Autoprac: Most recent http://autoprac.com Pulse http://autoprac.com/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) Sat, 23 Mar 2019 04:53:33 +0000 http://autoprac.com/pulse Perineal tear http://autoprac.com/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) Sat, 23 Mar 2019 01:13:44 +0000 http://autoprac.com/perineal-tear Group and hold http://autoprac.com/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]] Sat, 23 Mar 2019 04:45:57 +0000 http://autoprac.com/group-and-hold Gravidity and parity http://autoprac.com/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 Sat, 23 Mar 2019 02:01:19 +0000 http://autoprac.com/gravidity-and-parity Fluid replacement http://autoprac.com/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 Sat, 23 Mar 2019 04:05:31 +0000 http://autoprac.com/fluid-replacement Bishop score http://autoprac.com/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 Sat, 23 Mar 2019 02:14:27 +0000 http://autoprac.com/bishop-score Pelvic exam http://autoprac.com/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) Sat, 23 Mar 2019 01:10:02 +0000 http://autoprac.com/pelvic-exam Measles http://autoprac.com/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 Fri, 22 Mar 2019 23:26:40 +0000 http://autoprac.com/measles Newborn examination http://autoprac.com/newborn-examination Newborn examination is an exam done of newborn babies in accordance with a checklist. [youtube]787D5wz1Fpk[/youtube] [faq]What is a newborn exam? I'm guessing it's an exam you do on all newborns? Exactly! So it's like a bit of a screening test, and it's a combo test, that involves a little bit of everything. So there's a bit of heart and lung exam, a bit of tummy exam, a bit of musculoskeletal, and neurology too... which is basically all the physical exams we do on patients ;). But we do a bit of everything, rather than everything in detail.[/faq] Classification Vitals: BP HR RR O2 sats Temperature Growth: Weight Length Head circumference General appearance: ABC's Distressed? Well vs unwell looking LOC Activity Quality of cry Malformations/abnormalities/dysmorphisms Posture/tone Size/maturity Color (pallor, plethora, jaundice, cyanosis/acrocyanosis) Skin: Color Vernix Milia Mongolian spots Hemangiomas Salmon patch, are small flat patches of pink or red skin with poorly defined borders. They become more intense in color and noticeable when the child is crying. Most lesions will spontaneously dissapear within the 1st year of life. Stork bites are those found at the nape of the neck, and angel's kiss are those found on the forehead between the eyebrows or on the yeelids. Stork bites tend to be more persistent and may remain unchanged into adult life in 50% of cases. Salmon patches are very common and occur in 40% of all newborns Cafe au lait spot/macule (French for "coffee with milk", aka giraffe spots), caused by a collection of pigmented-producing melanocytes in the epidermis of the skin. These spots are typically permanent, and may grow, or increase in number over time. It is often harmless, but may be associated with syndromes such as neurofibromatosis type 1 Petechiae or bruising [faq]So how do you examine a newborn bub? So we always start by placing our hands behind our backs, and looking. Start with vitals. We can look at growth, like weight, length, head circumference. Check out general appearance, so whether they're distressed, looking well, conscious, active, crying, any malformations, tone, size, color. If you think about it, a lot of this is actually the APGAR test. We can look at skin, so color, whether there are any patches or spots, bruising. Wait, what's the APGAR test again? Appearance, pulse, grimace, activity, and respiration. Great way to memorize it too ;).[/faq] Head: Head: Head molding, which is an abnormal head shape that results from pressure on the baby's head during childbirth Suture lines, where bony plates of the skull join together can be easily felt in the newborn infant Fontanelles (anterior, posterior, aka soft spot), which is the anatomical feature comprising of the soft sutures between the cranial bones. Fontanelles allow for rapid stretching and deformation of the neurocranium as the brain expands faster than the surrounding bone.  Bruising (caput seccedaneum, cephalohematomas, subgleal hematom) Eyes: Symmetry Set/shape Discharge Erythema Red [light] reflex, which is a reddish-orange reflection of light from the eye's retina observed when using an fundoscope from approximately 30cm. It is usually performed in a dimly lit or dark room. Leukocoria (aka white pupillary reflex) is abnormal white reflection from the retina, and can indicate cataract or retinoblastoma. Absence of a red reflex can indicate retinal detachment Dysmorphic features Flattened nasal bridge, which can indicate Down syndrome, fragile X syndrome, or FAS Epicanthal folds (aka eye fold), which are the skin fold of the upper eyelid, covering the inner corner of the eye. It is often associated with the nasal bridge, with a lower-rooted nose bridge more likely to cause epicanthic folds, and a higher-rooted nose bridge less likely to do so ENT Ear set/shape Nasal patency Palate Neck Palpate sternocleidomastoid muscles ROM of neck Palpate clavicles Webbing/redundant skin [faq]You then start from the top, at the head. What do you do? So we look from pressure spots on bub's head, suture lines of bub's skull, the soft spot in their skull which lets them grow quick, bruising. With eyes, you look at shape, discharge, redness, light reflexes. Dysmorphic features, like a flat nose, or eye folds. The ENT, including the ear shape, patency of the nose, palate. Neck, so their muscles, movement of the neck, and checking for webbing.[/faq] Chest: Inspect for: Asymmetry Breast hypertrophy Palpate for: Brachial pulses Femoral pulses Auscultate for: Air entry Crackles Heart sounds Murmurs [faq]Chest, I'm guessing you do a quick cardioresp... heart and lung exam? Yep ;). So look for asymmetry. Palpate for pulses, which are done at the arm or the legs, the legs are probably the most easily felt. And listening for air entry, crackles, heart sounds, and murmurs. So it's just a quicky check of everything.[/faq] Abdomen: Inspect for: Defects 3 vessel umbilical cord, with most babies have 1 vein and 2 arteries Diastasis recti Umbilical hernia Scaphoid abdomen Abdominal distension Palpate for: Liver Spleen tip? Kidneys [faq]So moving further down to the tummy? Yep, so we look for defects, herniation in the tummy, distension of the tummy. We look for the umbilical cord, which should usually have 3 vessels, 1 vein and 2 arteries. Like the lungs, it's the other way around, so the veins supply bub with oxygenated blood, and the arteries take away deoxygenated blood back to the placenta which connects them to mom's womb wall. We also want to feel for their liver on the upper RHS, spleen on the upper LHS, and kidneys at the flanks on both sides.[/faq] Genito-urinary: Inspect for: Ambiguous genetalia? Male: Testes present Scrotal swelling - hernia? hydrocele? Penis length Petechia or bruising Female: Labia majora Clitoromegaly? Anus: Patent Sacral dimple? [faq]Further down is the urinary system? So checking for genetalia. So in boys, checking testes are present, and there's no swelling, or bruising. Checking that the anus is patent.[/faq] MSK: Inspection for spontaneous symmetric movements? Hands: Polydactyly Syndactyly Abnormal dermatoglyphic patterns Feet: Polydactyly Syndactyly Talipes equinovarus Gap between toes Hip: Barlow maneuver, used to screen for development dysplasia of the hip. It is performed by adducting the hip (i.e. bringing the thigh towards the midline). If the hip is dislocatable, that is, if the hip can be popped out of the socket, this test is considered positive. The ortolani maneuver is then used to confirm the positive finding (i.e. the hip is actually dislocated) Ortolani maneuver, which relocates the dislocation of the hip joint that has just been elicited by the Barlow maneuver. The examiner flexes the hips/knees to 90 degrees, then with the examiner's index fingers placing anterior pressure on the greater trochanters, gently and smoothly abduct the infant's legs using the examiner's thumbs. A positive sign is a distinctive "clunk" which can be heard and felt as the femoral head relocates anteriorly into the acetabulum. Specifically, this tests for posterior dislocation of the hip. This test usually becomes negative after 2 months of age Spine: Scoliosis Spinal disraphisms, including: Tufts of hair, in the lower spine, indicating [[spina bifida]] Lipomas Hemangiomas Large dimple, in the lower spine, indicating spina bifida [faq]Now that we've worked down to the bottom, we work in, into the bones? Yep, so we make sure bub is moving both sides. Making sure their hands and feet are fine. There's special tests we do for the hip. And we check the spine as well, ensuring their spine is straight. Wait, what are the tests you do on the hips? So there's Barlow maneuver, where you bring the thighs towards the midline, and see if the hip can be dislocated. If it can be, we use Ortolani maneuver to ensure the hip IS actually dislocated, by relocating the dislocation, by flexing it to 90 degrees, which should make a distinctive "clunk" sound.[/faq] Neuro: Inspect for: Posture Alertness (with and without stimulation) Tone for suspension Reflexes: Plantar reflex, which is elicitated when the sole of the foot is stimulated with a blunt instrument. Whereas in adults, it should cause a downward response - in children, there should be an upward response known as the Babinski sign (aka Koch sign) - which although suggests a UMN lesion in adults, is normal a primitive reflex in infants which is only inhibited by 1-2yo Rooting reflex, is where an infant will turn its head towards anything that strokes its cheek or mouth, searching for the object by moving its head in steadily decreasing arcs until the object is found. After becoming used to responding this way, the infant will move directly to the object without searching. This reflex assists in the act of breastfeeding. It dissapears around 4mo, as it gradually comes under voluntary control Moro reflex (aka startle response, embrance reflex), which occurs when the infant's head suddenly shifts position, temperature changes abruptly, or they are startled by a sudden noise. The legs and head extend while the arms jerk up and out with the palms up and thumbs flexed. Afterwards, the arms are brought together, and the hands clench into fists, and the infant cries loudly. It normally dissapears by 3-4mo, but may last up to 6mo. Bilateral absent can mean damage to the CNS, whilst unilateral absence could mean injury due to birth trauma (e.g. fractured clavicle, injury to the brachial plexus). It has evolutionarily helped infants cling to their mothers whilst being carried around. If the infant lost its balance, the reflex caused the infant to embrace its mother and regain hold of the mother's bdy Palmar grasp reflex, where an object is placed in the infant's hand and strokes their palm, their fingers will close and they will grasp it with a palmar grasp. The grip is strong but unpredictable, they may release the grip suddenly and without warning. It persists until 5-6mo [faq]So the neurological exam's the last one? Yep. So we check for posture, alertness. And then the many, many reflexes. What sorts of reflexes are there? So there's the plantar reflex, which in kids, goes upwards, unlike adults. Rooting reflex, where bub turns it's head towards anything that strokes its cheek or mouth. Moro reflex, where bub's head suddenly shifts when startled by a sudden noise. And palmar grasp reflex, where bub will curl and grasp anything that strokes their palm.[/faq] Source: Learn pediatrics Sat, 23 Mar 2019 04:38:47 +0000 http://autoprac.com/newborn-examination Corticosteroid http://autoprac.com/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 Fri, 22 Mar 2019 22:53:48 +0000 http://autoprac.com/corticosteroid Jugular venous pressure http://autoprac.com/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 Fri, 22 Mar 2019 20:12:28 +0000 http://autoprac.com/jugular-venous-pressure Splinter hemorrhage http://autoprac.com/splinter-hemorrhage Tiny blood clots running vertically under the nails, and are associated with, inter alia, infective endocarditis, and trauma. At first, they are plumb colored, but darken to brown or black in a couple of days. Pathophysiology In cardio-related, clots can migrate from the affected heart valve, and find their way into various parts of the body, including the finger, which damages the capillaries, resulting in a splinter hemorrhage. [img]splinter-hemorrhage.jpg[/img] Source: http://www.dermaamin.com/site/images/clinical-pic/s/splinter-hemorrhages/splinter-hemorrhages7.jpg     Sat, 23 Mar 2019 00:54:04 +0000 http://autoprac.com/splinter-hemorrhage ECG http://autoprac.com/ecg ECG (electrocardiography) is a record of electrical activity of the heart over time, detected by electrodes attached to the skin surface (non-invasive) at various set locations. Method The standard 12-lead ECG involves 10 electrodes, attached at RA (right arm), LA (left arm), RL (right leg), and LG (left leg). The other 6 are named from V1 to V6, with: V1 at the 4th intercostal right of sterum V2 at the 4th intercostal left of sterum V4 at the 5th intercostal in the mid-clavicular line V6 at the mid-axillary line V3 lies between V2 and V4 V5 lies between V4 and V6 [img]12-lead-ecg-placement.png[/img] Source: EMT resource [img]ecg-anatomy.jpg[/img] Source: Life in the fast lane Interpretation [img]ecg-wave.jpg[/img] Source: Blogspot P wave, is atrial depolarization, causing atrial contraction QRS complex, is depolarization of the R and L ventricles, causing ventricular contraction Q wave, is depolarization of the interventricular septum (i.e. wall separating the R and L ventricles) R wave, is depolarization of the R and L ventricular walls S wave, is depolarization of the Purkinje fibers T wave, is repolarization of the ventricles. The T wave is positive, even though REpolarization (i.e. the opposite of DEpolarization) is occurring, because of a double negative - REpolarization occurs in the OPPOSITE direction. However, aVR, is normally negative Indications Common patterns include: Rhythm: Sinus rhythm (SR), which is normal, having a regularly regular rhythm, and a HR of between 60-100bpm Sinus bradycardia, where the HR is 100bpm. It is a tachycardia originating from the SA node Asystole, where the rhythm is flat, with no HR, no nothing. It is a state of no cardiac electrical activity, no contractions of the myocardium, no cardiac output or blood flow. It requires CPR Supraventricular tachycardia (SVT), which is between 140-220bpm, with the P wave often buried in a preceding T wave. The PR interval depends on the location of the supraventricular pacemaker. It involves impulses stimulating the heart that aren't generated by the sinus/AV node [of the atria], but rather, come from tissue around or involving the AV node [of the ventricle] Atrial fibrillation, which is irregularly irregular, with a HR>100 Atrial flutter, which has a regular rhythm, HR around 110bpm. P waves are around 300bpm, as they are replaced with multiple F (flutter) waves, at a ratio of 2:1 (F:QRS), or even 3:1 Heart block (see page) Bundle branch block (BBB, see page) Premature ventricular complex, which involves an early QRS, to the point that it occurs simultaneously with the p-wave. it is caused by the ventricles depolarizing prematurely in response to a signal in the ventricles Junctional rhythms, where HR is between 40-60bpm, P wave is  inverted in lead II. The SA node doesn't control the heart's rhythm, which can be caused by a block in conduction somewhere along the pathway. Rather, the heart's AV node takes over as the pacemaker Ventricular tachycardia (VT), where HR is 180-190bpm, QRS is prolonged, and P wave is not seen. It results from abnormal tissue in ventricles generating a rapid and irergular rhythm. It usually results in poor cardiac output, and thus cardiac arrest. If the Pt is unconscious and without a pulse, they will require shock Ventricular fibrillation (VF), where rhythm is irregular, HR is 300+ and disorganized, QRS is not recognizable, and P wave is not seen. It is caused by disorganized electrical signals causing the ventricles to quiver instead of contracting rhythmically. Condition may occur during or after MI. Pt is unconscious as blood isn't pumped into the brain. This Pt requires defibrillation quickly Myocardial infarct (MI), where ST is not isoelectric (i.e. there is depression or elevation) Source: Bioelectromagnetism Paperwork Paperwork for Electrocardiogram includes: Affix Pt label Data, including Requesting RMO sig, Date to be recorded, Date of previous ECG, Attended by, ECG serial No, Time recorded Section for Provisional Dx ___, Previous Medical Hx, IHD (Yes/No), M Infarction (Yes/No), Hypertension (Yes/No), Other, BP, Build Medications (cross out or daily dose), including YES/NO for Digitalis, Diuretics, Quinidine, Beta blockers, Tricyclics, Calcium antagonists, Other ___ Report ____, and Reported by___ Internal page has 4 vertical stickers, to permit the ECG to be stuck on Paperwork for Request for diagnostic services: Affix Pt label Please tick the approprite box, tick for Inpatient, Outpatient Tick for Stress ECG, Trans-thoracic Echocardiogram, Trans-thoracic Echocardiogram with 3D study, Holter monitoring, Trans-esophageal echocardiogram, Stress echocardiogram (also tickbox for Exercise, Pharmacological), 12 Lead ECG (outpatients only) Pacemaker/defibrillator check, including tick for Guidant, Medtronic, Biotronik, St Jude, Other Clinical summary Indication for test ECG changes List of cardiac medications Authentication, including Requesting Dr name, Date, Requesting Dr signature, pager No, Requesting Dr provider number (for outpatients only) See also [[CTG]] Sat, 23 Mar 