Exam 1 Flashcards
Rhino sinusitis most often caused by…
VIRUS
Think bacterial rhino sinusitis when..
- Symptoms >10 days w/o improvement
- Severe symptoms (fever >102, facial pain lasting longer than 3 days, purulent nasal drainage)
- Symptoms got better and then worse again
Rhinosinusitis treatment VIRAL
OTC analgesics, intranasal steroids (budesonide, flucticasone (flonase, nasacort, nasonex), decongestants sometimes (no longer than 3 days)
Rhinosinusitis treatment Bacterial
- amoxicillin or amoxicillin-clavulante (Augmentin is better, generally for pts with risk factors for resistance, give if pt looks sick – region with resistance, antibiotic use in past month, hospitalization in last 5 days, immunocompromise, comorbidities, severe infection-temp >102)
- (Penicillin allergic) Doxycycline (not in pregnancy) OR 3rd generation cephalosporin (cefixime, cefpodoxime) with or without clindamycin. OR respiratory fluoroquinolone (last line d/t side effects-prolonged QT, not in pregnancy) (levofloxacin, moxifloxacin)
Pharyngitis/tonsillitis most often caused by….
VIRAL
pharyngitis/tonsillitis when caused by bacteria think…
group A streptococcus
pharyngitis/tonsillitis can also be caused by….
Group C&G Strep, STI, diptheriae, EBV, Cytomegalovirus, Herpes simplex
Center scoring for rapid strep test…
Criteria Absence of cough: +1 Swollen, tender anterior lymph nodes: +1 Temp> 100.4 +1 Age 3-14 +1 15-44 0 45 or older -1
Score
1-2 no further testing or antibiotics
3-4 rapid strep test and treat
5 consider empiric treatment
Other diagnostics to order for pharyngitis/tonsillitis
throat culture (for high risk, DO NOT empirically treat before results are obtained), Monospot (false negative if tested within 7 days of symptom onset)-could do CMP (liver enzyme elevation with mono), CBC (lymphocytosis and atypical lymphocytes), cytomegalovirus will not show up on monospot, EBV & CMV serology testing may be used if repeat monospot is negative
Treatment for tonsillitis from group A Strep
- Penicillin V or Amoxicillin
- (penicillin allergy) Cephalosporins or Macrolide. Mild non-IgE reactions: 2nd or 3rd generation cefuroxime, cefdinir, cefpodoxime. Any possible IgE reaction/severe penicillin reaction: Macrolide- azithromycin, if macrolide resistant strep-clindamycin
Mono treatment
supportive care, no steroids in routine cases, avoid contact sports for a few months d/t spleenic rupture risk
Peritonsillar Abscess S/S
unilateral severe throat, muffled voice, fever, pooling saliva, drooling, neck swelling and pain, soft palate appears to be caving in
Peritonsillar Abscess diagnostics
CT
Peritonsillar Abscess treatment
ENT consult, steroids, Augmentin OR Clindamycin
Epiglottitis
EMERGENCY
Acute Otitis Media most common cause
upper respiratory infections, strep pneumoniae. May also be caused by H. influenza, moraxella cararrhalis, staph aureus
AOM S/S
earache, decreased hearing, dizziness, fever, donut looking bulging TM and yello purulent color (red TM does NOT indicate infection), decreased TM motility, otorrhea
AOM with effusion S/S
Fluid in middle ear without S/S of infection, TM dull non-bulging, decreased motility, ear-fluid lines
AOM Treatment
- Amoxicillin or Augmentin
- (penicillin allergy) Non IgE Cephalosporin (cefdinir, cefpodoxime, cefuroxime, ceftriaxone). Severe IgE allergy: doxycycline (NOT in pregnancy) OR macrolide (azithromycin, clarithromycin)
Upper respiratory infections cause
VIRAL
Otitis Externa cause
bacterial, P. aeruginose is most common, could also be staph epidermidis, staph aureus, fungal
Otitis Externa S/S
itching, plugging of ear, ear pain, ear discharge, pain on manipulation of pinnae, eczema of pinnae, ear canal red, containing discharge and debris
Otitis Externa Treatment
Clean ear canal and outer ear (peroxide with water). Antibiotics: Topical floroquinolones ofloxacin and ciprofloxacin or cipro combined with dextamethasone, Polymyxin B and neomycin (aminoglycoside), Tobramycin and gentamicin (NOT if TM is ruptured-ototoxic)
Labyrinthitis definition
ACUTE inflammation or viral infection of inner ear (labrynth)
Labrynthitis S/S
vertigo and hearing loss in one ear, n/v, ear fullness, tinnitus, nystagmus, upper respiratory symptoms
Labrynthitis Treatment
Antiemetics-zofran, antihistamines-meclizine, benzodiazepines, steroids
Meniere’s Disease definition
CHRONIC condition with recurrent inner ear attacks
Meniere’s S/S
