http://autoprac.com 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) Thu, 21 Nov 2024 17:18:53 +0000 http://autoprac.com/pulse 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) Thu, 21 Nov 2024 17:19:01 +0000 http://autoprac.com/perineal-tear 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 Thu, 21 Nov 2024 08:32:09 +0000 http://autoprac.com/gravidity-and-parity 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]] Thu, 21 Nov 2024 02:42:11 +0000 http://autoprac.com/group-and-hold 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 Thu, 21 Nov 2024 13:11:51 +0000 http://autoprac.com/fluid-replacement 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 Thu, 21 Nov 2024 04:34:04 +0000 http://autoprac.com/bishop-score 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 Thu, 21 Nov 2024 05:26:00 +0000 http://autoprac.com/jugular-venous-pressure 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) Thu, 21 Nov 2024 07:40:30 +0000 http://autoprac.com/pelvic-exam 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 Thu, 21 Nov 2024 04:24:12 +0000 http://autoprac.com/immunization 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 ( Thu, 21 Nov 2024 05:07:48 +0000 http://autoprac.com/route-of-administration 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 Thu, 21 Nov 2024 02:40:51 +0000 http://autoprac.com/newborn-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]] Thu, 21 Nov 2024 05:57:22 +0000 http://autoprac.com/neurological-examination 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]] Thu, 21 Nov 2024 10:14:28 +0000 http://autoprac.com/ecg 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 Thu, 21 Nov 2024 11:58:40 +0000 http://autoprac.com/measles 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]] Thu, 21 Nov 2024 01:38:15 +0000 http://autoprac.com/childbirth 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 Thu, 21 Nov 2024 09:32:50 +0000 http://autoprac.com/blood-test http://autoprac.com/kidney-function-test Kidney function tests are tests which help check the kidneys are working properly. Physiology Kidney is a bean shaped organs located at the rear of the abdominal cavity (retroperitoneum). It receives blood from the paired renal arteries, and drains into the paired renal veins. The kidneys excrete urine into its respective paired ureter, into the urinary bladder. It functions to: Natural filter of blood, removing water soluble wastes (e.g. urea, ammonium) which become urine Regulating electrolytes, reabsorbing water, glucose and amino acids Maintaining acid-base balance Regulating blood pressure (via salt and water balance) Produce hormones, including calcitriol, erythropoietin, and renin Classification UEC (Urea, electrolytes, creatinine, aka Basic metabolic panel) is a set of blood tests, providing information regarding kidney function. It involves: Electrolytes, which are acids/bases/salts that ionize in water. Phosphate sandoz are effervescent tablets that provide sodium and phosphate. These can additionally be tested in urine. The common electrolytes tested include: Sodium (Na+), normally 135-145mmol/L Chloride (Cl-), normally 95-105mmol/L Potassium (K+), normally 3.5-5mmol/L Total calcium (Ca2+), normally 2.1-2.5mmol/L Ionized calcium, 1.1-1.3mmol/L Magnesium (Mg2+), 0.7-0.95mmol/L Bicarbonate (HCO3-) Phosphate (HPO42-), 0.8-1.5mmol/L Inorganic phosphate, 1.3-1.5mmol/L BUN ([Blood] urea [nitrogen]), as liver produces urea as a waste product of digesting protein, and is excreted by the kidney Creatinine (Cr), a breakdown product of (creatinine phosphate in) muscle, which is usually produced at a fairly constant rate by the body. Creatinine is supposed to be excreted by the kidney. Do not mix creatinine with creatine. Low creatinine can be seen in conditions that result in decreased muscle mass BUN-to-creatinine ratio (aka urea-to-creatinine ratio) is the ratio of BUN and creatinine, both per blood. Both BUN and creatinine are freely excreted by the glomerulus, however, urea is REABSORBED by the tubules [whereas creatinine isn't]. The ratio can be: High, indicating prerenal problem, as urea reabsorption is increased, disproportionately to creatinine, thus indicating dehydration or hypoperfusion (e.g. bleeding) Normal, meaning postrenal problem, as urea reabsorption is within normal limits Low, indicating intrarenal problem, as renal damage causes REDUCED absorption of urea, thus lowering the urea:creatinine ratio Glucose [faq]What is BUN? It assess urea. Urea as in urine? Sort of. Urea is found in urine. It's a waste product that is excreted by the kidney. So if you're not getting rid of it, then kidney isn't working properly. How about creatinine, what's that? It's a breakdown product of muscle. The kidney also excretes that, so if you're not getting rid of it, then the kidney also isn't working properly. Practically, how do you collect UEC's? The bottle with the orange top. Sometimes, UEC's are given as 4 representative numbers. What are they? Sodium. Potassium. BUN. Creatinine.[/faq] Other tests for kidney function include: GFR (glomerular filtration rate), which describes the flow rate of filtered fluid through the kidney. eGFR should normally be 90-120mL/min. Thu, 21 Nov 2024 05:22:06 +0000 http://autoprac.com/kidney-function-test 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] Thu, 21 Nov 2024 17:18:45 +0000 http://autoprac.com/beta-agonist 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) Thu, 21 Nov 2024 10:26:47 +0000 http://autoprac.com/leopolds-maneuvers 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) Thu, 21 Nov 2024 03:09:11 +0000 http://autoprac.com/iv-cannulation 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 Wed, 20 Nov 2024 04:35:21 +0000 http://autoprac.com/pap-smear 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) Wed, 20 Nov 2024 15:17:37 +0000 http://autoprac.com/tachycardia 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 Thu, 21 Nov 2024 01:49:12 +0000 http://autoprac.com/oxygen-therapy 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]] Thu, 21 Nov 2024 09:32:24 +0000 http://autoprac.com/pregnancy 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 Thu, 21 Nov 2024 11:20:14 +0000 http://autoprac.com/angiography 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) Thu, 21 Nov 2024 01:32:52 +0000 http://autoprac.com/pelvic-organ-prolapse http://autoprac.com/health-care Health care is the Dx, Tx, and prevention of disease (also illness, injury, and other physical and mental impairments). Classification Primary care, who act as first point of consultation for all Pt's within the health care system. This can be a: GP Dentist Allied health, including: Physiotherapist (PT) Speech pathologist Dietitian Optometrist Pharmacist Psychologist Occupational therapist (OT), which uses purposeful activities or interventions designed to achieve improved function Social worker (SW) Chaplains, who are ministers (pastor, priest, rabbi, imam, or lay representative) of a religious tradition, attached to a secular institution (hospital, prison, military unit, school, police department, university, private chapel). Clinical pastoral education is the training that chaplains undertake Self care Secondary care, which is the provision of services by specialists that don't have first contact with patients, including: Cardiologists Urologists Dermatologists Tertiary care, which is specialized care, usually for inpatients on referral from a primary or secondary provider. It has personnel and facilities for advanced medical Ix and Tx, such as tertiary referral hospitals. OPD stands for outpatient department. Services include: Nursing staff Allied health staff Cancer Mx Surgeons Neurologists Cardiologists Oncologist Midwifery Palliative Home and community care, which is health care delivered outside of health facilities. This includes: Interventions of public health interest, such as food safety surveillance, obesity prevention, distribution of condoms and needle-exchange programs for prevention of STD's Professional services in residential and community settings, to support home living, aged care, Tx substance use disorders. NH is shorthand for nursing home Birthing centers, staffed by nurses, midwives, and assisted by doulas. It presents a more home-like environment than a labor ward, with more options including food/drink, music, and attendance of family/friends if desired. There may be non-institutional furniture such as queen-sized beds, and birthing tubs/showers for water births. Should additional assistance be required, the mother can be transferred to a hospital Community rehabilitation services, to assist with mobility and independence after loss of limbs Public health, which includes: Health promotion, which is the development of healthy public policy to address prerequisites of health (income, housing, food security, employment, quality working conditions) Notifiable diseases Screening, which is used to identify unrecognized disease in Pt's without Sx. It is thus unique as it is an Ix done in apparently well Pt's. Screening is designed to enable early intervention, to reduce mortality and suffering. Although screening may lead to earlier Dx, it is not always beneficial, and can result in overdiagnosis, misdiagnosis, and false sense of security. Tests must therefore have good sensitivity and acceptable specificity, particularly for diseases with low incidence. Types include: Universal screening, which involves screening of all people in a certain category (e.g. kids of a certain age) Case finding, which is screening a smaller group of people on the presence of risk factors (e.g. family member Dx with hereditary disease) Paperwork Paperwork for "Pediatric dietitian referral" includes: ID information, including Pt name, Date of birth, MRN (Medical record number) (if applicable), Parent/carer name, Phone, Address Current weight Current height Relevant medical Hx Reason for referral, including tick boxes for Malnutrition/growth faltering, Confirmed food allergy (please provide copy of test results), Food intolerance, Enteral feeding, Organ complication requiring therapeutic diet, Vitamin/mineral deficiency (please provide copy of blood results), Diabetes, Fussy eating, Obesity Detailed reason for referral Name of referrer Phone Address Signature Date Please fax referral to Nutrition department on ___ or post to Nutrition Dept ___ Hospital See also [[Determinants of health]] [[Preventative medicine]] Thu, 21 Nov 2024 00:23:45 +0000 http://autoprac.com/health-care http://autoprac.com/heart-attack Heart attack (aka myocardial infarction) is where blood [and thus oxygen] flow stops to a part of the heart, and heart muscle becomes damaged. [faq]What is a myocardial infarction, and how does it relate to a heart attack? They mean the same thing. Infarct means tissue dies because it's blood's supply is interrupted. Myocardium is the muscle tissue of the heart, that contracts to push blood out of the heart. So MI=heart attack. So what does heart attack exactly mean? Death of heart muscle, because it's blood supply is interrupted.[/faq] Pathophysiology Causes include: Complete blockage of a coronary artery caused by a rupture of an atherosclerotic plaque, most commonly Coronary artery spasm, which may be due to cocaine, significant emotional stress (Takotsubo cardiomyopathy), extreme cold Sx Sx of acute MI includes: Sudden chest pain or discomfort, felt behind the sternum or L of the chest, and sometimes travels to the LHS arm, LHS neck, shoulder, back or jaw. It lasts for more than few minutes. The discomfort may occasionally feel like heartburn. NB: Up to 64% of Pt's, especially women, do NOT experience chest pain, and is known as silent MI SOB Diaphoresis (cold sweat) Nausea, vomiting Palpitations Anxiety Weakness, fatigue (feeling tired) Presyncope (feeling faint) [faq]What happens in a heart attack? Sudden chest pain, which is felt behind the breastbone where the heart is. It sometimes travel to the left arm or neck. You also feel short of breath.[/faq] Risk factors For CAD and MI: Previous cardiovascular disease Old age Tobacco smoking Hyperlipidemia Diabetes HTN Lack of physical activity, obesity Chronic kidney disease Poor diet Excessive alcohol consumption Use of cocaine and amphetamines Family Hx of cardiovascular disease More common in men [faq]What makes it more likely for you to get a heart attack? If you've got other heart problems. Old age. Smoking. Lots of fat in your blood. Diabetes. High blood pressure. Being overweight. Not exercising. Problems with your kidney. Excessive alcohol intake. Use of recreational drugs. Other people in your family with heart problems. Being male.[/faq] Classification According to thickness: Transmural AMI (full thickness), is associated w/ atherosclerosis involving a MAJOR coronarya artery. It extends through the whole thickness of the heart muscle, and are usually a result of COMPLETE occlusion of the area's blood supply. It is evidenced on ECG by ST elevation, and Q waves. It includes: Anterior Posterior Inferior Lateral Septal Subendocardial AMI (partial thickness), involving a small area in the subendocardial wall of the L ventricle, ventricular septum, or papillary muscles. The subendocardial area is particularly susceptible to ischemia. It is evidenced on ECG by ST depression, and T wave changes According to the appearance of an ECG: For STEMI (ST elevation MI, i.e. where the ST traces higher than baseline) (30%), which presents with ST elevation, pathological Q waves, is a transmural infarction (i.e. full thickness of heart muscle), resulting in complete occlusion of the area's blood supply. It is associated with CAD For non-STEMI (non-ST elevation MI) (25%), which presents with ST depression, is a subendocardial MI [faq]What are the types of myocardium death? STEMI, and non-STEMI. STEMI means that on the ECG, there is ST elevation, and pathological Q waves. And non-STEMI where there isn't ST elevation, but rather, depression. What's this ST elevation or depression about? What is ST? ST should be flat. ST is the point between depolarization (QRS wave) and repolarization (T-wave) of the ventricles. So it should be flat. But if heart muscle is damaged, it's contractile and electrical properties change. This causes early repolarization, prematurely ending the pumping of the ventricle, called systole. Early repolarization explains why the full-thickness ST elevation happens. But why does ST depression happen? Where the the death of heart muscle is not full thickness, there is an elevated resting potential in heart cells. That makes the ST look like it's going down.[/faq] Dx For CAD and MI: For CAD only (and not suspected MI), cardiac stress testing ECG's, looking for: ST elevation (STEMI), which usually requires more aggresive Tx Pathological Q waves ST depression, in non-STEMI, alternatively [img]st-elevation-and-depression.jpg[/img] Source: Blogspot Blood tests, for cardiac markers, including: Troponin Creatinine kinase (CK-MB), which has since been largely replaced by troponin Coronary angiography, which is an x-ray with radiocontrast, in the coronary arteries [faq]How do you confirm a heart attack? Using an ECG, to see if there are any changes indicating heart damage. If there's nothing that can be seen, the patient can be challenged to exercise, whilst an ECG is being performed, to see if anything happens under exertion. You can also do an x-ray whilst contrast is being used to outline the arteries supplying the heart. Any blood tests you can do? Yeah, troponin and creatinine kinase. Troponin is released by heart muscle into blood, when it is damaged. Creatinine kinase is also released by heart muscles into blood, when it is damaged, although troponin is a better measure for this.[/faq] Tx For CAD and MI: For pain: GTN (nitroglycerin) Opioids Oxygen, in patients with low oxygen levels or SOB In STEMI, restoring blood flow to the heart, using: Reperfusion therapy (i.e. restoring circulation to the heart), using angioplasty (aka percutaneous coronary intervention, i.e. arteries are pushed open) Thrombolysis (i.e. blockage removed using medications) In non-STEMI, using: Heparin (blood thinner) Angioplasty, in those at high risk CABG (coronary artery bypass surgery), for Pt's with MULTIPLE blockages of the coronary arteries, particularly if they also have diabetes Address risk factors, after the MI, with: Lifestyle modification (healthy diet) Aspirin, preventing further blood clots, including in a suspected MI Address diabetes Address hypercholesterolemia, with statins Address HTN, with beta blockers [faq]What can be done about a heart attack? Thrombolysis drugs, can be used to remove blockages. Because heart muscle is damaged, an antiplatelet like aspirin can be given to prevent blood clots. GTN can also be given, which produces nitric oxide, which enlarges the blood vessels. The only problem with GTN is it can only be used in the short term, as it will result in tolerance after 2-3 weeks of use. You can also do things like address risk factors, including a healthy diet, address diabetes, high cholesterol, and high blood pressure. Any surgery you can do? Angioplasty, and CABG. Angioplasty is where a balloon is used to widen narrowed or obstructed arteries. CABG is where a vessel is used to divert blood flow away from an obstructed artery supplying the heart.[/faq] For Prinzmetal angina: Atropine [faq]Anything you can do for chest pain caused by spasm in the arteries supplying the heart? Atropine. It's an anticholinergic, so it inhibits the parasympathetics. This therefore causes dilation of the blood vessels.[/faq] Complications Acute complications, include: Heart failure, if the damaged heart is no longer able to pump blood adequately around the body Cardiac arrest Aneurysm of the LV myocardium Ventricular septal rupture, or free wall rupture Mitral regurgitation, in particular if the infarction causes dysfunction of the papillary muscle Dressler's syndrome Abnormal heart rhythms, e.g. ventricular fibrillation Ventricular tachycardia Atrial fibrillation Heart block Long term complications, including: Heart failure Atrial fibrillation Increased risk of a second MI [faq]What can death of heart muscle cause? The failure of the heart to work.