Autoprac: Most recent Pulse Pulse is measuring heart beat by palpating a peripheral artery by the fingertip (with the exception of using the thumb). Sometimes, there is delay, which is indicative of pathology. Method Pulses can be palpated at any place that allows an artery to be compressed against a bone, including: Head and neck: Carotid artery, located in the neck, between the anterior border of the sternocleidomastoid muscle, above the hyoid bone, and laterla to the thyroid cartilage. It should be palpated gently while the patient is sitting or lying down. Stimulating its baroreceptors with low palpation can provoke severe bradycardia, or even stop the heart in sensitive patients. A patient's 2 carotid arteries should NOT be palpated at the same time, as it may limit blood flow to the head, possibly causing fainting or brain ischemia [img]carotid-pulse.png[/img] Source: ClassConnection Facial artery, located on the mandible (lower jawbone), on a line with the corners of the mouth [Superficial] temporal artery, located on the temple directly in front of the ear Upper limb: Axillary pulse, located inferiorly of the lateral wall of the axilla Brachial artery, located on the inside of the upper arm, inside the elbow, frequently used in place of carotid pulse in infants [img]brachial-pulse.png[/img] Source: ClassConnection ​Radial artery, located on the lateral of the wrist, at the anatomical snuffbox, commonly measured using 3 fingers, so the finger closest to the heart occludes the pulse pressure, the middle finger otains a crude estimate of blood pressure, and the ring finger is used to nullify the effect of the ulnar pulses as the 2 arteries are connected via the palmar arches Ulnar artery, located on the medial of the wrist [img]radial-pulse.jpg[/img] Source: EasyMBBS Torso: Apical pulse, located at the 5th intercostal space, 1.25cm lateral to the midclavicular line. Unlike other pulse sites, it is not under an artery, but at the apex of the heart Lower limb: Femoral artery, located at the groin, in the inner thigh, at the mid-inguinal point, halfway between the pubic symphysis and ASIS (anterior superior iliac spine) Popliteal artery, located above and behind the knee, in the popliteal fossa, found by holding the bent knee. The knee is bent at apprximately 124 degres, and the doctor holds it in both ahdns to find the popliteal artery in the pit behind th eknee [img]popliteal.jpg[/img] Source: GLA Dorsalis pedis artery (on the foot), is located on top of the foot, immediately lateral to the extensor of hallucis longus [img]dorsalis-pedis.jpg[/img] Source: OSCE skills Posterior tibial artery, located on the medial side of the ankle joint, over Pimenta's Point, where 3 fingers are placed at the midpoint of an imaginary line drawn between the bony prominence of the medial maleolus, and the insertion of the achilles tendon [img]posterior-tibial.jpg[/img] Source: GLA​ [img]leg-pulses.png[/img] Source: Elsevier HR can also be measured by auscultating the heart beat using a stethoscope. [faq]What is pulse? It's the beating of the heart that you're feeling, right? Yep. So you're feeling the heart beat peripherally. How do you feel the heart beating peripherally? So you press the artery against a bone. You can do this in the head, at the carotid artery in the neck. You can do this in the arm, at the brachial artery inside the elbow, radial artery at the wrist. You can also do this in the feet, at the femoral artery at the groin, popliteal artery behind the knee, posterior tibial artery near the ankle joint, and dorsalis pedis artery on the foot.[/faq] Classification Rate, is in beats per minute (bpm), representing heart rate. It has the extremities of [[bradycardia]] and [[tachycardia]] Rhythm can either be: Regular Regularly irregular, is a regular but intermittent pulse, and can be caused by: Pulsus bigeminus 2nd degree AV block Irregularly irregular, which is irregularly and intermittent pulse, can be caused by: Atrial fibrillation Volume (aka amplitude, expansion, size of pulse), is the degree of expansion of the artery during diastole and systole. It includes: Hypokinetic pulse (aka weak pulse), indicates narrow pulse pressure. It can be caused by: Low cardiac output, e.g. shock, CHF Hypovolemia Valvular heart disease, e.g. aortic outflow tract obstruction, mitral stenosis, aortic arch syndrome Hyperkinetic pulse (aka bounding pulse), indicates high pulse pressure. It can be caused by: Low peripheral resistance, e.g. fever, anemia, thyrotoxicosis, AV fistula, Paget's disease, beriberi, liver cirrhosis Increased cardiac output Increased stroke volume, e.g. anxiety, exercise, complete heart block, aortic regurgitation Decreased distensibility of arterial system, e.g. atherosclerosis, HTN, and coarctation of aorta Force (aka compressibility of pulse), is a rough measure of systolic BP Tension, coresponds to diastolic BP. It includes: Pulsus mollis (low tension pulse), where the vessel is soft or impalpable between beats Pulsus durus (high tension pulse), where the vessels feel rigid even between pulse beats Equality/delay, comparing pulses at different places A discrepant/unequal pulse between the L and R radial artery, indicates: Anomalous/aberrant course of artery Coarctation of aorta Aortitis Dissecting aneurysm Peripheral embolism Unequal pulse between upper and lower extremities, e.g. radio-femoral delay, is seen in: Coarctation of aorta, where the femoral pulse may be significantly delayed compared to the radial pulse Supravalvar aortic stenosis Aortitis Block at bifurcation of aorta Dissection of aorta Iatrogenic trauma Arteriosclerotic obstruction Compressibility, as a normal artery is not palpable after flattening by digital pressure. A thick radial artery palpable 7.5-10cm up the forearm is suggestive of arteriosclerosis See also [[Doppler auscultation]] [[Tachycardia]] (higher than normal) Thu, 21 Sep 2023 15:52:58 +0000 Perineal tear Perineal tear is an unintended laceration of the skin and other soft tissue structures separating the vagina from the anus. Tears vary in severity. [faq]What is a perineal tear? It's where as a result of delivery of a baby - usually on the larger side - an accidental tear is made to the perineum. What is the perineum? It's the wall between the vagina and anus, and everything that is in it.[/faq] Cause It mainly occurs in women as a result of vaginal childbirth, which strains the perineum In humans, the head of the fetus is so large in comparison to the size of the birth canal, term delivery is rarely possible without some degree of trauma. As the head passes through the pelvis, the soft tissues are stretched and compressed [faq]What causes a tear in the wall between the vagina and anus? Childbirth, because the stretching causes straining of this wall. If you think about the big size of the head, giving birth without some degree of trauma is really quite difficult.[/faq] Risk factors Fetal head is oriented OP (occiput posterior, i.e. face forward) Primip (mother has not given birth before) Fetus is large [faq]What makes it more likely that you tear the wall between the vagina and anus? If bub's face is facing forward. Mom who hasn't given birth before. Or a big bub.[/faq] Classification 1st degree tear, where laceration is limited to the fourchette and superifcial perineal skin or vaginal mucosa 2nd degree tear, where laceration extends beyond fourchette, perineal skin and vaginal mucosa - to perineal muscles and fascia, but not the anal sphincter 3rd degree tear, where the fourchette, perineal skin, vaginal mucosa, muscles, and anal sphincter are torn. They can be subdivided into: 3a: Partial tear of the external anal sphincter involving 50% tear of the external anal sphincter 3c: Internal sphincter is torn 4th degree tear, where the fourchette, perineal skin, vaginal mucosa, muscles, anal sphincter, and rectal mucosa are torn [img]perineal-tear-degrees.jpg[/img] [faq]Whoa... That was a lot of words. So in simple terms, what's the difference between a 1st, 2nd, 3rd, and 4th degree tear? It's easiest to define it by what it doesn't involve. 1st degree doesn't involve the perineal muscles. 2nd degree doesn't involve the anal muscles. 3rd degree doesn't involve the anal mucosa.[/faq] Tx Superficial tears require no Tx Complications Chronic perineal pain Dyspareunia (painful sex) Fecal incontinence Fecal urgency [faq]What bad things can happen as a reuslt of a tear in the wall between the vagina and anus? There can be chronic pain where the tear is. Sex can be painful. And depending on the degree of the tear, there can be lost control over poop.[/faq] Prognosis 1st and 2nd degree tears rarely cause long term problems In women who've experienced a 3rd or 4th degree tear, 70% are asymptomatic after 12 months Severe tears can cause significant bleeding, long-term pain, or dysfunction Epidemiology The majority of tears are superficial 1st and 2nd degree perineal tears are the most common complicating condition for vaginal devlieries See also [[Episiotomy]] (intentional laceration, to facilitate delivery) Thu, 21 Sep 2023 16:28:42 +0000 Group and hold Group and hold (aka group and screen, G&S, or type and screen) are tests conducted prior to blood transfusion. [faq]What's group and hold? Tests done before a blood transfusion. What's a blood transfusion? Where you get blood products injected into your body, through your veins. Practically, which bottle do you use to collect a Group and hold? Pink top. For both Group and hold, and Crossmatch.[/faq] Method Blood typing (aka blood grouping), determining the Pt's blood group system, most importantly the ABO and Rh system Indirect Coombs test, to directly test for the presence of antibodies against a sample of donor tissues or blood, w/ blood group antibodies (BGA) Crossmatch (shorthand X-match) should be performed, where there ARE antibodies detected. It is performed prior to a blood transfusion, to determine if the donor's blood is compatible w/ the blood of an intended recipient Checking for previous transfusion and blood group records [faq]What does group and hold involve? There's the blood group, blood group antibody, and crossmatch. What are these 3 things? Blood group is your A, B, O, which can also be + or -. And there are various Rh, most commonly RhD, which can be + or -. There's blood group antibody, which are antibodies in blood, which can attack RBC's and cause hemolysis. And crossmatch is where you explore, whether these particular antibodies, are actually incompatible, by mixing the blood together and testing it out.[/faq] Risks Crossmatch specimens EXPIRES 72 hours after collection. A fresh sample will be required for any units not commenced w/in 72 hours See also [[Coombs test]] [[Transfusion]] Thu, 21 Sep 2023 06:15:53 +0000 Gravidity and parity Gravidity and parity (G/P/A) are terms relating to pregnancy. Definition It is the number of times a female has: Gravidity means having been pregnant, regardless of whether it has been brought to viability (yet alone term), including the current pregnancy: Gravida refers to a pregnant woman Nulligravida (nulli) is a woman who has been never pregnant Primigravida (primi) is a woman who is pregnant for the 1st time or has been pregnant 1 time. Elderly primigravida refers to being primi >=35yo Multigravida (multi) is a woman who has been pregnant more than 1 time Parity is carrying the pregnancy to viable gestational age, defined as >20 weeks gestation. Note therefore that G2P1 doesn't necessarily mean that the previous baby passed away. It could mean that the current baby is Thu, 21 Sep 2023 12:27:45 +0000 Fluid replacement Fluid replacement is the replenishment of bodily fluids lost through various means (sweating, bleeding, fluid shift, or other pathological processes). [faq]What is fluid replacement? It's where we replenish the body with fluids. This happens constantly, as we lose water through sweat, bleeding, fluid shift, or some other sort of diseased thing. We do this naturally, by... just drinking water ;).[/faq] Methods It includes: Oral rehydration therapy (drinking). Examples of oral rehydration solution to Tx dehydration, including Hydralyte, Gastrolyte [img]hydralyte.jpg[/img] Source: Pharmacy Daily [img]gastrolyte.jpg[/img] Source: CBSI Intravenous therapy (aka drip), which is the fastest way to deliver fluids and medications throughout the body. it employs a drip chamber, which prevents air from entering the blood stream forming an air embolus, and allows an estimation of flow rate Rectally (e.g. with a Murphy drip) Hypodermoclysis (aka interstitial infusion, subcutaneous infusion, i.e. direct injection of fluid into subcutaneous tissue) [faq]So you mentioned we can replenish fluid by drinking water. What else can we do? So we can do it with water, or we can do it with hydralyte or gastrolyte, which are specially formulated fluids with electrolytes. You can also do it through blood, called IV or drip. Up the buttock. Or under skin.[/faq] Indications Note that the fluid indications are independent of another, meaning they are a combination of, rather than "either": Resuscitation fluids, where the Pt is hypovolemic due to dehydration, blood loss, or sepsis, and requires urgent IV to correct the deficit. It is provided as a bolus. Fluid challenge is where a small amount of fluid (250mL) is given initially to see the Pt's response. It is reserved for hemodynamically unstable Pt's Constituency: 0.9% NaCl, with NO glucose or KCl → rapid K administration is harmful to the heart. Same for neonates Rate: Healthy adults: 500mL bolus. Elderly/cardiac problems: 250mL bolus. 20mL/kg bolus. In neonates, 10-20mL/kg bolus Rehydration/Replacement fluids, where lost fluid is replaced. It should not be provided in anticipation Constituency: Same as maintenance, namely 0.9% NaCl + 5% glucose +/- 20mmol/L KCl. In neonates, same as maintenance, namely, 0.45% NaCl + 10% glucose +/- 10mmol/500mL bag KCl Rate: (Weight in kg * % clinical dehydration * 10mL) per day, where % clinical dehydration depends on a table, ranging from 0 for "No clinical signs of dehydration" (reduced urine output, thirsty), 3% for "Mild" (+dry mucous membranes, mild tachycardia), 5% for "Moderate" (+tachycardia, abnormal respiratory pattern, lethargy, reduced skin turgor, sunken eyes), 10% for "Severe" (+signs of poor perfusion including or shock) Maintenance fluids (Maint), where the Pt is at negligible loss Constituency: 0.9% NaCl + 5% glucose +/- 20mmol/L KCl. In neonates, we give half the salts and double the glucose, namely, 0.45% NaCl + 10% glucose +/- 10mmol/500mL bag KCl Rate: In adults, approximately 100mLs/hr, which is 2.4L/day. Total maintenance per hour in kids is calculated either by 2 rules, which are NOT equal: 4, 2, 1 "hourly" rule, i.e. 4mL/kg/hr for the first 10kg, +2mL/kg/hr for the next 10kg, +1mL/kg/hr for every 1kg of the Pt's weight thereafter, up to a maximum of 2.5L/day 100, 50, 20 "daily" rule, i.e. 100mL/kg for the first 10kg + 50mL/kg for the next 10kg + 20mL/kg for every 1kg of the Pt's weight thereafter, up to a maximum of 2.5L/day The 100, 50, 20 rule may be easier to remember because the "2" and "5" and "00" can be obtained from the prior numbers, which equates 2500mL=2.5L ​Source: NSW Health [faq]So there are 3 sorts of fluids? Resus, replacement, and maintenance? Resus is given when there's been a big loss of blood, which happens in dehydration, blood loss, and blood infection. Replacement is given when there's been a loss, but not to that same degree, such that we're only a bit dehydrated here. Maintenance fluid is where there has been no loss, but you're just "topping up" because the patient is not or cannot drink water, so you give it by IV. What's in them? Do you give the same thing for everyone? Is it just water? When we give a big lot, we give salty water. We don't add anything to it, like glucose. In fact, given potassium super fast is dangerous to the heart. For both replacement and maintenance, we usually add glucose, and we can also add potassium too. That's like giving everyone, except those who you give a bolus, a banana. Bananas are high in sugar and potassium ;). Is it different little babies? Same stuff, just half the salt, double the sugar. That's sound like the sort of things kids would like :P. How fast do you give these fluids? So resus is all at once, because they really need it. Replacement depends on dehydration and weight. Maintenance is based on the 4-2-1 or 100-50-20 rule. Wait... why is there no "rate" listed for resus fluids? That's what the word "bolus" is there for. It means it's give as fast as possible. So you could think of the rate being 99999mL/hour ;) We give it so quickly we usually write it as "stat", which means it's all been given right now :D! But we don't give the same amount of sudden fluids to everyone. We give 2 cups, or 500mL in adults. But for those who are old or have haert problems, we give 1 cup only, 250mL.[/faq] Fluid types Crystalloids, are solutions containing small molecules that can easily cross cell membranes. It includes: Normal saline (NS) 0.9% w/v NaCl, which contains 154mmol/L of Na and Cl per 1L. Bags containing KCl are also available, usually either 20mmol/L or 40mmol/L [img]normal-saline.jpg[/img] Source: Lucky Pharmacy Liberia [faq]What's in Normal Saline? Is it just salty water? Yeaaap! It's exactly as it sounds. It is 0.9% w/v NaCl, which if you use the periodic table numbers, will get you, in a 1L bag, 154mmol of Na+ and 154mmol of Cl-.[/faq] Hartmann's [solution] (aka compound sodium lactate, CSL), which contains 131mmol/L Na, 111mmol/L Cl, 29mmol/L HCO3 (in form of lactate), 5mmol/L K+, 2mmol/L Ca2+ per 1L. It is more closely isotonic w/ blood than normal saline. It is used to replace body fluid and mineral salts that may be lost. It is especially suitable when losses cause acidemia. It is relatively contraindicated in Pt's with DM, as one of the isomers of lactate is gluconeogenic 5% Glucose or dextrose, which is a solution w/ sugar, where it may function both as a means of maintaining tissue hydration, and a means of parental nutrition. Types include: D5W (5% dextrose in water), which consists of 278mmol/L dextrose D5NS (5% dextrose in normal saline), which in addition contains NS (0.9% w/v of NaCl). Alternatively, D51/2NS, contains 5% dextrose (50g/L) in 1/2 the amount of NS (0.45% w/v of NaCl, or 154/2=77mmol/L Na and Cl) [img]hartmann's-solution.jpg[/img] Source: e-Safe anesthesia [faq]Alright, what's Hartmann's then? And how's it different from Normal Saline? It's more similar to blood (which in turn is similar to ECF), even with the Na and Cl. It has 131mmol Na+, 111mmol Cl-. In addition, it has 29mmol HCO3- (bicarbonate), 5mmol K+, and 2mmol Ca2+. So in addition to the salt, it has bicarbonate, potassium, and calcium. But it's still all within a 1L bag of water. [img]intracellular-and-extracellular-electrolytes.gif[/img] Source: Toddlee MD ECF is extracellular fluid. What is that, and how's that different from intracellular fluid? ECF is fluid outside cells. ECF includes blood plasma, along with interstitial fluid. Intracellular fluid is fluid inside cells, which is mostly cytosol, where organelles are suspended. 5% glucose? That's sugary rather than salty water? No. It's sugar in salt water. 5% glucose has 50g of glucose. Carbs have 4 calories per gram, so 50g glucose has around 200 calories. If it's prepared from dextrose, it only has 3.4 calories per gram, so 50g dextrose would have 170 calories.[/faq] Colloids, which contain larger molecules, such as gelatin or albumin, that remain within the intravascular space. They are thought to expand the intravascular space for a longer duration than the crystalloids. They are becoming less used because of their risk of anaphylaxis, and because in practice crystalloids are actually just as effective Blood products, which are ordered from the transfusion lab. It includes: Packed red cells Platelets Fresh frozen plasma (FFP) Side effects Pain Infection Phlebitis Infiltration/extravasation Fluid overload, which occurs when fluids are given at a higher rate, or in a larger volume, than the system can absorb or excrete. This can cause: HTN Heart failure Pulmonary edema Hypothermia Electrolyte imbalance Embolism Glucose, for energy Ix Measure hourly urine output and input Closely monitor U&E, and adjust fluid type accordingly Prognosis Fluid requirement is higher in younger kids, per kg, as indicated by the 4-2-1 rule, because of immature renal function Paperwork The paperwork for Pediatric daily fluid balance chart includes: Affix Pt label Date: __/__/____ Instructions for Use include All entries must be legible and written in black pen. IV Site/s Check - refer to local policy in relation to IV site check requirements. Urine and Vomitus Outputs - if it is usual business practice to record progressive totals please draw a diagonal line in the field and write the progressive total below the diagonal line. IV line change due ___. PT = Progressive Total Date: __/__/___ Instructions Daily weight There is a large table, which on the very LHS includes the Time, ranging from 0100, 0200, 0300... 2200, 2300, 2400, followed by Subtotal for that column. The various columns for the according times are: Under Input set of columns, Line A site (Solution and Volume have different cells), Line B site (Solution and Volume have different cells), Line C site (Solution and Volume have different cells); Parenteral total (P); IV Site/s Check, IV Press mmHg, Oral/Enteral (OE) (with cells for Type, Route, Fluid Volume), Expressed Breast Milk (EBMI) signature (which requires countersign); Oral/Enteral total (OE); Progressive total in (P+OE=X) Under Output set of columns, Urine/PT, Vomitus/PT, Gastric Aspirate, Drain 1 (with an additional cell underneath); Fecal/Other; Progressive total out (Y); Progressive Fluid Balance (X-Y) At the bottom row, Total input (X), Total output (Y), Total balance (X-Y) All entries must be legible and written in black pen. Also a note for, Note: Consider insensible losses The paperwork for Pediatric IV fluid order chart includes: Includes note that Rechart fluids orders at least daily, and Calculate all fluids on current weight Affix Pt label First prescriber to print Pt name and check label correct: ____ Weight (kg) Date weighed Height (cm) B.S.A. (m^2) (body surface area) Gestational age at birth (wks) Calculation of IV fluids, NB: Refer to Page 2 for assistance; MO to complete. Under: (A) Maintenance, if >28 days, 1st 10kg = ___mL, 11-20kg=___mL, >20kg=___mL, Total=___mL. If 20kg, daily 1500mL+(20mL/kg for each kg over 20kg), hourly 60mL+(1mL/kg/hr for each kg over 20kg). All of the following had type 0.45% sodium chloride + 5% glucose with or without potassium chloride 10mmol/500mL OR 20mmol/1000mL; OR 0.9% sodium chloride + 5% glucose with or without potassium chloride 10mmol/500mL OR 20mmol/1000mL WHERE there is pre-existing hyponatremia (sodium less than reference range), or increased risk of hyponatremia - such as sodium losses (e.g. gut) or high risk of non-osmotic ADH secretion (e.g. post-op, respiratory illnesses, CNS disease); OR Plasma-Lyte148 + 5% glucose (Children's Hospital ONLY) 3. Replacement fluid, where Calculation of deficit: Volume in mL=weight (kg) * % dehydration * 10. replace deficit at a constant rate over 24 hrs. Only calculate replacement volume to 5% dehydration in the first 24 hours. Fluid type: Neonates: 0.45% sodium chloride + 10% glucose with or without potassium chloride 10 mmol/500 mL OR 0.9% sodium chloride + 10% glucose with or without potassium chloride 10 mmol/500mL Infants and children: Infants and children: 0.9% sodium chloride + 5% glucose with or without potassium chloride 10 mmol/500mL OR 0.9% sodium chloride 5% glucose with or without potassium chloride 20 mmol/1000mL OR Plasma-Lyte148 + 5% glucose (Children's Hospitals ONLY) Ongoing GI losses: Measure and replace over an hourly or 4 hourly period Sample calculation of fluid deficit (for 24 hrs). Child with gastroenteritis: weight =22kg, estimated dehydration=5%. The majortiy of children will not require rehydration of more than 5% deficit in the first 24 hrs. Maintenance Fluid: For 22kg: 1500mL + (20mL/kg * 2) = 1540mL (A). Replacement deficit: 22kg * 5% * 10 = 1100mL (B). Total fluid replacement: 1540+1100=2640mL/24hr (C). =110mL/hr Consultation with a senior clinicial required for infants and children with, greater than or equal to 10% dehydration; infants less than 3 months of age (corrected for gestation) or Thu, 21 Sep 2023 16:21:18 +0000 Bishop score Bishop score (aka cervix score, cervical favorability) is a pre-labor scoring system. Cx is shorthand for cervix. [faq]What's the Bishop score? It's a way that we score how ready bub is ready to come out. We find that from a vaginal exam. How do we know that? We surmise this from where the cervix is found. How stretched the cervical hole is. How thin the cervix is, as caused by stretch of the descending baby. It's softness. And how low the fetal head has come down.[/faq] Purpose Predict whether IOL will be required, based on whether a spontaneous birth will occur [without the need of IOL] Assess the odds labor will commence spontaneously [faq]Why woud you want to know how ready bub is to come out? If it's taking too long, you might want to induce labor. That's because we don't want labor to be "prolonged". So if that's not going to happen spontaneously, we're going to have to induce. When do you consider labor to be prolonged? Prolonged labor is when the total duration of childbirth is >24 hours. Or the latent phase >8 hours. Or when the active phase is >12 hours. Wait... how do you know this until AFTER the event has happened? That'd be too late already? And why would you need a vaginal exam for this? You wouldn't. And that's why we look at progress. We want cervical dilation of at least 1cm per hour. And that's why we repeat the vaginal exam over time. Going back to the Bishop score then. What use is a single score? What can it tell us? Likelihood of spontaneous labor. The more stretched the cervix. The more softer. The lower the baby's head. The more likely spontaneous labor will happen.[/faq] Method The score is assessed based on 5 components of vaginal examination, including (which can be memorized with the mnemonic PEDSS): Cervical position (3), which varies between women. As the anatomical location of the vagina is actually downward facing, anterior and posterior relatively describe the upper and lower borders of the vagina. The anterior position is better aligned with the uterus, so there is an increased likelihood of spontaneous delivery Cervical effacement (3) (aka cervical ripening), which is a measure of stretch/thinning present in the cervix, which can be expressed as a percentage. It is analogous to a stretched rubber band, which as stretched further, becomes thinner. This depends on individual variation, and previous surgery (e.g. loop excision). The cervix begins like a long bottleneck, about 4cm in length. Throughout pregnancy, the cervix is tightly closed and protected by a plug of mucus. When the cervix effaces, the mucus plug is loosened and passes out of the vagina. The mucus may be tinged with blood, and the passage of the mucus plug is called a bloody show. As effacement occurs, the cervix then shortens (effaces), pulling up into the uterus and becoming part of the lower uterine wall. Effacement can be measured in percentages, from 0% (not effaced at all) to 100% (paper thin cervix) Cervical dilation (3), which is a measure of the diameter of the stretched cervix. It complements effacement, and is the most important indicator of progressor through the 1st stage of labor. The opening of the cervix (i.e. entrance to the uterus) can occur [generally] due to childbirth, miscarriage, induced abortion, or gynecological surgery Latent phase (0-3cm): In the later stages of pregnancy, the cervix may already open up to 1-3cm [or even more, but rarely] Active labor (4-7cm): During labor, repeated uterine contractions leads to further widening of the cervix to about 6cm Transition (8-10cm): Pressure from the presenting part (head in vertex births, or bottom in breech births), along with uterine contractions will cause further dilitation to 10cm, which is "complete" [img]cervical-dilation-and-effacement.jpg[/img] Source: Blogspot [youtube]odS3heDlshA[/youtube] Cervical softness/consistency (3), which is primigravid women, the cervix is tyipcally tougher/resistant to stretching, akin to a balloon that hasn't been previously inflated. For subsequent vaginal deliveries, the cervix becomes less rigid, allowing for easier dilitation at term. In young women, the cervix is also more resilient than in older women Fetal station (3), which describes the position of the fetus' head in relation to the distance from the ischial spines, which can be palpated deep inside the posterior vagina (approximately 8-10cm) as a bony protrusion. It is measured from -5 (floating), 0 (fully engaged), to +5 (crowning). The "zero" is at the ischial spines, with negative numbers indicating above, and positive numbes indicating below. Full engagement (@ 0) is notable because the widest diameter of the head has passed below the pelvic inlet. Crowning (@ +5) is notable because the fetal head appears at the vaginal orifice [img]fetal-station.jpg[/img] Source: Sweet haven [faq]Cervical dilation and effacement, are they related? It's a little hard to understand all these numbers :S...!!! Think of it like playdough being smashed from above, from something tower-shaped, to something flat. The cervical dilation is the horizontal measure, so that increases. The effacement is the vertical measure, so that decreases. When that happens, we don't say that it increases however - we say that effacement increases, because it becomes "more thinner", which is a step forward rather than a step back! Why can you measure effacement as a number or percentage? You can either measure the vertical length, which should decrease. Or express it as a percentage. Some people prefer the percentage, because it seems like it's "progressing" from 0 to 100%. Whereas when the number decreases - and it does because it gets "shorter"... it seems like things are going backwards ;)[/faq] Interpretation The highest score is 13, with scores: >8, indicates labor will most likely commence spontaneously Thu, 21 Sep 2023 18:08:53 +0000 Pelvic exam Pelvic exam is a physical exam of the female pelvic organs. Method External examination, including: Examination and palpate the vulva, perianal area, vaginal canal, for erythema, swelling, excoriation, rash, lesions, masses, trauma Examine for any areas of discomfort, irritation, or pain Palpation of stomach area Internal examination, including: Formalities: Informed consent Allow Pt to get undressed behind a curtain Offer a chaperone Wash hands, and wear gloves Speculum exam, which involves: Warm the speculum with warm [but not hot] water, test temperature by touching it to her thigh, apply a water-based lubricant to the speculum, and insert the speculum at a slight downward angle. Do not use the rotation method. The speculum handle should be 2cm away, before opening the speculum blade, and locking it in place by turning the screw on the thumb piece At the center of the speculum window, should be the cervical os (aka external orifice of the uterus, i.e. a small, circular aperture on the rounded extremity of the vaginal portion of the cervix) Examination for foreign bodies Cervical swabs taken, including pap smear which is a swab of the epithelial layer of the cervix High vaginal swab (HVS, aka vaginal wet mount, vaginal smear), where a cotton-tipped swab is used to sample vaginal discharge in the fornix of the vagina (i.e. recesses in the vagina), or along the vaginal wall. It is then sent for culture and sensitivity: Placed on pH paper to determine vaginal pH, which should be 4 (yellow), but if more alkalotic (blue) may indicate infection Smear on to a glass slide, apply KOH and saline to opposite sides of the slide, and cover the slide with cover slips. This is then observed by wet mount microscopy. It is used to find the cause of vaginitis and vulvitis, including: Vaginal yeast infection (candidal vulvovaginitis) Bacterial vaginosis (BV) Trichomonas vaginalis (TV) Group B strep Endocervical culture (aka vaginal culture), where a cotton-tipped swab is positioned in the cervical os for 30 seconds, which is placed in the medium provided, and top is secured. It is then cultured to identify infection (including STI's) in the female genital tract, including: Chlamydia Gonorrhea Herpes simplex  Warn the Pt, unscrew, and unlock the speculum. As you are removing the speculum, slowly close the blades. The blader should be completely closed when exiting the introitus. Examine the walls of the vagina as you are retracting the speculum Bimanual exam, where 2 fingers (2nd and 3rd fingers of the dominant hand) are inserted into the vagina Palpate for the vagina, cervix, uterus, and adnexa. The abdominal hand should sweep the pelvic organs down, whilst the vaginal hand is simultaneously elevating them. Determine the size, shape, symmetry, mobility, position, and consistency of the uterus. Check the adnexal region for appropriately sized ovaries, about 2x3cm Test for cervical motion tenderness (aka cervical excitation, chandelier sign, i.e. pain being so excruciating upon bimanual pelvic exam, that it is as if the Pt reaches up to motion the grabbing of a ceiling-mounted chandelier), as seen in PID, ectopic pregnancy, and used to differentiate from appendicitis Rectovaginal exam, placing the index finger of the dominant hand into the vagina, and concurrently place the middle finger into the rectum. Apply pressure laterally and anteriorly to palpate structures. Use the other hand to apply downward pressure on the abdomen [youtube]CCHPclA9Vmk[/youtube] In obese Pt's, the cervix can be difficult to visualize due to excess vaginal wall tissue. Cut off the distal thumb tip of a large latex-free examination glove to create a sleeve, and place this around the speculum. As the speculum is opened in the vaginal canal, the excess vaginal tissue will be kept out of the speculum by the sleeve. Contraindications Consider anesthesia for: Physical or mental disability Abnormal anatomy Physical immaturity, with an intact hymen Issues The exam shouldn't be excessively uncomfortable, but: Women with vaginal infections may feel pain when the speculum is inserted Palpation of the ovaries during the bimanual exam may be mildly discomfort, or even painful The pap test may cause some cramping, or a small amount of bleeding Trainee doctors use to perform pelvic exams on unconscious women, about to undergo surgery for unrelated causes, and were rarely informed. This practice is now forbidden, and informed consent in advance is now required Epidemiology Pelvic exam for screening in asymptomatic, nonpregnant, adult women is controversial. Physicians (ACP) issued a guideline recommending AGAINST it because there is little benefit in support of the exam, but there is evidence of harm, including distress and unnecessary surgery. OBGYN's (ACOG) disagreed, whilst although acknowledging routine annual pelvic exam was unsupported by scientific evidence, it is supported by anecdotal clinical experience of gyencologists, permitting recognition of issues like incontinence and sexual dysfunction, and other Pt concerns See also Speculum (device used in the internal pelvic exam) Papsmear (often performed) Thu, 21 Sep 2023 16:06:03 +0000 Jugular venous pressure Jugular venous pressure (JVP) is the indirectly observed pressure, over the venous system, as observed over the internal jugular vein. JVPNE/JVPNR is shorthand for JVP not elevated/raised. [faq]What is JVP. And what do doctors mean when they say it's elevated? JVP refers to the venous pressure of the internal jugular vein. What is venous pressure, and what is the internal jugular vein? Venous pressure just means the pressure of a vein. Rather than... an artery ;)! So it's the blood pressure, particularly, at the internal jugular vein. That vessel colects blood from the brain. The key thing though, is that it drains down into the part of the heart that receives blood from the body, down the brachiocephalic vein, at the superior vena cava. This means that if the pressure in the right atrium (where blood enters the heart) is sufficiently high, it can flow back into the internal jugular, and be seen as a pulsation.[/faq] [img]internal-jugular-vein.png[/img] Source: Teach me anatomy Method Pt is positioned under 30 degrees Looking ALONG the surface of the sternocleidomastoid muscle, as it is more easier to appreciate the movement relative to the neck, when looking from the side (cf looking at the surface at a 90 degree angle): To determine the filling level of the external jugular vein. In healthy Pt's, the filling level of the JVP should be Thu, 21 Sep 2023 13:21:44 +0000 Immunization Immunization is the process by which a Pt's immune system becomes fortified against a perpetrating immunogen. IUTD is a Medical abbreviation for Immunizations Up To Date, and UTD is an abbreviation for Up To Date. [faq]What is immunization? It's where we protect a patient's immune system, against things that make antibodies. How does that differ from a vaccination? What is that? Vaccination is where we give antigenic material that has its infective component inactivated or decreased, to stimulate a patient's immune system to become immune against the pathogen. It is basically a less risky, or no risk version of the disease. So the difference is that immunization can also occur through getting the disease, which would not be the vaccine drug.[/faq] Schedule The immunization schedule lists the vaccinations that should be provided from birth to adulthood. Immunizations include: Age Disease Vaccine   CHILDHOOD VACCINES   Birth [[Hepatitis B]] (Hep B) H-B-vaxx 2   [[Vitamin K]] (Not really a vaccine) 6 weeks (aka 2 months) [[Diptheria]], [[tetanus]], [[pertussis]], [[Haemophilus influenzae type B]], hepatitis B, [[polio]] Infanrix hexa   [[Pneumococcal]] Prevenar 13   [[Rotavirus]] Rotarix 4 months Diphtheria, tetanus, pertussis, Haemophilus influenzae type B, hepatitis B, polio Infanrix hexa   Pneumococcal Prevenar 13   Rotavirus Rotarix 6 months Diphtheria, tetanus, pertussis, Haemophilus influenzae type B, hepatitis B, polio Infanrix hexa   Pneumococcal Prevenar 13 12 months Haemophilus influenzae type B, [[meningococcal C]] Menitorix   [[Measles]], [[mumps]] and [[rubella]] MMR 2 or Priorix 18 months Measles, mumps, rubella, [[varicella]] Priorix tetra or Proquad   Diphtheria, tetanus, pertussis Infanrix or Tripacel 4 years Diphtheria, tetanus, pertussis, polio Infanrix-IPV   ADOLESCENT VACCINES   12 years (year 7 school vaccination program) Diphtheria, tetanus, pertussis Boostrix   [[Human papillomavirus]] (3 doses) Gardasil   Varicella (catch up only) Varivax or Varilrix   ADULT VACCINES   65 years+ Influenza Influenza   Pneumococcal Pneumovax 23 70 years Shingles Zostavax   AT RISK GROUPS   6 months and over with medical risk conditions Aboriginal 6 months to Thu, 21 Sep 2023 02:42:22 +0000 Corticosteroid Corticosteroids are anti-inflammatory. Topical steroid is topical form of corticosteroid. Purpose Tx rash, eczema, dermatitis Tx asthma → reduce airway inflammation Antenatal corticosteroids → given to women expecting preterm delivery. It is used help the lungs of a premature fetus develop before the fetus comes out. It takes 1-2 days to work, and lasts 7 days. It has been shown to reduce RDS, and may reduce risk of IVH. It is useful even in PPROM. Examples include dexamethasone and betamethasone, with dexamethasone preferred because of better prophylaxis of brain softening  Classification Examples of Hydrocortisone types, which are short to medium acting glucocorticoids, include: Hydrocortisone (Cortisol) (i.e. produced by the adrenal cortex, in response to stress and hypoglycemia) when used as a medication. An example is Proctosedyl, which is topical, and combined with Cinchocaine hydrochloride Hydrocortisone acetate Cortisone acetate Tixocortol pivalate Prednisolone, including ​Prednisolone sodium phosphate oral liquid (Redipred) [img]prednisolone.jpg[/img] Source: Pharma Danica Methylprednisolone Prednisone [img]prednisone.jpg[/img] Source: Health Central Examples of Acetonides are: Triamcinolone acetonide Triamcinolone alcohol Mometasone, for example, mometasone furoate (Nasonex) Amcinonide Budesonide Desonide Flucinonide Fluocinolone acetonide Halcinonide Examples of Betamethasone types are: Betamethasone Betamethasone sodium phosphate Dexamethasone Dexamethasone sodium phosphate Fluocortolone [img]dexamethasone.jpg[/img] Source: Emessa Labs Examples of Halogenated (less labile) are: Hydrocortisone-17-valerate Halometasone Alclometasone dipropionate Betamethasone valerate Betamethasone dipropionate (Diprosone) Prednicarbate Clobetasone-17-butyrate Clobetasol-17-propionate Fluocortolone caproate Fluocortolone pivalate Fluprednidene acetate Examples of Labile prodrug esters, are: Hydrocortisone-17-butyrate Hydrocortisone-17-aceponate Hydrocortisone-17-buteprate Ciclesonide, e.g. Alvesco Prednicarbate Examples of inhaled steroids include: Fluticasone (Flixotide) [img]fluticasone.gif[/img] Source: Eye Care and Cure Side effects Neuropsychiatric, including: Steroid psychosis Anxiety Depression Steroid euphoria, which is a feeling of artificiaal wellbeing, in therapeutic doses. It is due to sensitzation of the body to the actions of adrenaline. It should be given in the morning to mimic the body's diurnal rhythm. If given at night, it can interfere w/ sleep Cardiovascular, including: Sodium retention through a direction action on the kidney, in a manner analogous to the mineralocorticoid aldosterone. This can cause fluid retention and HTN Metabolic, including: Moon face (movement of body fat to the face) and buffalo hump (movement of body fat to the torso), and away from the limbs Muscle wasting, due to diversion of amino-acid to glucose, thus considered anti-anabolic Endocrine, including: Opposes the action of insulin, by increasing the production fo gluclse from amino acid breakdown, causing hyperglycemia, insulin resistance, and diabetes mellitus Skeletal, including: Steroid-induced osteoporosis Decreased height, if inhaled corticosteroids are used in kids w/ asthma GI, including: Collitis, although corticosteroids is autoimmune if used therapeutically in UC and Crohn's Peptic ulceration, if taken for over 1 mo Eyes, including: Chronic use may predispose to cataract and retinopathy Vulnerability to infection, suppressing immune reactions (hence their use in allergies), steroids may cause infections to flare up, notably candidiasis Pregnancy, as corticosteroids have a low but significant teratogenic effect, causing a few defects per 1k pregnant women Tx. They are thus contraindicated in pregnancy Habituation, including: Topical steroid addiction (aka red skin syndrome, topical steroid withdrawal), reported in long term topical users, who apply it to their skin over a long period. This causes an uncontrollable, spreading dermatitis, and worsening skin inflammation requiring a stronger topical steroid to get the same result as the original prescription. If the drug is not applied, the skin experiences redness, burning, itching, hot skin, swelling, or oozing See also Fludrocortisone (synthetic mineralocorticoid) Cushing's syndrome Thu, 21 Sep 2023 17:42:29 +0000 Neurological examination Neurological examination is assessment of sensory and motor to determine whether the nervous system is impaired. Classification [[MMSE]] [[Cranial nerve exam]] [[Upper limb exam]] [[Lower limb exam]] Sensation Dermatome is an area of skin that is mainly supplied by a single spinal nerve. Each of these nerves relays sensation (including pain) from a particular region of skin to the brain. It includes: [img]dermatome.jpg[/img] 8 cervical nerves: C1, being an EXCEPTION w/ no dermatome C2 C3 C4 C5 C6 C7 C8 12 thoracic nerves: T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 5 lumbar nerves: L1 L2 L3 L4 L5 5 sacral nerves: S1 S2 S3 S4 and S5 Movement Myotome are groups of muscles that a single spinal nerve root innervates. It is the motor equivalent of a dermatome. It includes: [img]myotome.jpg[/img] 8 cranial nerves: C1 and C2, neck flexion/extension C3, neck lateral flexion C4, shoulder elevation C5, shoulder abduction C6, elbow flexion/wrist extension C7, elbow extension/wrist flexion C8, finger flexion 1 thoracic nerves: T1, finger abduction 4 lumbar nerves: L2, hip flexion L3, knee extension L4, ankle dorsi-flexion L5, great toe extension 4 sacral nerves: S1, ankle plantar-flexion/ankle eversion/hip extension S2, knee flexion S3 and S4, anal wink [youtube]7iULrrIV4-s[/youtube] Paperwork Paperwork for the Neurovascular chart (extremity check) includes: Affix Pt label Diagnosis: ___ Always compare with unaffected limb. Frequency of observation: hourly for first 24 hours, then ___ hourly Area of observation - please circle: Arm / Leg For the table, it is requested to Please mark with a dot, NOT a cross or tick. The table for its upper row indicates to write in Date and Time. Along the very LHS includes an indication (includes beautiful illustrations!) of the innervations of the various nerves, including the Median nerve, Radial nerve, ulnar nerve, Deep peroneal nerve, Tibial nerve; and the Motor function of various nerves, including the Peroneal nerve (Dorsiflexion of ankle), Tibial nerve (Plantar flexion of ankle and toe flexion), Median nerve (opposition of thumb and little finger, note if can flex wrist), Ulnar nerve (abduction of all fingers), Radial nerve (hyperextension of thumb and wrist). To the right are various categories including: Sensation, including Normal for R and L, Pins and needles for R and L, or Numb for R and L Movement, including Present (not to be checked post tendon repair) for R and L, or Absent for R and L Color, including Pink/Natural for R and L, Pale for R and L, or Mottled for R and L Temperature, including Warm for R and L, Cool/Cold for R and L, or Hot for R and L Capillary refill, including Under 2 sec for R and L, or Over 2 sec for R and L Swelling, including Nil for R and L, Slight for R and L, Moderate for R and L, or Severe for R and L Pulse (indicating Which pulse ___), including Present for R and L, or Absent for R and L Pain, including Score 0-10 for R and L, or Unrelieved with analgesia for R and L Wound, relating to Bleeding/Ooze, Yes for R and L, or No for R and L Authentication, with initials at the bottom column The reverse side is a repeat (dupe) See also [[Dermatome]] [[Myotome]] Thu, 21 Sep 2023 14:27:56 +0000 Measles Measles (aka morbilli, rubeola) is a highly contagious infection caused by the measles virus. [faq]What is measles? It's a very contagious infection. It's caused by the measles virus.[/faq] Sx Sx develop 10-12 days after exposure Initially: Fever (often >40 degrees C) Cough Runny nose Red eyes 2-3 days after Sx, Koplik's spots (small white spots inside the mouth) [img]koplik's-spots.jpg[/img] Source: ATSU 3-5 days after Sx, red flat rash which usually starts on the face and spreads to the rest of the body [img]measles-rash.jpg[/img] Source: ABC Sx will last 7-10 days [faq]What happens when you have a contagious infection by the measles virus? So there's a small period between exposure, and when you start getting stuff. Initially, it starts with virus type things, so fever, cough, runny nose, red eyes. A little bit later, you then get Koplik's spots, which are small white spots inside the mouth. You also get a measles rash, which is a flat red rash, which starts on the face and spreads to the rest of the body.