Royal College: Emergency Medicine > GU & Gyne System > Flashcards

GU & Gyne System Flashcards

This deck covers Chapters 87-90 in Rosens, comprising all of urology and gynecology. (53 cards)

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1
Q

List EIGHT intrinsic renal diseases that can result in AKI.

A
  1. ATN
  2. AIN
  3. RTA
  4. HIV
  5. HSP
  6. SLE
  7. HUS
  8. Goodpasture’s
  9. PSGN
  10. Wegeners
  11. PAN
  12. Nephrotic
  13. Scleroderma
  14. Toxins
  15. Multiple myeloma
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2
Q

A peritoneal dialysis patient presents complaining of abdominal pain – he has diffuse tenderness on exam. You aspirate peritoneal fluid from his access site. How is the diagnosis of PD-related peritonitis made? What is the treatment?

A

Diagnosis

  • 2+ of:
  • Clinical features of peritonitis
  • Fluid WBC >100 (after dwell time of 2h) w/ 50% PMN
  • Culture positive

Treatment

  • Cefazolin 1g IP OD or Vancomycin 30 mg/kg IP and
  • Gentamicin 0.6 mg/kg IP OD or Ceftazidime 1 g IP OD
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3
Q

What 8 special groups might you consider getting a urine culture in?

A
  1. Young
  2. Old
  3. Men
  4. Immunocompromised
  5. On antibiotics
  6. Failed treatment UTI
  7. Patient seems sick
  8. Pregnancy
  9. Recurrent pyelonephritis
  10. Known anatomic issues (eg. solitary kidney)
  11. Serious comorbidities
  12. Recent instrumentation (Foley, scope)
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4
Q

Define AKI. Describe how AKI can be categorized using the RIFLE system & AKIN system.

A

RIFLE

  • Risk: Creat 1.5x , GFR down 25%+, UO <0.5cc/kg
  • Injury: Creat 2x, GFR down 50%+, UO <0.5cc/kg
  • Failure: Creat 3x or >350, GFR down 75%+, UO <0.3 cc/kg
  • Loss: 4 weeks
  • ESRD: 3 months

AKIN

  • I: creat 1.5-2x baseline, UO <0.5cc/kg
  • II: creatinine 2-3x baseline
  • III: 3x baseline
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5
Q

List 5 U/S findings and 5 CT findings of ovarian torsion.

A

U/S

  1. Edema
  2. Fluid
  3. Enlarged
  4. Loss of venous and arterial waveforms
  5. Whirlpool

CT

  1. Enlarged
  2. Thickened tube
  3. Fluid
  4. Hemorrhage
  5. Masses
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6
Q

List FIVE causes of non-traumatic hematuria.

A
  1. UTI
  2. Renal colic
  3. AVM
  4. GU tumour
  5. Vasculitis
  6. PSGN
  7. Blood thinners
  8. HSP
  9. Goodpastures
  10. SLE
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7
Q

A patient with ESRD on HD presents with hypotension. List SIX possible causes.

A
  1. Hyperkalemia
  2. Sepsis
  3. CHF
  4. Over-dialysed
  5. Dehydration
  6. Ischaemia
  7. Electrolyte abnormalities
  8. Anaphylaxis
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8
Q

A woman presents within 72 hours following sexual who wants emergency contraception. What are you going to prescribe? What patient population might it be less effective in?

A

Emergency Contraception

  • Copper IUD
  • Levonorgestrel (Plan B)
  • Take 0.75 mg q12hr x 2 or 1.5 mg x1
  • Will feel sick from high doses
  • ~89% effective
  • LESS EFFECTIVE in obese patients
  • Should be taken < 24hrs but can be given up to 72 hrs after intercourse
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9
Q

How do you manage a stable abnormal uterine bleed in a patient who is not pregnant?

A

Does the patient want to get pregnant?

  • NSAIDS during menses and TXA

Does the patient not want to get pregnant?

  • OCP - containing at least 20 mcg of estradiol
  • Assuming no contraindications
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10
Q

What is the critical size for the passage of kidney stones?

A

<5 mm (90% passage rate)

5-10 mm (15% - 40% passage rate)

>10 mm (need a urologist)

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11
Q

List 8 causes of low flow priapism.

A
  1. Injections: PGE1
  2. Drugs: vasodilators: eg. sildenafil, CCB
  3. Psych drugs: Trazodone, SSRI
  4. Anticoagulants
  5. Cocaine, Marijuana
  6. Testosterone
  7. Anemia, Leukemia, Sickle Cell
  8. Gout
  9. Carbon monoxide
  10. Black Widow spider venom
  11. Spinal cord injury
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12
Q

According to the Public Health Agency of Canada (PHAC), what are the diagnostic criteria for PID?

