An Obstetrics and gynecology presentation: A 20 years old single female undergraduate presents to the emergency unit with fever, lower abdominal pain and abnormal vaginal discharge of 5 days duration. Discuss her management
Uterine fibroid - Case scenarios and DiscussionHaynes Raja
This presentation is prepared to meet out the undergraduate medical student needs especially to understand the practical aspects of uterine fibroid and to rapidly revise some important viva questions.
Dedicated to my Great Teachers in the Dept. of Obstetrics & Gynaecology Dr. Lavanya Kumari and Dr. Sangeereni, Inspiring Friends Dr. Paulin Benedict, Dr. Jeyakumar Meyyappan and Dr. Hannah Jane and our REVELLIONZ 08’ batch.
An Obstetrics and gynecology presentation: A 20 years old single female undergraduate presents to the emergency unit with fever, lower abdominal pain and abnormal vaginal discharge of 5 days duration. Discuss her management
Uterine fibroid - Case scenarios and DiscussionHaynes Raja
This presentation is prepared to meet out the undergraduate medical student needs especially to understand the practical aspects of uterine fibroid and to rapidly revise some important viva questions.
Dedicated to my Great Teachers in the Dept. of Obstetrics & Gynaecology Dr. Lavanya Kumari and Dr. Sangeereni, Inspiring Friends Dr. Paulin Benedict, Dr. Jeyakumar Meyyappan and Dr. Hannah Jane and our REVELLIONZ 08’ batch.
India is the highest TB burden country accounting for more than one-fourth of the global incidence .Genital TB is found in 5-10% of women with infertility problems, with low rates in Australia (1%) and high rates of up to 19% in India (ICMR,2011)
I presented a hyperemesis case for a Case Study Seminar where university faculty were invited to attend and RD\'s from the community could receive CPE\'s for attending.
Clinical ScenarioREASON FOR CONSULTATION Desaturation to 64.docxbartholomeocoombs
Clinical Scenario:
REASON FOR CONSULTATION:
Desaturation to 64% on room air 1 hours ago with associated shortness of breath.
HISTORY OF PRESENT ILLNESS:
Mrs. X is 73-year-old Caucasian female who was admitted to the general surgery service 3 days ago for a leaking j-tube which was surgically replaced 2 days ago and is now working properly. This morning at 07:30, the RN reported that the patient was sleeping and doing fine, then the CNA made rounds at 0900 and Mrs. X was found be mildly dyspneic. Vital signs were checked at that time and were; temperature 38.6, pulse 120, respirations 22, blood pressure 138/38. O2 sat was 64% on room air. The general surgeon was notified by the nursing staff of the hypoxia, an order for a chest x-ray and oxygen therapy were given to the RN. The O2 sat is maintaining at 91% on 4L NC. The patient was seen and examined at 10:10 a.m. She reports that she has been having mild dyspnea for 2 days that has progressively gotten worse. She does not use oxygen at home. Her respiratory rate at the time of visit was 22 and she feels short of breath. She has felt this way in the past when she had pneumonia. She is currently undergoing radiation treatment for laryngeal cancer and her last treatment was 1 to 2 weeks ago. She reports that she has 2 to 3 treatments left. She denies any chest pain at this time and denies any previous history of CHF. Review of her vital signs show that she has been having intermittent fevers since yesterday morning. Of note, she was admitted to the hospital 3 weeks ago for an atrial fibrillation with RVR for which she was cardioverted and has not had any further problems. The cardiologist at that time said that she did not need any anticoagulation unless she reverted back into A-fib.
REVIEW OF SYSTEMS:
Constitutional:
Negative for diaphoresis and chills.
Positive for fever and fatigue.
HEENT:
Negative for hearing loss, ear pain, nose bleeds, tinnitus.
Positive for throat pain secondary to her laryngeal cancer.
Eyes:
Negative for blurred vision, double vision, photophobia, discharge or redness.
Respiratory:
Positive for cough and shortness of breath
. Negative for hemoptysis and wheezing.
Cardiovascular:
Negative for chest pain, palpitations, orthopnea, leg swelling or PND.
Gastrointestinal:
Negative for heartburn, nausea, vomiting, abdominal pain, diarrhea, constipation, blood in stool or melena.
Genitourinary:
Negative for dysuria, urgency, frequency, hematuria and flank pain.
Musculoskeletal:
Negative for myalgias, back pain and falls.
