Unit Three: Urinary Tract Infection, Diverticulitis and Kidney Disease

UNIT THREE Urinary Tract Infection Overview: UTIs in men occur when bacteria enter the urinary tract, causing infection in the urethra, bladder, or kidneys. Less common in men than in women but can be more complicated. Causes: Blockage: Enlarged prostate, kidney stones. Cat...

UNIT THREE Urinary Tract Infection Overview: UTIs in men occur when bacteria enter the urinary tract, causing infection in the urethra, bladder, or kidneys. Less common in men than in women but can be more complicated. Causes: Blockage: Enlarged prostate, kidney stones. Catheter use: Increases risk of infection. Unprotected sex: Risk of sexually transmitted infections. Rule out gonorrhea and chlamydia if sexually active, particularly in adolescent and young adult males. Chronic Conditions: Diabetes, urinary retention. Diverticulitis: Inflammation or infection of diverticula (small pouches) in the intestinal wall, typically in the colon. Diagnosis of Diverticulitis: The diagnosis of diverticulitis relies on: Patient history (LLQ pain, fever, bowel changes). Physical exam (LLQ tenderness). Imaging, such as a CT scan, which is the gold standard for confirming diverticulitis. Can be life threatening: Sepsis, small-bowel obstruction, hemorrhage, perforation, ileus and abscess. Patient History: Previous episodes of diverticulitis or known diverticulosis. Recent changes in bowel habits (constipation or diarrhea). Diet low in fiber or history of low physical activity. Symptoms: Left lower quadrant (LLQ) pain (most common), can be constant and severe. Fever, nausea, or vomiting. Possible bloating, tenderness, or abdominal distension. Changes in bowel movements (constipation or diarrhea). Physical Examination: LLQ tenderness upon palpation. Fever or elevated heart rate indicating systemic infection. Look for signs of peritonitis (rigid abdomen, rebound tenderness) in severe cases. Diverticulitis Diagnostics Laboratory Tests: CBC: Elevated WBC count suggests infection.  CRP (C-reactive protein) may be elevated. Imaging: CT scan of the abdomen and pelvis with contrast: o Gold standard for confirming diverticulitis. o Detects inflammation, abscesses, or perforation. Diverticulitis Management Uncomplicated Cases: Oral antibiotics, clear liquid diet, and follow-up. Complicated Cases (e.g., abscess, perforation): Hospitalization, IV antibiotics, and possible surgical intervention. Prevention Tips High-fiber diet, regular physical activity, and proper hydration to prevent diverticulosis. Cholecystitis Inflammation of the gallbladder, often due to gallstones blocking the cystic duct. Symptoms Right Upper Quadrant (RUQ) Pain: o Steady and severe, may radiate to the right shoulder or back. o Worsens after eating fatty foods. Fever, nausea, and vomiting. Positive Murphy’s sign: Pain upon palpation of the RUQ during deep inspiration Classic presentation is a patient complaining of sever right upper quadrant pain that occurs within 1 hour or more after eating a fatty meal. Pain may radiate to epigastric or right shoulder areas. Frequent nausea and vomiting. Diagnosis and Treatment Laboratory Tests: Elevated WBC count (indicates infection/inflammation). Elevated liver enzymes (AST, ALT) and bilirubin in some cases. Imaging: Ultrasound: First-line imaging; shows gallstones, thickened gallbladder wall, or pericholecystic fluid. HIDA Scan: Used if diagnosis is unclear after ultrasound. Treatment Cholecystectomy (surgical removal of the gallbladder):Laparoscopic (most common) or open procedure for severe cases. Urinalysis Interpretation Normal values are as follows: Color – Yellow (light/pale to dark/deep amber)  Clarity/turbidity – Clear or cloudy pH – 4.5-8 Specific gravity – 1.005-1.025 Glucose - ≤130 mg/d Ketones – None Nitrites – Negative Leukocyte esterase – Negative Bilirubin – Negative Urobilirubin – Small amount (0.5-1 mg/dL) Blood - ≤3 RBCs Protein - ≤150 mg/d RBCs - ≤2 RBCs/hpf WBCs - ≤2-5 WBCs/hpf Squamous epithelial cells - ≤15-20 squamous epithelial cells/hpf Casts – 0-5 hyaline casts/lpf Crystals – Occasionally Bacteria – None Yeast – None Yellow: Normal color, ranging from light to deep amber Dark yellow: May indicate dehydration or exercise Green or blue: May indicate a pseudomonal UTI or other conditions Orange: May indicate bile pigments, carrots, or other conditions Pink or red: May indicate hematuria, menstrual contamination, or other conditions Chemical composition pH: A pH below 5 may indicate an increased risk of kidney stones, while a pH above 7 may indicate a bacterial UTI Protein: Small increases in protein are usually not a cause for concern, but larger amounts may indicate kidney problems Sugar: The presence of sugar in urine may indicate diabetes or liver or pancreas disease Ketones: The presence of ketones in urine may