midterm - midterm pt 3 Flashcards
beta-HCG
-transvaginal US- >1,500
-you can see an ectopic earlier so order it anyway
-abdominal US- 6,000
Pre-eclampsia (PEC) & eclampsia
PRE-ECLAMPSIA:
-20wks-6wks postpartum
->140/>90 on 2 readings at least 4hrs apart
-PLUS 1:
-proteinuria
-thrombocytopenia- <100,000
-creatinine >1.1
-elevated LFT (2x)
-pulmonary edema
-HA, visual changes, epigastric pain
-ECLAMPSIA:
-generalized tonic-clonic seizure in pt who has pre-eclampsia
-Definitive tx: delivery of fetus and placenta (34wks rec for pre-) -> betamethasone to help fetus lung maturity
-SEIZURE:
-Magnesium sulfate 2-4mg IV
-after 3rd convulsion consider:
-Lorazepam (Ativan)
-Diazepam (Valium)
-HTN:
-1. LABETOLOL**
-20mg IV over 2 minutes -> double -> double -> after 3 doses still >160/ >110 -> hydralazine 10mg IV
-2. HYDRALAZINE
-3. NIFEDIPINE
ectopic pregnancy
-Unruptured ectopic- light bleeding, tender, adnexal mass
-Ruptured ectopic- peritoneal signs, cool, pale, syncope, severe pain, hypotension, tachy, N/V
-Unruptured US- yolk sac and embryo outside uterus, empty uterus, thickened endometrial lining
-hcg >1500 and IUP not seen -> high risk
-Ruptured POCUS/FAST- intraperitoneal fluid, collapsed gestation sac
Tx:
-Unruptured- methotrexate until HCG is 0
-only if stable, no cardiac activity, <3.5cm, <5000 hcg, normal kidney/liver
-Laparoscopy if methotrexate is CI
-Ruptured-
-ABCs, IVF, transfusion
-RhoGAM if Rh-
-salpingotomy/ectomy
ovarian torsion
-ovary and fallopian tube twists on its own bloody supply
-young (cysts), infertility
-sudden, severe stabbing unilateral pain
-N/V, radiation to groin
-bimanual- tender, mass (rare)
-peritoneal signs -> necrosis :(
-def dx- laparoscopy
-ovarian salvage time is 36hrs
PID
-mild to severe
-MC- midline lower pain
-!vaginal discharge, dysuria, dyspareunia
-abn bleeding, fever, N/V, malaise
-cervical motion tenderness (CMT)
-adnexal tenderness
-friable cervix
-cervical discharge, purulent
-Tuboovarian abscess (TOA)- severe pain/fullness worse on one side (bimanual)
-Causes- POLYMICROBIAL, STI, anaerobes (BV), enteric (ascending tract infection -> endometritis, salpingitis, oophoritis, myometritis)
-US- possible TOA -> complex thick walled adnexal structure
-R/o ruptured cyst, ovarian torsion
-Tx:
-PID: Cefoxitin or ceftriaxone, doxycycline, and metronidazole
-TOA: Even though abscess -> same tx as PID ->IV antibiotics and pain control
-if persistent, or very large -> surgically drained
empiric tx for possible infection with gonorrhea and chlamydia?
-CHLAMYDIA TX:
-Doxycycline 100 mg PO BID x 7 days - tx of choice
OR
-Azithromycin 1g PO 1x (pregnancy)
-GONORRHEA TX:
-Ceftriaxone 500mg IM once (1g if >150kg)
-If allergy: Gentamicin 240mg IM x 1 dose + Azithromycin 2g PO x 1 dose
-Expedited partner therapy (EPT): Cefixime 800mg PO once
LVG- lymphogranuloma venereum
-Chlamydia trachomatis serotypes L1-L3
-MC- rectal
-1. small painless genital ulcers -> heal
-2. painful swelling of inguinal lymph nodes
post partum hemorrhage
->500mL of bleeding -> hemorrhage
-Causes:
-MC- Uterine atony (80%)- no contraction
-Undiagnosed/unrepaired lacerations
-Retained POC
-Coagulopathies
-boggy uterus
-lacerations or uterine inversion
-previous venipuncture sites for bleeding -> DIC
-Emergency tx:
-ABCs, IV x 2
-O-neg to start
-Call OBGYN early!
