A
ACCUUTTEEAAPPPPEENNDDIICCIITTIISS SSUURRGGEERRYY
Etiology
o E.coli & Bacteroides fragilis
Clinical Manifestations
o Abdominal pain – cramping, severe, steady at the lower epigastric, within 4-6hrs localizes at RLQ (may vary from different locations of pain of the appendix)
o Anorexia o Vomiting
Signs:
o Direct and Indirect tenderness
o Rovsing's sign—pain in the RLQ when palpatory pressure is exerted in the LLQ (indicates site of peritoneal irritation) o Psoas sign – have patient lay on the left side as the examiner slowly extends the right thigh, thus stretching the iliopsoas
muscle (indicates an irritative focus proximal to that muscle)
o Obturator sign – passive internal rotation of the flexed right thigh with the patient supine
Laboratory Findings:
o CBC – mild leukocytsis, 10,000-18,000 cells/mm3 (acute uncomplicated AP) o Urinalysis – to rule out UTI
Imaging Studies
o Barium Enema – if barium fills the appendix, it is excluded o Plain films
o Chest radiograph – if referred pain for right lower lobe pneumonic process o CT scan – has minimal advantage (dye in the presence of vomiting)
o Laparoscopy – in lower abdominal complaints; in differentiating gynecologic problem
The Avogardo Scale for Diagnosing Appendicitis
Manifestations Value Symptoms Migration of pain 1 Anorexia 1 Nausea/vomiting 1 Signs RLQ tenderness 2 Rebound 1 Elevated temperature 1 Laboratory values Leukocytosis 2
Left shift 1
Total: 10
o Note: Rupture should be suspected in the presence of elevated temperature (>39°C) and a WBC of >18,000cells/mm3
Differential Diagnosis:
o Acute Mesenteric Adenitis – URTI is present, pain is diffuse, tenderness is not sharply localized as in AP; voluntary guarding and diarrhea are present; laboratory values are normal
o Pelvic Inflammatory Disease – right tube inflammation may mimic AP; nausea and vomiting are present in 50% of PID o Ovarian Cyst – ruptured right sided cyst may have similar manifestations of AP, patients develop RLQ pain, tenderness,
rebound, fever and leukocytosis
o Ruptured Ectopic Pregnancy – rupture of right tubal and ovarian pregnancies can mimic AP, development of RLQ pain may be the first symptoms, hematorcit falls due to internal abdominal hemorrhage
o Urinary Tract Infection – Acute pyelonephritis, on the right side particularly, may mimic a retroileal acute appendicitis. Chills, right costovertebral angle tenderness, pyuria, and bacteriuria are usually sufficient to make the diagnosis.
o Peptic Ulcer Disease – Perforated peptic ulcer closely simulates appendicitis if the spilled gastroduodenal contents gravitate down the right gutter to the cecal area and if the perforation spontaneously seals, minimizing upper abdominal findings
Treatment Plan:
o For possible operation, Adequate hydration should be ensured; electrolyte abnormalities corrected; and pre-existing cardiac, pulmonary, and renal conditions should be addressed
o Administer antibiotics to all patients with suspected appendicitis. If simple acute appendicitis is encountered, there is no benefit in extending antibiotic coverage beyond 24 hours. If perforated or gangrenous appendicitis is found, antibiotics are continued until the patient is afebrile and has a normal white blood cell count.
o Open Appendectomy
McBurney (oblique) or Rocky-Davis (transverse) incision o Laparoscopic Appendectomy
Under general anesthesia, use of 3-4 ports
A
ACCUUTTEEaannddCCHHRROONNIICCCCHHOOLLEECCYYSSTTIITTIISS SSUURRGGEERRYY ACUTE CHOLECYSTITIS
Clinical Manifestations:
o RUQ or epigastric pain that may radiate to the right upper part of the back or the interscapular area
o It is usually more severe than the pain associated with uncomplicated biliary colic o Fever, anorexia, nausea, vomiting are present; patient is reluctant to move, as the
inflammatory process affects the parietal peritoneum.
o On PE: focal tenderness and guarding at the RUQ; a mass, the gallbladder and adherent omentum, is occasionally palpable; however, guarding may prevent this.
o Murphy's sign, an inspiratory arrest with deep palpation in the right subcostal area, is characteristic of acute cholecystitis.
