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American Family Physician March 15, 2007 Issue

American Family Physician March 15, 2007 Issue. Presented April 26, 2007 Eddie Needham, MD, FAAFP Program Director Emory Family Medicine Residency Program. Subject Matter . Disaster-Related Health Infertility Impetigo Spider Bites Postpartum Hemorrhage Photo Quiz.

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American Family Physician March 15, 2007 Issue

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  1. American Family PhysicianMarch 15, 2007 Issue Presented April 26, 2007 Eddie Needham, MD, FAAFP Program Director Emory Family Medicine Residency Program

  2. Subject Matter • Disaster-Related Health • Infertility • Impetigo • Spider Bites • Postpartum Hemorrhage • Photo Quiz

  3. Disaster Medicine Take home points • Disasters happen • Be prepared – The motto of the Boy Scouts of America • American Red Cross defines a disaster as: • Affecting >100 people • 10 or more deaths • Appeal for assistance is requested • Poorest outcomes in: • Ethnic minorities • Lower income families

  4. Disaster Medicine Take home points • Have a clinic/hospital disaster plan ready BEFORE a disaster occurs. • Local disasters • Hurricane Katrina • Tornado in Americus, Georgia this year • Bus accident on I-75 killing many players of a baseball team

  5. Disaster Medicine Take home points • Mental health problems present in a patient before a disaster increase the risk of mental health problems after a disaster. • Most common post-disaster mental health problems include: • Depression • PTSD • Anxiety disorders

  6. Infertility

  7. Objectives - Infertility • I don’t think our residency program has this problem, based on the recent experiences of Tanya, Nazra, Sarah, and …?

  8. Infertility • Definition • One year of frequent, unprotected intercourse without becoming pregnant. • 10-15% couples are infertile. • Etiology • Unexplained 28% • Male factors 24% • Ovarian dysfunction 21% • Tubal factors 14% • Other 13%

  9. History • What to ask? • Coital practices • Medical history – genetic disorders, chronic illnesses, genital trauma, orchitis, h/o PID/STDs, endocrine problems • Medications – OCPs!!! • Previous fertility • Surgical history – BTL!!! • Substance abuse/toxin exposure

  10. Physical ExamWhat to specifically look for on exam? Males Females • Two marbles and a shooter  • Signs of infection • Testicular mass • Hydrocele • Varicocele • Signs of androgen deficiency • Decreased muscle, increased fat, decreased facial/body hair, small testes • Normal female anatomy • Testicular feminization • Breast formation • Galactorrhea • Signs of hyperandrogenism • Hirsutism, acne, clitoromegaly

  11. Hirsutism

  12. Acne and facial hair

  13. AcanthosisNigricans

  14. Infertility - Evaluation • Couple • Timing and frequency of intercourse • Time for midcycle LH surge/ovulation • Use of lubricants • Impairs fertility • Previous fertility • Consider asking some questions with couple separated • Have you had any STDs? • Have you been pregnant before? (Miscarriage, abortion)

  15. Infertility - Evaluation • Male Partner • Primary hypogonadism (testicular failure or dysfunction) is the most common cause of male infertility (30-40%) • Androgen insensitivity, medications, orchitis, radiation trauma • Altered sperm transport (10-20%) • Absent vas deferens, erectile dysfunction, retrograde ejaculation • Secondary hypogonadism (1-2%) • Unknown (40-50%)

  16. Infertility - Evaluation • Female Partner • Ovulation disorders (40%) • Aging, endocrine disorders, decreased ovarian reserve, PCOS, tobacco use, premature ovarian failure • Tubal Factors (30%) • Endometriosis (15%) Review Triad • Other (10%) • Uterine/Cervical factors (>3%) • Congenital uterine abnormalities (double cervix case), fibroids, polyps, uterine synechiae, poor cervical mucus (Robitussin )

  17. Special testing to consider Male Female • Semen analysis • GC/Chlamydia/urine cxprn • FSH, testosterone levels if hypogonadism suspected • CBC if infection considered • ?CMP – renal/liver eval. • Labs based on medical conditions • Prolactin/TSH • Testicular/transrectal ultrasound • Prolactin/TSH • Mid-luteal progesterone to confirm ovulation • Basal body charts • Home LH surge kit (urine) • 17a-hydroxyprogesterone, testosterone if hyperandrogenism suspected • Transvaginal ultrasound • Hysterosalpingogram • Laparoscopy