-Oxytocin or misoprostol (immediately after birth to prevent)
-Fundal massage
Sepsis
-Fever, tachycardia, tachypnea, +/- hypotension, with DELERIUM
- increased risk: over 65, nursing home, homeless, alcoholism, CHF, DM, COPD, immunosuppression
SIRS criteria:
-temp >38 (100.4) or <36 (96.8)
-HR > 90
-RR > 20 or CO2 < 32
-WBC > 12,000 or < 4,000 or >10% bands
-Sepsis = 2+ SIRS + infection
- severe: sepsis + lactate of 2 or EOD
- septic shock: sepsis + hypovolemic despite fluids or lactate > 4
qSOFA score:
-systolic BP <= 100
-RR >= 22
-GCS <15
Dx:
-central venous cath and arterial line
-CXR
-ECG if tachy
-labs: CBC, CMP, UA, VBG (for lactate), cultures (blood + urine),
-As indicated -> CT, CSF, SSTI wound cultures, joint cx
-Serial tests: vitals, PE, urine output, lactate
Tx in 1st 3 hrs:
- get rectal temp
- ABCs
- vascular access: CENTRAL venous catheter, peripheral IV, arterial line
- IV FLUIDS: LACTATED RINGER @ 30ml/kg*
-Empiric antibiotics
-Vasopressors- goal MAP >65: Norepinephrine -> vasopressin or epinephrine once norepi dose >15
-remove any sources of infection
Cellulitis vs DVT, stasis dermatitis, PAD, allergic rx
cellulitis: infection of dermis and SUBCUTANEOUS TISSUE
-red, warm, tender, FIRM
- Indistinct borders, unilateral
+/- Fever, chills, lymphangitic streaking
- etiology: Usually Strep pyogenes or Staph aureus infection from a site of trauma (cut, puncture, shave)
-fevers, chills, sweats, lymph nodes, streaking (ascending lymphangitis)
-US- cobblestoning from edematous fluid
- special cases: cat bites = AUGMENTIN, could get rabies; brackish river water, blisters = Vibrio - tx = doxy; fight bite = augmentin
- tx: CEPHALEXIN x 5-7 days
Stasis dermatitis: MC misdiagnosis as cellulitis!
-!bilateral and chronic!
-telangiectasia, varicose veins, hyperpigmentation, edema subsides with laying
-> wound clinic, elevate -> NO antibiotics
Contact dermatitis – itchy!
Allergic reactions – itchy!
PAD
DVT: venous cord, can check Homan’s sign (pain behind knee with dorsiflexion) -> duplex US
- Unilateral swelling, erythema, calf tenderness, warmth, but NO fever or skin changes
Mono-arthritis (septic/gout): suspect when cellulitis overlies a joint
PE: cellulitis vs abscess vs Necrotizing fasciitis
CELLULITIS:
-unilateral
-pain, red, swelling, warm, tender, streaking (ascending lymphangitis)
-FIRM
- indistinct border
-systemic sx
ABSCESS:
-FLUCTANT with surrounding induration!
