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Emergency Medicine Clerkship > GU > Flashcards

GU Flashcards

1
Q

Risk factors for ectopic pregnancy?

A 
Hx PID
Hx ectopic pregnancy
Tubal surgery including BTL
Previous pelvic or abdominal surgery
Tubal pathology
In utero DES exposure
IUD
Smoking
Infertility/infertility Rx
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2
Q

Classic presentation of ectopic pregnancy?

A

Abdominal pain, delayed menses, vaginal bleeding

Remember that paradoxic bradycardia can occur in ectopic pregnancy, so vital signs should not be reassuring.

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3
Q

Initial actions and primary survey in ectopic pregnancy?

A 
ABCs
Pregnancy test
Monitor, 2 large bore IVs
CBC, T&S, quantitative beta-hCG
Narcotic analgesia
Immediate bolus of NS if ill-appearing, severe pain, or abnormal vitals
Consider O- transfusion if hypotension
FAST exam if concern for rupture
Bedside pelvic US

Call Ob-Gyn immediately if +FAST with +pregnancy test

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4
Q

Diagnostic work-up in stable patients with possible ectopic pregnancy?

A

TVUS to evaluate for the presence or absence of an IUP. If visualized, concurrent ectopic pregnancy is statistically unlikely unless the patient has received fertility treatments.

Beta-hCG

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5
Q

Signs of IUP on TVUS?

A 
Earliest - double decidual sac sign (4.5-5 weeks after LMP)
Yolk sac (5-6 weeks)
Fetal pole and embryonic cardiac activity (6-7 weeks)
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6
Q

What has a 100% predictive value for IUP?

A

Yolk sac

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7
Q

Discuss interpretation of quantitative beta-hCG levels in early pregnancy.

A

Produced by trophoblasts, doubles Q48-72 hours in T1.

Discriminatory zone for when an IUP should be visible on TVUS: 1500-2000 mIU/mL

Ectopic is highly likely if level >1500 with absence of IUP on TVUS

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8
Q

If ectopic pregnancy is not ruled out in the ED, what can be done?

A

Outpatient OBG - serial US with serial serum quant beta-hCG levels. Rise in level slower than expected is highly suspicious.

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9
Q

Rx ectopic pregnancy?

A

If unstable - surgery

Fluid and blood resuscitation, pain management, OBG consultation

RhoGAM if Rh-negative

MTX (medical management) - can give 2 doses if 1st dose fails

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10
Q

Contraindications to MTX in ectopic pregnancy?

A

Hemodynamic instability, inability to follow-up, breastfeeding, immunodeficiency, renal/liver/pulmonary disease, PUD, blood dyscrasias

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11
Q

Initial actions and primary survey in patients with suspected PID?

A 
Pelvic exam
Pregnancy test (if pregnant, consider other causes of pelvic pain, as PID is less likely in pregnancy)
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12
Q

Classic presentation of PID?

A

Bilateral lower abdominal pain
Purulent vaginal discharge (vaginal bleeding less frequently)

Symptoms begin shortly after the start of the menstrual cycle when there are fewer defenses by the mucosal barrier to ascending infections

N/V, general malaise

Hx STDs, multiple sexual partners, IUD use, adolescence, sexual intercourse at an early age, recent instrumentation of the uterine cavity

Bilateral adnexal tenderness, purulent cervical discharge, cervical motion, uterine, lower abdominal tenderness

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13
Q

What physical exam finding suggests tubo-ovarian abscess?

A

Unilateral adnexal tenderness or fullness with PID symptoms

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14
Q

What physical exam finding suggests Fitz-Hugh-Curtis?

A

RUQ tenderness with PID symptoms

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15
Q

Dx testing for PID?

A

UA
CBC with diff
LFTs (if FHC is suspected)
PCR or DNA testing for CG (more sensitive than culture, can be run on cervical secretions or urine, more rapid)
Pelvic US if TOA is suspected or if diagnosis is unclear (r/o other diseases)
CT (not preferred, often ordered if appendicitis or other intraabdominal pathology is suspected)

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16
Q

Diagnose PID?

A

Negative pregnancy test + elevated WBC with fever, bilateral adnexal tenderness, and mucopurulent cervical discharge -> certain diagnosis

PCR positive for G/C in appropriate clinical setting

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17
Q

Who gets empiric Rx for PID?

A

All patients who meet minimum clinic criteria for PID (lower abdominal or pelvic pain + adnexal, uterine, or cervical motion tenderness in an at-risk patient with no other discernible cause)

18
Q

Complications of PID?

A

Chronic pelvic pain, dyspareunia, infertility, ectopic pregnancy, TOA, FHC syndrome

19
Q

Rx PID inpatient?

A

-Cefoxitin or Cefotetan 2g IV Q6hrs with Doxycycline 100 mg PO or IV Q12hrs

OR

-Clindamycin 900 mg IV Q8hrs with Gentamicin (if allergic to cephalosporins)

OR

-Unasyn 3g IV Q6hrs with doxycycline 100 mg PO or IV Q12 hrs

(Always give doxy PO when possible)

20
Q

Rx PID outpatient?

