I had a bunch of questions that I have been gathering and I was wondering if you could help me with them. Please take your time in answering them as there are many. I just thought it may be more convenient for you if I put all the questions together in one email, rather than emailing you separately every time I had one single question. Please let me know if the latter is more convenient for you, and please take your time in whatever help you may be able to offer me to figure out some of these concepts.
Here they are:
1. In secondary HTN secondary to renal artery stenosis, I wrote down from yoru lecture that you do MRA 1st. Is the best initial test Renal Ultra Sound with Doppler or MRA?
2. For Ulcerative Colitis, you said to do colonoscopy 10 years after diagnosis. Do you have to do it yearly after that? im not sure if i heard that incorrectly or not. So for example if someone gets ulcerative colitis at 25, he gets colonoscopy at 35 then 36, 37, 38 etc.?
3. I always have problems on when to answer cystoscopy vs. IVP vs. Renal U/S vs. VCUG. Mainly the first two though. Can you shed some light on that one?
4. If they give you a question with sinusitis with 4 of the criteria needed and they asked you which is the most appropriate test will you answer X-Ray, CT or Sinus Aspirate for Culture. I have seen all three in different sources.
5. If metronidazole causes mutagenesis as a side effect and is not safe in pregnancy, what do we use to treat bacterial vaginosis in pregnancy?
6. In duodenal atresia – 1st step is X-Ray and it is confirmed with U/S, is this the same with congenital pyloric stenosis or do we do U/S first in congenital pyloric stenosis?
7. Is menopause defined as 3 months of amennorhea or 1 year. Kaplans new books say 3 months thats the only reason I am asking this one
8. In the lecture it said we can use progestin only in patients with a history of DVT but UWORLD says its an absolute contraindication. Any thoughts on this one?
9. I always confuse transesophageal vs. transthoracic ECHO. If we have a case such as dissection, everythign says to do transthoracic first but i dont understand that because transesophageal has a higher specificity.
Thats it for now. I was collecting these questions since the lecture last week, and I thought it may be better t combine it all in one email rather than send 9 separate emails. Thanks for any help, and please take your time in answering because I know I slammed you with a lot. Thanks so much once again. Take care Dr.Red
A. MRA is the preferred screening test of choice now a days in renal artery stenosis due to atherosclerosis. Renal artery doppler can still be used but it has limitations like technical expertise issues and takes longer time to perform. So, where available or if they ask the best test, MRA is your choice
B. Yes, you are right – 10 years after first daignosis and then every year.
C. The answer to this is on a flow chart under Hematuria topic. First make sure this is a persistent or recurrent microscopy ( >3rbc/hpf on 2 or more occassions) hematuria that is not explained by benign causes ( menses, exercise, sex, strenuous physical activity). If patient has symptoms of UTI , treat UTI. Then evaluate for glomerular causes ( any casts ? any proteinuria or increased creatinine ) – if so, obtain renal biopsy to r/o glomerular pathology.
Once you know that hematuria is not from benign causes or if pt has risk factors for bladder CA, everything needs to be done ( upper tract imaging such as CT urogram, urine cytology and cystoscopy). If pt has no risk factors for bladder ca, do upper tract imaging first and then, if it is negative for any lesion, go for urine cytology and cystoscopy.
For upper tract imaging – preferred modality is CT Urogram. CT Urogram has replaced IVP now. Please keep that in mind
In pregnant women, use ultrasound. If you do not find CT Urogram in the choices, you can choose IVP+renal ultrasound for upper tract imaging ( remember IVP is not the most preferred now because it can not really charecterize between types of renal masses which will then necessitate CT any way in case there is a renal mass. CT urogram would be the best as it can look at everything. So, where available, CT urogram is first choice for imaging the upper tract. But if IVP is used it must be combined with renal ultrasound because IVP can not differentiate between cystic vs. solid mass – remember a solid mass goes more in favor of a renal cell cancer).
VCUG is usually used in children to r/o vesico ureteric reflux – indications are recurrent urinary tract infections, suspected bladder trauma or rupture or Stress incontinence in adults.
4) Answer to this Q is on the slides – please check the slides carefully again on criteria based approach. You do not do imaging if there is 4 out of 4 clinical criteria. If there are all 4 clinical criteria –> next step is no further investigation/ just treat
If 2 or 3 criteria –> next step sinus CT. / X-rays are out now
5) Answer to this is on the slides too –> answer is clindamcin in pregnancy
6) In congenital pyloric sten –> start with ultrasound
7) must be more than or equal to 12 months ( pts can have 3 months amenorrhea and can resume again — interesting to see that kaplan can give it wrong. are you sure?)
8.) Estrogen increases the risk of thrombosis not progestin. It is a preferred approach in patients who are at high risk for DVT/PE if they desire a contraceptive pill. It is also ok in patients who had hx of DVT or PE but not at this time . However, using it in active DVT is not recommended by WHO because we do not have enough studies about the risk . Did UW give a patient with active DVT or past DVT? If UW said it should be avoided in those with history of DVT also, then it is wrong.
( a cache from WHO : ” Teenagers with an active or resolved deep vein thrombosis or PE cannot use combination hormonal contraceptives. In the patient with an active DVT or PE, Progestin only methods should be avoided also, but they can be used safely after resolution of the acute event. Family history of DVT or PE does not preclude a teenager from using combined hormonal contraceptive methods unless a clotting disorder also was diagnosed. Patients diagnosed with hereditary thrombogenic mutations should avoid combination hormonal contraceptives, but they can use all types of progestin only methods safely)”
9) TTE is non invasive – if you do it and see a dissection, you need not invade further. However, if it is -ve it does not rule out dissection. So, TEE always is the best test of choice. After TEE, the next best is CT chest with contrast