OSCE MASTER — GI · GU/RENAL · REPRO

Combined master for the Term III graded OSCE | Last updated 2026-06-01 | ~90 conditions across 3 blocks
Sections per condition: Hx · ROS · PE · Dx · DDx · MDM · Tx · Pt Ed · Emergency Precautions

🛠️ Station Playbook — 20·10·30

The exam is 20 min H&P → 10 min oral A/P → 30 min SOAP note. AI is prohibited during the SOAP note. Static reference docs and hard-copy are allowed.

Phase I — H&P (20 min)

Phase II — Oral A/P (10 min) · Template

"This is a [age] [sex] presenting with [CC] for [duration].
Pertinent positives include … · pertinent negatives include …
Exam: vitals stable/abnormal at … · heart … · lungs … · abdomen … · [system-specific].
My assessment is most likely [leading Dx] because [reasoning].
Differential: [Dx 2] — less likely given …; [Dx 3] — ruled out by …; [Dx 4] — would expect …
Diagnostic plan: [labs / imaging / point-of-care].
Management plan: [acute stabilization · medications · procedures · disposition · patient education · follow-up · safety-net]."

Phase III — SOAP Note (30 min) · Skeleton

⚠️ Use this for memorization tonight, NOT as a copy-paste template in Canvas. Write the SOAP in your own structure tomorrow — a verbatim mirror of this layout (em-dashes, ← always documented annotations, bracketed slot tags) could read as AI-assisted to a grader.

S — Subjective
  CC: [one line]
  HPI: OPQRST narrative
  PMH/PSH: …       Meds: …        Allergies: …
  SH: …            FH: …
  ROS: [10-system focused — note positives + pertinent negatives]

O — Objective
  Vitals: T __  HR __  BP __  RR __  SpO2 __
  General: …
  HEENT: …
  CV: regular rate/rhythm, no murmur/rub/gallop  ← always documented
  Pulm: clear bilaterally, no wheeze/crackle      ← always documented
  Abd / GU / Pelvic / Breast / MSK / Neuro / Skin: focused
  POC: UA / β-hCG / fingerstick if provided

A — Assessment
  1. [Leading Dx] — supporting features: … / against: …
  2. [DDx #2] — supports: … / against: …
  3. [DDx #3] — would rule out with: …

P — Plan (numbered per problem)
  Diagnostics: [labs / imaging / cultures / special tests]
  Treatment:   [medications with dose/route/freq · IVF · procedures · consults]
  Patient Ed:  [diagnosis explanation · lifestyle · medication counseling]
  Disposition: [admit / discharge / observe]
  Follow-up:   [interval · with whom]
  Return precautions: [red flags → return now]

Universal Reminders

• Hand hygiene twice (on entry · before exam) — explicitly graded.
• Auscultate heart + lungs every encounter — per the doorway instructions.
• Acknowledge vitals even if "normal."
• Pertinent positives AND pertinent negatives — both score points.
• Don't perform maneuvers that don't help — focused beats exhaustive.
• Keep DDx broad early, narrow with data.
• If you forget a step, stay calm and continue — clinical reasoning > checklist.
• Sensitive exams (pelvic, GU, breast): explain why, offer chaperone, drape, ask permission.
• Always β-hCG in a reproductive-age female with abdominal pain or bleeding.
• Offer DRE when considering prostate, anorectal, or lower GI bleeding pathology — explain why, gain consent, offer chaperone.
• Close with: 1-line summary in plain English + education + return precautions + questions.

⭐ Most Likely Stations (Predicted) — by Block

Educated guess, not insider info — review these last; don't skip the other ~70.

GI · top 6

1. Acute Cholecystitis — 5 F's, fatty-food RUQ, Murphy sign, US → chole.
2. Appendicitis — periumbilical→RLQ, McBurney/Rovsing/psoas/obturator, β-hCG before CT.
3. GERD / PUD — alarm-feature screen + lifestyle + PPI + H. pylori test-and-treat.
4. Acute Pancreatitis — epigastric→back, lipase >3× ULN, LR resuscitation.
5. Diverticulitis — older + LLQ + fever → CT → antibiotics → colonoscopy in 6 weeks.
6. Acute GI Bleeding — stabilize first; BUN:Cr >20 = upper; cirrhotic → octreotide + ceftriaxone before EGD.

GU/Renal · top 6

1. Acute Cystitis vs Pyelonephritis — fever + CVA tenderness is the pivot; UA + culture; nitrofurantoin/TMP-SMX vs IM ceftriaxone → PO.
2. Testicular Torsion — acute scrotal pain, absent cremasteric reflex, high-riding horizontal lie, US Doppler, surgery <6 h.
3. Nephrolithiasis — colicky flank→groin, non-contrast CT, hydration + α-blocker (tamsulosin) for stones <10 mm.
4. BPH — LUTS in older man, IPSS, DRE smooth/enlarged, α-blocker ± 5-ARI.
5. AKI — prerenal vs intrinsic vs postrenal: FENa, sediment (muddy brown = ATN), renal US.
6. Hyperkalemia — EKG: peaked T → widened QRS → sine; Ca → insulin/D50 → albuterol → diuresis/Kayexalate → dialysis.

Repro · top 6

1. Ectopic Pregnancy — can't-miss; classic triad pain + spotting + amenorrhea; β-hCG + TVUS; MTX vs surgery.
2. Preeclampsia / Eclampsia / HELLP — BP ≥140/90 after 20 wk + proteinuria/end-organ; MgSO4 + antihypertensives + delivery.
3. PID — pelvic pain + CMT; treat empirically; Fitz-Hugh-Curtis = RUQ pain.
4. Ovarian Torsion — sudden unilateral pelvic pain + mass ≥5 cm; whirlpool sign; surgery <12 h.
5. Vaginitis trio — BV (fishy, clue cells, pH >4.5) vs VVC (curd, normal pH, pruritus) vs Trich (frothy, strawberry cervix).
6. Postpartum Hemorrhage — 4 T's (Tone-Trauma-Tissue-Thrombin); atony #1 → oxytocin + massage.

Block Index

• GI · Gastrointestinal — 33 conditions
• GU/RENAL — 27 conditions
• REPRO · Reproductive — 30 conditions

Use the sidebar to jump to a specific condition.

GI · GASTROINTESTINAL

ESOPHAGUS

1. GERD

Epidemiology: Very common; risk factors: obesity, hiatal hernia, pregnancy, late-night eating, alcohol/caffeine/nicotine, ~2/3 of patients have NERD (no erosions on EGD).

Critical History Questions

• Retrosternal burning, worse postprandial and when supine/bending over?
• Regurgitation, water brash, sour taste in mouth (esp. morning)?
• ⭐ Alarm symptoms? — dysphagia, odynophagia, weight loss, GI bleeding/melena, anemia, vomiting, age >50 new onset
• Chronic cough, hoarseness, sore throat, globus (extraesophageal)?
• Symptom triggers: large/fatty meals, chocolate, caffeine, alcohol, citrus, lying down after eating?
• NSAID use, smoking, alcohol?

ROS

• GI: heartburn, regurgitation, nausea, dyspepsia, dysphagia (if stricture/Barrett's)
• ENT/Pulm: chronic cough, hoarseness, wheezing, recurrent laryngitis
• Constitutional: ⭐ weight loss = alarm → escalate to malignancy DDx

Physical Exam

• Often normal
• Epigastric tenderness possible
• Assess BMI (obesity is modifiable driver)
• ⭐ No alarm findings (no lymphadenopathy, no occult blood on rectal) in uncomplicated GERD

Diagnostics

• ⭐ Clinical diagnosis with typical symptoms + no alarm features → empiric PPI × 8 weeks
• EGD if alarm symptoms or failure of empiric therapy
• 🔹 Ambulatory pH (Bravo) study if diagnosis uncertain
• Manometry only if surgery (fundoplication) considered or to exclude achalasia

DDx

• PUD (epigastric pain, H. pylori/NSAID)
• Achalasia (dysphagia to solids AND liquids)
• Esophageal cancer (progressive dysphagia + weight loss)
• Cardiac chest pain (rule out first if any concern)
• Eosinophilic esophagitis (young atopic male, food impaction)
• Biliary colic (postprandial RUQ pain)

MDM

• Typical symptoms, no alarms → empiric PPI + lifestyle
• Alarm symptoms OR age >50 new onset OR PPI failure → EGD/GI referral
• Long-standing GERD (>5 yr) → scope to evaluate for Barrett's

Treatment

• Lifestyle ⭐: weight loss, elevate head of bed, avoid late meals, reduce alcohol/caffeine/acidic/fatty foods, smoking cessation
• ⭐ PPI (most effective) — once daily before breakfast × 8 weeks; step down to lowest effective dose
• H2 blocker (famotidine) for mild/intermittent or nocturnal breakthrough
• Antacids for rapid symptomatic relief
• Refractory/volume regurgitation → Nissen fundoplication

Patient Education

• Take PPI 30–60 min before first meal of day
• Lifestyle is the foundation — especially for NERD where lifestyle > meds
• Long-term GERD increases Barrett's/adenocarcinoma risk — report new dysphagia or weight loss
• Symptom recurrence after stopping is common — discuss step-down vs. on-demand therapy

Emergency Precautions

• Dysphagia + weight loss + anemia → urgent EGD (rule out adenocarcinoma)
• New GI bleeding (melena, hematemesis) → stabilize → EGD
• Chest pain mimicking cardiac → do not anchor on GERD; rule out ACS

2. Achalasia

Epidemiology: Adults, no sex predilection; idiopathic loss of inhibitory neurons → failure of LES relaxation + loss of peristalsis. Chagas disease is a secondary cause.

Critical History Questions

• ⭐ Dysphagia to BOTH solids AND liquids (simultaneously, from onset)?
• Regurgitation of undigested food, especially nocturnal?
• Substernal chest pain, globus sensation?
• ⭐ Weight loss? (raises concern for pseudoachalasia/malignancy)
• Aspiration, nocturnal cough, recurrent pneumonia?
• Duration and progression (achalasia = slowly progressive)?

ROS

• GI: dysphagia, regurgitation, chest pain, weight loss
• Pulm: nocturnal cough, recurrent aspiration pneumonia
• Constitutional: weight loss, malnutrition in advanced disease

Physical Exam

• Often normal early
• Signs of weight loss/malnutrition in advanced disease
• Aspiration findings on lung exam (crackles) if recurrent

Diagnostics

• ⭐ Barium swallow (initial screen): "bird's beak" tapering at GEJ + dilated proximal esophagus
• ⭐ Esophageal manometry = GOLD STANDARD: elevated LES resting pressure + incomplete relaxation + absent peristalsis
• EGD mandatory to rule out pseudoachalasia (malignancy at GEJ mimicking achalasia)

DDx

• Pseudoachalasia (GEJ tumor) — older, rapid weight loss, short symptom duration
• Esophageal cancer
• Esophageal spasm (intermittent, corkscrew on barium)
• GERD with stricture (dysphagia to solids only)
• Scleroderma esophagus

MDM

• Confirm with manometry before any intervention
• Always EGD to exclude malignancy, especially if older or rapid weight loss
• Chronic stasis → ⭐ increased squamous cell carcinoma risk (long-term surveillance)

Treatment

• ⭐ Pneumatic balloon dilation (most common definitive; risk: perforation)
• Heller myotomy (surgical) or POEM (peroral endoscopic myotomy) — durable
• Botox injection — temporary, for poor surgical candidates
• Nitrates/CCBs — mild disease or bridge

Patient Education

• Chronic condition — interventions relieve obstruction but do not restore peristalsis
• Eat slowly, chew well, upright after meals, fluids with meals
• Report worsening dysphagia or weight loss (cancer surveillance)

Emergency Precautions

• Aspiration pneumonia from regurgitation → respiratory support + antibiotics
• Perforation after pneumatic dilation → emergent surgery
• Rapid weight loss + short duration → urgent EGD for pseudoachalasia

3. Eosinophilic Esophagitis

Epidemiology: ⭐ Young males with atopy (asthma, allergic rhinitis, eczema, food allergies); chronic antigen/immune-mediated.

Critical History Questions

• ⭐ Dysphagia and food bolus impaction ("food gets stuck")?
• History of atopy — asthma, eczema, seasonal allergies, food allergies?
• Heartburn not responding to PPI?
• Triggers — dairy, gluten, environmental allergens?
• Throat clearing, globus?

ROS

• GI: dysphagia, food impaction, refractory heartburn
• Allergy: asthma, atopic dermatitis, allergic rhinitis, known food allergies

Physical Exam

• Usually normal
• Atopic stigmata (eczema, allergic shiners)

Diagnostics

• ⭐ EGD with biopsy taken OFF acid suppression → ≥15 eosinophils/hpf
• 🔹 Endoscopic findings: concentric rings ("feline esophagus"), longitudinal furrows, whitish exudate/papules
• 🧠 PPIs reduce eosinophil counts — biopsy must be off PPI ≥4 weeks

DDx

• GERD (overlaps; PPI-responsive)
• Achalasia
• Esophageal stricture/Schatzki ring
• Pill esophagitis
• Infectious esophagitis

MDM

• Distinguish from GERD — biopsy off PPI is key
• Allergy referral for trigger identification
• Strictures may require dilation

Treatment

• ⭐ Dietary elimination (dairy first, then gluten)
• ⭐ Swallowed topical corticosteroid (fluticasone inhaler sprayed in mouth then SWALLOWED, or budesonide slurry) — NOT inhaled
• High-dose PPI (for coexisting GERD component)
• Esophageal dilation for fibrostenotic strictures

Patient Education

• Swallow (don't inhale) the steroid; no food/water for 30 min after
• Chronic relapsing condition — adherence to diet/meds prevents strictures
• Cut food into small pieces, chew thoroughly, eat slowly

Emergency Precautions

• Acute food bolus impaction with inability to handle secretions/drooling → urgent EGD
• ⚠️ Do NOT push impacted bolus blindly — perforation risk

4. Esophageal Cancer

Epidemiology: ⭐ Adenocarcinoma (distal esophagus/GEJ; chronic GERD + obesity + Barrett's; now most common in US). ⭐ Squamous cell (proximal/mid; tobacco + alcohol; achalasia stasis).

Critical History Questions

• ⭐ Progressive dysphagia — solids first, then liquids?
• ⭐ Unintentional weight loss?
• GERD/Barrett's history (adenocarcinoma) vs. tobacco + alcohol (SCC)?
• Odynophagia, hoarseness, persistent cough?
• Hematemesis/melena, iron-deficiency anemia symptoms?

ROS

• GI: progressive dysphagia, weight loss, regurgitation, GI bleeding
• ENT/Pulm: hoarseness (recurrent laryngeal), chronic cough, aspiration
• Constitutional: weight loss, fatigue, anorexia

Physical Exam

• Often normal early
• Cachexia, weight loss in advanced disease
• Advanced: ⭐ supraclavicular (Virchow) or cervical lymphadenopathy, hepatomegaly (mets)

Diagnostics

• ⭐ EGD with biopsy (tissue diagnosis required)
• Endoscopic ultrasound (EUS) — depth of invasion (T) + nodal staging (N)
• CT chest/abdomen + PET — distant metastases
• CBC (iron-deficiency anemia)

DDx

• Achalasia / pseudoachalasia
• Peptic stricture (benign, GERD history)
• Schatzki ring (intermittent, non-progressive)
• Eosinophilic esophagitis
• Extrinsic compression

MDM

• ⭐ Any progressive dysphagia + weight loss or anemia → EGD with biopsy same visit; do not empirically treat
• Stage with EUS + CT/PET before treatment
• Multidisciplinary (GI, surgical oncology, medical/radiation oncology)

Treatment

• Early/mucosal → endoscopic resection
• Localized → esophagectomy ± neoadjuvant chemoradiation
• Advanced/metastatic → chemoradiation, palliative stenting

Patient Education

• Smoking cessation + alcohol reduction (SCC); GERD/Barrett's surveillance (adeno)
• Nutritional support during treatment
• Barrett's patients: adhere to surveillance EGD schedule

Emergency Precautions

• Complete obstruction/inability to swallow secretions → urgent intervention/stent
• Massive GI bleed (tumor erosion) → stabilize, endoscopy
• Aspiration pneumonia → respiratory support

5. Boerhaave Syndrome

Epidemiology: Full-thickness esophageal rupture from forceful retching/vomiting; classic in alcoholics, bulimia, hyperemesis. Emergency.

Critical History Questions

• ⭐ Forceful retching/vomiting immediately preceding pain?
• ⭐ Sudden severe retrosternal/chest/upper abdominal pain?
• Dyspnea, neck swelling?
• Alcohol binge, eating disorder, recent endoscopy (iatrogenic)?

ROS

• GI: vomiting/retching, severe chest/epigastric pain
• Pulm: dyspnea, respiratory distress
• Constitutional: diaphoresis, signs of shock

Physical Exam

• ⭐ Subcutaneous emphysema (crepitus) over chest/neck — pathognomonic clue
• Mackler triad: vomiting + chest pain + subcutaneous emphysema
• Tachycardia, hypotension, fever (mediastinitis/sepsis)
• Hamman's crunch (mediastinal crepitus on auscultation)

Diagnostics

• ⭐ CXR: pneumomediastinum, mediastinal widening, left pleural effusion, free air
• CT chest (confirms, locates)
• ⭐ Water-soluble contrast esophagram (Gastrografin) shows extravasation — 🔹 NEVER barium (fatal mediastinal inflammation)

DDx

• Mallory-Weiss tear (mucosal only, painless hematemesis after retching)
• MI / aortic dissection
• PE
• Spontaneous pneumothorax
• Perforated peptic ulcer / pancreatitis

MDM

• ⚠️ Surgical emergency — time-critical; delay = high mortality
• NPO, IV fluids, broad-spectrum antibiotics, ICU
• Early thoracic surgery consult

Treatment

• ⚠️ Emergent surgical repair + mediastinal drainage
• Broad-spectrum IV antibiotics (cover oral flora + anaerobes), antifungal
• Aggressive resuscitation; some contained leaks managed with stent/drainage

Patient Education

• (Post-recovery) address underlying cause — alcohol use, eating disorder
• Recognize that this is life-threatening and required emergent surgery

Emergency Precautions

• ⚠️ Retching + sudden chest pain + subcutaneous emphysema = Boerhaave → call thoracic surgery immediately
• Sepsis/mediastinitis → ICU, vasopressors
• ⭐ Order Gastrografin, never barium

STOMACH

6. Peptic Ulcer Disease

Epidemiology: ⭐ H. pylori = most common cause; NSAIDs 2nd; smoking, alcohol contribute. Duodenal > gastric ulcers. Gastric ulcers carry malignancy concern.

Critical History Questions

• ⭐ Gnawing/burning epigastric pain — relationship to meals?
• Duodenal: pain 2–3 h AFTER eating + nocturnal (11pm–2am); ⭐ RELIEVED by food
• Gastric: pain WITH/shortly after eating; food avoidance → weight loss
• NSAID/aspirin use, smoking, alcohol?
• ⭐ Alarm features — weight loss, dysphagia, GI bleeding (melena/hematemesis), anemia, vomiting, age >55 new onset?
• Prior H. pylori, prior ulcers?

ROS

• GI: epigastric pain, dyspepsia, early satiety, nausea, melena/coffee-ground emesis
• Constitutional: weight loss (gastric ulcer/malignancy concern)

Physical Exam

• Epigastric tenderness
• ⭐ Signs of bleeding: pallor, tachycardia, orthostasis, melena on rectal exam
• ⚠️ Rigid/board-like abdomen + rebound = perforation (peritonitis)

Diagnostics

• ⭐ EGD with biopsy — gold standard; gastric ulcers MUST be biopsied to exclude cancer
• H. pylori testing: ⭐ urea breath test or stool antigen (off PPI ≥2 wk, off antibiotics ≥4 wk); biopsy CLO test at EGD
• CBC (iron-deficiency anemia); BUN:Cr (↑ with UGIB)
• ⚠️ Serology not recommended (stays positive after eradication)

DDx

• GERD
• Gastritis
• Gastric cancer (especially gastric ulcer)
• Pancreatitis / biliary colic
• Zollinger-Ellison (recurrent/refractory ulcers without H. pylori/NSAIDs)
• Cardiac (inferior MI can mimic epigastric pain)

MDM

• Test-and-treat H. pylori for uninvestigated dyspepsia <55 without alarms
• Alarm features or age >55 → EGD
• ⭐ Gastric ulcer → biopsy + consider repeat EGD to confirm healing (cancer can mimic benign ulcer)

Treatment

• ⭐ PPI: duodenal × 4 weeks, gastric × 8 weeks (larger, poorer vascularity, malignancy risk)
• Eradicate H. pylori → ⭐ bismuth quadruple therapy × 14d (PPI + bismuth + tetracycline + metronidazole); confirm eradication ≥4 wk after with UBT/stool antigen
• Stop NSAIDs; smoking/alcohol cessation
• Bleeding ulcer → EGD hemostasis + IV PPI infusion

Patient Education

• Complete full eradication course; confirm cure
• Avoid NSAIDs; if needed, co-prescribe PPI
• Report black/tarry stools, vomiting blood, dizziness immediately

Emergency Precautions

• ⚠️ Hematemesis/melena + hemodynamic instability → 2 large-bore IVs, transfuse if Hgb <7, urgent EGD
• ⚠️ Sudden severe pain + rigid abdomen + free air on imaging = perforation → emergent surgery
• Gastric outlet obstruction (vomiting, succussion splash) from scarring

7. Gastritis / H. pylori

Epidemiology: Mucosal inflammation without discrete ulcer; ⭐ MC causes H. pylori + NSAIDs; also alcohol, stress, steroids, autoimmune, bile reflux.

Critical History Questions

• Epigastric pain/discomfort, bloating, early satiety, nausea?
• NSAID/aspirin, alcohol, steroid use?
• ⭐ Red flags — dysphagia, GI bleed/anemia, weight loss, recurrent vomiting, new onset ≥55?
• Prior H. pylori, family history of gastric cancer?

ROS

• GI: epigastric pain, dyspepsia, bloating, nausea/vomiting, anorexia
• Constitutional: weight loss (alarm)

Physical Exam

• Mild epigastric tenderness
• Usually otherwise normal; check for occult blood / pallor if anemia suspected

Diagnostics

• Often clinical
• H. pylori testing (UBT or stool antigen)
• ⭐ EGD if red flags or no improvement
• CBC (iron-deficiency anemia if bleeding)

DDx

• PUD
• GERD
• Functional dyspepsia
• Gastric cancer
• Biliary/pancreatic disease

MDM

• ⭐ Remove the offending agent FIRST (NSAIDs, alcohol) — don't just stack a PPI on top
• Test-and-treat H. pylori if present
• Red flags or refractory → GI referral / EGD

Treatment

• Remove cause; treat H. pylori if positive
• Acid suppression: antacid → H2 blocker → PPI
• Persistent/refractory/alarm → EGD + GI referral

Patient Education

• Stop NSAIDs and alcohol
• Take medications as directed; report bleeding or weight loss
• H. pylori is transmissible/treatable — complete the regimen and confirm eradication

Emergency Precautions

• GI bleeding (hematemesis/melena) → stabilize → EGD
• Weight loss/anemia in older patient → urgent EGD for malignancy

8. Gastric Cancer

Epidemiology: Adenocarcinoma >90%; ⭐ H. pylori strongest modifiable risk (Correa cascade); male, >50, East Asian/Eastern European/South American; smoked/salted foods.

Critical History Questions

• Vague dyspepsia, early satiety, epigastric pain not improving on PPI?
• ⭐ Progressive weight loss, anorexia?
• Dysphagia, melena, hematemesis, fatigue (anemia)?
• H. pylori history, family history, diet (salted/smoked foods), smoking?

ROS

• GI: dyspepsia, early satiety, weight loss, GI bleeding, dysphagia
• Constitutional: weight loss, fatigue, anorexia

Physical Exam

• Often normal early
• Advanced: ⭐ Virchow node (left supraclavicular), ⭐ Sister Mary Joseph nodule (periumbilical), Krukenberg tumor (ovary), epigastric mass, hepatomegaly
• Pallor, occult blood positive

Diagnostics

• ⭐ EGD with biopsy
• Staging: EUS (mural depth, nodes), PET-CT (distant mets)
• CBC (iron-deficiency anemia)

DDx

• PUD (esp. gastric ulcer — biopsy distinguishes)
• Gastritis
• Lymphoma / MALT
• Pancreatic cancer
• Functional dyspepsia

MDM

• ⭐ Any middle-aged+ patient not improving on PPI, or with alarm features → EGD
• Don't miss exam findings (Virchow, Sister Mary Joseph)
• Multidisciplinary staging-based treatment

Treatment

• Stage-dependent: surgery (partial/total gastrectomy) ± perioperative chemotherapy ± radiation
• H. pylori eradication (risk reduction)
• Palliative care for advanced disease

Patient Education

• H. pylori eradication and smoking cessation reduce risk
• Nutritional support
• Surveillance for high-risk lesions (atrophic gastritis, intestinal metaplasia)

Emergency Precautions

• GI bleed (tumor erosion) → stabilize, EGD
• Gastric outlet obstruction → decompression
• Perforation → emergent surgery

SMALL BOWEL / ACUTE ABDOMEN

9. Appendicitis

✓ Previously tested in a test OSCE this block.

Epidemiology: Most common surgical abdomen; peak teens–20s; luminal obstruction (fecalith, lymphoid hyperplasia) → ischemia → perforation within ~36 h.

Critical History Questions

• ⭐ Pain starting periumbilical → migrating to RLQ (McBurney point)?
• ⭐ Anorexia (near-universal)?
• ⭐ Nausea/vomiting AFTER pain onset (vomiting before pain argues against)?
• Low-grade fever?
• ⭐ Last menstrual period / pregnancy possibility (women)?
• Duration (>36–48 h raises perforation concern)?

ROS

• GI: periumbilical→RLQ pain, anorexia, nausea/vomiting
• GU/GYN: rule out ectopic, ovarian, UTI
• Constitutional: low-grade fever (high fever/rigors → perforation or alternate dx)

Physical Exam

• ⭐ McBurney point tenderness; rebound + guarding
• ⭐ Rovsing sign (LLQ palpation → RLQ pain), Psoas sign (retrocecal), Obturator sign (pelvic appendix)
• Low-grade fever, tachycardia
• ⚠️ Diffuse peritonitis = perforation

Diagnostics

• ⭐ CT abdomen/pelvis with contrast (adults): appendix >6 mm + periappendiceal fat stranding
• ⭐ US first in children/pregnancy; MRI if US non-diagnostic in pregnancy
• CBC (leukocytosis with left shift)
• ⭐ Urine beta-hCG mandatory in childbearing-age women BEFORE CT

DDx

• Mesenteric adenitis / Yersinia (pseudoappendicitis)
• Ovarian torsion/cyst, ectopic pregnancy, PID
• Crohn's (terminal ileitis)
• Cecal diverticulitis, Meckel diverticulum
• UTI/nephrolithiasis

MDM

• ⭐ Pregnancy test before imaging in women
• Call general surgery early
• Uncomplicated → appendectomy (or, selected cases, antibiotics-first)

Treatment

• NPO, IV fluids, analgesia
• Broad-spectrum IV antibiotics (gram-negative + anaerobes)
• ⭐ Laparoscopic appendectomy (preferred)
• Contained abscess → CT-guided drainage + interval appendectomy at ~6 weeks

Patient Education

• Postoperative recovery expectations; wound care
• Return for fever, increasing pain, wound drainage

Emergency Precautions

• ⚠️ Perforation → peritonitis/sepsis → emergent surgery + resuscitation
• High fever + rigors → perforation/abscess
• Don't delay surgery in pregnancy — appendiceal perforation risks fetal loss

10. Small Bowel Obstruction

Epidemiology: ⭐ Adhesions (prior surgery) MC; hernias 2nd; also Crohn's, tumors, gallstone ileus, bezoars.

Critical History Questions

• ⭐ Prior abdominal/pelvic surgery (adhesions)?
• ⭐ Colicky/crampy abdominal pain?
• ⭐ Obstipation (no stool AND no gas)?
• Vomiting (more prominent/bilious with proximal obstruction)?
• Abdominal distension?
• Known hernia, prior obstruction, IBD, malignancy?

ROS

• GI: crampy pain, distension, vomiting, obstipation
• Constitutional: ⚠️ fever + tachycardia → strangulation concern

Physical Exam

• Distended, tympanitic abdomen
• Bowel sounds: early hyperactive/high-pitched → late hypoactive/absent
• ⭐ Examine ALL hernia sites (incarcerated hernia)
• Prior surgical scars
• ⚠️ Fever, tachycardia, peritoneal signs, pain out of proportion = strangulation

Diagnostics

• Plain XR (upright + supine): ⭐ ladder-like air-fluid levels, dilated loops, paucity of colonic gas
• ⭐ CT abdomen/pelvis: loops >2.5 cm, transition point; smooth beak = simple, serrated beak / pneumatosis / portal venous gas = strangulation
• ⭐ Serum lactate (ischemia)
• CBC, BMP

DDx

• Ileus (no transition point, diffuse air, post-op/electrolyte/opioid)
• Large bowel obstruction
• Colonic pseudo-obstruction (Ogilvie)
• Gastroenteritis
• Mesenteric ischemia

MDM

• Partial without ischemia → trial of conservative management
• Complete or strangulation → surgery
• Identify and reduce hernias; correct electrolytes

Treatment

• NPO, IV fluids, ⭐ NG tube decompression
• Correct electrolytes
• Partial/simple adhesive SBO → conservative trial (often resolves)
• ⚠️ Complete, strangulated, closed-loop, or failed conservative → surgery

Patient Education

• Recurrence risk with adhesions
• Return for worsening pain, fever, inability to pass gas/stool

Emergency Precautions

• ⚠️ Strangulation (fever, tachycardia, ↑lactate, peritonitis, CT signs) → emergent surgery
• Incarcerated hernia → urgent reduction/surgery
• Closed-loop obstruction → high perforation risk

11. Acute Mesenteric Ischemia

Epidemiology: Older patients with cardiovascular disease; ⭐ SMA embolism (A-fib) MC; also thrombosis, non-occlusive (NOMI), venous thrombosis. High mortality if delayed.

Critical History Questions

• ⭐ Sudden severe periumbilical pain — ⭐ OUT OF PROPORTION to exam?
• ⭐ Atrial fibrillation, recent MI, valvular disease, prior emboli?
• Nausea, vomiting, late bloody diarrhea?
• Hypercoagulable state (venous), hypotension/low-flow state (NOMI)?
• Chronic postprandial pain + weight loss (preceding chronic ischemia)?

ROS

• GI: severe pain, nausea/vomiting, later bloody diarrhea
• CV: palpitations (A-fib), prior emboli
• Constitutional: signs of shock as bowel infarcts

Physical Exam

• ⭐ Early: soft abdomen with minimal tenderness despite severe pain ("pain out of proportion")
• Irregularly irregular pulse (A-fib)
• ⚠️ Late: guarding, rebound, rigidity (transmural infarction/peritonitis), shock

Diagnostics

• ⭐ CT angiography = gold standard: arterial occlusion, bowel wall thickening, pneumatosis intestinalis, portal venous gas
• ⭐ Elevated lactate, leukocytosis, metabolic acidosis
• CBC, BMP, lactate, coags

DDx

• SBO with strangulation
• Perforated viscus
• Pancreatitis
• AAA rupture / aortic dissection
• Ischemic colitis (milder, hematochezia, watershed zones)

MDM

• ⭐ A-fib + pain-exam mismatch + ↑lactate = AMI until proven otherwise
• Emergent surgery + vascular consult
• Time-critical — every hour of delay increases bowel loss/mortality

Treatment

• NPO, aggressive IV fluids, broad-spectrum antibiotics
• ⭐ Revascularization (embolectomy, endovascular thrombectomy, bypass) = definitive
• Resection of necrotic bowel; second-look laparotomy as needed
• Anticoagulation per etiology

Patient Education

• (Survivors) anticoagulation/antiplatelet, rate/rhythm control of A-fib, risk factor modification

Emergency Precautions

• ⚠️ Don't dismiss a soft belly with severe pain — CT angiography STAT
• Peritonitis/necrosis → emergent laparotomy
• Sepsis/shock → ICU resuscitation

12. Intussusception

Epidemiology: ⭐ Children <2 yr (idiopathic/viral, Peyer patch hyperplasia); ileocolic MC. ⭐ Adults → pathologic lead point (malignancy) until proven otherwise. Emergency.

Critical History Questions

• ⭐ Intermittent colicky pain with pain-free intervals (child drawing knees up)?
• ⭐ "Currant jelly" stools (late, ischemia)?
• Vomiting (bilious if complete obstruction)?
• Lethargy between episodes?
• Recent viral illness (peds); in adults, weight loss/anemia (lead point)?

ROS

• GI: colicky pain, vomiting, bloody/mucoid stool
• Constitutional: lethargy, irritability (peds)

Physical Exam

• ⭐ Sausage-shaped mass (RUQ/mid-upper abdomen)
• Episodic distress alternating with calm
• ⚠️ Peritoneal signs, shock = ischemia/perforation

Diagnostics

• ⭐ Ultrasound (peds): target/donut sign (98–100% sensitive)
• ⭐ Air/contrast enema: coil-spring appearance — diagnostic AND therapeutic
• CT in adults (identifies lead point)
• CBC, lactate, stool occult blood

DDx

• Gastroenteritis
• Appendicitis
• Volvulus / malrotation
• Incarcerated hernia
• Meckel diverticulum

MDM

• ⭐ Stable child without peritonitis → air/contrast enema reduction
• ⚠️ Enema contraindicated if peritonitis, perforation, or shock
• ⭐ ALL adults → surgery (malignant lead point)

Treatment

• Air/contrast enema reduction (peds, stable)
• Surgery for: peritonitis, perforation, shock, failed enema, pathologic lead point, recurrence, all adults
• IV fluids, NPO; alert pediatric surgery before enema

Patient Education

• ~10% recurrence after enema reduction — return for recurrent symptoms
• Adults need lead-point workup

Emergency Precautions

• ⚠️ Peritonitis/perforation → emergent surgery
• Shock → resuscitate before reduction attempt
• Bilious vomiting in neonate → consider malrotation/midgut volvulus (surgical emergency)

COLON

13. Diverticulitis

✓ Previously tested in a test OSCE this block.

