PID cause
originates as a cervical infection with Neisseria gonorrheaand/or Chlamydia trachomatis, and becomes polymicrobial as it ascends into the
... [Show More] uterus, fallopian tubes and ovaries.
3 sx PID
-lower abd pain
-purulent vag d/c
-vag bleed
when getPID sx
Symptoms begin shortly after the start of the menstrual cycle, when there are fewer defenses by the cervical mucosal barrier to ascending infections.
PID with gonnoccal
more likely to appear toxic (fever, N/V)
dont forget one risk factor pid
-recent instrumentation of uterus
common exam findings pid
-b/l adenexal tenderness
-cervical d/c
cervical motion tenderness
-uterine tender
-lower abd tenderness
if pain is u/l think more
TOA
if RUQ tender think
Fitz-Hugh Curtis (perihepatitis, inflamation of liver capsule)
best test for gonorrohea and chlaymida
NAAT with PCR or DNA probes (either urine or cervical secretions)
if suspect TOA get
US
ruptured ovarian cyst shows
free fluid in pouch of douglas
ovarian torsion shows
absence of blood flow to one ovary on pelvic ultrasound with doppler
why US>CT
CT cannot eval for torsion bc there is no doppler
who gets abx for PID
-lower abdominal or pelvic pain coupled with adnexal, uterine or cervical motion tenderness on exam, in a patient at risk for STDs with no other discernible cause for the illness identified
complications of pid
-chronic pelvic pain
-infertility
-ectopic
-toa
-fitz-hiugh curtis
toa process
walled-off abscess that originates in the infected fallopian tube and extends to involve the ovary
how confirm dx of Fitz hugh curtis
elevated liver fxn tests
inpatient abx pid
-cefoxitin + doxy
or
-cefotentan + doxy
or
clinda+gentamycin
outpatient abx pid? add _____ if 2
-ceftriaxone
-doxy
-add metro if severe infection or hx of uterine instrumentation
who getsa dmitted
-toa
-fitz hugh curtis
-septic
-peritontiis
-pre-pubertal kid
-iud (which needs to be removed)
-pregnant
d/c with PID need what testing
test for other STD
describe whats going on in ovarian torsion
ovary, and often the fallopian tube as well (adnexal torsion) become twisted around their vascular pedicle.
progression of torsion
twisting initially obstructs venous flow, which causes engorgement and edema. The engorgement can progress until arterial flow is compromised, leading to ischemia and infarction
risk factors for torsion
ovary with a mass or cyst is more prone to twisting by virtue of its asymmetry
classic present torsion
sudden onset of unilateral lower abdominal pain which is initially visceral in character (ie, vague and poorly localized) and may be accompanied by nausea and vomiting. It may radiate to the groin or flank.
intermittent torsion
several episodes of pain over the course of hours, days, or even weeks,
why does current pregnancy inc risk of torsion
corpus lutem cyst on ovary
tests for torsion
There are no laboratory tests which are helpful in establishing the diagnosis of adnexal torsion
best way to dx torsion
US
careful with US:
important to note that the presence of Doppler blood flow does not exclude the diagnosis of torsion
signs of torsion on US
-enlargement/edema of ovary
-ovrian mass or cyst
-free pelvic fluid
what does CT torsion show
finding an enlarged ovary or ovarian mass
-assocaited free fluid
-thick fallopian tube
-deviation of uterus to the affected side
definitively dx torsion
OR
tx torsion
or (try and salvage ovary but testicle just gets removed)
torsion sotry often sounds like
kidney story
testicular torsion is
twisting of the testis and spermatic cord within the scrotum, with resulting in occlusion of venous return and and edema which can progress to arterial occlusion and ischemia
normal testicle anatomy and issue with torsion
anchored within the scrotum by the tunica vaginalis, which surrounds the testicle and attaches posteriorly to the scrotal wall and epididymis. The tunica vaginalis consists of a visceral and parietal layer with an interposed potential space. This potential space allows the testicle to rotate about the spermatic cord within the tunica vaginalis if a firm posterior scrotal attachment is lacking.
