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Care of Adults Midterm


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Early Adolescence
Emotional break from parents, adjustment to physical change, unisex peer group, concrete thinking, begin to question parents' moral system.
Mid Adolescence
14-16. Unsure about separation from family, Sexual experimentation, Begin heterosexual peer group, Self centered.
Late adolescence
17-21. integrate independence with family ties. Begin to combine satisfying body image with personality, Individual relationships more important than peer group, Ability to abstract, Self centered idealism.
Between 11-21, how often should adolescents have a preventive service visit?
When should adolescents receive a complete physical?
Once between 11-14, once between 15-17, once 18-21. 3x in the time period.
Puberty in Girls
Develop 2 yrs before boys. Starts at age 8. Begins with breast buds.
Puberty in boys
Begins about 12. Testicle enlargement is usually the first secondary sexual change in boys.
Tanner staging girls
Secondary sex changes between 8-13. Tanner 2-5 takes about 3 yrs. Axillary hair usually appears 2 yrs after pubic hair. Menarch usually occurs when breasts are Tanner 3-4.
Tanner staging in boys
Increase in size of testes is first reliable sign and usually occurs between the ages 9-13.
Tanner 2-5 takes an avg. of 3 yrs.
Ejaculation occurs as boys approach Tanner 3.
Health Risks of teens
Preventable, r/t behavior and lifestyle. Accidental injury, suicide, sexual activity, substance, violence.
Communication with teens
Direct questions for young teens. Open ended questions for middle and late teens. No phony teen talk. private questions in private. History, immunizations from parents.
Infectious Respiratory problems
Viral rhinitis
Otitis Media and Externa
Non infectious resp. problems
Allergic rhinitis
Serous otitis
Eustachian tube dysfunction
hearing loss/change
Viral rhinitis
Rhinovirus, parainfluenza, RSV, coronavirus.
Major sx: nasal congestion, rhinorrhea, sneezing, cough, sore throat.
TX: analgesics, decongestants, antitussives, fluid, rest
Influenza Presentation
Abrupt onset of fever up to 105
headache, malaise,sore throat, cough.
PE:Fever, flushed,conjunctival inflammation, clear nasal discharge, hyperemic throat w/o exudate, tender cervical nodes
Influenza Treatment
Tamiflu is sx relief.
Amantadine or Flumantadine if seen in first 48 hrs of sx.
Treat sx.-decongestants, BR, fluids, tylenol.
F/u in 48 hrs.
Allergic Rhinitis
Sneezing, watery eyes, runny nose, postnasal drip, nasal congestion.
Exam-Pallor and swelling of conjunctiva. Pale turbinates. Allergic shiners, nasal crease, dull immobile tympanic membrane.
Treat Allergic Rhinitis
Avoid allergens. Antihistamines,decongestants (not in htn or glaucoma), Claritin or flonase otc.
Hx of URI>1wk. Teeth pain, puralent nasal drainage>1wk, congestion, cough, h/a, fever, facial pain eye pain.
Do neuro exam if headache.
Puralent exudate, red nasal mucosa, tenderness over sinuses. Hyperemic oropharnyx with green/yellow PND, Halitosis
Sinusitis diagnostics
Decreased transillumination, nasal culture, sinus xrays will show air:fluid levels
thickening of mucosa
sinus ct with consult.
Treat Sinusitis
Amoxicillin, Bactrim, cephalosporins, Biaxin* and Zithromax, Decongestants, steroid sprays, saline spray 3-4 days, analgesics. No antihistamines (dries mucous and stays up there!)
Acute Otitis Media
Otalgia, hx of URI, drainage, decreased hearing, fever. OBJ-
Fever?, auricle tender, TMJ, loss of cone of light, obscured landmarks, bulging membrane, Cloudy infected fluid behind TM, Nose, throat, neck, lungs and heart. No diagnostics.
Acute Otitis Media- What does inner ear look like?
Can be dark gray drum. acute is bulging drum. Ruptured- see hole where it separates. Sudden relief of pain might mean rupture- relief of pressure.
Managing Otitis Media
Zpack, Amoxicillin, Ceclor.
Bactrim (sulfa).Biaxin (macrolide). Decongestants, no antihistamines.
Serous Otitis
Fullness of ear and decreased hearing.
Retraction of TM, air bubbles, or air:fluid levels. Decreased membrane mvmt.
Treating Serous Otitis
Unless infected, no abx.
Relieve congestion with decongestants if r/t URI or allergy. antihistamines if allergic rhinitis is culprit.
Eustachian Tube Dysfunction
Ear pain, decreased hearing improves with yawn, hx URI, allergic rhinitis, OM.
Retracted TM, decreased motility, typical findings of URI or rhinitis.
Managing Eustachian Tube dysfunction
Oral decongestants. Tx underlying. Avoid air travel or diving.
Sudafed 30 min before takeoff.
Otitis Externa
Swimmers Ear
Ear pain, decreased hearing sensation of obstruction, green or yellow discharge.
Pain with mvmt of auricle, edema of ext. canal, tender, red canal, lymphadenopathy
Treat Otitis Externa
Antimicrobial ear gtt, remove foreign body, Fungal- Clotrimazole gtts. Floxacin for infection.
Nose bleed p trauma, forceful blowing, certain meds.
