HY lecture notes:
“Small blue cells” on prostate or renal biopsy specimens, especially in a patient who has fever, should scream infection. These are leukocytes.
68M + urinary hesitancy + interrupted stream + 100F + tender prostate; Dx? –> prostatitis
72M + urinary hesitancy + interrupted stream + biopsy of prostate shows small blue cells; Dx? –> prostatitis –> most older men will have BPH, but if they give you the blue cells, choose prostatitis.
Exquisitely tender prostate on digital rectal exam; Dx? –> prostatitis.
Prostatitis Tx? –> ciprofloxacin, OR ampicillin + gentamicin.
82M + treated for prostatitis + sore ankle when he goes out metal detecting; Dx? –> Achilles tendonitis from ciprofloxacin.
Costovertebral angle tenderness + fever; Dx? –> pyelonephritis.
Costovertebral angle tenderness + granular casts –> pyelonephritis –> correct, super-weird; NOT acute tubular necrosis; this is on 2CK NBME; apparently “granular casts” can be seen in a variety of conditions; it’s the muddy/dirty brown granular casts that indicate ATN.
Is chronic pyelonephritis ever an answer? –> usually young patient, i.e., 3-4-year-old, who has recurrent bouts of acute pyelo –> need to know recurrent acute pyelo is what causes chronic pyelo. For Step 1 level, they will show an image of a small, scarred kidney and give you the aforementioned description, then the answer is simply “vesicoureteral reflux” as the mechanism. They might also ask what you see on biopsy; answer = “tubular atrophy.” Ultrasound shows “broad scars with blunted calyces.” The phrase “thyroidization of the kidney” is buzzy and more Qbank, not NBME. You need to walk away knowing that chronic pyelo will produce scarred renal calyces in someone who’s had recurrent acute pyelo.
Innervation of external urethral sphincter –> pudendal nerve (somatic; voluntary).
Innervation of internal urethral sphincter –> hypogastric nerves (sympathetic).
Innervation of detrusor muscle –> pelvic splanchnic nerves (parasympathetic; S2-4).
What is Brenner tumor? –> ovarian tumor with bladder (transitional cell) epithelium.
Tx for simple UTI –> nitrofurantoin is classic answer (need not be cystitis in pregnant women; this is listed as the correct answer in many 2CK-level NBME/CMS Qs); TMP/SMX is also classic combo.
Q asks best initial Mx to prevent UTIs –> answer = postcoital voiding. If unsuccessful, NBME wants “postcoital nitrofurantoin prophylaxis” next; if not listed, choose “daily TMP/SMX prophylaxis.” The latter sounds incredibly wrong, and I agree, sounds outrageous, but it’s correct on one of the obgyn CMS forms and everyone gets it wrong.
22F + Sx of dysuria for 6 months + anterior vaginal wall pain + U/A completely normal + afebrile; Dx? –> chronic interstitial cystitis –> answer on one of the obgyn forms. Must have at least 6 weeks of UTI-like Sx without any identifiable pathology.
Tx for asymptomatic bacteriuria –> if pregnant, must Tx. If not pregnant, do not Tx. Exceedingly HY for 2CK.
Why must Tx asymptomatic bacteriuria in pregnancy? –> progesterone slows ureteric peristalsis, increasing the risk of pyelo.
