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the inservice exam
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Feb 25, 2009
Short term  $$$ (moonlighting, Mets)
Long term  $$$$$$ (licensure, career in EM)
But also: intro to EM practice
• Similar questions to ABEM
• Last year: 207 questions counted
• Physician’s Evaluation and Educational Review VII
• Las Vegas Board Review Course MP3s (2003?)
• EMEDS Review sinaiem.org/files/articles/BR-emeds/ … jar files
This lecture series
• Board review: Five months, 20 lectures…
• Different than Dr. Cherkas sessions
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This year:
More engagement than 2005-6
More questions, buzzwords than last year
More repetition
More candy
OB+GYN+GU
• About 19 questions in PEER VII (out of 410)
• Some overlap in ID, S+S, Procedures + Skills
• Last year’s inservice: it was 8+7 out of 207
• CV, GI, Pulm, Trauma each ~20
• Likely emphasis: details that make or break ED
diagnosis or management
OB+GYN+GU
• Today: Pregnancy, UTI, PID
• Select Male Concerns: scrotal and penile
• No renal / stones / HD / PD complications
• You already got some STDs from Jim Hinchey
Warning: Graphic Photos
of our Holiday Parties
Question 1
A 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?
a) Olanzapine
Not the psych drug (Zyprexa) you should be thinking of…
b) Pseudoephedrine
No – this is a therapy (only if given early)
c)
Terbutaline
No – this is a therapy (0.25 mg subQ q30 min … in the deltoid)
d) Trazodone
Most causes of priapism are iatrogenic, from anti-HTN or psych meds
e) Venlafaxine
Also linked to priapism but much less common than trazodone
Priapism
Low flow (90%, ischemia), venous
obstruction
– Meds (psychotropics,
antihistamines, anti-HTN,
viagra, cocaine)
– Hematologic (sickle cell,
leukemia, thalassemia)
– Intra-cavernosal injections
(pre-1998)
– Spinal cord injuries
– Painful
– 12+ hours  to thrombosis and
ischemia  impotence
High flow (10%), arterial source
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Secondary to groin or straddle injury
Arterial cavernosal shunt
Less pain, no fibrosis
Treat with embolization
Priapism Rx
• General Treatment:
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Focus on pain control, urinary obstruction, hydration, O2 (sicklers)
• Alpha-adrenergic antagonists: terbutaline IM, intracorporal
phenylephrine
– Corporal aspiration
– Shunt surgery
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Sickle cell: PRBCs, hyperbaric oxygen
Iatrogenic (due to penile injections for impotence)
Leukemia: terbutaline, chemo
Non-reversible causes: idiopathic, high spinal cord injury,
meds
Question 2
A 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?
a) Balanoposthitis
Balanitis (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!
b)
Fournier’s gangrene
Patient not immunocompromised, no systemic signs or spreading beyond tip.
c)
Herpes simplex
Vesicles… not discharge.
d)
Paraphimosis
Can’t extend. Vicious cycle; true emergency. Give ice, sugar, puncture… slit?
e)
Phimosis
Can’t retract. Can lead to pain, UTI. Dilate, plus 4-6 weeks of steroid cream.
Balanoposthitis
• Balanitis = inflammation of the glans
penis
• Posthitis = inflammation of the
foreskin
• Cause:
– Usually Staph/Strep, can be fungal
– Poor hygiene, undiagnosed DM,
seborrheic dermatitis
• Rx:
– Local measures: soap, drying
– Antifungal cream, possible broad
spectrum antibiotics (cephalosporin)
Phimosis / Paraphimosis
• Phimosis = inability to retract
foreskin
– Uncommon cause of urinary retention
– Congenitial or bc of chronic
balanoposthitis
• Paraphimosis = retracted skin that
cannot be reduced
– A true urologic emergency
– Can lead to gangrene of glans bc of
arterial compromise
– Leave foley in place if present
Rx: If unable to reduce manually
Use Local anesthetic at constricting band, make superficial
vertical incision to decompress
Question 3
A 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?
a) CT is the imaging study of choice
CT gives great anatomy… but who wants IV, radiation on a kid’s nads?
b)
Duplex ultrasonography provides little data about testicular anatomy
US is 100% specific for torsion, good anatomy. Manual detorsion shouldn’t wait.
c)
Positive cremasteric reflex confirms the diagnosis
Reflex should be absent in torsion
d)
Relief of pain with elevation reliably differentiates this condition from
epididymitis
Relief of pain with elevation (Prehn’s sign) suggests epididymitis… not reliable…
e)
The “bell-clapper” deformity predisposes patients to this condition
Tunica 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.
Testicular 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 pain
– Peak incidence in puberty but can occur at any age
– Sudden onset of pain, not changed by scrotal elevation
– Absence of cremasteric reflex (normal: stroking proximal
medial thigh causes testicle to elevate)
• Tests: Ultrasound Doppler, Nuclear Scan
• Rx: Emergent urology consult for surgical repair
– May try Manual Derotation while waiting
(rotate testicle in lateral direction, “open book.”
