Presentation on theme: "the inservice exam Feb 25, 2009 Short term $$$ (moonlighting, Mets)"— Presentation transcript:
1the inservice exam Feb 25, 2009 Short term $$$ (moonlighting, Mets) Long term $$$$$$ (licensure, career in EM)But also: intro to EM practiceSimilar questions to ABEMLast year: 207 questions countedPhysician’s Evaluation and Educational Review VIILas Vegas Board Review Course MP3s (2003?)EMEDS Review sinaiem.org/files/articles/BR-emeds/ … jar files
2This lecture series Board review: Five months, 20 lectures… Different than Dr. Cherkas sessionsThis year:More engagement thanMore questions, buzzwords than last yearMore repetitionMore candy
3OB+GYN+GU About 19 questions in PEER VII (out of 410) Some overlap in ID, S+S, Procedures + SkillsLast year’s inservice: it was 8+7 out of 207CV, GI, Pulm, Trauma each ~20Likely emphasis: details that make or break ED diagnosis or management
4OB+GYN+GU Today: Pregnancy, UTI, PID Select Male Concerns: scrotal and penileNo renal / stones / HD / PD complicationsYou already got some STDs from Jim Hinchey
8Question 1A 32 year old man presents with a painful erection that has lasted for more than 10 hours. Which of the following medications is the most likely cause of this condition?OlanzapineNot the psych drug (Zyprexa) you should be thinking of…PseudoephedrineNo – this is a therapy (only if given early)TerbutalineNo – this is a therapy (0.25 mg subQ q30 min … in the deltoid)TrazodoneMost causes of priapism are iatrogenic, from anti-HTN or psych medsVenlafaxineAlso linked to priapism but much less common than trazodone
9PriapismLow flow (90%, ischemia), venous obstructionMeds (psychotropics, antihistamines, anti-HTN, viagra, cocaine)Hematologic (sickle cell, leukemia, thalassemia)Intra-cavernosal injections (pre-1998)Spinal cord injuriesPainful12+ hours to thrombosis and ischemia impotenceHigh flow (10%), arterial sourceSecondary to groin or straddle injuryArterial cavernosal shuntLess pain, no fibrosisTreat with embolization
10Priapism Rx General Treatment: Sickle cell: PRBCs, hyperbaric oxygen Focus on pain control, urinary obstruction, hydration, O2 (sicklers)Alpha-adrenergic antagonists: terbutaline IM, intracorporal phenylephrineCorporal aspirationShunt surgerySickle cell: PRBCs, hyperbaric oxygenIatrogenic (due to penile injections for impotence)Leukemia: terbutaline, chemoNon-reversible causes: idiopathic, high spinal cord injury, meds
11Question 2A 47 year old uncircumcised, obese man presents with painful “tip of the penis.” Exam shows a swollen and tender glans and foreskin. On retraction, the foreskin appears excoriated and has a foul-smelling, purulent discharge. No other findings are present. What is the diagnosis?BalanoposthitisBalanitis (glans) + foreskin! Usually skin flora. Treat with sitz, cleaning, keflex. If it’s cheesy, it’s candida. May be the presenting sign for diabetes – check a FSBS!Fournier’s gangrenePatient not immunocompromised, no systemic signs or spreading beyond tip.Herpes simplexVesicles… not discharge.ParaphimosisCan’t extend. Vicious cycle; true emergency. Give ice, sugar, puncture… slit?PhimosisCan’t retract. Can lead to pain, UTI. Dilate, plus 4-6 weeks of steroid cream.
12Balanoposthitis Balanitis = inflammation of the glans penis Posthitis = inflammation of the foreskinCause:Usually Staph/Strep, can be fungalPoor hygiene, undiagnosed DM, seborrheic dermatitisRx:Local measures: soap, dryingAntifungal cream, possible broad spectrum antibiotics (cephalosporin)
13Phimosis / Paraphimosis Phimosis = inability to retract foreskinUncommon cause of urinary retentionCongenitial or bc of chronic balanoposthitisParaphimosis = retracted skin that cannot be reducedA true urologic emergencyCan lead to gangrene of glans bc ofarterial compromiseLeave foley in place if presentRx: If unable to reduce manuallyUse Local anesthetic at constricting band, make superficial vertical incision to decompress
14Question 3A 13 year old boy is brought in for sudden onset of groin pain. On exam, the patient’s right testis is swollen, tender, and slightly elevated in the scrotum. Which of the following statements regarding this condition is correct?CT is the imaging study of choiceCT gives great anatomy… but who wants IV, radiation on a kid’s nads?Duplex ultrasonography provides little data about testicular anatomyUS is 100% specific for torsion, good anatomy. Manual detorsion shouldn’t wait.Positive cremasteric reflex confirms the diagnosisReflex should be absent in torsionRelief of pain with elevation reliably differentiates this condition from epididymitisRelief of pain with elevation (Prehn’s sign) suggests epididymitis… not reliable…The “bell-clapper” deformity predisposes patients to this conditionTunica vaginalis (a fold of peritoneum) should just cover superior pole of testis and attach to posterior scrotum. If it covers entire testicle and attaches to spermatic cord, testis can rotate more freely.
