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214 Cards in this Set

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  • Back
What is the non-operative treatment for Hammer Toe?
pads and strapping to adjust the bones of the foot.
What is hammer toe?
abnl flexion position of proximal interphalangeal joint of one of the lesser 4 toes. small shoes, squeezing them together
What is the operative treatment of Hammer Toe?
Resection of the proximal interphalangeal joint. resection of the base of the proximal phalanx. resection of the distal third or fourth proximal phalanx. complete proximal phalangectomy. arthrodesis of proximal interphalageal joint.
what is the deformation in a bunion?
lateral deviation of the great toe
What is the non-op treatment of a bunion?
shoe modifications, excercise adjustments, and activities
what is the operative treatment of a bunion?
Chevron procedure
Akin procedure
what are corns?
hyperkeratotic lesions occuring over bony prominences and involving the stratum corneatum.
Clinically, corns are hard or soft, from pressure
what is the non-op tx of corns?
keratotic lesions should be managed non-op until a wide-variety of alternatives have been tried.
what is the operative tx of corns?
use a scalpel to remove the corn; correct a possible underlying deformity
what is the non-op tx of warts?
topical salicylic acid, liquid nitrogen, electrocautery
what is the op tx of warts?
what is the non-op tx of ingrown toe nail?
lift lateral edge from its embedded position
what is the operative treatment of ingrown toe nail?
removal of the toenail
what is a morton's neuroma?
interdigital neuroma. 3rd and 4th metatarsals, pain (burning, aching, cramping).
Third web space distal to the transverse inter-metatarsal ligament
what is carpal tunnel?
entrapment of the median nerve in teh carpal tunnel.
tingling, numbness of the median distribution. deep, aching pain, radiates up the forearm, thenar atrophy.
what are the diagnostic tests for carpal tunnel?
what are the surgical and non-surgical treatments of carpal tunnel?
injection of hydrocortisone into the carpal tunnel.
cutting the transverse carpal ligament
what is trigger finger?
digital stenosing tenosynovitis
anti-inflamm process involving the digital flexor tendon sheath.

Symps- hand pain, painful triggering, usually 1 digit, pain over the flexor tendon with resisted flexion, pain with passive stretching
what are some medical causes of trigger finger?
what are the treatments for trigger finger?
splinting, steroids, surgery
What is Acute Hematogenous Osteomyelitis?
in bone, hematogenous spread. in kids. metaphyseal capillaries turn sharply back and create turbulence. Increased pressure-> pain. children have severe pain at the end of the bone and guard the limb.
Where does the organism come form in acute hematogenous osteomyelitis?
0-3 months- from the vag
3 months-3 years- H. flu
all age groups- staph
adults- (after open fracture)
after total joint- staph epi
how do you work-up and treat osteomyelitis?
blood cultures and bone marrow aspirate
Tx- parenteral Abx to cover organisms appropriate for that age group.
Surgical- if no improvement in 24 hrs- open drainage
what is septic arthritis?
infection of the joint
can cause rapid destruction of the joint surface. in kids can cause osteomyelitis.
infects hip, elbow, shoulder.
what is the PEX and Rx of septic arthritis?
PEX- restricted movement, tender joint.
Rx- surgical incision of the joint, abcess drainage, joint debridement, irrigation, IV abtics, wound packed open.
What is cellulitis?
infection of the skin and underlying tissue caused by strep, staph, or other bacteria.
- erethema, warmth, edema, and pain.
Tx- empiric Abtics, aimed at staph and strep, dicloxicillin, erythromycin,
What is a felon?
infection of the top portion of the finger, pad of the skin above the first joint.
- staph aureus
- Tx- soak and abx
- surgical- cut and drain
What is a paronychia?
run around infection, S aureus to the soft tissue fold around the fingernail. associated with hang-nail and poor nail hygeine

HSV can be confused with this
What are the 4 kinds of meniscal tears?
What physical exam techniques can pinpoint a meniscal tear?
Squat walk- pain when squatting
McMurray- external rotation and valgus stretch (lateral), Internal rotation and vagus stretch (medial)
what is the Rx for meniscal tear?
treatment determined based on capacity to heal. look at tear length, tear location, tear pattern. Corrected by arthroscopy
how do you detect a torn ACL on PEX? What is the classic history?
anterior drawer sign
non-contact change of direction, deceleration, jumping. not able to get up. not able to resume activity.
What innervates the penis?
autonomic center is at the intermediolateral nucleus of the spinal cord at S2-4 and T12-L2.- thoracolumbar-> hypogastric plexus-> pelvic plexus (cavernous nerves)

Somatic erection center is in the ventral horn S2-4. motor fibers join the pudendal-> bulbocarvernous and ischiocarvernous muscles
Where does penile blood come from?
paired intermal pudendal arteries off of the internal iliac
What causes erections?
sexual stim and arousal cause neurologic events-> NO released-> increased cGMP -> corporal smooth muscle relaxation-> arterial dilation-> increased blood flow, decreased venous outflow.
what are common causes of erectile dysfuntion
Arterial- aging, atherosclerosis, DM

-trauma, (prostate, rectal surgery)
- spinal cord injury
- peripheral neuropathy (DM, alcohol, vitamins)
- MS

