IV Notes 💉

A 37-year-old smoker woman comes to you due to occasional episodes of nocturnal substernal chest pain that wake her during sleep. The pain is occasionally associated with sweating, palpitations, and nausea , no exertional dyspnea. The pain episodes resolve spontaneously after 10-15 minutes. she has no past medical history , Blood pressure is 120/70 mm Hg, pulse is 75/min and regular, and respirations are 14/min. There is no jugular venous distension. The thyroid is normal. Lungs are clear. Extremities have no edema. ECG shows transient ST-segment elevation in leads I, aVL, and V4-V6 during her episodes of pain. She is referred for coronary angiogram, which shows no significant coronary obstruction.

This patient has no urinary frequency or dysuria, but her urinalysis is positive for leukocyte esterase and nitrite, and her urine culture grows E. coli, all of which indicates asymptomatic bacteriuria. Amoxicillin/clavulanate is a first-line antibiotic agent for asymptomatic bacteriuria during pregnancy. Pregnancy increases the risk of bacteriuria and recurrent urinary tract infections because of increased pressure on the bladder from the growing uterus, urinary stasis, and immunosuppression. Screening for asymptomatic bacteriuria is recommended for all pregnant women in the first trimester. Other antibiotic agents used to treat cystitis that are safe during pregnancy include oral cephalosporins (cephalexin), fosfomycin, and nitrofurantoin (during the 2nd and 3rd trimesters except in the last month of pregnancy). Ciprofloxacin is frequently used to treat complicated urinary tract infections in nonpregnant patients. However, fluoroquinolones are contraindicated during pregnancy. Trimethoprim/sulfamethoxazole should be avoided in this patient because trimethoprim is a folate antagonist, which may cause fetal neural tube defects in the first trimester of pregnancy. Renal ultrasound can be performed to evaluate for urinary retention and signs of pyelonephritis. This pregnant patient's asymptomatic bacteriuria puts her at increased risk of developing pyelonephritis. However, she does not currently have any features that would suggest upper urinary tract involvement (e.g., flank pain, fever, or chills). Asymptomatic bacteriuria should always be treated promptly during pregnancy. This patient is at a higher risk of developing pyelonephritis from asymptomatic bacteriuria than a nonpregnant woman because, during pregnancy, the widened ureters and increased glucose levels in the urine facilitate the ascension of organisms to the kidney. Furthermore, if left untreated, there is also an increased risk of prematurity and low birth weight.

A 23-year-old woman, gravida 2, para 1, at 12 weeks' gestation comes to the physician for her initial prenatal visit. She feels well. Medications include folic acid and a multivitamin. Vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 12-week gestation. Urine dipstick is positive for leukocyte esterase and nitrite. Urine culture shows Escherichia coli (> 100,000 colony forming units/mL).

لينك الجروب للنقاشات https://t.me/IVNOTESCHAT

Air under diaphragm labeled with green color

This patient has acute abdomen with signs of peritonitis (rigid abdomen, rebound tenderness, leukocytosis). The chest x-ray shows free air under the diaphragm, indicating that peritonitis is due to a GI perforation. Given the history of NSAID and steroid use (risk factors for peptic ulcer disease), the most likely site of perforation is the stomach or duodenum. An exploratory laparotomy should be performed in patients with a stomach or bowel perforation and signs of sepsis or generalized peritonitis. The stomach and bowel are carefully examined under direct vision to localize and repair the perforation. Afterward, a peritoneal lavage is performed to clean the peritoneal cavity. If PUD is suspected or confirmed, Upper GI endoscope is indicated for patients older than 50 years with new-onset dyspepsia, and for patients of any age when alarm symptoms suggestive of malignancy or structural disease are present (e.g., upper GI bleeding, iron deficiency anemia, weight loss, dysphagia or odynophagia). It is not indicated for stomach or bowel perforation in a patient with spontaneous gastric or duodenal perforation, the edges of the perforation are friable and have decreased tissue compliance, meaning closure with clips during endoscopy would likely be ineffective. ERCP is commonly used to treat patients with complicated gallstone disease (i.e., involving obstructive jaundice, cholangitis, and/or gallstone pancreatitis). The procedure does not play a role in the treatment of a stomach or bowel wall perforation. In a patient with an acute abdomen, a contrast abdominal CT is commonly used to confirm suspected acute appendicitis, acute pancreatitis, diverticulitis, acute mesenteric ischemia, or complicated inflammatory bowel disease. A contrast abdominal CT may also be used to confirm perforation of the stomach or bowel if an abdominal x-ray does not show air under the diaphragm. This patient's x-ray has already confirmed a gastrointestinal perforation, therefore a CT scan is unnecessary. In patients with acute abdomen, abdominal ultrasonography is a cheap, available diagnostic tool for quickly assessing organs, the biliary tract, potential bleeding, and the quantity of intraperitoneal fluid. This patient's x-ray findings already indicate a perforated stomach or bowel, which necessitates a management step other than ultrasound.