2019 05:11:43 +0000 http://autoprac.com/ecg Route of administration http://autoprac.com/route-of-administration Route of administration is the path by which a drug is taken into the body. Oral po is shorthand for Per oral Rectally PR is shorthand for Per rectum (it can also refer to Rectal examination depending on context) Topical Buccal is where drugs are given in the buccal area (in the cheek) to diffuse through the oral mucosa (tissues which line the mouth), and enter directly into the blodstream. It may provide better bioavailability of some drugs, and a more rapid onset of action compared to oral administration, because the Rx doesn't pass through the digestive systme, and thus avoids 1st pass metabolism (i.e. where the concentration of a drug is greatly reduced before it reaches systemic circulation, lost during absorption related to the liver and gut wall) Inhalation Inh is shorthand for By inhalation [Metered-dose] inhaler (MDI, aka puffer) is a device that delivers a specific amount of medication to the lungs, in the form of short bursts of aerosolized medication that is self-administered by the Pt via inhalation. MDI's commonly deliver a bronchodilator and/or corticosteroid to Tx asthma and COPD [youtube]Rdb3p9RZoR4[/youtube] To reduce the need for precise synchronization of pressing the puffer and breathing at the same time, spacers are often used. Spacers help to deliver more drug into lungs, and can help reduce side effects because less drug sticks in the mouth and throat. Large volume spacers are oval shaped and bigger, and should only be used in kids>5yo. Small volume spacers are more tube-shaped, and more convenient so fit into handbags/schoolbags easier, and can be used in any age group [youtube]IfEsOiR9K_s[/youtube] Young kids ( Fri, 22 Mar 2019 20:00:48 +0000 http://autoprac.com/route-of-administration Tachycardia http://autoprac.com/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) Sat, 23 Mar 2019 01:03:23 +0000 http://autoprac.com/tachycardia Blood test http://autoprac.com/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 Sat, 23 Mar 2019 01:54:33 +0000 http://autoprac.com/blood-test Childbirth http://autoprac.com/childbirth Childbirth is the expulsion of newborn(s) from a woman's uterus, following a period of pregnancy. Full term is when childbirth usually occurs, about 39-40 weeks after conception. Early term is just before, between 37-38 weeks. Late term is just after, between 41-42 weeks. At either extremity, preterm is 42 weeks. Perinatal means during birth. [faq]What is childbirth? The birth of a child ;) lol. Specifically, it's where it comes out from where it's stored in a woman, which is in her uterus. What's a uterus? It's also known as the womb. It's found just above the vagina (through the cervical opening). And is central, to the 2 fallopian tubes dangling on its side. How does it take before bub pops out? There's standard timing. It can be due before date, or after date. So standard is 40 weeks. 39-40 is considered normal. 41-42 weeks is considered late term. 37-38 is considered early term. We still consider 37-42 not too bad. But anything outside of that is considered abnormal, and we call 42 weeks post dates. Perinatal. That sounds a bit like Perry the platypus. We know that platypuses don't do much :P Well mom pushes during pregnancy ;).[/faq] Dx Labor is said to have "onset" when there is both: Regular contractions occuring less than 10 minutes apart Progressive cervical dilation or cervical effacement, between consecutive vaginal examinations [faq]When do we say that the process of "childbirth" has started? We define it with 2 things. Contractions, which have to be regular, at least once every 10 minutes. Vaginal exams should also show progressive cervical dilation and effacement. Dilation. Effacement. You're speaking gibberish :P? Dilation is the opening of the cervix, which of course is necessary for bub to pass out of the womb, through the cervical opening, into the vagina, and out. Effacement is the thinning of the cervical opening, which makes sense as bub stretches the cervix as it passes through the cervix. Just think of it like passing your head through a jumper with a tight neck.[/faq] Sx Signs of onset of labor may occur at any time and in any order, with some women experiencing only contractions, until well into advanced labor. Thus, these are not required to establish labor: Bloody show, which is a passage of a small amount of blood or blood-tinged mucus through the vagina, towards the end of pregnancy, just before labor begins. As the cervix changes shape, mucus and bleed that occupies the cervical glands or cervical os is freed. It doesn't signify increased risk tot he mother or baby, and is normal. A large bleed however, should rule out placental abruption or placenta previa Rupture of membranes (waters breaking) Onset of tightenings/contractions, that move the infant down the birth canal It can also present with: Possible distress (fear, anxiety), depending on prior childbirth experience, cultural perception of childbirth and pain, mobility during labor, and support provided during labor [faq]How do you know childbirth is starting? You can pass blood, which we call a bloody show. You can pass water, which we call rupture of membranes. Or you might start feeling contractions, which can be painful. What is rupture of membranes? Why does rupture happen? Membranes just means the amniotic sac. It's the balloon of water that surrounds the baby, protecting it. Just before giving birth, this balloon pops. Amniotic fluid is made from mom's blood, and bub's kidneys. Bub "drinks" it through their skin and gut.[/faq] Physiology There are 3 stages of labor: 1st stage: ​Latent phase (aka quiescent phase, prodromal labor, pre-labor), which begins when the woman receives uterine contractions [not including Braxton Hicks]. It ends with cervical effacement (i.e. thinning and stretching of the cervix) and cervical dilation. Degree of effacement is felt by vaginal exam, and a long cervix implies effacement hasn't occured yet Active phase, which is cervical dilation of >3cm, cervical effacement >80%, more than 2 contractions in 10 minutes, or rupture of membranes. The definition by cervical dilation has been increased in some jurisdictions to increase NVD rates. The duration of the active phase ranges from 8 hours in primi's, and shorter to those who are multi's, and is considered prolonged when the cervix dilates 10cm), progresses as the baby descends, and ends when the baby is born. It is stimulated by prostaglandins and oxytocin. As pressure on the cervix increases, women have a sensation of pelvic pressure, and have an urge to push. Crowning causes an intense burning/stinging sensation. Delaying clamping the umbilical cord for >1 minute after birth is recommended as there is ability to Tx jaundice if it occurs, decreases risk of anemia, but may increase risk of jaundice. Clamping is followed by painless cutting of the cord 3rd stage (placenta delivery), which begins after fetal expulsion. It begins as separation of the placenta from the wall of the uterus. It usually lasts 11 minutes. Duration >30 minutes raises concern for retained placenta. Delivery en caul is where membranes are intact, which can occur when the maniotic sac hasn't ruptured during labor/pushing 4th stage (postnatal, postpartum), begins after child birth, extending for a bout 6 weeks. If there is an episiotomy or a perineal tear, it is stitched. The mother's hormone levels and uterus size return to it's non-pregnant state, and the newborn adjusts to life outside their mom's body. Nonetheless, afterpains (similar to menstrual cramps) and lochia (vaginal discharge after giving birth, containing blood mucus and uterine tissue, initially bright red fading to yellow/white; that is sterile in the 1st 2-3 days, but not so by the 3rd-4th day as the uterus begins to be colonized by vaginal bacteria, e.g. non-hemolytic streptococci and E coli) continues. Recommendations include skin to skin contact, and breast feeding [faq]The stages of labor. What are they? There are 4. The 1st stage begins when there's contractions, which we call the latent phase. The active phase is when a certain dilation or effacement has been achieved. Specifically, when the cervical opening is >3cm wide. Or when it has thinned by 80% of its original thickness. It can also be triggered by regular contractions of >2 in 10 minutes. Or rupture of membranes. The next stage. The 2nd stage. When does it start? When the cervix is fully dilated. And that's when it hits 10cm wide in diameter. As there's pressure on the cervix, women get the urge to push. 10cm. Why are we using that particular number? It's based on the average minimum length required for bub's head to pop out. What's 3rd stage then? It happens after bub has popped out. And involves the placenta coming out. It usually takes 10 minutes to happen, but if it takes longer than 30, we worry. Stage 4, what's that? Postnatal, which lasts for about 6 weeks. It's that period of time when everything returns to normal for mom, and baby adjusts to the outside world. Because it's important, we do a lot of follow up and community nursing in this period.[/faq] Methods Vaginal delivery (aka normal vaginal delivery, NVD) is childbirth (naturally) through the vagina, used to contrast vaginal delivery [whether assisted or induced] to contrast from C-section. It thus includes: Spontaneous vaginal delivery (SVD), where labor occurs without the use of drugs or other techniques (forceps, vacuum extraction, C-section) to induce labor Assisted vaginal delivery (AVD), where labor [with or without drugs, or other techniques to induce labor], requires: Instrumental delivery, where special instruments are used to deliver the baby vaginally, including: Forceps Vacuum extractor (aka ventouse) Episiotomy Caesarean section (aka C-section, C/s) is where surgical incisions are made through a mother's abdomen and uterus, to deliver newborn(s). It is performed when vaginal delivery would put the baby or mother's life or health at risk. They can be performed upon request (and is requested more frequently than necessary) and is a practice health authorities would like to reduce, as it increases bad outcomes in low risk pregnancies. It should not be performed before 39 weeks [as this is considered full term for child development] without medical indication to perform surgery. It includes: Lower uterine segment C-section (LSCS), the most commonly used. It involves a transverse cut just above the edge of the bladder, and results in less blood loss, and easier repair Classical C-section, involving a midline longitudinal incision, allowing a large space to deliver the baby, but is rarely performed as it is more prone to complications Participation of medical managment can either be: Active management of labor, which results in slightly reducing C-section, but doesn't affect assisted deliveries. It is recommended in the 3rd stage of all vaginal deliveries to help prevent PPH. It involves: Frequent assessment of cervical dilation IOL, where if dilation doesn't occur, oxytocin is offered Administering syntocinon within 1 minute of fetal delivery, controlled traction of the placenta, and uterine massage every 15 minutes for 2 hours Augmentation, where oxytocin is given to speed progress of labor Expectant management involves watchful waiting Ix Hx: Waters breaking → can indicate labor will onset ABC's, including vitals CTG, Doppler fetal monitor, even fetal scalp electrode → fetal wellbeing Palpating, for: Presentation → assist w/ delivery Uterine contraction, noting this can NOT be accurately read from the CTG Vaginal exam, inspecting for: Pregnancy bleeding Cervical dilation/effacement → progressive changes indicates labor has onset Contractions → >1 in 10 indicates labor has onset Tx Preparation Pain relief Support Epidemiology Onset of term labor more commonly occurs at late night or early morning, due to nocturnal increases in melatonin and oxytocin See also [[Menstruation]] [[Pregnancy]] (phase before childbirth) [[Labor induction]] (used to induce childbirth) [[Preterm]] (extremity) [[Post dates]] (extremity) [[Birthing center]] [[Stages of labor]] Fri, 22 Mar 2019 20:17:49 +0000 http://autoprac.com/childbirth Maternal nutrition http://autoprac.com/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 Fri, 22 Mar 2019 17:51:40 +0000 http://autoprac.com/maternal-nutrition Angiography http://autoprac.com/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 Fri, 22 Mar 2019 23:03:42 +0000 http://autoprac.com/angiography Labor induction http://autoprac.com/labor-induction Labor induction (induction of labor, IOL) is artificially stimulating childbirth. [faq]What is labor induction? It's when you want to bring about childbirth, without waiting for nature to run it's course. You do something to help stimulate it.[/faq] Methods Mechanical approaches, including: Membrane sweeping (aka membrane stripping, stretch and sweep), where during an internal exam, the Dr moves their finger to separate the membranes around the baby (amniotic sac), from the cervix (mouth of the uterus). This causes a release of hormones, which may soften the cervix, and prepare the uterus to contract. Contractions may help the cervix open ARM (artificial rupture of membranes) Extra-amniotic saline infusion, where a Foley catheter is inserted into the cervix, and the distal portion with a baloon is expanded to dilate the cervix, to induce it to, itself release prostaglandins Intrauterine catheters, which compress the cervix mechanically to generate release of prostaglandins in local tissues Medications, including: Prostaglandin, administered intravaginal, endocervical, or extra-amniotic, including either: Dinoprostone (prostaglandin E2, product name Cervidil, Prostin) [img]cervidil.jpg[/img] Source: The wicked mommy [img]prostin.jpg[/img] Source: Express cheap generic Misoprostol (prostaglandin E1 analog), with Dinoprostone having most evidence behind it ​Oxytocin (synthetic), administered IV, with a high dose not seeming to have greater benefits than a standard dose Mifepristone, which is described, but rarely used in practice, as it is uced to induce abortion [faq]How can you artificially stimulate childbirth to start? There are things you can do mechanically. As well as drugs you can give. What can you do mechanically? You can try to separate the amniotic sac suspending the baby, from the cervix, to help hormones release. You can insert a balloon and inflate it to dilate the cervix, again, to induce hormone release. You can also break the amniotic sac, by literally piercing it, which we call ARM or breaking waters. With drugs, what can you give? Prostaglandin. Or oxytocin.[/faq] Indications Postterm pregnancy (i.e. pregnancy gone past the 41st week), improving outcomes for the baby by inducing at or after term, and decreasing the number of C-sections required IUGR (intrauterine fetal growth restriction) Health risks to the woman in continuing the pregnancy (e.g. pre-eclampsia) PROM (premature rupture of membranes, where the membranes have ruptured, but labor doesn't start within a specified period of time) Abortion (premature termination of pregnancy) Fetal death in utero, or previous Hx of stillbirth Twin pregnancy continuing beyond 38 weeks PMH that puts risk on the woman and/or her child, e.g. diabetes, HTN [faq]Why artificially induce labor? Why not let nature run it's course? If the baby's still not wanting to come out, after the due date, which we call post dates. If the baby is small for dates because there's some medical problem, which we call IUGR. There's a health risk to mom, such as impending seizure, called pre-eclampsia. The amniotic sac may already have ruptured, so it's dangerous for bub to remain in the womb. A dead fetus, due to abortion or stillbirth. If there are twins.[/faq] Prognosis Induction in those either at or after term improves outcomes for the baby, and decreases the number of C-sections performed [faq]What do you say to people who say mother nature prefers it when you use the natural approach? Research shows that if you induce at or after term, it improves the outcome for bub. And it decreases the need to do a C section.