Diffuse dilation of conjunctival vessels.

What is this?

What is most common cause?

conjunctivitis

most common: viral

diffuse dilation of conjunctival blood vessels with:

clear, runny eye

vs.

greenish, yelow pus coming out of eye

vs

itchy

What's the difference?

clear, runny eye= viral (most common)

greenish yellow pus= bacterial

itchy= allergic

Conjunctivitis:

what pathogen plays major role in newborn?

what pathogen causes the greatest threat to integrity of the eye?

later in childhood?

newborn: chlamydia trachomatis

greatest threat: neisseria gonorrhea

later in childhood: h.influenza

non-contact:

polymixin B-trimethoprim

Contact lens wearers: worry about pseudomonas

Cipro, oflozacin, or tobramycin (each .3%); lens discarded

Severe purulent discharge witha hyperacute onset (1ithin 12-24 hrs) related to conjunctivitis.

What do you do?

prompt emergent consult for aggressive workup for possible gonococcal conjunctivitis

abx: ceftriazone IM or Cipro drops

VERY contagious!

cool compresses 4 times daily prn

naphalozine/pheniramine 1 drop 3 to 4 times daily prn

follow  up with opthalmology in 7 to 14 days

if clear distinction btw viral and bacterial etiologies can't be made- add topical abx

Pt states they think they have an infection in their eye.

They are extended contact wearers- admit to sleeping with lenses.

Admit to pain, redness, tearing and photophobia.

What could it be? How do you treat?

Corneal ulcer

Slit lamp examination shows a staining corneal defect with surrounding white hazy infiltrate.

CORNEAL ULCER

Occassionally a hypopyn (leukocyte exudate-able to see pus) may be seen.

Topical oflozacin .3% or cipro .3% opthalmic solution is used (2 drops q 15 min for 6 hrs then 2 drops q 30 min for remainder of day, then 2 drops q 1 hr during second day then 2 drops q 4 hours for days 3 to 14)

Topical cycloplegics such as cyclopentolate 1% 1 drop 3 times dailyfor pain releif

Opthalmolgoist shoudl see pt within 12 to 24 hours.

What is a hordoleum?

How do you treat?

stye is an acute infection of an oil gland at the lash line that appers as a pustule.

tx: warm, wet compresses 4 times dialy and erythromycin .5% opthalmic ointment twice daily for 7 to 10 days.

what is anterior uveitis?

What is treatment?

·         Secondary to trauma, systemic disease, unknown

·         Cell/flare in A/C

·         Photophobia **

·         Pain

Tx: topical glucocorticoids (ie. prednisolone acetate opthalmic)

Pt classically presents with eye pain or headache,  clody vision, colored halos around lights, conjunctival injection and fixed mid-dilated pupil, and increased IOP of 40 to 70 mm Hg (normal is 10-20 mm Hg)

What is it? What's tx?

acute angle closure glaucoma

tx to decrease IOP started emergently: timolol .5% 1 drop

If IOP does NOT decrease then try: pilocarpine 1-2% 1 drop every 15 min.

Immed opthalmologic consultation

Severe unilateral pain

Use tonopen: very high IOP- could be higher than 40-50 mmHg.

Why does this happen?

pupil mid-dilated- stuck

no way for acqeous matter to leave causing increased pressure

asians- far sighted so smaller eyes

movie theatre: pupil dilated when went in dark room so closed off drainage so pressure immed skyrocketed

Pt has dry eyes and states they have been using Visine.

Why is that bad?

Visine acts as blood vessel constrictor so temporarily helps the red eye, but once wears off blood vessesl will dilate again causing cyclic pattern if pt continues to use Visine

eventually they will become dependant and have rebound dilatation

So use artifical tears 3-4 times a day

Constant contact lens wearer with corneal ulcer and infection. What could it be?

What do u NEED to do during exam?

Giant papillary conjunctivitis

make sure to flip eye lid

Pt presents after fight/trauma with the following:

Diplopia upward gaze

Periorbital ecchymosis

Exophthalmus

Enophthalmus

Entrapped EOM

Step-off

Infra-orbital Hypoesthesia

What could it be?