Laboratory Findings:
o mild to moderate leukocytosis (12,000 to 15,000 cells/mm3); but some patients may have a normal WBC
o high WBC (>20,000) is suggestive of a complicated form of cholecystitis such as gangrenous cholecystitis, perforation, or associated cholangitis
o Serum liver chemistries are usually normal, but a mild elevation of serum bilirubin, < 4 mg/mL, may be present along with mild elevation of alkaline phosphatase, transaminases, and amylase.
o Severe jaundice is suggestive of common bile duct stones or obstruction of the bile ducts by severe pericholecystic inflammation secondary to impaction of a stone in the infundibulum of the gallbladder that mechanically obstructs the bile duct (Mirizzi's syndrome).
Differential Diagnosis:
o peptic ulcer with or without perforation, pancreatitis, appendicitis, hepatitis, pleuritis CHRONIC CHOLECYSTITIS (Biliary Colic)
Clinical Manifestations:
o Recurrent attacks of pain, episodic
o Pain is constant and increases in severity over the first half hour or so, typically lasts 1-5 hours. It is located in the epigastrium or right upper quadrant and frequently radiates to the right upper back or between the scapula o Pain is occurs typically during the night or after a fatty meal
o Often associated with nausea and vomiting o On PE: RUQ tenderness during an episode of pain
Laboratory Findings:
o WBC count and liver function tests are usually normal in uncomplicated gallstones o Ultrasound – standard diagnostic test for gallstones
o CT scans – show extrahepatic biliary tree status and adjacent structures
o Endoscopic retrograde cholangiography (ERCP) and Endoscopic ultrasound – rarely needed for uncomplicated gallstones but for the stones in the common bile duct, in particular when associated with obstructive jaundice, cholangitis or gallstone pancreatitis.
Management:
o For symptomatic gallstones, elective laparoscopic cholecystectomy is the procedure of choice.
o Diabetic patients with symptomatic gallstones should undergo cholecystectomy promptly as they are prone to develop acute cholecystitis
o In pregnant women, elective laparoscopic cholecystectomy is allowed during the 2nd trimester
C
CHHOOLLEEDDOOCCHHOOLLIITTHHIIAASSIISS SSUURRGGEERRYY - “Common bile duct stones”
- RUQ tenderness, nausea, vomiting
- Symptoms such as pain and jaundice may be intermittent
Imaging Studies:
o Magnatic Resonance Cholangiography (MRC) – provides excellent anatomic detail and has a sensitivity and specificity of 95 and 89%, respectively
o Ultrasonography
o Endoscopic cholangiography is the gold standard for diagnosing common bile duct stones
Management:
o Endoscopic cholangiogram
o Sphincterotomy and ductal clearance of stones followed by laparoscopic cholecystectomy
Charcot’s Triad: 1. Fever 2. RUQ Pain 3. Jaundice Reynold’s Pentad: 1. Fever 2. RUQ Pain 3. Jaundice 4. Shock 5. Changes in sensorium
M
MYYOOCCAARRDDIIAALLIINNFFAARRCCTTIIOONN((SSTT--SSEEGGMMEENNTTEELLEEVVAATTIIOONN)) MMEEDDIICCIINNEE - May precipitate various physical exercise, emotional stress or a medical or surgical illness
- Chest pain – deep and visceral, heavy, squeezing and crushing
- Similar to discomfort of angina pectoris, occurs at rest but more severe, lasts longer
- Accompanied by weakness, sweating, nausea and vomiting, anxiety and a sense of impending doom, pallor, substernal chest pain of more >30 minutes
- Pericardial friction rub is usually heard
Laboratory Findings:
o ECG – ST elevation, Q wave
Transmural MI is present if the ECG demonstrates Q wave and loss of K waves
Nontransmural MI is considered if ECG shows only transient ST segment and T wave changes o Serum Cardiac Biomarkers
Cardiac-specific troponin-T and troponin-I are biochemical markers which usually rise in patients with STEMI not seen in healthy individuals.
