What dx would you think if a pt presented with microscopic hematuria?
Nephrolithiasis
What 5 sxs would indicate that a pt with nephrolithiasis needs to be admitted to the hospital?
- Concomitant obstruction and infxn
- Intractable vomiting
- Uncontrollable pain
- Urinary extravasation
- Hypercalcemic crisis
What is the MC type of bladder cancer?
Transitional cell carcinoma
What are the risk factors for bladder cancer?
- Cigarette smoking
- Industrial (aniline) dye
What is the MC type of prostate cancer?
Adenocarcinoma
What are the risk factors for prostate cancer?
- Age
- AA
- High fat diet
- Fam hx
- Exposure to herbicides and pesticides
What is the MC type of testicular cancer?
Germ cell tumor-Seminomas (95%)
What are the risk factors for testicular cancer?
- Cryptorchidism
- Painless mass/lump
- Firmness of teste
- Gynecomastia
- Klinefelter syndrome
What is the MC type of penile cancer?
Squamous cell
What are the risk factors for penile cancer?
- 7th decade of life
- Uncircumcised
- HSV and HPV 18
When treating incontinence what do you treat first, urge or stress?
Treat urge before stress
What are the Urge/OAB treatment options (both pharm and non-pharm)
- Bladder training: timed/prompted voiding helps avoid full bladder
- Antimuscarinics: Oxybutynin
What is the MOA of Oxybutynin?
MOA: relax/block excess detrusor activity
What are the treatments for stress incontinence?
- Kegel exercises
- Beta-3 Agonist (Mirabegron)
- Estrogen therapy
- Paralytic agents: botulinum toxin A intravesical injection
- Pessary
- Surgery: mid urethral sling
What is the MOA of Beta-3 Agonist (Mirabegron)?
MOA: relaxes the detrusor smooth muscle during urine storage phase thus increasing bladder capacity
What is the MOA of Estrogen therapy?
MOA: plumps up tissue around bladder sphincter
What is stress incontinence d/t?
D/t increase abdominal pressure under stress (weak pelvic floor muscles)
[coughing, sneezing, or laughing]
Tell me if there are any of these in stress incontinence?
- Urgency
- Frequency
- Nocturia
- Episode during physical activity
- Leakage volume
- Urgency: Rare
- Frequency: Rare
- Nocturia: No
- Episode during physical activity: Yes
- Leakage volume: Small
What is urge incontinence d/t?
D/t involuntary contraction of bladder muscles occurring day or night.
Tell me if there are any of these in urge incontinence?
- Urgency
- Frequency
- Nocturia
- Episode during physical activity
- Leakage volume
- Urgency: Yes
- Frequency: Yes
- Nocturia: Yes
- Episode during physical activity: Rare
- Leakage volume: Large
What is overflow incontinence d/t?
D/t blockage of the urethra, poor stream, and incomplete emptying
Tell me if there are any of these in overflow incontinence?
- Urgency
- Frequency
- Nocturia
- Episode during physical activity
- Leakage volume
- Urgency: Yes
- Frequency: Sometimes
- Nocturia: No
- Episode during physical activity: Rare
- Leakage volume: Small
What would you see on a UA in a pt with nephrolithiasis?
- Microscopic or gross hematuria
- Pyuria or bacteriuria
- Crystal composition
- pH: acidic
What would you see on a UA in a pt with UTI (acute cystitis)?
- Bacteriuria >1 organism
- Pyuria >10 leukocytes
- Leukocyte Esterase
- Nitrites
What would you see on a UA if it was not a clean catch?
Presence of squamous epithelial cells = vulvar or urethral contamination
What would you see on a UA in a pt with pyelonephritis?
- Leukocyte casts
- Pyuria
- Bacteriuria
- Hematuria and proteinuria may be noted
What would you see on a UA in a pt with hemorrhagic cystitis?
- WBC (sterile pyuria)
- RBC
- Bacteria usually negative
What would you see on a UA in a pt with bladder cancer?
Painless hematuria
What would you see on a UA in a pt with bacterial prostatitis?
Numerous sheets of leukocytes
What is Phenazopyridine used for?
- Tx for dysuria, numbs the bladder
- Use BID in the 1st and 2nd day of UTI
What should you tell your pts when prescribing Phenazopyridine?