What's management?

Orbital floor fracture

OMFS consult

Ophtho consult

Decongestants

No nose blowing

Abx-PCN/1^st generation Cephalosporin/Clinda

Surgery

Pt presents after maxillofacial trauma.

Coronal Ct scan shows hanging tear drop sign.

What could that be indicative of?

Pt presents after four wheeler adventure and fell onto porcupine. Porcupines are rabid (ie. have rabies)

What do you do?

How do you treat?

What two organisms are you worried about in a puncture wound?

what's tx?

pseudomonas and staph aureus

tx: superficial wound cleaning

tetanus prophylaxis

low pressure irrigation

derbidement

prophylactic abx: oral fluroquinolone-cipro or levofloxacin

CT

MRI is good but cant be used for metallic objects

Burn pt:

they have blisters

what degree burn?

Burn pt:

painless

•Leathery, dry, waxy eschar (eschar brown to yellow to white color)

What degree burn?

what are examples of how this may have happened?

third degree

examples: flame, electrical, or chemical injury

Second degree superficial burn:

painful; blisters slugh to reveal pink to red, moist wound

second degree partial thickness:

Involves entire epidermis and at least two thirds of dermis

less painful

•Pink to red to white (mottled), moist wound

Pt scalded with hot water.

What type of burn could that be?

pt presents from burn injury with

Black, charred eschar

•Painless

what degree could it be?

fourth degree

extends through all layers of skin to involve ligaments, muscle and bone

What is the rule of Nine?

What is it used for ONLY?

Head = 9%

Back, chest = 18% each

Upper extremities = 9% each

Perineal area = 1%

Lower extremities = 18% each

Total is 100%

Only used to assess 2^nd and 3^rd degree burns

•Foley catheter: to assess urine output; Urine output is important to assess the adequacy of fluid resuscitation. 

Lactated Ringers for fluid resucitation-half of calculated amt given in first 8 hours and second half given over next 16 hours.

•Assess blood supply to peripheral tissues.  Decreased blood supply may require escharotomy or fasciotomy. 

•Pain management: morphine used

•Cover thermal burn with clean sheets, irrigate chemical burn for at least 20 minutes. Burns should be cooled immediately by immersion in cold water.

•Baseline blood work includes CBC, CMP, BUN, UA.  Also obtain a baseline CXR.

Special cases

•Inhalation injury: ABG, carboxyhemoglobin

•Electrical injury: EKG, continuous cardiac monitor, cardiac enzymes

•Tetanus shot: if no within last 5 yrs- get booster

When is silvadene contraindicated?

Dental fractures:

What is the difference btw:

Ellis I-

Ellis II-

Ellis III-

Ellis I-thru enamel only

Smooth rough corners dental drill/emory board

Ellis II-thru enamel and dentin

Cover with zinc oxide or Calcium hydroxide paste (Dycal)

Ellis III-thru enamel, dentin and pulp

Dycal  (most painful antibiotic)

Anterior Bleeding

Nasal Septum-most common

Kiesselbach Plexus

Treatment

Grasp/pinch nose x 10mins

Chemical cautery with Silver Nitrate: standard of care for ED cautery of ant epistaxis

Packing

Vaseline Gauze

Merocel

Rapid Rhino

Blood dripping posterior naso-pharynx

Epistaxis Both nares

Treatment

Posterior Balloon

abx prophylax with cephalexin 25-500 mg PO q6h or amox/calulanate 250/125 mg PO q8h

PNC allergic pts can get clinda or bactrim

Grave's disease: third and fourth decades of age

Toxic multidnodular and toxic (adenoma) nodular goiters: older population, commonly with previous hx of simple goiter

assoc with diffuse hoiter, opthalmopathy, and local dermopathy.

due to autoimmune thyroid-stimulating antibody that activates teh thyrotropin receptor on thyroid cells

inflammation of extraocular msucles and periorbital tissue leading to bulging of eyes

pretibial myxedema- non-pitting edema on anterior knee

Pt complains of heat intolerance, palpitations, weight loss, sweating, tremor, nervousness, weakness, and fatigue.