Relief of pain indicates success.)
Testicular Appendage
Torsion
• Cause: twisting of pedunculated structures on the
epididymis or testis
– More common than testicular torsion in prepubertal boys
• Findings:
– “Blue Dot Sign:” pathognomonic, represents hemorrhage of
appendage visualized through thin scrotal skin.
• Tests: Doppler ultrasound
• Rx: Possible surgery. May not be necessary if doppler of
testicle is normal.
Epididymitis
• Cause: Inflammatory process (gradual)
– Can be infectious or due to reflux of sterile urine
– Young boys: think of congenital abnormalities
• Gram neg. Secondary to structural, neurologic,
functional abnormalities of lower tract
– Sexually active: usually STD-related
• If Gram neg, give erythromcin
– Elderly: think of obstruction (prostate, stricture)
• Usually E.coli and Klebsiella
– 5-25% of testicular cancers are initially misdiagnosed as epididymitis
• S/Sxs: gradual onset of pain
– Prehn’s sign = relief of pain with elevation of scrotum
• Rx: Abx as indicated by age, NSAIDs, bed rest, scrotal support,
intermittent ice packs
Acute Prostatitis
• Cause:
– Sexually Active: consider STD (GC)
– Elderly: consider E.coli
• S/Sxs:
– Perineal pain, dysuria, frequency,
fever/chills, urinary retention
– “Boggy” enlarged, tender prostate
• Prostate massage is contraindicated
– May lead to bacteremia
Question 4
A 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?
a)
High-dose intravenous penicillin
b)
Hyperbaric oxygen therapy
c)
Intravenous piperacillin/tazobactam
d)
Suprapubic catheterization
e)
Surgical debridement
Question 4, continued
A 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?
a)
High-dose intravenous penicillin
Not enough coverage (most common Cx is E. coli, Bacteroides, and staph…)
b)
Hyperbaric oxygen therapy
An adjunct, and a controversial one. Certainly not initial therapy.
c)
Intravenous piperacillin / tazobactam
Could go for pen (for G+ and C. perfringes) plus aminoglycoside or 3g cephalo for
gram negs, plus anaerobe coverage with metronidazole or clinda.
d)
Suprapubic catheterization
May become necessary, depending on extent. But not initial therapy for this pt.
e)
Surgical debridement
Almost certainly necessary, but not the initial treatment.
Scrotal Abscess
• Must differentiate between abscess
of the skin (hair follicle
carbuncle/furuncle) vs. Abscess of
scrotal contents
– Skin abscess Rx: I&D, no abx
– Intra-scrotal abscess can be a
complication of epididymitis
• Ultrasound can help to distinguish
• Must differentiate from Fournier’s
– Low threshhold for Urologic Consultation
Fournier’s Gangrene
• Surgical Emergency
– Extensive tissue loss and increased
mortality with delayed diagnosis
• Cause:
– Polymicrobial infxn of subcutaneous
tissue that originates either in the skin,
urethra, rectum
– Immunocompromised at risk (DM,EtOH, IVDA,
chronic steroids)
• Findings:
– Can start as a benign infection or abscess
– Quickly becomes “virulent” with crepitus
– Always consider this in any pt with scrotal,
rectal or genital pain or tachycardia out of
proportion to clinical findings
Question 5
In the treatment of a 3 year-old boy with UTI, which of the following
additional signs is the strongest indication for hospital admission?
a) Localized myalgias
whatever
b) Maculopapular rash
not really associated with UTI at any age
c)
Marked fever
no – this is often the presenting symptom
d) Mucoid diarrhea
may help distinguish UTI from AGE at this age, shouldn’t affect dispo
e) Persistent vomiting
Vomicking  unable to take ABx, mandates IV therapy and admission
Question 6
A 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?
a) Order a urine culture and treat with an appropriate ABx for 3 days
Rosen’s and Tintinalli say no culture is necessary, only 10-20% will fail empiric tx
b)
Order a urine culture and treat with an appropriate ABx for 7 days
Not pregnant, not a male, not elderly, not diabetic, no hx of prior UTI’s…
c)
Treat with an appropriate ABx for 3 days
Empiric therapy without UCx is appropriate if no risk factors for complications
d)
Treat with an appropriate ABx for 7 days
3d is enough. Use local abiogram to guide ABx choice.
e)
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.
Urinary Tract Infection
• Cause:
– E.coli (90%), Klebsiella, Proteus, Enterobacter (5-20%
combined)
– Males usually secondary to urologic disease
• Dx:
– Sxs + 100 CFUs of single pathogen
• Relapse = same organism & serotype,
< 1 month since initial infection
• Reinfection = recurrence of sxs 1-6 months
after initial infection, usually different
organism
UTIs: Deeper Thoughts
• Complicated UTIs
– Underlying urologic pathology, pregnancy,
immunocompromised, usually not E.coli
• Asymptomatic bacteriuria:
– Can progress to symptomatic infection,
especially in pregnancy
• Acute Urethral Syndrome
– +Dysuria, but with low (or no) bacterial count in urine cultures. UA
often positive.