[/faq] Paperwork In the form "Labor induction assessment", affix the Pt Label Under Initial Assessment to Plan Method of Induction: Indications ACM Code(s) EDB: __/__/____ Gestation Gravida Parity BMI Method of Induction, including ticking for PGE2, 1mg, 2mg, Dinoprostone (Cervidil), ARM, Syntocinon Booking Date: __/__/___ (enlisting to Page a particular number) Date of Induction: __/__/____ Midwife/Doctor booking induction Authorized by Reg/Consultant Tick whether Prostaglandin ordered on medication chart by Registrar/Consultant Modified Bishop Score, as shown in an assessment table, which is a Score of 0, 1, 2, or 3, based on whether Dilation is 1, 1.2, 3.4, 5; Length Cx (cm) is 3, 2, 1 or 0; Station is -3, -2, -1.0, or +1/+2; Consistency is Firm, Medium or Soft; Position is Posterior, Mid, Anterior. Table allows the Total summation of the score. Criteria for ARM is a Bishop Score of 7 or Greater Maternity Unit Assessment to Determine Method of Induction: CTG, including ticks for whether Pre Prostin, or Post Prostin Ticks for PGE 2, including ticks for 1mg or 2mg, including Date and Time Tick for Dinoprostone (Cervidil), including tick for 10mg, and Date and Time Tick for Bishop Score 7 or Greater: Registrar Notified There is also a repeat Modified Bishop Score table here which can be filled Authentication, including Inserted by Name, Signature, Designation, Date; and Supervised by Name, Signature, Designation, Date Repeat Assessment (As Required): CTG, including ticks of Pre Prostin or Post Prostin Tick for PGE2, including tick for 1mg, and Date and Time Repeat of the Modified Bishop Score Authentication, including Inserted by Name, Signature, Designation, Date; and Supervised by Name, Signature, Designation, Date See also Childbirth Bishop score (used to assess for need to IOL) Sat, 23 Mar 2019 01:14:10 +0000 http://autoprac.com/labor-induction Beta agonist http://autoprac.com/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: Seretide.co.nz 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] Sat, 23 Mar 2019 05:05:31 +0000 http://autoprac.com/beta-agonist Neurological examination http://autoprac.com/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]] Fri, 22 Mar 2019 22:23:36 +0000 http://autoprac.com/neurological-examination Abdominal examination http://autoprac.com/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]] Sat, 23 Mar 2019 04:11:35 +0000 http://autoprac.com/abdominal-examination Leopold's maneuvers http://autoprac.com/leopolds-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) Fri, 22 Mar 2019 23:43:45 +0000 http://autoprac.com/leopolds-maneuvers Pap smear http://autoprac.com/pap-smear Pap smear (short for Papanicolaou, also known as Cervical smear) is the screening for potentially pre-cancerous and cancerous processes in the cervix (i.e. opening of the uterus or womb), i.e. cervical cancer. As a screen, unusual findings are followed by more specific Dx, and if warranted, intervention to prevent progression to cervical cancer. Examples of a pap test include ThinPrep Pap Test. [img]thinprep-pap-test.jpg[/img] Source: Hologic [faq]What is a pap smear? It is used to check for a possibility of cervical cancer. Wait... what is the cervix? It is the opening to the uterus (which is also known as the womb). What do you mean by a "screening test"? It means if it comes back negative, you most probably don't have it. But if it comes back positive... you need to do more tests, to confirm whether you have it or not! So if it comes back positive :( does that mean I have cancer :'(??! No. We are only testing for abnormal cells on the pap smear. It increases the likelihood of cancer, but it isn't cancer. Even HSIL/CIN 3 is still only considered "carcinoma in situ", a "pre-cancer". So it's not cancer ;), but just cell changes caused by HPV infection.[/faq] HPV DNA testing is a screen for the virus causing abnormal cells on the cervix, and can be done alongside the pap test. [faq]Wait... why have 2 screens? Why not just use 1? Because they test different things. Pap smear tests for abnormal cells. HPV tests for the HPV virus - which causes the abnormal cells. Sorry, what was HPV again :huh:? It's the virus that is implicated in 70% of cervical cancers.[/faq] Pathophysiology Human papillomavirus (HPV) is a sexually transmitted virus that infects skin or mucous membranes, and is usually subclinical, causing no Sx. It can however, cause warts or papillomas (i.e. benign epithelial tumor), and even cancers of the cervix, vulva, vagina, throat, penis, and anus There are more than 40 types of HPV transmitted typically through sexual contact, and infects the anogenital region, but HPV16 and 18 are implicated in 70% of cervical cancer cases High risk HPV types are different from the ones that cause skin warts, and may progress to cancer Most infections do not cause disease 70% of clinical HPV infections regress to sub-clinical in 1 year In 7% of women, subclinical infection persists, and there is high risk of developing precancerous lesions which can progress to invasive cancer Purpose Early detection of pre-cancerous and cancerous processes in the endocervical canal of the female reproductive system The test may also detect infections and abnormalities in the endocervix and endometrium, but is not designed to do so Indications Pap smear is recommended from 18yo until 70yo, every 2 years Abnormal results should be followed up by a repeat test in 6-12 months If the Pt is menstruating heavily, they should use the liquid-based cytology method, as RBC's can obscure the cervical cells on a traditional slide; cf with liquid technology, RBC's can be filtered out Pap smears CAN be undertaken during pregnancy, ideally 40yo Source: NSW Health [faq]Who gets papsmears? Do men do them? No :lol:, because men don't have cervixes!! Because papsmears test for the HPV virus which is sexually transmitted, it is done when a woman becomes sexually active AND is sexually active. So if you're not sexually active, you don't need to do them? Yeaaap ;)! A "complete hysterectomy" is where the uterus is removed with the cervix, right? Well, if you do that, do you still need the papsmear given you don't have a cervix anymore??! It depends. In practice, most women continue to have papsmears, and they should particularly if they are at high risk, such as having had the hysterectomy done for a cancerous condition. But if they're not high risk, they don't have to.[/faq] Method Opening the vaginal canal with a speculum, then collecting epithelial cells from the outer opening of the cervix, at the transformation/transitional zone (i.e. the squamo-columnar junction of the cervix between the ectocervix and endocervix). There are 2 methods of collection, of which either can be used: Conventional pap, where samples are obtained using the conventional spatula, placed against the face of the cervix, and rotate 360 degrees. Then, the cylindrical endobrush is placed into the cervical os, and rotated 360 degrees. The specimen is then smeared on to a microscope glass slide by rolling or twisting the spatula/brush on to the slide. Fixitive is then applied Liquid based cytology, where samples are obtained using the arrow-shaped broom brush, rotating the brush several times. Disconnect the brush tip, and suspend it in a bottle of preservative Squamous cells are examined under a microscope to look for abnormal, potentially pre-cancerous changes called cervical intraepithelial neoplasia (CIN), caused by HPV. CIN involves dysplasia (abnormal growth) of squamous cells on the epithelium (surface) of the cervix. Most CIN remains stable or is eliminated by the immune system without intervention. However, a small proportion progress to cervical cancer, usually cervical SCC if untreated. An alternative system used to describe abnormalities is the SIL (squamous intraepithelial lesion) system. Squamous cell abnormalities include: CIN SIL   Normal cervical epithelium ASC-US (atypical squamous cells of undetermined significance)   ASC-H (atypical squamous cells of High grade significance)   CIN 1 LSIL (low-grade squamous intraepithelial lesion) Involves mild dysplasia (abnormal cell growth), confined to the basal 1/3rd of the epithelium. It can usually be cleared by the immune response, but may take several years CIN 2 HSIL (high-grade squamous intraepithelial lesion) Involves moderate dysplasia confined to the basal 2/3rd of the epithelium CIN 3 (aka cervical carcinoma in situ) Involves severe dysplasia, that spans more than 2/3rds of the epithelium, and involves the full thickness SCC (squamous cell carcinoma)   Glandular epithelial cell abnormalities: Adenocarcinoma AGC-NOS (atypical glandular cells not otherwise specified, formerly atypical glandular cells of undetermined significance, AGUS) Abnormal findings are often followed up by more sensitive Dx procedures, and if warranted, interventions that aim to prevent progression to cervical cancer Vault smear is where the pap smear is taken from the top of the vagina, in women who've had their cervix removed, to test for cancer of the vagina [faq]So what does the pap smear involve? A swab is inserted into the vagina, twisted around the walls of walls, to get a sample of cells on to the swab. That swab is then tested.[/faq] Side effects Can cause spotting and minor bleeding following the pap smear Follow up LSIL (low grade abnormal) or CIN 1, will be monitored w/ a repeat pap smear in 1 year. (Usually papsmears are done every 2 years.) Notably, NO colposcopy is necessary. If the repeat pap smear STILL shows low-grade, it is referred for colposcopy. If the pap smear returns normal, a pap smear will be repeated at 12 months, which if normal again, will revert to the 2 year cycle HSIL (high grade abnormal) or CIN 2/3, will be referred to colposcopy, and biopsy/Tx as required. Pap smear and colposcopy will be repeated in 4-6 mo after Tx. Pap smear and HPV test will be repeated in 12 mo after Tx twice, which if 2 in a row are negative, return to normal 2 year screening Colposcopy in pregnancy is safe Source: CancerScreening (page 26) [faq]OK, papsmear has been done. it's come back "low grade abnormal". What to do? First of all, understand that what's come back positive is not a "cancer". It's a viral infection that's been detected. Now because it's "low grade", most likely it will clear within 1-2 years, so we just leave it. How about if it's "high grade"? Or... the same case from before, but now I've done a repeat papsmear, and it's come back positive... again :@?! You will be referred for colposcopy. Col... what? Coles supermarkets :D :lol:? Colposcopy ;). It's where a colposcope is used to magnify the cervix. We then use acetic acid, which should turn abnormal areas white. If that fails, we use Lugol's idone, which should turn abnormal areas yellow. OK, "abnormal areas detected". What next ;)? We loop it and take that biopsied loop. We can also freeze it, but that destroys the sample, so we prefer to loop it. If it's severe, we want to take it out PLUS a margin around it, done so in the form of a cone-shaped wedge, which is called a "cone biopsy". That "looping" sounds a bit like a good ole Western... yeeeehah :D ;)! Where we loop it and yank the ole fella out! True indeed. Does the colposcopy have any side effects? It's not uncommon to feel discomfort for a short time. You might also get some "spotting" of blood aftewards. Now that I've been treated, anything else I need to know? Screening now changes for you. We repeat a papsmear in 6 months, and from 12 months both the papsmear and HPV DNA test, and if they are negative for 2 years in a row, you return back to the normal schedule of screening every 3 years.[/faq] Epidemiology 80% of people will be infected with HPV some time in their lives, and may not even know about it See also Cervical cancer (for more information about follow up) Pelvic exam (method for taking the swab) Colposcopy Sat, 23 Mar 2019 03:45:10 +0000 http://autoprac.com/pap-smear Pregnancy http://autoprac.com/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]] Sat, 23 Mar 2019 04:54:23 +0000 http://autoprac.com/pregnancy IV cannulation http://autoprac.com/iv-cannulation IV cannulation (IVC, aka peripheral venous catheter) is the insertion of a cannula into a vein. Arterial cannulation is a variation involving insertion into an artery (commonly the radial artery) to measure beat-to-beat blood pressure, and draw repeated blood samples. [faq]Wait. Catheter, cannula, is it the same thing? A catheter is plastic. A cannula is metal, so a needle. When you draw blood, you insert the metal bit to puncture, and allow blood flow. However, if you want to keep it there, you don't want to keep a piece of metal there, because it can cause trauma to the blood vessel. So you use a piece of metal to pierce through skin, but you retract it, and only keep plastic in there.[/faq] Indications Administering IV fluids Obtaining blood samples Administering medicines Method In kids, a local anesthetic gel (e.g. lidocaine) is applied ot the insertion site to facilitate placement Usually placed in a vein on the arm or hand Introduced into the vein by a needle, similarly to blood drawing, which is subsequently removed, while the small plastic tube of the cannula remains in place. Modern catheters consist of synthetic polymers, e.g. teflon, but in the 1950's were PVC plastic The catheter is then fixed by taping it ot the patient's skin, unless there is an allergy to adhesives Newer catheters are equipped with safety features to avoid needlestick injuries [youtube]NuQzHwkP8bg[/youtube] Classification Needle gauge describes a variety of outer diameters. Note that small gauge numbers indicate larger OUTER diameters. INNER diameter depends on both gauge and wall thickness. Gauges include, starting from the LARGEST to SMALLEST cannulas: Commercially less available: 7, has outer diameter of 4.572mm 8, has outer diameter of 4.191mm 9, has outer diameter of 3.759mm 10, has outer diameter of 3.404mm 11, has outer diameter of 3.048mm 13, has outer diameter of 2.413mm Large bores (aka trauma lines), including: 12, has outer diameter of 2.769mm. It is capable of delivering large volumes of fluid very fast, thus popular in ED 14, has outer diameter of 2.108mm. It is a very large cannula, used in resuscitation settings 16, has outer diameter of 1.651mm. It is a mid sized line, used for blood donation and transfusion 18, has outer diameter of 1.270mm. It is an all purpose line for infusion and blood draws 20, has outer diameter of 0.9081mm. It is another all purpose line for infusion and blood draws 22, has outer diameter of 0.7176mm, and an inner diameter of 0.152 22s, has outer diameter of 0.7176mm, and an inner diameter of 0.337 24, has outer diameter of 0.5652mm 26, has outer diameter of 0.4636mm, and an inner diameter of 0.260mm 26s, has outer diameter of 0.4737mm, and an inner diameter of 0.127mm Commercially less available, since it is odd sizes: 15, has outer diameter of 1.829mm 17, has outer diameter of 1.473mm 19, has outer diameter of 1.067mm 21, has outer diameter of 0.8192mm 23, has outer diameter of 0.6414mm 25, has outer diameter of 0.5144mm Commercially less available: 27, has outer diameter of 0.4128mm 28, has outer diameter of 0.3620mm 29, has outer diameter of 0.3366mm 30, has outer diameter of 0.3112mm 31, has outer diameter of 0.2604mm 32, has outer diameter of 0.2350mm 33, has outer diameter of 0.2096mm 34, has outer diameter of 0.1842mm The wall thickness become lower, and therefore the inner diameters become proportionately larger (but still smaller in absolute measure). [faq]Sizes. How does it work? The smaller the gauge, the bigger the size. The larger the gauge, the smaller the size. So it's contrary. Large bore which we use in trauma, because we want blood fast and in large amounts, is 12-14 bore. Transfusion is done with a 16 gauge. Infusion is done with an 18 gauge. And 20 is an all purpose line.[/faq] Complications Hematoma (aka bruise, i.e. collection of blood), due to failure to puncture the vein when the cannula is inserted or removed. This can be prevented by selecting an appropriate vein and gently applying pressure slightly above the insertion point on removal of the cannula Infiltration, where the contents enter the subcutaneous tissue instead of the vein. This can be prevented by selecting an appropriate cannula, and fixing it in place firmly Embolism, caused by air, thrombus, or fragment of catheter breaking off and entering the venous system, potentially causing PE. This can be prevented by using a smaller cannula Phlebitis (i.e. inflammation of the vein), caused by mechanical or chemical irritation, or from infection. This can be avoided by carefully choosing the site for cannulation, and checking for entry contents Infection, which thus should be replaced every 4 days Extravasation, is accidental administration of IV infused drugs into the extravascular space/tissue around the infusion sites, either by leakage (e.g. because of brittle veins in very elderly Pt's), previous venipuncture (e.g. from blood drawn from lab tests prior to therapy), or direct leakage from mispositioned venous access devices Hemorrhage/bleeding Epidemiology Given to most ED and surgical patients In the USA, >25m patients get a peripheral venous line each year Paperwork Paperwork for Vascular access device (VAD) care plan includes: Affix Pt label Type of device: Tick for PICC, CVC, PORT-A-CATH, MIDLINE, HICKMAN Date of insertion __/__/____ Inserted by ___ No of cannulation attempts VAD care plan insertion site, tick Left or Right Vein, tick for Basilic, Brachial, Femoral, Cephalic, Median, Subclavian, Internal Jugular, Other ___ Placement, tick for SVC, Mid Clavicular, Femoral, Midline, Other ___ Catheter Data, tick for Internal, External, Trimmed; Arrow, Bard, Cook, Other ___; Single Lumen, Doubel Lume, Triple Lumen, Quad Lumen; 3F, 4F, 5F; 20cm, 30cm Maximum flow ___ PICC arm circumference, tick for 10cm, 15cm above cubital fossa General guidelines, include No BP or venepuncture above PICC site; no syringe less than 10mL to be used for injecting; observed site daily of infection, swelling, bleeding; do NOT turn fluids off; do NOT disconnect e.g. for showering; make sure all lines are without tension; line change due Monday and Thursday; dressing, Statlock and positive pressure valve (PPV) changes weekly Table, which for columsn includes Insertion day, Day 1 __/__/____, Day 2 __/__/___, Day 3__/__/____... Day 18 __/__/____, Day 19 __/__/____, Day 20 __/__/____. Rows include External catheter measurement; Arm circumference (for PICC only); site pain (0 to 10); inflammation; swelling; bleeding; dressing, Statlock, PPV change due; IV line change due; signature; and designation Legend includes N=Nil, S=slight, M=moderate, L=large See also Venipuncture French scale CVC (inserted in a central vein, usualy the internal jugular vein of the neck or the subclavian vein of the chest) Arterial catheter (placed ina  peripheral as well as a centarl artery) Fri, 22 Mar 2019 18:09:20 +0000 http://autoprac.com/iv-cannulation Oslers node http://autoprac.com/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 Fri, 22 Mar 2019 22:33:32 +0000 http://autoprac.com/oslers-node Immunization http://autoprac.com/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 Sat, 23 Mar 2019 04:20:10 +0000 http://autoprac.com/immunization Tar staining http://autoprac.com/tar-staining Cigarette causes tar staining on the fingers. [img]tar-staining.jpg[/img] Source: http://upload.wikimedia.org/wikipedia/commons/f/f2/Nicotine_stains10.JPG     Fri, 22 Mar 2019 11:20:06 +0000 http://autoprac.com/tar-staining Edema http://autoprac.com/edema Edema (aka hydropsy) is an abnormal accumulation of fluid in the interstitium, located beneath the skin and in cavities of the body which cause severe pain. It manifests as swelling. Pathophysiology The amount of interstitial fluid is determined by the balance of fluid homeostasis, and the increased secretion of fluid into the interstitium, or the impaired removal of the fluid can cause edema It is caused by inability of this fluid to be removed by normal processes Classification Pitting edema is where indentation persists after release of a pressure. It results from water retention Sacral edema is palpated at the lower back, and is associated with heart failure [img]sacral-edema.jpg[/img] Source: OSCE Skills Anasarca (aka extreme generalized edema) involves widespread swelling of the skin, due to effusion of fluid into the extracellular space. It is usually caused by liver failure (cirrhosis of the liver), renal failure/disease, right sided heart failure, as well as severe malnutrition/protein deficiency. The increase in salt and water retention caused by low cardiac output can also result in anasarca as a long term maladaptive response Cause Increased hydrostatic pressure, including: Heart failure Decreased osmotic pressure, including: Nephrotic syndrome Liver failure See also Peripheral edema Sat, 23 Mar 2019 00:58:34 +0000 http://autoprac.com/edema Surgery http://autoprac.com/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 Sat, 23 Mar 2019 01:05:56 +0000 http://autoprac.com/surgery Fluid thrill test http://autoprac.com/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. Sat, 23 Mar 2019 02:44:06 +0000 http://autoprac.com/fluid-thrill-test Pelvic organ prolapse http://autoprac.com/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) Sat, 23 Mar 2019 03:00:00 +0000 http://autoprac.com/pelvic-organ-prolapse Mitral facies http://autoprac.com/mitral-facies Plum-red discoloration of the cheeks, associated with mitral stenosis, due to CO2 retention and its vasodilatory effects. [img]malar-flush.jpg[/img] Source: MyHealthyFeeling Sat, 23 Mar 2019 02:15:33 +0000 http://autoprac.com/mitral-facies Hematoma http://autoprac.com/hematoma Hematoma is a collection of blood within the tissue (outside the blood vessels). [faq]What is hematoma? I'm guessing it relates to heme, so blood? Yeah, so it's a collection of blood, within tissue. So that's outside of blood vessels.