What could it be?

how do you treat?

hyperthyroid

palliative tx for mild hyperthyoidism: beta blocker ( ie. propranolol)

long-term antithyroid medication (e.g., propylthiouracil, methimazole, or carbimazole), radioactive iodine , or subtotal thyroidectomy.

What is the most common form of thyroiditis?

What are sxs?

who gets?

what can it cause?

Hashimoto thyroiditis-autoimmune disease

sxs: enlargement of thyroid with or without pain and tenderness

more common in women

usually causes dysphagia or hypothyroidism

What labs will be elevated in Hashimoto thyroiditis?

how do you treat?

serum titers of antimicromosal and anti-thyroglobulin antibodies elevated

treat: small doses of thyroid hormone

If there is no residual thyroid function, the daily replacement dose of levothyroxine is usually 1.6 g/kg body weight (typically 100–150 g). In many patients, however, lower doses suffice until residual thyroid tissue is destroyed. In patients who develop hypothyroidism after the treatment of Graves' disease, there is often underlying autonomous function, necessitating lower replacement doses (typically 75–125 g/d).

Adult patients under 60 without evidence of heart disease may be started on 50–100 g levothyroxine (T4) daily. The dose is adjusted on the basis of TSH levels, with the goal of treatment being a normal TSH, ideally in the lower half of the reference range. TSH responses are gradual and should be measured about 2 months after instituting treatment or after any subsequent change in levothyroxine dosage. The clinical effects of levothyroxine replacement are often slow to appear. Patients may not experience full relief from symptoms until 3–6 months after normal TSH levels are restored. Adjustment of levothyroxine dosage is made in 12.5- or 25-g increments if the TSH is high; decrements of the same magnitude should be made if the TSH is suppressed. Patients with a suppressed TSH of any cause, including T4 overtreatment, have an increased risk of atrial fibrillation and reduced bone density.

Pt presents to ER with hyperreflexia, muscle wasting, and proximal myopathy without fasciculation. Chorea is a rare feature. Sweating and heat intolerance.

Also: cardiovascular manifestation is sinus tachycardia, often associated with palpitations, occasionally caused by supraventricular tachycardia.

what are you thinking?

What labs indicate what you're thinking?

thyrotoxicosis

The main antithyroid drugs are the thionamides, such as propylthiouracil, carbimazole, and the active metabolite of the latter, methimazole. All inhibit the function of TPO, reducing oxidation and organification of iodide.

 Labs: TSH low and uncombined T4 high

Acute adrenal insufficiency → life threatening! b/c it affects ALL hormones secreted by adrenal cx!!!! (contrast with hyperfunction – affects separate hormones)

What's the difference between acute and chronic renal insuffiency?

in terms of clinical manifestation

Acute:  hypotension (dizziness, syncope, LOC), circulatory failure, n/v, FUO, hypoglycemia, abd/flank pain

Chronic:  weakness, fatigue, anorexia, wt loss, hypotension w/ orthostatic changes (80/50), pigmentation changes

Low cortisol, high ACTH – primary insufficiency

Low Na, high K – primary

Cosyntropin (ACTH) stimulation test

replace glucosteroids  hydrocortisone

                Caution:  bone density, other side effects of chronic steroid therapy (Cushing’s sdr!)

Primary dis:  also replace mineralcorticoids with fludrocortisone – monitor replacement based on plasma renin activity and BP.

Androgens:  Some benefits with DHEA replacement

abrupt termination of steroid treatment

why? steroid tx is exogenous neg feedback to the pituitary

pt presents with weight loss, abdominal pain, anorexia, nausea, vomiting, dehydration, weakness.

Hyperpigmentation of exposed and unexposed skin and mucous membranes.

If this pt is a woman- may notice thinning of pubic and axillary hair.

What could it be? How will you test?

