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A woman with a history of depression should be always be referred for a formal psychiatric opinion during pregnancy C generic 10mg vardenafil otc erectile dysfunction evaluation. New mothers who commit suicide are more likely to die by violent means rather than overdose E purchase cheap vardenafil on-line erectile dysfunction pills review. The Edinburgh depression scale may be used to screen for the risk of a psychotic depressive illness occurring Answer [ ] 7 Following a ward round with the registrar on labour ward you are left with a list of tasks to do vardenafil 20 mg without prescription erectile dysfunction pills uk. Clerking a new patient admitted with raised blood pressure at 39 weeks of gestation B. Discharging a patient recovering after a severe postpartum haemorrhage to the postnatal ward C. Obtaining consent for postmortem from a mother who is waiting to be discharged having delivered her stillborn baby 6 hours ago E. She reports that she did have some pain and ‘felt shivery’ when she was discharged from hospital 3 days before. You take a midstream urine specimen and can see that she needs readmis- sion for antibiotic treatment. Which of the following investigations would be the most appropriate to check for an underlying cause when she gets to hospital? As well as the pelvic pain, which one of the following is a recognised symptom of endometriosis? Superfcial dyspareunia Answer [ ] 10 Two years after her last menstrual period a woman aged 51 presents with severe dyspareunia that is so bad that she can no longer tolerate inter- course. She was glad to see the end of her periods because they were becoming increasingly troublesome and has not experienced any vasomo- tor symptoms. On speculum examination the vulva and vagina look very atrophic and opening the speculum causes a small amount of bleeding by splitting the skin at the introitus. Vaginal estradiol pessaries Answer [ ] 11 A postmenopausal woman presents to gynaecology clinic with an advanced utero-vaginal prolapse. Which of the following clinical problems is not likely to be attributable to the prolapse: A. Vaginal bleeding Answer [ ] 12 Following a normal delivery a baby is unexpectedly in poor condition and you are the first person on the scene. His body has some muscle tone and he grimaces when pinched but is not yet making any respiratory effort. Prevent subsequent medico-legal problems if she does not respond to treatment Answer [ ] 14 You are counselling a woman about having an evacuation of uterus to deal with her first trimester miscarriage. With regard to the surgical manage- ment of miscarriage, which of these statements is correct? Histological proof that the uterus contained trophoblastic tissue will always exclude ectopic pregnancy C. Medical management is associated with an increased incidence of pelvic infection D. Perforation of the uterus during surgical evacuation is more likely in incomplete rather than missed miscarriage. Answer [ ] 15 A woman with preexisting type 2 diabetes which was previously treated with metformin and glibenclamide switched to insulin during pregnancy to improve her blood glucose control. Select the most appropriate management advice during the time she is breast-feeding: A. There is an increased risk of hypoglycaemia during breast-feeding Answer [ ] 16 A 25-year-old woman presents to the Early Pregnancy Unit with brown vaginal discharge. She is unsure of her last menstrual period but thinks the gestational age might be about 7 weeks. Which of the following is the most appropriate treatment option for her menorrhagia? Tranexamic acid Answer [ ] 18 A 14-year-old schoolgirl attends the Teenage Family Planning Clinic requesting emergency contraception after a mid-cycle condom breakage. Her parents are unaware of her sexual activity and do not approve of the relationship with her 22-year-old partner because he has another girlfriend who is currently pregnant. Referral to social services to investigate her sexual relationship with an adult C. Turner syndrome Answer [ ] 20 Having presented at 34 weeks of gestation with an antepartum haemor- rhage, a multigravid woman is found to have a major degree of placenta praevia. She has experi- enced trouble tolerating oral iron preparations in her previous pregnancies because of constipation. She has just had a swab taken at the hospital as part of a routine screen and the result showing bacterial vaginosis has been faxed to the surgery. Uterine contractions cease Answer [ ] 23 A primigravid woman who is 16 weeks pregnant asks for advice because she has been exposed to a case of chickenpox 5 days ago. She cannot remember having chickenpox as a child and there is nothing about that in her records at the surgery, so a serum test was taken just after exposure that was negative for IgG antibodies. The community midwife has only just left the labour ward on her way to the house, having collected a cylinder of Entonox. The woman’s husband telephones the surgery to say that her waters have just gone and he can see the cord hanging out of the vagina. Avoid sexual intercourse until he has a plasma viral load of less than 5000 copies/ml B. She has no symptoms at all, so this is an incidental finding Select the best management option: A. The number of maternal deaths per thousand pregnancies Answer [ ] 30 A 45-year-old woman presenting with urinary incontinence is diagnosed with overactive bladder and starts treatment with immediate-release oxy- butynin tablets. Which of these statements is appropriate advice to give her regarding this side effect of oxybutynin? Adverse effects such as constipation indicate that the treatment is starting to work B. Every patient should routinely take laxatives whilst they are taking oxybutynin E. The chance of the tablets causing constipation is less than 1 per cent Answer [ ] 31 A 23-year-old woman presents to the surgery complaining of intermen- strual and postcoital bleeding. Squamous cancer of the cervix Answer [ ] 32 Obstetric units often audit the decision-to-delivery interval for caesarean section as a marker of their performance. No time limit for this category Answer [ ] 33 An immigrant woman presents late for antenatal care at 39 weeks of gesta- tion having just arrived in the country from Latvia. The baby is presenting by the breech and external cephalic version is indicated but she cannot sign the consent form as she has no English at all. She is 27 years old and her general health is good although she does smoke ten cigarettes daily.