[/faq] Classification Petechia, 1cm caused typically by coagulation disorders [img]ecchymosis.jpg[/img] Source: Skin care guide Bruise (aka contusion), a specific type of hematoma cause by trauma in which capillaries and sometimes venules are damaged by trauma, allowing blood to seep, hemorrhage, or extravasate into the surrounding interstitial tissues. Not blanching on pressure, bruises can involve capillaries at the level of the skin, subcutaneous tissue, muscle, or bone [faq]There are different types of blood collections in tissue? Yeah, so petechia is the smallest, 1cm. And bruise, which is a specific type that is caused by trauma.[/faq] Dx Unlike erythema, they do not blanch. They are not bruises, which are caused by trauma See also [[Hemangioma]] (abnormal buildup of blood vessels in the skin or internal organs) Fri, 22 Mar 2019 22:43:30 +0000 http://autoprac.com/hematoma Oxygen therapy http://autoprac.com/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 Sat, 23 Mar 2019 04:29:40 +0000 http://autoprac.com/oxygen-therapy Arachnodactyly http://autoprac.com/arachnodactyly Arachnodactyly (aka spider fingers, achromachia) is where the fingers and toes are abnormally long and slender, in comparison to the palm of the hand and arch of the feet. Sx Patient's thumbs tend to also be pulled inward towards the palm Pathophysiology It can be idiopathic, but is usually associated with certain medical conditions, including Marfan syndrome It has thus been linked to the fibrillin gene [img]arachnodactyly.jpg[/img] Source: WF Fun Epidemiology It can be present at birth, or develop in later life Sat, 23 Mar 2019 02:44:14 +0000 http://autoprac.com/arachnodactyly Preterm birth http://autoprac.com/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 Fri, 22 Mar 2019 23:55:00 +0000 http://autoprac.com/preterm-birth Dissociated sensory loss http://autoprac.com/dissociated-sensory-loss [Dissociated] sensory loss is where there is SELECTIVE loss of fine touch and proprioception WITHOUT loss of pain and temperature, or vice viersa. Pathophysiology Caused by neurological damage by a lesion, to a single tract in the spinal cord (or brainstem) The presentation depends on the location of the cord lesion. It can be memorized with the mnemonic that the posterior dorsal column relates to touching a girl on her back on her date, which involves touch, as well as proprioception (trying to find her back in 3D); and the anterolateral spinothalamic tract involves being karate kicked in the tummy, causing pain and hot temperature sensation. This includes: Loss of pain and temperature is due to damage to the anterolateral spinothalamic tracts, which cross the central part of the cord close to the level where they enter it, and ascend contralaterally (i.e. travel up the spinal column on the opposite side to the one they innervate). Note that a lesion of the lateral spinothalamic tract at a given level will NOT result in a sensory loss for the dermatome at the SAME level, due to the fibers of the tract of Lissauer which transmit the neuron 1-2 levels ABOVE the affected segment, thus bypassing the segmental lesion on the contralateral side → this means that a lesion of the spinothalamic tracts will cause loss of pain and temperature below the lesion on the OPPOSITE side to it Loss of fine touch and proprioception are due to damage to the dorsal columns, which don't cross the cord until the brainstem, and so ascend ipsilaterally (i.e. travel up the column on the same side to the one they innervate) → this means that a lesion of the dorsal columns will cause loss of touch and proprioception below the lesion and on the SAME side as it Cause Diabetes mellitus Syringomyelia Brown-Sequard syndrome Lateral medullary syndrome (aka Wallenberg's syndrome) Anterior spinal artery thrombosis Tangier disease Subacute combined degeneration Multiple sclerosis Tabes dorsalis Friedreich's ataxia (or other spinocerebellar degeneration) See also Peripheral neuropathy Sat, 23 Mar 2019 02:14:27 +0000 http://autoprac.com/dissociated-sensory-loss Calcium channel blocker http://autoprac.com/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: http://www.drsfostersmith.com/images/Categoryimages/normal/p-50944-55115P_001.jpg 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 Fri, 22 Mar 2019 17:57:06 +0000 http://autoprac.com/calcium-channel-blocker Antenatal care http://autoprac.com/antenatal-care Antenatal care are regular check-ups that allwo doctors and midwives to Dx, Tx, and prevent potential health problems througout the course of pregnancy. The sessions also provide an opportunity to promote healthy lifestyles, receive medical information rearding maternal physiological changes during pregnancy, nutritional requirements (including vitamins). Fetus is a child before birth. Neonate (from Latin "neonatus" meaning "newborn") is a child in their first 28 days of birth. Infant is a child between 1 month-1 year old. Schedule Initial visit, in trimester 1 (weeks 1-12) → blood group and antibodies, FBC, syphilis, rubella, hepatitis B, hepatitis C, HIV, offer papsmear (if last had >2 years), smoking/alcohol cessation counselling, urine dipstick (MSU), pre-pregnancy weight/height/BMI, chromosomal abnormality screen (free beta-hCG, PAPP A), confirm, pregnancy, Trimester 1 U/S Monthly visits, in trimester 2 (weeks 13-27), at: Week 12 → Early morphology U/S (see page), CVS (see page) (if required) Week 16 → Amniocentesis (if required), EDS Week 20 → Morphology U/S Week 24 → Rhesus antibody screen, GCT Fortnightly visits, in trimester 3 (weeks 28-39), at: Week 26 Week 28 → anti-D Week 30 Week 32 Week 34 → anti-D, EDS Week 36 Week 38 Weekly visits, after term, at (weeks 40+): Week 40 Week 41 → offer IOL for 42 weeks Postnatal visits (see page), at: Home visit service 6-8 week check → EPDS Source: QLD Health Method After the initial antenatal visit, and with the aid of a checklist, the pregnant woman will be classified into "Normal" or "High" risk Calculate gestational age Prenatal screens and/or Dx, which is testing for disease/conditions in a fetus before it is born. It includes screening for: Down syndrome Hx (contractions/pains, vaginal bleeding, 1st passing of urine following delivery should be within 6 hours) Monitoring the mother's health, including: Mother's medical Hx, including: Maternal drinking Maternal smoking Checking the mother's BP → maternal HTN Mother's height and weight Pelvic exam Mother's blood and urine tests → maternal proteinuria Screening tests, including: Rh status → give anti-D @ 28 and 34 weeks, and as required during sensitizing events Nuchal scan → early morphology (nuchal translucency) @ 10-14 weeks, and morphology (nuchal fold) @ 18-20 weeks Down syndrome Dx test → CVS @11-13 weeks, or amniocentesis @ 16-18 weeks, if indicated Conduct or book papsmear → Fri, 22 Mar 2019 14:44:41 +0000 http://autoprac.com/antenatal-care Birth control http://autoprac.com/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. Fri, 22 Mar 2019 19:54:14 +0000 http://autoprac.com/birth-control Aminoglycoside http://autoprac.com/aminoglycoside Aminoglycoside is a Gram-negative antibiotic that inhibits protein synthesis, and contains as a portion of the molecule an amino-modified glycoside (i.e. sugar). It generally has effect against gram-negative aerobes and some anaerobic bacilli where resistance hasn't arisen yet, but generally not against Gram-positive and anaerobic Gram-negative bacteria. [faq]Aminoglycoside, what's that? It sure doens't sound like an antibiotic like penicillin? Remember that penicillins are beta lactams, and that probably doesn't sound like an antibiotic too ;). It's a type of antibiotic that has an amino modified sugar. It is effective against Gram negative bacteria. Gram negatives, what's that? Gram negative means that it has an outer membrane, that makes it so that the dye can't penetrate, and stain the bacteria. So they're usually considered more harder to crack than gram positives. Gram positives are things like Strep, Staph, and Enterococcus. Most other bacteria are Gram negatives. Anaerobes, what's that? So anaerobes can strictly be classified as either Gram positive or Gram negative. But, we tend not to erfer to them that way, because anaerobes tend to require special drugs to treat.[/faq] Classification Streptomyces (-mycin): Streptomycin Dihydrostreptomycin Neomycin, including: Framycetin Paromomycin Ribostamycin Kanamycin, including: Amikacin Arbekacin Bekanamycin Dibekacin Tobramycin Spectinomycin Hygromycin B Paromomycin Micromonospora (-micin): Gentamicin (aka Gent), which is not used for N. gonorrhoeae, N. meningitidis or L. pneumophilia. It is also ototoxic and nephrotoxic, which is a major clinical problem. It includes: Netilmicin Sisomicin Isepamicin Verdamicin Astromicin [img]gentamicin.jpg[/img] Source: Clinical Pharmacology [faq]What are some examples of amino modified sugar antibiotics? Gentamicin is the biggy.[/faq] See also [[Antibiotics]] Fri, 22 Mar 2019 23:11:49 +0000 http://autoprac.com/aminoglycoside Observation chart http://autoprac.com/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) Sat, 23 Mar 2019 00:52:55 +0000 http://autoprac.com/observation-chart Health record http://autoprac.com/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 Sat, 23 Mar 2019 00:48:14 +0000 http://autoprac.com/health-record Labored breathing http://autoprac.com/labored-breathing Labored breathing is the physical presentation of SOB, as evidenced by increased effort to breathe. [faq]What is labored breathing? It's what you see in a patient, who has difficulty breathing.[/faq] Classification Chest recession is a sign of respiratory distress in kids, which occurs due to increasingly negative intrathoracic pressures cause indrawing of part of the chest. It isn't applicable in adults because structures in the chest wall are much more bony. Recession can be of: Subcostal recession [img]subcostal-recession.jpg[/img] Source: Wikimedia Intercostal recession (aka chest wall recession) Sternal recession [img]intercostal-recession.jpg[/img] Source: Quizlet Use of accessory muscles of respiration, which can be seen in infants as head bobbing Stridor Tracheal tug, which is visible in the suprasternal notch during inspiration Nasal flaring, where the nostrils widen whilst a person is breathing Grunting, which are short, deep, hoarse sounds in expiration, occurring because the glottis briefly stops the flow of air, halting the movement of the lungs and surrounding structures. It is made to try preventing airway collapse, and improve oxygenation. It indicates severe respiratory distress Gasping, is a sign of severe hypoxia, and indicates impending respiratory arrest [faq]What do you see in a patient who has difficulty breathing? Sucking in of the chest, particularly between the ribs, as well as below the ribs. There can be use of the supportive muscles of breathing, which usually aren't required in unproblematic breathing. A harsh sound, called stridor. Grunting sounds. And widening of the nostrils, called nasal flaring.[/faq] See also [[SOB]] [[Respiratory exam]] Sat, 23 Mar 2019 00:59:09 +0000 http://autoprac.com/labored-breathing Urinalysis http://autoprac.com/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]] Fri, 22 Mar 2019 04:19:56 +0000 http://autoprac.com/urinalysis Smoking http://autoprac.com/smoking Smoking tobacco causes various effects for both the smoker, as well as those around them. Cigs is shorthand for cigarettes. Pathophysiology Nicotine is addictive, making the process of quitting very prolonged and difficult Assessment The statement "Smoker" indicates the Pt smokes X/day indicates the Pt smokes X cigarettes a day (not packages) Pack-year is a way of measuring how much a Pt has smoked, calculated by multiplying the number of packs of cigarettes smoked per day, by the number of years smoked. 1 pack is equivalent to 20 cigarettes, although this by law is the minimum amount. Cigarette packs are usually 25 per pack, the minimum by law is 20 per pack, but can also be sold in 30, 40 or 50 packs. It is useful to determine degree of tobacco exposure, where it is correlated to risk of disease (e.g. lung cancer) Effects Effects on self, which depends on how much, and for how long, the Pt has smoked: Heart, including HTN, heart attacks, strokes, peripheral vascular disease Liver Lungs, including COPD Cancer Reproductive, including erectile dysfunction Effects on pregnancy, including: PROM Placental abruption Placenta previa Premature birth Miscarriages Premature birth Birth defects, including: Cardiovascular/heart defects Musculoskeletal defects Limb reduction defects Missing/extra digits Clubfoot Craniosynostosis Facial defects Eye defects Orofacial cleft GI defect Gastroschisis Anal atresia Hernia Undescended testes Cerebral palsy SIDS Lower birth weight Future teen obesity in child Diabetes in child HTN in child CVD in child Increased likelihood to smoke in child Effects on others, known as second hand smoke, including: SIDS Asthma Lung infection Impaired respiratory function and slowed lung growth Crohn's disease Learning difficulties Neurobehavioral effects Increase in tooth decay Increased middle ear infections Ix Smokerlyzer, which is a test for nicotine dependence Tx Smoking cessation, involving discontinuing tobacco smoking. It can occur quitting without assistance , which can either include quitting cold turkey; or cutting down, then quit → caused by educational campaigns, tobacco control policies, limits where smoking is permitted Routine 5A's brief intervention, including: 1. Ask, about current (and previous) smoking at every opportunity, to routinely identify smokers If Pt has quit 10 mins advising smokers to quit yields higher abstinence rates, offering brief advice (as little as 3-5 mins) has been shown to have a significant impact on population smoking rates RCT's and systematic reviews show that supporting smokers to quit is more effective than leaving them to go it alone "cold turkey" Additional follow-up leads to further increases in smoking cessation rates, when compared to no follow-up Documenting tobacco use almost doubles the rate at which clinicians intervene w/ smokers, and results in higher rates of smoking cessation Predictors of relapse include withdrawl Sx, not being Mx w/ drugs, short periods of abstinence in previous quit attempts, low motivation to quit, low confidence in ability to quit, many smokers in the Pt's environment, high alcohol consumption, and cannabis use After quitting, it is very important to avoid any smoking at all, as it often leads to relaps See also NRT Varenicline Bupropion Sat, 23 Mar 2019 02:08:07 +0000 http://autoprac.com/smoking Leukonychia http://autoprac.com/leukonychia Leukonychia is white discoloration of the nail. [img]leukonychia.jpg[/img] Source: http://www.dermis.net/bilder/CD033/550px/img0063.jpg 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 Sat, 23 Mar 2019 03:04:47 +0000 http://autoprac.com/leukonychia Atrial flutter http://autoprac.com/atrial-flutter Atrial flutter is abnormal heart rhythm that occurs in the atria of the heart. [faq]What is atrial flutter, and how does it differ from atrial fibrillation? Let's start with atrial fibrillation. It's where electrical activity randomly starts all around the atria, rather than in a coordinated fashion from the SA node. In contrast, atrial flutter maintains coordinated firing originating from the SA node. However, the atrium is contracting far too quickly, to allow the signals to be conducted to the ventricles.