[/faq] Epidemiology Worldwide >3m people have STEMI's, and 4m have NSTEMI's STEMI occurs about twice as often in men as women In the developed world, the risk of death in those who have STEMI is about 10% Rates of MI for any given age have decreased globally between 1990 and 2010 Leading cause of death in the world In those >75yo, 5% have had an MI with little or no Hx of Sx See also Acute coronary syndrome (category) Unstable angina (cardiac markers are negative, cf positive cardiac markers in MI) Coronary artery disease/ischemic heart disease CABG (Tx) Angioplasty (Tx) Thu, 21 Nov 2024 16:28:05 +0000 http://autoprac.com/heart-attack 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 Thu, 21 Nov 2024 16:19:48 +0000 http://autoprac.com/surgery http://autoprac.com/ctg CTG (cardiotocography, from "cardio" meaning "heartbeat", "toco" meaning "uterine contractions", and "graphy" meaning "recording") is recording of the fetal heartbeat and uterine contractions during pregnancy, typically only in the 3rd trimester. The machine used to perform the monitoring is called an electronic fetal monitor (EFM, aka cardiotocograph). Classification Non-invasive monitoring (aka CTG), involving 2 transducers placed on the mother's abdomen, one above the fetal heart [to measure the fetal HR], and the other at the fundus [to measure contractions] Invasive fetal monitoring (aka fetal scalp monitor), involving a wired scalp/spiral electrode attached to the fetal scalp through the cervical opening [and thus vagina]. It is more accurate since movement doesn't affect it Interpretation Mnemonic Dr C Bravado: DR: Define risk C: Contractions, which is the number of contractions in any 10 minute window. Each big square is 1 minute, and the 10 minute marks may be outlined too. Both the duration and intensity of contractions cannot be assessed for from the CTG, but only by palpation BRa: Baseline rate, which is the average HR of the fetus in a 10 minute window (do not use a wider window), ignoring any accelerations or deceleration, and should be between 110-160bpm. Bradycardia is 160bpm V: Variability, which is the variation of the baseline fetal HR in any 10-minute window, excluding accelerations and decelerations. It is reassuring if >5bpm, non-reassuring if 15bpm for >15 seconds. The presence of accelerations is reassuring, and there should be at least 2 accelerations every 15 mins, especially if they occur alongside uterine contractions. The absence of accelerations however, in an otherwise normal CTG is indeterminate D: Decelerations (aka depressions), which are abrupt decreases in the baseline HR of >15bpm for >15 seconds. There are various types of decelerations. Be careful not to mistake the mother's HR for a deceleration; if this occurs, a fetal scalp monitor may be required. Types of decelerations include: Early deceleration, is a gradual deceleration of FHR associated with a uterine contraction. The trough from the deceleration occurs at the same time as the peak of the contraction. This means that the deceleration recovers at the same time, and therefore DUE TO the contraction. These decelerations occur due to increased fetal ICP caused by compression of the head by uterine contractions. It therefore quickly resolves once the contraction ends, and ICP reduces. It is therefore physiological Variable deceleration, is a sudden decrease in FHR, taking 2 minutes. It is non-reassuring if >2 minutes, and abnormal if >3 minutes. The deceleration however, is Thu, 21 Nov 2024 08:56:22 +0000 http://autoprac.com/ctg 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]] Thu, 21 Nov 2024 00:37:47 +0000 http://autoprac.com/abdominal-examination 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. Thu, 21 Nov 2024 10:23:16 +0000 http://autoprac.com/fluid-thrill-test 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) Thu, 21 Nov 2024 05:50:09 +0000 http://autoprac.com/observation-chart 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, Thu, 21 Nov 2024 09:35:43 +0000 http://autoprac.com/abdominal-pain 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) Thu, 21 Nov 2024 11:32:48 +0000 http://autoprac.com/hematoma 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 Thu, 21 Nov 2024 05:31:22 +0000 http://autoprac.com/preterm-birth 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 Thu, 21 Nov 2024 14:43:21 +0000 http://autoprac.com/life-support 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 Thu, 21 Nov 2024 00:04:33 +0000 http://autoprac.com/mitral-facies 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]] Thu, 21 Nov 2024 03:11:39 +0000 http://autoprac.com/respiratory-examination http://autoprac.com/antipsychotic Antipsychotics are used to Tx psychosis, in particular, schizophrenia. They can also be used to Tx acute mania, agitation, bipolar disorder, autism, major depressive disorder, and so forth. MOA Both generations block receptors in the brain's dopaminergic pathways Classification Typical antipsychotics (aka 1st generation antipsychotics) are more likely to cause extrapyramidal symptoms, including Parkinsonian type movements, body rigidity, and involuntary tremors. It includes: Butyrophenones, including: Benperidol Bromperidol Droperidol Haloperidol (Haldol) [img]haloperidol.jpg[/img] Source: Kern Pharma Timiperone Moperone (discontinued) Pimamperone (discontinued) Diphenylbutylpiperidine, including: Fluspirilene Penfluridol Pimozide Phenothiazines, including: Acepromazine Chlorpromazine Cyamemazine Dixyrazine Fluphenazine Levomepromazine Perazine Pericyazine Perphenazine Pipotiazine Prochlorperazine Promethazine Prothipendyl Thioproperazine (only available in Canada) Trifluoperazine Mesoridazine (discontinued) Promazine (discontinued) Thioridazine (discontinued) Triflupromazine (discontinued) Thioxanthenes, including: Chlorprothixene Clopenthixol Flupentixol Thiothixene Zuclopenthixol Others, including: Clotiapine Loxapine Prothipendyl In contrast, atypical antipsychotics (aka 2nd generation antipsychotics) have less extrapyramidal effect. Examples of atypical antipsychotics are: Amisulpride Amoxapine Aripiprazole Asenapine Cariprazine Clozapine [img]clozapine.jpg[/img] Source: ServIMG Blonanserin Iloperidone Lurasidone Melperone Nemonapride Olanzapine (Zyprexa, or in combination with the SSRI fluoxetine is known as Symbyax) [img]zyprexa.jpg[/img] Source: GPW Law [img]symbyax.jpg[/img] Source: PSIC of Armacos Paliperidone Perospirone Quetiapine (Seroquel) [img]seroquel.jpg[/img] Source: Schmidt and Clark Remoxipride Risperidone (Risperdal) [img]risperdal.jpg[/img] Source: CCHR Int Sertindole Sultopride Trimipramine Ziprasidone Zotepine See also [[Antidepressants]] [[Neuroleptic malignant syndrome]] Thu, 21 Nov 2024 09:33:59 +0000 http://autoprac.com/antipsychotic 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 By location: Cysts of the jaws Epithelial lined cysts Developmental Odontogenic Odontogenic keratocyst (prev known as keratocystic odontogenic tumor, KCOT), is a rare and benign, but locally aggressive developmental cyst. It most often affects the posterior mandible Dentigerous cyst (aka follicular cyst), is an epithelial lined developmental cyst formed by accumulation of fluid between REE and crown of unerupted tooth Eruption cyst/hematoma, is a bluish swelling that occurs on the soft tissue over an erupting tooth, usually found in children Calcifying [cystic] odontogenic cyst (COC), a rare developmental lesion that  is a proliferation of odontogenic epithelium and scattered nest of ghost cells and calcifications that may form the lining of a cyst, or present itself as a solid mass Developmental Non-odontogenic Nasopalatine duct cyst (NPDC, aka incisive canal cyst), occurs in the median of the palate, often between roots of upper CI's; radiographically may appear as heart-shaped radiolucency. Usually asymptomatic, but may sometimes produce elevation in anterior portion of palate Nasolabial/nasoalveolar cyst, is located superficially in the soft tissues of the upper lip. It is an extraosseous cyst, 1 that occurs outside of bone. It thus doesn't show up on an x-ray Inflammatory Radicular cyst (aka PA cyst, inflammatory cyst), is a cyst arising from epithelial residues (i.e. cell rests of Malassez) in the PDL, due to inflammation, usually following death of the pulp. It may develop rapidly from a PA granuloma, or untreated chronic PA periodontitis Residual cyst, is a radicular, lateral periodontal, dentigerous, or other cyst that has persisted after it's associated tooth has been lost Paradental cyst, is a family of inflammatory odontogenic cysts that appear in relation to crown or root of partially erupted molar teeth. It is usually in the D region of partially erupted 8's Non-Inflammatory Lateral periodontal cyst, a non-inflammatory cyst on the side of a tooth derived from remnants of the dental lamina Non-epithelial lined cysts Cysts associated w/ the maxillary antrum [Oral] Mucocele, is a swelling of CT consisting of a collection of fluid called mucus. This occurs because of a ruptured salivary gland duct [Mucus] Retention cyst, is a mucocele due to an obstructed or ruptured salivary duct Pseudocyst, which are formed between the inner surface of the bone wall and the CT layer, the sinus mucosa remaining on the outside Cysts of the soft tissues of the mouth, face and neck Dermoid and epidermoid cyst Branchial [cleft] cyst (cleft sinus), is a lump that develops in the neck or just below the collarbone Nasopharyngeal cyst, is a cystic swelling arising from the midline and lateral wall of the nasopharynx Wed, 20 Nov 2024 23:30:46 +0000 http://autoprac.com/cyst 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]] Wed, 20 Nov 2024 20:50:11 +0000 http://autoprac.com/antiviral 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 Wed, 20 Nov 2024 18:14:54 +0000 http://autoprac.com/fundal-height 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 Thu, 21 Nov 2024 16:43:11 +0000 http://autoprac.com/calcium-channel-blocker 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 → Thu, 21 Nov 2024 16:35:18 +0000 http://autoprac.com/antenatal-care 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 Thu, 21 Nov 2024 15:30:12 +0000 http://autoprac.com/oslers-node http://autoprac.com/breastfeeding Breastfeeding is the feeding of an infant with milk produced by the female breast via lactation. Babies have a primitive sucking reflex that when anything touches the roof of their mouth (the palate), the child instinctively presses it between their tongue and palate to draw out the milk. Working mothers can also express milk to be used for their child whilst cared by others. Colostrum (aka beestings, bisnings, first milk) is a form of milk produced by the mammary gland in late pregnancy, generated just prior to giving birth. it contains antibodies to protect the newborn against disease. Protein concenctration is substantially higher than in milk. Fat concentration is lower in colostrum than in breast milk, although in some animal species, it is higher (e.g. sheep, horses). FBF is an abbreviation for Fully breast fed. EBM is an abbreviation for Expressed breast milk, which can be expressed either by hand, or with a manual or electric breast pump. EBM must be collected and stored correctly to prevent risk of bacterial growth. Indications Children should be breastfed within one hour of birth, exclusively for the first six month, and in combination with nutritionally adequate and safe foods until 2yo. It can remain for as long as mutually desired by the mother and baby. Breastmilk NEVER loses its nutritional and protective value, and it changes to meet the needs of the child. Anthropologically, the natural age of weaning for humans has been between 2.5-7yo. Advantages Breast milk is the primary and best complete source of nutrition for newborns before they can eat other foods, before being introduced in combination with other foods when a toddler. Breastfeeding: Promotes child eating more due to faster digestion Assists in strengthening the child's jaw Decreases allergies Decreases risk of diabetes and celiac disease Decreases risks of SIDS Decreases risk of obesity in adulthood Improved cognitive development Better mental health through childhood and adolescence Benefits in the mother include: Assistance in uterine shrinkage Decreased risk of breast cancer Decreased depression Decreased osteoporosis Bonding experience for both mother and baby Less expensive than formula There are concerns about the effects of artificial formulas, and is associated with deaths from diarrhea. Exceptions are when: Mother is taking certain drugs Mother has active untreated TB Mother is infected with HTLV WHO has provided national authorities with the right to decide what practice will best avoid HIV infection transmission maternally Social attitudes Although breastfeeding was the rule in classically, with industrialization, mothers began dispensing breastfeeding in favor of work requirements, causing significant decline from 1900-1960, also due to negative social attitudes, and the introduction of infant formula. Since 1960's, breastfeeding has experienced a revival, although some negative attitudes still remain Under Austalian Law, you have a RIGHT to breastfeed your child in public. It is protected by the Sex Discrimination Act 1984 if you are discriminated against. You do not need to use a Baby Care Room. It doesn't matter if there is a "NO FOOD or DRINK ALLOWED" sign Problems Breastfeeding difficulties are problems that arise from breastfeeding, the feeding of an infant or young child with milk from a woman’s breasts. Although babies have a sucking reflex that enables them to suck and swallow milk, and although human breast milk is usually the best source of nourishment for human infants, there are circumstances under which breastfeeding can be problematic, or even, rarely, contraindicated. Difficulties can arise both in connection with the act of breastfeeding and with the health of the nursing infant. Problems include: Breast pain Inverted nipples Engorgement Nipple pain Candidiasis Milk stasis Mastitis Overactive let-down Raynaud’s of the nipple Alternatives Infant formula is a manufactured food designed/marketed to feed infants Wed, 20 Nov 2024 20:02:48 +0000 http://autoprac.com/breastfeeding 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. Wed, 20 Nov 2024 11:01:18 +0000 http://autoprac.com/birth-control 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 Thu, 21 Nov 2024 04:23:41 +0000 http://autoprac.com/leukonychia 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 Thu, 21 Nov 2024 12:51:47 +0000 http://autoprac.com/health-record http://autoprac.com/anticholinergic Anticholinergics inhibits parasympathetics, by blocking the neurotransmitter acetylcholine [specifically, its binding to its receptor in neurons]. Parasympathetics are responsible for involuntary movement of smooth muscle present in the GI, urinary tract, lungs, etc. [faq]What are anticholinergics? It's drugs that inhibit the parasympathetics, which is the rest and digest response, by blocking acetylcholine. So rest and digest includes digestion, urination, and constriction of the breathing tubes.[/faq] Indications GI disorders, including: Gastritis Diarrhea Pylorospasm Diverticulitis UC Nausea Vomiting Genitourinary disorders, including: Cystitis Urethritis Prostatitis Respiratory disorders, including: Asthma Chronic bronchitis COPD Sinus bradycardia, due to a hypersensitive vagus nerve Insomnia, although usually only on a short term basis Dizziness, including vertigo, and motion sickness-related Sx [faq]When do you want to give a drug to inhibit the rest and digest response? If there's a GI problem, like diarrhea, diverticulitis, ulcerative colitis, vomiting. If there's a urinary problem, like inflammation of the bladder, urethra, or prostate. If there's a breathing problem, like asthma, or COPD.[/faq] Categories Anticholinergics can be divided into their specific targets: Antimuscarinics, which block activity of the muscarinic ACh receptor. These include: Aclidinium bromide (Genuair) Atropine Atropine methonitrate Benzatropine Biperiden Chlorpheniramine Cyclopentolate Darifenacin Dicyclomine Dimenhydrinate Diphenhydramine Doxylamine Flavoxate Glycopyrronium bromide (aka Glycopyrrolate, Seebri) Hydroxyzine Ipratropium [bromide] (Atrovent), which relieves bronchspasms. It is used to Tx COPD and acute asthma Mebeverine Orphenadrine Oxitropium Oxybutynin Pirenzepine Procyclidine Scopolamine (Hyoscine) Solifenacin Tolterodine Tiotropium [bromide] (Spiriva), used to Mx COPD Trihexyphenidyl +/- Benzhexol Tropicamide Antinicotincs, including: Bupropion Dextromethorphan Doxacurium Hexamethonium Mecamylamine Tubocurarine [Post-]ganglionic blockers, by acting as a nicotinic antagonist Neuromuscular blockers, which act presynaptically via inhibition of acetylcholine ACh, or postsnaptically at the ACh receptors of the motor nerve end-plate. This causes paralysis of the affected skeletal muscles [faq]What are the different types of drugs that inhibit the rest and digest response? The biggies are the antimuscarinics and antinicotinics. As it's mentioned, it acts against the muscarinic and nicotinic receptors. They're both receptors that bind acetylcholine.[/faq] Side effects Decreased mucus production in the nose and throat, causing dry, sore throat Dry mouth w/ possible acceleration of dental caries Pupil dilation, causing photophobia (sensitivity to bright light) Tachycardia (increased HR) Diminished bowel movement, sometimes ileus (decreased motility via the vagus nerve) Urinary retention Ataxia (poor coordination) Dementia Stopping of sweating, causing decreased epidermal thermal dissipation causing warm, blotchy, or red skin Increased body temperature Loss of accommodation, loss of focusing ability, blurred vision Double vision Tendency to be easily startled Increased IOP (intraocular pressure), dangerous for Pt's w/ narrow-angle glaucoma [faq]What are the side effects of the drugs that inhibit the rest and digest response? Because you're inhibiting the rest and digest response, you'd be worried about promoting things associated with the fight and flight response. So things like decreased mucus production, dry mouth, pupil dilation, increased heart rate, slower bowel movement, urinary retention.[/faq] See also [[Mydriasis]] [[Muscarinic antagonist]] Thu, 21 Nov 2024 03:31:35 +0000 http://autoprac.com/anticholinergic http://autoprac.com/pregnancy-ultrasound Pregnancy ultrasound is the use of ultrasonography in pregnancy, where sound waves are used to create real-time visual images of the developing embryo/fetus in the mother's uterus/womb. Purpose Check for multiple fetuses Assess possible risks to the mother (e.g. miscarriage, ectopic pregnancy, or molar pregnancy) Check for fetal malformation (e.g. spina bifida, cleft palate, clenched fists) Monitor development of the fetus, and determine if IUGR exists Note the development of fetal body parts (e.g. heart, brain, liver, stomach, skull, other bones) Check the amniotic fluid and umbilical cord for possible problems Determine due date (based on measurements and relative developmental progress) Dx pregnancy (uncommon) Epidemiology Standard part of prenatal care in many countries Routine obstetric U/S before 24 weeks gestation can significantly reduce the risk of failing to recognize multiple gestations, and improve pregnancy dating to reduce the risk of IOL for post-dates pregnancy See also [[Fetal Doppler]] [[Antenatal care]] [[Nuchal scan]] [[AFI]] (component of pregnancy U/S) [[Early morphology]] [[Late morphology]] Thu, 21 Nov 2024 06:05:13 +0000 http://autoprac.com/pregnancy-ultrasound http://autoprac.com/menstruation Menstruation (aka period, monthly) is the periodic discharge of blood and mucosal tissue from the endometrium (i.e. inner lining of the uterus) through the vagina. [faq]What's menstruation? It's where a woman bleeds periodically, and that is discharged through her vagina. Is it just blood? It's blood, as well as the surface tissue from the inner lining of her womb.