A

Ceftriaxone 250 mg IM OR Cefoxitin 2g IM

and

Probenecid 1g PO

and

Doxycycline 100 mg BID for 14 days

Must add metronidazole 500 mg BID for 14 days if more severe infection or history of uterine instrumentation within 3 weeks

21
Q

Indications for admission in PID?

A 
Suspected TOA or FHC syndrome
Intractable vomiting
Septic patients
Peritonitis
Prepubertal children
Women with indwelling IUD
Pregnant patients

Strongly consider if nulliparous to preserve fertility, as well as women with comorbidities such as DM or HIV/AIDS

IUD removal after initiaiton of ABX

22
Q

DC instructions for PID treated outpatient?

A

Avoid sexual contact
Refer partners for treatment
Follow-up in 72 hours unless symptoms worsen
STD testing

23
Q

Initial actions and primary survey in suspected ovarian torsion?

A

Vitals and IV access
Focused H&P
US to assess for vascular flow
Consult gynecology early if torsion is suspected

24
Q

DDx - ovarian torsion?

A 
Ovarian cyst
TOA
Ectopic pregnancy
Appendicitis
Kidney stone
25
Q

Pathophysiology of ovarian torsion?

A

Ovary (and often the fallopian tube) twist around the vascular pedicle -> obstructs venous flow -> engorgement and edema -> arterial flow compromise -> ischemia and infarction

26
Q

Classic presentation of ovarian torsion?

A

Unilateral lower abdominal pain (initial visceral) +/- N/V, may radiate to groin or flank

May have several episodes over hours, days, or even weeks if intermittent torsion

Hx of prior cyst or mass, torsion, current pregnancy should increase suspicion

Lower abdominal tenderness
Adnexal tenderness or mass

Fever is uncommon, usually low-grade if present

27
Q

Dx testing for ovarian torsion?

A

Pregnancy test
UA (UTI, nephrolithiasis)
CBC (TOA)
US with Doppler (presence of blood flow does not exclude diagnosis)

CT is non-specific, may be helpful in ruling out DDx

28
Q

Most common US and CT finding in ovarian torsion?

A

Enlarged ovary

29
Q

Rx ovarian torsion

A

ABCs
IV line, treat pain and nausea
NPO
Surgery (best outcomes within 8 hours)

30
Q

Pathophysiology of testicular torsion?

A

Normally, the testicle is anchored within the scrotum by the tunica vaginalis, which surrounds the testicle and attaches posteriorly to the scrotal wall and epidiymis.

Tunica vaginalis consists of a visceral and parietal layer with an interposed potential space which allows the testicle to rotate about the spermatic cord if a firm posterior scrotal attachment is lacking. When the tunica attaches higher up on the cord, the testicle can move and twist within the scrotum (bell-clapper deformity)

Appendix testes are also prone to torsion

31
Q

Initial actions/primary survey in suspected testicular torsion?

A 
VS, IV access
Focused H&P
IV pain control
US
Consult urology early if torsion is suspected
32
Q

DDx - testicular torsion

A 
Appendix testis torsion
Epididymitis
Orchitis
Renal colic
Varicocele
Kidney stone
Appendicitis
Hernia
Hydrocele
Testicular trauma
33
Q

Classic presentation of testicular torsion?

A

Most common in the first year of life and at puberty; can occur at any age

Fairly sudden severe unilateral testicular pain, sometimes radiating to the abdomen, associated with N/V
Urgency, frequency, dysuria

L>R

Possible trauma

Exam: distress, trouble walking, exquisite tenderness/swelling, high-riding in scrotum, may have transverse lie

Absence of cremasteric reflex

34
Q

Dx testing for testicular torsion?

A

UA or urethral swab for GC if infectious epididymitis or orchitis is suspected

US with comparison of asymptomatic and symptomatic testes.

35
Q

Compare the age of presentation of testicular torsion vs. appendage torsion vs. epididymitis.

A

Bimodal peak (infancy and puberty)

7-14 years

Adult

36
Q

Compare the features of pain/associated symptoms of presentation of testicular torsion vs. appendage torsion vs. epididymitis.

A

Entire testicle, onset over hours; assc. with nausea

Upper pole of testicle, onset over hours to days; no assc. symptoms

Epididymis, onset over days; assc. with fever/dysuria

37
Q

Compare the physical exam findings of testicular torsion vs. appendage torsion vs. epididymitis.

A

Cremasteric reflex absent, diffusely swollen tender testicle

Cremasteric reflex present

Cremasteric reflex present, epididymal tenderness +/- testicular tenderness

38
Q

Compare the lab findings of testicular torsion vs. appendage torsion vs. epididymitis.

A

Not helpful

Not helpful

WBC, LE, nitrites

39
Q

Compare the US findings of testicular torsion vs. appendage torsion vs. epididymitis.

A

Affected testicle large and hypoechoic compared to asymptomatic side, decreased flow

Body similar to asymptomatic side with focal hypoechoic area

Body similar to asymptomatic side with hypoechoic epididymis

40
Q

Compare the Rx of testicular torsion vs. appendage torsion vs. epididymitis.

A

Surgical detorsion and bilateral orchiopexy

Supportive

ABX

41
Q

If you anticipate any delay in getting a patient with testicular torsion to the OR, what should be done?

A

Attempt manual detorsion (rotate away from the midline)

Emergency Medicine Clerkship (18 decks)

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