Medical Notes on Papilledema, Retinal Detachment, and Other Eye Conditions PDF

now that we\'re done with that we\'re going to go into papyl edema pablo edema this one\'s very very highly tested so make sure you know how to treat it and how it presents so papa edema uh this patient\'s going to be presenting with a headache they\'ll have a headache that\'s worse with coughing...

now that we\'re done with that we\'re going to go into papyl edema pablo edema this one\'s very very highly tested so make sure you know how to treat it and how it presents so papa edema uh this patient\'s going to be presenting with a headache they\'ll have a headache that\'s worse with coughing nausea and vomiting loss of consciousness some sometimes you\'ll see pupillary dilation they\'ll have pulsatile tinnitus sometimes visual symptoms are absent in these patients and you\'re going to see blurred disc margins that\'s usually what is associated with papilloedema also congested disc for papilloedema flame hemorrhages infections and you\'re gonna see white cotton wool spots okay white cotton wool spots and we\'re gonna diagnose these with a fundoscope exam for papal edema and what are some of the causes of papilloedema so it\'s usually due to a secondary cause so things like increase in intracranial pressure whether it\'s from some type of tumor whether the patient has hypertension they\'re having a hemorrhagic stroke acute subdural hematoma pseudotumor cerebri so this these are common some of the causes of papilloedema and how are you going to treat this we\'re going to treat the underlying cause so the next one we\'re going to go into is going to be retinal detachment retinol detachment is a separation of the retina from the pigmented epithelial layer commonly begins at the superior temporal retinal area and the tear can happen sometimes spontaneously or sometimes it can be secondary to trauma usually these patients are going to have myopia they\'ll have inflammatory changes in the vitreous retina or choroid they\'ll be presenting with acute onset of painless blurred or blackened vision that occurs over several minutes to hours and progresses to complete or partial monocular blindness usually in the question stem is going to say that the patient has uh they feel like there\'s a curtain that was drawn over their eye from the top to the bottom so that\'s usually patho mnemonic for your retinal detachment is that curtain drawn over the eye these patients were also going to be saying that they see floaters or flashing lights at the initiation of symptoms and if you try to do a tonometer to look at their intraocular pressure you\'re gonna see that it\'s no more it\'s reduced for these patients so once again with retinal detachment they\'re gonna be presenting with floaters or flashing lights they\'re gonna have this complete or partial monocular blindness you\'re gonna have a curtain that\'s drawn over the eye from the top to the bottom okay and we\'re going to treat these patients it\'s usually an emergency consult with ophthalmology we\'re going to do either laser surgery cryo surgery and then the patient if you have them in the clinic with you and they\'re presenting with this you want to make sure that they remain supine with their head turned to the side of their retinal detachment sometimes these patients will recover but these patients need to have laser surgery require surgery for the retinal detachment okay so retinol vascular occlusion is going to be the next one this is very commonly found in patients between 50 to 70 years old usually they have a history of coronary artery disease okay usually they\'re presenting with sudden painless monocular loss of vision they\'ll have retinal pallor retinol edema vascular narrowing and then usually what you\'ll see on the question stem it\'ll say boxcar appearance so boxcar appearance is usually associated with retinovascular occlusion diagnosis we want to make sure that we check their visual acuity and then treatment we can do the digital globe massage lower intraocular pressure and then of course make sure that we refer these patients out to go see an optometrist so once again renal vascular occlusion this is going to be set in painless monocular loss vision it\'ll say box cart appearance and treatment will do the digital global massage lower intraocular pressure and then make sure that we refer them immediately so now we\'re going to go into our form body of the eyes so foreign so what are some of the causes of this of course um any patient that has some type of injury to the eye right um explosion striking metal that goes inside the eye signs and symptoms this patient is going to be presenting with pain and irritation with their eye movement if it\'s just like a surface foreign body but if it\'s like lodged into the globe so if it\'s an intraocular foreign body these patients can be presenting with discomfort and blurry vision how are we going to diagnose this we want to make sure that we do a thorough history first we want to check their visual acuity so once again first thing we\'re going to do is visual cutie if the question asks you what\'s the next best step it\'s going to be you want to make sure you check their visual acuity if the patient has an intraocular foreign body we\'re going to do a slit lamp and then we\'re going to do also a ct or extra x-ray to make sure that we identify radio particles want to make sure that we don\'t do mris in these patients okay treatment for this is going to be usually with topical anesthetics like uh popericane we can give them also polymix ambassadors and erythromycins or topical antibiotics and you want to make sure that these patients are following up closely with their optometrists and then we also want to refer them out if we want to remove them we\'re going to do sterile saline irrigation we\'re going to remove it with the fine gauge needle and if it\'s a steel form body in the eye you want to look for the rust ring right and we want to remove the rust ring within 24 hours and then intraocular form body if it\'s in the eye these patients need to be referred emergently okay guys so now we\'re going to go into our our acute otitis media acute otitis media so acute otitis media there are several causes right we have viral and bacterial virus the most common cause of acute otitis media and otitis media is usually due to an infection of the middle ear okay most common cause like i said it\'s going to be viral so make sure that you know that even though they teach us in class so that we\'re always going to treat them with a with amoxicillin right because we\'re tr we\'re covering for uh streptococcus but the most common cause is gonna be viral very commonly found in infants and children why because the angle that they\'re that their um middle ear is makes them more prone to getting these infections in comparison to adults and with these patients um like i said it\'s most commonly found in children the bacterial organisms that are associated with the ketotis media make sure that you know these it\'s going to be streptococcus pneumonia mycoplasma cateralis cataracts and hemophilus influenza i memorized it is that anything that affects here is shaking my head right shaking my head shaking my head shaking my head so smh shaking my head streptococcus pneumonia marxella and then you have your haemophilus influenza which are commonly associated organisms with the ketotitis media but the common ones can be tested it\'s going to be streptococcus pneumonia so how is this patient going to present they\'re going to have otalgia they\'re going to be irritable crying they\'re going to be lethargic maybe pulling their ears complaining of an earache sometimes they\'ll have fever also when you look inside the ear you\'re going to see an arithmetic tympanic membrane the tympanic memory is going to be bulging it\'ll be retracted or perforated but usually just make sure that you know that it\'s going to be bulging and retracted it\'ll be like still so the tympanic membrane is going to be hypomobile that\'s usually what\'ll get you on the question stem is little you\'re reading the questions to me you know what this patient has achieved titus media and then it tells you how is it going to present on once you see once you look into the ear like how is it going to present and it\'ll try to trick you so make sure you put that you know that\'s going to be retracted it\'s going to be bulging and it\'s going to be hypomobile it\'s not going to move it\'s just going to be there still okay and you\'re going to have decreased hearing we\'re going to diagnose this with a tympanocentesis but of course that\'s never done because it\'s very painful and then treatment it\'s gonna be first line on oxycine okay if the patient is allergic to penicillin then we can give him a zetromycin once again first line is gonna be amoxicillin right because we\'re covering for our streptococcus pneumonia which is the most common cause of one of the most common causes of acute media and then if they\'re allergic to penicillin we\'re going to do azithromycin so now we have a ketotis externa so that\'s going to be inflammation of the external auditory canal right so otitis media which makes sense media and spanish medio it\'s gonna be the internal um infection of the middle ear sorry middle ear and then a ketotis externa which has a name right external it\'s going to be infection of the external auditory canal this is also known as swimmer\'s ears because patients or kids like to swim or your swimmers tend to get these infections very very common so some of the causes of acute externa to be remorse environments the patient had any type of water exposure also mechanical trauma very commonly found in diabetics if it\'s found in diabetics it\'s usually malignant in these patients what are some of the pathogens that are associated with the ketotis externa pseudomonas is a big one pseudomonas pseudomonas likes moist wet environments pseudomonas and i\'m going to bring up my burn again but hopefully this helped you helps you guys just remember this because it does for me whenever i\'m studying so in our patients that come in with burns we of course when they\'re burned they have wounds that are open and sometimes they\'re moist and this is like a perfect like area for these environment for like this bacteria to live in pseudomonas and sometimes with these patients what happens is that we once like if they need to go into surgery like they need to be grafted basically grafts means is that they get skin from another part of the body and they place it on the burned area because that burnt area has no skin right especially if it\'s like the your deeper burns so they\'ll graft it they\'ll place it on that and with these patients usually they have to put like zero form which is like a type of um covering on the graft or on the place where the donor site was where they got the graft from and sometimes these areas if the patient\'s not clean if they\'re wetting it um they can get pseudomonas and we know this because when we start peeling it off it\'s like green it\'s just really gross and it\'s pseudomonas this is like a perfect environment for pseudomonas to live in so once again this is why a keto type externa is very commonly associated with pseudomonas because you have like water there that sometimes doesn\'t get cleaned out that\'s why it\'s very commonly found in swimmers right when they\'re swimming that\'s why i\'m very very like anal about cleaning my ears when i shower when i get in like i always go in there i know i shouldn\'t be doing that but i\'m always scared that i\'m going to get a tightest external because that environment the ear canal is a perfect environment for this type of bacteria to live in so that\'s why pseudomonas is very commonly associated with the ketotis externa other infections are going to be your stop protease aspergillus also and then how is this patient going to present if a patient presents with a brown yellow discharge with a very strong order we want to think about polyacetoma okay usually with these patients the ketotis externa they\'ll have itching sometimes they\'ll have conductive hearing loss right because it involves the outer portion of the ear they\'ll have a swollen canal it\'ll be moist tender ear canal skin with oracle movement that is