USMLE 2 PART2
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v Most ectopics are found in the fallopian tube, although they can occasionally occur at other pelvic sites.
v If a tubal pregnancy is allowed to continue, it may eventually rupture the fallopian tube and cause life threatening haemorrhage.
v Early
diagnosis and treatment is, therefore, important, and may even allow the tube to
be saved.
Initially an ectopic pregnancy may appear just as a normal pregnancy –
with a missed menstrual period and symptoms such as sore breasts and nausea.
However, there is often abnormal vaginal bleeding which may occur at the time of (or a little later than) the expected period, and may, in fact, be mistaken for a period.
Pain on the side of the ectopic occurs commonly and may be associated with a feeling of light-headedness or a desire to use one's bowels.
If the tube ruptures, this usually results in severe
abdominal pain and fainting. EVEN SHOCK
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Ectopic pregnancy occurs once in every one hundred pregnancies. However, some women have a slightly higher risk than this. Important risk factors are:
Women who are at increased risk may be advised to have an ultrasound scan in early pregnancy, particularly if they have any vaginal bleeding.
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Diagnosis and
Treatment | |||
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General Measures
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TO RESUME
EXPLORATION | |||
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* Hospitalization may be required for surgery and
supportive care. Blood transfusion may be
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Medication | |||
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Pain-killers after surgery may be
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Activity | |||
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Diet | |||
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No special diet. | |||
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Possible
Complications | |||
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1. Diminished
fertility. | |||
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2. Infection. | |||
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3. Loss of reproductive organs after complicated
surgery. | |||
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4. Shock and death from internal
bleeding. | |||
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Prognosis | |||
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v
An ectopic pregnancy cannot progress to full
term or produce a viable fetus. v
Rupture of an ectopic pregnancy is an
emergency, requiring immediate hospitalization and
surgery. v
Full recovery is likely with early diagnosis
and surgery. v
Subsequent pregnancies are usually normal in
about 88% of patients. | |||
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v A
30-year-old woman presents to the emergency room with abdominal cramping
and vaginal bleeding. Her last menstrual period was 7 weeks ago. Physical
examination reveals a palpable left adnexal mass. She has a positive
pregnancy test with beta-HCG (human chorionic gonadotropin) of 14,000
IU/L. Which study do you request first?4/ Endovaginal ultrasound shows no intrauterine pregnancy. There is a gestational sac adjacent to the left ovary (LO) containing a yolk sac fetal pole and fetal heart The fetal heart rate is 139 bpm. A small amount of free fluid is visible in the cul-de-sac These findings are diagnostic of a left ectopic pregnancy. Algorithm for Ectopic Pregnancy
Ectopic pregnancy occurs in
1:100-400 pregnancies and accounts for 15% of maternal deaths. The only
sonographic finding that reliably excludes an ectopic pregnancy is a
demonstration of an intrauterine pregnancy since concomitant presence of
an intrauterine and an extrauterine pregnancy is extremely rare (except in
induced ovulation). Endovaginal ultrasound can detect a living embryo in
30% of ectopic pregnancies. Presence of an adnexal mass and/or cul-de-sac
fluid in a patient with no intrauterine gestation and measurable
circulating human chorionic gonadotropin (HCG) are highly specific for the
diagnosis of ectopic pregnancy. However, absence of these findings does
not exclude the diagnosis since up to 30% of women with extrauterine
gestations have no sonographic evidence of an adnexal mass or pelvic
intraperitoneal fluid. A pseudogestational sac (decidual reaction and
anechoic fluid collection in the endometrial cavity) can be seen in 10-20%
of ectopic pregnancies and should not be confused with an intrauterine
gestation. Ninety-five percent of ectopic pregnancies occur in the
fallopian tubes. Ovarian, abdominal, cervical and interligamentary
ectopics are rare. | ||||
Ectopic
Pregnancy
Incompetent Cervix
Miscarriage
Placenta
Praevia
Placental Insufficiency
Placental Separation
Pre-Eclampsia
& Eclampsia
Incompetent Cervix [DETAILS WILL BE ON OTHER WEB PAGES USMLE RELATED]
In normal pregnancy, the cervix is sealed
closed with a plug of mucus, which holds the foetus in the uterus
In an incompetent cervix, the cervix may
begin to open before the term of the pregnancy (usually in the third of fourth
month).
This leads to rupture of the amniotic sac
and miscarriage follows.
This condition is rare, but may occur if
the cervix has been damaged during previous pregnancies or surgery.
This condition is not usually diagnosed
until a first miscarriage has occurred.
If a previous miscarriage is thought to
have been caused by an incompetent cervix, preventative measures can be taken
for your next pregnancy. Rest is recommended.