indicate diabetes or illness Bilirubin: The presence of bilirubin in urine may indicate liver damage or disease Blood: The presence of blood in urine may indicate kidney damage, infection, or other conditions  Nitrites: The presence of nitrites in urine may indicate a bacterial infection Leukocyte esterase: The presence of leukocyte esterase in urine may indicate inflammation or infection Pancreatitis Inflammation of the pancreas, which can be acute or chronic. Acute Pancreatitis: Sudden inflammation that can be mild or life-threatening. Chronic Pancreatitis: Long-term inflammation leading to permanent damage. Causes: o Gallstones (most common cause). o Alcohol abuse (second most common). o Hypertriglyceridemia or hypercalcemia. o Certain medications, infections, trauma, or post-ERCP (Endoscopic Retrograde Cholangiopancreatography). Pancreatitis Assessment Symptoms Severe epigastric pain: o Often radiates to the back. o Worsens after eating, especially fatty meals. Nausea and vomiting. Fever and tachycardia. Abdominal tenderness and guarding. Pancreatitis Diagnosis Laboratory Tests: Elevated serum amylase and lipase (lipase is more specific). Elevated WBC count, liver enzymes (if associated with gallstones). Imaging: CT scan: Confirms diagnosis and assesses severity. Ultrasound: Evaluates gallstones or biliary obstruction. MRCP (Magnetic Resonance Cholangiopancreatography) for detailed biliary imaging. Treatment NPO (nothing by mouth) to rest the pancreas. Refer to the emergency department for V fluids and electrolyte management for hydration. Pain control: Analgesics. Antibiotics: Only if infection or necrosis is suspected. ERCP: For gallstone-related pancreatitis to remove obstruction Nephrolithiasis Renal calculi are a common cause of blood in the urine (hematuria) and pain in the abdomen, flank, or groin. They occur in 1 of every 11 people in the United States at some time in their lifetimes, with men affected 2 to 1 over women. Development of the stones is related to decreased urine volume or increased excretion of stone-forming components such as calcium, oxalate, uric acid, cystine, xanthine, and phosphate. Calculi may also be caused by low urinary citrate levels (an inhibitor of stone formation) or excessive urinary acidity. Renal calculi may present with excruciating pain, and most patients present to the emergency department in agony. A single event does not cause kidney failure, but recurrent renal calculi can damage the tubular epithelial cells, leading to functional loss of the renal parenchyma. he 4 major types and causes of renal calculi include: Calcium stones: due to hyperparathyroidism, renal calcium leak, absorptive or idiopathic hypercalciuria, hyperoxaluria, hypomagnesemia, and hypocitraturia Uric acid stones: associated with a pH of less than 5.5, a high intake of purine-rich foods (fish, legumes, meat), or cancer; may also be associated with gout Struvite stones: caused by Gram-negative, urease-producing organisms that break down urea into ammonia o Common organisms include Pseudomonas, Proteus, and Klebsiella. However, E coli does not produce urease and is not associated with struvite stones. Cystine stones: due to an intrinsic metabolic defect causing the failure of the renal tubules to reabsorb cystine, lysine, ornithine, and arginine; visually opaque and amber Of these, uric acid and cystine are the most likely stone types that develop recurrences. Many drugs are known to cause renal stones, including the following: Atazanavir Guaifenesin Indinavir Silicate overuse Sulfonamide Triamterene Ultrasound may be useful for assessing obstruction and resultant hydronephrosis, especially in pregnancy, where x-ray studies are discouraged. Ultrasound can also identify uric acid and other non-calcific renal stones if they are large enough (usually greater than 4 mm), but it can also miss the presence of stones less than 5 mm in size and cannot easily identify ureteral stones ( A non-contrast abdominal and pelvic computed tomography scan is considered the "gold standard" as it is the most sensitive and reliable test to diagnose urolithiasis and will also provide information regarding obstruction with resultant hydronephrosis. Renal calculi can be extremely painful when they cause a ureteropelvic junction or ureteral obstruction or they become infected. Pain control may require opioids, but intravenous (IV) nonsteroidal anti-inflammatory drugs can also be quite effective while avoiding narcotic side effects. As patients with renal colic will often experience nausea and vomiting, IV hydration and antiemetics may be required acutely. Many stones may be watched conservatively, with intervention planned as an outpatient. Smaller stones (35 years gram- E. coli Most common cause of acute scrotal pain in prepubertal boys. Epididymitis Presentation/Assessment HPI: Acute onset of red, swollen, painful scrotum. May have urethral discharge, UTI symptoms, fever. Risk factors: Multiple sex partners, STI hx, prolonged sitting, anal intercourse, UTI Exam shows unilateral testicular tenderness, scrotum swollen and erythematous with induration of the posterior epididymis. Sometimes accompanied by hydrocele. Hallmark: Positive Prehn’s sign (relief of pain with scrotal elevation). Cremasteric reflex present (stroking inner part of thigh causes muscle to retract and pull up testicle) Labs: Testing for gonorrhea and chlamydia Rule out testicular torsion Epididymitis Treatment < 35 years treat as if STI present for gonorrhea and chlamydia; may need to treat partner if + > 35 years treat with Levaquin (educate on risk of tendon injury while on med) Treat pain with NSAIDS or Tylenol + Codeine Scrotal elevation, ice packs, bed rest for a few days, stool softeners, no sex ED precautions if signs of sepsis (intractable pain, fever, abscess) Bowel Obstruction Small bowel obstruction : surgical emergency due to mechanical blockage of the bowel. Though it can be caused by many pathologic processes, the leading is intra-abdominal adhesions The patient may have a history of previous abdominal surgeries, inflammatory bowel disease, malignancy, or a hernia at a certain point in time. The most common presentation includes complaints of abdominal pain, distention, nausea, and vomiting. The abdominal pain may be progressive or intermittent in nature. It may be associated with constipation or obstipation with or without flatus and even loose bowel movements. The bowel sounds may be reduced and high pitched. Abdominal tenderness on physical examination may be diffuse or focal with the presence of distention. There may be signs of peritonitis such as rebound, guarding, and rigidity and signify late findings that may be present depending on the time of presentation. Evaluation for hernias, surgical scars, masses including in the rectum, and fecal impactions may demonstrate the possible etiology. There may be signs and symptoms of dehydration and sepsis as well A computed tomography scan of the abdomen is the gold standard Surgery consultation should be utilized without delay, as many small bowel obstruction patients require surgical management. Initial treatment of small bowel obstruction involves fluid resuscitation, pain control, antibiotics, and, often, nasogastric decompression. Antibiotics of choice for small bowel obstruction should target gut flora and cover both gram-negative and anaerobic bacteria. Ileus and partial small bowel obstructions can often be treated conservatively with nasogastric decompression. Surgical consultation should still be sought, but surgical intervention may not be required Large bowel obstruction is a critical condition often necessitating emergency intervention due to the risk of sepsis, dehydration, and hemodynamic instability. The etiologies of large bowel obstruction can be structural, such as from tumors, hernias, or volvulus; or functional, such as pseudo-obstruction. Patients with a competent ileocecal valve may experience closed-loop obstructions, leading to severe distension and pain, and are at higher risk for perforation. The obstruction frequently presents with symptoms such as abdominal pain, distension, and a lack of bowel movements, but symptoms vary based on the cause and site of the blockage Imaging typically begins with supine and upright or decubitus x-rays, which can reveal a dilated colon with a possible transition in the area of the obstruction and a lack of gas in the rectum or any site distal to the obstruction. Air-fluid levels may be evident in the colon. Evidence of necrosis or perforation may also be identified in an x-ray through findings such as pneumoperitoneum and gas in the bowel wall or portal venous system Before any surgical intervention, supportive therapies targeting fluid resuscitation and metabolic dysfunction correction are essential. Patients who have experienced marked cecal distension for several days are at increased risk of perforation and should be considered for some mode of decompression. Serial imaging is critical to monitor the extent of distension over time. Pneumatosis within the cecum or colon often indicates ischemia and possibly imminent perforation. Nasogastric tube insertion can help decompress the stomach in patients with a colonic obstruction and an incompetent ileocecal valve Testicular Torsion Spermatic cord becomes twisted and blood supply is interrupted. Presents with sudden onset of severe testicular pain with an extremely swollen, red testicle, higher than normal testicle. Nausea/vomiting. Exam: Cremasteric reflex absent, my have acute hydrocele. Call 911 (permanent damage if not corrected in first few hours) Torsion of the Appendix Testis Torsion of the Appendix