[/faq] Pathophysiology Airbone disease which spreads easily through the coughs and sneezes of those infected, affecting 90% who aren't immune who share a living space with an infected person. Can also be spread through contact with saliva or nasal secretions Complications Occur in about 30%, and include: Diarrhea Blindness Inflammation of the brain Pneumonia [faq]What bad things can happen in a contagious infection by the measles virus? Diarrhea. Blindness. Inflammation of the brain. Lung infection.[/faq] Dx Testing for the virus in suspected cases, is important for public health efforts DDx Morbilliform rash is a rash that looks like measles. It consists of macular lesions that are red, and usually 2-10mm in diameter, but may be confluent. It suggests: Measles, of course [[Kawasaki disease]] [[Meningococcal]] petechiae [[Waterhouse-Friderichsen syndrome]] [[Dengue]] Congenital [[syphilis]] [[Rubella]] Echovirus 9 [[Drug hypersensitivity]] reactions, in particular with certain classes of antiretroviral drugs, e.g. abacavir and nevirapine, and also the AED phenytoin Tx Advise infectiousness, including from 4 days before to 4 days after the start of the rash Prevention, with measles vaccine. Vaccination has resulted in a 75% decrease in deaths. 85% of kids globally are currently vaccinated No specific Tx is available Supportive care may improve outcomes, including: Giving oral rehydration solution (slightly sweet and salty fluids) Healthy foods Medications to help with the fever If pneumonia occurs, antibiotics Vitamin A supplementation is also recommended in the developing world [faq]What can you do about a contagious infection by the measles virus? The best treatment is prevention, which can be done with the measles vaccine, which is usually given as the MMR vaccine, which combines both measles, mumps and rubella, into a 3-in-1. Buy 1 get 2 free ;). Alright, but anything you can do to FIX measles once you have it? Like the chicken pox, not really. So you can ensure bub is eating and drinking, and drugs can help with the fever. If there is a lung infection, antibiotics might help. In the developing world, vitamin A can also help, because it decreases the risk of blindness.[/faq] Prognosis Pt's usually only get the disease at most once Epidemiology Measles affects 20 million per year Measles primarily occurs in developing areas of Africa and Asia Causes the most vaccine-preventable deaths of any disease Measles results in 96k deaths per year Most of those infected and die, are Thu, 21 Sep 2023 05:24:23 +0000 Blood test Blood tests (aka hematological test) are Ix performed on a blood sample usually extracted from a vein in the arm via needle, or via fingerprink. Serum is another word for blood. Blood panels are groups of multiple tests for specific blood components, used to Dx particular diseases. Panels include: Source: Mater Pathology Full blood count (FBC) Total RBC's (Erythrocytes), which when low indicates iron-deficiency anemia Hemoglobin, which when low indicates anemia Hematocrit (Hct, aka Packed Cell Volume, PCV), is fraction of blood volume containing RBC's MCV (Mean corpuscular volume), is average volume of RBC's, which can further classify anemia as microcytic (X-small) or macrocytic (X-large) MCH (Mean corpuscular Hg), is average amount of Hg per RBC MCHC (Mean corpuscular Hg concentration), is average concentration of Hg in cells RDW (RBC distribution width), is variation in cellular volume of RBC's Total WBC's (Leukocytes, WCC), which "With Differential" will also include: Lymphocytes, is elevated in some viral infections (e.g. glandular fever), chronic lymphocitic leukemia. It can be decreased in HIV infection Monocytes, is elevated in bacterial infection, TB, malaria, chronic ulcerative colitis Granulocytes, including: Neutrophils (Neut, aka polymorphonuclear leukocyte, PMN), may indicate bacterial, or acute viral infection. Neutropenia is when neutrophils are raised Eosinophils, are elevated in asthma, allergic reaction, parasitic infections Basophils, are elevated in bone marrow related conditions (e.g. leukemia, lymphoma) Total Platelets (Plt, Thrombocytes), which may also include: Size and Range of sizes MPV (Mean platelet volume), is average size of platelets Blood (RBC, WBC) can also be detected for in urinalysis, which should be absent. [faq]Practically, which bottle do I use to pick up FBC? The lavender top one. Purple top. If we're just given 4 numbers representative of the FBC, what do they represent? Hemoglobin. Platelets. White blood cells. Neutrophils.[/faq] Interpretation   Male Female Hemoglobin (g/L) 135-180 115-160 WBC (*10^9/L) 4-11 " Platelets (*10^9/L) 150-400 " MCV (fL) 78-100 " PCV 0.4-0.52 0.37-0.47 RBC (*10^12/L) 4.5-6.5 3.8-5.8 MCH (pg) 27-32 " MCHC (g/L) 310-370 " RDW 11.5-15 " Neutrophils 2-7.5 " Lymphocytes 1-4.5 " Monocytes 0.2-0.8 " Eosinophils 0.04-0.4 " Basophils Wed, 20 Sep 2023 22:25:43 +0000 Leopold's maneuvers Leopold's maneuvers (aka fetal palpation) are 4 maneuvers used to palpate a fetus inside a pregnant woman, from her abdomen. FMF is shorthand for fetal movement felt. Purpose Determines position of the fetus Determines presentation of the fetus Assessment of the shape of the maternal pelvis can indicate whether delivery is going to be complicated, or whether C-section is necessary Also used to estimate term fetal weight Method Ensure that the woman has emptied her bladder → comfort Lie on her back with her shoulders raised slightly on a pillow, and knees drawn up a little. Abdomen uncovered 1st maneuver (Fundal palpation), using both hands to palpate the superior border of the fundus. Most pregnancies are longitudinal (99%), such that the head and buttocks are palpable at each end of the uterus. Fundal height can also be measured as the distance between the pubic symphysis and the superior border of the fundus, but should only be carried out after 20 weeks gestation 2nd maneuver (Lateral palpation), palpating the Pt's (R) side with your (L) hand, and the Pt's (L) side with your (R) hand Feel for the lie of the fetus if it didn't seem to be longitudinal. Transverse lie is if the fetus is felt at right angles to the axis of the uterus. Oblique lie is if the head or buttocks are palpable on either side of the iliac fossa Feel for the number of pregnancies Feel for the spine/back of fetus, to determine fetal lie. It is the side the uterus feels "full", because although it isn't possible to feel fetal parts directly, as it is an irregularly shaped mass suspended in a bag of water, the "full" side corresponds to the back of the fetus due to increased resistance Feel and estimate the amount of liquor, where if there is an excessive amount lf fluid, the uterus will be tense, and it will be quite difficult to feel for fetal parts 3rd/4th maneuver (Presentation palpation), using either: Pelvic palpation, where both hands palpate the lower segment of the pelvis by pressing firmly on either side of the midline just above the pubic symphysis. Facing the end of the bed, use your (L) hand on the Pt's (L) side, and your (R) hand on the Pt's (R) side Pawlick's grip, where using the thumb and index finger of the (R) hand, firmly grip the presenting fetal part between the fingers. NB: this may cause pain and discomfort Palpating presentation assumes fetal lie is longitudinal, but can be breech or cephalic. In cephalic presentation, you can ballot the head by moving the head slightly from side to side. The head is usually quite firm compared to breech. Breech is harder to feel and cannot be balloted Feel for engagement of the fetal head, dividing the fetal head into 1/5ths. If only 2/5ths of the head is palpable in the abdomen, this indicates the head is engaged into the pelvis (i.e. the widest diameter has descended into the pelvis) Source: Fast bleep Complications Can be uncomfortable for women if care is not taken to ensure she is relaxed, and adequately positioned Epidemiology It is difficult to perform the maneuvers on: Obese women Women with polyhydramnios It is named after the gyencologist Christian Gerhard Leopold See also Fetal U/S (another method to determine position) Wed, 20 Sep 2023 10:30:47 +0000 Kidney function test Kidney function tests are tests which help check the kidneys are working properly. Physiology Kidney is a bean shaped organs located at the rear of the abdominal cavity (retroperitoneum). It receives blood from the paired renal arteries, and drains into the paired renal veins. The kidneys excrete urine into its respective paired ureter, into the urinary bladder. It functions to: Natural filter of blood, removing water soluble wastes (e.g. urea, ammonium) which become urine Regulating electrolytes, reabsorbing water, glucose and amino acids Maintaining acid-base balance Regulating blood pressure (via salt and water balance) Produce hormones, including calcitriol, erythropoietin, and renin Classification UEC (Urea, electrolytes, creatinine, aka Basic metabolic panel) is a set of blood tests, providing information regarding kidney function. It involves: Electrolytes, which are acids/bases/salts that ionize in water. Phosphate sandoz are effervescent tablets that provide sodium and phosphate. These can additionally be tested in urine. The common electrolytes tested include: Sodium (Na+), normally 135-145mmol/L Chloride (Cl-), normally 95-105mmol/L Potassium (K+), normally 3.5-5mmol/L Total calcium (Ca2+), normally 2.1-2.5mmol/L Ionized calcium, 1.1-1.3mmol/L Magnesium (Mg2+), 0.7-0.95mmol/L Bicarbonate (HCO3-) Phosphate (HPO42-), 0.8-1.5mmol/L Inorganic phosphate, 1.3-1.5mmol/L BUN ([Blood] urea [nitrogen]), as liver produces urea as a waste product of digesting protein, and is excreted by the kidney Creatinine (Cr), a breakdown product of (creatinine phosphate in) muscle, which is usually produced at a fairly constant rate by the body. Creatinine is supposed to be excreted by the kidney. Do not mix creatinine with creatine. Low creatinine can be seen in conditions that result in decreased muscle mass BUN-to-creatinine ratio (aka urea-to-creatinine ratio) is the ratio of BUN and creatinine, both per blood. Both BUN and creatinine are freely excreted by the glomerulus, however, urea is REABSORBED by the tubules [whereas creatinine isn't]. The ratio can be: High, indicating prerenal problem, as urea reabsorption is increased, disproportionately to creatinine, thus indicating dehydration or hypoperfusion (e.g. bleeding) Normal, meaning postrenal problem, as urea reabsorption is within normal limits Low, indicating intrarenal problem, as renal damage causes REDUCED absorption of urea, thus lowering the urea:creatinine ratio Glucose [faq]What is BUN? It assess urea. Urea as in urine? Sort of. Urea is found in urine. It's a waste product that is excreted by the kidney. So if you're not getting rid of it, then kidney isn't working properly. How about creatinine, what's that? It's a breakdown product of muscle. The kidney also excretes that, so if you're not getting rid of it, then the kidney also isn't working properly. Practically, how do you collect UEC's? The bottle with the orange top. Sometimes, UEC's are given as 4 representative numbers. What are they? Sodium. Potassium. BUN. Creatinine.[/faq] Other tests for kidney function include: GFR (glomerular filtration rate), which describes the flow rate of filtered fluid through the kidney. eGFR should normally be 90-120mL/min. Thu, 21 Sep 2023 11:25:24 +0000 Beta agonist Beta2-adrenergic agonists are drugs that act on the beta2-adrenergic receptor. [faq]What are beta agonists? It's a drug that acts on a receptor, that is usually activated by adrenaline. It does things like relax smooth muscles, and dilate the bronchi and bronchioles, which we call bronchodilation.[/faq] Classification SABA (Short-acting beta2-adrenergic receptor agonist) is used in the Tx of asthma and COPD. Rescue/emergency inhalers are SABA's. Examples include: Salbutamol/albuterol (Ventolin), which is to be stretched as deemed appropriate by respiratory assessment, but by no more than 1 hourly intervals at a time (e.g. 1->2 hours, 2->3 hours, 3->4 hours), except where stretch is denied by a consultant [img]ventolin.jpg[/img] Source: Dokter Online Levosalbutamol/levalbuterol (Xopenex) Terbutaline (Bricanyl) Pirbuterol (Maxair) Procaterol Clenbuterol Metaproterenol (Alupent) Fenoterol Bitolterol mesylate Ritodrine Isoprenaline Source: Children's Hospital Westmead LABA (Long-acting beta2-adrenergic receptor agonist) is used in the Tx of asthma and COPD. Examples include: Salmeterol (Serevent diskus) [img]serevent.jpg[/img] Source: Dokter Online   Fluticasone/salmeterol (Seretide) [img]seretide.png[/img] Source: Formoterol (Foradil) Budesonide/formoterol (Symbicort, Pulmicort) Bambuterol Clenbuterol Olodaterol (Striverdi) Vilanterol Indacaterol (Onbrez) [faq]What different sorts of drugs are there to act on beta receptors that are usually activated by adrenaline? There are short acting, and long acting. When you say short vs long, what do you mean? We mean 4-6 hours, as supposed to 12 hours. So the long acting ones lasts 2-3 times as long, therefore only requiring a puff twice a day, rather than every few hours for the short acting ones. Already, I'm ready for the sales pitch. Hit me with the common brand names? So under SABA's, there's salbutamol (brand name Ventolin). Under LABA's, there's salmeterol, which can be combined with fluticasone (brand name Seretide). Symbicort is another combination, of budesonide and formoterol.[/faq] Side effects Especially in parental administration, e.g. inhalation or injection: Tachycardia, secondary to peripheral vasodilation and cardiac stimulation. It can be accompanied by palpitations Tremor Excessive sweating Anxiety Insomnia Agitation More severe effects are exceptional, including: Pulmonary edema Myocardial ischemia Cardiac arrhythmia Asthma aggravation, in patients using large doses of beta2 agonists, but it is not known if it results from the spontaneous course of the disease, or adverse effects of the drugs. The excipients, particularly sulfite, could contribute to the adverse effects [faq]What bad things can happen because of beta agonists? Why do we wean patients from beta agonists when they're in hospital? Given that beta agonists work on the receptor activated by adrenaline, we'd expect a fight or flight response. So if this is overly crazy, it's things like fast heart rate, tremor, excessive sweating, anxiety, inability to sleep, agitation. It can also make asthma worse, we don't know why that happens, because, as we know, it's meant to HELP it, not make things worse![/faq] Thu, 21 Sep 2023 12:27:46 +0000 Maternal nutrition Maternal nutrition is nutrient intake and dietary planning undertaken before, during and after pregnancy. Physiology Fetal nutrition begins at conception, thus the nutrition of the mother is important from before conception [probably several months before], as well as throughout pregnancy, and breast feeding Nutrients can either be inadequate or excessive. It is possible to over-supplement Development of the baby can be affected in the early stages of pregnancy It involves: Smoking Alcohol Caffeine Use of prescribed drugs Use of illicit drugs Effects Folic acid, as folic acid is required for the development of every human cell. Deficiency thus causes defective cellular growth, and effects are most obvious on tissue which grows most rapidly. It can cause: Spina bifida Neural tube defects Iodine deficiency, can cause cretinism. It is required for normal thyroid function and mental development of the fetus Vitamin D deficiency, can cause rickets (i.e. disease causing weak bones) Higher intakes of polyunsaturated fatty acids have shown to decrease preterm delivery and low birth weight Iron is needed for healthy growth of the fetus and placenta, especially during trimester 2-3. It is essential before pregnancy for the production of hemoglobin Excess vitamin A (retinol) intake, which has been linked to birth defects and abnormalities Excessive alcohol causes FAS Low birth weight Malformations Neurological disorders Handicaps Affects risk throughout the child's life, for: Cancer CVD HTN Diabetes Tx Diets should provide sufficient calories for pregnancy, typically 2,000-2,5000 calories Mothers should follow instructions listed on particular vitamin packaging as to the correct/recommended daily intake (RDI) and maximal allowances if listed Prenatal vitamins contain levels of the following, found over the amounts in standard multivitamins: Folic acid supplementation, is recommended prior to conception, 0.4mg/day throughout trimester 1, 0.6mg/day through trimester 2-3, and 0.5mg/day whilst breast feeding. This is in addition to eating foods rich in folic acid (e.g. oranges, dark green leafy vegetables) Iodine supplementation, as iodine is frequently too low in pregnant women Vitamin D supplementation, which varies with exposure to sunlight. Although it was previously only supplemented in areas of high latitudes, there is a move to recommend supplementation of 1,000mg of vitamin D daily throughout pregnancy Polyunsaturated fatty acids, specifically DHA (docosahexaenoic acid) and EPA (eicosapentaenoic acid), which is very beneficial for fetal development. The best dietary source of omega-3 fatty acids is oily fish. Other omega-3 fatty acids not found in fish, can be found in flaxseeds, walnuts, pumpkin seeds, and enriched eggs Iron, where although there is no evidence hemoglobin>7g/100mL is detrimental to pregnancy, maternal hemorrhage is a major source of maternal mortality worldwide, and a reserve capacity to carry oxygen is desirable. Giving 100mg of elemental iron 3 times weekly is adequate during pregnancy. After pregnancy, if serum ferritin Thu, 21 Sep 2023 01:20:59 +0000 Tachycardia Tachycardia (from Greek "tachy" meaning "rapid", and "kardia" meaning "heart", aka tachyarrhythmia) is HR>normal resting rate. [faq]What is tachycardia? It's a fast heart rate.[/faq] Dx Dependent on age, including: 159bpm 166bpm 182bpm 179bpm 186bpm 169bpm 151bpm 137bpm 133bpm 130bpm 119bpm In >15yo (adults), HR>100bpm Also depends on the clinical picture, e.g. in sepsis >90bpm is considered tachycardia [faq]What does it mean that your heart rate is fast? That the beat is going at faster than 100 beats a minute, but that's just adults. What about kids then? When is heart rate fast? Within the 1st year, your heart rate is super high, as in it is normal, to have a heart rate of up to 160-190bpm. This then decreases gradually down to when you're 15 when you're considered an adult, back down to a threshold of 100bpm. So it can be almost double the rate (specifically, 60-90% the amount) of an adult, and still be normal in kids, especially those 150bpm. It can cause heart rates between 50-250bpm, but when new onset tends to be between 100-150bpm Atrial flutter ​AV nodal reentrant tachycardia Accessory pathway mediated tachycardia Atrial tachycardia Multifocal atrial tachycardia Junctional tachycardia Wide complex, which tend to originate in the ventricles: Ventricular tachycardia, any tachycardia that originates in the ventricles. It is potentially life threatening. It is a rate between 120-250bpm. It normally lasts only for a few seconds to minutes, but if persistent can lead to ventricular fibrillation Supraventricular tachycardia with aberrancy, which is any narrow complex tachycardia combined with a problem with the conduction system of the heart Supraventricular tachycardia with pre-excitation, which is a narrow complex tachycardia with an accessory conduction pathway, e.g. Wolff-Parkinson-White syndrome Pacemaker-tracked or pacemaker-mediated tachycardia Tachycardia can be further classified as regular or irregular. Mx Depends on type (wide complex vs narrow complex), whether the Pt is stable/unstable (i.e. whether other important organ functions are affected, or cardiac arrest is about to occur), whether the instability is due to the tachycardia, but includes: Cardioversion IV adenosine, in Pt's who are unstable w/ a narrow complex tachycardia Complications Ischemia → heart beats excessively/rapidly, heart pumps less efficiently, and provides less blood flow to the rest of the body, including the heart itself. It also leads to increased work and oxygen demand by the heart, which can cause rate-related ischemia See also [[Bradycardia]] (antonym) [[Tachypnea]] (fast breathing) Thu, 21 Sep 2023 00:21:52 +0000 Heart attack Heart attack (aka myocardial infarction) is where blood [and thus oxygen] flow stops to a part of the heart, and heart muscle becomes damaged. [faq]What is a myocardial infarction, and how does it relate to a heart attack? They mean the same thing. Infarct means tissue dies because it's blood's supply is interrupted. Myocardium is the muscle tissue of the heart, that contracts to push blood out of the heart. So MI=heart attack. So what does heart attack exactly mean? Death of heart muscle, because it's blood supply is interrupted.[/faq] Pathophysiology Causes include: Complete blockage of a coronary artery caused by a rupture of an atherosclerotic plaque, most commonly Coronary artery spasm, which may be due to cocaine, significant emotional stress (Takotsubo cardiomyopathy), extreme cold Sx Sx of acute MI includes: Sudden chest pain or discomfort, felt behind the sternum or L of the chest, and sometimes travels to the LHS arm, LHS neck, shoulder, back or jaw. It lasts for more than few minutes. The discomfort may occasionally feel like heartburn. NB: Up to 64% of Pt's, especially women, do NOT experience chest pain, and is known as silent MI SOB Diaphoresis (cold sweat) Nausea, vomiting Palpitations Anxiety Weakness, fatigue (feeling tired) Presyncope (feeling faint) [faq]What happens in a heart attack? Sudden chest pain, which is felt behind the breastbone where the heart is. It sometimes travel to the left arm or neck. You also feel short of breath.[/faq] Risk factors For CAD and MI: Previous cardiovascular disease Old age Tobacco smoking Hyperlipidemia Diabetes HTN Lack of physical activity, obesity Chronic kidney disease Poor diet Excessive alcohol consumption Use of cocaine and amphetamines Family Hx of cardiovascular disease More common in men [faq]What makes it more likely for you to get a heart attack? If you've got other heart problems. Old age. Smoking. Lots of fat in your blood. Diabetes. High blood pressure. Being overweight. Not exercising. Problems with your kidney. Excessive alcohol intake. Use of recreational drugs. Other people in your family with heart problems. Being male.[/faq] Classification According to thickness: Transmural AMI (full thickness), is associated w/ atherosclerosis involving a MAJOR coronarya artery. It extends through the whole thickness of the heart muscle, and are usually a result of COMPLETE occlusion of the area's blood supply. It is evidenced on ECG by ST elevation, and Q waves. It includes: Anterior Posterior Inferior Lateral Septal Subendocardial AMI (partial thickness), involving a small area in the subendocardial wall of the L ventricle, ventricular septum, or papillary muscles. The subendocardial area is particularly susceptible to ischemia. It is evidenced on ECG by ST depression, and T wave changes According to the appearance of an ECG: For STEMI (ST elevation MI, i.e. where the ST traces higher than baseline) (30%), which presents with ST elevation, pathological Q waves, is a transmural infarction (i.e. full thickness of heart muscle), resulting in complete occlusion of the area's blood supply. It is associated with CAD For non-STEMI (non-ST elevation MI) (25%), which presents with ST depression, is a subendocardial MI [faq]What are the types of myocardium death? STEMI, and non-STEMI. STEMI means that on the ECG, there is ST elevation, and pathological Q waves. And non-STEMI where there isn't ST elevation, but rather, depression. What's this ST elevation or depression about? What is ST? ST should be flat. ST is the point between depolarization (QRS wave) and repolarization (T-wave) of the ventricles. So it should be flat. But if heart muscle is damaged, it's contractile and electrical properties change. This causes early repolarization, prematurely ending the pumping of the ventricle, called systole. Early repolarization explains why the full-thickness ST elevation happens. But why does ST depression happen? Where the the death of heart muscle is not full thickness, there is an elevated resting potential in heart cells. That makes the ST look like it's going down.[/faq] Dx For CAD and MI: For CAD only (and not suspected MI), cardiac stress testing ECG's, looking for: ST elevation (STEMI), which usually requires more aggresive Tx Pathological Q waves ST depression, in non-STEMI, alternatively [img]st-elevation-and-depression.jpg[/img] Source: Blogspot Blood tests, for cardiac markers, including: Troponin Creatinine kinase (CK-MB), which has since been largely replaced by troponin Coronary angiography, which is an x-ray with radiocontrast, in the coronary arteries [faq]How do you confirm a heart attack? Using an ECG, to see if there are any changes indicating heart damage. If there's nothing that can be seen, the patient can be challenged to exercise, whilst an ECG is being performed, to see if anything happens under exertion. You can also do an x-ray whilst contrast is being used to outline the arteries supplying the heart. Any blood tests you can do? Yeah, troponin and creatinine kinase. Troponin is released by heart muscle into blood, when it is damaged. Creatinine kinase is also released by heart muscles into blood, when it is damaged, although troponin is a better measure for this.[/faq] Tx For CAD and MI: For pain: GTN (nitroglycerin) Opioids Oxygen, in patients with low oxygen levels or SOB In STEMI, restoring blood flow to the heart, using: Reperfusion therapy (i.e. restoring circulation to the heart), using angioplasty (aka percutaneous coronary intervention, i.e. arteries are pushed open) Thrombolysis (i.e. blockage removed using medications) In non-STEMI, using: Heparin (blood thinner) Angioplasty, in those at high risk CABG (coronary artery bypass surgery), for Pt's with MULTIPLE blockages of the coronary arteries, particularly if they also have diabetes Address risk factors, after the MI, with: Lifestyle modification (healthy diet) Aspirin, preventing further blood clots, including in a suspected MI Address diabetes Address hypercholesterolemia, with statins Address HTN, with beta blockers [faq]What can be done about a heart attack? Thrombolysis drugs, can be used to remove blockages. Because heart muscle is damaged, an antiplatelet like aspirin can be given to prevent blood clots. GTN can also be given, which produces nitric oxide, which enlarges the blood vessels. The only problem with GTN is it can only be used in the short term, as it will result in tolerance after 2-3 weeks of use. You can also do things like address risk factors, including a healthy diet, address diabetes, high cholesterol, and high blood pressure. Any surgery you can do? Angioplasty, and CABG. Angioplasty is where a balloon is used to widen narrowed or obstructed arteries. CABG is where a vessel is used to divert blood flow away from an obstructed artery supplying the heart.[/faq] For Prinzmetal angina: Atropine [faq]Anything you can do for chest pain caused by spasm in the arteries supplying the heart? Atropine. It's an anticholinergic, so it inhibits the parasympathetics. This therefore causes dilation of the blood vessels.[/faq] Complications Acute complications, include: Heart failure, if the damaged heart is no longer able to pump blood adequately around the body Cardiac arrest Aneurysm of the LV myocardium Ventricular septal rupture, or free wall rupture Mitral regurgitation, in particular if the infarction causes dysfunction of the papillary muscle Dressler's syndrome Abnormal heart rhythms, e.g. ventricular fibrillation Ventricular tachycardia Atrial fibrillation Heart block Long term complications, including: Heart failure Atrial fibrillation Increased risk of a second MI [faq]What can death of heart muscle cause? The failure of the heart to work.[/faq] Epidemiology Worldwide >3m people have STEMI's, and 4m have NSTEMI's STEMI occurs about twice as often in men as women In the developed world, the risk of death in those who have STEMI is about 10% Rates of MI for any given age have decreased globally between 1990 and 2010 Leading cause of death in the world In those >75yo, 5% have had an MI with little or no Hx of Sx See also Acute coronary syndrome (category) Unstable angina (cardiac markers are negative, cf positive cardiac markers in MI) Coronary artery disease/ischemic heart disease CABG (Tx) Angioplasty (Tx) Wed, 20 Sep 2023 17:42:03 +0000 Angiography Angiography (from Greek "angio" meaning "vessel", and "graphy" meaning "to write") is medical imaging to visualize the lumen (inside) of blood vessels and organs of the body, with particular interest in the arteries, veins and heart chambers. Angiogram (aka angiograph) is the film/image of the blood vessel. Angiogram is usually used synonymously with arteriogram, and the word venogram used more precisely. [faq]What is angiography? It's where you make an image of the inside of a blood vessel.[/faq] Method Injecting a radio-opaque contrast agent into the blood vessel and imaging using x-ray based techniques (e.g. fluoroscopy) Depending on the type of angiogram, access to the blood vessels is gained most commonly through the: Femoral artery, to look at the L side of the heart and at the arterial system Jugular or femoral vein, to look at the R side of the heart and the venous system Using a system of guide wires and catheters, a type of contrast agent (which shows up by absorbing the x-rays), is added to the blood to make it visible on the x-ray images X-ray images taken may either be still images displayed on an image intensifier or film, or as a movie (motion images) Digital subtraction angiography (DSA) is the technique used to take for all structures except the heart, which involves taking 2-3 frames per second, allowing the radiologist to evaluate the flow of the blood through vessel(s). This technique "subtracts" the bones and other organs so only the vessels filled with contrast agent can be seen Because DSA requires the Pt to remain motionless, it can't be used for the heart. Heart images are taken at 15-30 frames per second, not using a subtraction technique The techniques can allow a cardiologist to see stenosis (blockages/narrowings) inside the vessel, which may inhibit the flow of blood, and cause pain [faq]How do you take pictures of the inside of a blood vessel, when it's inside your body? Do you use an x-ray? X-ray doesn't show soft tissue very well. So we need to pump contrast into the blood system, to help highlight the blood vessels.[/faq] Classification Coronary angiography, one of the most common angiograms, performed to visualize the blood in the coronary arteries. A catheter (long, thin, flexible tube) is used to administer the x-ray contrast agent at the desired area to be visualized. The catheter is threateded into an artery in the forearm, and the tip is advanced through the arterial system into the major coronary artery. X-ray images of the transient radiocontrast distribution within the blood flowing inside the coronary arteries allowing visualization of the size of the artery openings. Presence/absence of atherosclerosis or atheroma within the walls of the arteries can NOT be clearly determined. CT is better than MRI to detect coronary artery disease, with both sensitivity/sepcificty, cheaper, and shorter breath-hold time Microaniography, used to visualize tiny blood vessels Neurovascular [digital subtraction] angiography, used to visualize the arterial and venous supply to the brain. Intervention work e.g. coil-embolization of aneurysms and AVM gluing can also be performed. This includes imaging of the Circle of Willis (aka cerebral arterial circle), which can be imaged together with the arch of aorta [img]arch-cow.png[/img] Source: Class Connection Peripheral angiography, done routinely through the femoral artery, but can also be performed through the brachial or axillary/arm artery. Any stenosis found may also be Tx using atherectomy. Peripheral angiography is performed to identify: Vessel stenosis (narrowing) in Pt's w/ leg claudication or cramps, caused by reduced blood flow down the legs and to the feet Pt's w/ renal stenosis, which commonly causes HTN Used in the head to find and repair stroke Post-mortem CTA for medicolegal cases Cholangiography, which is imaging of the bile duct (aka biliary tree) by x-rays. In both cases, fluorescent fluids are used to create contrasts that make the Dx possible. It has replaced the previously used method of intravenous cholangiography. It includes: Percutaneous transhepatic cholangiography (PTC), examination of liver and bile ducts by x-rays. This is done by insertion of a thin needle into the liver carrying a contrast medium to help see a blockage in the liver and bile ducts Endoscopic retrograde cholangiopancreatography (ERCP), although this is a form of imaging, it is both Dx and Tx, and often classified with surgeries rather than imaging Although the term is strictly defined as based on projectional radiography (i.e. based on x-rays), it has been applied to newer vascular imaging techniques (e.g. CT angiography and MR angiography) Isotope angiography, more correctly refers to an isotope perfusion scan Complications Risk of heart attack is actually narrowed down, as heart strength doubles after an angiogram surgery. A sudden shock can cause little pain at the surgery area, but heart attacks and strokes usually don't occur, like in bypass surgery Complications of cerebral angiography (e.g. digital subtraction angiography, or contrast MRI) include: Bleeding or bruising at the site where the contrast is injected Stroke Allergic reaction to the anesthetic or contrast medium Blockage or damage to one of the access veins in the leg Thrombosis and embolism formation Delayed bleeding See also X-ray CT Wed, 20 Sep 2023 14:04:01 +0000 Oxygen therapy Oxygen therapy is the administration of O2 as an intervention, and can be used either in chronic or acute Pt care. [faq]What is oxygen therapy? It's where we give oxygen as an intervention. It can be given in the long term, or in the short term.[/faq] Physiology Oxygen is essential for cell metabolism, and thus tissue oxygenation is essential for normal physiological function However, high blood/tissue levels of O2 can be damaging (not only helpful), depending on circumstances The purpose of O2 therapy is to increase the supply of O2 to the lungs, and thus increasing the availability of O2 to the body tissues, especially when the Pt is suffering from hypoxia and/or hypxemia Method Sources of oxygen include: Liquid oxygen, stored in chilled tanks until required, and then allowed to boil at -183 degrees C, to release oxygen as a gas. This is widely used at hospitals due to their high usage requirements Compressed gas storage, where oxygen gas is compressed in a gas cylinder, providing convenient storage, without the requirement for refrigeration found w/ liquid storage Instant usage, involving use of an electrically powered oxygen concentrator, which can create sufficient oxygen for a Pt to use immediately. Their advantage is continuous supply w/o the need for deliveries of bulky cylinders Oxygen passes through a pressure regulator, which controls the high pressure of oxygen delivered from a cylinder to a lower pressure. This lower pressure is controlled by a flowmeter, which is controlled by liters per minute, ranging from 0-15 Delivery of oxygen, can include, noting FiO2 (fraction of inspired oxygen) is the fraction/percentage f oxygen in the space being measured. We try to keep FiO2 Thu, 21 Sep 2023 17:38:02 +0000 Surgery ​Surgery are techniques involving manual and instruments. Purposes Investigation Treatment of diseases (or injuries) To improve bodily function For appearance Remove unwanted areas (e.g. perforated ear drum) Pre-operative preparation Nothing by mouth (NBM, aka Nil by mouth, Nil per os, NPO) is instruction to withhold oral food and fluids, with the exception of very small drink of water to take with their usual medication. Otherwise, if the Pt accidentally ingests food or water, the surgery would usually be cancelled, or postponed for at least 8 hours. It is used to: Prevent aspiration pneumonia (due to general anesthetic, or weak swallowing musculature) GI bleeding, GI blockage Acute pancreatitis Alcohol overdose that results in vomiting, or severe external bleeding Peri-operative preparation Scrubbing in is the preparation done before surgery. Remember at ALL times to keep hands higher than elbows at all times. The 1st scrub continues for 5 minutes, followed by 3 minutes subsequently: First 2 minutes, only required for the 1st scrub (1st minute): Dispose of nail cleaner Clean fingernails under running water Brush fingers, hands, and forearms, to 2.5cm ABOVE the elbows, paying particular attention to finger surfaces, webbing of the fingers, palms, sides, back/front of hands Brush nails Remove dirt from under finger nails Apply cleanser to fingernails Discard fingernail cleanser into sharps, and nail brush into the bin Open brush packet and rest near tap Minutes 3-5, or as soon as nails are done: Apply cleanser to foam hands, and with rotating movements cleansing the forearms in ONE direction only Wash and rinse hands and forearms thoroughly And, repeat once Source: QLD Health Classification By urgency/timing, including: Elective surgery, done to correct a non-life threatening condition, carried out at the Pt's request, subject to the surgeon's/facility's availability Emergency surgery, which must be done promptly to save life, limb, or functional capacity Semi-elective surgery, which must be done to avoid permanent disability/death, but can be postponed for a short time By purpose, including: Exploratory surgery, performed to aid/confirm a Dx Therapeutic surgery, to Tx a previously Dx condition By type of procedure, including: Amputation, involves cutting off a body part, usually a limb or digit Resection, is removal of all or part of an internal organ, or part of the body Replantation, involves reattaching a severed body part Excision (-ectomy), which involves cutting out an organ, tissue, or other body part from the Pt Reconstructive surgery (-oplasty), involves reconstruction of an injured, mutilated, or deformed part of the body Cosmetic surgery (-oplasty), done to improve thea pearance of an otherwise normal structure Transplant, which is the replacement of an organ or body part by insertion of another from a different human (or even animal) into the Pt By body part, including: Cardiac surgery, performed on the heart GI surgery, performed on the GI tract Orthopedic surgery, performed on bones/muscles By degree of invasiveness, including: Minimally-invasive surgery (-oscopy), involving small incisions to insert miniaturized instruments within a body cavity or structure Open surgery (-otomy), involving a large surgical incision to access the area of interest By equipment used, including: Laser surgery, involving use of a laser for cutting tissue instead of a scalpel Microsurgery, involving use of an operating microscope to see small structures Robotic surgery, using a surgical robot Techniques Minimally invasive procedures Forming a stoma (i.e. permanent or semi-permanent opening, -ostomy) Repair of damaged or congenital abnormal structures (-rraphy) Instruments Suction, used to vacuum debris and fluid Complications Perioperative mortality, which is defined as death within 2 weeks of a surgical procedure. Intraoperative complications, include: Complications during surgery, e.g. bleeding or perforation of organs may have lethal sequelae Mistakes (fracture, perforation, sexual dysfunction, artery/nerve injury, incision hernia) Allergies Postoperative complications, including: Chronic pain Recurrence Thrombosis/hemorrhage/DVT/shock Systemic Sx (fatigue) Muscle atrophy Anesthetic side effects (sore throat, sleepiness, confusion/delirium, spinal cord injury) Infection Postoperative fever Disordered wound healing See also Postoperative fever Delirium Postoperative oliguria Thu, 21 Sep 2023 11:18:56 +0000 Pelvic organ prolapse Pelvic organ prolapse (aka vaginal prolapse, female genital prolapse) is where a portion of the vaginal canal protrudes/prolapses from the opening of the vagina. [faq]What is pelvic organ prolapse? It's where something usually found inside the body, pokes out of the vagina.[/faq] Pathophysiology Pelvic floor collapses as a result of childbirth or heavy lifting, which can tear soft tissue, that is, herniating fascia membranes so that the vaginal wall collapses, resulting in cystocele, rectocele, or both [faq]Why does pelvic organ prolapse occur? It's usually as a result of childbirth. Especially in women who've had multiple births, or large children. It can also happen in heavy lifting. What happens is that it damages wall-like structures that divide organs from one another, causing things to poke out. It's a bit like when you stretch dough for your pizza too much, you start getting a hole in the middle.[/faq] Classification Pelvic organ prolapse can be graded according to Shaw's system, including: Vaginal vault prolapse, which may occur after a hysterectomy, as there is no uterus supporting the interior end of the vagina Anterior wall: Lower 1/3: Urethrocele (urethra into vagina), where there is weakening of the tissues that hold the urethra in place, leading to descent of the anterior distal wall of the vagina Upper 2/3: Cystocele (bladder into vagina), where the tough fibrous wall between a woman's bladder and vagina, the pubocervical fascia, is torn by childbirth, allowing the bladder to herniate into the vagina. It often occurs with urethroceles, known as cystourethrocele Posterior wall: Lower 1/3: Deficient perenium (i.e. wall between the vagina and anus) Middle 1/3: Rectocele (rectum into vagina), caused by a tear in the rectovaginal septum (i.e. tough fibrous divider between the rectum and vagina), causing rectal tissue to bulge through this tear into the vagina as a herniation. It is caused by childbirth or hysterectomy Upper 1/3: Enterocele (small intestine into vagina), which may also obstruct the rectum, causing obstructed defecation Uterine prolapse (uterus into vagina): Grade 0: Normal position Grade 1: Descent into vagina not reaching introitus (aka vaginal orifice, i.e. just behind the opening of the urethra) Grade 2: Descent up to the introitus Grade 3: Descent outside the introitus Grade 4: Procidentia (i.e. prolapse so severe the uterus is permanently protruding out of the vagina) [img]pelvic-organs-that-can-prolapse.jpg[/img] Source: ACOG [faq]There are so many words here. Urethrocele. Cystocele. Rectocele. Enterocele. Uterine prolapse. Procidentia. What's what? The ending "-cele" means a "hernia". Hernia is anything that pokes out of where it shouldn't. As seen on the picture, on the front wall, the lower "urethra" can pull down - that's called a urethrocele. The higher "bladder" can also pull down - that's called a cystocele. On the back wall, the lower "rectum" can pull down - that's called a rectocele. The higher "small intestine" can pull down - that's called an enterocele. Uterine prolapse is where the middle "uterus" falls down. And procidentia is where the uterus prolapses so much it is permanently sticking out of the vagina, so it gets it's own special name ;).[/faq] Other types include: Vaginal vault prolapse (roof of vagina), after hysterectomy (i.e. removal of the uterus), causing the roof of the vagina to fall down Tx Conservative: Dietary and lifestyle changes, fitness Physiotherapy, Kegel/pelvic floor exercises Pessary, which is a device inserted into the vagina to provide structural support. Types include: Ring pessary, used for grade 1-2 uterovaginal prolapses. It is the most common and easiest to use Hodge pessary, for less severe cystoceles in women with a narrow pubic arch Gehrung pessary, for cystoceles and rectoceles Cube pessary, used for grade 3+ uterovaginal prolapse. It has no drainage and thus has to be removed nightly Donut pessary, also used for grade 3+ uterovaginal prolapse. Compared with a ring pessary, it remains in place by having a larger diameter. To reach this diameter, it can be inflatable Gellhorn pessary,  also used in grade 3+ uterovaginal prolapse, with decreased perineal support. It remains in place by fitting against the cervix or vaginal cuff, and avoiding having to rely on tissue further down the tract Surgery, which is used to Tx Sx such as bowel or urinary problems, pain, or prolapse sensation It includes lifting the internal contents back internally, followed by: Transvaginal surgical mesh, in the from of a patch or sling, similar to its use for abdominal hernia Colpocleisis, which is closure of the vagina Hysterectomy (i.e. surgical removal of the uterus) Laparoscopic hysteropexy Sacrohysteropexy, a mesh-augmented procedure where the apex of the vagina is attached to the sacrum by a piece of mesh, thereby resuspending the prolapsed uterus to lift it and hold into place. It allows for normal sexual function and preserves childbearing function Manchester operation (aka Fothergill operation), which reduces the cystourethrocele, and repositions the uterus within the pelvis [faq]What can you do about it? Abdominal pressure puts pressure on things falling down, so we want to address that with lifestyle changes, to address things like weight loss. We can also try to improve muscle strength, because muscle is tough. It's strong. And it can help keep things in place. If that doesn't work, we use a pessary, which is a device inserted into the vagina to keep things from falling out. Essentially, it's a bit like a cap, physically blocking things from falling through. Another option is surgery, we can use a surgical mesh to keep things in place that way too. In postmenopausal women, they usually aren't concerned with sex anymore, so we can also permanently close the vagina.