Miscarriage [DETAILS WILL BE ON OTHER WEB PAGES USMLE RELATED]
The loss of a baby before 28 weeks is
termed a miscarriage while after 28 weeks, loss of the foetus is called a
stillbirth.
There are many known causes of
miscarriage, and some unknown causes.
Miscarriages usually occur in the first
trimester, sometimes before the pregnancy has even been suspected or diagnosed.
In the first few weeks of pregnancy
approximately 30% of all pregnancies end in miscarriage.
In some cases a period may be late and
heavy and the conception and miscarriage may not even have been realised.
When a couple experiences a miscarriage,
they are still likely to conceive again, however miscarriages can increase in
frequency with age and with the number of previous pregnancies.
Small numbers of women can experience up
to three or more miscarriages in a row and approximately 50% of these women may
still go on to have a successful pregnancy, even though they will have suffered
emotional pain, frustration and disappointment on previous occasions.
If bleeding occurs at any stage in your
pregnancy you must see your doctor. Bleeding is the most common symptom of
miscarriage.
Miscarriage can be caused by many factors
including:
·Genetic problems due to chromosomal
defects
·Environmental factors such as smoking,
alcohol and other recreational drugs
·Hormonal abnormalities
·Pre-existing disease or illness,
uterine abnormalities or other medical
conditions in the womb ·
Bacterial and viral infections
While most people generally understand
the need to grieve for the loss of a stillborn baby (after 28 weeks), often
others do not understand that a miscarriage can also cause grief and depression
Placenta Praevia [DETAILS WILL BE ON OTHER WEB PAGES USMLE RELATED]
In a normal pregnancy the placenta
implants itself in the top part of the uterus.
In placenta praevia the placenta implants
itself in the lower part or on the side of the uterus and can get in the way of
the baby’s passage at birth.
The cause of placenta praevia is unknown,
but it is more common in women who have had several children.
Symptoms are bleeding after the 20th week of pregnancy (possibly after
sex) and haemorrhage in the last two months of pregnancy.
Placenta praevia can be diagnosed by
ultrasound and treatment involves bed rest.
Placental Insufficiency [DETAILS WILL BE ON OTHER WEB PAGES USMLE RELATED]
A healthy placenta is vital for
maintaining a healthy baby.
An insufficient placenta can prevent your
baby from gaining essential nourishment.
Symptoms for placental insufficiency may
include
below average weight gain,
below average fetal development,
or slow growth of the uterus.
An ultrasound examination will determine
if growth of the fetus is adequate.
Another useful sign is the activity of
the baby in the last few months of pregnancy.
Placental Separation [DETAILS WILL BE ON OTHER WEB PAGES USMLE RELATED]
Sometimes the placenta can separate from
the uterus, either partially or completely.
This is more common in women who have had
more than two children, but the cause is unknown.
In mild cases, slight blood loss occurs
and the condition is treated with bed rest and monitored by ultrasound, however
labour may be induced if the pregnancy is close to term.
The condition is acute when more blood is
lost and a large amount of the placenta separates from the wall
Pre-Eclampsia & Eclampsia [DETAILS WILL BE ON OTHER WEB PAGES USMLE RELATED]
Pre-eclampsia is a form of high blood
pressure induced by pregnancy and occurrs in approximately 15% of pregnancies.
The condition relates to the health of
the placenta and is more likely to occur in first time pregnancy’s, women over
35, multiple pregnancy’s, severely obese women or women who have suffered from
pre-eclampsia in a previous pregnancy.
Symptoms can include:
increasing blood pressure,
protein in the urine,
disturbances in kidney
and liver function,
fluid retention,
swelling of face,
hands and feet and possibly headaches,
dizziness and nausea.
TRAUMA AND
NEURO:
Acute epidural hematomas generally result
from trauma to the side of the
head with fracture of the temporoparietal bone and severance of the middle
meningeal artery, which lies between the dura and the inner table of frontal
bone.
Arterial bleeding in an epidural hematoma
creates a potential space between the calvarium and dura, thus producing a true
epidural compartment.
Typically, the patient is initially
rendered unconscious and then regains consciousness (lucid interval). After 4 to
8 hours, when there is approximately 30 to 50 ml of blood in the space, the
patient develops evidence of raised intracranial pressure (e.g., papilledema,
convulsion) and may die of herniation unless the blood is surgically removed.
There is a 20% mortality rate.
Subarachnoid and intracerebral
hemorrhages are not associated with trauma.
Subdural hematomas are most common in
elderly individuals and chronic alcoholics who have cerebral atrophy.
DETAILS
AND CASES:
blood vessels tear, blood accumulates within the space between the dura and the skull.
This is known as an epidural
hematoma (epi-door-ul hem-a-to-ma), or blood clot at the covering of the
brain.