- hypogonadism (hypothalamic, pit tumor, egen anti-agen, orchiectomy)
- HyperPRL

Venous- blood leaks from corporal tissue

Drugs- SSRIs, anti-hypertensives
What is t he mechanism of sildenafil?
- inhibs phosphodiesterase which breaks down cGMP so smooth muscle relaxes like a mofo, and blood flow is crazy high.
What are the indicatiosn for sildenafil?
for men with organic or psychogenic cause of ED
what are the contraindications for viagra?
people on nitrates for CAD
- can cause extreme HTN
what are the SEs of sildenafil
headache ,flushing, dyspepsia, nasal congestion

loss of blue-green color discrimination
What is MUSE?
Medicated urethral system for erection
- urethral suppository (alprostadil)
- penile self-injection- papaverine, or phenoxybenzamine, phentolamine, Prosta E1-> art dilation

Vacuum erection device
- vacuum suction devie w/ a constrictive band placed at the base of the penis.
what are the complicaitons of penile prosthesis?
infection, prolonged pain, tenderness, and SST syndrome
what is SST syndrome?
inadequate length of a penile prosthesis can lead to ventral curvature of the glans.
What are the conditions associated with male infertility?
childhood- mumps, groin, scrotal, bladder surgery
Delayed or premature puberty
Previous viral- sperm takes 90 days
Medsd- cimetidine, macrodantin, azulfidine
toxin, marijuana, cigs
ejac dysfunction
teste failure
what are some gonadotoxins?
alkylating agents
anabolic steroids
egen disruptors
what fertility structure is disrupted in CF?
vas deferens
what labs to you get when working up infertility?
semen 2
immunobead test for antisperm abs.
monoclonal abs
what are the limits of adequacy for fertility?
ejaculate volume 1.5-5 cc
sperm density > 20 mil
Motility > 60%
Forward progression >2
- No significant sperm agglutination
No significant pyospermia, hematospermia, no hyperviscosity
what are some causes of stenosis?
what are the signs of ejaculatory duct obstruction on US?
seminal vesicle dilation
What is a vericocele? what is it's effect on fertility?
tortuocity and dilation of the of testicular vein in the cord. 90% on the left side.
causes infertility. correction improves sperm count, but not necessarily preggers.

Corrected by open and lapraroscopic methosds. inguinal and subinuinal approach.
what is the role of teste biopsy?
presence of sperm suggests obstructive azospermia
what are teh types of nonobstructive azospermia?
maturation arrest
sertoli cell only (germinal aplasia)
what are the indications of vasectomy reversal? what's the success rate?
indications: normal sized testes, non-elevated FSH, semen analysis showing presence of sperm indication some recanalization.

Success- 99.5% chance in semen if sperm are found. 50% preggers at 2 yrs
What are assisted reproductive technologies?
- Intrauterine insemination- sperm is collected, cleansed, and injected into the uterus.
- In vitro fertilization- removing eggs from the uterus, fertilizing, and transferring eggs tot he uterus. benifits males w/ very abnl sperm.

Intracytoplasmic sperm injection- injected directly into the egg cytoplasm, w/o motility, low number. sperm may be aspirated from the testicle in obstructive azospermia.
What are the symptoms of bacterial cystitis?
irritative voidding, dysuria, frequency, urgency, nocturia,. can have gross hematuria. NO fever.
what is the difference between recurrent and persistent infection?
recurrent- repeated infection by a different organism
persistent- same organism.
persistent means imaging for a source.
What factors promote UTIs?
Promote colonization

promote ascent
fecal incontinence
residual urine w/ ischemia

reduced urine flow
outflow obstruction
neurogenic bladder
inadequate uptake
What are the common bugs?
E. Coli

complicated- proteus, pseudomonas
what are indications for imaging in UTI?
Obstructive symps
History of urinary calculi
Neurogenic bladder
poor response to therapy.
what drug resistance is not carried by plasmid for UTIs?
what drug resistance is chromosomal?
What is the role of TMP/SMX in UTIs?
effective agains most pathogens, not pseudomonas or enterococcus

it is inexpensive
can cause skin rash, GI probs

Give for 3 days
What is the role of Nitrofurantoin in UTIs?
good for most pathogens, NOT psuedomonas or Proteus (Not for hospital aquired)
rapidly excreted into urine, not most body tissues (NOT upper UTIs)
GOOD: no effect on GI or vag flora

give for 7 days
What is the role of fluoroquinolones in UTIs?
highly ative against Enterobacter, psuedomonas, staph
poor anti-strep
normal vag, fecal flora cool
not nephrotoxic.

BAD: mad resistance in Europe.
What is the role of cephalos in UTIs?
high activity against enterobacteriaceae- not pseudomonas, enterococci
- less resistance among fecal bacteria.
- safe in preggers.
What are some urologic abnlties that cause resistance?
Ureteral stumps in nephrectomy
bladder cysts
chronic bacterial prostatitis
urethral diverticula
foreign bodies
what can cause a complicated UTI?
antimicrobial use
what are the causes of UTIs due to age?
anatomy- women
kids- reflux
young adults- sex, contraceptives
preggers- decresed ureteral tone, decreased ureteral peristaliss, temporary incompetence of the vesicoureteral valves; blatter cath at delivery.