Bloody discharge. difficult to observe if foreign body (pt anxious)
Tx-Stop bleeding, pack nose, may refer to ENT
Pharyngitis non infectious causes
Hep B, allergies, envt. sources, subacute thyroiditis, GERD
Pharyngitis Presentation
Dysphagia, throat pain, swollen/tender nodes, fever, HA, n/v. If epstein barr-fatigue
Pharyngitis Objective Presentation
Nonexudative/exudative erythema of pharnyx. Vesicular lesions with viral. size of tonsils, abscess formation unilateral. Viral is slimy shiny uvula.
Bacterial is white patches-treat!
Pharyngitis Diagnostics
Rapid strep and send to lab, serologic test for mono, CBC
Pharyngitis Management
PCN(Amoxicillin)x5d or PCN g inj for strep.
Viral-Tx symptoms
Warm salt water gargles, fluids, rest, soft diet. Avoid throat sprays with alcohol.
Refer peritonsillar abscess.
Immunosuppression or from inh steroids.
Teach to rinse mouth.
Diflucan po or Nystatin swish and swallow.
Precancerous lesions.
Oral surgeon referral.
Oral herpes
Apthous ulcer (canker sore)
GI distress or stress.
Tx-Trieminolone dental paste
Sensation of mvmt. of the head. Stand up too fast. Unsteady on feet.
Neuro checks with CN's, gait, Romberg.
Causes-Orthost. hypotn., Imbalance/ataxia, psychogenic dizziness, Hyperventilation.
Treat Vertigo
Hard! r/o CNS d/o.
Meclizine 25mg 1 po TID x7d.
Peripheral vs. central
ENT referral?
Diagnosing CAP
Acute infection of the pulmonary parenchyma.
Pt. can not have been hospitalized or residing in a long term care facility 14 d prior to onset of sx.
Infiltrate on CXR or ausc. findings of altered breathsounds or localized rales.
Leukocyte count and c reactive protein level may help.
Do not have to have secretions to be dx.
Negative CXR does not r/o pneumonia in mod to severe illness.
Presentation of CAP
Cough +/- sputum production.
Change in sputum color.
Fever, chills, Rigors, Malaise, Loss of appetite, Possible altered breath sounds, Rales.
S/S do not correlate with causative organism!
Risk factors for mortality of CAP
Age>65, immunosuppression, Other lung dx, CHF, DM, ETOH, Neuro d/o, Lab abnormalities.
Most CAP is strep pneumonia, then h.influenza, then viral..
Symptoms-Decongestants, mucolytic (Guaifenisen), Cough suppressants only if can't sleep, BR, humidifiers, Tylenol etc., stop smoking. Antimicrobials as indicated. Short term, high dose. Careful of resistance.
1. Fluoroquinolone-Levaquin 1poqdx5d. Esp. if >65 c comorbidities.
2. Macrolides Biaxin 1000mg qd or Zithromax 500mg qd. Esp if no comorbid. or <65.
Cephalosporins-Rocephin 500mg IM-(comorb. or nsg. home)
Augmentin (Betalactam)XR-2g BID
may combine meds.
Hospital tx- Azithromycin and Rocephin IV.
Primary vs Secondary HTN
Primary Htn- 95% of all cases. No identifiable cause. Uncommon before age 20.
Secondary Htn- Underlying cause present. Small # cases.
Patho of Primary Htn.
Genetic, Diet/Exercise, Increased SNS, Renin angiotensin system, Defective natiuresis, Na intake, Etoh, Nsaids, K intake.
Patho of Secondary Htn
Renal disease***
Renal vascular htn,
Primary hyperaldosteronism (low K, htn)
Cushing's syndrome (^sodium^h2o)
Coarctation of aorta
thyroid d/o
Untreated HTN
Complications of untreated Htn.
Hypertensive heart dx
Cerebrovasc. dx.
renal Dx-nephrosclerosis
Aortic dissection
LV hypertrophy>diastolic dysf.>HF, ischemia, arrythmia.
Staging HTN
Normal- <120/80
Pre- 120-139/80-89
Stage1- 140-159/90-99
Stage2- >160/100
Diagnostic Data for HTN
UA- Assess for hematuria, proteinuria, casts.
Fasting blood glucose (Diabetes with CV risk)
Lipids- ^CV risk
Serum uric acid levels (gout)
-Contraindic. thiazide diuretics)
EKG for LVH and ischemia
Echo for LVH
24hr urine for cortisol and metanephrines for Pheo/Cushings
Renal US
CT for Pheo (mass on adrenals)
When should drug therapy be initiated for HTN?
When BP >140/90
Pts with pre htn and at least one additional high risk condition.
Goal is <130/80
DM or renal patients start drug therapy sooner!
Which med to choose for HTN for different pt population?
Ca channel blockers>edema
Beta blockers-erectile dysf.
Blacks-CCB's and thiazide diur.
Elderly and obese-Thiazide diur.
DM- ACE or ARB. Usually combination of 2-3 meds.
Initial Drug choices for HTN
Stage 1-Thiazide Diur.
Consider ACEI, BB, CCB or combin.