When the blood accumulates between the dura and skull, swelling of the brain occurs.
There is no extra room within the skull to allow for the brain to swell and for the blood to accumulate.
The only way the brain can compensate is to shift the delicate structures out of the way.
This can cause pressure on vital functions, such as eye opening, speech, level of awakeness (or consciousness) or even breathing.
Generally, an epidural can cause serious problems and must be removed to prevent increased swelling of the brain.
The procedure of choice for removal of an epidural hematoma
is surgery to remove the blood clot.
An epidural hematoma can happen to anyone, at any age. Some common causes of
epidural hematoma include:
People at particular risk are those who:
The signs and symptoms of an epidural hematoma include
severe headache,
dizziness,
vomiting,
increased size of one pupil or sudden
weakness in an arm or leg.
As the epidural hematoma swells and the
brain structures are pushed together, more visible signs can occur.
A more dangerous sign of epidural
hematoma is a decreased level of consciousness, such as drowsiness, confusion or
inability to awaken from a very deep sleep (often called coma).
Because the brain controls all functions
of the human body, breathing pattern changes also can occur.
Shortness of breath, gasping for air or
very slow breathing can be a warning sign that the person needs help.
An epidural hematoma can be
life-threatening; therefore, if any of these signs or symptoms occur, the person
should be taken to a medical facility immediately.
a 47
year old right-handed construction worker who slipped off a ladder and fell from
a height of 8 feet. He landed on his left side, striking his head. He denies
loss of consciousness, but he did feel "groggy". He was taken by ambulance to
the Bellevue Hospital Emergency Room.
On exam, the patient
was alert and oriented. He recalled the details of the event. He was
neurologically intact. He had a 3 cm scalp laceration in the left parietal
region. Within several minutes of his arrival, however, he complained of severe
headache and vomited.
Click on an image to see full
size.
The CT scans above show
subarachnoid hemorrhage over the right cerebral convexity and
in the Sylvian fissure. In addition, there is a small, less than 1 cm thick left
temporal epidural hematoma. The bone windows show an overlying
temporal bone fracture.
The
patient's acute epidural hematoma located in the temporal region was felt to be
a life-threatening problem, requiring immediate surgical intervention. Although
the patient was neurologically intact and alert, this lesion has the potential
to cause uncal herniation and rapid deterioration or death without warning. In
addition, the overlying pterional fracture suggests a laceration of the middle
meningeal artery, with the probability that the hematoma will continue to
expand.
The subarachnoid
hemorrhage is probably traumatic in etiology. It is located over the convexity
and there is no basilar cistern subarachnoid blood. The patient clearly gave a
history of slipping on the ladder rather than experiencing symptoms which may
have caused the fall, such as headache or loss of consciousness. Therefore the
possibility of an aneurysm is low.
The
patient underwent a left temporal craniotomy and evacuation of the
epidural hematoma. The skull fracture noted on the CT was encountered.
The middle meningeal artery was lacerated in 2 separate locations and was
actively bleeding. The dura was tacked up the the bone edges. Intraoperative
ultrasound was used to be sure that no contusions or subdural hematomas had
formed since the time of the CT scan, and this looked normal. The contralateral
side was not visualized due to the limitations of the intraoperative ultrasound
technique. We considered leaving an intracranial pressure monitor, but because
the patient was alert and intact preoperatively we decided to observe his
neurologic exam instead.
In the
Recovery Room, the patient was somnolent but aroused to voice and followed
complex commands. Because of the somnolence, and because of the underlying right
hemisphere diffuse injury, we had a low index of suspicion for progression of
further injuries, and a CT scan was obtained.
The scan above
deomonstrates a large intracerebral hematoma in the right temporal
lobe, with mass effect and impingement of the uncus on the lateral
brainstem suggesting impending herniation. The left epidural hematoma has been
satisfactorily evacuated. At this time the patient had no third nerve palsy or
hemiparesis. The operating room was immediately mobilized and Mannitol was
given.
A
right frontotemporal craniotomy and partial anterior inferior temporal
lobectomy were performed. We encountered frank hematoma as well as
severely contused and necrotic temporal tissue, which were removed. The temporal
lobectomy extended from the upper border of the middle temporal gyrus
superiorly, medially just 0.5 cm short of the tentorial incisura, and
posteriorly 5 cm from the temporal pole. At the conclusion of the procedure the
brain was relaxed and pulsing well.