painful they\'ll have also discharged like during my pediatric rotation i saw so much and you can see like the discharge from here from the ear it\'ll be it they\'ll have it\'ll be idiot idiomatis sorry and they\'ll have also pair periodical lymphadenopathy but usually with these patients like when you read the question stem it\'ll just say that they\'ll have discharge to the external year and then whenever you move the ear it\'s like really really painful for them and treatment for this we want to make sure that we give them odic aminoglycoside so something like neomycin sulfates polymix and b sulfate we can also do corticosteroids quinolones if it\'s fungal we want to make sure that we give them amputation b remember fungal is usually associated with patients that are diabetic so amputaters and v for fungal infections some of the complications of acute headaches media in diabetics or your patients are immunocompromised it can get malignant external titus and i think i said this once during my ent rotation it was a patient that had this and it\'s really really like gnarly looking so these patients have malignant external otitis they\'ll be presenting with persistent foul oral discharge they\'ll have very like deep otalgia which means like painful their ear will be very painful and we have to get a ct to diagnose these patients so next one\'s going to be mastoiditis this is going to be an infection to the mastoid bone so mastoiditis uh there\'s with mastoiditis it\'s usually a complication of a titus media that has not been treated so that\'s why it\'s important that we treat these ear infections because they can go since it\'s so close to the brain i mean it can go anywhere and this is one of the complications of it it\'s mastoiditis how\'s this patient going to present they\'ll have redness behind the ear usually they\'ll show you a photo and there\'s like redness behind the ear like right here they\'re their pin is going to be displaced they\'ll have post auricular pain swelling tenderness fever a bulging tympanic membrane with these patients and then to diagnose them we\'re going to do a ct scan we\'re going to see coalescence of mastoid air cells due to destruction of bony septa right because that bacteria is invading that area that bone and then treatment for this is going to be iv antibiotics so your ampicillin your cepheroxin you can also do a merengotomy sometimes they\'ll do a mastoidectomy okay but iv antibiotics and then of course depending on how severe it is mastoidectomy also so barotrauma is going to be the next one this is going to be an injury due to barometric pressure changes very commonly found in your divers especially the divers that like the deep divers that like to go really really deep also airplanes mechanical respiratory support so usually with um these patients are going to be presenting with if it involves the external ear they\'re going to have a hemorrhagic blebs or ruptured tympanic membrane if it involves middle ear you\'re going to see an impaired eustachian tube and treatment for this of course tell the patient to just swallow or yawn okay you can also give them decongestants if it\'s severe or if it\'s recurrent then we can do a merengotomy or ventilating tubes where you just go in there and you put tubes in the ear right it\'s gonna decrease that pressure so that\'s a lot done during my uh ent rotation it was a great rotation um so that is barotrauma okay so if you think about it right you have your eustachian tube and you need to have a balance of pressure between that tube sometimes if there\'s an imbalance of pressure that\'s where these patients feel like they have like a congested ear that\'s how they would describe it when i was doing my ent rotation they feel like they need to pop their ear or they feel like they\'re on an airplane the entire time so they have like this muffled tearing and that\'s because there is an imbalance in the between the eustachian tube so usually what happens is if this patient um that\'s this is why we give them decongestants where we want to make sure that we decrease that congestion that\'s going on because if you have any type of like sinus infection because you have all your sinuses that will connect to your um your ears right your ear canals so if you have any type of infection or anything that\'s causing like a plugging that\'s why these patients can also have like trouble with their hearing we would see a lot of patients that had like like chronic sinusitis that they have you had ear problems because of the same reason and um usually with these patients that for example that they do have like a pressure because we would go in there measure the pressure of the ear and we did see an imbalance in the pressure we just go in there and just put tubes in there and that\'s going to cause like and it\'s dramatic for these patients because they\'re they feel so much better it decreases they can actually hear now they don\'t feel they don\'t hear that muffled sound right because you\'re basically you have the eardrum you go in there and you put like a little tube in there so that allows like air to go through and you have a balance now instead of basically covering it like this and there\'s not really a balance because you have pressure here right or it\'s not draining appropriately so yeah that\'s barrel trauma so next one\'s going to be tympanic membrane perforation this is going to be a hole in the tympanic membrane um some of the causes of this are usually middle ear infections like patients that have a ketotis media right so that pressure in that tympanic membrane if these patients don\'t get treated sometimes can just become perforated and sometimes they\'ll just feel like they\'ll have so much pain so much pain and it just perforates and it feels so much better um also barotrauma can cause sympathetic membrane right because you have that increased pressure that\'s not balancing between your in your eustachian tube and your eardrum and then other causes of this can also be trauma or cholecytoma so what are you going to see or how this patient going to present of course you\'re going to look into their ear they\'re going to have a whole new tympanic brain or sometimes they see they say that they feel like they have something in their tympanic brain um typanic membrane you also see maybe a central marginal perforation sometimes they can complain of pain so they\'ll say that they have acute onset of pain and hearing loss they\'ll have lot bloody like autorias like discharge of the ear bloody um treatment for this is usually not needed they will usually just heal by themselves and they don\'t need to get antibiotics for these patients so next one\'s going to be hematoma over the external ear this is going to be an irregular hematoma also known as your cauliflower out uh year right this can be chronic it\'s usually due to a direct trauma so like you know your boxers to the anterior article and very commonly found in your wrestlers like i said your boxers your martial artists and this patient\'s gonna be presenting with thickening or in duration of the pen and external ear sometimes you\'ll see like distortion of the contours of the ear and if it\'s not corrected it can um become deformed it can cause that cauliflower ears so that\'s why you want to make sure that these patients sometimes go in there and they can get they need incision drainage for these patients so vertigo it\'s going to be the next one this is very highly tested so make sure that you know this vertigo the sensation of motion or exaggerated motion when there is none so the patient feels like the room is spinning when it\'s not in these patients some of the causes is going to be ototoxic so if they are taking your medications like i mean a lot amino glycosides right those are very very well known for being auto toxic so your amino glycosides are going to be your uh streptomycin right um and those medications gentamicin neomycin all those also alcohol intoxication cause vertigo nicotine or caffeine if the patient\'s older than 50 and they had any type of head trauma that can cause vertigo or if they have any debris in the inner ear the patient is going to be presenting saying that they have like the they say that they have or they feel like the world is spinning around them they\'re going to be very dizzy drowsy lightheadedness they\'re going to have an imbalance also with these patients they\'re going to be nauseous and it gets worse whenever they change position so that\'s usually the key for this one for vertical so with vertigo though we have to differentiate whether it\'s a central cause something in the brain is going on whether the patient\'s probably having like a stroke a tumor or anything versus a peripheral cause so peripheral cause right anything that involves the ears that is just or the ear canal where the patient is just not having um a correct balance so we need to differentiate between the central peripheral cause usually with a central cause it\'s gradual on onset so it\'s not acute the patient is going to be saying that they\'ve been feeling dizzy for a while and it\'s getting worse like probably days weeks months versus peripheral it\'s going to be sudden onset like this morning i woke up and it\'s just like i feel so dizzy so it\'s gonna be sudden onset or just like a few minutes ago i feel really dizzy so usually what these patients are gonna be presenting like i said symptoms that are brought on whenever they change position of their head so if they tip their head back for example they feel more dizzy these are questions that you ask the patient whenever you are interviewing them and they present with dizziness or like vertigo like symptoms i had so many patients during my family medicine rotation that would present with vertigo symptoms and i don\'t know why i always had so much trouble with dizziness like with that diagnosis i just had so much trouble when i always mess it up because i didn\'t ask him hey is that like is the dizziness worse whenever you change position so it\'s really really important that these patients are going to be presenting with symptoms that are brought on whenever they change position of their head another thing about this is that episodes will last less than one minute and the dizziness is really triggered by lying dying or rolling over so once again whenever they change position so a way we\'re going to diagnosis is going to be by doing the hints exam it\'s going to be a horizontal head impulse nystagmus test of skew okay and then we\'re also going to do a dix hall pike maneuver which is going to be usually positive in these patients and they\'re going to have that burst of nystagmus right that\'s okay so vertigo it\'s really interesting so i\'m going to bring once again that i was in i was bringing i\'m going to bring an example from the burn unit we had a patient that came in last week um it was a gentleman that suffered an electrical injury so he had an electrical injury and then it was really bad that he actually passed out he lost consciousness and he hit his head and he had uh epidural hematoma so he had a brain bleed but it was really really small that it didn\'t need to have surgery we were just going to observe it but the patient was complaining of dizziness and he said that ever since he fell on his head he\'s felt like he\'s gotten like he feels really busy when he he he stands up he just feels like he\'s gonna pass out et cetera so we actually called her physical therapists and our occupational therapists are in the hospital they came and they evaluated the patient and they did these tests they did the dix-hallpark maneuver and they did the hints test to make sure that it\'s not anything related centrally and thankfully with that patient it was not everything was normal it was just peripheral so this is a way that you differentiate between a central cause versus a peripheral cause for these patients okay is by doing your dick\'s hotpot maneuver or your hints test which is your horizontal head impulse nystagmus test of skew okay training for this is gonna be usually uh we\'re gonna observe it right we can do the epley maneuver if it\'s a peripheral cause so an eppley maneuver what it does is that it\'s going to basically um reposition the particles that are disrupted which is causing that