Stage 2-2Drug combo-Usually Thiazide Diur + ACEI or BB,CCB
Diuretics-Decrease plasma volume and PVR
Thiazide- can use just for htn
Loop- never start for only htn. Also, start when thiazide loses potency GFR<60.
Good for blacks, elderly,obese
Replace K.
Beta Blockers- Decrease HR, CO, release of renin.
Beneficial in young caucasians.
Use cautiously in DM, reactive airway, brady-arrythmias, severe PVD, pheo (use alpha blocker)
Also helps angina, post mi,stable hf, migraines, anxiety.
ACE Inhibitors-Inhibit renin angiotensin aldosterone system. Inhibit bradykinin degradation. Stimulate prostaglandin release. Reduce SNS activity.
More effective in younger caucasians. Less effective in AA and elderly.
1st line for DM**Prevents proteinuria>renal disease.
Use in HF, decreased LV function.
Watch for hypotn, ARF, hyperkalemia, cough, dizzy, angioedema.
Cozaar. Less stroke, Less development of DM.
CCBs-Peripheral Vasodilation
Effective in all groups.
Dihydroperidines- Vasodilate (Cardene, Norvasc)
Non dihydroperidines- decrease contractility (Verapamil, Cardizem)
Adverse effects- edema** headache.
Arteriorlar Dilators-Relaxation of smooth muscle.
Profound peripheral vasodilation.
Arteriolar dilators-Not first line agent!!
Hydralazine, Minoxidil.
Edema, Hirsutism.
Central Sympatholytics-Stimulate alpha adrenergic receptors in cns.
Not first line therapy!!
Clonidine, Catapres patch.
SE- sedation, fatigue, dry mouth.
Alpha Adrenoreceptor agonists-
Relaxation of smooth muscle. Decrease PVR. Alpha receptor blocker.
Cardura, Hytrin, Terazosyn.
1st line for men with BPH.
Hypertensive drug therapy for DM
Ace/ARB-prevents proteinuria>renal failure.
Diuretics, BB/CCB.
Prevent CV events and nephropathy!
Hypertensive drug therapy for those with Heart Failure
Diuretics, ACE, BB. (3 drug comb?)
poor LV function, EF<40, diastolic failure-any CCB
Hypertensive drug therapy post MI
Chronic inflammatory dx.
Production of autoantibodies.
Immune complexes, directo autoantibody damage.
Bottom line-inflammation, clots.
Inflammation occurs in small blood vessels and connective tissue: skin, joint, kidney, pleura and pericardium.
More females, more blacks.
Lupus acute exacerbation triggers
Estrogen or lack of testosterone
Infectious agents?
Chemical exposures
Missing Meds
Presentation of Lupus
Low grade fever, wt loss, swollen glands, fatigue, aching.
Half have internal organ involvment, half don't.
Diagnose Lupus
4 or more of the following:
Serositis (pleuritis,pericarditis)
Oral ulcers
Blood disorder(decrease bc's)
Renal disorder (proteinuria)
Immunologic d/o (anti-dna,anti-sm,antiphospholipid)
Neuro d/o(seizures,psychosis)
Malar rash
Discoid rash
Lab tests for Lupus
Anti Sm and anti ds dna more specific
anti phospholipid ab if clotting hx.
CVC, chem, UA, 24hr urine
Complement levels
Complications of Lupus
Avascular necrosis
Cause of death- infections, renal failure, cns involvement, effects of treatment..Atherosclerosis (MI,CVA)
Treatment of Lupus
Topical steroids for skin
Calcium, vitamin D
Treat disease effects.
Avoid sun.
Monitoring Lupus
CBC/platelets, urinalyis,creatinine, yearly lipid panel, anti ds dna and complement levels
If on hydroxychloroquine-eye exam
If renal-24 hr urine, serum creat, calcium, phos, alk phos, na, k.. q 1-3 months.
Points to remember about LUPUS
Immune Complexes
Antiphospholipid antibodies
Ana+joint pain not always lupus
Lower doses prednisone for skin and joint
Higher doses prednisone for pleuritis, hematologic, cns, nephritis.
Hydroxychloroquine for everyone who can tolerate.
Protect heart and bones.
Osteoarthritis- Predisposing Factors
Trauma (ACL and meniscal tears)
Certain occupations/sports
African American
Etiology of Osteoarthritis
Disease of the cartilage
Mechanical stress
Chrondocyte metabolism altered
proteolytic enzymes produced
Cartilage degraded
Joint mechanics altered
Process b/c self perpetuating
Definition of Osteoarthritis
A gradual loss of articular cartilage combined with thickening of the subchondral bone; bony outgrowths (osteophytes) at joint margins; and mild chronic nonspecific inflammation
Clinical features of Osteoarthritis
Joint pain, stiffness, limitation
Pain increases with joint use and lessens with rest
Pain and stiffness modified by weather changes
Knee instability and buckling
Hip-groin pain that radiates to thigh.
Physical Exam of Osteoarthritis
Bony enlargment=DIPs-Herbendens nodes; PIPs-Bouchard's nodes
Tenderness at joint margins
Limitation of motion
Joint malalignment-varus is bowlegged, valgus is knock-knees.