Postoperatively, the patient was again somnolent but
following complex commands and nonfocal. CT showed resolution of mass effect and
the lobectomy cavity. He continued to improve and within 24 hours was alert and
neurologically intact. Visual fields were intact on formal ophthalmological
testing. He was discharged home on the 7th postoperative
day
A 31-year-old woman was brought
to the emergency room by an ambulance after being struck by a car. She was
initially responsive at the scene but subsequently lost consciousness and had to
be intubated. Her vital signs were stable and preliminary examination did not
show any sign of abdominal injury or open fractures. Her pupils were equal and
reactive and she responded to painful stimuli. Portable radiographs of the chest
and lateral cervical spine were unremarkable.
Computed tomography (CT) of the head obtained
without intravenous contrast enhancement shows a biconvex high-attenuation
epidural hematoma adjacent to the right frontal lobe The lesion extends
superiorly to the level of the body of the lateral ventricle and inferiorly to
the roof of the right orbit Mild mass effect is exerted on the subjacent brain
parenchyma. A fracture is visible extending through the right side of frontal
bone to the roof of the right orbit with associated extracranial soft tissue
swelling
epidural hematoma
Epidural hematomas are seen in 1-4% of patients with intracranial trauma but they account for 10% of fatal injuries. Laceration of the middle meningeal artery or a dural venous sinus by a skull fracture is responsible for 85-95% of patients with epidural hematomas; the remainder have venous bleeding or middle meningeal artery tear without a fracture. Ninety-five percent of epidural hematomas are unilateral and supratentorial, commonly occurring in the temporoparietal area. They are located between the skull and dura and have a characteristic biconvex or lentiform configuration on CT scans. Two thirds of acute epidural hematomas are hyperdense on CT; one third contain hypodense areas secondary to active bleeding. The overall mortality with epidural hematomas is 5%, and poor outcome is often due to delayed diagnosis or late surgical intervention.
Epidural hematoma: A 20-year-old man presented with a brief loss of consciousness following a fall from standing height. He had a brief lucid interval then became progressively less responsive. A computed tomography scan of the head reveals effacement of the third ventricle, quadrigeminal cistern, and compression of the anterior and posterior horns of the lateral ventricle. A lenticular-shaped hyperdense area consistent with an acute epidural hematoma is seen on the right. (L.S.)
A 36-year-old man with a history
of alcohol abuse presented with left-sided weakness and memory loss.
Axial CT images of the brain show a large
isodense right-sided subdural hematoma extending from the high convexities to
the low frontal lobe. It is producing extensive right to left midline shift with
subfalcine and right uncal herniation. There is trapping of the
ventricles and left temporal horn with acute ependymal cerebrospinal fluid
seepage, predominantly in the left periatrial and occipital regions .
Cerebral and cerebellar atrophy is also present.
Note the difference in the sulci of the two hemispheres.
The main differential
considerations include subdural and epidural hematoma. Epidural hematomas (EDH)
form in the space between the dura and the inner table of the skull. Unlike
subdural hematomas, EDH can cross the midline, but will not cross the cranial
sutures where the dura is firmly attached. The subdural hematoma (SDH), however,
may freely cross the midline insertion of the falx or the tentorial attachment.
Also in comparison to SDH, EDH is often associated with skull fractures (85 -
95% of adult cases) which disrupts the middle meningeal artery, resulting in a
lenticular or biconvex extra-axial collection.
Subarachnoid hemorrhages can be distinguished
radiographically from SDH by their extension into cerebrospinal fluid space, and
appearance on CT as linear areas of high attenuation within the cisterns and
sulci.
Subacute subdural hematoma.
Subdural hematoma (SDH) is the
most common extra-axial collection and is seen in 5% of head trauma patients.
SDH occurs between the dura and the arachnoid membrane, most often due to venous
bleeding from the "bridging" subdural veins which connect the cerebral cortex to
the dural sinuses. However, SDH may also result from disruption of the
penetrating branches of superficial cerebral arteries. These ollections tend to
conform to the shape of the brain and the cranial vault, exhibiting concave
inner margins and convex outer margins. Occasionally, SDH may be straight or
even concave in appearance.
Patients with SDH commonly present after acute
deceleration injury from a fall or motor vehicle accident, but are rarely
associated with skull fracture. More rarely, coagulopathies, tumors, or
aneurysms may be responsible for SDH.
SDH may be classified as hyperacute (low density) if less than 12 hours from the acute event, acute (high density) if less than few days, subacute (isodense) from a few days to 2-3 weeks, and chronic (low density) if more than 3 weeks after the time of injury.
A 75-year-old man was brought to
the emergency room by his family because of an acute change in his mental
status. He had reportedly fallen at home the evening before but did not have any
complaints at that time. On exam, he was disoriented to place and time but had
no focal neurologic deficit. His laboratory values were unremarkable. Plain
films of the cervical spine showed degenerative spondylosis but no fracture.