o MB isoenzymes of CK – more specific but not diagnostic of a myocardial rather than a skeletal muscle source of ↑CKMB o Non-specific reaction to myocardial injury is associated with PMN leukocytosis, WBC often reaches 12,00-15,00; ESR rises
more slowly than WBC
o 2D-Echo cardiac imaging – provides abnormalities of wall motion
o High-resolution MRI –contrast agent (gadolinium) is administered, and images are obtained after a 10-minute delay; a bright contrast appears in areas of infarction
Differential Diagnosis: o Acute Pericarditis
Chest discomfort radiating from trapezius is not seen in STEMI o Pulmonary Embolism
STEMI may present with sudden onset of breathlessness that may progress to pulmonary edema and embolism
Initial Management: o Pre-hospital Care
Patient may manifest arrhythmias or mechanical complications (pump failure) May cause sudden ventricular fibrillation
o Management in Emergency Department
Aspirin in suspected STEMI causes inhibitin of cyclooxygenase I followed by reduction of thromboxane A2 If there is hypoxemia, O2 administration with nasal cannula or face mask at 2-4L/min
o Control of Chest Discomfort
Nitroglycerine (sublingual) up to 3 doses of 0.4mg at about 5mins interval should be administered, or IV nitroglycerine if with ongoing ST segment ischemia shifts.
IV β-blockers – diminishes O2 demand
Hospital Phase Management:
o Activity – ambulation should be encouraged if without complication o Diet – diet rich in potassium, magnesium and fiber but not sodium o Bowel – use of stool softener
o Sedation – diazepam or lorazepam (adverse effect: delirium)
Pharmacotherapy:
o Antithrombotic Agents – its role is to maintain patency of infarct related artery and reduce thrombosis that can lead to embolization
Clopidogrel – reduces risk of clinical events, reinfarction, stroke and death Heparin + Aspirin – may help about 6 liver per 1000 patients
o Beta-adrenergic blocker – improves the myocardium O2 demand, reduces pain, reduces infarct site, reduces arrhythmias o Inhibition of RAAS – reduces mortality rate; reduction in ventricular remodeling with subsequent reduction in the risk of
CHF, indolent to ACE inhibitors
N
NOORRMMAALLSSPPOONNTTAANNEEOOUUSSDDEELLIIVVEERRYY((NNSSDD)) OOBB--GGYYNN 1. Secure consent for procedure
2. Transfer patient to OR 3. Wear cap and mask
4. Place patient in dorsal lithotomy position 5. Asepsis, antiseptic technique
6. Straight catheterization
7. IE (fully dilated cervix, fully effaced, cephalic, intact BOW, station?) 8. Apply sterile drapes
10. Do RML episiotomy
11. Once baby’s head is out, rotate gently then pull upward and downward then slide head on fetal back and hold fetal legs 12. Clamp the cord, place one clamp 2cms above the umbilicus, another
13. Deliver placenta using Ritgen’s maneuver 14. Once placenta is out, inspect cotyledon 15. Give oxytocin, check BP first
16. Do episiorapphy 17. Do final IE
18. Final asepsis and antisepsis