Skin:
Negative for itching and rash.
Neurological:
Negative for dizziness, tingling, tremors, sensory changes, speech changes.
Endocrine/hematologic/allergies:
Negative for environmental allergies or polydipsia. Does not bruise or bleed easily.
Psychiatric:
Negative for depression, hallucinations and memory loss.
PAST MEDICAL HISTORY:
Diabetes mellitus that was diagnosed 12 years ago with neuropathy. This resolved after gastric.
India is the highest TB burden country accounting for more than one-fourth of the global incidence .Genital TB is found in 5-10% of women with infertility problems, with low rates in Australia (1%) and high rates of up to 19% in India (ICMR,2011)
I presented a hyperemesis case for a Case Study Seminar where university faculty were invited to attend and RD\'s from the community could receive CPE\'s for attending.
Clinical ScenarioREASON FOR CONSULTATION Desaturation to 64.docxbartholomeocoombs
Clinical Scenario:
REASON FOR CONSULTATION:
Desaturation to 64% on room air 1 hours ago with associated shortness of breath.
HISTORY OF PRESENT ILLNESS:
Mrs. X is 73-year-old Caucasian female who was admitted to the general surgery service 3 days ago for a leaking j-tube which was surgically replaced 2 days ago and is now working properly. This morning at 07:30, the RN reported that the patient was sleeping and doing fine, then the CNA made rounds at 0900 and Mrs. X was found be mildly dyspneic. Vital signs were checked at that time and were; temperature 38.6, pulse 120, respirations 22, blood pressure 138/38. O2 sat was 64% on room air. The general surgeon was notified by the nursing staff of the hypoxia, an order for a chest x-ray and oxygen therapy were given to the RN. The O2 sat is maintaining at 91% on 4L NC. The patient was seen and examined at 10:10 a.m. She reports that she has been having mild dyspnea for 2 days that has progressively gotten worse. She does not use oxygen at home. Her respiratory rate at the time of visit was 22 and she feels short of breath. She has felt this way in the past when she had pneumonia. She is currently undergoing radiation treatment for laryngeal cancer and her last treatment was 1 to 2 weeks ago. She reports that she has 2 to 3 treatments left. She denies any chest pain at this time and denies any previous history of CHF. Review of her vital signs show that she has been having intermittent fevers since yesterday morning. Of note, she was admitted to the hospital 3 weeks ago for an atrial fibrillation with RVR for which she was cardioverted and has not had any further problems. The cardiologist at that time said that she did not need any anticoagulation unless she reverted back into A-fib.
REVIEW OF SYSTEMS:
Constitutional:
Negative for diaphoresis and chills.
Positive for fever and fatigue.
HEENT:
Negative for hearing loss, ear pain, nose bleeds, tinnitus.
Positive for throat pain secondary to her laryngeal cancer.
Eyes:
Negative for blurred vision, double vision, photophobia, discharge or redness.
Respiratory:
Positive for cough and shortness of breath
. Negative for hemoptysis and wheezing.
Cardiovascular:
Negative for chest pain, palpitations, orthopnea, leg swelling or PND.
Gastrointestinal:
Negative for heartburn, nausea, vomiting, abdominal pain, diarrhea, constipation, blood in stool or melena.
Genitourinary:
Negative for dysuria, urgency, frequency, hematuria and flank pain.
Musculoskeletal:
Negative for myalgias, back pain and falls.
Skin:
Negative for itching and rash.
Neurological:
Negative for dizziness, tingling, tremors, sensory changes, speech changes.
Endocrine/hematologic/allergies:
Negative for environmental allergies or polydipsia. Does not bruise or bleed easily.
Psychiatric:
Negative for depression, hallucinations and memory loss.
PAST MEDICAL HISTORY:
Diabetes mellitus that was diagnosed 12 years ago with neuropathy. This resolved after gastric.
Give an example from your own experience or research an article or.docxhanneloremccaffery
Give an example from your own experience or research an article or the media in which a business executive did something of significance that is morally right. Use APA format to cite your material from your sources.
Is there a relationship between obesity and socio-economic status? Should obese people be considered a protected class under Title VII of the Civil Rights Act?
1:
2:
3.
4.
5.
Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP Note should include. Remember that nurse practitioners treat patients in a holistic manner, and your SOAP Note should reflect that premise.