A

Minimum

  • Lower abdominal tenderness
  • Cervical motion tenderness (CMT)
  • Adnexal tenderness

Supporting the diagnosis

  • Temperature > 38.3 °C
  • WBCs on vaginal secretion wet mount or Gram stain
  • Elevated ESR or CRP
  • Positive test for Neisseria gonorrhoeae or Chlamydia trachomatis

Definitive

  • Ultrasound showing tubo-ovarian abscess or tubal thickening
  • Endometrial biopsy showing endometritis
  • Laparoscopy (gold standard) showing tubal erythema, edema, or mucopurulent exudate
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13
Q

List 6 causes of an acute painful scrotum.

A
  1. Torsion
  2. Epididymitis
  3. Torsion of appendix teste
  4. Neoplasm
  5. Trauma
  6. Orchitis
  7. Hernia
  8. Fournier’s
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14
Q

What should you assume for a > 20-week pregnant woman with a PV bleed? What should you not do? What should you do?

A
  • Assume it’s a placental previa
  • Do not do a speculum exam
  • Get an ultrasound
  • Give RhoGam if Rh-
  • Discuss with Obstetrics
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15
Q

In general, what are 6 contraindications to OCP therapy?

A
  1. Pregnant
  2. Undiagnosed uterine bleed
  3. Thromboembolic disease
    * History of or current DVT/PE
    * History of Factor V Leiden, Protein S/C def, APLS
  4. Cerebrovascular disease
  5. CAD
  6. CV disorders
  7. Uncontrolled HTN
  8. Estrogen dependent tumors – breast, uterus
  9. Impaired liver function
  10. Age >35 and smoker
  11. DM with evidence of end-organ damage
  12. SLE with AP antibodies
  13. Migraine with focal neuro symptoms
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16
Q

List 3 sites of narrowing in the ureters where stones are most likely to get stuck.

A
  1. Pelviureteric junction (PUJ) - at kidney
  2. As ureter crosses the common iliac artery bifurcation
  3. Vesicoureteric junction (VUJ) - at bladder
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17
Q

Define pelvic inflammatory disease (PID). What are 3 etiologic agents? What are 4 risk factors for PID?

A

PID

  • Upper GU infection
  • Endometritis
  • Salpingitis
  • Peritonitis
  • Tubo-ovarian abscess

Etiology

  • N. gonorrhea
  • C. trachomatis
  • Mycoplasma

Risk Factors

  • Young age
  • Multiple sexual partners
  • Smoking
  • Menses
  • IUD (only in 1st 3 weeks after insertion)
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18
Q

List 3 absolute and 4 relative indications for hospital admission for urolithiasis.

A

Absolute

  1. Intractable Pain
  2. Urinary Extravasation
  3. Hypercalcemic crisis
  4. Septic Stone

Relative

  1. Transplant
  2. Solitary kidney
  3. ++ WBC
  4. High grade obstruction
  5. Psychosocial factors
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19
Q

List 5 indications for emergency dialysis.

A

AEIOU

  • Acidosis
  • Electrolyte abnormalities
  • Ingestions
  • Overload
  • Uremia
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20
Q

According to PHAC (Canadian Guidelines), what are SIX criteria for hospitalization for PID patients?

A
  1. Failed outpatient treatment
  2. Pregnant
  3. Hemodynamically unstable/high fever/severe
  4. Tuboovarian abscess
  5. Unable to tolerate PO
  6. Social (HIV/Youth/At-risk group)
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21
Q

Provide a 6-item DDX for altered mental status in dialysis patients.

A

DIMES

  • Drugs
  • Interactions
  • Infection
  • Sepsis
  • Metabolic
  • Dialysis dysequilibrium syndrome
  • Electrolyte
  • Uremic encephalopathy
  • Electrolyte derangement
  • Structure
  • Brain bleed

Dialysis Dysequilibrium Syndrome

  • Headache, n/v
  • Muscle cramps, malaise
  • Seizures
  • Due to rapid changes in lytes/fluids post-dialysis
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22
Q

List FIVE causes of heme pigment-induced AKI.

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A

Muscle Breakdown or Hemolysis

  1. Rhabdomyolysis
  2. Compartment syndrome
  3. Trauma
  4. Burns
  5. Myositis
  6. Tissue damage
  7. Valves
  8. Malaria
23
Q

What are the 4 major types of kidney stones?