Less common-local inflammation
Common sites of Osteoarthritis
Lumbar and cervical spine
first carpometacarpal joint
distal interphalangeal joints
proximal interphalangeal joints
firstmetatarsophalangeal joint
Non pharmacologic tx of Osteoarthritis
Self mgmt course
Weight loss
Assistive devices
Drug therapy for osteoarthritis
Nsaids or salicylates
Tramadol (narcotics last resort)
Then, Intraarticular Synvisc,
Local corticosteroids,
Refer for Joint Replacement
Rheumatoid Arthritis
Chronic, inflammatory, systemic disease.
Increases with age, More common in females,
Genetic Predisposition
Pathology of Rheumatoid Arthritis
Initiating Event is unknown
Synovial membrane inflammation
Synovial hypertrophy and graulation tissue
Destruction of periarticular bone/cartilage
Joint deformity(not reducable,permanent)
Diagnosis of rheumatoid arthritis
>4 of 7 Criteria for >6wks:
Morning stiffness>1hr
Arthritis of >3 joint areas
Arthritis of hand joints
Symmetric arthritis
Rheumatoid nodules
Serum rheumatoid factor
xray changes-bony erosions
RA deformities
ulnar deviation, chronic MCP changes and intrinsic muscle wasting.
Swan Neck
MCP subluxation
Bony erosions
Extra articular manifestations of RA
Rheumatoid nodules
Severe fatigue
Pulmonary fibrosis
Lab findings for RA
elevated ESR and correlates with degree of synovial inflamation.
Rheumatoid factor. Autoantibodies to IgG in most pts.
Management of RA
Early diagnosis and aggressive tx.
Education, OT, PT, self help
Nsaids or Celebrex
DMards- hydroxychloroquine, Methotrexate***(category x)(low doses, and increase)
Anti TNF drugs- Remicade, Enbrel, Orencia
IL 1 receptor agonist-Kineret.
A skeletal disease marked by low bone mass and microarchitectural deterioration that leads to an increased susceptibility to fracture.
Etiol. of Osteoporosis
Peak bone mass age 25
Stable until menopause
Risk factors (nonmodifiable) for Osteoporotic Fractures
Hx of fracture as adult
History of fx in first degree relative
Poor Health/Fragility
Risk factors for osteoporotic fractures (potentially modifiable)
Low body weight
Estrogen deficiency
Early menopause <45 or bilateral oophorectomy
Prolonged premenopausal amenorrhea >1yr
Low lifelong calcium intake
Impaired eyesight
Recurrent falls
Inadequate physical activity
Poor health
(ETOH,immobile, steroids,anticonvulsants, excessive thyroid supplement)
Measurement of Bone Mineral Density
Essential for diagnosis of low bone mass
Assessment of future fracture risk
Assessment of response to therapy
Central and peripheral skeleton devices
DEXA scan is central device.
Tscores with Osteoporosis
Osteopenia-T score between -1 to-2.5
Osteoporosis T score <-2.5
Severe <-2.5 and one or more fragility fractures.
Who should get BMD testing?
Women >65 yrs
Postmenopausal women <65 with risk factors
Men >70
Adults with fragility fracture
Disease or meds associated with decreased bone mass or increase in loss.
Anyone considered for drug therapy or needs monitoring for drug effect.
Osteoporosis clinical features
Common fracture sites- hip, spine**, wrist
Vertebral fx may be asymptomatic
Acute verteral fx symptoms-intense localized pain and reduced spine
Pharmacologic tx of osteoporosis
Indicated for women with osteoporotic fx. Preventive if Tscore -2.0 or -1.5 with risk factors.
Bisphosphonates (Fosamax, Actonel)(Take on empty stomach, full glass of water, sit up, no eating for 30 min, then can lie down p eating)
Estrogen(prevent. of loss in recent menopausal women)
Calcium 1200mg qd
Vit d 400-800 iu qd
Prevention/Treatment of Osteoporosis
Avoid smoking and heavy caffeine
Fall risk reduction
Vertebroplasty and kyphoplasty
Fibromyalgia definition
Widespread pain >3 mths
Above and below waist
Demonstrated tender points
Heightened neuron sensitivity-> exaggerated response to a peripheral stimulus
Pain and Fatigue!!
Fibromyalgia Triggers
Genetic predisposition
Psychosocial stress
Other disease (arthritis)
Fibromyalgia Clinical Features
Diffuse aching, stiffness, fatigue
Multiple tender points in specific areas(>11 out of 18)
Sleep disturbance
Normal labs (r/o hypothyroid)
Associated sx
Associated sx of Fibromyalgia
Restless legs,cramps
Multiple chemical sensitivities
Impaired memory, concentration
Cold intol.
Tender points of Fibromyalgia
Predefined points that are considered + when an individual c/o pain upon application of pressure (blanch a nail)
Tx Fibromyalgia
Heat, massage
Regular sleep
Meds for sleep:
Elavil and Flexeril**
Start low 10mg several hrs pHS
Build to 40mg of cyclobenzaprine or 70-80mg of amitriptyline.
Ambien (short term only)
Seratonin boosting drugs- Prozac, paxil, zoloft, effexor, celexa, lexapro.
Analgesics- Tylenol, Nsaids, ultram.
BPH-Benign adenomatous hyperplasia of the periurethral prostate gland.
Increased DHT (active form of testosterone)
Increased estrogen
Stimulation of alpha adrenergic endings interfering with the opening of the bladder neck internal sphincter.