19. Monitor VS q15 for 1 hour then q30 for the next hour, and then q4 thereafter
D
DEENNGGUUEEHHEEMMOORRRRHHAAGGIICCFFEEVVEERR PPEEDDIIAATTRRIICCSS
Clinical Manifestations: o Fever of 2-7 days
o Headache, muscle and joint pain o Nausea and vomiting
o Rashes (Herman’s rash)
Laboratory Findings:
o Low platelet count (<100,000/mm3) o Elevated hematocrit (>20% from baseline) o Low albumin
o Pleural or other effusions
Dengue Shock Syndrome
o 4 criteria for DHF, plus:
Evidence of circulatory failure Rapid and/or weak pulse Narrow pulse pressure Cold clammy skin o Shock
Differential Diagnosis:
o Typhoid fever, measles, rubella
Management:
o Rehydration management o Palliative treatment, antipyretics
o Monitor vital signs, hematocrit, platelet count, level of consciousness
P
PCCAAPP––PPEEDDIIAATTRRIICCCCOOMMMMUUNNIITTYYAACCQQUUIIRREEDDPPNNEEUUMMOONNIIAA PPEEDDIIAATTRRIICCSS
Clinical Manifestations:
o 3mos-5yrs – fever, tachypnea and chest indrawing o 5-12yrs – fever, tachypnea, crackles
o 12yrs and above – fever, tachypnea, tachycardia, at least one abnormal chest finding of diminished breath sounds, rhonchi, crackles or wheezes
Classification: Variables PCAP-A Minimal Risk PCAP-B Low Risk PCAP-C Moderate Risk PCAP-D High Risk
Comorbid illness None Present Present Present
Compliant caregiver Yes Yes No No
Ability to follow-up Possible Possible Not possible Not possible
(+)Dehydration None Mild Moderate Severe
Ability to feed Able Able Unable Unable
Age >11 mos >11 mos <11 mos <11 mos
Respiratory rate, age 2-12mos ≥50/min >50/min >60/min >70/min Respiratory rate, age 1-5 yrs ≥40/min >40/min ≥50/min >50/min Respiratory rate, age >5 yrs ≥30/min >30/min ≥35/min >35/min
Signs of Respiratory Failure:
PCAP-A PCAP-B PCAP-C PCAP-D
Retraction None None Intercostals/subcostal Supraclavicular
Head bobbing None None Present Present
Cyanosis None None Present Present
Grunting None None None Present
Apnea None None None Present
Sensorium Awake Awake Irritable Lethargic/Stupurous/Comatose Respiratory Complications None None Present Present
Action Plan OPD OPD Admit to regular ward Admit to PICU
Diagnostics:
o PCAP A & B – Clinical o PCAP C & D:
CXR PA-Lateral WBC count Pleural fluid C/S Blood C/S for PCAP-D
Tracheal aspirate upon initial intubation Blood gas and pulse oximetry
Sputum C/S for older children
Treatment:
o For PCAP A or B – DOC: oral amoxicillin (40-50mg/kg/day in 3 divided doses) o For PCAP C and D:
(+)HiB vaccine – pen G (100,000u/kg/day in q4) (-)Hib vaccine – IV ampicillin (100mg/kg/day q4) S
SEEPPSSIISSNNEEOONNAATTOORRUUMM PPEEDDIIAATTRRIICCSS
Characteristics:
o temperature instability, hypotension, poor perfusion with pallor and mottling of skin, metabolic acidosis, tachycardia or bradycardia, apnea, respiratory distress, grunting, cyanosis, irritability, lethargy, seizures, feeding intolerance, abdominal distention, jaundice, petechiae, purpura, bleeding.