[/faq] Epidemiology Occurs in 9.3% of all females See also Urinary incontinence (can be caused by pelvic organ prolapse) Wed, 20 Sep 2023 17:29:35 +0000 Health care Health care is the Dx, Tx, and prevention of disease (also illness, injury, and other physical and mental impairments). Classification Primary care, who act as first point of consultation for all Pt's within the health care system. This can be a: GP Dentist Allied health, including: Physiotherapist (PT) Speech pathologist Dietitian Optometrist Pharmacist Psychologist Occupational therapist (OT), which uses purposeful activities or interventions designed to achieve improved function Social worker (SW) Chaplains, who are ministers (pastor, priest, rabbi, imam, or lay representative) of a religious tradition, attached to a secular institution (hospital, prison, military unit, school, police department, university, private chapel). Clinical pastoral education is the training that chaplains undertake Self care Secondary care, which is the provision of services by specialists that don't have first contact with patients, including: Cardiologists Urologists Dermatologists Tertiary care, which is specialized care, usually for inpatients on referral from a primary or secondary provider. It has personnel and facilities for advanced medical Ix and Tx, such as tertiary referral hospitals. OPD stands for outpatient department. Services include: Nursing staff Allied health staff Cancer Mx Surgeons Neurologists Cardiologists Oncologist Midwifery Palliative Home and community care, which is health care delivered outside of health facilities. This includes: Interventions of public health interest, such as food safety surveillance, obesity prevention, distribution of condoms and needle-exchange programs for prevention of STD's Professional services in residential and community settings, to support home living, aged care, Tx substance use disorders. NH is shorthand for nursing home Birthing centers, staffed by nurses, midwives, and assisted by doulas. It presents a more home-like environment than a labor ward, with more options including food/drink, music, and attendance of family/friends if desired. There may be non-institutional furniture such as queen-sized beds, and birthing tubs/showers for water births. Should additional assistance be required, the mother can be transferred to a hospital Community rehabilitation services, to assist with mobility and independence after loss of limbs Public health, which includes: Health promotion, which is the development of healthy public policy to address prerequisites of health (income, housing, food security, employment, quality working conditions) Notifiable diseases Screening, which is used to identify unrecognized disease in Pt's without Sx. It is thus unique as it is an Ix done in apparently well Pt's. Screening is designed to enable early intervention, to reduce mortality and suffering. Although screening may lead to earlier Dx, it is not always beneficial, and can result in overdiagnosis, misdiagnosis, and false sense of security. Tests must therefore have good sensitivity and acceptable specificity, particularly for diseases with low incidence. Types include: Universal screening, which involves screening of all people in a certain category (e.g. kids of a certain age) Case finding, which is screening a smaller group of people on the presence of risk factors (e.g. family member Dx with hereditary disease) Paperwork Paperwork for "Pediatric dietitian referral" includes: ID information, including Pt name, Date of birth, MRN (Medical record number) (if applicable), Parent/carer name, Phone, Address Current weight Current height Relevant medical Hx Reason for referral, including tick boxes for Malnutrition/growth faltering, Confirmed food allergy (please provide copy of test results), Food intolerance, Enteral feeding, Organ complication requiring therapeutic diet, Vitamin/mineral deficiency (please provide copy of blood results), Diabetes, Fussy eating, Obesity Detailed reason for referral Name of referrer Phone Address Signature Date Please fax referral to Nutrition department on ___ or post to Nutrition Dept ___ Hospital See also [[Determinants of health]] [[Preventative medicine]] Thu, 21 Sep 2023 10:35:29 +0000 Pregnancy Pregnancy (or gestation) is the development of [one or more] embryo (first 8 weeks following fertilization) and later fetus (9th week afer fertilzation) in a woman's uterus. Gest is shorthand for Gestation. Gravid means pregnant. Classification Pregnancy is divided into 3 trimesters [of 3 months, or 12 weeks each]. This includes: Trimester 1 (week 1-12): carries the highest risk of miscarriage Trimester 2 (week 13-27): can be easier to monitor and diagnose. The point of fetal viability (i.e. fetus can survive outside the uterus) coincides with the late 2nd or early 3rd trimester [although birth constitutes high risk for having medical conditions and dying] Trimester 3 (week 28-birth): marked by further growth of the fetus and development of fetal fat stores Sx Sx typically appear within the first few weeks after conception Missed menstrual period Nausea and vomiting Excessive tiredness and fatigue Carvings for certain foods that aren't normally sought out Frequent urination, particularly during the night Physiology Embryogenesis is the development of the embryo. Once a sperm fertilizes an egg, a zygote cell results, posessing half the DNA of its 2 parents Amniotic fluid is the protective liquid contained by the amniotic sac, helping to cushion against blows to the mother's abdomen, for fetal movement, and promoting musculoskeletal development. The fluid originates from the maternal plasma through fetal membranes. Although amniotic fluid is originally mainly water with electrolytes, by 12-14th week, also contains proteins, carbohydrates, lipid, phospholipids, and urea, which all aid the growth of the fetus. The volume of amniotic fluid is correlated with the growth of the fetus. The volume slightly decreases when the fetus begins to breathe and swallow, and plateaus at 28 weeks gestation. The fetus inhales and exhales amniotic fluid, which also creates urine and forms meconium (i.e. pre-stool). Water breaking is when the amnion ruptures Dx Sx Pregnancy test Test of progesterone levels can also help determine how likely a fetus will survive in a threatened miscarriage (i.e. bleeding in early pregnancy) Obstetric U/S, can detect: See gestational sac, as early as 4.5 weeks gestation, and the yolk sac about 5 weeks gestation. Embryo can be observed and measured by 5.5 weeks. Heartbeat can be seen as early as 6 weeks, and usually visible by 7 weeks gestation Some congenital diseases at an early stage Estimate the due date Detect multiple pregnancy Risk factors Maternal: Rh negative status → check BGA, and do anti D at 28 and 34 weeks GBS positive status Advanced maternal age → screen for birth defects Maternal alcohol Maternal smoking → counselling Maternal obesity Maternal hypertension Maternal proteinuria/pre-eclampsia → regular BP, urinalysis Poor maternal nutrition Non-immune to rubella → postnatal MMR Maternal exposure to chickenpox Hepatitis B infection Hepatitis C infection → do hep C RNA/LFT's, avoid invasive procedures HIV/AIDS infection Maternal diabetes Iron deficiency anemia Vaginal bleeding (threatened miscarriage, APH) Maternal depression Toxins, including tobacco smoke, mercury, lead, dioxin, air pollution, pesticides Drugs (see pregnancy category) PMH of: Multiparity Low birth weight C section → consider VBAC, but note risk of uterine rupture Postnatal depression PPH FH of: Diabetes Fetal: LGA, per fundal height SGA, per fundal height → serial growth scans, to monitor growth Complications Maternal: Perineal tearing Hyperemesis gravidarum Pelvic girdle pain HTN DVT Anemia Infection Incontinence Postpartum depression PTSD Fetal: Ectopic pregnancy Placental abruption Multiple pregnancies Vertically transmitted infection Prognosis Pregnancies in teenagers are at greater risk of poor outcomes Epidemiology The prevalence of denial of pregnancy (i.e. refusal to acknolwedge pregnancy) is 1 in 475 women at 20 weeks, and 1 in 2500 women at delivery. In contrast, women can also have false pregnancy (i.e. non-pregnant women with strong belief they are pregnant with some physical changes) See also [[Menstruation]] [[Childbirth]] [[Gravidity and parity]] (medical notation) [[Water breaking]] [[Preterm birth]] [[Pregnancy test]] [[Maternal death]] [[Pregnancy category]] (drugs) [[Gestational age]] Wed, 20 Sep 2023 10:28:34 +0000 Fluid thrill test Fluid thrill test is a test for ascites. Pt pushes their hands down on the midline of the abdomen. Examiner taps one flank, while feeling the other flank for the tap. Pressure on the midline prevents vibrations through the abdominal wall, whilst the fluid allows the tap to be felt on the other side. The test is less sensitive than shifting dullness, and is only positive in massive ascites. Wed, 20 Sep 2023 14:56:12 +0000 Abdominal examination Abdominal examination assesses the abdomen. Method Ensure stomach has adequate exposure Nails: Leukonychia, of hypoalbuminemia of liver disease Koilonychia, of iron deficiency anemia Clubbing, via Schamroth’s window test, of liver disease Palm: Palmar erythema, of liver disease Palmar crease pallor, of anemia Dupuytren’s contracture, of alcoholism Liver flap, of hepatic encephalopathy Wrist: Elevated pulse, of sepsis Arm: Track marks, of IV drug usage In the eye: Arcus senilis, a white/gray/blue ring encircling the iris, of hypercholesterolemia Kayser-Fleischer rings, dark rings encircling the iris, of Wilson's disease Jaundice, yellowish coloration of the sclera, of hyperbilirubinemia, of liver disease. Yellow discoloration of skin that doesn’t include the sclera could be due to carotenemia (i.e. a harmless condition, due to excessive intake of carrots) Conjunctival pallor, of anemia Xanthelasma, of hypercholesterolemia In the mouth: Buccal mucosa ulcers, of Crohn's disease Red and fat tongue, of anemia In the neck: Lymphadenopathy, asking the patient to clench teeth, and feel- Supraclavicular lymph nodes, which drains the thoracic duct, which drains the entire abdomen and the left thorax General inspection, including observing for: Conscious level, of hepatic encephalopathy Hydration, weight, and other nutritional information Spider nevi, especially >5, of hyperestrogenemia, of liver disease Gynecomastia, of hyperestrogenemia, of liver disease Abdomen, including- Inspection: Request patient to breath in and out, and cough, to look for hernia No abdominal distension, of the 6 F’s– fat, feces, fetus, flatulence, fluid (ascites), a filthy big tumor Auscultation: Done first because of the impact of subsequent tests on auscultation Of all 9 quadrants, including growling sounds (of bowel obstruction), absence of sounds (of peritonitis) [img]9-abdominal-regions.jpg[/img] Source: Healthfixit RLQ is an abbreviation of Right Lower Quadrant. RUQ is an abbreviation of Right Upper Quadrant Palpation, asking first about pain, which should be last to be touched or guarding may make the examination difficult: First lighter palpation (singer hand), then deeper (double hand), in all 9 areas, starting from lower RHS, moving in clockwise direction, and then central. Looking at the Pt's face, but examining for: Tenderness Rebound tenderness (tender when pressure is removed, of peritonitis) Guarding (of inflammed organs) Organ palpation, for organomegaly, including of the: Usually hidden: Liver (from lower RHS to upper RHS, underneath the RHS costal margin; on in-breath) Spleen (from lower RHS to upper LHS, underneath the LHS costal margin; on in-breath) Ever present: Kidneys (putting hand on top down, and flapping other hand up) Can also palpate the abdominal aorta for expansion, of aneurysm Percussion, from resonant to dull, starting from the stomach and moving upwards. Percuss hard for deeper structures, to soft for superficial structures. Percuss ribs between ribs. And testing for ascites, including: Shifting dullness, testing for ascites. Starting at umbilicus, percussing down. Then, turn the patient around to the side just percussed down, and see if the same region (that was dull) is now resonant. If it is, there is ascites Or alternative test, fluid test, which involves putting their hands together in clap position, down tummy line. One side is hit, and the other side felt (simultaneously) for fluid To complete the exam: Examination of genitalia Rectal examination Urinalysis A picture of an elongated hexaogan represents an abdomen, no scribbles on it indicates no abnormally large organs, no surgical scars and no masses felt. See also [[Tenderness]] [[Bowel movement]] Wed, 20 Sep 2023 22:01:53 +0000 CTG CTG (cardiotocography, from "cardio" meaning "heartbeat", "toco" meaning "uterine contractions", and "graphy" meaning "recording") is recording of the fetal heartbeat and uterine contractions during pregnancy, typically only in the 3rd trimester. The machine used to perform the monitoring is called an electronic fetal monitor (EFM, aka cardiotocograph). Classification Non-invasive monitoring (aka CTG), involving 2 transducers placed on the mother's abdomen, one above the fetal heart [to measure the fetal HR], and the other at the fundus [to measure contractions] Invasive fetal monitoring (aka fetal scalp monitor), involving a wired scalp/spiral electrode attached to the fetal scalp through the cervical opening [and thus vagina]. It is more accurate since movement doesn't affect it Interpretation Mnemonic Dr C Bravado: DR: Define risk C: Contractions, which is the number of contractions in any 10 minute window. Each big square is 1 minute, and the 10 minute marks may be outlined too. Both the duration and intensity of contractions cannot be assessed for from the CTG, but only by palpation BRa: Baseline rate, which is the average HR of the fetus in a 10 minute window (do not use a wider window), ignoring any accelerations or deceleration, and should be between 110-160bpm. Bradycardia is 160bpm V: Variability, which is the variation of the baseline fetal HR in any 10-minute window, excluding accelerations and decelerations. It is reassuring if >5bpm, non-reassuring if 15bpm for >15 seconds. The presence of accelerations is reassuring, and there should be at least 2 accelerations every 15 mins, especially if they occur alongside uterine contractions. The absence of accelerations however, in an otherwise normal CTG is indeterminate D: Decelerations (aka depressions), which are abrupt decreases in the baseline HR of >15bpm for >15 seconds. There are various types of decelerations. Be careful not to mistake the mother's HR for a deceleration; if this occurs, a fetal scalp monitor may be required. Types of decelerations include: Early deceleration, is a gradual deceleration of FHR associated with a uterine contraction. The trough from the deceleration occurs at the same time as the peak of the contraction. This means that the deceleration recovers at the same time, and therefore DUE TO the contraction. These decelerations occur due to increased fetal ICP caused by compression of the head by uterine contractions. It therefore quickly resolves once the contraction ends, and ICP reduces. It is therefore physiological Variable deceleration, is a sudden decrease in FHR, taking 2 minutes. It is non-reassuring if >2 minutes, and abnormal if >3 minutes. The deceleration however, is Wed, 20 Sep 2023 17:30:12 +0000 Murmur Murmur is an auscultatable sound caused by turbulent flow of blood, caused by stenosis (i.e. restriction of heart valve opening) or regurgitation (i.e. allowing backflow of blood through an incompetent valve that incompletely closses). This can occur within or outside the heart. Murmurs can be physiological (benign) or pathological (abnormal). HS is shorthand for heart sounds. HSDNM is shorthand for Heart sounds dual, no murmurs. 0m or 0 murmurs (with the 0 superscripted) is shorthand for no murmurs. Classification Systolic murmurs, which occur after S1. As the S/L valves are open, and the A/V valves are closed, it can be caused by: S/L stenosis, including: Aortic valve stenosis Pulmonary valve stenosis A/V regurgitation, including: Tricuspid valve regurgitation ​​Mitral valve regurgitation Diastolic murmurs, which occur after S2. As the A/V valves are open, and the S/L valves are closed, it can be caused by: A/V stenosis, including: Tricuspid valve stenosis Mitral valve stenosis S/L regurgitation, including: Aortic valve regurgitation Pulmonary valve regurgitation, which is a diastolic decrescendo murmur best heard at the left lower sternal border Continuous murmurs The region where a heart murmur can be best heard roughly reflects a specific part of the heart, including: Aortic region, at the RHS 2nd intercostal space parasternal Pulmonic region, at the LHS 2nd intercostal space parasternal Tricuspid region, at the LHS 4/5th intercostal space parasternal Mitral region (aka apex), at the LHS 5th intercostal space mid-clavicular. It is known as the "apex" as it correlates with the apex of the heart [img]heart-valve-locations.jpg[/img] Source: Pinimg Murmurs will radiate generally in the direction of blood flow. See also [[Heart sounds]] [[Aortic stenosis]] (most common) [[Mitral regurgitation]] (most common) Thu, 21 Sep 2023 14:27:59 +0000 Observation chart Observation chart (obs chart) is a chart used to quickly determine the degree of illness of a Pt. Being between the flags (aka early warning score, EWS) means that the observations are within an appropriate range. Method It is derived from: 4 vital signs (aka vitals), which are physiological readings assessing general physical health of a Pt, giving clues to possible diseases, and show progress towards recovery. The SPOC chart is drawn in the order of ABCDE, as you go from the LHS to RHS. Normal ranges vary with age, weight, gender, and overall help. These include: Systolic BP [or even, BP generally] HR [which can be measured by pulse] RR Body temperature 1 observation: LOC, via AVPU Interpretation Notice anything outside the flags, i.e. in the yellow or red zones. Rapid response should be initiated as soon as any of the obs enters the red zone Trend in obs Altered calling criteria Check for patients in a high risk group, e.g. 38.5 degrees C; BGL 2-3 mmol/; concern by you or any staff or family member Consider if your Pt's deterioration could be due to sepsis, dehydration/hypovolemia/hemorrhage, or an overdose/over sedation Red zone response: If your Pt has any red zone observations or addtional criteria# you MUST call for a rapid response (as per local CERS) AND, (1) Initiate appropriate clinical care; (2) Inform the NURSE IN CHARGE that you have called for a Rapid Response; 93) Repeat and increase the frequency of observations, as indicated by your Pt's condition: (4) Document an A-G assessment, reason for escalation, Tx and outcome in your Pt's health care record; (5) Inform the Attending Medical Officer that a call was made as soon as it is practicable. #Additional Red zone criteria are, especially highlighted, Cardiac or respiratory arrest; Circulatory collapse; Pt unresponsive; New onset of stridor. Also includes Deterioration not reversed within 1 hour of Clinical review; 3 or more simultaneous "Yellow Zone" observations; Significant bleeding; Sudden decrease in Level of Consciousness (a drop of 2 or more points on the GCS); New or prolonged seizure activity; BGL =4 mmol/L; serious concern by you or any staff or family member See also Medical record (category) Thu, 21 Sep 2023 07:44:14 +0000 Abdominal pain Abdominal pain (aka stomach pain) is pain in the abdomen. SNT is shorthand for soft non-tender. By frequency Undetermined cause (30%) Gastroenteritis (13%) Irritable bowel syndrome (IBS) (8%) Urinary tract problems (5%) Gastritis (inflammation of the stomach) (5%) Constipation (5%) Gallbladder or pancreas problems (4%) Diverticulitis (3%) Appendicitis (2%) Cancer (1%) More common in the elderly, include: Mesenteric ischemia AAA (abdominal aorta aneurysms) [faq]What are the most common causes of tummy pain? So usually we don't know. Infection of the tummy and intestines. An irritable tummy system. Urinary tract problems, don't forget, because it's not necessarily the tummy system. Constipation is a biggy, particularly in kids. It can be the gallbladder, which stores bile, or the pancreas, which makes digestive enzymes. It can be inflammation of a diverticulum, which is an outpouching foudn in the large intestine. Appendicitis, which is inflammation of the appendix, which extends from the cecum, found just after ileocecal junction (i.e. junction of the ileum and cecum). It can be cancer. In the elderly, we also need to consider injury of the small intestine due to insufficient blood supply, or enlargement of the lower part of the major aorta artery.[/faq] By organ GI GI tract, including: Inflammatory: gastroenteritis, appendicitis, gastritis, esophagitis, diverticulitis, Crohn's disease, ulcerative colitis, microscopic colitis Obstruction: hernia, intussusception, volvulus, post-surgical adhesions, tumors, superior mesenteric artery syndrome, severe constipation, hemorrhoids Vascular: embolism, thrombosis, hemorrhage, sickle cell disease, abdominal angina, blood vessel compression (e.g. celiac artery compression syndrome), postural orthostatic tachycardia syndrome Digestive: peptic ulcer, lactose intolerance, celiac disease, food allergies Glands: Bile system: Inflammatory: cholecystitis, cholangitis Obstruction: cholelithiasis, tumors Liver: Inflammatory hepatitis, liver abscess Pancreatic: Inflammatory: pancreatitis Renal and urological: Inflammation: pyelonephritis, bladder infection Obstruction: kidney stones, urolithiasis, urinary retention, tumors Vascular: L renal vein entrapment Gynecological or obstetric: Inflammatory: PID (pelvic inflammatory disease) Mechanical: ovarian torsion Endocrinological: menstruation, Mittelschmerz Tumors: endometriosis, fibroids, ovarian cyst, ovarian cancer Pregnancy: ruptured ectopic pregnancy, threatened abortion Abdominal wall: Muscle strain or trauma Muscular infection Neurogenic pain: herpes zoster, radiculitis in Lyme disease, abdominal cutaneous nerve entrapment syndrome (ACNES), tabes dorsalis Referred pain: From the thorax: pneumonia, pulmonary embolism, ischemic heart disease, pericarditis From the spine: radiculitis From the genitals: testicular torsion Metabolic disturbance: Uremia, diabetic ketoacidosis, porphyria, C1-esterase inhibitor deficiency, adrenal insufficiency, lead poisoning, black widow spider bite, narcotic withdrawal Blood vessels: Aortic dissection, AAA (abdominal aortic aneurysm) Immune system: Sarcoidosis Vasculitis Familial Mediterranean fever Idiopathic: Irritable bowel syndrome, affecting up to 20% of the population, IBS is the most common cause of recurrent, intermittent abdominal pain [faq]What can cause pain in the tummy? The most obvious one, is something relating to your eating system, which also includes your liver, which helps clean blood, and also makes bile. The pancreas, which makes digestive enzymes. And the bile system, which transports and stores bile. It can also be your kidneys, although they're a little off to the sides. Women's reproductive system, don't forget. Musculoskeletal type pain. The aorta blood vessel, which is also found in the region. It can also be referred from a further distance, like the chest, the spine, or testicles.[/faq] By location [img]abdominal-organs.jpg[/img] Source: Wikimedia Upper RHS (hypochondric), can be: Liver: hepatomegaly, caused by fatty liver, hepatitis, liver cancer, abscess Gallbladder and biliary tract: gallstones, inflammation Colon: bowel obstruction, colon cancer Upper middle (epigastric), can be: Stomach: gastritis, stomach ulcer, stomach cancer Pancreas: pancreatitis, pancreatic cancer, which can radiate to the LHS Duodenum: duodenal ulcer, diverticulitis Appendix: appendicitis, which migrates to the lower RHS Upper LHS (hypochondric), can be: Spleen: splenomegaly Pancreas Colon: bowel obstruction, colon cancer Middle (umbilical; or if towards the sides, lumbar; or if lower, hypogastric), can be: Appendix: appendicitis Small intestine: inflammation Lower RHS (iliac), can be: Cecum: intussusception, bowel obstruction Appendix: appendicitis Lower middle: Diarrhea Colitis Dysentery Lower LHS (iliac), can be: Sigmoid colon: polyps, volvulus, obstruction Pelvic pain: Bladder: cystitis (may be secondary to diverticulum), bladder stone, bladder cancer Pain in women: uterus, ovaries, fallopian tubes Lower back pain: Kidney pain: kidney stone, kidney cancer, hydronephrosis Ureteral stone pain R lower back pain: Liver pain (hepatomegaly) R kidney pain L lower back pain: Less in spleen pain L kidney pain [faq]You can also classify a tummy ache, based on location? Yep, so we like to divide the tummy into 9 areas, using lines drawn like noughts and crosses. On the upper RHS, there's the liver, gallbladder which stores bile, and the bile system. In the middle upper, there's the tummy, the pancreas which lies behind the tummy, the duodenum which is the 1st part of the small intestine. The upper LHS, where there is the spleen, just to the right of the tummy and liver. The pancreas, as it lies behind the tummy, also extends to the RHS. In the middle at the belly button, there's the small intestine, it's a bit like a swirl so the small intestine is central, and the large intestine is towards the outer edges. The lower RHS has the appendix and the cecum, which is the 1st part of the large intestine. The lower middle is the large intestine, so it can be diarrhea, or inflammation of the large intestine. The lower LHS is the sigmoid part of the large intestine, which is the S shaped part that is found just before the rectum. That's quite a big mouthful. But there's also a few other side locations? Yep, so pelvic pain, can be the bladder, or women's reproductive tract. There's also lower back pain, it can be a urinary tract stone, or kidney pain, which can also be towards the side. If it's towards the right back, it can be the liver, or if in the left back it can be the spleen, although recall that it's found at the front on the upper RHS.[/faq] Acute abdomen Acute abdomen is sudden, severe abdominal pain of unclear etiology, Wed, 20 Sep 2023 15:46:42 +0000 Preterm birth Preterm birth (aka premmies) is where a baby is born 34-36 weeks gestation. The cause of preterm birth is often unknown, but there are risk factors associated. TPL is short term for threatened preterm labor. Sx Uterine contractions, which occur more often than every 10 mins Leaking of fluid from the vagina [faq]How do you know a preterm birth is happening? When childbirth starts, at or before 36 weeks. How do you know chidlbirth is starting? Uterine contractions more often than every 10 minutes indicates labor has started. Alternatively, there may be rupture of membranes, which causes a gush of fluid to come out from the vagina. What is the membranes? It's the amniotic sac that cushions and surrounds bub.[/faq]​ Pathophysiology After the 42nd week of gestation, the placenta, which supplies the baby with nutrients and oxygen from the mother, starts aging and will eventually fail Cause Cause unknown Artificial induction for medical reasons for early delivery, including preeclampsia [faq]Why would a baby pop out at or before 36 weeks? There might be a medical reason, such as impending seizure, which we call preeclampsia. We don't really know why it happens naturally, but there are risk factors we've identified.[/faq] Risk factors Diabetes Hypertension Being pregnant with more than one baby Being either obese or underweight Number of vaginal infections Tobacco smoking Psychological stress [faq]What are these risk factors for bub coming out at or before 36 weeks? High blood glucose, which we call diabetes. High blood pressure. Having twins, triplets, and so forth. Being overweight or underweight. Vaginal infection. Smoking. Just being stressed out.[/faq] Classification Preterm, is 34-36 weeks. These weeks must be completed, so if it is 36 weeks+6 days, it is technically still late preterm Prematurity (aka premature birth), is Thu, 21 Sep 2023 15:00:15 +0000 Respiratory examination Respiratory exam is performed as part of a physical exam. AE is shorthand for Air entry, referring to the intensity of breath sounds. A drawing of lungs with arrows through them, indicates there is nothing abnormal to find on auscultation of the chest. Pediatric source: OSCE stop Indications Respiratory Sx, including: SOB/dyspnea Cough Chest pain Hx that suggests pathology of the lung Very rarely performed in it's entirity Usually merged w/ the cardiac exam to cover DDx's, thus rarely performed in isolation [faq]When do you want to assess the breathing system? So when there's some sort of breathing symptom, like finding it difficult to breathe, coughing, or chest pain. If we find some previous problem with the lung. We rarely do the whole exam, because it takes so long ;) And we usually merge it with the heart exam, to exclude certain alternatives we may be thinking.[/faq] Method Fingers: Clubbing via Schamroth's window test, of interstitial lung disease Tar staining, of smoking Resistance test, of weakness and wasting. This involves asking the patient to move their fingers against your fingers, or towards your fingers Palms Peripheral cyanosis, of hypoxia Hands Flapping tremor, of carbon dioxide narcosis, asking patient to "put hands up, like a policeman doing a stop sign" Wrist Pulse, including for the regularly irregular pulse of pulsus paradoxus Subliminally counting for extreme respiratory rate, for of bradypnea and tachypnea Head Ptosis eyelids of Horner's syndrome, of apical lung cancer Central cyanosis, of hypoxia, asking patient to raise tongue to roof of mouth Neck Tracheal deviation, of deviation towards fibrosis, or deviation away from pleural effusion or pneumothorax. Note to patient this might feel a bit uncomfortable Lymphadenopathy, starting to palpate at the top of the jaw line, moving towards and down the neck, to the supraclavicular area. Comment on having felt for postauricular nodes, submandibular nodes, cervivical nodes, and supraclavicular nodes, and that no lymphadenopathy could be felt [faq]So the exam of the breathing system, we start with the hands? Yep, so we look for clubbing, which can be seen in various diseases including interstitial lung disease. Tar staining, for smoking. Resistance test, for weakness and wasting. We move up to the palms, to look for blueness, of low oxygen. Moving up again, to the hands, to see if there's a flapping tremor, of carbon dioxide poisoning. Wrist, for pulse, including regularity, subliminally counting very slow or fast breathing rates. Next to head? Yep. So looking for drooping eyelids of Horner's syndrome, which we see in apical lung cancer. Central blueness, of low oxygen. We then move down to the trachea, to see if it's deviate, which it does TOWARDS dead tissue called fibrosis, or AWAY from air or fluid, such as a pleural effusion or pneumothorax. And lymph nodes, starting from behind the knees to above the clavicles.[/faq] Chest, starting from anterior, then posterior (remember "IPPA"): Inspection, asking patient to breathe out and in: No evidence of breathlessness of COPD No obvious wheeze of asthma, or stridor of inhaled objects No obvious chest deformities or scars Not evidently using his accessory muscles to breathe Palpation: Displaced apex beat, of moving towards the area of lung collapse (only on front) Chest expansion, such as hyperexpansion of chest in COPD, by placing the thumbs together, and asking the patient to breathe out and in, and ensuring the fingers sufficiently move away from each other Vocal fremitus, of pleural effusion, which is a palpable vibration on the body, found by asking the patient to repeat "999" (a low frequency vocalization), and feeling the patient's chest. It is indicative of friction Percussion: Percussion for the hyperresonance of pneumothorax, or the hyporesonance of consolidation, from top to bottom, on one side, then the other side, starting supraclavicular and going downwards (3x sets) (When doing the back, you must remember to ask patient to hug themselves, so you don't percuss their clavicle) Ask patient to lift arm up, then percuss the two sides of the body (once on either side) Auscultation: Listening for asymmetric and abnormal breath sounds of wheeze of asthma, stridor of inhaled objects, or crackles of pulmonary edema, asking patient to breathe normally, again starting supraclavicular, on either side, then going downwards (3x sets). Also doing the sides Vocal resonance, of pleural effusion. It is again starting supraclavicular, on either side, 3 sets, but asking the patient to repeat "999" each time the stethescope is on the chest (only on back) For completion: Sputum pot Bed side peak flow Obs chart, paying particular attention to the temperature and oxygen sats [faq]So now we go to the meaty part, the chest exam. How do we do that, and how do we memorize what we do? So the mnemonic is IPPA, so inspection, palpation, percussion and auscultation. So we look for breathing type things, like breathlessness, wheeze, stridor, chest deformities, scars, use of accessory muscles. We feel for a displaced apex beat, which shifts towrds an area of lung collapse. We test for chesst expansion, specifically, when it super expands, in COPD. And vocal fremitus, where we can feel for a vibration when the patient talks, indicating friction. We then tap for a super loud sound when there's air in the lung called pneumothorax, or a super dull sound when there's water in the lung called consolidation. We then listen for asymmetric breath sounds, and abnormal breath sounds like wheeze of asthma, stridor of inhaled objects, or crackles of lung edema. And the listening version of vocal fremitus, called vocal resonance. That's it? So to finish off we might want to take a look at the sputum pot. Have a look at the bed side peak flow, which shows the rate at which patients can blow air into a meter after a deep breath, over time. And the observation chart, which tells us the patient's vitals.[/faq] See also [[Labored breathing]] Thu, 21 Sep 2023 12:15:09 +0000 Ultrasound Ultrasound is a Dx technique for visualizing soft tissue, including tendons, muscles, joints, vessels, and internal organs, for possible pathology/lesions. Method U/S is the use of sound waves with a frequency too high for human hearing U/S involves sending a pulse of U/S into tissue using a U/S transducer (hand-held probe), that is directly placed on or moved over the Pt. This reflects from different parts of tissue, and these echoes are recorded and create an image Typical Dx sonographic scanners operate between 1-18MHz. The choice of frequency is a trade-off between spatial resolution of the image and imaging depth: Low frequencies (1-6MHz), produce less resolution but images deeper into the body. This provides lower axial and lateral resolution but greater penetration. This is used to image deeper structures including: Liver Kidney High frequencies (7-18MHz), have a smaller wavelengths, and thus capable of reflecting/scattering from small structures. They also have a larger attenuation coefficient and thus are more readily absorbed in tissue, limiting the depth of penetration of the sound wave into the body. This provides better axial and lateral resolution. This is used to image superficial structures, including: Muscles Tendons Testes Breast Thyroid and parathyroid glands Neonatal brain Classification A-mode (amplitude mode), the simplest type of U/S. A single transducer scans a line through the body w/ the echoes plotteed on screen as a function of depth. Therapeutic U/S aimed at a specific tumor or calculus is also A-mode, to allow for pinpoint accurate focus of the destructive wave energy B-mode (aka 2D mode, brightness mode), the most well known, where a linear array of transdducers simultaneously scans a plane through the body that can be viewed as a 2D cross-section image of tissue on the screen C-mode, formed in a plane normal (at 90 degrees) to a B-mode image. A gate that selects data from a specific depth from an A-mode line is used, then the transducer is moved in the 2D plane to sample the entire region at this fixed depth. When the transducer transverses the area in a spiral, an area of 100 cm^2 can be scanned in around 10 seconds M-mode (motion mode), where pulses are emitted in quick succession, with each time, either an A-mode or B-mode image being taken. Over time, this produces a video recording showing motion of tissue over time, in U/S. As the organ boundaries that produce reflections move relative to the probe, this can be used to determine the velocity of specific organ structures Doppler mode, which uses the Doppler effect to measure and visualize blood flow (Doppler U/S). It includes: Color doppler, where velocity information is presented as a color-coded overlay on top of a B-mode image Continuous Doppler, where Doppler information is sampled along a line through the body, and all velocities detected at each time point are presented (on a time line) Pulse wave Doppler, where Doppler information is sampled from only a small sample volume (defined in 2D image), and presented on a timeline Duplex, which is simultaneous presentatino of 2D and pulsed wave Doppler information. Triplex is the combination of color Doppler with pulsed wave Doppler, because modern U/S machines tend to naturally use color Pulse inversion mode, where 2 successive pulses w/ opposite sign are emitted and then subtracted from each other. This implies that any linearly responding constituent will disappear while gases w/ non-linear compressibility stand out. Pulse inversion may also be used in a similar manner as in the Harmonic mode Harmonic mode, where a deep penetrating fundamental frequency is emitted into the body and a harmonic overtone is detected. This way noise and artifacts due to reverberation and aberration are greatly reduced Location of blood Presence of specific molecules Elastography (stiffness of tissue) 3D ultrasound (anatomy of a 3D region) Advantages Images are produced in real-time Portable Low cost Doesn't involve harmful ionizing radiation Effective for imaging SOFT tissue of the body Dx Tx, using U/S to guide interventional procedures (e.g. biopsies or drainage of fluid collections) Indications Used to guide injecting needles, when placing local anesthetic solutions near nerves Duplex U/S (B-mode vessels imaging combined w/ Doppler flow measurement), used in angiography to Dx arterial and venous disease Echocardiography, used to Dx, e.g. dilatation of parts of the heart, and function of heart ventricles and valves FAST exam, for assessing significant hemoperitoneum or pericardial tamponade after trauma. It is used in ED to exedite the care of Pt's w/ RUQ abdo pain who might have gallstones or cholecystitis Abdominal U/S, to: Image solid organs of the abdomen, although sound waves are blocked by gas in the bowel and attenuated in different degree by fat, so are limited Dx capabilities in this area. It includes: Pancreas Aorta IVC Liver Gallbladder Bile duct Kidney Spleen Appendix can SOMETIMES be seen when inflammed, as in appendicitis Endoanal U/S, is used particularly in the Ix of anorectal Sx, e.g. fecal incontinence or obstructed defecation. It images the immediate perianal anatomy and is able to detect occult defects e.g. tearing of the anal sphincter Gyencological U/S (see page) Obstetric U/S (see page), used during pregnancy to check the development of the fetus Head and neck U/S, including: Most structures of the neck, which are well visualized by high frequency U/S w/ exceptional anatomical detail. It includes the: Thyroid gland, the preferred imaging modality for thyroid tumors and lesions, and is critical pre-op and post-op for Pt's w/ thyroid cancer Parathyroid gland Lymph nodes Salivary glands Many other benign and malignant conditions in the head and neck, for both Dx and U/S-guided Tx In neonatology, transcranial doppler, for basic assessment of intracerebral structural abnormalities, bleeds, ventriculomegaly, or hydrocephalus, and anoxic insults (periventricular leukomalacia). The U/S can be performed through the fontanelle (soft spots in the skull of the newborn) until these completely close about 1yo, and form a virtually impenetrable acoustic barrier for the U/S. The most common site for cranial U/S is the anterior fontanelle. The smaller the fontanelle, the poorer the quality of the picture In neurology, including: Carotid ultrasonography, for assessing blood flow and stenosis in the carotid arteries Transcranial doppler, to assess the big intracerebral arteries Ocular U/S, imaging the eyes, including using A-scan U/S, and B-scan U/S Endobronchial U/S, where probes are applied to standard flexible endoscopic probes, and used by pulmonologists to allow for direct visualization of endobrachial lesions and lymph nodes prior to transbronchial needle aspiration. It can aid lung cancer staging by allowing for lymph node sampling, w/o the need for major surgery Pelvic U/S, which can be performed either transvaginally (in a woman) or transrectally (in a man). It can determine: Amount of fluid retained in a Pt's bladder Image the organs of the pelvic region, including the uterus, ovaries, or urinary bladder In males, to check the health of their bladder, prostate, or testicles (e.g. to DDx epididymitis from testicular torsion) In young males, to DDx more benign testicular masses (varicocele or hydrocele) from testicular cancer, which is highly curable but which must be Tx to preserve health and fertility Imaging of the pelvic floor, to provide Dx information regarding the precise relationship of abnormal structures w/ other pelvic organs, and Ix pelvic prolapse, double incontinence, and obstructed defecation Dx, and at higher frequencies, Tx (break up), kidney stones or nephrolithiasis (kidney crystals) Musculoskeletal U/S: Tendons, muscles, nerves, ligaments, soft tissue masses, and bone surfaces Fracture sonography, as an alternative to x-ray to detect fractures of the wrist, elbow and shoulder for Pt's Thu, 21 Sep 2023 03:12:00 +0000 Antipsychotic Antipsychotics are used to Tx psychosis, in particular, schizophrenia. They can also be used to Tx acute mania, agitation, bipolar disorder, autism, major depressive disorder, and so forth. MOA Both generations block receptors in the brain's dopaminergic pathways Classification Typical antipsychotics (aka 1st generation antipsychotics) are more likely to cause extrapyramidal symptoms, including Parkinsonian type movements, body rigidity, and involuntary tremors. It includes: Butyrophenones, including: Benperidol Bromperidol Droperidol Haloperidol (Haldol) [img]haloperidol.jpg[/img] Source: Kern Pharma Timiperone Moperone (discontinued) Pimamperone (discontinued) Diphenylbutylpiperidine, including: Fluspirilene Penfluridol Pimozide Phenothiazines, including: Acepromazine Chlorpromazine Cyamemazine Dixyrazine Fluphenazine Levomepromazine Perazine Pericyazine Perphenazine Pipotiazine Prochlorperazine Promethazine Prothipendyl Thioproperazine (only available in Canada) Trifluoperazine Mesoridazine (discontinued) Promazine (discontinued) Thioridazine (discontinued) Triflupromazine (discontinued) Thioxanthenes, including: Chlorprothixene Clopenthixol Flupentixol Thiothixene Zuclopenthixol Others, including: Clotiapine Loxapine Prothipendyl In contrast, atypical antipsychotics (aka 2nd generation antipsychotics) have less extrapyramidal effect. Examples of atypical antipsychotics are: Amisulpride Amoxapine Aripiprazole Asenapine Cariprazine Clozapine [img]clozapine.jpg[/img] Source: ServIMG Blonanserin Iloperidone Lurasidone Melperone Nemonapride Olanzapine (Zyprexa, or in combination with the SSRI fluoxetine is known as Symbyax) [img]zyprexa.jpg[/img] Source: GPW Law [img]symbyax.jpg[/img] Source: PSIC of Armacos Paliperidone Perospirone Quetiapine (Seroquel) [img]seroquel.jpg[/img] Source: Schmidt and Clark Remoxipride Risperidone (Risperdal) [img]risperdal.jpg[/img] Source: CCHR Int Sertindole Sultopride Trimipramine Ziprasidone Zotepine See also [[Antidepressants]] [[Neuroleptic malignant syndrome]] Thu, 21 Sep 2023 01:25:50 +0000 Urinalysis Urinalysis (U/A, aka Routine and Microscopy, R&M) is an array of tests performed on urine. Classification Urine dipstick, which is composed of 10 different chemical pads which change color when immersed and then removed from a urine sample. It can be read within 60-120 secs, although certain tests require longer. It tests for, noting that the reference values are for the prima facie value, are NOT displayed on the dipstick which only shows COLOR changes: Glucose (GLU), which should normally be from 4-6mmol/L. Glycosuria (aka glucosuria) is where it is elevated, and is most commonly due to untreated diabetes Bilirubin (BIL), is where CONJUGATED bilirubin is detected in the urine, indicating hepatic or post-hepatic disease. In contrast, biliuria means the presence of any bile pigment in the urine Urobilinogen (URO), which is a colorless by-product of bilirubin reduction via bacterial action in the intestine. Elevated urobilinogen can indicate pre-hepatic or hepatic disease. Urobilinogen is converted to the yellow pigmented urobilin apparent in urine Ketones (KET) or acetones, for Diabetes. Values are normally 1.01 however, may indicate mild dehydration Occult blood (BLO), which is blood that can't be seen with the naked eye, but can be with a microscope. Normal urine shouldn't contain any RBC's except women during menstruation pH, which is normally 6.2, within a range of 5.5-7 Acidic urine, in someone with hyperuricosuria can cause formation of uric acid stones in the kidneys, ureters, or bladder. Can also be caused by diets high in protein from meat and dairy, or alcohol consumption. Drugs can also do it, e.g ammonium chloride, chlorothiazide diuretics, and methenamine mandelate Basic urine, can be caused by a diet high in fruit and vegetables, or drugs e.g. acetazolamide, potassium citrate, and sodium bicarbonate Protein (PRO), indicating proteinuria Nitrites (NIT), for UTI's Leukocyte esterase (LEU), for UTI's [faq]What do you do in a urine dipstick? So it involves getting a sample of urine, and dipping one of these test strips into the urine, to test it. You can test sugar. Bilirubin. Ketones. Specific gravity. Blood that can't be seen with the eye. pH. Protein. Urobilinogen, which if it is higher than normal, can indicate a problem at or before the liver. Nitrites and white cells for UTI's. So urine glucose. That's your BSL's, right? Not really, BSL's is sugar in blood. This is in urine. So urine glucose is from 4-6mmol/L. It's a little different from blood glucose, which varies a lot throughout the day, but is usually >4mmol/L even when not eating. When not eating, it should get higher than >8mmol/L, or that's starting to sound like diabetes. Usually, nearly ALL glucose is reabsorbed in the PCT of the kidney, but the capacity may be exceeded if BSL increases a lot, as it does in diabetes, the threshold being 40-45mmol/L. Bilirubin in urine. That's bilirubinemia, right? Again, not really. This is in urine, not blood. So the kidney can't touch unconjugated bilirubin, because it's not water soluble. However, with conjugated bilirubin, if the liver's function is impaired, or when drainage of bile is blocked, some conjugated bilirubin leaks out of the liver, and appears in the urine. How does it differ from urobilinogen? So this is where conjugated bilirubin is successfully excreted from the bile duct into the intestine, and converted by bacteria in the intestine into urobilinogen and stercobilinogen. Some of this is reabsorbed by the intestine into circulation, and filtered out by the kidneys. Urobilinogen is thus elevated in hemolytic and liver disease. Ketones in urine. What makes it elevated? They're products of metabolism of fatty acids, so they're made because fats are getting metabolized. This can happen because of starvation, malabsorption, inability to metabolize carbohydrates (as in diabetes), or losses from frequent vomiting. Specific gravity, the weight of urine? Sort of. We compare it with water, which is considered to be 1. It should normally be a little heavier than water. However, if it's heavy, it probably means there is dehydration, reducing the water content in comparison. pH of urine. How does that work? Urine is acidic right? It sort of burns? Neutral pH is 7, so yes, urine is sort of acidic, around 6.2. Acidic makes it more likely for uric acid stones to form, can be caused by diets high in protein. Urine can be basic, with diets high in fruit and veggies. Certain drugs can also make urine pH go both ways, depending on the drug. Protein in urine. What does this mean? So it usually means early kidney disease. Small proteins like albumin are let through by the glomerulus, and needs to be reabsorbed by the tubules. Nitrites and leukocyte esterase in urine? Urine is usually sterile, right? Nitrite indicates a specific cause of UTI's by Gram negative bacteria, that have enzymes that reduce nitrate present in urine, to nitrite, so it can mean E coli, Enterobacter, Klebsiella, Citrobacter, or Proteus. Leukocytes can sometimes be found in urine, due to vaginal contamination, but leukocyte esterase is found only in urinary infection.