Will turn urine bright orange
What is the clinical presentation of Nephrolithiasis?
- Sudden onset of severe pain
- Pain begins in the flank then radiates towards groin
- N/V
- Hematuria
- UTI
What is the MC to least common stone type?
- Calcium oxalate: bipyramidal/biconcave ovals
- Calcium phosphate: amorphous
- Uric acid: flat square plaques
- Struvite: staghorn
- Cystine: haxagon shape
What imaging would you get for a pt with Nephrolithiasis?
- Initial imaging: plain film XR
- Gold standard for dx and most sensitive: spiral CT scan w/o contrast
- IVP: more useful for defining the degree and extent of urinary tract obstruction
- Renal US: detection of hydronephrosis of hydroureter (where blockage is)
What stones are radiopaque (seen on XR)?
- Calcium oxalate
- Calcium phosphate
- Struvite
What stones are radiolucent (seen on CT, US, IVP)?
- Uric Acid
- Cystine
What is the management for a pt with Nephrolithiasis?
- Vigorous IV hydration
- Analgesics: opioids, Ketorolac
- Antibiotics: if UTI present
- Tamsulosin: smooth muscle to easier pass stone
- Consult if not passed in 3 days
- Surgery
What are the surgical options for Nephrolithiasis?
- Extracorporeal shock wave lithotripsy
- Ureteroscopic stone removal
What is extracorporeal shock wave lithotripsy? and what size stone is best for this tx?
- MC surgical method
- Breaks stones into small pieces
- Best for stones >5mm but <2 cm in diameter
What is Ureteroscopic stone removal? and what size stone is best for this tx?
- Used if shock wave fails
- Best for larger stones
- Surgical removal and may incorporate use of stent
What are the dietary prevention measures for a pt with Nephrolithiasis?
- High fluid intake (2L/day)
- Natural lemonade
- Limit animal protein
- Limit calcium intake
What are the pharm prevention measures for a pt with Nephrolithiasis?
- Thiazide diuretics
- Allopurinol
What is a spermatocele?
Epididymal cyst containing sperm aka: scrotal mass
What are the characteristics of a spermatocele?
- > 2 cm
- Painless, cystic testicular mass on PE
- Round, soft, freely mobile
- Benign
What are the characteristics of the testicular cancer: germ cell embryonal carcinoma? and what are the mets?
- Highly malignant
- Hemorrhage and necrosis are common
- Mets to abdominal lymphatics and lungs early
What are the characteristics of the most aggressive testicular cancer: germ cell choriocarcinoma? and what are the mets?
- Rare
- Metastases usually occur prior to diagnosis
What are the characteristics of the non-germ cell testicular cancer: Leydig cell tumor?
- Hormonally active, secretes estrogen and androgens
- Associated precocious puberty in children
- Gynecomastia in adults
- Usually benign but poor prognosis if metastasize
What is Fournier’s gangrene?
Rapidly spreading necrotizing infxn of scrotum that progresses to gangrene and may travel to abdomen
What are the risk factors for Fournier’s gangrene?
- DM
- Obesity
- Pelvic trauma
- Immunocompromised
What is the causative agent for Fournier’s gangrene?
- Polymicrobial
- Causative agent may originate from integumentary, urethra, or rectum.
What is testicular torsion? and is the onset acute or gradual?
- Ischemia to teste leading to infarction, twisting of 3 spermatic cords
- Onset: Acute
What are the clinical manifestations of testicular torsion?
- Swelling and tenderness
- Elevated testicle (bell clapper deformity)
- Absent prehns sign
- Absent cremasteric reflex
What is the diagnostic studies used to dx testicular torsion?
- UA: normal
- Doppler US or clinical dx
What is the tx for testicular torsion?
Emergent surgery within 6 hrs
What is Epididymitis? and is the onset acute or gradual?
- Inflammation of epididymis, erythematous, painful swelling
- Onset: Gradual
What is associated with sexually transmitted Epididymitis? and what are the MC causative agents?
- Associated with urethritis
- MC agents: C. trachomatis and N. Gonorrhea
What is associated with non-sexually transmitted Epididymitis? and what are the MC causative agents?
- Associated with prostatitis or acute cystitis
- MC agents: E. coli, Pseudomonas, Klebsiella
What are the clinical manifestations of Epididymitis?