Initial S/S in Newborn Infants:
o General – fever, temperature instability, poorly feeding, edema
o Gastrointestinal – abdominal distention, vomiting, diarrhea, hepatomegaly o Respiratory – apnea, dyspnea, tachypnea, retractions, flaring, grunting, cyanosis
o Cardiovascular – pallor, mottling, cold, clammy skin, tachycardia, hypotension, bradycardia o Renal – oliguria
o CNS – irritability, lethargy, tremors, seizure, hyperreflexia, hypotonia, abnormal Moro reflex, irregular respirations, bulging fontanels, high pitched cry
o Hematologic system – jaundice, splenomegaly, pallor, petechiae, purpura, bleeding
Differential Diagnosis:
o Respiratory Distress Syndrome
o Aspiration Pneumonia – amniotic fluid, meconium or gastric content
Laboratory Studies:
o Blood and CSF culture o Antigen detection (urine, CSF) o Autopsy
Evidence of Inflammation:
o Leukocytosis, ↑immature/total neutrophil count ratio o Acute-phase reactions; ESR, CRP
o Cytokines, interleukins o Pleocytosis in CSF
Treatment:
o Initial treatment with ampicillin and aminoglycoside (gentamicin)
o Nosocomial infections – methicillin or nafcillin for S.aureus (antistaphylococcal drugs, or) vancomycin for CONS or MRSA o Pseudomonas infections – piperacillin, ticarcillin, ceftazidine or an aminoglycoside
o Antifungal therapy in infants with very low birth weight
o Most gram(-) enteric bacteria – ampicillin and an aminoglycoside or 3rd gen cephalosporin (Cefotaxime or Ceftazidine) o Enterococci – penicillin (ampicillin or piperacillin) + an aminoglycoside
o Anaerobic infections – clindamycin or metronidazole o GBS – penicillin
T
TYYPPHHOOIIDDFFEEVVEERR PPEEDDIIAATTRRIICCSS//FFAAMMIILLYYMMEEDDIICCIINNEE
Salmonella typhi (etiologic agent)
Acquired through contaminated foods and water or close contact with infected person
Clinical Manifestations:
o High grade fever (39-40°C) o Headache
o Rose spots on chest and abdomen o Cough, epistaxis
o Abdominal pain, with either constipation or diarrhea o Weakness and fatigue
o Severely ill patients may experience delirium, shock, and intestinal hemorrhage
Diagnosis:
o Culture – blood, urine, stool
1st week – blood (+) 40% in the first week 2nd week – urine and stool, highly (+)
Bone marrow – single most sensitive test, (+) in 85-90%, less sensitive if influenced by prior antimicrobial therapy o Typhi Dot
IgM IgG Interpretation (+) (-) Acute infection (+) (+) Recent infection (-) (+) Equivocal
Management:
o Susceptible strains – 14 day-treatment
Chloramphanicol 50-60mg/kg/day in 4 divided doses, or Cotrimoxazole 800/160 1 tab BID, or
Ampicillin or Amoxicillin 100mg/kg/day in 3-4 divided doses o Resistant strains
Ceftriaxone, 7-10 days, 3gm TIV, or Ciprofloxacin (507 days) 500mg tab BID o Chronic Carrier
High dose IV ampicillin or oral amoxicillin with probenecid for 4-6 weeks For adult carriers: Ciprofloxacin
M
MEENNIINNGGIITTIISS PPEEDDIIAATTRRIICCSS
Etiology:
o First 2 months – groups B and D Streptococci, Gram (-) enteric bacilli, and Listeria monocytogenes o 2 months to 12yrs – S.pneumoniae, N.meningitidis, H.influenza type B
Epidemiology:
o Close contact (e.g. household, daycare centers, military barracks), crowding, poverty, male gender
Transmission:
o Person to person contact through respiratory tract secretions or droplets
Clinical Manifestations: o Several days of fever
o Upper GI or respiratory symptoms
o Meningeal irritation – nuchal rigidity, back pain, Kernig sign, Brudzinski sign o Headache, vomiting, cranial nerve neuropathies (10-20%)
o Seizures due to cerebritis, infarction or electrolyte disturbances (20-30%)