[/faq] Cause It begins with the onset of menarche (i.e. the first menstrual cycle in women) at or before sexual maturity, and stops around menopause (end of a female's reproductive life) Menstruation typically stops when women conceive or are breastfeeding Menstruation that stops for longer than 90 days in the absence of pregnancy or breastfeeding, menopause, and hormonal contraception to prevent reproduction, is abnormal Physiology Menstrual cycle is the cycle that occurs in the uterus and ovary that makes sexual reproduction possible in fertile women. It helps to produce eggs, and prepare the uterus for pregnancy. The average menstrual cycle ranges from 21-35 days, the average being 28 days. The length of a menstrual cycle is counted in days from the first day of menstrual bleeding. Day Ovarian cycle Uterine cycle 1-5 Follicular phase, where through the action of rising FSH (follicle stimulating hormone) the ovarian follicles mature and get ready to release one which will dominate and mature into an egg Menstruation, a sign that a woman has not become pregnant. Refer above 5-14 Proliferative phase, where estrogen causes proliferation (i.e. grow) of the endometrium (lining the uterus). As the egg matures, levels of estradiol (and estrogen) increase Ovulation, where the mature egg is released from the ovarian follicles into the oviduct. Whereas estradiol suppressed luteinizing hormone (LH) production in the follicular phase, as the egg matures, levels of estradiol reach above a threshold which reverses the effect, instead stimulating LH in an LH surge, which matures the egg, and weakens the wall of the follicle. After release from the ovary, the egg is swept into the fallopian tube by the fimbria 14-28 Luteal phase, where FSH and LH cause remaining parts of the dominant follicle to transform into corpus luteum, which produces progesterone. Progesterone induces production of estrogen. The corpus luteum also suppresses production of FSH and LH that the corpus luteum needs to maintain itself, so the corpus luteum atrophies Secretory phase, where the corpus luteum produces progesterone, which makes the endometrium receptive to implantation of the blastocyst and supportive of early pregnancy Last menstrual period (LMP) is where pregnancies are dated in weeks starting from the first day of a woman's last menstrual period. The due date can be estimated by adding 280 days (9 months and 7 days) to the LMP. This method assumes accurate recall by the mother, regular 28 day cycles, and that conception occurs on day 14 of the cycle. It may overestimate the duration of the pregnancy, and be subject to an error of more than 2 weeks. → Pregnancy U/S done in the 1st trimester should be used to determine gestational age [faq]So why do women bleed in a cycle? So the cycle happens so that a woman can be fertile. It helps produce eggs, and prepare mom's womb for pregnancy. Is the cycle... cyclical ;)? It should be. It's usually 28 days, but can be +/- 1 week, so between 21-35 days. How does the cycle exactly occur? So there are 2 major parts to it. Follicular and luteal phase. Follicular constitutes the 1st half of the cycle, so day 1-14, where rising FSH causes the ovarian follicles to mature. Menstruation occurs at day 1. Proliferation begins at day 5, where estrogen causes the lining of the womb to grow. Ovulation happens at day 14, at the middle of the cycle, where a mature egg is released from the ovarian follicles. How about the luteal phase? So it's the 2nd half of the cycle, or day 14-28. It's where the remaining parts of the dominant follicle, transform into the corpus luteum. The corpus luteum makes progesterone, which is why it's also called the secretory phase. Progesterone makes the inner lining of the womb more receptive to implantation, and supportive of pregnancy. The corpus luteum also suppresses the production of FSH and LH, that it needs to maintain itself. So, the corpus luteum itself dies. [/faq] Tx Tampons (see page) [Sanitary] pad (aka sanitary napkin, sanitary towel, menstrual pad, maxi pad) is an absorbent item worn by women during menstruation, recovering from vaginal surgery, for PPH, after an abortion, or in any other situation where it is necessary to absorb blood flow from the Pt's vagina [img]sanitary-pad.jpg[/img] Source: Glam Check See also [[Pregnancy]] [[Childbirth]] [[Vaginal bleeding]] [[Menorrhagia]] (abnormally heavy/prolonged menstruation at regular periods) [[Dysmenorrhea]] (abnormally painful periods) [[Irregular periods]] [[Hormone levels]] [[Vaginal discharge]] [[Incontinence pads]] (for urinary incontinence, although menstrual pads can also be used for this purpose) Thu, 21 Nov 2024 15:02:45 +0000 http://autoprac.com/menstruation 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 Thu, 21 Nov 2024 09:31:41 +0000 http://autoprac.com/insulin 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) Thu, 21 Nov 2024 09:33:07 +0000 http://autoprac.com/crackle 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]] Wed, 20 Nov 2024 23:57:45 +0000 http://autoprac.com/aminoglycoside http://autoprac.com/uti UTI is an infection that affects part of the urinary tract. [faq]What's a UTI? Infection of the urinary tract![/faq] Sx Lower UTI's: Painful urination Burning sensation in the urethra, may hbe present even when not urinating, in some cases Frequent urination Urinary urge Higher UTI's, cause lower UTI Sx in addition to: Systemic Sx, including fever Flank pain Vague or non-specific Sx at the extremities of age [faq]What does it feel like when your urinary tract is infected? It depends on where the infection is. If it's down lower, there may be pain peeing, a burning like sensation. There may also be changes in peeing, like wanting to go more often, or having the sudden urge to pee. If the infection works it's way up higher, you can get pain higher, up at the groin area. And if the infection works it's way throughout the body, you can get systemic type things, like a fever.[/faq] Causes E. coli, mainly, although other bacteria, virus or fungi may rarely be the cause Female anatomy, because the urethra is much shorter and closer to the anus Sexual intercourse, particularly anal intercourse Family Hx Previous UTI (recurrence is common) Although sexual intercourse is a risk factor, UTI’s are not classified as STI’s [faq]What causes UTI's? Any reason why bacteria can get into the urinary tract. E coli is found in the GI tract of healthy people, and because especially in women, where the urethra is so close to the GI outlet, it's a common entrance. Also, the urethra is much shorter in females, as for males it has to travel through the penis, so the distance bacteria has to travel is shorter, so it's quicker. Certain forms of sexual intercourse can introduce bacteria. Family history and previous UTI can contribute ot future likelihood too.[/faq] Classification Cystitis, which is infection of the bladder, thereby confined to the lower urinary tract Pyelonephritis, which is infection of the kidney, thereby affecting the upper urinary tract. It usually follows cystitis, but can also result from bacteremia (i.e. blood-borne infection) [faq]What are the different types of UTI's? UTI's are classified based on what part of the urinary tract is infected. The higher, the more concerned we are :(. So the next question is the route of the urinary tract ;). And that's the urethra, the bladder, the looooong ureter, and then kidneys. Any part can be infected. What are their names? Pyelonephritis, which is infection of the kidney. Now you may wonder how does the word "pyelo" relate to the kidneys, and the answer is that "pyelo" means "pelvis", which is where the kidneys are... generally ;) located lol. And "nephr" deriving from the word "nephron", which is the functional unit of the kidney. So that's at the very top, at the kidneys. There's also cystitis, which is infection of the bladder. We prefer that, because it hasn't travelled up the ureter and affected the kidneys.[/faq] Dx Dx in young healthy women is based on Sx alone In those with vague Sx, because bacteria can be present w/o there being an infection Nitrituria, which is nitrites in urine, as gram negatives (most commonly E coli) make an enzyme, that changes urinary nitrates to nitrites Leukocyte esterase, which tests for WBC in urine, indicating UTI Urine culture, in complicated cases, or if Tx has failed (i.e. Sx not improving in 2-3 days after Tx) [faq]How can you check whether someone has an infection of the urinary tract? You test urine. You might find nitrites, or white blood cells in it. Which isn't normal. Or you can try to culture urine, and see if anything grows in it. You can also work out what antibiotics will work against it by doing that. Nitrites and white blood cells. Why are these abnormal, and what are they? Nitrite is something that is created by bacteria, by converting it from a nitrate, which is the waste normally found in urine. White blood cells indicate an infection, which shouldn't normally be found in urine, because urine should be sterile.[/faq] Tx Prevention, w/: Low dose abx, in those w/ frequent infections Cranberry juice, which may assist with recurrent UTI's Short course of abx, if uncomplicated, although resistance is increasing. Complicated cases may require a longer course or IV abx. Note that women who have bacterial or WBC in the urine, but have NO symptoms, abx are generally not required, except in pregnant women Nitrofuran is a class of antibiotics with a furan ring with a nitro group. It includes Nitrofurantoin (NIT, Macrodantin) and Nifurtoinol which are both used in the Tx of UTI's Trimethoprim, abx used mainly in the Tx of bladder infections. Bactrim is trimethoprim + sulfamethoxazole Urinary alkalinsers, e.g. Citralite, Citravescent or Ural sachets, help neutralize the acid in the urinary tract, while assit with eliminating organisms that cause infection Antiseptics, e.g. hiprex [faq]How do you treat a bacterial infection of the urinary tract? Antibiotics ;). Of course. You do a short course if there's no biggie, or a long course or IV in complicated cases. We generally use the Nitrofuran class of antibiotics. What about if we find a patient with NO symptoms, but have bacteria or even WBC's in urine? We only use it in patients who have symptoms. If they've got no symptoms, we don't use it ;).[/faq] Prognosis Pyelonephritis, if it occurs, usually follows a bladder infection but may also result from a blood-borne infection Epidemiology Occur more commonly in women than men, affecting 50% of women at least once in their lives In women, UTI's are the most common form of bacterial infectino, w/ 10% developing UTI's annually Thu, 21 Nov 2024 09:30:48 +0000 http://autoprac.com/uti http://autoprac.com/peptic-ulcer Peptic ulcer [disease] is a break in the lining of the stomach (aka stomach ulcer) [or even the first part of the small intestine (aka duodenal ulcer), or the lower esophagus]. [faq]What is a peptic ulcer? Has it got anything to do with pepper? Not really. It's basically an ulcer in the stomach. An ulcer is just a break in the mucus lining. The problem is that the tummy is pretty acidic, so it's not as straightforward as an ulcer in the mouth.[/faq] Sx Upper abdominal pain, causing: Waking up at night, due to pain Pain improves w/ eating Burning or dull aching pain Gastric ulcer would give epigastric pain DURING the meal, as gastric acid production is increased as food enters the stomach Duodenal ulcers would initially be RELIEVED by a meal, as the pyloric sphincter closes to concentrate the stomach contents, thus acid is not reaching the duodenum. Duodenal ulcer pain would manifest mostly 2-3 hours AFTER the meal, when teh stomach begins to release digested food and acid into the duodenum Belching Vomiting Weight loss Poor appetite Asymptomatic (33% of older Pt's) [faq]What does it feel like to have a break in the lining of the tummy? Pain, where the break is. The stomach is in the upper part of the tummy, so it'll be painful. The pain is less after eating, because the tummy is less acidic, because it is diluted by food. There can be more burping, even vomiting. You might not feel like eating, and may even lose weight.[/faq] Causes H pylori, bacteria, which increases risk w/ alcohol consumption NSAID's, especially sensitive in older Pt's Less commonly: Tobacco smoking Malignancy (gastric cancer) Stress due to serious illness Crohn disease Liver cirrhosis [faq]What can cause a break in the stomach's lining? The biggie is a particular bacteria, H pylori. NSAID's, although used to reduce pain, have the awful side effect of causing ulceration in the stomach, and therefore, GI bleeds. There are also other things that can contribute to it, like smoking, stress, and disease of the GI and the liver.[/faq] Dx Suspected clinically Confirmed, if the Sx don't resolve after a few weeks of Tx, or if the Pt>45yo, or has other Sx e.g. weight loss, because stomach cancer can cause similar Sx, w/: Endoscopy, esophagogastroduodenoscopy (EGD), to directly visuallly identify, the location and severity of an ulcer Barium swallow contrast x-rays H pylori can be Dx by: Urea breath test, which uses radioactive carbon to detect H pylori. The Pt will drink a tasteless liquid which contains carbon, that the H pylori bacteria breaks down. After 1 hour, the Pt is asked to blow into a bag that is sealed. if the Pt is infected w/ H pylori, the breath sample will contain radioactive CO2. This can thus help monitor response to Tx used to eradicate H pylori Culture of a biopsy of the stomach from the EDG, although most labs aren't set up to perform a H pylori culture Rapid urease test, to detect urease activity in a biopsy Measure antibody levels in blood, although it is controversial, because it is NOT reliable, because of their inability to distinguish between past exposure to bacteria, and current infection. It can also be falsely negative if taking abx, or PPI's Stool antigen test Histological exam and staining of an EGD biopsy CXR, showing "free gas" in the peritoneal cavity. This is because if a peptic ulcer perforates, air will leak from inside the GI tract (which always contains some air) into the peritoneal cavity (which normally NEVER contains air). If the Pt is standing erect for the CXR, the gas will float to a position under the diaphragm [img]perforated-duodenal-ulcer.jpg[/img] Source: Medicalopedia [faq]How do you know if someone has a break in the lining of their tummy? Apart from their symptoms, and it getting when you give drugs to decrease stomach acid. You can use a camera down the throat. You can also do an x-ray, but because you can't see the inside of the tummy well because it's soft tissue, you can outline it with contrast, by getting the patient to drink barium. Having said that, if the tummy system has a hole through it, air will escape from the tummy system, into where you usually wouldn't find it. H pylori itself can be detected using a breath test, on biopsy of the tummy, and in the stool.[/faq] Tx Note that diet does NOT cause or prevent ulcers Stop smoking Stop NSAID's Stop alcohol Drugs to decrease stomach acid, w/ 4 weeks of Tx initially recommended, including of: PPI's (proton pump inhibitor) H2 blocker If due to H pylori, add abx Amoxicillin AND Clarithromycin, although as abx resistance is increasing, Tx may not always be effective Endoscopy, for bleeding ulcers, or if unsuccessful, open surgery [faq]What can you do about a break in the tummy's lining? You can take away things which irritate the tummy's lining, like smoking, NSAID's, alcohol. The biggie is using drugs to decrease stomach acid, which includes PPI's and Histamine-2 blockers. If you know it's H pylori causing the problem, you can also give antibiotics. A camera down the throat might also be needed, if the ulcer is bleeding.[/faq] DDx Stomach cancer Coronary heart disease Gastritis (stomach inflammation) Cholelithiasis (gallbladder inflammation) Complications GI bleeding (15%), the most common complication. Sudden large bleeding can be life threatening. It occurs when the ulcer erodes one of the blood vessels, e.g. the gastroduodenal artery (i.e. small blood vessel in the abdomen, that supplies blood to the pylorus, that connects the stomach and duodenum) GI perforation (perforated ulcer), where an untreated ulcer can burn through the full thickness of the wall of the stomach (or duodenum), allowing digestive juices and food to leach into the abdominal cavity. Perforation at the anterior surface of the stomach causes acute peritonitis, initially chemical, and later bacterial peritonitis. The 1st sign is often sudden intense abdominal pain, an example is Valentino's syndrome (i.e. named after the silent film actor, who experienced this pain before his death). Posterior wall perforation leads to bleeding due to involvement of gastroduodenal artery that lies posterior to the 1st part of the duodenum → can be Dx by erect abdominal/CXR (seeking air under the diaphragm), and Tx requires immediate surgery Gastric outlet obstruction [faq]What things can happen, due to a break in the stomach's lining? Bleeding is the biggie. Eventually, the full thickness of the tummy's line can also break. This is a massive problem, because stuff in the tummy can leak into the abdominal cavity.[/faq] Epidemiology Affects 4% of the population at any 1 time, and 10% throughout their life time Results in 301k deaths per year, although this number is decreasing Incidences of perforated uclers is steadily declining, although it still occurs See also Upper GI bleed Perforated ulcer Thu, 21 Nov 2024 09:35:08 +0000 http://autoprac.com/peptic-ulcer 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 Thu, 21 Nov 2024 01:56:11 +0000 http://autoprac.com/genetic-disorder http://autoprac.com/alcoholism Alcoholism (aka alcohol use disorder, alcohol dependence syndrome) is any drinking of alcohol that results in problems. Alcohol is a drink that contains ethanol. ETOH is shorthand for alcohol. Source: Standard drinks Dx 2 or more of the following is present: Pt drinks large amounts over a long tie period has difficulty cutting down Acquiring and drinking alcohol takes up a great deal of time Alcohol is strongly desired usage results in not fulfilling responsibilities Usage results in social problems Usage results in health problems Usage results in risky situations Withdrawal occurs when stopping Alcohol tolerance has occured w/ use Questionnaires Certain blood tests Interpretation Blood alcohol [level] (BAL, or blood alcohol concentration BAC) is the percentage of alcohol/ethanol in blood, mass per unit volume.  