630 likes | 780 Views
American Family Physician March 15, 2007 Issue. Presented April 26, 2007 Eddie Needham, MD, FAAFP Program Director Emory Family Medicine Residency Program. Subject Matter . Disaster-Related Health Infertility Impetigo Spider Bites Postpartum Hemorrhage Photo Quiz.
E N D
American Family PhysicianMarch 15, 2007 Issue Presented April 26, 2007 Eddie Needham, MD, FAAFP Program Director Emory Family Medicine Residency Program
Subject Matter • Disaster-Related Health • Infertility • Impetigo • Spider Bites • Postpartum Hemorrhage • Photo Quiz
Disaster Medicine Take home points • Disasters happen • Be prepared – The motto of the Boy Scouts of America • American Red Cross defines a disaster as: • Affecting >100 people • 10 or more deaths • Appeal for assistance is requested • Poorest outcomes in: • Ethnic minorities • Lower income families
Disaster Medicine Take home points • Have a clinic/hospital disaster plan ready BEFORE a disaster occurs. • Local disasters • Hurricane Katrina • Tornado in Americus, Georgia this year • Bus accident on I-75 killing many players of a baseball team
Disaster Medicine Take home points • Mental health problems present in a patient before a disaster increase the risk of mental health problems after a disaster. • Most common post-disaster mental health problems include: • Depression • PTSD • Anxiety disorders
Objectives - Infertility • I don’t think our residency program has this problem, based on the recent experiences of Tanya, Nazra, Sarah, and …?
Infertility • Definition • One year of frequent, unprotected intercourse without becoming pregnant. • 10-15% couples are infertile. • Etiology • Unexplained 28% • Male factors 24% • Ovarian dysfunction 21% • Tubal factors 14% • Other 13%
History • What to ask? • Coital practices • Medical history – genetic disorders, chronic illnesses, genital trauma, orchitis, h/o PID/STDs, endocrine problems • Medications – OCPs!!! • Previous fertility • Surgical history – BTL!!! • Substance abuse/toxin exposure
Physical ExamWhat to specifically look for on exam? Males Females • Two marbles and a shooter • Signs of infection • Testicular mass • Hydrocele • Varicocele • Signs of androgen deficiency • Decreased muscle, increased fat, decreased facial/body hair, small testes • Normal female anatomy • Testicular feminization • Breast formation • Galactorrhea • Signs of hyperandrogenism • Hirsutism, acne, clitoromegaly
Infertility - Evaluation • Couple • Timing and frequency of intercourse • Time for midcycle LH surge/ovulation • Use of lubricants • Impairs fertility • Previous fertility • Consider asking some questions with couple separated • Have you had any STDs? • Have you been pregnant before? (Miscarriage, abortion)
Infertility - Evaluation • Male Partner • Primary hypogonadism (testicular failure or dysfunction) is the most common cause of male infertility (30-40%) • Androgen insensitivity, medications, orchitis, radiation trauma • Altered sperm transport (10-20%) • Absent vas deferens, erectile dysfunction, retrograde ejaculation • Secondary hypogonadism (1-2%) • Unknown (40-50%)
Infertility - Evaluation • Female Partner • Ovulation disorders (40%) • Aging, endocrine disorders, decreased ovarian reserve, PCOS, tobacco use, premature ovarian failure • Tubal Factors (30%) • Endometriosis (15%) Review Triad • Other (10%) • Uterine/Cervical factors (>3%) • Congenital uterine abnormalities (double cervix case), fibroids, polyps, uterine synechiae, poor cervical mucus (Robitussin )
Special testing to consider Male Female • Semen analysis • GC/Chlamydia/urine cxprn • FSH, testosterone levels if hypogonadism suspected • CBC if infection considered • ?CMP – renal/liver eval. • Labs based on medical conditions • Prolactin/TSH • Testicular/transrectal ultrasound • Prolactin/TSH • Mid-luteal progesterone to confirm ovulation • Basal body charts • Home LH surge kit (urine) • 17a-hydroxyprogesterone, testosterone if hyperandrogenism suspected • Transvaginal ultrasound • Hysterosalpingogram • Laparoscopy
ManagementTreatment of the Couple • Time intercourse during the five days preceding and the day of ovulation. • Consider alternating days in order to allow the sperm count to increase in the semen after ejaculation • Clear stringy mucus is a sign of ovulation • Avoid lubricants and douches • Avoid alcohol and tobacco • Consider supportive counseling during the difficult time
ManagementMale Factor Infertility • Treat hyperprolactimenia with dopamine agonists (bromocriptine) • Treat erectile dysfunction as needed • Varicocele repair has not been shown to improve fertility rates, although it does increase sperm counts. • In general, seminal fluid abnormalities warrant referral to a specialist.
