Case: 20 yo female with 4 day history of dysuria, burning, vaginal itchiness/tenderness. Physical exam reveals multiple 5-10 mm ulcerated lesions, significant mucopurulent discharge, and extreme tenderness.
Tapa: Hearing the words painful ulcerated lesion should trigger every medical student to think about Herpes (and also H. ducreyi). Although we have been clasically taught that diagnosis is confirmed with a Tzank smear, in clinical Emergency Medicine practice, Herpes can be diagnosed clinically.
An important point to remember is that patients can often have more than one disease process occurring at the same time. In this case, the patient's vaginal discharge is likely secondary to gonorrhea and/or chlamydia. Due to vaginal tenderness, an accurate cervical examination could not be performed to assess for PID. If unsure, always ere on the side of treating for PID, rather than vaginitis.
Finally, never forget a pregnancy test!
Work-up: UPT, UA, GC/Chlamydia swabs, Wet prep swabs for trichomonas/BV
Treatment:
Primary Herpes - Acyclovir 400 mg, 5 times/day for 5-10 days
PID (always cover GC and Chlamydia) - Ceftriaxone 250 MG IM x1, Doxycycline100 mg PO x10 days
September 04, 2010
September 02, 2010
Anaphalyxis Considerations
Case: 65 yo man presents after being stung by a bee. Complains of wheezing, shortness of breath and tightness in his throat. SBP 95, O2 sat 97%, tachypneic and tachycardic. PMHx HTN treated with atenolol. Management?
Initial Considerations/Tapas:
-ABCs- pts prone to rapid airway compromise, sensation of "lump" or "fullness" in throat is omnious sign, consider definitive airway mgmt
-Epi is mainstay of treatment- 0.3mg of IM epi (1:1000 concentration) q15 minutes as needed for mgmt of hypotension, edema (DO NOT give IV epi unless you are coding the pt(i.e. they are not "alive")- if IV dosing required, 1mg of 1:10,000 epi IV)
-pt's on B-blockers may have blunted response to epi- administer 1g IV glucagon
-antihistamines (H1 and H2 blockers) 50mg IV push of diphenhydramine (H1) and raniditine (H2); use cimetidine with caution, as can increase 1/2 life of B-blockers)
-steroids (onset 4-6 hours after administration); methylpred 125mg
-pt should be observed 4-6 hours (can rarely have phenomenon of relapse 4-6 hours after initial event)
General Anaphalyxis Pearls:
-Anaphalyxis caused by IgE mediated type I hypersensitivity rxn. Preformed antibodies cross-linked by exposure to antigen, results in massive mast-cell degranulation, release of histamine and leukotrienes.
-Common precipitants of anaphalyxis include bee/insect stings, food allergies (particularly nuts), drug allergies (PCN, sulfa drugs), radiocontrast agents (anaphalactoid rxn- not IgE mediated)
Initial Considerations/Tapas:
-ABCs- pts prone to rapid airway compromise, sensation of "lump" or "fullness" in throat is omnious sign, consider definitive airway mgmt
-Epi is mainstay of treatment- 0.3mg of IM epi (1:1000 concentration) q15 minutes as needed for mgmt of hypotension, edema (DO NOT give IV epi unless you are coding the pt(i.e. they are not "alive")- if IV dosing required, 1mg of 1:10,000 epi IV)
-pt's on B-blockers may have blunted response to epi- administer 1g IV glucagon
-antihistamines (H1 and H2 blockers) 50mg IV push of diphenhydramine (H1) and raniditine (H2); use cimetidine with caution, as can increase 1/2 life of B-blockers)
-steroids (onset 4-6 hours after administration); methylpred 125mg
-pt should be observed 4-6 hours (can rarely have phenomenon of relapse 4-6 hours after initial event)
General Anaphalyxis Pearls:
-Anaphalyxis caused by IgE mediated type I hypersensitivity rxn. Preformed antibodies cross-linked by exposure to antigen, results in massive mast-cell degranulation, release of histamine and leukotrienes.
-Common precipitants of anaphalyxis include bee/insect stings, food allergies (particularly nuts), drug allergies (PCN, sulfa drugs), radiocontrast agents (anaphalactoid rxn- not IgE mediated)
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