Diagnosis:
o CSF analysis
o CBC, platelet count, blood C/S, ESR, ABG o Na, K, BUN, Creatinine, RBS
o Urinalysis, Urine G/S, C/S o Stool, throat, nasal C/S
o Viral cultures (Coxsakie, Echinococcus, Mumps, EBV, HSV, CMV, Arbovirus) o CXR, ECG, CT scan, MRI, EEG
Cerebrospinal Fluid Analysis Normal Acute Bacterial
Meningitis Viral Meningitis TB Meningitis Fungal Meningitis Anaerobic Meningitis Pressure (mmH2O) 50-80 Usually high
(100-300) Normal or slightly high Usually elevated Usually elevated Elevated Leukocytes (mm3) 75, ≥75% lymphocytes 100 to 10,000 or more; usually 300-2000 PMN Rarely >1000 cells 10-500, PMN early, then lymphocytes predominates in most cases 5-50, PMN early but mononuclear cells predominate in most cases 1000-10,000 or more, PMN predominates CHON (mg/dL) 20-45 100-500 30-100 100-3000 25-500 50-500 Glucose (mg/dL) >50 <40 Generally normal <50 in most cases <50 Normal or slightly low Others Usually seen on gram stain recovered by culture HSV, encephalitis by focal CT scan findings
Acid fast almost never seen in smear; can be detected by PCR or CSF Budding yeasts may be seen Mobile amoeba can be seen Management:
1. Diet – regular, fluid restriction if with ↑ICP 2. IVF – D5W at KVO
A. Meningitis Empiric Therapy (15-50 y.o)
1. Pen G 4 million units IV or Ampicillin IV, plus 2. Ceftriaxone 2gm IV q12
Or Ceftazidine 2gm IV q8
Or Chloramphenicol IV (if allergic to PenG)
B. Empiric Therapy for Patients above 50 years, Alcoholic, taking Corticosteroids, or with Hematologic Malignancy, or other debilitating conditions
1. Ampicillin IV or Pen G
2. Cefotaxime of Ceftriaxone or Ceftazidine or Aztreonam and TMP-SMX C. Therapy based on Specific Etiologic Agent
1. S. pneumonia – Pen G
2. S. aureus - Oxacillin IV or Vancomycin IV
3. N. meningitides – Pen G IV, or Chloramphenicol IV 4. H. influenza – Ampicillin IV or Cefuroxime IV
5. Gram (-) bacilli (not P.aeruginosa or Enterobacter) – Cefotaxime IV or Ceftriaxone IV or Ceftazidine IV 6. P. aeruginosa – Ceftazidine IV or Piperacillin-Tazobactam IV
D
DIIAABBEETTEESSMMEELLLLIITTUUSS MMEEDDIICCIINNEE&&FFAAMMIILLYYMMEEDD
HbA1c – primary target for blood sugar control
Clinical Manifestations:
o 3 Ps: polyuria, polydypsia, polyphagia o Weight loss
o Easy fatigability o Body weakness
o Slow healing wounds or frequent infection
Risk Factors: o Family history o Weight o Sedentary lifestyle o Race o Age o Gestational diabetes Diagnosis:
1. Fasting Blood Sugar (FBS)
- At least 8hrs fasting is required - Normal FBS is <100mg/dL (5.6 mmol/L)
2. 75gram oral glucose tolerance test
- Normal value: <140mg/dL (7.8 mmol/L)
- 2 hr plasma glucose of 140-100mg/dL (7.8-11.0 mmol/L) is impaired glucose tolerance - 2 hr plasma glucose of ≥200mg/dL (11.1 mmol/L) is diabetes
Management:
A. Non-Pharmacologic (Step 1)
1. Diabetic diet ( low salt, low fat) 2. Lifestyle modification, exercise 3. Weight reduction
B. Pharmacologic (Step 2) 1. Sulfonylureas
For older patients: Glipizide (Minidiab)
For younger patients: Glibenclamide (Euglucon) 2. Biguanides
If still uncontrolled with sulfonylureas
Metformin (Glucophage) 500mg tab TID 3. Alpha-glucosidase inhibitors
If with post-prandial hyperglycemia
Acarbose (Glucobay) 50-100mg tab TID with first mouthful of food 4. Thiazolinediones
Rosiglitazone (Avandia) 4-8mg tab OD C. Insulin Treatment (if still uncontrolled)
1. Short Acting – lispro, insulin aspart to regular (Humulin R, Actrapid HM) 2. Intermediate Acting – NPH (Humulin N, Insulatard), Lente
3. Long Acting – Ultralente (Humulin U), Glargine