– Generally indicates infection & should be treated
• Dysuria Ddx: chlamydia, herpes, GC, vaginitis
UTIs: 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 urine
• Pyuria = 2-5 WBC in females,
1-2 WBC in males
• Bacteriuria = any bacteria in an uncentrifuged
gram stain smear, or > 15/HPF in
centrifuged specimen
• Chlamydia infection can be associated with low
WBC and low bacterial counts
UTIs: When to Culture?
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Pyelonephritis, recent hx pyelonephritis
Underlying urologic pathology
Children, Males
Diabetics, Immunocompromised
Recent Instrumentation, Indwelling catheter
Prolonged Sxs prior to Rx
3 or more UTIs in the past year
DO NOT need to culture young, healthy women with
uncomplicated UTIs
DO need to r/o other sources of pyuria/dysuria: STDs,
prostatitis, pyelonephritis, epididymitis
Adult UTI Treatment
• Female, lower tract,
nonrecurrent, simple
– TMP/SMZ BID x 3d
– Quinolone x 3d
• Female, lower tract,
complicated / or Male,
upper tract
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TMP/SMZ x 10d
Macrobid x 10d
Cefadroxil x 10d
Amox/Augmentin x 10d
Quinolone x 10d
• Female, lower tract,
suspected STD
– Doxycycline x 10d
– TMP/SMZ x 10d
– Erythromycin x 10d (E.coli not
covered)
– culture for chlamydia, GC
• Think Pseudomonas in highrisk patients
– Cover with broad spectrum
Abx
High-Risk
Pyelonephritis
• Pregnancy:
– Incidence of pyelonephritis increases in the 3rd trimester and may
precipitate preeclampsia, sepsis & miscarriage
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DM, Sickle Cell Anemia
Renal Calculi / obstruction
Elderly / Debilitated
Carcinoma, Chemotherapy
Recent hospitalization
Recent instrumentation of UT
Pyelonephritis = leading cause of perinephric abscess
Question 7
A 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:
a) azithromycin
this is not chlamydial urethritis or PID! (chlamydia is #1 reported STI)
b)
ceftriaxone
this is not gonococcal urethritis or PID!
c)
fluconazole
if it were fungal, they would have said cottage cheese..
d)
levofloxacin
this is not a UTI! and levaquin has poor anaerobe coverage…
e)
metronidazole
therapy 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).
Gardnerella (BV)
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New term: Anerobic Vaginosis
Gram negative rod, faculatative anaerobe
“fishy” order, rather than maldorous
Clue 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.
Trichomonas
Women: Frothy, grey, malodorous
Men: asymptomatic, urethritis
Drop it on slide: see swimming things
Word STRAWBERRY: GOES WITH TRICH
Other strawberries: tongue
A 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 partner
Single dose therapy
In Pictures: look like fat sperm
Candida
• Yeast
• Risk factors:
– diabetes (common presentation of new onset DM)
– contraception
– antibiotics
• Cottage cheese, no smell
• Drop on slide: KOH dissolves other elements, leaves
behind hyphae (spaghetti) and spores (meatballs)
• RX: single treatment of fluconazole, or lotrimin
suppository
Question 8
A 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) A physician who can provide followup care
It’s hard to discharge PID: Poor followup, adolescence, HIV, N/V, ambiguity…
b)
Pelvic abscess
Um, no. This would be a reason for IV ABx, admission
c)
Positive urine pregnancy test
No. Pregnancy should actually protect against PID – this presentation is ominous.
d)
Already taken antibiotics for similar complaints
So they’ve failed outpatient therapy and need IV ABx and admission
e)
Temperature greater than 38.8C
Fever is not uncommon but I guess the PEER folks found this concerning
PID/Salpyngitis
Causes: Neisseria gonorrhoeae, chlamydia
trachomatis (#1), Gardnerella vaginalis,
anerobes
• Ascending disease: starts in cervix, goes
through tubes
• Risk Factors: anything that mucks up the
tubes. Previous PID, IUD, adolescent
w/multiple partners
PID, continued
• Can’t be ruled on physical exam. FORGET CMT
• CMT, adnexal tenderness, elevated temperature,
discharge
• DON’T NEED TO ADMIT ALL PATIENTS Consider for:
– Pregnancy—this is very uncommon
– Immunosuppressed
– IUD
– Clinically ill
– Outpatient compliance issues
– Fertility issues
– TOA
– peritonitis
More on PID
• Cervical culture not correlates with actually causative
organism. Treatment always empiric
• Complicatons:
– Chronic pain/dyspareunia
– TOA
– infertility (most common cause of infertility)
• Fitz-Hugh-Curtis: RUQ pain w/o biliary disease
– Watch out in RUQ pain questions on boards. What is the
next thing you do? answer is pelvic exam
– F-H-C catch phrase: violin strings (adhesions between
capsule of liver and abdominal wall)
PID
• Rx: treat Gonorrhea and chlamydia.
