Internal Medicine
Board Review

Educational Objective:

Diagnose patient with painful genital ulcer.

Key Point:

Chancroid and herpes simplex cause painful genital ulcers. Syphilis, lymphogranuloma venereum and granuloma inguinale cause painless genital ulcers.

Explanation:

Of the five sexually transmitted diseases that cause ulceration, only two are painful: herpes simplex and chancroid. Herpes typically manifests vesicles and ulcers that are painful and some lymphadenopathy, while chancroid presents with a painful ulcer and more impressive inguinal lymphadenopathy.. There is some overlap in the presentations of these two diseases and testing is often needed to distinguish them especially during their earlier stages. In patients with chancroid, coinfection with syphilis, HSV and HIV is very common and should be considered.

(The three ulcerative diseases with mostly painless ulcers are syphilis, lymphogranuloma venerum, and granuloma inguinale).

References:

Workowski KA, Bolan GA. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recomm Rep 2015; 64 (No 3): pgs 26-27.

Birnbaumer DM. Sexually Transmitted Diseases. in Rosen's Emergency Medicine. 2014; 98: 1312-1325

Hicks C. Chancroid. UpToDate Online. 2012.

Nobay F, Promes S. Sexually Transmitted Diseases, in in Tintinalli JE et al (eds.) : Emergency Medicine: A Comprehensive Study Guide, ed 7. New York, McGraw-Hill, 2011, Ch 144.

Educational Objective:

Discuss how to diagnose ulcerative colitis.

Key Point:

Patients with chronic diarrhea, hematochezia, abdominal pain, tenesmus, and urgency may have ulcerative colitis. The diagnostic method of choice is colonoscopy with biopsy. Radiologic changes may be suggestive but will not confirm the diagnosis.

Explanation:

This patient’s symptoms are most likely due to ulcerative colitis, the symptoms of which include chronic diarrhea, hematochezia, abdominal pain, tenesmus, and urgency. The most appropriate method for definitively diagnosing inflammatory bowel disease is via colonoscopy with terminal ileum intubation. Biopsies will show chronic inflammatory changes of the colonic mucosa.

Findings on CT may suggest changes consistent with inflammatory bowel disease, but they cannot rule out other causes of colonic inflammatory changes, including infectious or ischemic colitis. Abdominal x-ray and barium enema are not useful for the diagnosis of inflammatory bowel disease.

References:

Ferri FF. Ferri’s Clinical Advisor. 2017.

Walls R, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2017.

Educational Objective:

Recognize risk factors for postcoital UTIs in women.

Key Point:

Spermicide use may predispose for recurrent postcoital UTIs in females.

Explanation:

Spermicide use has been found to be an independent risk factor for recurrent UTI. Other risk factors include multiple sex partners, frequent intercourse and failure to clean the perineum following intercourse.

References:

Hooton TM, Scholes D, Hughes JP, et al. A prospective study of risk factors for symptomatic urinary tract infection in young women. N Engl J Med 1996; 335:468.

Arnold JJ, Hehn LE and Klein DA. Common Questions about Recurrent Urinary Tract Infections in Women. American Family Physician. 2016; 93: 560-569

Educational Objective:

Recognize common pathogens in acute pyelonephritis.

Key Point:

E. Coli causes up to 90% of cases of community-acquired pyelonephritis.

Explanation:

Studies vary widely, especially with regards to different severities of pyelonephritis. It is clear that community-acquired pyelonephritis is caused by E coli in 50 to 90 % of cases. The other bacteria account roughly equally (<5% per organism) for the remaining cases and are most often found in patients treated on multiple occasions for recurrent upper urinary tract infections.

References:

Diagnosis and Management of Acute Pyelonephritis in Adults, American Family Physician Vol 71 No. 5 March 1 2005.

Hooton, T. Acute complicated cystitis and pyelonephritis. Up To Date, January 2017

Educational Objective:

Discuss the differential diagnosis of large masses occupying the abdomen and pelvis.

Key Point:

Mucinous cystadenomas are among the largest ovarian tumors.

Explanation:

Mucinous tumors comprise approximately 15% of all ovarian tumors. They consist of epithelial cells filed with mucin. They are among the largest ovarian neoplasms, often measuring 20-30 cm in diameter. Mucinous tumors are found most commonly in women 30-50 years old. They are usually unilateral. Possible complications of mucinous cystadenoma are perforation and rupture, which can lead to the deposit and growth of mucin-secreting epithelium in the peritoneal cavity called pseudomyxoma peritonei. Serous cystadenomas most commonly occur in 50-60-year-old women and are often bilateral. They rarely would attain the size of the tumor that occurred in this patient. Fibromas are the most common benign solid tumor of the ovary. Meigs' syndrome is the association of an ovarian fibroma, ascites, and hydrothorax. Both the ascites and the hydrothorax resolve after removal of the ovarian tumor. The diameter of a fibroma is important clinically, because the incidence of associated ascites is directly proportional to the size of the tumor. Ascites is present in 10% to 15% of cases of ovarian fibromas greater than 10 cm in diameter.

References:

Coleman RL, et al. Neoplastic disease of the ovary. In: Lentz GM, et al. Comprehensive Gynecology. 6^th ed., 2012:731-772. 

Joshi M. Sonography of adnexal masses. Ultrasound Clinic. 2007;2:133-153. 

Kumar V. Robbins & Cotran Pathologic Basis of Disease. 8th ed., 2009.