These alternatives are usually clearer in their objectives and may have less haemodynamic consequences order 10mg vardenafil free shipping erectile dysfunction latest treatments. If the ventilator is triggered during this period purchase discount vardenafil line erectile dysfunction caused by prostate removal, the mandatory breath due to be delivered is synchronized with patient effort buy generic vardenafil line erectile dysfunction drugs cost comparison. The flow pattern is usually constant (square wave), although modern microprocessors allow some variation to this pattern (e. The inspiratory phase characteristics are determined by the frequency, volume, and inspiratory flow set by the clinician and their relationship to the respiratory system compliance and resistance. Peak and plateau airway pressures and the breathing cycle time depend on the interaction of these factors. Expiratory time should be sufficiently long to allow complete emptying (> three expiratory time constants, minimal end expiratory flow). This is particularly useful in locations where mechanical ventilation is often commenced by non-physician healthcare personnel. It unloads the respiratory muscles, improves gas exchange, and allows complete respiratory muscle rest without having to paralyse or significantly sedate the patient. Adverse effects • May compromise cardiac output and oxygen delivery, especially if there is significant patient ventilator asynchrony. Causes include: • Trigger too sensitive • Presence of a ventilator circuit leak • Movement of fluid or debris in the ventilator circuit, leading to significant changes in circuit flow and pressure • Cardiac oscillations. Patient comfort should improve (decreased respiratory rate, heart rate, blood pressure, agitation, and sedation requirements). Incomplete expiration Recognized as persistent end expiratory flow at the start of the next inspiration. Dynamic hyperinflation is the start of inspiration before the respiratory system has reached its resting volume. The limiting factor at this point is the upper maximum airway pressure alarm limit, and indeed the diagnosis is often made because of a continually sounding maximum airway pressure alarm. Solutions • Lengthen expiratory time (increase inspiratory flow rate, reduce respiratory rate or tidal volume). Since plateau airway pressure is by definition always less than peak airway pressure, this early titration ensures one is within the safe airway pressure zone. Under-recognized disadvantages include unidentified ventilator patient dysynchrony, excessive support, and poor sleep. Basics Inspiratory triggering Inspiration is triggered by the patient, or by changes in pressure or flow (see b Triggering and cycling, p 109). The mechanisms for these changes are discussed in depth in b Effect of mechanical ventilation on control of breathing, p 257. Generally overall V/Q· · increases and there is some alveolar recruitment, reducing shunt and improving · · V/Q mismatch. The effect of mechanical ventilation on oxygenation is discussed in detail in b Effect of mechanical ventilation on oxygenation, p 282. Problems with synchronization Ventilator inspiration and expiration should start and finish as closely as possible to neural inspiration and expiration. While modern ventilators perform much better than older ventilators, problems still exist. Trigger delay Trigger delay is recognized when the patient seems to be attempting to inspire but there is no inspiratory flow for a period at the start of inspira- tion. Ineffective breaths are more common immediately following breaths with large tidal volumes where expiration takes longer, particularly with long expiratory time constants. Also, ventilator inspiratory time (vTi) may extend into neural expiratory time (nTe), thereby lowering the time before the next neural (and ventilator) inspiration. Auto-triggering Auto-triggering is the triggering of inspiratory support by something other than the patient’s respiratory effort. For example: • Leaks in the circuit or round a mask (interpreted as patient respiratory effort by the ventilator) • Motion of liquid that has collected in the ventilator tubing • Cardiac oscillations (especially in high output states). Recognition and treatment • The clue is a high respiratory rate without apparent patient effort or any decrease in the pressure tracing preceding delivery of positive pressure (see b Patient ventilator asynchrony, Fig. This will result in slightly increased effort to initiate inspiration, but improved synchrony. Double cycles Double cycles are two episodes of ventilator support during only one patient effort. Causes • Premature cycling to expiration because the expiratory trigger is too high. Cycling • Ideally the end of vTi should perfectly