15Testicular Torsion Cause: twisting of the spermatic cord Maldeveloped testes (at baseline tend to lie more horizontal than vertical = bell clapper deformity)Findings: Young male with abdominal painPeak incidence in puberty but can occur at any ageSudden onset of pain, not changed by scrotal elevationAbsence of cremasteric reflex (normal: stroking proximal medial thigh causes testicle to elevate)Tests: Ultrasound Doppler, Nuclear ScanRx: Emergent urology consult for surgical repairMay try Manual Derotation while waiting(rotate testicle in lateral direction, “open book.”Relief of pain indicates success.)
16Testicular Appendage Torsion Cause: twisting of pedunculated structures on the epididymis or testisMore common than testicular torsion in prepubertal boysFindings:“Blue Dot Sign:” pathognomonic, represents hemorrhage of appendage visualized through thin scrotal skin.Tests: Doppler ultrasoundRx: Possible surgery. May not be necessary if doppler of testicle is normal.
17Epididymitis Cause: Inflammatory process (gradual) Can be infectious or due to reflux of sterile urineYoung boys: think of congenital abnormalitiesGram neg. Secondary to structural, neurologic,functional abnormalities of lower tractSexually active: usually STD-relatedIf Gram neg, give erythromcinElderly: think of obstruction (prostate, stricture)Usually E.coli and Klebsiella5-25% of testicular cancers are initially misdiagnosed as epididymitisS/Sxs: gradual onset of painPrehn’s sign = relief of pain with elevation of scrotumRx: Abx as indicated by age, NSAIDs, bed rest, scrotal support, intermittent ice packs
20Acute Prostatitis Cause: S/Sxs: Prostate massage is contraindicated Sexually Active: consider STD (GC)Elderly: consider E.coliS/Sxs:Perineal pain, dysuria, frequency, fever/chills, urinary retention“Boggy” enlarged, tender prostateProstate massage is contraindicatedMay lead to bacteremia
21Question 4A 56 year old man with DM II presents with 3-4 days of fever and groin pain. There is no hx of recent illness, but glucose levels have been difficult to control for over a week. His exam is in the next figure. What is the most appropriate initial treatment? Can we do this, Cherkas-style?High-dose intravenous penicillinHyperbaric oxygen therapyIntravenous piperacillin/tazobactamSuprapubic catheterizationSurgical debridement
23Question 4, continuedA 56 year old man with DM II presents with 3-4 days of fever and groin pain. There is no hx of recent illness, but glucose levels have been difficult to control for over a week. His exam is in the next figure. What is the most appropriate initial treatment?High-dose intravenous penicillinNot enough coverage (most common Cx is E. coli, Bacteroides, and staph…)Hyperbaric oxygen therapyAn adjunct, and a controversial one. Certainly not initial therapy.Intravenous piperacillin / tazobactamCould go for pen (for G+ and C. perfringes) plus aminoglycoside or 3g cephalo for gram negs, plus anaerobe coverage with metronidazole or clinda.Suprapubic catheterizationMay become necessary, depending on extent. But not initial therapy for this pt.Surgical debridementAlmost certainly necessary, but not the initial treatment.
24Scrotal AbscessMust differentiate between abscess of the skin (hair follicle carbuncle/furuncle) vs. Abscess of scrotal contentsSkin abscess Rx: I&D, no abxIntra-scrotal abscess can be a complication of epididymitisUltrasound can help to distinguishMust differentiate from Fournier’sLow threshhold for Urologic Consultation
25Fournier’s Gangrene Surgical Emergency Cause: Findings: Extensive tissue loss and increasedmortality with delayed diagnosisCause:Polymicrobial infxn of subcutaneoustissue that originates either in the skin, urethra, rectumImmunocompromised at risk (DM,EtOH, IVDA, chronic steroids)Findings:Can start as a benign infection or abscessQuickly becomes “virulent” with crepitusAlways consider this in any pt with scrotal, rectal or genital pain or tachycardia out of proportion to clinical findings
26Question 5In the treatment of a 3 year-old boy with UTI, which of the following additional signs is the strongest indication for hospital admission?Localized myalgiaswhateverMaculopapular rashnot really associated with UTI at any ageMarked feverno – this is often the presenting symptomMucoid diarrheamay help distinguish UTI from AGE at this age, shouldn’t affect dispoPersistent vomitingVomicking unable to take ABx, mandates IV therapy and admission
28Question 6A 24 year old woman complains of dysuria, urgency, and frequency. She denies f/c, no n/v, no back pain. She has no known drug allergies and a urine pregnancy test is negative. Bedside urine dip shows 3+ blood, 1+ nitrites, and 1+ leukocyte esterase. What is the most appropriate course?Order a urine culture and treat with an appropriate ABx for 3 daysRosen’s and Tintinalli say no culture is necessary, only 10-20% will fail empiric txOrder a urine culture and treat with an appropriate ABx for 7 daysNot pregnant, not a male, not elderly, not diabetic, no hx of prior UTI’s…Treat with an appropriate ABx for 3 daysEmpiric therapy without UCx is appropriate if no risk factors for complicationsTreat with an appropriate ABx for 7 days3d is enough. Use local abiogram to guide ABx choice.Wait for microscopic analysis of the urine before deciding whether to order a urine culture.Wait for FEW ORG SEEN ??? A UTI patient should be your fastest dispo of the day.