Clinical Presentation of BPH
Seen in men >50
Obstructive symptoms (weak stream, straining, hesitancy, intermittency, incomplete bladder emptying and terminal dribbling.
Frequency, nocturia, frequency
Complications of BPH
Urinary incontinence, infection, retention ->UTI
Diagnosis of BPH
Sensation of not emptying bladder p urination.
Occurrence of the need to urinate within 2 hrs of last void.
Episodes of having to start/stop during urination.
Difficulty postponing urination.
Weak urinary system.
Occurrence of needing to push and strain during urination.
Number of times got up from bed to urinate at night.
Physical exam of BPH
Distended bladder
Renal tenderness
DRE(do PSA before DRE)
Gland is enlarged, firm, smooth, symmetrical with oblierated median sulcus.
Diagnostics for BPH
UA to r/o UTI and hematuria
Creatinine to assess renal function.
PSA 0-4 normal
Management for BPH
Limit fluids p dinner
Avoid decongestants
Cut back on caffeine and etoh
Balloon dilation
Surgery for men with recurrent UTIs, gross hematuria, bladder or renal insufficiency
Meds for BPH
Always do DRE and PSA before meds
Terazosin 2-10mg qd.(alpha blocker)
Avodart (androgen hormone
Cardura-heart and bph. 1-16mg qd. long acting alpha blocker.
Take med at qhs.
Proscar is effective in decreasing prostatic size, increasing peak flow rate and reducing sx.
Prostate Cancer
Malignant neoplasm of prostate gland.
High fat diet?
S/S Prostate CA
Many asymptomatic
Mimic BPH with frequency, dribbling, nocturia.
Occasionally bone pain from mets
uremia due to urethral obstruct.
Prostate CA assessment findings
May present with lymphadenopathy
May have distended bladder
DRE- prostate feels harder than normal and normal boundaries of gland may be obscured. Nodules may be present.
Diagnosing Prostate CA
Transperineal or transrectal needle biopsy.
PSA levels >10
Transrectal US to guide biopsy and aid in ID of nodules
Bone scan
Acute Bacterial Prostatitis
Ecoli or other gram- baceria are most common.
Young men-more prone to non bacterial prostatitis where causative agent includes mycoplasma, gaidnerella&chlamydia.
Presentation of Prostatitis
Fever, chills, malaise}
Low back pain}never do DRE
Dysuria, urgency, nocturia frequency, suprapubic discomfort
Perineal pain increased with defecation and sex
Occasional hematuria
Prostatitis PE, Diagnostics and TX
Fever, Prostate is firm or boggy, warm and tender
UA with bacteria,WBCs
Bactrim DS 1po BID 2-4weeks or Cipro 250-500mg BID 2-4weeks
BR, Sitz bat tid for 30min
FU in 48-72
Avoid sex until resolution
Chronic Bacterial Prostatitis
One of the most common causes of recurrent UTIs in men: client is asymptomatic and urine is sterile between episodes.
Occurs esp. in older men.
Presentation of Chronic Bacterial prostatitis
Milder than acute...
Relapsing UTI***
Urinary frequency, dysuria
Vague lower abd pain, lumbar and perineal pain
Fever and urethral d/c uncommon
May have swelling and tender scrotum
prostate may be tender, irregularly indurated or boggy
Tx Chronic bacterial prostatitis
Bactrim 1po BIDx4wks, Cipro
Analgesics and stool softener
Refer to urologist if >50yrs old...usually associated with BPH
Non bacterial prostatits
Most common type of prostatitis
Mild perineal pain, dysuria, frequency and urgency.
No s/s of systemic illness. Penil d/c common
WBC's but no bacteria in urine and expressed prostate secretions cultures.
Epididymitis-acute intrascrotal infection
infection from bladder, urine, prostate or urethra. Men <35 usually chlamydia.
Men >35 usually bladder bacteriuria.
Presentation of Epididymitis
Usually unilateral
Painful scrotal swelling, may radiate up spermatic cord into lower abd.
Scrotal heaviness
Phren's sign (passive elevation of testis may relieve pain)
UTI, prostatitis sx
Fever, chills, malaise
Diagnostics for epididymitis
STD tests
scrotal US
Tx of epididymitis
Rocephin 250 mg IM plus Doxy 100mg BIDx10days if <35
Bactrim DS 1BID x10d or Cipro 250 BIDx10days if >35.
Scrotal elevation
Avoid sex until abx complete
Ice early heat late
F/U in 48 hrs.
Testicular Torsion
Twisting of the spermatic cord which results in compromised testicular blood flow.
Surgery within 24 hours or risk sterility/necrosis.
Testicular Torsion Presentation
Some have acute pain and swelling
Sudden onset of pain that radiates to groin.
Lower abd pain which leads to erroneous dx of appendicitis or gastroenteritis.
No fever, urethral d/c or dysuria.
PE- Testis may be high in scrotum, tender and not posterolateral. Cremasteric reflex absent in torsion, present in epididymitis.
Collection of peritoneal fluid trapped in processus vaginalus. May form secondary to testicular pathology such as testicular tumors.
Hydrocele presentation
Flat scrotum in a.m. with increase in fluid during the day.
Rarely resolve and potential for herniation of the intestine.