Patient Initials: _______
Age: _______
Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Sara Jones is a 65-year-old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last 3 days. She reported that the “cold feels like it is descending into her chest.” The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4 last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but it returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.
Medications:
1.) Lisinopril 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Serovent daily
4.) Salmeterol daily
5.) Over-the-counter Ibuprofen 200mg -2 PO as needed
6.) Over-the-counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs - rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and hand held nebulizer treatments.
2.) Hypertension – well controlled
3.) Gastroesophageal reflux (GERD) – quiet, on no medication
4.) Osteopenia
5.) Allergic rhinitis
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Total abdominal hysterectomy (TAH) 1998
Sexual/Reproductive History:
Heterosexual
G1P1A0
Non-menstruating – TAH 1998
Personal/Social History:
She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.
Immunization History:
Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.
Significant Family History:
Two brothers – one with diabetes, dx at age 65, and the other with prostate CA, dx at age 62. She has one daughter in her 30s, healthy, living in nearby neighborhood.
Lifestyle:
She is retired, has been widowed x 8 years, and lives in the city in a moderate crime area with good public transportation. She is a college graduate, owns her home, and receives a pension of $50,000 annually – financially stable.
She has a primary care nurse practitioner provider and goes for annual and r ...
BMS 561, Hematology Fall 2016 Case studiesThe following case .docxAASTHA76
BMS 561, Hematology Fall 2016 Case studies
The following case studies are not actual patients. They combine elements from different cases to emphasize important aspects
Case 1
HISTORY: Patient Presentation
A four-year-old African American male diagnosed with sickle cell disease in the newborn period was admitted to the hospital with abdominal pain. Two days prior to admission, he was seen in the emergency room for abdominal pain and sent out on pain medicine.
PHYSICAL EXAM
Height
100 cm (25th percentile on growth chart)
Weight
15 kg (25th percentile on growth chart)
Temperature:
38.9ºC
Heart Rate:
135
Respiratory Rate:
40
Blood Pressure
100/60 mmHg
Oxygen Saturation Level:
87% (normal range: 92%-98%)
HEENT:
Normocephalic, pupils reactive, tympanic membranes clear, oropharynx clear
Neck:
No adenopathy
Chest:
Mild subcostal retractions. Audible rales at lung bases.
Heart:
Tachycardic with III/VI murmur
Abdomen:
Mild distension, diffusely tender to palpation
Genitourinary:
Circumcised male, no priapism
Extremities:
Warm
Neurologic:
Crying, alert boy. Face was symmetric. Moved all extremities.
LABORATORY DATA
Patient Value
Normal Value
WBC
15,000
4,000-12,000/μL
HGB
6.3
11.5-13.5 g/dL
HCT
18
34%-40%
PLT
560,000
140,000-440,000/μL
MCV
89.0
75-87 fl
Retic %
14%
0.5%-1.5%
Rectic Absolute
0.2125
0.024-0.084 M/μL
1 What history, including symptoms, would be most helpful in evaluating this patient?
2 What does a prior history of abdominal pain reflect? What does Bone pain and swollen, painful fingers (dactylitis) reflect in this disease?
3 He had a temperature of 101 degrees Fahrenheit yesterday.what does that indicate?
4 He has been coughing 2-3 times a day and intermittently through the night.what does that indicate??
5 Does family history indicate sickle disease?
6 What additional physical findings might occur in patients with sickle cell disease? Discuss Jaundice and Splenomagaly??
7 What other labs would you request? Compare the lab findings with normal ranges
Discuss Peripheral smear, hemoglobin electrophoresis,
Blood culture; Blood Type and screen for antibodies
LDH; Haptoglobin levels
Amylase and Lipase
8 Discuss MCV, MCH, RDW, ESR, Hematocrit and red cell morphology in this disease
9 What was your differential diagnosis when you first saw the patient? Discuss the following in diagnosing the disease
Cholecystitis; Pneumonia; Upper respiratory tract infection; Vaso-occlusive pain crisis
10 what are the differences between sickle cell disease, HbC, HbE and Thalassemia diseases?
11 Discuss Iron deficiency anemia, thalassemia syndromes and sickle cell anemia
12 How would you treat this patient?
Case 2
On review of symptoms, The patient reports difficulty concentrating, fatigue, feeling faint when she stands quickly, and vague gastrointestinal discomfort with some decrease in appetite.