[/faq] Sx Tachycardia (>100bpm), usually, when it first occurs [faq]What does it feel like if the atrial rhythm is really quick? The heart rate will be really high.[/faq] Cause Pt's w/ cardiovascular disease, including: HTN CAD Cardiomyopathy Diabetes mellitus May occur spontaneously in Pt's w/ otherwise normal hearts Dx [img]atrial-flutter-ecg.gif[/img] Source: RNCeus Prognosis Typically not a stable rhythm Frequently degenerates into AF (atrial fibrillation) Rarely persists for months to years See also Supra-ventricular tachycardia (category) Atrial fibrillation Fri, 22 Mar 2019 09:55:28 +0000 http://autoprac.com/atrial-flutter Pharmaceutical drug http://autoprac.com/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]] Fri, 22 Mar 2019 23:19:25 +0000 http://autoprac.com/pharmaceutical-drug Life support http://autoprac.com/life-support Life support are emergency techniques performed support life after the failure of one or more vital organs. [faq]What is life support? It's where you try to "support life", after 1 or more of the vital organs fail. What are the vital organs? They are the 5 organs essential for survival. They're the brain, heart, kidneys, liver, and lungs.[/faq] Method Basic life support (BLS, DRSABCD, aka first aid), is provided by bystanders before emergency services arrive. A✓B✓C✓ is shorthand for Airway, breathing and circulation are all normal. It includes: Check for Danger Assess for Response, verbalizing to patient, placing hand on their forehead, and shaking their arm Send for help, shout for help, emergency response button, or emergency response phone number (77) Open and clear Airways, using head tilt/chin lift in adults, or jaw thrust and in neutral position in children [youtube]PdkgnRCoci4[/youtube] [faq]Basic life support. Advanced life support. What's the difference? Basic life support is what the layperson can do. Advanced life support is what doctors do. What is basic life support then? DRSABCD. Watch out for any danger. Check for response. Send for help. Open and clear airways. Assess breathing. Assess circulation. And if things are going bad, start compressions. Attach the defibrillator as soon as you can. How do you assess response? Dry and stimulate bub. For adults, shake and pinch. How do you open and clear airways? Jaw thrust. Or chin lift and head tilt. Jaw thrust is where you place fingers under angle of lower jaw, and lift the jaw up, by the rear, at the jaw bone. You don't need to tilt the head up for that, which is useful if there's an injury, particularly of the spine. Chin lift and head tilt, is where you change the angle of the whole head, by lifting up the chin, and pushing the forehead back.[/faq] Assess Breathing, by placing face above infant, so that their ear is over nose, cheek over mouth, and eyes looking over chest, look (for movement, especially rise/fall of abdomen), listen (for life indicating sounds, e.g. breathing, swallowing), and feel (for breath on cheek) for 10 seconds. Also place palm on abdomen, to check for changes in pressure of abdomen against hand. If the Pt is unresponsive and not breathing, normally then give 2 rescue breaths w/ a bag and mask, mouth to mask, or mouth to mouth/nose, depending on availability. For mouth to mouth, the nose is pinched closed. Infants use a mouth to mouth and nose Assess Circulation, and commence Compressions (aka CPR) if Pt is unresponsive and not breathing normally, and pulse is not palpable within 10 seconds (at the femoral, brachial, or carotid) or Fri, 22 Mar 2019 22:09:48 +0000 http://autoprac.com/life-support Genetic disorder http://autoprac.com/genetic-disorder Genetic disorder is a problem caused by one or more abnormalities in the genome, that is present from birth (congenital). The most common genetic disorders, ecxluding [[chromosomal abnormalities]] (a sub-type), includes: [[22q11.2 deletion syndrome]] [[Canavan disease]] [[Charcot-marie-Tooth disease]] [[Color blindness]] [[Cri du chat]] [[Cystic fibrosis]] [[Duchenne muscular dystrophy]] [[Hemochromatosis]] [[Hemophilia]] [[Neurofibromatosis]] [[Phenylketonuria]] [[Polycystic kidney disease]] [[Sickle-cell disease]] [[Spinal muscular atrophy]] [[Tay-Sachs disease]] Pathophysiology Heritable (i.e. passed down from the parents' genes), including: Single-gene disorders, of which probabilities can be calculated with a Punnett square as they follow Mendelian inheritance, including: Autosomal dominant, where only 1 mutated copy of the gene is required (i.e. only 1 affected parent required). The chance a child will inherit the mutated gene is 50%. Examples include familial hypercholesterolemia, polycystic kidney disease, neurofibromatosis type 1, hereditary spherocytosis, Marfan syndrome, Huntington's disease Autosomal recessive, where 2 mutated copies of the gene is quired (i.e. both parents must be affected). If parents are both carriers, children have a 25% risk. Examples include sickle cell anemia, cystic fibrosis, Tay-Sachs disease, phenylketonuria, mucopolysaccharidoses, lysosomal acid lipase deficiency, glycogen storage diseases, galactosemia X-linked dominant, which are caused by mutations in the X chromosome. Both males and females are affected. Males are more SEVERELY affected. All of an affected man's daughters will be AFFECTED, but his sons will not be (since they receive the father's Y chromosome). A woman's children have 50% chance of being affected X-linked recessive, which are caused by mutations in the X chromosome. Males are more FREQUENTLY affected than females. All of an affected man's daughters will be CARRIERS, and his sons will not be affected. A woman's children have 50% chance of being carriers. Examples include Duchenne muscular dystrophy, hemophilia Y-linked, which are caused by mutations on the Y chromosome. They are only transmitted from fathers to their sons. Females can never be affected since they do not have a Y chromosome. Examples include infertility Mitochondrial (aka maternal inheritance), are mutations in mitochondrial DNA. Because only egg cells contribute to mitochondria, only mothers can pass on mitochondrial conditions. Examples include Leber's hereditary optic neuropathy Multifactorial and polygenic disorders Non-heritable (sporadic mutation), where defects may be caused by new mutations or changes to the DNA. Where this occurs, the defect will only be heritable if it occurs in the germ line The same disease (e.g. some forms of cancers), can be inherited in some condition, a new mutation in others, and caused by environmental causes in still others [faq]How do you remember that blokes are XY, and ladies are XX? Blokes tend to sit with their legs wide open in a Y shape. Ladies tend to sit with their legs crossed, in an the X therefore meaning a cross.[/faq] Risk factors Almost always affected by the environmental factors and events in a person's development Dx Screening: Alpha-fetoprotein (see page) Nuchal translucency (see page) Confirmation: Amniocentesis (see page) Chorionic villus sampling (see page) Peripheral umbilical blood sampling (PUBS, aka cordocentesis), is a prenatal test, to Dx genetic and other fetal problems (e.g. fetus hemolytic disease). Fetal and maternal blood is typically connected in utero with 1 vein and 2 arteries. The umbilical vein is responsible for delivery oxygenated blood to the fetus from the other. It is usually done in trimester 2-3, when the umbilical cord vessels can be punctured with a needle. Alternatively, it can provide rapid chromosome analysis, when information can't be obtained through amniocentesis, CVS, or U/S, or the results of these tests were inconclusive. The test carries a significant risk of bleeding of the puncture site, and has a higher risk of miscarriage [than amniocentesis or CVS] at 3% [faq]It seems like PUBS causes a higher risk, of 3%, and is also better done later :argh:. So unless if there's good reason, the choice is usually between amniocentesis and CVS. What's the difference between them :huh:? It's a weigh of choices. Amniocentesis has a lower risk of miscarriage of 0.5%, but you have to wait until 15 weeks gestation. CVS on the other hand, has a higher risk of miscarriage, but is the preferred method before 15 weeks gestation. So it's weighing "knowing earlier" with "risk of miscarriage". That all depends on the risk, and thoughts and feelings of the parents ;).[/faq] Tx Depends on the genetic defect or abnormality Epidemiology Most genetic disorders are quite rare, affecting 1 person in every several thousand or millions Some recessive gene disorders confer an evolutionary advantage in certain environments, when only 1 copy of the gene is present See also Chromosomal abnormality (type of genetic disorder) Down syndrome (contains more screens, specific for Down's) Alpha-fetoprotein Sat, 23 Mar 2019 02:31:42 +0000 http://autoprac.com/genetic-disorder Diabetes http://autoprac.com/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]] Fri, 22 Mar 2019 16:41:32 +0000 http://autoprac.com/diabetes Monoamine reuptake inhibitor http://autoprac.com/monoamine-reuptake-inhibitor XXRI's are antidepressants, used to treat depression, and other mental illnesses. MOA Increases certain monoamine levels, by inhibiting its reuptake into the presynaptic cell, thereby increasing the amount of the monoamine in the synaptic cleft available to bind to the postsynaptic receptor So for SSRI's, this is serotonin; for SNRI's, this is serotonin and norepinephrine They also have varying degrees of selectivity for other monoamines, but pure's only have weak affinity for non-stated monoamines Classification Examples of SSRIs include: Sertraline (Zoloft) [img]zoloft.jpg[/img] Source: Wikimedia Fluoxetine (Prozac), which is the only anti-depressant approved for the Tx of bulimia [img]prozac.jpg[/img] Source: Schmidt and Clark Escitalopram (Lexapro) [img]lexapro.jpg[/img] Source: Remedy Mart Examples of SNRIs include: Venlafaxine (Effexor) [img]effexor.jpg[/img] Source: Acosta Williams Desvenlafaxine (Pristiq) [img]pristiq.jpg[/img] Source: Psych Central Duloxetine (Cymbalta) [img]cymbalta.jpg[/img] Source: Schmidt Law Fluvoxamine (Luvox) [img]luvox.jpg[/img] Source: Wikimedia Fluoxetine (Lovan) Source: Acosta Williams Side effects Serotonin syndrome, due to overdose Antidepressant discontinuation syndrome, where following the interruption, dose reduction, or discontinuation of antidepressant drugs, including SSRI's or SNRI's. The Sx can include flu-like Sx and disturbances in sleep, senses, movement, mood, and thinking. In most cases, Sx are mild, short lived, and resolve wihtout Tx. More severe cases are often successfully Tx with reintroduction of the drug, which usually leads to resolution within 1 day See also [[Antidepressant]] Sat, 23 Mar 2019 02:43:16 +0000 http://autoprac.com/monoamine-reuptake-inhibitor Pneumonia http://autoprac.com/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 Sat, 23 Mar 2019 04:35:48 +0000 http://autoprac.com/pneumonia Abdominal pain http://autoprac.com/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, Fri, 22 Mar 2019 21:22:32 +0000 http://autoprac.com/abdominal-pain Oral contraceptive pill http://autoprac.com/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) Sat, 23 Mar 2019 04:18:05 +0000 http://autoprac.com/oral-contraceptive-pill Oxytocin http://autoprac.com/oxytocin Oxytocin (Oxt) is a drug and hormone that acts as a neuromodulator in the brain, used in sexual reproduction of both sexes, in particular during and after childbirth. An example of synthetic oxytocin is Syntocinon. [img]syntocinon.jpg[/img] Source: eHive Oxytocics are drugs relatd to oxytocin. Drugs that are indirect oxytocinergics include: 5-HT1A receptor, a protein responsible for inducing the secretion of oxytocin Serotonergic, a drug which acts upon serotonin and 5-HT1AR, resultin gin oxytocin release Purpose Cause contraction of the uterus, thus used to: Induce labor (start labor) Augmentation (increase the speed of labor), which is the process of facilitating further labor. It can be used to increase the rate of vaginal delivery in those wiht a slow progress of labor Stop PPH (bleeding following delivery), specifically, prevention and Tx of uterine atony Indications Used by injection by IM or IV Physiology Produced by the hypothalamus, and stored in the posterior pituitary gland Released due to stretching of the cervix and uterus during labor, and with stimulation of the nipples from breastfeeding It helps with birth, bonding with the baby, and lactation (milk production) Side effects Excessive contraction of the uterus, that can cause distress in an unborn baby Maternal: Nausea Bradycardia (slow HR) Water intoxication Uterus rupture, due to excessive dose See also Uterotonics (category) Tocolytic (antonym) Sat, 23 Mar 2019 02:04:31 +0000 http://autoprac.com/oxytocin Cyst http://autoprac.com/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 Fri, 22 Mar 2019 16:28:30 +0000 http://autoprac.com/cyst Erythema http://autoprac.com/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 Sat, 23 Mar 2019 03:35:01 +0000 http://autoprac.com/erythema Heart sounds http://autoprac.com/heart-sounds Heart sounds are the noises generated by a beating heart, and noise generated by the heart valves shutting, which can be listened by a stethescope. [faq]What are heart sounds? They're sounds that you can listen using a stethescope, that the heart makes. The heart makes music ;)? Sort of. It's the valves that create the noise.[/faq] Heart sounds The normal sound is a "lub-dub": S1 (1st heart sound), produced during systole (ventricular contraction, thus also when the pulse is felt), due to closing of the AV valves (mitral, tricuspid). M1 normally precedes T1 slightly [Systole occurs due to/after S1] S2 (2nd heart sound), produced during diastole (ventricular relaxation), due to closing of the semilunar valves (aortic, pulmonary). A2 normally precedes P2 [Diastole occurs due to/after S2] [youtube]X0p9GqvaKDw[/youtube] [faq]So the heart pumps twice. "Lub-dub". What does each mean? The 1st sound is the mega pump. It's when the ventricles contract. So it's when the middle AV valves close. The 2nd sound is the upper pump (because it's a lot more weaker, it can even be thought of as a leak). It's when the atria contract. So it's when the bottom SL valves close. I understand that what's normal is the "lub-dub". But, if the sound's not normal, how do you know which is which? By feeling the pulse. You can either do it on the one in the hand, or the neck. The pulse coincides with the mega pump. Which is the 1st sound. So the "lub".[/faq] Abnormal sounds include: S3 (3rd heart sound), indicating heart failure. It occurs just after ventricular relaxation, as blood rushes in from the atria, rapidly filling and expanding the ventricle w/ great volume [youtube]g8x4NM3PuuM[/youtube] S4 (4th heart sound), indicating hypertrophic ventricle. It occurs just after ventricular relaxation, as the atria must further contract to overcome an abnormally stiff ventricle [youtube]ntNNvRR1U38[/youtube] [faq]What about if there's more than 2 heart sounds? So that's S3 or S4. S3 sounds like a beat after the lub-dub. S4 is quite strange because it sounds like a beat BEFORE the lub-dub, because it's so late. So what does S3 and S4 mean? S3 is the sound of so much blood, that it takes longer to rush from the upper atria into the bottom ventricles, that it's heard as a 3rd sound. And S4 is just like S3, but because the ventricle is SO enlarged that the upper atria must contract even further to pump the blood into the bottom ventricles. So S3 is due to extra blood, and S4 is due to a big ventricle.[/faq] See also Stethoscope Breath sounds Murmurs Sat, 23 Mar 2019 03:04:41 +0000 http://autoprac.com/heart-sounds Respiratory examination http://autoprac.com/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]] Sat, 23 Mar 2019 03:34:59 +0000 http://autoprac.com/respiratory-examination HIV/AIDS http://autoprac.com/hiv-aids HIV (human immunodeficiency virus) is where the immune system progressively fails, allowing life threatening opportunistic infections/cancers. AIDS (acquired immunodeficiency syndrome) refers to the Sx of the late stage. [faq]What's HIV? AIDS? Are they the same thing? HIV is the virus. It causes the immune system to become progressively weak, permitting infections and cancers to happen, which wouldn't normally in a healthy person. AIDS is a word that helps to explain that state of immuno-deficiency.[/faq] Sx Brief period of flu-like Sx Followed by a prolonged period w/o Sx Sx of complications Pathophysiology HIV infects vital immune cells, including CD4+ T helper cells, macrophages, dendritic cells Transmits by body fluids: Blood, via IV drug usage, tattoo/piercing, blood transfusion prior to 1985 [that is contaminated], hypodermic needles Sexual (semen, vaginal fluids, pre-ejaculate), via unprotected vaginal sex, anal sex, oral sex Mother, during pregnancy, vaginal delivery, breast milk Unless contaminated by blood, there is NO risk of acquiring HIV from feces, nasal secretions, saliva, sputum, sweat, tears, urine, or vomit Within these bodily fluids, HIV is present as both free virus particles and virus within infected immune cells HIV infection leads to low levels of CD4+ T cells through a number of mechanisms, including pyroptosis of abortively infected T cells, apoptosis of uninfected bystander cells, direct viral killing of infected cells, and killing of infected CD4+ T cells by CD8 cytotoxic lymphocytes that recognize infected cells When CD4+ T cell numbers decline below a critical level, cell-mediated immunity is lost, and the body becomes progressively more susceptible to opportunistic infections Classification Primary HIV infection, which may be either asymptomatic or associated w/ acute retroviral syndrome Stage 1, where HIV infection is asymptomatic w/ a CD4+ T cell count>500/µL of blood. It may include generalized lymph node enlargement Stage 2, where there are mild Sx which may include minor mucocutaneous manifestations and recurrent URTI's. A CD4 count of Fri, 22 Mar 2019 22:11:31 +0000 http://autoprac.com/hiv-aids Antiviral http://autoprac.com/antiviral Antiviral are drugs used to Tx viral infections. Like antibiotics (for bacteria), specific antivirals can Tx specific viruses. Unlike most antibiotics, antivirals don't destroy the target pathogen, but rather inhibits their development. Classification Before cell entry: Entry inhibitor Uncoating inhibitor During viral synthesis: Reverse transcription, e.g. acyclovir Integrase Transcription Translation/antisense Translation/ribozymes Protein processing and targetting Protease inhibitors Assembly Release phase See also [[Antimicrobial]] Sat, 23 Mar 2019 03:50:08 +0000 http://autoprac.com/antiviral Growth chart http://autoprac.com/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 ( Sat, 23 Mar 2019 02:23:42 +0000 http://autoprac.com/growth-chart Oliguria http://autoprac.com/oliguria Oliguria (from Greek "oligo" meaning "small", aka hypouresis) is low output of urine. [faq]Oliguria, what is it? I know it's related to urine, but what is "oligo"? "Oligo" is like "oligopoly", where there are only a few competitors, but not yet a monopoly where there's 1 dominant company. So there's little urine output. But there's not no urine at all - that's what we call anuria.