Epidemiology: Older adults, low-fiber Western diet; ⭐ sigmoid colon (highest pressure); fecalith obstructs diverticular neck → microperforation.

Critical History Questions

• ⭐ Gradual LLQ pain over days?
• Low-grade fever, change in bowel habits (constipation or loose stools)?
• Anorexia, nausea?
• Prior diverticulitis episodes?
• ⚠️ Pneumaturia/fecaluria (colovesical fistula), inability to pass stool/gas (obstruction)?

ROS

• GI: LLQ pain, altered bowel habits, nausea
• GU: dysuria/pneumaturia (fistula); sterile pyuria possible
• Constitutional: low-grade fever

Physical Exam

• ⭐ LLQ tenderness
• ⚠️ Rebound/guarding/rigidity = perforation/peritonitis
• Palpable mass (phlegmon/abscess)
• Fever, tachycardia

Diagnostics

• ⭐ CT abdomen/pelvis with contrast (study of choice): wall thickening >4 mm + pericolonic fat stranding; identifies abscess, free air, fistula, obstruction
• CBC (mild leukocytosis); UA (sterile pyuria)
• ⚠️ Avoid colonoscopy/barium enema acutely (perforation risk)
• ⭐ Colonoscopy 4–6 weeks AFTER resolution to exclude colorectal cancer

DDx

• Colorectal cancer (overlapping; colonoscopy after resolution)
• IBS / diverticulosis
• Ischemic colitis
• PID / ovarian pathology
• UTI / nephrolithiasis

MDM

• Uncomplicated → often outpatient (selected: no antibiotics in mild immunocompetent per current guidelines)
• Complicated (abscess/perforation/obstruction/fistula) → admit + GI/surgery
• ⭐ After 2nd attack or complications → discuss elective colectomy

Treatment

• Uncomplicated outpatient: ⭐ ciprofloxacin + metronidazole (or amoxicillin-clavulanate); clear liquids advancing as tolerated; reassess 2–3 days
• Inpatient: IV pip-tazo OR ceftriaxone + metronidazole × 5–7 d → oral
• Abscess ≥4 cm → IR percutaneous drainage
• Free perforation → emergency surgery

Patient Education

• High-fiber diet + hydration after recovery (nuts/seeds restriction is outdated)
• Follow-up colonoscopy 4–6 weeks post-resolution
• Return for worsening pain, high fever, inability to tolerate PO

Emergency Precautions

• ⚠️ Free perforation/peritonitis → emergent surgery
• Abscess → IR drainage
• Colovesical fistula (pneumaturia) → elective surgery
• Obstruction → NPO/NG + surgery

14. Colorectal Cancer

Epidemiology: 2nd leading cancer death; adenoma-carcinoma sequence (APC→KRAS→p53); risk: age, family history, polyps, IBD, FAP/Lynch. ⭐ Screening starts at age 45 (average risk).

Critical History Questions

• ⭐ Right-sided: fatigue, iron-deficiency anemia, occult bleeding, weight loss (no obstruction)
• ⭐ Left-sided: hematochezia, pencil-thin stools, constipation, obstruction
• Change in bowel habits, tenesmus, rectal bleeding?
• Family history (1st-degree CRC, FAP, Lynch), personal IBD/polyp history?
• Screening history (last colonoscopy)?

ROS

• GI: rectal bleeding, change in caliber/habits, tenesmus, abdominal pain
• Constitutional: weight loss, fatigue (anemia)

Physical Exam

• ⭐ DRE (low rectal masses, occult blood)
• Pallor (anemia); abdominal mass; hepatomegaly (liver mets)
• Lymphadenopathy in advanced disease

Diagnostics

• ⭐ Colonoscopy with biopsy = gold standard (diagnosis + surveillance)
• CBC (iron-deficiency anemia), LFTs (liver mets)
• ⭐ CEA — monitoring/surveillance only, NEVER screening
• CT chest/abdomen/pelvis (staging); pelvic MRI for rectal cancer

DDx

• Diverticular disease / bleeding
• Hemorrhoids (don't anchor — exclude cancer in >40/50)
• IBD
• Ischemic colitis
• Infectious colitis

MDM

• ⭐ IDA in a man or postmenopausal woman = GI malignancy until proven otherwise
• New rectal bleeding in adults >40–50 → colonoscopy (don't blame hemorrhoids)
• Multidisciplinary stage-based treatment

Treatment

• ⭐ Surgical resection = primary treatment
• Chemotherapy: stage III, high-risk stage II, metastatic
• Radiation: rectal > colon (neoadjuvant for rectal)
• Surveillance: CEA + colonoscopy at 1 yr + CT periodically

Patient Education

• ⭐ Screening at 45 (average risk); earlier with family history/IBD
• FIT preferred over FOBT; Cologuard for average-risk only
• High-fiber diet, limit red/processed meat, alcohol, tobacco

Emergency Precautions

• ⚠️ Obstructing left-sided tumor (apple-core lesion) → decompression/stent → surgery
• Massive lower GI bleed → stabilize, localize
• Perforation → emergent surgery

15. Sigmoid Volvulus

Epidemiology: ⭐ Elderly, institutionalized, chronically constipated/laxative-dependent; redundant sigmoid twists on mesentery. (Cecal volvulus = younger; surgery first.)

Critical History Questions

• ⭐ Sudden abdominal pain + distension + obstipation?
• Chronic constipation, laxative use, neuropsychiatric meds, nursing-home resident?
• Prior episodes?
• Nausea/vomiting (later)?

ROS

• GI: distension, obstipation, crampy pain
• Constitutional: ⚠️ fever/instability suggests ischemia

Physical Exam

• Markedly distended, tympanitic abdomen
• ⚠️ Peritoneal signs = ischemia/perforation
• Otherwise minimal tenderness if bowel viable

Diagnostics

• ⭐ Plain XR: "coffee bean" / bent inner tube sign, apex pointing to RUQ
• CT: whirl sign, transition point, signs of ischemia
• Contrast enema: bird-beak narrowing
• CBC, lactate

DDx

• Cecal volvulus (dilated loop to LUQ — surgery first)
• Large bowel obstruction (CRC)
• Ogilvie syndrome (pseudo-obstruction)
• Toxic megacolon
• SBO

MDM

• ⭐ Stable, no ischemia → endoscopic decompression first
• ⚠️ Ischemia/perforation/peritonitis/failed scope → emergent colectomy
• ⭐ Plan ELECTIVE sigmoid colectomy after decompression (high recurrence)

Treatment

• ⭐ Endoscopic decompression (flexible sigmoidoscopy/colonoscopy) + rectal tube
• Then elective sigmoid colectomy (anatomic predisposition persists)
• Emergent colectomy ± colostomy if ischemia/perforation

Patient Education

• High recurrence without surgery — definitive colectomy recommended
• Bowel regimen / address constipation

Emergency Precautions

• ⚠️ Peritonitis/ischemia → emergent surgery (skip the scope)
• Closed-loop with cecal distension → perforation risk
• Failed endoscopic reduction → surgery

16. Ischemic Colitis

Epidemiology: ⭐ Most common form of intestinal ischemia; >60 with vascular disease; transient low-flow at watershed zones (splenic flexure, rectosigmoid). Usually self-limited.

Critical History Questions

• ⭐ Crampy LLQ/left abdominal pain + urgent bloody diarrhea (hematochezia)?
• Recent hypotension, cardiac event, dehydration, vasoconstrictors, marathon, dialysis?
• Vascular disease, A-fib?
• (Contrast with AMI: ischemic colitis is milder, usually no shock)

ROS

• GI: crampy pain, hematochezia, urgency
• CV: vascular disease, recent low-flow event

Physical Exam

• Mild-moderate abdominal/LLQ tenderness
• Usually hemodynamically stable
• ⚠️ Peritoneal signs/instability → gangrene/transmural infarction

Diagnostics

• ⭐ Colonoscopy (stable patients): mucosal erythema, edema, erosions, ulceration at watershed zones (splenic flexure)
• CT: colonic wall thickening at splenic flexure/rectosigmoid WITHOUT a mass
• CBC, lactate (severity)

DDx

• ⭐ Diverticular bleeding (painless)
• Infectious colitis (C. diff, E. coli O157)
• IBD flare
• Acute mesenteric ischemia (more severe, small bowel, pain out of proportion)
• Colorectal cancer

MDM

• Most cases mild → supportive, resolve in days
• ⭐ Hematochezia + crampy pain at splenic flexure = ischemic colitis (not painless diverticular bleed)
• Moderate-severe → antibiotics; gangrene/perforation → surgery

Treatment

• ⭐ Supportive: bowel rest, IV fluids, optimize perfusion, stop offending vasoconstrictors
• Antibiotics for moderate-severe disease
• Surgery for gangrene, perforation, or persistent ischemia/stricture

Patient Education

• Usually self-limited; address cardiovascular risk factors and hydration
• Return for worsening pain, fever, increasing bleeding

Emergency Precautions

• ⚠️ Peritoneal signs / rising lactate → transmural necrosis → surgery
• Fulminant pancolitis → high mortality
• Persistent symptoms → evaluate for stricture

INFLAMMATORY / FUNCTIONAL BOWEL

17. Ulcerative Colitis

Epidemiology: Young adults; mucosal/submucosal inflammation; ⭐ continuous from rectum proximally, NO skip lesions, never transmural. Smoking is protective (unlike Crohn's).

Critical History Questions

• ⭐ Bloody diarrhea, fecal urgency, tenesmus?
• ⭐ LLQ crampy pain?
• Number of bowel movements/day, nocturnal symptoms, blood amount?
• Weight loss, fatigue (anemia)?
• Extraintestinal: joint pain, eye redness (uveitis), skin lesions (erythema nodosum, pyoderma), jaundice (PSC)?
• Family history of IBD; recent infections/antibiotics (rule out infectious)?

ROS

• GI: bloody diarrhea, urgency, tenesmus, LLQ pain
• MSK/skin/eye: arthritis, erythema nodosum, pyoderma gangrenosum, uveitis, episcleritis
• Hepatobiliary: PSC association
• Constitutional: weight loss, fever, fatigue

Physical Exam

• LLQ tenderness; blood on rectal exam
• Pallor (anemia)
• Extraintestinal findings (joints, eyes, skin)
• ⚠️ Severe: fever, tachycardia, distension (toxic megacolon)

Diagnostics

• ⭐ Colonoscopy + biopsy = gold standard: continuous inflammation from rectum, friability, loss of vascular pattern, superficial ulceration, NO skip lesions
• ⭐ Stool studies NEGATIVE (exclude C. diff, Salmonella, Campylobacter, E. coli)
• ⭐ Fecal calprotectin elevated (IBD vs IBS)
• CBC (↓Hgb, ↑plt, ↑WBC), CRP/ESR, CMP (↓albumin, ↓K)
• Severity (Truelove-Witts): severe = >6 bloody BM/day + fever + HR >90 + Hgb <10.5 + ESR >30

DDx

• ⭐ Crohn's disease (RLQ, skip lesions, transmural, perianal)
• Infectious colitis (stool cultures)
• C. difficile colitis
• Ischemic colitis
• Colorectal cancer

MDM

• Rule out infection (stool studies) before labeling IBD
• Severity-based treatment; refer all new cases to GI
• ⭐ CRC surveillance colonoscopy beginning ~8 years after colonic disease onset

Treatment

• Mild: ⭐ mesalamine (5-ASA) first-line (oral ± topical)
• Moderate: add systemic corticosteroids if 5-ASA inadequate
• Severe (hospitalized): IV corticosteroids → biologics (anti-TNF/JAK) if refractory
• ⭐ Colectomy = CURATIVE
• Screen latent TB + Hep B before biologics; avoid live vaccines on immunosuppression

Patient Education

• Chronic relapsing-remitting; medication adherence prevents flares + cancer
• Surveillance colonoscopy is lifesaving
• Surgery is curative if needed

Emergency Precautions

• ⚠️ Toxic megacolon (fever + tachycardia + distension + colon >6 cm) → surgical emergency
• ⚠️ NEVER give antidiarrheals/opioids in active flare (precipitate toxic megacolon)
• Massive hemorrhage / perforation → surgery

18. Crohn's Disease

Epidemiology: Young adults; ⭐ transmural inflammation, anywhere mouth→anus, MC terminal ileum, skip lesions; ⭐ smoking WORSENS disease (strongest modifiable risk).

Critical History Questions

• ⭐ RLQ pain (terminal ileum — can mimic appendicitis)?
• ⭐ Chronic diarrhea, LESS commonly bloody (vs UC)?
• Weight loss, fever, fatigue?
• ⭐ Perianal disease — fistulas, abscesses, skin tags, fissures?
• Smoking history?
• Extraintestinal symptoms (joints, eyes, skin); B12-deficiency symptoms (terminal ileal)?

ROS

• GI: RLQ pain, chronic diarrhea, weight loss, perianal drainage/pain
• MSK/skin/eye: arthritis, erythema nodosum, pyoderma, uveitis
• Constitutional: fever, weight loss, fatigue

Physical Exam

• ⭐ RLQ tenderness ± palpable mass (phlegmon)
• ⭐ Perianal exam mandatory (fistulas, abscesses, skin tags)
• Aphthous oral ulcers
• Signs of malnutrition / extraintestinal findings

Diagnostics

• ⭐ Colonoscopy + biopsy: cobblestoning, deep ulcers, skip lesions, rectal sparing
• CT/MR enterography for transmural complications (fistulas, abscesses, strictures)
• ⭐ Macrocytic anemia + low B12 = terminal ileal involvement
• Fecal calprotectin elevated; stool cultures negative
• CBC, iron studies, B12, CRP

DDx

• ⭐ Ulcerative colitis (continuous, rectal, mucosal, bloody)
• Appendicitis / Yersinia (RLQ)
• Intestinal TB
• Infectious enteritis
• Celiac / IBS

MDM

• Perianal exam + B12/iron studies; CT enterography to stage complications
• ⭐ Drain abscesses BEFORE starting biologics
• Pre-biologic screening (latent TB, Hep B)

Treatment

• Mild ileocecal: ⭐ budesonide for induction
• Moderate-severe induction: prednisone or IV methylprednisolone
• Maintenance: azathioprine or methotrexate
• Moderate-severe/fistulizing/refractory: ⭐ anti-TNF biologics (infliximab, adalimumab)
• ⚠️ 5-ASA (mesalamine) is NOT effective for Crohn's (common trap)
• ⭐ Surgery for complications only — NOT curative

Patient Education

• ⭐ Smoking cessation worsens flares and biologic response
• Lifelong management; adherence reduces complications
• Report perianal drainage, abscess, obstruction symptoms

Emergency Precautions

• ⚠️ Abscess → drainage; bowel obstruction (stricture) → decompression/surgery
• Perforation/peritonitis → emergent surgery
• Toxic megacolon (colonic Crohn's) → surgical emergency

19. Irritable Bowel Syndrome

Epidemiology: Common; ⭐ 2/3 women; multifactorial (dysmotility, visceral hypersensitivity, gut-brain dysregulation); diagnosis of exclusion.

Critical History Questions

• ⭐ Recurrent abdominal pain ≥1 day/week, related to defecation?
• Change in stool frequency or form (IBS-D, IBS-C, IBS-M)?
• ⭐ Does pain wake patient from sleep? (functional → NO)
• Bloating; relief with defecation?
• ⭐ Alarm features ABSENT — no weight loss, no GI bleeding, no anemia, no nocturnal symptoms, onset <50, no family history of CRC/IBD/celiac?

ROS

• GI: crampy lower abdominal pain, altered bowel habits, bloating
• ⭐ Negative for: weight loss, hematochezia, fever, nocturnal diarrhea (these = red flags)

Physical Exam

• Normal exam (mild diffuse/LLQ tenderness at most)
• No mass, no organomegaly, no occult blood
• Normal vitals, no weight loss

Diagnostics

• ⭐ Rome IV clinical criteria: recurrent pain ≥1 day/week × 3 months + ≥2 of (relation to defecation, change in frequency, change in form)
• Limited labs to exclude mimics: CBC, CRP, celiac serology, fecal calprotectin (IBS vs IBD)
• ⭐ Colonoscopy if age ≥45 or any alarm feature

DDx

• IBD (calprotectin, alarm features)
• Celiac disease
• Microscopic colitis
• Lactose intolerance / SIBO
• Colorectal cancer (if alarm features)

MDM

• Positive diagnosis using Rome IV + exclude red flags (avoid over-testing in young patients without alarms)
• Reassurance is therapeutic
• Subtype-directed therapy

Treatment

• Reassurance + dietary: ⭐ low-FODMAP diet, soluble fiber (psyllium), peppermint oil
• IBS-C: secretagogues (linaclotide); IBS-D: loperamide, rifaximin, bile acid sequestrants
• Antispasmodics for pain; ⭐ low-dose TCA (IBS-D) or SSRI (IBS-C) for refractory
• ⭐ NOT recommended: gluten-free diet (unless celiac), routine anticholinergics

Patient Education

• Chronic but benign — no increased cancer risk
• Identify/avoid triggers; stress management; dietitian for FODMAP
• Pain that wakes you, blood, or weight loss is NOT IBS — report it

Emergency Precautions

• New alarm features (bleeding, weight loss, anemia, nocturnal symptoms) → re-evaluate, colonoscopy
• Age ≥45 without screening → colonoscopy

20. C. difficile Colitis

Epidemiology: ⭐ Recent antibiotics (clindamycin classic), hospitalization, PPIs, advanced age; spore-forming; toxins A+B → pseudomembranous colitis.

Critical History Questions

• ⭐ Recent/current antibiotics (within 1–2 months)?
• Watery diarrhea (≥3 loose stools/day), crampy abdominal pain, fever?
• Recent hospitalization, nursing home, PPI use?
• ⚠️ Sudden cessation of diarrhea + distension (toxic megacolon)?

ROS

• GI: watery diarrhea (occult blood), crampy pain, nausea
• Constitutional: fever, malaise; severe → dehydration

Physical Exam

• Abdominal tenderness, distension
• Fever, tachycardia
• ⚠️ Severe/fulminant: peritoneal signs, hypotension, ↓bowel sounds (toxic megacolon/ileus)

Diagnostics

• ⭐ Stool: GDH antigen + toxin A/B EIA simultaneously; if discordant → NAAT/PCR
• CBC (leukocytosis, can be marked); BMP (renal, lactate in severe)
• Sigmoidoscopy: yellow-white pseudomembranous plaques (if needed)
• AXR/CT if toxic megacolon suspected

DDx

• Other infectious diarrhea
• IBD flare
• Ischemic colitis
• Microscopic colitis
• Antibiotic-associated (non-C. diff) diarrhea

MDM

• Stop the inciting antibiotic if possible
• ⭐ Contact precautions + soap and water (hand sanitizer does NOT kill spores)
• Severity-based treatment; surgery for fulminant disease

Treatment

• ⭐ Oral vancomycin OR fidaxomicin (first-line)
• ⚠️ Oral (not IV) vancomycin — IV doesn't reach gut lumen; add IV metronidazole for fulminant
• Fulminant/ileus: high-dose oral vanc + IV metronidazole ± vancomycin enema
• Recurrent: fidaxomicin, tapered vanc, ⭐ fecal microbiota transplant (~90% success)

Patient Education

• ⭐ Soap and water handwashing (alcohol gel ineffective on spores)
• Complete the course; ~25% relapse — report recurrence
• Avoid unnecessary antibiotics + PPIs

Emergency Precautions

• ⚠️ Toxic megacolon / fulminant colitis → surgery (colectomy)
• ⚠️ Avoid antimotility agents (loperamide) in severe disease
• Sepsis → ICU, resuscitation

21. Toxic Megacolon

Epidemiology: ⭐ Severe UC flare MC; also Crohn's colitis, C. diff; precipitated by ⭐ hypokalemia and ⭐ antimotility agents/opioids/anticholinergics. Life-threatening.

Critical History Questions

• ⭐ Known IBD or recent C. diff with worsening course?
• High fever, rapid pulse, severe distension?
• ⭐ Recent loperamide/opioid/anticholinergic use, or hypokalemia?
• Bloody diarrhea that suddenly stopped (ominous)?

ROS

• GI: distension, bloody diarrhea (may decrease as colon dilates), pain
• Constitutional: fever, tachycardia, signs of sepsis

Physical Exam

• ⭐ Massively distended, tympanitic abdomen
• Fever, tachycardia, hypotension
• ⭐ Decreased/absent bowel sounds
• ⚠️ Guarding + rebound = impending/actual perforation

Diagnostics

• ⭐ AXR or CT: colonic dilation >6 cm (classically transverse colon), loss of haustra, thumbprinting; free air = perforation
• CBC, ⭐ CMP (check K+/Mg2+), CRP, ⭐ lactate (ischemia/sepsis)
• Blood cultures

DDx

• Sigmoid/cecal volvulus
• Ogilvie syndrome (pseudo-obstruction)
• Large bowel obstruction
• Severe colitis without megacolon

MDM

• Admit; early surgical consult
• Serial abdominal exams + serial radiographs
• ⭐ 48–72 h window: surgery if perforation, worsening dilation, or no improvement

Treatment

• NPO, IV fluids, ⭐ aggressive electrolyte correction (K+, Mg2+)
• ⭐ IV corticosteroids (methylprednisolone 40–60 mg/day) for IBD-associated
• Broad-spectrum antibiotics; treat C. diff if cause
• ⚠️ STOP all antidiarrheals/opioids/anticholinergics
• Surgery (colectomy) if perforation, deterioration, or no improvement in 48–72 h

Patient Education

• (Recovery) trigger avoidance; IBD optimization
• Recognize this was a surgical-level emergency

Emergency Precautions

• ⚠️ Free air / perforation → emergent colectomy
• ⚠️ "Big belly + sick patient + IBD/C.diff" = toxic megacolon until proven otherwise
• ⚠️ Never give loperamide/opioids in inflammatory diarrhea

ANORECTAL

22. Hemorrhoids

Epidemiology: Very common; straining, constipation, pregnancy, portal HTN. Internal (above dentate line, painless) vs external (below, painful).

Critical History Questions

• ⭐ Internal: painless bright red blood (BRBPR) on toilet paper/coating stool, prolapse, fullness?
• ⭐ External: painful perianal swelling; acute severe pain (thrombosed)?
• ⭐ Time of onset if thrombosed (48-hour window for excision)?
• Straining, constipation, pregnancy, heavy lifting?
• ⭐ Age >40–50, weight loss, anemia, change in bowel habits (exclude cancer)?

ROS

• GI: rectal bleeding, perianal pain/swelling, pruritus, mucoid discharge
• ⭐ Red flags: weight loss, anemia symptoms, altered bowel habits

Physical Exam

• External inspection: external/thrombosed (tense bluish nodule), skin tags, prolapse
• DRE (internal hemorrhoids often not palpable); ⭐ anoscopy = gold standard for internal
• ⭐ Concentric mucosal rings = prolapse vs radial folds = hemorrhoids
• Check for occult blood

Diagnostics

• ⭐ Anoscopy (internal hemorrhoids, gold standard); DRE unreliable for internal
• ⭐ Colonoscopy if >40–50, anemia, weight loss, family history, or atypical bleeding (exclude CRC)
• Internal hemorrhoid grading (Stage 1–4)

DDx

• ⭐ Colorectal/anal cancer (must exclude in older patients)
• Anal fissure (painful, knife-like with defecation)
• Anorectal abscess/fistula
• IBD
• Rectal prolapse

MDM

• Grade internal hemorrhoids → escalate treatment by stage
• ⭐ Thrombosed external: <48 h → excision; >48 h → conservative
• Don't attribute bleeding to hemorrhoids in older patients without excluding cancer

Treatment

• ⭐ Stage 1–2 internal: fiber, fluids, stool softeners, limit toilet time, topical agents
• Recurrent bleeding (Stage 1–3): rubber band ligation / sclerotherapy / coagulation
• Stage 3–4 / refractory: hemorrhoidectomy
• External: sitz baths, fiber, topical; ⭐ thrombosed <48 h → elliptical excision (leave open)

Patient Education

• High-fiber diet + hydration; avoid straining + prolonged sitting on toilet
• Sitz baths for comfort
• Report bleeding that persists or changes — get screened for CRC if due

Emergency Precautions

• Strangulated/necrotic internal hemorrhoid → urgent surgery
• Significant ongoing bleeding with anemia → workup
• Severe pain with fever → exclude abscess

23. Anal Fissure

Epidemiology: Linear anoderm tear below dentate line; ⭐ 90% posterior midline; cycle of high sphincter tone → ischemia → poor healing. MC cause of rectal bleeding in infancy.

Critical History Questions

• ⭐ Severe "knife-like"/tearing anal pain DURING and after defecation?
• ⭐ Small amount bright red blood (on paper/stool surface)?
• Constipation/hard stools or diarrhea preceding?
• ⭐ Duration (acute <6 wk vs chronic ≥6 wk)?
• ⭐ Lateral or multiple fissures (atypical → IBD/malignancy/STI/HIV workup)?

ROS

• GI: anal pain with defecation, BRBPR, pruritus
• Consider IBD symptoms if atypical location

Physical Exam

• Gentle inspection (DRE often too painful acutely)
• Acute: superficial midline laceration
• ⭐ Chronic: sentinel pile (skin tag), fibrotic/rolled edges, visible internal sphincter fibers
• ⭐ Lateral/multiple fissures = red flag

Diagnostics

• ⭐ Clinical inspection (visual diagnosis)
• Lateral/atypical/refractory → evaluate for IBD, malignancy, infection (HIV, syphilis, TB)

DDx

• Hemorrhoids (painless internal)
• Anorectal abscess/fistula
• Crohn's disease
• Anal cancer
• STI/proctitis

MDM

• Acute → conservative; chronic → topical relaxants; refractory → surgery
• Atypical features → broaden workup

Treatment

• Acute: ⭐ stool softeners, fiber, fluids, sitz baths, topical anesthetic/steroid
• Chronic (50–80% heal): ⭐ topical nifedipine 0.5% or diltiazem 2% or nitroglycerin 0.2–0.4% (relax sphincter); botulinum toxin
• Refractory: ⭐ lateral internal sphincterotomy (risk: incontinence)

Patient Education

• ⭐ Topical NTG causes headaches (counsel)
• High-fiber diet + hydration to prevent recurrence
• Sitz baths after BMs

Emergency Precautions

• Fissure + fever/fluctuance → exclude abscess
• Lateral/multiple/non-healing → workup for IBD, malignancy, HIV

24. Anorectal Abscess

Epidemiology: Infection of anal glands at dentate-line crypts; perianal MC; ⭐ risk: Crohn's, diabetes, immunocompromise/HIV. ~40% progress to fistula.

Critical History Questions

• ⭐ Severe, unremitting (constant) perianal pain — not just with BMs?
• Perianal swelling, redness, warmth, drainage?
• ⭐ Fever (more likely with deeper abscess)?
• Crohn's, diabetes, immunocompromise, HIV?
• ⭐ Inability to tolerate DRE (clue to deeper abscess)?

ROS

• GI: perianal pain, drainage, painful BMs
• Constitutional: fever, malaise (deeper/systemic)

Physical Exam

• ⭐ Perianal: fluctuant, erythematous, warm, tender mass
• ⭐ DRE too painful to perform → suspect deeper (ischiorectal/supralevator) abscess
• Fever, tachycardia if systemic

Diagnostics

• ⭐ Clinical exam (perianal abscess obvious — no imaging needed)
• CT/MRI for deep (ischiorectal, supralevator) abscess or to define extent
• CBC (leukocytosis)

DDx

• Thrombosed external hemorrhoid
• Anal fissure
• Fistula-in-ano
• Pilonidal disease
• Crohn's perianal disease
• Fournier gangrene (necrotizing — emergency)

MDM

• ⭐ I&D is definitive — don't treat with antibiotics alone
• ⭐ Antibiotics ONLY for: immunocompromise, diabetes, IBD, prosthetic valve/joint, systemic signs
• Deep abscess → OR

Treatment

• ⭐ Incision and drainage (gold standard) — perianal in office/ED, deeper in OR
• Add antibiotics only for high-risk comorbidities/systemic infection
• Sitz baths post-procedure
• Monitor for fistula formation

Patient Education

• ~40% develop fistula → return for chronic drainage
• Wound care, sitz baths
• Glucose control (diabetics); IBD optimization

Emergency Precautions

• ⚠️ Fournier gangrene (crepitus, necrosis, sepsis, rapidly spreading) → emergent surgical debridement + broad-spectrum antibiotics
• Sepsis/immunocompromised → admit, IV antibiotics, urgent drainage
• Supralevator abscess → surgical management

HEPATIC

25. Cirrhosis & Complications

Epidemiology: ⭐ MC causes: alcohol, chronic HCV, MASLD; irreversible fibrosis + regenerative nodules. Compensated vs decompensated determines prognosis.

Critical History Questions

• Alcohol use (quantify), viral hepatitis risk factors, metabolic syndrome?
• ⭐ Decompensation: abdominal distension (ascites), confusion/sleep reversal (encephalopathy), hematemesis/melena (varices), jaundice?
• Easy bruising/bleeding, leg swelling?
• Medications, NSAIDs, sedatives (precipitate HE)?

ROS

• GI: distension, GI bleeding, jaundice, anorexia
• Neuro: confusion, day-night reversal, asterixis
• Skin: jaundice, spider angiomata, palmar erythema, bruising
• GU: gynecomastia, testicular atrophy

Physical Exam

• ⭐ Stigmata: jaundice, spider angiomata, palmar erythema, gynecomastia, caput medusae, testicular atrophy
• ⭐ Firm nodular liver, splenomegaly
• Ascites (shifting dullness, fluid wave), peripheral edema
• ⭐ Asterixis, fetor hepaticus (encephalopathy)

Diagnostics

• LFTs, ⭐ albumin + PT/INR + bilirubin + platelets (synthetic function); FIB-4, elastography
• ⭐ Child-Turcotte-Pugh + MELD scores (prognosis/transplant)
• ⭐ EGD to screen for varices
• US/Doppler (nodular liver, splenomegaly, ascites, flow reversal); biopsy if needed
• ⭐ Diagnostic paracentesis for new ascites → SAAG ≥1.1 confirms portal HTN; PMN ≥250 = SBP

DDx

• Other causes of ascites (cardiac, malignancy, TB) — SAAG distinguishes
• Acute hepatitis
• Budd-Chiari
• Constrictive pericarditis

MDM

• Treat underlying cause; abstain alcohol
• ⭐ Screen for varices (EGD), HCC (US ± AFP q6mo)
• Manage each complication; transplant evaluation for end-stage

Treatment (by complication)

• ⭐ Varices: prophylaxis = nonselective beta-blocker (carvedilol/nadolol) + band ligation; acute bleed = octreotide + ceftriaxone + EGD banding; TIPS if refractory
• ⭐ Ascites: Na restriction ≤2 g/day + spironolactone + furosemide; large-volume paracentesis + albumin; avoid NSAIDs/ACE/ARB; TIPS for refractory
• ⭐ SBP: PMN ≥250 → IV cefotaxime now (don't wait for culture); prophylaxis cipro/TMP-SMX
• ⭐ Hepatic encephalopathy: identify precipitant + lactulose (titrate to 2–3 stools/day) + rifaximin
• Hepatorenal syndrome: albumin + octreotide + midodrine; transplant

Patient Education

• Alcohol abstinence; avoid hepatotoxins/NSAIDs/sedatives
• Low-sodium diet; daily weights
• Vaccinate (HAV, HBV, pneumococcal, influenza)
• Recognize encephalopathy/bleeding warning signs

Emergency Precautions

• ⚠️ Variceal hemorrhage → ICU; octreotide + ceftriaxone before scope; massive transfusion protocol
• ⚠️ SBP → cefotaxime immediately at PMN ≥250
• ⚠️ Worsening encephalopathy/coma → airway protection, find precipitant
• Rising creatinine → check for SBP, evaluate HRS

26. Viral Hepatitis

Epidemiology: ⭐ HAV/HEV fecal-oral (no chronic state); HBV/HCV/HDV blood/sexual (chronic risk). HEV ⚠️ dangerous in pregnancy. HCV is curable.

Critical History Questions

• ⭐ Risk factors: travel/shellfish (HAV), IV drug use/transfusion/sex (HBV/HCV), pregnancy + endemic travel (HEV)?
• Prodrome (malaise, fever, anorexia, nausea, ⭐ loss of taste for coffee/cigarettes), then jaundice, dark urine, pale stools, RUQ pain?
• Vaccination history (HAV, HBV)?
• Chronic symptoms: fatigue, cirrhosis features?

ROS

• GI: jaundice, RUQ pain, anorexia, nausea, acholic stools, dark urine
• Constitutional: fever, malaise, fatigue, arthralgias (HBV)

Physical Exam

• Jaundice, scleral icterus
• Tender hepatomegaly
• Chronic/cirrhotic stigmata if advanced

Diagnostics

• ⭐ ↑↑ ALT/AST (hepatocellular); ↑ bilirubin
• ⭐ HAV: IgM anti-HAV (acute); IgG (immunity)
• ⭐ HBV: HBsAg (infection), anti-HBc IgM (acute), HBeAg (active replication), anti-HBs (immunity/vaccination); window period = only anti-HBc IgM+
• ⭐ HCV: anti-HCV screen → confirm with HCV RNA; genotype
• HDV: anti-HDV (only with HBsAg+); HEV: serology + travel history

DDx

• Alcohol-associated / drug-induced liver injury
• Autoimmune hepatitis
• Biliary obstruction (cholestatic pattern)
• Wilson disease, hemochromatosis (younger/metabolic)
• Ischemic hepatitis

MDM

• Identify type via serology; report to public health where applicable
• Screen contacts; vaccinate susceptible contacts
• Chronic HBV/HCV → HCC surveillance + treatment

Treatment

• ⭐ HAV/HEV: supportive (self-limited); HAV vaccine + immunoglobulin for contacts
• ⭐ HBV: acute = supportive; chronic active = entecavir or tenofovir; neonate of HBsAg+ mother = vaccine + HBIG within 12 h
• ⭐ HCV: direct-acting antivirals (curable); vaccinate against HAV/HBV; alcohol abstinence
• HDV: prevent via HBV vaccination

Patient Education

• HAV/HEV: hand/food/water hygiene
• HBV/HCV: avoid sharing needles/razors; safe sex; HCV is curable — get treated
• Vaccinate (HAV, HBV); pregnant + endemic travel → HEV caution
• Avoid alcohol/hepatotoxins during recovery

Emergency Precautions

• ⚠️ Fulminant hepatic failure (coagulopathy + encephalopathy) → transplant center
• ⚠️ HEV in pregnancy → high fatality; close monitoring
• Chronic HBV sudden deterioration → test for HDV superinfection

BILIARY

27. Acute Cholecystitis

Epidemiology: Complete cystic duct obstruction (gallstones ~95%) → GB inflammation. ⭐ 5 F's: Female, Fat, Forty, Fertile, Fair.

