Case Presenation

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By Muzna Al Sawaafi

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Case Presenation

  1. 1. Muzna al sawwafi Emergency medicine/R1
  2. 2. <ul><li>Outlines: </li></ul><ul><li>*approaching the case, </li></ul><ul><li>*analyzing the data, </li></ul><ul><li>*key notes, </li></ul><ul><li>*home messages. </li></ul>
  3. 3. <ul><li>Presentaion: </li></ul><ul><li>46 yr old lady with lower abd.pain. </li></ul>
  4. 4. <ul><li>*HTN, DM, 3 DAYS H/O BILATRAL LOWER ABD.PAIN, COLICKY, REFERED TO THE BACK AND LEGS, NO NAUSEA, VOMITTED ONCE, </li></ul><ul><li>*NORMAL BOWEL MOTION, NO URINARY SYMPTOMS, </li></ul><ul><li>*HAS VAGIANL DISCHARGES:YELLOW, PURULLENT, SMEELY, LARGE AMOUNT, </li></ul><ul><li>NO VAGINAL ITCHING, </li></ul><ul><li>*FIRST TIME, </li></ul><ul><li>*AFEBRILE , </li></ul>
  5. 5. <ul><li>*WAS SEEN AT LHC AND RECVIEVED MEDICATIONS, AB? NO IMPROVEMENT, </li></ul><ul><li>*REFERED AS THE PAIN IS MORE SEVER AND TO WORK UP FOR SURGICAL CAUSE(APPENDICITES?), AND VAGINAL DISCHARGES. </li></ul><ul><li>*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). </li></ul>
  6. 6. <ul><li>*HAD BILATRAL TUBE LIGATION 13 YRS AGO, </li></ul><ul><li>*MOTHER OF 9, OLDER IS 29 YRS AND THE YOUNGEST IS 13 YRS, HAD 3 LSCS, </li></ul><ul><li>*WAS IN F/U AT PSYCHIATRY 2 YRS AGO FOR SOMATIZATION DISORDER AFTER AN ACCIDENT, CURRENTLY NOT IN F/U OR MEDICATIONS, </li></ul>
  7. 7. <ul><li>CLINICALY: </li></ul><ul><li>IN PAIN,PALE, AFEBRILE, P:100, BP:112/82, </li></ul><ul><li>CHEST:CLEAR, </li></ul><ul><li>ABD:WASEM SCARS, CS SCAR, SOFT, TENDER ON DEEP PALPATION AT THE LOWER ABD.BILATRALY AND SUPRAPUPIC, </li></ul><ul><li>REBOUND TENDRNESS(+)VE </li></ul><ul><li>NO ORGANOMEGALY/MASESS, </li></ul><ul><li>BS(+)VE, </li></ul>
  8. 8. <ul><li>PV EXAMINATIONS: </li></ul><ul><li>SPECULUM EXAM: CLOSED OS, PURULENT DISCHARGES,CERVICAL MUCUSA APPEARED NORMAL, </li></ul><ul><li>HVS TAKEN, SENT, </li></ul><ul><li>PR EXAMINATIONS:MILD TENDRNESS ANTERIRLY, </li></ul><ul><li>URINE DIPSTIK: NILL, </li></ul><ul><li>UPT:NEGATIVE, </li></ul>
  9. 9. <ul><li>IMPRESSION? </li></ul>
  10. 10. <ul><li>INVESTIGATIONS: </li></ul><ul><li>CBC, U&E, URINALYSIS, URINE MICROSCOPY, CRP:ALL NORMAL, </li></ul><ul><li>U/S ABD:VERY DIFFICULT DUE TO INCREASED ADIPOSITY, </li></ul><ul><li>BOTH OVARIES NOT VISUALISED, BULKY UTERUS, APPENDIX NOT VISUALISED, PROBE TENDERNESS NOTED AT RIF. </li></ul><ul><li>IMPRESSION: </li></ul><ul><li>LIMITTED STUDY, APPENDICITIS AND OVARIAN PATHOLOGY CANNOT BE RULED OUT. </li></ul>
  11. 11. <ul><li>ABD.+PELVIS CT: </li></ul><ul><li>CT ABD WITH IV AND ORAL CONTRAST: </li></ul><ul><li>*LIVER, GB, SPLEE, PANCREAS AND BOTH KIDNEYS APPEAR NORMAL. </li></ul><ul><li>*DIFFICULT TO DISCERN THE APPENDIX, HOWEVER, NO FREE FLUID NOTED IN THE ABD/PELVIS. </li></ul><ul><li>NO FAT STRANDING IR INFLAMMATORY CHANGES SEEN. </li></ul><ul><li>SUBCENTEMETRRIC MESENTERIC LN NOTED, </li></ul><ul><li>BULKY UTERUS, RT.OVARY:NORMAL,LT.OVARY: FOLLICULAR CYST. </li></ul><ul><li>CONCLUSION: </li></ul><ul><li>NORMAL OVARIES. THE APPENDIX IS NOT SEEN BUT NO SIGNS OF APPENDICITIS OR INFLAMMATORY CHANGES . </li></ul>