Elderly- decreased bladder elasticity, emptying, neurogenic bladder dysfunction, 2ry to DM and other diseases. Bone demineralization.
What can be done to minimize frequency of infections?
cleanse genital and urinary regions front to back after bowel movements.
Avoid tight fitting pants
wear cotton crotch under wear, change 1nce a day
take showers, not baths
avoi bath oils, feminine hygiene sprays, douches, poweders.
sanitary napkins over tampons
urinate frequently.

keep genital and anal areas clean before and after
urniate before and after intercourse, to empty the blatter nad decrease bacteria
contraception w/o spermicide
avoid sex w/ multiple partners.
- topical estrogen helps.
What are the symptoms of pyelonephritis?
fever, flank pain, UTI, and costovertebral angle tenderness
what zone does BPH affect
what are the obstructive symps of BPH? what are the irritative symps
hesitancy, incomplete bladder emptying, dribbling, intermittence

irritative- frequency, urgency, nocturia
What is the method for determining level of symps of BPH
1-5 grade on the following:
feeling of unempty bladder
urinating at <2hrs
stopping and starting multiple times
difficult postponing urination
weak urinary stream
forcing pee
what is the normal size of the prostate
What is the role of PVR, urodynamic testing, Transrectal ultrasound
not the best, but can evaluate best therapy, can diagnose retention. can measure size.
What is the role of alpha-blockers?
help relax the prostate by blocking alpha receptors.

5-alpha-reductase inhibitors prevent growth of the prostate (finasteride)

Alphas are better for smaller prostates.
when should you use surgery in BPH?
>60g prostate
renal failure
poor emptying, recurrent UTIs
severe symps
What is the differenct between TURP and open prostatectomy for BPH?
TURP- through the urethra, minimally invasive.

open- done with >100 g prostate, large bladder stones, bladder diverticulum, concurrent inguinal hernia; rarely needs follow up surgery
What are the complications of urinary retention?
Poor bladder emptying
Urinary retention
Detrusor Instability
Renal insufficiency
What are the adverse effects of alpha blockers for BPH?
asthenia, postrual hypotension, dizziness, somnolence, nasal congestion
fatigue, hypotension, Edema, dizziness, dyspnea
How does prostate cancer present clinically?
early stage- no symps. can have obstructive voiding. W/ advanced disease may have pelvic pain, ureteral obstruction, or bone pain from mets.
What part of the prostate is affected in prostate cancer?
peripheral zone.
How do we screen for prostate cancer?
DRE- nodule, induration, assymetry
PSA- >4 is high and is associated with benign changes. PSA velocity of < .75 is acceptable. free PSA < 20-25% = cancer
High free PSA is more BPH.

Acid phosphatase- produced in the prostate, high in mets, but less sensitive than PSA. Means poor prognosis
How is Prostate Cancer staged?
Grading- gleason scores 5-7 is intermediate, 8-10 is bad, 2-4 is differentiated.

Staging- T0- none
T1- no clinical tumor
T1a- incdental hito of 5% or less
T1b- incidental histo > 5%
T1c- tumor by needle biopsy w/ elevated PSA
T2- tumor confined to prostate
T2a- tumor involves one lobe
T2b- tumor invovles both lobes
T3- Tumpor extends through the prostate capsule
T3a- extracapsular extension (unilateral or bilateral)
T3b- Tumor invades seminal vesicles
T4- Tumor is fixed or invades
What is the Treatment for localized prostate disease?
in men w/ < 10 yrs, observation may be appropriate.
Removal of the prostate and rads will treat. interstitial implantation.

LHRH w/ anti-androgen. Rx for 18-24 months.
What is the Rx for Mets prostate cancer?
LHRH and antiandrogen.
What are the different types of prostatitis?
symps- urinary frequency, urgency, dysuria. hesitancy, dribbling, difficulyt

acute- fever, back pain, chills, dysuria. boggy, warm gland. G-, E. coli. catheter placed, abcss nees resctoscope or needle aspiration

chronic- discomfort in the perineum, back, or pelvis. Urine-> WBCs. 6 wks of broad spectrum antibiotics

Nonbacterial Prostatitis- similar to chronic prostatitis, can treat with antibiotics, prostate massage, NSAIDS.
what are the common sites of prostate cancer mets?
spine, liver, lung, adrenal
What is the most common organism to infect the prostate?
gonorrhea, chlamydia in young adults
Acute- E. coli, enterobacter, serratia, pseudomonas, enterococcus, proteus

Nonbacterial- C trach, ureaplasma
What are the causes of hematuria?
Bladder Cancer
Cystitis (chemo, rads)
Kidney lesion
What are the differences between initial, termal and total hematuria?
initial- at beginning of urniation, disease distal to external sphincter (stricture, urethritis)

Terminal- end, proximal urethra, or bladder neck, (prostate)

Total hematuria- bladder or UTI.
What is microscopic hematuria?
Spun sample- > than 5 RBCs per HPF
Unspon- > 2 RBCs per HPF
> 3 confirms Dx
What is the workup for hematuria?
Hx- course, symps; color; drug use, DM, renal, FHx
PEX- ab, tenderness, kidney, bladder. GU exam, extrarenal clues for underlying diagnosis.