Hydrocele physical exam
transilluminate scrotum-Light will appear as red glow with serous fluid, but not with blood or tissue.
Dilated plexus of scrotal veins situated above the testis in the scrotum.
Bag of worms
sperm count drop
Vessels very dilated.
Causes-tumors, intraabd. pathology
Refer for surgery if voluminous and rapidly expanding.
Undescended testes
mechanical factor from birth
Lack of hormones
Risk of malignancy, infertility, stress, trauma
Protrusion of an abdominal viscus or part of a viscus through abd wall.
Incarcerated-Cannot reduce and the contents of the hernial sac cannot be returned to the peritoneal cavity.
Strangulated- Blood supply to viscera lying within the hernial sac is obliterated or cut off.
Clinical picture of hernia
Mild pain, dull ache in groin
Bulge localized in the groin or extended into the scrotum.
Strangulated hernia: Colicky, abd. pain, N/V, abd distention and hyperperistalsis.
Treatment of UTI
Bactrim DS 800mg q12
Cipro 250 bidx5-7d
Never give fluoroquinolones to seizure pts!
Three Major Pathways of Voiding
Sympathetic-bladder neck tighten, and bladder relaxation
Parasympathetic-Initiates voiding
Pudendal nerve-voluntary control of the urethral sphincter muscle which allows voluntar contraction or relation of the muscle.
Sympathetic voiding pathway
Carry relax and store message
Contributes to urine storage and promotes continence.
Drugs-sympathomimetics (sudafed)
Reduce leakage
Parasympathetic voiding pathway
Cholinergic drugs-Detrol
Carry contract message
Pudendal nerve voiding pathway
Factors that contribute to urethral resistance/continence
Urehtral length (greater in males)
Urethral curvatures (2 in men, none in women)
Effects of aging on continence
Increased production of urine in nighttime hrs.
Reduced bladder capacity
Reduced strength of bladder contractions
Increased irritability of detrusor muscle
Delayed recognition of bladder filling
BPH in men
Loss of estrogen in women causes bladder irritability and reduced urethral resistance
Effects of meds on urinary tract function
Sympathomimetic/Adrenergic-increased urethral resistance, relaxation of bladder wall.
alpha adrenergic blocking-Reduced urethral resistance (men) Hytrin,Minipress,Cardura
Cholinergics-Increased bladder contractility (urecholine)
Anticholinergic- Reduced bladder contractility (*Enablex-Vesicare, Detrol)
Stress Incontinence
Leakage of urine associated with increase in abd pressure due to sphincter dysfunction:permits leakage of urine in absence of a bladder contraction
Stress Incontinence Diagnosis and TX
Qtip test, urethral pressure profile, Abd leak point pressure
Treat-Pelvic exercises, Electric stim, Sympathomimetics, pessaries*(holds bladder off of vaginal wall)
Bladder tack
Overactive Bladder (Urge Incontinence)
Not well understood-damage to cerebrocortical centers that regulate bladder function.
Perceives fullness and urgency despite low volumes. Bladder may contract and empty when it should be filling. Sense of urgency at low volumes.
Motor urgency with unstable detrusor muscles that contracts with no warning in response to triggers such as filling volues, increased abd pressure.
Etiol of overactive bladder
Conditions affecting the brain or spinal cord can cause loss of ability to inhibit bladder contractions. Lesions in the pons decreases their ability to store urine.
S/S of overactive bladder
Frequency (>8voids in 24 hr)
Low voided volumes
Leakage in response to common stimuli
Key in lock syndrome
*Detrusor instability diagnosis can be made with cystometrogram that documents unstable detrusor contractions
Tx of overactive bladder
Elimination of bladder irritants/infections
Envt. modifications, bladder retraining
Functional Incontinence
Incontinence in individuals with normal voiding patterns and normal bladder function;usually related to cognitive status, motivation or mobility issues.
Functional Incontinence Causes
Unclear, r/t cognitive status or mobility
Most common in long term care centers
S/S of functional incontinence
Large volume urinary leakage at regular intervals
Individual may or may not be aware
No specific diagnostic study
Functional incontinence Tx
Dependent on clinical presentation
Prompted or timed voiding
Containment or absorptive products
Reflex Incontinence
Total loss of voluntary bladder control in individuals with spinal cord lesions above the sacral cord level.
the bladder empties by means of the reflex arc. 'Detrusor hyperreflexia'.
Causes of Reflex Incontinence
Suprasacral spinal cord lesion
Bladder filling triggers the reflex arc between the bladder and spinal cord that results in bladder contraction
Sphincter may or may not open to permit unobstructed voiding.
Etiol of Reflex Incontinence
Spinal cord injury above s2
Myelomeningocele above s2
Clinical signs-No awareness of bladder filling, no ability to inhibit or initate voiding.
Bladder/sphincter dyssnergia
Reflex incontinece diagnostics and treatment
Neurologic Lesion
condom drainage
Indwelling catheter
Sphincterectomy or intraurethral stent plus condom drainage for males.
>35 y/o yearly
Cyclic pain common
Noncyclic pain-custal ectasia, fibroadenoma, CA, costochondritis
Eval-hx, physical, mammogram, US
Fibrocystic changes in breast
common.Fluctuates with cycle. Benign.
