First Aid for the USMLE Step 2 CS

Section 3. Minicases

Other Urinary Symptoms

Key History

Duration, obstructive symptoms (hesitancy, diminished stream, sense of incomplete bladder emptying, straining, postvoid dribbling, leakage with cough or sneeze, incontinence), irritative symptoms (urgency, frequency, nocturia), constitutional symptoms; bone pain; medications; history of UTIs, urethral stricture, or urinary tract instrumentation; stones, diabetes, alcoholism.

OTHER URINARY SYMPTOMS (cant'd)

Key Physical Exam

Vital signs; abdominal exam (including suprapubic percussion to assess for a distended bladder); genital and rectal exams; focused neurologic exam.

Presentation

Differential

Workup

■ 60 yo M presents with nocturia, urgency, weak stream, and terminal dribbling. He denies any weight loss, fatigue, or bone pain. He has had 2 episodes of urinary retention that required catheterization.

Benign prostatic hypertrophy (BPH)

Prostate cancer

UTI

Bladder stones

Rectal exam UA

CBC

BUN/Cr

Alkaline phosphatase

U/S—prostate

(transrectal) PSA

■ 71 yo M presents with nocturia, urgency, a weak stream, terminal dribbling, hematuria, and lower back pain for the past 4 months. He has also experienced weight loss and fatigue.

Prostate cancer

BPH

Renal cell carcinoma

UTI

Bladder stones

Rectal exam

UA

CBC

BUN/Cr

PSA

U/S—prostate

(transrectal)

Prostate biopsy

Alkaline phosphatase

CT—pelvis

MRI—spine

■ 18 yo M presents with a burning sensation during urination and urethral discharge. He recently had unprotected sex with a new partner.

Urethritis

Cystitis

Prostatitis

Genital, rectal exams

UA, urine culture

Gram stain and culture of urethral discharge

Chlamydia and gonorrhea

PCR

■ 45 yo diabetic F presents with dysuria, urinary frequency, fever, chills, and nausea for the past 3 days. There is left CVA tenderness on exam.

Acute pyelonephritis

Nephrolithiasis

Lower UTI (cystitis, urethritis)

Renal cell carcinoma

UA, urine culture and sensitivity

Blood culture

CBC

BUN/Cr

U/S—renal

CT—abdomen

OTHER URINARY SYMPTOMS (cant'd)

Presentation

Differential

Workup

■ 55 yo F presents with urinary leakage after exercise. She loses a small amount of urine when she coughs, laughs, or sneezes. She also complains of vague low back pain. She has a history of multiple vaginal deliveries, and her mother had the same problem after the onset of menopause.

Stress incontinence

Mixed incontinence

Urge incontinence

Overflow incontinence Functional incontinence

UTI

Diabetes mellitus

UA, urine culture

BUN/Cr

Urodynamic testing

IVP

Cystourethroscopy

■ 33 yo F presents with urinary leakage. She is unable to suppress the urge to urinate and loses large amounts of urine without warning. She has a history of UTIs and a family history of diabetes mellitus. She drinks 8 cups of coffee per day. She has been under stress since her sister passed away a few months ago.

Urge incontinence

Mixed incontinence

Stress incontinence

Overflow incontinence

Functional incontinence

UTI

Diabetes mellitus

CBC

Electrolytes, BUN/Cr, glucose

UA, urine culture

Urodynamic testing

IVP

Cystourethroscopy

       

 

Erectile Dysfunction (Ed)

Key History

Duration, severity, ± nocturnal erections, libido, stress or depression, trauma, associated incontinence; gynecomastia or loss of body hair; medications (and recent changes); medical history (hypertension, diabetes, high cholesterol, known atherosclerotic vascular disease, prior prostate surgery, liver disease, thyroid disease, neurologic disease); smoking, alcohol, and drug use.

Key Physical Exam

Vital signs; cardiovascular exam; genital and rectal exams.

Presentation

Differential

Workup

■ 47 yo M presents with impotence that started 3 months ago. He has hypertension and was started on atenolol 4 months ago. He also has diabetes and is on insulin.

Drug-related ED

ED caused by

hypertension

ED caused by diabetes

mellitus

Psychogenic ED

Peyronie’s disease

Genital exam

Rectal exam

Glucose

CBC

Testosterone level





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