nystagmus with these patients and then this involves like moving the head in like four positions for these patients so once again make sure that you don\'t mess these up because i know i messed these up all the time so for vertigo we\'re going to differentiate between our central and our peripheral cause central is going to be more chronic versus uh peripherals going to be more like acute it\'ll be quick on onset with these patients okay and we\'re going to diagnose and we\'re going to do a hint exam right because we want to see whether it\'s our peripheral or central cause and then we also want to do a dick\'s hepatic maneuver and if it\'s positive we\'ll see that burst of nystagmus and then we\'re going to treat this with an epley maneuver we\'re going to do particle repositioning moving the head into four positions and then of course we want to make sure that we find the underlying cause of due to a central cause so next one\'s going to be labyrinthitis this is a unilateral infection or inflammation of the vestibular system or inner ear so it\'s an inflammation of the vascular system or inner ear it\'s usually due to a virus a patient will present with a history of an upper respiratory infection that just happened like a week ago they got better and then they\'re presenting with dizziness and this is how they\'re going to present they\'re going to present with vertigo like symptoms after like having the flu a week ago and so how\'s this patient going to present it\'s going to be once again it\'s going to have acute onset of dizziness right because it\'s going to be a peripheral cause they\'re going to have nystagmus nausea and vomiting they\'re going to feel really sick and they\'ll have rotational vertigo that remains like vertigo when the patient opens or closes their eyes uh they can also be presenting with hearing loss and tinnitus which is bringing in the ears for these patients and treatment\'s going to be self-limiting sometimes it takes a few weeks to recover but we can help them by giving them like diazepam meclazine these medications that are going to help them with their symptoms right so it\'s symptomatic treatment so once again labyrinthitis the patient\'s usually going to say or in the questions that they had a history of an upper respiratory infection and now they\'re presenting with dizziness they\'re going to be presented with tinnitus or green in the ears hearing loss and then usually this is self-limiting we can\'t give them symptomatic treatment like diazepam uh meclizine or diamond hydrant hydronids so foreign body of the ear this is commonly found in children right or even like your older patients that have like uh neurologic problems um sometimes they\'ll put stuff in their ear these patients are gonna represent you with pain sometimes they even have uh discharge from the ear they\'re gonna have irritation because whatever\'s in there whether it\'s an insect i have yet to see one of these but i\'ve heard stories from my classmates that have seen a bunch of these during their rotations so if it\'s an insect we want to make sure that we put lidocaine in there okay first so we want to make sure that we put light in first and then we can remove it if it\'s an insect and we do not want to irrigate anything that\'s an organic material okay because like foods like beans because we can these can swell okay so tympanosclerosis is going to be the next one this is a calcification of the sub-epithelial connective tissue of the tympanic membrane and middle ear so once again tympanosclerosis is a calcification of the sub-epithelial connective tissue of the tympanic membrane and middle ear this patient is usually going to have a history of a chronic with titus media tympano tympanostimy tubes or equalistatoma they\'re going to be presenting with progressive hearing loss it\'ll say they have white chalky patches on a tympanic membrane or middle ear and we\'re going to diagnosis usually a clinical diagnosis you can do a ct if needed treatment for this is usually surgery and then um also your hearing aids so next one\'s going to be your acubacterioperatitis this is an a parotid inflammation an inflammation of the parotid gland the most common bacterial cause of this is going to be staph aureus that\'s the most common cause of your acute bacterial paratitis it can also be polymicrobial but the most common cause is going to be staph some of the risk factors for this is going to be if the patient is older if they had just surgery if they\'re dehydrated or if they had any type of plural oral hygiene symptoms for this is patients doing presenting with the firm arithmetic swelling of the pre and post auricular areas so have dysphagia so trouble swallowing purulent discharge and sometimes they\'ll have systemic symptoms like fever and chills diagnosis we want to make sure that we do a fine needle aspiration with that\'s ultrasounded guided we want to make sure that we culture and gram stain the exudate we can do a cbc usually we\'re going to see leukocytosis right because it\'s a bacterial infection we\'ll see increased amylase which makes sense um we can do an ultrasound and then we can do a ct scan if we think that like there\'s an extension of that inflammation treatment with these patients is usually with antibiotics something like nasal and plus metronidazole or clindamycin or augmented and then make sure that we are telling these patients to hydrate themselves so next topic is going to be sinusitis so sinusitis uh the thing about sinusitis is that you need to differentiate between acute sinusitis and a chronic sinus sinusitis and of course it\'s going to be depending on how long the patient is presenting with symptoms or if they have recurrent episodes of sinusitis so acute is going to be anything that is less than four weeks subacute it\'s going to be between four to 12 weeks and chronic is going to be a patient that\'s presenting with these symptoms more than 12 weeks what are some of the causes of sinusitis it\'s due to impaired mycociliary clearance and ost osteomedial complex obstruction there\'s an accumulation of mucus secretions and edema some of the causes of acute sinusitis is rhinovirus like your common cold usually the most common cause is going to be a viral cause okay parent influenza influenza rsv bacterial infections involve streptococcus pneumonia right shaking my head anything that\'s involved in there so streptococcus ammonia marxilla catarralis and your hemophilus influenza uh rhizopus also mucor aspergillus these are usually found in your immunocompromise these are your fungal infections okay so how is this patient going to present they\'re going to be presented with fever they\'re higher they\'ll have a discolored purely purulent nasal drainage they\'ll have congestion and they\'ll be complaining of facial pain especially in like the maxillary sinuses so that\'s why whenever we see these patients we go like this right see do you have any pain here do you have any pain here i did so much like that but here here right because we have those sinuses there that get congested and the most common one is going to be your maxillary sinus sometimes these patients will also be presenting with tooth pain i actually had sinusitis once and i had tooth pain i thought i had a toothache but no i had sinusitis so these patients would be presenting with tooth pain so just make sure that you keep them in the back of your mind also they\'ll be presenting with headache they\'ll have halitosis so that like nasty breath they\'ll have tenderness to palpative sinuses whenever they\'re bending forward and then diagnosis we can do an x-ray we\'re going to see a pacification air fluid and thick mucus but our test of choice is going to be ct scan on our ct scan we\'re going to see bone destruction air fluid levels and thick mucosa so during my ent rotation we saw patients that had chronic sinusitis or they just had recurrent sinusitis where they would get referred to us from their primary care doctors and the first thing that we would do for these patients is that we do a ct scan and we would do ct scan and we would look at the sinuses and sometimes like some of these patients just had like on their their like the nasal mucosa like they had polyps like in their nose that were just really really large and they were causing obstruction which was causing their recurrent sinus symptoms like whenever they look you looked in their nose you can\'t see it but you did that ct scram and you would see right because we have this right here you would see just like where the air just cannot go through because they had like polyps which are like this like nasal mucosa that will grow in your nose and it was just so enlarged that it was just blocking or you would see them with like a really bad sinusitis where you would see just like it\'s supposed to be black here right because that means it\'s air and that\'s how it should be but no you would see it like filled with just fluid and yuckiness so that\'s why we would do a ct scan for these patients with sinusitis so sinusitis so once again um we\'re gonna do our test of choice is gonna be ct scan we\'re gonna see bone destruction air fluid levels like i said thick mucosa um if it\'s due to like your polyps right i guess they\'re obstruction they\'re obstructing that airflow that\'s why this patient is presenting with these symptoms um another thing is not only pubs like i said the patient can also have like thick mucosa like just around that is just obstructing that airflow in this patient is why they\'re having these recurrent sinusitis so treatment for this if it\'s acute we\'re going to treat them for 10 to 14 days we can give them oral decongestants like pseudoephedrine nasal decongestants analgesics antibox first line is usually going to be amoxicillin cavilani right your augmentin you can also do doxycycline and then some of the complications for sinusitis if the patient is not treated is that they can get osteomyelitis right an infection of the bone they can get cavern cavernous sinus thrombosis because we have like our sinuses are just so close to the to the brain and that bone is just so thin that it can easily go to the um brain and it was really interesting because when i i saw a lot of surgeries like nasal surgeries and it was just amazing because you would see how thin that bone is so that\'s why it can go up there and it can cause all these things in the brain so that\'s why it\'s really important that we treat sinusitis if we think it\'s a bacterial cause and then of course orbital cellulitis like we mentioned earlier so once again sinusitis make sure that you know that cute is less than four weeks sub-acute is four to twelve weeks chronic is more than 12 weeks okay uh we can diagnose these patients with ct scan that\'s our choice of tests truman is for acute it\'s going to be uh augmentin for 10 to 14 days so next one\'s going to be allergic rhinitis this is inflammation of the nasal mucosa with allergic rhinitis we want to think about our triad right so our atopic disease of asthma eczema and then you\'re allergic rhinitis sometimes when i read a question stem and it says that the patient has a history of asthma and they have eczema and this patient patient is presenting with like itchy water watery eyes i\'m like you know that\'s allergic rhinitis right because if you know that try tried it can help you so much also some of the causes of allergic relief sometimes i\'ll have a family history allergen exposure right or ige is what\'s causing all this like inflammation that allergies patient\'s gonna be presenting with itchy and watery eyes so whenever i think about itchiness anywhere whether it\'s in the eyes i think about allergies right because you\'re having that histamine release that is causing all that itchiness your mast cells so itchiness you want to think about allergic rhinitis so itchiness watery eyes sneezing nasal congestion dry cough nasal discharge they\'re going to have their allergic shiners right nasal salute my sister actually has this as a child she suffers from allergies a lot and she always we do this a lot and she actually has a fold right here she has that fold right here and that\'s what the nasal solute is because they would go like this a lot and she has it um clear rhinorrhea they\'ll have pal boggy bluish mucosa