Treat with oral contraceptives
Discharge of nipple
Pathologic if:
Unilateral, spontaneous. Bloody, colored.
Mammogram, biopsy.
Intraductal papillomas
tumor in lactiferous ducts. Excise surgically or will b/c malignant.
Breast CA
Normally painless.
Risk factors:
Increase with age
Family hx
1st child p 30yrs old
Early menstruation
?oral contraceptives
Menopause >50
Post menopausal obesity
Chest wall radiation as a child
Breast CA clinical...
Scaliness of nipple
Swelling, dimpling, orange peel
Usually painless!
Cervical CA
Most common gyn CA
Risk factors:
Age of first sex before 18
Greater than 3 lifetime partners
precancerous changes
No barrier contraception
DES exposure inutero
HIV or immunocompromised
HPV, TX for abnormal Pap smear and or hx of chlamydia.
Pap smears, who and how often
Extremely Low risk-Virginal or >65yo. with consecutive negative findings.Qat age 60 or later
Low risk- Negative paps yearly x3:q3or3years.
High risk-yearly.
DES daughter-ist pap age 14 or menarche or sexual activity.
Vaginal and cervical paps q6-12mths until age 30, then yearly.
Post hysterectomy-
cervical or uterine malignancy:q3mthsx2yrs,q6mthsx3yrs, then yearly.
premalignant cervical lesion:q6mthsx2-3yrs.
Benign cervix and uterus:no pap
Usually causative agent to cervical CA.
Uterine Myomas
Leimyoma arises from smooth muscle-a proliferation of tissue that continues even after original stimulus is lost
Uterine Myomas S/S
Pelvic pain, dysmenorrhea*, dyspareunia, fullness
Decreased bladder capacity
Abnormal uterine bleeding
Abd. pouching
Uterine Myoma/Fibroid Diagnosis and treatment
Bimanual exam-check height of fundus
Remove when size of 4mth fetus.
Treatment depends on desire for fertility.
More comon in middle years.
Location r/t symptoms more than size.
Primary dysmenorrhea
Severe cramps
Oral Contraceptives
GnRH agonists
Secondary dysmenorrhea
Treat uderlying problem
Treat with same as primary dysmenorrhea.
Oral contraceptives, long acting progestins, GNRH agonists
Multiorganism infection of the pelvic organs.
Chandelier's sign.
Results in sterility.
pain with mvmt of cervix.
Residul infection in uterus
Increases with each STD
Risk factors for PID
Multiple partners
IUD placement
Hx of previous infection
Diagnosing PID
Based on presentation
Some have fever, cultures, US useful when pelvic exam difficult.(may demonstrate free fluid)
Treating PID
**high dose,inj. in office
Cefoxitin 2gm IM with Probenecid 1g po
Ceftriaxone 250mg IM and Doxycycline 100mg po x10-14d.
Azithromycin 1gm plus dosy 100mgpo x10-14d
Reassess in 48hours, if no improvement-admit.
Dosing changes b/c of strains*
Ovarian cysts
Single sided pain or discomfort
Absence of menses
Pelvic pressure
Ruptured-Severe stabbing pain, starts out on one side, then begins to dull and b/c burning sensation as fluid from cyst disperses throughout perioneum.
Diagnosis and Tx of Ovarian cysts
Clinical exam, US, CT
oral contraceptives
Palpate ovary on post menopausal woman usually cancer.
Ectopic pregnancy
Torsion of ovary
Bleeding in adnexa or infection
Appendicitis or PID differential
Send to OBGYN
Dysfuctional uterine bleeding
Intermenstrual bleeding with no clinical cause.
R/O pregnancy, consider cancer, meds, surgery, hypothyroidism.
Always consider endometrical or cervical cancer if postmenopausal.
Ovarian Cancer
over age 40. Vague nonspecific discomfort. If palpate ovary in post menopause-suspect CA.
Transvaginal ultrasound.
Causes of vaginitis
Bacterial, Candidiasis, Trichomoniasis, Gonorrhea, Chlamydia, Herpes, HPV
NonInfectious: Atrophic vaginitis, foreign bodies
Causes of candidiasis (vaginal)
Candidia albicans usually
Diagnostic Findings of Cadidiasis (vaginal)
Itching, Burning, Discharge
pH 4.0-4.5
Discharge-white, curdy, cottage cheese
Odor-absent, KOH may mislead
Microscopic-Mycelia, budding yeast, pseydohyphae with KOH prep
Treatment of Vulvovaginal Candidiasis
Start with OTC if not severe
Fluconazole(Diflucan)150mgpo x1
Caused by a parasite (protozoan)
Most are asymptomatic
Concomitant infections common.
**Strawberry punctate marks on cervix.
White thin luminous discharge
Treat Trichomoniasis
Metronidazole 2gmpo single dose
Metronidazole 500mg po BIDx7d
Topical therapy.
No etoh while on drug
Treat partner concurrently.
Screen and treat in pregnancy.
Bacterial Vaginosis
Most prevalent vaginal infection
Sexually associated
underdiagnosed (50% asymptomatic)
Causes/Predisposing Factors for Bacterial Vaginosis
Causes-Unknown, alteration in vaginal flora, Lactobacilli.