It is the most commonly used metric lf alcohol intoxication. The effects of blood alcohol at the various levels include: 0.01-0.03%, impairment is subtle. Behavior appears normal 0.03-0.06%, causes impaired concentration. Behavior includes decreased inhibition, talkativeness, joyousness, relaxation, and mild euphoria 0.06-0.09%, causes impaired reasoning, depth perception, peripheral vision, and glare recovery. Behavior includes blunted feelings, disinhibition, extroversion 0.1-0.2%, causes impaired reflexes, reaction time, gross motor control, staggering, slurred speech, temporary erectile dysfunction, possibility of temporary alcohol poisoning. Behavior includes over-expression, emotional swings, anger or sadness, boisterousness, decreased ilbido 0.2-0.3%, causes severe motor impairment, loss of consciousness, memory blackout. Behavior includes tupor, loss of understanding, impaired sensations, possibility of falling unconscious 0.3-0.4%, causes impaired bladder function, breathing, dysequilibrium, heart rate. Behavior includes severe CNS depressino, unconsciousness, possibility of death 0.4-0.5%, causes impaired breathing, heart rate, positional alcohol nystagus. Behavior includes general lack of behavior, unconsciousness, possibility of death >0.5%, causes high risk of poisoning, possibility of death Binge drinking is any one time peak above 0.08%. For motorists, it should be: In drivers with a L or P plate, truck/bus drivers, driving instructors, DUI drivers, 0% (i.e. prohibition) For taxi drivers, 0.02% For general motorists, 0.05% [faq]Practically, what bottle do you use to collect for blood alcohol level? The one with the light green top.[/faq] Effects Can affect all part sof th ebody, but particularly affects the brain, heart, liver, pancreas, and imune system In the short term, it causes: Intoxication Dehydration In the long term, it causes: Malnutrition Cancers (esp of the respiratory and digestive system) Neuropsychiatric impairment Cardiovascular disease Liver disease, Liver failure Pancreatitis Aging Mental illness Wernicke Korsakoff syndrome Arrhythmia It stimulates insulin production, so can cause hypoglycemia in diabetics In pregnant women, FAS (fetal alcohol spectrum disorders) in the child Risk factors Women, are generally more sensitive to alcohol's harmful physical and mental effects than men High stress levels Anxiety Inexpensive easily accessible alcohol Environmental factors, including social, cultura, and behavioral influences Genetics, w/ a Pt w/ a parent/sibling w/ alcoholism 3-4 times more likely to be alcohol themselves To prevent or improve Sx of withdrawal, continuing drinking or drinking partly Tx Limit insult: No more than 2 standard drinks on a day, to reduce the lifetime risk of harm form alcohol-related disease or injury. The lifetime risk of harm from drinking alcohol increases with the amount consumed No more than 4 standard drinks on a single occassion, reduces the risk of alcohol-related injury injury arising from that occasion. The risk of alcohol related injury on a single occasion of drinking increases with the amount consumed For kids Thu, 21 Nov 2024 06:02:52 +0000 http://autoprac.com/alcoholism 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]] Thu, 21 Nov 2024 04:28:09 +0000 http://autoprac.com/diabetes http://autoprac.com/menorrhagia Menorrhagia (aka hematomunia) is abnormally heavy and prolonged menstrual period [at regular intervals]. [faq]What is menorrhagia? I'm guessing it's related to menstruation? That's correct. The ending "rrhage" means excessive flow, like as in "hemorrhage" which means "bleeding". So it's excessive period bleeding. What do you mean excessive? Like a lot of bleeding? Yeah, so it's the amount, or length of bleeding.[/faq] Sx Depending on cause, it may be associated with dysmenorrhea (painful periods) Eventually, Sx of anemia (SOB, tiredness, weakness, tingling/numbness in extremities, headaches, depression, becoming cold more easily, poor concentration) Causes Abnormalities with blood clotting, including: → required to stop blood flow, following shedding of endometrial lining's blood vessels Bleeding disorders (e.g. von Willebrand) Anticoagulants (e.g. warfarin) Disruption of normal hormonal regulation of periods Excessive build up in endometrial lining [of the uterus], including: Physiologically, just after the onset of menstruation (menarche), and just before menopause PID → painful → irritation of the endometrium IUD → irritation of the endometrium Uterine fibroids → painless → can increase the endometrium's surface area [faq]What causes excessive or prolonged menstrual bleeding? So it can be due to problems with blood clotting, like bleeding disorders or use of drugs that prevent blood clotting. The normal hormonal regulation of periods can be disrupted. And there can be excessive build up of the inner lining of the womb, which is more common just after you get your periods, or just before menopause; also, PID  or IUD's which irritates the lining; and fibroids in the womb, which increases it's surface area.[/faq] Ix Pelvic and rectal exam → locate source of bleeding Pelvic U/S → identify structural abnormalities Endometrial biopsy → exclude endometrial cancer/hyperplasia Hysteroscopy → endometrial polyp, uterine fibroid Tx Tx the underlying cause Reassurance, if the degree of bleeding is mild, and there is no sinister underlying cause. Clear heavy periods at menarche (start of periods) and menopause (cessation of periods) may settle spontaneously Drugs, including: Iron tablets, if there is iron deficient anemia Pills (COCP, progesterone-only pills), to prevent proliferation of the endometrium; and for DUB, which commonly occurs at menarche and menopause, when contraception will also be sought anyway IUD w/ progesterone Tranexamic acid (i.e. antifibrinolytic), may reduce loss by 50%, and can be combined with hormonal medication Anti-inflammatories (e.g. NSAID's), first line in ovulatory menorrhagia, resulting in reduction of 33% in menstrual blood flow Surgery, including: Myomectomy, to remove small fibroids Endometrial ablation, where the inner lining of the womb is vaporized, chipped, or otherwise destroyed Uterine artery embolisation (UAE), which is using a catheter to deliver small particles that block the blood supply to the womb Hysterectomy (remove uterus), to remove fibroids >3cm, and/or if other options have been exhausted [faq]How can you fix more or longer menstrual bleeding? If there's an underlying cause, you can treat that.  Usually, there's no need to do anything. If there is iron deficiency, you can give iron. Hormone, given through oral contraceptive pills or IUD can prevent the womb's inner lining from proliferating. Tranexamic acid is a drug that inhibits the breakdown of fibrin in blood clots, so it helps to maintain clots. It can also be painful, so we can give NSAID's. What about if none of that works, and there's still more or longer menstrual bleeding? We can try surgery. So we can remove fibroids, if that's the cause. We can destroy the inner lining of the womb. We can block the blood supply to the womb. We can also remove the womb itself.[/faq] Complications Social stress of dealing w/ prolonged and heavy period Anemia, due to chronic blood loss depletes body iron reserves Epidemiology The use of hysterectomy for menorrhagia has almost halved in the last 20 years Up to 64% of women will cancel a hysterectomy See also [[Dysmenorrhea]] (painful periods) [[Hypomenorrhea]] (antonym) [[Metrorrhagia]] (irregular bleeding, particularly between expected menstrual periods) Thu, 21 Nov 2024 14:32:52 +0000 http://autoprac.com/menorrhagia http://autoprac.com/flapping-tremor Flapping tremor is, when the hand is outstretched, and wrist is bent upward, the Pt is unable to actively maintain the position, but instead, tremors with jerky movement, resembling a bird flapping its wings. [img]flapping-tremor.jpg[/img] [youtube]ZCXT9_KbgIo[/youtube] Cause Abnormal function of the diencephalic/forebrain motor centers of the brain, which regulates the muscles involved in maintaining position. It can be a sign of hepatic encephalopathy, where the liver is unable to metabolize ammonia to urea, which thus damages brain cells. Thu, 21 Nov 2024 16:16:28 +0000 http://autoprac.com/flapping-tremor http://autoprac.com/shortness-of-breath SOB (shortness of breath, aka dyspnea, respiratory distress) is feelings of distress associated with impaired breathing. It can cause the tripod position (i.e. sits or stands, leaning forward, supporting the upper body w/ hands on the knees or another surface). WOB (work of breathing) is the effort required to inspire air into lungs, and accounts for 5% of total body oxygen consumption in normal resting state, but can increase dramatically during acute illness. Air hunger is the feeling of having not enough oxygen. [faq]Puff-puff-puff-puff. What's happening to me :O?! It seems like you're short of breath ;)! Short of breath. And work of breathing. What's the difference? Short of breath is that awful feeling you feel when you need to breathe, but can't. Work of breathing is the effort required to satisfy the need to breathe.[/faq] Pathophysiology SOB is caused by a mismatch in the afferent signal (need for ventilation) and the efferent signal (not being matched by physical breathing) Afferent neurons originate from the carotid bodies (chemoreceptors near fork of carotid artery, detecting partial pressure of oxygen in blood), medulla oblongata (inter alia, respiratory center), lungs, and chest wall Efferent neurons innervate the respiratory muscles (diaphragm, intercostal muscles, abdominal muscles, etc) [faq]What exactly makes you short of breath? Because there's a difference between 2 signals. The need to breathe. And the physical breath being taken. How are these 2 things exactly signals? The need to breathe is detected by receptors which detect oxygen, at the fork of the carotid artery, and elsewhere around the brain and lungs. The physical breath being taken is initiated by muscles of breathing.[/faq] Classification Intensity of distinct sensations Degree of distress involved Burden/impact on ADL's [faq]Is being short of breath it? Anything more to it? Yeah. You can be at different levels of shortness, of the breath, depending on your shortage of oxygen. It can also feel different, depending on what's causing it. And it can affect people's lives in different ways, because everybody's different.[/faq] DDx Causes include: Physiological, due to heavy exertion Respiratory: Asthma Pneumonia → fever Interstitial lung disease COPD, emphysema Bronchiolitis Bronchitis URTI, like diptheria, croup Choking Pulmonary embolism → can have fever Lung cancer Pulmonary fibrosis Pneumothorax Anaphylaxis, allergic reaction Cardiac: Cardiac ischemia Congestive heart failure Rib fracture, obesity, causing ineffective respiratory muscle action Psychogenic causes, including: Panic attacks Anxiety Poor ventilation, High altitudes with low oxygen levels [faq]What makes you short of breath? Well first and foremost, it can be normal ;)! But if there is a true problem, the big ones we're concerned is something related to your breathing, or even heart! It could also be musculoskeletal, as in a fracture of your ribs. Or it could be psychological, or even something to do with the air itself...! Let's start with your breathing. What about it? Well just about anything that can affect your airways can cause problems. It could be asthma, pneumonia, COPD, bronchiolitis, choking, anaphylaxis. Really, just anything that can go wrong with your breathing, can be an issue. How about your heart, what can cause shortness of breath there? Heart failure, cardiac ischemia. Blood is required to deliver oxygen, so without blood... you're going to feel short of breath![/faq] Ix Hx, including: Onset and progression Relieving and exacerbating factors, including: Rest or exertion. Quantify exercise tolerance, before getting SOB, including previous and current performance Orthopnea or paroxysmal nocturnal dyspnea Duration Attempts to Tx SOB Associated Sx, including: Angina Cough Fever Pleuritic chest pain [faq]How do you look further into, being short of breath? You can ask questions. Like when it started, what's happened throughout time, how long it's gone on for. What makes it better or worse. For example, whether moving makes it worse, resting helps. Whether it's worse when the patient is lying down. Whether it wakes the person up from sleep. Any treatment they've tried. What do you mean by associated symptoms? It's like when someone buys a burger, asking whether they had fries with it. It's just stuff that commonly goes together. So for example chest pain, might suggest a heart attack. Cough, or pain when breathing harder, might suggest a breathing problem. Fever might suggest an infection.[/faq] Tx Depends on underlying cause See also [[Labored breathing]] [[Chest tightness]] Thu, 21 Nov 2024 04:23:54 +0000 http://autoprac.com/shortness-of-breath http://autoprac.com/epileptic-seizure Epileptic seizures (aka fits) is a brief episode of Sx, due to abnormal excessive or synchronous neuronal activity in the brain. It ranges from a momentary loss of awareness, to convulsions (i.e. muscles contract and relax rapidly and repeatedly, causing uncontrollable shaking). Epilepsy (from Greek meaning "to seize, or possess) aka seizure disorder) are diseases of the brain, involving an enduring predisposition to generate epileptic seizures. Thus, seizures can also occur in patients who DON'T have epilepsy. [faq]What is epilepsy? Epilepsy is discharge of electrical signals in the brain, when it is sudden and uncalled for. This misfiring causes chaotic effects, depending on what the signals mean, but includes twitches and spasms. What's the difference between epilepsy and seizure? Why not give it a less obscure name, like seizure, rather than epilepsy? Epilepsy causes seizures. But it isn't the only cause of seizure. Non-epileptic seizures do not have abnormal electrical activity. However, epilepsy and non-epileptic seizures look exactly the same, which makes it tricky to identify ;)![/faq] Sx Pre-ictal, the period before the seizure Post-ictal, the period after the seizure. It is the period before a normal level of consciousness returns, may last 3-15 minutes, but may last for hours, and includes: Feeling tired Headache Difficulty speaking Abnormal behavior Todd's paralysis, which is local weakness, after a partial seizure Psychosis is relatively common, occuring in 8% of Pt's Patients often don't remember what happened during this time Psychological and social well-being, including: Social islation Stigmatization Disability, including learning disabilities Depression Anxiety OCD Migraine ADHD Classification All seizures involve a loss of consciousness, and usually without warning. Generalized seizures, which are distributed within the brain, including: Tonic-clonic (aka grand mal), with uncontrolled jerking movement, involving both contraction and extension of limbs Tonic, is muscle stiffness/rigidty Clonic, is repetitive jerking movements Myoclonic, is sporadic/isolated jerking movements Absence (aka petit mal), is a brief loss of consciousness, often only involving subtle turning of the head or eye blinking. The person often doesn't fall over, and may be immediately normal after seizure ends, but there may be post-ictal disorientation Atonic, is loss of muscle tone [[Focal seizures]] (see page), which are localized in the brain. Although now described what what has occured during seizure, it used to be divided into: Simple partial, affecting only small region of brain, often retaining consciousness Complex partial, usually with unilateral cerebral hemisphere involvement, altering consciousness [[Epileptic syndromes]] (see page) Status epilepticus is a prolonged seizure >5 mins without recovery, with mortality around 25%. [faq]That's a lot of different types! Why does it seem so complicated? It's really quite simple. Seizure can either be generalized or focal. Generalized is where strange electrical signals occur right throughout the brain. Focal is where you can localize it to some location. Then what are all of the other things :'(!! For instance, under general, there's tonic, clonic, myoclonic, absence, atonic... I thought the whole brain got affected though?? When we say the whole brain is affected, we don't mean every part of the brain is being affected!! What we mean is that it isn't confined to a certain area of the brain. So the classification is on what it looks like. Tonic is where your muscles become stiff and rigid. Clonic is where you repetitively jerk. Myoclonic is the same as clonus, but where it's occurs sporadically only, so isolated. Absence is where you lose consciousness. Atonic is where you lose muscle tone, so the opposite of tonic ;)! That makes it a lot more simple. How about focal? What's the difference between simple and partial? Simple is where only a small region is affected. Complex is where an entire hemisphere is involved. So it's still not the whole brain, but it's half of one![/faq] Pathophysiology Due to excessive and abnormal neuron activity [in the cerebral cortex of the brain] Causes Most often unknown, but can be due to, depending on age group: In neonates and early infancy: Hypoxic ischemic encephalopathy CNS infections Trauma Birth defects of the CNS Known genetic mutations, directly linked in a small proportion of cases Metablic disorders In children: [[Febrile seizure]] Well-defined epilepsy syndromes In adolescent and young adulthood: Non-compliance with drug regimen Sleep deprivation Pregnancy, labor, childbirth, post-natal period, especially if there are complications like eclampsia During adulthood: Drug side effect, including of caffeine, corticosteroids, estrogens, fentanyl, insulin, olanzapine, prednisone, risperidone, TCA, certain antibiotics (metronidazole, penicillin), illicit drugs (amphetamines, cocaine), alcohol Drug withdrawal, from alcohol, benzodiazepines, barbiturates, anesthetics Strokes Trauma CNS infections, including encephalitis, [[meningitis]] Brain tumors In older adults: Cerebrovascular disease, e.g. stroke CNS tumor, e.g. brain tumors Head trauma, including brain injury Other degenerative diseases, e.g. dementia Reflex epilepsy, are seizures as the result of sensory stimuli caused by the environment, and include: Photosensitive epilepsy Reading epilepsy Hot water epilepsy Music induced epilepsy Other causes: Hypoglycemia Electrolyte problems Stress MS Lupus [faq]What can cause abnormal electrical activity in the brain? Anything that affects the brain. So low blood sugar. Stress. It can be a side effect of drugs. Or withdrawing from drugs. A fever. And a range of diseases. It all depends on age though, what's common varies with age. Alright. So let's start with the elderly, and work backwards. So in the elderly, it's things like clot in the brain, brain tumors, head trauma, or degenerative brain diseases like dementia. In adults, it's things like drugs, again there's blood clots in the brain, trauma, brain infections like meningitis, and brain tumors once again. Seizure is also more common in pregnancy, it's what we call eclampsia. In adolescents, it's things like not complying to their epilepsy treatment, or sleep deprivation - don't you know it ;)! In kids, there's seizure due to high temperature, and onset of your epilepsy syndromes, which usually start at this age. And in the very, very young, it's things like brain infections, trauma. And since they're young, congenital brain diseases, and metabolic disorders.