[/faq] Microscopy, which tests for: Hematuria (RBC) Pyuria (WBC) Eosinophiluria RBC casts WBC casts Granular casts Crystalluria Calcium oxalatin Waxy casts [faq]Urine microscopy. What's the difference between a dipstick and microscopy? Dipstick is where you dip a chemical test strip in urine. Microscopy is where you view urine under a microscope. So you might find red or white blood cells in the urine, and a few other things too.[/faq] It can also involve: Urine culture, which is a microbiological culture of urine sample, detecting bacteriuria, indicated when UTI suspected. Sensitivity testing (aka MC&S) isw here the effectiveness of antibiotics against bacteria present is trialled Methods Midstream urine (MSU) is used to obtain sterile urine (i.e. no bacteria present), important to test for urine infection, and which antibiotics to use. To obtain a sample of urine from the middle of the Pt's bladder, involves passing some urine into the toilet, before catching urine mid-stream in the sterile bottle [youtube]a1K_KiAGv4Y[/youtube] Urine catheterization Suprapubic aspiration (aka bladder aspiration), involves putting a needle into the bladder just above the pubic bone. It can be used to collect urine in a child who isn't toilet trained, especially to Dx UTI's [youtube]iB4YhdyK8PA[/youtube] [faq]How do you test urine? So to test urine, you need to collect it. You don't just want any urine, because there's usually some contaminants, particularly at the start of the stream. So you can get the middle part of the stream. You can use a tube, which feeds directly up to the bladder to get urine, so it won't be contaminated. You can also get it from a needle inserted into the bladder, just above the pubic bone.[/faq] See also [[Bacteria]] [[Urine]] [[Pyuria]] [[UTI]] Thu, 21 Sep 2023 16:38:49 +0000 Calcium channel blocker CCB's (calcium channel blockers) reduce blood pressure. MOA Disrupts movement of calcium through calcium channels, thereby: Reducing BP Slowing HR Reducing force of contraction of the heart Unlike beta blockers, CCB don't decrease responsiveness of heart to the SNS, hence the baroreceptor reflex. CCB's thus permit better maintenance of blood pressure than beta blockers. However, as a result, the baroreceptor thus increases sympathetic effect, increasing heart rate and contractility N-type, L-type, and T-type voltage-dependent calcium channels are present in the zona glomerulosa of the human adrenal, and CCB's can directly influence the biosynthesis of aldosterone in adrenocortical cells, thus influencing the Tx of HTN Indications They are particularly effective against large vessel stiffness, one of the common causes of elevated systolic BP in elderly Pt's Alter heart rate Prevent cerebrovasospasm Reduce chest pain caused by angina pectoris Classification Dihydropyridine (-dipine, DHP), which are used to reduce systemic vascular resistance and arterial pressure. It includes: Amlodipine (Norvasc), used to lower BP, and prevent chest pain Aranidipine Azelnidipine Barnidipine Benidipine Cilnidipine Clevidipine Isradipine Efonidipine Felodipine Lacidipine Lercanidipine Manidipine Nicardipine Nifedipine (Procardia, Adalat), used as an antianginal (especially Prinzmetal's angina) and as an anti-HTN. It is also used as a tocolytic in preterm labor Nilvadipine Nimodipine Nisoldipine Nitrendipine Pranidipine Non-dihydropyridine, including: Phenylalkylamine, which are relatively selective for myocardium, reducing myocardial oxygen demand, and reverse coronary vasospasm, thus often used to Tx angina. It includes: Verapamil (Calan, Isoptin) Gallopamil Fendiline Benzothiazepine, which are an intermediate class between phenylalkylamine and dihydropyridines in their selectivity for vascular calcium channels. By having both cardiac depressant and vasodilator actions, they are able to reduce arterial pressure w/o prdoucing the same degree of reflex cardiac stimulation caused by dihydropyridines. It includes: Diltiazem (Cardizem) Non-selective, including: Mibefradil Bepridil Flunarizine Fluspirilene Fendiline Side effects Dizziness, headache, redness in the face Peripheral edema (i.e. fluid buildup in the legs and ankle) Rapid HR, palpitations Slow HR Constipation Gingival overgrowth Fatigue, dizziness, sleepiness, nausea, headache Stomach pain [img]amlodipine.jpg[/img] Source: Prognosis Shown to result in marginally significant lower cardiovascular mortality than w/ beta blockers, but they may also have multiple side effects POtential major risks are mainly associated w/ short-acting CCB's See also HTN Beta blocker Thu, 21 Sep 2023 13:16:45 +0000 Urinary incontinence Urinary incontinence (aka enuresis) is any leakage of urine. It is especially problematic if it occurs repeatedly, and in Pt's old enough expected to exercise such control. [faq]What is urinary incontinence? Number one's are a bit like a tap. So it's where your tap leaks - that is, when urine leaks.[/faq] Physiology Urine is produced in the kidney and stored in the bladder Urination is the emptying of urine through the urethra, and is controlled by relaxation of the internal and external urethral sphincters, which are supported by the pelvic floor muscles When the bladder is full, stretch receptors send a signal to the brain. When it is not time to urinate, the brain returns an inhibitory signal to keep the urethral sphincters shut. When it is time to urinate, the inhibition is removed, and the detrusor muscle which empties the bladder contracts [faq]Before we get into urinary incontinence, how does normal urination exactly occur? Urine is produced by the kidney. It's stored in the bladder. The storage usually doesn't "leak" because a set of muscles ("urethral sphincters" and "pelvic floor muscles") - keeps it from doing so. However, when storage is full, and you want to pee, the brain tells those muscles - "you can relax now". At the same time, another set of muscles ("detrusor muscles") contract to empty the bladder.[/faq] Types In adults: Mixed incontinence, which is a combination of urge and stress incontinence. It is not uncommon in elderly females, and can sometimes be complicated by urinary retention [[Stress incontinence]] (see page) [[Urge incontinence]] (see page) [[Overflow incontinence]] (see page) [[Functional incontinence]] (see page) [faq]I've heard of "stress" and "urgence" incontinence - in short, what's the difference :huh:? "Urge". That's just just as it sounds. You have overwhelming "urge" to pee. It's usually because you constantly need to go to the toilet. As compared with "stress". Again, that's just as it sounds. Whenever you face any "stress", you pee. That can be anything from coughing, jumping, bouncing ;)... well, anything :D. Without wanting to. That's more so to do with the fact that the muscles controlling having-to-pee, are weak. "Mixed incontinence". I know in skateboarding, you have "combo" tricks like a 360 shove it+double heel flip. So is this like any "combo" of the urinary incontinences? Not entirely. It involves only 2 of the most common ones. And we've chosen this "combo" because it's common in women. That is - the "stress". And "urgence" types. I see. How about the other 2 types of incontinence? Overflow? And functional? Overflow is like the opposite of urge incontinence. Whereas urge incontinence was too much contraction of the bladder-emptying muscles - usually caused by constant urges to pee. Overflow incontinence is too little contraction of the bladder. Causing retention of urine. Functional on the other hand, just means you simply can't be bothered going to the toilet. Or because of some medical condition, you can't get there.[/faq] Other classifications in adults: Transient incontinence, which is temporary incontinence. It can be triggered by medication, adrenal insufficiency, mental impairment, restricted mobility, stool impaction (severe constipation) Double incontinence, combining both urinary and fetal incontinence. Due to involvement of the same muscle group (levator ani) in bladder and bowel continence, Pt's are likely to have both → can be caused by damage from childbirth, complications from surgery especially involving the anal sphincters Post-void dribbling, where urine remains in the urethra after voiding the bladder, and slowly leaks out after urination → common and usually benign, but can indicate prostatitis, or post-prostate cancer surgery Coital incontinence, an urinary leakage that occurs during either penetration or orgasm, and can occur with a sexual partner or with masturbation → can be caused by pelvic floor disorders In children: [[Bedwetting]] (see page) [[Daytime wetting]] (see page) [faq]How about in kids? We divide this into wetting during night time, and day time. The stuff during day time is very similar to that in adults - so urge incontinence caused by an UTI, stress incontinence caused by giggling, or functional incontinence caused by not being bothered going to the toilet. So it's the same stuff in adults, but because for kid-related reasons. So night time wetting. Why does it occur? It can be normal. Kid's normally wet the bed if they're not toilet trained. This is usually under 6yo for girls, and boys tend ot be 1 year later - at 7yo. Because not all kids are the same, some kids may just have slower physical development - that is, their bladder - which stores pee - the size of that organ, is still growing. They might have slower neurological development - not enough chemicals signalling "stop producing pee" is produced at night time. Kids can be anxious. It may be genetic. And rarely - although parents usually worry about this one - there is a structural abnormality causing urine to back up.[/faq] Hx HPC of voiding: How often do you go to the toilet? → Urinary frequency Do you have to pee at night? → Nocturia When you have to go, do you have to go suddenly? → Urge incontinence Or can you not make it because something is stopping you? → Functional incontinence Do you ever leak urine? → Incontinence Do you use pads? And if so, how often do you change them? → Polyuria/urge incontinence Do you leak urine when you're giggling, laughing? → Stress incontinence Do you ever feel like, when you go to the toilet, you can't empty your bladder? → Overflow incontinence Do you have to strain when taking a pee? → Overflow incontinence Drug use → Diuretics/Urge incontinence Recent surgery? → Stress incontinence Physical exam: Tumors blocking the urinary tract → Overflow incontinence Stool impaction → Fecal incontinence Poor reflexes or sensations → Neurological cause/Overflow incontinence Ix Measurement of bladder capacity and post-void residual urine → inadequate bladder emptying/Overflow incontinence Stress test, where the Pt relaxes, then coughs vigorously as the Dr watches for loss of urine → Stress incontinence Urinalysis, for evidence of: Bacterial infection → UTI → Urinary frequency/Urge incontinence Urinary stones → Overflow incontinence Glucose → DM → Polyuria/Urge incontinence Other contributing causes Blood tests, examined for substances related to causes of incontinence U/S, to visualize the kidneys, ureters, bladder, and urethra → Overflow incontinence Urodynamic testing, which are techniques used to measure pressure in the bladder and the flow of urine → Overflow incontinence Cystoscopy, where a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder Keep a bladder diary from 1 day-1 week, to record the pattern of voiding, noting times and amounts of urine produced Mx [faq]What can be done about urinary incontinence? That entirely depends on the type of urinary incontinence.  I see ;). So let's say stress incontinence. What can you do about it? Remember that this type is related to the pelvic floor muscles causing urination "on stress". So we want to do things to help those muscles. Pelvic floor exercises is at the top of the list, any muscle that you exercise is going to build up. You can also build those muscles by practising waiting to go to the toilet. Just like how there are electrical stimulation devices to build your abs - there's also this available for the pelvic floor muscles. Where none of that works, we can do surgery. The idea behind surgery is to give support to those pelvic floor muscles. Also, there's weight loss, that always helps to reduces abdominal pressure. How about urge incontinence. What can you do about that? Remember that this type is related to producing too much urine and an overactive bladder causing the "urge" to pee. So there are common things we do that cause us to urinate. Drinking caffeine, drinking close to bed time, that's all behavioral things. Because urge is also related to an overactive bladder that involves spasms of the bladder muscles, we can also use drugs known as "anticholinergics" and "antimuscarinics". These block "parasympathetics", which in short, is the "rest and digest" system, including the urinary tract. So we prevent the process involved in urination from doing it's thing![/faq] Epidemiology Stress incontinence and urge incontinence are the most common types of urinary incontinence in women Stress incontinence is more common than urge incontinence Urinary incontinence affects 4% of the population, and 10% in those 65yo+ Affects less as age progresses, including 33% of 5yo, 25% of 7yo, 15% of 9yo, 8% of 11yo, 4% of 13yo, 3% of 16yo Diurnal/day enuresis, is much less common [than noctural/night enuresis] In childhood, 60% are male, but this ratio increases such that by 11yo there are 2x as many boys [as girls]. In adulthood, women suffer from urinary incontinence 4x more than men Incidence is greater amongst those of lower socioeconomic status See also [[Urinary urgency]] [[Frequent urination]] [[Pelvic organ prolapse]] (cause of stress incontinence) [[Fecal incontinence]] Thu, 21 Sep 2023 12:09:11 +0000 Tar staining Cigarette causes tar staining on the fingers. [img]tar-staining.jpg[/img] Source:     Thu, 21 Sep 2023 13:03:48 +0000 Fundal height Fundal height (aka McDonald's rule) is a measurement of the size of the uterus, as an indication of proper fetal growth/development and amniotic fluid development, during pregnancy. SFH is shorthand for symphysis-fundal height. Method Measured from the palpable top of the uterus (rounding, using the fifth finger of a flat palm), to the superior edge of the pubic symphysis (cartilaginous prominence, uniting the left and right pubic bones) The top of the uterus (i.e. the fundus) should be able to be located at: Week 12, at the pubic symphysis Week 20, at the umbilicus Week 36, xiphoid process of sternum Week 37-40, regression of fundal height back down to as low as 32cm [youtube]kCDHn1lmir0[/youtube] Interpretation Measurement is taken in centimeters, which should roughly correspond to gestational age Fundal height should correspond from 16 weeks gestation forth, but in practice, beginning around 20 weeks' gestation Shorter fundal height, indicates: Fetus descent into the pelvis, normally seen 2-4 weeks before delivery Error in estimated date of pregnancy based on the 1st day of LMP Fetus is physically small, but actually healthy Oligohydramnios Non-longitudinal lie, as fundal height corresponds only for a vertex fetus SGA or IUGR Longer fundal height, indicates: Multiple birth (e.g. twins) Error in estimated date of conception Fetus is physically large, but actually healthy Gestational diabetes causing a larger baby Polyhydramnios LGA Molar pregnancy/hydatidiform mole Breech birth Fundal height may stop correspond after 36 weeks gestation, thereby making it less accurate towards the end of pregnancy Post partum, where: 12 hours after delivery, the fundus is usualy 1cm above the umbilicus Within 1 week, the uterus descends into the pelvis approximately 1-2cm/day, until 7 days when the fundus should be half way between the umbilicus and pubic symphysis This continues until 6 weeks, when the uterus returns to its natural position Epidemiology It is generally recorded for each prenatal visit Thu, 21 Sep 2023 08:40:56 +0000 Cyst Cyst is a nodule (non fluid-filled, 5-10mm) that has expressible material, such as liquid, semi-sold or solid material, inside. [img]cyst.jpg[/img] Classification Benign (dysfunction) tumors, due to plugged ducts or other natural body outlets for secretions, including: Acne cyst Arachnoid cyst Baker's cyst (aka popliteal cyst) Bartholin's cyst Breast cyst Buccal bifurcation cyst Calcifying odontogenic cyst Ceruminous cyst Chalazion cyst Chocolate cyst of ovary Choroid plexus cyst Colloid cyst Cysticercal cyst Dentigerous cyst Dermoid cyst Epididymal cyst Fibrous cyst Ganglion cyst Glandular odontogenic cyst Glial cyst Gartner's duct cyst Hydatid cyst Hydrocele Keratocyst Liver cystic disease Meibomian cyst Mucoid cyst Mucous cyst of the oral mucosa Myxoid cyst Nabothian cyst Nasolabial duct cyst Odontogenic cyst Ovarian cyst Pancreatic cyst Paradental cyst Parapelvic cyst Paratubal cyst Periapical cyst Pericardial cyst Peritoneal cyst Pilar cyst Pilonidal cyst Renal cyst PCOS (polycystic ovary syndrome) Pineal love Radicular cyst Residual cyst Sebaceous cyst Skene's duct cyst Spermatocele Stafne static bone cyst Tarlov cyst Thyroglossal cyst Trichilemmal cyst Vocal fold cyst However, some are considered neoplasms, including: Dermoid cyst Keratocystic odontogenic tumor Calcifying odontogenic cyst By location: Cysts of the jaws Epithelial lined cysts Developmental Odontogenic Odontogenic keratocyst (prev known as keratocystic odontogenic tumor, KCOT), is a rare and benign, but locally aggressive developmental cyst. It most often affects the posterior mandible Dentigerous cyst (aka follicular cyst), is an epithelial lined developmental cyst formed by accumulation of fluid between REE and crown of unerupted tooth Eruption cyst/hematoma, is a bluish swelling that occurs on the soft tissue over an erupting tooth, usually found in children Calcifying [cystic] odontogenic cyst (COC), a rare developmental lesion that  is a proliferation of odontogenic epithelium and scattered nest of ghost cells and calcifications that may form the lining of a cyst, or present itself as a solid mass Developmental Non-odontogenic Nasopalatine duct cyst (NPDC, aka incisive canal cyst), occurs in the median of the palate, often between roots of upper CI's; radiographically may appear as heart-shaped radiolucency. Usually asymptomatic, but may sometimes produce elevation in anterior portion of palate Nasolabial/nasoalveolar cyst, is located superficially in the soft tissues of the upper lip. It is an extraosseous cyst, 1 that occurs outside of bone. It thus doesn't show up on an x-ray Inflammatory Radicular cyst (aka PA cyst, inflammatory cyst), is a cyst arising from epithelial residues (i.e. cell rests of Malassez) in the PDL, due to inflammation, usually following death of the pulp. It may develop rapidly from a PA granuloma, or untreated chronic PA periodontitis Residual cyst, is a radicular, lateral periodontal, dentigerous, or other cyst that has persisted after it's associated tooth has been lost Paradental cyst, is a family of inflammatory odontogenic cysts that appear in relation to crown or root of partially erupted molar teeth. It is usually in the D region of partially erupted 8's Non-Inflammatory Lateral periodontal cyst, a non-inflammatory cyst on the side of a tooth derived from remnants of the dental lamina Non-epithelial lined cysts Cysts associated w/ the maxillary antrum [Oral] Mucocele, is a swelling of CT consisting of a collection of fluid called mucus. This occurs because of a ruptured salivary gland duct [Mucus] Retention cyst, is a mucocele due to an obstructed or ruptured salivary duct Pseudocyst, which are formed between the inner surface of the bone wall and the CT layer, the sinus mucosa remaining on the outside Cysts of the soft tissues of the mouth, face and neck Dermoid and epidermoid cyst Branchial [cleft] cyst (cleft sinus), is a lump that develops in the neck or just below the collarbone Nasopharyngeal cyst, is a cystic swelling arising from the midline and lateral wall of the nasopharynx Thu, 21 Sep 2023 00:21:59 +0000 Oslers node Osler's nodes are painful, red, raised lesions found on the hands and legs, associated with infective endocarditis. Pathophysiology Caused by deposition of immune complexes, resulting in swelling, redness, and pain. [img]oslers-node-vs-janeway-lesion.gif[/img] Source: Stanford University Thu, 21 Sep 2023 17:44:29 +0000 Birth control Birth control (aka contraception, fertility control) are methods/devices used to prevent pregnancy. Family planning is the planning, provision and use of birth control. Methods Hormonal contraceptives, including: [[Oral contraceptive pill]] (see page) [Contraceptive] patch, which is a transdermal patch applied to skin which releases synthetic estrogen and progestin hormones to prevent pregnancy. It has been shown to be as effective, if not more effective than OCP's Vaginal rings, which provide controlled release of drugs for intravaginal administration, over extended periods of time. The ring is inserted into the vagina and provides contraception. Leaving the ring in for 3 weeks slowly releases estrogen and/or progestogens. These hormones stop ovulation and thicken the cervical mucus, creating a barrier preventing sperm from fertilizing an egg. Worn continously for 3 weeks on, followed by 1 week off, each vaginal ring provides 1 month of birth control. Examples include NuvaRing Combined injectable contraceptive (CIC), which is a monthly injection of progestin and a synthetic estrogen to suppress fertility Barriers, including: Condoms, including: [[Male condom]] (see page), which is put on an erect penis and physically blocks ejaculated semen from entering the body of the sexual partner. It also help prevent STI's [[Female condom]] (see page), which is worn internally by the female partner and provides a physical barrier to prevent exposure to ejaculated semen. It is a thin, soft, loose-fitting sheath with a flexible ring at each end. The inner ring at the closed end of the sheath is used to insert the condom inside the vagina, and hold it in place during intercourse. The roller outer ring at the open end of the sheath remains outside the vagina and covers part of the external genitalia. It also helps prevent STI's [[Diaphragms]] (see page), which are a soft latex or silicone dome with a spring molded into the rim. The spring creates a seal against the walls of the vagina Spermicides, which are a contraceptive substance that destroys sperm, inserted vaginally prior to intercourse to prevent pregnancy. It is unscented, clear, unflavored, non-staining, an lubricative [[Contraceptive sponge]] (see page), which combines a barrier with a spermicide. It is inserted vaginally before intercourse, and must be placed over the cervix to be effective Long-acting reversible contraception, which provide contraception for an extended period without requiring user action. It includes: [[Intrauterine devices]] (see page), which can be hormonal, or nonhormonal (copper) [[Subdermal contraceptive implants]] (see page) [[Depot medroxyprogesterone acetate injection]] (see page) Combined injectable contraceptive, which is a monthly injection of a progestin and synthetic estrogen to suppress fertility Sterilization, the most effective method, but not usually reversible, by: [[Vasectomy]] (males), which is surgical sterilization of a man, where the male vasa deferentia are severed, and then tied/sealed, so as to prevent sperm from entering into the ejaculate, thereby preventing fertilization [[Tubal ligation]] (females), which is surgical sterilization of a woman, where the woman's fallopian tubes are clamped and blocked, or severed and sealed, preventing eggs from reaching the uterus for implantation. However, fertilization can still occur in the fallopian tubes Behavioral Sexual abstinence, but abstinence-only sex education may increase teen pregnancies if offered without contraceptive education, due to lack of compliance Fertility awareness, where the infertile phases of a menstrual cycle are identified, to avoid pregnancy. It involves observing changes in fertility signs (basal body temperature, cervical mucus, cervical position), tracking menstrual length, and identifying the fertile window accordingly. Other signs may include breast tenderness or mittelschmerz (ovulation pains). It can also be determined using ovulation prediction kits, or microscopic examination of saliva or cervical fluid Withdrawal by the male before ejaculation Emergency, including: Morning-after pill (aka emergency contraceptives), intended to disrupt or delay ovulation or fertilization IUD's, sometimes Dual protection Source: ARHP birth control tool | ASHA sexual health Indications Particularly effective in reducing teen pregnancy, include long-acting reversible birth controls, including implants, IUD's, and vaginal rings After delivery of a child, a woman who isn't exclusively breastfeeding may become pregnant in as soon as 4-6 weeks. Some birth control methods can be started immediately following birth, whilst others require delay of up to 6 months In minors (i.e. Wed, 20 Sep 2023 05:17:19 +0000 Health record Health record is health data and information relating to the care of a patient. ED (or trauma) notes are records authored by the ED (or trauma) team. GP case notes are record authored in a GP consultation. Electronic health record is where this information is collected in a digital format that can be theoretically shared across different health care settings. Personal health record is where this information is collected and maintained by the patient (or the patient's parents). Blue book is a personal health record provided by the government to all newborn babies, and maintains all consultations with health professionals, developmental checklists, and vaccination history. Source: Contents of the Blue book Medical abbreviations are short hands used in medicine. Source: NSW Health Patient label Patient label is a printed sticker with the Pt's uniquely identifying information, and can be affixed to forms instead of manually having to fill them out. It includes: Unique barcode Name of the hospital, and LOCATION/WARD name Pt's MRN (Medical record number) Pt's M/C (Medicare number) H/F (Health fund), the private insurer number Pt's surname in capital letters, first name in normal case Pt's D.O.B. (date of birth), age, and gender Address, PH (phone number) M.O. (medical officer) responsible ADM (date admitted) Date the label was printed FIN (financial), which for public hospitals is "Non-Charge/Public" All paperwork will also provide the opportunity to insert: Contains the title of the form ("Shoulder dystocia management") and unique identifier of the form (including catalog number) Affix the Pt label Circle facility name (i.e. a hospital may have several branches) Progress notes Progress notes (aka Clinical notes) paperwork includes: Affix Pt labels Document is presented like a classic school page like format, with a margin on the LHS, which is for insertion of Date and Time (use 24 hr clock) There is a note that All entries must be legible, written in balck pen and include the health care provider's printed name, designation and signature. The document is otherwise just a page with lines At the bottom of the page, includes AMO___ (attending medical officer) I attest that I have reviewed the notes, including Signed and Date The form indicates which is Page 1 of 2, and which is 2 of 2 Handover Paperwork for "Patient safety handover checklist pediatric" includes: Affix Pt label Mention that, All sections must be completed at the Pt's bedside with handover nurse at the end of each shift. Handover will utilize the ISBAR Handover framework. A variance and any action taken as a result of this process must be documented in Pt's progress notes. Medication incidents  entered in IIMS. Please mark Y=Yes, or N=No in all appropriate boxes and initial at the bottom. "N/A" denotes not applicable for this Pt. "A" denotes Pt is absent from the ward EDD (Estimated date of discharge) There is then a table under Pt safety handover checklist, Acute changes in Pt status = Medical review. There are repeats of various groups of vertical columns, including a date __/__/___, ND (not done), AM (morning), PM (afternoon). For this table, there are rows in accordance with: Introduction: Correct ID band on Pt (red if medication allergy) Situation/background: Immediate or parental concerns/care escalated. YES/NO Assessment: Vital signs are condition/age appropriate Medication administred as prescribed, documentation completed IV site access free from redness/inflammation IV fluids administered according to orders using a burette and infusion pump and documented hourly Input/Output Fluid Balance Chart completed Weight recorded Wounds, drains, rashes identified Mobility/safety/falls risk checked Infection control signage correct Oxygen and suction equipment functioning Equipment monitor alarms audible with appropriate parameters set Pain assessment recorded Pt/Carer in attendance Recommendations: Discharge education/information Initials: Nurse/midwife handing over care Initials: Nurse/midwife accepting care Referral Paperwork for "Referral/consultation medical record copy" includes: Affix Pt label Referring Dr, including Provider number, Pt status (circle) Public/Private Attending specialist (AMO) Referred to: ___ (name) of ___ (dept) (complete both) Date, and Signature Consult team contacted? Tick box. & Date, and Time Reason for consultation Provisional Dx Summary of clinical condition Object of consultation, including tick boxes for Advise on Mx, Share Mx, Take over care of Pt Consultant's report, with note to (Use Clinical notes if more space is needed) As requested I shall, tick box for Advise on Mx, Share Mx, Take over care of Pt Authentication, including Date, and Signature Billable Pts only (To be completed by Medical Officer undertaking consultation), with Date Seen, Item, AMO initial, which is repeated 3x horizontally The white copy is the Medical record copy, which is CC'ed on the yellow Consultant's copy, and the green Billy services copy Discharge Discharge summary is a document ensuring continuity of care between hospital and community. D/C is shorthand for discharge. The Paperwork for the Discharge summary includes: Affix Pt label Admission date, and Discharge date VMO (Visiting medical officer) and LMO (Local medical officer) Final Dx Operations Complications Presenting problem Tx as an inpatient, including relevant Ix Pneumococcal vaccination indicated: Yes/No Follow-up services arranged Ix not to hand at discharge Drug allergies or reactions (new or existing) Estimated time of discharge Table of drugs, including Drug name, Strength, nstructions, Qty, Notes Authentication, including Signature, Name (print), and Date, or Medical Officer, and Pharmacist There are 3 copies of the sheet (2 CC's), the White going to Clinical Information Serices, Pink to LMO, Yellow to Pharmacy, Blue to VMO The Paperwork for "Discharge Against Medical Advice" includes: Affix Pt label There are 3 alternate portions which can be filled out Discharge of self, which is This is to certify that I, ___ am leaving ___ Hospital at my own insistence and against the advice of the attending Medical Staff. I acknowledge that I have been informed of the risks involved and possible consequences of my decision, including but, not limited to ________. I hereby release the Medical Staff and ___ Health Service from any responsibility and liability for any ill effects which may result from my leaving the Hospital at this time. This is followed by a Signed, Date, and Time. I certify taht I have Assessed the Pt as being physically and mentally capable of making a decision regarding discharge against advice; Counselled the Pt as to the possible consequences of self-discharge as listed above. And place for DOCTOR (print name), and DOCTOR (sign) Discharge by self - refusal to sign, which is This is to certify that ___ (Pt name) was given advice as listed above, but refused to acknolwedge the same. ___ (Pt name) refused to sign this document. And place for Staff Name, Date, and Time Discharge by guardian, which is This is to certify that I, ___ being the guardian of ___ am remmoving him/her from __ HOspital at my own insistence and against the advice of the attending Medical Staff. I acknowledge that I have been informed of the risks involved and possible consequences of my decision, including but limited to ___. I hereby release the Medical Staff and ___ Health Service from any responsibility and liability from any ill effects which may result from leaving the hospital at this time. Places for Signed, Relationship, Date, Time. I certify that I have Counselled the guardian as to the possible consequences of discharge as listed above. DOCTOR (print name), and DOCTOR (sign) See also Obs chart Thu, 21 Sep 2023 13:40:34 +0000 Anticholinergic Anticholinergics inhibits parasympathetics, by blocking the neurotransmitter acetylcholine [specifically, its binding to its receptor in neurons]. Parasympathetics are responsible for involuntary movement of smooth muscle present in the GI, urinary tract, lungs, etc. [faq]What are anticholinergics? It's drugs that inhibit the parasympathetics, which is the rest and digest response, by blocking acetylcholine. So rest and digest includes digestion, urination, and constriction of the breathing tubes.[/faq] Indications GI disorders, including: Gastritis Diarrhea Pylorospasm Diverticulitis UC Nausea Vomiting Genitourinary disorders, including: Cystitis Urethritis Prostatitis Respiratory disorders, including: Asthma Chronic bronchitis COPD Sinus bradycardia, due to a hypersensitive vagus nerve Insomnia, although usually only on a short term basis Dizziness, including vertigo, and motion sickness-related Sx [faq]When do you want to give a drug to inhibit the rest and digest response? If there's a GI problem, like diarrhea, diverticulitis, ulcerative colitis, vomiting. If there's a urinary problem, like inflammation of the bladder, urethra, or prostate. If there's a breathing problem, like asthma, or COPD.[/faq] Categories Anticholinergics can be divided into their specific targets: Antimuscarinics, which block activity of the muscarinic ACh receptor. These include: Aclidinium bromide (Genuair) Atropine Atropine methonitrate Benzatropine Biperiden Chlorpheniramine Cyclopentolate Darifenacin Dicyclomine Dimenhydrinate Diphenhydramine Doxylamine Flavoxate Glycopyrronium bromide (aka Glycopyrrolate, Seebri) Hydroxyzine Ipratropium [bromide] (Atrovent), which relieves bronchspasms. It is used to Tx COPD and acute asthma Mebeverine Orphenadrine Oxitropium Oxybutynin Pirenzepine Procyclidine Scopolamine (Hyoscine) Solifenacin Tolterodine Tiotropium [bromide] (Spiriva), used to Mx COPD Trihexyphenidyl +/- Benzhexol Tropicamide Antinicotincs, including: Bupropion Dextromethorphan Doxacurium Hexamethonium Mecamylamine Tubocurarine [Post-]ganglionic blockers, by acting as a nicotinic antagonist Neuromuscular blockers, which act presynaptically via inhibition of acetylcholine ACh, or postsnaptically at the ACh receptors of the motor nerve end-plate. This causes paralysis of the affected skeletal muscles [faq]What are the different types of drugs that inhibit the rest and digest response? The biggies are the antimuscarinics and antinicotinics. As it's mentioned, it acts against the muscarinic and nicotinic receptors. They're both receptors that bind acetylcholine.[/faq] Side effects Decreased mucus production in the nose and throat, causing dry, sore throat Dry mouth w/ possible acceleration of dental caries Pupil dilation, causing photophobia (sensitivity to bright light) Tachycardia (increased HR) Diminished bowel movement, sometimes ileus (decreased motility via the vagus nerve) Urinary retention Ataxia (poor coordination) Dementia Stopping of sweating, causing decreased epidermal thermal dissipation causing warm, blotchy, or red skin Increased body temperature Loss of accommodation, loss of focusing ability, blurred vision Double vision Tendency to be easily startled Increased IOP (intraocular pressure), dangerous for Pt's w/ narrow-angle glaucoma [faq]What are the side effects of the drugs that inhibit the rest and digest response? Because you're inhibiting the rest and digest response, you'd be worried about promoting things associated with the fight and flight response. So things like decreased mucus production, dry mouth, pupil dilation, increased heart rate, slower bowel movement, urinary retention.[/faq] See also [[Mydriasis]] [[Muscarinic antagonist]] Thu, 21 Sep 2023 14:27:42 +0000 Oral contraceptive pill [Combined] oral contraceptive pill (OCP's, aka birth control pills) are drugs taken by mouth for birth control. MOA Prevent ovulation by suppressing the release of gonadotropins (FSH, LH), thus inhibiting follicular development and preventing ovulation Progestogen negative feedback, decreases the pulse frequency of GnRH release by the hypothalamus, which decreases secretion of FSH and LH by the anterior pituitary. Decreased FSH inhibits follicular development, preventing an increase in estradiol levels. Progestogen negative feedback and the lack of estrogen positive feedback on LH secretion, prevents a mid-cycle LH surge. Inhibition of follicular development and the absence of a LH surge prevent ovulation Estrogen was originally included in OCP's for better cycle control, as it stabilizes the endometrium, thereby reducing the incidence of breakthrough bleeding. However, it was found that it also inhibits follicular development, and helps prevent ovulation. Estrogen negative feedback on the anterior pituitary, decreases the secretion of FSH, which inhibits follicular development, and helps prevent ovulation Progestogen also inhibits sperm penetration through the cervix into the upper genital tract (uterus and fallopian tubes), by decreasing the water content, and increasing the viscosity of the cervical mucus Classification Male oral contraceptives are currently not available commercially. Female oral contraceptives include: Taken once per day: Combined oral contraceptive pill, containing estrogen and progestin, including: 1st generation, which are COCP's, containing >=50µg ethinyl estradiol 2nd generation, which are COCP's containng 35yo Liver tumors Hepatic adenoma Severe cirrhosis of the liver Migraine w/ aura Known or suspected breast cancer Method COCP should be taken orally at the same time each day. If forgotten for more than 12 hours, protection will be reduced For the 28-pill packs, one is taken each day for the 28 day cycle, where the last week of pills is placebo/sugar pills. They may contain iron supplement, as iron requirements increase during menstruation For the 21-pill packs, one is taken each day for 3 weeks, following by 1 week of no pills If pills have been missed: If 1 is missed [or started a new pack 1 day late], take the last pill missed now, even if this means taking 2 pills in one day. Then, carry on taking the rest of the pack as normal. No extra contraception is required If 2+ pills are missed [or started a new pack 2+ days late], take the last pill missed now, even if this means taking 2 pills in one day. Leave any earlier missed pills. Carry on taking the rest of the pack as normal. Use extra contraception (e.g. condoms) for the next 7 days If there has been unprotected sex in the previous 7 days and 2+ pills are missing in the first week of a pack, emergency contraception may be necessary, including either: Morning after pill (aka emergency contraceptive pill), including ulipristal acetate which has to be taken within 3 days of sex, or levonorgestrel which has to be taken within 5 days of sex, both of which prevent or delay ovulation IUD, which can be inserted into the uterus up to 5 days after unprotected sex, or up to 5 days after the earliest time the Pt could have ovulated. It may stop an egg from being fertilized or implanting in the Pt's womb Whilst on the COCP, withdrawal bleed will occur during the placebo week, but will still protect from pregnancy during this week Risk factors Mistakes of the user, including: Forgetting to take the pill one day (especially an active pill) Not going to the pharmacy on time to renew the prescription Decreased intestinal absorption of the active pill due to vomiting or diarrhea Drug interactions of the active pill, by: Decreasing contraceptive estrogen or progestogen levels, including: Rifampicin Barbiturates Phenytoin Carbamazepine Impair bacterial flora, including: Ampicillin Doxycycline Mistake of those providing instructions, including information regarding: Frequency of intake Conscious non-compliance with instructions Side effects Unintended pregnancy, the probability of pregnancy during the 1st year of "typical" use is 9%, contrasted with 0.3% for "perfect" use Spotting, especially during the first few months of use → breakthrough bleeding Irregular periods, especially during the first few months of use Reductions in menstrual flow, and even amenorrhea Leukorrhea (increased vaginal secretions) Mastalgia (breast tenderness) Increased blinking (32% more) In older, high-dose COCP's (not seen in current low-dise formulations): Nausea, vomiting Increased BP Melasma (facial skin discoloration) Headache Bloating Swelling of the ankles/feet, weight gain → fluid retention Positive side effects, include improving conditions Complications It does NOT protect against STD's → use condoms Increased risk of: CVD risk, including: HTN Ischemic stroke DVT PE Breast cancer, which dissapears 7 years after use has stopped Cervical cancer, in those affected w/ HPV Liver cancer Gallstones → excess estrogen increases cholesterol in bile, decreases gallbaldder movement There is insufficiently strong evidence it causes: Weight gain Depression (especially relating to progestin-only contraceptives) Decreased risk of: Ovarian cancer Endometrial cancer Colorectal cancer Anemia Epidemiology Used by more than 100 million women worldwide Use varies depending on country, age, education, and marital status 50% of new time users to end the pill before the end of the 1st year, due to breakthrough bleeding or amenorrhea See also [[Birth control]] (information regarding prescribing to minors) Wed, 20 Sep 2023 17:31:40 +0000 Doppler auscultation Doppler auscultation is the use of a Doppler fetal monitor to listen to the fetal heartbeat for prenatal care. The monitor is a hand-held U/S transducer, which uses the Doppler effect to provide an audible simulation of the heart beat. FHS is shorthand for fetal heart sound. FHR is an abbreviation for Fetal Heart Rate. Purpose Listen to the fetal heart beat Display the HR in bpm, in some models Procedure Apply the U/S gel to the tip of the Doppler fetal monitor Switch the monitor on, and adjust the volume as necessary Shift the monitor around the stomach until the heart beat can be located [youtube]c8DwfGKrbgg[/youtube] Epidemiology Recommended against for home use, because of possible harm to the developing fetus. It should only be used by medical professionals for the benefit of the mother and child See also [[Fetal stethoscope]] (provide similar listening experience) [[Pregnancy ultrasound]] [[Fetal palpation]] (another Ix modality) [[Doppler scan]] (general) [[CTG]] Wed, 20 Sep 2023 08:30:57 +0000 Menstruation Menstruation (aka period, monthly) is the periodic discharge of blood and mucosal tissue from the endometrium (i.e. inner lining of the uterus) through the vagina. [faq]What's menstruation? It's where a woman bleeds periodically, and that is discharged through her vagina. Is it just blood? It's blood, as well as the surface tissue from the inner lining of her womb.