Adrenal insufficiency-primary

test: ACTH test

secondary: aldosterone levels are not signif affected bc of resultion through renin-angiotensin system--so hyperpigmentation and hyperkalemia not seen

shock and latered mental status in addition to

weakenss, dehydration,  hypotension, anorexia, vomiting, weight loss, abdominal pain

draw a bseline cortisol level and then admin cosyntropin.25 mg IM or IV

after 60 min, repeat cortisol level--should be double baseline

if primary: cortisol will NOT respond to ACTH

In secondary and tertiary: adrenal cortex WILL respond and increase coritsol level

<20 microgram/dL in severe distress

What's #1 reason for adrenal insufficiency?

What are other causes?

#1 abrupt steroid withdrawal or exposure to increased physiologic stress such as injury, illness or surgery

others:

autoimmune, infection, heparin therapy, sarcoidosis

1. outpt management: steroid replacement therapy

2. Adrenal crisis: crystalloid fluids, glucocorticoids, mineralcorticoids to correct volume, glucose and sodium deficits.

5% dextrose NS: initial fluid of choice

hydrocortisone 100 to 300 mg IV q 6 to 8 hours provides adequate glucocorticoid and mineralcorticoid activities.

What causes DKA?

Who can get DKA?

noncompliance with insulin therapy, infection, stroke, MI, trauma, pregnancy, other physiologic stress

Type I or type II can get DKA!!!

hyperglycemia causes osmotic diruesis with dehydration, hypotension, and tachycardia

Ketonemia causes acidosis with myocardial depression, vasodilation and compensatory Kussmaul respiration

N/V and abdominal pain are common

severe labored breathing

related to metabolic acidosis

diagnosis based on clinical presentation and lab values

glucose >250 mg/dL

bicarb below 15

pH below 7.3

mod ketonemia

serum glucose

electrolytes

BUN/Cretinine

Phosphorus

Magnesium

CBC

UA

1. Isotonic fluid resuscitation (Normal saline): most imp initial step to restore intravascular volume and tissue perfusion; avg pt has total body water deficit of 5 to 10 L

2. Continuous infusion of insulin .1 units/kg per hour is recommended

3. Potassium--try ot begin 30 min before insulin to avoid hypokalemia

4.Phosphorus--helsp with energy production and oxygen  delivery and szyme reactions

5. Magnesium

6. Monitor blood glucose, anion gap, K and bicarb hourly until recovery well establish

What defines hypoglycemia?

what are some common symptoms?

serum glucose <60 mg/dL

sxs: dizziness, confusion, headache, duiplopia, dysarthria, lethargy, coma, seizures

diaphoresis, anxiety, nausea, tremors, palpitations

What diabetic medication is commonly assoc with hypoglycemia?

why?

sulfonyureas

why?logn duration of action, particularly after overdose, what can lead to delayed hypoglycemia as late as 16 hours after ingestion

What's tx for hypoglycemia?

What do you give specifically if sulfonyurea overdose?

50 mL IV bolus of 50% dextrose solution; repeat glucose determination shoudl be performed q 30 to 60 min after intial dexrose admin

if IV access can't be established- give glucagon 1 to 2 mg IM

if sulfonyurea overdose: DIAZOXIDE 300 mg IV--

What's the screening test of choice for rib fractures?

When should you suspect rib fractures?

xrays

suspect if localized pain or tenderness after chest trauma

If a patient with fractured ribs, especially ribs 9, 10, and 11, becomes hypotensive and does not have a large hemothorax or tension pneumothorax, what should be suspected?

What are signs of hypercapnia?