Imaging- IVP, US, CT, MRI
Cystoscopy- localize source
What is the DDx for a filling defect ona contrast study?
Common- Transitional cell carcinoma, blood clot, stones
Less common- fungus ball, sloughed papilla, fibroepithelial polyp
What aer the readiopaque stones in the Urinary Tract?
Ca Oxalate- RFs, Hx, metabolic disorders, poor hydration, immobilization.
MgNH- struvite (infection, organisms Proteus, Klebsiella, Psuedomonas)
Calcium Phosphate- PTH abnlties
Cystine- AR inheritance of defective AA transporter
What is the most common stone?
calcium oxalate
Formed by hypercalciuria- altered intestinal response to Vit D; increased Ca, increased Ca levels, depression of PTH function; restricting Ca intake can be helpful
What stones are radiolucent?
Uric acid- hyperuricosemia (lesch-nyhan, gout, cell turnover), dehydration, hyperuricosuria (thiazides, salicylates)

Medicines- Ephedrine, indinavir, triamterrene, rifampin

Matrix stones
Where are stones most likely to obstruct?
ureteropelvic junction
pelvic brim where uterers are crossed by the iliac vessels. Uterovesical junction.
What are the common signs and symps of stones?
sharp, intermittent colicky pain, flank, CV angle.
Can have nausea, vomiting
What is the history for symptomatic urolithiasis?
Hx- FHx (gout, cystinuria, Renal acidosis); Diet- water, Ca, Oxalate, NA; systemic disease- HyperPT, sarcoid, lymphoma
What does a UA in urolithiasis look like?
pH- uric acid, cystine=acidic; struvite=alkaline
What is teh blood workup doen for urolithiasis?
ca, P
uric acid
what is the radiography done in urolithiasis
KUB X-ray
Ultrasound- if IVP can't be obtained (preggers)
CT scan- radiolucent stones not on xray
what is the best management for urolithiasis, obstruction and fever?
obstructive pyelonephritis is an emergency- flank pain, fever, infected urine. Abtics are not sufficient. internal stend needed. or percutaneous nephrostomy. Removing the stone can cause sepsis.

>8mm do not pass w/o intervention.

stent, rigid ureteroscopy w/ stone fragmentation- best for distal ureteral stones.

shock wave lithotripsy- best in renal stones. (not staghorn, or > 2.5cm)

Uric acid stones can be treated medically. dissolve when pH is increased. alkalize urine., increase fluid.

< 5 mm, ureteral; treated w/ analgesics, hydration, serial x-ray.
Components fo metabolic stone eval
24 urnine collection, done 2x
- volume, pH, ca, uric acid, citrate, oxalate, phosphorus, Na and Creatinine
What is medical therapy for uric acid stones?
alkalize urine- NaHCO3, Kcitrate,
Limit purine and protein intake
Allopurinol- xanthine oxidase inhibitor
what ist eh management of CaOx stones if due to absorptivie hyperCa?
Diet- ca and Na restriction, increased fiber
Hydrate- no cola, fruit juice, tea
Cellulose phosphate- inhibs Ca absorbtion
Orthophosphates- decrease urinary excretion of Ca and increasae excretion.
What is the medical management of CaOx stones if due to renal hyperCa?
Thiazides- decrease renal excrestion of Ca; increase Ca reabsorp in distal tube.
What is medical management of CaOx stones if caused by Renal Tubular Acidosis?
Hydration, NaHCO3, NaK citrate to alkalinize the urine
What is the medical management of CaOx stones if due to hyperoxaluira?
Pyridoxine administration- lowers urinary oxalate levels
Restrict oxalate rich stones
What is teh management of CaOx stones if due to hyperuricosuria
Limit purines
What is the medical therapy for hypocitrateuria?
What are teh different mechanisms that result in stress incontinence?
- Urethral sphincter incompetence and poor coaptation of urethra lead to poor urethral resistance. Overcomes the resistance provided by the sphincter.
- when bladder neck is hypermoblie that leats to poor coaptation of the urethra. compromises perineal muscle support of the sphincter.
What is periurethral collagen injections?
Women who are not candidates for surgery and who have a mild degree of stress incontinence w/o bladder hypermobility
What is the treatment for detrusor instability?
What is the Marshall-Marchetti-Krantz procedure?
anterior abdominal approach. Bladder and urethra are dissected. sutures are in the vaginal fascia on either side of the bladder neck and the urethra.
When is a bladder sling used?
w/ urinary incontinence. urethral sphincter incontinence.
What is neurogenic bladder?
detrusor- parasymps. S3, S4;
Trigone and bldder neck- symps, T11-L2.
External Sphincter- S2, somatic. Disruption causes neurogenic bladder
Common causes of "failure to store"
any pathology that interferes w/ cerebral inhibition of bladder reflexes
- Tumor
- CP
- Dementia
- Neuro lesions above the brain stem
- Parkinsons
- MS
What are the common causes of "failure to empty"
path that interupts sensory pathways
-tabes dorsalis
- diabetes
- syringomelia
- pelvic surgery
- Herpes
- anemia
What pharm encourages bladder emptying?
cholinergic agonists (stim detrusor), alpha blockers.
intermittent catherterization.
what are some drugs that inhib bladder emptying?
what are obstructive voiding symps?
hesitancy, decrease in force, dribbling, intermittence, feeling of incomplete emptying
what path can cause obstructive symps?
BPH, cancer, stricture of urethra