- Swelling and tenderness
- Fever/Chills
- Urethral d/c
- Positive Prehns sign
- Positive Cremasteric reflex
What is the diagnostic studies used to dx Epididymitis?
- UA: may develop pyuria
- Doppler US to distinguish between testicular torsion
What is the tx for Epididymitis?
Antibiotics
What is varicocele and what does it result from?
- Dilation of veins that drained into the internal spermatic veins
- Results from incompetent internal spermatic vein valves
What are the S/Sxs and PE findings in a pt with varicocele?
- Dilated tortuous veins “bag of worms”
- Heavy sensation
- Swelling decreases when pt is laying supine
What is the cause of primary varicocele?
Usually idiopathic in nature.
What is the cause of secondary right side varicocele?
Abdominal mass compression of the renal veins
What is the cause of secondary left side varicocele?
Superior mesenteric artery compression of the left renal vein (aka “Nutcracker Syndrome”) MC’y d/t RCC
What are S/Sxs of prostate cancer?
- Asymptomatic in early course
- Begins in periphery of gland then moves centrally (starts to press on urethra)
- Difficulty in voiding/starting stream
- Dysuria
- Increased urinary frequency
- Weight loss
Where are the mets for prostate cancer?
Mets to lymph nodes or bone (spine and pelvis)
- Causes back pain
What are the DRE findings in a pt with prostate cancer?
Hard, nodular, irregular in morphology (feels like knuckle)
What is the management for prostate cancer?
- Radical prostatectomy: MC complications are ED and urinary incontinence.
- Orchiectomy: used in pts who were noncompliant w/ medical therapies
What is characteristics of acute bacterial prostatitis?
- Less common
- Younger men
What are the causative agents for both acute and chronic bacterial prostatitis?
- > 35 YOA: E. coli
- <35 YOA: N. gonorrhea and C. Trachomatis
What are the S/Sxs of acute bacterial prostatitis?
- Fever/Chills
- Dysuria
- Perineal pain
- LBP
- Increased urinary frequency, hesitancy, urgency, and retention
What are the DRE findings in a pt with acute bacterial prostatitis?
Bogy, exquisitely tender prostate
What is the tx for acute bacterial prostatitis?
If severe hospitalize, start on antibiotics:
- Trimethoprim-sulfamethoxazole
- Fluoroquinolones
- Doxy
- Ceftriaxone
What is characteristics of chronic bacterial prostatitis?
- More common
- Men 40-70 yo
What are the S/Sxs of chronic bacterial prostatitis?
- Commonly asymptomatic
- Fever is uncommon and typically don’t appear ill.
If sxs are present they are:
- Frequent UTI w/ irritative urination and/or obstructive sxs
- Dull poorly localized pain in LB, perineum, scrotum, or suprapubic region.
What are the DRE findings in a pt with chronic bacterial prostatitis?
Enlarged usually non-tender
What is the tx for a pt with chronic bacterial prostatitis?
Fluoroquinolone: Cipro, levofloxacin, etc.
What are the S/Sxs of BPH?
HI FUN
- H: hesitancy
- I: intermittence, incontinence
- F: frequency, fullness
- U: urgency
- N: nocturia
What is the dx study for BPH?
DRE: enlargement of prostate
What is the tx for BPH?
- Alpha 1 blockers: Tamsulosin, Doxazosin, Alfuzosin, Silodosin
- 5-alpha reductase inhibitors: Finasteride, Dutasteride
- Surgical: TURP
What are the pathogens responsible for Prostatitis?
- E. coli
- N. gonorrhea
- C. Trachomatis
What are the pathogens responsible for Epididymitis?
- N. gonorrhea
- C. Trachomatis
- E. coli
- Pseudomonas
- Klebsiella
What are the pathogens responsible for Balanitis?
Candida albicans
What is the MCC of ED?
Decreased arterial flow d/t progressive vascular disease
What are other causes/risk factors for ED?
- HTN
- Smoking
- Dyslipidemia
- DM
What is Priapism?
Painful, prolonged erection >4hrs long
What are the medications that causes of Priapism?
- Trazodone
- Phenothiazine
- PDE5-Inhibitors
- Papaverine injection
Aside from medications what are the other causes of Priapism?