recurrent attacks of hearing loss, tinnitus, vertigo, ear fullness, pallor, sweating, n/v
Dental Infections
most often gram + bacterial
treat with Pencillin G, amoxicillin, Augmentin, Clindamycin
Sialothiasis s/s
unilateral pain and swelling around involved gland, aggravated by eating, compression of salivary gland without saliva output, stones are rock hard and small
Sialthoiasis treatment
Increased fluid intake, tart hard candy, stop anticholinergic medications, NSAIDs
Parotitis cause
most commonly poly microbial, Staph aureus, strep pneumonia, strep viridians, h. influenzae
Parotitis S/S
pt looks sick, fever, unilateral swelling (if bilateral swelling think mumps), warmth, redness, over cheek, purulent drainage from stensons ducts
Parotitis treatment
Send to ED for IV antibiotics-recommended, Oral antibiotics- Clindamycin with ciprofloxacin OR amoxicillin-clavulanate with or without linezolid
Mumps s/s
parotid swelling usually bilateral lasting >2 days with no other causes, may have fever, neck ache, and malaise
TB S/S
stuffy nose, runny nose, post nasal drip, sneezing, productive cough, purulent yellow sputum, hemoptysis: coughing up blood or blood tinged mucous
PPD induration results
Induration >5mm + in: HIV infected pts, persons w/fibrotic changes on CXR consistent with prior TB, organ transplants, immunosuppressed (taking the equivalent of >15mg/day of prednisone for 1 month or longer, taking TNF-alpha antagonists). Induration > 10mm + in: recent immigrants <5yrs, IVDU, residents and employees of high risk settings, mycobacteriology lab personnel, persons with clinical conditions that put them at risk, children <4. Induration >15mm or more + in anyone
TB management
Preferred regimen for treating adults consists of 2 intensive phases of 3 months of isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and ethambutol (EMB) followed by a continuation phase of 4 months of INH and RIF. Avoid once weekly regimen of INH 900/RPT 600
Lung cancer, most common
NSCLCs are about 85% of malignancies, primary types (in order of prevalence) are adenocarcinoma, squamous-cell carcinoma, large cell carcinomas.
SCLCs are 13% of malignancies. Smoking is most related to SCLCs and squamous cell carcinoma.
Lung cancer S/S
cough, weight loss, dyspnea, wheezing, chest pain, pleural effusions, absent or diminished breath sounds, diminished resonance on percussion, decreased tactile fremitus, clubbing, anemia
Lung cancer diagnostics
CBC: anemia, leukocytosis, thrombocytosis, Hct: <40 males, < 35 females, Calcium: elevated, Baseline PFT’s, CXR, CT with contrast, Flexible fiberoptic bronchoscopy, Transthoracic percutaneous fine needle aspiration biopsy
Acute bronchitis cause
Most often caused by VIRUS, rarely bacteria, usually fall and winter.
Influenza A & B, parainfluenza, and RSV most common, less common coronavirus, adenovirus, rhinovirus, and metapneumovirus
H. influenza and strep pneumoniae
Chronic bronchitis should be considered when…
Chronic bronchitis should be considered only for pts who have had cough and sputum production on most days of the month for at least 3 months of the year during 2 consecutive years.
Acute bronchitis treatment
Smoking cessation. Humidification, rest, fluids
Bronchodilators x 7 days, Beta-adrenergic bronchodilators could be used in patients with acute bronchitis and wheezing associated with cough
Cough suppressants (dextromethorphan cough preparation every 4 hours, benzonatate, codeine, or hydrocodone if cough is severe)
Oral steroids x 5 days
Acute bronchitis treatment for influenza
Influenza is most common pathogen in acute bronchitis therefore if influenza is suspected or confirmed, antivirals medications such as oseltamivir, zanamivir may be effective within 48 hours of illness onset
Acute bronchitis treatment if pertussis is suspected
Antibiotic therapy if pertussis is suspected, pertussis is gram-negative bacterium. Suspicion of pertussis should be limited to individuals with a high probability of exposure, such as in community outbreaks. Pts w/ confirmed or probable pertussis should receive antibiotic therapy and be isolated for 5 days from the start of treatment. Macrolides are first line-azithromycin, erythromycin, clarithromycin. Second line therapy is trimethoprim sulfamethoxazole (Bactrim). Erythromycin has been the drug of choice. Azithromycin can cause QT prolongation and shouldn’t be used in those with CVD.