um i\'ve yet to see that on exam but yes you\'ll look into their mucosa and it\'s gonna be pal buggy and blue and they\'re gonna have watery clear discharge so the thing like i said you want to know is that they\'re going to be presenting with itchy watery eyes so whenever i had a patient during my ent rotation that i would go and see and i had diagnosed him with her it was with sinusitis a rhinitis i always asked him like do you have itchiness and if it\'s itchiness and i\'m like you know what i know it\'s allergic rhinitis so it\'s a question you always have to ask i had treatment for this you want to make sure that you educate them on avoiding whatever is causing their allergies if it\'s a pet if it\'s going to a certain area just to make sure that they avoid that and then also you can give them intranasal corticosteroids antihistamines like your h1 uh blockers also topical steroids and then you can give a mastosterol stabilizer like your hormonal and sodium so anterior epistaxes so we have our anterior and posterior epistaxes i\'ve seen so many cases of this in the hospital in the clinic so it\'s really important that you\'re familiar with these and it\'s very very highly tested so anterior epistaxis is nosebleeding that originates from the kaizo back plexus or kiselbach plexus this is very highly tested so make sure you know this once again anterior pystaxis is going to be nosebleeding that originates from the hisobac plexus it\'s um coming from the anterior nasal septum so some of the causes of this the most common cause of an anterior episaxis is going to be your digital trauma so it\'s going to be a child that just picks their nose right digital trauma especially if it\'s like unilateral you want to think about digital trauma other causes can be infection trauma right after hit their head your cocaine abusers hypertension allergic rhinitis atrophic rhinitis coagulopathy or tumors but usually the most common one is going to be your digital trauma sinus symptoms it\'s usually going to be unilateral like i said it\'s just going to be involving one nostril i\'ve seen all the cases that i\'ve seen it it\'s been unilateral but of course like if you hit your head or something you can be bilateral but it\'s usually unilateral um you\'re going to see on your exam the side of bleed usually if you look inside the nose you can see and it\'s very easily seen and treatment for this is going to be direct pressure you\'re going to do ice packs you\'re gonna tell the patient to sit and lean forward right for some reason whenever i grew up and i had nosebleeds my own plug my nose and she would go like this which is what you don\'t want to do you\'re gonna tell tell the patient to lean forward okay and then after that um \[Music\] basically with these patients you can also give them nasal decongestants so it\'s anything that causes vasoconstriction and then finally like you\'ve done all that it\'s not working you\'re gonna go in there and cauterize it uh with silver nitrate if you can find only the vessel that is bleeding so if you go in there and you cauterize it you only cauterize it if you can see the whatever\'s bleeding and then nasal packing for 24 hours or petroleum packing so once again i\'m going to discuss two cases that i had this so i had a patient two weeks ago she was a patient with sjf stephen johnson syndrome um unfortunately she got sgs from backdrom and she wanted to be prior to getting back to him she went to shock and they gave her background and then on top of that they gave her basic press was right just to give her her epi because she was going to shock she was tanking so they gave her vasopressors they gave her back to him and they threw a bunch of antibiotics we\'ll just develop sjs secondary tobacco and due to vasopressors remember in our pharmacology class they taught us not to inject like epi in the fingers or in the penis or anything like that because it can cause uh necrosis well it\'s right right well in this patient she got necrosis um and she needed to get bilateral below the knee amputation so she got her knees amputated and she got fingers amputated also and poor lady she was just and on top of that she had sjs so it was just bad so i was in the hospital they had called this because she was having like nosebleeds so i went in there and of course there was only one nostril that was bleeding and the first thing that we did is that we i closed your nose applied pressure and i had her like this and i was i did that for like 10 minutes i was sitting there with her for 10 minutes and i was talking to her and we did that for a while and still like it did not go away so then after that what we did is that we packed it so we packed it and then we also called in ent because she is like a sgs patient we want to just make sure that it\'s not anything related to that and um what they did is that they went in there they get these like fancy like things where they can just look and they can see the vessels that\'s bleeding they just grab like a i forgot what they\'re called i apologize and they go in there and then they cauterize it just a silver nitrate stick silver nitrate stick that will go in there and they\'ll just cauterize it and it was fine okay so that was just a case of enter epistaxes and then i\'m going to say another cause another case i had real quick uh during my ent rotation we had an older lady that came in she was very very hypertensive she was like at 120 over 120. i\'m sorry she was like 160 over like 110 very hypertensive and she was coming in for a nosebleed she had been referred from her primary care doctor she was coming in for a nosebleed but she had not been taking her hypertension medication for the past two weeks so of course she had uncontrolled hypertension so we went in there since it\'s uh since it\'s ent of course we went in there and we packed it we packed it nasally and then of course we restarted the patient on our hypertensive medications i talked to her on the phone and educated her on how important it\'s for her to take her hypertension medications because this may have been a cause of the bleeding right because if you\'re thinking about it hypertension is just when you have increased pressures like i said before through the through like a hose right through your vessels so if you have increased pressure it can cause these bleeds and this is what i had explained to this patient and so i told her to follow up the next day if she\'s not getting better but we were going to call her anyways well she ended up calling the next day the daughter did and saying that her bleeding had not stopped so she came in and we went in there and of course her fancy little thing and cauterized it that\'s how it was so that\'s an example of anterior epistaxis so next one\'s going to be posterior epistaxis is going to be nose bleeding that originates from where from the woodruff\'s plexus so anterior pysexus is from the kisobak kezoback plexus and then posterior is going to be from your wardrobe\'s plexus okay so these patients are usually going to be older uh they\'re going to have like a significant past medical history with like comorbidities for example like diabetes mellitus hypertension they\'ll have atherosclerosis hypertension is a huge one they\'re going to be presenting with profuse bleeding hematomisis hemoptysis blood in the oral pharynx so you\'ll look in the in the back of the throat and you\'ll see the blood there and sometimes like when you try to look in the the narrows and you\'re like you know what i\'m trying to see if there\'s a vessel and you you can\'t find it in these patients you won\'t be able to visualize the source and this usually involves both uh nearest so it\'s gonna be bilateral and air bleeding with these patients to diagnose them it requires endoscopic instruments to make sure that you localize where is the bleeding coming from treatment for this we\'ll do a sponge pack a balloon tamponade and then with these patients it\'s you have to admit these patients also some of the complications is that they can have a septal hematoma this can necrosis of the cartilage and lead to perforated septum and with these patients they need to be drained and packed but these patients need to be admitted to the hospital with a posterior epistaxis you\'re gonna do a balloon tamponade uh sponge pack also so next one\'s gonna be foreign body of the nose so we talked about foreign bodies in the ears now we have foreign bodies of the nose so this is usually like small rocks foods beads clay toys magnets batteries buttons erasers coins tissue okay they\'re getting presenting with drainage and usually it\'s going to be once again unilateral and it\'s going to be really gross and nasty it\'s going to be very smelly also um so once again it\'s going to be drainage that we present to a nosebleed uh sneezing itching troll breathing it\'ll be unilateral also and of course i want to treat it we\'re going to go in there and remove it so next topic is going to be acute pharyngitis so the common causes of acute laryngitis once again it\'s going to be viral it\'s the most common cause but also you have your bacterial infections like your group a beta hemolytic strip right this is your famous strep throat your streptococcus pyogenes and how this patient gonna present what they have group a strap they\'re gonna be presenting with sore throat fever they\'re gonna have anterior once again anterior cervical lymphadenopather lymphadenopathy when you look in the back of your throat you\'re gonna see tonsiller exudates okay they\'re going for presenting with chills dysphagia tti but they will not have any cough okay make sure you know this this is very very highly tested right your centaur criteria is very highly tested so once again it\'s going to be anterior cervical lymphadenopathy this is how i differentiate this between mono because on your question stem you have a patient that presents with mono uh i\'m sorry symptoms of like pharyngitis and it tells you oh there\'s accidents in the back of the throat the patient has no no cough and and you\'re like okay well and it tells you is this strep or mono you\'re like well you didn\'t tell me more like where the exudates like white does the patient have like splenomegaly tell me more and they don\'t but it will say that they have posterior anterior cervical lymphadenopathy that\'s how you differentiate between both of them if it is anterior cervical lymphedemopathy then it\'s going to be associated with your group a strep your strep throat if it\'s posterior cervical lymphadenopathy then that\'s going to be your mono make sure you know that so strep throat once again anterior cervical adenopathy sore throat fever tonstar exudates chills petechiae but they won\'t have any cough if they do a cough that\'s not strep throat i mean you can\'t but usually it\'s not not according to the central criteria so diagnosis we can do the center criteria if it\'s positive then we\'re going to do a throat swab culture and we\'re going to do rapid antigen detection testing treatment for this is going to be with your penicillins or amox\'s sun right what are some of the complications if you don\'t treat strep throat why it\'s really important that you educate your patients that they need to finish their antibiotic regimen even if they start feeling better after the first or second day this is something that i always coach my patients on during my pediatrics rotation i make sure i talk to the patient and the mother or the father it\'s important that this child finishes their antibiotic they change their toothbrushes and that they\'re not sharing any water any drinks with anyone why they\'re infected because it\'s very very highly infectious because if they don\'t finish their antibiotic and this is without with home that infection can go to their heart it can cause what rheumatic fever it can go to their kidneys it can cause what glomerulonephritis so it\'s really really important that they finish their antibiotic regimen this is very highly tested so make sure you know this how i\'ve seen this question is that you have a patient that\'s presenting with post-streptococcal glomerulonephritis right they\'re having that that cochlear colored urine they\'re having that edema of the face and it\'s a child and it\'ll tell you what would you likely find