bell clapper deformity
When the tunica vaginalis attaches higher up on the spermatic cord, the testicle can move and twist within the scrotum. inc risk of torsion
2 most common ages get torsion
1st year of life and in puberty
hx of testicular torsion
airly sudden, severe unilateral testicular pain, sometimes radiating into the abdomen, associated with nausea and vomiting
-may have urgency, freuqency, dysuria
which testicle most common
left
weird cause of torsion
trauma
exam
-testicle is tender and swollen
-sits higher in sac
-sits in transverse lie
-loss of cremasteric reflex (rise hihgerthan .5cm)
labs in torsion
usually not helpful
best way to dx testicle torsion? what show2
US: painful testicle is enlarged and hypeochoic as ocmpread to good side. can show absence of flow but this is alte finding
torsion v. epididymitis
usually associated with increased blood flow to the testicle and the epididymis, as part of the body's inflammatory response.
torsion of testicular appendage
-age of pop
-where is pain
-timeline of paiin
-creamsteric reflex
-us shows
-tx
-outcome
-7-14yrs
-upper pole of testicle
-hrs-day
-reflex is present
-Body of testis similar to asymptomatic side with focal hypoechoic area
-supportive
-Infarction and resorption of appendage, no effect on fertility
epididymis
-timeline
-2 sx
-cremasteric reflex
-exam shows
-2 labs
-US shows
-tx
-outcome
-over days
-fever, dysuria
-present
-Epididymal tenderness with or without testicular tenderness
-wbc and nitrites
-Body of testis similar to asymptomatic side with hypoechoic epididymis
-abx
-Possible scarring, possible impaired fertility
definitive dx testicle torsion
OR
if delay in getting to OR what do
manual detorsion (rotat eit way from midline at least 360)
-know it owrked if dec pain within minutes
how know twist right way
-if hard to untwist, try twisting the other way
when susepct trauma is cause of torsion
testicular trauma who still has pain 1-2 hours after an injury.
to US for torsion must
compare side to side
when managing torsion
do not delay OR trip to use US as torison is mostly a clinical dx
4 types of intracranial hemorrhages
-epidural
-subdural
-subarachnoid
-intracerebral
sx of all intracrnial hemorrhages 4
-headache
-N/v
-altered
-seizure
who is at risk for big bleed even with minor trauma
-old
-alcohol
-anticoagulated
subarachnoid hemorrhage classic
-thunderclap ha
-reach max intensity within sec
sah sx
-loc
-vomit
-neck stiff
sentinel ha
-small headache=small bleed before a much larger bleed
grading system for sah
hunt and hess
most common cause sah
saccular aneurysms
interestng risk factor for sah
recent exertion
epidural hematoma patho
-trauma causes fracture of temporal bone to rupture middlemeningeal artery
classic story of epidural. but really
-brief LOC after blow to head then lucid period than loc again
-but most either dont hve loc or if they do, they dont get better
subdural hematomas patho
bridging eins are sheared during acceler-decel of head
timeline of subdural/ esp what pop, why
-can present late because the hematoma gros slow
-esp delayed in those with brain atrophy bc there is more space in head for blood
subdural in kid
think childabuse
shaken baby syndrome 3
-subdural
-retinal hemorrhages
-long bone fractures
chronic subdural in 2 pops? 2 reasons why
-old and alcoolic bc most prone to atrophy and coaugloapthy
cushings triad=
htn
-brady
-abnormal resp patterns
signifcance of cushings
physiologic response to rapidly increasing intracranial pressure and imminent brain herniation
colors of blood on ct by time
-white if acute
-3-14d then same color as brain
-after 2 weeks=hypodense
diagnostic pathway of sah
-CT
-then LP if after 6hrs of start of sx
subdural on ct
crescent
sah on ct
starfish. fillls sulci
epidural on ct
lens
CSF of Sah
-absence or clearing of blood
-xanthocromia
blood in csf ddx 3
-sah
-infection
-traumatic tap
how know its traumatic tap
if fourth tube has almost no lbood in it
if CT or LP pos in CAH next step
angiogprahy
if unsure if should get head ct
-canadian ct rules
what consider in hemorrhages
seizure prophylaxis
control inc ICP 5
-lower BP
-elevate head of bed 30degrees
-provide adequate sedation and analgesia
-consider mannitol
-or higer ventilation (goal CO2 around 30)
3 ways to have to stroke
-embolus
-thrombosis
-bleed (under 15%)
aca stroke sx
-LE>UE (weak and sensory loss)
mca stroke sx
-weak and sneosry loss of face and upper extremitiy with aphasia or neglect
pca stroke sx
homonomynous hemianopsia [Show Less]