Asthma S/S
symptoms are variable and intermittent, wheezing, dyspnea, coughing, prolonged expiration due to air trapping (they won’t sound like they are exhaling, you won’t hear anything, you’ll hear a big breath in, a short breath out and nothing else), may be worse at night and cause pt to awaken
Asthma Diagnosis
FEV1/FVC <80% AND reversal of obstruction after bronchodilator administration
FVC
Forced Vital Capacity (FVC) shows the amount of air a person can forcefully and quickly exhale after taking a deep breath
FEV1
Forced expiratory volume is measured during the forced vital capacity test, the forced expiratory volume (FEV1) in one second measurement shows the amount of air a person can fully exhale in one second of the FVC test.
Intermittent asthma classification..
Symptoms: <2 days/wk
Nighttime awakenings: <2/month
SABA use for symptoms: <2 days/wk
Interference with normal activity: none
Lung function: Normal FEV1, FEV1 >80%, FEV1/FVC normal
Exacerbations requiring oral systemic steroids: 0-1/yr
Recommended step for initiating treatment: Step 1
Mild Persistent asthma classification
Symptoms: >2 days/wk but not daily
Nighttime awakenings: 3-4/month
SABA use for symptoms: >2 days/wk but not daily, and not more than 1/day
Interference with normal activity: minor limitation
Lung function: FEV1 >80%, FEV1/FVC normal
Exacerbations requiring oral systemic steroids:>2/yr
Recommended step for initiating treatment: Step 2
Moderate Persistent Asthma classification…
Symptoms: daily
Nighttime awakenings: >1/wk but not nightly
SABA use for symptoms: daily
Interference with normal activity: some limitation
Lung function: FEV1 >60%, FEV1/FVC reduced 5%
Exacerbations requiring oral systemic steroids: >2/yr
Recommended step for initiating treatment: Step 3 & consider course of oral steroids
Severe Persistent Asthma classification
Symptoms: throughout the day
Nighttime awakenings: often nightly
SABA use for symptoms: several time a day
Interference with normal activity: extremely limited
Lung function: FEV1 <60%, FEV1/FVC reduced > 5%
Exacerbations requiring oral systemic steroids: >2/yr
Recommended step for initiating treatment: Step 4 or 5 & consider course of oral steroids
Asthma treatment step 1
SABA PRN (albuterol, levalbuterol, peributerol)
Asthma treatment step 2
Preferred: Low-dose ICS (beclomethasone, budesonide, flunisolide, fluticasone, mometasone, triamcinolone)
Alternative: Cromolyn,
Leukotriene receptor agonist- LTRA (montelukast, zafirlukast), Theophylline (class: methylxanthines)
SABA PRN
Asthma treatment step 3
Preferred: Low-dose ICS + LABA (salmeterol, formoterol) or Medium-dose ICS
Alternative: Low-dose ICS + LTRA, theophylline, or zileuton
SABA PRN
Asthma treatment step 4
Preferred: Medium-dose ICS + LABA
Alternative: Medium-dose ICS + LTRA, theophylline, or zileuton
SABA PRN
Asthma treatment step 5
Preferred: High-dose ICS + LABA AND consider omalizumab for allergy pts
SABA PRN
Asthma treatment step 6
Preferred: High-dose ICS + LABA + oral steroid (prednisone) AND consider omalizumab for allergy pts
SABA PRN
Short Acting Beta Agonists (SABA)
albuterol, levalbuterol
Quick relief, rescue med
bronchodilators , relax smooth muscle
Side effects: tachycardia, HTN, HA, dizziness, tremors, hyperactivity, tremors, insomnia, nausea, muscle cramps
When they don’t promptly resolve symptoms of bronchoconstriction, systemic corticoids are indicated
Systemic corticosteroids
prednisone
Used short term for asthma exacerbations not controlled by SABA’s, do NOT taper dose
Inhaled corticosteroids (ICS)
beclomethasone, budesonide, flunisolide, fluticasone, mometasone, triamcinolone
Most effective long term asthma control medication
Recommended for every pt with persistent asthma
Side effects: hoarseness, oral thrush, prevented with good oral hygiene and spacers
Long Acting beta agonsits (LABA)
salmeterol, formoterol