[/faq] Definition Oliguria is where urine output is Sat, 23 Mar 2019 02:48:10 +0000 http://autoprac.com/oliguria Nail clubbing http://autoprac.com/nail-clubbing [Nail] clubbing (aka Hippocratic fingers) is deformity of fingernails, causing loss of the angle when corresponding nails are placed against each other, in Schamroth's window test. [img]nail-clubbing.jpg[/img] Pathophysiology Vasodilation (relating to cardio) and secretion of growth factors (from the lungs), is thought to cause clubbing Cause Lung disease: Lung disease, mainly non-small-cell, not frequently seen in small-cell Interstitial lung disease, most commonly fibrosing alveolitis Complicated TB Suppurative lung disease, including: Lung abscess Empyema Bronchiectasis CF Mesothelioma of the pleura AV fistula or malformation Heart disease: Any disease featuring chronic hypoxia Congenital cyanotic heart disease, the most common cardiac cause Subacute bacterial endocarditis Atrial myxoma (benign tumor) ToF GI and hepatobiliary: Malabsorption Crohn's disease and UC Cirrhosis, especially primary biliary cirrhosis Hepatopulmonary syndrome, a complication of cirrhosis Others: Graves' disease (autoimmune hyperthyroidism), in this case called thyroid acropachy Familial and racial clubbing and pseudoclubbing, where people of Afircan descent often have what appears to be clubbing Vascular anomalies of the affected arm, e.g. axilliary artery aneurysm, in unilateral clubbing Idiopathic, but it is rare Epidemiology 60% of cases are idiopathic Hippocrates was the 1st to document lcubing as a Sx of disease Although many diseases are associated with clubbing, particularly lung diseases, these reports are relatively ANECDOTAL. There are insufficient prospective studies to draw conclusive evidence of these associations Fri, 22 Mar 2019 20:12:24 +0000 http://autoprac.com/nail-clubbing Fundal height http://autoprac.com/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 Sat, 23 Mar 2019 02:44:13 +0000 http://autoprac.com/fundal-height Uterotonic http://autoprac.com/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) Fri, 22 Mar 2019 22:13:39 +0000 http://autoprac.com/uterotonic Vomiting http://autoprac.com/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]] Fri, 22 Mar 2019 23:26:10 +0000 http://autoprac.com/vomiting Coagulation test http://autoprac.com/coagulation-test Blood clotting tests (aka coagulation tests, coagulation screen, coags) are lab tests used to Dx hemostasis. A coagulometer makes analytics based on diffrent methods of activation and observation of development of blood clots in blood [or its plasma]. Physiology The coagulation cascade results from injury to a blood vessel's endothelial lining, causing activation, adhesion, and aggregation of platelets, resulting ultimately to deposition and maturation of fibrin Although in the lab, the pathway can begin either with the intrinsic or extrinsic pathways, in real life, it can only do so from the extrinsic arm. During the cascade, the extrinsic arm is turned off, as there is sufficient thrombin to continue propagating the intrinsic arm Components Platelet count Bleeding time for platelet function PR (prothrombin ratio) for the tissue factor pathway (extrinsic pathway). PTT (prothrombin time test, aka internationalized normalized ratio, INR) is a ratio of a Pt's PT (prothrombin time) to the PT of a normal sample of blood. Thus, a result of 1-1.5 is considered normal. A result 1 means blood is too thin (doesn't clot enough). It is primarily used to monitor warfarin therapy, where the aim is to maintain an elevated INR within a certain range, e.g. 2-3 aPTT (activated partial thromboplastin time), which tests the contact activation pathway (intrinsic pathway) TCT or fibrinogen assay for the final common pathway (thrombin time) More detailed and specific coagulation tests, include: Specific factor assays, including: Fibrin degradation products D-dimer, indicating possibility of completed thrombosis Thrombin time Platelet aggregation Specific factor inhibitor assays, including: Protein C TFPI Antithrombin See also Blood count (often performed together, to detect other hematological abnormalities) LFT's (to exclude liver disease, as a cause of coagulation factor deficiency) Sat, 23 Mar 2019 03:24:41 +0000 http://autoprac.com/coagulation-test Miscarriage http://autoprac.com/miscarriage Miscarriage (aka spontaneous abortion, or pregnancy loss) is the natural death of an embryo/fetus, before it is able to survive independently. Miscarriage is death in the first 2 trimesters, set at  Sat, 23 Mar 2019 02:34:12 +0000 http://autoprac.com/miscarriage Bradycardia http://autoprac.com/bradycardia Bradycardia (aka bradyarrhythmia) is a slow heart rate Dx Resting HR Fri, 22 Mar 2019 13:26:52 +0000 http://autoprac.com/bradycardia Uterine contraction http://autoprac.com/uterine-contraction Uterine contraction is contraction of the myometrium (i.e. middle layer of the uterine wall, consisting of uterine smooth muscle cells, its main function being to induce uterine contractions). Birth pains are caused by tonic contractions of the uterus. Cause Throughout the entire menstrual cycle, the uterus contracts frequently. In the early follicular phase, these contractions occur 1-2 per minute, lasting 10-15 seconds, with a low amplitude of 30mmHg. Towards ovulation, the frequency increases to 3-4 per minute. During the luteal phase, the frequency and amplitude decrease, to facilitate any implantation. If implantation doesn't occur, the amplitude (strength of contraction) increases dramatically to between 50-200mmHg, producing labor-like contractions during menstruation, known as menstrual cramps, which can not only be uncomfortable, but even painful, but are generally significantly less painful than contractions during labor. They are also of higher duration and frequency than the rest of the menstrual cycle As part of the process of childbirth, the motion of the uterus is known as contractions. Along with labor, it releases the hormone oxytocin into the body. As labor intensifies, contractions become longer. Prior to actual labor, women may experience Braxton Hicks contractions (aka false labor) Postpartum pain in the 1st 3 days is also due to uterine contractions During female orgasm, where the uterus and vagona contract. It may not be noticed by all women, and pregnant women are most likely to notice these by late 2nd and 3rd trimesters DDx Braxton Hicks contractions (aka practice contractions, false labor), are uterine contractions that sometimes start around 6 weeks, but not usually felt until 2nd-3rd trimester. It is infrequent, irregular, and usually only involves mild cramping. It is considered a genuine contraction when cramping is strong and frequent. It is caused by tightening of the uterine muscles for 1-2 minutes, aiding the body in its preparation for birth, but not involved with effacement of the cervix Ix For childbirth contractions, monitoring by tocography (i.e. band around the belly, which measures pressure required to flatten a section of the wall, to estimate internal pressure) Tx For menstrual cramps, a hot water bottle, or exercising can help For childbirth contractions, always consult a medical professional, as some methods can be harmful to the mother/baby, may worsen the pain, or lengthen the labor See also [[Menstruation]] [[Dysmenorrhea]] [[Uterotonic]] (drugs causing contractions) [[Tocolytics]] (drugs preventing contractions) Sat, 23 Mar 2019 02:47:06 +0000 http://autoprac.com/uterine-contraction Stroke http://autoprac.com/stroke Stroke (aka cerebrovascular accident, CVA) is the brain version of a heart attack, and is where there is disturbance in blood supply to an area of the brain. [faq]What is a stroke? It's the brain version of a heart attack. So remember, a heart attack is when there's not enough blood supplying the heart. So for a brain attack, there's not enough blood supplying the brain. What, that sounds a bit like a TIA, what's the difference? TIA is a temporary version of stroke. So it's a bit like the angina of stroke. And just like how heart attack causes permanent damage, so does stroke.[/faq] Sx Loss of function supplied by the relevant area of the brain, including: Contralateral paralysis (i.e. inability to move limbs) Sudden weakness or numbness Amaurosis fugax (i.e. sudden dimming or loss of vision) Homonymous hemianopia (loss of vision on 1 side) Receptive aphasia (i.e. failure to understand) or expressive aphasia (i.e. failure to express language) Dysarthria (i.e. slurred speech) Vertigo (feeling like the world is spinning) Mental confusion Sx often appear soon after the stroke has occurred If Sx last Sat, 23 Mar 2019 04:02:20 +0000 http://autoprac.com/stroke Crackle http://autoprac.com/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) Sat, 23 Mar 2019 00:25:05 +0000 http://autoprac.com/crackle Hemolytic disease of the newborn http://autoprac.com/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 Sat, 23 Mar 2019 00:17:52 +0000 http://autoprac.com/hemolytic-disease-of-the-newborn Fifth disease http://autoprac.com/fifth-disease Fifth disease (aka slapped cheek syndrome) is one of several possible manifestations of infection by parvovirus B19. It is known as "5th disease" because of its place on the standard list of rash-causing childhood diseases (i.e. 1 measles, 2 scarlet fever, 3 rubella, 4 Dukes' disease, 5 Fifth disease, 6 roseola infantum). Sx Low grade fever Headache Rash [img]fifth-disease-rash.jpg[/img] Source: Info diseases Cold-like Sx, e.g. runny or stuffy nose Pathophysiology Parvovirus B19 (from Latin “parvum” meaning “small”) was the 1st known human virus in the Parvoviridae family, measuring only 23-26nm in diameter, ranking amongst the smallest DNA viruses. It is most known for causing disease in the pediatric population however it can also affect adults See also [[Measles]] [[Scarlet fever]] [[Rubella]] [[Dukes' disease]] [[Erythema infectiosum]] [[Roseola infantum]] Sat, 23 Mar 2019 02:36:49 +0000 http://autoprac.com/fifth-disease Molar pregnancy http://autoprac.com/molar-pregnancy Molar pregnancy (aka hytadiform mole) is an abnormal pregnancy, where a non-viable fertilized egg implants in the uterus, and will fail to come to term. [faq]In short, what's a molar pregnancy? Is it a baby or not? Not really. The egg may be fertilized, so conception has taken place. But because the placental tissue grows so fast, proliferating uncontrollably, it doesn't support the growth of the fetus. In short, complete hydatidiform moles have no fetal tissue at all. Partial hydratidiform moles however, do have a fetus, but it won't survive.[/faq] Sx Heavy irregular vaginal bleeding in the 4th-5th month of pregnancy, that is painless Anemia → due to bleeding Hyperemesis (more vomiting than expected) HTN Proteinuria Sx of hyperthyroidism → extremely high hCG produced by the syncytiotrophoblast, mimics TSH because alpha-hCG is also found in TSH Classification Characterized by presence of a hydatidiform mole (from Greek “hydatisia” meaning “a drop of water”, and Latin “mola” meaning “false conception”), where a mole is used to denote a clump of growing tissue, or a growth. It can be either: Complete mole (most common, constituting 90%), where a single (incidence is 90%) or 2 (10%) sperm combines with an egg without a nucleus [thus without DNA], the sperm therefore reduplicating to form a "complete" 46 chromosome set. Because the egg has no maternal DNA, it has no function. Thus, it does not produce fetal tissue. It involves uncontrollable proliferation of cells in the syncytiotrophoblast (i.e. outer layer of the to-be-placental tissue, that connects more so with the uterine wall itself). The genotype is typicaly 46,XX (diploid) due to subsequent mitosis of the fertilizing sperm, but can also be 46,XY (diploid). 46,YY (diploid) is not observed. It has a higher risk of developing into a choriocarcinoma, a magliantn tumor of trophoblast cells [than do p artial moles] Partial mole (10%), where a normal egg [with a nucleus] is fertilized by multiple sperm, causing an over-complete chromosome set, including triploid (69,XXY, 69 chromosomes, the most common), or tetraploid (92,XXXY, 92 chromosomes). Thus, it does produce fetal tissue, but because it has 3 chromosome sets rather than 2, it will be spontaneously aborted in late 1st trimester to early 2nd trimester. It involves uncontrolable proliferation of cells in the cytotrophoblast (i.e. inner layer of the to-be-placental tissue) [faq]Complete and partial mole. What's the difference? Complete molar pregnancies occur when an egg without a nucleus, which is where "DNA" is located, is fertilized by a sperm. Because there isn't a copy of the 23 chromosomes from mom, dad's chromosomes are instead duplicated to form the complete 46 chromosome set. The problem is that this is 100% dad's tissue.[/faq] Pathophysiology A molar pregnancy is a gestational trophoblastic disease, which grows into a mass in the uterus that has swollen chorionic villi. Thus, it is a pregnancy related tumor These villi grow in clusters that resemble grapes   Risk factors Extremities of age (35yo) Hx of GTD → risk is 30% following Hx of 2 molar pregnancies Diets low in protein, folic acid, and beta carotene Use of oral contraceptive Cigarette use Ix No fetal heart sound on Doppler auscultation On abdo palpation; Uterus that is large for dates Ovaries may be enlarged → ovarian/luteum cyst → hCG mimics FSH/LH which can cause luteum cysts FBC → anemia Coag studies → anemia Maternal Rh status → anti-D for Rh -ve mother Type and screen → high potential for bleeding, and need for transfusion Dx hCG levels, in: Complete mole, dramatically high, >100,000 → hCG is produced by the syncytiotrophoblast [in complete molar pregnancies] Partial mole, mildly elevated → hCG is produced by the syncytiotrophoblast, and partial moles involve proliferation of the cytotrophoblast U/S, with a: Complete mole, resembling a bunch of grapes ("snow storm appearance" instead of seeing a fetus) Partial mole, with multiple defects (e.g. hydrocephalus, IUGR) Definitive Dx requires D&C, biopsy, and send for histology Tx Tx ASAP to avoid risks of choriocarcinoma, including: Baseline hCG, so you can compare before-and-after Evacuate the uterus by: Surgical D&C, preferred Uterine suction Carboprost (PGF2alpha, i.e. an oxytocic), to contract the uterus Syntocin, to reduce PPH Follow up with weekly serum hCG levels, until it has fallen to an undetectable level, usually 14 weeks for a complete mole, and 8 weeks for a partial mole Give prophylactic anti-D for Rh -ve mother, even though there isn't really a fetus present Cancer (i.e. invasive/metastatic moles) may require chemotherapy, and often respond well to methotrexate, due to the presence of paternal antigens Advised not to conceive for 1 year after a molar pregnancy, as the chances of having another molar pregnancy in this time is approximately 1%. This also allows to check hCG level has gone down consistently, indicating the molar has been completely eradicated Prognosis More than 80% of hydatidiform moles are benign 12.5% of hydatidiform moles develop into invasive moles, called persistent trophoblastic disease (PTD) 2.5% of hydatidiform moles develop into choriocarcinoma (i.e. malignant, rapidly growing, metastatic form of cancer) Occurs in 0.1% of pregnancies, although geographically differs, with especially higher rates in Japan See also [[Ectopic pregnancy]] [[Miscarriage]] [[Gestational trophoblastic disease]] (category) Sat, 23 Mar 2019 01:39:58 +0000 http://autoprac.com/molar-pregnancy Insulin http://autoprac.com/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 Fri, 22 Mar 2019 19:18:44 +0000 http://autoprac.com/insulin Dietary minerals http://autoprac.com/dietary-minerals Dietary minerals are chemical elements required by living organisms, other than C, H, N, and O. Classification It includes: Major dietary elements: Calcium (Ca2+) → deficiency is [[hypocalcemia]] Phosphorus Potassium. The daily potassium requirement in adults is 100mmol in men, and 72mmol in women (source) → deficiency is [[hypokalemia]] Sulfur Sodium, of which the daily sodium requirement in adults is 20-40mmol (source) → deficiency is [[hyponatremia]] Chlorine Magnesium → deficiency is [[hypomagnesia]] Trace dietary elements: Iron → deficiency is iron deficiency Cobalt Copper Zinc, which is essential in numerous biochemical pathways. It affects many organ systems, including the skin, GI tract, CNS, immune, skeletal, and reproductive systems. Deficiency most commonly includes increased rates of diarrhea, pneumonia, and