– Gonococci: ceftriaxone/cefuroxime or quinolone
(single dose)
– Chlamydia/anaerobes: doxy 10 days (slower
turnover rate)
If recurrent/chronic/fails treatment, think
anaerobes. FLAGYL
Question 9
The side effects of emergency contraception meds can be reduced by:
a)
Avoiding their use in smokers
Risk of VTE goes up with OCP use and age over 35, obesity, and smoking
b)
Peri- or post-ovulatory administration
Actually there’s theoretical risk of ectopic here – the P might cause ciliary dysfxn.
c)
Taking the pill before a meal
Symptoms of n/v, headache, fatigue are benign. Abd pain must get ectopic w/u
d)
Using a progestin-only regimen
WHO ‘98 says P dosing within 72 hours is more effective than Yuzpe, fewer AE
e)
Using combination pills with both estrogen and progestin
Yuzpe ‘74 method is two E+P doses, twelve hours apart, within 72 hours of sex.
Miscarriages (definitions old fashioned)
• Threatened: if pain and bleeding but os is closed.
Both internal and external have to be closed
– Instructions: don’t put anything in your vagina
• Inevitable: same thing, but os open
• Incomplete: passed some, not all tissue (at the os)
• Missed: baby dies, don’t have abortion. Not
common.
Abortions, cont.
• Board question: if missed situation described
& pt has fever: septic abortion.
– Worry about DIC in these cases
– polymicrobial
• Septic abortion: most common is
polymicrobial (“polymicrobial” also associated
with diabetic foot ulcer questions)
Question 10
A 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?
a)
Admit for observation
Lots of overlap between appendicitis (nausea, WBC, pain) and pregnancy.
b)
Discharge with instructions to return in 12 hours for repeat exam
This is a high-risk patient who should not leave.
c)
CT of abdomen and pelvis
Risk to fetus is low, but specialists’ input is preferable.
d)
Consult surgery and OB
She’s febrile and pregnant with abd pain. They’re going to need to get involved.
e)
Start IV fluid hydration and observe in the ED for six hours
Delaying the diagnosis of appy can lead to increased M+M, fetal loss (up to 20%)
Safe 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  teratogen
• Weeks 8-15: Neuro development at risk
• Weeks 15+ … much less risk
Question 11
Which of the following conditions is most likely to be associated with
a hydatiform mole?
a) Abdominal pain
It’s not more common than pain with normal pregnancy
b) Abnormally low beta-hCG
Not an ectopic! beta-hCG will actually be much higher than dates suggest
c)
Hyperemesis
Most likely to be associated with the Mole.
d) Hypothyroidism
The Mole will make its own thyroid hormones, may trigger pre-eclampsia
e) Vaginal discharge
May present with bleeding, sure. Also see large uterus, large ovaries, may be
passing grape clusters (hydropic villi).
Molar pregnancy
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Associated with Asians, first pregnancies, teens or 40’s
1st and 2nd trimester bleeding
The only possible cause of first-trimester pre-eclampsia
Chorionic villi tumor, not actually a fetus
46XX 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
Normal pregnancy
• Morning sickness: associated with good overall
outcomes
• 12 wks: pelvic brim
• 20 wks: umbilicus
• Highest at 36th week, then fundus descends
• Increased CO 20-30%
• Most women get a hydronephrosis of pregnancy
• Chadwick’s sign: soft, blue cervix (venous, ok)
• Rabbit done died?
Human Chorionic Gonadotropin
• Doubles every 48-72 hours
– Becomes positive after implantation, about a
week (8-9 days) after intercourse
– After first missed period, you will be positive
– Miscarriage: works in reverse. Gets cut in half
every 2-3 days.
Pregnancy Complications
• Appendicitis: most common surgical condition
in pregnancy (same incidence as in agematched nonpregnant patients).
• Difficult to diagnose: already have increased
wbc, appy in RUQ
• UTI in preg: consider as upper tract infections.
Longer course (10 day), send culture
• If pyelonephritis, admission +/- if sick
Question 12
Which of the following is a characteristic of the HELLP syndrome?
a) Increased LDH
Why not HELLDHLP? Hemolytic anemia implies elevated LDH
b) Neurologic symptoms
May help distinguish HELLP from TTP (but bad HELLP can cause seizures)
c)
Normal antithrombin III
Helps distinguish HELLP (low) from TTP, HUS (normal)
d) Occurs early in pregnancy
Occurs late, and 30% postpartum (TTP occurrence is even throughout preg)
e) Renal symptoms
Helps distinguish HELLP from TTP (but bad HELLP can cause ARF)
Preeclampsia
• Proteinuria > 300 mg in 24 hours +/- edema
• Hypertension (140/90 or 30/15 over baseline)
• Presents as headache, blurry vision, CNS changes,
or just HTN
• After 20 weeks, unless molar pregnancy
• Risk Factors:
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–
–
–
Primagravids and grand-multiparous
DM
Age
Obesity
HELLP Syndrome
• Hemolysis, Elevated Liver enzymes, Low
Platelets
– Variant of pre-eclampsia
– May present as epigastric/RUQ pain
– Hemolysis: schistocytes on peripheral smear
– Abnormal coagulation profile
Eclampsia
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Pre-eclampsia + seizure: eclampsia
Headache, CNS, visual changes, hyperreflexia
Worse w/poor prenatal care, DM, obesity
Rx: magnesium sulfate, hydralazine
Definitive treatment is DELIVERY
Not the same as primary hypertension: more like
withdrawl htn, pheo. Don’t use typical drugs!