Never to be used for quick relief, used in conjunction with ICS for long term control and prevention in moderate or severe persistent asthma, of all therapies, LABAs are preferred to combine with ICS
Side effects: watch using them in pts with heart issues (rare sudden cardiac death)
Combination ICSs and LABAs: fluticasone/salmeterol (Advair), fluticasone/vilanterol (BreoEllipta), budesonide/formoterol (Symbicort)
Cromolyn
Good for pts w/allergies
Used in prophylaxis of mild to moderate asthma, useful when exposure to identifiable trigger triggers symptoms and may be useful when a known trigger cannot be avoided, safe
Leukotriene receptor agonists (LTRA)
montelukast (singulair), pranlukast, zafirlukast, zileuton
Increase persistent dilation to reduce symptoms, reduce medication use, and decrease the need for quick relief therapy
Side effects: increase prothrombin times, elevate liver enzymes and will increase levels of theophylline
Methylxanthines
theophylline, aminophylline
Bronchodilators that also have inotropic effect on the diaphragm
narrow therapeutic index, many drugs affect the metabolism and careful monitoring of serum levels in needed
Toxicity may cause HA, N/V/D, arrhythmias, seizures
Immunomodulators
omalizumab
Monoclonal antibody that prevents the binding of IgE to mast cells, it is used as adjunctive therapy in those 12 and older who have moderate to severe persistent asthma caused by hypersensitivity reactions
High costs
Pts must be monitored for anaphylaxis after administration
COPD S/S
tachypnea, resp. Distress, cyanosis, (increased AP diameter) barrel chest, distant heart sounds, JVD, dyspnea upon exertion, gough, sputum, purulent sputum, pursed lip breathing, resonance on chest percussion
Lung disease causes hypertrophy of R ventricle resulting in cor pulmonale, which may reveal neck vein distention, peripheral edema, hepatomegaly from elevated R arterial pressure, pulmonary hypertension and R ventricle distention
S/S indicating deterioration of COPD
Increased dyspnea, increased sputum, increased purulence
COPD diagnostics
Perform spirometry if any s/s present > 40yo
Gold standard of diagnosis
FEV1/FVC less than 0.70 is considered diagnostic of airflow limitation (COPD)
GOLD 1: Mild COPD
FEVI/FVC <70%, FEV1 >80% predicted
GOLD 2: Mild COPD
FEVI/FVC <70%, FEV1 50%- <80% predicted
GOLD 3: Mild COPD
FEVI/FVC <70%, FEV1 30%- <50% predicted
GOLD 4: Mild COPD
FEVI/FVC <70%, FEV1 < 30% predicted
Mild COPD treatment
SABA (albuterol, levalbuterol) PRN first choice for pts w/intermittent symptoms.
Anticholinergics (Ipratropium bromide-Atrovent, Tiotropium-Spiriva, Aclidinium-Pressair) are first line for pts w/daily symptoms
Spiriva dosed 6x daily (short acting), others are once a day (long acting)
Group A (UptoDate) Recommendation SABA or SABA + anticholinergic. Alternative LABA
Moderate COPD treatment
SABA PRN, anticholinergic, or LABA
LABA (salmeterol, formoterol) may be helpful in pts w/nocturnal symptoms
Combination meds of anticholinergic and SABA have been shown to be superior than any drug alone,
Ipratropium + albuterol or anticholinergic umeclidinium + LABA vilanterol is combination med Anoro Ellipta
Methylxanthine (theophylline) therapy is 3rd line
Watch for toxicity with other meds (H2 blockers and fluoroquinolones)
Group B (more symptomatic, less risk of exacerbations) First choice: Long acting anticholinergic, or LABA, SABA PRN. For persistent symptoms: Long acting anticholinergic + LABA combination
Group C (less symptomatic, more risk of exacerbations) First choice: Long acting anticholinergic, SABA PRN. For exacerbations: Long acting anticholinergic + LABA (less preferred) OR LABA + ICS
Severe COPD treatment
Same as Moderate+ ICS
ICS (budesonide, ciclesonide, celomethaone)
Phosphodiesterase inhibitors (roflumilast) can be used for pts with severe COPD to reduce exacerbations Reduces inflammation Not for monotherapy and contraindicated w/liver dysfunction
