| Some Stuff |
|
| Some MORE Stuff |
|
|
| Acoustic neuroma |
A tumor arising from Schwann cells of the 8th cranial nerve (most often the vestibular division, rather than the acoustic division). Neurofibromatosis type II strongly predisposes patients to acoustic neuromas.
SYMPTOMS: unilateral hearing loss and other neurologic findings when the tumor compresses the cerebellum, pons, or facial nerve.
CAUSES: Unknown
TREATMENT: Surgical excision
SYNONYMS: Acoustic schwannoma |
|
|
|
| Acne rosacea |
Chronic skin eruption with flushing and dilation of small blood vessels in the face, especially nose and cheeks. Sometimes associated with ocular symptoms (ocular rosacea).
Predominant age: 30-50
Predominant sex: Female > Male
SIGNS AND SYMPTOMS are skin flush - prominent at onset, redness - lower half of nose, sometimes whole nose, forehead, cheeks, chin, conjunctivae red - (sometimes), erythema, dusky - (in advanced cases), blood vessels in involved area collapse under pressure, acne lesions form papules, pustules, and nodules; comedones are rare, telangiectasia, and rhinophyma (sometimes) more common in males
CAUSES:
•No proven cause.
*Possibilities include
•Thyroid and gonadal disturbance
•Alcohol, coffee, tea, spiced food overindulgence (unproven)
•Demodex follicular parasite (suspected)
•Exposure to cold, heat, hot drinks
•Emotional stress
•Dysfunction of the gastrointestinal tract
PATHOLOGICAL FINDINGS:
•Inflammation around hypertrophied sebaceous glands, producing papules, pustules and cysts
•Absence of comedones and blocked ducts
•Vascular dilatation and dermal lymphocytic infiltrate
ACTIVITY:
No restrictions. Support physical fitness.
DIET:
Avoid any food or drink that causes facial flushing, e.g., hot drinks, spiced food, alcohol
Precautions:
•Tetracycline: may cause photosensitivity; sunscreen recommended
Significant possible interactions:
•Tetracycline: avoid concurrent administration with antacids, dairy products, or iron
•Broad-spectrum antibiotics: may reduce the effectiveness of oral contraceptives; barrier
method recommended
ALTERNATIVE DRUGS:
•For severe cases, isotretinoin orally for 4 months.
POSSIBLE COMPLICATIONS:
•Rhinophyma (dilated follicles and thickened bulbous skin on nose), especially in men
•Conjunctivitis
•Blepharitis
•Keratitis
EXPECTED COURSE AND PROGNOSIS:
•Slowly progressive
•Subsides spontaneously (sometimes)
PREGNANCY:
Use of oral isotretinoin contraindicated |
|
|
|
| Acanthosis nigricans |
A circumscribed melanosis consisting of a brown pigmented velvety verrucosity or fine papillomatosis appearing in the axillae and other body folds. Occurs in association with endocrine disorders, underlying malignancy, administration of certain drugs, or as in inherited disorder. Usual course - chronic.
CAUSES:
•congenital
•associated with malignant disease
•obesity
•idiopathic
TREATMENT
•treat underlying cause
•malignancy workup |
|
|
|
| Abruptio placentae |
Premature separation of otherwise normally implanted placenta. Sher's grades:
1: minimal or no bleeding; detected as retroplacental clot after delivery of viable fetus.
2: viable fetus with bleeding and tender irritable uterus.
3: type A with dead fetus and no coagulopathy; type B with dead fetus and coagulopathy (about 30% of grade 3's).
It is a second or third trimester vaginal bleeding greater than one pad or tampon per hour. Patient usually complained of back pain, abdominal pain, uterine tenderness, hypertonia, or high frequency contractions. Blood loss may be concealed; clinical signs of shock may occur with little vaginal bleeding. Since blood volumes increase in pregnancy, volume lost may exceed 30% before signs of shock or hypovolemia. Vital signs may be preserved even with significant loss.Fetal distress or demise. Idiopathic preterm labor with or without fetal distress Causes are cocaine use and abuse, trauma of variable amounts; especially blunt abdominal trauma in which external signs of trauma may be incongruent with fetal injury (motor vehicle accidents or domestic violence), sudden decompression of over-distended uterus as in hydramnios or twin gestation
RISK FACTORS:
•Prior abruption
•Maternal smoking
•Severe small for gestational age birth
•Alcohol abuse
•Hypertension: pregnancy-induced and chronic
•Increased risk if hypertensive and parity > 3
•Preterm rupture of membranes, especially if bleeding occurs during observation interval
•Vaginal bleeding before spontaneous rupture of membranes
LABORATORY:
•Blood type, Rh, Coombs
•CBC with platelet count
•Prothrombin time (PT) , partial thromboplastin time (PTT), fibrinogen levels
•Cross match at least three units
SPECIAL TESTS:
•Kleihauer-Betke for fetal-maternal transfusion
•Bedside clot test with red top tube of maternal blood with poor or non-clotting blood after 7-10 minutes indicating coagulopathy
•Apt test for fetal blood origin: mix vaginal blood with small amount tap water to cause hemolysis, centrifuge several minutes, mix pink hemoglobin containing supernatant with 1 cc 1% sodium hydroxide (NaOH) for each 5 cc supernatant, reading color in two minutes with fetal Hgb staying pink and adult turning yellow-brown
