PANCE Blueprint Genitourinary (6%)

PANCE Blueprint Genitourinary (6%)
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PANCE Blueprint Genitourinary (6%)

Follow along with the NCCPA™ PANCE and PANRE Genitourinary Content Blueprint

  • 37 PANCE and PANRE Genitourinary Content Blueprint Lessons (FREE)
  • 72 Question Comprehensive Genitourinary Exam (available to smartypance members)
  • Genitourinary Pearls Flashcards (available to smartypance members)
  • Genitourinary Pearls high yield summary tables (FREE)
  • ReelDX™ integrated video content (available to smartypance members)

Lessons

  1. Genitourinary System Flashcards (Members Only)

  2. Genitourinary 72 Question Comprehensive Exam (Members Only)

    1. Enlargement of transitional zone - In men with BPH, avoid use of anticholinergic and antihistamines
      • PSA is often elevated - considered normal < 4
      • PSA > 4 think BPH, prostate CA and prostatitis
      • Symptomatic: Alpha blocker (Tamsulosin)
      • Decrease prostate size: 5 alpha reductase inhibitors (Finasteride)
      • Definitive: TURP
    2. If still non-palpable at 6 mo well-child exam, refer to urology/surgery for evaluation and possible orchiopexy
      • ↑ Risk in premature infants 30%
      • If not repaired risks infertility and malignancy
      • Treatment: Orchiopexy by age 1
    3. The most common vascular cause is atherosclerosis. Consider psychological cause.
      • Nocturnal penile tumescence used to evaluate sleep erections
      • Phosphodiesterase 5 inhibitors Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra)
      • Do not use with nitrates may cause hypotension
    4. Hydrocele: On physical exam mass will transilluminate Varicocele: Dilation of the pampiniform plexus
      • Bag of worms in scrotum (made worse when patient is upright and improves when patient is supine)
      • More common on left
    5. Stress: urine leakage due to abrupt increases in intra-abdominal pressure (eg, with coughing, sneezing, laughing, bending, or lifting)
      • Treatment: strengthen pelvic floor or surgery
      Urge: results from an overactive detrusor muscle. Increased frequency. Vaginal delivery.
      • Treatment: Oxybutynin
      Overflow: Cannot empty bladder, just leaks. High PVR
      • Treatment: Self catheterization
      Functional: mobility issue Mixed: (combo of stress and urge) most common.
    6. Flank pain radiating to groin, hematuriaCVA tenderness.
      • Lithotripsy: Stones > 1 cm unlikely to pass. Lithotripsy is indicated in patients with stones > 6 mm in size or intractable pain.
      • Hydration:  Stones < 5 mm likely to pass.
      • Calcium oxalate (80%): Most common, excess oxalate, hyperparathyroidism, radiopaque.
      • Struvite (10%): Associated with UTI with Klebsiella and Proteus species, radiopaque.
      • Uric Acid (7%): Excess meat/alcohol, gout, radiolucent.
      • Cystine (1%): Rare genetic, radiolucent.
    7. Paraphimosis: Inability to return foreskin to normal position causes tourniquet effect, is a medical emergency
      • Entrapment of the foreskin behind glans
      • More acute than phimosis
      Phimosis: Inability to retract the foreskin, usually resolves by age 5, betamethasone topically, if no improvement circumcision
      • Unable to retract foreskin
      • More chronic than paraphimosis
    8. Asymmetric high riding testicle bell clapper deformity”, negative prehn's sign (lifting of testicle will not relieve pain). Teenage males.
      • Very tender to palpation. Cremaster reflex absent.
      • Blue dot sign: Tender nodule 2 to 3 mm in diameter on the upper pole of the testicle.
      • Diagnosis: Radionuclide study and ultrasound
      • Surgical emergency: Repair both testes within 4-6 hours
    1. Cystitis