Hypercapnia can be related to what serious condition (there are many but this is a big one..)

peripheral and conjunctival hyperemia, HTN, tachycardia, tachypnea, impaired consciousness, papilledema, asterixis

Acute respiratory failure

1. supplemental O2 to maintain a pulse ox reading >95%

2. IV access should be secured and crystalloid IV fluids given to augment preload and correct hypotension.

3. Anticoagulation with a heparin is standard tx for acute PE. (Dosing of unfractionated heparin should be weight based, with 80 units/kg given as an initial bolus followed by 18 units/kg per hour. Low molecular weight heparin (ie. Enoxaprin) safe and effective for acute PE

Absolute Contraindications: intracranial hemorrhage or active GI hemorrhage

If high pretest probability and no contraindications: start heparin therapy before diagnostic testing

4. Thromboembolytic therapy should be considered for pts who require aggressive tx for PE (ie pts with hemodynamic instability) Ex: Pts with ECG evidence of rt ventricular dysfunction

What do these findings suggest?

1) an acute onset of upper extremity hypertension,

2) difference in pulse amplitude between the upper and lower extremities

 3) the presence of a harsh systolic murmur over the precordium or posterior interscapular area. 

aortic injury

possible traumatic aortic injury

sudden, severe pelvic or low abdominal pain. GI sxs are absent, pt is afebrile and without leukocytosis.

what could it be?

In pts with hypothermia, what type of cardiac dysrrythmia so you need to be wary of?

why could it happen?

Vfib

could happen if too much manipulation of body ie. moving around rapidly or chest compressions

True or False:

You canNOT determine degree of frostbite until patient has been rewarmed.

1st: NO BLISTERS

2nd: BLISTER FLUID IS CLEAR

3rd: HEMORRHAGIC BLISTERS/blue gray discoloration

4th: muscle, tendon and bone freezing; dry, black mummified

• remove wet clothing/ apply dry clothing
• apply constant warmth by exterting gentle pressure with a warm hand
• separa digits
• elevate/protect from trauma
• gentle rangle of motion
• rapid rewarming in 40-42 deg celcius water for 20-30 min or until flush
• parenteral opioids (i.e morphine .1 mg/kg IV)

Do NOT RUB!

you can apply pressure, but NO RUBBING!

hypoglycemic

malnutrition

alcohol abuse

hypopituitarism

DM

burns

drug overdose

extreme age

elderly

young

drugs ie. diuretics, cocaine

fire fighters

chronic disease--hyperthyroid, malnutrition

Most soft tissue infections are caused by _________ (name the organism)

Most plantar puncture woulds related to osteomyelitis are due to _____ (name the organism)

face 

scalp

areas that are well vascularized---can wait up to 24 hours

Human bites:

what organisms could be involved? (3)

True or False.

Puncture type bite wounds, wounds greater than 6 hours old, and wounds of the hand and foot should be left open.

Pt presents with the following: appear acutely ill with fevers, chills, dysphagia, trismus, drooling, or a muffled or "hot potato" 

Involved tonsil is anteriorly and medially displaced.

What could it be? How do you treat?

Peritonsillar abscess

Penicillin, a macrolide, or clindamycin are most commonly used.

severe sore throat and inspiratory stridor in addition to drooling..what do u think?

what is tx?

epiglottitis

admit pt

abx: ceftriaxone

seizure is one episode

epilepsy is condition where u have multiple seizures

Pt is anxious.

What's the tx of choice?

panic attack

Panic attacks may be treated in several ways. A sublingual dose of lorazepam (0.5-2 mg) or alprazolam (0.5-1 mg) is often effective for urgent treatment. SSRI’s are commonly used for sustained treatment.

HCG TEST

hCG production begins __-__ days after conception or during days __-__ of the cycle. It reaches peak concentration at __-__ weeks of gestation and then gradually decreases until retuning to normal within _-_ days after normal full-term delivery. This test can be most accurately performed from __ days to __ weeks after missed menses.

What are some examples of when you might use whole bowel irrigation?

what are contraindications?

recent ingestion of lithium or iron...body packers...consider in extended release ingestion

contraindications: aspiration risk, bowel perforation or obstruction

single dose activated charcoal

whole bowel irrigation

gastric lavage

syrup of ipecac

When would you want to alkalinize the urine?

How do u do it?

examples

if someone overdosed on weak acid

3 amps of bicarb

barbs, salicylcates

sulfonylurea

TCAs

When would you use hemodialysis for overdose?