• Beta-blocker contraindicated: “unopposed alpha
stimulation”
Ectopic Pregnancy
• Leading cause of first trimester maternal death
• 2nd in $$ for claims against EM docs
• Risk factors: Anything that mucks up your tubes
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–
–
–
–
PID
previous ectopic
IUD
tubal surgery
Infertility treatment
• ?Unilateral, ?intermittent pain (95%)
• bleeding (80%, not constant) 5-8 wks after LMP
Ectopic Pregnancy
• Region: distal ampulla of fallopian tube (90%)
• Need positive hcg
• Then do ultrasound
Ectopic workup
• Indicators of IUP, all should be visible on TV by 5-6 weeks:
– yolk sac
– fetal heart
– fetal pole
• Heterotopics: 1:30,000 (but 5x higher if on fertility treatment)
• If not IUP
– Too early
– Ectopic
– Abnormal IUP
• Get quant hcg.
– If above discrim zone (1000-2000, 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.
Ectopic, cont.
• Happen at around 4-5 wks
• Culdocentesis: rarely used. The positive is
NON CLOTTING BLOOD
• Indication 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.
RhoGAM
• 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 weeks
• Test for mixing: Kleinhauer Betke: look for
nucleated RBC (of fetus) in maternal blood
Third 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 this
– Risk factors: HTN, older, multitip, smoke, cocaine
• Previa: painless, bright red.
– Ultrasound always helpful
– Don’t do pelvic exam in this situation
– Admit, stabilize, RhoGAM if Rh-Neg, C-section if
remains unstable
Question 13
A 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…
a)
Acetaminophen
Safe in pregnancy (B) and breastfeeding (“Safe”)
b)
Caffeine
Safe in pregnancy (C?) and breastfeeding (“N/A”)
c)
Ergotamine
Passes through milk, causes v/d and seizures in infants.
d)
Morphine
Passes through milk at 1% of maternal dose, no adverse affects reported
e)
Promethazine
Phenergan is C: Safe in pregnancy, “potentially unsafe” in breastfeeding
Safe drugs in pregnancy
•
•
•
•
•
•
FDA ranked A,B,C,D,X (low risk→high risk)
Most asthma meds (steroids, albuterol, etc.)
HTN: beta blockers, calcium channel blockers
Heparin (not warfarin)
Killed vaccines (tetanus)
Antibiotics: PCN, cephalosporins, clinda, INH,
ethambutol
Safe drugs in pregnancy
• Meds in pregnancy:
– Almost nothing is category A (RCT shows no risk)
– Localize, topicalize if you can.
– Congestion meds: all C
– Antipyretics: Mostly B at first, D for third term
– Antiemetics: Doxylamine is A, ‘trons are B, all else C
– Antibiotics: Pen, Cephalos, Azithro, Vanc: B
– Analgesics: Oxycodone, Hydrocodone = B. Codeine C.
Question 14
A 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:
a)
Lorazepam 1 mg IV
Class D and not indicated for eclampsia (if pt had SE with hx of szs, sure…)
b)
Magnesium 6g IV over 20 minutes
IV beats IM. Keep levels between 4-7 mg/dL. Drip at 2g/hr. Check reflexes.
c)
Nifedipine 10 mg PO
Magnesium won’t control BP, but an oral agent has no role here.
d)
Phenobarbital 1g IV
Class B but not the solution here.
e)
Phenytoin 1g IV over 25 minutes
Class D and not indicated for eclampsia.
Safe drugs in pregnancy
• Midazolam, Diazepam are D
• Haldol, Droperidol are D
• Pentobarb, Ketamine are B
• Lidocaine, 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.
Trauma in Pregnancy
• Initial trauma care same as non-pregnant
• Causes of fetal death: #1 maternal death, #2
abruption
• Remember RhoGAM
• No radiologic test should be withheld for
appropriate maternal evaluation
Trauma in Pregnancy
• Fetal monitoring >20 weeks
–
–
–
–
Minimum of four hours
Signs of fetal distress
> 8 contractions/hour suggest abruption
Kleihauer-Betke test (fetal-maternal hemorrhage)
• For hypotension—turn pt to left side (to displace
uterus off IVC), fluid bolus
Maternal stabilization is the most important factor in
determining fetal survival
Safe 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  teratogen
• Weeks 8-15: Neuro development at risk
• Weeks 15+ … much less risk
Pre-term Labor
• Labor at 20-35 weeks
• Sterile speculum
• Risk factors: multiple births, DES, cocaine, PIH,
abruptio, alcohol, smoking
• Admit, IV Fluids, bed rest, tocolytics (mag,
terbutaline … you won’t be giving…)
Premature Rupture of Membranes
(PROM)
• Rupture >20 weeks and prior to labor
• Nitrazine test: blue (positive)
• Sterile speculum exam: ferning (due to high
quantity of salts in amniotic fluid)
• Avoid bimanual
• Risks: Infection, premature labor, prolapsed cord
• Admit them, they’re not going. Start monitoring
in the ED, consider tocolytics.