Neurogenic- tabes, DM, syringo

What is the workup for obstructive symps?
urodynamics- PVR volume, urinary flow rate, urethral pressure profile, phyincter electomyography, fluoroscopic cystography.
What are the irritative voiding symps?
frequency, urgency, nocturia, dysuria
What is the path of irritative voiding symps?
Bladder Cancer
What is the workup for irritative voiding symps?
Post-void residual
How would one distinguish neoplastic, infectious and neuromuscular etiologies of irritative voiding symps?
neoplasm- PSA, ultrasound

infection- fever, chills, dysuria, rapid onsed. swollen, warm, tender prostate

Neuromuscular etiologies- anti-ch
how does obstruction of the bladder neck cause irritative symps?
increased pressure on the bladder-> urgency.

can predispose one to infection.
what is the management for irritative symps?
H&P, UA, Urine culture
Abx if pos
if neg- urodynamics.
if obstruction- alpha blocker
if sphincter/bladder- anticholinergic.
Whis is Phimosis?
inability to retract foreskin
- Rx- hygiene, elective circumcision
What is paraphimosis?
foreskin stuck retracted
Rx- emergency, incision or full circumcision
What is testicular torsion?
infants- extravaginal- painless swelling of teste. loss of cremaster reflex, epididymus in abnl locatio, testicle may be bluish.

adolescent- intravaginal- sudden onset of inteste pain, swollen, generalized teste tenderness; possible retraction.

Rx- manually untwisting. Or emergent surgical intervention.
What is the difference between epididymitis, torsion and tumor?
epididmytis- slow onset, pt is comfertable except when epididymus is examined. Moderate pain, pyuria, swollen. Still have cremater. Tenderness on palpation (Tx- abtics)

Tumor- solid, painful, indurated mass

torsion- sudden onset, intense pain.
What scrotal masses transilluminate?
Hydrocele- change in size w/ activity (grows as the day goes. surgery- ligate w/ communicating processus vaginalis
Spermatocele- fluid filled cyst w/ sperm, smooth, spherical, usually at the head of the epididymis in adolescence. Tx- not necessary unless it continues to enlarge
Epididymal cyst- fluid filled cyst w/o sperm. Tx unneccesary unless it enlarges
What are the causes of epistaxis?
Nose Picking
Sinus Infection
Allergic/Atrophic rhinitis
What are the Rx for a bloody nose?
direct pressure
Ant. bleed- 90%
- Kiesselback's plexus, nasal packing, IR embolization of ethmoidal artery

Post bleed- 10%
- sphenopalatine artery
Tx- foly catheter in the nose and filled w/ saline, pack nose w/ foly to sandwich the bleed. IR, embolize sphenopalatine artery
What is scoliosis?
lateral curvature of the spine > 10 degrees, usually thoracic or lumbar. Rotation of vertebrae.

Mobile- Could be caused by bad posture, muscle spasm from a disc, shor leg.
fixed- rotational deformity, not correctable by posure.

congenital deformities, neruo symps, neurofibromatosis. (usually at a young age and rapid progression, usualy have neural tube defect.
What are the clinical symps of scoliosis?
appears in early adolescence, girls > boys. 10-16 y/o. "child's close do not 'hang' correctly" Pain means a bone tumor, tethered spinal cord or other abnlties.
noticed when bending forward. (trunk is laterally shifted) (decompensated)
what is the progression of scoliosis?
lung damage, spinal joint pain.
What is the Rx for scoliosis?
small- observation, brace if > 50 degrees.
w/ neuromuscular disorder- surgery.
What's kyphosis?
gentle posterior curve of the normal thoracic spine of 20-40 degrees is normal. more than that is kyphosis
What is the Rx for Kyphosis?
thoracisspine in skeletally immature pts w/ a milwakee brace. Surgery for > 75 degrees, pain, or unresponsive bracing
What is lumbar radiculopathy?
referred neurogenic dysfunction in the leg. Sciatica is most commonly an irritation of the fith lumbar or first sacral nerve roots. Result of herniated disc.
What is the Rx of sciatica?
NSAIDS, could last only 6 wks. Sit as little as possible, more lying and standing. Bed rest can help at first. Should resolve. Most will improve in 2 wks.
What is lumbar degenerative disk disease?
chronic low back pain, longer than 3 months. recurrent, episodic. some have unremititng. Improvement in disability is the most important goal. Trauma, infection, heredity, and tobacco. Disk loses height, tight ligaments become loose-> sliding, twisting-> tears
What is the Rx for lumbar degenerative disk disease?
NSAIDS, antidepressants. Physical activity, exercise, weight reduction is important.
what nerve is affected when the patellar reflex is out? The achilles?
L4- patellar, ant tib out, medial leg out
S1- achilles, peroneus longus and brevis, lateral foot sensation out
L5- no reflex, extensor hollicus longus, lateral leg and dorsum of foot.
How does TCC present?
gross painless hematuria, microhematoria
- bladder irritability, increased frequeny, urgency, and dysuria. (in situ, invasive)
- flank pain from ureteral obstruction
- Lower extremity edema
- Pelvic Masses
- symps of advanced disease- ab pain, bone pain, weight loss
what are the risk factors associated with bladder cancer?
cigarretes; industrial carcinogens. rubber/textile, coal/oil
auto workers, truck drivers
analgesic abuse- phenacetin
pelvic rads
What is the workup for bladder cancer?
urine cytology, malignant urothelial cells.
Bimanual exam
Cystoscopy- look for tumors
IVP- large tumors filing defect.
retrograde pyleogram, for pts w/ contrast allergy or poor visualization.
CT scan
When is transurethral resection done for TCC?
transurethral resection- low risk of recurrence- small, single, low-grade tumors, normal DNA ploidy, limited to urothelium.
What intravesical therapy done for TCC? When is it used?
bacillus Calmette- Guerin- standard
thiotepa, mitmycin C, interferon.