Computed tomography without intravenous contrast
enhancement indicates a crescentic hyperdense right subdural hematoma extending
from the skull base to the high convexity The subdural collection extends into
the interhemispheric fissure anteriorly There is a minimal compression of the
body of the right lateral ventricle Soft tissue swelling is present over the
left parietal region but no fracture is evident
Subdural hematoma
Subdural hematomas are seen in 10-20% of patients with intracranial trauma and account for 30% of fatal injuries. The most common etiology of subdural hematomas is stretching and tearing of bridging cortical veins in the subdural space due to sudden change in velocity of the head. A definite history of trauma may be absent, especially in elderly patients. Subdural hematomas occur between the dura and arachnoid. The characteristic CT appearance of an acute subdural hematoma is a crescentic, hyperdense extraaxial collection that spreads diffusely over the affected hemisphere. Subdural hematomas commonly occur over the frontoparietal convexities and in the middle cranial fossa. Subdural hematomas undergo clot lysis and organization over time. Within a few days to a few weeks after trauma, subacute subdural hematomas become nearly isodense with the underlying brain parenchyma. Chronic subdural hematomas are typically low attenuation. In 5% of cases, recurrent hemorrhage into a preexisting chronic subdural hematoma produces a mixed density collection. Mortality rates from a traumatic acute subdural hematoma is very high, ranging from 50 to 85%.
1 year old male with mental status changes
CT
Left occipital skull fracture extending thru the skull base to the
spheno-occipital fissure. Large epidural occipital hematoma with compression of
the fourth ventricle - hydrocephalus.
Basilar Skull Fracture-Epidural Hematoma
A subdural and epidural hematoma may be differentiated from
one another in that an epidural hematoma, as in this case, can cross falcine
boundaries/ dural boundaries. However, it will not cross suture line (vice
versa). Most commonly, occipital epidural hematomas are secondary to venous
sinus injury. However, it may also result from injury to a branch of the
posterior meningeal artery. This patient's lack of history of significant trauma
is incongruous with the above findings raising a suspicion of non-accidental
trauma. head trauma is the leading cause of morbidity and mortality in the
abused child (esp. under the age of 2). Manifestations of injury include SDH
(most common, often chronic), SAH, cerebral contusion and DAI (often in the
"shaken baby") as well as contre-coup injury. Skull fractures are seen in 45% of
affected children. Multiple fractures, stellate fractures, bilateral fractures,
depressed fractures and fractures which are > 5 mm wide at presentation
should raise a suspicion of NAT. MRI may be useful in recognizing intracranial
bleeds of differing ages. Common presentations include that of an irritable or
abnormally subdued child or seizures.
After brain injury, the contents may change. The brain tissue may swell,
causing it to take up more room in the skull. This is called edema. When this
occurs, the swollen brain tissue will push the other contents to the side.
Brain with Edema
There may be bruising called contusions or a collection of blood called a
hematoma or clot. This may also push the other contents to one side.
Brain with a Hematoma
The flow of CSF may also become blocked. This will cause the open spaces
(ventricles) to become enlarged. This is called hydrocephalus.
Brain with Hydrocephalus
Every injury is different. Most injuries are a result of
bruising, bleeding, twisting, or tearing of brain tissue. Damage to the brain
may occur at the time of injury. It may also develop after the injury due to
swelling or further bleeding. Patients may have more than one type of brain
injury.
Skull Fracture:
a break in the bone that surrounds the brain.
These fractures often heal on their own. Surgery may be needed if there has been
damage to the brain tissue below the fracture.
Contusion/Concussion:
a mild injury or bruise to the brain which
causes a short loss of consciousness. It may cause headaches, nausea, vomiting,
dizziness, and trouble remembering or concentrating. This injury will not need
surgery.
Coup-Contra Coup:
A French word that describes contusions that
occur at two sites in the brain. The force of the impact causes the brain to
bump the opposite side of the skull. Damage occurs at the site of impact and on
the opposite side of the brain.
Epidural Hematoma:
A blood clot that forms between the skull and
the top lining of the brain (dura). This blood clot can cause fast changes in
the pressure inside the brain. Emergency surgery may be needed. The size of the
clot will determine if surgery is needed.
Subdural Hematoma:
A blood clot that forms between the dura and
the brain tissue. If this bleeding occurs quickly it is called an acute subdural
hematoma. If it occurs slowly over several weeks, it is called a chronic
subdural hematoma. The clot may cause increased pressure and may need to be
removed surgically.
Intracerebral Hemorrhage:
A blood clot deep in the middle of the
brain that is hard to remove. Pressure from this clot may cause damage to the
brain. Surgery may be needed to relieve the pressure.
Diffuse Axonal Injury (DAI):
Damage to the pathways (axons) that
connect the different areas of the brain. This occurs when there is twisting and
turning of the brain tissue at the time of injury. The brain messages get slowed
or lost. Treatment is aimed at managing swelling in the brain because torn axons
can not be repaired.