      Infection of the bladder and is characterized by dysuria without urethral discharge. E. coli (most common)
      • Treat with Nitrofurantoin (not over age 65), Bactrim, Fosfomycin
      • Ciprofloxacin- reserved for complicated cases
      • Postcoital UTI: single-dose TMP-SMX or cephalexin may reduce frequency of UTI in sexually active women
      Lower UTI in pregnancy
      • Nitrofurantoin (Macrobid): 100 mg PO BID × 7 days
      • Cephalexin (Keflex): 500 mg PO BID × 7 days
    2. Epididymitis is characterized by dysuria, unilateral scrotal pain and swelling.
      • + Prehn's sign: relief with elevation is a classic sign
      • men < 35 chlamydia and gonorrhea: Doxycycline 100mg PO BID for 10 days + Ceftriaxone 250 mg IM × 1
      • men > 35 E.coli: Treat with Levofloxacin x 10 days
    3. Unilateral swollen testicle with erythema and shininess of the overlying skin. Orchitis is rarely seen without epididymitis unless patient has mumps.
      • 25 % are associated with MUMPS
      • Over 35: E. coli, Levofloxacin
      • Under 35:  Gonorrhea and chlamydia, Ceftriaxone + doxycycline/azithromycin
    4. Sudden onset of fever, chills, and low back pain combined with urinary frequency, urgency and dysuria.
      • Men < 35: Chlamydia and Gonorrhea - ceftriaxone and azithromycin (or Doxycycline)
      • E coli in men > 35 -  treat with fluoroquinolones or bactrim x 1 month
      • Chronic prostatitis  - treat with fluoroquinolones or bactrim x 6-12 weeks
      • If you suspect acute prostatitis do not massage the prostate this can lead to sepsis
    5. Irritative voiding + Fever + flank Pain + nausea and vomiting + CVA tenderness
      • Organism: E. coli
      • Urinalysis: Bacteria and WBC casts
      • Outpatient: ciprofloxacin/levofloxacin +/- ceftriaxone IM
      • Inpatient: Ciprofloxacin/levofloxacin or imipenem for more severe disease
    6. In urethritis, the main symptoms are dysuria and, primarily in men, urethral discharge.
      • Diagnosis: nucleic acid amplification test (NAAT)
      • N. gonorrhoeae (gram negative diplococci) and C. trachomatis
        • Ceftriaxone 250 mg intramuscular in a single dose for treatment of gonococcal infection PLUS Azithromycin (1 gram in a single oral dose) for possible additional activity against N. gonorrhoeae and for treatment of potential chlamydia coinfection.
        • Doxycycline (100 mg orally twice daily for seven days) is an alternate option for a second agent to administer with ceftriaxone.
    1. Bladder cancer

