolled HTN
Tx: self limited, check blood pressure
Yellow eye (icterus) caused by
bilirubin staining the sclera
yellow vision seen in what drug toxicity?
digoxin
Blue vision due to what drug use?
Viagra
Blue sclera seen in what 2 dz?
Osteogenesis imperfecta
OR
Marfans
Opaque Eye DDx
Cataracts Tumor Glaucoma congenital Diabetes- sorbital precipitation Hurler's disease
If child has opaque eye, what to r/o?
Retinoblastoma
Defect in iduronidase causing multiorgan mucopolysaccaride accumulation, dwarfism, hepatosplenomegaly, corenal clouding, progressive mental retardation, death by age 10
Hurler’s disease
How long after diabetes does retinopathy occur?
about 10 years
What is the best predictor of diabetic retinopathy?
direct correlation of A1c
What are the 2 types diabetic retinopathy?
Background type
Proliferative type
What does the retina look like in background type retinopathy? tx?
Flame hemorrhages, microaneurysms and hard/soft exudates (cotton-wool spots) on retina
tx: strict glucose and HTN control
What does the retina look like in proliferative type diabetic retinopathy? tx?
More advanced dz, with neovascularization easily visible around the fundus (hyperemia) and hard exudates.
Tx: photocoagulation (laser ablation of blood vessels in the retinal) which slows the progression but is not curative.
Painless loss of visual acuity and presents with altered pigmentation in the macula. Pt retains peripheral vision. Dx? tx?
Age related macular degeneration
antioxidants, and anti-VEGF
Presents with painless dark vitreous floaters, flashes of light (photopsias), blurry vision, eventually progressing to a cutain of blindness as it worsens. dx? Tx?
Retinal detachment
Tx urgent opthamology consult
Slowly progressive defect in night vision (often starts in young children) with ring shaped scotoma (blind spot) that gradually increases in size to obscure more vision. Dx? Cause? What syndrome is this part of? Tx?
Retinitis Pigmentosa
Hereditary, not clcear
part of Laurence-Moon-Biedl syndrome
No Tx
Absent red reflex, actually appears white seen in retinoblastoma
Leukocoria
small hemorrhagic spots with central clearing associated with endocarditis
Roth Spots
Copper wiring, flame hemorrhages, AV nicking seen in what?
subacute HTN and/or arthrosclerosis
_______ appears as disk hyperemia, blurring, and elevation. associated with increased intracranial pressure
Papilledema
________ neovascularization seen in sickle cell anemia
Sea Fan
______ Seen on retina during retinal detachment
Wrinkles
_________ seen on macula seen in Tay Sachs, Niemann pick dz and central renal artery occlusion
Cherry red spot macula
Yellow cholesterol emboli in retinal artery
Hollenhorst plaque
Brown raised macule on the retina
Malignant melanoma (MC intraocular tumor in adults)
Read about glaucoma p 444
open vs closed glaucoma?
What is the most common adult orbital tumor?
cavernous hemangioma - large well circumscribed vascular tumor (proptosis of the eye)
From where do most of the metastases to the oribit come from?
breast, lung, prostate
What kind of orbital tumors show a spectrum from benign reactive lymphoid hyperplasia to lymphoma in older pts?
Lymphoid tumors
Mesenchymal orbital tumor
fibrous hystiocytoma
cystic mass of sinuses caused by duct obstruction, frontal and ethmoid sinuses most commonly involves.
Mucocele
Bony tumor -orbital
fiberous dysplasia
Tumor of the peripheral nerve seen in neurofibromatosis
schwannoma
what’s the most common orbital tumor in children (vascular)? Dx? tx?
capillary hemangioma
tx: beta blockers
benign cystic mass with connective tissue and skin appendages (hair, sebaceous glands)
Dermoid cyst
What is the most common orbital malignancy in children?
rhabdomyosarcoma
tumor of early childhood with large lymph channels, often have hemorrhage
lymphangioma
Most common metastatic tumor in children, ecchymosis with proptosis
neuroblastoma
what is the gold standard for imaging orbit esp for foreign body?
CT scan, never MRI bc magnet might move object if it’s metallic.
Review p 448- 451
eye-related trauma and opthalmic medications