29Urinary Tract Infection Cause:E.coli (90%), Klebsiella, Proteus, Enterobacter (5-20% combined)Males usually secondary to urologic diseaseDx:Sxs CFUs of single pathogenRelapse = same organism & serotype,< 1 month since initial infectionReinfection = recurrence of sxs 1-6 months after initial infection, usually different organism
30UTIs: Deeper Thoughts Complicated UTIs Asymptomatic bacteriuria: Underlying urologic pathology, pregnancy,immunocompromised, usually not E.coliAsymptomatic bacteriuria:Can progress to symptomatic infection,especially in pregnancyAcute Urethral Syndrome+Dysuria, but with low (or no) bacterial count in urine cultures. UA often positive.Generally indicates infection & should be treatedDysuria Ddx: chlamydia, herpes, GC, vaginitis
31UTIs: Lab Tests Nitrite: specific (90%) but not sensitive (50%) Based on bacteria-induced change of nitrate to nitrite (varies by bug, urine incubation)Leukocyte Esterase: similar (80% sp, 48% sn)Based on presence of WBCs in urinePyuria = 2-5 WBC in females,1-2 WBC in malesBacteriuria = any bacteria in an uncentrifuged gram stain smear, or > 15/HPF in centrifuged specimenChlamydia infection can be associated with low WBC and low bacterial counts
32UTIs: When to Culture? Pyelonephritis, recent hx pyelonephritis Underlying urologic pathologyChildren, MalesDiabetics, ImmunocompromisedRecent Instrumentation, Indwelling catheterProlonged Sxs prior to Rx3 or more UTIs in the past yearDO NOT need to culture young, healthy women with uncomplicated UTIsDO need to r/o other sources of pyuria/dysuria: STDs, prostatitis, pyelonephritis, epididymitis
33Adult UTI Treatment Female, lower tract, nonrecurrent, simple TMP/SMZ BID x 3dQuinolone x 3dFemale, lower tract, complicated / or Male, upper tractTMP/SMZ x 10dMacrobid x 10dCefadroxil x 10dAmox/Augmentin x 10dQuinolone x 10dFemale, lower tract, suspected STDDoxycycline x 10dTMP/SMZ x 10dErythromycin x 10d (E.coli not covered)culture for chlamydia, GCThink Pseudomonas in high-risk patientsCover with broad spectrum Abx
34High-Risk Pyelonephritis Pregnancy:Incidence of pyelonephritis increases in the 3rd trimester and may precipitate preeclampsia, sepsis & miscarriageDM, Sickle Cell AnemiaRenal Calculi / obstructionElderly / DebilitatedCarcinoma, ChemotherapyRecent hospitalizationRecent instrumentation of UTPyelonephritis = leading cause of perinephric abscess
35Question 7A 17 year old woman complains of dysuria x3 days. She denies f/c, no n/v/d, no abd pain. Pelvic exam reveals a homogenous white discharge that coats the vaginal walls. Pregnancy test is negative. Wet mount shows clue cells. The best treatment is:azithromycinthis is not chlamydial urethritis or PID! (chlamydia is #1 reported STI)ceftriaxonethis is not gonococcal urethritis or PID!fluconazoleif it were fungal, they would have said cottage cheese..levofloxacinthis is not a UTI! and levaquin has poor anaerobe coverage…metronidazoletherapy of choice in both pregnant and nonpregnant patients. A seven-day course of clinda cream or pills is also acceptable. Metronidazole also works on trichomonas, which can present similarly to vaginosis (but is described with dyspareunia, dysuria, and a wet mount that shows flagellates).
36Gardnerella (BV) New term: Anerobic Vaginosis Gram negative rod, faculatative anaerobe“fishy” order, rather than maldorousClue cells: anaerobes sticking to squamous epithelial cells. Looks like a fried egg with salt and pepper under microscope.Rx: Flagyl.Truly, flagyl in first trimester is controversial.