A 43-year-old woman is brought to the emergency department for evaluation of worsening abdominal pain that suddenly started 2 hours ago. The patient also has nausea and has vomited twice. She has hypothyroidism, systemic lupus erythematosus, major depressive disorder, and osteoarthritis. Current medications include levothyroxine, prednisone, fluoxetine, brufen, and a chondroitin sulfate supplement. She appears distressed. Her temperature is 37.9°C , pulse is 101/min, and blood pressure is 115/70 mm Hg. Examination shows a diffusely rigid abdomen with rebound tenderness; bowel sounds are hypoactive. Laboratory studies show a leukocyte count of 13,300 and ESR 70 mm/h. A chest x-ray is shown.

A tender left lower quadrant mass with leukocytosis and fever is consistent with acute diverticulitis. The inflamed diverticula that are situated in the distal sigmoid colon can be palpated on digital rectal examination CT scan of the abdomen with contrast (oral and intravenous) is the test of choice for diagnosing diverticulitis. Typical CT findings include bowel wall thickening (> 4 mm) and inflammation of the pericolonic fat with fat stranding (visible traces of fluid in the fat). A CT scan is also helpful in ruling out complications such as abscess , obstruction (dilated intestinal loops, air-fluid levels), perforation (free air in the abdominal cavity), and fistula (air in organs other than the bowel). Abdominal x-ray is not useful to confirm the diagnosis of diverticulitis, as it may fail to demonstrate the presence of colonic diverticula and the expected bowel wall thickening. However, it can be used to visualize some of the complications of diverticulitis, such as abscesses, obstructions, ileus, and perforation (pneumoperitoneum). Exploratory laparotomy may be considered in patients with severe abdominal pain that cannot be evaluated sufficiently by noninvasive diagnostic methods. This patient's clinical presentation strongly suggests diverticulitis, which can be confirmed or ruled out with a diagnostic test. Abdominal ultrasound is not the test of choice for the diagnosis of diverticulitis. However, can be performed if other imaging techniques are unavailable Colonoscopy is contraindicated in this patient with an acute episode of diverticulitis because the inflammation may be exacerbated by the procedure and the risk of perforation is increased. Colonoscopy is typically performed once the inflammation has subsided (typically after 6 weeks) to assess the extent of diverticulitis and rule out malignancy. Rectal cancer is an important differential diagnosis in a patient with a palpable mass on DRE. However, given the acute presentation with systemic signs of inflammation (fever, leukocytosis) and the tenderness of the mass, diverticulitis is more likely.

A 55-year-old obese smoker woman comes to the emergency department because of a 24-hour history of severe lower abdominal pain. She has had two episodes of nonbloody vomiting today . She didn't pass stool since yesterday. She has hypertension, hyperlipidemia, and osteoarthritis. She had a cholecystectomy 5 years ago. Current medications include thiazide diuretic, atorvastatin, and Brufen. Her temperature is 38.8°C , pulse is 102/min, respirations are 20/min, and blood pressure is 118/78 mm Hg. There is moderate left lower quadrant tenderness. A tender mass is palpated on digital rectal examination. There is no guarding or rebound tenderness. Laboratory studies show: Hemoglobin 13.3 g/dL Hematocrit 40% Leukocyte count 17,000/mm3 Platelet count 188,000/mm3 Serum Na+ 138 mEq/L K+ 4.1 mEq/L Cl- 101 mEq/L HCO3- 22 mEq/L Urea nitrogen 18.1 mg/dL Creatinine 0.9 mg/dL

This patient has an anterior STEMI causing acute heart failure with pulmonary edema demonstrated by dyspnea, lung crackles, and hypoxemia. Emergency coronary reperfusion is the main ttt To help stabilize a patient with acute heart failure for emergency PCI, a loop diuretic (eg, furosemide) should be administered along with ventilatory support (eg, intubation) as needed. Loop diuretics stimulate potent diuresis to reduce cardiac preload and relieve acute pulmonary edema. Intravenous nitrates can also help reduce cardiac preload and relieve acute pulmonary edema. However, both loop diuretics and nitrates can worsen hypotension and must be used with caution. amlodipine is primarily used for the management of hypertension and are not indicated for acute MI. Digoxin slows conduction through the atrioventricular node and also increases cardiac contractility. The increased contractility increases myocardial oxygen demand, making digoxin relatively contraindicated in acute MI. metoprolol improve mortality in acute MI, likely due in part to decreased myocardial oxygen demand and reduced infarct size. However, beta blockers are contraindicated in decompensated heart failure because their negative chronotropic and inotropic effects may worsen pulmonary edema. Intravenous normal saline is indicated in the management of acute right ventricular MI, which should be suspected when there is ST-segment elevation in the inferior leads. Pulmonary edema is not expected with right ventricular MI and is indicative of left ventricular MI, for which intravenous fluids are contraindicated.