-pain, tender, red
NECROTIZING FASCIITIS:
-swelling, severe pain -> out of proportion
-poorly define margins
-bullae
-gangrenous skin
-crepitus
-wooden feel
- appears like cellulitis initially, then will have RAPIDLY SPREADING bruising, POOP, wooden feeling of the skin, poorly defined margins with tenderness that extends beyond the area of involvement -> bullae, gangreneous skin
bacterial Meningitis
-MCC- s. pneum
sx:
-triad: Fever, neck stiffness, AMS
-HA (MC)
-Seizures
-!Kernigs: Hip is flexed, but knee cannot be straightened
-!Brudinski’s: Flexion of the neck (by you) leads to flexion of the hip (by the patient)
-Head jolt sign
-Do not delay ANTIBIOTICS for CT/ LP/blood cultures! Goal < 60 mins
CT before LP if:
->60yo
-Hx of CNS ds
-Immunocompromised state
-Seizure <1 week before
-AMS
-Focal neuro deficits
CSF testing = Gold standard
-CSF opening pressure
-Gram stain
-Cell count
-Glucose level
-Protein level
Tx:
-Empiric: !Vancomycin + Ceftriaxone!
-!Add ampicillin for listeria if >50yo
-!Add acyclovir IV if HSV
-Neonates: ampicillin + gentamicin
-Consider !dexamethasone! to decrease M&M (controversial)
aseptic and fungal meningitis
Aseptic = MC type of meningitis
- Viral, non-infective (SAH, autoimmune)
- CSF + PCR testing for enterovirus, HSV, VZV
- Conservative tx
+/- acyclovir if HSV/VZV
Fungal
- immunocompromised pts, recent neurosurgical intervention, IVDU
- HIV: cryptococcal
- DM or recent sinus infection: mucormycocis
- immunosuppression = asperigillus, candida
- presentation: subacute or chronic meningitis (wks - yrs)
- CSF: INDIA INK stain for cryptococcus; fungal culture
- tx: cryptococcus - amphotericin B, flucytosine; aspergillosis, candida, coccidiodomycosis - fluconazole, voriconazole
flexor tenosynovitis
-bite or trauma prior
- remember: flexor tendon injures = WORSE - closed sheath increases risk of rapid bacterial spread;
Kanavel signs: FLEX - indicate infectious flexor tenosynovitis, a surgical emergency
-Fusiform digit swelling (entire thing)
-Finger held in passive flexion (contracted)
-Pain with extension
-Tender over the flexor tendon sheath
Bites
-Augmentin!!!
-If severely infected +/- sepsis -> IV antibiotics
- cat: 2x more infectious than dogs, small and innocuous, deep puncture, rabies vaccination screen
- dog: more likely to be crush injury with more initial trauma, get Xray, rabies vaccination screen
- human bites: closed/clenched fist = high rates of serious infections, do HIV and hepatitis test, severely infected: go to OR for surgical debridgment and IV abx
-PEP:
-anytime bat involvement
-if you catch the animal wait and test it
-high risk animals
-Human rabies immune globulin (HRIG) IM into wound and then rest into deltoid or thigh
-dont need HRIG if previous vaccine
-Vaccine IM in CONTRALATERAL deltoid -> days 0,3,7,14 (+28 if immunocompromised)
rabies PEP indication
PEP:
* can delay if you can catch and observe animal for 10 days/autopsy
* Bat/high risk animal bite: always give PEP and assume a small bite
* Raccoons, skunks, foxes, coyotes, wolves, mongooses
* Unvaccinated stray dogs, cats, or ferrets in rabies-endemic areas
Rabies vaccine
* human rabies immune globulin: Give on Day 0 (only once)
* Infiltrate as much as possible into the wound
* Inject the remainder IM in a different site (deltoid vs anterolateral thigh, NOT gluteal)
* provides immediate abx
* vaccine: 1 mL IM in DELTOID contralateral to the HRIG
* inject on days: 0, 3, 7, 14, and + 28 day if immunocompromised
* pre-exposure prophylaxis: travel to endemic area, vets, animal handlers
* prevention: vaccinate your cats and dogs
rabies stages:
* incubation: 10 days - 2 yrs
* prodrome: nonspecific sx
* acute neurological period: encephalitis, hyperactivity, AMS, hydrophobia, hypersalivation; if paralytic form (20%): ascending flaccid paralysis
* coma
* death
kawasakis disease
-ALWAYS consider in child with prolonged fever and rash
