meningitis, heat stroke, Bell's, PID Flashcards
order of tests/tx if suspect bacterial meningitis in altered 30 yo
blood culture, steroids, abx, head CT, LP
neuroimaging indicated due to AMS, but do not delay abx for imaging, and steroids should be given before abx
Heat stroke is distinguished from other heat illnesses by ?
loss of thermoregulation, tissue damage, and multiorgan failure. Classically, these patients present with hyperpyrexia and CNS dysfunction
The treatment of heat stroke consists of ?
stabilizing the ABCs, rapid cooling, replacing fluid and electrolyte losses, and treating any complications (eg, shivering, seizures, rhabdomyolysis)
heat exhaustion vs heat stroke
heat stroke: Severe dehydration with core temperature greater than 40°C + CNS disturbances (exhaustion 38-40 (100-104))
heat stroke differential
alcohol withdrawal; salicylate toxicity; PCP, cocaine, and amphetamine toxicity; tetanus; sepsis; NMS; encephalitis, meningitis, and brain abscess; malaria; typhoid fever; malignant hyperthermia; anticholinergic toxicity; status epilepticus; cerebral hemorrhage; DKA; and thyroid storm
how to initiate cooling in heat stroke
Evaporative cooling using cool mist and fans
ice packs to the groin and axillae, cooling blankets, ice water immersion, peritoneal lavage, and cardiopulmonary bypass
Antipyretics are not effective
shivering in heat stroke can be controlled with ?
rhabdo can be tx with ?
benzodiazepines or phenothiazines
mannitol and alkalinization
The most common complications of heat stroke
rhabdomyolysis, renal failure, liver failure, DIC, heart failure, pulmonary edema, and CV collapse
meds that can cause urinary retention
Anticholinergics (Atropine, benztropine, antihistamines, phenothiazines, TCAs, ipratropium)
β-Agonists (Isoproterenol, terbutaline)
Detrusor muscle relaxants (Nifedipine, dicyclomine, hyoscyamine, oxybutynin, diazepam, NSAIDs, estrogen)
Narcotics (Morphine, hydromorphone)
Spinal anesthesia
Ephedrine derivatives, amphetamines
azotemia
Presence of nitrogenous bodies, especially urea, in the blood that develops in urinary tract obstruction when overall excretion function is impaired
untreated urinary obstruction may lead to ?
Loss of urinary concentrating ability, azotemia, renal tubular acidosis, hyperkalemia, and renal salt wasting
RTA I
distal, prob. in distal H- secretion
Hypokalemic hyperchloremic metabolic acidosis, urine pH >5.5**
Autoimmune and genetic disorders, amphotericin, toluene, nephrocalcinosis, tubulointerstitial diseases
tx: oral NaHCO3-, K+
RTA II
decreased proximal resorption of HCO3-
Hypokalemic hyperchloremic metabolic acidosis, urine pH <5.5
Primary hyperPTH, MM, Fanconi syndrome, acetazolamide
tx: oral NaHCO3-, K+
RTA III
Glomerular insufficiency; impaired ability to generate NH3
Normokalemic** hyperchloremic metabolic acidosis, urine pH <5.5
RTA IV
Antagonism or deficiency of aldosterone → decreased distal acidification and sodium resorption
Hyperkalemic** hyperchloremic metabolic acidosis, urine pH <5.5
Urinary obstruction, diabetes, SCD, Addison disease
tx: oral NaHCO3- for significant acidosis; furosemide for hyperkalemia
Bell’s palsy:
Taste sensation is intact because ?
If the nerve to the stapedius muscle is involved there is often ?
If the geniculate ganglion or the motor root proximal to it is involved ?
the lesion is beyond the site where the chorda tympani has separated from the main trunk of the facial nerve
hyperacusis
lacrimation and salivation may be reduced
Other causes of nuclear or peripheral facial nerve palsy
Lyme disease, tumors of the temporal bone (carotid body, cholesteatoma, dermoid), Ramsey Hunt syndrome (herpes zoster of the geniculate ganglion), and acoustic neuromas
Malignant otitis externa, stroke, Guillain-Barré, polio, sarcoid, and HIV
peripheral facial nerve palsy vs. supranuclear type
supranuclear: frontalis and orbicularis oculi muscles are spared because innervation to the upper facial muscles is bilateral and that of the lower facial muscles is mainly contralateral
if the patient has drooping of the mouth but is able to wrinkle his or her forehead normally, an intracranial process should be suspected
Over half of the patients with Bell palsy will recall a preceding ?
