New content quiz January 2014

Infection is traditionally considered present if > 10,000 colonies of pure growth/mm-3 are present with associated pyuria. This definition has a sensitivity of about 80% and specificity of 99% for EColi UTI in premenopausal women. However infection is still possible with lower colony counts with counts of only >100 colonies of pure growth/mm-3 of E Coli being 94% sensitive and 89% specific for UTI in premenopausal women. (link)

Infection is traditionally considered present if > 10,000 colonies of pure growth/mm-3 are present with associated pyuria. This definition has a sensitivity of about 80% and specificity of 99% for EColi UTI in premenopausal women. However infection is still possible with lower colony counts with counts of only >100 colonies of pure growth/mm-3 of E Coli being 94% sensitive and 89% specific for UTI in premenopausal women. (link)

Complex partial status is usually readily diagnosed on clinical grounds, however most other causes of non convulsive status require EEG for diagnosis. The EEG may also be of use in assessing seizure activity in patients who are paralysed or who have received large, heavily sedating doses of anticonvulsants. The EEG during non convulsive status usually demonstrates continuous or virtually continuous paroxysmal activity, and usually improvement and clinical response to IV anticonvulsant therapy. The EEG diagnosis is relatively easy in generalised absence status when there is a prolonged state of altered consciousness associated with generalised 3 Hz spike wave EEG activity. The EEG is less useful in simple partial status, in which the EEG is unchanged or non-specific and in patients with acute cerebral injury of any cause as abnormalities may be due to the primary pathology. (link)

Following complete rupture of an Achilles tendon, patients are usually unable to walk and cannot stand on their toes, although weaker plantar-flexion is still possible due to the action of tibialis posterior. Achilles tendon rupture is also associated with: rheumatoid arthritis; SLE; CRF; long term steroid use; and fluoroquinone use. Examination may reveal a palpable defect in the tendon, usually 2-6 cm proximal to the calcaneum. Pain and localised tenderness without a defect may represent a partial tear. The Thompson-Doherty-Simmons squeeze test is approximately 95% sensitive and specific for complete rupture and is performed in the prone patient with their feet hanging off the end of the examination table. The mid-calf is squeezed at the point of maximum girth – an intact Achilles will cause the  foot to plantar flex, a complete rupture causes no plantar flexion. (link)

E coli is by far the most common organism responsible for UTI. Staph saprophyticus, Proteus, Strep faecalis are the next most common organisms. Klebsiella and Staph aureus may cause UTI in neonates, but Enterococcus faecalis, and Streptococcus agalactiae (group B streptococcus) are common contaminants in an MSU sample. (link)

The positive likelihood ratios of the following features are: dysuria 1.5, fever 1.6, urinary frequency 1.8, haematuria 2.0, a self diagnosis of UTI 4.0, and suprapubic pain / discomfort 1.1. So if a patient tells you they think they have a UTI, they probably do! The presence of dysuria, frequency with no vaginal discharge or irritation has a very impressive LR+ of 24.6. (link)

Non-tunnelled catheters are the most common type inserted in the ED. They have the line and ports protrude directly from the entry site and are intended for use up to 3 weeks duration. Tunnelled catheters (Hickman or Groshong) are inserted with a subcutaneous tunnel from the vessel entry site to the skin entry site. The line access ports sit external to the skin and there is usually a cuff to reduce line colonisation along the catheter tract. A Groshong catheter has a 3 way valve that restricts blood back flow and prevents air embolism. Fully implantable catheters have the entire line and port subcutaneously, and the port must be accessed by a non-coring needle to prevent damage. (link)

Urinary protein in this situation is considered abnormal if > 300 mg/24hrs or at least ‘+’ on bedside testing and indicates increased capillary permeability. It does not necessarily indicate renal damage and is not useful in monitoring disease progression or severity. The amount of proteinuria is no longer considered a marker of severity of disease due to poor correlation with fetal outcome. (link)

Although hypertension in pregnancy is considered present if sBP ≥ 140mmHg or dBP 90mmHg, antihypertensive agents are only indicated if sBP ≥ 160mmHg or dBP ≥110mmHg. (link)

The presence of either item is about 98% sensitive and 55% specific for delirium. (link)

Indications for admission are regional lymphadenopathy, inability to open the mouth > 2cm, drooling or other features of airway obstruction. The other features listed are just features of a dental abscess (link)

With retinal detachment, visual loss appears like a shade over the eye, initially peripheral, becoming progressively more central. The onset is usually slow, over hours. Flashes are usually very brief, occur over the temporal field and may be triggered by eye movement. Zig zag lines that persist for minutes are usually migranous. Visual acuity may be normal if the macula is not involved. An asymmetrical red reflex may be present. (link)

Vitreous haemorrhage is associated with large black floaters, that have shapes of varying translucency, are more prominent against a bright background and move when attempts are made to look at them, then return to their original position. Large floaters may interfere with central vision so visual acuity is usually reduced. Visual loss is usually sudden and painless and an asymmetrical red reflex may be present. The retina is often obscured due to blood. (link)

Global clotting factor depletion is thought to be responsible for 40% of trauma related coagulopahty, the activation of protein C and fibrinolysis for 15%, factor VII elevation and VIII depletion for 10% and unknown reasons for 35%. (link)

Global clotting factor depletion predicts mortality and is associated with penetrating injury, injury severity and INR/PTT elevation. Activation of protein C and fibrinolysis predicts infection, end-organ failure, and mortality. It is associated with acidosis, multi-organ failure and lung injury but not associated with changes in INR or PTT. Factor VII elevation and VIII depletion is associated with elevated PTT but not associated with adverse outcomes. (link)