-VASCULITIS of medium sized arteries (coronary :()
-MC- 6mo–5yo
-high risk for aneurysm - risk of TIA/strokes
Dx criteria:
-OVER 5 days of fever (can be shorter if high suspicion) PLUS
-B/L conjunctivitis
-Cervical lymph node >1.5CM
-Polymorphous exanthem
-Cracked lips or strawberry tongue
-Erythema, edema, cracking or peeling of the hands/feet
-NONBLANCHING rash
Echo- inflammation of coronary arteries
Tx- high dose ASA, IVIG, PPI
✅ Diagnostic Criteria: “Warm + CREAM”
Fever ≥ 5 days + 4/5 of the following:
C conjunctivitis (bilateral, nonexudative)
R rash (polymorphous - NONBLANCHING, no vesicles or bullae)
E erythema & edema of hands/feet → desquamation in late phase
A adenopathy (unilateral cervical lymph node >1.5 cm)
M mucositis (strawberry tongue, cracked red lips, pharyngeal erythema)
fever and rash
-meningococcal
-lyme
-RMSF
-necrotizing fasciitis
-toxic shock syndrome
-endocarditis
-kawasaki
-HIV
-dengue
-chikungunya
epididymitis
-MC intrascrotal infection
-posterior pain + swelling
-<35yo - STI
->35yo- E.coli UTI
-dysuria, frequency, discharge, pyruria
-NO N/V or fever
-+Prehn’s sign- decreased pain with lifting of scrotum
-US- increased blood flow + inflammation
-Tx-
-STI- ceftriaxone, doxycycline
-Enteric- fluoroquinolone
-Admit if signs of systemic infection
testicular torsion
-1st year of life- undescended testicle
-Puberty/adolescence- rapid increase in testicular size
-MCC- testicle not strongly attached to scrotum at birth
-other causes- minor trauma around scrotum, vigorous physical activity or during sleep
-Sudden onset
-hours after exercise
-!!N/V
-swollen, tender UNILATERAL
-transverse lie of testicle- bell clapper
-ABSENT CREMASTERIC REFLEX
-US-
-Hyperechoic enlarged testicle
-False negatives- Early in ds, Degree of twisting, Intermittent torsion
-False positives- Prepubertal patients have decreased or absent testicular blood flow at baseline
-blue dot sign- torsion of the appendix
-Tx:
-manual detorsion- opening the book
-surgical detorsion + orchiopexy
non painful scrotal mass
-transillumination- hydrocele
-bag of worms that increases valsalva maneuvers- varicocele
-reducable- hernia
phimosis VS paraphimosis
PHIMOSIS
-foreskin stuck in distal -> cant retract
-cant void -> EMERGENCY
-<5yo -> if no urgency -> grow out of it -> DO NOT RETRACT
->5yo -> topical steroids (hydrocortisone), gentle retraction
PARAPHIMOSIS
-EMERGENCY
-swelling + pain in glans in uncircumcised male
-vascular compromise possible
-call urology ->
- tx: Manual reduction -> prepuce injection -> puncture technique -> dorsal slit
blunt penile trauma
-high riding prostate or blood at urethral meatus
-BLOOD AT URETHRAL MEATUS INDICATES ANTERIOR URETHRAL INJURY
- if unable to void: retrograde urethrogram to assess for injury
- penile fracture = erect penile tear at tunica albuginea
UTI/pyelonephritis
-MC- E.coli
Pyelonephritis/ascending infection sx:
-CVAT or flank tenderness
-FEVER
-chills
-N/V
-flank pain (CVAT)
-Tx UTI
- nitrofurantoin 100 mg PO BID x 5 days (cannot give if PYELO or renal insufficiency)
- trimethoprim-suldamethoxazole
- fosfomycin
- asymptomatic bacteriuria in pregnancy: amoxicillin, nitrofurantoin, cefpodoxime (3-7 days)
- dysuria: PHENAZOPYRIDINE HCL TID for 3 days - turns urine red-orange (CI: hypersensitivity, G6PD, renal insuffiency)
-Tx for pyelo
- outpatient: fluoroquinoloes: cipro, levo (monotherapy) OR ceftriaxone IV paraenteral 1 dose and send home with trimethoprim-sulfamethoxazole/cephalosporin for 10-14 days
-ADMIT PYELO IF…intractable N/V, sepsis/shock, obstruction, emphysematous pyelo, pregnancy, immunocompromised, foley, failed outpt, poor social support
- complicated pyelo: ceftriaxone OR piperacill-tazo, fluoroquinolone IV for 2 days then switch to 14 days of extended spectrum PCN +/- aminoglycoside
prostatitis
-consider this in pts who dont respond to tx for cystitis
-fever
-flu like sx - n/v, chills
-urge incontinence, RETENTION!!