Critical History Questions

• ⭐ Severe constant RUQ/epigastric pain >4–6 h (vs biliary colic <3 h)?
• ⭐ Radiation to right shoulder/scapula?
• ⭐ Fatty food trigger; postprandial onset?
• Fever, nausea/vomiting?
• Prior biliary colic episodes, known gallstones?
• ⚠️ Jaundice, dark urine, pale stools (suggests CBD stone/cholangitis)?

ROS

• GI: RUQ pain, nausea/vomiting, fatty food intolerance, anorexia
• Constitutional: fever, malaise

Physical Exam

• ⭐ Murphy sign (inspiratory arrest on RUQ palpation)
• RUQ tenderness, guarding; possibly Blumberg (rebound)
• Fever, tachycardia; ill-appearing
• ⚠️ Jaundice → suspect choledocholithiasis/cholangitis

Diagnostics

• ⭐ RUQ ultrasound (first-line): gallstones, wall thickening >5 mm, pericholecystic fluid, sonographic Murphy, double-wall sign
• HIDA scan if US equivocal (non-filling GB; sensitivity ~95%)
• CBC (leukocytosis), LFTs (↑ bilirubin/alk phos → CBD stone), lipase

DDx

• Biliary colic (self-limited <3 h, afebrile, normal labs)
• Choledocholithiasis / ascending cholangitis
• Acute pancreatitis
• Peptic ulcer / perforation
• Hepatitis; right lower lobe pneumonia; appendicitis (high/retrocecal)

MDM

• ⭐ Murphy + fever + leukocytosis + thickened wall on US → admit, surgery
• ↑ Bilirubin → evaluate for CBD stone (MRCP/ERCP)
• High surgical risk → percutaneous cholecystostomy

Treatment

• NPO, IV fluids, analgesia (IV ketorolac), antiemetics
• ⭐ IV antibiotics: pip-tazo OR ceftriaxone/levofloxacin + metronidazole
• ⭐ Laparoscopic cholecystectomy within 24–72 h
• Percutaneous cholecystostomy if not a surgical candidate

Patient Education

• Cholecystectomy is definitive; low-fat diet pre-op
• Post-op: most tolerate normal diet; some looser stools initially
• Return for fever, jaundice, worsening pain

Emergency Precautions

• ⚠️ Untreated → gangrene (~20%), perforation (~10%), fistula
• ⚠️ Jaundice + fever + RUQ pain (Charcot triad) → ascending cholangitis → urgent ERCP
• Sepsis → resuscitation, urgent source control

28. Choledocholithiasis & Ascending Cholangitis

Epidemiology: Gallstone in CBD (10–15% of gallstone patients); stasis + bacterial superinfection → ⭐ ascending cholangitis (E. coli, Klebsiella). Cholangitis is an emergency.

Critical History Questions

• ⭐ RUQ/epigastric pain + jaundice + dark urine + pale stools?
• ⭐ Charcot triad — RUQ pain + jaundice + fever?
• ⚠️ Reynolds pentad — + altered mental status + hypotension (suppurative cholangitis/sepsis)?
• Known gallstones, prior cholecystectomy, PSC?

ROS

• GI: RUQ pain, jaundice, dark urine, pale stools, nausea
• Constitutional: fever, rigors; ⚠️ confusion (pentad)

Physical Exam

• RUQ tenderness, jaundice/scleral icterus
• ⭐ Charcot triad: RUQ pain + jaundice + fever
• ⚠️ Reynolds pentad: + AMS + hypotension = septic shock
• Courvoisier sign (palpable nontender GB) — more typical of malignant obstruction

Diagnostics

• ⭐ Cholestatic LFTs: ↑↑ alk phos + GGT + conjugated (direct) bilirubin
• ⭐ RUQ US (CBD >6–10 mm, stones — less reliable post-chole/elderly)
• ⭐ MRCP (non-invasive, >90% sensitive — dark filling defects)
• ⭐ ERCP (diagnostic + therapeutic)
• CBC (leukocytosis → cholangitis), blood cultures, lipase (rule out gallstone pancreatitis)

DDx

• Acute cholecystitis (no jaundice unless CBD involved)
• Gallstone pancreatitis
• Pancreatic/biliary malignancy (painless jaundice, Courvoisier)
• Hepatitis
• PSC (beaded ducts on MRCP, UC association)

MDM

• Cholestatic LFTs + dilated CBD → MRCP to confirm → ERCP
• ⭐ Cholangitis = emergency: antibiotics + biliary decompression (ERCP)
• Cholecystectomy after stabilization
• ⚠️ ERCP pancreatitis risk 4–6% — check lipase

Treatment

• Choledocholithiasis: ⭐ ERCP + sphincterotomy + stone extraction → then laparoscopic cholecystectomy
• Ascending cholangitis: ⚠️ IV antibiotics (pip-tazo OR ceftriaxone + metronidazole) + ⭐ urgent ERCP with sphincterotomy/decompression; ICU if pentad
• Aggressive IV fluids; sepsis management

Patient Education

• ERCP clears the duct; cholecystectomy prevents recurrence
• Report recurrent jaundice, fever, pain
• PSC patients: cholangiocarcinoma surveillance

Emergency Precautions

• ⚠️ Reynolds pentad → ICU + emergent biliary decompression
• Suppurative cholangitis / sepsis → vasopressors, urgent ERCP/PTC
• Gallstone pancreatitis → urgent ERCP

PANCREAS

29. Acute Pancreatitis

Epidemiology: ⭐ #1 gallstones (~45%), #2 alcohol (~25%); also hypertriglyceridemia (>1000), hypercalcemia, ERCP, drugs, trauma. Premature trypsin activation → autodigestion.

Critical History Questions

• ⭐ Severe constant boring epigastric pain radiating to the back?
• ⭐ Worse supine/walking, better leaning forward?
• Nausea/vomiting?
• ⭐ Alcohol use; gallstone history; hypertriglyceridemia; recent ERCP?
• Medications, prior episodes?

ROS

• GI: epigastric/back pain, N/V, abdominal distension (ileus)
• Constitutional: fever, tachycardia; signs of dehydration/shock if severe

Physical Exam

• Epigastric tenderness, guarding; decreased bowel sounds (ileus)
• Tachycardia, fever, possible hypotension
• ⚠️ Cullen sign (periumbilical bruising) + Gray Turner sign (flank bruising) = retroperitoneal hemorrhage (necrotizing)
• ⭐ Chvostek/Trousseau signs = hypocalcemia (fat saponification)

Diagnostics

• ⭐ Lipase >3× ULN (more sensitive/specific than amylase; stays up ~14 days)
• ⭐ Diagnosis = 2 of 3: characteristic pain + enzymes >3× ULN + imaging
• ⭐ ALT >150 → gallstone etiology; triglycerides, calcium
• ⭐ RUQ ultrasound (gallstones, CBD dilation) — same day if gallstone suspected
• CT with contrast = best for complications (avoid if Cr >1.5); ⭐ Cr >1.8 at 48 h → necrosis risk
• Severity: Ranson, BISAP ≥3 = high mortality

DDx

• Perforated peptic ulcer
• Acute cholecystitis / cholangitis
• Mesenteric ischemia
• Bowel obstruction
• Inferior MI, AAA, ectopic pregnancy

MDM

• ⭐ All admit
• Determine etiology (gallstone vs alcohol vs TG) — drives specific management
• Severity stratification; ICU for severe/necrotizing

Treatment

• ⭐ Aggressive IV fluids — lactated Ringer preferred over NS
• NPO initially → ⭐ early enteral nutrition > TPN as tolerated
• Analgesia (opioids acceptable — sphincter of Oddi concern outdated)
• ⭐ Gallstone → laparoscopic cholecystectomy same admission; gallstone pancreatitis with obstruction/cholangitis → urgent ERCP
• Hypertriglyceridemia → IV insulin
• ⚠️ NO routine prophylactic antibiotics; infected necrosis → imipenem + necrosectomy/drainage

Patient Education

• Alcohol + smoking cessation (alcohol etiology)
• Cholecystectomy prevents recurrence (gallstone etiology)
• TG/lipid management
• Return for fever, persistent pain, vomiting

Emergency Precautions

• ⚠️ Necrotizing pancreatitis (instability, ↑Cr, skin signs, ≥30% non-enhancement on CT) → ICU
• ⚠️ Infected necrosis → antibiotics + necrosectomy/drainage (NOT prophylactic abx)
• Hypocalcemia with tetany → IV calcium gluconate
• ARDS, organ failure → ICU support

30. Pancreatic Adenocarcinoma

Epidemiology: ⭐ 3rd leading cancer death; ~13% 5-yr survival; ⭐ smoking = greatest risk; also DM, obesity, chronic pancreatitis, hereditary (BRCA2, Lynch, Peutz-Jeghers); median age 71.

Critical History Questions

• ⭐ Painless obstructive jaundice (head tumor)?
• ⭐ New-onset diabetes after age 45?
• Progressive weight loss, fatigue, anorexia, steatorrhea?
• LUQ/back pain (tail tumor)?
• Smoking, chronic pancreatitis, family history?
• Migratory thrombophlebitis (Trousseau syndrome)?

ROS

• GI: jaundice, weight loss, anorexia, steatorrhea, abdominal/back pain
• Endocrine: new diabetes
• Constitutional: weight loss, fatigue

Physical Exam

• Jaundice, scleral icterus, excoriations (pruritus)
• ⭐ Courvoisier sign: palpable NON-tender distended gallbladder + jaundice (malignancy, not stones)
• ⭐ Late: Virchow node (L supraclavicular), Sister Mary Joseph nodule (periumbilical)
• Cachexia, hepatomegaly (mets)

Diagnostics

• ⭐ Pancreatic-protocol CT (multiphase thin-cut) = first-line: hypoenhancing mass, double-duct sign, vascular invasion
• EUS + biopsy (histologic diagnosis)
• ⭐ Disproportionate ↑ alk phos + GGT vs ALT/AST; ↑ bilirubin
• ⭐ CA 19-9 — monitoring only, NOT screening

DDx

• Choledocholithiasis / cholangitis (painful, fever)
• Cholangiocarcinoma
• Chronic pancreatitis (calcifications)
• Ampullary/duodenal tumors
• Pancreatic neuroendocrine tumors

MDM

• ⭐ Painless jaundice in an older patient = pancreatic cancer until proven otherwise → pancreatic-protocol CT
• Multidisciplinary (GI, surgical/medical/radiation oncology, palliative)
• Resectability determines approach

Treatment

• Resectable head: ⭐ Whipple (pancreaticoduodenectomy) + adjuvant chemo
• Resectable tail: distal pancreatectomy
• Advanced: chemotherapy ± radiation; biliary stenting (palliation)
• Palliative care: pain control, nutrition, biliary decompression

Patient Education

• Smoking cessation (primary prevention)
• Nutritional support, pancreatic enzyme replacement
• Realistic prognosis discussion + early palliative care

Emergency Precautions

• ⚠️ Cholangitis from biliary obstruction → antibiotics + decompression
• Gastric outlet obstruction → stent/bypass
• VTE (Trousseau) → anticoagulation

HERNIA / BLEEDING / MALABSORPTION

31. Inguinal & Femoral Hernia

Epidemiology: ⭐ Inguinal = most common hernia overall (indirect MC, males); ⭐ femoral more common in women + highest incarceration/strangulation risk.

Critical History Questions

• ⭐ Groin bulge worse with standing/coughing/straining, reduces lying down?
• ⭐ Pain, or new constant pain (incarceration concern)?
• Extends into scrotum (indirect inguinal)?
• ⚠️ Nausea/vomiting/obstipation, irreducible tender bulge (incarceration/strangulation)?
• Heavy lifting, chronic cough, constipation, prior hernia/surgery?

ROS

• GI: groin bulge, discomfort; ⚠️ vomiting/obstruction if incarcerated
• GU: testicular/inner-thigh referred pain (indirect)

Physical Exam

• Inspect/palpate groin standing + Valsalva
• ⭐ Inguinal: above inguinal ligament; indirect → comes to fingertip in canal, may enter scrotum; direct → pushes against side of finger (Hesselbach triangle), medial
• ⭐ Femoral: below inguinal ligament, medial to femoral vessels, lateral to pubic tubercle; never into scrotum
• ⚠️ Irreducible, tender, erythematous, skin changes = incarceration/strangulation

Diagnostics

• ⭐ Clinical diagnosis
• Ultrasound (dynamic Valsalva — preferred when uncertain, esp. femoral)
• CT for complex/recurrent or to assess obstruction
• Lactate/CBC if strangulation suspected

DDx

• Lymphadenopathy
• Lipoma / soft-tissue mass
• Hydrocele / varicocele / testicular pathology
• Femoral artery aneurysm
• Psoas abscess

MDM

• ⭐ Femoral hernia → repair regardless of symptoms (high strangulation risk)
• Inguinal → elective repair if symptomatic; watchful waiting acceptable for asymptomatic minimally symptomatic males
• ⚠️ Incarceration/strangulation → emergent surgery

Treatment

• ⭐ Surgical repair (open or laparoscopic + mesh)
• Femoral → repair even if asymptomatic
• ⚠️ Strangulated → emergent surgery + bowel assessment

Patient Education

• Avoid heavy lifting until cleared post-op
• ⭐ Return immediately for irreducible/tender bulge, vomiting, severe pain (strangulation)
• Recurrence possible; manage chronic cough/constipation/weight

Emergency Precautions

• ⚠️ Strangulation (irreducible + tender + skin changes + obstruction/peritonitis) → emergent surgery
• Incarceration with obstruction → urgent reduction/surgery
• Femoral hernias often present as incarcerated emergencies

32. Acute GI Bleeding

Epidemiology: ⭐ UGIB (proximal to ligament of Treitz): PUD MC, also varices, Mallory-Weiss, Dieulafoy, malignancy. ⭐ LGIB (distal): diverticulosis MC in elderly, angiodysplasia, hemorrhoids, colitis, cancer.

Critical History Questions

• ⭐ Hematemesis or coffee-ground emesis (UGIB) vs hematochezia (LGIB) vs melena (usually upper)?
• ⭐ Preceding retching/vomiting (Mallory-Weiss)?
• NSAID/aspirin/anticoagulant use, alcohol, known cirrhosis/varices?
• Lightheadedness, syncope (volume loss)?
• Prior bleeds, weight loss/anemia (malignancy), known diverticulosis?

ROS

• GI: hematemesis, melena, hematochezia, epigastric pain
• CV: palpitations, lightheadedness, syncope (hypovolemia)
• Constitutional: fatigue, weight loss (malignancy)

Physical Exam

• ⭐ Vitals first: tachycardia, hypotension, orthostatic changes (tilt test)
• Pallor, diaphoresis
• ⭐ DRE: melena vs hematochezia; identify hemorrhoids/masses
• Stigmata of liver disease (varices likely): ascites, spider angiomata, caput medusae
• Abdominal tenderness (PUD, ischemia)

Diagnostics

• CBC (Hgb — may lag acutely), ⭐ BUN:Cr >20 suggests UGIB, type & screen/cross, coags/INR, lactate
• ⭐ EGD = first-line for UGIB (diagnostic + therapeutic; Forrest classification)
• ⭐ Colonoscopy for LGIB after stabilization; CT angiography if unstable/brisk (extravasation)
• Risk scores: Glasgow-Blatchford (UGIB), Oakland (LGIB)

DDx

• UGIB sources: PUD, varices, Mallory-Weiss, Dieulafoy, esophagitis, malignancy
• LGIB sources: diverticulosis, angiodysplasia, hemorrhoids, ischemic/infectious colitis, cancer
• Swallowed blood (epistaxis); pseudo-melena (iron/bismuth)

MDM

• ⭐ Stabilize FIRST — ABCs, 2 large-bore IVs, fluids, transfuse if Hgb <7 (higher threshold if active cardiac ischemia/massive bleed)
• Reverse anticoagulation as appropriate
• ⭐ Cirrhotic + UGIB → start octreotide + ceftriaxone before endoscopy (presume varices)
• IV PPI for suspected ulcer bleed
• ⭐ Always exclude colorectal cancer in new LGIB / positive FOBT in adults >40–50

Treatment

• Resuscitation: crystalloid, blood products, correct coagulopathy
• UGIB: IV PPI; EGD hemostasis (clips, thermal, epinephrine); ⭐ varices = octreotide + ceftriaxone + band ligation, TIPS if refractory
• LGIB: colonoscopic hemostasis; angiographic embolization or surgery if unstable
• Dieulafoy/obscure: repeat EGD, angiography, capsule endoscopy

Patient Education

• Avoid NSAIDs/aspirin (or co-prescribe PPI); limit alcohol
• H. pylori eradication if ulcer; varices → beta-blocker + banding program
• Return for recurrent bleeding, black stools, dizziness

Emergency Precautions

• ⚠️ Hemodynamic instability → massive transfusion protocol, ICU
• ⚠️ Variceal bleed → octreotide + ceftriaxone + urgent banding; airway protection
• Ongoing brisk bleed despite endoscopy → IR embolization or surgery

33. Celiac Disease

Epidemiology: Autoimmune T-cell response to gluten (wheat, barley, rye); ⭐ HLA-DQ2/DQ8; villous atrophy → malabsorption. Associated with type 1 DM, autoimmune thyroid, Down syndrome.

Critical History Questions

• ⭐ Chronic diarrhea, bloating, weight loss, steatorrhea?
• ⭐ Iron-deficiency anemia WITHOUT a bleeding source?
• Fatigue, osteoporosis/fractures, neuropathy?
• ⭐ Intensely pruritic rash on extensor surfaces (dermatitis herpetiformis)?
• Family history of celiac/autoimmune disease?
• Relationship of symptoms to gluten intake?

ROS

• GI: diarrhea, steatorrhea, bloating, weight loss
• Heme: anemia symptoms (fatigue, pallor)
• MSK/skin/neuro: bone pain, DH rash, paresthesias
• Constitutional: weight loss, failure to thrive (children)

Physical Exam

• Signs of malnutrition/weight loss, pallor
• ⭐ Dermatitis herpetiformis (pruritic papulovesicles on elbows, knees, buttocks)
• Aphthous ulcers; signs of vitamin deficiency
• Abdominal distension

Diagnostics

• ⭐ IgA anti-tissue transglutaminase (tTG-IgA) + total IgA (if IgA deficient → IgG-based testing)
• ⭐ Confirm with upper endoscopy + duodenal biopsy: villous atrophy, crypt hyperplasia, intraepithelial lymphocytes
• ⭐ Do NOT start gluten-free diet before testing (normalizes serology/histology → false negatives)
• CBC (IDA), iron studies, B12/folate, vitamin D, DEXA

DDx

• IBS
• Lactose intolerance / food intolerance
• IBD (Crohn's)
• Pancreatic insufficiency
• Tropical sprue / SIBO
• Microscopic colitis

MDM

• ⭐ IDA without blood loss → think celiac
• ⭐ Dermatitis herpetiformis → check celiac serology even without GI symptoms
• Confirm with biopsy before committing to lifelong diet; dietitian referral; monitor nutrition annually

Treatment

• ⭐ Lifelong gluten-free diet (no wheat, rye, barley)
• Replace deficiencies: iron, folate, calcium, vitamin D, B12
• ⭐ Dermatitis herpetiformis: gluten-free diet + dapsone (monitor for hemolysis/methemoglobinemia — check G6PD)
• Dietitian referral; treat associated autoimmune conditions

Patient Education

• Strict lifelong gluten avoidance — even small amounts trigger injury
• Read labels; hidden gluten sources; cross-contamination
• Symptoms + serology improve with adherence; non-adherence → osteoporosis, lymphoma risk
• Screen first-degree relatives

Emergency Precautions

• Celiac crisis (severe diarrhea, dehydration, electrolyte derangement) — rare, supportive care
• Refractory celiac / new alarm symptoms → evaluate for enteropathy-associated T-cell lymphoma
• Functional asplenia → ensure vaccinations

QUICK REFERENCE TABLES — GI

DDx: Dysphagia

DDx: Acute Abdominal Pain by Location

UGIB vs LGIB

Ulcerative Colitis vs Crohn's Disease

Infectious Diarrhea: Antibiotics?

Ascites — SAAG

SBP: paracentesis PMN ≥250/μL → IV cefotaxime now (don't wait for culture).

Biliary Disease Spectrum

Acute Pancreatitis Pearls

GU/RENAL

GU INFECTIONS

1. Acute Cystitis

Epidemiology: Young women (16–35) >> men; E. coli 75–90% of uncomplicated cases; S. saprophyticus 5–15%.

Critical History Questions

• Dysuria, urinary frequency/urgency, nocturia?
• Hematuria (gross or microscopic)?
• Suprapubic/pelvic pain?
• ⭐ Fever, chills, rigors? (→ fever = escalate to pyelonephritis DDx)
• Vaginal discharge? (rules out vaginitis/PID)
• Recent sexual intercourse, new partner, diaphragm/spermicide use?
• Prior UTIs? Frequency? (recurrent = ≥3/yr)
• Pregnancy status?
• Urologic instrumentation/catheter history?

ROS

• GU: dysuria, frequency, urgency, hesitancy, hematuria, suprapubic pressure, cloudy/malodorous urine
• GYN: vaginal discharge (present → broaden DDx away from cystitis)
• Constitutional: ⭐ NO fever in uncomplicated cystitis — any fever → think pyelo

Physical Exam

• Vitals: ⭐ afebrile — fever flags pyelonephritis
• Abdomen: suprapubic tenderness on palpation; no rebound/guarding; normal bowel sounds
• Pelvic exam (if discharge present): no CMT, no adnexal tenderness (those = PID)
• No CVA tenderness

Diagnostics

• UA (dipstick): leukocyte esterase ✓, nitrites ✓, hematuria — supportive but not definitive
• 🧠 Never hang your hat on UA alone — send urine C&S (gold standard); culture takes 3–4 days
• WBC >5/hpf on microscopy; hematuria >3 RBC/hpf
• Imaging: rarely warranted unless anatomic concern or recurrent disease

DDx

• Vaginitis (discharge present, no pyuria)
• PID (fever, cervical motion tenderness, adnexal tenderness)
• Urethritis/STI (urethral discharge, sexual exposure history)
• Pyelonephritis (fever + CVA tenderness)
• Interstitial cystitis (pain RELIEVED by voiding, no pyuria, >6 weeks)

MDM

• Uncomplicated if: non-pregnant woman, no anatomic anomaly, no recent instrumentation → short-course antibiotic, outpatient
• Complicated if: male, pregnant, immunocompromised, recent instrumentation, anatomic anomaly → longer course, guide by culture

Treatment

• ⭐ 1st line (uncomplicated): TMP-SMX 160/800 mg q12h × 3 days OR Nitrofurantoin 100 mg q12h × 5 days OR Fosfomycin 3 g × 1 dose
• 2nd line: Ciprofloxacin 250 mg q12h × 3d (NOT 1st line — resistance + tendon risk)
• Pregnancy: Nitrofurantoin or cephalexin × 7d; ⭐ avoid TMP-SMX (folate antagonism), avoid Cipro; avoid nitrofurantoin last month (neonatal hemolytic anemia risk)
• Males: Cipro or TMP-SMX × 7–14d
• Symptomatic relief: Phenazopyridine (Pyridium) 100–200 mg TID ≤3–4 days (analgesic only — does NOT treat infection)

Patient Education

• Fluids >2 L/day
• Void before and after intercourse
• Avoid spermicides and diaphragm use (↑ E. coli adhesion)
• Front-to-back wiping technique
• Complete full antibiotic course even if symptoms improve
• Return if fever develops (pyelonephritis escalation)

Emergency Precautions

• Fever developing during treatment → escalate to pyelo workup; consider imaging
• Pregnancy + any UTI = always treat (risk of preterm labor)
• Recurrent UTIs (≥3/yr) → urology referral + imaging to exclude anatomic anomaly

2. Acute Pyelonephritis

Epidemiology: Women more common; often ascending from untreated cystitis; MCC = E. coli. Hematogenous: S. aureus (think IVDU).

Critical History Questions

• ⭐ Fever with rapid onset? Shaking chills/rigors?
• Dysuria, frequency, urgency (preceding cystitis symptoms)?
• ⭐ Unilateral flank/back pain?
• N/V, diarrhea?
• Pregnancy?
• DM, immunocompromise, urologic anomalies?
• Prior UTIs or pyelonephritis?
• IVDU? (S. aureus hematogenous spread)
• Recent urologic procedure?

ROS

• GU: dysuria, frequency, urgency, hematuria
• GI: N/V, diarrhea
• Constitutional: ⭐ fever (high, spiking), rigors, malaise, tachycardia

Physical Exam

• ⭐ Fever — distinguishing feature from cystitis
• Tachycardia
• ⭐ Unilateral CVA tenderness — very pronounced (can be bilateral)
• Mild suprapubic tenderness
• Normal pelvic exam — no CMT, no adnexal tenderness (if present → PID on DDx)
• No vaginal discharge (if present → pursue gynecologic cause first)

Diagnostics

• UA + C&S: pyuria, bacteriuria, hematuria
• 🔹 Leukocyte casts = upper tract infection — specific for pyelonephritis
• CBC: leukocytosis with left shift
• BMP: check Cr/BUN
• Blood cultures: 20–30% bacteremia
• Imaging: US (enlarged kidney or hydronephrosis); 🔹 CT → perinephric fat stranding (characteristic)
• Imaging indications: new eGFR <40 mL/min, suspected stone, urine pH ≥7.0

DDx

• Cystitis (afebrile, no CVA tenderness)
• Renal abscess (pyelo not responding to abx at 72h; palpable flank mass)
• PID (CMT + adnexal tenderness)
• Appendicitis (RLQ tenderness, different pain character)
• Ovarian cyst/torsion (acute pelvic pain, ultrasound)
• Nephrolithiasis (colicky, hematuria without pyuria)

MDM

• Severity determines inpatient vs. outpatient
• Inpatient: sepsis, severe illness requiring IV abx, pregnancy, immunocompromise, N/V limiting oral intake, urinary retention/obstruction
• Moderate illness tolerating PO → ED/observation; discharge if stable
• Failure to improve in 48h → imaging to rule out abscess or obstruction

Treatment

• Inpatient empiric IV:
• Ampicillin 1g IV q6h + gentamicin 1 mg/kg IV q8h
• Ceftriaxone 1g IV daily
• Ciprofloxacin 400 mg IV q12h
• Outpatient: Initial IM/IV ceftriaxone 1g, then PO:
• Ciprofloxacin 750 mg PO BID × 7–14d
• Levofloxacin 750 mg PO daily × 5d
• TMP-SMX × 10–14d
• ⭐ Nitrofurantoin does NOT penetrate renal tissue — NEVER use for pyelonephritis
• IV until afebrile 24h → PO to complete 14-day total course
• Tailor to C&S; follow-up urine culture mandatory

Patient Education

• ⭐ Fever may persist up to 72h on appropriate antibiotics — expected, not failure
• Complete full antibiotic course (14 days total)
• Return if no improvement after 48h or fever worsens
• Adequate hydration; rest during acute illness
• Prevent recurrence: void post-intercourse, hydration, avoid spermicides

Emergency Precautions

• ⭐ Failure to improve in 48h → CT imaging to rule out abscess or obstruction
• Sepsis/septic shock → ICU, aggressive fluid resuscitation, vasopressors
• Emphysematous pyelonephritis (diabetic + gas on CT + failing IV abx) → emergent percutaneous drainage + abx
• Abscess >3 cm or no improvement 48h → percutaneous drainage

3. Urethritis (STI)

Epidemiology: 15–35 yo; MSM higher risk; women often asymptomatic with chlamydia. Gonococcal (GC) = Neisseria gonorrhoeae; Non-gonococcal (NGU) = Chlamydia trachomatis (MCC).

Critical History Questions

• Urethral discharge? Color and consistency? (purulent/yellow-green = GC; clear/mucoid = Chlamydia)
• Dysuria? Urethral pruritus?
• Urinary frequency/urgency?
• ⭐ Fever? (fever → think PID, DGI, or epididymitis)
• Sexual history: number of partners, unprotected sex, STI history, MSM?
• ⭐ Women: any symptoms at all? (often asymptomatic → routine screening only)
• Last STI testing?

ROS

• GU: dysuria, urethral discharge, itching/burning
• Constitutional: typically afebrile — fever = complication
• Systemic: joint pain (DGI), rash (DGI — consider in any young sexually active patient with arthritis + genital symptoms)

Physical Exam

• Males: discharge at meatus (or expressed by milking urethra), erythema, urethral tenderness; ± epididymal tenderness
• ⭐ GC discharge = purulent thick yellow-green; Chlamydia = mucoid/clear
• Females: minimal urethral findings; cervicitis = mucopurulent discharge + friable cervix
• Typically afebrile; lymphadenopathy not prominent in uncomplicated urethritis

Diagnostics

• 🔹 NAAT (PCR) = gold standard for GC/Chlamydia
• Men: first-catch urine (highest sensitivity)
• Women: vaginal or cervical swabs (preferred)
• UA: pyuria, positive LE; 🔹 WBCs in urine WITHOUT bacteria → think NGU/Chlamydia
• Screen for HIV, syphilis, hepatitis B/C

DDx

• Cystitis (dysuria + pyuria + bacteriuria)
• Epididymitis (scrotal tenderness, may have discharge)
• PID in women (fever, CMT, adnexal tenderness)
• Disseminated gonococcal infection (fever, migratory arthralgia, rash, +/- discharge)

MDM

• ⭐ Treat empirically at presentation — DO NOT wait for NAAT results
• ⭐ Always treat for BOTH GC AND Chlamydia simultaneously (co-infection common)
• Notify/treat all sexual partners
• Retest in 3 months (reinfection common)

Treatment

• ⭐ Dual therapy:
• Ceftriaxone 500 mg IM once (GC coverage)
• Doxycycline 100 mg PO BID × 7 days (Chlamydia coverage)
• Alternative if doxy not tolerated: Azithromycin 1g PO once (less preferred — higher resistance)
• Persistent/recurrent: consider Mycoplasma genitalium (PCR required)

Patient Education

• Abstain from sexual activity until treatment complete AND asymptomatic
• All sexual partners must be treated
• Consistent condom use; limit number of partners
• ⭐ Retest in 3 months regardless of symptoms
• Chlamydia is often silent in women — routine screening at every gynecologic visit

Emergency Precautions

• Disseminated gonococcal infection (DGI): fever + migratory arthralgia + skin lesions + genital symptoms → hospitalize, IV ceftriaxone
• PID: fever + CMT → separate management pathway

4. Acute Bacterial Prostatitis

Epidemiology: Most common urologic diagnosis in males <50. MCC gram-negative rods (E. coli, Klebsiella, Pseudomonas); GC/Chlamydia in STI-risk patients.

Critical History Questions

• ⭐ Acute onset fever and chills?
• ⭐ Perineal/pelvic pain, low back pain?
• Dysuria, frequency, hesitancy?
• Age <50?
• STI risk factors?
• Recent urologic procedure or catheterization?
• History of prior prostatitis or recurrent UTIs?
• Immunocompromise?

ROS

• GU: dysuria, frequency, urgency, hematuria
• Musculoskeletal/pelvic: perineal/low back/pelvic pain
• Constitutional: ⭐ fever, chills, malaise — distinguishes from chronic prostatitis

Physical Exam

• ⭐ Fever (high) — key distinguishing feature
• Tachycardia if systemically ill
• ⭐ DRE: boggy, warm, exquisitely tender prostate — hallmark
• ⭐ DO NOT perform vigorous prostate massage — risk of bacteremia/sepsis
• Suprapubic tenderness possible

Diagnostics

• Urine culture (positive) + UA with pyuria
• CBC: leukocytosis + left shift
• Blood cultures if septic appearance (ER presentation)
• PSA: elevated (infection drives PSA — do NOT use for cancer screening during acute prostatitis)
• ⭐ Persistent fever 24–48h after antibiotics → pelvic CT to rule out prostatic abscess → if abscess → surgical drainage

DDx

• Chronic bacterial prostatitis (afebrile, recurrent)
• BPH (no fever, gradual, older, obstructive pattern)
• Epididymo-orchitis (testicular tenderness, younger)
• Acute cystitis (no perineal pain, no prostate tenderness)
• Pelvic inflammatory disease / rectal abscess

MDM

• Outpatient if mild-moderate and able to tolerate oral intake
• Inpatient if: sepsis, systemically ill, unable to tolerate PO, urinary retention

Treatment

• Outpatient: Ciprofloxacin 500 mg BID OR TMP-SMX DS BID × 4–6 weeks
• Inpatient/IV: Ampicillin + gentamicin → step down to oral when tolerating
• Duration ≥4–6 weeks mandatory (shorter → chronic prostatitis risk)
• Abscess identified on CT → surgical drainage

Patient Education

• Complete full antibiotic course — minimum 4–6 weeks
• Sexual abstinence until resolved and partner treated if STI etiology
• Sitz baths for comfort
• No vigorous DRE or prostate massage during acute episode
• Return if fever persists 24–48h after starting antibiotics

Emergency Precautions

• ⭐ Fever persisting 24–48h after antibiotics → pelvic CT to rule out abscess
• Prostatic abscess → urgent surgical drainage
• Sepsis / septic shock → ICU, IV abx, fluid resuscitation, vasopressors
• Urinary retention → catheterization (suprapubic preferred to avoid prostate trauma)

5. Fournier Gangrene

⭐ SURGICAL EMERGENCY — never miss. Mortality 20–40%.

Epidemiology: Men >> women; peak age 50–70. #1 risk factor = diabetes mellitus. Polymicrobial (gram-positive + gram-negative + anaerobes).

Critical History Questions

• ⭐ Perineal/scrotal pain — is it out of proportion to visible skin findings?
• Diabetes? Alcohol use disorder? CKD? HIV?
• Recent urologic procedure, catheterization, or surgery?
• Urethral strictures?
• Fever, malaise?
• Systemic signs: tachycardia, hypotension?

