Rosen & Barkin's 5-Minute Emergency Medicine Consult (754 page)

FOLLOW-UP

• Disseminated gonococcal infection
  
• Sepsis secondary to foreign body
  
• PID toxicity
  
• Pain control, consequent inability to urinate or pass stool (HSV)
  

Most can be discharged. Follow-up in ∼1 wk is suggested.

• Vaginal discharge and vaginitis can be safely managed as an outpatient by the patient’s primary physician or gynecologist:
  
  • Suggested follow-up in 1 wk
    

• Recommend good hygiene
  
• Advise patient to return to the ED or see her doctor if:
  
  • Symptoms do not resolve in 3–5 days
    
  • Abdominal pain or cramping
    
  • Fever or chills
    
  • Pain during sexual intercourse
    
  • Lower back or flank pain
    
  • Difficulty urinating or urinary frequency
    

• pH of BV is often >4.5
  
• Candidiasis often presents right before menses and can be precipitated by antibiotic use, DM, and immunosuppression.
  
• Trichomoniasis often presents after menses and has similar risk factors as other sexually transmitted diseases, including number of sexual partners and sexual practices.
  
• Partner treatment required for gonococcal and chlamydial infection, trichomoniasis.
  

• Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints.
  JAMA.
  2004;291(11):1368–1379.
  
• Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines. 2010.
  
• Egan ME, Lipsky MS. Diagnosis of vaginitis.
  Am Fam Physician
  . 2000;62(5):1095–1104.
  
• Gore H. Vaginitis.
  Emedicine
  . October 27, 2011.
  
• Hainer BL, Gibson MV.
  Vaginitis. Am Fam Physician.
  2011;83:807–815.
  
• Wilson JF. In the clinic. Vaginitis and cervicitis.
  Ann Intern Med.
  2009;151:ITC3-1--ITC3-15.
  

CODES

• 131.01 Trichomonal vulvovaginitis
  
• 616.10 Vaginitis and vulvovaginitis, unspecified
  
• 627.3 Postmenopausal atrophic vaginitis
  

BASICS

• Mitral stenosis:
  
  • Obstruction of diastolic blood flow into the left ventricle (LV)
    
• Mitral regurgitation:
  
  • Inadequate closure of the leaflets allows retrograde blood flow into the left atrium (LA).
    
  • Acute: Pressure overload in LA and pulmonary veins causing acute pulmonary edema
    
  • Chronic: LV volume overload with dilatation and hypertrophy with LA enlargement
    
• Aortic stenosis:
  
  • Obstruction of LV outflow with increased systolic gradient
    
  • Progressive increase in LV systolic pressure and concentric hypertrophy
    
• Aortic regurgitation:
  
  • Acute LV pressure and volume overload leading to left-heart failure and pulmonary edema
    
  • Chronic volume overload with LV dilation and hypertrophy
    

Pregnancy is associated with significant hemodynamic changes that can aggravate valvular heart disease and increase the risk of thromboembolic events.

• Degenerative valvular disease is most common (aortic stenosis and mitral regurgitation)
  
• Aortic valve replacement is the most common surgical procedure
  

• Mitral stenosis:
  
  • Rheumatic fever
    
  • Cardiac tumors
    
  • Rheumatologic disorders (lupus, rheumatoid arthritis)
    
  • Myxoma
    
  • Congenital defects: Parachute valve
    
• Mitral regurgitation (acute):
  
  • Ruptured papillary muscle (infarction, trauma)
    
  • Papillary muscle dysfunction (ischemia)
    
  • Ruptured chordae tendineae (trauma, endocarditis, myxomatous)
    
  • Valve perforation (endocarditis)
    
  • Weight-loss medications (fenfluramine, dexfenfluramine)
    
• Aortic stenosis:
  
  • Congenital aortic stenosis: Male > female (4:1)
    
  • Congenital bicuspid valve (1–2%)
    
  • Rheumatic aortic stenosis
    
  • Calcific aortic stenosis
    
• Aortic regurgitation:
  