in this patient\'s past medical history strep throat okay or sometimes it\'ll give you rheumatic fever right this patient is presenting with rheumatic fever symptoms they\'ll ask you what was most commonly found in this patient\'s past medical history a history of a recent strep infection so how are you going to treat this once again we\'re going to treat it with amoxicillin penicillins so what if it\'s a virus cause once again this is more commonly found the more common cause of acute pharyngitis is viral it\'s usually gonna be more insidious they\'re gonna have kariza they won\'t have any exudates so you look at the back of the throat it\'s just inflamed they won\'t have any acidates they\'re gonna have a low-grade fever and we\'re gonna diagnosis if you need to you can do viral culture even though we don\'t do that treatment is usually symptomatic where you\'re gonna give them ibuprofen tylenol what if it\'s mono so remember we talked about the difference between strep and mono if it\'s mononucleosis you\'re gonna be presenting with melees they\'re gonna have tender adenopathy right and it\'s gonna be what posterior lymphadenopathy also they\'re gonna have shaggy white or purple taunts or exudates sometimes the question won\'t tell you what it is or the color it\'ll just say it\'s tons of oxidate so that\'s how you have to know the difference is by anterior posterior postural and pharynopathy from mono you\'re going to have an enlarged spleen sometimes we\'ll give that to you in the question stem and then also jaundice diagnosis for these patients we\'re going to do a mono spot usually for these patients okay you\'re going to see reactive lymphocytes entry for this is supportive you want to make sure you tell patients to limit contact sports right because you don\'t want them to have any injury to that enlarged spleen that can just cause it to erupt so and another thing you have to know want to know is that with epstein-barr virus you want to avoid ampicillin okay you want to avoid ampicillin sometimes it\'ll give you a question some of a patient that was on mono you thought it was strap right you gave them ampicillin and they had this rash like oh that was mono so next topic we\'re going to go to is peritons or abscess so peritonsis is an abscess formation between the anterior and the posterior tonsil pillars and the superior pharyngeal constrictor muscle so it\'s going to be an abscess in the tonsils so it\'s usually a complication of untreated tonsillitis or peritons or cellulitis or mononucleosis also complication right over strep throat patient doesn\'t get strep throat they can get this doesn\'t get treated for the strep throat or does not finish once again their antibiotic regimen they can get these abscesses very commonly found in patients that are older than 30 and commonly caused by like multiple microbes so it\'s poly microbial that\'s going to be usually the etiology this patient is going to be presenting with fevers or throat trouble swallowing right your dysphagia pain whenever they\'re open their mouth sometimes it\'s described as trismus a muffled voice so they\'ll have that hot potato voice like when they talk like they have a hot plate or though like they just can\'t pull a pink bowl that\'s what i talk they\'re going to be having also unilateral neck pain you\'ll see unilateral throat fullness and the thing about this one that we\'ll give it away when you read the questions that they\'re going to have uvular deviation so you\'re looking in the back of the throat the uv that is not there it\'s going to be deviated usually your deviation are shifting sometimes you\'re going to be drooling right because they can\'t swallow and diagnose for this is going to be leukocytosis you\'re going to do a ct scan also you\'re going to see abscess and edema and if you uh you also need to do aspiration so you\'re going to make sure you ask for aspirated and culture it to see like what the bacterial cause of it so we can appropriately treat it so with these patients we want to make sure that we treat them surgically do an ind and tonsillectomy um this is an emergency there was actually a case a case and it was a patient that came in with the peritons for abscess and she was intubated but not correctly and her area closed and she\'d actually ended up dying and so this is an emergency it can cause significant airway obstruction and the patient can die so this is this is emergency so once again treatment it\'s going to be surgical incision and drainage or tonsillectomy antibiotics we\'re going to give metronidazole clindamycin or penicillin so next topic is going to be your acute laryngitis it\'s going to be an infection of the larynx very commonly found in your smokers these patients are gonna present with hoarseness they\'re gonna have a hot potato voice also they\'ll have a weak or strained voice throat they feel like it\'s like they have a tickle in the back of their throat they\'re gonna have this dry cough okay rawness dysphonia they\'re gonna have this urge or feeling that they have to clear their throat they\'re gonna be presenting with fever malaise cough that\'s worse at night okay basically with these patients in the question stem they\'re gonna be complaining of voice problems so they\'re going to have like this strained voice or sometimes it\'ll say that it\'s like a singer also or someone that was just giving a speech i\'ve read questions of like fans i would a rock concert right they\'re like ah and so they present with like that they\'re like speaking really low they can\'t really speak or they\'re speaking like this because they have like they lost their voice yeah so if anything i might get lemongrass after this right because i\'ve been recording this video for the past several hours so yes so how are we going to diagnosis um basically it\'s just a clinical diagnosis treatment for this is supportive right we\'re going to tell them to make sure that they rest their vocal cords vocal rest dental abscess is going to be the next one this is going to be a brick in the mucosa bacteria that leads to the infection okay some of the causes of this of course your dental caries if they have any tropical trauma plaque collection medical procedures food foreign objects they\'re going to be presenting with local pain and swelling fever malaise affected teeth will loosen they\'ll have a fistula in the mouth of the cheek the fluctuance uh diagnosis usually a clinical diagnosis but of course we can do an x-ray ct scan treatment is that we\'re going to go in there and do ind and then we\'re going to give them antibiotics right make sure that they follow up with their dentist if it\'s like a really really deep abscess and it involves a root canal then they need to get a root canal right i\'m sorry if it involves the the nerves in the tooth they need to get a root canal and get the tooth extracted so next topic is going to be respiratory acidosis so we\'re going to go into your urology and reno you\'re all junior yay **Urology/ Renal** i love urology and reno i was very very um i was able to do a rotation in with the renal doctor for my internal medicine like block and so i learned so much but i still struggle with it i think reno is amazing kidneys is amazing but it\'s just a very difficult topic i struggle with so urology and renal next topic now why don\'t we go into our respiratory acidosis so respiratory acidosis is due to an inadequate alveolar ventilation that leads to carbon dioxide retention so you have high co2 and you have a low ph it causes your acidosis so what are some of the causes of respiratory acidosis the most common cause is going to be hypoventilation right you\'re not able to get rid of that carbon dioxide so you\'re keeping it all in this is why these patients have increased co2 and they\'re becoming acidotic because they\'re not getting rid of it whenever we breathe in and we read that we\'re getting rid of carbon dioxide if a patient is not breathing at all whether it\'s about trauma to the head they\'re overdosed on a certain medication and they\'re just right there\'s like deep very slow breathing then these patients can develop respiratory acidosis and it\'s very commonly found in these patients okay other causes of this is going to be respiratory arrest overdose like i said any type of obstruction to the airway your patients have congestive heart failure pneumonia cardiac arrest they\'re going to be presenting with what dyspnea trouble breathing right to kidney because they\'re trying to get more um aaron they\'ll have these slow shallow respirations these patients are going to be presenting with confusion because they\'re retaining all that co2 they\'re going to be presenting with convulsions they\'re going to have this warm flesh skin why once again because they retain all that co2 they\'ll have ultra liver consciousness or be cyanotic and diagnosis is going to be once again what low ph but high pco2 because they\'re retaining it okay but they\'re going to have a normal bicarb of course if it\'s uncompensated though now we\'re going to go to in respiratory alkalosis so respiratory alkalosis is hyperventilation that leads to carbon dioxide deficiency okay so we said that respiratory alkalosis had an increased amount of carbon dioxide right they\'re retaining it well respiratory alkalosis is going to be the opposite they are hyperventilating so they\'re breathing like super duper fast and they are getting rid of all their carbon dioxide so they have decreased amount of carbon dioxide so low co2 leads to a high ph which is your alkalotic state the most common cause is going to be hyperventilation patients that are in severe pain right patients that have some type of trauma also to their head um if a patient is pregnant also aspirin overdose is very commonly associated with respiratory alkalosis and then other causes is going to be your anxiety right if a patient is anxious or they\'re having a panic attack they\'re going to be reading really really fast so they\'re getting rid of that carbon dioxide they can present and they are going to present with symptoms of tinnitus rain in the ear vertigo like your dizziness dry mouth blurred vision rapid and deep respirations you\'re gonna feel light-headed you\'ll have paresthesias paresthesias are very commonly associated with what general anxiety disorder because they\'re hyperventilating hyperventilation leads to what respiratory alkalosis syncope convulsions coma also diagnosis you\'re gonna have a high ph low pco2 and the bicarb is going to be normal if it\'s uncompensated now we\'re going to go into metabolic acidosis this is an excess accumulation of fixed acids through the metabolism or ingested food or excessive loss of fixed bases so we have different types of metabolic acidosis you have your non-anion gap and then you have your anion gap you need to know the difference between both of them what are the causes of each one so non-ion gap is commonly caused by diarrhea okay your gi bicarb loss renal tuberositosis carbonic anhydrase inhibitors whether the patient is having tpn right tube feeds um or rehydration chlorine gas exposure some of the causes of anion gap is going to be your methanol uremia dka is a big one for your high anion gap metabolic acidosis peralta hyde asani lactic acidosis alcohol rhabdomyolysis salicylates right so this is where your mud piles pneumonia comes in so your methanol for m u is going to be uremia d is going to be dka p is going to be a paraaldehyde and then i is going to be your um isoniazide l is going to be lactic acidosis and then for e alcohol and then s is going to be salicylates and of course you can add rhabdomyolysis on there and yeah so that\'s going to be for your anion gap metabolic acidosis how\'s this patient going to present they\'re going to have the kuzma breathing that\'s usually a patho mnemonic for metabolic acidosis and for dka so it\'s going to be your kuzma breathing they\'re going to be lethargic drowsy they\'re gonna be in stupid position comma they\'re gonna have a headache flush to dry skin right because these patients are usually dehydrated they\'re gonna have peripheral vasodilation they\'re gonna have fruity breath which is usually very commonly associated with dka i\'m yet and i have yet to smell that fruity breath uh nausea and vomiting convulsions