ROS

• ⭐ Severe perineal pain dramatically out of proportion to exam findings — most critical symptom
• Constitutional: fever, malaise, rapidly progressive
• GU: discharge, swelling, dysuria

Physical Exam

• ⭐ Pain out of proportion to skin findings — early hallmark; always triggers necrotizing fasciitis dx
• Early: perineal/scrotal swelling, erythema, tenderness
• ⭐ Late findings: skin necrosis (black tissue), bullae, crepitus (pathognomonic — gas in tissue), foul-smelling discharge
• Systemic: tachycardia, hypotension (septic shock)
• Any perineal pain + crepitus + systemic toxicity = Fournier until proven otherwise

Diagnostics

• ⭐ Clinical diagnosis — DO NOT delay treatment for imaging
• Labs: leukocytosis, elevated CRP + lactate
• CT (if patient stable): demonstrates gas in soft tissues — confirms but don't wait for it
• Blood cultures (before antibiotics if possible)

DDx

• Cellulitis (no crepitus, no systemic toxicity, no necrosis)
• Scrotal abscess (fluctuant, localized, afebrile unless complicated)
• Epididymo-orchitis (testicular tenderness, gradual onset)
• Hernia with strangulation

MDM

• ⭐ Do NOT wait for imaging — clinical diagnosis = emergency action
• Immediately transfer to ED / surgical suite
• Early surgery consult is mandatory

Treatment

• ⭐ Most important: immediate surgical debridement — repeat debridement frequently
• Broad-spectrum IV antibiotics: piperacillin-tazobactam + vancomycin (gram+, gram−, anaerobes)
• ICU hemodynamic support: IV fluids, vasopressors if septic shock
• Hyperbaric oxygen: optional adjunct
• Wound care and reconstruction deferred until stabilized

Patient Education

• Diabetes control is the most modifiable risk factor
• Seek care immediately for any unusual perineal swelling, pain, or discoloration
• Immunocompromise increases susceptibility

Emergency Precautions

• ⭐ Immediate surgical debridement — delay = significantly increased mortality
• Septic shock → ICU + vasopressors + broad-spectrum IV abx
• Any perineal crepitus in a diabetic patient = Fournier until proven otherwise

URINARY TRACT / BLADDER

6. Nephrolithiasis (Renal Colic)

Stone types: Calcium oxalate (most common, radiopaque), uric acid (radiolucent, pH <5.5), struvite (infection stone, Proteus), cystine (genetic), calcium phosphate (pH ≥6.5).

Critical History Questions

• ⭐ Acute onset severe colicky flank pain radiating to groin/scrotum/labia?
• ⭐ Fever or chills? (infected obstructing stone = emergency)
• N/V?
• Hematuria (gross or microscopic)?
• Prior kidney stones? Stone composition?
• Family history of nephrolithiasis?
• High-risk diet: animal protein, high sodium, low fluid intake?
• Medications: indinavir, corticosteroids, probenecid, loop diuretics?
• History of gout, hyperparathyroidism, recurrent UTIs?
• Can patient stay still? (colicky patient CANNOT — "kidney stone dance")

ROS

• GU: hematuria, dysuria, urgency, frequency (stone at UVJ mimics UTI)
• GI: N/V common
• ⭐ Constitutional: fever/chills = emergency (infected stone)

Physical Exam

• ⭐ Patient unable to stay still — pacing, restless (differentiates from peritoneal irritation)
• Flank tenderness; CVA tenderness
• No peritoneal signs (rebound/guarding) — if present, expand DDx
• Abdominal auscultation: normal bowel sounds
• Check vital signs carefully — fever → infected stone emergency; hypotension → AAA on DDx

Diagnostics

• UA: hematuria (micro or gross); ⭐ absence does NOT rule out stone (especially with complete obstruction)
• ⭐ Non-contrast CT abdomen/pelvis = gold standard (most accurate)
• KUB + renal US: identifies most stones; US preferred in pregnancy/children
• Strain urine → collect stone for composition analysis
• BMP: electrolytes, creatinine, calcium
• Serum PTH if hyperparathyroidism suspected; uric acid if gout history
• CBC/WBC if fever present

DDx

• ⭐ Never miss: dissecting/rupturing AAA — can mimic renal colic; check vitals
• Pyelonephritis (fever + CVA tenderness + pyuria + leukocyte casts)
• Appendicitis, cholecystitis, diverticulitis
• Ectopic pregnancy, ovarian torsion (women)
• Herpes zoster pre-rash
• Ureteral stricture

MDM

• Outpatient if: pain and N/V controlled, able to tolerate oral intake, afebrile, no obstruction + infection
• Hospitalize if: intractable pain/N/V, unable to take orals, ⭐ infected obstructing stone
• Surgical threshold: stone fails to pass within 4 weeks; fever; intractable symptoms; work/travel need

Treatment

• Medical expulsive therapy (stones 5–10 mm): Tamsulosin (Flomax) 0.4 mg PO daily — dilates ureter, improves passage. (<5 mm typically pass without MET.)
• Pain control: Ketorolac (Toradol) — NSAID of choice (max 60 mg IM, max 30 mg IV); avoid opioids if possible; ≤5 days
• Euvolemia goal — forced fluids do NOT help
• ⭐ Infected obstructing stone = emergency: antibiotics + prompt ureteral drainage (stent or PCN tube) — antibiotics alone are INSUFFICIENT
• Surgical by location/size:
• Proximal/intrarenal: ESWL or ureteroscopy
• Distal ureter: ureteroscopic extraction (preferred)
• Renal calculi >1.5 cm / staghorn: percutaneous nephrolithotomy (PCNL)
• Stone-type prevention:
• CaOx: chlorthalidone (reduces urine calcium ~50%); adequate dietary calcium; ↓ sodium/oxalate
• Uric acid: potassium citrate (alkalinize to dissolve); allopurinol if refractory
• Struvite: PCNL + prevent UTIs; E. coli does NOT produce urease (Proteus, Klebsiella do)
• Cystine: 3–4 L/day fluid; alkalinize pH >7.0; tiopronin if refractory

Patient Education

• Drink ≥2.5–3.0 L fluid daily (target clear to light yellow urine)
• ⭐ Return immediately if fever or chills develop — infected stone is an emergency
• Strain urine to catch stone for analysis
• Diet: adequate calcium (paradoxically protective); ↓ animal protein, ↓ sodium
• Lemon/citrus water increases citrate (natural inhibitor of CaOx stones)
• Asymptomatic stones: serial imaging every 6–12 months

Emergency Precautions

• ⭐ Fever + obstructing stone = emergency — urgent drainage mandatory; antibiotics alone are inadequate
• Bilateral hydronephrosis or solitary kidney with obstruction → urgent nephrology/urology
• Intractable pain/N/V → hospitalize
• Anuria → catheterize, evaluate post-void residual, emergent imaging

7. Urge Incontinence / OAB

Mechanism: Detrusor overactivity → uninhibited bladder contractions → sudden overwhelming urge. Most common incontinence type in older adults (⅔ of established cases).

Critical History Questions

• ⭐ Sudden overwhelming urge to void that cannot be postponed?
• Leakage before reaching the toilet?
• Frequency, nocturia?
• Onset: abrupt or gradual? ⭐ Abrupt + hematuria → rule out tumor/stones before treating as OAB
• Medications (diuretics, opioids, CCBs)?
• Caffeine intake?
• Neurologic history (MS, stroke, Parkinson)?
• Cognitive changes (delirium)?
• Infection (recent UTI)?

ROS

• GU: urgency, frequency, nocturia, urge-associated leakage
• Constitutional: rule out delirium (transient cause — DIAPPERS mnemonic)
• Neurologic: screen for MS, stroke, Parkinson (neurogenic OAB)

Physical Exam

• Vitals: normal
• Abdominal: no distension (vs overflow)
• Pelvic: atrophic vaginitis in postmenopausal women (transient cause)
• Neurologic: intact sensation, reflexes (screen for spinal cord lesion)
• Post-void residual (PVR): ⭐ normal in urge incontinence (vs elevated in overflow)

Diagnostics

• UA + culture (rule out infection — transient cause)
• Bladder diary: record time/volume of voids over 24–72h
• PVR: normal (<100 mL)
• Urodynamic testing: if diagnosis uncertain or failed treatment

DDx

• Stress incontinence (leakage only with effort — coughing/sneezing; no urgency)
• Overflow incontinence (dribbling, elevated PVR, BPH or neurogenic)
• Interstitial cystitis (pain relieved by voiding, no pyuria, >6 weeks)
• ⭐ Bladder cancer (abrupt onset urge incontinence + hematuria → cystoscopy)
• UTI (transient; positive culture)

MDM

• ⭐ Always rule out transient causes first (DIAPPERS): Delirium, Infection, Atrophic vaginitis, Pharmaceuticals, Psychological, Excess output, Restricted mobility, Stool impaction
• ⭐ Abrupt onset + hematuria → cystoscopy before OAB treatment
• Behavioral therapy first, medications second

Treatment

1. Bladder training (1st line): void on schedule based on shortest interval recorded; lengthen by 30 min/week; relaxation techniques
2. Lifestyle: weight loss, ↓ caffeine/alcohol, Kegel exercises
3. Pharmacologic:
   - Beta-3 agonist: ⭐ Mirabegron (Myrbetriq) — detrusor relaxation; preferred for elderly (less anticholinergic SE)
   - Anticholinergic/antimuscarinic: ⭐ Oxybutynin (prototype), tolterodine, fesoterodine — ⭐ side effect = urinary retention
4. Advanced: Botulinum toxin A injections into detrusor; transcutaneous nerve stimulation

Patient Education

• Bladder training technique: strict scheduled voiding, urge suppression techniques
• ↓ caffeine, alcohol, carbonated beverages
• ↓ evening fluid intake to reduce nocturia
• Pelvic floor exercises (Kegel)
• Anticholinergic SE: dry mouth, constipation, urinary retention, confusion (elderly risk)

Emergency Precautions

• Abrupt onset + hematuria → urgent cystoscopy (bladder cancer)
• Urinary retention from anticholinergic use → hold medication, catheterize if needed

8. Stress Incontinence

Mechanism: Urethral incompetence — pelvic floor weakness → urethra cannot close against increased intra-abdominal pressure. 2nd most common in older women.

Critical History Questions

• ⭐ Leakage ONLY with coughing, sneezing, laughing, lifting, or exercise?
• No urgency (this distinguishes from urge incontinence)?
• Multiparous? Vaginal deliveries?
• Prior pelvic surgery?
• BMI/obesity?
• Postmenopausal?

ROS

• GU: leakage with exertion only; dry at rest; no urgency component
• GYN: parity history, menopausal status

Physical Exam

• ⭐ Cough test (stress test): patient coughs with full bladder → observe for leakage at urethral meatus
• Pelvic exam: anterior vaginal wall bulge (if concurrent cystocele), atrophic changes
• Valsalva: leakage confirmed
• PVR: normal

Diagnostics

• UA + culture: rule out infection
• PVR: normal
• Urodynamic testing: if uncertain or planning surgical repair

DDx

• Urge incontinence (urgency-driven; leakage before reaching toilet)
• Mixed incontinence (both stress and urge components)
• Overflow incontinence (elevated PVR)
• Fistula (constant wetness not related to exertion — vesicovaginal or urethrovaginal)

MDM

• First-line non-surgical; surgery if conservative fails and symptoms bothersome

Treatment

1. Lifestyle: limit caffeine, weight loss
2. Pelvic floor physical therapy (1st line) — Kegel exercises; biofeedback with vaginal pressure sensor + EMG
3. Pessary: mechanical support option for non-surgical candidates
4. ⭐ Mid-urethral sling (surgical gold standard): rapid recovery, high cure rate; offered when conservative fails
   - ⚠️ No pharmacologic agents are primary treatment for stress incontinence (contrast with urge incontinence)

Patient Education

• Kegel exercises: squeeze pelvic floor as if stopping urination; 3 sets of 10 reps daily
• Weight loss significantly improves symptoms
• Pessary care if used: removal, cleaning, refit schedule
• Surgical options: mid-urethral sling has excellent success rates

Emergency Precautions

• No acute emergencies; rule out fistula if leakage is constant/severe

9. Overflow Incontinence

Mechanism: Bladder outflow obstruction (BPH, stricture) or detrusor underactivity (neurogenic bladder) → bladder cannot empty → overflow leakage.

Critical History Questions

• ⭐ Dribbling after voiding? Frequent small-volume leaks?
• Sensation of incomplete emptying?
• Hesitancy, weak stream, straining?
• BPH history? Prostate cancer?
• Spinal cord injury or neurologic disease?
• Medications: anticholinergics, opioids, decongestants?

ROS

• GU: hesitancy, weak stream, frequency (small volume), nocturia, incomplete emptying, dribbling
• Neurologic: spinal cord injury, MS, Parkinson, DM neuropathy

Physical Exam

• ⭐ Palpable suprapubic distension (large post-void residual)
• DRE: enlarged prostate (BPH)
• Neurologic exam: check for saddle anesthesia, rectal tone, lower extremity reflexes
• Post-void residual: ⭐ ELEVATED (>100 mL confirms overflow)

Diagnostics

• PVR (bladder ultrasound or catheterization): ⭐ elevated — confirms retention
• UA: rule out infection (UTI from urinary stasis)
• PSA + DRE: evaluate for BPH/prostate cancer
• Creatinine: assess for renal damage from chronic retention
• Urodynamics: if neurogenic cause suspected

DDx

• Urge incontinence (urgent urge precedes; PVR normal)
• BPH (obstructive cause; DRE shows enlarged prostate)
• Neurogenic bladder (neurological history, exam findings)
• Urethral stricture (young men, history of trauma/instrumentation)
• Medications (anticholinergics causing retention)

MDM

• Address underlying cause: BPH, neurogenic, medication-induced, stricture

Treatment

• Bladder decompression: intermittent or indwelling catheterization first (acute retention)
• Pharmacologic (BPH): Alpha-blockers (tamsulosin, terazosin) + 5-ARI (finasteride) if large prostate
• Augmented voiding: double voiding, Credé maneuver (suprapubic pressure) for detrusor weakness without mechanical obstruction
• Surgical if medications fail or mechanical obstruction (TURP for BPH)

Patient Education

• BPH medications: alpha-blockers improve stream; 5-ARIs take 6 months for effect
• Report signs of urinary retention: severe distension, inability to void, abdominal pain
• Avoid anticholinergic medications

Emergency Precautions

• Acute urinary retention → immediate catheterization
• AKI from chronic obstruction → urgent decompression + nephrology
• Post-obstructive diuresis after catheterization → monitor electrolytes and fluid status

10. Interstitial Cystitis / Painful Bladder Syndrome

Definition: Chronic bladder pain >6 weeks, no infection or identifiable cause. F:M = 10:1. Diagnosis of exclusion.

Critical History Questions

• ⭐ Pain, pressure, or discomfort associated with bladder filling?
• ⭐ Pain RELIEVED with urination? (key differentiator from UTI — UTI pain worsens with urination)
• Duration >6 weeks?
• Multiple negative urine cultures?
• Urgency, frequency, nocturia?
• History of IBS, fibromyalgia, chronic back pain, vulvodynia? (chronic overlapping pain conditions)
• Prior urologic procedures or treatments tried?

ROS

• GU: urgency, frequency, nocturia; pelvic/suprapubic pain with bladder filling; pain relieved with voiding
• Chronic pain conditions: fibromyalgia, IBS, chronic pelvic pain, vulvodynia
• Psychiatric: depression, anxiety, history of adverse childhood experiences

Physical Exam

• Suprapubic tenderness with bladder filling (often present)
• Pelvic floor tender on bimanual exam (pelvic floor dysfunction component)
• Normal urethral meatus
• No fever, no CVA tenderness

Diagnostics

1. ⭐ UA: completely CLEAN (no pyuria, no bacteria) — key distinguishing finding
2. Urine culture: negative
3. Urine cytology: normal (no malignant cells)
4. ⭐ Cystoscopy with biopsy: Hunner lesions (submucosal hemorrhages/"petechial hemorrhages") = hallmark; assess bladder capacity; biopsy to rule out malignancy
5. Intravesical anesthetic challenge: instill anesthetic → pain resolves = bladder-localized; persists = extrablader pain
6. Urodynamic testing: if voiding dysfunction present

DDx

• UTI (positive UA/culture, pyuria, pain worsened by voiding — NOT relieved)
• Bladder cancer (hematuria, abnormal cytology, cystoscopy with mass)
• Endometriosis (cyclic pain, menstrual correlation)
• Pelvic inflammatory disease (cervical motion tenderness, discharge)
• Vulvodynia/pelvic floor dysfunction (pain at introitus, not storage-related)

MDM

• Diagnosis of exclusion; establish after ruling out infection, malignancy, other causes
• Multidisciplinary approach (urology, gynecology, PT, psychology)
• No cure — symptom management

Treatment

All patients (1st line): Patient education + dietary modification (avoid spicy food, caffeine, acidic foods) + pelvic floor physical therapy + psychosocial support (CBT)

Oral pharmacologic:
- ⭐ Pentosan polysulfate (PPS) — only FDA-approved oral med for IC; restores epithelial integrity; ⭐ maculopathy → permanent vision loss risk — refer to ophthalmology if visual symptoms; specialist-managed
- Amitriptyline (TCA) — neuropathic pain, especially useful if fibromyalgia/depression overlap
- Hydroxyzine (antihistamine), gabapentin/pregabalin (neuropathic pain)

Intravesical:
- ⭐ DMSO (dimethyl sulfoxide) = only FDA-approved intravesical medication for IC
- Heparin + lidocaine instillations

Procedures: Hydrodistention (20–30% improvement, limited duration); Botulinum toxin Type A; neuromodulation

Patient Education

• IC is a chronic condition — no cure, but symptoms are manageable
• Identify dietary triggers using elimination diet
• Bladder diary to track symptoms
• IC is NOT an infection — antibiotics will not help once cultures are negative
• ⭐ PPS side effect: vision changes → stop immediately and see ophthalmology

Emergency Precautions

• Severe pain → rule out infection or malignancy before escalating IC treatment
• PPS-associated visual changes → urgent ophthalmology

11. Bladder Cancer

Epidemiology: 2nd most common urologic cancer; 3:1 M:F; mean age 73. ⭐ Cigarette smoking = #1 risk factor (60% of cases). 90% = urothelial/transitional cell carcinoma.

Critical History Questions

• ⭐ Painless hematuria — gross or microscopic? Chronic or intermittent?
• Cigarette smoking history? Pack-years?
• Industrial exposures (dyes, solvents)?
• Irritative voiding symptoms (less common than hematuria)?
• Age? Weight loss, fatigue?
• Prior episodes of hematuria evaluated?

ROS

• GU: ⭐ painless hematuria (gross or microscopic) — PRIMARY symptom
• Constitutional: weight loss, fatigue (advanced disease)
• Minimal dysuria/urgency unless high-grade or CIS

Physical Exam

• ⭐ Most patients have NO signs on exam
• Bimanual exam: palpable abdominal mass (advanced disease only)
• Lymphadenopathy (metastatic disease)
• Hepatomegaly (liver mets)

Diagnostics

• UA: hematuria + pyuria
• BMP: azotemia (obstruction)
• CBC: anemia
• Urine cytology: sensitive for high-grade/high-stage tumors
• Imaging (CT, US): may identify mass — NOT diagnostic alone
• ⭐ Cystourethroscopy with biopsy = gold standard — confirms tumor, determines grade/stage/histology

DDx

• UTI (hematuria + pyuria + dysuria; treat and recheck UA)
• Nephrolithiasis (colicky pain + hematuria)
• Renal cell carcinoma (flank mass + hematuria + flank pain)
• BPH (obstructive symptoms; older men)
• Prostate cancer (PSA elevation; DRE findings)

MDM

• ⭐ Painless hematuria in an older smoker → cystourethroscopy with biopsy, NOT empiric antibiotic treatment
• Stage determines treatment

Treatment

• Non-muscle invasive (Tis/Ta/T1): TURBT + single-dose intravesical chemotherapy
• High-grade: ⭐ BCG (intravesical immunotherapy) = standard of care post-resection
• Muscle invasive (T2+): Neoadjuvant chemotherapy + radical cystectomy + urinary diversion
• ⭐ Cisplatin = chemotherapy of choice (MVAC regimen)
• Radiation: bladder preservation option or palliative
• Immunotherapy: checkpoint inhibitors (anti-PDL-1) for non-cisplatin candidates or metastatic disease

Patient Education

• Smoking cessation (most important modifiable factor)
• ⭐ Any blood in urine — even once — warrants evaluation regardless of presence of UTI symptoms
• Surveillance cystoscopy schedule after treatment (recurrence risk is high)
• 40% develop metastasis within 2 years of cystectomy → follow-up mandatory

Emergency Precautions

• Hematuria causing urinary clots → urologic emergency (clot retention → catheterization + irrigation)
• Metastatic disease with cord compression → emergency MRI + neurosurgery/radiation

PROSTATE / MALE GU

12. Benign Prostatic Hyperplasia (BPH)

Epidemiology: Most common benign tumor in men. 20% at 40s → 50% at 50s → 90% at 80s. DHT-driven transitional zone growth → urethral compression.

Critical History Questions

• ⭐ IPSS score (International Prostate Symptom Score)?
• Obstructive symptoms: hesitancy, weak stream, straining to void, feeling of incomplete emptying?
• Irritative symptoms: frequency, urgency, nocturia, dysuria?
• Urinary retention — complete inability to void?
• Hematuria (rules out malignancy)?
• ED (tadalafil has dual indication)?
• Cataract surgery planned? (tamsulosin → floppy iris syndrome — must inform surgeon)

ROS

• GU: weak stream, hesitancy, frequency, urgency, nocturia, incomplete emptying, dribbling
• Sexual: erectile dysfunction (common comorbidity)
• Constitutional: no fever (that = prostatitis)

Physical Exam

• DRE: ⭐ smooth, symmetrically enlarged prostate (transitional zone — NOT palpable directly, but gland enlarges palpable size)
• No tenderness (vs prostatitis = tender)
• No firm nodules (vs cancer = firm/irregular peripheral zone)
• PVR: elevated if significant retention

Diagnostics

• IPSS score: 0–35; 1–7 = mild; 8–19 = moderate; 20–35 = severe
• UA + culture: rule out infection, hematuria
• PSA: obtain as baseline; ⭐ 5-ARIs reduce PSA by 50% — must double PSA for accurate cancer screening
• PVR: if retention suspected
• No biopsy for BPH — clinical/symptomatic diagnosis

DDx

• Prostate cancer (firm irregular nodule on DRE, elevated PSA, older male)
• Urethral stricture (prior trauma, instrumentation, STI)
• Neurogenic bladder (neurologic history)
• Acute bacterial prostatitis (fever, tender prostate)
• Bladder cancer (hematuria)

MDM

• Severity-matched treatment per IPSS score
• Prostate volume >40g → 5-ARI indicated; <40g → alpha-blocker only
• Indications for urology referral: refractory symptoms, urinary retention, hematuria, AKI from obstruction

Treatment

• Alpha-blockers: Selective (tamsulosin, alfuzosin, silodosin) — less hypotension; ⭐ SE = retrograde ejaculation; ⭐ IFIS (inform cataract surgeon)
• 5-ARIs (finasteride/dutasteride): Shrink prostate 20–30% over 6 months; indication = prostate >40g; SE = ↓ libido, ED, gynecomastia; ⭐ reduces PSA by 50%

Patient Education

• Reduce fluid intake after 6 PM (nocturia)
• Limit caffeine, alcohol
• Scheduled voiding
• ⭐ Tamsulosin: inform any cataract surgeon before scheduling procedure (floppy iris)
• ⭐ 5-ARIs: PSA appears halved — tell all providers
• Return if complete urinary retention or hematuria develops

Emergency Precautions

• Acute urinary retention → catheterization; urology consult
• AKI from chronic obstruction → urgent decompression + nephrology
• Hematuria → evaluate for malignancy

13. Prostate Cancer

Epidemiology: Most common non-cutaneous cancer in US men; 2nd leading cause of cancer death. 95% adenocarcinoma from peripheral zone. ⭐ Black race = higher incidence AND more aggressive.

Critical History Questions

• Elevated PSA on routine screening?
• Abnormal DRE finding?
• ⭐ Black race? Family history (2.5× risk with 1 FDR)?
• BRCA2 mutation?
• Lower urinary tract symptoms?
• Bone pain (metastatic disease)?
• Back pain, neurologic symptoms (spinal cord compression from mets)?
• On 5-ARI? (must double PSA)

ROS

• GU: often asymptomatic early; LUTS if obstructing; hematuria
• Skeletal: bone pain (mets to vertebrae, pelvis, ribs)
• Constitutional: weight loss, fatigue (advanced)

Physical Exam

• DRE: ⭐ firm, hard, or irregular nodule in peripheral zone = cancer until proven otherwise
• Smooth/symmetric = BPH; tender/boggy = prostatitis; nodule = cancer
• Lymphadenopathy: inguinal or pelvic (advanced)
• Bony tenderness over spine/pelvis (metastatic)

Diagnostics

• ⭐ Free PSA ratio <10% = ~56% cancer probability (more concerning)
• PSA velocity: >0.75 ng/mL/year if PSA >4 = concerning
• TRUS-guided biopsy (≥12 cores) — indicated for elevated/rising PSA or abnormal DRE
• Gleason score: 6 = low; 7 = intermediate; 8–10 = high risk
• Staging: CT abdomen/pelvis; bone scan (if PSA >10 or symptoms); MRI pelvis
• ⭐ Bone mets = osteoblastic (sclerotic) — NOT lytic (distinguish from multiple myeloma)

DDx

• BPH (smooth enlargement, IPSS symptoms, PSA proportional to size)
• Prostatitis (fever, tender, elevated PSA during infection)
• Bladder cancer (hematuria + cystoscopy)

MDM

• Screening discussion: USPSTF = ages 55–69 (individualized decision); AUA = discuss at 45–50 (earlier for Black race, BRCA2, FH)
• Active surveillance vs treatment based on Gleason, PSA, staging, patient preference
• ⭐ After radical prostatectomy: PSA undetectable at 6 weeks; rising PSA = recurrence
• ⭐ After radiation: PSA does NOT become undetectable ("PSA nadir") — rising from nadir = recurrence

Treatment

Patient Education

• PSA screening: shared decision-making, age, race, family history
• ⭐ Active surveillance is appropriate for low-risk disease — not all cancers need immediate treatment
• Bone health: ADT causes osteoporosis → calcium, vitamin D, bisphosphonates
• Sexual side effects of ADT: hot flashes, libido loss, gynecomastia
• Radiation vs prostatectomy tradeoffs (continence, potency, cancer control)

Emergency Precautions

• Spinal cord compression (back pain + neurologic signs in known prostate cancer) → emergency MRI + radiation/neurosurgery
• Bone fracture from osteoblastic mets → immobilize, urgent orthopedics
• Urinary obstruction from local extension → catheterization or TURP

TESTICULAR / SCROTAL

14. Testicular Torsion

⭐ SURGICAL EMERGENCY — 6-hour salvage window.

Epidemiology: Adolescent males, primarily age 10–20. Bell-clapper deformity = pathognomonic anatomic variant.

Critical History Questions

• ⭐ Acute, sudden-onset severe testicular pain?
• Age 10–20?
• Nausea and vomiting?
• Prior similar episodes that spontaneously resolved? (intermittent torsion)
• History of trauma? (trauma does not cause torsion — its absence supports torsion)
• Fever? (less common in torsion; fever → epididymitis)
• Prior testicular surgery or undescended testicle?

ROS

• GU: severe unilateral testicular pain, acute onset, ± swelling
• GI: N/V (from sympathetic activation and referred pain)
• Constitutional: tachycardia (pain response); typically afebrile or low-grade

Physical Exam

1. ⭐ High-riding testicle — pulled toward pelvic wall by shortened spermatic cord
2. ⭐ Horizontal lie (bell-clapper deformity) — testicle lies transverse instead of vertical
3. ⭐ Absent cremasteric reflex — stroking inner thigh → NO testicular elevation on affected side
4. Scrotal erythema/edema developing
   - Pain NOT relieved by scrotal elevation (vs. epididymitis where elevation relieves)

Diagnostics

• 🔹 Doppler ultrasound = diagnostic test of choice → shows absent/decreased blood flow
• ⭐ If clinical suspicion is HIGH → go directly to surgery; DO NOT delay for US
• UA: usually normal (not an infection)

DDx

MDM

• ⭐ DO NOT delay surgery for labs or imaging if clinical presentation is classic
• Absent cremasteric reflex + acute onset in adolescent = torsion until proven otherwise

Treatment

• ⭐ Surgical orchiopexy — emergent
• Manual detorsion if surgical delay: rotate counterclockwise ("open the book") — temporary; still requires surgery
• ⭐ 6-hour window: nearly 100% salvage if detorsed within 6 hours; salvage drops sharply after
• Bilateral orchiopexy performed (prevents future contralateral torsion)

Patient Education

• Any sudden severe testicular pain = go to ER immediately — 6-hour window is critical
• Absence of trauma does NOT rule out torsion
• After orchiopexy: routine follow-up; small risk of infertility if prolonged torsion occurred

Emergency Precautions

• ⭐ Do NOT give analgesics and observe — get to surgery
• ⭐ Do NOT delay for UA or STI swabs — this is a surgical emergency
• After 6 hours without treatment: orchiectomy (non-viable tissue) likely required

15. Epididymitis

Epidemiology: Age <35 = STI (Chlamydia MCC, then GC); age >35 = E. coli. Gradual onset.

Critical History Questions

• Gradual onset unilateral testicular/scrotal pain?
• Urethral discharge?
• Fever?
• Age, sexual history?
• STI history, MSM?
• Dysuria, frequency?
• Recent heavy lifting or exercise?

ROS

• GU: unilateral pain (gradual), urethral discharge, dysuria
• Constitutional: ± low-grade fever
• Sexual: sexual history, STI risk

Physical Exam

• Tenderness located at posterior border of testis (epididymis location)
• ⭐ Prehn's sign positive — scrotal elevation RELIEVES pain (opposite of torsion)
• Cremasteric reflex: present (vs absent in torsion)
• ± Urethral discharge, ± reactive hydrocele
• Testicle in normal position (vs high-riding in torsion)

Diagnostics

• Scrotal ultrasound with Doppler: confirms epididymal inflammation, increased blood flow (vs absent in torsion)
• UA: pyuria, leukocyte esterase
• NAAT: GC/Chlamydia if STI risk
• Urine culture: if >35 or urinary tract source suspected

DDx

• Testicular torsion (see table above — absent cremasteric reflex, acute onset, adolescent)
• Orchitis (fever, harder testis, mumps exposure if prepubescent)
• Scrotal abscess (fluctuant mass)
• Testicular cancer (painless firm mass, not inflammatory)

MDM

• Age-based treatment selection
• Scrotal support and NSAIDs for pain

Treatment

• Age <35 (STI likely): Ceftriaxone 500 mg IM once + doxycycline 100 mg BID × 10 days
• Age >35 or insertive anal intercourse (E. coli): Levofloxacin 500 mg PO daily × 10 days OR ofloxacin 300 mg PO BID × 10 days
• Scrotal elevation + NSAIDs (analgesic + anti-inflammatory)
• Treat sexual partners if STI etiology

Patient Education

• Scrotal elevation with jockstrap or tight underwear to relieve pain
• Complete full antibiotic course
• Partners must be evaluated and treated
• NSAIDs scheduled (not just PRN) for first several days

Emergency Precautions

• If clinical picture cannot definitively distinguish from torsion → urologic surgical evaluation immediately (torsion is the never-miss diagnosis)
• High-grade fever + epididymo-orchitis → consider abscess; ultrasound to evaluate

16. Testicular Cancer

Epidemiology: ⭐ Most common solid malignancy in males age 15–35. >90% overall cure rate (most curable solid tumor). 95% from germ cells. #1 risk factor = cryptorchidism.

Critical History Questions

• ⭐ Painless testicular mass or heaviness?
• Age 15–35?
• History of cryptorchidism?
• Gynecomastia? (hCG-producing tumor)
• Back or abdominal pain (retroperitoneal lymph node involvement)?
• Neck mass (supraclavicular node)?
• Daily marijuana use?
• Klinefelter syndrome, Down syndrome, HIV?

ROS

• GU: painless scrotal mass, heaviness
• Endocrine: gynecomastia (hCG elevation)
• Musculoskeletal: back pain (bulky retroperitoneal disease)
• Respiratory: cough, hemoptysis (lung mets)

Physical Exam

• ⭐ Examine normal testicle first (establish baseline)
• ⭐ Firm, hard, fixed intrascrotal mass = cancer until proven otherwise
• Does NOT transilluminate (vs hydrocele which does)
• Check supraclavicular lymph nodes (metastatic)
• Gynecomastia if hCG elevated

Diagnostics

• ⭐ Tumor markers BEFORE any treatment (surgery/chemo alters values):
• AFP (elevated in non-seminomas)
• B-HCG (elevated in non-seminomas; may be elevated in seminoma)
• LDH (reflects tumor burden)
• ⭐ Seminoma requires NORMAL AFP — any AFP elevation = reclassify as non-seminoma
• Scrotal ultrasound: confirms mass, evaluates contralateral
• CT abdomen/pelvis: retroperitoneal LN staging
• CXR / chest CT: lung mets
• ⭐ NO biopsy — risk of seeding; orchiectomy is both diagnostic and therapeutic

DDx

• Epididymitis (tender, inflammatory, posterior border of testis)
• Hydrocele (transilluminates, anechoic on US)
• Varicocele ("bag of worms," disappears supine, left-sided)
• Orchitis (infectious, fever, tender)
• Hematocele (trauma history)

MDM

• ⭐ Radical inguinal orchiectomy — never biopsy first; orchiectomy is both diagnosis AND treatment
• Stage-based follow-up therapy

Treatment

• Stage I seminoma: orchiectomy alone (85% cured) → surveillance
• Stage II seminoma with LN: radiation (radiosensitive)
• Metastatic: BEP chemotherapy (bleomycin, etoposide, cisplatin)
• Non-seminoma: RPLND for retroperitoneal disease; BEP chemo

Patient Education

• Testicular self-exam monthly after puberty
• Cryptorchidism history: higher cancer risk even after orchiopexy — continued surveillance
• Sperm banking before chemo/radiation
• Overall excellent prognosis — >90% curable even at advanced stage
• Follow-up tumor markers after treatment

Emergency Precautions

• Rising markers post-orchiectomy → metastatic workup urgently
• Severe back pain + neurologic signs → retroperitoneal mass compressing spinal cord → emergent imaging

PENILE

17. Erectile Dysfunction

Most common cause: vascular (atherosclerosis, HTN, DM).