malaria Manganese Molybdenum Iodine Bromine Selenium See also [[Vitamin]] [[Fluid replacement]] [[Iron studies]] Fri, 22 Mar 2019 19:17:56 +0000 http://autoprac.com/dietary-minerals Nuchal scan http://autoprac.com/nuchal-scan Nuchal scan (aka nuchal translucency, nuchal fold) is an U/S prenatal screen assessing the quantity of fluid collecting within the nape of the fetal neck. Method Examined on the early morphology conducted at the end of trimester 1 (weeks 0-12), carried out at 11-13 weeks gestation. The scan is obtained with the fetus in saggital section, and a neutral position of the fetal head (neither hyperflexed nor extended, as it can influence nuchal translucency thickness). The fetal image is enlarged to fill 75% of the screen, and the maximum thickness is measured, from edge to edge. It is important to distinguish the nuchal lucency, from the underlying amniotic membrane Purpose Increased thickness measurements are associated with: Higher chances for chromosomal conditions, e.g. Down syndrome in a fetus, particularly for older women who have higher risks of such pregnancies, tending to have an increased amount of fluid around the neck. High definition imaging may also detect other less common chromosomal abnormalities Also associated with congenital heart defect Confirms both the accuracy of the pregnancy dates, and fetal viability Pathophysiology The fluid seen as translucency, can be edematous skin at the back of the neck, or dilated lymphatic sacs filled with fluid, due to altered normal embryological connections Nuchal translucency however, is ONLY useful to measure between 11-14 weeks gestation, when the fetal lymphatic system is developing, and the peripheral resistance of the placenta is high. After 14 weeks, the lymphatic system is likely to have developed sufficiently to drain away any excess fluid, and changes to the placental circulation will result in a drop in peripheral resistance. Fluid accumulated will thus correct itself after this time Interpretation If the screening is POSITIVE, it should be followed up with CVS (earlier) or amniocentesis (later), to confirm the Dx. However, because it carries a small risk of miscarriage, SCREENING should be used to minimize miscarriage Epidemiology The nuchal scan 1st came into widespread use in 2003 See also [[Down syndrome]] [[Pregnancy ultrasound]] [[Late morphology]] Fri, 22 Mar 2019 04:20:01 +0000 http://autoprac.com/nuchal-scan Blood sugar http://autoprac.com/blood-sugar Blood sugar level (GLU, BSL, BGL) is the amount of glucose present in blood. [faq]What is blood sugar? The amount of glucose in blood? Yep, it's that ;). Practically, which bottle do I use to collect blood to test blood glucose in? The grey top.[/faq] Source: Mater Pathology Physiology Glucose is the primary energy source for the body, with fats being a storage of energy. The breakdown of fatty acids also causes release of ketones, which can cause ketoacidosis. Glucose is transported from the intestines (recent intake) or liver (stored) into blood. It is made available for cell absorption via the hormone insulin, produced primarily in the pancreas Method Fasting blood glucose is easy to measure Glucose tolerance test (GTT), is a test where glucose is given, and blood samples taken afterward to determine how quickly it is cleared from blood. The most common version is the oral GTT (OGTT) where a standard dose of glucose is ingested by the mouth, and blood levels checked 2 hours later. It is not preferred because it takes 2 hours to complete, and offers no prognostic advantage over the fasting test Interpretation BSL's are usually regulated between a narrow range of 4.4-6.1mmol/L, as tested by a fasting BSL test Normal mean BSL's is 5.5mmol/L Normal BSL's when fasting for diabetics, should be below the mean, or 3.9-5.5mmol/L Glucose is generally the lowest in the morning before breakfast (known as the fasting glucose level), and rises after meals for 1-2 hours by a few mmol, in non-diabetics temporarily up to 7.8mmol//L or slightly more Alcohol intake causes an initial surge of blood sugar, and a subsequent drop of blood sugar Drugs can also alter blood glucose [img]bsl-levels.jpg[/img] Source: Web node [faq]So what's exactly up with sugar levels in blood. Why does it seem to fluctuate so much? Well it's because it's sugar, which is energy. So you get it from eating. So it's going to jump up after you eat to create these massive peaks, and then it drops as it's converted for storage. It's allowed to stay down overnight, until just before breakfast where it's the absolute lowest, because you haven't eaten since the night before. So overall, in  a normal person, what should blood glucose be? So that depends on if you're eating or not. If you're not eating, so we take that 1st reading in the morning, after not eating, it should be between 3.9-5.5mmol/L. So 5.5 is the average throughout the day, and below 3.9 is going into the low blood sugar area. After eating, it's normal for blood sugar to shoot up to as high as 7.8, or even higher, so immediately after eating is not a really good value to use, as to whether someone has high blood sugar or not.[/faq] Disease Hyperglycemia (fasting BSL>5.5mmol/L), is persistently high blood glucose, where fasting BSL>5.5mmol/L Diabetes is fasting BSL>6.9mmol/L. The BSL range for diabetics should be 5-7.2mmol/L before meals, and Sat, 23 Mar 2019 05:00:44 +0000 http://autoprac.com/blood-sugar Post dates http://autoprac.com/post-dates Post dates (aka postterm pregnancy, postmature birth, prolonged pregnancy) is where a baby hasn't been born >42 weeks gestation, 2 weeks beyond the normal 39-40 weeks gestation. [faq]Full term. Late term. Post term. There's a lot of terms here, what's what? Full term is 39-40 weeks. Late term is 41-42 weeks. Post term is >42 weeks.[/faq] Complications Can carry risks for both the mother and the infant: Fetal malnutrition, as after the 42nd week gestation, the placenta (which supplies the baby with nutrients and oxygen from the mother) starts aging and will eventually fail If the fetus passes meconium (its fecal matter), which is not typical until after birth, and the child breathes it in, the baby could become sick with meconium aspiration syndrome [faq]What can happen to the baby if it keeps staying in mommy's tummy? Does the food supply run out :(? Not exactly. Because mom can keep eating and there's essentially an unlimited supply ;). However, like all technology, things get a bit rusty :(. Same thing with the placenta. It starts to age and will eventually fail. What's worse is, the baby needs to poop! If it does, it might accidentally eat it's own poop... Ewewewewewe alert :S!!! Indeed. That's why we want to deliver ;)![/faq] Tx May be a reason to induce labor [faq]My baby is taking foreeeever to deliver :(. It's now post dates!! What can we do about it? Induce. We do certain maneuvers and use certain drugs which can help the baby pop out ;).[/faq] Complications Fetal and neonatal risks, including: Reduced placental perfusion, as the placenta starts to deteriorate. Towards the end of the pregnancy, calcium is deposited on the walls of the blood vessels, and proteins are deposited on the surface of the placenta, which changes the placenta. This limits the blood flow through the placenta and ultimately leads to placental insufficiency, and the baby is no longe properly nourished Oligohydramnios Meconium aspiration Fetal malnutrition Maternal risks, including: LGA Forceps assisted, vacuum assisted or C section birth, as post-term babies may be larger than average Shoulder dystocia, due to difficulty in delivering the shoulder of large babies Prolonged labor, as the baby's head is too big to pass thorugh the mother's pelvis, called cephalopelvic disproportion Psychological stress Labor induction [faq]If the baby is taking longer than normal to come out, what bad things can happen? There are risks to bub, and to mom. The placenta may become calcified, so blood flow may decrease. There's going to be less amniotic fluid, because of the decreased placental function. The baby is going to poop, so this can cause it to eat it, called "meconium aspiration". And the baby may have malnutrition, because the placenta is how the baby get's its nutrient. How about mom? What problems for her? Big baby. That makes it more likely to require assistance with delivery, like forceps, vacuum or C section. The shoulder can get stuck, called shouder dystocia. Labor can take longer than usual. It could be stressful. It also makes it more likely that we'll try to speed things up, using "induction".[/faq] See also [[Full term]], [[late term]] (normal) [[Preterm]] (antonym) Fri, 22 Mar 2019 15:00:47 +0000 http://autoprac.com/post-dates Bowel obstruction http://autoprac.com/bowel-obstruction Bowel/intestinal obstruction is mechanical/functional obstruction of the intestine, preventing normal transit of feces. SBO is shorthand for Small bowel obstruction. [faq]What is bowel obstruction? Bowel is just another word for intestine. So it's just anything that's obstructing the intestine from what it normally does, which is carry feces.[/faq] Sx Sx depends on the level of obstruction Abdominal pain, which tends to be: In small bowel obstruction: Colicky (cramping and intermittent) in nature, w/ spasms lasting a few minutes Pain tends to be central and mid-abdominal In large bowel obstruction: Pain felt lower in the abdomen, w/ spasms lasting longer Constipation occurs earlier Proximal obstruction of the large bowel may present as small bowel obstruction Swollen abdomen Abdominal distension Vomiting, including fecal vomiting In small bowel obstruction, vomiting may occur before constipation In large bowel obstruction, vomiting may be less prominent Constipation, absence of normal stool/flatus Increased bowel sounds [faq]What is it like if you get an intestinal obstruction? Constipation happens, because feces can't get through. The tummy can be enlarged, because feces is building up. If feces keeps building out, it can come out the mouth, as fecal vomiting. Is there any tummy pain? Tummy pain, is seen in both obstruction of the small and large intestine. But whereas the pain is more central and colicky in the small intestine... when it gets to the later large intestine, the pain is lower, and the spasms last longer.[/faq] Pathophysiology Can occur at any level distal to the duodenum (of the small intestine) Cause Small intestine obstruction, including: Adhesions from previous abdominal surgery, most commonly Pseudoobstruction hernias containing bowel Crohn's disease, causing adhesions or inflammatory strictures Neoplasms, benign or malignant Intussusception in children Volvulus Superior mesenteric artery syndrome, a compression of the duodenum by the superior mesenteric artery and abdominal aorta Ischemic strictures Foreign bodies, e.g. gallstones in gallstone ileus, swallowed objects Intestinal atresia Large intestine obstruction, including: Neoplasms Diverticulitis/diverticulosis Hernias Inflammatory bowel disease Colonic volvulus (sigmoid, cecal, transverse colon) Adhesions Constipation Fecal impaction Fecaloma Colon atresia Intestinal pseudoobstruction Endometriosis Narcotic induced, especially w/ the large doses given to cancer or palliative care Pt's Dx Blood tests Imaging, including: Abdo x-ray, which may show bowel distension, and presence of multiple (>6) gas fluid levels on supine and erect abdominal radiographs. The appearance of water-soluble contrast in the cecum on abdo x-ray w/in 24 hours of oral administration predicts resolution of an adhesive small bowel obstruction [img]x-ray-of-small-vs-large-bowel-obstruction.jpg[/img] Source: Slideshare CDN Luminal contrast studies, including contrast enema, small bowel series, or CT, can define the level of obstruction, whether the obstruction is partial or complete, and define the cause of obstruction U/S Biopsy, to determine the nature of the mass, if a mass is identified Colonoscopy, small bowel investigation w/ ingested camera or push endoscopy, and laparoscopy [faq]What can you do to look further into an obstruction in the intestine? You can start with bloods. You can also take images, including an x-ray of the tummy. Because x-rays aren't that good to see soft tissue, you can use contrast to outline the inside of the GI tract. Or you can use ultrasound or CT, which is better for soft tissue. You can also put a camera down the throat, to look inside, and pinch a bit of the thing that's causing the blockage.[/faq] DDx Ileus Pseudo-obstruction or Ogilvie's syndrome Intra-abdominal sepsis Pneumonia, or other systemic illness Tx Mostly Tx conservatively over 2-5 days (e.g. in Crohn's disease, peritoneal carcinomatosis, sclerosing peritonitis, radiation enteritis, and postpartum bowel obstruction), because in many cases, the bowel will open up. Some adhesions loosen up, and the obstruction resolves. However, this requires close monitoring, examined several times a day, and x-rays taken to ensure the Pt is not clinically getting worse. It includes: Insertion of an NG tube, to correct dehydration and electrolyte abnormalities Opioid pain drugs, can be used for Pt's w/ severe pain Antiemetics, if the Pt is vomiting Surgical intervention to Tx the causative lesion, in surgical emergencies (e.g. volvulus, closed-loop obstructions, ischemic bowel, incarcerated hernias, fully lodged foreign object, malignant tumor), including bowel resection or lysis of adhesions Endoscopically placed self-expanding metal stents, may be used to temproarily relieve the obstruction as a bridge to surgery, or as palliation, in malignant large bowel obstruction NG tube inserted from the nose into the stomach, to help decompress the dilated bowel. The tube is uncomfortable but does relieve the abdominal cramps, distension and vomiting IV therapy Catheter in the bladder, to monitor urine output [faq]What can you do about an obstruction in the intestine? If the patient isn't eating, you can put a tube down their nose and feed them that way. If they're in pain or vomiting, you can also fix that. You can do open surgery. Or you may be able to use a stent to relieve any obstruction that you find.[/faq] Complications Dehydration Electrolyte abnormalities, due to vomting Respiratory compromise, from pressure on the diaphragm by a distended abdomen, or aspiration of vomitus Bowel ischemia or perforation from prolonged distension or pressure from a foreign body [faq]What are the things you're worried about, in an obstruction in the intestines? All the vomiting can cause a patient to become dehydrated, and affect electrolytes. The expanding mass in the tummy, can also put pressure on the diaphragm, even affecting the patient's breathing. A blockage can also cause the tummy system to blow up, or put pressure against it's blood supply, and kill parts of it.[/faq] Prognosis It is a medical emergency Some causes of bowel obstruction may resolve spontaneously 6% of small bowel obstruction, are ultimately fatal if Tx is delayed See also Abdominal examination Fri, 22 Mar 2019 23:13:51 +0000 http://autoprac.com/bowel-obstruction Gestational diabetes http://autoprac.com/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 Fri, 22 Mar 2019 04:59:20 +0000 http://autoprac.com/gestational-diabetes Irregular periods http://autoprac.com/irregular-periods Irregular periods (aka irregular menstruation, irregular cycles) is irregular/abnormal variation in length of menstrual cycles, but can also be used to refer to other conditions that mimic it. [faq]What are irregular periods? So it's where there's are variations in the length of the menstrual cycle.[/faq] Classification Variations in cycle length, between the shortest and longest cycle: 35 days, thus only permitting 4-9 periods in a year) Polymenorrhea (intervals Fri, 22 Mar 2019 14:17:49 +0000 http://autoprac.com/irregular-periods Lung function test http://autoprac.com/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: http://dynamicmt.com/dataform3.html 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]] Fri, 22 Mar 2019 22:56:02 +0000 http://autoprac.com/lung-function-test Chickenpox http://autoprac.com/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 ( Sat, 23 Mar 2019 02:54:32 +0000 http://autoprac.com/chickenpox Postpartum hemorrhage http://autoprac.com/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 Sat, 23 Mar 2019 00:55:02 +0000 http://autoprac.com/postpartum-hemorrhage Hepatitis B http://autoprac.com/hepatitis-b Hepatitis B (formerly serum hepatitis) is liver inflammation caused by hepatitis B virus (HBV). It can cause acute and chronic infections. [faq]What is hepatitis B? And how it's different from hepatitis? So hepatitis inflammation. This can happen because of lots of reasons. Hepatitis A is spread by by eating contaminated foods. Hepatitis B and C are similar, both transmissible through blood, although hepatitis B is also an STI. There is no vaccination for hepatitis C.[/faq] Sx Most are asymptomatic, especially during the initial infection, or in those w/ chronic disease Rapid onset of sickness Vomiting Jaundice Fatigue Dark urine Abdominal pain Sx often last a few weeks May take 30-180 days for Sx to begin [faq]What happens in hepatitis B? So usually nothing. But there can be problems with the liver, causing you to become yellow. Fatigued. Dark urine. Abdominal pain. Vomiting.