[/faq] Dx Rule out DDx's, i.e. [[non-epileptic seizure]] (see page) Confirm with EEG, recommended only on those suggestive to have epilepsy on the basis of Sx; and is only required in kids after a 2nd seizure → rules out non-epileptic seizure Blood tests, including: Blood glucose → rule out as cause Blood calcium → rule out as cause Metabolic panel → metabolic disorders Serum prolactin → partial seizure, to DDx from psychogenic seizure. However, it doesn't DDx from syncope as it can be elevated due to stress too ECG, if indicated → rule out problems with rhythms of the heart LP, if indicated by petechial rash → rule out meningitis [faq]What can you do to check out abnormal electrical activity in the brain? You can do an EEG if you're expecting to see this abnormal activity. You can also check blood glucose and calcium to see if it's a cause. Other things can cause loss of consciousness, so you can do an ECG to rule out problems with the heart.[/faq] Ix After a 1st non-febrile seizure, MRI brain (preferred when available, except when bleeding is suspected) and MRI brain (more sensitive, and more easily available) → structural abnormalities around the brain If seizures are well controlled, it is usually unnecessary to routinely check drug levels in blood Tx ABCDE's, involving: Rolling a patient with an active seizure onto their sides, and into the recovery position, to prevent fluids getting into their lungs Take efforts to prevent further self-injury Spinal precautions are generally NOT required If a seizure occurs for >5 minutes, or there are >2 seizures in an hour without return to normal level of consciousness between them, it is a medical EMERGENCY, called status epilepticus. This may require airway Mx, e.g. nasopharyngeal airway. Benzodiazepine drugs such as midazolam at home, or rectal diazepam, or in hospital, IV lorazepam, may be used. If 2 doses of benzo is not effective, other drugs e.g. phenytoin are used. Convulsive status epilepticus that doesn't respond, is Tx with thiopentone or propofol Putting fingers, bite block or tongue depressor in the mouth is NOT recommended, as it can make a patient vomit, or result in the rescuer being bitten A 1st seizure generally doesn't require Tx unless there is high risk, e.g. a specific problem on EEG or brain imaging. Tx includes: Avoiding the trigger, if there is a particular cause Antiepileptic drugs (AED's), works in 70% of cases, possibly for the Pt's entire life. It is dependent on seizure type, other medications taken, other health problems, and age. A single medication is recommended initially, subsequently switching. Combo's are used only if single drugs don't work. Drugs include: Partial seizure: Phenytoin, 1st line Lamotrigine, 1st line Valproate, 2nd line due to cost and side effects Generalized seizure: Valproate, 1st line, as it is particularly effective against myoclonic, tonic and atonic seizures Lamotrigine, 2nd line Absent seizure: Ethosuximide Valproate If unresponsive to drugs: Surgery Neurostimulation Dietary changes, to one that is ketogenic (i..e high fat, low carb) Epileptic Pt's have ability to drive restricted or disallowed, but can return to driving after a period of time without seizures [faq]What can you do about abnormal electrical activity in the brain? You can give drugs called anti-epileptic drugs. These act on the ion channels, to help control electrical signals in the brain from going out of hand. If that doesn't work, you can also do surgery, eat more fat and less carbs, and do neurostimulation. What is neurostimulation? It sounds like something that excites the brain? It is. It's like a pacemaker, but electricity is used to excite the brain, rather than the heart.[/faq] Prognosis Doesn't always persist lifelong, and a substantial number of Pt's improve to the point that medication is no longer needed Seizures tend to recur. The probability of seizure following first is 50% Complications Physical injuries, including occasionally broken bones Epidemiology Epilepsy affects about 1% of the population currently, and 4% of the population at some point in time It affects 22m patients worldwide Most of patients affected (80%) live in developing countries It results in 116k deaths, up from 112k deaths in 1990 Onset of new cases occurs most commonly in infants and the elderly, due to the differences in frequency of the underlying causes 8% of people who live to 80yo have at least 1 epileptic seizure The chance of experiencing a 2nd seizure is 45% Paperwork Paperwork for Pediatric seizure chart includes: Affix Pt label Please list regular medications and doses Loading dose given, tickbox for Yes/No Medication used *Refer to guidelines overleaf to complete seizure record chart. *Refer to medical notes +/_ Medication chart for Seizure medication protocol Table including various rows, with columns Date __/__/____, Time __:__, Length of seizure, Pre seizure activity Note 1, Description event Anatomical location affected and type of activity (Refer to atached chart) Note 2, AVPU Note 3, SpO2, BGL, Postictal Phase Note 4, Medications Y/N Oxygen Y/N (incl Details), and Sign Over the page, Gduielines for Seizure chart observation & documentation. Recording a seizure: Note 1: Pre-seizure, Document whether the beginning of the seizure was witnessed and the time the seizure started. Describe activity/circumstances prior to the vent (e.g. waking, drowsy, screaming/upset, exercising, playing video games, feeding) Note 2: Description of event, Document the area of the body affected and type of limb/body activity using a head to toe approach and note level of consciousness: Auras - e.g. auditory, visual (lights/images), smell, unusual feeling like butterflies in the stomach. Eyes - Deviations of eyes - left/right/upwards; Flickering/dilation/PEARL of eyes/staring/open/closed. Head - head turning - left/right/down, head nodding. Face - Lip smacking/chewing/grimacing/twitching/speech jumbled, repetitive phrases/swallowing/drooling/vomiting. Neck - Hypeextension, gasp for breath/cry. Body - Rigid/limp/sitting/laying/trembling/jerking; Muscle contractions flexion/& extension/ Loss of muscle tone/ Incontinence - urinary/fecal; Rhythmical/non rhythmical +/ symmetrical/asymmetrical. Limbs - Muscle contractions flexion /+ extension Right/Let/Bilateral; Loss of muscle tone Right/Left; Symmetrical/asymmetrical. Skin - Flushed/cyanosed/cool/warm/clammy Note 3: AVPU Quick Assessment of level of consciousness, A - Alert Eyes open & talking spontaneously; V- Verbal Responds to verbal commands; P - Pain Responds to painful stimuli; U - Unconscious Does not respond. Contact Dr if P or U assessed Note 4: Postictal stage. Document: Length of time, amnesia, drowsiness/exhaustion headache, confusion or disorientation, altered behavior e.g. rage, irritability, facial palsy or weakness See also [[Febrile seizure]] (common in kids) [[Non-epileptic seizure]], which look like epileptic seizures but are NOT. They are thus a good DDx list [[Partial seizure]] [[Epilepsy syndrome]] Thu, 21 Nov 2024 02:03:06 +0000 http://autoprac.com/epileptic-seizure http://autoprac.com/developmental-delay Developmental delay (aka delayed milestone) is where a child doesn't reach 1 of the milestone stages at the expected age, which can be in one of the 4 developmental domains: However, a wide variety of ages can be considered normal, and not a cause for medical concern. Milestones are often measured using percentiles, and milestones between the 5th and 95th percentile don't require intervention, but values towards the edges of that range can be associated with other medical conditions. It is not possible to treat. Global developmental delay (GDD) is delay that occurs in 2 or more developmental domains. [faq]What is developmental delay, and GDD? It's where there are delayed milestone in 1 of the 4 domains, so that's gross motor, fine motor, language, and social. People have also come up with extra ones, but these are the biggies. GDD is where there is delay in 2 or more of these 4 domains. Wait. You said language and social, aren't these 2 things basically autism? It is, but the diagnosis of autism requires that it's not better accounted for by GDD ;).[/faq] Milestones Developmental milestones are recognized norms of pattern of development that children are expected to follow. In premature infants ( Thu, 21 Nov 2024 09:36:18 +0000 http://autoprac.com/developmental-delay http://autoprac.com/bleeding-during-pregnancy Bleeding during pregnancy (aka threatened miscarriage), is bleeding in the first 2 trimesters (weeks 0-28), specifically, 24 weeks (i.e seen during pregnancy prior to viability), and has yet to be assessed further. [faq]What is a threatened miscarriage? It's bleeding that we think is more likely to be caused by a miscarriage, than by another cause, because it's happened so early in a pregnancy. It doesn't cover the entire 1st 2 trimesters, but extends up to 24 weeks.[/faq] Cause Physiological, including: Implantation bleeding, which is spotting within the first 6-12 days after you conceive, as the fertilized egg implants itself in the lining of the uterus Rupture of a small vein on the outer rim of the placenta Spotting Miscarriage → strong cramps. It has a risk of 24% with heavy 1st trimester bleeding, compared to 12% in pregnancies without any 1st trimester bleeding Ectopic pregnancy → pain in the lower abdomen. Commonly in the tube, and may lead to bleeding, internally, that could be fatal if untreated. It is found in 6% with heavy bleeding and an obstetric U/S of pregnancy of unknown location (no visible intrauterine pregnancy) Molar pregnancy → rapid enlargement of the uterus Vaginal bleeding (see page) for non-pregnant reasons (e.g. STI, sexual intercourse, pap test) Gestational trophoblastic neoplasia Chorionic hematoma Lower genitourinary tract causes, including: Vaginal bleed Cervical bleed [faq]What's the cause of bleeding in early pregnancy? It's not a good thing. Yes, you can sometimes get normal bleeding, but it's very early on. It can mean the death of bub, called a miscarriage. It can be a pregnancy outside the womb. It can be that there is no bub, but it's an abnormal tissue growth. Cancer. Occasionally, you can get bleeding that is not pregnancy related, due to bleeding from the vagina or cervix too.[/faq] Ix Hx, including: ABC's/vitals → bleeding Amount of bleeding → spotting may be physiological Pain → less likely to be physiological Pelvic exam → cervical dilation → inevitable miscarriage U/S → ectopic will show an absence of intrauterine pregnancy Tx As a preventative measure, women who are rhesus negative are given prophylactic anti-D, if they are >12 weeks (1st trimester) [faq]What do you do about bleeding in early pregnancy? You can give anti-D. But you don't need to give it too early in pregnancy, only after 12 weeks.[/faq] Prognosis On further Ix, it may be found that the fetus remains viable, and pregnancy continues without further issue 50% of those who have a threatened miscarriage, go on to miscarry, and 50% will bring the fetus to term Epidemiology Bleeding is common particularly in the 1st trimester, occurring in 20% of women See also APH (>24 weeks) PPH (>birth) Postmenopausal bleeding (>menopause) Vaginal bleeding (category) Thu, 21 Nov 2024 00:32:10 +0000 http://autoprac.com/bleeding-during-pregnancy http://autoprac.com/chemotherapy Chemotherapy (CTx) is Tx of cancer with cytotoxic chemotherapeutic agents. The objective can be either curative or to relieve suffering. It can either be used as a single-agent, or in combination. Chemoradiotherapy (CRT) is the combination of chemo and radio. It can also be used with hyperthermia, and surgery. [faq]What is chemotherapy? They're drugs which are cytotoxic. This means they are toxic to cells.[/faq] Indications Cancer Other conditions, including: AL amyloidosis Ankylosing spondylitis Multiple sclerosis Crohn's disease Psoriasis Psoriatic arthritis SLE Rheumatoid arthritis Scleroderma MOA Cytotoxic means that it kills cells that divide rapidly, as it is a main property of most cancer cells. This is also what causes the main side effects. Some newer drugs are more targeted (rather than indiscriminately cytotoxic), targetting proteins abnormally expressed in cancer cells and essential for their growth, known as targeted therapy or biologic therapy [faq]Wait. Toxic to all cells? Isn't this bad? No. Only toxic to cells that divide rapidly. Because that's what cancers basically do. It's also what causes their main side effects.[/faq] Classification Alkylating antineoplastic agents, which are an alkylating agent, that attaches an alkyl group (CnH2n+1) to DNA. Since cancer cells in general proliferate faster and with less error-correcting than healthy cells, cancer cells are more sensitive to DNA damage, e.g. being alkylated. It includes: Nitrogen mustards, including mechlorethamine, cyclophosphamide, melphalan, chlorambucil, ifosfamide, busulfan Nitrosoureas, including N-Nitroso-N-methylurea, carmustine, lomustine, semustine, fotemustine, streptozotocin Tetrazines, including dacarbazine, mitozolomide, temozolomide Aziridines, including thiotepa, mytomycin, diaziquone Cisplatins and derivatives, including cisplatin, carboplatin, oxaliplatin Non-classical alkylating agents, including procarbazine, hexamethylmelamine Antimetabolites, which inhibit the use of a metabolite, which is another chemical that is apart of metabolism. It is often similar ins tructure ot the metabolite it interferes with, e.g. antifolates interfere with the use of folic acid. The presence of antimetabolites can have toxic effects on cells, e.g. halting cell growth and cell division. Examples include: Azathioprine Mercaptopurine Anti-microtubule agents, which block cell growth by stopping mitosis (cell division). It interferes with microtubules (cellular structures that help move chromosomes during mitosis) Topoisomerase inhibitors, which interfere with the action of topoisomerase enzymes (topoisomerase 1 and 2), which are enzymes that control the changes in DNA structure, by catalyzing the breaking and rejoining of the phosphodiester backbone of DNA strands during the normal cell cycle. It includes: Topoisomerase 1 inhibitors, including irinotecan, topotecan, camptothecin, lamellarin D Topoisomerase 2 inhibitors, including etoposide (VP-16), teniposide, doxorubicin (Adriamycin), daunorubicin, mitoxantrone, amsacrine, aurintricarboxylic acid, HU-331 Cytotoxic antibiotics, which are drugs that interrupt cell division. It includes: Anthracycline, including doxorubicin, daunorubicin Actinomycin Bleomycin Plicamycin Mitomycin Side effects Harms rapidly dividing cells, including cells in the: Bone marrow Immune system, causing myelosuppression (decreased production of blood cells), causing immunosuppression Digestive tract, causing mucositis (inflammation of GI lining) Hair follicles, causing alopecia (hair loss) [faq]What are the main side effects of drugs that kill rapidly dividing cells? They can kill cells OTHER than cancer, that rapidly divide. This includes bone marrow. The GI lining. And hair. They all have quick turnover, so they're also targets for these drugs. That's why during chemo treatment you lose all your hair. You can get lots of tummy problems. And have bone problems.[/faq] Wed, 20 Nov 2024 08:23:39 +0000 http://autoprac.com/chemotherapy 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]] Thu, 21 Nov 2024 03:29:17 +0000 http://autoprac.com/pharmaceutical-drug http://autoprac.com/digoxin Digoxin is used in the Tx of various heart conditions, by increasing heart contractility, and decreasing heart rate. Product names include Cardigox, Cardiogoxin, Cardioxin, Cardoxin, Coragoxine, Digacin, Digicor, Digomal, Digon, Digosin, Digoxine Navtivelle, Digoxina-Sandoz, Digoxin-Sandoz, Digoxin-Zori, Dilanacin, Eudigox, Fargoxin, Grexin, Lanacordin, Lanacrist, Lanicor, Lanikor, Lanorale, Lanoxicaps, Lanoxin, Lanoxin PG, Lenoxicaps, Lenoxin, Lifusin, Mapluxin, Natigoxin, Novodigal, Purgoxin, Sigmaxin, Sigmaxin-PG, Toloxin. MOA Inhibits the Na/K ATPase mainly in the myocardium, increasing intracellular sodium levels, thus reversing the action of the sodium-calcium exchanger This increases the intracellular calcium available to contractile proteins, and thus the calcium stored in the sarcoplasmic reticulum This thus increases the contractility (i.e. force of contraction) of the heart, without increasing expenditure of energy Although it mainly affects the heart, effects OUTSIDE the heart are the cause of it's adverse effects Effective digoxin levels in blood depend on the indication, and include: For heart failure, 0.5-1 ng/ml, w/ higher levels possibly associated w/ icnreased mortality rates For HR control (AFib), 1-2 ng/ml, typically considered therapeutic for HR control, but levels are less defined, and generally titrated to a goal HR Digoxin for Tx should typically not be given above the narrow therapeutic index of 0.5-2 ng/mL, or digoxin overdose can happen [faq]What does digoxin do? It's a drug that increases the force that the heart contracts with. And it magically does this without requiring it to use more energy. By just increasing the amount of calcium stored by the contracting proteins.[/faq] Indications Atrial fibrillation Atrial flutter Heart failure, that can't be controlled by other drugs, sometimes [faq]When do you use digoxin? When you want the heart to beat with more force. So when the heart is quivering, as in atrial fibrillation and atrial flutter. And when the heart just doesn't have the strength to beat, as in heart failure.