4. Combinations – 70% NPH - 30% regular (Mixtard 30, Humulin 70/30), Novomix 30 P
PYYEELLOONNEEPPHHRRIITTIISS MMEEDDIICCIINNEE
Clinical Manifestations:
o Abdominal or flank pain o Fever
o Malaise
o Nausea and vomiting o Occasional diarrhea
Diagnostics:
o CBC, UA, Blood C/S o Urine G/S, C/S
o RBS, BUN, Creatinine, Renal Ultrasound
Management: o Regular diet o IVF: D5NM 1L x 8hrs
o Symptomatic medications – pain relievers o For moderately ill, non-septic pyelonephritis:
Treat for 14 days
Cephalexin 500mg 1cap QID or 2gm 1 dose PO
or Ciprofloxacin, norfloxacin, ofloxacin, co-amoxiclav, co-trimoxazole o For severely ill, septic pyelonephritis:
Gentamicin 1.5mg/kg q7 x 21 days or Tobramycin/Amikacin IV Ampicilin IV 1 gram q6 x 21days
or Ceftriaxone IV, Ceftazidine IV, Ciprofloxacin IV, Co-amoxiclav IV, Ampicillin/Sulbactam IV
E
ECCTTOOPPIICCPPRREEGGNNAANNCCYY OOBB--GGYYNN
- "eccyesis”; Implantation of fertilized ovum outside the endometrium
Pathology: o Salpingitis o IUD
o Previous ectopic pregnancy o Failed bilateral tubal ligation o Myomas, adnexal masses o Idiopathic
Clinical Manifestations:
Symptoms (Classic Triad) Signs
Abdominal pain, colicky Wiggling tenderness (most common sign) Amenorrhea Uterus smaller than AOG
Vaginal bleeding hemoperitoneum
Diagnosis:
o CBC – hemoglobin, hematocrit, and leukocyte count o Lower HCG and progesterone levels
o Ultrasound diagnostic criteria: 1. Detection of adnexal mass
2. Absence of gestational sac using transvaginal UTZ when HCG >2,500 mIU/mL at 5-6wks 3. Intrauterine gestational sac rules out an ectopic pregnancy except in a heterotropic pregnancy
Management:
o Unruptured Eccyesis
1. Medical management a. Methotrexate
b. RU-486 – competes for progesterone binding sites
2. Surgical management – partial salpingectomy, salpingostomy, salpingotomy o Ruptured Eccyesis (primarily surgical)
1. Radical
a. Hysterectomy
b. Total salpingectomy with our without oophorectomy 2. Conservative – segmental resection
A
ABBOORRTTIIOONN OOBB--GGYYNN
- termination of pregnancy prior to 20 weeks' gestation or with a fetus born weighing less than 500g
Clinical Manifestations: o Vaginal bleeding
o Passage of “meaty tissue” o Foul-smelling uterine discharge o Fever
o Profuse sweating o Moderate tachycardia
Diagnostics:
o CBC, UA, Urine chemistry, Electrolytes, Uterine discharge G/S, C/S o Blood culture, CXR, blood chem.
o Close monitoring of VS and UO
Management:
o Blood transfusion with 7 ‘u’ PRBC
o Antimicrobial therapy – ampicillin + gentamicin + clincamycin/metronidazole (TIV) o Completion curettage – prompt evacuation of products of conception as follows:
1. Patient placed in dorsal lithotomy position under spinal anesthesia 2. Asepsis/antisepsis
3. Sterile drapes applied
4. Straight catheterization and internal examination posterior vaginal retractor applied to visualize the cervix 5. Anterior lip of the cervix grasped using tenaculum forcep
6. Evacuation of products of conception using ovum forcep 7. Initial hysterometry
8. Curettage done using blunt followed by sharp curette until frothy, gritty and bright red blood obtained 9. Final hysterometry Types of Abortion Uterine contraction Bleeding Cervical dilatation Uterine size VS gestation BOW Others
Threatened +/- +/- Closed Compatible Intact (+) FHT
Imminent ++ + Open Compatible Intact (+)FHT
Inevitable +++ ++ Open Incompatible Ruptured (+)FHT
Incomplete +/- ++ Open Incompatible Not appreciated Meaty tissue
Complete - +/- Closed Incompatible Not appreciated Absent of signs of preg.