STUMBLES

Salicylates

Theophylline

Valproic acid

Massive acetaminophen (over 750 mcg/dl)

Lithium

Ethylene Glycol or Methanl

mild: tinnitis, Gi irritaiton

Moderate: tinnitus, hyperventilate, sweating, emesis

Severe: seizures, hypoglycemia, renal failure, severe cardiotoxicity

What is the toxic exposure to APA?

What is used to treat overdose?

140 mg/kg

140 mg/kg N-acetylsteine

banana bag: MVI, thiamine, mag, folate

D5 and 1/2 or just NSS

OVerdose pt comes in with the following sxs:

blindness

sluggishly reactive pupils

fixed and dilated pupils

lethary confusion 

severe abdominal tenderness

nausea

what are u thinking?

how do u treat?

Methanol overdose

2 amps of bicarb in D5W

Maintain Etoh level of 100 to 150..prevents breakdown of methanol

fomepizole--greater affinity than Etoh

Pt presents with odor of Etoh

ataxia, nystagmus, papilledema, stupor

about 12-24 hours after ingestion you notice: pt is now tachycardic, hyptensive, pulmonary edema, CHF...

if you wait 24 more hours...there will be renal toxicity.

Why? What is wrong with pt? what od u do?

Ethylene glycol: ie detergents...radiator fluid

NSS at 250 to 500 ml/hr to prevent deposiiton of oxalate crystals in kidneys

bicarb for acidosis

Pyridoxine and Thiamine replacement

Consult nephrology

MOther brings in daughter who she found agistated, possibel seizure and decreased MS.

You get the EKG and it shows widening of the intervals and terminal r in AVR

What could it be?

TCA overdose

charcoal if normal EKG and not horribly sick

intubate

alkalinize with bicarb drip and fluids

treat prophylactically with abx

(trimethoprim)

What is this:

longitudinal mucosal lacerations of the distal esophagus/proximal stomach

Mallory Weiss Tear

Initial treatment is supportive as the vast majority of Mallory-Weiss tears stop bleeding spontaneously. Ongoing hemorrhage can require treatment with electrocoagulation, sclerotherapy, and laser photocoagulation. Angiographic embolization or surgical intervention remain options as well.

What does this describe:

There is a short prodrome consisting of various combinations of the following symptoms and signs: fever, myalgias, vomiting, diarrhea, and pharyngitis. Patients then develop shock (SBP <80 mm Hg) with fever (>39°C) and signs of multiple organ dysfunction. At the time of presentation to the emergency department or within 24 hours of admission to the hospital, a diffuse, blanching, macular erythema appears, accompanied by signs of mucous membrane inflammation (pharyngitis, conjunctivitis, vaginitis, and strawberry tongue). The rash fades in about 3 days, but desquamation of the hands and feet occurs in all patients 5–12 days after the rash disappears. Patients typically prefer to remain motionless in bed because of intense myalgias. Confusion and agitation occur in about half of patients. Pedal edema is common.

What organisms is most commonly assoc with toxic shock syndrome?

What is tx?

Staph aureus

Remove the vaginal tampon or nasal or wound packing if present. Begin volume replacement with saline or colloid solutions and with vasopressors, if necessary. Admit the patient to an ICU, and monitor hemodynamic status. Start treatment with a first-generation cephalosporin, penicillinase-resistant synthetic penicillin, or vancomycin intravenously.

Gonorrhea and chlamdyia in males <35

E.Coli in older men

Pt presents with sudden severe onlet of pain felt in the testis. On PE you note a blue dot appearance of a cyanotic appendage that you see illuminated through thin prepubertal scortal skin.

What are you thinking? What you found on PE, is pathognominic for what?

Urologic consult indicated- imaging tests can be time consuming

ER physician can attempt manual detorsion. Most testis twist in a lateral to medial direction, so detorsion is performed in a medial to lateral direction (sim to reading a book)...End point for successful detorsion is pain relief

if pt appears toxic: Ceftriaxone or Bactrim

outpt tx if pt is NOT toxic:

pt younger than 40: Doxy, ofloxacin

if pt older than 40 cipro or levofloxacin

What is tx for gonorrhea?