coincide with the patient’s nTi. Problems with pressure delivery Pressure ramp Increased patient effort should result in increased delivered flow and volume. The initial inspiratory flow rate will alter the rate of pressuriza- tion (pressure ramp). However, too fast a rate may cause initial pressure overshoot, an early termination of inspiration, and double breaths or an increased respiratory rate (increasing inspiratory flow increases respiratory rate through an immediate neural mechanism). Over-support At high levels of support there is a tendency to encourage hyperventi- lation, resulting in a respiratory alkalosis. This alkalosis leads to apnoeas, desaturations, and micro arousals, resulting in more sleep disturbance than is seen in other ventilatory modes and is the reason many weaning units fully ventilate patients overnight. This mainly results from a sine wave flow pattern as opposed to a deceler- ating flow pattern, or because active expiration is started by the patient before cycling. In these circumstances, the down slope of the expiratory flow curve is so steep that the time between, for example, 50% and 5% is minimal and changes do not have a clinically significant impact. This may be due to a neural mechanism secondary to extension of vTi into nThe (b Effect of mechanical ventilation on control of breathing, p 257). No matter how diligent a clinician is in setting these parameters, the limiting factors may be the electronic logic, the patient’s physiology and pathology, and the underlying assumptions made in the inspiratory and expiratory triggers. Levels of support are titrated to breathing pattern, signs of respiratory distress, and arterial blood gases. Some ventilators will automatically reduce support according to pre-programmed algorithms (Adaptive Support Ventilation, SmartCare). In controlled ventilation the chest wall is often passive, reducing the compliance of the respiratory system. Therefore it is usually possible to deliver a higher tidal volume and minute ventilation for a given airway pressure. Hypoxaemia An integrated approach to the management of hypoxaemia in ventilated patients can be found in b Effect of mechanical ventilation on oxygena- tion, p 282. Reported advantages include reduced shunt and dead space, reduced sedation requirements, and improved cardiovascular function and end organ perfusion. This occurs predominantly in the postero-basal portions of the lung as a result of hydrostatic forces, raised intra-abdominal pressure, and diaphragmatic elevation.

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O ne should remember t hat almost all t hyroxine ( T ) circulates 4 bound to protein cheap 20mg vardenafil with mastercard royal jelly impotence, but it is the free or unbound fraction that is able to diffuse into cells an d become act ive buy vardenafil 10 mg on-line erectile dysfunction premature ejaculation treatment. Patients may be 4 asymptomatic or report the vague and subtle symptoms of hypothyroidism discount 20mg vardenafil with mastercard erectile dysfunction caused by hernia, such as fat igue. About h alf of such pat ient s will progress t o overt hypot hyroidism wit h in 5 year s. T h yroid h or mon e replacement can be prescr ibed in an at t empt t o relieve sympt oms or possibly t o reduce cardio- vascu lar r isk, or if p o sit ive an t it h yr oid an t ib o d ies are p r esen t. The overwhelming majority of patients with hypothyroidism can be treated with once-daily dosing of synthetic levothyroxine, which is biochemi- cally ident ical t o the n at ur al h or mon e. Levothyroxine is relatively inexpensive, has a long half-life (6-7 days), allowing once-daily d o sin g, an d gives a p r ed ict ab le r esp on se. Older thyroid preparations, such as desiccated thyroid extract, are available but are not favored because they have a high content of T, wh ich is r apid ly absor bed an d 3 can produ ce t ach yar rh yt h mias, an d the T cont ent is less predict able. In older patients and in those with known cardiovascular disease, dosing should start at a lower level, such as 25 t o 50 µg/ d, and be increased at similar increments once every 4 to 6 weeks until the patient achieves a euthyroid st ate. O verly rapid replacement wit h the sudden increase in metabolic rate can overwhelm the coronary or cardiac reserve. She denies excess dieting, alt hough she does work out wit h her t eam 3 hours daily. Sh e h as b een r ead in g ab ou t h er diagnosis on the Internet and wants to try desiccated thyroid extract instead of the medicine you gave her. O n examination, she weighs 175 lb, her heart rate is 64 bpm at rest, and her blood pressure is normal. Tell her that this delay in resolution of symptoms is normal and schedule a follow-up visit with her