Umbilical Cord Prolapse
•
•
•
•
Seen in up to 8%, but perinatal mortality: 50%
Pulsating cord on exam
Put patient in knee to chest position
Emergent c-section
Stop the delivery, elevate the presenting part,
Trendelenburg can help, but call GYN
Amniotic Fluid Embolism
• 2nd/3rd Trimester
• Immune response to amniotic fluid in circulation
• First described in 1941. More like anaphylaxis?
• Shock, bleeding, dyspnea, hypoxia, coagulopathy
• Mortality = 50% at 1 hour, 80% at 4-5 hours
• All we can really do is pressors, FFP, maybe HD,
emergency C-section
Fetal Distress
• Fetal hypoxia and/or acidosis
• Late decels (early decels expected with
contractions)
• Severe variable decels are concerning
• Decreased variation is concerning
• Treatment: left lateral position, oxygen, IV fluids,
consider delivery (emergency C-section)
Late Decelerations
Delivery
Ask yourself:
What is GA? (betamethasone if < 34 weeks)
How many feti?
Meconium + resp depression  ET intubation
History of maternal drug use? Consider narcan
8 stages: Head out by stage 3-4, then anterior
shoulder, then posterior shoulder
Wait 30 min for placenta, pull gently, check it
Dystocia
•
•
•
•
•
Difficult labor
Abnormal fetal presention
Cephalopevlic disproportion
Gestational diabetes
Treatment:
– Fetal manipulation (could cause brachial plexopathy)
– Suprapubic pressure
– Generous episiotomy
APGAR Score
• Indicator of neonatal depression
• Measured at 1 and 5 min
• Appearance (color), Pulse, Grimace (reflex),
Activity (tone), Respiration
• Score 0-2 each
Emergency C-section
• Maternal cardiopulmonary arrest
• Indicators of fetal survival
– Cause of maternal death
– Quality of CPR
– Gestational Age (>23 weeks)
– Arrest to delivery time (after 20 minutes, survival
is unlikely)
• Vertical abdominal and uterine incision
Question 15
Which of the following is the least likely risk factor for postpartum
endometritis?
a)
Cesarean delivery
C-section is actually the biggest risk factor.
b)
Chorioamnionitis
Really, any opportunity for bacteria to get into the uterus is a risk factor
c)
Many vaginal exams during labor
So this is also a risk factor
d)
Time since rupture of membranes
And this is, too.
e)
Urinary tract infection
UTI is on the differential, naturally, but no obvious way for bacteria to go from
here to uterus… thus, not a risk factor
Endometritis
•
•
•
•
•
Diagnosed by H+P, fever, uterine tenderness
WBC, Cx, sono/CT may support diagnosis
Polymicrobial, foul smelling, fever
High rate in c-section patients
Risks
–
–
–
–
–
PROM
Prolonged labor
Chorioamnionitis
Multiple exams
Internal monitoring devices
• Treat outpatient with doxy or clinda, with low threshold for
admission and IV cephalosporins
Mastitis
• Pain, erythema, swelling
• Staph infection.
• Nurse with other breast, express milk, anti
staph treatment (cephalosporin,
erythromycin)
Question 16
A 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:
a)
Lower genital tract laceration
You would see this on exam, and there’d be no bleeding FROM os…
b)
Normal menses
Not 1 week out, not in a breastfeeder…
c)
Retained placenta
Many causes of postpartum hemorrhage, this one fits best. Visibile on sono. D+C indicated.
d)
Uterine atony
Would be boggy or doughy. Most common cause of immediate postpartum hem (ie, 24 hr)
e)
Uterine rupture
This would present as continued bleeding despite firm tone. More pain and irritation.
Postpartum Hemorrhage
• Uterine atony
– Most common cause in first 24 hrs
– Risks: overdistended uterus, prolonged/precipitous labor,
high parity
– Treatment: fundal massage, oxytocin, IV fluids
• Ruptured uterus
–
–
–
–
Seen with Previous c-section, excessive pressure, trauma
Tachycardia, hypotension, bleeding, absent heart tones
Fluid resuscitation, immediate c-section
Consider hysterectomy
Postpartum Hemorrhage
• Retained placenta
–
–
–
–
Early or delayed post-partum hemorrhage
Sudden, brisk, painless bleeding
Boggy, enlarged uterus
Oxytocin, D&C, fluid resuscitation
• Uterine inversion
–
–
–
–
Excessive traction on umbilical cord
OB emergency- IV, 02, tocolytic drugs
Do not separate placenta
Manual reimplantation or emergent laparatomy
• Lower genital tract laceration
• Coagulopathy (von Willebrand)
Lymphogranuloma Venereum
• Organism: Chlamydia
trachomatis
• S/Sxs primary infection:
– Uncommon in U.S.