      Painless hematuria in a smoker, transitional cell carcinoma is the most common type.
    2. Most common area: Peripheral zone. Digital Rectal Exam: hard, irregular, nodular prostate Tumor marker: PSA. (also elevated in BPH)
      • PSA is considered normal < 4
      • PSA > 4 think BPH, prostate CA and prostatitis
      Recommended age to start annual prostate screening:
      • White male average risk: 50 years old
      • Black male + Family History or + BRCA mutations: 40 years old
    3. Classic triad of flank pain + hematuria + painless abdominal/renal mass
      • Renal clear cell carcinoma is the most common type (80%)
      • Transitional cell is the second most common type (20%)
      • Smoking is the most significant risk factor
    4. Presents as a firm, painless, non tender testicular mass
      • Seminoma is the most common type (60%)
      • Risk factors include history of cryptorchidism
      • Diagnostic studies: Initial-Ultrasound. Tumor markers: AFP, βHCG
    5. Child with painless, unilateral abdominal mass with no other signs of symptoms, also known as nephroblastoma.
    1. Acute tubular necrosis (ATN)
      • Etiology: Kidney ischemia or toxins
      • Urinalysis: Muddy brown casts. Renal tubular epithelial cells + High Urine Osmolality
      • FENa > 2%
      Interstitial nephritis
      • Etiology: Immune-mediated response
        • Drugs: PCN, sulfa, NSAIDs, phenytoin etc.
        • Immunologic and infectious disease: strep, SLE, CMV, Sjogren's, Sarcoidosis
      • Urinalysis: WBC casts and eosinophils
      Glomerulonephritis
      • Etiology: IGA Nephropathy (Berger disease), postinfectious, membranoproliferative
      • Urinalysis: Oliguria, hematuria and RBC casts
    2. CKD is a progression of ongoing loss of kidney function (GFR) defined as < 60 mL/min/1.73 m² or presence of kidney damage (proteinuria, glomerulonephritis or structural damage from polycystic kidney disease) for > 3 months.
      • Measurement of GFR is the gold standard - The Cockcroft - Gault formula (requires age, body weight, and serum creatinine) or Modification of Diet in Renal Disease equation
      • Etiology: Diabetes, hypertension, glomerulonephritis
      • Findings: Fatigue, pruritus, Kussmaul respirations, asterixis (flapping tremor), muscle wasting, broad waxy casts
    3. Immune-mediated glomerular inflammation results in glomerular damage which results in urinary protein and RBC loss
      • Proteinuria, HTN, azotemia, oliguria (<400 ml urine/day), hematuria (RBC casts) hallmark, edema is not as much as nephrotic syndrome
      • Urinalysis: proteinuria < 3.5 grams per day, hematuria, RBC casts
      • Biopsy: hypercellular, immune complex deposition
      Etiologies of acute glomerulonephritis:
      • IgA Nephropathy (Berger disease): most common cause of acute glomerulonephritis worldwide - often affects young males within days  (24-48 hours) after URI or GI infection.
      • Postinfectious - Group A strep: 10-14 days after infection - diagnosed with ASO titers and low serum complement.
      • Membranoproliferative glomerulonephritis: due to SLE, viral hepatitis.
      • Rapidly progressive glomerulonephritis - crescent formation on biopsy due to fibrin and plasma protein deposition.
        • Goodpasture's syndrome: (+) anti-GBM antibodies, dx linear IgG deposits, treat with high dose steroids, plasmapheresis + cyclophosphamide.
        • Vasculitis: lack of immune deposits (+) ANCA antibodies.
    4. Urine outflow obstruction causes renal distention
      • Treat underlying cause
    5. Glomerular damage results in increased urinary protein loss
      • Proteinuria, hypoalbuminemia, edema, hyperlipidemia, edema is predominant feature, transudative pleural effusion
      • Urinalysis: proteinuria > 3.5 grams on 24-hour urinefatty casts, oval fat bodies
      • Biopsy: hypo-cellular minimal change disease loss of podocytes on microscopy
      The most common primary causes are:
      • Membranous nephropathy: most common in non-diabetic adults associated with malignancies.
      • Minimal change disease: 80% of nephrotic syndrome in kids. Responds to corticosteroids.
      • Focal segmental glomerulosclerosis:  obese patients, heroin, and HIV black males.
      The most common secondary causes are:
      • Lupus: both nephritic and nephrotic.
      • Diabetes: common cause of nephrotic syndrome and subsequent renal failure.
      • Preeclampsia
    6. Narrowing of one or both of the renal arteries, most often caused by atherosclerosis or fibromuscular dysplasia.
      • Renal Arteriography is Gold Standard for diagnosis
      • May hear a renal artery bruit on auscultation
      • Percutaneous transluminal angioplasty (PTA) plus stent placement or with surgical bypass of the stenotic segment
    1. Hyponatremia / Hypervolemia: serum sodium of < 135 mmol/L
      • Presentation: Muscle cramps and seizures
        • Hypervolemic hyponatremia – CHF, nephrotic syndrome, renal failure, cirrhosis
        • Euvolemic hyponatremia – SIADH (Picmonic), steroids, hypothyroid
        • Hypovolemic hyponatremia – sodium loss (renal, non-renal)
      • Serum Na should be corrected slowly—by ≤ 10 mEq/L over 24 h to avoid osmotic demyelination syndrome
    2. Hypernatremia / Hypovolemiaserum sodium of > 145 mmol/L
      • Etiology: Diarrhea, burns, diuretics, hyperglycemia, diabetes insipidus, deficit of thirst
      • Rapid overcorrection causes cerebral edema and pontine herniation
      • Diabetes insipidus - Low urine sodium (but high serum sodium) and polyuria usually indicate diabetes insipidus
  3. Average values "24/7 40/40"
    • 24 (HCO3, base) / 7.40 (pH) / 40 (CO2, acid)
    Respiratory Acidosis:
    • pH < 7.35, pCO2 > 45, HCO3 > 26
    • Lungs fail to excrete CO2 (Breathing too slow (holding onto CO2), pulmonary disease, neuromuscular disease, drug-induced hypoventilation - opiates, barbiturates)
    Respiratory Alkalosis:
    • pH > 7.45, pCO2 < 35, HCO3 < 22
    • Excessive elimination of CO2 (Breathing too fast (blowing of CO2), pulmonary embolism, fever, hyperthyroid, anxiety, salicylate intoxication, septicemia )
    Metabolic Acidosis
    • pH <7.35, pCO2 < 35, HCO3 < 22
    • Need to calculate anion gap: Anion Gap = Na – (Cl + HCO3-) = 10-16
    • Increased ion gap (>16): Addition of hydrogen ions (lactic acidosis (think metformin), diabetic ketoacidosis, aspirin overdose)
      •  MUDPILES:
        • Methanol
        • Uremia
        • Diabetic Ketoacidosis
        • Paraldehyde
        • Infection
        • Lactic Acidosis
        • Ethylene Glycol
        • Salicylates
    • Low anion gap (<16): Loss of bicarbonate (diarrhea, pancreatic or biliary drainage, renal tubular acidosis)
    Metabolic Alkalosis:
    • pH > 7.45, pCO2 > 45, HCO3 > 26
    • Loss of hydrogen (vomiting), bulimia, overdose of antacids, addition of bicarbonate (hyperalimentation therapy)

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