38Trichomonas Women: Frothy, grey, malodorous Men: asymptomatic, urethritisDrop it on slide: see swimming thingsWord STRAWBERRY: GOES WITH TRICHOther strawberries: tongueA protozoan. Rx: Flagyl (not intuitive)Think Flagyl if you have no idea what to use! (giardia, anaerboes, ameobas, other parasites)What else should you be doing after you treat the patient: treat partnerSingle dose therapyIn Pictures: look like fat sperm
40Candida Yeast Risk factors: Cottage cheese, no smell diabetes (common presentation of new onset DM)contraceptionantibioticsCottage cheese, no smellDrop on slide: KOH dissolves other elements, leaves behind hyphae (spaghetti) and spores (meatballs)RX: single treatment of fluconazole, or lotrimin suppository
43Question 8A 23 year old woman presents complaining of lower abdominal pain. Pelvic exam reveals yellow vaginal discharge, as well as moderate CMT. Adnexa are tender, but no masses are present. Outpatient management may be considered if the patient has:A physician who can provide followup careIt’s hard to discharge PID: Poor followup, adolescence, HIV, N/V, ambiguity…Pelvic abscessUm, no. This would be a reason for IV ABx, admissionPositive urine pregnancy testNo. Pregnancy should actually protect against PID – this presentation is ominous.Already taken antibiotics for similar complaintsSo they’ve failed outpatient therapy and need IV ABx and admissionTemperature greater than 38.8CFever is not uncommon but I guess the PEER folks found this concerning
44PID/SalpyngitisCauses: Neisseria gonorrhoeae, chlamydia trachomatis (#1), Gardnerella vaginalis, anerobesAscending disease: starts in cervix, goes through tubesRisk Factors: anything that mucks up the tubes. Previous PID, IUD, adolescent w/multiple partners
45PID, continued Can’t be ruled on physical exam. FORGET CMT CMT, adnexal tenderness, elevated temperature, dischargeDON’T NEED TO ADMIT ALL PATIENTS Consider for:Pregnancy—this is very uncommonImmunosuppressedIUDClinically illOutpatient compliance issuesFertility issuesTOAperitonitis
46More on PIDCervical culture not correlates with actually causative organism. Treatment always empiricComplicatons:Chronic pain/dyspareuniaTOAinfertility (most common cause of infertility)Fitz-Hugh-Curtis: RUQ pain w/o biliary diseaseWatch out in RUQ pain questions on boards. What is the next thing you do? answer is pelvic examF-H-C catch phrase: violin strings (adhesions between capsule of liver and abdominal wall)
50Question 9The side effects of emergency contraception meds can be reduced by:Avoiding their use in smokersRisk of VTE goes up with OCP use and age over 35, obesity, and smokingPeri- or post-ovulatory administrationActually there’s theoretical risk of ectopic here – the P might cause ciliary dysfxn.Taking the pill before a mealSymptoms of n/v, headache, fatigue are benign. Abd pain must get ectopic w/uUsing a progestin-only regimenWHO ‘98 says P dosing within 72 hours is more effective than Yuzpe, fewer AEUsing combination pills with both estrogen and progestinYuzpe ‘74 method is two E+P doses, twelve hours apart, within 72 hours of sex.
51Miscarriages (definitions old fashioned) Threatened: if pain and bleeding but os is closed. Both internal and external have to be closedInstructions: don’t put anything in your vaginaInevitable: same thing, but os openIncomplete: passed some, not all tissue (at the os)Missed: baby dies, don’t have abortion. Not common.
52Abortions, cont.Board question: if missed situation described & pt has fever: septic abortion.Worry about DIC in these casespolymicrobialSeptic abortion: most common is polymicrobial (“polymicrobial” also associated with diabetic foot ulcer questions)
53Question 10A 26 year old woman who is 6 weeks pregnant presents with RLQ pain opf 10 hours’ duration. The pain began periumbilically and migrated to the RLQ. She has nausea which she attributes to pregnancy. She has a fever of 38C and elevated WBC with left shift. UA is normal. Sono shows IUP, but the appendix was not visualized. What is the next appropriate management step?Admit for observationLots of overlap between appendicitis (nausea, WBC, pain) and pregnancy.Discharge with instructions to return in 12 hours for repeat examThis is a high-risk patient who should not leave.CT of abdomen and pelvisRisk to fetus is low, but specialists’ input is preferable.Consult surgery and OBShe’s febrile and pregnant with abd pain. They’re going to need to get involved.Start IV fluid hydration and observe in the ED for six hoursDelaying the diagnosis of appy can lead to increased M+M, fetal loss (up to 20%)
54Safe imaging in pregnancy Diagnostic Radiology in pregnancy:If it’s indicated, do it.D-dimer has no defined norms, just rises.Helpful if negative…Rad Threshold is 50 mSv. ?Others say fetus = 10.CXR = 0.02 mSv. CTAngio = 5-30… if it’s indicated, do it.Weeks 2-8: Organogenesis. Rads teratogenWeeks 8-15: Neuro development at riskWeeks 15+ … much less risk
58Question 11Which of the following conditions is most likely to be associated with a hydatiform mole?Abdominal painIt’s not more common than pain with normal pregnancyAbnormally low beta-hCGNot an ectopic! beta-hCG will actually be much higher than dates suggestHyperemesisMost likely to be associated with the Mole.HypothyroidismThe Mole will make its own thyroid hormones, may trigger pre-eclampsiaVaginal dischargeMay present with bleeding, sure. Also see large uterus, large ovaries, may be passing grape clusters (hydropic villi).
59Molar pregnancyAssociated with Asians, first pregnancies, teens or 40’s1st and 2nd trimester bleedingThe only possible cause of first-trimester pre-eclampsiaChorionic villi tumor, not actually a fetus46XX is complete, more likely to be malignant. Path needed to tell complete from incomplete (69XXXY, more benign)No fetal heart, uterus bigger than normal.Hcg very high (100,000s)“Snowstorm” appearance on ultrasound
61Normal pregnancyMorning sickness: associated with good overall outcomes12 wks: pelvic brim20 wks: umbilicusHighest at 36th week, then fundus descendsIncreased CO 20-30%Most women get a hydronephrosis of pregnancyChadwick’s sign: soft, blue cervix (venous, ok)Rabbit done died?
62Human Chorionic Gonadotropin Doubles every hoursBecomes positive after implantation, about a week (8-9 days) after intercourseAfter first missed period, you will be positiveMiscarriage: works in reverse. Gets cut in half every 2-3 days.