diagnosis is gonna be what low ph normal pco2 and then low bicarb if it\'s uncompensated they\'re gonna have they\'re gonna have a loss of bases so now let\'s go into our anion gap how do you calculate anion gap i actually had three questions on this yesterday when i was doing practice questions and i missed all of them so anion gap and ingap is calculated by the serum sodium minus the sternum chloride plus serum bicarb the normal range is between 9 to 16 anything greater than 20 is your metabolic acidosis okay once again normal ranges between 9 to 16\. i know textbooks 10 different between this but anything greater than 20 is in your anion golf it\'s going to be your metabolic acidosis so it\'s going to metabolic alkalosis this is going to be accumulation of fixed bases or excessive loss of fixed acids so you\'re going to have acid loss and you\'re going to have high ph and high bicarb this patient\'s been presenting with vomiting ng tube um i\'m sorry some of the causes are going to be vomiting ng tubes diuretics hypokalemia cushing syndrome hyper adoptionism usually it\'s very so commonly associated with metabolosis i just had a question on this when i was studying this is very highly tested once again hyperaldosteronism is metabolic alkalosis vomiting right is metabolic alkalosis diarrhea is metabolic acidosis so dka metabolic acidosis diarrhea metabolic acidosis vomiting metabolic alkalosis primary hyper aldosteronism is going to be what metabolic alkalosis very highly tested and why is it that hyperaldosteronism presents with metabolosis because they have increased renal secretion of bicarb chloride and potassium this is why these patients present with metabolosis that have hyperaldosteronism signs and symptoms you\'re going to have decreased respiration rate and depth they\'re going to have dizziness paresthesias that you\'re so sign right um nausea and vomiting irritability convulsions and common they\'re going to be dehydrated diagnosis is going to be you\'re going to see a high ph normal co2 and a high bicarb on your bbg or your abg\'s this is if it\'s uncompensated so they have an accumulation of bases versus or metabolic acidosis where they have a loss of bases so once again these are very highly tested make sure what they\'re associated with once again to go through the respiratory acidosis is due to what hypoventilation they\'re not getting rid of the carbon dioxide so they are holding it all in they\'re going to have increased co2 but their ph is going to be low common causes of this it\'s going to be any type of patient that is for example in a coma they\'re gonna have these like slow breathing okay and then we have our respiratory alkalosis which is the opposite these patients are getting rid of all their co2 so they\'re gonna have decreased co2 okay but they\'re gonna have an increased ph so these patients are usually commonly found in patients that for example is going to be anxiety that\'s very very commonly tested and also your aspirin i\'m sorry not your aspirin yeah it\'s gonna be your aspirin sorry overdose i can present with respiratory alkalosis so respiratory alkalosis your aspirin overdose okay these patients are gonna be hyperventilation right anxiety okay panic disorders metabolic acidosis with these patients they have an accumulation of acids and they have a loss of fixed bases their ph is going to be low and then their bicarb is going to be low okay we have non-ion gap and anion gap so you need to differentiate between these two and what are the causes commonly causes of anion gap is going to be your dka lactic acidosis and salicylates these patients have the kuzma breathing which is very commonly associated with dka and then we have metabolic alkalosis very commonly associated with what vomiting and also your hyperaldosteronism we said metabolic acidosis is with what diarrhea okay make sure you know these so next topic we\'re going to go into is going to be hypobulimia this is going to be isotonic fluid loss from extracellular space that can cause and progress to hypovolemic shock signs and symptoms is um or i\'m sorry some of the causes of this is going to be excessive fluid loss either from like a hemorrhage so a patient that got shot decreased fluid intake if the patient is just dehydrated or if they have third space shifting where like the vessels are just leaky and everything is just shifting out are these patients are presenting with metal mental status changes stirs they\'re gonna be tachycardic they\'re gonna have delayed capillary refill right because they\'re volume down hypovolemic they\'re gonna have orthostatic hypotension which makes sense right because your volume down once again they\'re gonna have low urine output why because they\'re volume down they\'re not getting the flow the blood flow to their kidneys like they should be so they\'re having volume down the um urine output it\'s going to be decreased because the kidneys are not functioning like they usually do they\'re going to have cool and pale extremities why because they\'re going to be once again volume down so hypovolemic okay treatment for this is going to be fluid replacement right we want to also give them album replacement blood transfusions if they have any type of hemorrhage of your dopamine to maintain their blood pressure and then assess fluids so why are these patients have pal extremities because the for example if a patient gets shot and they\'re in hemorrhagic shock for example there\'s gonna be blood that\'s gonna be shifted towards the vital organs like your brain and your heart it\'ll it won\'t go to areas where the body themes are not important so that\'s why you get your hellness and your coolness and your extremities because blood is being shifted towards the organs the body deems important this is why the kidneys get shot right the kidneys are usually like the first ones to go because you\'re not getting that blood flow to the kidneys okay you\'re not getting that volume to the kidneys they\'re not being profused so you\'re having low urine output these patients are not producing urine so these are symptoms of hypovolemia versus a contrast which is going to be hyper bulimia this is going to be isotonic fluid um i\'m sorry hypovolemia is going to be excess fluid and extracellular compartments due to fluid or sodium retention they\'re going to have this is due usually due to excessive intake or renal failure okay so this happens when compensatory mechanisms fail to restore fluid balance which leads to things like congestive heart failure and pulmonary edema so these patients are volume up right we said that hypokalemia is what volume down i mean hypovolemia is volume down hyper bulimia is volume up signs symptoms are going to be to kidney they\'re going to have dyspnea right they\'re gonna have trouble trying to catch bread right because they\'re volume overloaded they\'re gonna have crackles rapid bounding pulses hypertension s3 gallop especially in those patients that have congestive heart failure where you have that floppy heart right that isn\'t able to pump blood out and then you\'re going to have also um acute weight gain right because these patients are retaining all their fluid and patients that have congestive heart failure if they have kidney problems we always tell them to make sure that they take their weight every day to see whether they\'re retaining fluid or not so they\'re going to be presenting with awaken increased regular venous pressure edema and treatment for this is usually with fluid and sodium restriction diuretics because we want to make sure that we get rid of all that fluid uh mono or vital signs we want to make sure that we look at the breast sounds monitor um abg\'s and labs so i\'m gonna bring another example guys and i\'m sorry we had a patient and we still have a patient he\'s been there since like forever he\'s been with us six months because he doesn\'t have anywhere to go and so we have a patient that came in and um he has a history of copd and heart failure he has an ejection fraction of like 30 percent so he has a history of copd and heart failure and basically we\'re just monitoring him every day he\'s been fine but there was a specific day where he was complaining of trouble breathing and when you went inside the room you could see that he was really having trouble breathing he was you looked at him and he was using his like intercostal muscles to breathe and so of course we did an exam we did see that he had some edema to his lower extremities and so what did we do for him we gave him lasix okay of course we did a chest x-ray just to make sure to rule out anything that\'s bad we did also vbg venus blood class um just to see how he was if there was any abnormalities and then we give him a dose of furosemide so we gave him a high dose of iv times one of furosemites just so we can get rid of our fluid and then the next we saw menu is perfectly fine so once again these are symptoms of hyperbolemia okay so now we\'re going to go into our acute kidney injuries okay acute kidney injury so we have what you need to know about cute kidney injuries is um basically where are where is the kidney injury occurring so we have our pre-renal acute kidney injury which is before you get to the kidney just like it sounds your intrarenal which is something happening within the kidney and then you have your post ring which is something that\'s happened after the kidney okay it\'s really important that you differentiate between the differences in your acute kidney injury this is very highly tested and i\'ll be honest with you guys i always just test really low on my urology and real so a quick fact real quick i know i don\'t know what i\'m going to post to this video but right now this is during the cove pandemic when i was doing my rotation my internal medicine rotation which i ended up doing with the nephrologist like i said during that time i did it in the valley which is the mcallen texas at a brute texas and that area when i did it had the highest amount of copy cases at that time we had a lot of deaths from covet cases we had nurses from all over the u.s come down and help us because we had so many patients we can take care of the pediatric portion of the hospital was turned into an area for cobit patients we didn\'t have enough rooms for covert patients and we just had a lot of patients signed from coven so when i did my rotation with him nephrologist he had so many patients because a hundred percent of patients with cobit had acute kidney injury once again 100 of his patients had acute kidney injury okay so why because these patients would go into shock okay um they were going to shock they were not having volume appropriate volume going to their kidney okay so this is a pre-renal cause right and it was just shutting off the kidneys so 100 of our patients had acute kidney injury and it was really really sad these patients were having to have dialysis etc anyways i\'ll get off my soapbox let\'s go back so pre-renal acute kidney injury is going to be an injury that comes before the kidneys this is the most common form of acute kidney injury once again we have the the kidney right we have before you get to the kidney and then after you get to the kidney this is before you get to the kidney so this is pre-renal and some of the causes is going to be what due to decreased blood flow to the kidneys so the kidneys are not being perfused some of the signs and symptoms for these patients are going to be dehydrated they\'re going to have fluid loss renal hyperperfusion hypovolemia how are we going to diagnose this we\'re going to do a gfr we\'re going to see a decrease in the gfr this is because what does gfr measure gfr measures how much blood flow is is um \[Music\] or i\'m sorry how much blood is being filtered by the kidneys so if your gfr is low it\'s telling you that there\'s decreased blood flow so there\'s decreased blood that\'s being filtered right so you\'re gonna have a low gfr in these patients with pre-renal aki\'s you\'re gonna have increased sodium and water reabsorption you\'re gonna have low urine sodium okay this is what differentiates this between pre-renal and in your other causes pure renal is going to have low sodium okay low urine sodium they\'re going to be oliguric which means they\'re going to be producing very little urine