Critical History Questions

• ⭐ Loss of nocturnal/morning erections? (present = vascular or neurogenic; absent = psychogenic)
• Ability to achieve vs sustain erection?
• Ability with masturbation?
• Rapid vs gradual onset? (rapid = psychogenic or post-surgical nerve injury)
• Diabetes, HTN, atherosclerosis?
• Pelvic/prostate surgery? (cavernous nerve injury)
• Medications: thiazides, beta-blockers, SSRIs, antipsychotics?
• Smoking, alcohol, drug use?
• Depression, anxiety, relationship stress?
• ⭐ Currently on nitrates? (absolute contraindication to PDE5I)

ROS

• Sexual: libido level, ejaculatory function, penile curvature (Peyronie)
• Cardiovascular: chest pain, angina, exertional dyspnea
• Neurologic: neuropathy, sensation changes
• Endocrine: fatigue, cold intolerance (thyroid), visual changes (pituitary/prolactin)

Physical Exam

• Hair pattern (androgenic), gynecomastia (hormonal)
• Cardiovascular: peripheral pulses, blood pressure
• Genitalia: penile plaques/curvature (Peyronie), testis size, Tanner staging
• Neurologic: sensation, deep tendon reflexes

Diagnostics

• Fasting glucose / HbA1c, CBC, CMP, TSH, lipid panel
• ⭐ Total morning testosterone (if low → repeat, then FSH/LH, prolactin)
• Consider PSA if age-appropriate

DDx

• Psychogenic ED (normal nocturnal erections, rapid onset, stressor-related)
• Vascular (complete loss of nocturnal erections, atherosclerotic risk factors)
• Neurogenic (post-prostatectomy, DM neuropathy, MS, Parkinson)
• Hormonal (low testosterone, hyperprolactinemia)
• Medication-induced (thiazides, BB, SSRI, antipsychotics)

MDM

• Address reversible causes (medications, lifestyle, hypogonadism, vascular risk factors)
• PDE5I first-line pharmacologic treatment
• ⭐ NEVER prescribe PDE5I if patient is on nitrates

Treatment

• Lifestyle: smoking cessation, weight loss, exercise (major improvement in vascular ED)
• Testosterone replacement if hypogonadal (normalize T first before PDE5I)
• ⭐ PDE5 inhibitors (1st line): sildenafil, tadalafil, vardenafil, avanafil
• ⭐ ABSOLUTE CONTRAINDICATION with nitrates → profound hypotension
• Vacuum erection devices, intraurethral alprostadil, intracavernosal injections
• Penile prosthesis: surgical; last resort when all else fails

Patient Education

• ED is often a vascular disease marker — cardiac evaluation may be warranted
• Smoking cessation and weight loss are among the most effective interventions
• ⭐ Do NOT take sildenafil (Viagra) if prescribed nitrates for angina
• Take sildenafil 30–60 min before sexual activity; tadalafil can be taken daily

Emergency Precautions

• Erection lasting >4 hours after PDE5I → see priapism section
• New ED in young man post-pelvic trauma → evaluate for perineal arterial injury

18. Priapism

⭐ Ischemic priapism >4 hours = urologic emergency.

Types: Ischemic (low-flow, >95%), non-ischemic (high-flow, trauma-related), stuttering (recurrent ischemic).

Critical History Questions

• ⭐ Duration of erection?
• ⭐ Pain? (ischemic = very painful; non-ischemic = less painful)
• Recent intracavernosal injection?
• Sickle cell disease?
• Trazodone, chlorpromazine, thioridazine use?
• Cocaine, recreational drugs?
• Recent perineal or penile trauma (non-ischemic)?
• Prior episodes?

ROS

• GU: persistent painful erection; inability to reach detumescence
• Hematologic: sickle cell crisis symptoms

Physical Exam

• ⭐ Ischemic: rigid, very painful corpora cavernosa; glans NOT rigid (glans doesn't swell in priapism)
• Non-ischemic: less painful, less rigid, tumescent; look for perineal ecchymosis/trauma
• Dusky/blue/black glans → late sign; arterial compromise → emergency

Diagnostics

• ⭐ Corporal blood gas aspiration — distinguishes ischemic vs non-ischemic:

• CBC, hemoglobin electrophoresis (sickle cell), toxicology, coagulation panel
• Color duplex ultrasound: blood flow assessment

DDx

• Ischemic vs non-ischemic (blood gas is definitive)
• Medication-induced vs sickle cell vs trauma

MDM

• ⭐ Ischemic >4 hours = emergency; irreversible damage begins ~48 hours
• ⭐ Non-ischemic: do NOT aspirate or inject alpha-agonist (wrong treatment)

Treatment

Ischemic (EMERGENCY):
1. Analgesia, hydration
2. ⭐ Corporal aspiration + irrigation (1st procedural line)
3. ⭐ Intracavernosal phenylephrine (alpha-agonist → vasoconstriction)
4. Surgical distal shunt if above fails
5. Penile prosthesis if >48h or refractory

Non-ischemic:
- Conservative initially
- ⭐ Treatment of choice: selective arterial embolization (interventional radiology)
- Surgical ligation if embolization fails

Stuttering: Treat acute episode as ischemic; prevent recurrence (hormonal therapy for sickle cell)

Patient Education

• Seek care immediately for erection lasting >4 hours
• ⭐ DO NOT attempt to relieve with repeated sexual activity — doesn't work
• Sickle cell disease: hydration, avoid triggers, have a plan for priapism episodes
• Trazodone warning: sexual side effects including priapism possible

Emergency Precautions

• ⭐ Any ischemic priapism >4 hours → emergency urologic consultation
• Dusky/ischemic glans → immediate intervention to prevent necrosis and auto-amputation

19. Paraphimosis

⭐ UROLOGIC EMERGENCY

Definition: Retracted foreskin cannot be returned behind glans → constricting ring → vascular compromise.

Critical History Questions

• ⭐ Recent catheterization, cystoscopy, or genital exam?
• Recent sexual activity with prolonged foreskin retraction?
• Uncircumcised? Partially circumcised?
• Phimosis history (predisposing factor)?
• Diabetes or CKD?
• Duration since foreskin became stuck?

ROS

• ⭐ Acute penile pain
• GU: urinary difficulty (urethral compression)
• Systemic: fever (if infected; late)

Physical Exam

• ⭐ Foreskin retracted and stuck behind glans, forming a constricting ring
• Edematous, swollen glans
• Early: erythema, edema, tenderness
• ⭐ Late/emergency signs: dusky, blue, or black glans (arterial compromise), decreased sensation

Diagnostics

• Clinical diagnosis — no routine imaging
• Labs only in complicated cases: BMP (DM, CKD), CBC, wound cultures if necrotic

DDx

• Phimosis (foreskin CANNOT be retracted — opposite problem)
• Penile edema from lymphatic obstruction
• Penile carcinoma (unusual mass preventing retraction)

MDM

• ⭐ Urologic emergency — immediate manual reduction
• Do NOT rely on conservative osmotic measures alone if arterial compromise is suspected

Treatment

• Conservative (edema reduction ~2h): ice packs, osmotic agents (sugar/mannitol compress), elastic compression
• ⭐ Manual reduction (1st-line definitive): gently compress glans → push back through foreskin; lidocaine infiltration or hyaluronidase injection assist
• If manual fails:
• Needle puncture technique (release edema fluid)
• Dorsal slit procedure (incises constricting band)
• Circumcision (definitive; prevents recurrence)

Patient Education

• ⭐ "If you pull it back, you put it back" — always replace foreskin after any retraction
• Teach all healthcare providers: always replace foreskin after catheterization/exam
• Treat phimosis proactively to reduce paraphimosis risk
• Diabetes control

Emergency Precautions

• ⭐ Dusky/blue glans → do NOT wait 2 hours on ice — immediate urologic intervention
• Necrosis → emergency OR for dorsal slit or circumcision
• Healthcare providers: hospital protocol should require foreskin replacement after every catheter/exam in uncircumcised males

KIDNEY DISEASE

20. Acute Kidney Injury (AKI)

Three categories: Prerenal (volume depletion/hypoperfusion), Intrinsic (ATN, glomerulonephritis), Postrenal (obstruction).

Critical History Questions

• Recent illness with vomiting/diarrhea, poor oral intake? (prerenal)
• Recent medications: NSAIDs, ACE-I, ARB, contrast dye, aminoglycosides, cisplatin? (nephrotoxic)
• Sepsis, hemorrhage, heart failure exacerbation?
• Dark/cola-colored urine? Recent crush injury, extreme exercise, rhabdomyolysis?
• ⭐ Decreased urine output? For how long?
• Recent streptococcal infection 1–3 weeks ago? (post-strep GN)
• Known obstructing stone, BPH, prostate/bladder cancer?
• Recent urologic procedure?

ROS

• GU: decreased UO, dark urine, hematuria
• GI: N/V, diarrhea (volume loss)
• Musculoskeletal: muscle pain, weakness (rhabdo)
• Constitutional: fatigue, edema, dyspnea (volume overload)

Physical Exam

• Prerenal: Tachycardia, orthostasis, dry mucous membranes, decreased JVD, poor skin turgor
• Intrinsic (ATN): Signs of sepsis or shock; muscle tenderness (rhabdo); dark urine
• Intrinsic (GN): Hypertension, periorbital edema, palpable purpura (vasculitis)
• Postrenal: Suprapubic distension (urinary retention), palpable bladder, CVA tenderness if infected

Diagnostics

• UA dipstick positive for blood but no RBCs on microscopy = myoglobinuria (rhabdo)
• Post-void residual: elevated in postrenal retention
• CK elevated in rhabdomyolysis (>5,000 = diagnostic)
• ⭐ RBC casts = glomerulonephritis (pathognomonic for nephritic)

DDx

• Prerenal vs ATN vs postrenal (see table above)
• CKD vs AKI (baseline creatinine, kidney size on imaging — small echogenic = CKD)
• Specific cause of intrinsic AKI: ATN vs GN vs interstitial nephritis

MDM

• Prerenal: correct volume deficit; avoid nephrotoxins; monitor response
• ATN: treat underlying cause; rhabdo requires aggressive hydration; no quick fix
• Postrenal: relieve obstruction first (catheter or PCN/stent); creatinine usually improves rapidly
• INDICATIONS FOR DIALYSIS: A.A.A.A.A. — Acidosis, Anuria, Volume overload (pulmonary edema), Uremia (encephalopathy), Hyperkalemia (refractory)

Treatment

• Prerenal: Isotonic saline fluid resuscitation; treat underlying cause; hold ACE-I/ARB/NSAIDs
• ATN (rhabdo): Aggressive hydration (NS); maintain UO >200 mL/h; sodium bicarbonate (alkalinize urine pH >6.5 to prevent myoglobin precipitation)
• Postrenal: ⭐ Catheterization for bladder obstruction; ureteral stent or PCN tube for upper obstruction; monitor post-obstructive diuresis (electrolytes)
• ⭐ Infected obstructed system (pyonephrosis): urgent drainage + antibiotics — DO NOT give antibiotics alone

Patient Education

• Adequate hydration, especially with illness
• Report dark urine, severe muscle pain, decreased urine output
• Avoid NSAIDs during illnesses or dehydration
• Statin users: report muscle pain/weakness immediately (rhabdomyolysis risk)

Emergency Precautions

• ⭐ Hyperkalemia (K >6.5 with EKG changes): calcium gluconate → insulin + glucose → albuterol → dialysis
• Anuria >6h despite fluids → evaluate for postrenal obstruction immediately
• Pulmonary edema (volume overload) → diuretics/dialysis
• pH <7.1 → consider ICU + dialysis
• ⭐ Infected obstructed system → urgent decompression is more important than antibiotics alone

21. Chronic Kidney Disease (CKD)

Definition: GFR <60 mL/min/1.73m² OR kidney damage (albuminuria, abnormal imaging) for ≥3 months. ⭐ DM = #1 cause worldwide; HTN = #2.

Critical History Questions

• Diabetes? Duration? Glucose control?
• Hypertension? Duration? Control?
• Fatigue, weakness, edema?
• Nausea, anorexia, pruritus, bone pain? (uremia symptoms — advanced disease)
• Family history of CKD or PKD?
• NSAIDs, herbal supplements, contrast dye exposure?
• Prior imaging showing small kidneys?
• Urine changes: nocturia, foamy urine (proteinuria)?

ROS

• GU: nocturia, oliguria (late), foamy urine
• Constitutional: fatigue, pallor (anemia), weakness
• GI: nausea, anorexia (uremia)
• Skin: pruritus (uremia), pallor
• Cardiovascular: edema, dyspnea (volume overload, anemia)
• Skeletal: bone pain, muscle cramps (renal osteodystrophy)

Physical Exam

• Hypertension (present >90% of CKD patients)
• Periorbital and lower extremity edema
• Pallor (anemia)
• Uremic odor (advanced)
• Asterixis (encephalopathy — late)
• JVD elevation (volume overload)

Diagnostics

• ⭐ Serum creatinine + BUN → calculate GFR (CKD-EPI equation)
• UA: proteinuria, hematuria, casts
• Urine albumin-to-creatinine ratio (UACR): >30 mg/g = albuminuria
• Renal ultrasound: small echogenic kidneys = advanced CKD; rule out obstruction
• ⭐ Electrolytes: hyperkalemia risk (stage 4–5)
• ⭐ Phosphorus/calcium (inverse relationship in advanced CKD); ⭐ elevated PTH (secondary hyperparathyroidism)
• CBC: anemia (normocytic/normochromic — EPO deficiency)

DDx

• AKI vs CKD (history, baseline Cr, kidney size on imaging — small echogenic = CKD)
• Reversible causes masquerading as CKD: obstruction, drug-induced, volume depletion
• Primary renal disease requiring biopsy (if atypical presentation)

MDM

• Refer to nephrology: stage 3b or worse, rapid progression, uncertain etiology
• Coordinate diabetes/BP management, anemia, bone-mineral disease
• Prepare patient for renal replacement therapy options as stage 5 approaches

Treatment

• ⭐ ACE inhibitor or ARB (1st line): slows progression, reduces proteinuria; do NOT use if Cr rises >30% or K >5.5
• BP control: target <120 (individualize)
• Glycemic control: HbA1c 7–8% in DM
• Phosphate binders (sevelamer, calcium carbonate): if hyperphosphatemia
• EPO/ESA (erythropoiesis-stimulating agents): for anemia (target Hgb 10–11; higher = thrombosis risk)
• Vitamin D (calcitriol): for secondary hyperparathyroidism/hypocalcemia
• Loop diuretics: for volume overload (if GFR <30)
• Dietary: ↓ protein (0.8 g/kg/day), ↓ sodium, ↓ potassium, ↓ phosphate (advanced)
• ⭐ Avoid nephrotoxins: NSAIDs, contrast, aminoglycosides, herbal supplements

Patient Education

• Disease progression: explain natural history, staging
• Medication compliance (ACE-I, BP meds, phosphate binders)
• Dietary restrictions: sodium, potassium (bananas, oranges, potatoes), phosphate (dairy, processed foods)
• Monitor weight and blood pressure at home
• Vaccinations: influenza, pneumococcal (before uremia impairs immunity)
• Prepare early for dialysis/transplant discussion (stage 4)

Emergency Precautions

• ⭐ Hyperkalemia (K >6.5 with EKG changes) → calcium gluconate → insulin + glucose → albuterol → dialysis
• Pulmonary edema → diuretics, oxygen, ICU/dialysis
• pH <7.1 → bicarbonate + consider dialysis
• Uremic encephalopathy (asterixis, confusion) → urgent dialysis
• Hypertensive emergency → antihypertensives + ICU

22. Nephrotic Syndrome

Definition: Massive proteinuria >3.5 g/day → hypoalbuminemia → edema + hyperlipidemia + hypercoagulability.
Top causes: Children = Minimal Change Disease (MCD); Adults = Membranous Nephropathy (5th–6th decade).

Critical History Questions

• Progressive edema (periorbital, LE, ascites)?
• Frothy/foamy urine?
• Age (child vs adult)
• Recent viral illness or bee sting? (MCD association)
• Malignancy history (lung, stomach, breast, colon)? Hepatitis B/C? SLE?
• NSAIDs? Captopril? (membranous secondary)
• DVT, PE, or leg swelling? (⭐ Membranous = highest hypercoagulability risk)
• Black race, obesity, HIV? (FSGS risk)

ROS

• GU: frothy urine, decreased UO
• CV/Venous: leg swelling, DVT symptoms, SOB (PE)
• Constitutional: fatigue, weight gain from edema
• Skin: periorbital edema (especially morning)

Physical Exam

• Periorbital edema (worse in morning)
• Pitting lower extremity edema → anasarca in severe cases
• Ascites/pleural effusion (severe hypoalbuminemia)
• Pallor (anemia)
• No RBC casts in urine (bland sediment = nephrotic; dirty sediment = nephritic)

Diagnostics

• UA: massive proteinuria; "oval fat bodies" = lipiduria; Maltese cross under polarized light
• 24h urine protein: >3.5 g/day
• Serum albumin: low (<3.0 g/dL)
• Lipid panel: hyperlipidemia (liver compensatory synthesis)
• ⭐ Serum albumin <2.5 g/dL → higher DVT/PE risk; anticoagulate
• Complement: normal in MCD/membranous/FSGS
• ⭐ Anti-PLA₂R Ab: positive → primary membranous nephropathy (no biopsy needed if positive)
• Hepatitis B/C, ANA, ANCA, HIV (secondary causes workup)
• Kidney biopsy: often required (except children with classic MCD)

DDx

MDM

• ⭐ Children with classic nephrotic syndrome → empiric prednisone WITHOUT biopsy
• Adults → evaluate for secondary causes (malignancy, hepatitis, SLE) before attributing to primary
• All → refer nephrology
• Thrombosis risk: anticoagulate for any DVT/PE; consider prophylactic anticoagulation if albumin <2.5

Treatment

• All: ACE/ARB (antiproteinuric); SGLT-2 inhibitor; statins
• MCD: ⭐ Prednisone 1 mg/kg/day × 4–8 weeks (up to 16 wk); remission typical
• FSGS: Prednisone ± calcineurin inhibitor; ⭐ APOL1/hereditary FSGS = NO immunosuppression
• Membranous: Rituximab (preferred) OR corticosteroids + cyclophosphamide × 6 months; treat secondary cause first

Patient Education

• Salt restriction (reduce edema)
• Elevate legs; compression stockings
• Infection risk (loss of immunoglobulins): hand hygiene, vaccinations, seek care for early infection signs
• Thrombosis risk: report calf pain, swelling, dyspnea
• ⭐ Do not stop steroids abruptly (MCD: taper)

Emergency Precautions

• DVT/PE in hypercoagulable state → anticoagulation urgently
• Severe anasarca with pulmonary compromise → diuresis + possible albumin infusion
• Spontaneous bacterial peritonitis (ascites + fever + abdominal pain) → antibiotics + hospital

23. Nephritic Syndrome

Definition: Inflammation of glomeruli → hematuria (RBC casts) + proteinuria (1–3.5 g/day) + hypertension + AKI.
Top causes: Post-streptococcal GN (children); IgA nephropathy (most common worldwide).

Critical History Questions

• Recent streptococcal infection (pharyngitis, impetigo)?
• ⭐ Timing: 1–3 weeks after strep = post-strep GN; concurrent URI 1–2 days before hematuria = IgA nephropathy
• Cola/brown/tea-colored urine?
• Periorbital edema?
• Hypertension (new or worsening)?
• Autoimmune history (lupus, vasculitis)?
• Recent endocarditis, hepatitis?
• Hemoptysis (anti-GBM disease — Goodpasture)?

ROS

• GU: ⭐ cola/brown urine (hematuria), decreased UO, frothy urine
• Cardiovascular: hypertension, edema
• Constitutional: fatigue
• Respiratory: hemoptysis (Goodpasture — RPGN emergency)

Physical Exam

• Periorbital edema (low-pressure area fills first)
• Hypertension (sodium retention)
• No specific renal findings
• Palpable purpura (IgA vasculitis/Henoch-Schönlein)
• Rash (lupus)

Diagnostics

• UA: ⭐ RBC casts + dysmorphic RBCs = pathognomonic for GN
• Blood + protein on dipstick
• Serum Cr: rising
• ⭐ Post-strep: ASO titer elevated; C3 disproportionately lower than C4
• ⭐ IgA nephropathy: Normal complement; concurrent (not post-) URI; diagnosis requires biopsy (mesangial IgA on IF)
• Serologies: ANA, ANCA, anti-GBM, complement levels
• Biopsy: if etiology unclear or RPGN suspected

DDx

MDM

• ⭐ Children with recent strep + nephritic features → clinical diagnosis WITHOUT biopsy
• RPGN (rapidly progressive GN) → crescent formation → urgent nephrology + possible plasma exchange
• All glomerulonephritis → nephrology referral

Treatment

• Post-strep GN: ⭐ Supportive ONLY (antihypertensives, salt restriction, diuretics); NO steroids; treat active infection
• IgA nephropathy: ACE/ARB (antiproteinuric); systemic corticosteroids if persistent proteinuria despite 90 days optimized ACE/ARB; budesonide (targets GI mucosal IgA source)
• All: salt restriction, antihypertensives, diuretics for BP/edema

Patient Education

• Cola-colored urine should always be evaluated (even if resolved)
• Complete strep treatment to prevent progression
• Monitor for CKD development (follow-up creatinine)
• Avoid nephrotoxins
• Dietary sodium restriction if hypertensive

Emergency Precautions

• ⭐ RPGN (rapidly rising creatinine, worsening hematuria) → urgent nephrology, consider pulse steroids + plasma exchange
• Pulmonary hemorrhage + AKI (hemoptysis + dark urine) → consider anti-GBM (Goodpasture) → plasma exchange urgently
• Severe hypertension with neurologic symptoms → antihypertensive therapy, ICU

ELECTROLYTES / SODIUM

24. Hyponatremia / SIADH

Most common electrolyte abnormality (~15–30% of hospitalized patients). Usually = water excess, not sodium deficiency.

Critical History Questions

• Recent illness with nausea/vomiting, diarrhea?
• Excessive fluid intake (psychogenic polydipsia, beer potomania)?
• Medications: SSRIs, diuretics (thiazides most commonly), carbamazepine, oxcarbazepine, PPIs, opioids?
• CNS pathology: head injury, stroke, meningitis, subarachnoid hemorrhage?
• Pulmonary pathology: pneumonia, tuberculosis, small cell lung cancer?
• CHF, cirrhosis, nephrotic syndrome (hypervolemic hyponatremia)?
• Hypothyroidism, adrenal insufficiency?
• ⭐ Symptoms: headache, nausea, confusion, ataxia, seizures?

ROS

• Neurologic: headache, confusion, disorientation, ataxia, areflexia, seizures, coma (severe)
• GI: nausea, vomiting
• Constitutional: fatigue

Physical Exam

• Volume status assessment is critical:
• Hypervolemic: peripheral edema, elevated JVP, crackles (CHF, cirrhosis, nephrotic)
• Euvolemic: normal exam (SIADH, hypothyroidism)
• Hypovolemic: tachycardia, orthostasis, dry mucous membranes (GI losses, diuretics, adrenal insufficiency)
• Neurologic: altered mental status (AMS), focal findings, hyperreflexia

Diagnostics

3-step algorithm:
1. Serum osmolality:
- Normal (280–295) → Pseudohyponatremia (lab artifact)
- Hypertonic (>295) → hyperglycemia/mannitol
- Hypotonic (<280) → go to step 2
2. Urine osmolality:
- <100 → Primary polydipsia / beer potomania (ADH-independent; kidneys diluting maximally)
- >100 → ADH active → step 3
3. Volume status + urine sodium:
- Euvolemic + urine Na >40 + urine osm >100 → ⭐ SIADH (excess ADH production)
- Hypovolemic + urine Na <20 → extrarenal losses (diarrhea, sweating)
- Hypervolemic + urine Na <20 → CHF/cirrhosis/nephrotic
- Hypervolemic + urine Na >40 → CKD/AKI (kidneys losing sodium)

SIADH diagnosis (all 4 required):
- Serum Na <135, serum osm <280
- Urine osm >100 mOsm/kg (concentrated despite low serum osm)
- Urine Na >40 mEq/L
- Euvolemia (no edema, no hypovolemia)
- Normal thyroid and adrenal function (must rule out hypothyroidism, Addison)

DDx

• SIADH (euvolemic, urine concentrated, high urine Na)
• Hypothyroidism (similar to SIADH — check TSH)
• Adrenal insufficiency (check morning cortisol, ACTH stim)
• CHF/cirrhosis/nephrotic (hypervolemic)
• Diuretic-induced (hypovolemic)
• Primary polydipsia (dilute urine, water intake history)
• Pseudohyponatremia (hyperglycemia, myeloma)

MDM

• ⭐ Determine acuity: acute (<48h) vs. chronic (>48h) — determines safe correction rate
• ⭐ Correction rate: DO NOT correct faster than 8–10 mEq/L per 24h (chronic) → risk of osmotic demyelination syndrome (ODS)
• Symptomatic (seizures, coma) → treat urgently regardless of chronicity

Treatment

• SIADH: Fluid restriction 500–1000 mL/day (1st line); treat underlying cause
• If refractory: Tolvaptan (V2 receptor antagonist — aquaretic, removes free water)
• If severe SIADH: 3% hypertonic saline (slow, controlled) with q1–2h Na monitoring
• Hypovolemic: Isotonic saline (0.9% NaCl) — replaces volume and allows kidneys to suppress ADH
• Hypervolemic (CHF/cirrhosis): Fluid + sodium restriction; diuretics; treat underlying cause
• Symptomatic (seizures): ⭐ 3% hypertonic saline 100–150 mL IV over 15–20 min × 1–3 doses → raise Na by 4–6 mEq/L rapidly to stop seizures; then slow correction

Patient Education

• Fluid restriction instructions (SIADH): measure all fluids including coffee/soup
• SSRI and thiazide diuretics can cause hyponatremia — report headache, confusion, weakness
• Avoid excessive water intake with exercise (hyponatremia risk with marathon training)
• Osmotic demyelination syndrome (ODS): risk with too-rapid correction → dysarthria, dysphagia, weakness appearing days after Na correction

Emergency Precautions

• ⭐ Seizures/coma from hyponatremia: 3% hypertonic saline × 1–3 boluses immediately; target 4–6 mEq/L rise in Na to stop seizures; then slow controlled correction
• ⭐ Overcorrection risk (ODS): if Na rises >10–12 mEq/L in 24h → give free water (D5W) or DDAVP to slow correction; neurology consult
• Brain herniation (Na <115 with rapid onset) → ICU + neurosurgery

25. Hyperkalemia

⭐ Cardiac emergency when K >6.5 mEq/L with EKG changes.

Critical History Questions

• ⭐ ACE-I, ARB, spironolactone, NSAIDs, TMP-SMX use?
• CKD, AKI, oliguria?
• Recent crush injury, extreme exercise, rhabdomyolysis?
• Acidosis (DM, renal disease)?
• Adrenal insufficiency?
• Palpitations, muscle weakness?
• ⭐ Pseudohyperkalemia: hemolysis during blood draw? Leukocytosis? Thrombocytosis?

ROS

• Cardiac: palpitations, syncope
• Neuromuscular: ascending muscle weakness, paralysis (severe)
• GU: decreased urine output (if from AKI/CKD)

Physical Exam

• Often asymptomatic until severe
• Muscle weakness, flaccid paralysis (K >6)
• Cardiac arrhythmias on EKG

Diagnostics

• ⭐ EKG (progressive changes):
• K 5.5–6.0: tall peaked (tented) T waves
• K 6.0–7.0: PR prolongation, widened QRS
• K >7.0: absent P waves, sine wave (⭐ cardiac arrest imminent)
• Serum K >5.5 mEq/L (normal 3.5–5.0)
• BMP: creatinine (renal function), glucose, bicarbonate
• Repeat draw if hemolysis suspected (pseudohyperkalemia)

DDx

• True hyperkalemia vs. pseudohyperkalemia (hemolysis, leukocytosis, thrombocytosis)
• Cause: medication, renal insufficiency, acidosis, cell lysis

MDM

• ⭐ EKG changes present → treat IMMEDIATELY regardless of exact K level
• Three goals: (1) stabilize cardiac membrane, (2) shift K intracellularly, (3) remove K from body

Treatment

If EKG changes present — EMERGENCY SEQUENCE:
1. ⭐ Calcium gluconate 10% 10 mL IV push → stabilizes cardiac membrane (effect 1–3 min; repeat if needed)
2. ⭐ Insulin 10 units IV + Dextrose 25g IV → shifts K intracellularly (effect 10–20 min; duration 4–6h)
3. Albuterol 10–20 mg nebulized → shifts K intracellularly (effect 30 min; duration 2–4h)
4. Sodium bicarbonate → if acidosis present; alkalinization shifts K into cells
5. Furosemide + NS → urinary excretion of K (if kidneys working)
6. Cation exchange resin (Kayexalate): binds K in GI tract; onset slow (hours); chronic management
7. ⭐ Dialysis → if renal failure, severe refractory hyperkalemia, or muscle paralysis

Chronic management: Dietary K restriction (avoid bananas, oranges, tomatoes, spinach, potatoes); adjust ACE-I/ARB dosing; treat underlying cause

Patient Education

• ⭐ Low-potassium diet: avoid high-K foods (bananas, oranges, tomatoes, spinach, potatoes, beans)
• Report palpitations, muscle weakness, chest discomfort
• Regular K+ monitoring if on ACE-I/ARB or with CKD
• Take blood pressure medications as prescribed — do not double-dose

Emergency Precautions

• ⭐ K >6.5 with peaked T waves or widened QRS = cardiac emergency — calcium gluconate immediately, continuous EKG monitoring, prepare for dialysis
• Sine wave pattern on EKG → arrest imminent → CPR ready, emergency dialysis
• Flaccid muscle paralysis → ICU, treat aggressively

NEOPLASMS / STRUCTURAL

26. Renal Cell Carcinoma

Epidemiology: Median age 64; males; originates from proximal tubule (renal cortex). ⭐ Cigarette smoking = strongest modifiable risk. VHL syndrome = 70% lifetime risk of clear cell RCC.

Critical History Questions

• Incidentally found on imaging?
• ⭐ Classic triad (present only 9%): hematuria + flank pain + palpable mass?
• Weight loss, night sweats, fever?
• Smoking history?
• VHL syndrome family history?
• HTN, obesity, CKD?
• Leg swelling (IVC involvement)?
• Cough, hemoptysis, bone pain (mets)?

ROS

• GU: hematuria, flank pain
• Constitutional: fever, weight loss, fatigue
• Respiratory: cough, dyspnea, hemoptysis (lung mets)
• Skeletal: bone pain, pathologic fracture (bone mets)
• LE: edema, ascites (IVC tumor thrombus)

Physical Exam

• ⭐ Most patients asymptomatic — incidental finding on imaging
• Palpable lower pole renal mass — non-tender, firm, moves with respiration
• Lower extremity edema (IVC involvement)
• Varicocele (new, right-sided, or won't decompress supine → renal vein involvement)
• Lymphadenopathy

Diagnostics

• ⭐ CT abdomen/pelvis with AND without IV contrast = preferred imaging
• Contrast enhancement = key finding distinguishing RCC from benign cyst
• Solid mass with irregular/thickened walls
• CBC: normocytic anemia OR polycythemia (EPO secretion)
• BMP: hypercalcemia (paraneoplastic)
• ⭐ No pre-operative biopsy — histologic diagnosis after nephrectomy
• Bone scan: if symptoms of bone mets
• MRI brain: if neurologic symptoms

DDx

• Benign renal cyst (thin walls, no enhancement on CT)
• Angiomyolipoma (contains fat on CT — Hounsfield units negative)
• Wilms tumor (pediatric, does not cross midline)
• Transitional cell carcinoma of renal pelvis (central location, different histology)

MDM

• Stage-based (I–IV); surgery is curative for localized disease
• ⭐ No biopsy before surgery; nephrectomy is both diagnostic and therapeutic

Treatment

• Localized (I–III):
• T1 (<7 cm): partial nephrectomy (nephron-sparing, preferred)
• Larger/central: radical nephrectomy
• Metastatic:
• Clear cell: immunotherapy (nivolumab + ipilimumab) + antiangiogenic therapy (VEGF/TKI)
• Non-clear cell: tailored to subtype
• 5-year survival: Stage I = 90%; Stage IV = ~12 months

Patient Education

• Smoking cessation (most important modifiable risk)
• Monitor blood pressure (HTN is a risk factor)
• Follow-up imaging per schedule (T1 treated with surveillance)
• VHL syndrome: regular surveillance imaging required

Emergency Precautions

• Massive hematuria from tumor → urologic emergency (possible embolization or nephrectomy)
• Spinal cord compression from vertebral mets → MRI + emergent radiation/neurosurgery
• Hypercalcemia from paraneoplastic secretion → aggressive IV hydration, loop diuretics, bisphosphonates

27. Polycystic Kidney Disease (ADPKD)

Most common (ADPKD1): PKD1 gene, chromosome 16; onset ~50s. Less severe (ADPKD2): PKD2, chromosome 4; onset ~74. ⭐ Autosomal dominant — 50% family inheritance.