– Primary lesion followed by inguinal
buboes
– Buboes grow and rupture or form
firm inguinal masses
• Rx: Doxycycline
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Lymphogranuloma Venereum (LGV)
•
•
•
•
Caused by certain serotypes of Chlamydia
1-3 week incubation (vs days with herpes)
BUBOES=painful inguinal nodes
Usual scenario: Swollen gland in groin, a little
bit sick with it—fevers, chills, myalgias
LGV
• No high fevers/non-toxic
• Catchphrase: obligate intracellular organism,
similar to virus. Doesn’t turn over quickly.
Subacute disease process
• Use doxy or macrolide
• Since it turns over slowly, should do extended
course (21 days)
• Complications: urethral scarring
Chancroid
• Organism: Haemophilus ducreyi
• S/Sxs primary infection:
– Tender painful papule followed by ulceration
– Multiple lesions may be present, and
coalesce
– Painful inguinal adenopathy in 50%
– May evolve to buboes and rupture
• Culture Lesion
• Rx: azithromycin, ceftriaxone (single
dose of both)
QuickTime™ and a
TIFF (U ncompressed) decompressor
are needed to see t his picture.
Chancroid
• Gram negative bacillus: Haemophilus ducreyi
• Seen in developing countries
• Incubates over 2-5 days
• Vesiculo-pustulo, develops into ulcer
+
= CHANCROID
Chancroid, continued
• Painful (Painless: primary syphillis)
• Penis picture: must have pain clue!
• Treatment: macrolide usually not wrong
– Azithromycin, erythromycin, ceftriaxone
Gonococcal Urethritis
• Organisms: N. gonorrhea, associated with chlamydial
infection (30-50%)
• S/Sxs:
– Copious yellow pus
– Virtually always symptomatic (dysuria)
• Tests:
– Gram-neg intracellular diplococci, send GC
– Consider testing for syphilis
– Test both partners
• Rx: Treat for G & C
– IM Ceftriaxone, or fluoroquinolone, or
one-dose cefixime + azithro
Non-gonococcal urethritis
• Organism: usually Chlamydia (the most common STD)
– Less commonly Ureaplasma, herpes, trichomonas, candida
• S/Sxs:
– Watery discharge, or no discharge
– No leuks on smear (in 30%)
– Often asymptomatic
• Tests:
– PCR or enzyme immunoassay
• Rx: 1gm azithromycin once or doxy 100mg BID x 10d
Chlamydia
• #1 sexually transmitted disease
• Major cause of female infertility
• Symptoms of local disease:
–
–
–
–
–
–
Discharge
Dysuria
Women: cervicitis, urethritis, PID
Men: epididymitis, urethritis, proctitis
Vag bleeding
Asymptomatic 3-20%
• Rx: azithromycin, doxycycline
Condyloma Acuminatum (venereal warts)
•
•
•
•
Human Papilloma Virus
1-3 month incubation
Related to cervical carcinoma
Soft, vegetative clusters: Think
cauliflower/broccoli
• Transmitted through direct contact
Condyloma 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
Herpes
• Organism: Herpes Simplex (HSV-1
or 2)
• S/Sxs of primary infection:
– Painful pustular or ulcerative lesions
– Constitutional sxs common
(headache, fever, myalgias)
– Lymphadenopathy (80%)
• Rx: Acyclovir 200mg 5x/day for
10d
Genital Herpes
• Type 1: above waist, type 2 below waist
• This is not always true, but 60-80% of genital
lesions are type 2
• All primary infections present like a
generalized infection: they have
fever/flu/adenopathy
• Lesions develop at 2-8 days: shallow, painful
vesicles
HSV, continued
• Differential dx: mono, primary HIV
• Primary infection is worst, infection gets
better, then it breaks out from nerves.
Relapses associated with stress
• Tzacnk smears: scraped from BASE of vesicle in
epithelial cells. Multinucleate giant cell the
key phrase
HSV
• Active at time of birth: need GYN consult
• Rx: -cyclovir. Indicated for primary symptoms,
immunosuppressed. Also decreases relapse
• Complications: a good question, not obvious. Young
person, febrile, jaundice…not hep virus but herpes!
– Hepatits, meninigitis, encephalitis, cervical CA,
– Erythema multiforma also a known rash
– Urinary retention: invasion of virus into sacral root ganglia.
Not from pain. In young women with urinary retention,
think herpes!