She denies any history of previous trauma, diplopia, dysphagia, vertigo, vision loss, loss of consciousne ...
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
1. John
Martinelli
Ob/Gyn
Case:
Uterine
Fibroids/Anemia
11/17/13
Identifying
Data:
B.C.
is
a
pleasant
36-‐year-‐old
African-‐American
woman,
G0,
who
was
admitted
to
NBIMC
per
the
ED
on
October
25,
2013.
Chief
Complaint:
Approximately
3
hours
prior
to
her
hospital
visit,
she
reported
“I
felt
dizzy
and
faint…I
thought
I
was
passing
out”.
History
of
Present
Illness:
B.C.
presented
to
the
NBIMC
ED
on
the
afternoon
of
October
25,
2013
after
experiencing
severe
syncope-‐like
symptoms
while
working
alone
in
her
kitchen
at
home.
Her
sister
accompanied
her
and
was
responsible
for
driving
her
directly
to
the
ED
after
they
spoke
by
phone.
B.C.
stated
she
has
noticed
similar
symptoms
increasing
in
severity
over
a
period
of
approximately
5
years;
however,
she
never
pursued
medical
care
or
treatment.
She
felt
this
particular
episode
was
the
most
dramatic
which
prompted
her
to
seek
emergency
care.
Specifically,
the
presenting
event
lasted
approximately
2
–
3
minutes
and
was
consistent
with
possible
transient
bilateral
amaurosis
fugax,
lower
extremity
weakness,
as
well
as
vertigo.
She
did
not
believe
she
lost
consciousness
and
did
not
fall.
She
revealed
she
was
currently
having
her
menses
with
particularly
heavy
flow.
Past
Medical
History:
B.C.
admitted
she
has
not
seen
a
physician
in
approximately
8
years,
however,
she
did
recall
being
previously
diagnosed
with
anemia.
She
does
not
remember
being
given
a
reason
for
anemia.
At
that
time
she
was
advised
to
take
iron
supplements
and
a
daily
vitamin,
however,
she
has
not
been
compliant
due
to
lack
of
affordability.
Her
systemic
history
is
otherwise
unremarkable
and
she
denies
diabetes,
hypertension,
asthma,
thyroid
dysfunction,
SLE,
or
renal
disease.
Obstetrical
History:
None.
G0.
Gynecologic
History:
Upon
questioning,
was
significant
for
an
approximate
5-‐year
history
of
menorrhagia
and
menometrorrhagia
with
irregular
prolonged
heavy
menses
occurring
every
28
–
45
days
lasting
7
–
10
days
and
random
spotting.
Her
menses
is
often
associated
with
intermittent
abdominal
and
pelvic
pain
along
with
transient
vertigo,
which
seems
to
be
increasing
in
frequency
and
duration.
1
2. Medications:
None.
Allergies:
NKA/NKDA.
Surgical
History:
None.
Social
History:
B.C.
is
a
housewife
living
in
a
rented
apartment
with
her
husband
who
works
as
a
laborer.
They
have
no
children.
She
believes
her
environment
is
safe
and
states
she
is
happily
married.
She
and
her
husband
do
their
best
to
maintain
a
healthy
and
balanced
diet.
There
is
no
evidence
of
abuse
and
she
denies
cigarettes,
alcohol,
or
illicit
drug
use.
Family
History:
Mother
–
Hypertension,
controlled
with
medication.
Father
–
Unknown/Deceased.
Siblings
–
None.
Review
of
Systems:
General:
(?)
Vertigo
(prior
to
ED
visit).
No
Fever/Chills.
Skin:
(-‐)
Rash.
Head:
(-‐)
Headache.
Eyes:
(?)
Transient
Bilateral
Amaurosis
Fugax
(prior
to
ED
visit).
Ears:
(-‐)
Hearing
loss.
Neck:
(-‐)
Neck
pain/Stiffness.
Cardio:
(-‐)
Chest
pain/Palpitations.
Pulm:
(-‐)
Respiratory
Distress.
Gastro:
(-‐)
Nausea/Vomiting/Diarrhea.
GU:
(-‐)
Vaginal
Discharge/Urethral
Discharge/Dysuria/Hematuria.
Neuro:
(?)
Transient
Lower
Extremity
Weakness
(prior
to
ED
visit).
Musc:
(?)
Transient
Lower
Extremity
Weakness
(prior
to
ED
visit).