Testis is a relatively common cause of acute scrotal pain in prepubertal and adolescent boys, though it is much less common in adults. Here are some key points about its prevalence and the blue dot sign: Prevalence: It accounts for approximately 50% of acute scrotal pain in boys aged 7-14 years. It is the most common cause of testicular pain in this age group, more frequent than testicular torsion. Although it can occur at any age, it is rare in infants and adults. Blue Dot Sign The blue dot sign is a classic physical exam finding associated with torsion of the appendix testis. It presents as a small, tender, blueish discoloration visible under the skin of the scrotum, typically near the upper pole of the testis. Frequency: o The blue dot sign is not always present; it can be seen in approximately 21 - 40% of cases. o It is more likely to be observed early in the presentation, before swelling and inflammation obscure the view. While torsion of the appendix testis is common in young boys, the blue dot sign is a helpful but not definitive clinical indicator, seen in less than half of cases. Cremasteric Reflex The testicle is elevated toward the body in response to stroking the inner thigh on same side as affected testicle. Absent in testicular torsion Nausea and Vomiting Nausea is a commonly encountered symptom in healthcare that is difficult for any patient. Causes may be as simple as the body's defense against an ingested toxin to a complex association set of signals activated by motion, medications, anesthesia, position, stress, pregnancy, psychiatric disorder, or fear. Multiple or single neurohumoral pathways may be involved. Indications for the treatment of symptoms require astute evaluation by the treating provider. Hydrocele Collection of serous peritoneal fluid within scrotum. Presents with painless swelling of scrotum, scrotum feels heavy and enlarged. Exam: Scrotum will transilluminate (solid mass will not) 10% of testicular malignancies present with hydrocele Exam: Scrotal ultrasound, transillumination Observation until 2 y/o. Surgery referral if > 2 y/o or uncomfortable in adult. Scrotal support. Rectal Bleeding Rectal bleeding can occur due to a number of possible reasons, including hemorrhoids, anal fissures, infections, and more serious conditions. Causes Hemorrhoids: Swollen veins in the rectum that can cause bright red blood Anal fissures: Tears in the anal lining that can cause sudden bleeding and pain Infections: Sexually transmitted infections (STIs) and other pathogens can cause rectal bleeding Diverticulitis: Damage to the colon or rectum caused by abnormal pouches in the colon Crohn's disease: An inflammatory bowel disease that can cause bleeding lesions in the colon or rectum Ulcerative colitis: An inflammatory bowel disease that can cause bleeding lesions in the colon or rectum Colorectal cancer: A more serious condition that can cause rectal bleeding Varicocele Collection of abnormally large dilated veins in the scrotum. Majority occur on the left. If on right side or sudden onset on either side in adult need further evaluation (renal carcinoma, thrombosis. More frequent in older adolescents. Presents: Infertility, fullness, bag full of worms, bluish discoloration of scrotum.  Grade I-III. Refer to urology. Pinworm Infection Enterobius vermicularis, also called pinworm, is one of the most common helminth infections in the world, with most cases occurring in children Approximately a third of patients with Enterobius vermicularis are asymptomatic. The most common symptom associated with pinworm infestation is perianal itching. Perianal erythema may be seen due to the itching and scratching. Sometimes a superficial bacterial infection can occur at the scratching sites resulting in erythema and warmth. Persistent itching can cause disturbances in sleep and may lead to insomnia. Enterobius can be diagnosed through a cellophane tape test or pinworm paddle test where an adhesive tape-like material is applied to the perianal area and then examined under a microscope. The examination might reveal characteristic ova which are 50 by 30 microns in size and have a flattened surface on one side or may reveal the worm Treatment consists of the following antihelminthic medications: Albendazole: Given on an empty stomach, a 400-mg, one-time dose followed by a repeat dose in 2 weeks OR Mebendazole: A 100-mg, one-time dose followed by a repeat dose in two weeks OR Pyrantel Pamoate: Available over the counter in the United States; Dose of 11 mg/kg up to a maximum 1 gm given 2 weeks apart Enterobiasis can cause recurrent reinfection, so treating the entire household, whether symptomatic or not is recommended to prevent a recurrence Testicular Cancer Symptoms and Screening #1 cancer in adolescent and young adult males (ages 15-35 years) 80% of all cases diagnosed between