  • Infective endocarditis
    
  • Rupture of sinus of Valsalva
    
  • Acute aortic dissection
    
  • Chest trauma
    
  • Following valve surgery
    
  • Bicuspid aortic valve
    
  • Rheumatic fever
    
  • Weight-loss medications (fenfluramine, dexfenfluramine)
    
  • Collagen vascular or connective-tissue diseases
    
  • Systematic lupus erythematosus
    
  • Marfan syndrome
    
  • Pseudoxanthoma elasticum
    
  • Ankylosing spondylitis
    
  • Ehlers–Danlos syndrome
    
  • Polymyalgia rheumatica
    

DIAGNOSIS

• Mitral stenosis:
  
  • Malar flush (“mitral facies”)
    
  • Prominent jugular A-waves
    
  • Right ventricular lift
    
  • Loud S1
    
  • Opening snap
    
  • Low-pitched diastolic rumble
    
  • Exertional dyspnea
    
  • Fatigue
    
  • Palpitations
    
  • Paroxysmal nocturnal dyspnea
    
  • Orthopnea
    
  • Hemoptysis
    
  • Systemic emboli
    
  • Pulmonary edema
    
• Mitral regurgitation:
  
  • Acute pulmonary edema
    
  • Jugular venous pressure (JVP) exhibits cannon A-waves and giant V-waves.
    
  • Harsh blowing apical crescendo–decrescendo murmur radiating to the axilla
    
  • Palpable thrill at apex
    
  • S3 and S4
    
  • Palpitations
    
  • Atrial fibrillation
    
  • Dyspnea
    
  • Orthopnea
    
  • Nocturnal paroxysmal dyspnea
    
  • Peripheral edema
    
  • Systemic emboli
    
  • Normal JVP
    
  • Left ventricular hypertrophy (LVH)
    
  • Apical high-pitched pansystolic murmur
    
  • Decreased or obscured S1
    
  • Widely split S2
    
  • S3
    
• Aortic stenosis:
  
  • Exertional angina
    
  • Syncope (during exercise)
    
  • CHF (initially diastolic failure, then systolic)
    
  • Sudden death secondary to ventricular fibrillation
    
  • Harsh crescendo–decrescendo (diamond-shaped) systolic murmur at aortic focus radiating to carotids
    
  • Absent aortic component of S2
    
  • Delayed upstroke in peripheral pulse (pulsus parvus et tardus)
    
  • S4 gallop
    
  • Ejection click
    
• Aortic regurgitation:
  
  • Fatigue
    
  • Dyspnea on exertion
    
  • Paroxysmal nocturnal dyspnea
    
  • Orthopnea
    
  • Syncope
    
  • Acute pulmonary edema
    
  • High-pitched blowing decrescendo diastolic murmur at aortic area
    
  • Accentuated A2 heart sound
    
  • Wide pulse pressure
    
  • Corrigan pulse (collapsing pulse)
    
  • Duroziez sign (to-and-fro murmur)
    
  • De Musset sign (head bobbing with systole)
    
  • Quincke pulse (nail bed pulsations)
    
  • Austin Flint murmur (soft diastolic rumble)
    

• History and symptoms
  
• Thorough cardiopulmonary exam
  
• ECG
  

• Blood cultures
  
• Presumed endocarditis
  
• CBC:
  
  • Anemia
    

• CXR:
  
  • Mitral stenosis:
    
    • Enlarged LA
      
    • Pulmonary vascular congestion (Kerley B lines)
      
    • Prominent pulmonary arteries
      
  • Mitral regurgitation:
    
    • LV and LA enlargement in chronic cases
      
    • Pulmonary edema and normal LV and LA dimensions in acute cases
      
  • Aortic stenosis:
    
    • LVH
      
    • Aortic calcification
      
    • Dilation of ascending aorta
      
    • Pulmonary congestion and cardiomegaly
      
  • Aortic regurgitation:
    
    • Acute = normal cardiac silhouette and pulmonary edema
      
    • Chronic = enlarged LV and dilated aorta
      
• ECG:
  
  • Quality assessment of valvular structures
    
  • Measurements of flow through valves
    
  • Identification of regurgitation
    
  • Ventricular dilatation or hypertrophy
    
• Spiral CT scan:
  
  • To exclude aortic dissection with acute aortic regurgitation