Missed - Spotting Closed Incompatible Not appreciated (-) FHT
B
BRROONNCCHHIIAALLAASSTTHHMMAA MMEEDDIICCIINNEE&&PPEEDDIIAATTRRIICCSS - Pathophysiologic Hallmark: reduction in airway diameter
- “Hypoxia” - universal finding during acute exacerbations
Classic Symptom Triad: (1) Wheezing, (2) Dyspnea, (3) Cough
Typical Acute Attack:
o Often occurs at night
o With occupational asthma, attacks may occur at work or after work
o Patients experience a sense of constriction in the chest, often with a nonproductive cough o Respiration becomes audibly harsh
o Wheezing is first noted during expiration and then with inspiration as well o Expiration becomes prolonged
o Mucus plugging and impending suffocation
o Accessory muscles become visibly active, and a paradoxical pulse often develops
o The end of an episode is frequently marked by a cough that produces thick, stringy mucus
4 Major Classification of Asthma Severity by Clinical Features o Mild, intermittent
- Symptoms occur 2 or fewer times per week. - Asymptomatic between attacks
- Exacerbations are brief (hours to at most days) and of varying intensity. - Nocturnal symptoms are rare, less than twice a month.
- The FEV1 is >80% predicted during episodes. o Mild, persistent
- Symptoms occur more than 2 times a week but less than once a day. - Exacerbations may affect normal activity.
- Nocturnal symptoms occur more than twice a month. - FEV1 is >80% predicted during episodes.
o Moderate, persistent - Symptoms occur daily.
- Exacerbations occur more than twice a week and may last days. - Exacerbations affect normal activity.
- Nocturnal symptoms occur more than twice a month. - FEV1 is between 60% and 80% during episodes. o Severe, persistent
- Symptoms are continual. - Physical activity is limited. - Exacerbations are frequent. - Nocturnal symptoms are frequent.
- FEV1 is always abnormal and < 60% predicted during episodes.
Differential Diagnosis: 1. Chronic Bronchitis 2. Foreign Body Aspiration 3. Chemical Pneumonias 4. Acute Left Ventricular Failure
Diagnosis:
o Reversibility – ↑15% in FEV1 after 2 puffs of B-adrenergic agonist o Positive wheal and flare reactions to skin tests
o Sputum and blood eosinophilia o Chest radiograph
Management:
o Eliminate allergen first, avoid trigger factors o Oxygen at 2-6 lpm via nasal cannula o Nebulization
- Salbutamol neb/inhaler q3-6hours (1 neb/2-4 puffs), or - Ipatropium bromide + Salbutamol (Combivent) o Drug Therapy:
1. Quick-Relief Medications (Relievers)
a. Adrenergic Stimulants – catecholamines, resorcinols, salegenins b. Methylxanthines – theophylline
2. Long-Acting Medications (Controllers) a. Glucocorticoids (inhaled) - Methylprednisolone - Prednisolone - Prednisone b. Combined medications - Fluticasone/Salmeterol c. Mast cell stabilizing agents
- Cromolyn - Nedocromil d. Leukotriene antagonists - Montelukast - Zafirlukast - Zilueton I IMMMMUUNNIIZZAATTIIOONN PPEEDDIIAATTRRIICCSS
Expanded Program of Immunization (EPI)
Vaccine Route Dosing
BCG ID At birth to 1 week
Hepa B IM At birth to 1 week → 4 weeks → 14 weeks DPT IM 6 weeks → 10 weeks → 14 weeks OPV IM/PO 6 weeks → 10 weeks → 14 weeks HiB IM 6 weeks → 10 weeks → 14 weeks
Rotavirus PO 6 weeks
Measles SC 9 months
MMR SC 12 months
Recommended Vaccines:
Hepa A – 12 months (IM)
PCV – 6 weeks (IM)
Influenza – 6 months (SC/IM)
Varicella – 12 months (SC)
HPV – 10 years (IM)
Contributors:
