By X. Karmok. Chadron State College.

Considering she has a history of hypertension in a previous pregnancy cheap coumadin 2mg on line, high blood pressure on presentation coumadin 5mg with amex, severe headache purchase line coumadin, and history of generalized tonic-clonic seizure, she most likely has eclampsia and should first be stabilized. She will need magnesium sulfate and delivery of her baby but first she must be stabilized. This patient has severe preeclampsia since her systolic blood pressure is > 160 mm Hg and she has 2+ proteinuria. She is appropriately treated with magnesium sulfate, which has a narrow therapeutic index. Toxic levels of magnesium sulfate can cause decreased deep tendon refexes and respiratory depression to the point of respiratory compromise and death. In the event of magnesium toxicity, the magnesium should be stopped and then the patient should receive calcium gluconate. Since her blood pressure is <160/1 10 mm Hg, she has gestational hypertension and not severe gestational hypertension. Moderate preeclampsia not only has an ele­ vated blood pressure, but also involves proteinuria. The treatment of gestational hypertension involves weekly antepartum monitoring of the mother and the fetus. Hydralazine and labetalol are used for severe hypertension but are not used for hypertension <160/1 10 mm Hg. Women with gestational hypertension are accustomed to this elevated blood pressure, and decreasing their blood pressure to normal may cause hypoperf­ sion of vital organs such as the placenta and the brain. Magnesium sulfate is administered for seizure prophylaxis and is usually not given until the blood pressure is >160/1 10 mm Hg or the patient is experiencing signs of organ dys­ fnction including headache, changes in vision, oliguria, or right upper quad­ rant pain. This diagnosis cannot be made based on a single seizure, even ifanticonvulsant treatment is administered. She developed acute pyelonephritis and was hospitalized on intravenous antibiotic treatment the previ­ ous day. The patient was doing well until this morning, when she complained of acute and progressive shortness of breath. Thus this patient has significant acidosis and is retaining2 C0 • The other factor involves monitoring the fetal status and developing a2 delivery plan if needed. To describe the considerations of management of the critically ill patient who is pregnant. Describe the methods of monitoring fetal status and considerations for fetal intervention in the critically ill patient. The patient was admitted for acute pyelonephritis 1 day pre­ viously and has developed acute respiratory failure leading to being intubated and placed on the ventilator. Pregnancy is associated with physiological alterations in respiratory system, leading to a primary respiratory alkalosis and par­ tially compensated metabolic acidosis. Likewise, the normal Pco in pregnancy is 30 mm Hg due to the increased minute ventila­2 tion. A bedside ultrasound to assess for gestational age and fetal weight is important to establish whether the fetus is viable. In general, 24 to 26 weeks is con­ sidered to be the lower limits of viability, that is, survival of the baby if delivered. If the fetus is considered potentially viable, then discussion with the patient and fam­ ily is important to establish whether cesarean intervention for fetal interest would be considered for persistent fetal bradycardia. Additionally, a delivery plan should be established; for instance, should the patient go into preterm labor, whether the delivery would be vaginal or cesarean. This lateral change in heart position can be misinterpreted on chest x-ray as cardiomegaly. Other changes in the structure of the heart resemble those found as a result of physical training. Heart rate begins to rise in the first trimester and continues to rise until it peaks at 15 to 20 beats above normal at 34 weeks. It is highest in the knee-chest and lateral recumbent positions and lowest in the supine position (some 30% lower). Late in pregnancy, because of the development of a dilated paravertebral collateral circulation, venous return from the lower extremities is maintained in the supine position even when the vena cava is completely occluded by the pregnant uterus. This may rep­ resent a failure of those women to develop an adequate paravertebral collateral system. It gradually rises until term but even then remains approxi­ mately 20% lower than prior to pregnancy. This phenomenon is thought to be a direct efect of progesterone on the smooth muscle in the capillary beds, and increased levels ofcirculating nitric oxide and cyclic adenosine monophosphate also play a role. Consequently2 2 edema, hemorrhoids, varicose veins, and an increased risk of deep vein thrombosis are common. It is often dificult to distinguish between the signs and symptoms caused by phys­ iologic adaptations to pregnancy and those oftrue cardiac disease. S1 becomes louder by the end of the first trimester, and 90% of pregnant women will develop an Sy Systolic ejection murmurs along the left sternal border develop in more than 90% of pregnant women, and is thought to be caused by increased blood fow across the pulmonic and aortic valves. Respiratory System Because of increased hyperemia and estrogen levels, the nasopharyngeal mucosa becomes edematous and irritated. Nasal stufiness, epistaxis, and nasal polyps occur fequently during pregnancy, and resolve spontaneously postpartum. Due primarily to change in the size and shape of the chest cavity, the following alterations in lung capacities are seen: 1. Functional residual capacity-decreased 20% During pregnancy, increased levels ofprogesterone cause a state of relative hyper­ ventilation, resulting in a chronic respiratory alkalosis. This relatively low Pco in2 the pregnant mother is beneficial in clearing C0 from the fetal circulation. Since at mid-pregnancy the plasma volume increases more than that of red blood cell mass, there appears a transient physiologic anemia of pregnancy. A gradual decline in platelets has been observed throughout pregnancy, 3 but 98% of pregnant women will have platelet counts of > 116,000/mm • Values below this should be evaluated for causes of thrombocytopenia.