[/faq] Pathophysiology Virus is transmitted by exposure to infectious blood or body fluids. It can NOT be spread by holding hands, sharing eating utensils, kissing, hugging, coughing, sneezing, or breastfeeding Risk factors It is most frequently contracted by: Perinatal infection Contact with other people's blood during childhood IV drug use Sexual intercourse Working in healthcare Blood transfusions Dialysis Living with an infected person Travel in countries where the infection rate is high Living in an institution Dx Can be Dx 30-60 days after exposure Blood test, to detect either: Antigens produced by the virus, and antibodies produced by the host against these antigens, including: HBsAg (hepatitis B surface antigen), most frequently, as it is the first detectable viral antigen to appear during infection. However, it may not be present early in an infection. Also, if the host is able to clear the infection, HBsAg will become undetectable. Pt's who remain HBsAg positive for >6 mo are considered to be hepatitis B carriers HBcAg (hepatitis B core antigen), which is an inner core particle enclosing the viral genome. During the window in which the host is infected but is successfully clearing the virus, IgM antibodies specific to HbcAg (anti-HBcIgM) may be the only serological evidence of disease. The absence of HBsAg but presence of anti-HBs thus indicates clearing of an infection, or a previous vaccination. If the host is able to clear the infection, [following the dissapearance of HBsAg], anti-HBs and anti-HBc IgG will become undetectable HBeAg (hepatitis B e antigen), which appears shortly after the appearance of HBsAg. Traditionally, HBeAg was associated with higher rates of viral replication and enhanced infectivity, but variants of HBV don't produce the "e" antigen, so this rule doesn't always hold true. Being seroconverted to HBeAg negative status, in particular in those who acquired the infection as adults, have very little viral multiplication, and hence may be at little risk of long term complications or transmitting the infection to others Measure viral load, by PCR, indicating the amount of HBV. it is used to assess the Pt's infection status and monitor Tx Elevated liver enzymes, including ALT, will occur in Pt's w/ chronic hepatitis B (carriers) [faq]How do you check for for hepatitis B? So blood tests are the biggy. You can also check using the tests for liver function, to check the extent of damage made to the liver. What blood tests can you do for hepatitis B? So you want to check whether you have it (or had it in the past, or were vaccinated against it). And, if you have it, how much of the virus you have. So you can test for antigens, which are antibodies made by the body against hepatitis B. So this includes the surface antigen, the 1st appearing one, indicating a current infection. Core antigen, indicates a past infection. There's also viral load, which indicates how much of the hepatitis B virus you have.[/faq] Tx Preventable, by: Vaccination on the 1st day of life. 2-3 more doses are required at a later tme for full effect All blood is tested for hepatitis B before transfusion Condoms be used to prevent infection There is NO evidence that breastfeeding after proper prophylaxis contributes to maternal transmission of HBV For children of pregnant women with hepatitis B: Hepatitis B vaccine HBIg (immunoglobulin) During initial infection, care is based on Sx In those who develop chronic disease, antivirals (e.g. tenofovir or interferon), but are expensive For cirrhosis, [[liver transplantation]] Complications In chronic disease: Cirrhosis Liver cancer Prognosis Rarely does the initial infection result in death In those who are infected at birth, 90% develop chronic hepatitis B In those who are infected >5yo, 10% develop chronic hepatitis B Liver complications result in death in 20% Epidemiology Tattooing and acupuncture previously caused significant cases of hep B in the 1980's, but is now less common w/ improved sterility WHO recommends vaccination on the 1st day of life if possible Vaccination works 95% of the time 180 countries give the vaccine as part of their national program About 33% of the world has been infected at one point in their lives, including 295 million who have chronic infections Over 750k people die annually due to hepatitis B. 300k is due to liver cancer The disease is now only common in East Asia and sub-Saharan Africa, where 7% of adults have chronic disease Research is looking to create foods that contain the HBV vaccine Without intervention, a mother who is HBsAg positive, has a 20% risk of passing the infection during childbirth. A mother who is HBeAg positive, has a 90% risk of passing the infection during childbirth HBV is 75 times more infectious than HIV See also [[Hepatitis C]] [[Hepatitis]] (category) Fri, 22 Mar 2019 19:03:03 +0000 http://autoprac.com/hepatitis-b Heart valve http://autoprac.com/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 Fri, 22 Mar 2019 23:36:59 +0000 http://autoprac.com/heart-valve Anti-D http://autoprac.com/anti-d Anti-D (aka Rh0(D) immune globulin) is a medication given by IM, to prevent Rh disease (aka hemolytic disease of newborn, i.e. immunological condition). It is a solution of IgG anti-D (anti-RhD) antibodies, that take out any fetal RhD-positive erythrocytes which have entered the maternal blood stream from fetal circulation, before maternal immune system can react to them, thus preventing maternal sensitization. [faq]What is anti-D? Who is D? And why don't we like them :P? D refers to Rhesus D. Rhesus is just a particular blood group type that causes antibodies to be made, which we call that an antigen. Anti-D is just something we use to destroy all these antibody generators, or antigens.[/faq] Physiology In a Rhesus-negative mother, anti-D can prevent temporary sensitization of the maternal immune system to D antigens, by binding any fetal RBC's with the D antigen before before the mother is able to produce an immune response and form anti-D IgG D antigens can cause rhesus disease in the current OR in subsequent pregnancies The D antigen is composed of IgG antibodies, and therefore is able to cross the placenta In rare cases, this can cause a baby to have a weakly positive DAT (direct antiglobulin test) due to sensitization of fetal cells from mothers who have received multiple doses of anti-D. However, no Tx is necessary as the clinical course is benign [faq]Wait. What's up with the Rhesus thing? Who has it, how do they get it, and what exactly happens? So it happens when the mom doesn't have Rhesus. But the father has Rhesus, and bub can inherit Rhesus. Now remember mom doesn't have Rhesus, but bub does. Therefore, if bub's blood mixes with mom's, the mother will have an allergic reaction. So she creates antibodies to the Rhesus antibody generators in bub's blood. These antibodies can cross the lacenta, and attack bub's blood.[/faq] Indications Rh-negative mother. Although RhD is only theoretically required where the father is RhD positive, even though a dad may test RhD negative, he may actually have traces of D antigen, or a weak/partial variant of D antigen, so is given anyway. The only exception when it is confirmed that the fetus is known to be D-negative Mother is not alloimmunized to D (i.e. they have an anti-D antibody), unless it is due to antenatal administration of anti-D Prophylactically, at: 28 weeks, w/ anti-D 625IU 34 weeks, w/ anti-D 625IU Within 72 hours of giving birth, of a Rh +ve fetus Sensitizing events, Fri, 22 Mar 2019 22:38:54 +0000 http://autoprac.com/anti-d Level of consciousness http://autoprac.com/level-of-consciousness [Altered] level of consciousness (LOC) is a measure of arousal other than normal. LOC refers to a Pt's arousability and responsiveness to stimuli from the environment. Classification Lethargy, which is a mildly depressed LOC or alertness, and can be aroused with little difficulty Obtunded, have a more depressed LOC and can't be fully aroused Stuporous, who are unable to be aroused from a sleep-like state Coma (see page), which is the inability to make any purposeful response Pathophysiology Deficit in LOC suggests that there is injury to: Both cerebral cortex, the grey matter (i.e. group of tight, dense matter, composed of th enuclei of neurons whose axons form the white matter) that forms the outer layer of the brain. It is responsible for perception, relay of sensory input via the thalamic pathway, and other neurological functions including complex thinking RAS (reticular activating system), a more primitive strucutre located in the brainstem, that is tightly in connection with the reticular formation. Specifically, of the ascsending tract (i.e. ACh-producing neurons, which works to arouse and wake up the brain, from the RF, through the thalamus, and then finally to the cerebral cortex) Cause Alteratiosn in the chemical environment of the brain, e.g. exposure to poisons or intoxicants Insufficient oxygen or blood flow in the brain Excessive intracranial pressure (pressure within the skull) Dx Consciousness is is measured by the glasgow coma scale (GCS), which is a scale scored between 3 (deep unconsciousness) and 15 (originally, it was 14). It includes:   1 2 3 4 5 6 Eye Does not open eyes Opens eyes in response to painful stimuli Opens eyes in response to voice Opens eyes spontaneously     Verbal Makes no sounds Incomprehensible sounds Utters inappropriate words Confused, disoriented Oriented, converses normally   Motor Makes no movements Extension to painful stimuli Abnormal flexion to painful stimuli Flexion / Withdrawal to painful stimuli Localizes painful stimuli Obeys commands Brain injury is classified as: =13, minor AVPU scale is a simplification of the GCS, which assess only its acronym, "alert, voice, pain, unresponsiveness". Like GCS, it works on Eye, Verbal and Motor, looking for the best response in each. Again, it indicates LOC. However, rather than providing a score out of 13, it provides a binary score for each section, providing a maximum score of 4. Prognosis Prolonged unconsciousness is a medical EMERGENCY Decreased LOC correlates to increased morbidity (sickness) and mortality (death), and thus considered by some to be a vital sign See also [[Loss of consciousness]] (usual abbreviation for LOC) Fri, 22 Mar 2019 11:43:27 +0000 http://autoprac.com/level-of-consciousness Pre-eclampsia http://autoprac.com/pre-eclampsia Pre-eclampsia (from Greek "eclampsia" meaning "lightning", previously called pre-eclamptic toxemia, PET) is a disorder of pregnancy. The disorder usually occurs in trimester 3 of pregnancy, and gets worse over time. Rarely, pre-eclampsia may begin postpartum (i.e. after delivery). [faq]What is pre-eclampsia, and how does it differ from eclampsia? It's 2 things. High blood pressure. And protein in urine. How does it differ from eclampsia? Eclampsia is one step up. It's where you also get seizure. What's the difference between high blood pressure+end organ damage, and gestational hypretension then? Isn't that high blood pressure? Yes, but gestational hypertension doesn't have protein in urine.[/faq] Sx Generally, none of the signs of preeclampsia are specific, even convulsions are more likely to have causes other than eclampsia. Thus, the final proof is their regression after delivery: Swelling, especially pitting edema, especially in the face, hands and ankles → edema → water follows protein Weight gain → edema SOB → pulmonary edema If severe, warning signs for eclampsia will show: Severe headache, that doesn't dissapear with normal painkillers Visual disturbances (blurred vision, flashes of light) Right hypochondrial, or epigastric pain Vomiting End organ damage → circulatory effect Dizziness Epigastric pain → liver damage Impaired liver function Fetal growth restriction Kidney dysfunction Other end organ damage Eventually, seizure (known as eclampsia) [faq]How do I know if I have high blood pressure+end organ damage? What will I experience? Remember that pre-eclampsia without protein in urine is not pre-eclampsia. It's gestational hypertension. So we can expect the results of finding protein in urine. Swelling. Weight gain. Water in the lungs. I'm concerned +seizure is about to happen. How do I know? Severe headache. Visual disturbances. Right hypochondrial or epigastric pain. Vomiting.[/faq] Dx BOTH: Hypertension, where systolic>=140, OR diastolic>=90, at 2 separate times, more than 4 hours apart, in a woman >20 weeks of pregnancy. Where a Pt has essential HTN =30mmHg, or an increase of diastolic BP >=15mmHg Proteinuria, of >=0.3g in a 24 hour urine sample, or a spot urinary protein to creatinine ratio >=0.3, or a urine dipstick reading of 1+ → kidney damage. Note however, that 10% of Pt's w/ Sx of preeclampsia Alternatively, in some jurisdictions, evidence of end organ damage, including: Oligouria, elevated creatinine levels → kidney dysfunction Impaired LFT's → impaired liver function Platelets=160, or diastolic >=110 Proteinuria >5g in a 24 hour urine sample Even if the Dx criteria is not met (i.e. >=140/90), if baseline BP rises 30mmHg systolic, or 15mmHg diastolic, is still important to note. [faq]I read on some web sites you don't need protein in urine though, to have high blood pressure+end organ damage? That's correct. The definition depends on where you are in the world. Instead of protein in the urine, some definitions replace that with just any "end organ damage".[/faq] Ix Hx: Sx of eclampsia, including hyporeflexia, hypotonia, clonus BP → HTN HELLP syndrome, is a life-threatening obstetric complication usually considered to be a variant or complication of pre-eclampsia. Both conditions usually occur during the later stages of pregnancy, or sometimes after childbirth. It includes 3 main features: Hemolysis → damaged small blood vessels Elevated liver enzymes (AST, ALT, LDH) → liver damage Low platelets (thrombocytopenia, 37 weeks), and how severe the pre-eclampsia is (if Fri, 22 Mar 2019 05:24:40 +0000 http://autoprac.com/pre-eclampsia Brain lesioning http://autoprac.com/brain-lesioning Brain lesioning (aka ablative brain surgery, from Latin "ablation" meaning "carried away") is the surgical ablation of the brain, to Tx neurological or psychological disorders. Method Doesn't involve removing brain tissue, but rather destroying tissue, and leaving it in place There is some target nuclei for ablative surgery [and deep brain stimulation], including the motor thaalmus, the globus pallidus, and the subthalamic nucleus Side effects The lesions it causes is irreversible Epidemiology Experimental ablation is the removal of various different parts of the nervous system from animals, to observe what effects would be caused, e.g. inability ot move its arm. This could thus find what areas of the nervous system correspond to what function. This can also be done to observe behavioral effects. This research is considered unethical on humans however, due to its irreversible effects, and damages caused by the lesion. However, if these lesions are caused by accidents or disease, these can also be used to draw conclusions on the functions of different parts of the brain Fri, 22 Mar 2019 21:53:37 +0000 http://autoprac.com/brain-lesioning Blind insertion airway device http://autoprac.com/blind-insertion-airway-device Blind insertion airway device (BIAD, blind insertion device) is a device used for airway Mx, that ensures an open pathway between a patient's lungs and the outside world, as well as reducing the risk of aspiration, which can be placed without visualization of the glottis. Purpose They are often used in the pre-hospital and emergency setting Classification Laryngeal mask airway (LMA), is composed of an airway tube tht connects to an elliptical mask with a cuff which is inserted through the Pt's mouth, down the windpipe, and once deployed forms an airtight seal on top of the glottis [unlike tracheal tubes which pass through the glottis], thereby securing the airway. It is used by anesthetists to channel O2 or anesthesia gas to a Pt's lungs during surgery and in the pre-hospital setting for unconscious Pt's Nasopharyngeal airway (aka NPA, nasal trumpet, nose hose), is a tube designed to be inserted into the nasal passageway to secure an open airway. When a patient becomes unconscious, the muscle sin the jaw commonly relax and can allow the otngue to slide back and obstruct the airway. The purpose of the flared end is to prevent the device from becoming lost inside the patient's nose. The correct size is measured from the tip of the nose to the tragus of the ear. The suitable diameter is one that fits just into the nostril, without causing sustained blanching of the alae nasi. Do not use a nasopharyngeal airway if there is possibility of fracture of the base of the skull Oropharyngeal airway (aka oral airway, OPA, Guedel pattern airway) prevents the tongue from covering the epiglottis, which could prevent the person from breathing. When a patient becomes unconscious, the muscles in their jaw relax and allow the tongue to obstruct the airway. It should only be used on onconscious or obtunded patients, as if the patient is awake with an intact gag reflex, it may not be tolerated and induce vomiting. The correct size is measured from the center of the incisors, to the angle of the jaw/mandible. Ensure the Guedel follows the natural curvature of airway, with direct visualization. If inserted blindly, insert it upside down, and twist it to follow the curve once in. A tongue depressor or laryngoscope blade can help hold the tongue out of the way during insertion Laryngeal tube, is inserted blindly through the oropharynx into the hypopharynx to create an airway during anesthesia and CPR so as to enable mechanical ventilation of the lungs Combitube (aka esophageal tracheal airway, esophageal tracheal double-lumen airway), is a cuffed, double-lumen tube that is inserted through the patients mouth to secure an airway and enable ventilation. Generally, the distal (tube 2) enters the esophagus, where the cuff is inflated and ventilation is provided through the proximal tube (tube 1), which opens at the level of the larynx Disadvantage Risk of aspiration is higher than using endotracheal intubation See also [[Endotracheal tube]], although this can too be blindly inserted in ertain circumstances Fri, 22 Mar 2019 15:07:01 +0000 http://autoprac.com/blind-insertion-airway-device Colectomy http://autoprac.com/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 Fri, 22 Mar 2019 19:38:25 +0000 http://autoprac.com/colectomy