NMS Q&A Family Medicine

110 NMS Q&A Family MedicineExamination Answers1. The answer is D. Metoclopramide, the one choice thatwould not be appropriate in the treatment of stressincontinence. The 1 adrenergic agonists pseudoephedrineand phenylpropanolamine stimulate the bladderneck and proximal urethra, hence sphincter tone. Thetricyclics such as imipramine have both 1 adrenergicagonist effects and anticholinergic activity, the latterreducing bladder tone. Clean intermittent catheterizationhas a place with both stress incontinence and hypotonicbladder.2. The answer is D. A patient with fever, pyuria, and suggestionsof systemic illness or symptoms more specific forupper tract involvement has a 98% chance of havingpyelonephritis. Chances are quite good, but not certain,that upon examination she will manifest definite costovertebralangle tenderness. Cystitis usually presents withsymptoms of frequency and dysuria. Urolithiasis manifestscolicky lateralizing pain, at least when the stone ismoving. Bladder cancer and hypernephroma (renal cellcarcinoma) are notorious for painless hematuria with noparticular pyuria. Trigonitis is a syndrome encountered inmature females consisting of irritative bladder symptomsthat are out of proportion to clinical findings.3. The answer is A. E . coli is the cause of 88% of cases ofuncomplicated pyelonephritis (e.g., cases in nonelderlyindividuals, nonrecurrent cases, cases with the absence ofdiabetes mellitus, and cases without known anatomicalbases for recurrence, without indwelling catheters, andwithout clinical sepsis). Diabetics tend to have UTIscaused by Klebsiella, Enterobacter, Clostridium, or Candidaorganisms. Other complicated cases of pyelonephritisalso involve Pseudomonas but usually not Candidaorganisms. Immunosuppressed patients tend to developsubclinical pyelonephritis caused by nonenteric, aerobicGram-negative rods and Candida organisms.4. The answer is B. With the suspicion of pyelonephritis,treatment of this serious infection comes first. Beforeantibacterial therapy can be started, a culture and sensitivitymust be obtained to avoid wasting precious time intreating with ineffective anti-infectious agents while riskingsterilizing the urine and blood for culture and sensitivityafter the fact. The fluoroquinolones are a good firstchoice while one is awaiting the culture results; sulfamethoxazole/trimethoprim,being bacteriostatic as opposedto bacteriocidal, would be a poor choice with suspectedpyelonephritis. The diagnostic studies mentioned areimportant but should take place after therapy is underwayand the infection is abating.5. The answer is A. Costovertebral angle tenderness in anuncomplicated case is not an indication for hospitalizationwithin itself. However, each of the other factorsmentioned are such indications. Others are outpatienttreatment failure, sepsis or suspected sepsis, age 60 years,inadequate access to follow-up care, and uncertainty ofdiagnosis.6. The answer is E. Pregnant women who are between12 and 16 weeks gestation, if tested by urine culture(rather than urinalysis), will have significantly fewer UTIs,as well as a lower risk of low birth weight babies and ofpreterm delivery. In no other category, culture of asymptomaticpatients is supported by evidence at this time.7. The answer is E. Vaginal lactobacillus has been replacedwith rectal coliform bacteria. The coliform bacteria nowin the vagina and introitus can easily ascend through theurethra into the bladder. The absence of lactobacillusraises vaginal pH and creates a more favorable vaginaland periurethral environment for these bacteria. Onlyabout 1% of adult women (nongeriatric) with recurrentcystitis have an identifiable anatomic abnormality. Theconditions that predispose a woman to this developmentinclude sexual activity without voiding both before andafterward; entrapping clothing (more often resulting inCandida infection but leading also to coliform vaginalinoculation); wiping from anus forward after voidinginstead of from the vaginal opening backward; voidingwithout adequately spreading the knees (caused by inadequatelowering of tight underwear); and occasionallychanging hormone status, as in inauguration of contraceptivemedication. Oral contraceptives, for example,increase in vaginal secretions, providing a culture mediumfor bacteria and contamination of clothing near the analorifice. All people with recurrent UTIs should take inmore water and other fluids than otherwise inclined.8. The answer is D, magnesium ammonium phosphatefrom urease-producing organisms. These are called struvitestones, and insofar as they become molded by thecalyceal collecting system, they are often referred to as“staghorn” calculi.9. The answer is C. P . mirabilis is associated with struvitestone formation, as are Pseudomonas, Providencia, and,less commonly, Klebsiella, Staphylococcus, and Mycoplasmaorganisms. These organisms commonly produce aurease, which causes the hydrolysis of urea to ammoniaand carbon dioxide. The result is an alkaline urine, whichis more conducive to struvite stone formation.