Critical History Questions

• Family history of PKD, renal failure, intracranial aneurysm?
• Hypertension (often earliest sign)?
• Flank/abdominal pain from bleeding, stones, or cysts?
• Hematuria?
• Recurrent UTIs?
• Headache (intracranial aneurysm)?
• ⭐ Subarachnoid hemorrhage in family history? (berry aneurysm association)

ROS

• GU: flank pain, hematuria, recurrent UTIs, nephrolithiasis
• Cardiovascular: hypertension (early), cardiovascular disease
• Neurologic: headache (intracranial aneurysm — berry aneurysm risk)
• Hepatic: abdominal fullness (hepatic cysts)

Physical Exam

• ⭐ Large, palpable, bilateral, nodular kidneys (classic finding)
• Hypertension
• Abdominal fullness/organomegaly from enlarged cystic kidneys and liver

Diagnostics

• ⭐ Renal ultrasound: bilateral cysts (diagnostic if family history + age-appropriate cyst count)
• Age <30: ≥2 cysts; Age 30–59: ≥4 cysts; Age ≥60: ≥8 cysts
• CT or MRI: more sensitive, better characterization
• Genetic testing (PKD1/PKD2 mutation): if diagnosis unclear, for family screening, for transplant evaluation
• MRI brain/MRA: screen for intracranial aneurysms (family history of rupture or prior to high-risk procedures)
• BMP: creatinine, GFR monitoring
• UA: hematuria, proteinuria

DDx

• Simple renal cysts (usually unilateral, no family history, no symptoms)
• Tuberous sclerosis (angiomyolipomas + renal cysts + skin findings)
• Von Hippel-Lindau (clear cell RCC + renal cysts + retinal/CNS hemangioblastomas)

MDM

• Genetic counseling for affected patients and family members
• Monitor GFR every 6–12 months
• Aggressive management of hypertension (delays CKD progression)
• Refer to nephrology once GFR declines

Treatment

• ⭐ Tolvaptan (V2 receptor antagonist): only FDA-approved treatment; slows cyst growth and GFR decline; for rapidly progressive ADPKD (MRI-based total kidney volume)
• ⭐ Aggressive BP control (ACE-I or ARB): target BP <110/75
• Treat complications: antibiotics for cyst infections, analgesics for pain
• Nephrolithiasis: dietary modification, hydration
• ESKD → dialysis or transplant (excellent transplant outcomes)

Patient Education

• Autosomal dominant: each child has 50% risk — recommend genetic counseling for family members
• Intracranial aneurysm risk (5–10%): discuss surveillance MRA; avoid activities with sudden BP elevation
• Monitor BP at home; maintain adequate hydration
• Avoid NSAIDs, nephrotoxins
• Plan for potential renal replacement therapy (1/2 of ADPKD1 patients reach ESKD by age 60)

Emergency Precautions

• ⭐ Subarachnoid hemorrhage (sudden severe headache "worst of my life" + PKD history) → non-contrast CT head + neurosurgery
• Infected renal cyst (fever + flank pain + elevated WBC in PKD patient) → fluoroquinolone or TMP-SMX (penetrate cyst wall); CT to evaluate
• Gross hematuria (cyst hemorrhage): bed rest, hydration, analgesia; most resolve spontaneously
• Acute cyst infection with sepsis → hospitalize + IV antibiotics + imaging

GU TRAUMA

28. Traumatic Urethral Injury

✓ Previously tested in a test OSCE this block.

Epidemiology: ⭐ Posterior (membranous) urethra — pelvic fracture, MVCs; ⭐ anterior (bulbar) urethra — straddle injury (bicycle, fence). Almost exclusively male. ⚠️ Time-critical — an improperly placed catheter can convert a partial transection into a complete one.

Critical History Questions

• ⭐ Mechanism — pelvic fracture / high-energy MVC (posterior) or straddle injury / kick to perineum (anterior)?
• ⭐ Blood at the urethral meatus?
• ⭐ Inability to void after the trauma?
• Hematuria; last successful void?
• Perineal / scrotal / penile pain or swelling?
• Associated injuries — abdominal, pelvic, vascular, spine?

ROS

• GU: meatal blood, urinary retention, hematuria
• MSK / pelvic: pelvic pain, instability
• Constitutional: signs of hemorrhagic shock from associated injuries

Physical Exam

• ⭐ Blood at the urethral meatus — pathognomonic clue; assume urethral injury until proven otherwise
• ⭐ Perineal / scrotal "butterfly" hematoma (anterior); ⭐ high-riding / boggy / non-palpable prostate on DRE (posterior)
• Palpable distended bladder (inability to void)
• Pelvic instability / open-book deformity on compression
• ⚠️ DO NOT perform repeated or forceful attempts at urethral catheterization

Diagnostics

• ⭐ Retrograde urethrogram (RUG) = gold standard — extravasation of contrast localizes the injury
• CT pelvis with contrast — associated pelvic fracture, bladder injury, vascular injury
• CT cystogram if intra- vs extraperitoneal bladder injury suspected
• CBC, BMP, type & crossmatch, coags
• FAST / trauma workup as indicated

DDx

• Bladder rupture (intra- vs extraperitoneal)
• Urethral contusion (no extravasation on RUG)
• Penile fracture (eggplant deformity, swelling, ecchymosis)
• Renal / ureteral injury (rare in blunt trauma)
• Scrotal / testicular rupture

MDM

• ⭐ Suspect urethral injury → STOP catheterization → RUG first
• ⭐ Posterior injury (pelvic fracture) → ⭐ suprapubic cystostomy for urinary diversion + delayed reconstruction (months)
• Anterior partial → may attempt single careful endoscopic realignment by urology; otherwise SPC
• Always urology + trauma surgery consult
• Manage associated pelvic fracture / hemorrhage simultaneously

Treatment

• ⭐ Suprapubic cystostomy catheter — definitive urinary diversion in posterior or complete injury
• Urology evaluation for endoscopic realignment vs delayed urethroplasty
• Pelvic binder for unstable pelvic fracture; resuscitation per ATLS
• Tetanus prophylaxis if open injury
• Antibiotics if open injury or instrumented

Patient Education

• ⭐ High rate of long-term complications: stricture, ED, urinary incontinence
• Definitive repair typically delayed 3–6 months (allow inflammation to resolve)
• Multi-stage surgical repair often required
• Pelvic-floor PT for incontinence; urology follow-up indefinite
• Counsel on sexual function expectations

Emergency Precautions

• ⚠️ Hemodynamic instability + pelvic fracture → trauma activation, pelvic binder, mass transfusion, IR / OR
• ⚠️ NEVER pass a Foley with: blood at the meatus, perineal hematoma, high-riding prostate, or inability to void after pelvic trauma
• ⚠️ Combined bladder + urethral injury → both addressed; cystogram + RUG before any catheter
• ⚠️ Open-book pelvic fracture → unstable → emergent pelvic binder + angiography

QUICK REFERENCE TABLES — GU/RENAL

DDx: Testicular Pain

DDx: Hematuria

DDx: Urinary Incontinence

AKI: Prerenal vs Intrinsic vs Postrenal

Hyperkalemia EKG Progression

Treatment sequence: Calcium gluconate → Insulin + Dextrose → Albuterol → Furosemide → Kayexalate → Dialysis

Prostate Gland DDx

Nephritic vs Nephrotic

REPRO · REPRODUCTIVE

30 high-yield OSCE conditions across early/late pregnancy, postpartum, menstrual/hormonal, GYN malignancy, acute GYN, vaginitis/STIs, breast, and prolapse.

Repro reminders: Always β-hCG first in any reproductive-age female with abdominal pain or bleeding. Always offer a chaperone for pelvic/breast/GU exams. Always Rh status and always RhoGAM if Rh(–) with any pregnancy bleeding or delivery event.

EARLY PREGNANCY · CAN'T-MISS

RE-1. Ectopic Pregnancy

Epidemiology: Implantation outside endometrial cavity; ⭐ 95% in fallopian tube. Risk factors: PID, tubal surgery, IUD in place, ART, prior ectopic, smoking, endometriosis, DES exposure. Leading cause of 1st-trimester maternal death.

Critical History Questions

• ⭐ Last menstrual period (LMP)? Pregnancy known?
• ⭐ Classic triad: sudden unilateral pelvic/abdominal pain + vaginal spotting + amenorrhea?
• Shoulder pain (diaphragmatic irritation from hemoperitoneum)?
• Lightheadedness, syncope (rupture)?
• Prior PID/STI, prior ectopic, IUD in place, ART/IVF?
• Risk factors: smoking, tubal surgery, endometriosis?

ROS

• GU/GYN: pelvic pain, spotting, amenorrhea
• GI: nausea, vomiting (early pregnancy or peritoneal irritation)
• CV: lightheadedness, syncope (rupture)
• Constitutional: shoulder-tip pain (referred)

Physical Exam

• Vitals — ⚠️ tachycardia, hypotension (paradoxical relative bradycardia possible from vagal stimulation)
• Abdominal: unilateral lower-quadrant tenderness; rebound/guarding = rupture
• Pelvic: cervical motion tenderness, adnexal tenderness, possible adnexal mass
• ⚠️ Peritoneal signs + instability = ruptured ectopic — surgical emergency

Diagnostics

• ⭐ Urine β-hCG (95–100% sensitive)
• ⭐ Quantitative serum β-hCG: plateau or abnormally slow rise (<53% in 48 h)
• ⭐ TVUS: empty uterus with β-hCG above discriminatory zone (1,500–3,500 mIU/mL) + adnexal mass / "tubal ring" / free fluid
• Progesterone <5 ng/mL = 100% specific for abnormal pregnancy
• CBC, blood type/Rh, type & screen
• Rh(–) → RhoGAM

DDx

• Threatened/inevitable/missed/complete abortion
• Ovarian torsion
• Ruptured ovarian cyst (hemorrhagic corpus luteum)
• Appendicitis (always order β-hCG)
• PID / tubo-ovarian abscess
• Endometriosis

MDM

• ⭐ Reproductive-age female + pain + missed period + β-hCG+ = rule out ectopic until proven otherwise
• Empty uterus + β-hCG above discriminatory zone = ectopic until proven
• Stable + small/declining hCG + no fetal cardiac activity → MTX or expectant
• ⚠️ Unstable / ruptured / fetal cardiac activity / hCG >5,000 / mass >3.5 cm → surgery

Treatment

• ⚠️ Unstable / ruptured: ABCs, 2 large-bore IVs, transfuse → laparoscopic salpingostomy (tube-sparing) or salpingectomy
• Methotrexate (single-dose 50 mg/m² IM): for stable, hCG <5,000, mass <3.5 cm, no fetal cardiac activity, follow hCG day 4 & 7 (expect ≥15% drop)
• ⚠️ Contraindications: hepatic/renal/hematologic disease, active PUD, lung disease, breastfeeding
• ⭐ Expect pain 2–3 days post-MTX — drug effect, NOT failure
• Expectant management: only if asymptomatic + declining hCG
• RhoGAM if Rh(–)

Patient Education

• Avoid sex, exercise, alcohol, NSAIDs, folic-acid-containing vitamins after MTX
• Adhere to serial β-hCG follow-up until undetectable
• Future pregnancy risk: ~10–15% recurrent ectopic
• Return immediately for severe pain, dizziness, heavy bleeding

Emergency Precautions

• ⚠️ Sudden severe pain + syncope/hypotension = rupture → surgery now
• ⚠️ Shoulder-tip pain = hemoperitoneum
• Failure of hCG to decline after MTX → surgery

RE-2. Spontaneous Abortion

Epidemiology: Pregnancy loss <20 weeks (or <500 g); most common pregnancy complication; 80% in 1st trimester. ⭐ MC 1st-tri cause = aneuploidy (~50%, trisomies > polyploidy > monosomy X).

Critical History Questions

• Last menstrual period; gestational age?
• ⭐ Vaginal bleeding (amount, clots, tissue passed)?
• ⭐ Crampy suprapubic pain?
• Prior pregnancy losses, prior D&C?
• Rh status, blood type known?
• Recent trauma, infection, medical comorbidities?

ROS

• GU/GYN: bleeding, cramping, passage of tissue
• Constitutional: fever (septic abortion — emergency)

Physical Exam

• Vitals — tachycardia/hypotension if heavy bleeding
• Abdominal: suprapubic tenderness
• ⭐ Speculum: cervical os open (inevitable/incomplete) or closed (threatened/missed/complete); active bleeding; products of conception visible
• ⚠️ Septic abortion: fever, uterine tenderness, foul discharge

Diagnostics

• ⭐ Quantitative β-hCG (serial — normally doubles q48 h in viable pregnancy)
• ⭐ TVUS: gestational sac at 4–5 wk, yolk sac at 5.5 wk, embryo + cardiac activity expected when CRL ≥7 mm
• CBC, blood type + Rh, RhD antibody screen
• ⭐ Classify: threatened (closed os, viable IUP) · inevitable (open os, products at os) · incomplete (some POC passed, some retained) · complete (all POC passed) · missed (fetal demise, closed os) · septic (infected, fever)

DDx

• Ectopic pregnancy
• Subchorionic hemorrhage
• Cervical/vaginal lesion
• Molar pregnancy (high hCG, snowstorm US)
• Implantation bleeding (early, light, viable IUP)

MDM

• ⭐ Always check Rh — give RhoGAM if Rh(–)
• Stable threatened → expectant + close follow-up
• Unstable or septic → admit, resuscitate, D&E + IV antibiotics

Treatment

• Threatened: pelvic rest, serial hCG, serial US; ~50% progress to loss
• Inevitable / incomplete / missed: expectant management (up to 2 wks) OR misoprostol PV OR D&C/D&E
• Complete: confirm with US and declining hCG; counsel
• ⚠️ Septic abortion: D&E + broad-spectrum IV antibiotics
• ⭐ ALL Rh(–) patients → RhoGAM

Patient Education

• Most early losses are due to chromosomal abnormalities — not preventable, not your fault
• Resume cycles in 4–6 weeks; try again after 1 normal cycle if desired
• Watch for heavy bleeding (>1 pad/hour), fever, foul discharge
• Grief is normal — offer support resources

Emergency Precautions

• ⚠️ Hemodynamic instability → admit, transfuse, urgent D&E
• ⚠️ Septic abortion (fever, hypotension, foul discharge) → IV antibiotics + emergent D&E
• Recurrent loss (≥2) → workup (karyotype, APS, anatomy, endocrine, thrombophilia)

RE-3. Hyperemesis Gravidarum

Epidemiology: Severe N/V of pregnancy; most common cause of 1st-trimester hospitalization. ⭐ Associated with multiple gestation and molar pregnancy (higher hCG).

Critical History Questions

• ⭐ Severe vomiting unresponsive to OTC measures?
• ⭐ ≥5% prepregnancy weight loss?
• Dehydration symptoms (decreased urination, dizziness)?
• Triggers (odors, fatigue, hunger)?
• Family/prior history of HG?
• Last menstrual period, multiple gestation?

ROS

• GI: persistent vomiting, intolerance of PO
• GU: oliguria, dark urine
• Neuro: dizziness, weakness (consider Wernicke if prolonged)
• Constitutional: weight loss, fatigue

Physical Exam

• ⭐ Dehydration: tachycardia, orthostasis, dry mucosa, ↓ skin turgor
• Weight loss documentation
• ⭐ Abdominal exam usually benign
• Neuro: rule out Wernicke (confusion, ataxia, ophthalmoplegia)

Diagnostics

• ⭐ UA: ketonuria, high specific gravity
• CBC: hemoconcentration, leukocytosis
• ⭐ CMP: hypokalemia, hypochloremic metabolic alkalosis, ↑BUN/Cr
• TSH (hCG cross-reactivity), AST/ALT
• TVUS to confirm singleton vs multiple/molar

DDx

• Normal morning sickness (no weight loss / dehydration)
• Molar pregnancy (very high hCG, snowstorm US)
• Multiple gestation
• Gastroenteritis, gastritis, PUD
• Cholecystitis, pancreatitis
• DKA, thyrotoxicosis, intracranial process

MDM

• ⭐ ≥5% weight loss + ketonuria = HG (not just morning sickness)
• Rule out molar / multiple gestation
• Admit for refractory disease

Treatment

• ⭐ Step 1: B6 (pyridoxine) + doxylamine (Diclegis) PO
• Step 2: add ondansetron OR promethazine OR metoclopramide
• Severe/refractory: IV fluids (D5LR or NS), electrolyte correction, IV antiemetics
• ⭐ Thiamine BEFORE dextrose (Wernicke prophylaxis)
• Hospitalize if persistent dehydration / weight loss / ketosis

Patient Education

• Small frequent meals, bland foods, ginger, acupressure
• Avoid triggers (strong odors, fatty foods)
• Adequate hydration, take prenatal at bedtime
• Most resolves by 16–20 weeks

Emergency Precautions

• ⚠️ Persistent dehydration / weight loss → admit
• ⚠️ Neurologic symptoms → Wernicke encephalopathy → IV thiamine
• ⚠️ Severe electrolyte derangement (K+, Mg+) → telemetry

RE-4. Hydatidiform Mole (GTD)

Epidemiology: Abnormal trophoblastic proliferation. Complete mole (46,XX paternal only, no fetus) vs partial mole (triploid, may have fetal tissue). ⭐ 2–3% → choriocarcinoma after evacuation.

Critical History Questions

• ⭐ 1st-trimester vaginal bleeding?
• ⭐ Hyperemesis, breast tenderness, signs of hyperthyroidism?
• ⭐ Uterus larger than expected for dates?
• Passage of grape-like vesicles?
• Prior molar, advanced maternal age, Asian ancestry?

ROS

• GU/GYN: bleeding, pelvic pressure
• GI: hyperemesis
• Endocrine: tremor, heat intolerance (β-hCG TSH-like activity)
• ⭐ 2nd-trimester preeclampsia (rare; molar until proven otherwise)

Physical Exam

• ⭐ Uterus large for dates
• No fetal heart tones (complete) / discordant (partial)
• Bilateral adnexal masses (theca lutein cysts from high hCG)
• Possible hyperthyroidism signs

Diagnostics

• ⭐ β-hCG markedly elevated (often >100,000; can be millions with complete mole)
• ⭐ TVUS: "snowstorm" / cluster-of-grapes appearance; no fetus (complete); bilateral theca lutein cysts
• CXR for pulmonary mets
• TSH, free T4, LFTs, blood type/Rh, CBC

DDx

• Multiple gestation (also high hCG)
• Threatened/missed abortion
• Hyperemesis gravidarum alone
• Choriocarcinoma (post-evacuation)

MDM

• ⭐ Refer OB; never delay evacuation
• Post-evac surveillance: weekly hCG until negative ×3, then monthly ×6 months
• ⚠️ Reliable contraception required to interpret hCG trend (no pregnancy ×6 months negative hCG)
• Rising/plateauing hCG → persistent GTD or choriocarcinoma → MTX

Treatment

• ⭐ Suction curettage (definitive initial)
• RhoGAM if Rh(–)
• β-blocker if hyperthyroid before evacuation
• ⚠️ Do NOT resect theca lutein cysts (resolve with hCG)
• Persistent / metastatic → methotrexate (low-risk) or multi-agent chemo (high-risk choriocarcinoma)

Patient Education

• High cure rate; ~85% 5-yr survival even with metastatic choriocarcinoma
• Strict contraception ×6 months negative hCG
• Recurrence risk 1–2%; close surveillance for future pregnancies

Emergency Precautions

• ⚠️ Heavy bleeding → resuscitate, urgent evacuation
• ⚠️ Thyroid storm with anesthesia → β-blocker + medical management
• Persistent / rising hCG → urgent GTD workup

LATER PREGNANCY · HYPERTENSIVE & BLEEDING

RE-5. Gestational Diabetes

Epidemiology: Pathologic insulin resistance unmasked by placental hormones (hPL, progesterone, cortisol); ⭐ universal screen at 24–28 weeks; risk factors: obesity, prior GDM, PCOS, prior macrosomic infant, family history.

Critical History Questions

• Gestational age, prior GDM, prior macrosomic infant?
• Family history of T2DM?
• Symptoms of hyperglycemia (rare in GDM): polyuria, polydipsia?
• Recurrent vaginitis/UTI (sugar in urine)?
• BMI / weight gain pattern?

ROS

• GU: polyuria, recurrent UTI/candidiasis
• OB: large for dates, polyhydramnios, excessive weight gain
• Often asymptomatic

Physical Exam

• Fundal height larger than expected (macrosomia, polyhydramnios)
• BMI, weight tracking
• Otherwise typically normal

Diagnostics

• ⭐ 24–28 wk universal screen — 1-hour 50 g GCT: ≥140 mg/dL → proceed to confirmatory
• ⭐ 3-hour 100 g OGTT: fasting >95, 1 hr >180, 2 hr >155, 3 hr >140 — ≥2 abnormal = GDM
• Earlier screening (1st trimester) if high-risk
• HbA1c (less sensitive in pregnancy)
• Postpartum: 75 g OGTT at 6–12 weeks

DDx

• Pregestational T2DM (HbA1c ≥6.5% early in pregnancy)
• Stress hyperglycemia
• Cushing, hyperthyroidism (rare)

MDM

• Diet + lifestyle first (most patients controlled with diet)
• Self-monitor blood glucose: fasting <95, 1 hr postprandial <140
• ⭐ Failure to meet targets → insulin (preferred); glyburide or metformin alternatives
• Fetal surveillance (growth US, NST in 3rd trimester)
• Postpartum: screen for T2DM at 6–12 weeks + every 1–3 years

Treatment

• Nutrition: ~40% carbs, 40% fat, 20% protein; 3 meals + 2–3 snacks
• Exercise (walking after meals)
• ⭐ Insulin SQ if diet fails (preferred; doesn't cross placenta)
• Glyburide or metformin as alternatives (limited placental transfer)
• Delivery timing per glycemic control + fetal growth

Patient Education

• ⭐ ↑ Lifetime T2DM risk (up to 50%) — annual screening
• Breastfeeding reduces future T2DM risk
• Fetal risks: macrosomia, shoulder dystocia, hypoglycemia, hyperbilirubinemia
• Lose pregnancy weight, maintain healthy lifestyle

Emergency Precautions

• ⚠️ DKA in pregnancy = obstetric emergency (rare in GDM; more in T1DM)
• ⚠️ Macrosomia → planned C-section if EFW ≥4,500 g (diabetic) / ≥5,000 g (non-diabetic)
• ⚠️ Shoulder dystocia preparation at delivery

RE-6. Gestational Hypertension

Epidemiology: New-onset BP ≥140/90 after 20 wk in previously normotensive woman without proteinuria/end-organ damage. ⭐ ~25% progress to preeclampsia.

Critical History Questions

• ⭐ Gestational age (must be ≥20 wk)?
• BP at booking visit (rule out chronic HTN)?
• ⚠️ Symptoms of preeclampsia: headache, visual changes, RUQ pain, dyspnea, swelling?
• Decreased fetal movement?
• Risk factors: nulliparity, twins, prior preeclampsia, chronic HTN, DM, obesity, age >40?

ROS

• Cardiovascular: typically asymptomatic; rule out preeclampsia features
• Neuro: headache, visual changes, scotomata (preeclampsia)
• GI: RUQ/epigastric pain (HELLP)
• Resp: dyspnea (pulmonary edema)

Physical Exam

• ⭐ BP ≥140/90 on ≥2 occasions ≥4 h apart
• Edema (non-specific in pregnancy)
• Hyperreflexia / clonus (preeclampsia)
• Funduscopy if severe
• Fetal heart tones, fundal height

Diagnostics

• BP monitoring 1–2×/week
• ⭐ Spot urine protein:creatinine ratio (≥0.3 = preeclampsia threshold) or 24-hr urine
• CBC (platelets), CMP (LFTs, Cr), uric acid (preeclampsia risk)
• Weekly NST + fetal US q3 wk for growth

DDx

• ⭐ Preeclampsia (any proteinuria/end-organ → upgrade)
• Chronic hypertension (predates 20 wk)
• White-coat HTN
• Pheochromocytoma (rare)

MDM

• Confirm absence of proteinuria + end-organ involvement → gestational HTN
• ⭐ Develop ANY proteinuria/symptoms/lab abnormality → preeclampsia
• Severe-range BP (≥160/110) → admit, urgent treatment

Treatment

• ⭐ Antihypertensives if BP ≥160/110: labetalol IV, hydralazine IV, or nifedipine PO
• Outpatient maintenance: labetalol, nifedipine, methyldopa (NOT ACE-I/ARB — teratogenic)
• Delivery at 37–39 wk for stable gestational HTN
• Close surveillance for preeclampsia

Patient Education

• Self-BP monitoring at home; report ≥160/110 or symptoms immediately
• Headache, visual changes, RUQ pain, decreased fetal movement = come in now
• Most normalize by 12 weeks postpartum; persistence = chronic HTN

Emergency Precautions

• ⚠️ BP ≥160/110 = severe-range → urgent treatment (10–15 min)
• ⚠️ Headache + visual changes + RUQ pain → preeclampsia/eclampsia/HELLP → admit + MgSO4
• ⚠️ Seizure → eclampsia → MgSO4 + delivery

RE-7. Preeclampsia / Eclampsia / HELLP

Epidemiology: ⭐ BP ≥140/90 after 20 wk + (proteinuria or end-organ damage). Eclampsia = + seizure. HELLP = Hemolysis + ↑ LFTs + Low Platelets. Magnesium sulfate is the drug of choice for seizure prevention/treatment.

Critical History Questions

• Gestational age (must be ≥20 wk; can occur up to 6 wk postpartum)?
• ⭐ Headache (often frontal, throbbing)?
• ⭐ Visual changes (scotomata, blurriness, photopsia)?
• ⭐ RUQ/epigastric pain (HELLP — hepatic capsule stretch)?
• Dyspnea (pulmonary edema)?
• Decreased fetal movement?
• Prior preeclampsia, chronic HTN, DM, autoimmune disease, multiple gestation?

ROS

• CV: hypertension, edema (face/hands = concerning)
• Neuro: headache, scotomata, photopsia, hyperreflexia, seizure
• GI: RUQ/epigastric pain, nausea/vomiting
• Resp: dyspnea (pulmonary edema)
• GU: oliguria (renal involvement)

Physical Exam

• ⭐ BP ≥140/90 (≥160/110 = severe) on ≥2 occasions ≥4 h apart
• Generalized edema, especially face/hands
• ⭐ Hyperreflexia, clonus
• ⭐ RUQ tenderness (hepatic involvement)
• Funduscopy: papilledema (severe)
• Pulmonary: rales (pulmonary edema)
• Fetal heart tones

Diagnostics

• ⭐ Urine protein:creatinine ratio ≥0.3 OR 24-hr urine ≥300 mg
• ⭐ Severe features: BP ≥160/110, plt <100K, Cr >1.1 or doubled, LFTs ≥2× baseline, pulmonary edema, neuro symptoms, persistent RUQ pain
• HELLP labs: ↑ LDH, ↓ haptoglobin, schistocytes on smear, ↑ indirect bilirubin
• CBC, CMP, LFTs, LDH, uric acid, coag panel, U/A

DDx

• Chronic HTN
• Gestational HTN
• Acute fatty liver of pregnancy
• TTP / HUS (similar to HELLP)
• SLE flare with nephritis
• Cholelithiasis / pancreatitis (RUQ)

MDM

• Confirm by criteria; classify severity
• Severe features → admit, MgSO4, urgent BP control, delivery planning
• Eclampsia → ICU, MgSO4, deliver after stabilization
• HELLP → ICU, MgSO4, dexamethasone (some centers), urgent delivery

Treatment

• ⭐ Magnesium sulfate IV (4–6 g load, then 1–2 g/hr) — seizure prophylaxis AND treatment
• ⭐ BP control (target <160/110): labetalol IV / hydralazine IV / nifedipine PO
• ⭐ Delivery is the definitive treatment
• ≥37 wk + any preeclampsia → deliver
• <34 wk + stable → expectant management with steroids if feasible
• Severe features at any GA → deliver (after stabilization + steroids if <34 wk)
• Mg toxicity: ↓ DTRs → respiratory depression → cardiac arrest → calcium gluconate antidote

Patient Education

• Postpartum can still develop preeclampsia/eclampsia — return for headache/visual/RUQ symptoms
• Future pregnancies: ↑ recurrence; consider low-dose aspirin starting at 12 wk
• Long-term cardiovascular risk increased
• Magnesium causes warmth/flushing — expected

Emergency Precautions

• ⚠️ Eclamptic seizure → IV magnesium load, lateral decubitus, airway, deliver
• ⚠️ HELLP → ICU, transfuse platelets if <50K + bleeding/surgery, urgent delivery
• ⚠️ Mg toxicity (areflexia, resp depression) → stop Mg, IV calcium gluconate
• ⚠️ Stroke / pulmonary edema → emergent intervention

RE-8. Third-Trimester Bleeding (Abruption vs Previa)

Epidemiology: ⭐ Abruption = premature separation, PAINFUL, often with tetanic uterus and fetal distress. ⭐ Previa = placenta over internal os, PAINLESS bright red bleeding. Never perform a digital cervical exam for 3rd-tri bleeding until previa excluded.

Critical History Questions

• ⭐ Painful (abruption) vs painless (previa) bleeding?
• Gestational age?
• ⭐ Trauma, cocaine use, hypertension, smoking (abruption)?
• Prior C-section, prior previa, multiparity, multiple gestation, advanced maternal age, ART (previa)?
• Color (bright red = previa often; dark/mixed = abruption)?
• Fetal movement?
• Contractions (timing, intensity)?

ROS

• OB: bleeding, contractions, fetal movement
• CV: tachycardia, lightheadedness (volume loss)
• Neuro/CV: cocaine effects

Physical Exam

• Vitals — tachycardia, hypotension if heavy loss
• ⭐ Abdomen: abruption = rigid, tetanic, tender uterus; previa = soft, non-tender
• ⚠️ NO DIGITAL CERVICAL EXAM until previa excluded by US (risk of catastrophic hemorrhage)
• Speculum after US confirms no previa
• Fetal heart tones; fetal monitoring

Diagnostics

• ⭐ TVUS first to localize placenta — excludes previa before any digital exam
• CBC, blood type/Rh, type & cross, coag panel, fibrinogen (DIC risk with abruption)
• ⭐ Kleihauer-Betke to size RhoGAM dose in Rh(–)
• Fetal monitoring (continuous)
• Cocaine UDS if suspected

DDx

• Bloody show (labor)
• Vasa previa (fetal vessels over os — rare, catastrophic)
• Cervical/vaginal lesion (polyp, cancer, trauma)
• Uterine rupture (prior C-section, severe pain, loss of station)
• DIC (severe coagulopathy)

MDM

• ⭐ US first to localize placenta
• ⚠️ Hemodynamic instability or fetal distress → emergent delivery
• Previa stable → expectant, pelvic rest, plan C-section at 36–37 wk
• Abruption stable → close monitoring, steroids if preterm, deliver per status
• ⭐ All Rh(–) → RhoGAM (Kleihauer-Betke to size)

Treatment

• ⚠️ Unstable / fetal distress / severe abruption → emergent C-section + resuscitation
• Previa, stable: pelvic rest, no sex, no digital exam, plan elective C-section at 36–37 wk
• Abruption, stable preterm: steroids, MgSO4 if <32 wk, expectant; deliver if non-reassuring
• Massive transfusion protocol; correct coagulopathy (FFP, platelets, fibrinogen)
• RhoGAM if Rh(–)

Patient Education

• Previa: pelvic rest, return for any bleeding/contractions; C-section delivery planned
• Abruption: cocaine cessation, smoking cessation, BP control; recurrence risk
• Watch for fetal movement; daily kick counts

Emergency Precautions

• ⚠️ Painful bleeding + rigid uterus + fetal distress = abruption → emergent delivery
• ⚠️ Massive painless bleeding = previa hemorrhage → emergent C-section
• ⚠️ Sudden fetal bradycardia + bleeding + loss of station = uterine rupture / vasa previa
• DIC from abruption → ICU, blood products, deliver

RE-9. PROM / PPROM

Epidemiology: ⭐ PROM = ROM at ≥37 wk before labor; ⭐ PPROM = ROM <37 wk before labor. Major risks: chorioamnionitis, cord prolapse, fetal lung immaturity (PPROM).

Critical History Questions

• ⭐ Sudden gush of fluid, ongoing leakage?
• Gestational age (key for management)?
• Color of fluid (clear vs meconium-stained)?
• Time of rupture (>18 h = GBS prophylaxis trigger)?
• Contractions, vaginal bleeding?
• Fetal movement?
• Fever / chills (chorioamnionitis)?
• GBS status?

ROS

• OB: fluid leakage, contractions, fetal movement
• Constitutional: fever, chills (chorioamnionitis)

Physical Exam

• Vitals — fever, tachycardia (maternal/fetal) = chorioamnionitis
• ⭐ Sterile speculum (NOT digital exam — infection risk): pooling of fluid in posterior fornix
• ⭐ Nitrazine test (amniotic fluid turns paper blue, pH alkaline)
• ⭐ Ferning on slide (dried sample looks like ferns under microscope)
• Avoid digital exam unless in active labor
• Fetal heart tones, monitor

Diagnostics

• Clinical + pooling + nitrazine + ferning
• POC tests: PAMG-1 (Amnisure), IGFBP-1 (Actim PROM)
• Sterile speculum sample for GBS culture if unknown
• US: AFI (oligohydramnios supports), fetal presentation, EFW
• CBC, CRP if chorioamnionitis suspected

DDx

• Urinary incontinence
• Increased vaginal discharge
• Bloody show
• Vaginitis

MDM

• ⭐ Term (≥37 wk) PROM → induce labor (oxytocin) — reduces chorioamnionitis, NICU
• ⭐ PPROM 34–36 wk → deliver vs expectant (shared decision)
• ⭐ PPROM 24–33 wk → expectant management bundle (see treatment)
• <24 wk → individualize (periviable counseling)
• ⚠️ ROM >18 h → GBS prophylaxis regardless of culture status
• ⚠️ Chorioamnionitis → deliver + IV antibiotics

Treatment

• Term PROM: induce + GBS prophylaxis if >18 h or GBS+
• ⭐ PPROM 24–33 wk bundle:
• ⭐ Admit + bed rest + monitor
• ⭐ Antenatal corticosteroids (betamethasone) — fetal lung maturity
• ⭐ Latency antibiotics (ampicillin + erythromycin or azithromycin) — prolongs latency
• ⭐ GBS prophylaxis (penicillin G IV)
• ⭐ Magnesium sulfate <32 wk — fetal neuroprotection
• Chorioamnionitis → ampicillin + gentamicin IV + deliver

Patient Education

• Pelvic rest; nothing in vagina
• Daily kick counts; report decreased movement, contractions, fever
• Risk of preterm birth, neonatal complications
• Plan: delivery hospital with NICU

Emergency Precautions

• ⚠️ Chorioamnionitis (fever, fetal tachy, tender uterus, foul fluid) → IV antibiotics + delivery
• ⚠️ Cord prolapse → manual elevation, knee-chest, emergent C-section
• ⚠️ Placental abruption can occur after PPROM

RE-10. Group B Strep / Postpartum Endometritis

Epidemiology: ⭐ GBS colonizes 10–25% of pregnant women — universal vaginal-rectal culture at 36–37 wk; leading cause of neonatal sepsis if untreated. ⭐ Endometritis — postpartum uterine infection; biggest risk factor = C-section.