[/faq] Cause It begins with the onset of menarche (i.e. the first menstrual cycle in women) at or before sexual maturity, and stops around menopause (end of a female's reproductive life) Menstruation typically stops when women conceive or are breastfeeding Menstruation that stops for longer than 90 days in the absence of pregnancy or breastfeeding, menopause, and hormonal contraception to prevent reproduction, is abnormal Physiology Menstrual cycle is the cycle that occurs in the uterus and ovary that makes sexual reproduction possible in fertile women. It helps to produce eggs, and prepare the uterus for pregnancy. The average menstrual cycle ranges from 21-35 days, the average being 28 days. The length of a menstrual cycle is counted in days from the first day of menstrual bleeding. Day Ovarian cycle Uterine cycle 1-5 Follicular phase, where through the action of rising FSH (follicle stimulating hormone) the ovarian follicles mature and get ready to release one which will dominate and mature into an egg Menstruation, a sign that a woman has not become pregnant. Refer above 5-14 Proliferative phase, where estrogen causes proliferation (i.e. grow) of the endometrium (lining the uterus). As the egg matures, levels of estradiol (and estrogen) increase Ovulation, where the mature egg is released from the ovarian follicles into the oviduct. Whereas estradiol suppressed luteinizing hormone (LH) production in the follicular phase, as the egg matures, levels of estradiol reach above a threshold which reverses the effect, instead stimulating LH in an LH surge, which matures the egg, and weakens the wall of the follicle. After release from the ovary, the egg is swept into the fallopian tube by the fimbria 14-28 Luteal phase, where FSH and LH cause remaining parts of the dominant follicle to transform into corpus luteum, which produces progesterone. Progesterone induces production of estrogen. The corpus luteum also suppresses production of FSH and LH that the corpus luteum needs to maintain itself, so the corpus luteum atrophies Secretory phase, where the corpus luteum produces progesterone, which makes the endometrium receptive to implantation of the blastocyst and supportive of early pregnancy Last menstrual period (LMP) is where pregnancies are dated in weeks starting from the first day of a woman's last menstrual period. The due date can be estimated by adding 280 days (9 months and 7 days) to the LMP. This method assumes accurate recall by the mother, regular 28 day cycles, and that conception occurs on day 14 of the cycle. It may overestimate the duration of the pregnancy, and be subject to an error of more than 2 weeks. → Pregnancy U/S done in the 1st trimester should be used to determine gestational age [faq]So why do women bleed in a cycle? So the cycle happens so that a woman can be fertile. It helps produce eggs, and prepare mom's womb for pregnancy. Is the cycle... cyclical ;)? It should be. It's usually 28 days, but can be +/- 1 week, so between 21-35 days. How does the cycle exactly occur? So there are 2 major parts to it. Follicular and luteal phase. Follicular constitutes the 1st half of the cycle, so day 1-14, where rising FSH causes the ovarian follicles to mature. Menstruation occurs at day 1. Proliferation begins at day 5, where estrogen causes the lining of the womb to grow. Ovulation happens at day 14, at the middle of the cycle, where a mature egg is released from the ovarian follicles. How about the luteal phase? So it's the 2nd half of the cycle, or day 14-28. It's where the remaining parts of the dominant follicle, transform into the corpus luteum. The corpus luteum makes progesterone, which is why it's also called the secretory phase. Progesterone makes the inner lining of the womb more receptive to implantation, and supportive of pregnancy. The corpus luteum also suppresses the production of FSH and LH, that it needs to maintain itself. So, the corpus luteum itself dies. [/faq] Tx Tampons (see page) [Sanitary] pad (aka sanitary napkin, sanitary towel, menstrual pad, maxi pad) is an absorbent item worn by women during menstruation, recovering from vaginal surgery, for PPH, after an abortion, or in any other situation where it is necessary to absorb blood flow from the Pt's vagina [img]sanitary-pad.jpg[/img] Source: Glam Check See also [[Pregnancy]] [[Childbirth]] [[Vaginal bleeding]] [[Menorrhagia]] (abnormally heavy/prolonged menstruation at regular periods) [[Dysmenorrhea]] (abnormally painful periods) [[Irregular periods]] [[Hormone levels]] [[Vaginal discharge]] [[Incontinence pads]] (for urinary incontinence, although menstrual pads can also be used for this purpose) Thu, 21 Sep 2023 17:35:47 +0000 UTI UTI is an infection that affects part of the urinary tract. [faq]What's a UTI? Infection of the urinary tract![/faq] Sx Lower UTI's: Painful urination Burning sensation in the urethra, may hbe present even when not urinating, in some cases Frequent urination Urinary urge Higher UTI's, cause lower UTI Sx in addition to: Systemic Sx, including fever Flank pain Vague or non-specific Sx at the extremities of age [faq]What does it feel like when your urinary tract is infected? It depends on where the infection is. If it's down lower, there may be pain peeing, a burning like sensation. There may also be changes in peeing, like wanting to go more often, or having the sudden urge to pee. If the infection works it's way up higher, you can get pain higher, up at the groin area. And if the infection works it's way throughout the body, you can get systemic type things, like a fever.[/faq] Causes E. coli, mainly, although other bacteria, virus or fungi may rarely be the cause Female anatomy, because the urethra is much shorter and closer to the anus Sexual intercourse, particularly anal intercourse Family Hx Previous UTI (recurrence is common) Although sexual intercourse is a risk factor, UTI’s are not classified as STI’s [faq]What causes UTI's? Any reason why bacteria can get into the urinary tract. E coli is found in the GI tract of healthy people, and because especially in women, where the urethra is so close to the GI outlet, it's a common entrance. Also, the urethra is much shorter in females, as for males it has to travel through the penis, so the distance bacteria has to travel is shorter, so it's quicker. Certain forms of sexual intercourse can introduce bacteria. Family history and previous UTI can contribute ot future likelihood too.[/faq] Classification Cystitis, which is infection of the bladder, thereby confined to the lower urinary tract Pyelonephritis, which is infection of the kidney, thereby affecting the upper urinary tract. It usually follows cystitis, but can also result from bacteremia (i.e. blood-borne infection) [faq]What are the different types of UTI's? UTI's are classified based on what part of the urinary tract is infected. The higher, the more concerned we are :(. So the next question is the route of the urinary tract ;). And that's the urethra, the bladder, the looooong ureter, and then kidneys. Any part can be infected. What are their names? Pyelonephritis, which is infection of the kidney. Now you may wonder how does the word "pyelo" relate to the kidneys, and the answer is that "pyelo" means "pelvis", which is where the kidneys are... generally ;) located lol. And "nephr" deriving from the word "nephron", which is the functional unit of the kidney. So that's at the very top, at the kidneys. There's also cystitis, which is infection of the bladder. We prefer that, because it hasn't travelled up the ureter and affected the kidneys.[/faq] Dx Dx in young healthy women is based on Sx alone In those with vague Sx, because bacteria can be present w/o there being an infection Nitrituria, which is nitrites in urine, as gram negatives (most commonly E coli) make an enzyme, that changes urinary nitrates to nitrites Leukocyte esterase, which tests for WBC in urine, indicating UTI Urine culture, in complicated cases, or if Tx has failed (i.e. Sx not improving in 2-3 days after Tx) [faq]How can you check whether someone has an infection of the urinary tract? You test urine. You might find nitrites, or white blood cells in it. Which isn't normal. Or you can try to culture urine, and see if anything grows in it. You can also work out what antibiotics will work against it by doing that. Nitrites and white blood cells. Why are these abnormal, and what are they? Nitrite is something that is created by bacteria, by converting it from a nitrate, which is the waste normally found in urine. White blood cells indicate an infection, which shouldn't normally be found in urine, because urine should be sterile.[/faq] Tx Prevention, w/: Low dose abx, in those w/ frequent infections Cranberry juice, which may assist with recurrent UTI's Short course of abx, if uncomplicated, although resistance is increasing. Complicated cases may require a longer course or IV abx. Note that women who have bacterial or WBC in the urine, but have NO symptoms, abx are generally not required, except in pregnant women Nitrofuran is a class of antibiotics with a furan ring with a nitro group. It includes Nitrofurantoin (NIT, Macrodantin) and Nifurtoinol which are both used in the Tx of UTI's Trimethoprim, abx used mainly in the Tx of bladder infections. Bactrim is trimethoprim + sulfamethoxazole Urinary alkalinsers, e.g. Citralite, Citravescent or Ural sachets, help neutralize the acid in the urinary tract, while assit with eliminating organisms that cause infection Antiseptics, e.g. hiprex [faq]How do you treat a bacterial infection of the urinary tract? Antibiotics ;). Of course. You do a short course if there's no biggie, or a long course or IV in complicated cases. We generally use the Nitrofuran class of antibiotics. What about if we find a patient with NO symptoms, but have bacteria or even WBC's in urine? We only use it in patients who have symptoms. If they've got no symptoms, we don't use it ;).[/faq] Prognosis Pyelonephritis, if it occurs, usually follows a bladder infection but may also result from a blood-borne infection Epidemiology Occur more commonly in women than men, affecting 50% of women at least once in their lives In women, UTI's are the most common form of bacterial infectino, w/ 10% developing UTI's annually Thu, 21 Sep 2023 16:47:14 +0000 Insulin Insulin [analog] (aka insulin receptor ligand) is an altered form of insulin, differing from any occurring in nature, but still avialable to the human body for performing the same action as human insulin in terms of glycemic control. Classification Long/slow acting, to maintain basal insulin, supplying the basal level of insulin required during the day and particularly at night time, that is released slowly over a period between 8-24 hours, including: Detemir insulin (Levemir) Degludec insulin (Tresiba) Glargine insulin (Lantus) Isophane insulin (Protaphane) Fast acting, to maintain prandial insulin, through a bolus level of insulin needed at mealtime, which are more readily absorbed from the injection site and thus act faster than natural insulin injected subcutaneously. Correction factor (aka insulin sensitivity) is how much 1 unit of rapid acting insulin will lower BSL's over 2-4 hours when in a fasting or pre-meal state. It includes: Lispro Aspart (NovoRapid) Glulisine Method Insulin can't be taken orally presently, as like all other proteins introduced into the GI tract, it is reduced to fragments (even single amino acid components), where all insulin activity is lost. Routes include: Subcutanoeus injection, by single use syringes with needles, an insulin pump, or by repeated use insulin pens with needles. Patients who wish to reduce repeated skin puncture often use an injection port in conjunction with synringes. Administration schedules often mimic the physiological secretion of insulin by the pancreas, so both long-acting and short-acting insulin are typically used Insulin pump, which has better control over background/basal insulin dosage, with bolus doses calculated to fractions of a unit, and calculators in the pump used to determine the bolus infusion dosages. The limitations are cost, catheter problems, hypoglycemic and hyperglycemic episodes, and no closed looop so controlling insulin delivery is based on current BSL's 1 IU (international unit) of insulin is the biological equivalent of 34.7μg pure crystalline insulin. It is derived from the 1 USP insulin unit, which is the amount required to reduce the concentration of blood glucose in a fasting rabbit to 2.5mmol/L MOA Through genetic engineering of the underlying DNA, the amino acid sequence of insulin can be changed to alter it's ADME (absorption, distirbution, metabolis, excretion) Epidemiology The 1st insulin analog approved for humans was insulin Lispro rDNA, created by Eli Lilly and Company Thu, 21 Sep 2023 08:54:37 +0000 Growth chart Growth charts are used by pediatricians to follow a child's growth over time. Method They compare specific measurements of a child compared with expected parameters of children of the same age/gender, including: Prenatal/intrauterine, for 26 weeks gestation forth: → can indicate SGA/IUGR, LGA Birth length Head circumference Birth weight Postnatal: Height Weight Head circumference Where an infant is born preterm ( Wed, 20 Sep 2023 21:32:54 +0000 Leukonychia Leukonychia is white discoloration of the nail. [img]leukonychia.jpg[/img] Source: Causes Harmless, most commonly caused by minor injuries whilst the nail is growing Caused by hypoalbuminemia (low albumin), of chronic liver disease. In this instance, there is leukonychia totalis, which is where the entire nail is whitened Tx None Leukonychia gradually dissapears as the nail grows out Thu, 21 Sep 2023 18:34:14 +0000 Crackle Crackles (aka crepitations, rales, from French "rale" meaning "rattle") are discontinuous crackling/clicking/rattling noises made by either/both lungs in Pt's with a respiratory disease. Sx Discontinuous, non-musical, and brief Much more common during inspiration than expiration, but they may be heard during expiratory It can be: Fine crackles, are soft, high pitched, and very brief. The sound can be simulated by rolling a strand of hair between fingers near the ears. They are usually late-inspiratory. It indicates an interstitial process, e.g. pulmonary fibrosis or CHF Medium Coarse crackles, are somewhat louder, low pitched, and last longer than fine crackles. They are usually early inspiratory. Their presence usually indicates an airway disease, e.g. bronchiectasis [faq]Crackles. I know there are fine and coarse crackles. What does it mean? Fine crackles are softer and higher pitched. Coarse crackles are louder and lower pitched. Fine means that it's some issue in the lung's vessels further out, what we call an interstitial problem. Coarse means that it's some issue in the bigger airway vessel. That makes sense because higher pitched notes are produced with a narrower tube.[/faq] Location of the crackles: Basal crackles (aka basilar crackles) are those heard in or near the base of the lung Bilateral crackles are crackles present in both lungs. Bibasal crackles (or bibasilar crackles, bilateral basal crackles) are crackles at the bases of both the L and R lungs Crackles that: Don't clear after a cough, may indicate pulmonary edema, or fluid in alveoli due to heart failure, pulmonary fibrosis, or ARDS (acute respiratory distress syndrome) Partially clear, or change after coughing, may indicate bronchiectasis [youtube]9C5RFb1qWT8[/youtube] Pathophysiology Caused by explosive popping open of small airways and alveoli collapsed by fluid or otherwise, thereby lacking air during expiration (when breathing out) Often associated w/ inflammation/infection of the small bronchi, bronchioles, and alveoli [faq]What causes the crackle sound? It's a sound of explosive popping of the alveoli grapes, of the lungs. Why do they explosively pop? That's not normal... right? No, it's not normal. It explosively pops because something's causing it to collapse. For example, if it's got fluid in it. Or if it's wall is thickened, because of scarring.[/faq] Indications Pneumonia Pulmonary edema, secondary to L sided CHF (heart failure) Atelectasis Pulmonary fiborsis Acute bronchitis Bronchiectasis Interstitial lung disease Post-thoracotomy Metastasis ablation See also Wheeze Breath sounds (category) Thu, 21 Sep 2023 13:07:43 +0000 Vomiting Vomiting (aka emesis) is the involuntary, forceful expulsion of stomach's contents, through the mouth, and sometimes the nose. Nausea is the feeling one is about to vomit, but doesn't necessarily result in vomiting. Regurgitation (aka posseting) is return of undigested food back up to the mouth, without the force/displeasure of vomiting. D&V is shorthand for diarrhea and vomiting. [faq]What is vomiting, and how does it differ from nausea? Vomit is where stuff inside the tummy, involuntarily and forcefully comes out of the mouth. Nausea is where you feel like vomiting.[/faq] Sx Vomitus includes: Gastric secretions, which are highly acidic Recent food intake Malodorous Pathophysiology Vomiting is caused by stimulation of receptors in the chemoreceptor trigger zone, on the floor of the 4th ventricle of the brain, known as the area postrema The area postrema is a circumventricular organ (i.e. structures in the brain charcterized by their extensive vasculature, and lack of normal BBB, allowing for linkage between the CNS and the peripheries), and thus can be stimulated by blood-borne drugs, that can stimulate or inhibit vomiting There are various inputs to the vomiting center, including: Stimulation of different receptors in the chemoreceptor trigger zone (e.g. dopamine D2 receptors, serotonin 5-HT3 receptors, opioid receptors, acetylcholine receptors, substance P), in different pathways, in which the final common pathway involves substance P Vestibular system, sends information to the brain via CN8 (vestibulocochlear), which plays a major role in motion sickness, and is rich in muscarinic and histamine H1 receptors CN10 (vagus) is activated when the pharynx is irritated, causing a gag reflex Vagal and enteric nervous system inputs information regarding the state of the GI system. Irritation of the GI mucosa by chemotherapy, radiation, distension, or acute infectious gastroenteritis activates 5-HT3 receptors of these inputs CNS mediates vomiting that arises from psychiatric disorders and stress from higher brain centers Causes Digestive, including: Gastritis Gastroenteritis GERD (gastroesophageal reflux disease) Bowel obstruction Overeating Food allergies (often also causing hives/swelling), including allergic reaction to cow's imlk protein (milk allergy, lactose intolerance) Cholecystitis, pancreatitis, appendicitis, hepatitis Food poisoning Systemic, as in: Brain tumor Elevated ICP (intracranial pressure) Overexposure to ionizing radiation [faq]What can cause vomiting? It can be a problem with the tummy system. So for example, an infection. Eating something dodgy. Reflux. An obstruction. Eating too much . An allergy. It can also be infection of one of the tummy organs, say the liver, gallbladder, pancreas, or appendix. The cause can also be somewhere in the brain, such as brain cancer.[/faq] Classification Contents: Fresh blood, called [[hematemesis]], is vomit that is bright red, and suggests bleeding from the esophagus Dark red vomit with liver-like clots, suggests profuse bleeding in the stomach, e.g. from a perforated ulcer Coffee ground vomiting, where there is altered blood resembling coffee grounds, as the iron in the blood is oxidized. This suggests bleeding in the stomach, because the gastric acid has had time to change the composition of the blood Bile, is vomit that is green or yellow, which can enter vomit during subsequent heaves due to duodenal contraction if the vomiting is severe. It indicates the pyloric valve is open, and bile is flowing into the stomach from the duodenum. Sometimes, gastric contents can have a yellow tinge, which is not bile. It can indicate: Mechanical bowel obstruction Volvulus Bowel ischemia Fecal vomiting (aka stercoraceous vomiting, copremesis) is vomiting, in which partially or fully digested matter is expelled from the intestines, into the stomach. It is often a consequence of intestinal obstruction or a gastrocolic fistula. Though it is not usually fecal matter that is expelled, it smells noxious Dry heaves (non-productive emesis) is where the vomiting reflex continues for an extended period with NO appreciable vomitus. It can be painful and debilitating Projectile vomiting is vomiting that ejects the gastric contents w/ great force. It is a classic Sx of infantile hypertrophic [[pyloric stenosis]], in which it typically follows feeding and can be so forceful that some materials exits through the nose [faq]Are there different types of vomit, or is vomit just vomit? You can differentiate it based on its contents, and the color of vomit. These things are sort of related. So there can be blood, which can be fresh or coffee ground colored. Bile. Fecal content. Color, can be bright red, dark red, or coffee ground, with the bleed going further down the tract as the color goes darker, and more digestion of blood has occurred. Yellow suggests bile.[/faq] Tx Antiemetics to suppress nausea/vomiting Where dehydration results, rehydration/IV fluids [faq]What can you do for someone who's vomiting? You can give anti-vomiting drugs, a popular one being ondansetron. Because vomiting can also cause dehydration, you may need to give fluids.[/faq] Complications Aspiration of vomit Dehydration and electrolyte imbalance, as prolonged and excessive vomiting depletes the body of water, and alters electrolyte status Gastric vomiting directly causes loss of acid (H+) and chloride (Cl-) directly. Alkaline tide is where normally after eating a meal, the stomach's parietal cells will produce bicarbonate ions (alongside HCl), which is basic, thereby increasing blood pH. This causes hypocholeremic metabolic alkalosis (i.e. low Cl, basic pH, high bicarbonate). This causes the kidney to try compensate for alkalosis (too much +) by excreting more potassium, causing hypokalemia If vomiting of intestinal contents occurs, which is less frequent, this will include bile acids and bicarbonate, and can cause metabolic ACIDOSIS Cachexia, if the Pt loses intake of food Mallory-Weiss tear Dentistry [faq]What bad things can happen as a result of vomiting? The vomit can come up, and you can breathe it in. That can cause a chest infection. You can also lose fluid that way, and it can disrupt the electrolyte balance of your body. It can cause a tear of that part where your stomach, and the tube just above connects to it, because of the refluxing acid. And it can ruin your teeth, because of the acidic contents of the tumy.[/faq] See also [[Valvular regurgitation]] [[Diarrhea]] [[Nausea]] Wed, 20 Sep 2023 14:45:15 +0000 Pneumonia Pneumonia is inflammation of the lung's alveoli (i.e. microscopic air sacs). Prognosis is that in the very young and very old, and chronically ill, pneumonia is a leading cause of death. [faq]People usually say pneumonia is a lung infection, is that correct? Sort of. It's specifically of the alveoli in the lungs. Bronchioles are also in the lungs, but inflammation of that is called bronchiolitis! So to say it's a lung infection is correct but imprecise ;)! What are alveoli? Air sacs that look a bit like grapes! They are the interface of the lung and the blood system, in a spherical shape to maximize the surface area over which gas can be exchanged. I'm feeling hungry :D[/faq] Sx Fever → infection Productive cough (bacterial pneumonia is green, yellow, or red-brown; in viral/mycoplasma is thin and whitish) → LRTI SOB → LRTI Chest pain → LRTI Fatigue → overcompensation for SOB [faq]What happens when an infection works down to the chest? As in all infection, fever. Because there's fluid in the lungs, there'll be a cough that brings up sputum, and shortness of breath. A lot of coughing will also cause chest pain, and a feeling of tiredness.[/faq] Causes Infections, by: Bacteria, the most common cause of CAP (community-acquired pneumonia). The most common include: Strep penumoniae (50%) Haemophilus influenzae (20%) Chlamydophila pneumoniae (13%) Mycoplasma pneumoniae (3%) (mycoplasma is considered a tween of viruses and bacteria) Viruses, including: Rhinovirus Coronaviruses Influenza virus RSV Adenovirus Parainfluenza Even other microorganisms Certain drugs [faq]What causes chest infections? Infections. Some drugs can also cause problems. Things that cause infection, can either be a bacteria, which is more common, or a virus. Bacteria include strep pneumoniae, the most common. It can also be haemophilus influenzae, chlamydophilia pneumoniae, and mycoplasma pneumoniae. Viruses can include rhinovirus, coronavirus, influenza virus, RSV, adenovirus, and parainfluenza. Other organisms can also cause problems.[/faq] Risk factors Predisposing factors: Extremities of age (newborns65yo) Smoking Immunocompromised, as in autoimmune diseases (HIV, diabetes), asthma, COPD, kidney disease, liver disease, or premature or sick newborns Alcoholism Acid suppressing medications (PPI's, H2 blockers) [faq]What factors make it more likely for you to get a chest infection? People who don't have a very good immune system, such as the very young, the very old, those who have autoimmune diseases or chronic diseases, premature newborns. Alcohol and smoking, can also affect immunity.[/faq] Pathophysiology Microorganisms (usually bacteria), defeating immune responses, cause inflammation of the lung's alveoli → chest pain, fever Inflammation causes exudate to fill the alveoli sacs → productive cough The exudate reduces the surface area over which gas can be exchanged → SOB Classification Classification by acquisition, including: Community-acquired pneumonia (CAP), which is contracted outside of the healthcare system Hospital-acquired pneumonia (HAP), is more serious because it is in addition to a pre-existing condition Ventilator-associated pneumonia (VAP), which occurs in Pt's on a ventilator (i.e. breathing machine) Classification by cause: Aspiration pneumonia, is a caused by entrance of foreign materials into the lungs, usually oral or gastric contents (including food, liquid, or even vomit). If the aspirate is acidic, it can cause chemical pneumonitis Opportunistic pneumonia, which occurs in immunocompromised Pt's, such as AIDS, organ transplant, chemotherapy, and can be caused by agents that are usually healthy for the body Anatomical distribution of consolidation: Broncopneumonia, affects patches of the bronchiole tubes Lobar pneumonia, affects a continuous area of the lung's lobes [the right lung has 3 lobes, and the left one has 2 lobes due to the cardiac notch] Historically, divided into typical and atypical, where atypical pneumonia (aka walking penumonia) is pneumonia not caused by the traditional pathogens (e.g. strep pneumoniae), which was thought to present less typically (respiratory Sx, lobar pneumonia), and more atypically with "generalized" Sx (fever, headache, myalgia, bronchopneumonia) [faq]What are the different types of chest infections? You can get it from a bug found in the hospital, or one out in the community. You can also get it from being on a ventilator. You can accidentally breathe in foreign materials. It can happen in immunocompromised patients. You can also divide it into which part of the lung it affects.[/faq] CURB-65 score, can help determine need for admission in adults, if the score is 0-1 Pt's can be Mx at home, 2 a short hospital stay or close follow up needed, and 3-5 hospitalization is recommended. It is an acronym for: Confusion Urea (BUN) >7mmol/L RR >30 Systolic BP Thu, 21 Sep 2023 02:51:55 +0000 Alcoholism Alcoholism (aka alcohol use disorder, alcohol dependence syndrome) is any drinking of alcohol that results in problems. Alcohol is a drink that contains ethanol. ETOH is shorthand for alcohol. Source: Standard drinks Dx 2 or more of the following is present: Pt drinks large amounts over a long tie period has difficulty cutting down Acquiring and drinking alcohol takes up a great deal of time Alcohol is strongly desired usage results in not fulfilling responsibilities Usage results in social problems Usage results in health problems Usage results in risky situations Withdrawal occurs when stopping Alcohol tolerance has occured w/ use Questionnaires Certain blood tests Interpretation Blood alcohol [level] (BAL, or blood alcohol concentration BAC) is the percentage of alcohol/ethanol in blood, mass per unit volume.  It is the most commonly used metric lf alcohol intoxication. The effects of blood alcohol at the various levels include: 0.01-0.03%, impairment is subtle. Behavior appears normal 0.03-0.06%, causes impaired concentration. Behavior includes decreased inhibition, talkativeness, joyousness, relaxation, and mild euphoria 0.06-0.09%, causes impaired reasoning, depth perception, peripheral vision, and glare recovery. Behavior includes blunted feelings, disinhibition, extroversion 0.1-0.2%, causes impaired reflexes, reaction time, gross motor control, staggering, slurred speech, temporary erectile dysfunction, possibility of temporary alcohol poisoning. Behavior includes over-expression, emotional swings, anger or sadness, boisterousness, decreased ilbido 0.2-0.3%, causes severe motor impairment, loss of consciousness, memory blackout. Behavior includes tupor, loss of understanding, impaired sensations, possibility of falling unconscious 0.3-0.4%, causes impaired bladder function, breathing, dysequilibrium, heart rate. Behavior includes severe CNS depressino, unconsciousness, possibility of death 0.4-0.5%, causes impaired breathing, heart rate, positional alcohol nystagus. Behavior includes general lack of behavior, unconsciousness, possibility of death >0.5%, causes high risk of poisoning, possibility of death Binge drinking is any one time peak above 0.08%. For motorists, it should be: In drivers with a L or P plate, truck/bus drivers, driving instructors, DUI drivers, 0% (i.e. prohibition) For taxi drivers, 0.02% For general motorists, 0.05% [faq]Practically, what bottle do you use to collect for blood alcohol level? The one with the light green top.[/faq] Effects Can affect all part sof th ebody, but particularly affects the brain, heart, liver, pancreas, and imune system In the short term, it causes: Intoxication Dehydration In the long term, it causes: Malnutrition Cancers (esp of the respiratory and digestive system) Neuropsychiatric impairment Cardiovascular disease Liver disease, Liver failure Pancreatitis Aging Mental illness Wernicke Korsakoff syndrome Arrhythmia It stimulates insulin production, so can cause hypoglycemia in diabetics In pregnant women, FAS (fetal alcohol spectrum disorders) in the child Risk factors Women, are generally more sensitive to alcohol's harmful physical and mental effects than men High stress levels Anxiety Inexpensive easily accessible alcohol Environmental factors, including social, cultura, and behavioral influences Genetics, w/ a Pt w/ a parent/sibling w/ alcoholism 3-4 times more likely to be alcohol themselves To prevent or improve Sx of withdrawal, continuing drinking or drinking partly Tx Limit insult: No more than 2 standard drinks on a day, to reduce the lifetime risk of harm form alcohol-related disease or injury. The lifetime risk of harm from drinking alcohol increases with the amount consumed No more than 4 standard drinks on a single occassion, reduces the risk of alcohol-related injury injury arising from that occasion. The risk of alcohol related injury on a single occasion of drinking increases with the amount consumed For kids Thu, 21 Sep 2023 00:24:27 +0000 Diabetes Diabetes (DM) is high blood sugar over a prolonged period. Pathophysiology [[Type 1 diabetes]], where the pancreas fails to produce enough insulin (thus formerly known as insulin-dependent diabetes). Its onset is in childhood (thus formerly known as juvenile diabetes). The cause is unknown [[Type 2 diabetes]], where insulin resistance (i.e. cells fail to respond to insulin properly) (thus formerly known as non insulin-dependent diabetes, NIDDM), which can also progress to a lack of insulin. Its onset is in adulthood (thus foremrly known as adult-onset diabetes). The cause is excsesive body weight and insufficient exercise [[Gestational diabetes]] (GDM), see page Epidemiology 387 million people worldwide, or 8.3% of the adult population, have diabetes Equal rates of men and women are affected with diabetes 90% of diabetes is type 2 Diabetes results in 3.2 million deaths per year Diabetes at least doubles the risk of death The global economic cost of diabetes is $612bn annually, with the USA constituting 40% of this cost Impaired glucose tolerance is a major risk factor for progression into full blown DM, as well as CVD Paperwork The paperwork for Diabetic chart is: Affix Pt label Instructions: Blood glucose = Glucose monitor reading (Blue or black) (mmol/L) Various blocks of columns are repeated for additional Date/Time. The rows include Date __/__/____, Time __:__, blood glucose mmol/L (for various sub-divided cells, including 24, 20, 16, 12, 8, 4 ___), blood glucose (GMR) mol/L, (extra) insulin type and units, hypoglycemic episodes and Tx, and urinalysis for glucose (subdivided cells for 28++++, 18+++, 3/48++, 1/28+, 1/48 trace, Nil), and Ketones The paperwork for Pediatric insulin infusion chart is: Affix Pt label Allergies/ADR Weight of Pt Date ADD 50 units of ___ insulin to a 500mL 0.9% sodium chloride bag (final concentration 1 unit per 10mL) Date ___. Commence insulin infusion @ ___ mL/hour. Medica officer Name and Signature Under section Insulin infusion orders (Must be written every 24 hours or when infusion rate changed), there are various rows, under the columns Date, Time, Drug, Fluid, Rate (mL/hr), MO Under section Insulin infusion preparation (before commencing infusion), there are various rows, under the columns Date, Time, 1st check/Nurse sign, 2nd check/Nurse sign Note that, Insulin infusion must be delivered via an infusion pump. Insulin infusions are to be titrated according to a predetermined Pt specific prescription written by a Medical officer. Insulin infusion and compatible maintenance fluids must run through the same cannula Under section Infusion rate changes, there are various rows, under the columns Date/Time, Blood glucose level mmol/L, Infusion rate mL/hr, Potassium mmol/L, Ketones specifiy type (blood/urine). The final column is To sign when infusion rate altered (with a subdivided cell for Nurse 1, Nurse 2) On the reverse side, information, for IV insulin infusion for diabetic ketoacidosis - adjustment algorithm (FOR USE BY MEDICAL OFFICERS ONLY). The table indicates the change in insulin rate from the current hourly rate according to the current BGL and rate of change of BGL in the previous hour. The table itself has rows with various Current BGL (mmol/L), including >15mmol/L, 10.1-15mmol/L (when BGL first falls to 4 mmol/L/hr. For a different combination of these cells, there are different decisions to No change, Increase, or Decrease by 10%, 20%, and so forth. This chart can be found on Page 19 (of 22) of this document from Children's Hospital at Westmead * Recheck BGL in 30 mins. NB: Call the endocrinologist on call if acidosis is not improving Maintenance fluids if BGL >15mmol/L is 0.9% sodium chloride; BGL >8-15 mmol/L is 0.45% sodium chloride 500mL & 5% dextrose with 20 mmol Potassium; BGL ___mmol/L, which is subdivided into Start time 00:00, and mmol/L decrease per 1 unit of insulin The section Current pump setings continues, with Duration of insulin action ___ hours. Target blood glucose ___ mmol/L. Authentication, including Medical officer name, signature, date __/__/___, review date __/__/____ Please ensure a referral is made to Diabetes educator, Dietitian and Endocrine team Table with various rows, with the columns Date/Time __/__/____ __:__, blood glucose level (mmol/L), meal CHO (grams or exchanges), meal bolus - MB (insulin units), correction bolus - CB (insulin units), slighted pump dose record (RN, RM, accredited EN & a patient/parent to witness each change of MB or CB), comments (e.g. Ketones, cannula site change, temporary basal, hypoglycemia Tx, fasting procedure) See also [[Diabetes insipidus]] [[DKA]] Thu, 21 Sep 2023 12:12:00 +0000 Menorrhagia Menorrhagia (aka hematomunia) is abnormally heavy and prolonged menstrual period [at regular intervals]. [faq]What is menorrhagia? I'm guessing it's related to menstruation? That's correct. The ending "rrhage" means excessive flow, like as in "hemorrhage" which means "bleeding". So it's excessive period bleeding. What do you mean excessive? Like a lot of bleeding? Yeah, so it's the amount, or length of bleeding.[/faq] Sx Depending on cause, it may be associated with dysmenorrhea (painful periods) Eventually, Sx of anemia (SOB, tiredness, weakness, tingling/numbness in extremities, headaches, depression, becoming cold more easily, poor concentration) Causes Abnormalities with blood clotting, including: → required to stop blood flow, following shedding of endometrial lining's blood vessels Bleeding disorders (e.g. von Willebrand) Anticoagulants (e.g. warfarin) Disruption of normal hormonal regulation of periods Excessive build up in endometrial lining [of the uterus], including: Physiologically, just after the onset of menstruation (menarche), and just before menopause PID → painful → irritation of the endometrium IUD → irritation of the endometrium Uterine fibroids → painless → can increase the endometrium's surface area [faq]What causes excessive or prolonged menstrual bleeding? So it can be due to problems with blood clotting, like bleeding disorders or use of drugs that prevent blood clotting. The normal hormonal regulation of periods can be disrupted. And there can be excessive build up of the inner lining of the womb, which is more common just after you get your periods, or just before menopause; also, PID  or IUD's which irritates the lining; and fibroids in the womb, which increases it's surface area.[/faq] Ix Pelvic and rectal exam → locate source of bleeding Pelvic U/S → identify structural abnormalities Endometrial biopsy → exclude endometrial cancer/hyperplasia Hysteroscopy → endometrial polyp, uterine fibroid Tx Tx the underlying cause Reassurance, if the degree of bleeding is mild, and there is no sinister underlying cause. Clear heavy periods at menarche (start of periods) and menopause (cessation of periods) may settle spontaneously Drugs, including: Iron tablets, if there is iron deficient anemia Pills (COCP, progesterone-only pills), to prevent proliferation of the endometrium; and for DUB, which commonly occurs at menarche and menopause, when contraception will also be sought anyway IUD w/ progesterone Tranexamic acid (i.e. antifibrinolytic), may reduce loss by 50%, and can be combined with hormonal medication Anti-inflammatories (e.g. NSAID's), first line in ovulatory menorrhagia, resulting in reduction of 33% in menstrual blood flow Surgery, including: Myomectomy, to remove small fibroids Endometrial ablation, where the inner lining of the womb is vaporized, chipped, or otherwise destroyed Uterine artery embolisation (UAE), which is using a catheter to deliver small particles that block the blood supply to the womb Hysterectomy (remove uterus), to remove fibroids >3cm, and/or if other options have been exhausted [faq]How can you fix more or longer menstrual bleeding? If there's an underlying cause, you can treat that.  Usually, there's no need to do anything. If there is iron deficiency, you can give iron. Hormone, given through oral contraceptive pills or IUD can prevent the womb's inner lining from proliferating. Tranexamic acid is a drug that inhibits the breakdown of fibrin in blood clots, so it helps to maintain clots. It can also be painful, so we can give NSAID's. What about if none of that works, and there's still more or longer menstrual bleeding? We can try surgery. So we can remove fibroids, if that's the cause. We can destroy the inner lining of the womb. We can block the blood supply to the womb. We can also remove the womb itself.[/faq] Complications Social stress of dealing w/ prolonged and heavy period Anemia, due to chronic blood loss depletes body iron reserves Epidemiology The use of hysterectomy for menorrhagia has almost halved in the last 20 years Up to 64% of women will cancel a hysterectomy See also [[Dysmenorrhea]] (painful periods) [[Hypomenorrhea]] (antonym) [[Metrorrhagia]] (irregular bleeding, particularly between expected menstrual periods) Wed, 20 Sep 2023 20:22:34 +0000 Shortness of breath SOB (shortness of breath, aka dyspnea, respiratory distress) is feelings of distress associated with impaired breathing. It can cause the tripod position (i.e. sits or stands, leaning forward, supporting the upper body w/ hands on the knees or another surface). WOB (work of breathing) is the effort required to inspire air into lungs, and accounts for 5% of total body oxygen consumption in normal resting state, but can increase dramatically during acute illness. Air hunger is the feeling of having not enough oxygen. [faq]Puff-puff-puff-puff. What's happening to me :O?! It seems like you're short of breath ;)! Short of breath. And work of breathing. What's the difference? Short of breath is that awful feeling you feel when you need to breathe, but can't. Work of breathing is the effort required to satisfy the need to breathe.[/faq] Pathophysiology SOB is caused by a mismatch in the afferent signal (need for ventilation) and the efferent signal (not being matched by physical breathing) Afferent neurons originate from the carotid bodies (chemoreceptors near fork of carotid artery, detecting partial pressure of oxygen in blood), medulla oblongata (inter alia, respiratory center), lungs, and chest wall Efferent neurons innervate the respiratory muscles (diaphragm, intercostal muscles, abdominal muscles, etc) [faq]What exactly makes you short of breath? Because there's a difference between 2 signals. The need to breathe. And the physical breath being taken. How are these 2 things exactly signals? The need to breathe is detected by receptors which detect oxygen, at the fork of the carotid artery, and elsewhere around the brain and lungs. The physical breath being taken is initiated by muscles of breathing.[/faq] Classification Intensity of distinct sensations Degree of distress involved Burden/impact on ADL's [faq]Is being short of breath it? Anything more to it? Yeah. You can be at different levels of shortness, of the breath, depending on your shortage of oxygen. It can also feel different, depending on what's causing it. And it can affect people's lives in different ways, because everybody's different.[/faq] DDx Causes include: Physiological, due to heavy exertion Respiratory: Asthma Pneumonia → fever Interstitial lung disease COPD, emphysema Bronchiolitis Bronchitis URTI, like diptheria, croup Choking Pulmonary embolism → can have fever Lung cancer Pulmonary fibrosis Pneumothorax Anaphylaxis, allergic reaction Cardiac: Cardiac ischemia Congestive heart failure Rib fracture, obesity, causing ineffective respiratory muscle action Psychogenic causes, including: Panic attacks Anxiety Poor ventilation, High altitudes with low oxygen levels [faq]What makes you short of breath? Well first and foremost, it can be normal ;)! But if there is a true problem, the big ones we're concerned is something related to your breathing, or even heart! It could also be musculoskeletal, as in a fracture of your ribs. Or it could be psychological, or even something to do with the air itself...! Let's start with your breathing. What about it? Well just about anything that can affect your airways can cause problems. It could be asthma, pneumonia, COPD, bronchiolitis, choking, anaphylaxis. Really, just anything that can go wrong with your breathing, can be an issue. How about your heart, what can cause shortness of breath there? Heart failure, cardiac ischemia. Blood is required to deliver oxygen, so without blood... you're going to feel short of breath![/faq] Ix Hx, including: Onset and progression Relieving and exacerbating factors, including: Rest or exertion. Quantify exercise tolerance, before getting SOB, including previous and current performance Orthopnea or paroxysmal nocturnal dyspnea Duration Attempts to Tx SOB Associated Sx, including: Angina Cough Fever Pleuritic chest pain [faq]How do you look further into, being short of breath? You can ask questions. Like when it started, what's happened throughout time, how long it's gone on for. What makes it better or worse. For example, whether moving makes it worse, resting helps. Whether it's worse when the patient is lying down. Whether it wakes the person up from sleep. Any treatment they've tried. What do you mean by associated symptoms? It's like when someone buys a burger, asking whether they had fries with it. It's just stuff that commonly goes together. So for example chest pain, might suggest a heart attack. Cough, or pain when breathing harder, might suggest a breathing problem. Fever might suggest an infection.[/faq] Tx Depends on underlying cause See also [[Labored breathing]] [[Chest tightness]] Wed, 20 Sep 2023 09:41:52 +0000 Flapping tremor Flapping tremor is, when the hand is outstretched, and wrist is bent upward, the Pt is unable to actively maintain the position, but instead, tremors with jerky movement, resembling a bird flapping its wings. [img]flapping-tremor.jpg[/img] [youtube]ZCXT9_KbgIo[/youtube] Cause Abnormal function of the diencephalic/forebrain motor centers of the brain, which regulates the muscles involved in maintaining position. It can be a sign of hepatic encephalopathy, where the liver is unable to metabolize ammonia to urea, which thus damages brain cells. Wed, 20 Sep 2023 07:35:21 +0000 Epileptic seizure Epileptic seizures (aka fits) is a brief episode of Sx, due to abnormal excessive or synchronous neuronal activity in the brain. It ranges from a momentary loss of awareness, to convulsions (i.e. muscles contract and relax rapidly and repeatedly, causing uncontrollable shaking). Epilepsy (from Greek meaning "to seize, or possess) aka seizure disorder) are diseases of the brain, involving an enduring predisposition to generate epileptic seizures. Thus, seizures can also occur in patients who DON'T have epilepsy. [faq]What is epilepsy? Epilepsy is discharge of electrical signals in the brain, when it is sudden and uncalled for. This misfiring causes chaotic effects, depending on what the signals mean, but includes twitches and spasms. What's the difference between epilepsy and seizure? Why not give it a less obscure name, like seizure, rather than epilepsy? Epilepsy causes seizures. But it isn't the only cause of seizure. Non-epileptic seizures do not have abnormal electrical activity. However, epilepsy and non-epileptic seizures look exactly the same, which makes it tricky to identify ;)![/faq] Sx Pre-ictal, the period before the seizure Post-ictal, the period after the seizure. It is the period before a normal level of consciousness returns, may last 3-15 minutes, but may last for hours, and includes: Feeling tired Headache Difficulty speaking Abnormal behavior Todd's paralysis, which is local weakness, after a partial seizure Psychosis is relatively common, occuring in 8% of Pt's Patients often don't remember what happened during this time Psychological and social well-being, including: Social islation Stigmatization Disability, including learning disabilities Depression Anxiety OCD Migraine ADHD Classification All seizures involve a loss of consciousness, and usually without warning. Generalized seizures, which are distributed within the brain, including: Tonic-clonic (aka grand mal), with uncontrolled jerking movement, involving both contraction and extension of limbs Tonic, is muscle stiffness/rigidty Clonic, is repetitive jerking movements Myoclonic, is sporadic/isolated jerking movements Absence (aka petit mal), is a brief loss of consciousness, often only involving subtle turning of the head or eye blinking. The person often doesn't fall over, and may be immediately normal after seizure ends, but there may be post-ictal disorientation Atonic, is loss of muscle tone [[Focal seizures]] (see page), which are localized in the brain. Although now described what what has occured during seizure, it used to be divided into: Simple partial, affecting only small region of brain, often retaining consciousness Complex partial, usually with unilateral cerebral hemisphere involvement, altering consciousness [[Epileptic syndromes]] (see page) Status epilepticus is a prolonged seizure >5 mins without recovery, with mortality around 25%. [faq]That's a lot of different types! Why does it seem so complicated? It's really quite simple. Seizure can either be generalized or focal. Generalized is where strange electrical signals occur right throughout the brain. Focal is where you can localize it to some location. Then what are all of the other things :'(!! For instance, under general, there's tonic, clonic, myoclonic, absence, atonic... I thought the whole brain got affected though?? When we say the whole brain is affected, we don't mean every part of the brain is being affected!! What we mean is that it isn't confined to a certain area of the brain. So the classification is on what it looks like. Tonic is where your muscles become stiff and rigid. Clonic is where you repetitively jerk. Myoclonic is the same as clonus, but where it's occurs sporadically only, so isolated. Absence is where you lose consciousness. Atonic is where you lose muscle tone, so the opposite of tonic ;)! That makes it a lot more simple. How about focal? What's the difference between simple and partial? Simple is where only a small region is affected. Complex is where an entire hemisphere is involved. So it's still not the whole brain, but it's half of one![/faq] Pathophysiology Due to excessive and abnormal neuron activity [in the cerebral cortex of the brain] Causes Most often unknown, but can be due to, depending on age group: In neonates and early infancy: Hypoxic ischemic encephalopathy CNS infections Trauma Birth defects of the CNS Known genetic mutations, directly linked in a small proportion of cases Metablic disorders In children: [[Febrile seizure]] Well-defined epilepsy syndromes In adolescent and young adulthood: Non-compliance with drug regimen Sleep deprivation Pregnancy, labor, childbirth, post-natal period, especially if there are complications like eclampsia During adulthood: Drug side effect, including of caffeine, corticosteroids, estrogens, fentanyl, insulin, olanzapine, prednisone, risperidone, TCA, certain antibiotics (metronidazole, penicillin), illicit drugs (amphetamines, cocaine), alcohol Drug withdrawal, from alcohol, benzodiazepines, barbiturates, anesthetics Strokes Trauma CNS infections, including encephalitis, [[meningitis]] Brain tumors In older adults: Cerebrovascular disease, e.g. stroke CNS tumor, e.g. brain tumors Head trauma, including brain injury Other degenerative diseases, e.g. dementia Reflex epilepsy, are seizures as the result of sensory stimuli caused by the environment, and include: Photosensitive epilepsy Reading epilepsy Hot water epilepsy Music induced epilepsy Other causes: Hypoglycemia Electrolyte problems Stress MS Lupus [faq]What can cause abnormal electrical activity in the brain? Anything that affects the brain. So low blood sugar. Stress. It can be a side effect of drugs. Or withdrawing from drugs. A fever. And a range of diseases. It all depends on age though, what's common varies with age. Alright. So let's start with the elderly, and work backwards. So in the elderly, it's things like clot in the brain, brain tumors, head trauma, or degenerative brain diseases like dementia. In adults, it's things like drugs, again there's blood clots in the brain, trauma, brain infections like meningitis, and brain tumors once again. Seizure is also more common in pregnancy, it's what we call eclampsia. In adolescents, it's things like not complying to their epilepsy treatment, or sleep deprivation - don't you know it ;)! In kids, there's seizure due to high temperature, and onset of your epilepsy syndromes, which usually start at this age. And in the very, very young, it's things like brain infections, trauma. And since they're young, congenital brain diseases, and metabolic disorders.