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A
  1. Calcium oxalate – 75%
    * Hyperexcretion of calcium = major contributor
    * Ingesting large quantities of milk, hyperPTH, PUD
    * Also influenced by diet, IBD, radiation enteritis
    * DDx: ethylene glycol poisoning
  2. Magnesium-ammonium-phosphate (struvite) – 15%
    * Due to UTIs with urea-splitting organisms – Proteus, Providencia, Klebsiella, Pseudomonas, Staph (KPS)
    * Can form staghorn calculi
  3. Uric acid – 10%
    * Occurs with symptomatic gout – uric acid in urine
    * Stones are radiolucent
  4. Cysteine – rare
    * Caused by inborn errors of metabolism
    * Forms staghorns
24
Q

What are the FOUR indications for imaging in peds with UTI?

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A
  1. Children <2 yo with a first febrile UTI
  2. Children with recurrent febrile UTIs
  3. Children with FHx of GU disease, poor growth, or HTN
  4. Children who do not respond to ABx
25
What are FOUR mechanisms of **drug-induced renal failure**?
1. **Intravascular volume depletion** * Lasix 2. **Decreased renal perfusion** * ACEi/ARB inhibit efferent renal arteriolar vasoconstriction 3. **Increased catabolism** * Tetracycline 4. **ATN** * Contrast 5. **AIN** * Penicillins 6. **Inhibition of renal PG synthesis** * NSAIDs inhibit PG and cause vasoconstriction of the afferent renal arteriole
26
Provide a DDx for **abnormal uterine bleeding** (List 10).
**PALMCOINE** * **P**olyps * **A**denomyosis * **L**eiomyomas * **M**alignancy * **C**oagulopathy * **O**vulatory * **I**atrogenic (IUD, OCP) * **N**ot yet classified * **E**ndometrial
27
List 8 risk factors for **urolithiasis**.
1. Hypercalcemia 2. Dehydration 3. Crohn's 4. Hyperuricemia/Gout 5. Family history 6. Sarcoid 7. Recurrent UTI 8. White men
28
List FIVE causes of **postrenal AKI**.
1. BPH 2. Tumour 3. Neurological dysfunction 4. Obstructing stones 5. Clot 6. Trauma 7. Phimosis/stricture 8. Posterior urethral valves
29
List 5 disorders EACH for **ulcerative and nonulcerative STIs**.
**Ulcerative STIs** 1. Syphilis 2. LGV 3. HSV 4. HPV 5. Chancroid **Non-ulcerative STIs** 1. Chlamydia 2. Gonorrhea 3. HIV 4. BV 5. Trichomonas 6. Candida
30
List 10 causes of **hematuria**.
**Kidney** 1. PSGN 2. Pyelonephritis 3. Trauma 4. Anticoagulation 5. Neoplasm 6. Vasculitis (HSP) **Ureter** 1. Trauma 2. Stone 3. Neoplasm **Bladder** 1. Neoplasm 2. Stones 3. Infection 4. Trauma 5. Radiotherapy **Prostate** 1. Infection 2. Radiotherapy **Other** 1. Coagulopathy 2. SLE 3. Sickle Cell Disease
31
List 4 causes of **CKD** with normal or large kidney size.
1. Polycystic kidney disease 2. Amyloidosis 3. Diabetic nephropathy 4. Malignant HTN 5. Multiple myeloma 6. Hydronephrosis
32
A guy comes in with a 5 hr **painful erection**. Outline your management.
1. Analgesia 2. Exercise may help * Get him to run up and down stairs/do squats etc. * Assuming it's not sickle cell 3. Give a penile block 4. 10 and 2 o'clock insert a 19G and aspirate 5. May need to inject phenylephrine (100-500 mcg)
33
Using urinalysis, UNa, FENa and urine-to-plasma creatinine ratio, **differentiate prerenal azotemia** from **ATN**.
**Pre-renal** * UNa \<20 mEq * FeNa \<1% * Urine:Plasma Cr \>40 * Hyaline casts **ATN** * UNa \>40 mEq * FeNa \>2% * Urine:Plasma Cr \<20 * Granular casts FeNa = _Urine Na x Serum Cr_ Serum Na x Urine Cr
34
List EIGHT causes of **nephrotic syndrome**. What are the THREE characteristics of nephrotic syndrome?
1. Minimal change disease 2. DM 3. SLE 4. HSP 5. Wegeners 6. Amyloid 7. NSAIDS 8. Heroin 9. IE 10. HIV 11. Tumours /malignancy 12. HTN 13. Transplant Rejection **Characteristics:** 1. Hypoalbuminemia 2. Heavy proteinuria (\>3.5g/d) 3. Edema (low oncotic P) 4. Hypertriglyceridemia (often have, not required)