- Spinal cord injury
- Sickle cell
- Leukemia
What are the CI for testosterone therapy?
- Prostate CA
- Elevated Hematocrit >55% -polycythemia
- CHF
- Women/Pregnancy
What is phimosis?
Inability to retract the foreskin
What is paraphimosis?
- Inability to reduce the foreskin back to the anatomic position
- a medical emergency, the foreskin can create tourniquet effect on penis
What is balanitis?
Inflammation of the superficial tissues of the glans (mushroom top)
What is balanoposthitis?
Inflammation of the foreskin and glans
What is hypospadias?
Urethral meatus opens onto the ventral side of the penis
Coronal is MC
What is Peyronie’s disease? and what is the cause?
- Abnormal curvature and shortening of the penis during an erection.
- Caused by scarring of the tunica albuginea
What is the clinical presentation of Peyronie’s disease?
- Tenderness over the scar tissue area of penile shaft
- Painful curvature of erected penis
- Eggplant deformity
What condition is associated with Peyronie’s disease?
Dupuytrens contracture
What is the causative agent for Chlamydia?
Chlamydia trachomatis
MC bacterial sexually transmitted infxn
What is the causative agent for Gonorrhea?
Neisseria Gonorrhoeae
What is the causative agent for Syphilis?
Treponema pallidum - spirochetal infxn
What is the causative agent for Chancroid?
Haemophilus Ducreyi
- MC in subtropical and tropical regions of the Caribbean and Africa
What is the causative agent for Phthisis Pubis?
Lice-smaller and wider than head lice
What is the causative agent for Genital herpes?
HSV-2
What is the clinical presentation in men and women with Chlamydia?
- Men: dysuria, purulent urethral d/c, scrotal pain and swelling, fever
- Women: purulent urethral d/c, intermenstrual or postcoital bleeding, dysuria
What is the clinical presentation in men and women with Gonorrhea?
- Men: purulent d/c, dysuria, urethral meatus erythema and edema, increased urinary frequency
- Women: usually asymptomatic, purulent d/c, dysuria, intermenstrual bleeding, dyspareunia
What is the tx for Chlamydia?
Azithro 1g PO or Doxy x7 days
+
tx for gonorrhea: Ceftriaxone IM x1
What is the tx for Gonorrhea?
Ceftriaxone IM x1 + Azithro 1g PO x1
What are complications in men and women caused by Chlamydia?
- Men: epididymitis, proctitis
- Women: infertility d/t tubal scarring, PID/salpingitis, tubo-ovarian abscess, ectopic pregnancy, fitz-high-curtis syndrome
What are complications caused by Gonorrhea?
Disseminated gonococcal infection:
- Fever, arthralgias, tenosynovitis (hands and feet)
- Endocarditis
- Skin rash on palms and soles (erythematous halos, necrotic center)
- Ocular gonorrhea
What are S/Sxs of primary stage of syphilis?
- Chancre- painless crater like “punched out” lesions
- Clean bases
- Appears 3-4 wks after exposure
Is primary stage contagious and how do you treat this stage?
- Highly contagious
- Heals in 1-4 wks w/o management
What are S/Sxs of secondary stage of syphilis?
- Maculopapular and papulosquamous rash, including palms and soles.
- Condylomata lata: moist lesions on genitals
Is secondary stage contagious and what happens if it is left untreated?
- Highly contagious
- If left untreated can develop into latent syphilis
What are S/Sxs of latent stage of syphilis?
Asymptomatic
What are S/Sxs of tertiary stage of syphilis?
- May occur anytime (40+ yrs)
- CV effects
- Neurosyphilis
- Gummas
- Tabes Dorsalis
- Argyll-roberson pupils
What are the CV effects caused by the tertiary stage of syphilis?
Syphilitic aortitis w/ ascending aortic aneurysm
What are the neuro caused by the tertiary stage of syphilis?
Dementia, personality changes, HA, hearing/vision loss
What are Gummas caused by the tertiary stage of syphilis?
SubQ granulomas
What are Tabes Dorsalis caused by the tertiary stage of syphilis?
Posterior column deterioration, leading to ataxia, areflexia, burning pain and weakness
What are Argyll-roberson pupils caused by the tertiary stage of syphilis?