Used for people with high chance of recurrance- multiple, high-grade, abnl DNA ploidy, Carcinoma in situ, tumor penetration into lamina propria
What is the treatment for invasive bladder cancer?
radical cystectomy
Males- removal of the bladder, prostate, seminal vesicles, proximal urethra, proximal vas deferens, margin of adipose tissue and peritoneum.

Females- removal of bladder, urethra, uterine tubes, ovaries, anterior vaginal walls, fascia

Chemo- MVAC- methotrexate, vinblastine, adriamycin, cisplatin
What is the standard management for TCC involving the renal collecting system and proximaal ureter?
Conservative- pyelotomy, partial nephrectomy
- single, low-stage tumors; preserves renal function

Radical surgery- nephrectomy, nephroureterectomy- large, high-grade, invasive tumors

Rads and chemo
What ist he management for TCC involving the ureter?
1. biopsy and ablation
2. open surgical excision.
- ureterectomy, ureterstomy- for non-invasive, low-grade tumors of proximal ureter or large distal tumors that can't be removed enoscopically.

- rads and chemo.
How do you stage TCC?
Cytological and cystoscopiceval w' imaging, CT, MRI, US< Chest radiograph, bone scan, etc.

Superficial vs. invasive
Localized vs. mets

T1- invasion into lamina propria
T2- invasion into muscle
T3- invasion into fat
T4- invastion into visera
N1- node less than 2cm
N2- node 2-5cm or multiple nodes
N3- nodes > 5cm
M0- no distal mets
M1- distal mets
What is the chemo for mets of TCC?
MVAC- methotrexate, vinblastine, adriamycin, cisplatin
- complete response in 20%
- rare long-term disease free survival is rare
- tox- neutropenia, fever, sepsis

Gemcitabine- sincle chemo or w/ cisplatin
Taxans- (paclitaxel, docetaxel)
Who is at risk for testicular cancer?
20-34 men
Cryptorchidism- 5-10% of pts.
Aquired- Trauma, DES moms, atrophy- mumps
What are the common signs and symps of teste cancer?
nodule or painless swelling of one gonad. 30-40% complain of dull ache, or heavy sensation, 10% pain.

10% present from mets. Neck- cough/SOB, anorexia, nausea, vomiting, hemorrhage, Bone Pain

Gynecomastia in 5%
What is the role of AFP, bHCG, and LDH?
AFP- youlk sac; embyonal carcinoma, teratocarcinoma, yolk sac, combined tumor
1/2 life is 5-7 days

bHCG- germ cells. Syncytiotrophoblastic cells. Choriocarcinoma; 40-60% w/ embryonal carcinoma, -10% w/ seminoma

LDH- LDH compares directly to tumor burden; Short serum half-life of 24 and 36 hrs. makes it a good marker for evavluation of Rx response. Higher the LDH, worse the bprognosis.
What is teh reasons for orchiectomy as proper Rx?
histologic diagnosis; controls locally w/ 100% effectiveness.
Cure of pts w/ tumor confined to the testis
minimal morbidity and mortality
How is teste cancer staged?
I- tumor limited to testis w/ no evidence of spread through the capsule or to the spermatic cord
Stage II- clinical or rads evidence of tumor extension beyond the testicle but contained w/in the regional lymph nodes.
Stage III- disseminated disease above the diaphragm.
What are the sites of lymph node mets in teste cancer?
Right- ineraortal caval lymph nodes then precaval, preaortic, paracaval nodes

Left- primary to perihilar/aortic para-aortic nodes just belw left renal vein and to the preaortic nodes.
what chromosome is involved in testis cancer?
12p, in >80%, worse prognosis, more chemoresistance
WHat is the management of a low-grade seminoma?
inguinal orchiectomy plus 3 wk rads to lymph nodes.
What is the management of advanced stage of seminoma?
irradaiton is only effective in 50%. Rx of choice is chemo, compo of cisplatin, vinblastine, and bleomycin
What is the management of low stage mixed germ cell tumor?
radical orchiectomy