63Pregnancy Complications Appendicitis: most common surgical condition in pregnancy (same incidence as in age-matched nonpregnant patients).Difficult to diagnose: already have increased wbc, appy in RUQUTI in preg: consider as upper tract infections. Longer course (10 day), send cultureIf pyelonephritis, admission +/- if sick
65Question 12Which of the following is a characteristic of the HELLP syndrome?Increased LDHWhy not HELLDHLP? Hemolytic anemia implies elevated LDHNeurologic symptomsMay help distinguish HELLP from TTP (but bad HELLP can cause seizures)Normal antithrombin IIIHelps distinguish HELLP (low) from TTP, HUS (normal)Occurs early in pregnancyOccurs late, and 30% postpartum (TTP occurrence is even throughout preg)Renal symptomsHelps distinguish HELLP from TTP (but bad HELLP can cause ARF)
66Preeclampsia Proteinuria > 300 mg in 24 hours +/- edema Hypertension (140/90 or 30/15 over baseline)Presents as headache, blurry vision, CNS changes, or just HTNAfter 20 weeks, unless molar pregnancyRisk Factors:Primagravids and grand-multiparousDMAgeObesity
67HELLP Syndrome Hemolysis, Elevated Liver enzymes, Low Platelets Variant of pre-eclampsiaMay present as epigastric/RUQ painHemolysis: schistocytes on peripheral smearAbnormal coagulation profile
68Eclampsia Pre-eclampsia + seizure: eclampsia Headache, CNS, visual changes, hyperreflexiaWorse w/poor prenatal care, DM, obesityRx: magnesium sulfate, hydralazineDefinitive treatment is DELIVERYNot the same as primary hypertension: more like withdrawl htn, pheo. Don’t use typical drugs!Beta-blocker contraindicated: “unopposed alpha stimulation”
69Ectopic Pregnancy Leading cause of first trimester maternal death 2nd in $$ for claims against EM docsRisk factors: Anything that mucks up your tubesPIDprevious ectopicIUDtubal surgeryInfertility treatment?Unilateral, ?intermittent pain (95%)bleeding (80%, not constant) 5-8 wks after LMP
70Ectopic Pregnancy Region: distal ampulla of fallopian tube (90%) Need positive hcgThen do ultrasound
71Ectopic workupIndicators of IUP, all should be visible on TV by 5-6 weeks:yolk sacfetal heartfetal poleHeterotopics: 1:30,000 (but 5x higher if on fertility treatment)If not IUPToo earlyEctopicAbnormal IUPGet quant hcg.If above discrim zone ( , depending on ref), call gyn.If lower, may be too early. You don’t know what you have. Call gyn, will likely go home to f/u in 2 days for serial HCG.
72Ectopic, cont. Happen at around 4-5 wks Culdocentesis: rarely used. The positive is NON CLOTTING BLOODIndication for methotrexate: in stable ectopics/no fluid in belly. If they’ve started to leak, don’t use MTX. Failure rate 5-10%Our job is mostly stabilization, coordination.
74RhoGAM If they’re Rh Negative, give it Passive antibody if mother RH negative and any mixing of blood between circulations (vag bleeding, trauma)50 mcg if <12wks, 300mcg if >12 weeksTest for mixing: Kleinhauer Betke: look for nucleated RBC (of fetus) in maternal blood
75Third trimester bleeding Placental abruption: normal placenta (in fundus, near head), painful bleeding. Takes a while to ooze out: painful, darker color.Ultrasound CAN’T always diagnosis thisRisk factors: HTN, older, multitip, smoke, cocainePrevia: painless, bright red.Ultrasound always helpfulDon’t do pelvic exam in this situationAdmit, stabilize, RhoGAM if Rh-Neg, C-section if remains unstable
77Question 13A 30 year old woman presents complaining of a ‘typical’ migraine. She is 4 weeks post-partum and currently breastfeeding. Which of the following medications is contraindicated? Thank goodness this isn’t a question on HELLP, IIH/pseudotumor, SAH, where they’d be asking about optimal imaging…AcetaminophenSafe in pregnancy (B) and breastfeeding (“Safe”)CaffeineSafe in pregnancy (C?) and breastfeeding (“N/A”)ErgotaminePasses through milk, causes v/d and seizures in infants.MorphinePasses through milk at 1% of maternal dose, no adverse affects reportedPromethazinePhenergan is C: Safe in pregnancy, “potentially unsafe” in breastfeeding
79Safe drugs in pregnancy Meds in pregnancy:Almost nothing is category A (RCT shows no risk)Localize, topicalize if you can.Congestion meds: all CAntipyretics: Mostly B at first, D for third termAntiemetics: Doxylamine is A, ‘trons are B, all else CAntibiotics: Pen, Cephalos, Azithro, Vanc: BAnalgesics: Oxycodone, Hydrocodone = B. Codeine C.