Group D (more symptomatic, high risk) First choice: LABA + long acting anticholinergic combination. LABA plus ICS may be preferred if symptoms of asthma/COPD overlap. SABA PRN. Long acting anticholinergic alone if LABA contraindicated. For further exacerbations: Long acting anticholinergic + LABA +ICS. If exacerbations continue may add roflumilast (if FEV1 <50%), OR theophylline, stop ICS
Acute Exacerbation of COPD cause
Bacteria: H. influenzae (most common), S. pneumoniae, M. Catarrhalis
Advanced patients: pseudomonas
Degree of COPD exacerbation criteria and grading
Major criteria (Increased sputum volume, Increased sputum purulence, Worsening baseline dyspnea)
Additional criteria: (Upper resp infection in the last 5 days, Fever of unknown cause, Increase in wheezing and cough, Increase in RR and HR 20% above baseline
Nonspecific S&S (fatigue, depression, insomnia))
Mild-1 major criterion + 1 or more additional criteria
Moderate-2 major criteria
Severe-all 3 major criteria
S/S of COPD acute exacerbation
Hypoxia, tachypnea, shallow, pursed-lip breathing, diminished breath sounds, prolonged expiratory phase, rhonchi, wheezes, barrel-shaped chest, cyanosis, clubbing
Diagnostics of COPD acute exacerbation
CXR, Procalcitonin will show whether it is pneumonia, COPD exacerbation, bacterial infection, Sputum culture to know what you are treating, CT, Spirometry/PFT’s
Treatment of COPD acute exacerbation
Supportive: oxygen, hydration, nutrition
Corticosteroids
SABA or Anticholinergics.
Choice of antibiotic depends on symptom severity
First line: Doxycycline (not in pregnancy), macrolides (azithromycin, clarithromycin, prolong QTc), Trimethoprim-sulfamethoxazole (Bactrim, know kidney function)
Second line & outpts: Azithromycin, cefpodoxime, cefprozil, cefuroxime, fluoroquinolones (levofloxacin, moxifloxacin, not good for elderly, tendon rupture risk)
Community aquired pneumonia causes
Strep pneumoniae, H. influenza, moraxella catarrhalis, mycoplasma & chlamydophila (atypical), viruses
Community aquired pneumonia S/S
fever, chills, cough, purulent sputum (possibly), pleuritic chest pain. Elderly may present with confusion.
CAP diagnostics
CXR: PA and lateral
Labs: CBC w/diff, d-dimer, culture, ABG’s, PCT, Oximetry
CAP treatment previously healthy pts
Previously healthy with no recent ATB (within 3 months) and no comorbidities, should be afebrile 48-72h & no other instability
Azithromycin, Clarithromycin, Doxycycline
CAP treatment, co-morbidity
Pts w/ co-morbidities (COPD, DM, RF, CHF, use of ATB in 3 mnths) (smokers are more common to have atypical bacteria)
Respiratory quinolones: moxifloxacin (Avelox), gemifloxacin, levofloxacin (Levaquin), or a beta lactam (amoxicillin, amoxicillin-clavulanate (Augmentin), cefpodoxime, cefuroxime, ceftriaxone) PLUS either a macrolide (azithromycin, clarithromycin, erythromycin) OR doxycycline
CAP treatment for influenza
Oseltamivir or zanamivir is recommended
CURB 65 Index for CAP
1 point for each positive symptom
1-2 points total: can treat outpt
3 or more points total: consider hospitalization
4-5 consider ICU
Confusion: 1 Urea >7mmol/l:1 Resp rate > 30:1 SBP <90:1 DPB<60:1 Age >65: 1
Prostatitis S/S
fever, chills, malaise, myalgia, hesitancy, frequency, urgency, notcuria, dysuria, incomplete bladder emptying, UTI, scrotal pain
Prostatitis causes
nonbacterial- most common (irritation, nerve disorders, viruses, bicycle riding, , bacterial- gram negative organisms (E. coli, proteus, klebsiella, Enterobacter and Serratia are most common) gram + (staph Aureus, strep, enterococci, gonorrhea, chlamydia)
Prostatitis Diagnostics
DRE- prostate enlarged, tender, indurated. Urinalysis, culture, CBC (left shift, increased leukocytes), STI screen
Prostatitis Treatment
sitz baths, analgesics, antipyretics, stool softeners, outpt meds: trimethoprim-sulfamethoxazole (Bactrim) and fluoroquinolones (levofloxacin, ciprofloxacin) 6 weeks
hospitalization-IV fluoroquinolones