do pts recover?
what is the most favorable prognostic sign?
viral prodrome
80% of patients recover within weeks to a few months
incomplete paralysis in the first week is the most favorable prognostic sign
Associated symptoms in Bell palsy may include
pain behind the ear, ipsilateral loss of taste sensation, decreased or overflow tearing, and hyperacusis
+/- heaviness and numbness on the affected side of the face; however, no sensory loss is demonstrable
Bell’s palsy management: eyes
eye protection: eye patch while sleeping to protect the eye and prevent corneal drying and abrasions, apply artificial tears to the affected eye every hour
Tearing of the affected eye (epiphora) occurs because paralysis of the orbicularis oculi muscle prevents closure of the eyelids and causes the lacrimal duct opening to sag away from the conjunctiva
medical therapy for Bell’s
prednisone 1 mg/kg/d can be given orally for 7 to 10 days (with or without a taper) (to decrease facial nerve edema)
+/- valacyclovir and famciclovir, acyclovir (HSV)
if unsuccessful, may benefit from surgical decompression of the facial nerve
Red Flags for Suspected Facial Nerve Palsy
Cranial nerve involvement other than VII
facial numbness
Bilateral facial weakness
Weakness, numbness of arms or legs
Unaffected upper facial muscles (forehead)
Headache, visual deficits, nausea or vomiting
History of travel through woods, tick bite
Recurrent unilateral facial paralysis
Slow progression of symptoms
Ulceration or blisters near ear
if discover PID and get wet prep and Gc/Chlamydia PCR, next diagnostic steps?
TVUS to r/o tubo-ovarian abscess, CBC, and screen for STIs
if cannot tolerate PO (n/v) or high temperature (102), inpatient tx
U/S or CT of the abdomen/pelvis may be useful if suspect PID as the ddx is broad, including ?
appendicitis, ectopic pregnancy, endometriosis, ovarian torsion, hemorrhagic corpus luteum cyst, benign ovarian tumor, IBD
what is considered the “gold standard” in establishing the diagnosis of PID?
laparoscopy, by visualizing purulent discharge from the tube, and is generally considered when a patient has acute symptoms, sepsis, or is not improving on therapy
organisms in PID
N gonorrhoeae and C trachomatis most commonly
others: Bacteroides fragilis, Escherichia coli, Peptostreptococci sp, Haemophilus influenzae, and aerobic streptococci
risk of PID is greatest at what point in menstrual cycle?
what can be protective against PID?
- ^risk mid-cycle: estrogen is high, progesterone is low, mucus is thin and bacteria can easily ascend
- also ^risk during menses, cervical mucous plug is lost
- decreased risk when progesterone is high after ovulation, cervical mucous is thick and more difficult for bacteria to penetrate
- progestin-containing OCPs or depot medroxyprogesterone acetate (depo provera) decreases the incidence of PID
long-term sequelae or complications from acute PID include?
tubal damage leading to infertility, pelvic adhesions leading to chronic pelvic pain, risk of ectopic pregnancy, Fitz-Hugh-Curtis syndrome, and chronic PID
Of note, postinfectious tubal infertility is the second most common reason for female infertility in the US!
should PID be tx as outpatient or inpatient?
outpatient if uncomplicated inpatient if: pregnant unable to tolerate PO, n/v severe illness, high fever no response to PO abx TOA cannot r/o sx emergencies (appendicitis) IUD in place adolescent, nulliparous, or questionable compliance
outpatient antibiotic tx of PID
Ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg PO bid for 14 d with or without metronidazole 500 mg PO bid for 14 d
-seen back in 48 hours to assess for improvement
alternate outpatient abx PID tx
- Cefoxitin 2 g IM in a single dose and probenecid, 1 g PO administered concurrently in a single dose plus doxycycline 100 mg PO bid for 14 d with or without metronidazole 500 mg PO bid for 14 d
- Other parenteral third-generation cephalosporin (eg, ceftizoxime or cefotaxime) plus doxycycline 100 mg PO bid for 14 d with or without metronidazole 500 mg PO bid for 14 d
inpatient PID abx tx
-Cefotetan 2 g IV q12h or cefoxitin 2 g IV q6h and doxycycline 100 mg PO or IV q12h
-Clindamycin 900 mg IV q8h and gentamycin 2 mg/kg IV loading dose followed by 1.5 mg/kg q8h
alternative:
-Ampicillin/sulbactam (Unasyn) 3 g IV q6h and doxycycline 100 mg PO or IV q12h
if suspect TOA
include clindamycin or metronizadole (anaerobes)
no need to drain since majority can be tx with abx
1/3 of TOAs will need sx
classic triad of symptoms for diagnosing PID include?
lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness
Patients with a ruptured TOA present how?
in shock. This is a surgical emergency.
nephrolithiasis ddx
Appendicitis Ectopic pregnancy Salpingitis Diverticulitis Bowel obstruction Renal artery embolism Biliary stones Ovarian torsion PUD AAA Gastroenteritis
the most common type of renal stone?
calcium oxalate and/or calcium phosphate stones, account for more than 75%
others: magnesium ammonium phosphate, uric, and cystine stones
Uric acid stones tend to occur in patients with?
low urine pH (<6.0) and with hyperuricosuria
Cystine stones occur in the setting of cystinuria, which is a ?
relatively common autosomal-recessive condition causing defects in the GI and renal transport of cystine, ornithine, arginine, and lysine
Magnesium ammonium phosphate (struvite) stones are more common in ? and are usually associated with ?
women
urinary infections with urease-producing organisms (Proteus, Pseudomonas?, and Klebsiella).
Pee CHUNKSS: Proteus, Cryptococcus, H pylori, Ureaplasma, Nocardia, Klebsiella, S epidermidis,
S saprophyticus
renal stone presentation PLUS fever, pyuria, and severe CVA tenderness usually indicate a medical emergency, because ?
pyelonephritis caused by obstruction often leads to sepsis and rapid clinical deterioration
Urinalysis in nephrolithiasis
microscopic hematuria is present in 90% of cases BUT the amount of hematuria does not correlate with the degree of obstruction, complete ureteral obstruction may present without hematuria
also, analysis of urine sediment for crystals a culture and sensitivity should be performed
nephrolithiasis imaging
- KUB radiograph (good for radiopaque stones- 90%)
- intravenous pyelogram (IVP) has been the gold standard: it gives information about degree of obstruction as well as renal function
- helical CT imaging without contrast is the preferred imaging method of choice for the evaluation of acute renal colic (more sn/sp than IVP but no assessment of renal function), can also asses other abdominal organs
- U/S if pregnant or child
risk factors for kidney stones
Hypercalciuria, Hyperuricosuria, Hypocitraturia, Hyperoxaluria, Primary hyperPTH, RTA
30-50 yo, male 3:1, diet: ^Ca2+, protein, oxalate, low SES, hot, dry, ^sun
meds that ^risk nephrolithiasis
loops, antacids, acetazolamide (diamox), steroids, theophylline, allopurinol, probenecid, triamterene, acyclovir, indinavir, vit D and C
risk factors for nephrotoxicity with contrast dye
Age >60 y Dehydration Hypotension MM Hyperuricemia History of IV contrast within 72 h Debilitated condition Known CV disease, especially on a diuretic Asthma Renal insufficiency DM
The critical issues surrounding nephrolithiasis are ?
how to address them?
pain control: IV opiates, T3, meperidine, NSAIDs, morphine PLUS IVF
degree of obstruction: most small stones (<6 mm) in diameter will produce symptoms but will typically pass without intervention
presence of infection: +/- abx
indications for urgent urologic consultation in nephrolithiasis are ?
inadequate oral pain control, persistent n/v, associated pyelonephritis, large stone (>7 mm), solitary kidney, or complete obstruction
If the patient is being managed expectantly:
increase fluid intake and strain the urine
-CCB or a-blocker to facilitate stone passage
Surgery is indicated in patients with stones larger than ? as well as ?
5 to 8 mm
persistent pain, or failure to pass the stone despite conservative management
Stones located in the lower urinary tract system may be removed using a ?; upper urinary tract stones can be treated by ?
ureteroscope
ESWL
constant vs colicky pain in nephrolithiasis
constant: most likely to be located in the kidney
colicky: in the ureter and is caused by the stretching caused by the stone and inflammatory processes in the lumen
Most stones in the renal pelvis or bladder are asymptomatic