Psych:
(-‐)
Depression,
Anxiety,
AAO
x
3.
Physical
Exam:
Vitals:
T:
98.6
PP:
71
RR:
20
BP:
166/97
SpO2:
100%
(RA)
H:
5ft
6in
W:
206lbs
BMI:
33.13
2
3. Skin:
No
Bruising,
Lesions,
or
Rash.
Head:
Normocephalic/Atraumatic.
Eyes:
PERRLA(-‐)APD,
EOM’s:
Full
(-‐)Diplopia,
CVF:
Full
360degs
OU,
ONH:
0.2/0.2
(-‐)Disc
Edema
OU,
Retina:
(-‐)Heme/Exudate
to
mid-‐
periphery
OU,
Macula:
Healthy
OU,
Ant
Segment:
WNL/Anicteric
OU,
(-‐)Subconjunctival
or
Petechial
Hemes,
VA:
20/20
OU.
Ears:
No
Hearing
Loss.
Otoscopic
Exam
N/A
(deferred).
Neck:
Supple,
No
JVP,
No
Thyromegaly,
No
Lymphadenopathy.
Cardio:
RRR,
S1,
S2,
No
Murmur/Gallop.
Pulm:
Clear
to
Auscultation
b/l.
Gastro:
Lower
Abdomen
with
Firm
Mass
palpated,
(-‐)Tenderness.
Pelvic:
Menses
(deferred).
Neuro:
AAO
x
3,
DTR
3+
b/l,
Normal
Gait.
Musc:
Normal
Tone/Strength
at
UE/LE
Psych:
AAO
x
3.
Appropriate
Affect.
Imaging:
Pelvic
ultrasound
revealed
a
14-‐week
size
uterus
with
multiple
fibroids
evident.
Labs:
WBC:
7.7
Hgb/Hct:
9.4/30.4
Plt:
504
Na:
140
Cl:
111
BUN:
11
K:
4.6
HCO3:
26
Cr:
0.62
Glu:
68
PT:
9.9
PTT/INR:
32/0.9
Assessment
and
Plan:
B.C.’s
5-‐year
history
of
menorrhagia
and
menometrorrhagia
coincides
with
her
increasing
symptomatology
and
frequency
of
episodic
vertigo.
This
appears
to
have
culminated
in
a
near
syncope
event
with
lower
extremity
weakness
along
with
transient
bilateral
amaurosis
fugax.
The
significance
of
the
pelvic
ultrasound
findings
revealing
an
enlarged
uterus
secondary
to
multiple
fibroid
proliferation
sets
the
stage
for
her
diagnosis
and
treatment
plan.
Understanding
the
pathophysiology
of
uterine
fibroid
proliferation,
its
potential
consequences,
diminished
hemoglobin
and
hematocrit,
combined
with
B.C.’s
symptomatology,
leads
to
a
classic
top
differential.
However,
perhaps
exacerbating
her
clinical
presentation,
is
a
relatively
low
random
blood
glucose.
In
addition,
her
blood
pressure
was
found
to
be
significantly
elevated
which
may
be
a
contributing
factor
as
well.
3
4. Differential
Diagnosis:
1. Multiple
uterine
leiomyoma’s
(fibroids)
leading
to
dysfunctional
uterine
bleeding
(menorrhagia/menometrorrhagia)
creating
hemorrhagic
iron
deficiency
anemia
with
secondary
transient
neurologic
sequelae
of
vertigo,
lower
extremity
weakness,
and
bilateral
amaurosis
fugax.
2. Hypertension
with
possible
peripheral
vascular
disease
and
associated
ischemia/hypoxia
contributing
to
the
syncope-‐like
episode(s).
3. Hypoglycemia
as
a
contributor
to
the
syncope-‐like
episode(s).
Plan:
1. Open
abdominal
myomectomy
(patient
refuses
hysterectomy
to
preserve
fertility).
Scheduled
11/8/13.
2. Monitor,
will
schedule
PCP
evaluation
post-‐myomectomy.
3. Monitor,
will
schedule
PCP
evaluation
post-‐myomectomy.
Operative
Course:
B.C.
underwent
an
open
abdominal
myomectomy
under
general
anesthesia
on
her
scheduled
date.
26
fibroid
masses
of
various
sizes,
most
of
which
were
submucosal,
were
excised
and
subsequently
sent
to
pathology.