[/faq] Dx Rule out DDx's, i.e. [[non-epileptic seizure]] (see page) Confirm with EEG, recommended only on those suggestive to have epilepsy on the basis of Sx; and is only required in kids after a 2nd seizure → rules out non-epileptic seizure Blood tests, including: Blood glucose → rule out as cause Blood calcium → rule out as cause Metabolic panel → metabolic disorders Serum prolactin → partial seizure, to DDx from psychogenic seizure. However, it doesn't DDx from syncope as it can be elevated due to stress too ECG, if indicated → rule out problems with rhythms of the heart LP, if indicated by petechial rash → rule out meningitis [faq]What can you do to check out abnormal electrical activity in the brain? You can do an EEG if you're expecting to see this abnormal activity. You can also check blood glucose and calcium to see if it's a cause. Other things can cause loss of consciousness, so you can do an ECG to rule out problems with the heart.[/faq] Ix After a 1st non-febrile seizure, MRI brain (preferred when available, except when bleeding is suspected) and MRI brain (more sensitive, and more easily available) → structural abnormalities around the brain If seizures are well controlled, it is usually unnecessary to routinely check drug levels in blood Tx ABCDE's, involving: Rolling a patient with an active seizure onto their sides, and into the recovery position, to prevent fluids getting into their lungs Take efforts to prevent further self-injury Spinal precautions are generally NOT required If a seizure occurs for >5 minutes, or there are >2 seizures in an hour without return to normal level of consciousness between them, it is a medical EMERGENCY, called status epilepticus. This may require airway Mx, e.g. nasopharyngeal airway. Benzodiazepine drugs such as midazolam at home, or rectal diazepam, or in hospital, IV lorazepam, may be used. If 2 doses of benzo is not effective, other drugs e.g. phenytoin are used. Convulsive status epilepticus that doesn't respond, is Tx with thiopentone or propofol Putting fingers, bite block or tongue depressor in the mouth is NOT recommended, as it can make a patient vomit, or result in the rescuer being bitten A 1st seizure generally doesn't require Tx unless there is high risk, e.g. a specific problem on EEG or brain imaging. Tx includes: Avoiding the trigger, if there is a particular cause Antiepileptic drugs (AED's), works in 70% of cases, possibly for the Pt's entire life. It is dependent on seizure type, other medications taken, other health problems, and age. A single medication is recommended initially, subsequently switching. Combo's are used only if single drugs don't work. Drugs include: Partial seizure: Phenytoin, 1st line Lamotrigine, 1st line Valproate, 2nd line due to cost and side effects Generalized seizure: Valproate, 1st line, as it is particularly effective against myoclonic, tonic and atonic seizures Lamotrigine, 2nd line Absent seizure: Ethosuximide Valproate If unresponsive to drugs: Surgery Neurostimulation Dietary changes, to one that is ketogenic (i..e high fat, low carb) Epileptic Pt's have ability to drive restricted or disallowed, but can return to driving after a period of time without seizures [faq]What can you do about abnormal electrical activity in the brain? You can give drugs called anti-epileptic drugs. These act on the ion channels, to help control electrical signals in the brain from going out of hand. If that doesn't work, you can also do surgery, eat more fat and less carbs, and do neurostimulation. What is neurostimulation? It sounds like something that excites the brain? It is. It's like a pacemaker, but electricity is used to excite the brain, rather than the heart.[/faq] Prognosis Doesn't always persist lifelong, and a substantial number of Pt's improve to the point that medication is no longer needed Seizures tend to recur. The probability of seizure following first is 50% Complications Physical injuries, including occasionally broken bones Epidemiology Epilepsy affects about 1% of the population currently, and 4% of the population at some point in time It affects 22m patients worldwide Most of patients affected (80%) live in developing countries It results in 116k deaths, up from 112k deaths in 1990 Onset of new cases occurs most commonly in infants and the elderly, due to the differences in frequency of the underlying causes 8% of people who live to 80yo have at least 1 epileptic seizure The chance of experiencing a 2nd seizure is 45% Paperwork Paperwork for Pediatric seizure chart includes: Affix Pt label Please list regular medications and doses Loading dose given, tickbox for Yes/No Medication used *Refer to guidelines overleaf to complete seizure record chart. *Refer to medical notes +/_ Medication chart for Seizure medication protocol Table including various rows, with columns Date __/__/____, Time __:__, Length of seizure, Pre seizure activity Note 1, Description event Anatomical location affected and type of activity (Refer to atached chart) Note 2, AVPU Note 3, SpO2, BGL, Postictal Phase Note 4, Medications Y/N Oxygen Y/N (incl Details), and Sign Over the page, Gduielines for Seizure chart observation & documentation. Recording a seizure: Note 1: Pre-seizure, Document whether the beginning of the seizure was witnessed and the time the seizure started. Describe activity/circumstances prior to the vent (e.g. waking, drowsy, screaming/upset, exercising, playing video games, feeding) Note 2: Description of event, Document the area of the body affected and type of limb/body activity using a head to toe approach and note level of consciousness: Auras - e.g. auditory, visual (lights/images), smell, unusual feeling like butterflies in the stomach. Eyes - Deviations of eyes - left/right/upwards; Flickering/dilation/PEARL of eyes/staring/open/closed. Head - head turning - left/right/down, head nodding. Face - Lip smacking/chewing/grimacing/twitching/speech jumbled, repetitive phrases/swallowing/drooling/vomiting. Neck - Hypeextension, gasp for breath/cry. Body - Rigid/limp/sitting/laying/trembling/jerking; Muscle contractions flexion/& extension/ Loss of muscle tone/ Incontinence - urinary/fecal; Rhythmical/non rhythmical +/ symmetrical/asymmetrical. Limbs - Muscle contractions flexion /+ extension Right/Let/Bilateral; Loss of muscle tone Right/Left; Symmetrical/asymmetrical. Skin - Flushed/cyanosed/cool/warm/clammy Note 3: AVPU Quick Assessment of level of consciousness, A - Alert Eyes open & talking spontaneously; V- Verbal Responds to verbal commands; P - Pain Responds to painful stimuli; U - Unconscious Does not respond. Contact Dr if P or U assessed Note 4: Postictal stage. Document: Length of time, amnesia, drowsiness/exhaustion headache, confusion or disorientation, altered behavior e.g. rage, irritability, facial palsy or weakness See also [[Febrile seizure]] (common in kids) [[Non-epileptic seizure]], which look like epileptic seizures but are NOT. They are thus a good DDx list [[Partial seizure]] [[Epilepsy syndrome]] Thu, 21 Sep 2023 16:19:26 +0000 Pharmaceutical drug Pharmaceutical drug (aka medication) is a drug used in health care, for the purposes of Dx, Tx, or prevention. Pharmacies administer drugs. Drug discovery and development are complex and expensive endeavors undertaken by pharmaceutical companies, academic scientists, and governments. Governments regulate the marketing of drugs, and in some jurisdictions, control drug pricing. Classification The main division of drugs are: Over-the-counter (OTC) drugs, which consumers can order for themselves Prescription drugs, which a pharmacist can dispense only on the order of a physician, physician assistance, or qualified nurse Other means of differentiating include: Modes of action Routes of administration Biological system affected Therapeutic effects Common WHO publishes a Model List of Essential Medicines which is updated every 2 years. It includes: Anesthetics: GA and oxygen Inhalation: halothane, isoflurane, nitrous oxide, oxygen Injectable: ketamine, propofol Local anesthetic: bupivacaine, lidocaine, lidocaine+epinephrine, ephedrine Perioperative and sedation: atropine, midazolam, morphine Pain and palliative care: Nonopioids and NSAID's: aspirin, ibuprofen, paracetamol Opioids: codeine, morphine Palliative: amitriptyline, cyclizine, dexamethasone, diazepam, docusate sodium, fluoxetine, haloperidol, hyoscine butylbromide, hyoscine hydrobromide, lactulose, loperamide, metoclopramide, midazolam, ondansteron, senna Antiallergics and anaphylaxis: dexamethasone, adrenaline/epinephrine, hydrocortisone, loratadine, prednisolone Antidotes and poisonings: Nonspecific: activated charcoal Specific: acetylcysteine, atropine, calcium gluconate, methylthioninium chloride (methylene blue), naloxone, penicillamine, potassium ferric hexacyanoferrate (prussian blue), sodium nitrite, sodium thiosulfate, deferoxamine, dimercaprol, fomeprizole, sodium calcium edetate, succimer Anticonvulsants/AED's: carbamazepine, diazepam, lorazepam, magnesium sulfate, phenobarbital, phenytoin, valproic acid (sodium valproate), ethosuximide Anti-infective: Antihelminthics Intestinal antihelminthics: albendazole, levamisole, mebendazole, niclosamide, praziquantel, pyrantel Antifilarials: albendazole, diethylcarbamazine, ivermectin Antischistosomals and other antinematode: praziquantel, triclabendazole, oxamniquine Antibacterials Beta lactam: amoxicillin, amoxicillin/clavulanic acid, ampicillin, benzathine benzylpenicillin, benzylpenicillin, cefalexin, cefazolin, cefixime, ceftriaxone, cloxacillin, phenoxymethylpenicillin, procaine benzylpenicillin, cefotaxime, ceftazidime, imipenem/cilastatin Other: azithromycin, chloramphenicol, ciprofloxacin, clarithromycin, doxycycline, erythromycin, gentamicin, metronidazole, nitrofurantoin, spectinomycin, sulfamethoxazole + trimethoprim, trimethoprim, clindamycin, vancomycin Antileprosy: clofazimine, dapsone, rifampicin Antituberculosis: ethambutol +/- isoniazid +/- pyrazinamide +/- rifampicin, rifabutin, rifapentine, streptomycin, amikacin, bedaquiline, capreomycin, cycloserine, delamanid, ethionamide, kanamycin, levofloxacin, linezolid, p-aminosalicylic acid, streptomycin Antifungal: amphotericin B, clotrimazole, fluconazole, flucytosine, griseofulvin, nystatin, potassium iodide Antiviral: Antiherpes: aciclovir Antiretrovirals: NRTI's: abacavir (ABC), lamivudine (3TC), stavudine (d4T), tenofovir disoproxil fumarate (TDF), zidovudine (ZDV, AZT) NNRTI's: efavirenz (EGV or EFZ), nevirapine (NVP) Protease inhibitors: atazanavir, darunavir, lopinavir + ritonavir (LPV/r), ritonavir, saquinavir (SQV) Fixed dose combinations: abacavir + lamivudine, efavirenz +/- emtricitabine + tenofovir, lamivudine +/- nevirapine +/- stavudine +/- zidovudine Other antivirals: oseltamivir, ribavirin, valganciclovir Antihepatitis Hepatitis B: NRTI's: entecavir, tenofovir disoproxil furamate (TDF) Hepatitis C: Nucleotide polymerase inhibitors: sofosbuvir Protease inhibitors: simeprevir NS5A inhibitors: daclatasvir Non-nucleoside polymerase inhibitors: dasabuvir Other antivirals: ribavirin, pegylated interferon alpha 2a or 2b Fixed dose combinations: ledipasvir + sofosbuvir, ombitasvir + paritaprevir + ritonavir Antiprotozoal Antiamoebic and antigiardiasis: diloxanide, metronidazole Antileishmaniasis: amphotericin B, miltefosine, paromomycin, sodium stibogluconate or meglumine antimoniate Antimalarial: Curative: amodiaquine, artemether +/- lumefantrine, artesuna e+/- amodiaquine +/- mefloquine, chloroquine, doxycycline, mefloquine, primaquine, quinine, sulfadoxine + pyrimethamine Prevention: chloroquine, doxycycline, mefloquine, proguanil Antipneumocystosis and antitoxoplasmosis: pyrimethamine, sulfadiazine, sulfamethoxazole + trimethoprim, pentamidine Antitrypanosomal 1st stage African trypanosomiasis: pentamidine, suramin sodium 2nd stage African trypanosomiasis: eflornithine, melarsoprol, nifurtimox American trypanosomiasis: bernznidazole, nifurtimox Antimigraine Acute attack: acetylsalicylic acid, ibuprofen, paracetamol Prevention: Propranolol Antineoplastic and immunosuppressive Immunosuppressive: azathioprine, ciclosporin Cytotoxic and adjuvants: all-trans retinoic acid, allopurinol, asparaginase, bendamustine, bleomycin, calcium folinate, capecitabine, carboplatin, chlorambucil, cisplatin, cyclophosphamide, cytarabine, dacarbazine, dactinomycin, daunorubicin, docetaxel, doxorubicin, etoposide, fludarabine, fluorouracil, filgrastim, gemcitabine, hydroxycarbamide, ifosfamide, imatinib, irinotecan, mercaptopurine, mesna, methotrexate, oxaliplatin, paclitaxel, procarbazine, rituximab, thioguanine, trastuzumab, vinblastine, vincristine, vinorelbine Hormones and antihormones: anastrozole, bicalutamide, dexamethasone, hydrocortisone, leuprorelin, methylprednisolone, prednisolone, tamoxifen Antiparkinsonism: biperiden, levodopa + carbidopa Affecting blood Antianemia: ferrous salt +/- folic acid, hydroxocobalamin Coagulation: enoxaparin, heparin sodium, phytomenadione, protamine sulfate, tranexamic acid, warfarin, desmopressin Hemoglobinopathies: deferoxamine, hydroxycarbamide Blood products and plasma substitutes Blood and its components: fresh frozen plasma, platelet concentrates, RBC's, whole blood Plasma derived: HUman immunoglobulins: anti-D immunoglobulin, anti-rabies immunoglobulin, anti-tetanus immunoglobulin, human normal immunoglobulin Blood coagulation factors: coagulation factor VIII, coagulation factor IX Plasma substitutes: dextran 70 Cardiovascular Antianginal: bisoprolol, glyceryl trinitrate, isosorbide dinitrate, verapamil Antiarrhythmic: bisoprolol, digoxin, adrenaline, lidocaine, verapamil, amiodarone Antihypertensive: amlodipine, bisoprolol, enalapril, hydralazine, hydrochlorothiazide, methyldopa, sodium nitroprusside Heart failure: bisoprolol, digoxin, enalapril, furosemide, hydrochlorothiazide, spironolactone, dopamine Antithrombotic Antiplatelet: acetylsalicylic acid, clopidogrel Thrombolytic: streptokinase Lipid lowering: simvastatin Dermatological (topical) Antifungal: miconazole, selenium sulfide, sodium thiosulfate, terbinafine Anti-infective: mupirocin, potassium permanganate, silver sulfadiazine Anti-inflammatory and antipruritic: betamethasone, calamine, hydrocortisone Skin differentiation and proliferation: benzoyl peroxide, coal tar, fluorouracil, pedophyllum resin, salicylica cid, urea Scabicide and pediculicides: benzyl benzoate, permethrin Diagnostic Ophthalmic: fluorescein, tropicamide Radiocontrast media: amidotrizoate, barium sulfate, iohexol, meglumine iotroxate Disinfectants and antiseptics Antiseptics: chlorhexidine, ethanol, polyvidone iodine Disinfectants: alcohol based hand rub, chlorine base compound, chloroxylenol, glutaral Diuretics: amiloride, furosemide, hydrochlorothiazide, mannitol, spironolactone GI: Pancreatic enzymes Antiulcer: omeprazole, ranitidine Antiemetic: dexamethasone, metoclopramide, ondansetron Anti-inflammatory: sulfasalazine, hydrocortisone Laxatives: senna Diarrhea Oral rehydration: oral rehydration salts Diarrhea in kids: zinc sulfate Hormone, endocrine, and contraceptives Adrenal hormones and synthetic substitutes: fludrocortisone, hydrocortisone Androgens: testosterone Contraceptives Oral hormonal contraceptives: ethinylestradiol +/- levonorgestrel +/- norethisterone Injectible hormonal contraceptives: estradiol cypionate +/- medroxyprogesterone acetate, norethisterone enantate Intrauterine devices: copper containing device, levonorgestrel releasing intrauterine system Barrier methods: condoms, diaphragms Implantable contraceptives: etonogestrel releasing implant, levonorgestrel releasing implant Intravaginal contraceptives: progesterone vaginal ring Estrogens Insulin and diabetes: gliclazide, glucagon, insulin injectible, intermediate-acting insulin, metformin Ovulation inducers: clomifene Progestogens: medroxyprogesterone acetate Thyroid hormones and antithyroid: levothyroxine, potassium iodide, propylthiouracil, lugol's solution Immunologicals Dx agents: tuberculin, purified protein derivative (PPD) Sera and immunoglobulins: antivenom immunoglobulin, diphtheria antitoxin Vaccine: BCG vaccine, cholera vaccine, diptheria vaccine, haemophilus influenzae type B vaccine, hepatitis A vaccine, hepatitis B vaccine, HPV vaccine, influenza vaccine, pentavalent vaccine, Japanese encephalitis vaccine, measles vaccine, meningococcal meningitis vaccine, mumps vaccine, pertussis vaccine, pneumococcal vaccine, poliomyelitis vaccine, rabies vaccine, rotavirus vaccine, rubella vaccine, tetanus vaccine, tick-borne encephalitis vaccine, typhoid vacine, varicella vaccine, yellow fever vaccine Muscle relaxants (peripheral) and cholinesterase inhibitors: atracurium, neostigmine, suxamethonium, vecuronium, pyridostigmine Ophthalmological Anti-infective: aciclovi, azithromycin, gentamicin, ofloxacin, tetracycline Anti-inflammatory: prednisolone Local anesthetic: tetracaine Miotics and antiglaucoma: acetazolamide, latanoprost, pilocarpine, timolol Mydriatics: atropine, adrenaline Anti-VEGF (vascular endothelial growth factor): bevacizumab Oxytocics and tocolytics Oxytocics: ergometrine, misoprostol, oxytocin, mifepristone-misoprostol Tocolytics (antioxytocics): nifedipine Peritoneal dialysis solution: intraperitoneal dialysis solution of appropriate composition Mental and behavioral disorders Psychotic disorders: chlorpromazine, fluphenazine, haloperidol, risperidone, clozapine Mood disorders Depressive disorders: amitriptyline, fluoxetine Bipolar disorders: carbamazepine, lithium carbonate, valproic acid (sodium valproate) Anxiety disorders: diazepam Obsessive compulsive disorders: clomipramine Psychoactive substance use: NRT (nicotine replacement therapy), methadone Respiratory tract Antiasthmatic and COPD: beclomethasone, budesonide, adrenaline, ipratroprium bromide, salbutamol Correcting water, elecrolyte and acid-base disturbances Oral: oral rehydration salts, potassium chloride Parental: glucose +/- sodium chloride, potassium chloride, ssodium hydrogen carbonate, sodium lactate compound solution Water for injection Vitamins and minerals: ascorbic acid, calcium, cholecalciferol, ergocalciferol, iodine, nicotinamide, pyridoxine, retinol, riboflavin, sodium fluoride, thiamine, calcium gluconate ENT in kids: acetic acid, budesonide, ciprofloxacin, xylometazoline Neonatal care Neonate: caffeine citrate, chlorhexidine, ibuprofen, prostaglandin E, surfactant Mother: dexamethasone Joints Gout: allopurinol Disease modifying agents in rheumatoid disorders: chloroquine, azathioprine, hydroxychloroquine, methotrexate, penicillamine, sulfasalazine Juvenile joint diseases: acetylsalicylic acid Side effects Polypharmacy, is the use of >=4 drugs by a Pt, generally Pt's >65yo. Although it can be appropriate, it is more often inappropriate. It is often associated w/ decreased quality of life, decreased mobility and cognition. The issue is it is impossible to accurately predict side effects of a combination of drugs w/o studying the particular subject, and even pharmacological profiles of individual drugs do not assure accurate prediction of the side effects of combinations of these drugs. Concerns include increased: Adverse drug reactions (ADR), which are injuries caused by taking drugs. It can occur following a single dose or prolonged administration of drug/s. Adverse drug event is any injury occuring at the time a drug is used, whether or not the drug caused the injury Drug interactions, which is where a substance (usually another drug, but also includes foods, plants, even effects of the drug itself e.g. dehydration) affects the activity of a drug when administered together. The action can be synergistic (increasing the drug's effect), antagonistic (decreasing the drug's effect), or produce a new effect that neither drug produces on its own. Interactions can occur due to accidental misuse or lack of knowledge about active ingredients. Taking synergistic drugs can cause overdose. Drug interaction can also increase the risk of side effects. Taking antagonistic drugs can cause the therapeutic effect to be ceased because it is under dosage. Interactions can occur before drug administration has occurred Prescribing cascade, which is where side effects of drugs are misdiagnosed as Sx of another problem, resulting in further prescriptions, and further side effects and unanticipated drug interactions. It has to be reversed through deprescribing Higher costs. Terms prn is an abbreviation for Latin "pro re nata" meaning As circumstances require mdu is an abbreviation for Latin "more dicto utendus", meaning To be used as directed Rx (from Latin meaning "recipe" meaning meaning "to take") means prescription. Rx'd is thus shorthand for prescribed Epidemiology Polypharmacy most commonly affects the elders, affecting 40% of adults living in their own homes 21% of adults w/ intellectual disability are also exposed to polypharmacy Paperwork Attach ADR sticker, or fill out the ADR (Allergies and adverse drug reactions). There is an option to tick "Nil known", "Unknown", or to fill out the table enlisting the "Drug (or other"), "Reaction/Type/Date", and "Initials". Then Sign, Print (name) and Date. Enter name of "First Prescriber to Print Patient Name and Check Label Correct" Weight (kg) and Height (cm) of Pt Facility/Service, Ward/Unit Medication Chart No ___ of ___, to indicate how many Medication Charts the Pt has (which should be checked for as indicated on form) Tick Additional charts, including IV Fluid, Palliative Care, BGL/Insulin, Chemotherapy, Acute Pain, IV Heparin, and Other Once only, pre-medication and nurse initiated medicines. Table to fill out including Date Prescribed, Medication (Print Generic Name), Route, Dose, Date/Time of dose, and for the Prescribe/Nurse initiator (NI) their Signature and Print Your Name, Given by (requiring signing AND counter signing), Time Given, and Pharmacy Telephone orders (To be be signed within 24 hours of order), including Date Time, Medication (Print Generic Name), Route, Dose, Frequency, Nurse Initials (2 boxes, one for Nr 1, and another for Nr 2), Dr Name, Dr Sign, Date, and Record of Administration (4 sets of boxes which are subdivided into Time, and Given by) Medicines taken Prior to Presentation to Hospital (Prescribed, over the counter, complementary). Tick Y or N for "Own medications brought in?", and fill in "Administration Aid (Specify)". 2 sets of Tables for either the GP or Community Pharmacy, both of which include the columns Medication, Dose & frequency, and Duration. Authentication, including Documented by "Sign" and "Date", and "Medicines usually administered by" Regular medications, filling out Year 20__. To the right of all of the rows of medications is a vertical column stating "Continue on discharge? Yes/No". "Dispense? Yes/No". "Duration: ___ days. Qty: ___". There is also a mass vertical column stating Prescribers Signature, Print Name, Contact, Date, Pharmacist, Date. Not all of the rows are equivalent even though it looks like so, because some boxes are pre-filled Variable dose medication, including Date, Medication (Print Generic Name), Route, Frequency (Prescriber to enter dose times and individual dose), Indication, Pharmacy, Prescriber Signature (including Print Your Name), and Contact. For the table, it includes the columns "Date and month", "Drug level", "Time level taken", "Dose", "Prescriber", "Time to be given", "Time given and sign" Drug given for VTE prophylaxis. VTE risk assessed requires ticking for "Yes", "Prophylaxis not required", or "Contraindicated", including Signature and Date. Drug information, including Date, Medication (Print Generic Name), Route, Dose (Frequency and NOW Enter Times), Indication (already has pre-written "VTE Prophylaxis"), Pharmacy, Prescriber Signature (including Print Your Name), Contact Below is a row for Mechanical Prophylaxis, Prescriber/NI Signature (including Print Your Name), Contact. Includes a row for "AM" and "PM" Pre-filled row specifically for Warfarin (select brand Marevan/Coumadin). Drug information, including Date, Medication (already is pre-filled for Warfarin), Route, Prescriber to enter individual doses, Target INR Range, Indication, Pharmacy, Prescriber Signature (including Print Your Name), and Contact. Rows include INR Result, Dose (in mg), Prescriber, 1600 (Nurse 1), and Nurse 2 Standard drug row, which states "DOCTORS MUST ENTER administration times". Drug information, including Date, Medication (Print Generic Name), "Tick if Slow Release", Route, Dose, Frequency and NOW ENter Times, Indication, Pharmacy, Prescriber Signature (including Print Your Name), and Contact. There is an arrow for "Enter Times", to a specific slot on the LHS of the other columns Form also includes: Recommended Administration Times (Guidelines only) for at what time to give Morning (Mane), Night (Nocte), Twice a day (BD), Three times a day (TDS), Regular 6 hourly (6 hrly), Regular 8 hourly (8 hrly), Four times a day (QID) Warfarin Education Record, including Patient Educated by, Sign, Date, Given Warfarin Book, Sign, Date Explanation of what "Tick if Slow Release" means Legend for Reason for Nurse Not Administering (Codes MUST be circled), including Absent, Fasting, Refused (notify Dr), Vomiting, On leave, Not available - obtain supply or contact Dr, Withheld (enter reason in clinical record), Self Administered As Required "PRN" medications, including Date, Medication (Print Generic Name), Route, Dose and Hourly frequency (pre-filled with PRN on the RHS), Max PRN dose/24 hrs), Indication, Pharmacy, Prescriber Signature (including Print Your Name), and Contact. Rows include Date, Time, Dose/Route, and Sign. Vertical column on RHS of specific drugs include "Continue on discharge? Yes/No", "Dispense? Yes/No", "Duration ___days/Qty ___". Mass vertical column on RHS include "Prescriber's Signature, Print Name, Contact, Date, Pharmacist, Date" Source: Safety and Quality Australia (GP e-version) See also [[Drug companies]] [[Tx]] Wed, 20 Sep 2023 11:54:36 +0000 Medical career Medical education is as follows: University degree in medicine, including MBBS (6 years) and MD (4 years). There is a pre-clinical portion, followed by a clinical portion (final 2 years) during medical school Resident medical officers (RMO), who are employed on 12 month temporary contracts: Internship (postgraduate year 1, PGY1), where medical graduates are required to complete at least 1 year of internship (with rotations in various fields) to gain full registration to demonstrate fitness to practice Residency (1-3 years), which represents full registration with the medical board, and can practice independently. It includes: Junior medical officer (JMO, PGY2) Senior resident medical officer (SRMO, PGY3) Registrar (3-6 years), who have been accepted into a Specialist training program, or General practice training program, to specialize in a particular branch of medicine. The entrance (usually competitive), length, and content is governed by the Medical Colleges Consultants (aka Bosses), including: GPs Staff Specialists Visiting medical officer (VMO), who are specialists who have their own private practice, who choose to practice within hospitals on a part time basis [faq]A lot of words here! In short, what's the hiearchy? Consultants are bosses. They're at the very top. Next are registrars, who are employees. Residents are junior employees. Interns are just as the word means - they're just testing the waters and try a bit of everything out. Like the Vince Vaughn and Owen Wilson movie, where they did a bit of everything at Google ;) Yep![/faq] Source: AIDA Queensland Health Map My Health Career Thu, 21 Sep 2023 02:58:36 +0000 Peptic ulcer Peptic ulcer [disease] is a break in the lining of the stomach (aka stomach ulcer) [or even the first part of the small intestine (aka duodenal ulcer), or the lower esophagus]. [faq]What is a peptic ulcer? Has it got anything to do with pepper? Not really. It's basically an ulcer in the stomach. An ulcer is just a break in the mucus lining. The problem is that the tummy is pretty acidic, so it's not as straightforward as an ulcer in the mouth.[/faq] Sx Upper abdominal pain, causing: Waking up at night, due to pain Pain improves w/ eating Burning or dull aching pain Gastric ulcer would give epigastric pain DURING the meal, as gastric acid production is increased as food enters the stomach Duodenal ulcers would initially be RELIEVED by a meal, as the pyloric sphincter closes to concentrate the stomach contents, thus acid is not reaching the duodenum. Duodenal ulcer pain would manifest mostly 2-3 hours AFTER the meal, when teh stomach begins to release digested food and acid into the duodenum Belching Vomiting Weight loss Poor appetite Asymptomatic (33% of older Pt's) [faq]What does it feel like to have a break in the lining of the tummy? Pain, where the break is. The stomach is in the upper part of the tummy, so it'll be painful. The pain is less after eating, because the tummy is less acidic, because it is diluted by food. There can be more burping, even vomiting. You might not feel like eating, and may even lose weight.[/faq] Causes H pylori, bacteria, which increases risk w/ alcohol consumption NSAID's, especially sensitive in older Pt's Less commonly: Tobacco smoking Malignancy (gastric cancer) Stress due to serious illness Crohn disease Liver cirrhosis [faq]What can cause a break in the stomach's lining? The biggie is a particular bacteria, H pylori. NSAID's, although used to reduce pain, have the awful side effect of causing ulceration in the stomach, and therefore, GI bleeds. There are also other things that can contribute to it, like smoking, stress, and disease of the GI and the liver.[/faq] Dx Suspected clinically Confirmed, if the Sx don't resolve after a few weeks of Tx, or if the Pt>45yo, or has other Sx e.g. weight loss, because stomach cancer can cause similar Sx, w/: Endoscopy, esophagogastroduodenoscopy (EGD), to directly visuallly identify, the location and severity of an ulcer Barium swallow contrast x-rays H pylori can be Dx by: Urea breath test, which uses radioactive carbon to detect H pylori. The Pt will drink a tasteless liquid which contains carbon, that the H pylori bacteria breaks down. After 1 hour, the Pt is asked to blow into a bag that is sealed. if the Pt is infected w/ H pylori, the breath sample will contain radioactive CO2. This can thus help monitor response to Tx used to eradicate H pylori Culture of a biopsy of the stomach from the EDG, although most labs aren't set up to perform a H pylori culture Rapid urease test, to detect urease activity in a biopsy Measure antibody levels in blood, although it is controversial, because it is NOT reliable, because of their inability to distinguish between past exposure to bacteria, and current infection. It can also be falsely negative if taking abx, or PPI's Stool antigen test Histological exam and staining of an EGD biopsy CXR, showing "free gas" in the peritoneal cavity. This is because if a peptic ulcer perforates, air will leak from inside the GI tract (which always contains some air) into the peritoneal cavity (which normally NEVER contains air). If the Pt is standing erect for the CXR, the gas will float to a position under the diaphragm [img]perforated-duodenal-ulcer.jpg[/img] Source: Medicalopedia [faq]How do you know if someone has a break in the lining of their tummy? Apart from their symptoms, and it getting when you give drugs to decrease stomach acid. You can use a camera down the throat. You can also do an x-ray, but because you can't see the inside of the tummy well because it's soft tissue, you can outline it with contrast, by getting the patient to drink barium. Having said that, if the tummy system has a hole through it, air will escape from the tummy system, into where you usually wouldn't find it. H pylori itself can be detected using a breath test, on biopsy of the tummy, and in the stool.[/faq] Tx Note that diet does NOT cause or prevent ulcers Stop smoking Stop NSAID's Stop alcohol Drugs to decrease stomach acid, w/ 4 weeks of Tx initially recommended, including of: PPI's (proton pump inhibitor) H2 blocker If due to H pylori, add abx Amoxicillin AND Clarithromycin, although as abx resistance is increasing, Tx may not always be effective Endoscopy, for bleeding ulcers, or if unsuccessful, open surgery [faq]What can you do about a break in the tummy's lining? You can take away things which irritate the tummy's lining, like smoking, NSAID's, alcohol. The biggie is using drugs to decrease stomach acid, which includes PPI's and Histamine-2 blockers. If you know it's H pylori causing the problem, you can also give antibiotics. A camera down the throat might also be needed, if the ulcer is bleeding.[/faq] DDx Stomach cancer Coronary heart disease Gastritis (stomach inflammation) Cholelithiasis (gallbladder inflammation) Complications GI bleeding (15%), the most common complication. Sudden large bleeding can be life threatening. It occurs when the ulcer erodes one of the blood vessels, e.g. the gastroduodenal artery (i.e. small blood vessel in the abdomen, that supplies blood to the pylorus, that connects the stomach and duodenum) GI perforation (perforated ulcer), where an untreated ulcer can burn through the full thickness of the wall of the stomach (or duodenum), allowing digestive juices and food to leach into the abdominal cavity. Perforation at the anterior surface of the stomach causes acute peritonitis, initially chemical, and later bacterial peritonitis. The 1st sign is often sudden intense abdominal pain, an example is Valentino's syndrome (i.e. named after the silent film actor, who experienced this pain before his death). Posterior wall perforation leads to bleeding due to involvement of gastroduodenal artery that lies posterior to the 1st part of the duodenum → can be Dx by erect abdominal/CXR (seeking air under the diaphragm), and Tx requires immediate surgery Gastric outlet obstruction [faq]What things can happen, due to a break in the stomach's lining? Bleeding is the biggie. Eventually, the full thickness of the tummy's line can also break. This is a massive problem, because stuff in the tummy can leak into the abdominal cavity.[/faq] Epidemiology Affects 4% of the population at any 1 time, and 10% throughout their life time Results in 301k deaths per year, although this number is decreasing Incidences of perforated uclers is steadily declining, although it still occurs See also Upper GI bleed Perforated ulcer Thu, 21 Sep 2023 18:15:18 +0000 Fetal position Fetal position is the orientation of the fetus in the womb, identified by the location of the presentating part (i.e. anatomical part closest to the pelvic inlet of the birth canal), relative to the mother's pelvis. Positions Longitudinal lie: Cephalic presentation, which is where the head is 1st. Malpresentation is any presentation other than a vertex presentation (with the top of the head 1st). Although the head comes out 1st, it can specifically include siniciput (forehead), eyebrows, face, or chin. It includes: LOA (Left occipitoanterior), where the occiput faces anteriorly and left ROA (Right occipitoanterior), where the occiput faces anteriorly and right ROP (Right occipitoposterior), where the occiput faces posteriorly and right LOT (Left occipitotransverse), where the occiput faces left ROT (Right occipitotransverse), where the occiput faces right Breech presentation (see page) Transverse lie: Shoulder presentation, which can present 1st with the arm, shoulder or trunk. It includes: Left scapula-anterior (LSA) Right scapula-anterior (RSA) Left scapula-posterior (LSP) Right scapula-posterior (RSP) See also Breech Wed, 20 Sep 2023 12:21:23 +0000 Antiepileptic drug Antiepileptic drugs (AED's, aka anticonvulsant) is used to Tx epileptic seizures. They can also be used to Tx bipolar disorder, mood stabilizer, and neuropathic pain. MOA Block sodium channels, or enhance GABA. This thus suppresses rapid, excessive firing of neurons during seizures. They also prevent the spread of seizure within the brain Classification Examples include: Aldehydes: Paraldehyde Aromatic allylic alcohols: Stiripentol Barbiturates: Phenobarbital Methylphenobarbital Barbexaclone Benzodiazepines: Clobazam Clonazepam Clorazepate Diazepam Midazolam Lorazepam Bromides: Potassium bromide Carbamates: Felbamate Carboxamides: Carbamazepine (Tegretol), a popular anticonvulsant available in generic formulations Oxcarbazepine Eslicarbazepine acetate Fatty acids: Valproates, including valproic acid, sodium valproate (Epilim), divalproex sodium Vigabatrin Progabide Tiagabine Fructose derivatives: Topiramate (Topamax) GABA analogs: Gabapentin (Neurontin), which is used as an anticonvulsant and analgesic. Originally it was developed to Tx epilepsy, but is also used to Tx neuropathic pain and restless legs syndrome. It is recommended 1st line for Tx neuropathic pain arising from diabetic neuropathy, post-herpetic neuralgia, and central neuropathic pain Pregabalin (Lyrica) Hydantoins: Ethotoin Phenytoin Mephenytoin Fosphenytoin Oxazolidinediones: Paramethadione Trimethadione Ethadione Propionates: Beclamide Pyrimidinediones: Primidone Pyrrolidines: Brivaracetam Levetiracetam (Keppra) Seletracetam Succinimides: Ethosuximide Phensuximide Mesuximide Sulfonamides: Acetazolamide Sultiame Methazolamide Zonisamide Triazines: Lamotrigine (Lamictal) Ureas: Pheneturide Phenacemide Valproylamides (amide derivatives of valproate): Valpromide Valnoctamide Other: Perampanel Side effects May reduce IQ in children See also [[Epilepsy]] Wed, 20 Sep 2023 06:22:22 +0000 Postpartum hemorrhage Postpartum hemorrhage (PPH) is significant loss of blood following childbirth. Dx Loss >500mL of blood within the first 24 hours, in a vaginal delivery Loss >1,000mL, in a Caesar Some definitions worldwide also require hypovolemia, Sx, or even measure drops in hemoglobin [by 10%]. [faq]In short, what is PPH? Loss of blood after giving birth, significant enough for us to be concerned. It's defined differently in vaginal delivery, and in Caesar. That's because Caesar is a surgical operation, so we permit more bleeding. Half a liter in vaginal deliveries. And 1 liter in Caesars. Anything greater than that is PPH. So as a comparison, what proportion of blood is this to a normal woman? In humans, it is around 5L, slightly less in women than men. Therefore, 500mL is around 10%, and 1L is around 20%.[/faq] Sx Tachycardia → compensate for hypovolemia Tachypnea → compensate for hypovolemia Postural hypotension → due to hypovolemia As more blood is lost: Hypotension → due to hypovolemia Decreased urination → due to hypovolemia Feel cold → poor circulation to periphery Become restless or unconscious → poor circulation to the brain The condition can occur up to 6 weeks following delivery [faq]What will happen to me if I have PPH :O? The sorts of things you'd expect when you have a big bleed. To compensate for low blood volume, your heart rate and breath rate goes up. Because blood volume is low, low blood pressure, decreased urination. And because you've got less blood going around your body, you might feel cold, become restless, or even unconscious.[/faq] Pathophysiology The uterus maintains 33% of the cardiac output at term, so any compromise can cause large amounts of bleeding Following delivery of the baby, the placenta separates from the uterus, leaving vessels that supplied the placenta [from the uterus] broke/ruptured. However, the myometrium (i.e. muscular layer of the uterine wall) contracts, constricting these blood vessels to cease bleeding. This occurs because the myometrium is arranged in a criss-cross pattern latticing around the blood vessels, so contraction causes clamping of the vessels, forming a clot to cease bleeding Cause Interruption of any of the aforementioned events can thus cause PPH, including (known as the 4 T's): Atony of the uterus (77.5%, most common cause of PPH), which is poor contraction of the uterus following birth, usually due to distension of the uterus, and thus loss of tone in the uterine musculature. Normally, contraction of the uterine muscle compresses the vessels and reduces flow. This increases the likelihood of coagulation and prevents bleeds. Thus, lack of uterine muscle contraction can cause acute hemorrhage Trauma to the birth canal (i.e. uterus, cervix, vagina, or perineum) (20%), which are more vascular during pregnancy, and so bleed more substantially, and more susceptible to laceration, and includes tears in the uterus Tissue retention (10%), including retained placenta Clotting disorder (1%), where there is a failure of clotting, such as in coagulopathies, or impairment due to drugs [faq]What exactly causes PPH? 4 things, which we call the 4 T's, can cause problems with this. Tone, trauma, tissue retention, and thrombin. What's tone? Following delivery, blood vessels supplying the placenta from the uterus are broken. The uterus has to contract to constrict these vessels. If the uterus doesn't contract, these vessels don't constrict. What's trauma? If there is trauma to the birth canal, there's going to be bleeding wherever that trauma is. What's tissue retention? If there's tissue retention, anything that's not supposed to be there is going to cause the body to say - that's not supposed to be there, and cause a problem. Thrombin, that means blood clot, right? Yep. And if the body has a problem clotting blood, the uterus-placental vessels are going to have problems ceasing to bleed.[/faq] Classification Primary, which occurs within 24 hours after birth Risk factors Atony of the uterus: Large baby → uterus distension Multiple gestation → uterus distension Polyhydramnios → uterus distension Obese moms → weak muscles >40yo moms → weak muscles Prolonged labor → uterine fatigue Infection Use of oxytocin (per IOL/augmentation of labor) Drugs (particularly magnesium) Where drugs are used to induce labor Trauma to the birth canal: Episiotomy (i.e. incision to the perineum) Perineal tear Following C sections → potential uterine rupture Instrumental delivery (forceps/vacuum) Tissue retention: Retained placenta Placenta accreta Coagulopathies: Congenital coagulopathies (hemophilia) Placental abruption → DIC HELLP → low platelets Anemia → predisposition to blood disorder Asian Ix Feel for a soft non-contracting uterus → uterine atony Vaginal exam → trauma to the birth canal Looking at the placenta, ensuring it is whole → tissue retention FBC, coags (PT/INR) → coagulopathies Hx coagulopathies → coagulopathies [faq]What can you do to look into PPH further? It depends if you suspect a particular type. To test for tone, you can try feeling for a soft uterus that isn't contracting. To test for trauma, you can do an internal examination through the vagina. To test for tissue retention, we look at the placenta and ensure that it is whole. To test for coagulopathy, you may be asked about coagulopathies you know you have, and even have blood tests testing your coagulation.[/faq] Tx Prevention, involves decreasing known risk factors: Uterine massage after delivery, which is compression of the uterus, to help assist uterine contraction. This can also be done bimanually (i.e. with the other hand inserted vaginally) → for uterine atony Prophylactic uterotonic, preferably oxytocin 10 units IM, to stimulate the uterus to contract shortly after the baby is born → for uterine atony. Misoprostol can be used instead of oxytocin in resource poor settings Controlled traction of the umbilical cord, whilst putting light pressure against the fundus [of the uterus], to help the placenta detach from the uterus → prevent retained tissue It is incorrect that early clamping of the umbilical cord decreases risk, and may actually cause anemia, so is not usually recommended On occurence: ABC's: Oxygenation Replete blood volume w/ IV fluids via large bore IV's, blood transfusion Uterotonic agent (i.e. agent to help the uterus contract), e.g. ergotamine → for uterine atony Compression of the aorta by pressing on the abdomen Manual remove of retained tissue → retained tissue Surgically repair lacerations → trauma Blood transfusion of factors deficient in the Pt → for coagulopathies Non-pneumatic anti-shock garment (i.e. low-tech first-aid device to Tx hypovolemic shock), to help until other measures (e.g. surgery) can be carried out Hysterectomy, where all other options have been exhausted [faq]Given how common PPH is - the fact that it occurs in 10% of pregnancies. What will my doctor do to prevent it? To help prevent uterine atony, we massage the uterus to help it contract, and we give oxytocin to help stimulate the uterus to contract. To prevent retained tissue, we do controlled traction of the umbilical cord. OK. All the preventative stuff was done :D. But I still got PPH :(. What now? First things first. We make sure we have large bore IV access so we can give you IV fluids, and that you're oxygenated. Then, what you receive depends on what type you have. For uterine atony, we give you another drug to help the uterus contract. For retained tissue, we manually remove the retained tissue, which the practitioner will do by inserting their hand through your vagina, and pulling out retained tissue. For trauma, we will surgically repair lacerations. For coagulations, we will do a blood transfusion of factors deficient in the patient. So it depends a lot on the cause of PPH ;).