81Question 14A 20 year old woman presents by ambulance. EMS reports she just had a seizure. She is 7 months pregnant and has not had any prenatal care – her mother called 911 because she “wasn’t acting right.” On arrival, vital signs are 171/90, HR 90, RR 13, sat 99% on O2. She is unarousable. Management should include:Lorazepam 1 mg IVClass D and not indicated for eclampsia (if pt had SE with hx of szs, sure…)Magnesium 6g IV over 20 minutesIV beats IM. Keep levels between 4-7 mg/dL. Drip at 2g/hr. Check reflexes.Nifedipine 10 mg POMagnesium won’t control BP, but an oral agent has no role here.Phenobarbital 1g IVClass B but not the solution here.Phenytoin 1g IV over 25 minutesClass D and not indicated for eclampsia.
82Safe drugs in pregnancy Midazolam, Diazepam are DHaldol, Droperidol are DPentobarb, Ketamine are BLidocaine, Propofol are B.ACE-I, ARBS are X or D.Hydralazine is only C, fenoldepam, esmolol are B.Ethanol, Phenytoin, Valproate, Tetracycline all D. Quinolones C.
83Trauma in Pregnancy Initial trauma care same as non-pregnant Causes of fetal death: #1 maternal death, #2 abruptionRemember RhoGAMNo radiologic test should be withheld for appropriate maternal evaluation
84Trauma in Pregnancy Fetal monitoring >20 weeks Minimum of four hoursSigns of fetal distress> 8 contractions/hour suggest abruptionKleihauer-Betke test (fetal-maternal hemorrhage)For hypotension—turn pt to left side (to displace uterus off IVC), fluid bolusMaternal stabilization is the most important factor in determining fetal survival
85Safe imaging in pregnancy Diagnostic Radiology in pregnancy:If it’s indicated, do it.D-dimer has no defined norms, just rises.Helpful if negative…Rad Threshold is 50 mSv. ?Others say fetus = 10.CXR = 0.02 mSv. CTAngio = 5-30… if it’s indicated, do it.Weeks 2-8: Organogenesis. Rads teratogenWeeks 8-15: Neuro development at riskWeeks 15+ … much less risk
86Pre-term Labor Labor at 20-35 weeks Sterile speculum Risk factors: multiple births, DES, cocaine, PIH, abruptio, alcohol, smokingAdmit, IV Fluids, bed rest, tocolytics (mag, terbutaline … you won’t be giving…)
87Premature Rupture of Membranes (PROM) Rupture >20 weeks and prior to laborNitrazine test: blue (positive)Sterile speculum exam: ferning (due to high quantity of salts in amniotic fluid)Avoid bimanualRisks: Infection, premature labor, prolapsed cordAdmit them, they’re not going. Start monitoring in the ED, consider tocolytics.
88Umbilical Cord Prolapse Seen in up to 8%, but perinatal mortality: 50%Pulsating cord on examPut patient in knee to chest positionEmergent c-sectionStop the delivery, elevate the presenting part, Trendelenburg can help, but call GYN
90Amniotic Fluid Embolism 2nd/3rd TrimesterImmune response to amniotic fluid in circulationFirst described in More like anaphylaxis?Shock, bleeding, dyspnea, hypoxia, coagulopathyMortality = 50% at 1 hour, 80% at 4-5 hoursAll we can really do is pressors, FFP, maybe HD, emergency C-section
91Fetal Distress Fetal hypoxia and/or acidosis Late decels (early decels expected with contractions)Severe variable decels are concerningDecreased variation is concerningTreatment: left lateral position, oxygen, IV fluids, consider delivery (emergency C-section)
93Delivery Ask yourself: What is GA? (betamethasone if < 34 weeks) How many feti?Meconium + resp depression ET intubationHistory of maternal drug use? Consider narcan8 stages: Head out by stage 3-4, then anterior shoulder, then posterior shoulderWait 30 min for placenta, pull gently, check it
95APGAR Score Indicator of neonatal depression Measured at 1 and 5 min Appearance (color), Pulse, Grimace (reflex), Activity (tone), RespirationScore 0-2 each
96Emergency C-section Maternal cardiopulmonary arrest Indicators of fetal survivalCause of maternal deathQuality of CPRGestational Age (>23 weeks)Arrest to delivery time (after 20 minutes, survival is unlikely)Vertical abdominal and uterine incision
98Question 15Which of the following is the least likely risk factor for postpartum endometritis?Cesarean deliveryC-section is actually the biggest risk factor.ChorioamnionitisReally, any opportunity for bacteria to get into the uterus is a risk factorMany vaginal exams during laborSo this is also a risk factorTime since rupture of membranesAnd this is, too.Urinary tract infectionUTI is on the differential, naturally, but no obvious way for bacteria to go from here to uterus… thus, not a risk factor
99Endometritis Diagnosed by H+P, fever, uterine tenderness WBC, Cx, sono/CT may support diagnosisPolymicrobial, foul smelling, feverHigh rate in c-section patientsRisksPROMProlonged laborChorioamnionitisMultiple examsInternal monitoring devicesTreat outpatient with doxy or clinda, with low threshold for admission and IV cephalosporins
100Mastitis Pain, erythema, swelling Staph infection. Nurse with other breast, express milk, anti staph treatment (cephalosporin, erythromycin)
101Question 16A 22 year old woman who is 1 week postpartum and breastfeeding presents complaining of vaginal bleeding more than expected, that started 2 days prior. She says the previous lochia had not been malodorous and had been light red in color. She denies fever or vomit. Vital signs are normal, save for a mild tachycardia. She has minimal abdominal pain. Pelvic shows normal vagina and cervix, no CMT. She is bleeding from the OS. Uterus feels firm and globular. The most likely diagnosis is:Lower genital tract lacerationYou would see this on exam, and there’d be no bleeding FROM os…Normal mensesNot 1 week out, not in a breastfeeder…Retained placentaMany causes of postpartum hemorrhage, this one fits best. Visibile on sono. D+C indicated.Uterine atonyWould be boggy or doughy. Most common cause of immediate postpartum hem (ie, 24 hr)Uterine ruptureThis would present as continued bleeding despite firm tone. More pain and irritation.