Pathology
confirmed
the
diagnosis
of
multiple
uterine
leiomyoma.
B.C.
tolerated
the
procedure
well
with
minimal
blood
loss
and
without
complication.
Her
immediate
post-‐operative
course
was
uneventful.
Discussion:
Uterine
leiomyoma’s
or
fibroids
are
the
most
common
neoplasia
found
in
the
female
reproductive
system
occurring
in
20-‐25%
of
all
women.
They
are
found
even
more
frequently
in
approximately
40%
of
menstruating
women
over
the
age
of
50
and
occur
twice
as
frequently
in
black
women
in
comparison
to
the
Caucasian
or
Asian
population.
Uterine
leiomyoma’s
can
occur
at
any
time
between
menarche
and
menopause
with
their
highest
prevalence
in
women
35-‐49
years
of
age.
Fibroids
represent
dysregulated
production
of
myometrial
extracellular
matrix
with
multiple
etiologic
theories.
If
myomectomy
is
required,
fibroids
have
been
shown
to
recur
after
surgery
in
anywhere
from
10-‐50%
of
cases.
This
is
largely
dependent
on
the
initial
size
and
number
of
fibroids
prior
to
myomectomy.
However,
they
tend
to
eventually
resolve
with
decreased
hormonal
stimulation
characteristic
of
menopause.
4
5. There
are
three
major
classifications
of
uterine
fibroids
based
on
their
anatomic
location
or
extension:
1. Submucosal
–
least
frequent.
Because
of
the
close
association
with
endometrial
tissue,
submucosal
fibroids
are
particularly
associated
with
heavy
and
prolonged
menses
(menorrhagia)
as
well
as
an
increased
incidence
of
pregnancy
loss.
They
may
extend
and
become
pedunculated
into
the
uterine
cavity
or
even
prolapse
into
the
vagina.
2. Intramural
–
within
the
uterine
wall.
Increased
proliferation
and
growth
is
linked
primarily
to
mass-‐effect.
This
can
include
abdominal
pain
and
distention
due
to
gastrointestinal
compression
with
potential
obstruction.
Urinary
urgency
and
frequency
can
also
ensue
secondary
to
bladder
compression.
3. Subserosal
–
with
peripheral
uterine
extension.
As
with
submucosal
fibroids,
these
can
also
become
pedunculated
with
extension
into
the
abdomen
and
peritoneum.
The
uterine
ligaments,
ureters,
bladder,
sidewall,
as
well
as
any
abdominal
structure
can
potentially
become
involved
depending
on
the
anatomical
location,
duration,
and
rate
of
extension.
It
should
be
understood
that
most
women
who
are
found
to
have
fibroids
are
often
without
symptoms.
Routine
gynecologic
examinations
normally
lead
to
the
diagnosis,
with
observation
the
only
treatment
indicated.
However,
in
those
women
who
present
with
complications
from
fibroid
proliferation,
management
is
structured
based
on
any
variety
of
findings.
Initial
signs
and
symptoms
can
be
mild
to
severe,
and
again,
are
dependent
on
the
degree
of
neoplastic
proliferation
and
involved
structures.
This
may
include
dysfunctional
uterine
bleeding,
iron
deficiency
anemia,
fibroid
torsion,
pelvic
pain
and/or
pressure,
abdominal
pain
and/or
distention,
constipation,
bowel
obstruction,
genitourinary
complications,
dysuria,
urinary
frequency/urgency,
ureteral
compression
with
secondary
hydronephrosis,
renal
failure,
peripheral
edema,
premature
uterine
contractions,
recurrent
pregnancy
loss,
infertility,
and
others.
Pathophysiology:
With
respect
to
pathophysiology,
a
uterine
fibroid
is
known
to
be
a
leiomyoma.
In
general,
leiomyoma’s
are
monoclonal
tumors
of
smooth
muscle,
which
may
occur
anywhere
in
the
body
that
contains
smooth
muscle.
The
trigger
for
this
neoplastic
proliferation
is
not
well
understood,
however,
studies
involving
genotypic
patterns,
prenatal
and
lifetime
hormonal
exposure,
race,
nulliparity
(increased
estradiol
exposure),
obesity
(increased
aromatization),
polycystic
ovarian
syndrome
(increased
estrone
exposure),
diabetes,
as
well
as
hypertension
have
revealed
certain
clues.