they\'re going to have higher urine osmolality it\'s going to be more concentrated they\'re going to have an increased burning creatinine that\'s greater than 20 uh 1. they\'re going to have metabolic acidosis they\'re going to have azotemia which is less syria and creatinine that\'s being filtered out they\'re going to have increased white blood cells if it\'s due to some type of infection so how are we going to treat these since we said the number one cause is hypoperfusion we have to do aggressive normalization of volume so we want to make sure we give fluids fluids fluids we want to make sure we do volume repletion okay that\'s pre-renal aki now when we go into intra-renal aki intra-renal aki is going to be an injury within the kidneys anatomical structures so it\'s something that\'s occurring within the kidneys whether it\'s affecting the glomerulus whether it\'s affecting the the tubes something within the kidney is causing that kidney injury so this is an injury that is within the kidneys like i said a reabsorption infiltration is impaired you have direct kidney damage some of the causes of this is damage to kidney anatomy that prevents it from functioning correctly nephrotoxic medications sometimes like contrast right every iv contrasts whether it\'s there\'s metastasis whether it\'s radiation a diagnosis for this is going to be a decreased gfr they\'re going to be oligarchic once again low urine osmolality but they\'re going to have a high urine sodium okay higher in sodium why are they gonna have a high urine sodium why because it\'s not being reabsorbed the kidneys are not working so they\'re dumping everything versus your pre-renal cause it\'s nothing with the kidney the kidney still works fine it\'s just that it\'s not being perfused adequately okay so this is why in your pre-renal you\'re gonna have low sodium and in your intrarenal within the kidney where the kidney\'s not working it\'s by itself it\'s dumping everything out it\'s going to be high so sodium is going to be high in your intrarenal that\'s how you differentiate between both of them they\'re going to have elevated beyond creatinine abnormal urine analysis sometimes you\'ll see protein blood casts xenophils why because that kidney\'s not working the glomerulus is not filtrating everything out everything\'s passing through it and it\'s spilling out and um yeah it\'s spilling out and your urine okay and then also where you can diagnose is also with the renal ultrasound so treatment is usually going to be uh if it\'s like something like um nephritis or vasculitis and we\'re going to give immunosuppressants in plasma freezes so other causes of your intranal aki can be like your nephritic and nephrotic syndromes right that can lead to your acute kidney injury also so now we\'re going to go into our post renal causes so this is an injury after the kidneys right so injury after the kidneys usually it involves like the ureters the bladder the urethra and it\'s usually bilateral because unilateral will compensate right it makes sense if it\'s if one of the ureters is involved that\'s fine but if it\'s bilateral that\'s when you have acute kidney injury so once again it has to involve bilateral because unilateral compensate some of the causes of this is uh the most common cause is going to be your kidney stones which makes sense where you have a kidney stone that is just causing obstruction of that fluid it causes that um kidney to be swollen causes hydronephrosis and the kidney isn\'t working as well so kidney stones other causes of these can be history of cancer if they have any type of metastatic cancer like bladder cancer for example it\'s enlarging it\'s just compressing on the ureters causing like obstruction of outflow of the urine these patients are presenting with hesitancy frequency urgency weak stream dribbling incomplete bladder emptying flank pain they\'ll have a history of stones other causes of this commonly found in ben men right it\'s going to be ph so benign prosthetic hypoplasia if that prostate is really enlarged right it can compress the ureters and it can cause that oh obstruction and then there won\'t be any outflow of the urine so that\'s another cause also spinal cord injury this patient\'s gonna be presenting with decreased gfr they\'ll have a low urine osmolality elevated beyond creatinine ratio and then also an abnormal urine analysis where blood cell calcified lots of calciums and crystals right which are involved with what sometimes involved with your um kidney stones right what\'s the treatment you want to remove whatever whatever\'s obstructing of it if it\'s cancer if it\'s metastasized you want to remove that if it\'s a kidney stone you want to remove that right bph they need to go through the chirp surgery so you want to remove whatever is causing the obstruction to prevent severe damage okay so once again free renal most common causes hypovolemia right the kidneys not being perfused intrarenal you have your toxic causes like your um so you have your toxic causes like your certain medications that are nephrotoxics um uh iv drug contrasts other infections like glomerulonephritis nephrox syndrome acute or necrosis so something that\'s happening within the kidney it\'s gonna be intra-renal and then we have post renal which is past the kidney which is happening when the patient has any type of obstruction right so bph kidney stones metastasis from a cancer the way you differentiate between pre-renal and post renal is that you look at the sodium because they\'re going to present very very similar sodium is going to be low in pre-renal sodium is going to be high in intrinsic okay or your phena so once again sodium is going to be low in pre-renal but it\'s going to be high and intrinsic because the kidney is not working anymore orange arena intra-renal aki so let\'s go into our next topic which is going to be acute and transition arthritis this is the presence of inflammatory cells in the renal interstitial space this is immune-mediated injury the most common cause is going to be caused by medications so your antibiotics your bbis your nsaids your penicillin fluoroquinolones vancomycin sofa sulfonamides and rifampin um infection or autoimmune can also cause this this patient\'s gonna be presenting with a fever a rash that\'s gonna be macropapillar uh peripheral aesinophilia so whenever i think about a xenophiles it\'s your body attacking itself right so you\'re gonna have isinophilia oliguria which means they have decreased urine output right uh these patients are gonna be diagnosed with um you\'re gonna see pyreal with white blood cell cast and hematuria with what is in the fields okay you\'re going to see a decrease in gfr a rise in the creatinine and then if you do a biopsy of the kidney you\'re going to see low iron treatment is going to discontinue whatever is affecting right that\'s going to be the number one treatment if it\'s nsaids tell them to stop taking insects and then glucocorticoids are usually reserved beds if it\'s severe renal failure so now we\'re going to go into into a atn acute tubular necrosis this is prolonged severe ischemia okay due to all the causes of severe prolinal disease like shock renal ischemia the most common cause of intrinsic renal failure is usually um \[Music\] i\'m sorry so the most common cause of acute necrosis is going to be intrinsic renal failure usually it can be nephrotoxic or ischemic if it\'s medication induced it\'s going to be your nsaids ace inhibitors and your angiotensin receptor blockers why because they decrease renal blood flow and the thing about acute necrosis that you need to know is that on diagnosis you\'re going to see these muddy brown granular epithelial cast these are usually pathodemonic for atn it\'s gonna be your muddy brown granular epithelial cast you\'re gonna see also free epithelial cells fine granular casts on labs you\'re gonna see hyperkalemia hyperprophysphotemia bun and creonin it\'s going to be less than 20 or 1 and your phena is going to be greater than one percent so you\'ll have high sodium treatment is going to be supportive for these patients so once again acute necrosis is prolonged severe ischemia it\'s the most common causes of intrinsic renal failure and usually with these patients are going to present with muddy brown casts so now let\'s go into acute glomerulonephritis so acute glomerulonephritis this is an acute immunological inflammation of glomeruli that causes protein and red blood cell leakage into the urine so it\'s an inflammation of the glomerulus where so the glomerulus functions how i think about it is it functions like a basket right so it\'s a basket not a lot of things can go through it okay or you would say some type of like filter okay so it\'s a filter not a lot of things go through it but when the glomerulus is damaged that\'s when you\'re gonna have big things go through it if it\'s damaged and it\'s porous you\'re gonna have your big red blood cells going through you\'re gonna have your proteins go through it which in normal kidneys normal glomeruli it doesn\'t do that so when that there\'s any damage or inflammation or infection to that glomerulize to that little you would say um uh like i said like a basket right and the basket\'s ripped everything\'s gonna go through it and it\'s going to spill in the urine and that\'s what\'s occurring with acute glomerulonephritis so it\'s an immunological inflammation of the glomeruli like i said that causes protein and red blood cell leakage into the urine some of the causes of this is going to be ag iga nephropathy it\'s actually one of the um most common causes of glomerulonephritis also known as burger disease very commonly found in young males so usually you\'ll see a question stem and it\'ll be a patient that had just had some type of upper respiratory infection or gi infection and they\'re presenting with like this like coca-cola urine okay and they\'re having like this edema then you want to think about iga nephropathy okay and it\'s usually due to iga immune complexes treatment for your iga neuropathy is going to be your ace inhibitors and prednisone and then we have another type of acute glomerulonephritis which is going to be your pro post-streptoco glomerulonephritis i know i kind of mentioned this a little bit when we were discussing about strep throat but post-streptoclamia nephritis is due to group a beta hemolytic strep okay other causes is impetigo these patients are presenting with that coca-cola urine like i said they\'ll have facial edema they\'ll have positive aso titers treatment is usually supportive and then if we suspect that the patient has an active strep infection then we can treat it with amoxicillin and then we have member pro membrano pluriliferative glomerulonephritis which is due to sle or hepatitis okay um and then we have a rapid progress progressive glomerular nephropathy i\'m sorry glomerulonephritis which is going to be a rapid progression to end-stage renal disease we\'re going to diagnose this with crest information on biopsy and treatment of steroids and cyclophosphamide so there\'s two of these that fall under rpgn which is going to be your wagner\'s granulomatosis which is a necrotizing vasculitis with these patients you\'re going to see a positive c inca and then you have good pastures which involves the kidneys and lung they\'ll have kidney failure and it\'ll present usually with a woman that is having a cough um hemoptysis and then they have kidney failure on top of that and they have these symptoms of glomerulonephritis right and you\'ll also see positive anti-igm antibodies and you can treat this with steroids and cyclophosphamide uh signs and symptoms overall for like glomerulonephritis so these fall under that umbrella so scientists for these overall is going to be your hematuria so that coca-cola coca-cola urine red blood cell cast hypertension peripheral edema they\'ll have azotemia um fever abdominal pain flank pain they\'ll have all the curia and treatment is usually self-limited and for the edema we can do loop diuretics calcium channel blockers or ace inhibitors and then we can also give them steroids recycle phospholipid all right guys so nephrologist is going to be the next one this is also known as kidney stones what\'s the most common location of nephrologists make sure you know this