Board Review with The Chiefs. October 17, 2016 October 23, 2016

Transcription

1 Board Review with The Chiefs October 17, 2016 October 23, 2016

2 Overview Registration Exam Details Test Day Details Study Resources Study Strategies Women s Health Men s Health

3 What to Expect: Exam Registration Registration Period: December 1, 2016 to April 15, 2017 Process Register on website Token/ID comes in snail mail Sign up for dates (6 exam dates in August ) Cost $1,365 :( Can re-schedule/cancel on website

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5 What to Expect: The Test 240 questions total (4 sections, 60 questions) 2 hours per section (2 minutes/question) minutes break time + Tutorial/Pledge of Honesty (40 minutes) All multiple choice questions Clinical Calculator Audio and Visual

6 What to Expect: Exam Day Starts at 8 A.M.; end time is up to you (around 2:30 to 5:00 p.m) Sign-in Process 2 forms of non-expired I.D Breaks Lockers

7 After the test Immediately After: Celebrate/Cry Then, try to forget about it Exam results can take up to 3 months, but will usually come out in October NOT CURVED Passing ~ 67% - 70%

8 Study Resources MKSAP 16/17 MKSAP Board Basics MKSAP Question Bank MKSAP Extra Questions MKSAP Audio UWorld Question Bank MedStudy Review Books (ex: First Aid) Dasgupta s Board Review

9 Study Strategies When is optimal time to start studying? Is there anything that surprised you about the test? How did you study for this test? Any tips for exam day? Is there anything you wish you did differently?

10 Men s Health

11 Topics Androgen Deficiency Erectile Dysfunction BPH Acute Scrotal Pain Acute Prostatitis

12 Question 1 A 35-year-old man is evaluated for a 2-month history of low libido. The patient had a normal puberty. Family history is unremarkable. He drinks two beers per week and takes no medication. On physical examination, vital signs are normal; BMI is 23. Visual field examination findings are normal, as is testicular size. No gynecomastia is noted. Studies: Follicle-stimulating hormone: 6 mu/ml (6 units/l) Luteinizing hormone: 5 mu/ml (5 units/l) Thyroid-stimulating hormone: 2.5 µu/ml (2.5 mu/l) Total testosterone (4 PM): 200 ng/dl (7 nmol/l)

13 Which of the following is the most appropriate next diagnostic test? A.Measurement of serum ferritin and iron saturation levels B. Morning serum free testosterone measurement C.Morning serum total testosterone measurement D.Testicular ultrasonography

14 Androgen Deficiency Symptoms/Signs: Fatigue, decreased strength, poor libido, ED, gynecomastia Initial Test: 8:00 AM total testosterone levels If >350 ng/dl, the hypogonadism is excluded If <200 ng/dl, then obtain second confirmatory morning level (needs 2 measurements) If in between these values, then obtain serum free testosterone Sex Hormone Binding Globulin Low in obesity, Type 2 DM, hypothyroidism, acromegaly High in hyperthyroidism, HIV, hepatitis, patients taking anticonvulsants If low, check FSH/LH. If FSH/LH high = Primary Testicular Failure Ex: Klinefelter, Atrophy 2/2 mumps, AI destruction, hemachromatosis, Previous XRT or chemo If low or normal FSH/LH = Secondary hypogonadism Hyperprolactinemia, hypothalamic/pituitary disorders (ex: Sarcoid, hemochromatosis), Use of opiates/anabolic steroids, glucocorticoids Side effects of androgen replacement therapy: Worsening sleep apnea, increased hematocrit, BPH, dyslipidemia

15 Androgen Deficiency Side effects of androgen replacement therapy: Worsening sleep apnea, increased hematocrit, BPH, dyslipidemia Therapy contraindicated if patients with prostate nodules, breast or prostate cancer, PSA >4 ng/ml or 3 ng/ml and at risk for prostate cancer, hematocrit >50%, severe lower urinary tract symptoms. Do NOT screen for androgen deficiency in asymptomatic men, regardless of age

16 Question 2 A 72-year-old man comes to your office for a routine health exam. He mentions that he cannot maintain an erection, and is seeking help. He denies decreased libido or loss of morning erections. His PMH is significant for diabetes mellitus, peripheral vascular disease, and CAD with stable angina. He is a former smoker, but quit 25 years ago. He drinks 2-3 alcoholic drinks per night approximately 5 nights/week. His medication list includes aspirin, atenolol, isosorbide dinitrate, and glipizide. Patient s vitals are 98.7F, 138/78, HR 61. BMI is 25. Physical exam, including genital exam, is normal. You counsel him on lifestyle modifications. Three months later he returns, with no improvements after he stopped his alcohol consumption. 8:00 AM Testosterone levels are 394 ng/dl, HgA1C is 6.7.