Prostate Cancer S/S
hesitancy, urgency, nocturia, frequency, and hematuria, although usually asymptomatic in early stages. Symptoms will increase in intensity during a 1-2 month period (whereas BPH has a slow, gradual progression
Prostate Cancer diagnostics
DRE- prostate firm, nodule, induration, stony, asymmetric
PSA screening
not recommended <40, for men 55-69 screening every 2 yrs is based on individual preference, none if >70,
PSA results
<4 normal, 4-10 early cancer or other benign conditions, >10 cancer
high PSA can be triggered by prostatitis, prostate exam, or intercourse, get baseline PSA if going on meds that shrink the prostate
Prostate Cancer Treatment
Low risk – active surveillance, radiation therapy or radical prostatectomy
Med risk– active surveillance if low life expectancy, radiation therapy or radical prostatectomy
High risk- radiation therapy, radical prostatectomy with extended lymph node dissection
BPH cause
obstruction -static tissue build up blocks flow
Dynamic constriction-increase in muscle tone through adrenergic stimulation blocks flow
Tricyclic antidepressants, antihistamines can lead to urinary retention
BPH S/S
Episodic and be be present over many years with gradual increase in intensity
Symptoms are usually either obstructive or irritative, obstructive: urinary hesitancy, decreased caliber and force of the stream, post void dribbling. Irritative symptoms: frequency, urgency, nocturia which occur as a result of decreased bladder capacity and instability or infection. On occasion, hematuria may accompany BPH
BPH diagnosis
DRE- uniform focal prostate enlargement, non-tender, rubbery, smooth, UA to exclude UTI
BPH treatment Alpha-1 agonists
Silodosin, Terazosin, Doxazosin, Tamsulosin (flomax), Alfuzosin
main treatment, work by relaxing smooth muscle in the bladder neck, prostate capsule, and urethra
Initiate at bedtime to avoid postural hypotension
BPH treatment 5-alpha reductase inhibitors
Finasteride, dutasteride
work by shrinking the prostatic glandular hyperplasia but may take up to 6-12 months to notice improved symptoms
can be used for men with mild to moderate BPH symptoms who also have ED
Epididymitis cause
Most often infectious STI, or UTI, may be caused by trauma or autoimmune disease
Epididymitis S/S
Gradual onset of scrotal pain, sometimes radiating to the groin over 1-2 days. May have urethral discharge symptoms of UTI. Entire scrotum becomes red and swollen, the testes become indistinguishable from the epididymis; scrotal wall becomes thick and indurated. Epididymis is tender to palpation, elevation of the testes/epididymis reduces discomfort (Prehn sign), cremasteric reflex is present (if absent think testicular torsion). May have low grade fever, chills, and heavy sensation
Epididymitis diagnostics
+ phrens sign (elevation of testicles reduces pain), + cremasteric reflex, UA/ culture, NAAT for STI’s
Epididymitis supportive treatment
bed rest, activity restiriction, scrotal elevation, stool softeners, ice pack
Epididymitis treatment sexually active men <35
First line doxycycline for 10 days (chlamydia coverage), plus ceftriaxone IM (gonorrhea coverage)
Epididymitis treatment men >35, no suspected STI
(fluoroquinolones) levofloxacin, ofloxacin, ciprofloxacin
Testicular Torsion S/S
acute onset of pain, often during period of inactivity, nausea and vomiting are common. Pain is sudden and extremely painful, may wake patient from sleep, may have fever and abdominal pain. A testicle that rides high in the scrotum, testicle is swollen and very tender, scrotum is enlarged, red, edematous, and painful, cremasteric reflex is absent, pain is not relieved with scrotum elevation (neg prehns sign).
Testicular torsion diagnostics
doppler US by demonstrating lack of blood flow, - phrens signs (elevation of testicles does not relieve pain), - cremasteric reflex
testicular torsion treatment
SURGICAL CONSULTATION!