5
6. Neoplastic
proliferation
is
strongly
associated
with
levels
of
both
estrogen
and
progesterone.
However,
even
this
correlation
is
not
completely
understood
in
that
estrogen
and
progesterone
have
lead
to
growth
restriction
in
certain
circumstances.
In
addition,
it
is
known
that
fibroids
during
pregnancy
remain
relatively
stable,
implying
that
extremely
high
steroid-‐based
hormone
levels
during
pregnancy
may
actually
be
protective.
It
has
been
postulated
that
a
possible
interaction
occurs
between
estrogen
receptors
and
oxytocin
receptors
suppressing
the
usual
proliferative
effect
of
these
hormones.
The
exact
downstream
proliferative
effect
of
estrogen
and
progesterone
is
quite
complex
and
is
believed
to
involve
a
multitude
of
interactions.
Estrogen
has
been
found
to
up-‐regulate
IGF-‐1,
EGFR,
TGF-‐beta1,
TGF-‐beta3,
and
PDGF.
The
perpetual
survival
of
leiomyoma
cells
is
permitted
by
down-‐regulation
of
the
tumor
suppressor
gene
p53,
increased
expression
of
the
anti-‐apoptotic
factor
PCP4,
and
increased
antagonizing
PPAR-‐gamma
signaling.
Prolactin
is
believed
to
also
play
a
role
in
this
cascade
of
events.
In
addition,
progesterone
is
thought
to
promote
and
sustain
leiomyoma
proliferation
through
the
up-‐regulation
of
EGF,
TGF-‐beta1,
as
well
as
TGF-‐beta3,
and
permitting
survival
via
the
up-‐regulation
of
another
anti-‐
apoptotic
protein
Bcl-‐2
in
conjunction
with
the
down-‐regulation
TNF-‐alpha.
In
the
pre-‐menopausal
period,
uterine
fibroids
have
been
associated
with
an
overexpression
of
both
estrogen
and
progesterone
receptors.
Regarding
the
black
population
and
an
increased
prevalence
and
incidence
of
uterine
fibroids,
a
unique
estrogen
receptor
genotype
of
ER-‐alpha
has
been
found
to
be
present
to
a
greater
extent.
Therefore,
the
greater
frequency
of
this
genotype
in
black
women
may
also
explain
the
high
prevalence
and
incidence
of
fibroids
in
this
group.
The
robust
nature
of
leiomyoma’s
and
uterine
fibroids
is
exemplified
in
their
inherent
ability
to
promote
their
own
growth.
This
is
achieved
via
the
aberrant
expression
of
both
aromatase
and
17-‐beta-‐hydroxysteroid
dehydrogenase.
It
is
through
these
enzymes
that
circulating
androstenedione
is
aromatized
creating
even
greater
levels
of
estradiol.
The
disease
process
has
the
ability
to
essentially
feed
itself.
Therefore,
aromatase
inhibitors
are
currently
being
considered
for
treatment.
Furthermore,
aromatase
overexpression
is
known
to
be
particularly
pronounced
in
black
women.
Genetic
studies
and
karyotyping
have
shown
that
approximately
40-‐50%
of
leiomyoma’s
demonstrate
a
detectable
chromosomal
abnormality.
Interestingly,
multiple
fibroids
obtained
from
the
same
individual
will
oftentimes
have
unrelated
genetic
irregularities.
However,
it
has
been
discovered
that
specific
mutations
of
a
protein
known
as
MED12
have
been
present
in
70%
of
leiomyoma’s.
Epidemiologic
studies
concentrating
on
patterns
of
inheritance
have
revealed
first-‐degree
relatives
having
a
2
½
fold
risk
with
a
6-‐fold
risk
for
early
onset
cases.
In
addition,
monozygotic
twins
have
a
double
concordance
rate
for
hysterectomy
due
to
fibroid
complications
versus
dizygotic
twins.
6
7. It
is
interesting
to
note
that
leiomyoma’s
including
uterine
fibroids
have
reduced
vascularity.
This
is
in
contrast
to
most
neoproliferative
disease,
which
requires
significant
neovascularization
in
order
to
maintain
and
sustain
tissue
growth.
Cyr61
is
a
gene
found
in
leiomyoma’s
(and
other
tumors),
which
in
addition
to
being
involved
in
tumor
suppression,
is
also
known
for
its
role
in
promoting
vasoproliferation.