17 What is the next step? A.Prescribe testosterone gel B. Prescribe sildenafil C.Offer intraurethral alprostadil D.Obtain LH and FSH levels E. Continue lifestyle modifications

18 Erectile Dysfunction Many causes Vascular Neurogenic Endocrine Trauma/XRT/surgery to perineal/pelvic region Antihypertensive /antidepressant/anticonvulsant/antiadrogen/nsaid use EtOH/Tobacco/cocaine/opiate/marijuana High-Yield Points: 1st line therapy: lifestyle modifications (smoking/etoh cessation, exercise, etc.) PDE inhibitors (sildenafil, vardenafil or tadalafil) Contraindicated in men who receive nitrate therapy and history of nonarteritic anterior ischemic neuropathy (NAIN) Intraurethral/intracavernous alprostadil Intracavernous alprostadil contraindicated in severe coagulopathy/thrombocytopenia

19 Benign Prostate Hyperplasia Symptoms: nocturia, urinary frequency, urgency, incomplete bladder emptying, urinary retention, decreased urinary stream Perform DRE, obtain baseline AUA symptom index score UA to rule out underlying infection PSA testing is not required for diagnosis, does not need to be followed for therapy Lifestyle modifications: reduced fluid intake, timed voiding, limiting caffeine and EtOH consumption, discontinuing exacerbating medications Medications: Peripheral alpha-blockers (ex: tamsulosin) and 5-alpha-reductase inhibitors (ex: finasteride) Surgical interventions: TURP vs open prostatectomy

20 Acute Scrotal Pain Testicular Torsion EMERGENCY/RAPID SURGICAL DECOMPRESSION More common in men younger than 30 y.o Acute onset pain, nausea/vomiting Exam: absent cremasteric reflex, elevated/high-riding testis Doppler US shows diminished flow to affected testicle Epididymitis Pain less acute than torsion usually; may be accompanied by lower urinary tract symptoms Younger than 35 yo: ceftraixone/doxycycline. Older men and men who practice anal intercourse: ceftriaxone + Fluoroquinolone Noninfectious epididymitis: caused by reflux of urine into epididymis, leading to inflammation Treatment: scrotal support, ice, NSAIDs

21 Question 3 A 28-year-old man is evaluated for a 6-month history of pelvic pain, urinary frequency, and painful ejaculation. He has been treated with antibiotics for urinary tract infections three times in the past 6 months, each time with temporary relief of symptoms but recurrence shortly after completion of antibiotics. On physical examination, vital signs are normal. There is minimal suprapubic tenderness with palpation. The prostate is of normal size with minimal tenderness and no nodules. Urinalysis shows multiple leukocytes, bacteria, and no erythrocytes.

22 Which of the following is the most appropriate treatment of this patient? A.1-week course of trimethoprim-sulfamethoxazole B. 1-month course of ciprofloxacin C.Cognitive Behavioral Therapy D.Finasteride

23 Prostatitis Symptoms: pain in perineum, testes, penis, or suprapubic area; dysuria, urinary frequency, incomplete bladder emptying Initial studies; UA w/micro, urine culture (only needs imaging if you suspect abscess) Category I: Acute bacterial prostatitis 4-6 weeks of bactrim/fluoroquinolone If requires hospitalization: IV fluoroquinolone +/- gent (also obtain blood cultures) Category II: Chronic bacterial prostatitis 4-6 weeks of fluoroquinolone Category III: Chronic abacterial prostatitis/chronic Pelvic Pain Syndrome (CPPS) Trial of antibiotic, but mostly supportive care (ex: NSAIDs, alpha blockers) Category IV: No symptoms (detected by biopsy or presence of WBCs in semen samples)