35
List 5 causes of **ovarian torsion**.
1. Tumors 2. Cysts 3. PCOS 4. Ovarian hyperstimulation syndrome (IVF) 5. Complication of pregnancy 6. Normal ovary (rare)
36
Describe the stages of **syphilis**.
**Primary (9-90 days)** * Painless chancre * Pen G 2.4 million units IM x1 **Secondary (5-8 weeks)** * Rash on hands * Malaise, generalized unwell feeling +/- condyloma lata * Pen G 2.4 million units IM x1 if no neuro symptoms **Latent (Years)** * No symptoms * Can be spread to kid * Pen G 2.4 million units IM qWeekly x3 **Tertiary (Years/Decades)** * Heart/Aorta involvement * Pen G 2.4 million units IM qWeekly x3 **Neurosyphilis (any time)** * Altered LOC/Meningitis * Admit * Pen G 4 million units IV q4h **Jarisch Herxheimer Reaction** * When you start treatment and everything gets worse
37
What is the treatment for the following **STIs**: * Chlamydia * Gonorrhea * Uncomplicated urethral, cervical or rectal * Pharyngeal * Adult conjunctivitis * Disseminated * Syphilis * Primary, secondary, or early latent * Late latent, tertiary * Neuro * HSV * 1st Episode * Recurrent * Chancroid * Lymphogranuloma venereum
* **Chlamydia** * Doxycycline 100 mg PO BID * **Gonorrhea** * Uncomplicated urethral, cervical or rectal * CTX 250 mg IM + Azithro * Pharyngeal * CTX 250 mg IM + Azithro * Adult conjunctivitis * CTX 1 g IM/IV + Azithro * Disseminated * CTX 1 g IM/IV x7d + Azithro once * **Syphilis** * Primary, Secondary or Early latent * Benzathine PCN G 2.4M U IM x1 * Late latent, Tertiary * Benzathine PCN G 2.4M U IM qWeekly x3 * Neuro * Pen G 4M U IV q4h x10d * **HSV (Genital)** * 1st Episode * Valacyclovir 1g BID x7d * Recurrent * Valacyclovir 1g daily x5d * Valacyclovir 500mg BID x3d * **Chancroid** * Azithromycin 1 g PO once * Ceftriaxone 250 mg IM/IV once * Ciprofloxacin 500 mg BID x3d * **LGV (type of Chlamydia)** * Doxy 100 mg BID x21d
38
List **prophylaxis options** (including dose) for the following: * Gonorrhea * Chlamydia * Trichomoniasis * Hepatitis B * Hepatitis C * HIV * Pregnancy
**Gonorrhea** * Ceftriaxone 250 mg IM/IV of cefixime 800 mg PO **Chlamydia** * Azithro 1g PO or Doxy 100 mg PO BID **Trichomonas** * Metronidazole 500 mg PO **Hepatitis B** * HBIG 0.06 mL/kg up to 14 days after exposure (if unvaccinated or insufficient titers) * Hepatitis B vaccine at 0, 1, 6 months (if unvaccinated or unsure) **Hepatitis C** * Doesn't exist **HIV** * Triple therapy (Truvada + NNRTI) **Pregnancy** * Plan B 1.5 mg PO or Copper IUD
39
What are the treatment options for **PID** as per the **Canadian guidelines**?
**Inpatient** * Cefoxitine 2g IV q6h + Doxy 100 mg PO BID * Clinda 900 mg IV q8h + Gent 5 mg/kg q24h * Two week course **Outpatient** * CTX 250 mg IM/IV once + Doxy 100 mg BID x14d * Moxi 400 mg PO daily + Flagyl 500 mg BID * Levoflox 500 mg PO daily + Flagyl 500 mg BID * Two week course
40
List FIVE causes of **prerenal azotemia**.
1. Dehydration 2. Hemorrhage 3. Sepsis 4. GI losses 5. Burns 6. CHF
41
Provide **treatment options** for uncomplicated UTI, uncomplicated pyelonephritis, and complicated UTI.
**Uncomplicated UTI** * Nitrofurantoin x5d * Septra x3d * Keflex x7d **Uncomplicated Pyelonephritis** * Ciprofloxacin x10d * Amox-Clav x10d * Septra x10d **Complicated UTI** * Levofloxacin x10d * Amox-Clav x10d * Ciprofloxacin x10d * +/- Gentamycin
42
List THREE causes of **vulvovaginitis**. For EACH cause, indicate the appearance of the vaginal discharge, appearance on wet mount microscopy, and treatment.