-boggy, tender, warm prostate on DRE but do not aggressively massage prostate -> bacteremia/sepsis
-edema
tx:
- TMP/SMX or fluoroquinolones
- STI tx if suspected
Epididymitis = Scrotal pain, Prehn’s sign positive, tender epididymis
Prostatitis = Perineal pain, boggy prostate, urinary symptoms, NO scrotal tenderness
Both can have dysuria, but prostatitis has more obstructive urinary symptoms
kidney stones
-colic, radiates to groin
-N/V, dysuria, hematuria
-proximal ureter or renal pelvis -> radiation to ipsilateral testicle, flank region
-middle third of ureter -> lower and anterior flank
-level of ureterovesical junction -> lower flank radiates to scrotal or vulvar skin
-fever, hypotensive, AMS- infection
-US- hydronephrosis, renal abscess, distal hydroureter
-CT scan- spiral non-contrast!- renal calculi, hydroureter, hydronephrosis, gas and renal abscess
-Tx-
-<5mm -> discharge
->5mm -> expulsive therapy- tamsulosin (alpha-1 blocker)
>7-10mm -> surgery, shock wave lithotripsy, ureteroscopy
acute urinary retention
-10-12hrs
-may have AKI
-may have overflow incontinence
-Causes- BPH!, Ca, mass, stone, prolapse, fibroid, constipation, stricture, UTI, prostatitis!, abscess, HSV, meningitis, cauda equina!, antihistamines!, anti-cholinergics!
->100mL post-void residual -> rules in retention
-1st line relief -> urethral foley catheter
-correct size, coude tip in BPH, small tip in strictures
-never FORCE -> can cause urethral damage (bleeding) -> suprapubic foley catheter is indicated
Opportunistic infections at different CD4 levels
-PCP- CD4 <200
-TB- CD4 <500
-toxoplasmosis- CD4 <100
-cryptococcus- CD4 <100
-CMV, TB colitis- CD4 <50
-esophagitis (CMV, HSV, candida)- CD4 <100
- candidia: oropharyngeal candida - clotrimazole, nystatin
- CMV retinitis
- opportunistic diarrhea: cryptococcus, crytosporidium, isopora -> fever + diarrhea = DONT GIVE antidiarrheal - want to get things out
- if CD4 < 200 or AIDS + FEVER = SEPSIS WORKUP and empirical abx
-HAART can cause diarrhea, lactic acidosis, SJS, pancreatitis, kidney stones
Differentiate between simple URI vs. bronchitis vs. pneumonia
-URI
-nasal, sinus, pharynx, larynx
-virus
-low grade fever
-lung sounds/xray are normal
-supportive tx
-BRONCHITIS
-virus
-NO fever
-persistent cough
-ronchi
-peribronchial thickening
-supportive tx
-PNA
-alveoli
-DYSPNEA
-bacteria MC
-high fever
-purulent sputum
-crackles
-CXR- consolidation, air bronchograms
-Antibiotics for tx