•Wright stain vaginal blood, observe for nucleated RBC's - usually of fetal origin
•Lecithin/sphingomyelin (L/S) ratio if delay of delivery is an option and length of pregnancy is preterm
IMAGING:
•Although ultrasound may show sonolucent retroplacental clot, rounded placenta margin or thickened placenta, it is often not definitive - especially with posterior placement or mild abruption
DIAGNOSTIC PROCEDURES:
•External uterine monitoring often shows elevated baseline pressure and frequent low amplitude contractions
GENERAL MEASURES:
•History and physical exam with past medical history, allergies, prior ultrasounds this gestation, and time of last meal
•In general, severe abruption best managed by delivery of fetus
•Sher's grade 1 - usual labor protocol
•Sher's grade 2 - rapid delivery most often by cesarean section
•Sher's grade 3 - vaginal delivery preferable if mother stable
•In trauma monitor inpatient at least 4 hours for evidence of fetal insult, abruption, fetal-maternal transfusion
•Early aggressive restoration of maternal physiology to protect fetus and maternal organs from hypoperfusion/DIC
•Stabilize vitals, keep Hct >30, urine output >30 cc/hr
•Bedrest with external fetal and labor monitoring, if fetus is viable
•Large bore 16-18 gauge IV crystalloid infusion, central line placement only after coagulation status has been assessed
•Transfusions of whole blood may be necessary
•Follow hemoglobin/hematocrit (H/H) and coagulation status every 1-2 hours
•Place intrauterine pressure catheter (IUC) since fetal risk climbs with elevated pressure
•Role of amniotomy to prevent amniotic fluid embolism is debatable but will speed delivery
•Positioning on left side may enhance venous return and cardiac output
•Oxygen for all patients
•If trauma without compromise after observation or small abruption and preterm may observe outpatient encouraging reduction of risk factors
SURGICAL MEASURES:
May need cesarean section after maternal stabilization if fetus viable and situation urgent
ACTIVITY:
Bedrest until status defined
DIET:
NPO until status defined and cesarean section possibility ruled out
POSSIBLE COMPLICATIONS:
•Infection transfusion risks: Hepatitis, cytomegalovirus infection, HIV and others
•Sensitization from blood product transfusion
EXPECTED COURSE AND PROGNOSIS:
•0.5% to 1% fetal mortality and 30-50% perinatal mortality
•With trauma and abruption 1% maternal and 30-70% fetal mortality
•Labor typically more rapid but hypotonus from blood suffusion may occur |
|
|
|
| Abortion, spontaneous |
Abortion is the separation of products of conception from the uterus prior to the potential for fetal survival outside the uterus. Gestationally, the point at which potential fetal viability exists has been the subject of much legal and scientific debate, and definitions vary from state to state; however, a "potentially viable" fetus generally weighs at least 500 grams and/or has a gestational age over 20 weeks.
•Spontaneous abortion: refers to expulsion of all (complete abortion) or part (incomplete abortion) of the products of conception from the uterus prior to the 20th completed week of gestation. The placenta, either in whole or in part, can be retained and leads to continuing vaginal bleeding (sometimes profuse). Abortion is "threatened" when vaginal bleeding occurs early in pregnancy, with or without uterine contractions, but without dilatation of the cervix, rupture of the membranes, or expulsion of products of conception. Cervical dilation, rupture of membranes or expulsion of products in the presence of vaginal bleeding portends "inevitable abortion." Differentiation between threatened and inevitable abortion is desirable since management differs.
•Missed abortion: Failed first trimester pregnancy but without the usual signs and symptoms such as bleeding or cramping. Term blighted ovum replaced with anembryonic gestation. Ultrasound findings of "empty sac."
•Induced abortion: refers to the evacuation of uterine contents/products of conception by either medical or surgical methodology
•Infected abortion: infection involving the products of conception and the maternal reproductive organs
•Septic abortion: dissemination of bacteria (and/or their toxins) into the maternal circulatory and organ system
•Habitual spontaneous abortion: three or more consecutive spontaneous abortions. Risk of another spontaneous abortion is approximately 25-30% with 70% rate of successful pregnancy in subsequent pregnancy.
Approximately 2/3 of first trimester spontaneous abortions have significant chromosomal anomalies with 1/2 of these being autosomal trisomies and the remainder being triploidy, tetraploidy, or 45X monosomies
Approximately 10-15% of all clinically recognized pregnancies end in spontaneous abortion. Biochemical pregnancy manifests itself by the presence of β-HCG in the blood 7-10 days after conception. When both clinical and biochemical pregnancies are considered, more than 50% of conceptions are spontaneous aborted. Increases with advancing age, especially after 35 years of age. At age 40, the loss rate is 2 times that of age 20.