because it\'s very highly tested so the most common location is going to be your ureteral ureteral vesicular junction and it\'s very commonly found in males than females so more commonly found in mouse especially um why because just commonly found in mouse and so i\'m sorry i was going to go into more into that but i don\'t want to misguide you guys so we\'re just going to go into it\'s more commonly fundamentals also very commonly found in patients are dehydrated if they have a history of hyperparathyroidism which is where the parathyroid gland is just over secreting calcium then we\'re prone to getting these like calcium oxalate stones also their diet if they have peptic ulcer disease irritable bowel disease especially crohn\'s is very commonly associated with nephilithiasis which i thought was very very interesting uh family history of certain medications can also make them more prone to getting kidney stones right like you\'re certain diuretics uh if the patient\'s obese if they have a history of diabetes mellitus or renal tubular acidosis so what type of stone is the most common stone so the most common stone is going to be your calcium oxalate okay like i said this is commonly found in patients that suffer from crohn\'s peptic ulcer disease if the patient had a gastric bypass a resection or increased dietary oxalate and then we have our second most common one which is going to be our struvite this one is the one that\'s commonly found in females so he said in general stones are just commonly found in men but struvite are more commonly found in females why are they more commonly found in females and mouse because they are very commonly associated with utis and who gets utis more women do so that\'s why struvite is more commonly found in woman these are also known as your staghorn stones they\'re coffin shaped and they\'ll usually have a very alkaline ph so very high ph and it\'s usually due to ureas producing bacteria especially which one your proteus mirabilis so proteus mirabilis uh is a urease producing bacteria and this is why patients that get urinary tract infections that are associated with this type of bacterial infection are more prone to getting these kidney stones uh the struvite ones and then we have uric acid this is like the third one uh commonly found in patients that have gout right because they have increased uric acid and they have under secretion of uric acid so they\'re not secreting it it stays in their bodies with uric acid so gout also commonly found in patients are dehydrated um hot climates like the summer high protein diet okay and then we have cysteine this is not very common it is found in patients that have like a autosomal recessive disorder called cystinuria so these patients with cystitis are prone to get cysteine stones and uh with these patients with this type of stone it\'s hexagonal shape and it\'s semi-translucent so how is this patient going to present they\'re going to have acute onset of flank pain they\'re gonna have colicky pain that goes from the loin to the groin cva tenderness right so you go back there and you look like this and it\'s gonna be positive without the hematuria which is blood in the urine they\'ll be happy tachycardic hypertensive nausea and vomiting and we\'re gonna diagnosis um we\'re basically doing a kub right we do a kub and then what we\'re gonna see is the stones depending on which type it is so which one is radiolucent so radiolucent is going to be uric acid this is very highly tested make sure that you know how they present on an x-ray how i memorize it is that radiolucent has a u right so it has a u radiolucent uric acid so that\'s how i memorized it for radiolucent this one\'s very highly tested um for radio pack it\'s going to be your calcium oxalate in your struvite stones and an intramed it\'s going to be cysteine but the one highly tested it\'s going to be radiolucent uric acid you can also do a ultrasound but what is a gold standard so the gold standard it\'s going to be a ct without contrast this is going to be the gold standard to diagnose a kidney stone but of course these are contraindicated in pregnancy so what is a treatment for these patients first step is that we want to control their pain so we want to give them pain medication whether it\'s oral or iv want to make sure that we hydrate these patients also and what\'s tested on this is basically what is a treatment depending on what is the size of the stone so if the stone is greater than six millimeters with these patients then uh with these patients and they\'re having obstructive signs they\'re pregnant they have a hit an infection going off fever they weren\'t able to pass urine right so they\'re anuric which is they\'re not passing urine whatsoever and they or they have not passed a stone after four weeks or they have chills fever nausea and vomiting with these patients they need to be hospitalized okay so what if the stone is less than five millimeters if it\'s less than five millimeters you\'re usually likely to pass spontaneously but if it\'s greater than eight millimeters it\'s unlikely to pass so these patients might need lithotripsy and then of course if it\'s larger like 10 millimeters or a centimeter these patients need surgery so make sure you know the difference once again i know that textbooks will differ but if it\'s less than five millimeters these patients can go home and just make sure you observe them tell them to drink plenty of fluids that they\'re probably gonna pass them you can give them something like an alpha blocker which is gonna help them but usually these patients can go home if it is greater than eight millimeters it probably won\'t be able to pass and this patient is going to be lithotris tripsy which is basically just like moving and it\'s going to help that it\'s like a vibration that they have like this type of tool that causes vibrations where the patient will be able to pass a stone but if it\'s greater than one centimeter or greater than 10 millimeters the patient\'s going to need surgery another thing you need to take in consideration is that your struvite stones these are large right these are sag here and stone and sometimes with these patients they won\'t pass spontaneously sometimes they might need surgery so also keep that in the back of your mind so next topic is gonna be cystitis cystitis is an infection of the bladder it\'s a lower urinary tract infection and then we have chronic cystitis also which is persistence of urinary tract infections or more than three urinary tract infections a year the thing about these though if you have a patient that presents like this you want to think about maybe other causes diabetes is very commonly associated with urinary tract infections so make sure that you work up these patients for diabetes mellitus so cystitis most commonly found in women of course right uh the most common bacteria associated is going to be your e coli of course there\'s different types of bacteria but e coli is going to be the most common one and it\'s usually due to an ascending infection from either the urethra or the decent or descending infection like a kidney down uh it\'s complicated cases of cystitis we\'re going to be in dwelling catheters renal calculi enlarged prostate neurogenic bladder diabetics aids pregnant all males your sepsis hospitalization estrogen depletion and spinal cord injuries so these are complicated cases of cystitis and usually these patients need to be hospitalized or they need to require a large a longer dose of medications which we\'ll get into and a different type of medication so how\'s this patient going to present they\'re going to represent with burning frequency urgency cloudy urine nocturia which means they\'re having to go to the restroom at night hesitancy they\'ll have superpubic tenderness hematuria and flank pain usually the way you\'re presenting with that urgency like they go to the restroom and nothing comes out and they\'re having to go over and over and over and over again and then they have like this pelvic pain it\'s just really uncomfortable usually these patients will present within like the first day or the second day because it\'s very uncomfortable and diagnosis for this we\'re going to do a ua we\'re going to see positive leukocyte s-rates positive nitrates positive white blood cells and then we can also do a urine culture and sensitivity if it\'s a complicated case of urinary tract infection and usually on the culture we\'ll see more than 10 to the fifth power cfu per milliliters okay so we can also do imaging like an ultrasound in children or older patients treatment for this is uh education we want to make sure that we educate the patient to have good hygiene right to make sure that if they are sexually active to urinate after they have sex um another thing that we can tell them is to make sure that they\'re not holding their urine and that they drink a lot of fluids so they increase their fluids and it\'s important that they don\'t hold your urine because anything that causes stasis is a great environment for bacteria to to grow in okay you can also tell them to avoid caffeine alcohol tomatoes pelvic rest until done with antibiotics and to make sure that they finish their antibiotics so how are we going to treat these patients if it\'s an uncomplicated uti we\'re going to give them bactrim it\'s usually for three days or if they have some type of allergy to supplementoxazole then we can give him cipro another alternative is nitropharanten for three to five days and then of course our analgesic of pyridium for two to three days if it\'s a complicated uh cystitis and we\'re gonna give him fluoroquinolone for seven days to 14 days and then repeat the urine culture two to four weeks post completion of the antibiotics to verify that the urinary tract infection has resolved and it\'s gone away okay so i just want to go over something that\'s very highly tested what is the antibiotic therapy for urinary tract infection in different age populations okay so like we said if it\'s an acute and complicated cystitis we can give them bacterium or nitro forant and bactrim is usually your choice three to four three days right if the patient has acute and complicated status with comorbid conditions then we can give him bactrim nitropharyntene or fluoroquinolone for seven days what if they have pyelonephritis if it\'s the patient has pyloritis and they\'re mild to moderately ill we can give them an oral fluoroquinolon or bacterium for seven days of fluoroquinolone in 14 days of backdrop if the patient is hospitalized and they have pyelonephritis but it\'s acutely uncomplicated then we\'re going to give iv fluoroquinolone or ampicillin gentamicin or third generation cephalosporin for 14 days if the patient has a complicated uti and they\'re mild to moderately ill we can give them oral fluoroquinolon or bacterium for 14 days if they\'re hospitalized then we\'re going to give them iv ampicillin gentamicin or imipenem selassin or fluoroquinolone or any type of third generation cephalosporin for 14 days if they\'re pregnant we\'re going to give them amoxicillin or bactrim or nitroforentine for seven days okay and the thing about bactrim is that um you don\'t give it in the first or light third trimester and nitropharynteum you don\'t give it in the light third trimester okay so next one\'s going to be pyelonephritis is going to be an upper urinary tract infection this involves the kidneys it\'s an infection of a kidney and usually it\'s a sequelae of an untreated urinary tract infection that\'s why it\'s really important that we educate our patients on the importance of getting seen whenever they have a uti and the importance of getting treated for urinary tract infection because that infection can ascend and affect the kidneys and these patients present more sick on exam so most common organism wants to once again associate with pyelonephritis utis is going to be your e coli commonly associated in women patients that are pregnant or if they have any type of a sickle urea reflux especially with children if you have a child that\'s coming in with you uti i mean there\'s two things that cross your mind okay i\'m not gonna say this anymore but the first one that crosses your mind is that the patient probably has of a secure uretal reflex especially if they\'ve c