Small irregular pupil that constricts normally to near accommodation but not to light
When is congenital syphilis transmitted?
Vertical transmission in 3rd month of pregnancy
What are the S/Sxs of congenital syphilis?
Skin and bone lesions:
- Hutchinson teeth
- Mulberry molars
- Saddle nose
- Hepatosplenomegaly
- Interstitial keratitis
- 8th nerve deafness
What is the tx for syphilis?
Penicillin G benzathine IM x1
What is the description of chancroid lesions?
- Begins as papules or nodules
- painful well circumscribed non-indurated soft ulcers, tender
- Inguinal lymphadenopathy
What are the clinical presentations in men and women with chancroid?
- Men: single lesion
- Women: multiple lesions (kissing ulcers)
What is pathognomonic for chancroid?
Painful ulcers + suppurative LAD
What is the tx for chancroid?
Azithro PO or Ceftriaxone IM
What is the complication of chancroid?
Tissue destruction
What is the clinical presentation of Phthisis Pubis?
- Intense pruritus, erythema, papules, excoriation hemorrhagic crusts
- Lesions may also be on lower abdomen, pubic/perianal region, and thighs
What is the tx for Phthisis Pubis?
5% permethrin cream or 1% lindane shampoo
- Permethrin cream safest and most effective
How do you tell your pt to use permethrin cream?
- Applied to all hair bearing areas and left on overnight
- Rinsed in the AM
- Repeat in 1 wk
What is the clinical presentation for first episode of genital herpes?
Most are asymptomatic but first episode are associated w/severe local sxs:
- Painful bilateral genital ulcer or vesicles
- Inguinal adenopathy
- Fever
- Malaise
- Myalgia
What is the clinical presentation for recurrent episodes of genital herpes?
- Prodromal itching
- Burning
- Tingling
What is the tx for genital herpes?
- Acyclovir
- Valacyclovir
- Famciclovir
What are the MC bugs that cause UTIs?
- > 35 YOA: E.Coli
- <35 YOA: Chlamydia Trachomatis
- Enterococcus: young females learning to wipe
What is the clinical presentation of an UTI?
- Fever
- Suprapubic tenderness
- Vomiting
- Dysuria
- Urgency
- Frequency
- Enuresis
- Change in urine color
- Foul odor
- Gross hematuria (sometimes)
What is the management for an UTI?
- TMP/SMX (Bactrum DS)
- Cephalexin (works against e.coli)
- Nitrofurantoin - do not use in early pyelo
- Fosfomycin- do not use in early pyelo
- Amoxicillin- less popular d/t high rates of resistant microbes
- Fluroquinolones (ciro levo) - warning tendonopathies
- Ceftriaxone + doxy or azithro if chlamydia is suspect
What is the dysuria management for a patient with an UTI?
Phenazopyridine: urinary analgesic
-Caution w/ sulfa allergy
What is the management for a pregnant women with an UTI?
- Ampicillin, amoxicillin, oral cephalosporins
- Avoid fluroquinolones
What is the management for a man with an UTI?
flouroquinolones due to good penetration into prostate tissue
What is the management for patients on warfarin and has an UTI?
- Penicillins, cephalosporins, doxy
- Avoid fluroquinolones and TMP/SMX
What is the most common bug causing pyelonephritis (upper UTI)?
E.coli
What are the signs and symptoms of pyelonephritis?
- Fever/Chills
- Flank pain
- Sxs of cystitis-dysuria
- N/V/D
- Tachycardia
- Appear more ill (septic)
- CVA tenderness
- Abdominal tenderness
What is the management for uncomplicated pyelonephritis?
- TMP/SMX or fluroquinolone
- Amoxicillin (good for S. saprophyticus and enterococci)
- Ceftriaxone or gentamicin (IM)
What is the management for complicated pyelonephritis?
Ampicillin + gentamicin or cipro
What is the etiology of interstitial cystitis?
- Unknown
- Negative urine culture
- Hx of pediatric bladder problems
- Thinning of epithelial lining
What are the symptoms of interstitial cystitis?
- Pain w/ filling bladder
- Relieved with micturition
- Increased frequency and urgency
- Nocturia
What is the management for interstitial cystitis?