if > 5 nodes, plus PEB (cisplatin, etoposide, bleomycin)
How do you manage an advanced staged mixed germ cell tumor?
advanced stage- radical orchiectomy plus PEB
observe if good response. If partial response, RPLND.
If cancer after RPLND, or after PEB, give VIP (vinblastine, ifosfamide, cisplatin)
What are the side effects of:
cisplatin- renal, nausea, neuropathy
etoposide- myelosuppresion, alopecia, renal insufficiency, 2ry leukemia
Bleomycin- pulm fibrosis
what is the efficacy of PEB in teste cancer?
favorable in 60%
When does ejaculatory dysfunction occur after RPLND?
sympathetic nerves at the thoracolumbar level control erection;
Iatrogenic damage occurs, leads to infertility by failure of seminal emission, ejac
Who is most at risk for penile cancer?
dirty old uncircumcised men.
What is teh presentation of penile cancer?
Suppuration of lesion
Symps are related to pain and discomfort
what are the implications of enlarged inguinal lymph nodes
may be the result of infection or mets. Delay 4-6 wks, Rx- abtics for this time. If persists=mets.
What are the borders of the femoral triangle?
inguinal ligament
adductor longus
what is the management of in situ penile cancer?
laser fulguration, exicion, topical -FU
What is the indication for partial vs. total penectomy?
partial- > 2 cm margin of normal tissue;
total for larger dital or proximal tumors
what is the rational for inguinal lymph node dissections in the managemen tof penile cancer?
sentinel nodes at junction of saphenous and femoral veins are the first site of mets; if neg biopsy, ilioinguinal lymph nodes are not necessary.
How is staging doen for penile canccer?
Jackson Classification for SCC:
Stage 1- limited to glans
Stage 2- invasion of corpora
Stage 3- to the nodes
Stage 4- distant mets
What are some of the management options available to pts w/ mets?
scrotum, pubic, ab wall-> radical excision.
- chemo.
What is the viral etiology for penile cancer?
HPV 16/18, 31,33,39
What is the classic triad of RCC?
Hematuria, Flank Pain, palpable flank mass.

(fever, increased ESR, anemia)
How do you distinguish cystic and solid masses w/in renal parenchyma?
Ultra sound- detects density;

solid mass- on Cat scan
How do you stage RCC?
T0 no primary tumor
t1- 7cm or less
T2- 7cm or more
T3- extends into major veins, or invades adrenal; not beyond gerota's fascia
T3a- adrenal or perinephris, not beyond gerota
T3b- grossly extends into renal veins below diaphragm
T3c- above the diaphragm
T4- invades gerota's facia.
When do we observe RCC?
< 3cm
What are nephron sparing surgeries?
partial nephrectomy- done in bilateral tumors, solitary kidneys, global renal insufficiency, polar tumor < 4 cm.

remove upper or lower pole
radiofrequency ablation.
what is the management of mets RCC?
sites of mets- lung, liver, bone, brain
Nodes- R- hilar, interaortocaval, lateral pericaval, mediastinu; L- hilar, lateral para-aortic, retrocrural, cisternal chyli, mediastinum
What are the differences in leasions in inherited vs. aquired lesions
inherited- multiple small lesions
aquired- single large lesion.
What are the 3 congenital renal carcinomas?
VHL- 3p25- clear cell RCC; (can have retinal/CNS hemangioblastomas; pheos; pancreatic cysts and neuroendocrine tumors; endolymphatic-sac tumors; epididymal and broad-ligament

Birt-Hogg-Dube- 17p11. Hybrid chromophobe RCC, oncocytic, clear cell; cutaneous papules, lung cysts
HPV- what is the presentation, what is the Rx
presentation- cutaneous warts well demarcated hyperkeratotic papules w/a rough surface occuring most commonly on dorsum of hand, between fingers, around nails, rarely on mucosal layers.

Anogenital warts- flesh to gray-colored, hyperkeratotic ; can experience burning, pain, itching, tenderness

Rx- topical salicylic and lactic acid pain for up to 12 wks. 69% cure, cyrotherapy 67%

anogenital- no good treatment, cryotherapy, topical podophyllin resin are common attempts at treatment
HSV II, what is the presentation, treatment?
presents asymptomatic in prostate or urethra of men and cervix of women; these people serve as carriers for disease

Genital Herpes- painful vesicular lesions in genital/perianal area; more severe and protracted in primary disease than in recurrences
Neonatal herpes- virus transfer through placenta to fetus from infected mother during delivery; congenital defects, abortion, neonatal encephalitis

Rx- acyclovir
what is the presentation of and Rx for gonococcal urethritis?
men- urethritis w/ dysuria, purulent discharge.
Women- endocervix, purulent vaginal discharge and intermenstrual bleeding
40-60% may be asymptomatic

Rx- ceftriaxone and tetracycline
What is non-gononcoccal urethritis? Rx?
chlamydia or urealyticum
dysuria, urethral discharge, itch, must exclude GC as a cause.

As w/ GU, many infections are asymptomatic.

Rx- azithromycin or doxycycline
Treponema Pallidum, what is 1ry, 2ry, 3ry? How do you Dx? How do you treat?
1ry- painless penile sore. small red papule, breaks down to form an indurated, punched out leasion.

2ry- 6 wks after chancre- condyloma lata, maculopapular rash on palms, soles, meningitis, arthritis, hepatitis
3ry- gummas, CV, CNS

Dx- scrapings should be taken from the base of the chancer and examined by darkfield or fluorescent antibody technique
Rx- penicillin
What does AIDS do in male genitalia?
penile and urethral infections. increased risk of genital tract infections w/ herpes, HPV, and syphillis-> atypical and prolonged infection

Prostate- opportunistic

Testes, scrotal infections ususally present as epididymoorchitis; epididymis w/ HIV 2ry to tubular obstruction.
What is the presentation of cervical radiculopathy and myelopathy
What is the radiographic eval and Rx options for radiculopathy and myelopathy?
cervical myelopathy- neck pain, referred pain to scapular region, arm, and hand
- pain with straining, coughing, sneezing, and spinal motion
- disc herniation: single nerve
- servical spinal stenosis: several spinal levels, may affect 1 root more severely. If severe: LMN weakness and numbness or radicular pain in arms and UMN weakness in legs

- disk- radicular numbness, weakness, w/ innervation of a single nerve root as well as reflex loss

C4-5- delt, C5-6- Biceps, C6-7- Triceps

Emergent if acute or subacute spinal cord compression. Uncomplicated- no spine film
Chronic spine- CT does not show herniations well
MRI and CT myelograms- most informative.