  18. ManagementTreatment of the Couple • Time intercourse during the five days preceding and the day of ovulation. • Consider alternating days in order to allow the sperm count to increase in the semen after ejaculation • Clear stringy mucus is a sign of ovulation • Avoid lubricants and douches • Avoid alcohol and tobacco • Consider supportive counseling during the difficult time

  19. ManagementMale Factor Infertility • Treat hyperprolactimenia with dopamine agonists (bromocriptine) • Treat erectile dysfunction as needed • Varicocele repair has not been shown to improve fertility rates, although it does increase sperm counts. • In general, seminal fluid abnormalities warrant referral to a specialist.

  20. ManagementFemale Factor Infertility • Ovulatory dysfunction • Correct endocrine abnormalities (PCOS - metformin, thyroid) • Consider laparoscopic ovarian drilling for PCOS (?) • Consider clomiphene citrate (Clomid) to treat women without obvious cause of ovulatory dysfunction and in women with PCOS. • Clomid is not effective in women with hypothalamic amenorrhea or in women with limited ovarian reserve.

  21. Clomiphene citrate (Clomid) • 80% of appropriately selected patients will ovulate. • Give 50 mg on days 5-9 (or days 3-7), check for ovulation. • May repeat x 3 months at 50mg dose. • Then increase to 100mg dose x 3 months. • If still no effect, refer. • Risks of Clomid • Ovarian hyperstimulation syndrome and twinning • Higher-order multiple gestations are rare.

  22. ManagementFemale Factor Infertility • Tubal, Uterine, Pelvic disease • Tubal disease – tubal reparative surgery, remove scars • Consider In-vitro fertilization (IVF) • Endometriosis – reparative surgery • Anecdotally, hysterosalpingogram has be thought to “flush out” the fallopian tubes and improve fertility

  23. Prognosis • Overall likelihood of successful treatment is 50%. • Infertility secondary to ovulatory dysfunction has the best prognosis, with success rates approaching 50%. • Success with tubal factors or endometriosis is approximately 20%.

  24. Impetigo

  25. Impetigo • Most frequently affects children 2-5 years old. • Highly contagious, spread through direct contact. • Staphylococcus aureus is the most common organism. • Two main types • Nonbullous • Host response to infection • Bullous • Caused by a staphylococcal toxin, no host response necessary • Nephritogenic strains of streptococcus pyogenes can cause post-strep. glomerulonephritis. • Occurs in 1-5% of nonbullous impetigo.

  26. Diagnosis • Clinical dx – classic honey-colored crusts • Treatment • Topical mupirocin • Mupirocin is as effective as oral antibiotics for localized disease • Oral antibiotics • Cephalexin • Amoxicillin/clavulanic acid • Macrolides • NOT penicillin V or plain amoxicillin

  27. Bullous Impetigo

  28. Bullous Impetigo

  29. Spider Bites Black Widow and Brown Recluse

  30. What caused this?(No shouting answers)

  31. Brown Recluse Spider

  32. Bite symptoms/signs • Pain at bite site in 3-4 hours, can be unnoticed bite • Formation of bulla • Progression to skin necrosis and ulcer formation

  33. Initial bite and progression

  34. Treatment • Observation in ER until at least 6 hours after the bite • Blood tests • CBC/platelets – look for DIC • BMP – check renal function • Local first aid • Clean wound, ice, elevation, immobilization, analgesia • Tetanus prophylaxis • No benefit to surgical excision of the wound • Excision is different from debridement

  35. Switch from Brown Recluse to Black Widow

  36. Black Widow Spider

  37. Bite symptoms/signs • Painful bite that has a neurotoxin that causes the release of all neurotransmitters in the synapse • Dull crampy pain – chest or abdomen • Progressive autonomic symptoms • Dizziness • Nausea/Vomiting • Headache • Dyspnea • Sweating • Weakness • Anxiety

  38. Treatment • Ice immediately and transport to ER • Clean wound – topical first aid • Tetanus prophylaxis • Observe for at least 6 hours post-bite • Labs: CBC/Platelets/BMP • If symptoms progressive admit and: • Diazepam for muscle cramps • Analgesia as necessary • Consider Antivenin (call poison control) • Administer for severe regional sx, systemic toxicity, uncontrolled HTN, seizures, respiratory arrest

  39. Antivenin is available

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