Hydrocele causes
Trauma, tumor, epididymitis, radiation, infection, VPS, or peritoneal dialysis
Hydrocele S/S
Swelling in scrotum or inguinal canal, painless, heaviness in the scrotum, may have pain radiating to lower back
Hydrocele diagnostics
Transillumination
Fluid appears pink, yellow, or red
Scrotal swelling that may fluctuate in size with position changes
Inguinoscrotal ultrasound
Varicocele definition
Abnormal venous dilation above the testes, engorgement of internal spermatic vein, may cause testicular atrophy and decreased sperm count/infertility
Varicocele S/S and grading
Pain and engorgement of testes, sensation like a bag of worms
Upright position: engorged veins may extend up into the external inguinal ring, valsalva maneuver while laying will cause increased venous dilation
Grade 1: palpable only during valsalva
Grade 2: palpable when standing
Grade 3: visual inspection and light palpation
Varicocele diagnostics and treatment
scrotal ultrasound
supportive care, scrotal support, surgeon referall
Gonorrhea S/S & Treatment
purulent urethral discharge, dyspuria, pruritus, anorectal burning, skin lesions, females frequently asymptomatic, abnormal uterine bleeding, cervical motion tenderness, vaginal discharge
Also treat chlamydia
Ceftriaxone IM single dose (gonorrhea) PLUS Azithromycin or doxycycline (chlamydia)
Chlamydia S/S & Treatment
often asymptomatic, male: dysuria, penile discharge, itching. Female: abnormal discharge yellow or green, bleeding, dysuria, cervical friability or edema
Azithromycin or doxycycline
Trichomonas S/S & treatment
men: asymptomatic, clear or mucopurulent discharge, dysuria, itching after intercourse. Women: asymptomatic, purulent, malodorous, thin discharge, burning, putuitis, dysuria, frequency, lower abdominal pain, post coital bleeding, erythema of vulva and vaginal mucosa, green-yellow frothy malodorous discharge
metronidazole
Bacterial vaginosis S/S & treatment
vaginal discharge, off white, thin, and odor “fishy smell”
metronidazole
Syphilis S/S & treatment
early infection: chancre painless heal over 3-6 wks, secondary infection: fever, HA, malaise, sore throat, weight loss, myalgias, adenopathy of cervical, axillary, inguinal, femoral, and epitrochlear nodes
Penicillin G or doxycycline (if penicillin allergic)
Herpes S/S & treatment
painful genital ulcers, dysuria, fever, lymphadenopathy, headache
Acyclovir, famciclovir, valacyclovir
Renal Calculi causes
dehydration, Diets high in salt, animal proteins, purines (Seafood, organ meats), oxalates (chocolate, colas), calcium, and phosphates, osteoporosis treatment
Renal Calculi S/S
depend on size and location, renal colic (pain), nausea, vomiting, hematuria, fever, chills, dysuria, severe flank pain, abdominal or groin pain, restlessness. Exam findings usually reveal fever, tachycardia, diaphoresis, pale, cool/clammy skin, CVA tenderness
Renal Calculi diagnostics
Non-contrast helical CT is best Renal and bladder US Dipstick/UA, hematuria Urine culture CBC w/diff CMP (looking for gout, hyperparathyroidism) Intravenous pyelogram (IVP)
Renal Calculi Treatment
hydration, pain meds, let it pass
Medication expulsion therapy: calcium channel blockers and alpha blockers relax smooth muscle (nifedipine and Tamsulosin)
procedures for large stonees
Uncomplicated UTI
UTI does not cross bladder, uncircumcised men and men that engage in anal sex
Complicated UTI
(pyelonephritis) UTI extends past bladder, fever >99.9, chills, rigors, malaise, flank pain, CVA tenderness, pelvic or perineal pain in men
4 clinical indicators of UTI
cloudy, malodorous urine, dysuria, nocturia
elderly women will not experience classic symptoms but will have delirium and weakness
UTI diagnostics
may need pelvic/reactal exam, UA/dipstick (leukocytes, nitrites, hematuria, bacteria), microscopic exam, culture
Uncomplicated UTI 1st line Treatment
- Nitrofurantoin-Macrobid (first line in young healthy females, don’t use if GFR <60 so don’t use for older women, bacteriostatic, slows bacteria but doesn’t kill it)
- Trimethoprim-sulfamethoxazole-Bactrim (treat UTI’s that can damage kidneys
- Fosfomycin
Uncomplicated UTI 2nd line Treatment
Beta lactams (amoxicillin-clavulanate, cefpodoxime, cefdinir, cefadroxil) If beta lactams cannot be used, fluoroquinolones (ciprofloxacin, levofloxacin)