Critical History Questions

• GBS culture status (date)?
• Time since delivery?
• Mode of delivery (C-section >> vaginal for endometritis)?
• ⭐ Postpartum fever ≥100.4°F?
• ⭐ Lower abdominal pain, foul-smelling lochia?
• PROM duration, multiple cervical exams, meconium?
• Prior GBS-infected infant?

ROS

• GU/GYN: lochia (color, smell, amount), uterine pain
• Constitutional: fever, chills, malaise

Physical Exam

• Vitals — fever, tachycardia
• ⭐ Uterine fundal tenderness
• ⭐ Foul-smelling or purulent lochia
• Abdominal exam (rule out other postpartum infections)
• Incision check (C-section) — separate wound infection

Diagnostics

• Clinical diagnosis: postpartum fever + uterine tenderness + foul lochia (≥2 of 3)
• CBC (leukocytosis, bandemia)
• Blood cultures if sepsis criteria; lactate
• US if retained products suspected
• (Cervical/endometrial cultures rarely helpful)

DDx

• Wound infection
• Mastitis / breast abscess
• UTI / pyelonephritis
• DVT / pulmonary embolism
• Atelectasis (post-op fever)
• Drug fever, septic pelvic thrombophlebitis

MDM

• ⭐ Postpartum fever ≥48 h = endometritis until proven otherwise
• C-section requires broader coverage
• Treat empirically; tailor to cultures

Treatment

• GBS prophylaxis indications: GBS+ culture, GBS bacteriuria, prior GBS-infected infant, unknown status with risk factors (preterm, ROM >18 h, intrapartum fever)
• ⭐ Penicillin G IV intrapartum (cefazolin if penicillin-allergic without anaphylaxis; clindamycin if anaphylaxis + susceptible; vancomycin if resistant)
• ⭐ Endometritis: clindamycin + gentamicin IV until afebrile 24–48 h (no oral step-down needed for uncomplicated)
• Add ampicillin if GBS+ or enterococcus suspected
• Drain retained products / abscess if present

Patient Education

• Postpartum: watch for fever, foul discharge, severe pain, breathing difficulty
• Pelvic rest 6 weeks; resume sex after postpartum check
• Importance of GBS prophylaxis for future pregnancies

Emergency Precautions

• ⚠️ Sepsis → ICU, broad-spectrum antibiotics, source control
• ⚠️ Necrotizing fasciitis (rare) → emergent surgical debridement
• ⚠️ Septic pelvic thrombophlebitis (persistent fever despite antibiotics) → add heparin

RE-11. Postpartum Hemorrhage (PPH)

Epidemiology: ⭐ ≥1,000 mL blood loss within 24 h of delivery. Top 5 cause of maternal mortality in US. ⭐ 4 T's: Tone (atony — #1, ~80%), Trauma (lacerations), Tissue (retained POC, accreta), Thrombin (coagulopathy).

Critical History Questions

• Time and mode of delivery?
• Estimated blood loss; ongoing bleeding rate?
• ⭐ Boggy vs firm uterus?
• ⭐ Risk factors: prolonged labor, oxytocin augmentation, multiple gestation, polyhydramnios, macrosomia, grand multiparity, prior PPH, chorioamnionitis, retained placenta, prior C-section (accreta)?
• Anticoagulation, bleeding disorder?

ROS

• CV: lightheadedness, syncope (volume loss)
• GU: heavy bleeding, clots passed
• Constitutional: weakness, dizziness

Physical Exam

• ⭐ Vitals — tachycardia → hypotension as loss progresses
• ⭐ Uterine tone — soft/boggy = atony (#1)
• ⭐ Inspect lower tract — lacerations of cervix, vagina, perineum
• Examine placenta — completeness
• Coagulopathy signs (oozing from IV sites, mucous membranes)

Diagnostics

• Quantitative blood loss
• CBC (Hgb may lag), platelets, coags, fibrinogen (<200 = concerning), type & cross
• ⭐ Bedside US for retained products
• Lactate, ABG if shock

DDx (the 4 T's)

• ⭐ Tone (atony) — boggy uterus → uterine massage + uterotonics
• ⭐ Trauma — lacerations, hematomas, uterine rupture
• ⭐ Tissue — retained POC, placenta accreta
• ⭐ Thrombin — DIC, von Willebrand, anticoagulation

MDM

• ⭐ Activate PPH protocol early
• Two large-bore IVs, transfuse early if ongoing bleeding
• Identify "T" → targeted intervention
• Escalate stepwise

Treatment

• ⭐ Initial / atony: bimanual uterine massage + IV oxytocin
• Stepwise uterotonics:
• ⭐ Oxytocin (first-line)
• ⭐ Methylergonovine IM — ⚠️ avoid in HTN/preeclampsia
• ⭐ Carboprost (Hemabate) IM — ⚠️ avoid in asthma
• ⭐ Misoprostol PR/PO
• Tranexamic acid IV
• Tamponade: ⭐ Bakri balloon, uterine packing
• Surgical: B-Lynch suture, uterine artery ligation, uterine artery embolization (IR)
• ⭐ Last resort: hysterectomy
• Transfuse: PRBCs, FFP, platelets, cryoprecipitate per loss; massive transfusion protocol

Patient Education

• Recurrence risk in future pregnancies; deliver at center with blood bank
• Iron / nutritional repletion
• Watch for delayed hemorrhage up to 12 weeks postpartum
• Sheehan syndrome possible after massive hemorrhage

Emergency Precautions

• ⚠️ Massive transfusion protocol; ICU
• ⚠️ DIC → FFP, cryo, platelets
• ⚠️ Inverted uterus → urgent replacement
• ⚠️ Sheehan syndrome (failure to lactate, hypopituitarism) post-MTP

RE-12. Postpartum Mood Spectrum (Blues / PPD / Psychosis)

Epidemiology: ⭐ Baby blues ~40% (2–3 d onset, resolves ≤2 wk). ⭐ PPD ~9% (DSM MDD criteria, up to 12 mo postpartum). ⭐ Postpartum psychosis 1–2/1,000 (within 2 wk, medical emergency, strong bipolar link).

Critical History Questions

• Time since delivery?
• ⭐ Mood symptoms — sadness, anhedonia, irritability, anxiety, sleep, appetite, energy, concentration, guilt, hopelessness?
• ⭐ Suicidal ideation? Thoughts of harming the baby?
• Hallucinations, delusions, confusion (psychosis)?
• Prior depression, anxiety, bipolar?
• Family/social support, IPV, financial stressors?
• Pregnancy complications, NICU stay?

ROS

• Psych: full mood + anxiety + psychosis screen
• Constitutional: sleep, appetite, energy
• ⭐ Always assess infant safety and bonding

Physical Exam

• Mental status: affect, mood, speech, thought process, suicidal/homicidal ideation, insight
• ⭐ Observe interaction with infant
• General exam to rule out organic cause (thyroid, infection, anemia)

Diagnostics

• ⭐ Edinburgh Postnatal Depression Scale (EPDS) — score ≥10 concerning, ⭐ ≥20 = strong PPD; question 10 specifically asks about self-harm
• TSH, CBC (rule out thyroid, anemia)
• Pregnancy/UDS if relevant
• Document onset relative to delivery

DDx

• ⭐ Baby blues: mild, days 2–3, resolves ≤2 wk
• ⭐ PPD: MDD criteria ≥2 wk, any time during pregnancy or first 12 mo
• ⭐ Postpartum psychosis: hallucinations/delusions/confusion within 2 wk — emergency
• Postpartum anxiety / OCD
• Thyroid dysfunction (postpartum thyroiditis)
• Bipolar disorder (psychosis often unmasks)
• Substance use

MDM

• Baby blues → reassurance + support + 2-week recheck
• PPD → therapy + SSRI ± referral
• ⭐ Postpartum psychosis → medical emergency, hospitalize, separate from infant safely, psychiatry stat
• Always assess safety of mother and infant

Treatment

• Baby blues: sleep optimization, partner/family support, watchful waiting
• PPD:
• Mild–moderate: CBT/IPT + exercise + peer support
• Moderate–severe: SSRI (⭐ sertraline first-line — breastfeeding safe)
• Refractory: ⭐ zuranolone (FDA-approved for PPD) or brexanolone IV
• If prior antidepressant worked → restart
• Postpartum psychosis: ⭐ hospitalize + antipsychotic (olanzapine) + lithium (if bipolar) + SSRI if depressed; ECT if severe/refractory

Patient Education

• Baby blues is common and resolves; PPD is treatable; psychosis is an emergency
• Treatment improves bonding and child outcomes
• Breastfeeding compatibility: sertraline, paroxetine considered safest
• Family involvement; reduce isolation
• Routine screening at 3-wk postpartum visit

Emergency Precautions

• ⚠️ SI / HI / thoughts of harming baby → ED, do not leave alone, no access to means
• ⚠️ Postpartum psychosis = leading cause of maternal death in 1st year via suicide/infanticide → hospitalize
• Postpartum thyroiditis can mimic mood disorder → check TSH

MENSTRUAL · HORMONAL

RE-13. Abnormal Uterine Bleeding (PALM-COEIN)

Epidemiology: Bleeding outside normal cycle (21–35 d interval, ≤7 d duration, ≤80 mL flow). ⭐ PALM structural (Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia) vs ⭐ COEIN non-structural (Coagulopathy, Ovulatory, Endometrial, Iatrogenic, Not classified).

Critical History Questions

• ⭐ Pattern: heavy, prolonged, frequent, intermenstrual, postcoital, postmenopausal?
• LMP, cycle length, regularity?
• Reproductive plans, sexual activity, contraception?
• ⭐ Easy bruising, gum bleeding, family bleeding hx (vWD — most common in young women)?
• Thyroid symptoms, hirsutism, weight changes (PCOS)?
• Medications (anticoagulants, hormonal, IUD)?
• ⭐ Age and red flags: postcoital bleeding, postmenopausal bleeding, weight loss?

ROS

• GYN: bleeding pattern, dysmenorrhea, dyspareunia
• Heme: bruising, epistaxis, gum bleeding
• Endo: thyroid symptoms, hirsutism, galactorrhea
• Constitutional: weight loss, fatigue (anemia)

Physical Exam

• ⭐ Vitals — orthostasis if heavy loss
• ⭐ Speculum: source of bleeding, polyp, cervical lesion
• Bimanual: uterine size (fibroids, adenomyosis), masses
• Skin: bruising, petechiae (coagulopathy)
• Signs of androgen excess (PCOS), thyroid

Diagnostics

• ⭐ β-hCG first in any reproductive-age female
• CBC (anemia), TSH, prolactin
• ⭐ Coagulation panel + von Willebrand workup if young + heavy bleeding from menarche
• ⭐ TVUS — fibroids, polyps, endometrial thickness
• ⭐ Endometrial biopsy if: age ≥45, age ≥35 with risk factors, postmenopausal, thickened stripe, failed medical management
• Pap smear current?

DDx (PALM-COEIN)

• ⭐ Polyp / Adenomyosis / Leiomyoma / Malignancy or hyperplasia
• ⭐ Coagulopathy (vWD MC in young) / Ovulatory dysfunction (PCOS, thyroid) / Endometrial / Iatrogenic / Not classified
• Pregnancy-related bleeding
• Cervical/vaginal lesions
• IUD malposition

MDM

• Always rule out pregnancy, malignancy (per criteria), and structural lesions
• ⭐ Postmenopausal bleeding = endometrial cancer until proven otherwise → TVUS + EMB
• Stabilize acute heavy bleeding first

Treatment

• ⭐ Acute heavy bleeding: IV estrogen, high-dose oral estrogens, TXA, oxytocin (rare), D&C
• Chronic management based on cause:
• Hormonal: combined OCP, LNG-IUS, progestin (depot or oral)
• Anti-fibrinolytic: tranexamic acid (heavy menses)
• NSAIDs for primary dysmenorrhea
• Surgical: polypectomy, myomectomy, endometrial ablation, hysterectomy
• ⭐ Atypical hyperplasia → hysterectomy, not hormonal therapy
• vWD → desmopressin (DDAVP), factor concentrate, OCP

Patient Education

• Track cycles (period app), report changes
• Iron replacement if anemic
• ⭐ Postmenopausal bleeding = needs evaluation (never normal)
• Discuss long-term plan based on fertility goals

Emergency Precautions

• ⚠️ Hemodynamic instability → admit, transfuse, urgent intervention
• ⚠️ Postmenopausal bleeding → TVUS + EMB always
• Coagulopathy → hematology workup

RE-14. Amenorrhea (Primary & Secondary)

Epidemiology: ⭐ Primary = no menses by age 15 (with secondary sex chars) or by age 13 (without). ⭐ Secondary = absence ≥3 months in previously menstruating woman. Pregnancy is the MC cause of secondary amenorrhea.

Critical History Questions

• ⭐ Has there ever been a menstrual period? (primary vs secondary)
• ⭐ Sexual activity, contraception, pregnancy possibility?
• Weight loss, eating disorder, excessive exercise, stress (hypothalamic)?
• Galactorrhea, headaches, bitemporal vision loss (prolactinoma)?
• Hirsutism, acne, weight gain (PCOS)?
• Cyclic pelvic pain without bleeding (outflow obstruction)?
• Hot flashes, vaginal dryness (premature ovarian insufficiency)?
• Prior D&C, uterine procedures, infection (Asherman)?
• Family history of menarche timing, Turner syndrome?
• Medications (contraceptives, antipsychotics, opioids)?

ROS

• Constitutional: weight changes
• Endo: thyroid symptoms, hirsutism, galactorrhea, hot flashes
• Neuro: headaches, vision changes
• GYN: pelvic pain, vaginal dryness

Physical Exam

• ⭐ Tanner staging (primary)
• BMI, signs of malnutrition or athleticism
• Thyroid exam, breast (galactorrhea)
• ⭐ External genitalia: outflow obstruction (imperforate hymen → bluish bulging membrane)
• Pelvic exam (if age-appropriate) for uterus presence
• Signs of androgen excess
• Turner stigmata (short stature, webbed neck, widely spaced nipples)

Diagnostics

• ⭐ β-hCG FIRST (especially secondary)
• ⭐ Next tier: TSH, prolactin, FSH, estradiol
• ± testosterone, 17-OH-progesterone (PCOS/CAH)
• ⭐ High FSH = primary ovarian/gonadal cause (POI, Turner, gonadal dysgenesis)
• ⭐ Low FSH = central (hypothalamic/pituitary)
• Pelvic US (anatomy, ovaries)
• Karyotype if Turner suspected (primary, short stature)
• ⭐ HSG / hysteroscopy if Asherman suspected
• MRI pituitary if prolactinoma suspected

DDx

• ⭐ Pregnancy (always first)
• Functional hypothalamic amenorrhea (low BMI, exercise, stress)
• Prolactinoma / hypothyroidism
• PCOS
• Primary ovarian insufficiency (POI / premature menopause)
• Turner syndrome (primary)
• Outflow obstruction (imperforate hymen, transverse vaginal septum)
• Müllerian agenesis
• Asherman syndrome

MDM

• ⭐ Always β-hCG first
• Workup tier: TSH/prolactin/FSH/estradiol
• Direct further workup based on results

Treatment

• ⭐ Treat underlying cause
• Functional hypothalamic: nutrition rehab, ↓ exercise, stress management, bone density support
• Prolactinoma: dopamine agonist (cabergoline > bromocriptine)
• Hypothyroidism: levothyroxine
• PCOS: OCP + metformin
• POI: hormone replacement (estrogen + progesterone)
• Turner: HRT to induce puberty, cardiac surveillance, donor egg for fertility
• Imperforate hymen: hymenectomy
• Asherman: hysteroscopic adhesiolysis + estrogen
• All hypoestrogenic causes: ⭐ calcium + vitamin D for bone health

Patient Education

• Address fertility implications
• Bone health if hypoestrogenic
• Importance of resuming normal menses for endometrial protection (anovulatory states)

Emergency Precautions

• ⚠️ Bitemporal hemianopsia + galactorrhea = prolactinoma → MRI urgently
• POI before 40 → bone density assessment, HRT
• Imperforate hymen + severe pain → urgent surgical drainage of hematocolpos

RE-15. Dysmenorrhea / PMS / PMDD

Epidemiology: ⭐ Primary dysmenorrhea (no pathology, prostaglandin-mediated) vs secondary (endometriosis, adenomyosis, fibroids, PID). ⭐ PMS ~10% true; PMDD 1–5% with functional impairment.

Critical History Questions

• ⭐ Timing relative to menses (primary = with/just before menses; secondary = later in cycle, progressive)?
• Pain characteristics, severity, impact on function?
• ⭐ Cyclic mood symptoms restricted to luteal phase, resolving with menses (PMS/PMDD)?
• ⭐ Functional impairment — work, relationships, suicidal ideation (PMDD)?
• Dyspareunia (deep — endometriosis), heavy bleeding (fibroids)?
• Infertility (endometriosis)?
• Symptom diary across cycles?

ROS

• GYN: dysmenorrhea, AUB, dyspareunia
• Psych: mood, irritability, anxiety, sleep
• GI: bloating, constipation
• MSK: headaches, breast tenderness

Physical Exam

• ⭐ Primary dysmenorrhea / PMS / PMDD: normal pelvic exam
• Secondary dysmenorrhea: pelvic findings (tender nodules, fixed retroverted uterus = endometriosis; boggy enlarged uterus = adenomyosis; bulky/irregular = fibroids)

Diagnostics

• ⭐ Primary dysmenorrhea: clinical
• PMS/PMDD: ⭐ prospective symptom diary across 2 cycles
• TSH if mood overlap
• TVUS if secondary suspected (endometriosis, fibroids, adenomyosis)
• DSM-5 criteria for PMDD (≥1 mood + ≥5 total symptoms, luteal-only, impairment)

DDx

• Endometriosis (deep dyspareunia, infertility, tender nodules)
• Adenomyosis (boggy uterus, heavy menses)
• Fibroids (bulky/irregular uterus)
• PID
• IBS / functional GI overlap
• MDD (continuous, not cyclic) — distinguishes from PMDD

MDM

• Primary dysmenorrhea / PMS / PMDD have normal exam
• Persistence despite treatment → reconsider secondary causes (TVUS, laparoscopy)

Treatment

• ⭐ Primary dysmenorrhea: NSAIDs first-line (start 1–2 d before menses); heat, exercise; ⭐ monophasic COCs second-line
• ⭐ PMS: lifestyle, exercise, calcium/vitamin B6, COCs
• ⭐ PMDD:
• Mild: lifestyle, CBT
• Moderate–severe: ⭐ SSRIs (sertraline, fluoxetine) — can dose continuously OR intermittently (luteal-only — effective within first cycle)
• Drospirenone-containing COCs
• Refractory: GnRH agonist + add-back estrogen/progesterone (prevents bone loss)

Patient Education

• Symptom tracking is key
• NSAIDs work best when started early (before pain peaks)
• SSRIs are effective for PMDD (mood, less so for physical bloating)
• Cyclic = PMDD; persistent = MDD (different treatment)

Emergency Precautions

• ⚠️ Suicidal ideation (PMDD cycle peak) → urgent psych
• Secondary dysmenorrhea with infertility → endometriosis workup (laparoscopy)

RE-16. Endometriosis & Adenomyosis

Epidemiology: ⭐ Endometriosis = endometrial tissue at ectopic peritoneal sites (~10% reproductive-age women); ⭐ Adenomyosis = endometrial glands within myometrium (boggy uterus). Both estrogen-responsive, regress after menopause.

Critical History Questions

• ⭐ Cyclic dysmenorrhea (worse over time)?
• ⭐ Chronic pelvic pain?
• ⭐ Deep dyspareunia?
• ⭐ Infertility (often presenting complaint)?
• Dyschezia (bowel involvement), dysuria (bladder), cyclic hematuria/hematochezia?
• ⭐ Heavy menses + boggy uterus (adenomyosis)?
• Family history?

ROS

• GYN: dysmenorrhea, dyspareunia, infertility, AUB
• GI: dyschezia, constipation
• GU: dysuria, cyclic hematuria

Physical Exam

• ⭐ Endometriosis: tender rectovaginal nodules (uterosacral), retroverted/fixed uterus, lateral cervical displacement; exam may be normal
• ⭐ Adenomyosis: diffusely enlarged, boggy, symmetric uterus

Diagnostics

• ⭐ Endometriosis: ⭐ laparoscopy = definitive (blue/black "powder-burn" lesions; biopsy); TVUS may show chocolate cysts (endometriomas)
• ⭐ Adenomyosis: TVUS (heterogeneous myometrium, asymmetric thickening); MRI most accurate; ⭐ histology at hysterectomy = definitive
• CA-125 NOT diagnostic
• Rule out other causes of pain/infertility

DDx

• Adenomyosis vs endometriosis (often coexist)
• Fibroids
• PID / chronic pelvic infection
• IBS, IBD
• Interstitial cystitis
• Ovarian masses

MDM

• ⭐ Don't anchor — endometriosis can mimic IBS/IBD/IC
• Tailored to fertility goals
• Surgery preserves fertility but recurrence common

Treatment

• Endometriosis (no fertility desire / pain control):
• Step 1: ⭐ NSAIDs for pain
• Step 2: ⭐ Continuous COCs (1st formal Tx)
• Step 3: progestins (LNG-IUS, norethindrone)
• Step 4: ⭐ GnRH agonists with add-back (prevents bone loss + vasomotor)
• Step 5: aromatase inhibitors
• Endometriosis (fertility): laparoscopic ablation + adhesiolysis; ART if needed
• Definitive: hysterectomy ± BSO
• Adenomyosis: hormonal suppression (COCs, LNG-IUS, GnRH); ⭐ hysterectomy = definitive

Patient Education

• Chronic disease with cyclic flares; multimodal treatment
• Fertility counseling early
• Recurrence common after conservative surgery
• Resolves with menopause

Emergency Precautions

• Ruptured endometrioma (hemoperitoneum) → emergent eval
• Ureteral obstruction from severe deep endometriosis → urology referral

RE-17. Uterine Fibroids (Leiomyoma)

Epidemiology: ⭐ Most common benign uterine tumor (up to 70–80% lifetime prevalence on imaging); estrogen/progesterone-driven; ⭐ more symptomatic in Black women; regress after menopause.

Critical History Questions

• ⭐ Heavy menstrual bleeding (menorrhagia)?
• Pelvic pressure, urinary frequency, constipation (mass effect)?
• Pelvic/back pain?
• ⭐ Infertility or recurrent pregnancy loss?
• Acute pain + fever (degeneration/necrosis)?
• Fertility plans (drives treatment)?

ROS

• GYN: heavy bleeding, dysmenorrhea, dyspareunia
• GI: constipation, bloating
• GU: urinary frequency, hesitancy
• Heme: fatigue, dyspnea on exertion (anemia)

Physical Exam

• ⭐ Bimanual: irregular, enlarged, firm uterus
• Abdomen: palpable suprapubic mass if large

Diagnostics

• ⭐ TVUS (first-line): heterogeneous focal masses, ± calcifications, ± degeneration
• MRI for surgical planning or atypical features
• ⭐ CBC for iron-deficiency anemia (heavy bleeding)
• Saline-infusion sonohysterography or hysteroscopy for submucosal fibroids
• Endometrial biopsy if perimenopausal AUB

DDx

• Adenomyosis (diffuse, boggy vs focal, irregular)
• Endometrial polyp
• Leiomyosarcoma (rare, rapid growth)
• Ovarian mass
• Pregnancy

MDM

• Asymptomatic → observation
• Symptomatic → match treatment to fertility goals
• ⚠️ Postmenopausal new growth → suspect leiomyosarcoma

Treatment

• Asymptomatic: observation; iron supplementation if borderline anemic
• Bleeding control: hormonal (COCs, progestins, ⭐ LNG-IUS — avoid if uterine distortion → expulsion risk)
• Symptomatic / pre-surgical bridge: ⭐ GnRH agonist (leuprolide) — shrinks fibroids (reversible)
• Definitive (preserve fertility): ⭐ myomectomy (hysteroscopic, laparoscopic, or open)
• Definitive (no fertility desire): hysterectomy
• ⭐ Uterine artery embolization (UAE) — fertility-uncertain
• Endometrial ablation = bleeding only (does NOT shrink fibroids)

Patient Education

• Many fibroids are asymptomatic — watch and wait reasonable
• Regress after menopause
• Pregnancy with fibroids: ↑ risk of malposition, preterm labor, abruption
• Iron repletion if anemic

Emergency Precautions

• ⚠️ Acute severe pain + fever + leukocytosis = fibroid degeneration/necrosis → analgesia, rule out infection
• ⚠️ Severe AUB with instability → admit, transfuse, IV estrogen, TXA, intervention
• Postmenopausal rapid growth → r/o leiomyosarcoma

RE-18. PCOS

Epidemiology: Most common cause of female infertility; 5–10% of reproductive-age women. ⭐ Rotterdam 2/3 criteria: oligo/anovulation + hyperandrogenism + polycystic ovaries on US.

Critical History Questions

• ⭐ Oligomenorrhea (<9 cycles/yr) or amenorrhea?
• ⭐ Hirsutism (terminal hair on face/chest/abdomen), acne?
• ⭐ Infertility, recurrent pregnancy loss?
• Weight gain, insulin resistance symptoms?
• Family history of PCOS, T2DM, CVD?
• Mood, sleep apnea symptoms?

ROS

• Endo: hirsutism, acne, alopecia, acanthosis nigricans
• GYN: irregular cycles, infertility
• Constitutional: weight, mood
• Sleep: snoring, daytime fatigue (OSA association)

Physical Exam

• BMI / waist circumference
• ⭐ Hirsutism (Ferriman-Gallwey score), acne, male-pattern hair loss
• ⭐ Acanthosis nigricans (insulin resistance)
• Pelvic exam: may be normal; possible enlarged ovaries
• Blood pressure

Diagnostics

• ⭐ Rotterdam 2/3 criteria (exclude other causes first)
• Labs:
• β-hCG, TSH, prolactin (rule out mimics)
• ⭐ Total testosterone (elevated in PCOS); free T, DHEAS, SHBG
• 17-OH-progesterone (rule out non-classical CAH) — early follicular, AM
• LH:FSH typically >2:1 (not required)
• ⭐ Fasting glucose / HbA1c, OGTT, lipid panel — all PCOS patients
• ⭐ TVUS: ⭐ "string of pearls" — ≥12 follicles or ovarian volume >10 mL (not required if both other criteria present)

DDx

• Hypothyroidism, hyperprolactinemia
• Non-classical CAH
• Androgen-secreting tumor (rapid virilization)
• Cushing syndrome
• Premature ovarian insufficiency

MDM

• Confirm by Rotterdam after excluding mimics
• ⭐ Screen all patients for diabetes + lipids + BP + endometrial protection
• ⭐ Long-term: unopposed estrogen → endometrial hyperplasia / cancer risk

Treatment

• ⭐ First-line: combined OCP — regulates cycles, antiandrogenic, endometrial protection
• ⭐ Metformin — insulin resistance; can restore ovulation in 30–50%
• Hirsutism: spironolactone (with reliable contraception due to teratogenicity), eflornithine cream
• Infertility: letrozole (first-line for ovulation induction) > clomiphene; metformin adjunct
• Endometrial protection (if avoiding OCP): cyclic progestin or LNG-IUS
• ⭐ Lifestyle: 5–10% weight loss restores ovulation in many
• Screen + treat OSA, dyslipidemia, T2DM

Patient Education

• Chronic condition; long-term cardiometabolic risk
• Fertility achievable with appropriate treatment
• Endometrial protection even without OCP
• Lifestyle dramatically improves outcomes

Emergency Precautions

• ⚠️ Rapid virilization, severe hyperandrogenism → r/o ovarian/adrenal tumor
• Endometrial hyperplasia/cancer screening if prolonged anovulation
• OHSS in fertility treatment

RE-19. Ovarian Torsion

Epidemiology: ⭐ Most common in patients with ovarian mass ≥5 cm (85% of cases); right > left (longer utero-ovarian ligament); reproductive-age women > children. Surgical emergency.

Critical History Questions

• ⭐ Sudden-onset unilateral pelvic pain (right > left)?
• ⭐ Nausea/vomiting (47–70%)?
• Intermittent pain (intermittent torsion/detorsion)?
• Known ovarian mass, dermoid, fibroid, recent fertility treatment (enlarged ovaries)?
• LMP, pregnancy possibility?
• Prior episodes?

ROS

• GYN: pelvic pain, possible mass
• GI: nausea/vomiting
• Constitutional: low-grade fever (ischemia/necrosis)

Physical Exam

• Vitals — typically stable
• Abdominal: unilateral lower-quadrant tenderness; possible palpable adnexal mass
• ⚠️ Peritoneal signs = necrosis/rupture
• Pelvic: adnexal tenderness, possible mass
• Always β-hCG first

Diagnostics

• ⭐ β-hCG to exclude ectopic (every time)
• ⭐ Pelvic US with Doppler (both ovaries):
• ⭐ "Whirlpool sign" (twisted vascular pedicle) — ~90% sensitive
• Absent/decreased Doppler flow
• Enlarged ovary, peripheral follicles, free fluid
• ⭐ Normal Doppler does NOT exclude torsion — intermittent or partial
• ⭐ Definitive diagnosis = surgical visualization
• CBC, BMP, lipase as needed

DDx

• Ectopic pregnancy
• Ruptured ovarian cyst / hemorrhagic corpus luteum
• Appendicitis
• PID / tubo-ovarian abscess
• Nephrolithiasis
• Endometriosis

MDM

• ⭐ Clinical + US suspicion = surgery, even with normal Doppler
• Time-critical (<12 h ideal)
• Detorsion + preserve ovary if possibly viable (dark/edematous ≠ non-viable)

Treatment

• ⭐ Emergent laparoscopic detorsion
• ⭐ Preserve ovary if any chance of viability (color change with detorsion)
• Cystectomy of underlying mass
• Salpingo-oophorectomy if clearly necrotic / malignant
• ⭐ Consider ovariopexy to prevent recurrence (controversial)
• IV fluids, analgesia, antiemetics pre-op

Patient Education

• ~10–15% recurrence
• Future fertility usually preserved if detorsion successful
• Report recurrent acute pelvic pain immediately

Emergency Precautions

• ⚠️ Don't delay surgery awaiting confirmatory Doppler
• ⚠️ Necrosis → sepsis risk
• Pediatric / pregnant patient → same urgency; US first

RE-20. Menopause / GSM

Epidemiology: ⭐ Menopause = 12 months amenorrhea at expected age (avg 51). ⭐ Premature menopause / POI = <40 (FSH ×2 ≥1 mo apart). GSM (genitourinary syndrome of menopause) very common, underreported.

Critical History Questions

• ⭐ Last menstrual period; ≥12 months absent at expected age?
• ⭐ Vasomotor symptoms (hot flashes, night sweats)?
• ⭐ Vulvovaginal dryness, dyspareunia, recurrent UTIs?
• Mood, sleep, libido changes?
• Bone density / fracture risk; family history?
• Personal/family hx of breast/endometrial cancer, VTE, CVD (HRT contraindications)?

ROS

• Vasomotor: hot flashes, night sweats
• GYN: vaginal dryness, dyspareunia, bleeding (postmenopausal bleeding = workup)
• GU: dysuria, frequency, recurrent UTI
• Psych: mood, sleep, anxiety
• MSK: fragility fractures, height loss

Physical Exam

• BMI, BP
• ⭐ GSM findings: pale, dry, smooth, shiny vaginal epithelium; narrowed introitus; petechiae; small cervix/uterus
• Breast exam, pelvic exam
• ⚠️ Postmenopausal bleeding → speculum + bimanual + workup

Diagnostics

• ⭐ Menopause = clinical diagnosis at expected age (no labs needed)
• ⭐ POI (<40) → FSH ×2 ≥1 mo apart + low estradiol
• TSH, prolactin (rule out other causes)
• ⭐ DXA scan at menopause (baseline); ⭐ T-score ≤–2.5 = osteoporosis
• ⭐ Any postmenopausal bleeding → TVUS + endometrial biopsy (stripe >4 mm = abnormal)

DDx

• Premature ovarian insufficiency
• Thyroid disease
• Pregnancy (perimenopausal)
• Prolactinoma
• Postmenopausal bleeding: endometrial cancer/hyperplasia, atrophy, polyp, fibroid

MDM

• Confirm menopause; treat symptoms based on severity + risk
• ⭐ HRT is safe and effective for most women <60 or within 10 yr of menopause
• Always offer vaginal estrogen for GSM (low systemic absorption)
• Bone health: calcium + vitamin D + weight-bearing exercise
• Cardiovascular risk reduction

Treatment

• Vasomotor symptoms:
• ⭐ Systemic HRT (transdermal preferred — lower clot risk):
  • Estrogen alone if hysterectomy
  • Estrogen + progestin if uterus present (endometrial protection)
• Non-hormonal: ⭐ SSRIs/SNRIs (paroxetine FDA-approved); gabapentin; ⭐ avoid SSRIs with tamoxifen → SNRIs instead
• GSM:
• ⭐ Step 1: vaginal moisturizers (2–3×/wk) + lubricants for sex + pelvic floor PT
• ⭐ Step 2: low-dose vaginal estrogen (cream, ring, insert) — minimal systemic absorption, no progestin needed
• Ospemifene (SERM) if estrogen CI; vaginal DHEA
• Osteoporosis:
• ⭐ HRT (33% hip fracture reduction)
• ⭐ Raloxifene if osteoporosis only (reduces breast cancer risk; ⚠️ ↑ VTE, does NOT treat hot flashes)
• Bisphosphonates (alendronate, zoledronic acid)
• Denosumab for refractory
• ⚠️ HRT contraindications: estrogen-sensitive cancer, undiagnosed AUB, VTE, active liver disease

Patient Education

• HRT decision shared with risk assessment
• Vaginal estrogen safe in most cancer survivors (discuss with oncology)
• Continue gynecologic screening
• Lifestyle: exercise, calcium 1200 mg + vitamin D 800–1000 IU
• Postmenopausal bleeding is never normal

Emergency Precautions

• ⚠️ Postmenopausal bleeding → endometrial cancer workup
• ⚠️ HRT side effects: leg swelling, chest pain, breast lump → evaluate
• Fragility fracture → workup + treat osteoporosis

GYN MALIGNANCY

RE-21. Cervical Cancer & Dysplasia

Epidemiology: ⭐ HPV-driven (especially types 16 and 18); squamous cell ~75–80%, adenocarcinoma ~15%. ⭐ Screening: cytology starting at age 21; co-testing (cytology + HPV) every 5 years ages 30–65.

