FCP III: disorders of the urinary tract pt 1 (exam 6)

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UA results consistent with cystitis
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diagnose and tx this pt
23 yr old male presents with dysuria and frequency x 2 days. He states his urine has been cloudy and malodorous. No penile discharge. UA dipstick shows elevated leukocytes. Pt is allergic to sulfa so you decide to not start empiric abx and instead send off for culture, which comes back positive for enterococcus.
what can be used for pts who are menopausal with vaginal atrophy, who experience recurrent UTIstopical vaginal estrogen to normalize vaginal floraHow to manage cystitis if pt has chronic indwelling catheterremove cath to remove biofilm → replace cath and obtain urine cx → treat w/ abxmost likely diagnosis and etiology - dysuria, profuse purulent urethral discharge, and urethral pruritusurethritis secondary to gonorrheamost likely diagnosis and etiology - dysuria, clear, purulent, or absent discharge, and urethral pruritusurethritis secondary to chlamydiafindings with first void UA and gram stain of urethral discharge that are c/w urethritisUA → leukocyte esterase > 10 WBC/hpf gram stain → >5 WBC/oil immersion fieldHow to confirm gonorrhea or chlamydia diagnosisurethral swab culture or NAATwhich provides pathogen sensitivities for gonorrhea → gonorrhea culture with urethral swab or NAATurethral swabWhen should urethral cultures or NAAT specimens be collectedat least 1 hr after the first voidWhat is the treatment for urethritis secondary to gonorrheaceftriaxone 250 mg IM x 1 dose alt. cefixime 400 mg PO x 1 dosewhat is the treatment for urethritis secondary to chlamydiaazithromycin 1g PO x 1 dose or doxycycline 100mg BID x 7 days (Dr. Paz mentioned doxy was now the preferred but that some providers still rec azithromycin lol...)Treat and counsel this pt 26 yr old male presents with c/o dysuria and penile discharge x 3 days. Discharge is purulent and malodorous. You perform a urethral swab culture and it comes back positive as gonorrhea.- Provide ceftriaxone 250mg IM and advise he abstain from sex until 7 days after tx was initiated (aka today). - He also needs to f/u in 3 mo to test for cureWhat additional step does a pt need to take if their gonorrhea tx regimen was as follows: - cefixime 400 mg PO x 1 dose, abstain from sex 7 days after treatment initiated, and f/u in 3 mo for test for cureIf alternative gonorrhea tx was used (cefixime) pt also needs to f/u in 1 wk to test for curegonorrhea/chlamydia does not require follow up test for curechlamydia (unless she prego)When should a pregnant pt who was treated for chlamydia follow up?f/u for test of cure 3-4 wks after completion of txAfter treating the pt for an STI, what else might you recommend (hint: think about their partner[s])refer sex partners for eval and treat those who had sexual contact within 60 days before onset of pts sx (RIP to all those one night stands)upper UTIspyelonephritis bacterial nephritis renal abscessdefine upper UTIinfection of kidneys, ureters, and/or perinephric spacemost likely diagnosis and cause 34 yr old female presents with c/o dysuria and abd pain x 5 days. She states she initially thought this was a mild UTI and started taking Azo however sx have progressively worsened. Temp is 100.5F and she has moderate left CVA tenderness.pyelonephritis likely secondary from ascending along urinary tract from bladderT/F if pt has upper UTI secondary to hematogenous spread, they will also usually complain of dysuria, frequency, and hematuriafalse → likely no urinary sx with hematogenous spreadUA and CBC c/w upper UTIUA → WBC and WBC casts CBC → leukocytosis w/ left shiftT/F imaging is always used in the diagnosis of an upper UTIfalse (only if unstable, septic, hx DM, immunocompromised, structural abnormality/obstruction, or unresponsive to abx)findings on CT nephrogram that may be c/w upper UTI (4)- perinephric stranding - kidney enlargement - decreased nephrogram - renal collecting system dilated (but not obstructed)Findings on renal US c/w upper UTIkidney enlargement and abnl echogenicityTreat this pt (hint: outpatient setting) 34 yr old female presents with c/o dysuria and abd pain x 5 days. She states she initially thought this was a mild UTI and started taking Azo however sx have progressively worsened. She started feeling feverish yesterday. Temp is 100.5F and she has moderate left CVA tenderness.fluoroquinolone x 7 days and initial long acting IV abx like ceftriaxonewhen should you consider hospital admission in a mildly ill pt with pyelonephritisif fever lasts >72 hrs or no clinical improvementHow do you manage this pt? 36 yr old female presents to ED with flank pain and vomiting x 2 days. Prior to this, she was experience dysuria and frequency. Temp is 104.1F and she is severely dehydrated.admit! - urine/blood cx plus renal imaging - empiric IV abx then adjust according to cx - once afebrile for 24-48 hrs, switch to PO abx - continue PO abx after discharge and f/u later for repeat cx and sensitivitywhat is acute bacterial nephritisbacterial interstitial nephritis of the renal cortex causing a renal mass but no liquefaction (aka acute lobar nephronia)Who is renal abscess more common inDM or immunocompromisedMC pathogens of renal abscessgram negative but if hematogenous spread then gram positive (like staph aureus)renal abscess tx- IV abx - percutaneous and surgical drainage - follow up imagingWhat is chronic pyelonephritis typically a result of?prior infections causing fibrosis/scarring of kidney leading to decreased functionChronic pyelonephritis clinical presentation (5)- HTN - anemia of chronic dz - proteinuria - renal insufficiency - recurrent UTIsradiographic findings c/w chronic pyelocalyceal bluntinggeneral treatment of chronic pyelonephritismanage UTI risk factors, control HTN, and consider nephrectomybladder cancer is the _____ most common cause of cancer death in males4thMC type of bladder cancerUrothelial carcinomaname the types of bladder cancerurothelial, transitional cell, SCC, and adenocarcinomaMC cause of bladder cancersmokingdudes/chicks have higher rate of bladder cancerdudes (male...)Name race with highest bladder cancer rate; what about lowest rate?highest → caucasian lowest → asianmuscle invasive bladder cancer treatmentcystectomyWhat are the 2 approaches used in cystectomy?robot assisted radical openOther than bladder cancer, why else would a pt need a cystectomyurinary incontinence and interstitial cystitistreatments for bladder cancer- TURBT - CBF (cystoscopy → bx → fulguration) - intravesical therapy - cystectomy