Uncomplicated, in the past 3 months if the pt has had a MDR gram - urinary infection, inpt hospital stay or ECF, use of antibiotic (fluoroquinolone, bactrim, or broad spectrum antibiotic), or travel to India, Israel, Spain, Mexico
Nitrofurantoin (Macrobid) or Fosfomycin
Complicated (pyelonephritis) with contraindications to fluoroquinolones (drug interactions)
Ceftriaxone (preferred), ertapenem, Gentamicin, tobramycin
Followed by non-floroquinolones, Trimethoprim-sulfamethoxazole -Bactrim, amoxicillin-clavulanate (Augmentin), cefpodoxime, cefdinir, cefadroxil
Complicated (pyelonephritis) with community prevalence of E coli resistance <10%
fluoroquinolones (ciprofloxacin, levofloxacin)
Complicated (pyelonephritis with community prevalence of E coli resistance >10%
Ceftriaxone, ertapenem, gentamicin, tobramycin
Followed by a fluoroquinolone (ciprofloxacin, levofloxacin)
Complicated (pyelonephritis) with risk factors for an MDR gram - infection (history of the following in past 3 months: MDR gram - urinary infection, inpt hospital/ecf stay, use of antibiotic (fluoroquinolone, bactrim, or broad spectrum antibiotic), travel to india, israel, spain, mexico)
Ertapenem IM
Followed by a fluoroquinolone (ciprofloxacin, levofloxacin)
Complicated (pyelonephritis) with risk factors for an MDR gram - infection (history of the following in past 3 months: MDR gram - urinary infection, inpt hospital/ecf stay, use of antibiotic (fluoroquinolone, bactrim, or broad spectrum antibiotic), travel to india, israel, spain, mexico) AND contraindication to fluoroquinolone or high risk for fluoroquinolone resistance (use of fluoroquinolone in past 3 months)
Ertapenem IM
And tailor other antimicrobial based on culture
UTI treatment in pregnant women
amoxicillin, amoxicillin-clavulanate (Augmentin), 3rd generation cephalosporins (cefuroxime, cephalexin), nitrofurantoin (Macrobid-only in 2nd trimester)
Fluoroquinolones
“floxacin” ciprofloxacin, levofloxacin, moxifloxacin, Gemifloxacin
Breaks bacteria DNA strands and inhibits DNA repair
cipro-kills below the belt
levofloxacin- idiots antibiotic will kill anything
Respiratory fluoroquinolones: moxifloxacin, Gemifloxacin
QT prolongation, tendon rupture risk, hypoglycemia, photosensitivity, hepatotoxicity, NOT safe in pregnancy
Tetracyclines
“cycline” doxycycline, minocycline, tetracycline
Inhibit bacterial protein synthesis
used for gram negative infections, can treat atypicals, gonorrhea, can be used for MRSA in pts who can’t take sulfonamides
Photosensitivity, N/V, Do NOT use in pregnancy or children (tooth discoloration, bone development)
Macrolides
“mycin” erythromycin, azithromycin, clarithromycin, fosfomycin
Inhibit RNA protein synthesis
Good activity against atypicals
Chemically big, have potential for interaction with other drugs
azithromycin (z-pack)
D/N/V, QT prolongation, safe in pregnancy
Sulfonamides
Sulfamethoxazole-trimethoprim (Bactrim), Sulfamethoxazole-trimethoprim (Septra)
inhibit folate synthesis
broad gram + and - coverage
stevens-johnsons syndrome, sulfa allergy, can cause renal impairment, can increase warfarin levels, contraindicated in late pregnancy and infants
Beta-Lactams
All penicillin’s and all cephalosporins
Antibiotics that work against beta-lactamase producing bacteria
Amoxicillin-clavulanate (Augmentin), amoxicillin-sulbactam (unasyn), pipercillin/tazobactam (Zosyn), 3rd generation cephalosporins (cefdinir, cefixime, cefoperazone, cefotaxime, cefpodoxime, ceftazidime, ceftibuten, ceftizoxime, ceftriaxone
Penicillin’s
“cillin” amoxicillin, ampicillin,
Inhibit cell wall synthesis, kills gram +, can work on some gram -
rash, N/V/D, anaphylaxis, sz,
Cephalosporins
“cef”
inhibit cell wall synthesis
start at more gram + coverage and goes to more gram - coverage
D, HA, rash
1st generation cephalosporins
cefadroxil (duracef), cefazolin, cephalexin (Keflex)
most effective against gram +, good for skin infections, staph
higher risk of penicillin reaction
2nd generation cephalosporins
cefaclor, cefotetan (caftan), cefoxtin, cefuroxime
less gram + activity, but more gram - activity
3rd generation cephalosporins
cefixime, cefdinir (omnicef), cefpodoxime, ceftriaxone (Rocephin) , cefotaxime, ceftazidime
good coverage against beta-lactamase producing bugs and gram -, not as good gram + (except for ceftriaxone and cefdinir)
Anticholinergics
“tropium” ipratropium, tiotropium
used for COPD, prevent bronchoconstriction
flushing, cognitive changes, increase IOP (watch for glaucoma), urinary retention, hot, dry, constipation