the ages of 20 and 35 years One of the most curable cancers if detected early. Monthly TSE important Risk factors: o History of cryptorchidism, white race, family history Assessment: Solid, firm, nontender unilateral testicular mass  Sensation of fullness, heaviness or dull ache in scrotum, lower abdomen, or perianal area Previous small testicle enlarges to size of normal testicle Mass does not illuminate Diagnosis Scrotal ultrasound is gold standard for diagnosis Prevention Monthly testicular self-exam Boys with cryptorchidism should undergo orchiopexy prior to age 13 years. Management Discuss cryopreservation of sperm before treatment Radical orchiectomy in all testicular cancers regardless of staging Radiation, chemotherapy Dysphagia Patients subjectively define dysphagia as difficulty swallowing and objectively defined by clinicians as an impairment in swallowing that results in an abnormal delay in the transit of a liquid or solid bolus from the oral cavity to the stomach. Dysphagia may be acute or chronic, intermittent or persistent. A globus sensation may accompany it. Dysphagia may be due to abnormalities in the oropharyngeal or esophageal phases of swallowing, or it may be mixed. Dysphagia is a common problem, particularly in the elderly population. The underlying etiology may be a mechanical obstruction or a motility disorder. Anatomical, neuromuscular, infectious, and inflammatory diseases may all present with or contribute to dysphagia Oropharyngeal Dysphagia Oropharyngeal dysphagia is the delay in the transit of liquid or solid bolus during the oropharyngeal phase of swallowing. A variety of anatomical and neuromuscular disorders can cause oropharyngeal dysphagia. Some causes of oropharyngeal dysphagia, such as that seen in the postoperative period following cervical discectomy and fusion, are multifactorial. Anatomical causes of oropharyngeal dysphagia are most commonly due to lesions that obstruct the lumen or cause external compression of the oropharynx. These include Zenker diverticulum, esophageal webs, oropharyngeal tumors and abscesses, goiters, and external compression by an aortic aneurysm called dysphagia aortica. Neuromuscular causes of oropharyngeal dysphagia are many. Dysphagia is common after cerebrovascular accidents, including brainstem infarctions with cranial nerve involvement. In addition, the basal ganglia lesions in Parkinson disease may cause dysphagia. Head injuries, multiple sclerosis, central nervous tumors, botulism, amyotrophic lateral sclerosis, and supranuclear palsy may all cause dysphagia. Muscular disorders such as polymyositis and myopathies may cause dysphagia. Due to its effect on the neuromuscular junction, myasthenia gravis is known to cause dysphagia. Esophageal Dysphagia Esophageal dysphagia may be caused by mechanical obstruction of the esophagus or a motility disorder. Mechanical obstruction is characterized primarily by dysphagia with solids, whereas motility disorders have dysphagia for both solids and liquids. Esophageal dysphagia may be intermittent or continuous. Esophageal dysphagia due to mechanical obstruction is most commonly due to a Schatzki ring, esophageal stricture or webs, esophageal carcinoma, and eosinophilic esophagitis. Causes of motility disorders resulting in dysphagia include esophageal spasm, achalasia, ineffective esophageal motility, and systemic sclerosis. Rheumatological Disorders and Dysphagia Several rheumatological disorders are known to cause dysphagia via multiple mechanisms. Each may also exacerbate dysphagia due to other causes. For example, Sjögren syndrome, an autoimmune disease affecting exocrine glands, causes dysphagia via xerostomia and changes in the motility of the proximal esophagus. Limited cutaneous systemic sclerosis (formerly CREST syndrome) is a well-known cause of esophageal dysmotility. Other commonly encountered rheumatologic disorders that may cause or complicate dysphagia are rheumatoid arthritis, systemic lupus erythematosus, and mixed connective tissue diseases. Medication-induced Dysphagia Several pharmaceuticals may contribute to the severity of dysphagia. The mechanisms by which these drugs may cause dysphagia include xerostomia and changes in esophageal motility. Also, dysphagia may be secondary to the development of drug-induced esophagitis or the result of gastroesophageal reflux disease as a side effect of medication use. Examples of these drugs are: Antipsychotics (eg, olanzapine, clozapine) Tricyclic antidepressants Potassium supplements Non-steroidal anti-inflammatory drugs Bisphosphonates Calcium channel blockers Nitrates Theophylline Alcohol Opioids Sexually Transmitted Infections The most common and curable STIs are trichomonas, chlamydia, gonorrhoea and syphilis. Viral STIs including HIV, genital herpes simplex virus (HSV), viral hepatitis B, human