**Bacterial Vaginosis** * White/Clear film * Clue cells * Metronidazole PV/PO (oral preferred if pregnant) **Trichomonas** * Yellow/green * Trichomonads on mount * Metronidazole PO **Candida** * White curds * Fluconazole PO 150 mg x1 or vaginal cream
43
What is the treatment of **epididymitis**?
**Sexually active? (\<35 yo)** * Ceftriaxone 250 mg IM/IV x1 * Azithromycin 1 g PO x1 **Non sexually active? (\>35 yo)** * Levoflox/Septra x7d **Prepubertal** * Get a urine culture and wait * Only treat if positive
44
List 8 causes of **urinary retention**.
**Penis** 1. Foreign body 2. Phimosis **Urethra** 1. Tumour 2. Stricture 3. Stone **Prostate** 1. BPH 2. Infection 3. Neoplasm **Neurological** 1. Spinal cord injury 2. Diabetes **Drugs** 1. Anticholinergics 2. Beta-blockers 3. Antihistamines 4. Opioids
45
List the type of each of these **urine casts**.
**A = Hyaline Cast** * Dehydration * Exercise * Glomerular proteinuria **B = RBC Cast** * Glomerulonephritis * Vasculitis **C = WBC Cast** * Renal parenchymal inflammation (AIN) * Papillary necrosis * Pyelonephritis **D = Granular Cast** * ATN
46
**Provide THREE DDX for:** * Low FENa (\<1%) and UNa \< 20 mEq/L * High FENa (\>1%) and UNa \> 40 mEq/L
**Low FENa (\<1%) and UNa \< 20 mEq/L** * Dehydration * Third spacing * HUS/TTP * DIC **High FENa (\>1%) and UNa \> 40 mEq/L** * SIADH * Hypothyroidism * Adrenal Insufficiency * Diuretics * Renal failure
47
With **hematuria**, how does the microscopic study help you determine the source of the bleeding?
**Renal Blood** * RBC casts * Proteinuria **Non-Glomerular/Lower Urinary Tract** * Clots
48
List 6 causes of **red-colored urine without hematuria**.
1. Rifampin 2. Deferoxamine 3. Beets 4. Rhubarb 5. Nitrofurantoin 6. Iodine
49
List 4 extra-genital presentations of **gonorrhea**.
1. PID 2. Anorectal disease 3. Pharyngitis 4. Conjunctivitis * Ophthalmologic emergency 5. Disseminated gonorrhea
50
**Differentiate** between testicular torsion, appendix torsion, and epididymitis.
**Testicular Torsion** * Bell clapper * Testicle at risk - immediate/sudden pain * Loss of cremaster reflex **Appendix Teste Torsion** * Point tenderness in superior pole * Pain management * Blue dot sign **Epididymitis** * Infection UTI/STI * Usually not profoundly swollen
51
What are the **Amsel criteria** for BV?
**Diagnosis of BV** 3+ of: 1. Thin, white discharge that coats the vaginal walls 2. Clue cells on microscopy 3. Vaginal fluid pH \> 4.5 (lack of lactobacillus) 4. Fishy odor before/after 10% KOH added (Whiff test)
52
Describe a typical **menstrual cycle**: length, phase, etc.
1st day of menses = 1st day of cycle Avg cycle = 28-35 days **Ovarian Phases** * **Follicular** * Begins with menses and ends the day before LH surge * Start with low estradiol and progesterone levels which gradually increase * As estrogen levels increase – endometrium thickens * Dominant follicle – releases ovum at the end of follicular phase (LH surge) * **Luteal** (**fixed 14 days in most)** * Begins with LH surge and ends with next menses * Progesterone is produced by corpus luteum * Progesterone matures lining of uterus * If implantation does not occur – CL dies – drops your estrogen/progesterone levels --\> menstruation
53
What are TWO risk factors for **contrast-induced nephropathy**? If you must do a test that requires contrast, list FOUR ways CIN be prevented?
**Risk Factors** 1. Dehydration 2. Pre-existing AKI 3. Age \>60 4. Use of ionic contrast media 5. DM 6. Multiple myeloma **Prevention (they love to ask this!)** 1. IVF hydration (0.9% NS) before and after study 2. NAC 3. CT without contrast or use another imaging modality (US) 4. Use low osmolal contrast 5. Use lower doses of contrast and limit repeat studies 6. Avoid NSAIDs
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