SIGNS AND SYMPTOMS:
•In a previously diagnosed intrauterine pregnancy
•Vaginal bleeding
•Uterine cramping
•Cervical dilation
•Ruptured membranes
•Passage of non-viable products of conception
RISK FACTORS:
•Chromosomal abnormalities
•Luteal phase defect
•Leiomyomas
•Incompetent cervix
•Infections
•Antifetal antibodies
•Autoimmune disease - phospholipid syndrome
•Alloimmune disease (shared paternal antigens)
•Drugs, chemicals, noxious agents (alcohol, smoking, caffeine)
•X-irradiation
•Contraceptive IUD
DIFFERENTIAL DIAGNOSIS:
•Ectopic pregnancy: a potentially life-threatening complication, difficult to distinguish from threatened abortion. Transvaginal ultrasonography can identify intrauterine gestational sacs at 32 days of gestation (at serum HCG levels of 1500-2000 IU). The absence of transvaginal ultrasound evidence of an intrauterine gestation with serum HCG over 2000 IU/L should be considered an ectopic pregnancy until proven otherwise.
•Cervical polyps, neoplasias, and/or inflammatory conditions can cause vaginal bleeding. This bleeding is not usually associated with pain/cramping and is apparent on speculum exam.
•Hydatidiform mole pregnancy usually ends in abortion prior to the 20th week of pregnancy. Bloody discharge prior to abortion is common. An intrauterine grape-like appearing mass on the ultrasound is diagnostic (a "snow storm" appearance). Human chorionic gonadotropin (HCG) is often high.
•Membranous dysmenorrhea: characterized by bleeding, cramps and passage of endometrial casts can mimic spontaneous abortion. HCG is negative.
•HCG secreting ovarian tumor
LABORATORY Pocedures:
Cultures - gonorrhea and chlamydia, CBC, Rh type, Human chorionic gonadotropin (HCG), Serial β-HCG measurements can assess viability of the pregnancy. Normal gestations have an approximate 67% increase over 2-day interval. Abnormal gestations do not rise appropriately, plateau, or decrease in level before the eighth week of gestation.
SPECIAL TESTS:
Progesterone levels > 25 ng/mL are consistent with normal intrauterine pregnancy and are rarely seen in ectopic and/or non-viable pregnancy. A progesterone of < 5 ng/mL is an indicator of a nonviable intrauterine gestation or an ectopic pregnancy.
IMAGING:
Ultrasound examination for fetal viability and to rule out ectopic pregnancy. Ultrasound imaging can be sensitive enough to confirm an intrauterine pregnancy in the fourth or fifth gestational week from last menstrual period
DIAGNOSTIC PROCEDURES:
Viable intrauterine pregnancy with fetal cardiac activity detected between 5-8 weeks from last menstrual period on transvaginal ultrasound. Transvaginal ultrasound criteria for nonviable intrauterine gestation include:
•5 mm fetal pole without cardiac activity, or
•16 mm gestational sac without a fetal pole
Fetal heart tones can be auscultated with doppler starting between 10-12 weeks gestation from last menstrual period for a viable pregnancy. Consider a diagnosis of spontaneous abortion in a woman, of childbearing age, presenting with abnormal vaginal bleeding
TREATMENT
APPROPRIATE HEALTH CARE:
Outpatient or inpatient, depending on severity of symptoms (bleeding or pain)
ACTIVITY:
If appropriate, bed rest; probably no effect on eventual outcome
PREVENTION/AVOIDANCE:
•Any vaginal bleeding in intrauterine pregnancy is abnormal and should be considered a "threatened" abortion. In reality, vaginal bleeding in early pregnancy is common (occurring in up to 1/3 of pregnancies) and often the bleeding source eludes diagnosis.
•In habitual abortion, the abortus should be sent for karyotyping. Explore other causes of habitual abortion with the couple to determine the best therapy.
•Special care and attention for the patient who has a subsequent pregnancy
POSSIBLE COMPLICATIONS:
•Complications of D&C include uterine perforation, infection and bleeding
•Possibly retained products of conception
•Depression and feelings of guilt (patient may need education and reassurance that she did not cause the miscarriage)
EXPECTED COURSE AND PROGNOSIS:
•If bleeding ceases, prognosis is excellent.
•Habitual abortion: prognosis is dependent on etiology. After a 2 consecutive abortions, most couples want some investigation of the problem. After 3 spontaneous abortions, evaluation is usually indicated. Prognosis is still excellent with up to 70% rate of success with subsequent pregnancy. |
|
|
|
| Aortic Regurgitation |
Retrograde flow from the aorta into the left ventricle through incompetent aortic cusps. Symptoms include dyspnea, shortness of breath, palpitations, orthopnea. Usual course - acute; chronic. Basic causes are bacterial endocarditis, aortic dissection, ankylosing spondylitis, aortic stenosis, rheumatic fever, giant cell arteritis, syphilis, Marfan's syndrome, osteogenesis imperfection, Reiter's syndrome, rheumatoid arthritis, cystic medial necrosis, sinus of Valsalva aneurysm, hypertension, arteriosclerosis, myxomatous degeneration of valve, dissection of aorta, bicuspid aortic valve. Treatment is aortic valve replacement. |
|
|
|
|
|