Anoxic Brain Injury:
An injury that results from a lack of oxygen
to a part of the brain. This is most often from a lack of blood flow due to
injury or bleeding. This will cause swelling of the brain tissue.
Any of these changes can cause increased intracranial pressure.
Patients with brain injury require frequent assessments and
diagnostic tests. These include:
· Neurological Exam: A series of
questions and simple commands to see if the patient can open their eyes, move,
speak, and understand what is going on around them. For example: What is your
name? Where are you? What day is it? Wiggle your toes. Hold up two fingers.
· X-ray: A picture that looks at
bones to see if they are broken (fractured). It can also be used to take a
picture of the chest to look at the lungs. This test may be done at the bedside
or in the X-ray department and takes between 5-30 minutes to complete.
· CT Scan (CAT Scan): A X-ray that
can take pictures of the brain or other parts of the body. The scan is painless
but the patient must lie very still. The test takes 30-60 minutes to complete.
· MRI (Magnetic Resonance Imaging
Scan): A large magnet and radio waves are used, instead of X-rays, to take
pictures of the body's tissues. It is painless but noisy. The machine is shaped
like a long tube. The patient must lie on a flat table in the middle of the
machine. The test takes about 60 minutes to complete.
· Angiogram: A test to look at the
blood vessels in the brain. Dye is put into a catheter in an artery (usually in
the groin) that supplies blood to the brain. This test can tell if the arteries
or veins have been damaged or are spasming. The test takes 1-3 hours.
· ICP Monitor: A small tube placed
into or just on top of the brain through a small hole in the skull. This will
measure the pressure inside the brain (intracranial pressure).
· EEG (Electroencephalograph): A test to measure electrical activity in the brain. Special patches called electrodes are applied to the head to measure the activity. The test is painless and can be done at the bedside or in the EEG department. The length of the test varies.
Carpal tunnel syndrome is caused by
compression of the median nerve at the level of the wrist.
The median nerve supplies sensation to
the radial 3 1/2 digits of the hand as well as innervation of the thenar
musculature.
Symptoms include numbness and tingling in
the fingertips and pain that can awaken the patient at night and that can travel
proximally up the arm.
On physical examination, Tinel's sign and Phalen's test are usually
positive, and there can be sensory loss in the median nerve
distribution and muscle weakness.
Pronator syndrome is a median nerve
entrapment in the proximal forearm. It is a pure sensory syndrome. The Phalen's
test is negative.
The cubital tunnel is a groove in the
posteromedial aspect of the elbow that contains the ulnar nerve.
Cubital tunnel syndrome is an ulnar nerve
neuropathy.
Ulnar nerve entrapment can occur at the
wrist in Guyon's canal. In both of these conditions, patients may complain of
numbness in the ulnar 1 1/2 digits and have weakness of the intrinsic
muscles.
De Quervain's disease is usually caused
by repetitive use of the thumb for some activity. Patients have pain and
tenderness at the region of the radial styloid.
Olympic cyclist is seen in the orthopaedic clinic with complaints of numbness in her fingertips and pain in her left hand that occasionally radiates up her arm. She is often awakened by the symptoms.
On physical examination, there is decreased sensation
over the radial 3 1/2 digits of the hand and the Phalen's test is
positive =Carpal
tunnel syndrome
Antimicrobial prophylaxis is indicated in surgery when the postoperative infection rate is 5% or greater under optimal conditions, the patient may be immunosuppressed from cancer chemotherapy and, therefore, may be at special risk. First- or second-generation cephalosporins (bacteriocidal) are the most frequently used antibiotics in this setting. Cefoxitin is slightly less active against gram-positive cocci than are first-generation drugs, but cefoxitin is more active against strains of Proteus, Serratia, and other penicillinase-producing gram-negative rods, and there is no reason not to use it in an immunosuppressed patient It is very unlikely that this reaction would have been avoided with a lower dose of cefoxitin but it might have been less severe. Erythromycin, which is usually bacteriostatic, would not have provided adequate coverage in this patient. Antimicrobial prophylaxis in surgical situations should be instituted immediately before the procedure, not 24 hours prior and should not normally be continued for longer than 12 hours postsurgically. a classic type I (immediate) allergic reaction, which commonly includes urticaria, anaphylaxis, and angioedema. Such reactions are more likely with penicillins than with cephalosporins Note: Partial cross-allergenicity (< 10%) exists between these two groups of b-lactam antibiotics. Hypoxia due to bronchoconstriction is likely to have
been responsible for the cardiopulmonary dysfunction, especially if the
patient had ischemic heart disease. Although skin tests may be useful, they often give false-negative results; therefore, drug hypersensitivity may not be revealed by such tests in all patients. However, the severity of the reaction could have been moderated if a test dose of cefoxitin had been administered 10 minutes before the full dose. A type IV or delayed hypersensitivity reaction is mediated by cells, not antibody Type IV reactions typically occur 24-72 hours after exposure of a sensitized individual to the offending antigen in contrast to type I hypersensitivity, which develops within minutes. The cardiovascular injury was probably secondary to hypoxia caused by the drop in blood pressure and respiratory problems. A type I allergic reaction is immunoglobulin E (IgE)-mediated. Type II
and III reactions are mediated by IgG or IgM
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Maintenance therapy after response
to antidepressants should generally be continued at an effective dose for 6
months after initial response.