- Hydrodistension
- Amitriptyline
- Nifedipine (CCB)
- Pentosan polysulfate sodium: restores epithelial integrity
What is the definition of cryptorchidism?
Undescended testicle, testicle is not within the scrotal sac and cannot be manipulated down into the scrotum
-Most descent spontaneously and within the first 6 mos of life
What is are bilateral undescended testicles suggestive of?
disorder of sexual development and lab evaluation is needed
What is done if the testicle is still undescended by 6 months of age?
Refer to urology for orchiopexy
- Viable undescended testicle is manipulated into scrotum and sutures into place
- If non-viable teste, it is removed
What is done if teste is distally located?
Hormonal therapy may be effective
- IM of human chorionic gonadotropin
What is nocturnal enuresis?
- Immature of cortical control of bladder
- Decreased function bladder capacity
(night time)
Are strong family history or genetics associated with nocturnal enuresis?
yes
Who is daytime incontinence most common in?
girls
What is daytime incontinence most commonly due to?
waiting too long to void
What is giggle (stress) incontinence?
- Sudden relaxation of urinary sphincter during giggling or Valsalva maneuver
- Results in loss of total urinary volume in bladder
- Girls ages 7-15
What is grade 1 of vesicoureteral reflux?
- Reflux into the ureter w/o dilation
- No tx needed
What is grade 2 of vesicoureteral reflux?
- Reflux into the ureter and collecting system w/o dilation
- No tx needed
What is grade 3 of vesicoureteral reflux?
- Reflux into the ureter and collecting system w/ mild dilation of ureter and blunting of calyces
- Prophylactic antibiotics w/ follow up VCUG to see if there is resolution
What is grade 4 of vesicoureteral reflux?
- Reflux into the ureter and collecting system w/ more significant dilation of ureter and blunting of calyces
- Surgical intervention
What is grade 5 of vesicoureteral reflux?
- Massive reflux w/ dilation and tortuosity of ureter and dilation of collecting system.
- Surgical correction
What is the follow-up eval for infant with recent febrile UTI?
renal/bladder ultrasound
What is the presentation of syphilis?
- Primary and secondary have painless ulceration lesions calls chancres. Highly infective at this stage.
- Tertiary: asymptomatic, organ involvement
What is the treatment for syphilis?
- Benzathine Pen G 1.4 million units IM
- Late latent infxn: Benzathine Pen G 2.4 million units q wk x3
- Beta-lactam allergy: doxy 100mg BID x 14 days
What is the treatment for pyelonephritis?
Empiric tx (PO, outpatient) is FQ
- Cipro 500mg PO BID x7days
- Levo 750mg PO 5-7 days
Consider initial dose of parenteral agent then complete tx based on culture and sensitivity
- Cipro 400mg IV x1 dose
- Ceftriaxone 1gm IM or IV x1 dose
What is the treatment for acute cystitis?
- Nitrofurantoin 100mg BID x5 days
- TMP/SMX BID x3 days
How is CroFab prepared?
- CroFab is a sheep-derived antivenim
- 18 mL of 0.9% Sodium Chloride is added to the vial and mixed by continuous manual inversion until no solid material is visible in the vial
- Do not shake
- Further dilute the entire dose with 0.9% Sodium Chloride to a total volume of 250 mL
How is CroFab administered?
- Slowly infuse then increase if tolerated, Infuse each dose intravenously over at least 1 hour
- Start with 6 vials, if initial control does not occur in 1 hr repeat 6 vials
- If initial control does occur maintain with 2 vials every 6 hours x3 if needed
What are the causes and clinical presentation for anticholinergic?
Mydriasis, dry flushed skin, delirium, hyperthermia, tachycardia, urinary retention, hypoactive bowels
“cant see, cant pee, cant shit, cant spit”,
ataxia, agitation, delirium, hallucinations, coma, incoherent speech, visual hallucinations
What is the antidote for atropine?
physostigmine
What is the antidote for TCAs?
Sodium bicarbonate
What are the causes/clinical presentations of cholinergic?
SLUDGE
- S: salvation
- L: lacrimation
- U: urination
- D: diaphoresis
- G: GI (diarrhea)
- E: emesis
What is the antidote for cholinergic?
