coffee talk 2

8/18/2019 Coffee Talk 2

1/19


2/19

• A 24-year-old gravida 3 para 1 isadmitted to the hospital at 29 weeks

gestation with a high fever, ank pain,and an abnormal urinalysis !ou orderblood and urine "ultures, a #$#,ele"trolyte levels, and a serum"reatinine level !ou also start her onintravenous uids and intravenousgentamy"in plus ampi"illin After 24hours of antibioti" treatment she is"lini"ally improved but "ontinues tohave fever spikes

• Appropriate management at this time

would be to%


3/19

• a& #ontinue "urrent management• b& #hange her antibioti"s, as her

infe"tion is likely due to a resistantorganism

• "& 'rder a plain abdominalradiograph to rule out a renal stone

• d& 'rder modi(ed intravenouspyelography to rule out urinary

tra"t obstru"tion• e& 'rder renal ultrasonography to

rule out a perinephri" abs"ess


4/19

• )*planation% +he "orre"t answer is a)• yelonephritis is the most "ommon serious

medi"al problem that "ompli"ates pregnan"ynfe"tion is more "ommon after midpregnan"y,

and is usually "aused by ba"teria as"ending fromthe lower tra"t )s"heria "oli is the o.endingba"teria in appro*imately /0 of "ases About10 of women with a"ute pyelonephritis areba"teremi" A "ommon (nding isthermoregulatory instability, with very highspiking fevers sometimes followed byhypothermia Almost 90 of women will be

afebrile by /2 hours owever, it is "ommon tosee "ontinued fever spikes up until that time +hus, further evaluation is not indi"ated unless"lini"al improvement at 4 -/1 hours is la"king fthis is the "ase, the patient should be evaluated

for urinary tra"t obstru"tion, urinary "al"uli and anintrarenal or erine hri" ab"ess ltrasono ra h


5/19

• A 32 year old white female "omes to see you be"ause ofmoderately severe pelvi" pain that has been present forseveral years and is worse with menses 5he des"ribes thepain as bilateral, deep in the pelvis, and intermittently"ramping and steady 5he has never been pregnant, althoughshe has not been using any "ontra"eption during the 6 yearsshe has been married 5he is not interested in fertility at thistime 5he has no history of previous se*ually transmitteddisease, 7 use, or abdominal or pelvi" surgery 5he

"urrently uses ibuprofen, 688 mg 3-4 times a day as needed,with moderate pain relief 5he is a nonsmoker• hysi"al e*amination reveals a blood pressure of 128 /8 mm

g and normal (ndings on e*amination of the heart, lungs,and abdomen +he vagina and "ervi* are normal inappearan"e $imanual e*amination reveals a normal-si:eduterus and adne*a with no masses, but mild tenderness onpalpation of the posterior uterus and posterior "ul-de-sa";e"ent s"reening laboratory work was normal, in"luding a#$#, thyroid fun"tion tests, lipid levels, and liver fun"tiontests


6/19

• a& ;eferral for

hysterosalpinography• b& res"ribing a #'>-2 inhibitor

su"h as rofe"o*ib ?@io**& or

"ele"o*ib ?#elebre*& to be usedinstead of ibuprofen• "& 5tarting her on an oral

"ontra"eptive "ontaining bothestrogen and progesterone• d& 5tarting her on a dana:ol

?7ano"rine&, 688 mg day


7/19

• +he "orre"t answer is "&

• )*planation%• +his patient most likely has endometriosis with

"hroni", "y"li"al pelvi" pain 5in"e she is notinterested in fertility, the ne*t reasonable step isto indu"e a hormonal pseudopregnan"y using"ombination oral "ontra"eptives


8/19

• A 34-year-old white female visits your o "e with a"hief "omplaint of pelvi" pain that intensi(es withher menstrual period 5he has a history of pain

during inter"ourse, whi"h started in her mid-twenties and has gradually be"ome worse 5hereports re"ently missing some work during hermenstrual period due to the pain 5he has hadtwo uneventful deliveries and the pain was absentduring and after ea"h pregnan"y, but graduallyreturned 5he and her husband do not wish tohave any more "hildren and her husband has hada vase"tomy

•

+he patient denies vaginal dis"harge or fever anda review of systems is negative A "ompletephysi"al e*amination is normal e*"ept formoderate non-spe"i(" tenderness on pelvi"e*amination n addition, her uterus is moderately

retroverted and has de"reased mobility•


9/19

• A& start her on a "ombination of oral

"ontra"eptives• $& Admit her immediately and go for a

"omplete hystere"tomy•

#& Admit her immediately and go for a"omplete oophore"tomy• 7& )*plain her "onseBuen"es related to

surgery and post 'p lifestyle "hanges• )& As she doesnCt want any more "hild

ask her to go for vase"tomy


10/19

•

+he "orre"t answer is b&• )*planation%• +his patient has endometriosis #ombination oral

"ontra"eptives should be (rst-line therapy forwomen with endometriosis who do not wish tobe"ome pregnant #onDugated estrogens is not atreatment for endometriosis 7epotmedro*yprogesterone a"etate and dana:ol area""epted treatments, but ea"h has undesirableside e.e"ts A "omplete hystere"tomy andbilateral oophore"tomy is "onsidered a radi"alsurgi"al approa"h, and is reserved for moredi "ult endometriosis "ases


11/19

• An 8 ,year-old man is admitted to thehospital with a massive intra"ranial bleed

• e has been pla"ed on a ventilator be"auseof the respiratory failure asso"iated withintra"ranial herniation,


12/19

a& ;emove the ventilatorb& Eake the patient 7F;"& la"e a nasogastri" tube to preventaspirationd& Get a "ourt order authori:ing you toremove the ventilatore& 7o an ))G ?ele"troen"ephalogram&

three times separated by si* hours ea"htime


13/19

• ?a& ;emove the ventilator• +he patient meets the "riteria for brain death +hese are%

negative "orneal re e*, no nystagmus in response to "alori"stimulation of the tympani" membranes, negative pupillary

and o"ulo"ephali" re e*es, and the absen"e ofsponontaneous respiration

• when the ventilator is held f there are no brainsten re e*esand the patient will not spontaneously breathe, then thepatient is brain dead +here is no hope of re"overy in this"ir"umstan"e An ))G is not ne"essary be"ause the "lini"alpresentation is "onsistent with brain death $rain death is thelegal de(nition of death


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coffee talk 2

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