[/faq] Side effects General use may increase risk of death In suspected toxicity/ineffectiveness, dig levels should be monitored Blood potassium also needs to be closely controlled for hypokalemia, as digoxin normally competes with potassium ions for the same binding site on the Na/K ATPase pump Quinidine, verapamil, and amiodarone increases blood levels of digoxin, by displacing tissue binding sites and depressing renal digoxin clearance, so dig levels must be monitored Adverse drug reaction is common, due to it's narrow therapeutic index (i.e. margin between effectiveness and toxicity). Adverse effects are RARE when digoxin in blood is Thu, 21 Nov 2024 16:16:53 +0000 http://autoprac.com/digoxin http://autoprac.com/roseola Roseola (aka sixth disease) is a disease of children  Sx In older children, manifestations limited to: Fever of about 3 days duration Transient rash (exanthem), that follows [img]roseola-rash.jpg[/img] Source: Prime health channel Pathophysiology Caused by 2 HHV (human herpesviruses), HHV-6 and HHV-7, aka roseolovirus Kids can be congenitally infected with HHV-6 via vertical transmission from mom Epidemiology Disease of kids, generally Thu, 21 Nov 2024 09:32:15 +0000 http://autoprac.com/roseola http://autoprac.com/antiepileptic-drug Antiepileptic drugs (AED's, aka anticonvulsant) is used to Tx epileptic seizures. They can also be used to Tx bipolar disorder, mood stabilizer, and neuropathic pain. MOA Block sodium channels, or enhance GABA. This thus suppresses rapid, excessive firing of neurons during seizures. They also prevent the spread of seizure within the brain Classification Examples include: Aldehydes: Paraldehyde Aromatic allylic alcohols: Stiripentol Barbiturates: Phenobarbital Methylphenobarbital Barbexaclone Benzodiazepines: Clobazam Clonazepam Clorazepate Diazepam Midazolam Lorazepam Bromides: Potassium bromide Carbamates: Felbamate Carboxamides: Carbamazepine (Tegretol), a popular anticonvulsant available in generic formulations Oxcarbazepine Eslicarbazepine acetate Fatty acids: Valproates, including valproic acid, sodium valproate (Epilim), divalproex sodium Vigabatrin Progabide Tiagabine Fructose derivatives: Topiramate (Topamax) GABA analogs: Gabapentin (Neurontin), which is used as an anticonvulsant and analgesic. Originally it was developed to Tx epilepsy, but is also used to Tx neuropathic pain and restless legs syndrome. It is recommended 1st line for Tx neuropathic pain arising from diabetic neuropathy, post-herpetic neuralgia, and central neuropathic pain Pregabalin (Lyrica) Hydantoins: Ethotoin Phenytoin Mephenytoin Fosphenytoin Oxazolidinediones: Paramethadione Trimethadione Ethadione Propionates: Beclamide Pyrimidinediones: Primidone Pyrrolidines: Brivaracetam Levetiracetam (Keppra) Seletracetam Succinimides: Ethosuximide Phensuximide Mesuximide Sulfonamides: Acetazolamide Sultiame Methazolamide Zonisamide Triazines: Lamotrigine (Lamictal) Ureas: Pheneturide Phenacemide Valproylamides (amide derivatives of valproate): Valpromide Valnoctamide Other: Perampanel Side effects May reduce IQ in children See also [[Epilepsy]] Thu, 21 Nov 2024 09:39:11 +0000 http://autoprac.com/antiepileptic-drug http://autoprac.com/medical-career Medical education is as follows: University degree in medicine, including MBBS (6 years) and MD (4 years). There is a pre-clinical portion, followed by a clinical portion (final 2 years) during medical school Resident medical officers (RMO), who are employed on 12 month temporary contracts: Internship (postgraduate year 1, PGY1), where medical graduates are required to complete at least 1 year of internship (with rotations in various fields) to gain full registration to demonstrate fitness to practice Residency (1-3 years), which represents full registration with the medical board, and can practice independently. It includes: Junior medical officer (JMO, PGY2) Senior resident medical officer (SRMO, PGY3) Registrar (3-6 years), who have been accepted into a Specialist training program, or General practice training program, to specialize in a particular branch of medicine. The entrance (usually competitive), length, and content is governed by the Medical Colleges Consultants (aka Bosses), including: GPs Staff Specialists Visiting medical officer (VMO), who are specialists who have their own private practice, who choose to practice within hospitals on a part time basis [faq]A lot of words here! In short, what's the hiearchy? Consultants are bosses. They're at the very top. Next are registrars, who are employees. Residents are junior employees. Interns are just as the word means - they're just testing the waters and try a bit of everything out. Like the Vince Vaughn and Owen Wilson movie, where they did a bit of everything at Google ;) Yep![/faq] Source: AIDA Queensland Health Map My Health Career Thu, 21 Nov 2024 16:36:42 +0000 http://autoprac.com/medical-career 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 Thu, 21 Nov 2024 09:41:47 +0000 http://autoprac.com/postpartum-hemorrhage 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]] Thu, 21 Nov 2024 02:59:57 +0000 http://autoprac.com/monoamine-reuptake-inhibitor http://autoprac.com/down-syndrome Down syndrome is a genetic disorder caused by a 3rd copy of genes on chromosome 21. Pathophysiology Caused by 3 copies of the genes on chromosome 21, rather than the usual 2. This is caused by: Trisomy 21 (most common cause, 93% of cases), is a complete extra copy of chromosome 21, caused by a failure of the 21st chromosome to separate during egg/sperm development. As the sperm/egg cell has an extra copy of chromosome 21, the cell has 24 [instead of 23] chromosomes. Thus, when combined, the baby has 47 [rather than 46] chromosomes, with 3 copies of chromosome 21. 88% of cases is due to nonseparation of the chromosomes in the mother, 8% from nonseparation in the father, and 3% after the egg and sperm have merged Mosaic Down syndrome (1.7%), where some cells in the body are normal and others have trisomy 21 Translocations (2.5%), which contain additional material from chromosome 21. It may be a new mutation, or previously present in one of the parents (aka familial Down syndrome) [faq]What exactly is Down syndrome, and why does it happen? It's where a baby receives 3 copies, rather than 2 copies of chromosome 21, a particular segment of code. It happens because rather than receiving 1 copy from mom, or 1 copy from dad, 2 copies are received instead.[/faq] Risk factors Increasing maternal age, with 1 in 1,500 chance at 20yo, 1 in 1,000 chance at 30yo, 1 in 350 at 35yo, 1 in 100 chance at 40yo, and 1 in 30 chance at 45yo 70% of kids with Down syndrome are born to women Wed, 20 Nov 2024 17:37:00 +0000 http://autoprac.com/down-syndrome http://autoprac.com/nsaid NSAID are used for relieving pain, alleviating fever, and in higher doses, anti-inflammatory. They are non-narcotic, and thus can be used as a non-addictive alternative to narcotics. They are non-steroidal, but still have the anti-inflammatory action of steroids. MOA Non-selective COX inhibitor, and so therefore has the unwanted GI side effects due to inhibition of COX-1. This includes: Salicylates, including: Aspirin (see page) Diflunisal Salicylic acid and other salicylates Salsalate Propionic acid derivatives, including: Ibuprofen, has some anti-platelet effect, although of shorter duration than aspirin (and other anti-platelets). Examples include Nurofen, Advil. Nurofen Plus has added Codeine phosphate [img]ibuprofen.jpg[/img] Source: Counsel Heal Dexibuprofen Naproxen Fenoprofen Ketoprofen Dexketoprofen Flurbiprofen Oxaprozin Loxoprofen Acetic acid derivatives, including: Indometacin (Indocid) Tolmetin Sulindac Etodolac Ketorolac Diclofenac (Voltaren) Aceclofenac Nabumetone Enolic acid (Oxicam) derivatives, including: Piroxicam Meloxicam (Mobic) Tenoxicam Droxicam Lornoxicam Isoxicam Phenylbutazone Anthranilic acid derivatives (Fenamates), including: Mefenamic acid Meclofenamic acid Flufenamic acid Tolfenamic acid Selective COX-2 inhibitors (Coxibs), including: Celecoxib (Celebrex) Rofecoxib Valdecoxib Parecoxib Lumiracoxib Etoricoxib Firocoxib Sulfonanilides, including: Nimesulide Others, including: Clonixin Licofelone Side effects GI ulcers, and bleeding; hence, COX-2 inhibitors may be preferred In kids, Reye's syndrome (i.e. fatal syndrome detrimenting brain, liver, hypoglycemia), so is only indicated in rheumatic fever and Kawasaki disease Contraindications Absolute: Peptic ulcer or stomach bleeding Uncontrolled HTN Kidney disease Past TIA (excluding aspirin) Past stroke (excluding aspirin) Past MI (exclusin aspirin) CAD (excluding aspirin) Undergoing CABG Taking aspirin for heart In 3rd trimester of pregnancy Pt's who have undergone gastric bypass Pt's who have a Hx of allergic or allergic-type NSAID hypersensitivity reactions, e.g. aspirin-induced asthma Relative: Irritable bowel syndrome Pt's >50yo, who have a FH of GI problems Pt's who have had past GI problems from NSAID use See also [[Antiplatelet]] [[Aspirin]] Wed, 20 Nov 2024 16:31:44 +0000 http://autoprac.com/nsaid 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 Wed, 20 Nov 2024 16:45:12 +0000 http://autoprac.com/stroke 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  Thu, 21 Nov 2024 09:33:33 +0000 http://autoprac.com/miscarriage http://autoprac.com/abortion Induced abortion is the intentional killing of a fetus/embryo, by forcing it out of a womb before it is able to survive of its own. Late termination of pregnancy (aka late-term abortion) is an induced abortion of a fetus that may be able to survive on its own. Methods Methods depend on gestational age, and include: Drugs (aka medical abortions), where abortion is induced by abortifacient drugs. In the 1st trimester are as effective as surgery: Mifepristone (RU-486), an antiprogestogen. It is the most common early 1st trimester medical regimen, and is used in combination with a prostaglandin analog (misoprostol or gemeprost) up to 9 weeks gestational age Prostaglandin analog alone, or with methotrexate, is used for up to 7 weeks gestation. Note however, that mifepristone-misoprostol combination regimen work faster and are more effective at later gestational ages than methotrexate-misoprostol combination regimens, and combination regimens are more effective than misoprostol alone Surgery, which by the 2nd semester, have lower risk of side effects than medications Vacuum aspiration (see page) D&C (dilation and curettage, aka sharp curettage) is the dilation/widening of the cervix and surgical removal of part of the lining of the uterus (and/or its contents) by curettage/scraping. Curettage is cleaning the walls of the uterus with a curette. It can also be used as a therapeutic procedure. It is the 2nd most common method of surgical abortion, and is a standard gynecological procedure performed for a variety of reasons, including examination of the uterine lining for possible malignancy, investigation of abnormal bleeding, and abortion. The WHO recommends this procedure, only when manual vacuum aspiration is unavailable Dilation and evacuation (D&E), involves opening the cervix of the uterus and emptying it using surgical instruments and suction  Intact dilation and extraction (aka intrauterine cranial decompression, or partial-birth abortion), used after the 16th week of gestation, which requires surgical decompression of the fetus’ head before evacuation. It has been federally banned in the USA Hysterotomy, a procedure similar to a C section and performed under general anesthesia. It requires a smaller incision than a C section and is used during alter stages of pregnancy Birth control (e.g. pill, intrauterine devices) can be started immediately after an abortion Labor induction abortion (aka induced miscarriage) can be done in places lacking the necessary medical skill for dilation and extraction, or where preferred by practitioners. It involves first inducing labor, and then inducing fetal demise if necessary. This procedure may be performed from 13 weeks gestation to 3rd trimester. It is very uncommon in the USA, but more than 80% of induced abortions throughout the 2nd trimester are labor induced abortions in Sweden and other nearby countries [faq]Ethics aside, there's lots of reasons why mothers' might decide to abort a fetus. How is this done? There are 2 ways. Using medications, or surgery. In the 1st trimester, medications are just as effective as surgery, and there's less complications, so we opt for that. In the 2nd trimester, we usually do surgery. We can either manually remove the child using a vacuum, or surgically scraping it out.[/faq] Prognosis Where lawful, it is a safe procedure, only causing maternal death in 0.7 per 100k procedures, or 13 times more safer than childbirth (8.8 maternal deaths per 100k) When performed legally and safely, induced abortions don’t increase the risk of long-term mental or physical problems In contrast, unsafe abortions results in 47k maternal deaths, and 5 million hospital admissions per annum globally WHO recommends safe and legal abortions be available to all women Epidemiology 44 million abortions are performed per annum globally, with slightly under 50% performed unsafely Abortion rates have plateud after declining, due to education about birth control 40% of the world's women had access to legal induced abortions without restriction as to reason, although there are limits regarding how far along the pregnancy they can be performed. Some jurisdictions legalize abortion based on specific conditions (e.g. incest, rape, problems with the fetus, socioeconomic factors, risk to a mother's health) There is widespread controversy over the morality and ethics of abortion. Supporters emphasize a woman's right to decide matters concerning her own body, and dissidents emphasize a right to life and find abortion and murder synonymous "Unlawful abortion' is a crime for both women and Dr's subject to 10 years imprisonment (NSW Crimes Act 1900 s82-84). "Lawful" was defined by Levine J in R v Wald (1971) 3 DCR (NSW) 25 as where a Dr believes on reasonable "economic, social or medical ground or reason" that an abortion was necessary to avoid a "serious danger to the pregnant woman's life or to her physical or mental health" at any point during pregnancy. Kirby J in CES v Superclinics ACES v Superclinics Australia Pty Ltd (1995) 38 NSWLR 47 expanded the period of which health concerns can be considered, to any period during the woman's life, even after the birth of the child. In NSW, a referral from a Dr is not required. Although it was thought to preclude successful prosecutions for illegal abortions, in R v Sood [2006] NSWSC 1141, Dr Suman Sood was convicted of 2 counts of performing an illegal abortion because she failed to enquire as to whether a lawful reason for performing the abortion existed See also Miscarriage (unintentional abortion) Wed, 20 Nov 2024 14:38:06 +0000 http://autoprac.com/abortion http://autoprac.com/cranial-nerve-examination Cranial nerves (CN's, aka cerebral nerves) are nerves emerging directly from the brain and brain stem (cf. spinal nerves which emerge from the spinal cord). Physiology CN's exchange information between brain and primarily the head and neck, reaching as far as the first cervical vertebrae CN's are paired and present on both sides. CN 0 (terminal), 1 (olfactory) and 2 (optic) emerges from the cerebrum (forebrain), and the remaining 10 pairs emerge from the brainstem CN's are apart of the PNS, with the exception of CN2 (optic) which is an extension of the brain Method Smell (1): Have you noticed any changes in your sense of smell? Say that you could, assess smell using scents Vision (2): Do you wear glasses? If so, keep them on Visual acuity test, looking at Snellen chart, cover each eye Visual field defects (aka confrontation), by covering each eye with the palm, asking patient when they see the object coming in from edges Unilateral visual inattention, doing apostrophes with the left, right, and then both Blind spot Accommodation, asking patient to look at finger, away, then back Shining light response, direct in that eye, consensual in the unstimulated eye, and the swinging light test. PEARL is shorthand for Pupils Equal and Reactive to Light Say that you could, test for color blindness using Ishihara plates Say that you could, do fundoscopy Eye movement (3, 4, 6): Hold on to patient’s head, asking them to follow your finger in a H shape. State that you saw no nystagmus, and ask if they saw double vision Face and jaw (5) Fine touch on temple, cheek and jaw (i.e. 3 distributions of trigeminal), and pin prick, asking patient if the same on either side, and tell difference Muscles of mastication: Ask patient to clench teeth, starting from the jaw, cheek, temple. Ask patient to open and close their mouth, and push their jaw to the side, against your resistance. Jaw jerk reflex (tap at the chin, which should not jerk mandible upwards) Say that you could, do corneal reflex (EXPLAIN: involuntary blinking of eyelid when cornea touched, mediated by ophthalmic branch of trigeminal, and the facial nerve) Facial expression (7) Ask patient to squint eyes , and open them against resistance Ask patient to puff cheeks against resistance Ask patient to smile, and a big Disney smile Hearing (8) Have you noticed any changes in your hearing or balance? Stand behind patient, and whisper a number in their ears, and ask patient to repeat, whilst rubbing fingers in the other Rinne test, which is using a tuning fork, the higher frequency (256Hz, mnemonic that it’s “higher” so they can “hear better”), placing it on bone behind ear asking that they hear it, when they stop hearing it, then switching to air (which they still should) Weber test, which is placing the tuning fork at the center of the forehead, asking if it is heard at the center. Memorized with mnemonic of a “Big W” at their forehead because they’re wankers Tongue (9, 10) Have you noticed any changes in taste? Ask patient to repeat the word “British constitution”. Can hear no hoarseness of voice Can you open your mouth and say argh. Observing palate. Check deviation of the uvula Ask patient to stick your tongue out, and move from side to side. Note no wasting, fasciculation or deviation Ask patient to move it to the side whilst mouth closed, against resistance Say that you could, do gag reflex (EXPLAIN: reflex contraction of back of throat, preventing choking, mediated by glossopharyngeal and vagus nerve) Shoulder (11) Ask patient to shrug shoulders against resistance Ask patient to turn head to either side against resistance Say that you could, also do upper limb exam, lower limb exam, MMSE Thu, 21 Nov 2024 05:58:15 +0000 http://autoprac.com/cranial-nerve-examination 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 Thu, 21 Nov 2024 09:42:38 +0000 http://autoprac.com/hemolytic-disease-of-the-newborn 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 Thu, 21 Nov 2024 01:33:56 +0000 http://autoprac.com/gestational-diabetes http://autoprac.com/beta-lactam Beta-lactam is a class of antibiotics, that contain a beta-lactam ring. [faq]Beta lactam. What's that? How's that different from an alpha lactam? So beta lactams are named this way, because they have a beta lactam ring. Lactam is just a ring version of the amide. Beta just means that the nitrogen is attached to the beta carbon, relative to the carbonyl carbon (double bonded to an oxygen).