[/faq] Source: NSW Health (page 17) Prognosis It is a medical emergency Epidemiology PPH is common, occurring in 10% of pregnancies globally It is the 3rd top cause of maternal mortality, accounting for 25% of maternal deaths Occurs in 2% of births Whereas 0.4 per 100k deliveries die of PPH in the UK, whereas 150 per 100k deliveries die of PPH in sub-Saharan Africa In the developing world, 3% of women with PPH die Globally it results in 65k deaths annually, making it the leading cause of death during pregnancy Practitioners tend to underestimate blood loss, so definition by volumetric loss may be inaccurate Oxytocin reduces PPH by 40% Rates of death have decreased substantially since at least the late 1800s in the West Wed, 20 Sep 2023 17:12:33 +0000 Digoxin Digoxin is used in the Tx of various heart conditions, by increasing heart contractility, and decreasing heart rate. Product names include Cardigox, Cardiogoxin, Cardioxin, Cardoxin, Coragoxine, Digacin, Digicor, Digomal, Digon, Digosin, Digoxine Navtivelle, Digoxina-Sandoz, Digoxin-Sandoz, Digoxin-Zori, Dilanacin, Eudigox, Fargoxin, Grexin, Lanacordin, Lanacrist, Lanicor, Lanikor, Lanorale, Lanoxicaps, Lanoxin, Lanoxin PG, Lenoxicaps, Lenoxin, Lifusin, Mapluxin, Natigoxin, Novodigal, Purgoxin, Sigmaxin, Sigmaxin-PG, Toloxin. MOA Inhibits the Na/K ATPase mainly in the myocardium, increasing intracellular sodium levels, thus reversing the action of the sodium-calcium exchanger This increases the intracellular calcium available to contractile proteins, and thus the calcium stored in the sarcoplasmic reticulum This thus increases the contractility (i.e. force of contraction) of the heart, without increasing expenditure of energy Although it mainly affects the heart, effects OUTSIDE the heart are the cause of it's adverse effects Effective digoxin levels in blood depend on the indication, and include: For heart failure, 0.5-1 ng/ml, w/ higher levels possibly associated w/ icnreased mortality rates For HR control (AFib), 1-2 ng/ml, typically considered therapeutic for HR control, but levels are less defined, and generally titrated to a goal HR Digoxin for Tx should typically not be given above the narrow therapeutic index of 0.5-2 ng/mL, or digoxin overdose can happen [faq]What does digoxin do? It's a drug that increases the force that the heart contracts with. And it magically does this without requiring it to use more energy. By just increasing the amount of calcium stored by the contracting proteins.[/faq] Indications Atrial fibrillation Atrial flutter Heart failure, that can't be controlled by other drugs, sometimes [faq]When do you use digoxin? When you want the heart to beat with more force. So when the heart is quivering, as in atrial fibrillation and atrial flutter. And when the heart just doesn't have the strength to beat, as in heart failure.[/faq] Side effects General use may increase risk of death In suspected toxicity/ineffectiveness, dig levels should be monitored Blood potassium also needs to be closely controlled for hypokalemia, as digoxin normally competes with potassium ions for the same binding site on the Na/K ATPase pump Quinidine, verapamil, and amiodarone increases blood levels of digoxin, by displacing tissue binding sites and depressing renal digoxin clearance, so dig levels must be monitored Adverse drug reaction is common, due to it's narrow therapeutic index (i.e. margin between effectiveness and toxicity). Adverse effects are RARE when digoxin in blood is Thu, 21 Sep 2023 02:40:51 +0000 Developmental delay Developmental delay (aka delayed milestone) is where a child doesn't reach 1 of the milestone stages at the expected age, which can be in one of the 4 developmental domains: However, a wide variety of ages can be considered normal, and not a cause for medical concern. Milestones are often measured using percentiles, and milestones between the 5th and 95th percentile don't require intervention, but values towards the edges of that range can be associated with other medical conditions. It is not possible to treat. Global developmental delay (GDD) is delay that occurs in 2 or more developmental domains. [faq]What is developmental delay, and GDD? It's where there are delayed milestone in 1 of the 4 domains, so that's gross motor, fine motor, language, and social. People have also come up with extra ones, but these are the biggies. GDD is where there is delay in 2 or more of these 4 domains. Wait. You said language and social, aren't these 2 things basically autism? It is, but the diagnosis of autism requires that it's not better accounted for by GDD ;).[/faq] Milestones Developmental milestones are recognized norms of pattern of development that children are expected to follow. In premature infants ( Thu, 21 Sep 2023 15:44:09 +0000 Blood type Blood type (aka blood group) is the classification of blood based on the presence (or absence) of inherited antigens (combination of proteins, carbohydrates, glycoproteins, glycolipids) on the surface of RBC's. There are 33 blood group systems, of which the 2 most important are: ABO, which can be A, B, AB, or O. It is the Rh factor, which can be Rh+ or Rh- [faq]I see, so when we say someone has O positive blood, we mean that their blood type is O, but their Rhesus factor is Rh negative? Yep, that it ;)![/faq] Implications Many pregnant women will carry a fetus with a blood type different from their own, so the mother can form antibodies against fetal RBC's. These maternal antibodies can be IgG, which can cross the placenta and cause hemolysis of fetal RBC's, causing low fetal blood count, known as hemolytic disease of the newborn Ix Blood grouping, to detect blood group and Rh status Coombs test, to detect for RBC antibodies Tx Anti-D, for a mother who is Rh negative See also [[Anti-D]] [[Hemolytic disease of the newborn]] [[Group and hold]] (blood test) Thu, 21 Sep 2023 15:41:09 +0000 Hemolytic disease of the newborn Hemolytic disease of the newborn (HDN, aka erythroblastosis fetalis) is an alloimmune condition that develops in a fetus. Sx Jaundice increase within 24 hours of birth → hemolysis causes elevated bilirubin levels, in addition to bilirubin not being cleared via the placenta from the neonate's blood Pallor → anemia Enlarged liver and/or spleen → hemolysis Generalized swelling → heart failure Respiratory distress → heart failure Pathophysiology Maternal IgG antibodies (as IgM doesn't cross the placenta) with specificity for the ABO blood group system, are produced when the mother is exposed to a foreign antigen and produces IgG. A woman can become sensitized (i.e. produce IgG antibodies against), due to: Fetal-maternal hemorrhage, where in subsequent pregnancies, if there is a similar incompatibility in the fetus, the antibodies generated can cross the placental into the fetall bloodstream, attach to RBC's, and cause hemolysis. For example, if a mother has anti-RhD IgG antibodies due to previously carrying a RhD +ve fetus, the antibody will affect a subsequent fetus w/ RhD +ve blood. Sensitization occurs in the previous pregnancy due to: Abortion Childbirth Ruptures in the placenta during pregnancy Medical procedures carried out during pregnancy that breach the uterine wall Blood transfusion, although typecasting of ABO blood group and RhD are routine. It has been suggested women of child bearing age or under should not be given a transfusion with Rhc +ve or Kell positive blood to avoid possible sensitization, but this is not done because of the strain of resource on blood transfusion, and considerd uneconomical to screen for those blood groups Blood type O, where whereas immune response to A and B antigens is production of IgM/IgG anti-A and anti-B antibodies, women w/ blood type O are more prone to making IgG anti-A and anti-B antibodies, which can cross the placenta. Although very uncommon, cases of ABO HDN have been reported in infants born to mothers with blood groups A and B IgG molecules produced by the mother pass through the placenta, to the fetal circulation Amongst these antibodies are some which attack RBC's in the fetal circulation. These RBC's break down, and the fetus can develop reticulocytosis and anemia Many erythroblasts (i.e. a baby RBC, that is the RBC's immediate precursor) may be present in fetal blood ABO is the best known surface antigen system, expressed in a wide variety of human cells Classification ABO hemolytic disease [of the newborn], which is generally a mild disease Anti-A antibodies Anti-B antibodies Rh disease [of the newborn], including RhD, RhE, RhC, RhE, RhC, and antibody combinations Anti-Kell hemolytic disease [of the newborn] Other blood group antibodies (Kidd, Lewis, Duffy, MN, P, etc) Dx On the newborn: Hyperbilirubinemia → jaundice Blood morphology showing increased immature RBC's (reticulocytes, normoblasts) → hemolysis Positive DAT/Coombs test → autoimmune hemolytic anemia On the mother: Positive IAT/Coombs test → screen for RBC antibodies that may cause HDN Tx Prevention: Rh -ve mothers are given anti-D at 28 weeks and at 34 weeks gestation, and within 48 hours after delivery to prevent sensitization to the D antigen Before birth: Intrauterine transfusion Early IOL, when pulmonary maturity has been attained, fetal distress is present, or 35-37 weeks gestation Maternal plasma exchange, to reduce circulating levels of the body by as much as 75% After birth: ABC's, temperature stabilization and monitoring Phototherapy Transfusion w/ compatible packed RBC Exchange transfusion w/ a blood type compatible with both the infant and mother Correct acidosis w/ sodium bicarbonate and/or assisted ventilation Complications Ranges from mild to very severe Kernicterus (i.e. bilirubin-induced brain dysfunction) High out heart failure (hydrops fetalis) → due to profound anemia Can result in stillborn or perinatal death Prognosis 50% of cases occur in a 1st born baby, and it doesn’t become more severe after further pregnancies, unlike Rh disease Epidemiology In Caucasians, 20% of all pregnancies have ABO incompatibility between the fetus and mother, but only a very small minority develop Sx ABO HDN See also Blood type Rhesus disease ABO incompatibility Wed, 20 Sep 2023 15:57:40 +0000 Abortion Induced abortion is the intentional killing of a fetus/embryo, by forcing it out of a womb before it is able to survive of its own. Late termination of pregnancy (aka late-term abortion) is an induced abortion of a fetus that may be able to survive on its own. Methods Methods depend on gestational age, and include: Drugs (aka medical abortions), where abortion is induced by abortifacient drugs. In the 1st trimester are as effective as surgery: Mifepristone (RU-486), an antiprogestogen. It is the most common early 1st trimester medical regimen, and is used in combination with a prostaglandin analog (misoprostol or gemeprost) up to 9 weeks gestational age Prostaglandin analog alone, or with methotrexate, is used for up to 7 weeks gestation. Note however, that mifepristone-misoprostol combination regimen work faster and are more effective at later gestational ages than methotrexate-misoprostol combination regimens, and combination regimens are more effective than misoprostol alone Surgery, which by the 2nd semester, have lower risk of side effects than medications Vacuum aspiration (see page) D&C (dilation and curettage, aka sharp curettage) is the dilation/widening of the cervix and surgical removal of part of the lining of the uterus (and/or its contents) by curettage/scraping. Curettage is cleaning the walls of the uterus with a curette. It can also be used as a therapeutic procedure. It is the 2nd most common method of surgical abortion, and is a standard gynecological procedure performed for a variety of reasons, including examination of the uterine lining for possible malignancy, investigation of abnormal bleeding, and abortion. The WHO recommends this procedure, only when manual vacuum aspiration is unavailable Dilation and evacuation (D&E), involves opening the cervix of the uterus and emptying it using surgical instruments and suction  Intact dilation and extraction (aka intrauterine cranial decompression, or partial-birth abortion), used after the 16th week of gestation, which requires surgical decompression of the fetus’ head before evacuation. It has been federally banned in the USA Hysterotomy, a procedure similar to a C section and performed under general anesthesia. It requires a smaller incision than a C section and is used during alter stages of pregnancy Birth control (e.g. pill, intrauterine devices) can be started immediately after an abortion Labor induction abortion (aka induced miscarriage) can be done in places lacking the necessary medical skill for dilation and extraction, or where preferred by practitioners. It involves first inducing labor, and then inducing fetal demise if necessary. This procedure may be performed from 13 weeks gestation to 3rd trimester. It is very uncommon in the USA, but more than 80% of induced abortions throughout the 2nd trimester are labor induced abortions in Sweden and other nearby countries [faq]Ethics aside, there's lots of reasons why mothers' might decide to abort a fetus. How is this done? There are 2 ways. Using medications, or surgery. In the 1st trimester, medications are just as effective as surgery, and there's less complications, so we opt for that. In the 2nd trimester, we usually do surgery. We can either manually remove the child using a vacuum, or surgically scraping it out.[/faq] Prognosis Where lawful, it is a safe procedure, only causing maternal death in 0.7 per 100k procedures, or 13 times more safer than childbirth (8.8 maternal deaths per 100k) When performed legally and safely, induced abortions don’t increase the risk of long-term mental or physical problems In contrast, unsafe abortions results in 47k maternal deaths, and 5 million hospital admissions per annum globally WHO recommends safe and legal abortions be available to all women Epidemiology 44 million abortions are performed per annum globally, with slightly under 50% performed unsafely Abortion rates have plateud after declining, due to education about birth control 40% of the world's women had access to legal induced abortions without restriction as to reason, although there are limits regarding how far along the pregnancy they can be performed. Some jurisdictions legalize abortion based on specific conditions (e.g. incest, rape, problems with the fetus, socioeconomic factors, risk to a mother's health) There is widespread controversy over the morality and ethics of abortion. Supporters emphasize a woman's right to decide matters concerning her own body, and dissidents emphasize a right to life and find abortion and murder synonymous "Unlawful abortion' is a crime for both women and Dr's subject to 10 years imprisonment (NSW Crimes Act 1900 s82-84). "Lawful" was defined by Levine J in R v Wald (1971) 3 DCR (NSW) 25 as where a Dr believes on reasonable "economic, social or medical ground or reason" that an abortion was necessary to avoid a "serious danger to the pregnant woman's life or to her physical or mental health" at any point during pregnancy. Kirby J in CES v Superclinics ACES v Superclinics Australia Pty Ltd (1995) 38 NSWLR 47 expanded the period of which health concerns can be considered, to any period during the woman's life, even after the birth of the child. In NSW, a referral from a Dr is not required. Although it was thought to preclude successful prosecutions for illegal abortions, in R v Sood [2006] NSWSC 1141, Dr Suman Sood was convicted of 2 counts of performing an illegal abortion because she failed to enquire as to whether a lawful reason for performing the abortion existed See also Miscarriage (unintentional abortion) Thu, 21 Sep 2023 10:57:44 +0000 Heart block Heart block are conditions that causes a fault within the heart's natural pacemaker, due to some kind of obstruction/block in the electrical condition system of the heart. Sx Asymptomatic, in some cases, despite the severe sounding name Occasional missed beats, in some cases, which can cause lightheadedness, syncope/fainting, and palpitations May require an artificial pacemaker to be implanted, depending upon exactly where in the heart conduction is being impaired and how significantly it is affected Pathophysiology The heart uses electrical signals to maintain and initiate the regular heart beat in a living person, so incorrect conduction can cause mild/serious Sx, depending upon the location of the blockage, and how severely conductino is being blocked Conduction is normally initiated by the SA node (sinoatrial, or sinus node), and then travels to the AV node (atrioventricular node), which also contains a secondary pacemaker, that acts as a backup for the SA Nodes, then to the bundle of His, and then via the bundle branches, to the point of the apex of the fascicular branches Classification Blockages are classified based on where the blockages occur, including: SA block, at the SA node, the electrical impulse is delayed or blocked, on the way to the atria, thus delaying atrial depolarization. It includes: 1st degree SA block 2nd degree SA block, including: 2nd degree type 1 (Wenckebach block) 2nd degree type 2 (Sinus exit block) 3rd degree SA block AV block, at the AV node, which occurs in the AV node and delays ventricular depolarization. It is divided into: 1st degree AV block, where the PR-interval is prolonged (>5 small squares). It is caused by a conduction delay through the AV nodes, but electrical signal eventually able to reach ventricles. Often trained athletes can have it. it rarely causes any problems 2nd degree AV block, divided into: Type 1 (aka Wenckebach block, Mobitz 1), which has a progressive lengthening PR interval, followed by a dropped P wave and QRS complex, due to failure of conduction of the atrial beat. It is caused by a conduction block of some, but not all atrial beats getting through to the ventricles Type 2 (aka Mobitz 2), where p-waves are usually at a ratio of 2:1 or 3:1, i.e. quite a few more dropped QRS. It is due to electrical excitation intermittently failing to pass through the AV node or bundle of His 3rd degree AV block (aka complete heart block), where atrial contractions are normal, but no electrical conduction is conveyed to the ventricles. Rather, the ventricles generate its own signal from somewhere within the ventricle. Rate is slow, QRS is prolonged, P wave is unrelated and faster than QRS [img]av-block-ecg.gif[/img] Source: My Kentucky Heart Intra-Hisian block, at the bundle of His Infra-Hisian block, below the bundle of His, which may occur: Bundle branch block, at the L or R bundle branches Fascicular block (aka hemiblock), the fascicles of the left bundle branch Tx Inserting an artificial pacemaker, in severe cases where the heart's ability to control and trigger heartbeats are completely ineffective/unreliable. It is a medical device that provides correct electrical impulses to trigger heat beats, compensating for the natural pacemaker's unreliability Prognosis Heart block frequently is asymptomatic, or has only mild/occasional effects, and is not life threatening in the vast majority of cases It is treatable in the more serious cases The blocks tend to have more serious potential the closer they are to the end of the electrical path (i.e. the muscles of the heart regulated by the heartbeat), and less serious effects the closer they are to the start (at the SA node). This is because the potential disruption becomes greater as more of the path is blocked, from it's end point. Thus, most of the important heart blocks are the AV nodal blocks and infra-Hisian blocks. In contrast, SA blocks are of lesser clinical significance, since in a SA block, the AV node contains a secondary pacemaker which would maintain a HR of 40-60bpm, sufficient for consciousness, and much of daily life in the majority of Pt's See also Arrhythmia (category) Coronary heart disease (damages the heart's blood VESSELS, and can cause angina/chest pain, or MI/heart attack) ECG Thu, 21 Sep 2023 00:22:04 +0000 Gestational diabetes Gestational diabetes [mellitus] (GDM) occurs when pregnant women without a previous Hx of diabetes, develops hyperglycemia during pregnancy, especially during her 3rd trimester. Source: NDSS [faq]What is gestational diabetes? Let's break it down. Diabetes is high blood sugar. Gestational just means pregnant. So it's high blood sugar, when you're pregnant.[/faq] Sx Usually asymptomatic, and it is most commonly Dx by screening during pregnancy Increased thrist Increased urination Fatigue Nausea and vomiting Bladder infection Yeast infections Blurred vision [faq]What happens when you have high blood sugar, during pregnancy? So the same sorts of things in diabetes. So increased thirst, urination. You can also get fatigue, nausea and vomiting. And it can predispose to infection, like of the bladder, and yeast infections. It can affect blood vessels, so cause blurred vision.[/faq] Pathophysiology Insulin receptors don't function properly, likely due to pregnancy-related factors, such as the presence of hPL that interferes with susceptible insulin receptors This causes inappropriately elevated blood sugar levels Risk factors PCOS, although evidence remains controversial PH of gestational diabetes, prediabetes, impaired glucose tolerance, or impaired fasting glycemia FH of a 1st degree relative w/ T2DM Maternal aging, especially >35yo Ethnicity, w/ higher risk for Africans, Hispanics, and South East Asians Overweight (2.1x), obese (3.6x), or severe obesity (8.6x) PMH of macrosomia (>90th percentile, or >4kg) Poor obstetric Hx Genetic factors Smoking (2x) Short stature, although it is controversial Dx Non-challenge blood glucose tests, used in some jurisdictions, for ultra-early screening, which involves measuring blood glucose without challenging the subject with glucose solutions, including: Random glucose test 11.1+ mmol/L, confirms GDM Fasting glucose test 5.1+ mmol/L, confirms GDM Glucose challenge tests, a 75g to be done at 24 weeks gestation, or in high risk women, a both at 12 weeks and repeated at 24 weeks gestation. In Australia, all women are subject to a screen with a 75g GCT, rather than w/ a non-challenge blood glucose test: Screening, for inappropriately high levels of glucose in blood, which is usually how it is Dx because it is usually asymptomatic Diagnostic, which can be done at the first antenatal visit for a woman in a high-risk pregnancy (e.g. PCOS, or acanthosis nigricans). Levels include: 1 hour 10+ mmol/L 2 hour 8.5+ mmol/L Fasting (>2 hours) 5.1+ mmol/L Post-pregnancy screening: Repeat OGTT, 6 weeks after delivery, to confirm that diabetes has dissapeared Afterwards, T2DM should be regularly screened too Not recommended is urinary glucose testing (glucosuria), as although dipstick is practised widely, the sensitivity is low. Also, increased GFR during pregnancy can contribute to 50% of women having glucose in their urine, so it also lacks specificity Source: NSW Health [faq]How do you know whether someone has this pregnancy version of high blood sugar? You can do tests that are non-challenge. Or challenge. Non-challenge are screening tests, you can do it randomly, after not having eaten for a while, or 2 hours after a meal. How does glucose challenge test work? Challenge is where you give someone a certain amount of sugar, and see how they respond. Specifically, it's defined as 10+ mmol/L after 1 hour, 8.5+ mmol/L after 2 hours, or 5.1+ mmol/L whilst fasting. Why are there different figures for fasting, 1 hour, 2 hours though? Obviously, straight after a meal, it's permitted to be higher, so over time, the threshold goes down. And if you've fasted, which you can view as the MOST amount of time, it's the absolute lowest threshold. And random. That's set at the absolute highest, at 11.1+ mmol/L? That's because you could've just eaten. Which would've shot it up.[/faq] Ix U/S, to monitor development of macrosomia HbA1c, to determine glucose control over a longer period of time [faq]Apart from the sugar tests, what else can you do? Ultrasound, to see whether there's a big baby. And HbA1c, to see what blood sugar is like over time.[/faq] Tx Prevention, including: Ingesting more fiber in foods w/ whole grains, fruits, and vegetables Breastfeeding, to reduce risk of diabetes, and related risks for both mother and child Lifestyle modification, including: Modified diet and introduction of moderate exercise together can sometimes even control gestational diabetes. Food plan, is 1st line. Diet modifications should avoid peaks in blood sugar, which can be done by spreading carbohydrate intake over meals, and using slow-GI releasing carbohydrate sources. Since insulin resistance is highest in mornings, breakfast carbohydrates need to be restricted more Regular moderately intense physical activity, although it has not been found to be significant for primary prevention of GDM, but it may be used as tertiary prevention for women who have already developed the condition Smoking cessation Antidiabetic drugs, in GDM which is uncontrolled on diet and medication: Insulin therapy, mostly fast-acting insulin, before eating to blunt glucose rises after meals. Care needs to be taken to avoid hypoglycemia due to excessive insulin. More injections can result in better control but requires more effort, and there is no evidence it has greater benefits Metformin, if required, may be better than just insulin. There is some evidence it is safe, or at least less dangerous to the fetus than poorly controlled diabetes. Metformin without insulin is asociated with greater weight gain, insufficient control, and in the absence of studies, long term complications from metformin. However, babies born Tx with metformin have been found to develop less visceral fat, thus less prone to insulin resistance in later life Education, regarding self monitoring of blood glucose levels, which should aim for: Fasting capillary BGL Wed, 20 Sep 2023 20:25:49 +0000 Ectopic pregnancy Ectopic pregnancy (aka eccyesis) is a pregnancy complication, where the embryo attaches outside the uterus. [faq]What's an ectopic? Ectopic generally means something in a location that it's not supposed to. In the context of pregnancy, it's where the baby is not in it's usual location, the uterus - or, which is also known as... "the womb" ;).[/faq] Sx Asymptomatic (in 10% of cases) Less than 50% will have BOTH of these Sx: Abdominal pain, which is sharp, dull, or champy. Pain may also spread to the shoulder if bleeding into the abdomen has occured Vaginal bleeding, in varying amounts Pelvic pain Tender cervix Adnexal mass, or tenderness Excessively mobile w/ upright posturing → decrease intrapelvic blood flow, which can lead to swelling of the abdominal cavity, and cause additional pain Rarely, systemic Sx (nausea, vomiting, diarrhea) Rupture of an ectopic can lead to: Abdominal distension Tenderness Peritonism Hypovolemic shock [faq]So how do I exactly know if I have an ectopic? Can I feel the baby somewhere else, is that how I'll know? Sometimes you can feel it. The usual way you'll know is abdominal pain and vaginal bleeding. Pain is a big one! Whether it's pain in the abdomen, or even pelvis, cervix, that sort of thing. What exactly is a "rupture" of an ectopic? It sounds horrendous :O!!! It sure isn't a nice thing to experience ;)! It's where the area containing the ectopic pregnancy breaks open - ruptures :O! We become really worried about this because blood loss, things seep into places where it shouldn't causing infection... How will I know if I've ruptured? Pain. That's a definite sign ;) But the bleeding can be to such a degree, your tummy grows in size. You might even feel like beginning to wanting to faint because you've lost so much blood :(.[/faq] Classification Implantation can occur in the: Tubal pregnancy (90%), which occur in the Fallopian tube. It can grow in the fimabrial end (5%), ampullary section (80%), the isthmus (12%), and the corneal and interstitial part of the tube (2%) Nontubal ectopic pregnancy (2%), which occur in the ovary, cervix or are intraabdominal (within the abdomen). Transvaginal U/S examination is usually able to detect a cervical pregnancy Heterotopic pregnancy, where rarely, there may be 2 fertilized eggs, 1 outside the uterus and the other inside Persistent ectopic pregnancy, which is continuation of trophoblastic growth after a surgical intervention to remove an ectopic pregnancy Pregnancy of unknown location (PUL, 8-10%), where there is a positive pregnancy test, but no pregnancy has been visualized using transvaginal U/S Risk factors PID, often due to Chlamydia infection Tobacco smoking Prior tubal surgery Hx of infertility Use of assited reproductive technology Previous ectopic pregnancy, are at much higher risk of having another one [faq]What makes an ectopic more likely? If you've had one previously, obviously, it's more likely to have another one! If you've used assisted reproductive technology, because that involves manual implantation, nature isn't doing it's work, so it could be caused by that. We also know that infections and smoking is a risk factor for it too.[/faq] Ix Hx: Usually presents at 7.2 weeks after the LMP, with a range of 4-8 weeks Pain → lack of pain, indicates miscarriage Palpate for tender adnexal mass → location of the ectopic Group and hold → potential transfusion, anti-D requirement b-hCG → bhCG>1500 IU/mL + empty uterus, indicates an ectopic. Alternatively, rises of >35% in serial b-hCG's over 48 hours may indicate a viable intrauterine pregnancy. [Falls in serial b-hCG's indicate a miscarriage.] Also methotrexate works well when b-hCG is low Vaginal ultrasound (i.e. U/S transducer applied in the vagina, thus performed within the vagina, to visualize organs within the pelvic cavity) → presence of an adnexal mass, in the absence of an intrauterine pregnancy, suggests ectopic; and presence of echogenic fluid in the rectouterine pouch indicates hemoperitoneum Tissue biopsy from D&C → presence of products of conception exclude an ectopic pregnancy, since it's not "ectopic" [faq]How does my doctor confirm whether I've got an ectopic or not? If they order a b-hCG and that comes back high, we know that there's a baby in there somewhere. That's the only way that b-hCG can be high ;)! Next, we do a vaginal ultrasound, and we should find nothing in the womb. Hopefully, we can locate where the baby actually is - it is usually somewhere in the region of the uterus.[/faq] DDx Miscarriage (i.e. loss of pregnancy in the first 2 trimesteres, i.e. 3.5 cm. It can also lead to accidental termination, or severe abnormality in an undetected intrauterine pregnancy, so requires a low hCG Surgery, which may be laparoscopic (keyhole) or laparotomy (a larger incision) to gain access to the pelvis. This can then be followed by removal of the affected tube with the pregnancy (salpingectomy), or salpingostomy, which is a surgical incision into the fallopian tube, to remove the ectopic pregnancy alone. It is still recommended if: The tube has ruptured, as evidenced by bleeding, or blood clot on U/S There is a fetal heartbeat The Pt's vital signs are unstable [faq]Why is it called a salpingectomy or salpingostomy? Why not a uterine tubotomy? Well, that's a question of history and linguistics! The word "salpingo" is Greek for "uterine tube". The word "ectomy" means "surgical removal", whereas "ostomy" means to create an opening - a "stoma", which is also where we get the word "stomach" from, as the Greek word "stoma" means a "mouth". So whereas with salpingectomy we remove the tube. With salpingostomy we just create a cut into it ;)![/faq] Prognosis With very rare exceptions (including tubal pregnancy, cornual, or cervical), the fetus is unable to survive Outcomes for the mother are generally good with Tx, but most fetuses die or are aborted Fertility following an ectopic depends on several factors, most importantly a prior Hx of infertility, but generally reduces pregnancy rate. The rate of intrauterine pregnancy 2 years after Tx of an ectopic is 67%, compared with 90% in women Thu, 21 Sep 2023 01:21:55 +0000 NSAID NSAID are used for relieving pain, alleviating fever, and in higher doses, anti-inflammatory. They are non-narcotic, and thus can be used as a non-addictive alternative to narcotics. They are non-steroidal, but still have the anti-inflammatory action of steroids. MOA Non-selective COX inhibitor, and so therefore has the unwanted GI side effects due to inhibition of COX-1. This includes: Salicylates, including: Aspirin (see page) Diflunisal Salicylic acid and other salicylates Salsalate Propionic acid derivatives, including: Ibuprofen, has some anti-platelet effect, although of shorter duration than aspirin (and other anti-platelets). Examples include Nurofen, Advil. Nurofen Plus has added Codeine phosphate [img]ibuprofen.jpg[/img] Source: Counsel Heal Dexibuprofen Naproxen Fenoprofen Ketoprofen Dexketoprofen Flurbiprofen Oxaprozin Loxoprofen Acetic acid derivatives, including: Indometacin (Indocid) Tolmetin Sulindac Etodolac Ketorolac Diclofenac (Voltaren) Aceclofenac Nabumetone Enolic acid (Oxicam) derivatives, including: Piroxicam Meloxicam (Mobic) Tenoxicam Droxicam Lornoxicam Isoxicam Phenylbutazone Anthranilic acid derivatives (Fenamates), including: Mefenamic acid Meclofenamic acid Flufenamic acid Tolfenamic acid Selective COX-2 inhibitors (Coxibs), including: Celecoxib (Celebrex) Rofecoxib Valdecoxib Parecoxib Lumiracoxib Etoricoxib Firocoxib Sulfonanilides, including: Nimesulide Others, including: Clonixin Licofelone Side effects GI ulcers, and bleeding; hence, COX-2 inhibitors may be preferred In kids, Reye's syndrome (i.e. fatal syndrome detrimenting brain, liver, hypoglycemia), so is only indicated in rheumatic fever and Kawasaki disease Contraindications Absolute: Peptic ulcer or stomach bleeding Uncontrolled HTN Kidney disease Past TIA (excluding aspirin) Past stroke (excluding aspirin) Past MI (exclusin aspirin) CAD (excluding aspirin) Undergoing CABG Taking aspirin for heart In 3rd trimester of pregnancy Pt's who have undergone gastric bypass Pt's who have a Hx of allergic or allergic-type NSAID hypersensitivity reactions, e.g. aspirin-induced asthma Relative: Irritable bowel syndrome Pt's >50yo, who have a FH of GI problems Pt's who have had past GI problems from NSAID use See also [[Antiplatelet]] [[Aspirin]] Wed, 20 Sep 2023 19:06:06 +0000 Beta blocker Beta blockers reduce blood pressure (antihypertensive) and heart rate. [faq]What are beta blockers? They're drugs used to reduce blood pressure, as well as heart rate. You diferentiated blood pressure from heart rate? Yep. You can reduce blood pressure by reducing heart rate. But you can also reduce blood pressure by other means, like causing someone to pee more, which would mean there would be less circulating blood.[/faq] Classification Nonselective B-blockers include: Propranolol [img]propranolol.jpg[/img] Source: Vet Book Bucindolol Carteolol Carvedilol Labetalol Nadolol Oxprenolol Penbutolol Pindolol Sotalol Timolol B1-selective blockers, which are cardioselective, include: Acebutolol Atenolol (Tenormin) Betaxolol Bisoprolol (Bicor) Celiprolol Esmolol Metoprolol (Lopressor) Nebivolol MOA Block the beta adrenergic receptor, which are found, inter alia, on the cells of the heart muscle. They are the target of adrenaline and noradrenaline, which usually cause sympathetic effect. Thus, by blocking it, it reduces the heart rate [faq]How do beta blockers work? What is beta? So beta is referring to beta adrenergic receptors. There is... beta and alpha? What is adrenergic? So adrenergic are just receptors that are the target of adrenaline. And yes, it's divided into alpha and beta, alpha has specific targets like the bronchioles in the airways, as supposed to beta which is more specific for the heart.[/faq] Side effects Especially in non-cardioselective agents (i.e. not beta-1 selective), beta 2 antagonism causes: Bronchospasm ==> Contraindicated in Pt's w/ asthma. If bronchospasm does occur, can be treated w/ anticholinergics Alters glucose and lipid metabolism Also causes: Nausea, diarrhea, fatigue, dizziness, dyspnea, cold extremities Hypotension, orthostatic hypotension, bradycardia, heart failure, heart block Hyperkalemia and hyponatremia Hypoglycemia ==> Should thus be used cautiously in diabetics. In diabetics, prefer to use ACE and ARBs, which actually decrease risk Alopecia (hair loss) Abnormal vision, hallucinations Sleep disturbances, e.g. insomnia, nightmares, vivid dreams Sexual dysfunction, erectile dysfunction Edema Ineffectiveness, especially in use to address alpha-adrenergic stimulant overdise (e.g. cocaine, amphetamine) ==> Contraindicated in Pt's w/ history of cocaine; rather, vasodilators, diuretics and alpha blockers should be used See also [[Hypertension]] (target) Thu, 21 Sep 2023 05:36:35 +0000 Uterotonic Uterotonic (aka ecbolic) is a drug used to induce contraction [or greater tonicity] of the uterus. [faq]What is a uterotonic? It's a drug which makes your uterus, also known as the womb, to contract.[/faq] Purpose Induce labor Reduce PPH → since contraction of the uterus causes the uterus-placental blood vessels to be severed, as they are broken following delivery which detaches the uterus from the placenta [faq]Why would you use a drug to make the womb contract? Use it to start labor. And to reduce bleeding after childbirth.[/faq] Types Oxytocin (see page), and oxytocics Methylergometrine, e.g. Ergometrine Prostaglandins, which are used both for IOL as well as to induce abortion. It includes: Prostaglandin E1 (PGE1), for example misoprostol, which is slow-acting, so is not used for PPH Prostaglandin F2α (PGF2α), for example, carboprost, which is fast-acting, so is used for PPH [faq]What are some examples of drugs to make the womb contract? You have oxytocin, an example of that being syntocinon. There's ergometrine. And prostaglandins.[/faq] See also Tocolytic (antonym) Thu, 21 Sep 2023 13:31:13 +0000 Heart valve Heart valves restrict blood flow to 1 direction. There are 2 sets of valves, including: Atrioventricular (AV), including the tricuspid and mitral valve. During systole, these shut to allow flow through the SL. Semilunar (SL), including the aortic and pulmonary valve. During diastole, these shut to allow flow through the AV. [img]auscultation-points.jpg[/img] Source: Nildram See also Heart sounds Wed, 20 Sep 2023 14:59:16 +0000 Erythema Erythema (from Greek "erythros" meaning "red") is redness of skin (or mucous membrane). [img]palmar-erythema.jpg[/img] Pathophysiology Caused by hyperemia (increased blood flow) of superficial capillaries. It occurs in: Skin injury Infection Inflammation Hypercholesterolemia, just like how it causes spider nevi too Dx Disappears on blanching (pressure). In contrast, hematoma/bleeding and pigmentation don't blanch Thu, 21 Sep 2023 15:50:08 +0000 Epilepsy syndrome Epilepsy syndromes are specific features that are present. These features include the age at which seizures begin, the seizure types, and EEG findings, among others. Identifying an epilepsy syndrome is useful as it helps determine the underlying causes as well as what AED should be tried. Classification Autosomal dominant nocturnal frontal lobe epilepsy Rolandic epilepsy (aka benign childhood epilepsy with centrotemporal spikes) Benign occipital epilepsy of childhood Childhood absence epilepsy Dravet's syndrome Epilepsy in females with mental retardation Febrile infection-related epilepsy syndrome Frontal lobe epilepsy Interictal dysphoric disorder Juvenile myoclonic epilepsy (aka Janz syndrome), a common idiopathic generalized epilepsy, representing 8% of all epilepsy cases. It typically 1st manifestst itself between 12-18yo, with brief episodes of involuntary muscle twitching occurring early in the morning. Most patients also have generalized seizures that affect the entire brain, and many also have absence seizures. There are at least 6 loci for the disease, with known causative genes. Most of these genes are ion channels, or affect ion channel currents Lennox-Gastaut syndrome Ohtahara syndrome Reflex epilepsy Progressive myoclonic epilepsis Rasmussen's encephalitis Ring chromosome 20 syndrome Temporal lobe epilepsy Tuberous sclerosis West syndrome Myoclonic astatic epilepsy (aka Doose syndrome) is a generalized idiopathic epilepsy. It involves development of myoclonic seizures and/or myoclonic astatic seizures Thu, 21 Sep 2023 13:16:43 +0000 Neonatal jaundice Neonatal jaundice is jaundice (yellowing of the skin and other tissues) in neonates. [faq]Neonatal jaundice is obviously jaundice in a neonate. What do those 2 words mean? "Neonate" is a child in their first month of life - specifically, their first 28 days. "Jaundice" is where a person's skin and eye white's become yellow in color. So it's essentially when a child in their first 28 days of life becomes yellow. What causes yellowness? Bilirubin. It gets created when red blood cells are broken down. Usually bilirubin is excreted in bile and urine - which is why urine is yellow! However, at higher level, it seeps out of blood vessels and is flung throughout the body.[/faq] Cause Unconjugated hyperbilirubinemia, meaning the problem occurs BEFORE the liver: Non-hemolytic causes: Physiological in newborns, as fetal hemoglobin is being rapidly broken down and replaced with adult hemoglobin. Also, hepatic machinery [for the conjugation and excretion of bilirubin] doesn't mature until approximately 2 weeks of age. It is often seen around the 2nd day after birth, lasting 10 days in term infants [up to 204 μmol/L], or 14 days in premature births [up to 225 μmol/L] Breast milk jaundice, as breast milk may contain factors that keep the baby's liver from breaking down bilirubin. It may run in families Dehydration → bilirubin will be more concentrated Formula suppplementation, or malnutrition → breast milk promotes intestinal absorption of bilirubin, so less reaches the liver Cephalohematoma (i.e. hemorrhage between skul and periosteum, due to rupture of blood vessels crossing the periosteum) UTI Hemolytic disorders, caused by: Sepsis Blood disorders, including: Hereditary spherocytosis Sickle cell disease G6PD deficiency ABO incompatibility Rh disease Conjugated/direct hyperbilirubinemia, meaning the problem occurs: AT the liver: Infection: Sepsis Hepatitis TORCH infections (toxoplasmosis, rubella, CMV, HSV) Cystic fibrosis Metabolic: Galactosemia Alpha-1-antitrypsin deficiency Cystic fibrosis Drugs AFTER the liver: Biliary atresia (i.e. common bile duct between the liver and small intestine is either blocked or absent) Bile duct obstruction [faq]That makes sense. But why is this "bilirubin" thing at extremely high levels in babies? What disease do they have? It can be normal. There's 2 reasons for this. One, because fetal hemoglobin is being rapidly destroyed, and replaced with adult hemoglobin. And two, because the liver, which is supposed to help process the bilirubin to get rid of it into pee, doesn't mature until 2 weeks of age. So it's not surprising that they're naturally yellow for some time. I see. But how about formula? Does that damage the liver or something? For some reason, breast milk improves the ability of the tummy to eat bilirubin - we call that absorption. So less reaches the liver. I see. It's also possible that newborns have disease, right? Yes. And because they're so young, it's usually "inbuilt" stuff. Diseases they were born with. In particular, we're concerned with blood cells being destroyed super quick. And this can occur in various disorders of blood, including blood cells getting destroyed because they're not their usual shape (i.e. hereditary spherocytosis), or conflict between the mother and baby's blood (i.e. blood type autoantibodies).[/faq] Sx Yellow discoloration of the sclera, the face, extending down onto the chest, and then the extremities Infants whose palms and soles are yellow, have serum bilirubin >255 μmol/l (15 mg/dL), and is more serious Sleepy Interfere with feeding Dx Clinical assessment of color: → jaundiced appearance 14 days indicates pathological jaundice Blanching the skin by pressure, so underlying skin and subcutaneous tissue is revealed Ingram icterometer, where a piece of transparent plastic with 5 transverse strips of graded yellow lines, is pressed against the nose, and matched. Bilirubin level is accordingly assigned Transcutaneous bilirubinometer, a portable device, which generates a yellow xenon light passing through the subcutaneous tissue. Reflected light returns through an optic fiber, which is measured and assigned a bilirubin level Serum bilirubin (SBR)>85 μmol/L (5 mg/dL), which is more than double the amount required to cause jaundice in adults (>34μmol/L). Serum bilirubin is differentiated in results into Unconjugated bilirubin ("indirect") and Conjugated bilirubin ("direct") → total bilirubin >331.5 μmol/L, or direct/conjugated bilirubin >34μmol/L indicates pathological jaundice [faq]Why is the threshold for bilirubin double that which is permitted in adults :O? Because the machinery in the liver that processes bilirubin doesn't mature until around 2 weeks of age. That's why it's normal to have bilirubin levels double that in newborns, as supposed to adults :D.[/faq] Ix Hx: Hx of illness → infection FH of jaundice FH of anemia → hemolytic disorder FH of neonatal death due to liver disease → liver disease Maternal illness (fever, rash, lymphadenopathy) → infection Maternal drugs → sulfonamides, antimalarials causing RBC destruction in G6PD deficiency Clinical assessment: Presence of IUGR Intrauterine infection, which can be evidenced by cataracts, small head, hepatomegaly, splenomegaly → infection Cephalohematoma → hemolytic disorder Bruising → hemolytic disorder Signs of bleeding in the ventricles → hemolytic disorder Maternal blood group and RBC antibodies → hemolytic disease Using baby's cord blood: Blood group → hemolytic disease DAT/Coombs test → ABO incompatibility/hemolytic disease FBC → hemolysis, unusually shaped RBC's, evidence of infection CRP → infection Billirubin with differential (conjugated, unconjugated) LFT → liver disease Tx Serum bilirubin normally subsides without intervention. Tx includes: Frequent and effective feedings → bilirubin is reduced through bowel movements and urination Bili light (i.e. exposing baby to intensive phototherapy) often used in any newborn w/ serum bilirubin>=360μmol/L → blue light (wavelengths at 458nm) oxidize bilirubin to biliverdin Sunbathing is also effective, with the advantage of UV-B which promotes vitamin D production. This condition has also been rising due to less time spent outdoors Exchange transfusions (i.e. exchange of a person's own blood cells with replacement products), in any newborn w/ bilirubin>428 μmol/l [faq]So what would my doctor do if my newborn had neonatal jaundice? First of all, ensure that the child is getting frequent and effective feeds. That's because bilirubin is excreted both by both number 1's, and number 2's. How about phototherapy - also known as "the paparazzi" :D? We do not in all cases of neonatal jaundice. Remember neonatal jaundice is defined as bilirubin>255. Well, we only use it if bilirubin >=360, which is more than 40% above the level where we started saying "there's elevated bilirubin here"! And how does this "paparazzi" work? It's UV light, right? Can't that cause cancer :O? We don't use UV light because it can increase risks of skin moles and cancers. We just use good ole plain blue light ;). That does not cause cancer :D![/faq] Complications Extreme jaundice can cause kernicterus (i.e. bilirubin-induced brain dysfunction, because bilirubin is highly neurotoxic), which presents w/ fever, seizure, high pitched crying [faq]So what if a child is a bit yellow. Is it really such a concern? Yes, because at very high levels, it can cause something called "kernicterus". It's because bilirubin damages the brain - it can cause brain dysfunction.