Tx with atropine: bronchorrhea, bronchospasm, bradycardia, hypoTN
-May have muscular weakness including diaphragm caused by nicotinic stimulation that will NOT response to atropine
What is the antidote for organophosphates?
- Atropine
- Pralidoxime
When do you give flumazenil?
reversal for pure benzo sedation, ie when benzo has been administered in hospital setting
When do you not give flumazenil?
not recommended to give to OD victims d/t seizure risks
Management for acetaminophen overdose - NAPQI
NAPQI is a toxic byproduct that is usually immediately detoxified in the liver however in conditions such as an APAP OD it is not effectively detoxified and causes severe liver necrosis.
What is the antidote for APAP OD?
NAC (N-acetylcysteine)
- Administered if >8hr post ingestion or if unknown time of ingestion.
- NAC replenishes glutathione (which is a key role in detoxifying reactions) and acts as a glutathione substitute to bind to NAPQI to make it a nontoxic product.
What is the antidote for cyanide?
Amyl nitrate then Hydroxocobalamin (Cyanokit): sodium nitrate then sodium thiosulfate
Is IV access needed to administer amyl nitrate?
no it isn’t
Is IV access needed to administer Cyanokit?
yes it is needed
What is the treatment for cyanide poisoning?
- Activated charcoal: Ingested cyanide salts
- Water: skin and eyes
- Hemodialysis: removed extracellular reserve of cyanide, corrects severe metabolic acidosis.
What is the antidote for carbon monoxide?
oxygen
What is the treatment for carbon monoxide poisoning?
treat cardiac arrest or dysrhythmias via ACLS guidelines and removed pt from area of exposure.
What is the antidote for serious bleeding after warfarin overdose
Kcentra
- Replacement produce indicated for urgent reversal of acquired coagulation factor deficiency induced by warfarin therapy in adult pts w/ acute major bleed or need for urgent surgery.
- Must be followed by IV Vitamin K as Kcentra has short half-life and clotting factors need to be rebuilt.
What is the antidote for warfarin overdose?
Vitamin K
- If serious bleed follow Kcentra with 10 mg IV Vitamin K (monitor for anaphylactoid rxns)
- If INR is >10 or <10 but needs to be decreased quickly hold warfarin and use PO Vitamin K if possible
What is the treatment for warfarin overdose?
- Replace missing clotting factors (Kcentra)
- Provide Vitamin K
- If it is an acute bleed both may be needed (INR >3, trauma INR 2-3)
- If no significant bleed may just be able to give Vitamin K
What is the antidote for lead?
Calcium EDTA, Dimercaprol (BAL), Succimer, or D-Penicillamine
-All are chelators
What should be given immediately after the second dose of BAL and continues for 5 days?
IV Calcium EDTA
What is the antidote for iron?
deferoxamine
What is the MOA for antimuscarinics?
relax/block excess detrusor activity
What is the MOA for Beta-3 agonist (mirabegron)?
relaxes the detrusor smooth muscle during urine storage phase thus increasing bladder capacity
What is the MOA for local estrogen (applied to vagina/external urethra)?
plumps up the tissue around the bladder sphincter
What is the MOA for paralytic agents: Botulinum Toxin A intravesical injection?
Prevents muscular contraction by inhibiting acetylcholine release at the neuromuscular junction
What is MOA of Alpha-1 blockers?
synthetic testosterone derivative, decreases synthesis of DHT
What is the MOA of 5-Alpha Reductase Inhibitor?
Reduce prostate volume
What is the MOA of 5-PDE inhibitors for BPH?
improves sxs of BPH by SM relaxation of prostate tissue
What are the indications for nitrofurantoin?
first line for simple acute cystitis and recurrent UTI
What medications have better penetration in management of first uncomplicated UTIs?
- Nitrofurantoin
- TMP/SMX
What is Torsion of Testicular Appendix?
- Small, hard, tender nodule
- ischemic appendage
- located: the superior aspect of testicle
How does torsion of Testicular Appendix differ from testicular torsion?
In Torsion of Testicular Appendix the testicle as a whole is not tender only the nodule.
What is a classic clinical finding of Torsion of Testicular Appendix? and when do you refer?
- The blue dot sign
- Referral to urology or primary care provider within 1 wk
What is the key neurotransmitter that initiates and sustains an erection?
Nitric Oxide