Critical History Questions

• ⭐ Postcoital bleeding?
• Intermenstrual or postmenopausal bleeding?
• Malodorous discharge?
• Pelvic pain, dyspareunia?
• ⚠️ Advanced symptoms: back pain, lower-extremity edema, hematuria, hematochezia, fistula?
• ⭐ Screening history (last Pap, last HPV), HPV vaccination?
• Risk factors: early sexual debut, multiple partners, smoking, immunosuppression (HIV), prior abnormal Pap, no screening?

ROS

• GYN: bleeding, discharge, pain
• GU: hematuria, dysuria
• GI: hematochezia, constipation
• MSK: back pain (advanced)
• Constitutional: weight loss (advanced)

Physical Exam

• ⭐ Speculum: visible cervical lesion (friable, exophytic, ulcerative), bleeding
• Bimanual: ⭐ fixed/immobile uterus = parametrial involvement (advanced)
• Rectovaginal exam for posterior extension
• Supraclavicular nodes (mets)
• LE edema (lymphatic obstruction)

Diagnostics

• ⭐ Pap + HPV co-testing; Bethesda classification (ASCUS, ASC-H, LSIL, HSIL, AGC)
• ⭐ Colposcopy + biopsy for abnormal cytology
• ECC (endocervical curettage) if endocervical involvement suspected
• ⭐ FIGO staging — CT/PET, cystoscopy, proctoscopy for advanced
• CBC, BMP, LFTs, BUN/Cr

DDx

• Cervical polyp / cervicitis
• Endometrial cancer (presenting via cervix)
• Vaginal cancer
• Trauma / foreign body
• Bleeding from atrophy / IUD

MDM

• Bethesda → algorithm-driven management:
• ASCUS + HPV– → repeat co-testing 3 yr
• ASCUS + HPV+ → colposcopy
• ASC-H, LSIL, HSIL, AGC → colposcopy
• CIN 1 often regresses; CIN 2/3 = precancer
• Refer all invasive cervical cancer to gynecologic oncology

Treatment

• CIN:
• CIN 1: observation (regresses ~57%)
• CIN 2/3: ⭐ LEEP (most common) or cold-knife conization; cryotherapy/laser ablative options
• FIGO-based:
• Stage 0 (CIS) → conization
• Stage IA1 → conization (fertility-sparing) or simple hysterectomy
• Stage IB1 → radical hysterectomy + pelvic LND
• Stage IB2–IIA → radical hysterectomy or chemoradiation
• Stage IIB–IVA → ⭐ chemoradiation (cisplatin-based)
• Stage IVB → systemic chemotherapy ± palliation
• ⭐ Refer all invasive cases to gyn-onc

Patient Education

• ⭐ HPV vaccination (Gardasil 9, ages 9–45) — primary prevention
• Smoking cessation, condom use
• Adhere to screening intervals
• After treatment: surveillance per protocol

Emergency Precautions

• ⚠️ Massive vaginal hemorrhage from tumor → vaginal packing → TXA → arterial embolization
• Ureteral obstruction → nephrostomy
• Bowel/bladder fistula → surgical management

RE-22. Endometrial Cancer

Epidemiology: ⭐ Most common GYN malignancy in US. Type I (endometrioid, ~90%) = ⭐ estrogen-driven (obesity, anovulation, unopposed estrogen, tamoxifen, late menopause, nulliparity); Type II = serous/clear cell, more aggressive. ⭐ Lynch syndrome = most common extracolonic manifestation.

Critical History Questions

• ⭐ Postmenopausal bleeding (any amount) — assume endometrial cancer until ruled out
• Premenopausal: heavy / irregular / intermenstrual bleeding?
• Risk factors: ⭐ obesity, ⭐ unopposed estrogen, ⭐ tamoxifen, PCOS, late menopause, nulliparity, T2DM, HTN?
• ⭐ Family/personal history of Lynch syndrome (colon, endometrial, ovarian, gastric)?
• Prior endometrial hyperplasia?

ROS

• GYN: bleeding, discharge, pelvic pressure
• GI: bowel changes (advanced)
• Constitutional: weight loss (advanced)

Physical Exam

• BMI (obesity = major risk)
• Pelvic exam: uterus size, mobility
• Lymphadenopathy (advanced)
• Vital signs

Diagnostics

• ⭐ TVUS first:
• Postmenopausal endometrial stripe >4 mm = abnormal → biopsy
• Premenopausal: less specific threshold
• ⭐ Endometrial biopsy (EMB) or D&C = definitive
• CT/MRI for staging if cancer confirmed
• ⭐ CA-125 NOT diagnostic (monitoring only in select cases)
• Pap may show atypical glandular cells (not a screen)
• Genetic counseling / Lynch syndrome screening

DDx

• Endometrial polyp
• Endometrial hyperplasia (non-atypical vs atypical)
• Fibroids
• Atrophy (postmenopausal bleeding can be from atrophy — still must rule out cancer)
• Cervical cancer
• Anticoagulation effect

MDM

• ⭐ Any postmenopausal bleeding → TVUS + EMB (never skip)
• Atypical hyperplasia → ⭐ hysterectomy (not hormonal therapy — high cancer rate)
• Refer confirmed cancer to gynecologic oncology

Treatment

• ⭐ Hyperplasia (non-atypical): progestin therapy (oral, IM, LNG-IUS) + repeat EMB in 3–6 mo
• ⭐ Atypical hyperplasia: hysterectomy ± BSO
• Endometrial cancer:
• ⭐ Total hysterectomy + BSO + sentinel/pelvic LND
• ⭐ Always remove fallopian tubes (possible origin site)
• Adjuvant radiation/chemo for high-grade/advanced
• Surveillance: pelvic exam q3–6 mo × 2 yr, then q6–12 mo × 3 yr (no Pap/imaging routinely)

Patient Education

• Weight loss, glycemic control reduce risk
• COCs reduce risk significantly (up to 50% with ≥1 yr use)
• Lynch syndrome → first-degree relative screening
• Surveillance after treatment

Emergency Precautions

• ⚠️ Hemorrhage from tumor → resuscitate + intervention
• Bowel/bladder involvement → multidisciplinary surgical planning

RE-23. Ovarian Cancer

Epidemiology: ⭐ Highest mortality of GYN cancers; epithelial ~90%. Risk: ⭐ BRCA1 (45% lifetime), BRCA2 (20%), ⭐ Lynch syndrome, nulliparity, early menarche, late menopause, postmenopausal HRT. Usually presents late.

Critical History Questions

• ⭐ Vague chronic GI/pelvic symptoms (bloating, early satiety, urinary urgency, pelvic pain) — present for weeks-months?
• Postmenopausal bleeding?
• Weight loss, fatigue?
• ⭐ Family history of breast / ovarian / colon cancer (BRCA, Lynch)?
• Ashkenazi Jewish ancestry (BRCA prevalence)?
• Prior CA screening?

ROS

• GI: bloating, early satiety, change in bowel habits, ascites
• GYN: pelvic pressure, postmenopausal bleeding
• GU: urinary urgency/frequency
• Constitutional: weight loss, fatigue

Physical Exam

• Vitals
• ⭐ Abdominal: distension, ⭐ ascites (shifting dullness, fluid wave), palpable mass
• ⭐ Pelvic: adnexal mass (postmenopausal = presume malignant), nodular cul-de-sac
• ⭐ Sister Mary Joseph nodule (periumbilical mass) = advanced
• Pleural effusion (lung mets)
• Lymphadenopathy (Virchow node)

Diagnostics

• ⭐ Pelvic US (first-line): complex solid/cystic mass, ascites
• ⭐ CA-125 — baseline + serial monitoring (elevated in 80% of epithelial; only 50% in early stage); ⭐ NOT a screening test alone in general population
• CT chest/abdomen/pelvis for staging
• ⭐ Genetic testing (BRCA1/2, Lynch) for all patients
• Tumor markers in young women: AFP, β-hCG, LDH, inhibin (germ cell/stromal)
• CBC, CMP, LFTs

DDx

• Ovarian cyst (functional, dermoid, endometrioma)
• Tubo-ovarian abscess
• GI malignancy with peritoneal spread
• Endometriosis
• Pelvic fibroid

MDM

• ⭐ Postmenopausal adnexal mass = presumed malignancy
• Refer all suspicious masses to gynecologic oncology
• Risk-of-Malignancy Index / OVA1 / ROMA can risk-stratify

Treatment

• ⭐ Surgical staging with hysterectomy + BSO + omentectomy + pelvic/para-aortic LND + peritoneal washings + biopsies (gyn-onc)
• ⭐ Platinum-based chemotherapy (carboplatin + paclitaxel) for stage IC and above
• ⭐ PARP inhibitors (olaparib, niraparib) — BRCA+ or HRD+ maintenance
• Bevacizumab in select cases
• Surveillance with CA-125 + exam ± imaging

Patient Education

• ⭐ Counsel all patients re: BRCA / Lynch testing implications
• Family member screening / risk-reducing surgery (BSO at 35–40 for BRCA1)
• Symptom diary for early detection in high-risk
• COCs / multiparity / breastfeeding reduce risk

Emergency Precautions

• ⚠️ Bowel obstruction (peritoneal disease) → palliative surgery / stent
• ⚠️ Pleural effusion with respiratory compromise → thoracentesis / pleurodesis
• ⚠️ Ascites → therapeutic paracentesis
• VTE common → anticoagulation

ACUTE GYN

RE-24. Pelvic Inflammatory Disease (PID)

✓ Previously tested in a test OSCE this block (gonococcal / chlamydia).

Epidemiology: Polymicrobial ascending infection of upper genital tract. ⭐ GC + chlamydia most common; also enteric (E. coli), BV-associated flora, M. genitalium. ⭐ 15% of untreated GC/chlamydia → PID. Major risk: age <25, new/multiple partners.

Critical History Questions

• ⭐ Lower abdominal/pelvic pain (most common)?
• Abnormal vaginal discharge?
• Dyspareunia, postcoital bleeding, intermenstrual bleeding?
• Fever, chills?
• ⭐ Sexual history — new partner, multiple partners, condom use, prior STI, IUD?
• LMP (always rule out pregnancy/ectopic)
• ⚠️ RUQ pain (Fitz-Hugh-Curtis perihepatitis)?

ROS

• GYN: pelvic pain, discharge, bleeding, dyspareunia
• GI: nausea/vomiting, RUQ pain (Fitz-Hugh-Curtis)
• GU: dysuria, urinary frequency
• Constitutional: fever, chills

Physical Exam

• Vitals — fever, tachycardia
• Abdomen: lower abdominal tenderness, ⚠️ peritoneal signs = severe/TOA
• ⭐ Speculum: mucopurulent cervicitis
• ⭐ Bimanual: cervical motion tenderness (CMT — "chandelier sign"), uterine tenderness, adnexal tenderness
• Adnexal mass = TOA
• RUQ tenderness = Fitz-Hugh-Curtis

Diagnostics

• ⭐ Clinical diagnosis — start treatment if any of CMT, uterine tenderness, or adnexal tenderness in a sexually active woman
• ⭐ Always β-hCG (ectopic mimic)
• ⭐ NAAT for GC + chlamydia
• CBC (leukocytosis), CRP/ESR
• ⭐ Pelvic US if TOA suspected (adnexal mass, complex multiloculated)
• HIV, syphilis, hepatitis screening

DDx

• Ectopic pregnancy
• Appendicitis
• Ovarian torsion
• Ruptured ovarian cyst
• Endometriosis
• UTI / pyelonephritis

MDM

• ⭐ Low threshold to treat empirically — delay of 2–3 days triples infertility/ectopic risk
• Admit if: pregnancy, severe illness, N/V intolerance of PO, no improvement on outpatient, TOA, surgical emergency cannot be excluded, adolescent, non-adherence concerns
• Always treat partners; report STIs

Treatment

• ⭐ Outpatient: ⭐ ceftriaxone 500 mg IM × 1 + doxycycline 100 mg PO BID × 14 d ± metronidazole 500 mg PO BID × 14 d
• ⭐ Inpatient (severe / TOA / pregnancy): ⭐ ceftriaxone IV + doxycycline IV + metronidazole IV
• TOA ≥8 cm or not responding → ⭐ IR drainage or surgery
• Treat partners empirically; abstain ×7 days post-treatment
• Test of reinfection in 3 months

Patient Education

• Sexual partner notification + treatment is critical
• Future risks: infertility, ectopic, chronic pelvic pain, Fitz-Hugh-Curtis
• Condom use, STI screening, vaccination (HPV, Hep B)
• Take full antibiotic course
• Return for fever, worsening pain, vomiting

Emergency Precautions

• ⚠️ Ruptured TOA = surgical emergency + septic shock → resuscitation + emergent surgery
• ⚠️ Sepsis → ICU
• Pregnancy + PID → admit (rare; rule out ectopic carefully)

RE-25. Bartholin Abscess

Epidemiology: Bartholin duct obstruction → mucus accumulates → bacterial infection → abscess at 5 or 7 o'clock. ⭐ MC pathogen now: E. coli (formerly thought polymicrobial).

Critical History Questions

• ⭐ Acute severe unilateral vulvar/labial pain and swelling?
• Inability to sit comfortably?
• Drainage (spontaneous rupture)?
• Sexual activity (rule out concurrent STI)?
• Prior episodes?
• ⭐ Postmenopausal new Bartholin mass → biopsy concern (malignancy)?

ROS

• GYN: unilateral vulvar pain, swelling, drainage, dyspareunia
• Constitutional: typically afebrile (focal abscess)

Physical Exam

• ⭐ Tense, warm, tender, fluctuant mass at 5 or 7 o'clock
• Surrounding cellulitis / labial edema
• ± Spontaneous drainage (purulent)
• Adjacent vulvar/vaginal exam for STI signs
• DRE if extension concern

Diagnostics

• ⭐ Clinical diagnosis
• Culture of drained fluid if STI / MRSA / immunocompromise / recurrent
• NAAT for GC/chlamydia
• ⚠️ ≥40 yr or postmenopausal new mass → ⭐ biopsy (rule out Bartholin carcinoma)

DDx

• Bartholin cyst (non-tender, no inflammation)
• Skene duct cyst/abscess
• Vulvar abscess / hidradenitis suppurativa
• Bartholin gland carcinoma (rare, older patients)
• Sebaceous cyst, lipoma

MDM

• ⭐ I&D is the treatment — antibiotics alone fail
• ⭐ Postmenopausal → biopsy with drainage
• Recurrent → marsupialization or excision

Treatment

• ⭐ I&D with Word catheter placement (inflate balloon with sterile saline; leaves in 4–6 wk to form fistulous tract and prevent recurrence)
• Alternative: marsupialization
• ⭐ Antibiotics only if: systemic signs, immunocompromise, diabetes, MRSA risk, recurrent
• First-line: TMP-SMX + metronidazole OR amoxicillin-clavulanate
• Doxycycline if chlamydia coverage needed
• Sitz baths + analgesia
• Treat concurrent STI

Patient Education

• Sitz baths × 2–3 wks after drainage
• Word catheter care (stays 4–6 wk)
• Sexual rest until healed
• Recurrence ~10–15% — return early for recurrent symptoms

Emergency Precautions

• ⚠️ Surrounding necrotizing fasciitis (rare, immunocompromised/diabetic) → emergent debridement + broad antibiotics
• Postmenopausal mass → biopsy mandatory

VAGINITIS & STIs

RE-26. Vaginitis (BV / VVC / Trich)

Epidemiology: ⭐ BV (Gardnerella, Lactobacillus loss) — MC cause of abnormal discharge. ⭐ VVC (Candida albicans 90%) — pruritus, antibiotic-triggered. ⭐ Trich (T. vaginalis, protozoan) — STI, often partner asymptomatic.

Critical History Questions

• ⭐ Discharge character (color, amount, odor, consistency)?
• ⭐ Pruritus, burning, dysuria?
• Postcoital bleeding, abnormal odor with sex/menses?
• Recent antibiotics, douching, new soaps, immunocompromise, diabetes, pregnancy?
• Sexual activity, new partners, condom use?
• Prior vaginitis episodes; self-treatment?

ROS

• GYN: discharge, pruritus, burning, dyspareunia
• GU: dysuria (overlap with UTI)
• Constitutional: typically afebrile

Physical Exam

• ⭐ Vulva: erythema, edema, excoriations (VVC), normal (BV)
• ⭐ Speculum: discharge character; cervix (strawberry cervix = trich)
• pH and KOH/wet mount at bedside if possible

Diagnostics

• ⭐ BV Amsel criteria (≥3/4): homogeneous discharge, pH >4.5, positive whiff test, clue cells (>20% epithelial cells)
• NAAT for Trichomonas if uncertain; co-test for GC/chlamydia

DDx

• Cervicitis (GC, chlamydia, HSV)
• Atrophic vaginitis (postmenopausal)
• Allergic / contact vulvitis
• Foreign body (retained tampon, pessary)
• Lichen sclerosus / planus

MDM

• Bedside pH + KOH + wet mount = rapid diagnosis
• ⭐ Treat partner for trich; ⭐ don't routinely treat partner for VVC (asymptomatic)
• BV partner treatment now considered in recurrent cases (per recent data)

Treatment

• ⭐ BV: ⭐ metronidazole 500 mg PO BID × 7 d OR metronidazole 0.75% gel intravaginally × 5 d OR clindamycin 2% cream; same regimen in pregnancy
• ⭐ VVC:
• ⭐ Uncomplicated: fluconazole 150 mg PO ×1 (repeat in 72 h if moderate) or topical azole
• ⭐ Pregnancy: ⭐ topical azole only ≥7 d (clotrimazole/miconazole) — NO oral fluconazole
• Complicated/recurrent: extended courses, maintenance fluconazole
• ⭐ Trich: ⭐ metronidazole 2 g PO ×1 (95–97% cure) — treat partner; alternative tinidazole; resistant → 500 mg BID × 7 d
• ⭐ Counsel: no alcohol × 72 h with metronidazole (disulfiram-like)

Patient Education

• ⭐ Avoid douching, scented soaps, tight clothing
• Probiotic / lactobacillus may help recurrent BV (limited evidence)
• VVC: cotton underwear, dry environment
• Treat sexual partner for trich; condom use
• Sex partner doesn't need treatment for BV/VVC routinely

Emergency Precautions

• ⚠️ Recurrent VVC → check for diabetes, HIV
• Pregnancy: ⭐ untreated BV/trich → preterm birth risk → treat
• Trich → ↑ HIV acquisition risk; screen and counsel

RE-27. Gonorrhea & Chlamydia

Epidemiology: ⭐ Chlamydia = MC bacterial STI in US; gonorrhea 2nd. ⭐ 50–70% asymptomatic in women → screen ≤25 annually. Co-infection common — always treat both.

Critical History Questions

• ⭐ Vaginal/urethral discharge (mucopurulent yellow-green = GC; thinner clear/white = chlamydia)?
• Dysuria, postcoital bleeding, intermenstrual bleeding?
• Pelvic pain (PID), RUQ pain (Fitz-Hugh-Curtis)?
• Anal / oral exposure (extragenital sites)?
• ⭐ Sexual history — new partners, condom use, prior STI, partner symptoms?
• LMP, contraception?

ROS

• GYN/GU: discharge, dysuria, abnormal bleeding
• Joint: reactive arthritis (Reiter — chlamydia)
• ⚠️ Disseminated GC: fever, migratory polyarthritis, tenosynovitis, pustular skin lesions

Physical Exam

• Vitals — fever (PID / DGI)
• Speculum: mucopurulent cervicitis, friable cervix, ± Bartholin tenderness
• Bimanual: CMT, adnexal tenderness (PID)
• Skin / joints (DGI)
• Pharynx, rectum if exposure history

Diagnostics

• ⭐ NAAT — vaginal swab (preferred in women), urine first-catch (men)
• ⭐ Always co-test for chlamydia + GC simultaneously
• Screen for HIV, syphilis, hepatitis B, trich
• Pregnancy test
• Pap/HPV current?
• GC culture + susceptibility if treatment failure or DGI

DDx

• BV / VVC / trich (cervicitis vs vaginitis)
• HSV cervicitis (vesicular)
• PID
• UTI

MDM

• ⭐ Treat empirically for both GC and chlamydia at presentation (don't wait for results)
• Always treat partners
• Test of reinfection at 3 months
• Report STIs per state requirement

Treatment

• ⭐ Uncomplicated: ⭐ ceftriaxone 500 mg IM ×1 + doxycycline 100 mg PO BID × 7 d
• Pregnancy: ceftriaxone IM + ⭐ azithromycin 1 g PO ×1 (avoid doxy)
• Disseminated GC: IV ceftriaxone + admission
• Cephalosporin allergy: gentamicin + azithromycin
• ⭐ Treat sexual partners — expedited partner therapy where allowed
• Abstain × 7 d after treatment

Patient Education

• Complete the antibiotic course
• ⭐ Partner treatment is essential — reinfection if untreated
• Condom use, limit number of partners
• Rescreen at 3 months
• HPV vaccination, hepatitis B vaccination
• Future risks if untreated: PID, infertility, ectopic, Fitz-Hugh-Curtis

Emergency Precautions

• ⚠️ Disseminated gonococcal infection (DGI) — fever + migratory arthritis + pustular skin lesions → admit + IV ceftriaxone
• ⚠️ PID / Fitz-Hugh-Curtis → empiric treatment + workup
• Neonatal conjunctivitis (GC blindness; chlamydia pneumonia) → universal eye prophylaxis at birth

RE-28. Syphilis & Genital HSV

Epidemiology: ⭐ Syphilis (T. pallidum spirochete, "Great Imitator") — rising; 40% co-infection with HIV. ⭐ Genital HSV (HSV-2 > HSV-1) — 1 in 6 ages 14–49; >85% unaware. Both screen with HIV.

Critical History Questions

• Syphilis: painless genital ulcer? Rash on palms/soles? Constitutional symptoms? Travel, sexual history, MSM?
• HSV: ⭐ painful vesicles/ulcers? Prior outbreaks (recurrent)? Prodrome (tingling, burning) before lesions? Triggers (stress, illness, sun)?
• Pregnancy status (HSV — delivery planning; syphilis — congenital risk)?
• HIV status, screening current?
• ⭐ Partner notification?

ROS

• Skin/mucosa: ulcers, rash, lymphadenopathy
• Constitutional: fever, malaise, lymphadenopathy
• Neuro: vision (ocular syphilis), AMS / cranial nerves / Argyll-Robertson pupils (neurosyphilis)
• CV: aortic insufficiency (tertiary syphilis)

Physical Exam

• ⭐ Syphilis:
• Primary: painless, firm, indurated chancre with clean base
• Secondary: symmetric maculopapular rash including palms + soles, condyloma lata, patchy alopecia, mucous patches, generalized lymphadenopathy
• Tertiary: gummas, aortic aneurysm, Argyll-Robertson pupils (accommodation intact, no light reflex), tabes dorsalis
• ⭐ HSV: painful vesicles → ulcers; tender inguinal lymphadenopathy; first outbreak more severe (flu-like)

Diagnostics

• ⭐ Syphilis:
• ⭐ Screen with non-treponemal: ⭐ RPR or VDRL
• Confirm with treponemal: ⭐ FTA-ABS / TP-PA
• Neurosyphilis: ⭐ CSF VDRL
• Co-test for HIV always
• ⭐ HSV:
• ⭐ PCR or viral culture of vesicular fluid (gold standard)
• Type-specific HSV-1/HSV-2 serology
• Pregnancy syphilis screening: 1st visit, 28 wk, delivery

DDx

• Painful ulcer: HSV, chancroid (undermined edges)
• Painless ulcer: syphilis, LGV (groove sign), traumatic
• Rash on palms/soles: syphilis (secondary), RMSF, hand-foot-mouth, drug rash
• Genital lesions in general: HPV warts, molluscum, Behçet, fixed drug eruption

MDM

• ⭐ Treat empirically based on clinical suspicion
• Always treat partner / report
• Always co-screen for HIV

Treatment

• ⭐ Syphilis: ⭐ Benzathine Penicillin G IM (only option in pregnancy — desensitize if allergic)
• Primary/secondary/early latent: 2.4 million units ×1
• Late latent / unknown duration: 2.4 million units weekly ×3
• Neurosyphilis: aqueous PCN G IV × 10–14 d
• ⚠️ Jarisch-Herxheimer reaction (fever, chills, myalgia hours after treatment) — supportive
• ⭐ HSV:
• First episode: acyclovir 400 mg PO TID × 7–10 d (or valacyclovir / famciclovir)
• Recurrence: shorter courses
• Suppression if ≥6 outbreaks/yr or partner uninfected: daily valacyclovir
• ⭐ Pregnancy: ⭐ suppressive acyclovir from 36 wk; C-section if active lesions / prodrome at labor

Patient Education

• HSV is lifelong but manageable; daily suppression reduces shedding ~50%
• ⭐ Condoms reduce transmission but don't eliminate (shedding asymptomatic)
• Avoid sex during outbreaks / prodrome
• Pregnant + HSV — adhere to suppressive therapy + report symptoms in labor
• Syphilis: complete treatment, expect Jarisch-Herxheimer, follow RPR titers (4-fold drop = cure)
• ⭐ HIV testing for all

Emergency Precautions

• ⚠️ Neonatal HSV / congenital syphilis = serious — adherence critical
• ⚠️ Disseminated HSV / encephalitis (immunocompromised) → IV acyclovir
• ⚠️ Tertiary syphilis (cardiovascular, neurosyphilis) → admit + IV PCN G
• HSV keratitis → ophthalmology emergency

RE-29. HPV

Epidemiology: ⭐ MC STI in US; ⭐ low-risk types 6, 11 → warts; ⭐ high-risk types 16, 18 → cervical/anal/oropharyngeal cancers. ⭐ Gardasil 9 vaccine 9–45 years; ⭐ many infections clear spontaneously (~60–90% within 2 yr).

Critical History Questions

• ⭐ Visible warts (anogenital) — onset, progression, treatment tried?
• ⭐ Abnormal Pap history?
• ⭐ HPV vaccination status?
• Immunocompromise (HIV, transplant)?
• Sexual history?
• Pregnancy status (treatment differs)?

ROS

• GYN/GU: warts, abnormal bleeding (cervical lesion)
• Oropharyngeal lesions
• HIV status, immunosuppression

Physical Exam

• ⭐ Anogenital warts: soft, pink/flesh-colored, "cauliflower-like" (condyloma acuminata)
• Speculum: cervical lesions, friability
• Anoscopy if anal lesions
• Oropharyngeal exam

Diagnostics

• ⭐ Clinical diagnosis for visible warts
• ⭐ Pap + HPV co-testing (cervical screening; ⭐ start at age 21)
• Colposcopy + biopsy for abnormal cytology
• Anoscopy ± high-resolution anoscopy in MSM with HIV
• HIV testing

DDx

• Condyloma lata (secondary syphilis) — flatter, moist, more vascular
• Molluscum contagiosum (umbilicated)
• Skin tags, sebaceous cysts
• Pearly penile papules (normal variant)
• Cervical/anal cancer

MDM

• Treat visible warts (cosmesis, symptomatic relief, transmission reduction)
• Cervical dysplasia follows Bethesda algorithm
• ⭐ Vaccinate all 9–45 (universal recommendation)

Treatment

• ⭐ Warts:
• Patient-applied: ⭐ podofilox, imiquimod, sinecatechins
• Provider-applied: ⭐ cryotherapy, trichloroacetic acid (TCA), surgical excision, laser
• ⭐ Pregnancy: TCA or cryotherapy/laser — ⚠️ NO podophyllin, podofilox, imiquimod
• ⭐ Cervical dysplasia: colposcopy → LEEP/cold-knife conization per CIN grade
• HPV-related cancers: surgical resection ± chemo/radiation per stage

Patient Education

• ⭐ HPV vaccination — even after infection (protects against other types)
• Condoms reduce but don't eliminate transmission
• Most infections clear spontaneously
• Adhere to cervical screening
• ⭐ Pap + HPV vaccination both needed; vaccination doesn't replace screening

Emergency Precautions

• ⚠️ Massive cervical lesion with bleeding → emergent workup for cancer
• Pregnancy with extensive warts → consider C-section if obstructing canal (rare); risk of neonatal respiratory papillomatosis

BREAST

RE-30. Breast Mass & Mastitis/Abscess

Epidemiology: ⭐ Most breast masses in <30 are benign (fibroadenoma); >50 = malignancy until proven otherwise. ⭐ Mastitis — postpartum breastfeeding women, S. aureus; abscess if untreated. ⭐ Inflammatory breast cancer mimics mastitis — biopsy any "mastitis" that doesn't resolve in 1–2 wk.

Critical History Questions

• ⭐ Mass: when noticed, growth, mobility, tenderness, skin/nipple changes, nipple discharge (bloody = papilloma vs cancer)?
• Cyclic vs constant (cyclic = fibrocystic)?
• ⭐ Risk factors: family history (BRCA), early menarche, late menopause, nulliparity, late first pregnancy, HRT, prior breast biopsy, atypical hyperplasia, dense breasts?
• Mastitis: postpartum, breastfeeding, cracked nipple, fever, unilateral erythematous painful breast?
• Trauma (rule out fat necrosis)?

ROS

• Breast: mass, pain, skin/nipple change, discharge
• Lymph: axillary, supraclavicular lumps
• Constitutional: fever (mastitis/abscess), weight loss (advanced cancer)

Physical Exam

• Vitals — fever (mastitis/abscess)
• ⭐ Inspect both breasts: skin dimpling (peau d'orange = IBC), nipple retraction, asymmetry, erythema
• ⭐ Palpate systematically: mass characteristics — size, shape, mobility, consistency, tenderness, location (clock face); ⭐ fixed, hard, irregular = cancer until proven; mobile rubbery = fibroadenoma
• Nipple discharge (single duct + bloody = papilloma or DCIS until proven)
• ⭐ Axillary, supraclavicular, cervical lymph nodes
• Mastitis: unilateral wedge-shaped erythema, warmth, tenderness; ± fluctuance (abscess)

Diagnostics

• ⭐ <30: ⭐ US first → fibroadenoma vs cyst
• ⭐ ≥30: ⭐ diagnostic mammogram + US
• MRI for high-risk screening, dense breasts, occult primary, problem-solving
• ⭐ Core needle biopsy for suspicious mass (BI-RADS 4–5)
• Cyst → aspiration: clear fluid OK; ⭐ bloody → biopsy + cytology
• Mastitis: clinical; ⭐ ultrasound if abscess suspected; culture if MRSA / failed antibiotics / not breastfeeding (atypical organisms)

DDx

• ⭐ Cancer (invasive ductal, lobular, IBC, DCIS, Paget)
• Fibroadenoma (young, mobile, rubbery)
• Fibrocystic changes (bilateral, cyclic, tender)
• Cyst (well-defined, can aspirate)
• Intraductal papilloma (bloody single-duct discharge)
• Fat necrosis (trauma history)
• Lipoma
• Mastitis / abscess

MDM

• ⭐ Triple test: clinical exam + imaging + biopsy — concordant?
• ⭐ Any mass that doesn't resolve / new in postmenopausal → biopsy
• ⭐ Mastitis not improved in 48 h → ultrasound + consider biopsy (rule out IBC)
• Refer to breast surgeon / oncology for malignancy

Treatment

• Fibroadenoma: observe if <3 cm and confirmed benign; excise if ≥3 cm, growing, atypical, or patient preference
• Cyst: aspirate symptomatic; biopsy if bloody/recurrent
• Cancer: stage-based — lumpectomy + sentinel LN biopsy + radiation OR mastectomy ± axillary dissection; systemic therapy (hormonal if ER/PR+; HER2 → trastuzumab; chemo per stage)
• ⭐ Mastitis: ⭐ dicloxacillin or cephalexin × 10–14 d; ⭐ continue breastfeeding/pumping; warm compresses; NSAIDs/acetaminophen
• ⭐ Abscess: ⭐ I&D (or ultrasound-guided aspiration) + antibiotics
• ⚠️ ⭐ Inflammatory breast cancer → biopsy + neoadjuvant chemo + mastectomy + radiation

Patient Education

• Self-breast awareness > formal SBE
• Screening: mammography start at 40–50 per guideline (USPSTF biennial 40–74); earlier with risk
• BRCA testing for strong family history → risk-reducing strategies
• Mastitis: complete antibiotics, breastfeed through, prevent recurrence (proper latch, full emptying)
• Don't stop breastfeeding for mastitis (helps resolve)

Emergency Precautions

• ⚠️ Inflammatory breast cancer → urgent biopsy
• ⚠️ Spinal cord compression / pathologic fracture (mets) → emergent eval
• Mastitis → sepsis → admit if systemically ill
• Pregnant + new breast mass → don't delay imaging/biopsy (mammogram + US safe with shielding)

REPRO · QUICK REFERENCE TABLES

Vaginitis at a Glance

Adnexal Mass / Acute Pelvic Pain DDx

3rd-Tri Bleeding — Abruption vs Previa

Hypertensive Disorders of Pregnancy

STI Treatment Cheat Sheet

Postpartum Hemorrhage — 4 T's & Stepwise Tx

Refractory: Bakri balloon → uterine artery embolization → B-Lynch suture → uterine artery ligation → ⭐ hysterectomy (last resort)

Cervical / Endometrial / Ovarian Cancer at a Glance

Amenorrhea Workup Flow

1. ⭐ β-hCG first (always)
2. TSH, prolactin → treat hypothyroidism / prolactinoma
3. FSH:
   - ⭐ High → primary ovarian / gonadal (POI, Turner)
   - ⭐ Low → central (hypothalamic, pituitary)
   - Normal + androgen excess → PCOS
4. Progestin withdrawal test: bleed = anatomy + estrogen intact (anovulatory)
5. Pelvic US ± MRI brain (prolactinoma) ± HSG (Asherman) ± karyotype (Turner)

End of REPRO section — 30 conditions

End of OSCE Master — GI · GU/RENAL · REPRO · ~90 conditions | Generated 2026-06-01
Good luck. Trust your training.