102Postpartum Hemorrhage Uterine atonyMost common cause in first 24 hrsRisks: overdistended uterus, prolonged/precipitous labor, high parityTreatment: fundal massage, oxytocin, IV fluidsRuptured uterusSeen with Previous c-section, excessive pressure, traumaTachycardia, hypotension, bleeding, absent heart tonesFluid resuscitation, immediate c-sectionConsider hysterectomy
103Postpartum Hemorrhage Retained placentaEarly or delayed post-partum hemorrhageSudden, brisk, painless bleedingBoggy, enlarged uterusOxytocin, D&C, fluid resuscitationUterine inversionExcessive traction on umbilical cordOB emergency- IV, 02, tocolytic drugsDo not separate placentaManual reimplantation or emergent laparatomyLower genital tract lacerationCoagulopathy (von Willebrand)
107Lymphogranuloma Venereum Organism: Chlamydia trachomatisS/Sxs primary infection:Uncommon in U.S.Primary lesion followed by inguinal buboesBuboes grow and rupture or form firm inguinal massesRx: Doxycycline
108Lymphogranuloma Venereum (LGV) Caused by certain serotypes of Chlamydia1-3 week incubation (vs days with herpes)BUBOES=painful inguinal nodesUsual scenario: Swollen gland in groin, a little bit sick with it—fevers, chills, myalgias
110LGV No high fevers/non-toxic Catchphrase: obligate intracellular organism, similar to virus. Doesn’t turn over quickly. Subacute disease processUse doxy or macrolideSince it turns over slowly, should do extended course (21 days)Complications: urethral scarring
111Chancroid Organism: Haemophilus ducreyi S/Sxs primary infection: Tender painful papule followed by ulcerationMultiple lesions may be present, and coalescePainful inguinal adenopathy in 50%May evolve to buboes and ruptureCulture LesionRx: azithromycin, ceftriaxone (single dose of both)
112Chancroid Gram negative bacillus: Haemophilus ducreyi Seen in developing countriesIncubates over 2-5 daysVesiculo-pustulo, develops into ulcer
115Chancroid, continued Painful (Painless: primary syphillis) Penis picture: must have pain clue!Treatment: macrolide usually not wrongAzithromycin, erythromycin, ceftriaxone
116Gonococcal Urethritis Organisms: N. gonorrhea, associated with chlamydial infection (30-50%)S/Sxs:Copious yellow pusVirtually always symptomatic (dysuria)Tests:Gram-neg intracellular diplococci, send GCConsider testing for syphilisTest both partnersRx: Treat for G & CIM Ceftriaxone, or fluoroquinolone, orone-dose cefixime + azithro
117Non-gonococcal urethritis Organism: usually Chlamydia (the most common STD)Less commonly Ureaplasma, herpes, trichomonas, candidaS/Sxs:Watery discharge, or no dischargeNo leuks on smear (in 30%)Often asymptomaticTests:PCR or enzyme immunoassayRx: 1gm azithromycin once or doxy 100mg BID x 10d
118Chlamydia #1 sexually transmitted disease Major cause of female infertilitySymptoms of local disease:DischargeDysuriaWomen: cervicitis, urethritis, PIDMen: epididymitis, urethritis, proctitisVag bleedingAsymptomatic 3-20%Rx: azithromycin, doxycycline
122Condyloma Acuminatum Don’t get confused with Condyloma lata (syphilis) Potential question: Patient presents with C.A. what is the next thing to do? (answer: look for other VDs)Treatment:Condylox (podofilox topical)Aldara (imiquimod topical)Cryotherapy
123Herpes Organism: Herpes Simplex (HSV-1 or 2) S/Sxs of primary infection:Painful pustular or ulcerative lesionsConstitutional sxs common (headache, fever, myalgias)Lymphadenopathy (80%)Rx: Acyclovir 200mg 5x/day for 10d
124Genital Herpes Type 1: above waist, type 2 below waist This is not always true, but 60-80% of genital lesions are type 2All primary infections present like a generalized infection: they have fever/flu/adenopathyLesions develop at 2-8 days: shallow, painful vesicles
126HSV, continued Differential dx: mono, primary HIV Primary infection is worst, infection gets better, then it breaks out from nerves. Relapses associated with stressTzacnk smears: scraped from BASE of vesicle in epithelial cells. Multinucleate giant cell the key phrase
127HSV Active at time of birth: need GYN consult Rx: -cyclovir. Indicated for primary symptoms, immunosuppressed. Also decreases relapseComplications: a good question, not obvious. Young person, febrile, jaundice…not hep virus but herpes!Hepatits, meninigitis, encephalitis, cervical CA,Erythema multiforma also a known rashUrinary retention: invasion of virus into sacral root ganglia. Not from pain. In young women with urinary retention, think herpes!