papillomavirus (HPV) and human T-lymphotropic virus type 1 (HTLV-1) lack or have limited treatment options. Vaccines are available for hepatitis B to prevent infection that can lead to liver cancer and for HPV to prevent cervical cancer. HIV, HSV and HTLV-1 are lifelong infections: for HIV and HSV there are treatments that can suppress the virus, but currently there are no cures for any of these viral STIs. Condoms used correctly and consistently are effective methods to protect against STIs and HIV. Screening with early diagnosis of people with STIs and their sexual partners offers the best opportunity for effective treatment and for preventing complications and further transmission. Diagnostic Testing and Lab Interpretation LFTS: Normal ranges Alanine transaminase (ALT): 7–56 units per liter (U/L) Aspartate aminotransferase (AST): 5–40 U/L Alkaline phosphatase (ALP): 40–129 U/L Albumin: 3.5–5.0 grams per deciliter (g/dL) Total protein: 6.3–7.9 g/dL Bilirubin: 0.1–1.2 milligrams per deciliter (mg/dL) Gamma-glutamyltransferase (GGT): 8–61 U/L Prothrombin time (PT): 9.4–12.5 seconds Elevated levels Elevated levels of ALT and AST can indicate liver damage. Elevated PT can indicate decreased clotting factors, vitamin K deficiency, or warfarin treatment CBC: Red blood cell count Male: 4.35 trillion to 5.65 trillion cells/L Female: 3.92 trillion to 5.13 trillion cells/L Hemoglobin Male: 13.2 to 16.6 grams/dL (132 to 166 grams/L) Female: 11.6 to 15 grams/dL (116 to 150 grams/L) Hematocrit Male: 38.3% to 48.6% Female: 35.5% to 44.9% White blood cell count 3.4 billion to 9.6 billion cells/L Platelet count Male: 135 billion to 317 billion/L Female: 157 billion to 371 billion/L Complete blood count (CBC) measures the number and types of cells in your blood, including red blood cells (RBCs), white blood cells (WBCs), and platelets. A CBC can help diagnose and monitor many conditions, such as anemia, infections, and bone marrow disorders. What do the values mean? Red blood cell (RBC) count The number of RBCs in your blood. A low RBC count could indicate anemia, while a high count could be due to heart and lung conditions. White blood cell (WBC) count The number of WBCs in your blood. A high WBC count could indicate an infection or reaction to medication, while a low count could indicate an autoimmune disorder or bone marrow disorder. Hematocrit (Hct) The percentage of your blood that is made up of RBCs. A low Hct could indicate iron deficiency, while a high Hct could indicate dehydration.  Hemoglobin (Hgb) The amount of hemoglobin in your blood, which is the protein that carries oxygen. A low Hgb could indicate anemia, while a high Hgb could indicate heart disease. Mean corpuscular volume (MCV) The average size of your RBCs. A high MCV could indicate low vitamin B12 or folate levels, while a low MCV could indicate anemia Acute Gastroenteritis Acute infectious gastroenteritis is a common illness seen around the world, and most cases are caused by viral pathogens. The acute diarrheal disease is generally self-limited. Several different viruses including rotavirus, norovirus, adenovirus, and astroviruses account for most cases of acute viral gastroenteritis. Most are transmitted via the fecal-oral route, including contaminated food and water. Transmission has also been shown to occur via fomites, vomitus, and possibly airborne methods. Norovirus is more resistant to chlorine and ethanol inactivation than other viruses The treatment of viral gastroenteritis is based on symptomatic support. The most important goal of treatment is to maintain hydration status and effectively counter fluid and electrolyte losses. Fluid therapy is a fundamental part of treatment. Intravenous fluids may be administered to those individuals who appear dehydrated or to those unable to tolerate oral fluids. Antiemetic medications such as ondansetron or metoclopramide may be used to assist with controlling nausea and vomiting symptoms. Patients demonstrating severe dehydration or intractable vomiting may require hospital admission for continued intravenous fluids and careful monitoring of electrolyte status Abdominal Pain Assessment Techniques (Rovsing's sign, Psoas sign, Obturator sign, DRE, Murphy's sign, McBurney's sign, auscultation, palpation) McBurney's Point: Indicates acute appendicitis. Cullen's Sign: Associated with pancreatitis and ruptured ectopic pregnancy due to intraperitoneal bleeding. Murphy's Sign: Suggests acute cholecystitis. Obturator Sign: Can indicate acute appendicitis, especially when the appendix is located in the pelvis. Psoas Sign: Suggests acute appendicitis, particularly if the appendix is retrocecal. Rovsing's Sign: Indicates appendicitis, and can also be a sign of peritonitis.  