What is tx for chlamydia?

Gonorrhea: ceftriaxone (alt. azithromycin)

Chlamydia: doxycycline and azithro (alt. erythromycin)

Primary occurs in individual with no antibodies to either viral type

o   Occurs within 7 days of exposure

o   Local symptoms

–      Burning and pain

–      Vesicles

o   Systemic symptoms; may be more severe than those listed

–      Fever

–      Malaise

–      Headache

–      Myalgias

–      Adenopathy

o   Lesions may last 2-6 weeks

treat: acyclovir

spirochete

Treponema pallidum

What does this describe?

•       Painless ulcer at site of inoculation

•       Well-demarcated raised borders

•       Occurs 10-90 days after exposure

•       Resolves with or without treatment

syphillis

Benzathine Penicillin G, 2.4 million units IM 

o   RPR (Rapid Plasma Reagin): in btw outbreaks will still stay (+)

o   VDRL (Venereal Disease Reference Laboratory)

o   FTA-ABS (Fluorescent Treponemal AB– Absorbed)

This is the clinical picture for what:

o   Most common symptom is unpleasant, fishy or musty vaginal odor

o   Increased vaginal discharge is common and it is usually thin, gray or white and homogenous and it tends to adhere to the vaginal wall.

o   Vaginal itching and irritation may be present

–      Uterine/adnexal tenderness

Cervical motion tenderness

o   Oral temp > 101^oF

o   Abnormal cervical or vaginal discharge

o   Presence of wbc on saline microscopy

o   Elevated sed rate or C-reactive protein

Ceftriaxone 250 mg IM in a single dose

or

Cefoxitin 2 g IM in a single dose and Probenecid 1 g administered concurrently

PLUS

Doxycycline 100 mg twice daily for 14 days

WITH or WITHOUT

Anemia in women Hgb < 12

Anemia in men Hgb < 13

Deficiency or defective RBC production

Nutritional deficiency: Fe, B12, folic acid

Bone marrow destruction, hypoproliferation

Increased destruction of RBC

Hemolysis: congenital, acquired

Serum iron

Ferritin

Transferrin

TIBC (total iron binding capacity)

RBC indices: MCV, MCHC, MCH

Folic acid, vit B12

Hgb electrophoresis; haptoglobin

Blood smear: < number of other cells (thrombocytes), parasites (malaria), variation in RBC’s size (anysocytosis), in shape (poikylocytosis)

What does this show:

CBC: low RBC count, low Hb, low Ht

Retic < 2/nl (depends on stage of anemia), MCV < 80, MCHC < 32 = microcytic, hypochromic

Blood smear: pale, small RBC, anisopoikilocytosis

Low ferritin, low Fe, TIBC high, later microcytosis and hypochromia 

IDENTIFY the cause of Fe deficiency

Replace iron: oral ferrous sulfate (empty stomach).  Frequent GI intolerance.  Add vit C, improves absorption

If malabsorption, use parenteral iron: IV, avoid IM

Improve diet

Severe cases: transfusion

F/U: in 3-4months (lifespan of RBC is 120 days), ck retic count.  If  tx is efficient, retic should increase in 10-14 days (towards normal values)

What is diagnostic of anemia of chronic disease?

iron

ferritin

TIBC

–Lab: retic <2, MCV nl/low (advanced dis)

–Iron low, ferritin high/nl, TIBC low

lThe major differentiation criterion: ferritin is increased/nl in anemia of chr dis vs decreased in iron deficiency anemia    

Pt presents with:

Neurological manifestation (dgn priority): disturbance in position and vibratory sense, incoordination, spasticity, positive Babinsky, can mimic Alzheimer with MS changes

What could it be?