[/faq] Classification Penicillin (aka penams) is a group of antibiotics, that are less effective, as many types of bacteria are now resistant. They were among the first effective against previously serious diseases (including syphilis, and infection by staphylococci and streptococci). They are now used in usually Gram-positive organisms. There are also now several enhanced penicillins. Examples are: Narrow spectrum: Beta-lactamase sensitive (1st generation), including: Benzylpenicillin (aka penicillin G, benpen), for syphilis, meningitis, endocarditis, pneumonia, lung abscesses and septicemia in kids [img]benzylpenicillin.jpg[/img] Source: Taj Pharma Benzathine benzylpenicillin Procaine benzylpenicillin Phenoxymethylpenicillin Propicillin Pheneticillin Azidocillin Clometocillin Penamecillin Beta-lactamase resistant (2nd generation), including: Cloxacillin, including: Dicloxacillin, effective against beta-lactamase-producing organisms, e.g. Staph aureus, which is otherwise resistant to most penicillins Flucloxacillin (aka fluclox), which unlike other beta-lactams has effect against Staph aureus as it is beta-lactamase stable [img]flucloxacillin.jpg[/img] Source: Bristol Labs     Oxacillin Nafcillin Methicillin Extended spectrum: Aminopenicillins (3rd generation): Amoxicillin (AMK, Amoxil), better absorbed orally than other beta-lactams, and one of most presribed for kids) [img]amoxicillin.jpg[/img] Source: AmazonAWS Ampicillin (aka amp), roughly equivalent to amoxicillin in terms of activity. It includes: Pivampicillin Hetacillin Bacampicillin Metampicillin Talampicillin Epicillin Carboxypenicillins (4th generation): Ticarcillin, and Timentin (TIM, Ticarcillin+cluvanate) Carbenicillin/Carindacillin Temocillin Ureidopenicillins (4th generation): Piperacillin (aka anti-pseudomonal penicillin), an extended spectrum beta lactam. It provides activity against the hospital pathogen Pseudomonas aeruginosa. It is commonly used w/ the beta lactamase inhibitor tazobactam (TAZ, product name Tazocin, Zosyn), although it still doesn't work against MRSA Azlocillin Mezlocillin [faq]Penicillins. They're so common. What are they? So penicillins are a type of these beta ringed amides. They are less effective than they previously were, because of antibiotic resistance, and is usually used for Gram positive organisms. Gram positive, what's that? So it lacks the outer membrane, and therefore stains. It includes the famous Staph and Strep, basically, and Enterococcus too. Most other things are Gram negative.[/faq] Penems, including: Faropenem Carbapenems, including: Ertapenem Antipseudomonal, including: Doripenem Imipenem Meropenem Biapenem Panipenem Cephalosporins is originally derived from the fungus Acremonium (previously known as Cephalosporium). Successive generations after the 1st generation, have increased activity against Gram negative bacteria, albeit often with reduced activity against Gram positive organisms. Examples are: 1st generation, predominantly against Gram positive, including: Cephalexin (Cefalex) Cefazolin 2nd generation 3rd generation, including: Ceftriaxone Cefotaxime Ceftazidime 4th generation 5th generation [faq]Cephalosporins, these are quite common. I can't believe they're in the same category as Penicillins? Aren't cephalosporins... plants? Spores? They are beta ringed amides, so yes, they are in the same category as Penicillins. And sort of, not plants, but fungus. So there are numerous generations? Do they become stronger with each generation? Sort of. The 1st generations are similar to Penicillins, as in being effective against Gram positives. With the later generations, they become more effective against Gram negatives, but this is often at the expense of becoming less effective against Gram positives.[/faq] Monobactams, including: Aztreonam Tigemonam Carumonam Nocardicin A Beta-lactamase inhibitors, because the weakness of beta lactams is bacteria often develop resistance by synthesizing beta-lactamase, an enzyme which attacks the beta-lactam ring. This includes: Penam, including: Sulbactam Tazobactam Clavam, including clavulanic acid: ​Augmentin [duo forte], which is Amoxicillin + Clavulanic acid Avibactam [faq]Beta lactamase. What's that? Oooh. It's quite nasty, it's enzymes made by bacteria, to make it resistant to beta lactams, and therefore makes antibiotics like penicillin and cephalosporins INeffective :(! I see. So beta lactamase inhibitors can be used to prevent bacteria from resisting the beta ringed amide antibiotics. Why would you do that? So you can use the beta ringed amide antibiotics ;).[/faq] MOA Acts by inhibiting the synthesis of the cell wall of bacteria Weakness MRSA (Methicillin-resistant Staph aureus) is a bacterium responsible for several difficult-to-treat infections in humans. It is any strain of Staphyloccocus aureus that has developed, through the process of natural selection, resistance to beta-lactam antibiotics, which include the penicillins (methicillin, dicloxacillin, nafcillin, oxacillin, etc) and the cephalosporins. The evolution of such resistance doesn’t cause the organism to be more intrinsically virulent than strains of S aureus, that have no antibiotic resistance, but resistance does make MRSA infection more difficult to treat with standard types of antibiotics and thus more dangerous. It is especially troublesome in hospitals, prisons, and nursing homes, where patients with open wounds, invasive devices, and weakened immune systems are at greater risk of nosocomial infection than the general public. MRSA began as a hospital-acquired infection, but has developed limited endemic status, and is now sometimes community-acquired. The terms healthcare-associated MRSA and community-associated MRSA reflect this distinction MSSA (Methicillin-sensitive Staph aureus) are strains UNABLE to resist these antibiotics are classified as, i.e. the antonym to MRSA [faq]MRSA. What's that? I've heard it, and it's meant to be a super nasty bug? Yeah. So it's a Gram positive, it's Staph. But whereas Staph can usually be attacked by Beta lactams, MRSA cannot. What does it stand for? Methicillin-resistant Staph aureus. Methicillin is only 1 type of penicillin, but it's just the 1 that's chosen. It actually refers to all of the penicillins, and in fact, cephalosporins too, so basically, it means it's resistant to beta amide ring antibiotics generally.[/faq] See also [[Antibiotics]] (category) Thu, 21 Nov 2024 17:40:58 +0000 http://autoprac.com/beta-lactam http://autoprac.com/beta-blocker Beta blockers reduce blood pressure (antihypertensive) and heart rate. [faq]What are beta blockers? They're drugs used to reduce blood pressure, as well as heart rate. You diferentiated blood pressure from heart rate? Yep. You can reduce blood pressure by reducing heart rate. But you can also reduce blood pressure by other means, like causing someone to pee more, which would mean there would be less circulating blood.[/faq] Classification Nonselective B-blockers include: Propranolol [img]propranolol.jpg[/img] Source: Vet Book Bucindolol Carteolol Carvedilol Labetalol Nadolol Oxprenolol Penbutolol Pindolol Sotalol Timolol B1-selective blockers, which are cardioselective, include: Acebutolol Atenolol (Tenormin) Betaxolol Bisoprolol (Bicor) Celiprolol Esmolol Metoprolol (Lopressor) Nebivolol MOA Block the beta adrenergic receptor, which are found, inter alia, on the cells of the heart muscle. They are the target of adrenaline and noradrenaline, which usually cause sympathetic effect. Thus, by blocking it, it reduces the heart rate [faq]How do beta blockers work? What is beta? So beta is referring to beta adrenergic receptors. There is... beta and alpha? What is adrenergic? So adrenergic are just receptors that are the target of adrenaline. And yes, it's divided into alpha and beta, alpha has specific targets like the bronchioles in the airways, as supposed to beta which is more specific for the heart.[/faq] Side effects Especially in non-cardioselective agents (i.e. not beta-1 selective), beta 2 antagonism causes: Bronchospasm ==> Contraindicated in Pt's w/ asthma. If bronchospasm does occur, can be treated w/ anticholinergics Alters glucose and lipid metabolism Also causes: Nausea, diarrhea, fatigue, dizziness, dyspnea, cold extremities Hypotension, orthostatic hypotension, bradycardia, heart failure, heart block Hyperkalemia and hyponatremia Hypoglycemia ==> Should thus be used cautiously in diabetics. In diabetics, prefer to use ACE and ARBs, which actually decrease risk Alopecia (hair loss) Abnormal vision, hallucinations Sleep disturbances, e.g. insomnia, nightmares, vivid dreams Sexual dysfunction, erectile dysfunction Edema Ineffectiveness, especially in use to address alpha-adrenergic stimulant overdise (e.g. cocaine, amphetamine) ==> Contraindicated in Pt's w/ history of cocaine; rather, vasodilators, diuretics and alpha blockers should be used See also [[Hypertension]] (target) Thu, 21 Nov 2024 05:41:17 +0000 http://autoprac.com/beta-blocker 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]] Thu, 21 Nov 2024 05:54:29 +0000 http://autoprac.com/nuchal-scan http://autoprac.com/vaginal-bleeding Vaginal bleeding is any bleeding through the vagina. PV is shorthand for blood loss per vaginam (Latin for "through the vagina"). [faq]What is vaginal bleeding? It's bleeding through the vagina. What is a vagina? The vagina is a muscular tube which is part of the female reproductive system.[/faq] Pathophysiology Commonly caused by bleeding from another location of the female reproductive system. Can also be caused by bleeding from the vaginal wall itself Typically arises from lining of the uterus (endometrium), but may arise from lesions of the uterine, cervix, vagina, and rarely from the Fallopian tube Classification Minimal vaginal bleeding (aka spotting), involving few drops of blood → metorrhagia Mild bleeding, soaking 3 hours Moderate bleeding, soaking >1 pad/tampon in 3 hours Severe vaginal bleeding, soaking 1-2 pads/tampons in 1-2 hours, unless it is normal for the Pt. It may also involve passing clots of blood from the vagina. The exception is if the Pt is pregnant, and there is a single gush of blood, or passing of a clot, that is not considered severe Cause In children, before menarche: Precocious puberty Foreign body in the vagina Molestation Vaginitis (vaginal infection) Tumor, rarely Genital tract bleed: Vaginal bleeding: Physiological, during menstrual cycle (shedding when a woman is not conceiving) Bleeding relating to OCP use, including breakthrough bleeding and/or withdrawal bleeding Hormonal/organic problems of the reproductive system Trauma Neoplasm Cervical bleeding: Cervicitis Cervical neoplasm Cervical polyp [[Dysfunctional uterine bleeding]] (see page) STI In pregnancy: [[Threatened miscarriage]] (see page), 24 weeks [[Postpartum bleeding]] (see page), >birth [[Postmenopausal bleeding]] (see page), >menopause Non-genital tract bleed: GI bleed: Hemorrhoids IBD Urinary tract bleed (aka hematuria): UTI Predisposition, due to coagulopathy [faq]Why would a woman bleed through her vagina? So in kids, before a girl has her 1st period, it could be... well, early puberty. It could be a foreign body, molestation, vaginal infection, even a cancer. Then, we divide the bleed into genital, or non-genital. And, just general predisposition into bleeding. Wait... non-genital? We said woman bleeding through her vagina... :O? Strictly speaking, it should be her vagina, but... it could be a GI bleed. Or, it could be a urinary bleed. So, we just want to be sure :) Alright. So genital, big one, I'm guessing, given we are strictly talking about bleeding from the vagina? So we can still divided, into vaginal bleeding, bleeding from the opening to the womb, bleeding from the womb itself. Then there's special situations, like STI's, during and after pregnancy, and bleeding after menopause, when it's supposed to have stopped.[/faq] Ix Hx: Characterization, including when it started, duration, pattern/regularity, amount (number of pads and tampons), frequency Pain → trauma Children → trauma from childbirth Drugs, including OCT, HRT → estrogen causing thickening of endometrium/uterine lining → uterine cancer PMH, including of bleeding, anemia → coagulopathy SH → STI Diet, especially of estrogen (e.g. from soy) → endometrial hyperplasia, uterine cancer Smoking → risk factor for cervical cancer O/E, focused on finding the source of bleeding, and looking for any abnormalities that could cause bleeding: Visualization of the cervix with a speculum Bimanual exam Rectovaginal exam Abdominal examination and palpation, to ascertain if the bleeding is abdominal in origin Pregnancy test FBC, if bleeding is excessive or prolonged, to check for anemia Hysteroscopy w/ biopsy or D&C, to Ix an abnormal endometrium Transvaginal U/S, which is 1st line procedure to identify which women are at higher risk of endometrial cancer. A cut off threshold of Wed, 20 Nov 2024 22:06:05 +0000 http://autoprac.com/vaginal-bleeding 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 Thu, 21 Nov 2024 10:30:44 +0000 http://autoprac.com/erythema http://autoprac.com/otoscopy Otoscope (aka auriscope) is a device used to look into the ears, especially the outer and middle ear, by providing a view of the ear canal and tympanic membrane (aka eardrum, which is the border separating the external ear canal and middle ear, so can indicate disease of the middle ear space). The view can be obscured though, with ear wax (cerumen), shed skin, pus, canal skin edema, foreign body, and various ear diseases. Design The device most commonly involves a handle and head. The head contains a light source and low-powered magnifying lens (around 8 diopters) The end of the otoscope has an attachment for disposable plastic ear specula, so infections aren't transferred between patients Wall mounted models can be easily charged using the electric outlet. Portable models use batteries, which need to be swapped Otoscopes are often sold with fundoscopes as a Dx set Binocular otoscopes provide a 3D view, and are superior to monocular otoscopes (which are used ubiquitously in practice) Method The ear canal is straightened by pulling the pinna, and the speculum (side of the otoscope) inserted into the external ear Place the index finger or little finger against the head, thereby bracing the hand holding the otoscope, to avoid injury to the Pt's ear canal Look through the lens on the rear of the instrument, to see inside the ear canal [youtube]FE0sot4OoAE[/youtube] [img]tympanic-membrane.jpg[/img] Source: UCSD Source: WA Health [faq]I'm going in for gold... looking into the ear ;) I've pulled up the top bit, that "pinna" of the ear, and inserted the pointy "speculum" of the otoscope into the ear. What am I seeing :O ? Let's choose an ear... the left one :D! You're going to see a volcano in the middle, that comes in from the side. The center of that volcano is the "umbo". The walkway to the island is the "handle of the malleus". A second walkway is called the "incus". The cone of light that projects from the umbo to the other side is called the "light reflex". The entire walkway that is elevated is called the "pars flaccida". The "pars tensa" is everything that looks relatively depressed. So if I was to ask, which way does the umbo point...? It points down at around 45 degrees, and points AWAY from where the head is facing (i.e. the nose). And what's the whole thing called? The tympanic membrane.[/faq] Other features of particular models: Lens can be removed, so instruments can be inserted into the ear canal, such as for removing earwax Insertion point for a bulb capable of pushing air through the speculum (known as a pneumatic otoscope). This puff of air allows the examiner to test the mobility of the tympanic membrane The device can also be used to examine the Pt's: Nose (with the same speculum) Upper throat (with the speculum removed) Dx Otitis media (middle ear infection) Otitis externa (oute rear infection) See also Fundoscope Stethoscope Endoscopy Thu, 21 Nov 2024 04:59:36 +0000 http://autoprac.com/otoscopy 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) Wed, 20 Nov 2024 18:45:38 +0000 http://autoprac.com/uterotonic http://autoprac.com/body-temperature Body temperature (shorthand Temp) is measured by a thermometer. Pathophysiology It depends on a number of factors, including: Location of measurement, typically from highest to lowest, being internal (rectal, vaginal), oral, and then skin. Typical internal temperature (gold standard to measure core temperature) is 37° C, or slightly cooler at 36.8 °C ± 0.4 °C Time of day, varying during the day by about 0.5 °C, with temperatures lower in the morning, and higher in the afternoon/evenings. Body temperature also tends to be lowest in the 2nd half of the sleep cycle Activity level of Pt Hunger Sleepiness Cold Classifications Hypothermia, is 37.5 °C. The difference between Fever and Hyperthermia is whereas Fever is an increase in the temperature setpoint that the body attempts to maintain, Hyperthermia is the production/absorption of more heat than it can dissapate. Hyperpyrexia, is >40 °C Ix Thermometers, to take a patient's temperature, in various sites, including: Rectal, in the anus Oral, in the mouth Axillary, under teh arm Tympanic, in the ear Vaginal, in the vagina In the bladder On the skin of the forehead over the temporal artery See also [[Fever]] Thu, 21 Nov 2024 04:26:50 +0000 http://autoprac.com/body-temperature http://autoprac.com/neonatal-jaundice Neonatal jaundice is jaundice (yellowing of the skin and other tissues) in neonates. [faq]Neonatal jaundice is obviously jaundice in a neonate. What do those 2 words mean? "Neonate" is a child in their first month of life - specifically, their first 28 days. "Jaundice" is where a person's skin and eye white's become yellow in color. So it's essentially when a child in their first 28 days of life becomes yellow. What causes yellowness? Bilirubin. It gets created when red blood cells are broken down. Usually bilirubin is excreted in bile and urine - which is why urine is yellow! However, at higher level, it seeps out of blood vessels and is flung throughout the body.[/faq] Cause Unconjugated hyperbilirubinemia, meaning the problem occurs BEFORE the liver: Non-hemolytic causes: Physiological in newborns, as fetal hemoglobin is being rapidly broken down and replaced with adult hemoglobin. Also, hepatic machinery [for the conjugation and excretion of bilirubin] doesn't mature until approximately 2 weeks of age. It is often seen around the 2nd day after birth, lasting 10 days in term infants [up to 204 μmol/L], or 14 days in premature births [up to 225 μmol/L] Breast milk jaundice, as breast milk may contain factors that keep the baby's liver from breaking down bilirubin. It may run in families Dehydration → bilirubin will be more concentrated Formula suppplementation, or malnutrition → breast milk promotes intestinal absorption of bilirubin, so less reaches the liver Cephalohematoma (i.e. hemorrhage between skul and periosteum, due to rupture of blood vessels crossing the periosteum) UTI Hemolytic disorders, caused by: Sepsis Blood disorders, including: Hereditary spherocytosis Sickle cell disease G6PD deficiency ABO incompatibility Rh disease Conjugated/direct hyperbilirubinemia, meaning the problem occurs: AT the liver: Infection: Sepsis Hepatitis TORCH infections (toxoplasmosis, rubella, CMV, HSV) Cystic fibrosis Metabolic: Galactosemia Alpha-1-antitrypsin deficiency Cystic fibrosis Drugs AFTER the liver: Biliary atresia (i.e. common bile duct between the liver and small intestine is either blocked or absent) Bile duct obstruction [faq]That makes sense. But why is this "bilirubin" thing at extremely high levels in babies? What disease do they have? It can be normal. There's 2 reasons for this. One, because fetal hemoglobin is being rapidly destroyed, and replaced with adult hemoglobin. And two, because the liver, which is supposed to help process the bilirubin to get rid of it into pee, doesn't mature until 2 weeks of age. So it's not surprising that they're naturally yellow for some time. I see. But how about formula? Does that damage the liver or something? For some reason, breast milk improves the ability of the tummy to eat bilirubin - we call that absorption. So less reaches the liver. I see. It's also possible that newborns have disease, right? Yes. And because they're so young, it's usually "inbuilt" stuff. Diseases they were born with. In particular, we're concerned with blood cells being destroyed super quick. And this can occur in various disorders of blood, including blood cells getting destroyed because they're not their usual shape (i.e. hereditary spherocytosis), or conflict between the mother and baby's blood (i.e. blood type autoantibodies).