Quick relapse is more likely if
antidepressants are tapered or stopped earlier
Some studies suggest much longer
treatment after recovery from a depressive episode if the patient has a history
of multiple relapses.
Therapy should not be switched to
fluoxetine
Loss
of urine with genuine stress incontinence occurs only when intra-abdominal
pressure exceeds intravesicle pressure, as occurs when coughing, sneezing, or
laughing.
Because these actions rarely occur during
sleep, urine will not be lost while the patient is sleeping.
A
characteristic of urge incontinence is bladder muscle (detrusor) contractions.
The patient is unable to suppress these
involuntary detrusor contractions.
This mechanism of urine loss is different
from that of genuine stress incontinence in which detrusor contractions do not
occur.
Antidepressant medications may be helpful
in the treatment of urge incontinence by suppressing the involuntary detrusor
contractions.
They are not useful in treating other
kinds of urinary incontinence.
Overflow
incontinence is characterized by a bladder that is denervated either
anatomically or functionally.
This denervation results in the inability
of the patient to sense when bladder filling and distention are
occurring.
Functional denervation can be caused by ganglionic blockers,
anticholinergic medications, or epidural/spinal anesthetics.
Bypass
incontinence results when the normal urethral sphincter mechanism is bypassed.
This may occur because of a fistula from
the ureter or bladder to the vagina after radical pelvic surgery or pelvic
radiation.
An
irritative condition of the lower urinary tract may cause urinary urgency,
frequency, dysuria, and loss of urine.
Processes associated with this may
include urinary infections (such as cystitis), neoplastic processes (such as a
bladder tumor), or a foreign body in the bladder.
A simple urinalysis will help identify
these irritative processes.
A urinalysis will show white blood cells
and bacteria if there is a urinary infection, whereas it will show red blood
cells in the presence of a neoplastic process or a bladder foreign body.
Loss
of pelvic floor tone may result in genuine stress incontinence.
In postmenopausal women, this may be a
consequence of decreased estrogen levels.
Replacing the estrogen through hormone
therapy may improve the tissue tone to the point where the involuntary urine
loss is relieved.
Urge incontinence has been
epidemiologically associated with a history of sexual abuse or sexual assault.
The mechanism and pathophysiology
of this association is not well understood.
Which of the following
urodynamic profiles is characteristic in urinary stress incontinence?
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XC. |
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a remnant of thyroid tissue in
the foramen cecum, which is the initial site for thyroid tissue before migration
into the neck.
In 80% of cases, this may be
the only thyroid tissue, and excision would render the patient hypothyroid.
Iodine-131 (131I) uptake is
useful diagnostically because it identifies the tissue as thyroid and determines
whether there is any thyroid tissue in the neck.
If thyroid hormone replacement therapy
does not cause the mass to regress, it should be surgically excised and the
patient should be kept on thyroid hormone.
Needle biopsies and throat cultures serve
no purpose in the work-up of these lesions.
