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Muzna al sawwafi Emergency medicine/R1

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By Muzna Al Sawaafi

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  • 1. Muzna al sawwafi Emergency medicine/R1

2.

  • Outlines:
  • *approachingthe case,
  • *analyzing the data,
  • *key notes,
  • *home messages.

3.

  • Presentaion:
  • 46 yr old lady with lower abd.pain.

4.

  • *HTN, DM, 3 DAYS H/O BILATRAL LOWER ABD.PAIN, COLICKY, REFERED TO THE BACK AND LEGS, NO NAUSEA, VOMITTED ONCE,
  • *NORMAL BOWEL MOTION, NO URINARY SYMPTOMS,
  • *HAS VAGIANL DISCHARGES:YELLOW, PURULLENT, SMEELY, LARGE AMOUNT,
  • NO VAGINAL ITCHING,
  • *FIRST TIME,
  • *AFEBRILE ,

5.

  • *WAS SEEN AT LHC AND RECVIEVED MEDICATIONS, AB? NO IMPROVEMENT,
  • *REFERED AS THE PAIN IS MORE SEVER AND TO WORK UP FOR SURGICAL CAUSE(APPENDICITES?), AND VAGINAL DISCHARGES.
  • *LMP:2WKS AGO, REGUALR, HAS HEAVY PERIOD *13 YR AGO: DIAGNOSTICLAPROSCOPE:PROLIFRATIVE ENDOMEETRIUM, WAS IN F/U AT AL WATYAH HC, NOT ON MEDICATIONS FOR THIS PROBLEM).

6.

  • *HAD BILATRAL TUBE LIGATION 13 YRS AGO,
  • *MOTHER OF 9, OLDER IS29 YRS AND THE YOUNGEST IS 13 YRS, HAD 3 LSCS,
  • *WAS IN F/U AT PSYCHIATRY 2 YRS AGO FOR SOMATIZATION DISORDER AFTER AN ACCIDENT, CURRENTLYNOT IN F/U OR MEDICATIONS,

7.

  • CLINICALY:
  • IN PAIN,PALE, AFEBRILE, P:100, BP:112/82,
  • CHEST:CLEAR,
  • ABD:WASEM SCARS, CS SCAR, SOFT, TENDER ON DEEP PALPATION AT THE LOWER ABD.BILATRALY AND SUPRAPUPIC,
  • REBOUND TENDRNESS(+)VE
  • NO ORGANOMEGALY/MASESS,
  • BS(+)VE,

8.

  • PV EXAMINATIONS:
  • SPECULUM EXAM: CLOSED OS, PURULENT DISCHARGES,CERVICAL MUCUSA APPEARED NORMAL,
  • HVS TAKEN, SENT,
  • PR EXAMINATIONS:MILD TENDRNESS ANTERIRLY,
  • URINE DIPSTIK: NILL,
  • UPT:NEGATIVE,

9.

  • IMPRESSION?

10.

  • INVESTIGATIONS:
  • CBC, U&E, URINALYSIS, URINE MICROSCOPY, CRP:ALL NORMAL,
  • U/S ABD:VERY DIFFICULT DUE TO INCREASED ADIPOSITY,
  • BOTH OVARIES NOT VISUALISED, BULKY UTERUS,APPENDIX NOT VISUALISED, PROBE TENDERNESS NOTED AT RIF.
  • IMPRESSION:
  • LIMITTED STUDY, APPENDICITIS AND OVARIAN PATHOLOGY CANNOT BE RULED OUT.

11.

  • ABD.+PELVIS CT:
  • CT ABD WITH IV AND ORAL CONTRAST:
  • *LIVER, GB, SPLEE, PANCREAS AND BOTH KIDNEYS APPEAR NORMAL.
  • *DIFFICULT TO DISCERN THE APPENDIX, HOWEVER, NO FREE FLUID NOTED IN THE ABD/PELVIS.
  • NO FAT STRANDING IR INFLAMMATORY CHANGES SEEN.
  • SUBCENTEMETRRIC MESENTERIC LN NOTED,
  • BULKY UTERUS, RT.OVARY:NORMAL,LT.OVARY: FOLLICULAR CYST.
  • CONCLUSION:
  • NORMAL OVARIES. THE APPENDIX IS NOT SEEN BUT NO SIGNS OF APPENDICITIS OR INFLAMMATORY CHANGES .

12.

  • OBS&GYNE ON CALL REVIWED:
  • PV: NO CERVICAL TENDRNESS,UTERUS NOT PALAPBLE BIMANUALLY DUE TO PENDIOLUS ABD. ADENEXA FREE,
  • TVS: POOR PICTURE, UTERUS WITH THIN STREAKS, BOTH OVARIES NORMAL, NO ADNEXAL MASS SEEN,
  • ==========
  • DISCHARGE FORM GYNE SIDE,
  • TRACE HVS AND URINE CULTURE.
  • SHOULD BE COVERED WITH DOXICYCLINE AND METRONIDAZOLE.

13.

  • SURGERY ON CALL,
  • ADMITT THE PT FOR OBSERVATIONAND STARTED ON AB. AND ANALGESIA.
  • NEXT DAY:STII IN PAIN,
  • IMPRESSION:
  • LESS LIKELY TO BE APPENDICITES, DISCHARGED ON CEFUROXIME AND DOXYCYCLINE..,

14. 15.

  • Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women of childbearing age, accounting for 40 to 50 % of cases.
  • Gardnerella vaginalis, Mycoplasma hominis, Prevotella species, Porphyromonas species, Bacteroides species, anaerobic Peptostreptococcus species, Fusobacterium species, and Atopobium vaginae

16.

  • Homogeneous, white discharge that smoothly coats the vaginal walls
  • Vaginal pH greater than 4.5
  • Positive whiff-amine test
  • Clue cells on saline wet mount

17.

  • Vaginal culture has norole in diagnosis because there are no bacteria that are specific for BV.
  • Gardnerella vaginalis:
  • the organism is detected in up to 50 to 60 percent of healthy asymptomatic women; thus, its presence alone is not diagnostic of BV.

18.

  • COMPLICATIONS
  • Pregnant women with BV are at higher risk of preterm delivery.
  • There is a causal relationship between BV and endometrial bacterial colonization, plasma-cell endometritis, postpartum fever, post-hysterectomy vaginal cuff cellulitis, and postabortal infection.
  • BV is a risk factor for HIV acquisition and transmission.
  • heavy growth of BV-associated microorganisms increased PID risk.

19.

  • TREATMENT:
  • Metronidazole,
  • Clindamycin,
  • Asymptomatic infection?
  • *treat asymptomatic BV prior to hysterectomy and before pregnancy termination to prevent postprocedure infection,
  • *PREGNANT?

20. Take home messages: 21.

  • *follow up you pt progress,
  • *BV is the most common cause of vaginitis and the most common infection encountered in the outpatient gynecologic setting.
  • *The prognosis for uncomplicated cases of bacterial vaginosis isgenerallyexcellent.
  • *asymtomatic pt with bv ususally need no intervention.