128Inclusion body= Chlamydia HSVThe classic picture of herpes lesion: Clustered vesicles on erythemetous base (Hand: herpetic whitlow)Tzank smear confusion:Inclusion body= Chlamydia
129Gonorrhea… “The clap” Localized disease symptoms: Dischargepain with urinationCervicitis, urethritis, proctitis, PIDVag bleedingAbdominal/pelvic painAsymptomaticRx: single dose therapyCefixime, ceftriaxone, quinolone
130Gonorrhea Complications of untreated disease PIDEpidiymitis/orchitis, prostatitisEye infectionDisseminated gonococcal diseaseSkin lesion: tender pustule on erythemetous baseArthritis/tenosynovitisEndocarditismeningitis
131Syphillis Organism: Treponema pallidum S/Sxs of Primary Syphilis: Painless chancreIndurated bordersNo constitutional sxsMinimal adenopathyDx: by darkfield microscopy, VDRL, FTA-ABS (to confirm)Rx: 2.4MU benzathine PCN G IMSecondary Syphilis
132Syphilis Treponema pallidum (spirochete) 3 different stages Primary PAINLESS ULCER on penis (chancre)RPR, FTA, VDRL negative in 1st stageLook for the positive dark fieldResolves spontaneouslyRx: PCN
133Secondary syphilisRash in young health person, not very sick: also think mycoplasma, pittyriasis roseaLow grade fever, not too itchyPalms and soles: others: gonnococcus (pustules), EM, RMSF, allergic reactions/contact dermatitisCondyloma latumSome fever, some painless adenopathy
135Tertiary syphilisBites you when you’re an old man, 25 years after primary infectionCNSTabes dorsalisNeuropathyMeningitisCardiovascular syphilisaortic aneurysmSkin lesions: gummasBenzathine penicillin drug of choice (Long acting penacillin: “LA” by nurses).Strep pharyngitis the only other indication for LA.Second line: docy, erythro, ceftriaxone. Not as good
137Syphilis Chancre- painless papule- hallmark of primary syphilis 2ndary syphilis 4-10 weeks- macular rash- trunk extremities- palms + soles oral lesions grey painless ulcersTertiary syphilis-untreated for years- 2 types-neurosyphilis after 10 yrs-meningovascualar vasculitis of vertebral or spinal vessels or tabetic syphilis-demylination and ataxiaCardiovascular only after yrs usually thoracic aorta- aortiv valve insufficiency
138STI’sCondyloma lata-secondary syphilis- typically-large painless flat topped lesions-typically in anogenital regionCondyloma acuminata- genital warts – HPV – pink to grey keritanized with papilliform growthsGonococcal proctitis- tenismus, anal itching and yellow dischargeGranuloma inguinale- bacterial infection with Calymmatobacterium granulomatis-painless papules beefy red ulcers with rolled edgesChancroid- Heomophilus Ducreyi- painful genital ulcer-
139Ovarian cysts Get terminology straight! Follicular cyst (before egg released), about 3 cmCorpus luteum cyst (after egg released, or pregnant)Nothing bad happens, unless >3 cm…can have torsion, rupture and bleeding!
140Ovarinan/Adnexal Torsion Twists around pedicleMust be tumor or large cyst to do thisDermoid cyst most commonSevere unilateral pain, nausea, vomitingSometimes bleeding, but not impressiveUnilateral tendernessDiagnosis: ultrasound, laparoscopyDifferential: ectopic, IUP, appendicitis, PID
141Ovarian tumor Post menopausal Usually advanced stage when diagnosed 2nd most common gyn malignancyMass on ultrasoundRefer
142Endometriosis Endometrium outside of the uterus Abdominal pain, cyclical in natureMost commonly on ovary, but can occur anywhere in abdomen, even in lung! Get cyclical pneumothoraxTreatment: hormonal therapy
143Uterine cancer Most common GYN cancer The case: Old lady with vag bleedingRisk factorsContinuous estrogenObesityDiabetesHypertension, nulliparityLate menopausePap smears don’t work for thisRefer to gyn
144Uterine prolapse Herniation into vagina Post menopausal, multiparous womenThink they have alien in their vaginaED Rx: reduce it! f/u gyn for possible surgery
145Dysfunctional Uterine Bleeding Think of anovulatory cycles due to hormonal imbalances.Most with starting periods (menarche), stopping (menopause)Consider cancerCycle with hormones, D&C
146Sexual assault/ Post-exposure prophylaxis You have to consider it in every case, but not necessarily do it in every casePlan B (levonorgestrel): give 1 dose now, then another in 12hrsNot 100% effective, gets less effective with more time from assaultWorks up to 3 days after sexual activityNausea and vomiting commonConsider in SA
147SA considerations Check for preg: underlying pregnancy HIV test: same as aboveSyphilis serology3 ways to tell if there was intercourse with ejaculation:Acid phosphatase (in seminal fluid)P30 (seminal marker)Looking for motile sperm