HSV
• The classic picture of herpes lesion: Clustered
vesicles on erythemetous base (Hand:
herpetic whitlow)
• Tzank smear confusion:
Inclusion body= Chlamydia
Gonorrhea… “The clap”
• Localized disease symptoms:
– Discharge
– pain with urination
– Cervicitis, urethritis, proctitis,
PID
– Vag bleeding
– Abdominal/pelvic pain
– Asymptomatic
• Rx: single dose therapy
– Cefixime, ceftriaxone, quinolone
Gonorrhea
Complications of untreated disease
•
•
•
•
PID
Epidiymitis/orchitis, prostatitis
Eye infection
Disseminated gonococcal disease
– Skin lesion: tender pustule on
erythemetous base
– Arthritis/tenosynovitis
– Endocarditis
– meningitis
• Organism: Treponema pallidum
• S/Sxs of Primary Syphilis:
–
–
–
–
Painless chancre
Indurated borders
No constitutional sxs
Minimal adenopathy
• Dx: by darkfield microscopy, VDRL,
FTA-ABS (to confirm)
• Rx: 2.4MU benzathine PCN G IM
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Syphillis
Secondary Syphilis
Syphilis
• Treponema pallidum (spirochete)
• 3 different stages
• Primary
–
–
–
–
–
PAINLESS ULCER on penis (chancre)
RPR, FTA, VDRL negative in 1st stage
Look for the positive dark field
Resolves spontaneously
Rx: PCN
Secondary syphilis
• Rash in young health person, not very sick: also think
mycoplasma, pittyriasis rosea
• Low grade fever, not too itchy
• Palms and soles: others: gonnococcus (pustules), EM,
RMSF, allergic reactions/contact dermatitis
• Condyloma latum
• Some fever, some painless adenopathy
Secondary Syphilis
Tertiary syphilis
• Bites you when you’re an old man, 25 years after primary
infection
• CNS
– Tabes dorsalis
– Neuropathy
– Meningitis
• Cardiovascular syphilis
– aortic aneurysm
• Skin lesions: gummas
• Benzathine 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
Syphilis
• Chancre- painless papule- hallmark of primary
syphilis
• 2ndary syphilis 4-10 weeks- macular rash- trunk 
extremities- palms + soles oral lesions grey painless
ulcers
• Tertiary syphilis-untreated for years- 2 typesneurosyphilis after 10 yrs-meningovascualar
vasculitis of vertebral or spinal vessels or tabetic
syphilis-demylination and ataxia
• Cardiovascular only after 20-40 yrs usually thoracic
aorta- aortiv valve insufficiency
STI’s
• Condyloma lata-secondary syphilis- typically-large painless flat
topped lesions-typically in anogenital region
• Condyloma acuminata- genital warts – HPV – pink to grey
keritanized with papilliform growths
• Gonococcal proctitis- tenismus, anal itching and yellow
discharge
• Granuloma inguinale- bacterial infection with
Calymmatobacterium granulomatis-painless papules beefy
red ulcers with rolled edges
• Chancroid- Heomophilus Ducreyi- painful genital ulcer-
Ovarian cysts
• Get terminology straight!
– Follicular cyst (before egg released), about 3 cm
– Corpus luteum cyst (after egg released, or
pregnant)
• Nothing bad happens, unless >3 cm…can have
torsion, rupture and bleeding!
Ovarinan/Adnexal Torsion
• Twists around pedicle
– Must be tumor or large cyst to do this
– Dermoid cyst most common
•
•
•
•
•
Severe unilateral pain, nausea, vomiting
Sometimes bleeding, but not impressive
Unilateral tenderness
Diagnosis: ultrasound, laparoscopy
Differential: ectopic, IUP, appendicitis, PID
Ovarian tumor
•
•
•
•
•
Post menopausal
Usually advanced stage when diagnosed
2nd most common gyn malignancy
Mass on ultrasound
Refer
Endometriosis
• Endometrium outside of the uterus
– Abdominal pain, cyclical in nature
– Most commonly on ovary, but can occur anywhere
in abdomen, even in lung! Get cyclical
pneumothorax
• Treatment: hormonal therapy
Uterine cancer
• Most common GYN cancer
• The case: Old lady with vag bleeding
• Risk factors
–
–
–
–
–
Continuous estrogen
Obesity
Diabetes
Hypertension, nulliparity
Late menopause
• Pap smears don’t work for this
• Refer to gyn
Uterine prolapse
• Herniation into vagina
– Post menopausal,
multiparous women
• Think they have alien
in their vagina
• ED Rx: reduce it! f/u
gyn for possible
surgery
Dysfunctional Uterine Bleeding
• Think of anovulatory cycles due to hormonal
imbalances.
• Most with starting periods (menarche),
stopping (menopause)
• Consider cancer
• Cycle with hormones, D&C
Sexual assault/
Post-exposure prophylaxis
• You have to consider it in every case, but not
necessarily do it in every case
• Plan B (levonorgestrel): give 1 dose now, then
another in 12hrs
• Not 100% effective, gets less effective with more
time from assault
• Works up to 3 days after sexual activity
• Nausea and vomiting common
• Consider in SA
SA considerations
•
•
•
•
Check for preg: underlying pregnancy
HIV test: same as above
Syphilis serology
3 ways to tell if there was intercourse with
ejaculation:
– Acid phosphatase (in seminal fluid)
– P30 (seminal marker)
– Looking for motile sperm