Causes:

folate deficiency in alcoholism, low intake (body stores last 3 months), malabsorption, drugs (phenytoin, methotrexate), high utilization – pregnancy, infants

B12 deficiency due to alcohol, extreme diet (body stores last up to year), or, true pernicious anemia = lack of IF (intrinsic factor) due to autoimmune disease. Lack of IF frequently assoc with achlorhydria (gastric cancer).

Whta could this be:

o   Symptoms: weakness, fatigue, lethargy, dyspnea with minimal exertion, palpitations, and orthostasis.

o   Signs:  orthostatic hypotension; tachycardia; skin, nail bed, and mucosal pallor; systolic ejection murmur; bounding pulse; and widened pulse pressure. 

·      inadequate dietary intake (eg hemodialysis, elderly), malabsorption, alcoholism 

·      Vitamin B12 deficiency may be caused by pernicious anemia, poor diet, malabsorption (eg, partial or total gastrectomy, ileal resection, tropical sprue, small bowel lymphoma, inflammatory bowel disease, pancreatic insufficiency), nitrous oxide (N2O) inhalation, small intestine parasite infestation (fish tapeworm), bacterial overgrowth of small intestine, drugs (eg, Metformin, cholestyramine, neomycin, colchicine), congenital disorders (eg, transcobalamin II deficiency).

·      Most common cause of vitamin B12 (cobalamin) deficiency is not inadequate intake, but inability to absorb

·      Schilling test can be performed to determine if underlying cause of B12 deficiency is pernicious anemia: 

What could this be:

midepigastric or left upper quadrant pain.

constant, boring pain that often radiates to the back as well as the flanks, chest, or lower abdomen.

 The pain is exacerbated in the supine position and can be relieved when sitting with the trunk and knees flexed.

Nausea and vomiting are common, and abdominal bloating from gastric and intestinal hypomotility is a frequent complaint.

fluid resuscitiation with NS

parenteral narcotics and antiemetics

Empiric antibiotics are not indicated in mild to moderate pancreatitis but should be considered in severe disease

if severe: Intravenous imipenem or a quinolone (ofloxacin or ciprofloxacin) in combination with metronidazole are recommended and have demonstrated high tissue levels as well as bactericidal activity.

Pt recently returns from traveling and complains of fever, flatulence, nausea, emesis and abdominal pain which is usually spasmodic and colicky.

What could it be?

How do u treat?

gastroenteritis

if vomiting: fluid resuscitation

if diarrhea for more than 10 to 14 days with fever, systemic symsptom or blood or pus in stool: empiric therapy with ampicillin OR bactrim

peritonitis

perforation

septic shock

DO NOT!

hydroceles DO TRANSLUMNINATE

Pt presents with right lower quad pain

pain before vomiting

absence of previous similar pain

abdominal rigidity

pain migration

positive psoas sign

What is it? what is diagnostic study of choice?How do u treat?

appendicitis

CT is image study of choice

sort acting opiod analgesics: fentanyl 1-2 micrograms/kg IV q 1-4 h are preferred bc you can reverse by naloxone if needed

abx treatment: piperacillin/tazobactam or ampicillin/sulbactam

I&D by trained professional

Prior to aspiration, lidocaine spray or gel orbenzocaine-tetracaine spray (Cetacaine) is used to topically anesthetize the overlying mucosa. Then 1 to 2 mL of lidocaine withepinephrine is injected into the mucosa of the anterior tonsillar pillar using a 25-gauge needle. Once adequate anesthesia is achieved, an 18-gauge needle should be introduced just lateral to the tonsil, approximately halfway between the base of the uvula and the maxillary alveolar ridge, until the abscess cavity is encountered. The abscess then should be aspirated.The needle should penetrate no more than 1 cm because the internal carotid artery usually lies laterally and posterior to the posterior edge of the tonsil. 

Following needle aspiration, 10 days of high-dose penicillin or clindamycin for penicillin-allergic patients is the treatment of choice

Neonates: group B or D strep, nongroup B strep, E Coli, Listeria monocytogenes.

Infants and Children: H influenzae, S pneumonia, N meningitidis