Rebound Tenderness: Indicates peritonitis, and may be associated with conditions like appendicitis, diverticulitis, PID, and cholecystitis. Diarrhea Diarrhea is a common condition that varies in severity and etiology. Its evaluation varies depending on duration, severity, and the presence of certain concurrent symptoms. Treatment also varies, though rehydration therapy is an important aspect of managing any patient with diarrhea Diarrhea is categorized into acute or chronic and infectious or non-infectious based on the duration and type of symptoms. Acute diarrhea is defined as an episode lasting less than 2 weeks. Infection most commonly causes acute diarrhea. Most cases result from a viral infection, and the course is self-limited. Chronic diarrhea is defined as a duration lasting longer than 2 weeks and tends to be non-infectious. Common causes include malabsorption, inflammatory bowel disease, and medication side effects An important aspect of diarrhea management is replenishing fluid and electrolyte loss.] Patients should be encouraged to drink diluted fruit juice, Pedialyte, or Gatorade. In more severe cases of diarrhea, IV fluid rehydration may become necessary.] Eating foods that are lower in fiber may aid in making stool firmer. A bland 'BRAT' diet, including bananas, toast, oatmeal, white rice, applesauce, and soup/broth, is well tolerated and may improve symptoms. Anti-diarrheal therapy with anti-secretory or anti-motility agents may be started to reduce the frequency of stools. However, they should be avoided in adults with bloody diarrhea or high fever because they can worsen severe intestinal infections. Empiric antibiotic therapy with an oral fluoroquinolone can be considered in patients with more severe symptoms. Probiotic supplementation has been shown to reduce the severity and duration of symptoms and should be encouraged in patients with acute diarrhea Ectopic Pregnancy: Ectopic pregnancy must be considered in sexually active females of child- bearing age. Importance: Ectopic pregnancy: A pregnancy outside the uterine cavity, most commonly in the fallopian tube. It is a medical emergency due to the risk of rupture and hemorrhage. If ectopic pregnancy is confirmed or highly suspected refer to emergency department. Key Considerations: All women of reproductive age presenting with abdominal pain should be assessed for ectopic pregnancy. Early identification is crucial for preventing complications.  Leading cause of death for women in first trimester due to rupture and intraperitoneal bleeding Ectopic Pregnancy Assessment Patient History: Last menstrual period (LMP). Symptoms: Spotting, vaginal bleeding, or dizziness. May report amenorrhea to light menses in the previous 6 to 7 weeks Risk factors: Previous ectopic pregnancy, tubal surgery, infertility treatments, PID, IUD. Classic presentation is pelvic pain that is diffuse or localized to one side that may be abrupt or more insidious. Pain can be dull or sharp but not crampy and may be referred to the shoulder. Physical Examination: Abdominal tenderness, pelvic exam for cervical motion tenderness. Check for signs of hypotension or shock (may indicate rupture). Ectopic Pregnancy Diagnostics Definitive diagnosis: Serum quantitative β-hCG levels levels and transvaginal ultrasonography. Laboratory Tests: β-hCG levels: Confirm pregnancy status. Serial measurements to assess viability (in normal pregnancy, levels double every 48-72 hours). Imaging: Transvaginal ultrasound: Detects intrauterine pregnancy (IUP) or ectopic pregnancy. Absence of an IUP with elevated β-hCG (>1,500 mIU/mL) is highly suspicious for ectopic pregnancy. Appendicitis Inflammation of the appendix, a small, finger-like pouch attached to the large intestine. Most common in individuals aged 10-30 years. Symptoms Abdominal Pain: o Starts around the navel and shifts to the right lower quadrant (RLQ) (McBurney's point). o Pain worsens with movement, coughing, or sneezing. Other Signs: o Nausea, vomiting, and loss of appetite. o Fever and elevated white blood cell count. o Possible Rovsing's sign: Pain in the RLQ when the LLQ is palpated. Appendicitis Diagnosis  Physical Examination: o RLQ tenderness, guarding, and rebound tenderness. o Positive Rovsing's sign, Psoas sign, or Obturator sign may be present. Laboratory Tests: o Elevated WBC count (indicating infection). Imaging: o Ultrasound: Useful, especially in children and pregnant women. o CT scan: Gold standard for confirming diagnosis. Rovsing's sign and other physical exam findings can aid in diagnosis but should be confirmed with imaging. Appendicitis Management Complications o Perforation: Can lead to peritonitis and abscess formation. o Sepsis: A life-threatening complication if left untreated. o Treatment Refer to emergency department for surgical removal (appendectomy) is the standard treatment. Cryptorchidism: Incomplete descent of one or both testicles into the scrotum (typically occurs during 7-8th month in utero). 