A 9-year-old child is having
difficulty swallowing. There is a painless mass located in the midline at
the base of the tongue. There is no cervical adenopathy. Which of the
following would be most useful in confirming the
diagnosis? |
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Needle biopsy |
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Excisional biopsy |
XC. |
Iodine-131 (131I)
uptake |
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Throat
culture |
PREMORBID |
Before the injury. Most
clients and families don't like this term because of the word morbid. When
there is an insult to the brain, some of the cells die. Premorbid is the
time before the death of certain cells. |
EXPRESSIVE
APHASIA |
A person's inability to
express his or her thoughts. Although the person may know exactly what he
or she wants to say, the words just don't come out of the mouth. Sometimes
the person may be able to get the words out, but knows instantly that
something is wrong. He or she knows because his or her partner repeats in
awe, "You want me to eat the fireplace"? In the meantime, he or she wanted
to say "Eat your dinner". |
CLOSED
HEAD INJURY |
Damage to the brain which is
not accompanied by a penetrating injury (head collides with another
object). |
OPEN HEAD
INJURY |
Damage to the brain which is
accompanied by a penetrating injury (gun shot wound to the
head). |
COGNITION |
Thinking,understanding and
reasoning,acquiring knowledge and verifying information. After a traumatic
brain injury our cognitive,or thinking abilities are often altered. The
way we formerly gathered,understood and acted on what we learned,will also
change. |
SHUNT |
A tube that is surgically
placed in the brain and runs down into the large veins of the neck and
abdominal cavity. It will drain excess fluids away from the brain. This
fluid often builds up after a traumatic insult. Some shunts are permanent
and some can later be removed. |
ATAXIA |
Uncoordinated movement or
interruption of smooth movement. What this simply means is the muscles
that normally pull together as a team now work independently and often
opposite each other. There is often no actual muscle damage, which causes
the ataxia, but damage only to the part of the brain that send the
messages to the muscles. |
BRAIN
STEM |
The lower portion of the
brain which connects it to the spinal column. The brain stem coordinates
the body’s vital functions (breathing, blood pressure and pulse). It also
houses the reticular formations, which controls consciousness, drowsiness
and attention. |
CORTEX |
The largest part of the
brain consisting of two cerebral hemispheres which are connected by a band
of tissue, the corpus callosum. This is the area where most “thinking” and
cognitive functioning take place. It is sometimes referred to as the
“cerebrum.” |
DYSARTHRIA |
Difficulty with
pronunciation due to weakness or poor coordination of the muscles of the
lips, tongue, jaw, etc. It may include speech that is slurred, talking
extremely fast or slowly, or improper pitch. |
APRAXIA |
The inability to perform a
movement when asked. The person may still be able to move, feel,
understand direction and move naturally (automatically) but, when asked,
the person cannot move to obey a command or an intention. There are two
types of apraxia. They are movement apraxia and word
apraxia. |
ABSTRACT
THINKING |
Being able to apply abstract
concepts to new situations and surroundings. |
CONCRETE
THINKING |
A style of thinking in which
the individual sees each situation as unique and is unable to generalize
from the similarities between situations. Language and perceptions are
interpreted literally so that a proverb such as "a stitch in time saves
nine" cannot be readily grasped. |
HEMATOMA |
The collection of blood in
tissues or a space following rupture of a blood vessel. |
EPIDURAL |
Outside the brain and its
fibrous covering, the dura, but under the skull. |
SUBDURAL |
Between the brain and its
fibrous covering (dura). |
INTRACEREBRAL |
In the brain
tissue. |
SUBARACHNOID |
Around the surfaces of the
brain, between the dura and arachnoid membranes. |
PERSEVERATION |
The inappropriate
persistence of a response in a current task which may have been
appropriate for a former task. Perseverations may be verbal or
motoric. |
KINESTHESIA |
The sensory awareness of
body parts as they move. |
IMPULSE
CONTROL |
Refers to the individual’s
ability to withhold inappropriate verbal or motor responses while
completing a task. Persons who act or speak without first considering the
consequences are viewed as having poor impulse control. |
JOB
ANALYSIS |
Involves the systematic
study of an occupation in terms of what the worker does in relation to
data, people, and things; the methods and techniques employed, the
machines, tools, equipment, and work aids used; the materials, products,
subject matter or services which result, and the traits required of the
worker. |
OCCUPATIONAL
THERAPY |
The therapeutic use of
self-care, work and play activities to increase independent function,
enhance development and prevent disability; may include the adaptation of
a task or the environment to achieve maximum independence and to enhance
the quality of life. The term occupation, as used in occupational therapy,
refers to any activity engaged in for evaluating, specifying and treating
problems interfering with functional performance. |
PHYSICAL
THERAPIST |
Evaluates components of
movement, including: muscle strength, muscle tone, posture, coordination,
endurance, and general mobility. The physical therapist also evalulates
the potential for functional movement, such as ability to move in the bed,
transfers and walking and then proceeds to establish an individualized
treatment program to help the patient achieve functional
independence. |
REHABILITATION
COUNSELOR |
Also called Vocational
Counselor. A specialist in social and vocational issues who helps the
patient develop the skills and aptitudes necessary for return to
productive activity and the community. |
TASK
ANALYSIS |
Breakdown of a particular
job into its component parts; information gained from task analysis can be
utilized to develop training curricula or to price a product or
service. |
VOCATIONAL
EVALUATION |
An organized and
comprehensive service staffed by specialists who systematically and
comprehensively utilize work activities (real or simulated) and/or
educational services as the focal point for educational and vocational
assessment and exploration. In addition, psychological testing,
counseling, social summaries, occupational information, etc., are other
evaluation tools that are used. It incorporates the medical,
psychological, social, vocational, educational, cultural, and economic
data for establishment and attainment of individual
goals |