Rx- rest for symptomatic segment, analgesics, anti-inflam, muscle relaxants; collar to limit motion.

Surgery- pts w/ no progress, worsened condition, marked weakness
Lumbar Radiculopathy:
Presentation of lumbar
Radiographic eval and Rx options for lumbar radiculopathy
disk- low back and leg pain, worse on weight bearing
Spinal stenosis- leg pain mimics disc disease, leg pain numbness, chronic weakness, bilateral, widespread. Increased after a distance. Similar to vascular.

Signs- disc herniation- radicular numbness and weakness of single nerve root

Spinal- radicualr numbness of many roots. positive straight leg raise
anteflexed position when standing and walking
pain worsens on bending backwards.

pint tenderness on lumbar spine, paraspinal muscle spasm. limited range of spinal motion. Observe gait.

Emergent if: sphincter dysfunction, sudden bilateral leg pain or numbness, bilateral foot weakness, disruption of bladder function.
what is the surgical Rx for cervical disk disease?
excision w/ microscope
percutaneus technique can be used.
Standard techniques for cervical and lumbar discectomy- posterior approach w/ limited removal of lamina on the side of the herniation.
- excision of ligamentum flavum
retraction of the root
removal of disc

ant approach also possible
presentation, workup, Rx for scoliosis?
lateral curvature > 10 degrees, thoracic or lumbar.
Idiopathic- early adolescence, girls 7x more likely to get it. Between 10 and 16 y/o. cltohes don't hang right.

Rx- idopathic curves, not needed. brace reserved for > 50%
presentation, workup, Rx for kyphosis
> 20=40 dgerees.
skeletally immature pt w/ milwaukee brace until maturity. Surgery reserved for select cases w/ curves > 75 degrees. have pain or are unresponsive to bracing.
what is the mech of injury, appropriate rads eval and Rx for the hip?
low energy in elderly. femoral neck, intertrochanteric. -cannot bear weight.

Femoral neck, Reduction- vascular supply- medical lateral circumflex. Fixation- younger patients. Prosthetic- old.

Intertochateric fracture is extracapsular, has a good blood supply and usually heals. Reduced w/ radiographic guidance. Fixed w/ screw, sideplate device. Surgery allows for patient mobilization and decreases problems related to prolonged bed confinement
what is the mech of injury, appropriate rads eval and Rx for the tibial shaft?
Shaft of the tibia and fibula occur far more often than the femur. Limited blood supply causes healing difficulty. risk of compartment syndrome. Rx complications are the most frequent cause of malpractice.

Closed redcution and above the knee cast immobilization are the standart treatment.
Open reduction and internal fixation used when acceptible reduction cannot be obtained.

External fixation
what is the mech of injury, appropriate rads eval and Rx for the Colles?
falling on an outstretched hand- transverse fracture of the distal radius, just proximal to the wrist.

Reduction maneuver- hyperextension o f the wrist deformity. Manual traction. Wrist and distal fragment are manipulated into flexion and ulnar deviation to correct the dorsal and radial displacement. Xray at 10 days

Complicatons- median nerve.
what is the mech of injury, appropriate rads eval and Rx for the Scaphoid?
tenderness in anatomic snuff box
what is the mech of injury, appropriate rads eval and Rx for the hip?
low energy in elderly. femoral neck, intertrochanteric. -cannot bear weight.

Femoral neck, Reduction- vascular supply- medical lateral circumflex. Fixation- younger patients. Prosthetic- old.

Intertochateric fracture is extracapsular, has a good blood supply and usually heals. Reduced w/ radiographic guidance. Fixed w/ screw, sideplate device. Surgery allows for patient mobilization and decreases problems related to prolonged bed confinement
what is the mech of injury, appropriate rads eval and Rx for the tibial shaft?
Shaft of the tibia and fibula occur far more often than the femur. Limited blood supply causes healing difficulty. risk of compartment syndrome. Rx complications are the most frequent cause of malpractice.

Closed redcution and above the knee cast immobilization are the standart treatment.
Open reduction and internal fixation used when acceptible reduction cannot be obtained.

External fixation
what is the mech of injury, appropriate rads eval and Rx for the Colles?
falling on an outstretched hand- transverse fracture of the distal radius, just proximal to the wrist.

Reduction maneuver- hyperextension o f the wrist deformity. Manual traction. Wrist and distal fragment are manipulated into flexion and ulnar deviation to correct the dorsal and radial displacement. Xray at 10 days

Complicatons- median nerve.
what is the mech of injury, appropriate rads eval and Rx for the Scaphoid?
tenderness in anatomic snuff box
contusion of nerve
nerve crush