95% descend by 1 y/o Refer to urology if not descended by 6 months of age. Increased risk of testicular cancer, infertility. The patient should be warm and relaxed for the examination. Place patient in frog-leg position, sitting, standing, or squatting. ⬇ Observation should precede the examination. Note the presence of any hypospadias or chordee. Does the patient have a normal stretched penile length? ⬇ Milk down, palpating from iliac crest to scrotum (soap or lubrication on fingertips may help). ⬇ What are the features of the scrotum and its contents (eg, hypoplasticity, bifidity, rugae, transposition, pigmentation)? ⬇ Is the contralateral testicle hypertrophic? ⬇ Is the undescended testis located in an unusual position, such as in an ectopic site (ie, superficial inguinal pouch or transverse scrotal, femoral, prepenile, perineal, or contralateral hemiscrotum)? ⬇ If the findings are equivocal, perform serial examinations. Phymosis and Paraphimosis: Definitions: Phimosis: Inability to retract the foreskin over the glans penis. o Can be physiologic (normal in young boys) or pathologic (due to scarring or infection). Paraphimosis: Foreskin is retracted behind the glans and cannot be returned to its normal position. o Considered a urological emergency. Causes: Phimosis: Chronic inflammation (e.g., balanitis). Scarring (fibrosis) or trauma. Repeated infections (balanoposthitis). Paraphimosis: Improper retraction (e.g., during catheterization or hygiene). Foreskin left retracted for prolonged periods. Symptoms: Phimosis: Tight foreskin, difficulty or pain when attempting retraction. Pain during urination or erections. Possible swelling and redness. Paraphimosis: Pain and swelling of the glans. Foreskin stuck behind the glans, causing constriction. Discoloration (bluish glans) and impaired blood flow. Treatment: Phimosis: Topical steroids (e.g., betamethasone cream). Good hygiene practices. Circumcision or preputioplasty for severe cases. Paraphimosis: Manual reduction (lubrication and gentle pressure). Emergency circumcision if manual methods fail. Prevention: Avoid forceful retraction of the foreskin in young boys. Maintain proper hygiene to prevent infections and inflammation. Educate about proper foreskin care, especially after catheter use. Definitions: Phimosis: Inability to retract the foreskin over the glans penis. Can be physiologic (normal in young boys) or pathologic (due to scarring or infection). Paraphimosis: Foreskin is retracted behind the glans and cannot be returned to its normal position. Considered a urological emergency. Balantis: Balanitis is an inflammation of the glans penis. More common in uncircumcised males. Causes: Infections: Bacterial, fungal (e.g., Candida), or viral. Irritants: Poor hygiene, harsh soaps, or skin allergies. Medical Conditions: Diabetes (increases risk), reactive arthritis. Trauma: Friction or injury from tight clothing or activities. Symptoms: Redness and swelling of the glans. Pain, itching, or burning sensation. Discharge or foul smell. Difficulty retracting the foreskin (phimosis in severe cases). Diagnosis: Physical Examination: Observation of the glans and foreskin. Swab and Culture: To identify any infectious organisms. Blood Glucose Testing: For diabetes screening if recurrent. Treatment Good Hygiene: Gentle washing with mild soap and water. Topical Antifungals: (e.g., clotrimazole) for fungal infections. Antibiotics: If bacterial infection is confirmed. Steroid Creams: For inflammation due to non-infectious causes. Address underlying conditions (e.g., diabetes management). Prevention: Maintain proper hygiene, especially for uncircumcised males. Avoid irritants like harsh soaps or chemicals. Manage blood glucose levels in diabetic patients. Priaprism: A prolonged, often painful, erection lasting more than 4 hours without sexual stimulation. Types: Ischemic (Low-flow): Most common; blood trapped in the penis. Considered a urologic emergency. Non-ischemic (High-flow): Rare; caused by unregulated blood flow into the penis. Causes: Medications: PDE5 inhibitors (e.g., Viagra), antidepressants, antipsychotics. Medical Conditions: Sickle cell disease, leukemia, spinal cord injury. Trauma: Injury to the genital area or pelvis. Symptoms: Persistent, painful erection. Rigid penile shaft with a soft glans. Pain increases over time (especially in ischemic priapism). Complications:  Permanent tissue damage. Erectile dysfunction if untreated. Treatment: Ischemic: Aspiration, medication (phenylephrine), surgery. Non-ischemic: Observation, ice packs, surgical intervention if needed. Prevention & Education: Manage underlying health conditions (e.g., sickle cell disease). Avoid recreational drugs and excessive use of ED medications. Immediate medical attention for erections lasting more than 4 hours.