Board Review with The Chiefs October 17, 2016 October 23, 2016

Overview

• Registration • Exam Details • Test Day Details • Study Resources • Study Strategies • Women’s Health • Men’s Health

What to Expect: Exam Registration

• http://www.abim.org/

• Registration Period: December 1, 2016 to April 15, 2017 • Process

• Register on website • Token/ID comes in snail mail • Sign up for dates (6 exam dates in August )

• Cost $1,365 :( • Can re-schedule/cancel on website

What to Expect: The Test

● 240 questions total (4 sections, 60 questions) ● 2 hours per section (2 minutes/question) + 100 minutes break time +

Tutorial/Pledge of Honesty (40 minutes) ● All multiple choice questions ● Clinical Calculator ● Audio and Visual

What to Expect: Exam Day

• Starts at 8 A.M.; end time is up to you (around 2:30 to 5:00 p.m) • Sign-in Process

• 2 forms of non-expired I.D

• Breaks • Lockers

After the test

• Immediately After: Celebrate/Cry • Then, try to forget about it

• Exam results can take up to 3 months, but will usually come out in October

• NOT CURVED • Passing ~ 67% - 70%

Study Resources

• MKSAP 16/17 • MKSAP Board Basics • MKSAP Question Bank • MKSAP Extra Questions • MKSAP Audio • UWorld Question Bank • MedStudy • Review Books (ex: First Aid) • Dasgupta’s Board Review

Study Strategies

When is optimal time to start

studying?

How did you study for this test?

Is there anything you wish you did

differently?

Is there anything that surprised

you about the test?

Any tips for exam day?

Men’s Health

Topics

Androgen Deficiency

Erectile Dysfunction

BPH

Acute Scrotal Pain

Acute Prostatitis

Question 1 A 35-year-old man is evaluated for a 2-month history of low libido. The patient had a

normal puberty. Family history is unremarkable. He drinks two beers per week and

takes no medication.

On physical examination, vital signs are normal; BMI is 23. Visual field examination

findings are normal, as is testicular size. No gynecomastia is noted.

Studies:

Follicle-stimulating hormone: 6 mU/mL (6 units/L)

Luteinizing hormone: 5 mU/mL (5 units/L)

Thyroid-stimulating hormone: 2.5 µU/mL (2.5 mU/L)

Total testosterone (4 PM): 200 ng/dL (7 nmol/L)

Which of the following is the most appropriate next diagnostic test?

A.Measurement of serum ferritin and iron saturation levels

B. Morning serum free testosterone measurement

C.Morning serum total testosterone measurement

D.Testicular ultrasonography

Androgen Deficiency • Symptoms/Signs: Fatigue, decreased strength, poor libido, ED, gynecomastia • Initial Test: 8:00 AM total testosterone levels

• If >350 ng/dL, the hypogonadism is excluded • If <200 ng/dL, then obtain second confirmatory morning level (needs 2 measurements) • If in between these values, then obtain serum free testosterone

• Sex Hormone Binding Globulin • Low in obesity, Type 2 DM, hypothyroidism, acromegaly • High in hyperthyroidism, HIV, hepatitis, patients taking anticonvulsants

• If low, check FSH/LH. If FSH/LH high = Primary Testicular Failure • Ex: Klinefelter, Atrophy 2/2 mumps, AI destruction, hemachromatosis, Previous XRT or chemo

• If low or normal FSH/LH = Secondary hypogonadism • Hyperprolactinemia, hypothalamic/pituitary disorders (ex: Sarcoid, hemochromatosis), Use of

opiates/anabolic steroids, glucocorticoids

• Side effects of androgen replacement therapy: • Worsening sleep apnea, increased hematocrit, BPH, dyslipidemia

Androgen Deficiency

• Side effects of androgen replacement therapy: • Worsening sleep apnea, increased hematocrit, BPH, dyslipidemia

• Therapy contraindicated if patients with prostate nodules, breast or prostate cancer, PSA >4 ng/ML or 3 ng/ML and at risk for prostate cancer, hematocrit >50%, severe lower urinary tract symptoms.

• Do NOT screen for androgen deficiency in asymptomatic men, regardless of age

Question 2

A 72-year-old man comes to your office for a routine health exam. He mentions that

he cannot maintain an erection, and is seeking help. He denies decreased libido or

loss of morning erections. His PMH is significant for diabetes mellitus, peripheral

vascular disease, and CAD with stable angina. He is a former smoker, but quit 25

years ago. He drinks 2-3 alcoholic drinks per night approximately 5 nights/week.