  12. 12. <ul><li>OBS&GYNE ON CALL REVIWED: </li></ul><ul><li>PV: NO CERVICAL TENDRNESS,UTERUS NOT PALAPBLE BIMANUALLY DUE TO PENDIOLUS ABD. ADENEXA FREE, </li></ul><ul><li>TVS: POOR PICTURE, UTERUS WITH THIN STREAKS, BOTH OVARIES NORMAL, NO ADNEXAL MASS SEEN, </li></ul><ul><li>========== </li></ul><ul><li>DISCHARGE FORM GYNE SIDE, </li></ul><ul><li>TRACE HVS AND URINE CULTURE. </li></ul><ul><li>SHOULD BE COVERED WITH DOXICYCLINE AND METRONIDAZOLE. </li></ul>
  13. 13. <ul><li>SURGERY ON CALL, </li></ul><ul><li>ADMITT THE PT FOR OBSERVATION AND STARTED ON AB. AND ANALGESIA. </li></ul><ul><li>NEXT DAY:STII IN PAIN, </li></ul><ul><li>IMPRESSION: </li></ul><ul><li>LESS LIKELY TO BE APPENDICITES, DISCHARGED ON CEFUROXIME AND DOXYCYCLINE….., </li></ul>
  14. 15. <ul><li>Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women of childbearing age, accounting for 40 to 50 % of cases. </li></ul><ul><li>Gardnerella vaginalis, Mycoplasma hominis, Prevotella species, Porphyromonas species, Bacteroides species, anaerobic Peptostreptococcus species, Fusobacterium species, and Atopobium vaginae </li></ul>
  15. 16. <ul><li>Homogeneous, white discharge that smoothly coats the vaginal walls </li></ul><ul><li>Vaginal pH greater than 4.5 </li></ul><ul><li>Positive whiff-amine test </li></ul><ul><li>Clue cells on saline wet mount </li></ul>
  16. 17. <ul><li>Vaginal culture has no role in diagnosis because there are no bacteria that are specific for BV. </li></ul><ul><li>Gardnerella vaginalis: </li></ul><ul><li>the organism is detected in up to 50 to 60 percent of healthy asymptomatic women; thus, its presence alone is not diagnostic of BV. </li></ul>
  17. 18. <ul><li>COMPLICATIONS </li></ul><ul><li>Pregnant women with BV are at higher risk of preterm delivery. </li></ul><ul><li>There is a causal relationship between BV and endometrial bacterial colonization, plasma-cell endometritis, postpartum fever, post-hysterectomy vaginal cuff cellulitis, and postabortal infection. </li></ul><ul><li>BV is a risk factor for HIV acquisition and transmission. </li></ul><ul><li>heavy growth of BV-associated microorganisms increased PID risk. </li></ul>
  18. 19. <ul><li>TREATMENT: </li></ul><ul><li>Metronidazole, </li></ul><ul><li>Clindamycin, </li></ul><ul><li>Asymptomatic infection? </li></ul><ul><li>*treat asymptomatic BV prior to hysterectomy and before pregnancy termination to prevent postprocedure infection, </li></ul><ul><li>*PREGNANT? </li></ul>
  19. 20. Take home messages:
  20. 21. <ul><li>*follow up you pt progress, </li></ul><ul><li>*BV is the most common cause of vaginitis and the most common infection encountered in the outpatient gynecologic setting. </li></ul><ul><li>*The prognosis for uncomplicated cases of bacterial vaginosis is generally excellent. </li></ul><ul><li>*asymtomatic pt with bv ususally need no intervention. </li></ul>

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