[/faq] Sx Yellow discoloration of the sclera, the face, extending down onto the chest, and then the extremities Infants whose palms and soles are yellow, have serum bilirubin >255 μmol/l (15 mg/dL), and is more serious Sleepy Interfere with feeding Dx Clinical assessment of color: → jaundiced appearance 14 days indicates pathological jaundice Blanching the skin by pressure, so underlying skin and subcutaneous tissue is revealed Ingram icterometer, where a piece of transparent plastic with 5 transverse strips of graded yellow lines, is pressed against the nose, and matched. Bilirubin level is accordingly assigned Transcutaneous bilirubinometer, a portable device, which generates a yellow xenon light passing through the subcutaneous tissue. Reflected light returns through an optic fiber, which is measured and assigned a bilirubin level Serum bilirubin (SBR)>85 μmol/L (5 mg/dL), which is more than double the amount required to cause jaundice in adults (>34μmol/L). Serum bilirubin is differentiated in results into Unconjugated bilirubin ("indirect") and Conjugated bilirubin ("direct") → total bilirubin >331.5 μmol/L, or direct/conjugated bilirubin >34μmol/L indicates pathological jaundice [faq]Why is the threshold for bilirubin double that which is permitted in adults :O? Because the machinery in the liver that processes bilirubin doesn't mature until around 2 weeks of age. That's why it's normal to have bilirubin levels double that in newborns, as supposed to adults :D.[/faq] Ix Hx: Hx of illness → infection FH of jaundice FH of anemia → hemolytic disorder FH of neonatal death due to liver disease → liver disease Maternal illness (fever, rash, lymphadenopathy) → infection Maternal drugs → sulfonamides, antimalarials causing RBC destruction in G6PD deficiency Clinical assessment: Presence of IUGR Intrauterine infection, which can be evidenced by cataracts, small head, hepatomegaly, splenomegaly → infection Cephalohematoma → hemolytic disorder Bruising → hemolytic disorder Signs of bleeding in the ventricles → hemolytic disorder Maternal blood group and RBC antibodies → hemolytic disease Using baby's cord blood: Blood group → hemolytic disease DAT/Coombs test → ABO incompatibility/hemolytic disease FBC → hemolysis, unusually shaped RBC's, evidence of infection CRP → infection Billirubin with differential (conjugated, unconjugated) LFT → liver disease Tx Serum bilirubin normally subsides without intervention. Tx includes: Frequent and effective feedings → bilirubin is reduced through bowel movements and urination Bili light (i.e. exposing baby to intensive phototherapy) often used in any newborn w/ serum bilirubin>=360μmol/L → blue light (wavelengths at 458nm) oxidize bilirubin to biliverdin Sunbathing is also effective, with the advantage of UV-B which promotes vitamin D production. This condition has also been rising due to less time spent outdoors Exchange transfusions (i.e. exchange of a person's own blood cells with replacement products), in any newborn w/ bilirubin>428 μmol/l [faq]So what would my doctor do if my newborn had neonatal jaundice? First of all, ensure that the child is getting frequent and effective feeds. That's because bilirubin is excreted both by both number 1's, and number 2's. How about phototherapy - also known as "the paparazzi" :D? We do not in all cases of neonatal jaundice. Remember neonatal jaundice is defined as bilirubin>255. Well, we only use it if bilirubin >=360, which is more than 40% above the level where we started saying "there's elevated bilirubin here"! And how does this "paparazzi" work? It's UV light, right? Can't that cause cancer :O? We don't use UV light because it can increase risks of skin moles and cancers. We just use good ole plain blue light ;). That does not cause cancer :D![/faq] Complications Extreme jaundice can cause kernicterus (i.e. bilirubin-induced brain dysfunction, because bilirubin is highly neurotoxic), which presents w/ fever, seizure, high pitched crying [faq]So what if a child is a bit yellow. Is it really such a concern? Yes, because at very high levels, it can cause something called "kernicterus". It's because bilirubin damages the brain - it can cause brain dysfunction.[/faq] Epidemiology Common in newborns, affecting >60% of babies in the 1st week of life [faq]Is jaundice in newborns really common? Yes. 60% will have it in their first week of life. You're not alone ;).[/faq] See also [[Jaundice]] Thu, 21 Nov 2024 02:30:20 +0000 http://autoprac.com/neonatal-jaundice http://autoprac.com/epilepsy-syndrome Epilepsy syndromes are specific features that are present. These features include the age at which seizures begin, the seizure types, and EEG findings, among others. Identifying an epilepsy syndrome is useful as it helps determine the underlying causes as well as what AED should be tried. Classification Autosomal dominant nocturnal frontal lobe epilepsy Rolandic epilepsy (aka benign childhood epilepsy with centrotemporal spikes) Benign occipital epilepsy of childhood Childhood absence epilepsy Dravet's syndrome Epilepsy in females with mental retardation Febrile infection-related epilepsy syndrome Frontal lobe epilepsy Interictal dysphoric disorder Juvenile myoclonic epilepsy (aka Janz syndrome), a common idiopathic generalized epilepsy, representing 8% of all epilepsy cases. It typically 1st manifestst itself between 12-18yo, with brief episodes of involuntary muscle twitching occurring early in the morning. Most patients also have generalized seizures that affect the entire brain, and many also have absence seizures. There are at least 6 loci for the disease, with known causative genes. Most of these genes are ion channels, or affect ion channel currents Lennox-Gastaut syndrome Ohtahara syndrome Reflex epilepsy Progressive myoclonic epilepsis Rasmussen's encephalitis Ring chromosome 20 syndrome Temporal lobe epilepsy Tuberous sclerosis West syndrome Myoclonic astatic epilepsy (aka Doose syndrome) is a generalized idiopathic epilepsy. It involves development of myoclonic seizures and/or myoclonic astatic seizures Thu, 21 Nov 2024 05:50:19 +0000 http://autoprac.com/epilepsy-syndrome http://autoprac.com/type-1-diabetes Type 1 diabetes (aka diabetes [mellitus] type 1, T1D[M], formerly insulin[-dependent] diabetes, juvenile diabetes) is DM that results from autoimmune destruction of the insulin-producing beta cells in the pancreas. [faq]What is type 1 diabetes, and why is it also called juvenile diabetes? It's called that because you get it as a kid. It's an autoimmune type thing. Specifically, the body attacks it's own beta cells in the pancreas. What does the beta cells do? What does the pancreas do? The pancreas secretes digestive enzymes. But it also creates some important hormones, one of which is insulin. Specifically, insulin is created by the beta cells of the pancreas. What is insulin? It's a hormone, that helps convert glucose in blood, to be stored as fat. It also helps the body use blood sugar.[/faq] Sx Polyuria (frequent urination) Polyldipsia (increased thirst) Polyphagia (increased hunger) Weight loss Pathophysiology Subsequent lack of insulin causes increased blood and urine glucose Cause of type 1 diabetes is unknown Dx To distinguish type 1 [from type 2] diabetes: Autoantibody testing C-peptide assay, which measures endogenous insulin production [faq]How can you tell whether high blood sugar, is due to problems making insulin by the beta cells of the pancreas, or the body not responding to insulin as it should? A blood test might show the presence of particular autoantibodies, that target the beta cells. You can also test for C-peptide, which is released as part of the body's production of insulin. Obviously, this will be low in type 1 diabetes, because insulin isn't being produced.[/faq] Tx Insulin therapy, including: Insulin injections, is ESSENTIAL for survival. It must be continued INDEFINETELY and doesn't usually impair normal daily activities. It must be prescribed externally, as it is no longer produced internally Insulin pump, is a way through giving short acting insulin 24 hours a day through a catheter placed under the skin [faq]What can you do if high blood sugar, is due to problems making insulin? You can give insulin. Which makes sense because the body's having problems making insulin.[/faq] Prognosis Pt's are usually trained to Mx their diabetes independently, however, for some this can be challenging Untreated, diabetes can cause many complications Complications Acute complications: Diabetic ketoacidosis (the type 1 version of nonketotic hyperosmolar coma) Hypoglycemia (low blood sugar) caused by excessive Tx Long-term complications, are serious, some of which have an autoimmune basis too, including: Heart disease Stroke Kidney failure Foot ulcers Diabetic neuropathy Diabetic retinopathy (damage to the eyes) [faq]What can happen, as a result of having high blood sugar, due to problems making insulin? There's stuff that happens in the short run, as well as in the long run. In the short run, insulin can become so unavailable, that the body is unable to use blood glucose, and switches to burning fat. This produces ketone bodies, which would be fine except they're acidic. This causes blood to become acidic. Like type 2 diabetes, blood sugar can get so high, that dehydration causes a coma. You mentioned that having high blood sugar, can cause low blood sugar... how does this work? It's not that high blood sugar causes low blood sugar. It's that when you treat high blood sugar, if a proper balance isn't made, you can get low blood sugar if you go overboard.[/faq] Comorbidities Other [[autoimmune disease]], including: [[Autoimmune thyroiditis]] (hypothyroid known as Hashimoto's, or hyperthyroid known as Graves') [[Celiac disease]] (of the small intestine, causing immune reaction to gluten protein in wheat) [[Addison disease]] (of the adrenal glands, and therefore glucocorticoids and mineralocorticoids) Eating disorders, especially diabulimia, where T1DM patients give themselves less insulin that they need, for the purpose of weight loss. This can also occur alongside bulimic behavior Depression and anxiety Impact on school Source: NIH Epidemiology Type 1 diabetes accounts for 7% of diabetes Globally it is estimated that 80k kids develop type 1 diabetes annually Lowest rates of new cases are in Japan and China at 1 per 100k, up to 35 per 100k in Scandinavia See also [[Diabetes]] (category) [[Type 2 diabetes]] [[Insulin]] Wed, 20 Nov 2024 17:39:32 +0000 http://autoprac.com/type-1-diabetes http://autoprac.com/gynecomastia Gynecomastia is benign enlargement of breast tissue in males. Up to 70% of adolescent boys have some breast development during puberty, but 75% of cases resolve within 2 years without Tx. In adolescent boys, this can cause pscyhological distress. [img]gynecomastia.jpg[/img] Source: Make Me Heal Causes Newborn males, due to influence of maternal hormones Adolescents, due to hormonal changes during puberty Klinefelter syndrome Certain cancers Disorders of the endocrine system, or metabolic dysfunction Use of certain medications Older males, due to natural decline in testosterone production Liver failure, since the liver metabolizes estrogen, so in liver failure/cirrhosis, there is hyperestrogenemia, and thus gynecomastia Pathophysiology Caused by an increase in estrogen (female) and decrease in androgen (male), thereby increasing size of male breast tissue Mx Usually unnecessary as self-resolves Aromatase inhibitors can be effective in chronic cases Surgical removal of excess tissue is usually required Thu, 21 Nov 2024 04:51:16 +0000 http://autoprac.com/gynecomastia http://autoprac.com/hypertension [Arterial] hypertension (aka high blood pressure, HTN) is chronically elevated BP in arteries. [faq]What is hypertension? High blood pressure. What is blood pressure? The pressure of blood against the wall of the vessels, that contain it.[/faq] Pathophysiology BP is expressed by systolic (maximum) and diastolic (minimum) pressures in the arterial system The systolic pressure occurs when the L ventricle is most contracted, the diastolic pressure when the L ventricle is most relaxed prior to the next contraction Normal BP at rest is between 100/60-140/90 systolic/diastolic, so HTN is present is BP>140/90 for aduts, and different numbers apply to kids [faq]So normal blood pressure is 120/80. What is high blood pressure defined as? The normal high is 140/90. So a systolic pressure greater than 140, or a diastolic pressure greater than 90, is called hypertension.[/faq] Classification Primary (essential) hypertension (95%), with no obvious underlying cause. It tends to be familial, and is likely the consequence of an interaction between environmental and genetic factors. The prevalence of essential hypertension increases with age, and patients with relatively high blood pressure at younger ages are at increased risk for subsequent development of hypertension. It can increase the risk of cerebral, cardiac, and renal events Secondary hypertension (5%), where HTN is due to an identifiable secondary cause, including: Chronic kidney disease Narrowing of the aorta or kidney arteries Endocine disorder, e.g. excess aldosterone, cortisol, or catecholamines Tumors Side effect of many drugs [faq]What are the different types of high blood pressure? Essential, where we don't know what the cause is. And secondary, where we can identify the cause. Well then... what are the causes of high blood pressure? The kidney excretes fluid, so if there's problem there, blood pressure will increase. There can be narrowing of an article somewhere, but it's particularly a problem if it's the vessel pumping blood out the heart, or the one in the kidney. Think about it, if the same amount of blood runs through a thinner tube, the pressure is higher. It can also be a hormone thing, causing the heart to beat faster, or the body to retain more water.[/faq] Tx Dietary and lifestyle changes can improve BP control, and decrease risk of complications Drugs, is often necessary in Pt's whom lifestyle changes are not enough or not effective Prognosis Tx of moderately arterial BP (>160/100mmHg) w/ drugs is associated w/ improved life expectancy Benefits of drug Tx for BP 140/90-160/100 is more controversial Complications Doesn't usually cause Sx initially Sustained HTN is a risk factor for: Hypertensive heart disease Coronary artery disease Stroke Aortic aneurysm Peripheral artery disease Chronic kidney disease See also Antihypertensive Pregnancy HTN Thu, 21 Nov 2024 08:49:06 +0000 http://autoprac.com/hypertension http://autoprac.com/cabg CABG (coronary artery bypass surgery, pronouncd "cabbage") is surgery involving that involves bypassing an obstructed coronary artery. Pathophysiology The obstruction being bypassed is due to arteriosclerosis, atherosclerosis, or both: Arteriosclerosis is characterized by thickening, loss of elasticity, and calcification of the arterial wall, most often resulting in a generalized narrowing in the affected coronary artery Atheroscolerosis is characterized by yellowish plaques of cholesterol, lipids, and cellular debris deposited into the inner layer of the wall of a large or medium-sized coronary artery, most often resulting in a focal partial obstruction in the affected artery Each can limit blood flow if it causes a cross sectional narrowing of >50% Indications Disease of the LMCA (L main coronarya rtery) Disease of all 3 coronary vessels (LAD, LCX, RCA) Diffuse disease not amnenable to Tx w/ a PCI Other high-risk Pt's, e.g. those w/ severe ventricular dysfunction (i.e. low ejection fraction), or diabetes mellitus Method Involves either: Diverting the L internal thoracic artery to the L anterior descending (LAD) of the L main coronary artery Harvested great saphenous vein of the leg, attaching the proximal end to the aorta (or 1 of its major branches), and the distal end to immediately beyond a partially obstructed coronary artery (the target vessel), usually a 50-99% blockage The purpose is to restore normal blood flow to that partially obstructed coronary artery Usually performed w/ the heart stopped, necessitating the usage of cardiopulmonary bypass. However, alternative techniques allow CABG to be performed on a beating heart: Off-pump surgery, without using cardiopulmonary bypass On-pump beating surgery, performing beating surgery using partial assistance of the cardiopulmonary bypass. This gathers the advantages of the on-pump stopped and off-pump while minimizing their respective side effects Outcomes Relieve angina unsatisfactorily controlled by maximum tolerated anti-ischemic drug Prevent or relieve LV dysfunction Reduce the risk of death Does NOT prevent heart attacks See also Angioplasty Wed, 20 Nov 2024 23:29:15 +0000 http://autoprac.com/cabg 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 ( Thu, 21 Nov 2024 15:50:51 +0000 http://autoprac.com/chickenpox http://autoprac.com/pregnancy-test Pregnancy tests, which detect hormones generated by the newly formed placenta. These tests can detect pregnancy after implantation, which is 6-12 days after fertilization. Types Blood tests are more sensitive than urine tests. Home tests are urine tests, normally detecting a pregnancy 12-15 days after fertilization. Blood tests can determine the approximate date of conception. hCG (see page) EPF (early pregnancy factor), which gives the quickest result after fertilization, which can be detected within 48 hours of fertilization. However, it is expensive and time consuming See also Pregnancy Tumor marker (category) hCG Thu, 21 Nov 2024 14:54:43 +0000 http://autoprac.com/pregnancy-test http://autoprac.com/antifungal Antifungals are used to Tx fungi, such as athlete's foot, ringworm, candidiasis (thrush). Classification Polyene antifungals, including: Amphotericin B Candicidin Filipin Hamycin Natamycin Nystatin Imidazole, including: Bifonazole Butoconazole Clotrimazole Econazole Fenticonazole Isoconazole Ketoconazole Luliconazole Miconazole Omoconazole Oxiconazole Sertaconazole Sulconazole Tioconazole Triazole, including: Albaconazole Efinaconazole Epoxiconazole Fluconazole Isavuconazole Itraconazole Posaconazole Propiconazole Ravuconazole Terconazole Voriconazole Thiazole, including: Abafungin Allylamines, inhibit squalene epoxidase, anotehr enzyme required for ergosterol synthesis. It includes: Amorolfin Butenafine Naftifine Terbinafine Echinocandins, including: Anidulafungin Caspofungin Micafungin Others, including: Benzoic acid Ciclopirox (ciclopirox olamine) Flucytosine or 5-fluorocytosine Griseofulvin Haloprogin Tolnaftate Undecylenic acid Crystal violet Balsam of Peru See also Antimicrobial Thu, 21 Nov 2024 09:34:08 +0000 http://autoprac.com/antifungal