It
is
paradoxically
down
regulated
in
this
particular
disease
process
resulting
in
the
decreased
vascularity
characteristic
of
fibroids.
With
respect
to
hypertension
and
its
association
with
fibroids,
the
mechanism
leading
to
neoplastic
proliferation
is
thought
to
be
two-‐fold.
It
has
been
hypothesized
that
hypertensive
uterine
artery
atherosclerosis
with
subsequent
tissue
inflammation
may
contribute
to
the
disease
process.
In
addition,
angiotensin
II
and
its
receptor
activity
in
the
hypertensive
state
have
been
implicated
as
well.
Overall
Impression:
B.C.
is
a
36-‐year-‐old
African-‐American
lady
who
presented
with
classic
signs
and
symptoms
of
uterine
fibroids
including
abdominal
pain,
palpable
abdominal
mass,
and
dysfunctional
uterine
bleeding
including
menorrhagia
and
menometrorrhagia.
She
reported
increasing
frequency
and
severity
of
her
symptomatology
over
a
period
of
approximately
5
years,
for
which
she
also
began
to
experience
episodes
of
vertigo.
This
culminated
in
near-‐syncope
with
vertigo,
amaurosis,
and
lower
extremity
weakness,
which
prompted
her
to
seek
immediate
emergency
medical
attention.
The
implication
of
progressive
hemorrhagic
iron
deficiency
anemia
and
associated
transient
neurologic
sequelae
can
be
characteristic
of
chronic
uterine
fibroids.
Her
presenting
findings
including
African-‐American
ethnicity,
nulliparity,
obesity,
pre-‐
menopausal
state,
hypertension,
diminished
hemoglobin/hematocrit,
physical
exam,
as
well
as
pelvic
ultrasound
results
support
active
fibroid
formation
and
proliferation.
Subsequent
abdominal
myomectomy
and
pathology
confirmed
the
diagnosis
of
multiple
uterine
fibroids.
With
an
intact
uterus
void
of
fibroid
proliferation,
the
prognosis
for
B.C.
is
good
with
respect
to
persistent
iron
deficiency
anemia
and
associated
symptoms.
However,
her
existing
factors
of
hypoglycemia
as
well
as
hypertension
can
potentially
produce
similar
symptomatology,
albeit
via
different
mechanisms
involving
glucose
load
and
peripheral
vascular
disease.
She
was
therefore
referred
to
a
new
primary
care
physician
for
appropriate
follow-‐up
care.
Finally,
regarding
B.C.’s
desire
to
possibly
have
children
in
the
future,
her
chances
to
have
a
successful
pregnancy
are
improved.
It
has
been
shown
that
myomectomy
for
submucosal
fibroids
will
indeed
improve
fertility,
however,
myomectomy
for
other
fibroid
types
have
not
been
shown
to
be
of
benefit
in
this
regard.
In
addition,
a
cesarean
section
may
be
indicated
related
to
the
extensive
nature
of
her
surgery
–
7
8. due
to
increased
potential
for
placenta
previa,
accreta,
abruption,
or
possible
uterine
rupture.
References:
1.
Fonseca-‐Moutinho
JA,
Barbosa
LS,
Torres
DG,
Nunes
SM.
Abnormal
uterine
bleeding
as
a
presenting
symptom
is
related
to
multiple
uterine
leiomyoma:
an
ultrasound-‐based
study.
Int
J
Womens
Health.
2013
Oct
18;5:689-‐94.
doi:
10.2147/IJWH.S50786.
PubMed
PMID:
24194648;
PubMed
Central
PMCID:
PMC3814927.
2.
Flake
GP,
Moore
AB,
Flagler
N,
Wicker
B,
Clayton
N,
Kissling
GE,
Robboy
SJ,
Dixon
D.
The
natural
history
of
uterine
leiomyomas:
morphometric
concordance
with
concepts
of
interstitial
ischemia
and
inanosis.
Obstet
Gynecol
Int.
2013;2013:285103.
doi:
10.1155/2013/285103.
Epub
2013
Sep
30.
PubMed
PMID:
24198832;
PubMed
Central
PMCID:
PMC3806153.
3.
Spencer
JM,
Amonette
RA.
Tumors
with
smooth
muscle
differentiation.
Dermatol
Surg.
Sep
1996;22(9):761-‐8.
[Medline].
4.
Vellanki
LS,
Camisa
C,
Steck
WD.
Familial
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