Sandbox: Fatima

Sputum Analysis

Sputum Analysis

Acid Fast Stain

Culture on Sabourad's medium

Direct Microscopic Examination

Gentain Voilet Stain

Aerobic Culture

Tuberculosis

Yeast and Fungi

Actinomyces and other mycelia of Fungi

Fusiform Bacteria and Spirochetes

Pyogenic organsims

DD

Rhinitis

Positive Skin Prick or RAST

Negative Skin Prick or RAST

Allergic Rhinitis

Non Allergic

Infectious

Vasomotor

Gustatory

Nonallergic eosinophilic rhinitis syndrome (NARES)

Acute Rhinosinisitis

Chronic Rhinosinusitis

Approach

Diagnostic Paracentesis ❑ Perform ascitic fluid cell count and differential ❑ Perform ascitic fluid culture (Inoculated at bedside)

PMN ≥ 250cells/mm³

If YES ❑ Presumptive SBP ❑ Begin empiric antibiotic therapy(eg:Cefotaxime 2g IV q8H and ❑ IV Albumin on day 1 & day 3 IF serum creatinine 1mg/dl, BUN > 30mg/dl or total albumin > 4mg/dl

IF NO ❑ Look for the signs/symptoms of Infection

Is Culture Positive ?

Absent Symptoms ❑ Is Culture Positive?

Symptoms Present ❑ Begin Empiric Antibiotic Therapy for SBP

Negative Culture ❑ Complete 5 day Antibiotic Course

Confirmed SBP ❑ Narrow the spectrum based on the susceptibility to complete the 5 day course

Culture Negative ❑ No Antibiotics indicated

Culture Positive ❑ Bacterascites: Repeat diagnostic paracentesis when the culture growth is discovered

Differential for Acute abdomen

✔ !✔/✘ !✔/✘ !✘

Classification of acute abdomen based on etiology		Presentation	Symptoms				Signs			Diagnosis		Additional Findings
			Fever	Abdominal Pain	Diarrhea	Constipation	Guarding	Rebound Tenderness	Bowel sounds	Lab Findings	Imaging Findings
Common causes of Peritonitis	Primary Peritonitis	Spontateous Bacterial Peritonitis	✔	Diffuse	✘	✘	✘	✘	Diminished	Ascitic fluid PMN >250cells/mm³ Culture: Positive for single organism
	Secondary Peritonitis	Perforated gastric and duodenal ulcer	✔	Diffuse	✘	✘	✔	✔	✘	Glucose < 50mg/dl Ascitic fluid LDH > serum LDH Total Protein > 1g/dl
		Acute Cholangitis	✔	RUQ	✘	✘	✘	✘	N	Increased LFT
		Acute Cholecystitis	✔	RUQ	✘	✘	✘	✘	N
		Acute Pancreatitis	✔	Diffuse	✔	✘	✘	✘	N	Increased Amylase / Lipase
		Acute Appendicitis	✔	RLQ	✘	✘	✘	✔	N
		Acute Diverticulitis	✔	LLQ	✔/✘	✔/✘	✘	✘	N
		Acute Salphingitis	✔	LLQ/ RLQ	✘	✘	✔/✘	✔/✘	N
Hollow Viscous Obstruction		Small Intestine obstruction	✘	Diffuse	✘	✔✔	✘	✘	Absent
		Volvulus		LLQ
		Biliary Colic		RUQ
		Renal Colic		Flank Pain
Vascular Disorders	Ischemic causes	Mesentric Ischemia		Periumbilical						Increased AG Acidosis
		Acute Ischemic Colitis
	Hemorrhagic causes	Ruptured Abdominal Aortic Aneurysm		Diffuse
		Intraabdominal or Retroperitoneal Hemorrhage		Diffuse
Gynaecological Causes	Ovarian Cyst Complications	Torsion of the Cyst		RLQ / LLQ
		Cyst Rupture		RLQ / LLQ
	Pregnancy	Ruptured Ectopic Pregnancy		RLQ / LLQ						Positive Urine beta HCG

Prostatitis

History and Physical Examination

❑ Urine culture : All patients ❑ Postresidual : If indicated

Mild to Moderately Ill ❑ TMP/SMX 160/800mg PO BID for 6 weeks OR ❑ Ciprofloxacin 500mg PO BID for 6 weeks

Seriously ill or Possible urosepsis ❑ Admit patient for inpatient care ❑ Ampicillin 2g IV q6h PLUS Gentamicin 5mg/kg q24h or 1.5mg/kg every eight hours till afebrile

Fever Persists or Not Improving ❑ Non contrast Pelvic CT with cuts through the prostate or ❑ Transrectal Ultrasonography

Negative ❑ Modify antibiotics based on culture results

Positive ❑ Confirms diagnosis of Prostatic Abcess ❑ Consult urology for drainage

Afebrile ❑ TMP/SMX 160/800mg PO BID for 6 weeks OR ❑ Ciprofloxacin 500mg PO BID for 6 weeks

Prostate

Chronic Prostatitis/CPPS

Primarily urinary symptoms ❑ Add Alpha blocker

Combination of urinary and pain symptoms ❑ Finasteride ❑ Non pharmacological therapy ( eg: Biofeedback) ❑ Phytotherapy ❑ Consult Urology

Primarily pain symptoms ❑ Add Anti inflammatory drugs

Approach to abdominal pain

Presence of signs and symptoms for peritonitis ❑ Abdominal pain ± Gaurding ❑ Fever ❑ Leukocytosis

Perform paracentesis and asicitic fluid analysis

PMN count ≥ 250cells/mm³

If NO ❑ Bacterial peritonitis ruled out ❑ Consider other causes of abdominal pain and Portal Hypertension

If YES Look for the presence of 2 of the following findings: ❑ Total Protein >1g/dl ❑ Glucose < 80mg/dl ❑ Ascitic fluid LDH ≥ 0.6 times upper limit of serum LDH

If NO Examine ascitic fluid after 48hours for reduction in PMN number following antibiotic therapy

If YES Evidence of surgically treatable cause of peritonitis

YES

NO

NO

YES

Consider Non Perforation Secondary Peritonitis

Spontaneous Bacterial Peritonitis

Evidence of localized infection on CT Abdomen

Perforation Peritonitis

Diagnosis of SBP OR No evidence of localized infection on CT

Evidence of localized infection on CT OR Perforation Peritonitis

Continue Antibiotics

Perform Laprotomy