Other common hereditary haemolytic anaemia—HbE disease purchase coumadin american express, thalassaemia E disease (double heterozygous) generic coumadin 5mg with amex. Case 07: Macrocytic Anaemia A 50-year-old woman presented with weakness and anorexia for 3 months purchase coumadin 1mg line. A: As follows: • Megaloblastic anaemia (as a result of vitamin B12 or folic acid defciency). A: As follows: • If macrocytosis is associated with megaloblasts in bone marrow: The diagnosis is megaloblas- tic anaemia. Most common cause is megaloblastic anaemia as a result of vitamin B12 or folic acid defciency. Case 08: Leukemoid Reaction A 60-year-old woman presented with fever, cough and weight loss. She was suffering from breast cancer, which was treated by mastectomy and chemotherapy. Leukemoid reaction means that the peripheral blood profle resembles leukaemia, but there is no leukaemia. Causes of lymphatic leukemoid reaction are viral (infectious mononucleosis, cytomegalovirus infection, measles, chickenpox), whooping cough and, rarely, tuberculosis and carcinoma. Case 09: Leucoerythroblastic Anaemia A 65-year-old woman presented with pain in the epigastrium, loss of appetite, fever, generalized body ache, night sweating, occasional headache, dizziness and weight loss for 3 months. Trephine biopsy is needed, which shows increased megakaryocyte, increased reticulin and fbrous tissue. In any elderly patient with a huge splenomegaly and leucoerythroblastic blood profle, the likely cause is myelofbrosis. Myelofbrosis is a disorder of an unknown cause, characterized by bone marrow fbrosis, extramedullary haemopoiesis and leucoerythroblastic blood profle as a result of neoplastic proliferation of primitive stem cells. Three years later, the patient presented with complaints of severe weak- ness, loss of weight, lethargy, epistaxis and pain in the left upper abdomen. The consequence of these changes is a mixture of initial thrombosis, followed by bleeding tendency as a result of consumption of coagulation factors and fbrinolytic activity. Case 02: Emphysema A woman of 42 years, housewife, had been suffering from breathlessness, occasional dry cough and weight loss for 2 years. The aforementioned symptoms associated with hypercalcaemia and nephrocalcinosis indicate hyperparathyroidism. It may be primary (as a result of adenoma, hyperplasia or carcinoma of the parathyroid), secondary (chronic renal failure, malabsorption, rickets or osteomalacia) or tertiary (autonomous from secondary). The clinical details given in the stem usually contain the information that you need to separate the correct option from the distracter(s). Double check the question again to make sure you haven’t missed a subtle fact and that you’ve interpreted the situation correctly. You will need some knowledge of the psychology of parenting (clinical knowledge gained from reading textbooks) and you will need to be aware of child protection issues and safety concerns (ethics and law). Applying your skills/experience, knowledge, and attitudes you can correctly select the answer E – ignore the child until it stops screaming – which will ensure that you fnish your shopping and avoid child protection services. Each option may be used more than once or not at all, that is, it is possible that one of the options could be the correct answer for two of the questions. If the list of options looks a bit unusual, the reason for this is that the committee writes many more questions to go with each option list so that there is a large bank of questions available looking at various aspects of a clinical scenario. An unusual option may belong to another question on the bank, so don’t fall into the trap of assuming that because it’s an unusual option that you hadn’t thought of, then it must be the correct answer. Remove the child to a safe place These options initially all look plausible and very similar, however if you refect on your reading of parenting manuals (textbooks) you will recall that bribing with sweets will set up a vicious cycle resulting in worsening behaviour, and your experience tells you that a toddler in a full-blown tantrum is not distract- ible. Leaving the store rewards bad behaviour, and if you review carefully the scenario it’s hard to imagine a supermarket as being a particularly dangerous place (experience) unless you ‘overthink’ the question and imagine the child to be next to an unstable display of baked bean cans or something similar. The message here is: carefully assess the information given but don’t read complexity into the scenario where there is none. In the actual examination, you can use the question booklet to write on and make notes (as it is not read when it is returned to the College), but you must transfer your answers to the computer-marked sheet before the examination fnishes. The risk of leaving gaps on the answer sheet as you progress through the examination is that you might incorrectly transcribe your answers and lose marks when your answers were originally correct. You are supplied with an eraser to make corrections, and you must be very careful when you’ve fnally chosen your answers to make sure that you complete the answer sheet correctly. The examiners try hard to avoid predictable patterns when selecting the ques- tions. Great care is also taken to avoid questions that have ‘always’ or ‘never’ as these are obviously incorrect given the nature of clinical medicine. If a question looks like an ‘always or never’ scenario, re-read it as you may have missed a crucial part of the question. These facts are unlikely to be the topic of your ward rounds, handovers, or refective practice sessions so it really does pay to revise. Each examination diet is blueprinted to ensure that all areas of the syllabus are covered, so the best advice is to ensure that you have covered the whole syl- labus in your reading and revision, rather than trying to ‘spot’ questions. In addition to the textbooks you used as an undergraduate, there are sev- eral books on the market covering issues relevant to women’s health in general practice, and we suggest that you also access specifc texts on contraception and genitourinary medicine. We have provided a list of websites where you will fnd helpful information about some topics that could come up in the examina- tion, and although this list is not exhaustive, we think you will fnd that the websites contain interesting revision material. Doing exam questions is a very good way to revise, and it is highly recom- mended that you re-read a topic where your score is disappointing – you will be even more disappointed if it comes up in the examination and you have neglected to revisit that topic and top up your knowledge. Whilst you are revising, don’t forget to eat, sleep, and relax too – all these things will improve your performance! To pass the exam reading and revision is required, but understanding the style of questions and practising questions will improve your chance of success. Learning Outcomes This module covers history taking; clinical examination and investigation; note keeping; legal issues relating to medical certifcation; time management and decision making; communication; and ethics and legal issues. It is easy to set clinical questions on history, examination, or investigation, but quite a challenge to set written questions to test the other areas.