Predisposing factors-Presence of concomitant STDs
Multiple or new sex partners
Earlier coital experience
IUD use
Looks like trich
Treating Bacterial Vaginosis
Metronidazole 500mgx7days.
May recur due to persistence of pathogens, failure of lactobacili to recolonize, persistence of unidentified host factor, reinfection from partner, continued douching
Polycystic Ovarian Syndrome
Goal is to alleviate symptoms
Ovulation induction for fertility
Oral contraceptives for menstrual irregularity, hirsutism.
Metformin for type II DM
How OCP's work
Prevent ovulation- inadequate FSH-LH to alow for ovulatory cycle which mimics pregnancy effects on pituitary gland resulting in non stimulation of the ovaries.
thin out phase endometrial layer to inhibit implantation
Capacitation of sperm inhibited
Thickened cervical mucous to trap sperm
Older OCP's
Lo Ovral, Nordette, Orthonovum, Lo estrim FE=have more estrogen and progesterone, risk for DVT, strokes
Newer OCP's
Orthotricyclen Lo
Yasmin (Drospirenone)
No androgens
Contraindicated in renal, hepatic or adrenal insufficiency; any meds that may increase K level; Wt loss; Acts like mild diuretic
Desogestrel (Mircette)
Risk of thromboembolic disease
Contraindicated in DVT, stroke, CAD, DM with neuro changes or DM>20yrs, Pregnancy, lactation<6wks; Liver probs; Migraines, >35/smoker;Htn;prolonged immobilization
Depo-Provera side effects
Irregular bleeding
Wt gain
Insert dep into deltoid, no massage.
prlonged return to fertility after ending use 3-18mths.
Reduced calcium in bones.
Ortho Evra Patch
Once a week. ethinyl estradiol and norelgestromin.
highly effective.
Stays on during activities.
Patch x3weeks, one week without.
Never apply to breast.
Anecdotals about Birth Control Pills
Nordette-More potent progestin, cyclic wt gain but good for dysmenorrhea.
LoEstrin-More androgenic, increase in waist size
Desogen-Loss of libido
Orthotricyclen-Mood swings, emotional
DMPA-mood changes, depression
Ortho Evra-Effectiveness concerns, rash
Nuva Ring-Increased vaginal lubrication
May last 5-15yrs.
Transitional period between reproductive and nonreproductive physiologic processes.
Increase or decrease in menstrual cycle length.
Complete cessation of menstruation for one year!
Avg age is 51.3
Organ systems affected by Menopause
CNS-Hot flashes, psychological
CV-Increased risk for MI,Stroke
Skin-Diminished skin thickness and increased wrinkling
GU-Vaginal itching, bleeding, and dyspareunia;vulvar pruritus and pain;dysuria;urgency/stress incontinence;Urinary frequency
Skeletal-Osteoporosis/increased risk for fractures
Hot flash concerns of women
Certain foods, hot drinks, etoh, hot weather, synthetic clothes, stress.
Treat-Estrogen and/or Progestin
Clonidine-alpha adrenergic receptor agonist
Estrogens are most comprehensive therapy. Start with low dose, for shortest amt of duration.
Local (cream, etc)Estrogen for urogenital symptoms. use patch for direct delivery of drug.
Postive treatment with HRT
Prevents osteoporosis
Relieves hot flashes
Relieves vaginal dryness and discomfort
Progestin component protects endometrium.
Estrogen ONLY for women who have had a hysterectomy!!
Estrogen and progest. for women who have a uterus.
vitamin E, soy, Black cohash are alternative therapies.
Health concerns of perimenopausal women
Urogenital atrophy (vulva flattened and thin, vaginal shortening and narrowing, Vaginal walls b/c thin &lose elasticity, Decrease in lubrication, Urethral opening shifts to nearer the introitus, Urethral wall and bladder thin, vaginal ph more alkaline)
All this increases infections, burning/irritation, trauma, dyspareunia, UTI, stress incontinence.
Increased risk for ovarian, endometrial, breast, and cervical CA
Treat with estrogen cream, lubricans, sitz bath, pelvic exercises, continue sexual activity!
Osteoporosis with Menopause
osteoblastic activity not ale to keep up with osteoclasts!
Prevent-Exercise, Ca++,Vit D, avoid smoking and glucocorticoids.,HRT
Estrogen therapy is best.
Combine with biphosphonates, calcitonin, parathyroid hormone, ca and vit d rich diet.
Drugs for osteoporosis
Boniva-1 q mth
Actonel- 1qwk. GI sx.
Fosamax- 1qwk
All rebuild bone with biphosphates, increase osteoblasts
Absolute contraindications for estrogen use
Undiagnosed vaginal bleeding
breast CA
Acute liver dx
Known or suspected pregnancy
Active thrombosis/thrombophlebitis
Endometrial adenocarcinoma or other estrogen dependent tumors
Risks of estrogen replacement
Endometrial or breast cancer
Eval Prior to HRT
Pap smear
Lipid Profile
Endometrial sampling?
Common HRTs
Conjugated equine estrogen-Premarin
Estrace, Estinyl, Estratab, Ogen
Others-Estring,Orthodienestrol cream, vagifem vaginal tablet.
SE's of Estrogen:
Nausea, HA, breakthru bleeding, HTN, breast tenderness, depression.

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