His medication list includes aspirin, atenolol, isosorbide dinitrate, and glipizide.

Patient’s vitals are 98.7F, 138/78, HR 61. BMI is 25. Physical exam, including genital

exam, is normal. You counsel him on lifestyle modifications.

Three months later he returns, with no improvements after he stopped his alcohol

consumption. 8:00 AM Testosterone levels are 394 ng/dL, HgA1C is 6.7.

What is the next step?

A.Prescribe testosterone gel

B. Prescribe sildenafil

C.Offer intraurethral alprostadil

D.Obtain LH and FSH levels

E. Continue lifestyle modifications

Erectile Dysfunction

• Many causes • Vascular • Neurogenic • Endocrine • Trauma/XRT/surgery to perineal/pelvic region • Antihypertensive /antidepressant/anticonvulsant/antiadrogen/NSAID use • EtOH/Tobacco/cocaine/opiate/marijuana

• High-Yield Points: • 1st line therapy: lifestyle modifications (smoking/EtOH cessation, exercise, etc.) • PDE inhibitors (sildenafil, vardenafil or tadalafil)

• Contraindicated in men who receive nitrate therapy and history of nonarteritic anterior ischemic neuropathy (NAIN)

• Intraurethral/intracavernous alprostadil • Intracavernous alprostadil contraindicated in severe coagulopathy/thrombocytopenia

Benign Prostate Hyperplasia

• Symptoms: nocturia, urinary frequency, urgency, incomplete bladder emptying, urinary retention, decreased urinary stream

• Perform DRE, obtain baseline AUA symptom index score • UA to rule out underlying infection • PSA testing is not required for diagnosis, does not need to be followed for

therapy • Lifestyle modifications: reduced fluid intake, timed voiding, limiting caffeine

and EtOH consumption, discontinuing exacerbating medications • Medications: Peripheral alpha-blockers (ex: tamsulosin) and 5-alpha-reductase

inhibitors (ex: finasteride) • Surgical interventions: TURP vs open prostatectomy

Acute Scrotal Pain

• Testicular Torsion • EMERGENCY/RAPID SURGICAL DECOMPRESSION • More common in men younger than 30 y.o • Acute onset pain, nausea/vomiting • Exam: absent cremasteric reflex, elevated/high-riding testis • Doppler US shows diminished flow to affected testicle

• Epididymitis • Pain less acute than torsion usually; may be accompanied by lower urinary tract symptoms • Younger than 35 yo: ceftraixone/doxycycline. • Older men and men who practice anal intercourse: ceftriaxone + Fluoroquinolone • Noninfectious epididymitis: caused by reflux of urine into epididymis, leading to inflammation

• Treatment: scrotal support, ice, NSAIDs

Question 3

A 28-year-old man is evaluated for a 6-month history of pelvic pain, urinary frequency, and painful

ejaculation. He has been treated with antibiotics for urinary tract infections three times in the past 6

months, each time with temporary relief of symptoms but recurrence shortly after completion of

antibiotics.

On physical examination, vital signs are normal. There is minimal suprapubic tenderness with

palpation. The prostate is of normal size with minimal tenderness and no nodules. Urinalysis shows

multiple leukocytes, bacteria, and no erythrocytes.

Which of the following is the most appropriate treatment of this patient?

A. 1-week course of trimethoprim-sulfamethoxazole

B. 1-month course of ciprofloxacin

C.Cognitive Behavioral Therapy

D.Finasteride

Prostatitis

• Symptoms: pain in perineum, testes, penis, or suprapubic area; dysuria, urinary frequency, incomplete bladder emptying

• Initial studies; UA w/micro, urine culture (only needs imaging if you suspect abscess)

• Category I: Acute bacterial prostatitis • 4-6 weeks of bactrim/fluoroquinolone • If requires hospitalization: IV fluoroquinolone +/- gent (also obtain blood cultures)

• Category II: Chronic bacterial prostatitis • 4-6 weeks of fluoroquinolone

• Category III: Chronic abacterial prostatitis/Chronic Pelvic Pain Syndrome (CPPS)

• Trial of antibiotic, but mostly supportive care (ex: NSAIDs, alpha blockers)

• Category IV: No symptoms (detected by biopsy or presence of WBCs in semen samples)