[/faq] Epidemiology Common in newborns, affecting >60% of babies in the 1st week of life [faq]Is jaundice in newborns really common? Yes. 60% will have it in their first week of life. You're not alone ;).[/faq] See also [[Jaundice]] Thu, 21 Sep 2023 08:56:11 +0000 Gynecomastia Gynecomastia is benign enlargement of breast tissue in males. Up to 70% of adolescent boys have some breast development during puberty, but 75% of cases resolve within 2 years without Tx. In adolescent boys, this can cause pscyhological distress. [img]gynecomastia.jpg[/img] Source: Make Me Heal Causes Newborn males, due to influence of maternal hormones Adolescents, due to hormonal changes during puberty Klinefelter syndrome Certain cancers Disorders of the endocrine system, or metabolic dysfunction Use of certain medications Older males, due to natural decline in testosterone production Liver failure, since the liver metabolizes estrogen, so in liver failure/cirrhosis, there is hyperestrogenemia, and thus gynecomastia Pathophysiology Caused by an increase in estrogen (female) and decrease in androgen (male), thereby increasing size of male breast tissue Mx Usually unnecessary as self-resolves Aromatase inhibitors can be effective in chronic cases Surgical removal of excess tissue is usually required Thu, 21 Sep 2023 14:43:50 +0000 Mechanical ventilation Mechanical ventilation is a method to mechanically assist or replace spontaneous breathing. Method Intubation, if necessary, inserting a tube into the body. This can include: Through the mouth (e.g. endotracheal tube) Through the skin (e.g. tracheostomy tube) Ventilator (i.e. a machine) A bag/set of bellows, compressed with the assistance of a medical personnel (i.e. registered nurse, physician, physician assistant, respiratory therapist, paramedic), including: Bag valve mask (aka manual resuscitator), which is a hand held device, used to provide PPV to patients who aren't breathing, or not doing so adequately. It can also be used whe patients rae dependent on mechanical ventilators, and that needs to be exmained for malfunction. It helps to force feed air or oxygen into the lungs in order to inflate them under pressure. It is preferred to mouth to mouth ventilation, either directly or using a pocket mask. If an adult mask is used on a child, use it in the upside down position. Pressure should be sufficient to make the chest rise. 250mL for very small babies, 500mL for infants, and 1.5L for larger children. The mask should be large enough to cover mouth and nose, but not too large to allow air leak. Mask should be held with a C grip, rest of the L hand supporting the airway, and other hand used to squeeze the bag. Ventilation should be given at 12-20bpm depending on the age of the child Classification Positive pressure ventilation (PPV), where air (or another gas mix) is pushed into the trachea Negative pressure ventilation (NPV), where air is sucked into the lungs [faq]There are 2 types of ways we mechanically help breathing? Yep, so there's positive and negative pressure. What's pressure, and what's the difference between these? So pressure is a force applied over a particular area, and it's pressures that makes the lung expand and contract in size, and also help with gas exchange. So positive pressure is where air is used to keep the airways open, to help forcibly pump air into the breathing tract. Negative pressure tries to duplicate natural breathing, which involves in sucking to decrease pressure in the lungs, to allow flow of ambient air into the lungs.[/faq] See also [[CPAP]] Thu, 21 Sep 2023 02:40:57 +0000 Hypertension [Arterial] hypertension (aka high blood pressure, HTN) is chronically elevated BP in arteries. [faq]What is hypertension? High blood pressure. What is blood pressure? The pressure of blood against the wall of the vessels, that contain it.[/faq] Pathophysiology BP is expressed by systolic (maximum) and diastolic (minimum) pressures in the arterial system The systolic pressure occurs when the L ventricle is most contracted, the diastolic pressure when the L ventricle is most relaxed prior to the next contraction Normal BP at rest is between 100/60-140/90 systolic/diastolic, so HTN is present is BP>140/90 for aduts, and different numbers apply to kids [faq]So normal blood pressure is 120/80. What is high blood pressure defined as? The normal high is 140/90. So a systolic pressure greater than 140, or a diastolic pressure greater than 90, is called hypertension.[/faq] Classification Primary (essential) hypertension (95%), with no obvious underlying cause. It tends to be familial, and is likely the consequence of an interaction between environmental and genetic factors. The prevalence of essential hypertension increases with age, and patients with relatively high blood pressure at younger ages are at increased risk for subsequent development of hypertension. It can increase the risk of cerebral, cardiac, and renal events Secondary hypertension (5%), where HTN is due to an identifiable secondary cause, including: Chronic kidney disease Narrowing of the aorta or kidney arteries Endocine disorder, e.g. excess aldosterone, cortisol, or catecholamines Tumors Side effect of many drugs [faq]What are the different types of high blood pressure? Essential, where we don't know what the cause is. And secondary, where we can identify the cause. Well then... what are the causes of high blood pressure? The kidney excretes fluid, so if there's problem there, blood pressure will increase. There can be narrowing of an article somewhere, but it's particularly a problem if it's the vessel pumping blood out the heart, or the one in the kidney. Think about it, if the same amount of blood runs through a thinner tube, the pressure is higher. It can also be a hormone thing, causing the heart to beat faster, or the body to retain more water.[/faq] Tx Dietary and lifestyle changes can improve BP control, and decrease risk of complications Drugs, is often necessary in Pt's whom lifestyle changes are not enough or not effective Prognosis Tx of moderately arterial BP (>160/100mmHg) w/ drugs is associated w/ improved life expectancy Benefits of drug Tx for BP 140/90-160/100 is more controversial Complications Doesn't usually cause Sx initially Sustained HTN is a risk factor for: Hypertensive heart disease Coronary artery disease Stroke Aortic aneurysm Peripheral artery disease Chronic kidney disease See also Antihypertensive Pregnancy HTN Wed, 20 Sep 2023 17:51:09 +0000 Colectomy Colectomy is surgical resection of any extent of the large intestine (colon). Indications Colon cancer Diverticulitis and diverticular disease of the large intestine Trauma IBD (inflammatory bowel disease), e.g. uclerative colitis → neither cures nor eliminates Crohn's, but removes part of the diseased large intestine only  Crohn's disease → cure for ulcerative collitis because the disease attacks only the large intestine, and won't flare up if the entire large intestine (cecum,a scending colon, transverse colon, descending colon, sigmoid colon) and rectum are removed Prophylactic colectomy → for some forms of polyposis, Lynch syndrome, and certain cases of IBD because of high risk for developing colorectal cancer Bowel infarction Typhlitis (i.e. inflammation of the cecum, part of the large intestine) Method Incision by either: Laparotomy (abdominal incision), traditionally Laparoscopy (minimally invasive) is growing in both indications and popularity Resection of any part of the colon entails mobilizationa nd ligation of the corresponding blood vessels Lymphadenectomy is usually performed through excision of the fatty tissue adjacent to these vessels (mesocolon), in operations for colon acncer When the resection is complete, the surgeon can immediately restore the bowel, by: Stitching or stapling together both the cut ends (primary anastomosis), which carries the risk of dehiscence (breakdown of stitches), which can cause contamination of the peritoneal cavity, peritonitis, sepsis and death Creating a colostomy (i.e. alternative channel for feces to leave the body), which is safer, but place a societal, psychological and physical burden on the Pt Classification Right and Left hemicolectomy, which refer to resection of the ascending colon (right) and descending colon (left) respectively. Extended hemicolectomy is when part of the transverse colon is also resected Transverse colectomy alone is possible, but uncommon Sigmoidectomy is resection of the sigmoid colon. Hartmann operation (aka proctosigmoidectomy) is when it includes part or all of the rectum, i.e. when sigmoidectomy is followed by terminal colostomy and closure of the rectal stump. Hartmann is usually performed when a double barrel (aka Mikulicz) colostomy is impossible, which is preferred because the reoperation to restore normal intestinal continuity by means of an anastomosis is considerably easier Total colectomy (aka Lane's operation) is when the entire colon is removed. Total proctocolectomy is if the rectum is also removed [in conjunction with the entire large intestine] Subtotal colectomy is resection of part of the colon or resection of all of the colon without complete resection of the rectum Epidemiology 40% of colon resections in the USA are performed via laparoscopy (i.e. minimally invasive) See also Colostomy Wed, 20 Sep 2023 14:13:19 +0000 Chickenpox Chickenpox (aka varicella) is a highly contagious disease caused by initial infection with varicella zoster virus (VZV). [faq]What is chickenpox? Anything to do with chickens? Not chickens, but chickpeas, or garbanzo beans. It's because they cause blisters that look like them. It's very contagious, and caused by the varicella zoster virus.[/faq] Sx Characteristic skin rash that forms small blisters, is itchy, and eventually scabs over [img]chickenpox.jpg[/img] Source: Kidspot Usually starts on the face, chest, and back; and then spreads to the rest of the body Fever Fatigue Headaches Sx usually last 5-10 days Disease is more severe in adults than children In trimester 3 of pregnancy, an infected mother is more likely to have severe Sx Fetal varicella syndrome, presents with: Damage ot the brain, including encephalitis, microcephaly, hydrocephaly Damage to the eye, including cataracts, optic atrophy Neurological disorders, including damage to the cervical and lumbosacral spinal cord, motor/sensory deficits Damage to the body, including anal and bladder sphincter dysfunction Skin disorders, including skin lesions, hypopigmentation [faq]What happens in an infection by varicella zoster virus, that causes chickpea blisters? So there are the blisters, that are itchy, and eventualy scab over. They spread over the body. There can also be flu-like symptoms, so fever, fatigue, headache. It's usually worse when it happens in adults. And it's super bad when it happens in a pregnant mom? Yep. Since it can cause fetal varicella syndrome, which can damage the brain, eyes, parts of the body, and skin. Bad stuff.[/faq] Pathophysiology Varicella zoster virus (VZV, aka chickenpox virus, HHV-3) is 1 of the 8 herpesviruses known to infect humans and vertebrates. It only affects humans, and commonly causes chickenpox in children, teens and young adults and herpes zoster (shingles) in adults and rarely in kids VZV multiples in the lungs, and causes a wide variety of Sx Airborne disease which spreads easily through coughs and sneezes, of infected persons Sx begin 10-21 days after exposure to the virus It is infectious from 1-2 days before the rash appears, until all lesions have crusted over Pt's with shingles (also caused by VZV) may spread chickenpox to those who aren't immune Pt's usually only get chickenpox once For pregnant women, antibodies produced due to immunization or previous infection are transferred via the placenta to the fetus → immunized women thus neither need to be concerned for themselves or their infant during pregnancy (and even after delivery, even if other siblings are infected, due to the presence of the mother's antibodies) In maternal VZV infection, the varicella infection can spread via the placenta and infect the baby. If it occurs in the first 28 weeks gestation, it can lead to fetal varicella syndrome (aka congenital varicella syndrome) Infection late in gestation or immediately following birth is neonatal varicella. The risk is greatest following exposure to infection from 7 days before delivery, up to 8 days following birth After the primary infection (chickenpox), the virus goes dormant in the nerves, including the cranial nerve ganglia, dorsal root ganglia, and autonomic ganglia Many years after the patient has recovered from chickenpox, VZV can reactivate to cause a number of neurologic conditions Dx Presenting Sx, especially the characteristic rash Tzanck smear (aka Tzanck test), scraping of the ulcer base to look for Tzanck cells PCR testing, of blister fluid or scabs Culturing the fluid, to see if the virus can be grown from a fluid sample Blood test, to identify: VZV-IgM (acute infection) VZV-IgG (previous infection and subsequent immunity) → identify previous chickenpox, thus protection, testing antibodies may be done to determine if a patient is or is not immune U/S, for prenatal Dx of fetal varicella infection, although a delay of 5 weeks following primary maternal infection is advised PCR (DNA) test of the motehr's amniotic fluid, although there is a risk of miscarriage. Also, having amniocentesis increase the risk of the baby evloping fetal varicella syndrome Tx Varicella vaccine, has resulted in a decrease in the prevalence (has 80% protection), and complications from the disease (protective from more severe disease). Routine immunization is recommended. Immunization even within 3 days of exposure may improve outcomes In infants of a mother with perinatal chickenpox: Give infant ZIG IM as soon as possible after birth or onset of maternal illness, which must be given within 72 hours. Continue to encourage breastfeeding unless lesions are on or near the nipple Give infant IV aciclovir (every 8 hours) in infants who develop chickenpox, didn't receive ZIG prophylaxis within 24 hours, are immunocompromised, or are premature ( Thu, 21 Sep 2023 10:36:38 +0000 Antifungal Antifungals are used to Tx fungi, such as athlete's foot, ringworm, candidiasis (thrush). Classification Polyene antifungals, including: Amphotericin B Candicidin Filipin Hamycin Natamycin Nystatin Imidazole, including: Bifonazole Butoconazole Clotrimazole Econazole Fenticonazole Isoconazole Ketoconazole Luliconazole Miconazole Omoconazole Oxiconazole Sertaconazole Sulconazole Tioconazole Triazole, including: Albaconazole Efinaconazole Epoxiconazole Fluconazole Isavuconazole Itraconazole Posaconazole Propiconazole Ravuconazole Terconazole Voriconazole Thiazole, including: Abafungin Allylamines, inhibit squalene epoxidase, anotehr enzyme required for ergosterol synthesis. It includes: Amorolfin Butenafine Naftifine Terbinafine Echinocandins, including: Anidulafungin Caspofungin Micafungin Others, including: Benzoic acid Ciclopirox (ciclopirox olamine) Flucytosine or 5-fluorocytosine Griseofulvin Haloprogin Tolnaftate Undecylenic acid Crystal violet Balsam of Peru See also Antimicrobial Wed, 20 Sep 2023 05:17:17 +0000 Otoscopy Otoscope (aka auriscope) is a device used to look into the ears, especially the outer and middle ear, by providing a view of the ear canal and tympanic membrane (aka eardrum, which is the border separating the external ear canal and middle ear, so can indicate disease of the middle ear space). The view can be obscured though, with ear wax (cerumen), shed skin, pus, canal skin edema, foreign body, and various ear diseases. Design The device most commonly involves a handle and head. The head contains a light source and low-powered magnifying lens (around 8 diopters) The end of the otoscope has an attachment for disposable plastic ear specula, so infections aren't transferred between patients Wall mounted models can be easily charged using the electric outlet. Portable models use batteries, which need to be swapped Otoscopes are often sold with fundoscopes as a Dx set Binocular otoscopes provide a 3D view, and are superior to monocular otoscopes (which are used ubiquitously in practice) Method The ear canal is straightened by pulling the pinna, and the speculum (side of the otoscope) inserted into the external ear Place the index finger or little finger against the head, thereby bracing the hand holding the otoscope, to avoid injury to the Pt's ear canal Look through the lens on the rear of the instrument, to see inside the ear canal [youtube]FE0sot4OoAE[/youtube] [img]tympanic-membrane.jpg[/img] Source: UCSD Source: WA Health [faq]I'm going in for gold... looking into the ear ;) I've pulled up the top bit, that "pinna" of the ear, and inserted the pointy "speculum" of the otoscope into the ear. What am I seeing :O ? Let's choose an ear... the left one :D! You're going to see a volcano in the middle, that comes in from the side. The center of that volcano is the "umbo". The walkway to the island is the "handle of the malleus". A second walkway is called the "incus". The cone of light that projects from the umbo to the other side is called the "light reflex". The entire walkway that is elevated is called the "pars flaccida". The "pars tensa" is everything that looks relatively depressed. So if I was to ask, which way does the umbo point...? It points down at around 45 degrees, and points AWAY from where the head is facing (i.e. the nose). And what's the whole thing called? The tympanic membrane.[/faq] Other features of particular models: Lens can be removed, so instruments can be inserted into the ear canal, such as for removing earwax Insertion point for a bulb capable of pushing air through the speculum (known as a pneumatic otoscope). This puff of air allows the examiner to test the mobility of the tympanic membrane The device can also be used to examine the Pt's: Nose (with the same speculum) Upper throat (with the speculum removed) Dx Otitis media (middle ear infection) Otitis externa (oute rear infection) See also Fundoscope Stethoscope Endoscopy Wed, 20 Sep 2023 20:42:01 +0000 COPD COPD (Chronic obstructive pulmonary disease) is an obstructive lung disease, characterized by chronic poor airflow. It includes both chronic bronchitis and emphysema. [faq]What is COPD? It's a lung disease involving poor airflow, which includes chronic bronchitis and emphysema. What's bronchitis and emphysema, and what's the difference? Bronchitis is airway inflammation. Emphysema is breakdown of lung tissue.[/faq] Sx SOB Wheezing Cough, including productive cough In ephysema, pink puffers (aka type A), including: Pink complexion Fast RR Pursed lips In chronic bronchitis, blue bloaters (aka type B), including: Cyanosis (bluish color of the skin and lips), from lower oxygen levels Ankle swelling +In acute exacerbation of COPD: Sputum, that is slightly streaked w/ blood, colored yellow/green, or thicker than usual, if due to a bacterial infection Flu-like Sx (weakness, fever, chills), in infection [faq]What does a patient with COPD appear? Remember that COPD means either the airways are inflammed, or lung tissue has broken down. So depending on which one it is, you can get shortness of breath, cough, including bringing up sputum. So that's the sort of thing you always have. What about if it suddenly gets worse? That's called acute exacerbation. When you have that, there's usually some sort of infection on top. So you might have more flu like things, like weakness, fever, chills. And rather than being clear, the sputum might be more yellow/green, thicker, or even have some blood in it.[/faq] Cause Tobacco smoking, most commonly Genetics Air pollution, commonly from poorly vented cooking and heated fires Acute exacerbation of COPD can be triggered by: Respiratory infection (50%), commonly due to Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella c. Less commonly, due to Chlamydia neumoniae and MRSA Allergens, e.g. pollens, wood/cigarette smoke, pollution Toxins, including various chemicals Failing to follow Tx, e.g. improper use of an inhaler [faq]What causes COPD? Smoking is the biggie. As with anything, if someone in your family has it, you're more likely to has it. And pollution is also another thing, that is also on the same lines as smoking. What can make COPD suddenly worse? If you get a respiratory infection, because you've already got problems with breathing, it's just going to make it worse. Allergies and other irritants can also cause problems. If the patient is supposed to take treatment, but doesn't do it properly, that can also cause problems.[/faq] Pathophysiology Long term exposure to these irritants causes an inflammatory response in the lungs resulting in narrowing of the small airways and breakdown of lung tissue known as emphysema [faq]What causes chronic poor airflow? Irritants. They cause inflammation in the lungs, which cause a combination of narrowing the airways, and breaking down lung tissue.[/faq] Dx Poor airflow, on PFT's. In contrast to asthma, the airflow reduction doesn't improve significant w/ the administration of drugs CXR, including: Overexpanded lungs Flattened diaphragm Increased retrosternal airspace Bullae Help exclude other lung diseases, e.g. pneumonia, pulmonary edema, or a pneumothorax High resolution CT of the chest, to: Show distribution of emphysema througout the lungs, although unless surgery is planned, this rarely affects Mx Exclude other lung diseases FBC ABG (arterial blood gas), used to determine the need for oxygen. It is recommended in Pt's w/ an FEV Wed, 20 Sep 2023 16:09:26 +0000 Meningococcal disease Meningococcal disease are infections caused by the bacteria Neisseria meningitidis (aka meningococcus). [faq]What is meningicoccal disease? Does it have anything to do with meningitis? Actually, it does. It's an infection be a bacteria, called meningococcus, and yes, it causes several problems, one of which is meningitis. What sort of bacteria is meningococcal? It's long name is Neisseria meningitidis, so meningococcal is like a nickname. It's a gram negative bacteria, that is round shaped.[/faq] Pathophysiology Colonizes a large number of the general population harmlessly, but in a very small percentage of Pt's, it invades the entire body through blood stream, notably the limbs and brain, causing serious illness Risk factors It is transmitted through saliva, and close, prolonged general contact with an infected Pt Sx Meningococcemia, which can cause DIC (disseminated intravascular coagulation), which is inappropriate clotting of blood within the vessels. DIC can cause ischemic tissue damage, when upstream clots obstruct blood flow, and hemorrhage, because clotting factors are exhausted. Small bleeds into skin, cause the characteristic petechial rash, which appears with a star shape. This is due to the release of toxins into blood, that break down the walls of blood vessels. Rash develops under the skin due to blood leakage that may leave red or brownish pinprick spots, which can develop into purple bruising. It can be tested by a glass test in which the rash doesn't fade away under pressure Meningitis, it's best known result Septicemia Rarely: Carditis Septic arthritis Pneumonia [faq]What happens in an infection by meningococcal? So meningitis, which is inflammation of the of the 3 layers that cover the brain and spinal cord. The bug can also spread into blood, and cause inappropriate clotting throughout the body, called DIC. Toxins in blood cause breakdown of the blood vessel walls, which causes blood leakage under skin, causing a rash that doesn't disappear when you press on it. And of course, since the bug is in blood, it can cause infection of the blood. Anything else? Since the bug is in bug, it can cause inflammation of the heart, joints, and lungs.[/faq] Tx Start Tx IMMEDIATELY, and NOT delayed whilst waiting for Ix IM administration of benzylpenicillin, and urgent transfer to hospital ABCDE's, including: IV fluids Oxygen Inotropic support, e.g. dopamine or dobutamine Mx of raised ICP IV abx, usually broad spectrum 3rd generation cephalosporins, e.g. cefotaxime or ceftriaxone. Benzylpenicillin and chloramphenicol are also effective Steroids may help in adult patients, but is unlikely to affect long term outcomes Prevention, w/ Meningococcal vaccine, which is a vaccine used against Neisseria meningitidis [faq]What can you do about an infection by meningococcal? You want to start immediately, and give benpen through muscle as soon as you can. Resuscitation is important, so give fluids, oxygen, and whatever help required. As soon as you're at hospital, we switch to antibiotics by IV. Is there any way to prevent an infection by meningococcal? Yep, with the meningococcal vaccine.[/faq] Complications Overwhelming bacterial infection meningococcemia, leads to: Massive blood invasion Organ failure Coma Hypotension/shock DIC with widespread purpura Waterhouse-Friderichsen syndrome (aka hemorrhagic adrenalitis, fulminant meningococcemia), which is adrenal gland failure, due to bleeding into the adrenal glands, comonly caused by severe bacterial infection, typically the meningococcus Neisseria meningitidis. Death [faq]What bad things happen in a bacterial infection by meningococcal? So the bug distributes right throughout blood. It can cause organs to fail. Coma, because it gets to the brain. Low blood pressure, and not enough blood going to the end organs. Widespread blood clots. Bleeding into the adrenal glands. And eventually, death.[/faq] Epidemiology Carries a high mortality rate if untreated Is a vaccine preventable disease Death occurs in 15% of cases The incidence is 10 times greater in developing countries than in developed countries Epidemic increases the incidence by 10 times Meningococcal vaccines have sharply reduced the incidence of Meningococcal disease in developed countries See also [[Vaccine]] (cateogry) Wed, 20 Sep 2023 19:30:07 +0000 Hypovolemia Hypovolemia (aka hypovolemic shock, oligemia) is a state of decreased blood volume, specifically, of blood plasma (i.e. intravascular component of volume contraction). [faq]What is hypovolemia? Low volume... and in this case, blood volume ;)![/faq] Cause Hemorrhage (internal and/or external), including: Burns Loss of fuid from the circulation, including: Vomiting Diarrhea Excess loss in urine due to DKA or diabetes insipidus Dehydration [faq]What causes low blood? So it can be loss of blood, or loss of fluid. So loss of blood is bleeding, whether that's internal or external. And loss of fluid can happen from the 2 ends, so vomiting at the top end, and diarrhea or excess urination at the bottom. And dehydration.[/faq] Pathophysiology Characterized by salt/sodium depletion, thus differs from dehydration (i.e. excessive loss of body water) Classification Stages of hypovolemic shock, include: Stage 1, which is Thu, 21 Sep 2023 11:47:56 +0000 Intrauterine device Intrauterine devices (IUD's, aka coil) are small devices, often T-shaped, containing either copper or levonorgestrel, inserted into the uterus. Examples include IUD with progestogen (Mirena), and IUD with copper. [img]mirena.jpg[/img] Source: Drug dangers [faq]What is an intrauterine device? It's a device you put inside the uterus, hence the name. Uterus just means a woman's womb.[/faq] Purpose It provides long-acting reversible contraception, with the Mirena approved to be used up to 5 years but studies showing it is effective up to 7 years Once removed, even after long use, fertility returns to normal IMMEDIATELY It is effective and safe to use in adolescents, and those who have and have not had children previously It doesn't affect breastfeeding, and can be inserted immediately after delivery It can be used immediately after an abortion [faq]Why would you want to put a device inside the womb? So it's a contraceptive, meaning it prevents pregnancy. What makes it different is that it can be used in the long term. When we say long we mean loooong, like up to 7 years for the Mirena. So if I want to get preggers, if I take it out, how long before I return to normal? Immediately. How about when breastfeeding? Yep, you can use it. Abortion? Immediately after.[/faq] Risks Substantial pain, for women undergoing IUD insertion, that requires active Mx, in 17% of nulli's, and 11% of parous women. NSAID's are effective for this Expulsion (2.3%) [[Uterine perforation]] ( Thu, 21 Sep 2023 02:41:05 +0000 Heart failure Heart failure (aka congestive cardiac failure, CCF) is where the heart is unable to provide sufficient pump to maintain blood flow needs of the body. [faq]Heart failure, what is it? Is it where the heart fails to work...? Won't you die? In a nutshell, that is correct.[/faq] Sx SOB, especially: Exercise intolerance (SOB usually worse w/ exercise), and thus usually limits ability to exercise Orthopnea (while lying down) Paroxysmal nocturnal dyspnea (may wake the Pt at night) Fatigue (excessive tiredness) Peripheral edema (leg swelling) [faq]So what does failure of the heart to work properly, present as? It depends on whether there's a problem with the right or left side. What if there are problems with the left, pumping side of the heart? It's going to back up into the lungs. So shortness of breath is the biggie. What if there are problems with the right side of the heart? It's going to back up to the legs, and cause swelling there.[/faq] Pathophysiology Either the structure or function of the heart is changed This in turn causes reduced force of contraction, due to increased workload, that is overloading of the ventricle In a healthy heart, per the Frank-Starling law, stroke volume increases in response to increased filling of the heart, thus causing a rise in cardiac output However, the ventricle is loaded with blood is loaded to the point, where heart muscle contraction becomes less efficient, due to reduced ability to cross-link actin and myosin filaments in over-stretched heart muscle Cause Any condition which reduces the efficiency of the heart muscle, through damage or overloading. This includes numerous conditions, including: CAD, including previous MI/heart attack, where heart muscle is starved of oxygen and dies HTN, which increases force of contraction needed to pump blood Atrial fibrillation Valvular heart disease Alcohol abuse (excess alcohol use) Infection Cardiomyopathy of an unknown cause Amyloidosis, where misfolded proteins are deposited in the heart muscle, causing it to stiffen High output states, where the ventricular systolic function is normal but the heart can't deal with an important augmentation of blood volume. It occurs in: Overload situations (blood or serum infusions) Kidney diseases Chronic severe anemia Beriberi (vitamin B1/thiamine deficiency) Hyperthyroidism Paget's disease AV fistulae AV malformations [faq]What causes the heart to stop working? If the heart loses it's blood supply, because it dies, which happens in a heart attack. Very high blood pressure can also weaken the effectiveness of the heart. Or essentially any other problem with the heart.[/faq] Classification Depending on ejection fraction, which is the proportion of blood pumped out of the heart during a single contraction. It illustrates the ability of the left ventricle to contract, or the heart's ability to relax, and includes: Systolic heart failure (aka HF due to reduced EF, HF due to LV systolic dysfunction, systolic heart failure), is where the EF16 cm H2O at the RA Jugular vein distensino Positive abdominojugular test Weight loss>4.5 kg in 5 days in response to Tx, sometimes classified as a minor criterion Minor criteria, which are ONLY acceptable if they CAN'T be attributed to another medical condition, e.g. pulmonary HTN, chronic lung disease, cirrhosis, ascites, or nephrotic syndrome. It includes: Tachycardia (abnormally fast HR>120bpm) Nocturnal cough SOB w/ physical activity Pleural effusion Decrease in the vital capacity by 1/3rd from maximum recorded Hepatomegaly (liver enlargement) Bilateraly ankle edema (swelling) [faq]How can you check to see whether the heart is failing? An ultrasound of the heart, which we call an echocardiogram.[/faq] Ix To determine cause: Blood tests ECG CXR BNP Monitoring, including: Fluid balance, calculating fluid intake and excretion Monitoring body weight, which in the shorter term reflects fluid shifts DDx Obesity Kidney failure Liver problems Anemia Thyroid disease Tx Depends on severity and cause of disease Lifestyle modifications, in Pt's w/ chronic stable mild HF, including: Smoking cessation Light exercise Dietary guidelines, regarding fluid and salt intake, being of particular importance Drugs, including: Left ventricular dysfunction: ACEi's or ARB's Beta blockers For severe disease: Aldosterone antagonist Hydralazine + nitrate Diuretics, to prevent fluid retention Implanted device, e.g. placemaker or an implantable cardiac defibrillator, depending on the cause Cardiac resynchronization therapy, or cardiac contractility modulation, in moderate to severe cases Ventricular assist device or heart transplant, may be required in those w/ severe disease despite all other measures [faq]What can you do when the heart fails? Lifestyle stuff, like quitting smoking, exercise, and improving diet. You can use things that affect the electrical system of the heart. You can get a new heart. And there are also some drugs you can use. What drugs can you take? You can take things that slow the heart, like beta blockers. You can take cause you to pee out fluid, like ACEi's, ARB's, even aldosterone antagonists. You can also take blood vessels which cause blood vessels to relax. These all decrease blood pressure.[/faq] Prognosis It is potentially fatal condition Epidemiology It is costly It is common, in developed countries, 2% of adults have HF, and in those >65yo this increases to 8% 1 year after Dx the risk of death is about 35%, after which it decreases to Thu, 21 Sep 2023 13:41:45 +0000 Hib vaccine Hib vaccine (aka Haemophilus influenzae type B vaccine) is a conjugate vaccine developed for the prevention of disease caused by Haemophilus influenzae type B bacteria. [faq]What is Hib vaccine? It's a vaccine made to prevent disease caused by Haemophilus influenzae type B bacteria.[/faq] Disease H influenzae type B (HiB) causes, in infants and young children, and therefore is redressed by the vaccine: Bacteremia Pneumonia Epiglottitis Acute bacterial meningitis Occasionally: Cellulitis Osteomyelitis Infectious arthritis Unencapsulated H influenzae strains are unaffected by the Hib vaccine, and cause: Ear infections (otitis media) Eye infections (conjunctivitis) Sinusitis Pneumonia [faq]What disease is caused by the Haemophilus influenzae type B bacteria? Bacterial infection of blood, of the lungs, of the membranes covering the brain. However, the vaccine doesn't help with unencapsulated organisms, which can still cause infections of the ear, eye, sinus, and lungs too.[/faq] Epidemiology Following routine use, the incidence of invasive Hib disease has decreased from 0.1% to less than 0.001% Hemophilus influenzae type B is a Notifiable disease Hib remains a major cause of LRTI's in infants and children in developing countries where the vaccine is not widely used See also [[Meningococcal vaccine]] [[Vaccine]] (category) Thu, 21 Sep 2023 04:42:00 +0000 Antepartum hemorrhage Antepartum hemorrhage (from Latin "ante" meaning "before", and "partus" meaning "to bring forth", APH) is genital bleeding during pregnancy, from the late 2rd trimester (weeks 0-28) forth, specifically, 24 weeks gestation to term. Intrapartum hemorrhage (IPH) is where it occurs during labor itself. [faq]Antepartum hemorrhage is bleeding in antepartum. What's that? Antepartum is before childbirth. But it's not just any time before birth. That's because any bleeding in the 1st, and most of the 2nd trimester, very strongly suggests a miscarriage. So that's why we call it a threatened miscarriage.[/faq] Cause Bloody show, most common cause of APH Placental: Maternal blood: Placental abruption, most common pathological cause → +uterine pain Placenta previa, 2nd most common pathological cause Fetal blood, which can be distinguished with an Apt test: Vasa previa, often leads to fetal demise Uterus: Uterine rupture Vaginal bleeding (see page), for non-pregnancy related reasons, including: Cervical polyp Cervicitis Cervical neoplasm Vaginal trauma Vaginal neoplasm STI Sexual intercourse Pap test Bleeding confused with vaginal bleeding, including: GI bleeds, including hemorrhoids, IBD Urinary tract bleed, including UTI [faq]What causes bleeding in that last trimester before birth? It can be the blood-tinged mucus that occurs just before birth, called a bloody show. It can be problems with the placenta, like when the placenta is blocking the womb at the cervix at the bottom, the fetal blood vessels can overly the cervix at the bottom, the placenta can be detached from the wall of the womb. The womb contents can spill into the peritoneal cavity. There can also be vaginal bleeding due to a reason outside of the pregnancy. Or bleeding that is not even vaginal, like from the tummy or urinary system.[/faq] Classification Severity of APH can be assessed by: Spotting, which is staining, streakking or blood spotting noted on underwear or sanitary protection Minor hemorrhage, which is blood loss 1000mL and/or signs of clinical shock Source: WA Health Ix Hx, of: Triggers, including sexual activity, trauma, exertion Bleeding occuring w/ ROM → ruptured vasa previa APH → bloody show, placenta previa, placenta abruption CTG, for FHR → fetal wellbeing Fetal doppler, for FHS → fetal wellbeing Palpate, for: FM → fetal wellbeing Uterine tone → Soft, non-tender uterus may suggest a lower genital tract cause, bleeding from the placenta, or vasa previa Increased uterine tone may indicate placental abruption Weigh pad before and after use, can indicate ongoing blood loss → severity → bloody show has limited bleeding Vaginal exam: Inspecting for clots → absence of clots in the presence of significant bleeding can indicate clotting abnormalities Loss of fetal station on manual vaginal exam → uterine rupture Transvaginal U/S → can show low lying placenta per placenta previa Tx Should be considered a medical emergency (regardless of whether there is pain) Prognosis Can be associated with reduced fetal birth weight If left untreated, can lead to death of the mother and/or fetus See also Threatened miscarriage (birth) Postmenopausal bleeding (>menopause) Vaginal bleeding (category) Thu, 21 Sep 2023 16:53:43 +0000 Benzodiazepine Benzodiazepine is a depressant drug, used to Tx anxiety, insomnia, agitation, seizure, muscle spasm, alcohol withdrawal, and premedication for medical or dental procedures. They can be either short, intermediate, or long acting. MOA Enhances the effect of the neurotransmitter GABA, at the GABA-A receptor, resulting in sedative, sleep-inducing, anti-anxiety, anticonvulsant, and muscle relaxant properties Side effects Cognitive impairments and paradoxical effects (aggression or behavioral disinhibition) occassionally occur. Long term use may cause adverse psychological and physical effects It is prone to cause tolerance, physical dependence, and upon cessation after long term use, withdrawal There is also controversy regarding safety of benzo in pregnancy, and may cause cleft palate They are much less toxic than their predecessor, barbiturates, and death rarely results when benzo is the only drug taken, however, can be toxic and cause fatal overdise when taken with other depressants like ethanol and opiates Examples of a short-acting benzo is: Brotizolam Midazolam Triazolam Example of an intermediate-acting benzo is: Alprazolam Estazolam Flunitrazepam Clonazepam [img]clonazepam.jpg[/img] Source: FastRelief4U Lormetazepam Lorazepam Nitrazepam Temazepam Example of a long-acting benzo is: Diazepam (Valium) [img]valium.jpg[/img] Source: NHS Clinical scientists Clorazepate Chlordiazepoxide Flurazepam See also Antidepressant (antonym) Wed, 20 Sep 2023 20:25:55 +0000 Colon cancer Colon cancer (aka colorectal cancer, rectal cancer, bowel cancer) is cancer in the large intestine (e.g. colon, appendix, rectum). [faq]What is colon cancer, and how does it differ from colorectal, rectal, and bowel cancer? Colorectal just means the colon and the rectum. The colon is another word for the large intestine. Bowel is just another word for intestine, but we're specifically talking about the large intestine here ;). So in short, we're trying to talk about any cancer of the large intestine here :).[/faq] Pathophysiology Typically starts as a benign tumor often in the form of a polyp, in the lining of the bowel If left untreated, it can become cancerous, growing into the muscle layers underneath, and then through the bowel wall [faq]How does large intestine cancer happen? It starts off as a polyp. Which is basically just an abnormal growth, which just grows off the side of the large intestine. And if you don't cut it out, it can become cancer, and spread.[/faq] Sx Blood in stool Rectal bleeding Anemia Unexplained weight loss Persistent changes in bowel habits Severe abdominal pain Persisting fatigue [faq]What will it be like if you had cancer in the large intestine? Well stool goes through the large intestine, so if there's a break in the lining of the large intestine, there might be stool in the blood. The bleeding can also cause low red blood cells. There might also be changes in bowel habits. Tummy pain. As with all cancer, you might also have systemic symptoms, like weight loss.[/faq] Risk factors Lifestyle, including: Diet, high in red, processed meat, or low in fiber Smoking Alcohol Lack of physical activity Increasing age Inherited genetic disorders, rarely ( Thu, 21 Sep 2023 16:25:10 +0000 Lung function test Lung function test (aka pulmonary function test, PFT's) measures how well the lungs work. It can be used to Dx asthma, COPD, and the extent of damage caused by pulmonary fibrosis and sarcoidosis. Method Tests include: Spirometry, which tets how much air you can breathe in and out, and how fast you can blow air out. Parameters include: FVC (Forced vital capacity), is the volume of air that can forcibly be blown out after fulll inspiration, measured in liters FEV1 (Forced expiratory volume in 1 second), is the volume of air that can be forcibly be blown out in 1 second, after full inspiration. Values between 80-120% of the average value are considered normal, depending mainly on gender and age, but also height, mass, and ethnicity. Can be calculated here: FEV1/FVC ratio (FEV1%), is the ratio of FEV1 to FVC. It should between 70-85%, declining with age. In OBSTRUCTIVE diseases (e.g. asthma, COPD, chronic bronchitis, emphysema), FEV1 is decreased because of increased airway resistance to expiratory flow. The FVC may be decreased too, due to premature closure of the airway in expiration, but not in the same proportion as FEV1. This combination creates a reduced FEV1/FVC ratio. In contrast, in RESTRICTIVE disease (e.g. pulmonary fibrosis), the FEV1 and FVC are both reduced proportionately, or even increased, due ot decreased lung compliance. FEV1% predicted is where this is divided by the average FEV1% in patients of similar age, gender, and body composition FEF (Forced expiratory flow), is the flow/speed of air coming out of the lung during the middle portion of a forced expiration. It is given at discrete times, defined by what fraction remains of the FVC (forced vital capacity). The intervals usually used are 25% (FEF25), 50% (FEF50), and 75% (FEF75). It can also be given as the average flow during an interval, deliinated by when specific fractions remain of FVC, usually 25-75% (FEF25-75%). Values ranging from 55% to 130% of the average are considered normal, depending on age, gender, height, mas, and ethnicity. Research suggests that FEF may be more sensitive than FEV1 to detect obstructive small airway disease PEF (Peak expiratory flow), is the maximal flow/speed achieved during the maximally forced expiration initiated at full inspiration, measured in L/min, or L/sec TV (Tidal volume), is the amount of air inhaled and exhaled normally at rest TLC (Total lung capacity), is the maximum volume of air present in the lungs DLCO (Diffusing capacity), is the carbon monoxide uptake from a single inspiration in a standard time, usually 10 seconds. Since air consists of only a trace of CO, 10 seconds is considered the standard time for inhalation, then rapidly blown out. The exhaled gas is tested to determine how much of the tracer gas was absorbed during the breath. It can help detect diffusion impairments, e.g. in pulmonary fibrosis. However, it has to be corrected for hemoglobin levels (as in anemia, or pulmonary ehmorrhage), and altitude/pressure MVV (Maximum voluntary ventilation), is a measure of the maximum amount of air that can be inhaled and exhaled in 1 minute. For the comfort of the patient, it is done over 15 seconds, and extrapolated to a value for 1 minute, and expressed as L/min. Average values are 140-180L/min in males, and 80-120L/min in females Cst (Static lung compliance), is where volume measurements are taken by the spirometry, in conjunction with pressure transducers, to simultaneously measure the transpulmonary pressure. Cst is the slope of the curve, of,the relations between changes in volume, vs changes in transpulmonary pressure, ΔV/ΔP. It is the most sensitive parameter for detecting abnormal pulmonary mechanics. It is considered normal if it is 60-140% of the average, in populations of similar age, gender, and body composition Lung diffusion capacity, which measures how well oxygen passes from the lungs to the bloodstream See also [[Asthma]] [[COPD]] Thu, 21 Sep 2023 12:11:25 +0000 Webster pack Webster pack is a system to manage medications, by pre-packing a week's worth of tablets in an easy to administer blister pack, segregated into a board which is in a calendar format, with times of days and dates. Wed, 20 Sep 2023 04:38:22 +0000