ManagementFemale Factor Infertility • Ovulatory dysfunction • Correct endocrine abnormalities (PCOS - metformin, thyroid) • Consider laparoscopic ovarian drilling for PCOS (?) • Consider clomiphene citrate (Clomid) to treat women without obvious cause of ovulatory dysfunction and in women with PCOS. • Clomid is not effective in women with hypothalamic amenorrhea or in women with limited ovarian reserve.
Clomiphene citrate (Clomid) • 80% of appropriately selected patients will ovulate. • Give 50 mg on days 5-9 (or days 3-7), check for ovulation. • May repeat x 3 months at 50mg dose. • Then increase to 100mg dose x 3 months. • If still no effect, refer. • Risks of Clomid • Ovarian hyperstimulation syndrome and twinning • Higher-order multiple gestations are rare.
ManagementFemale Factor Infertility • Tubal, Uterine, Pelvic disease • Tubal disease – tubal reparative surgery, remove scars • Consider In-vitro fertilization (IVF) • Endometriosis – reparative surgery • Anecdotally, hysterosalpingogram has be thought to “flush out” the fallopian tubes and improve fertility
Prognosis • Overall likelihood of successful treatment is 50%. • Infertility secondary to ovulatory dysfunction has the best prognosis, with success rates approaching 50%. • Success with tubal factors or endometriosis is approximately 20%.
Impetigo • Most frequently affects children 2-5 years old. • Highly contagious, spread through direct contact. • Staphylococcus aureus is the most common organism. • Two main types • Nonbullous • Host response to infection • Bullous • Caused by a staphylococcal toxin, no host response necessary • Nephritogenic strains of streptococcus pyogenes can cause post-strep. glomerulonephritis. • Occurs in 1-5% of nonbullous impetigo.
Diagnosis • Clinical dx – classic honey-colored crusts • Treatment • Topical mupirocin • Mupirocin is as effective as oral antibiotics for localized disease • Oral antibiotics • Cephalexin • Amoxicillin/clavulanic acid • Macrolides • NOT penicillin V or plain amoxicillin
Spider Bites Black Widow and Brown Recluse
Bite symptoms/signs • Pain at bite site in 3-4 hours, can be unnoticed bite • Formation of bulla • Progression to skin necrosis and ulcer formation
Treatment • Observation in ER until at least 6 hours after the bite • Blood tests • CBC/platelets – look for DIC • BMP – check renal function • Local first aid • Clean wound, ice, elevation, immobilization, analgesia • Tetanus prophylaxis • No benefit to surgical excision of the wound • Excision is different from debridement
Bite symptoms/signs • Painful bite that has a neurotoxin that causes the release of all neurotransmitters in the synapse • Dull crampy pain – chest or abdomen • Progressive autonomic symptoms • Dizziness • Nausea/Vomiting • Headache • Dyspnea • Sweating • Weakness • Anxiety
Treatment • Ice immediately and transport to ER • Clean wound – topical first aid • Tetanus prophylaxis • Observe for at least 6 hours post-bite • Labs: CBC/Platelets/BMP • If symptoms progressive admit and: • Diazepam for muscle cramps • Analgesia as necessary • Consider Antivenin (call poison control) • Administer for severe regional sx, systemic toxicity, uncontrolled HTN, seizures, respiratory arrest