in 2 mont hs. C h an ge h er m ed icat ion, as r eq u est ed, t o t h yr oid ext r act an d t it r at e. Hashimoto thyroiditis is the most common cause of hypothyroidism wit h goiter in t he United St ates. It is most commonly found in middle-aged women, alt h ough it can be seen in all age groups. Iodine deficiency is exceed- ingly uncommon in the Unit ed St at es because of iodized salt. Several different autoantibodies directed toward components of the thyroid gland will be present in t he pat ient’s serum; however, of these, ant i- T P O ant ibody almost always is detectable. O n thyroid biopsy, lymphocytic infiltration and fibrosis of the gland are pathognomonic. The presence of these autoantibodies pre- dicts progressive gland failure and the need for hormone replacement. In a young woman with oligomenorrhea, pregnancy should always be the fir st d iagn osis con sid er ed. Ur in e pr egn an cy t est s are easily p er for med in the clinic and are highly sensitive. In t his pat ient, t he next most likely diagnosis is hypot halamic hypogonadism, secondary to her strenuous exercise regimen. These young women are at risk for ost eoporosis and sh ould be counseled on adequat e nutrition and offered combined oral contraceptives if the amenorrhea per- sist s. The amount of hormone batch to batch and the patient dose response are believed to be more predictable than with other forms of hormone replace- ment, such as thyroid extract, which is made from desiccated beef or pork thyroid glands. There is no evidence that the natural hormone replacement is superior t o t he synt het ic form. Other medica- tions, especially iron-containing vitamins, should be taken at different times than levothyroxine because they may interfere with absorption. Hyp e rp ro la c t in e m ia fro m a n y ca u se in d u ce s h yp o t h a la m ic d ysfu n ct io n, le a d in g t o m e n st ru a l irre g u la rit ie s in wo m e n, a n d d im in ish e d lib id o a n d in fe rt ilit y in m e n. Guidelines for the treatment of hypothyroidism: prepared by the American Thyroid Association task force on thyroid hormone replacement. She spent the rest of the day lying down with mild, diffuse, abdominal pain and nausea. She reports several months of wors- ening fatigue, mild, intermittent, generalized abdominal pain, and loss of appetite with a 10- to 15-lb unintentional weight loss. Her medical history is significant for hypothyroidism for which she takes levothyroxine. She does become light-headed, and her heart rate rises to 125 bpm upon standing with a drop in systolic blood pressure to 70 mm Hg. He r c h e s t is c le a r, a n d h e r h e a r t rh yt h m is t a c h yc a rd ic b u t re g u la r. On a b d o m in a l examination, she has normal bowel sounds and mild diffuse tenderness without guarding. Initial la b o ra t o ry st u d ie s a re sig n ifica n t fo r Na 121 m Eq / L, K 5. All of this patient’s clinical features are consistent with acute adrenal insufficiency. The most common cause of adrenal insufficiency is idiopat hic aut o- immune dest ruct ion. Next step: After drawing a cortisol level, immediate administration of intrave- nous saline with glucose and stress doses of corticosteroids. Know the present ation of primary and secondary adrenal insufficiency and of adrenal crisis. Co n s i d e r a t i o n s This patient has a low-grade fever, which may be a feature of adrenal insufficiency, or it may signify infection, which can precipitate an adrenal crisis or produce a simi- lar clin ical pict ure. Becau se of the ad r en al in su fficien cy an d the ald ost er on e d eficien cy, sh e h as volu m e depletion, hypoglycemia, and hypotension. Thus, immediate intravenous replace- ment with normal saline with 5% glucose is critical. A low serum cortisol level wit h t he pat ient’s clinical present at ion and wit hout other explanat ion confirms t he diagnosis of adrenal insufficiency. The most common cause in the United States is autoimmune destruction of the adrenal glands. In primary adrenal insufficiency, the glands themselves are destroyed so that the patient becomes deficient in cor- t isol and aldosterone. Primary adrenal insufficiency is a relat ively uncommon dis- ease seen in clinical pract ice. A high level of suspicion, par t icu larly in in dividuals wh o have suggest ive signs or sympt oms, or wh o are suscept ible by virtue of associ- ated autoimmune disorders or malignancies must be maint ained.

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Avoidance of second-hand smoke cheap vardenafil online visa impotence at 16, aggravating occu­ pational exposures cheap 20 mg vardenafil fast delivery erectile dysfunction treatment surgery, and indoor and outdoor pollution is recommended discount vardenafil uk erectile dysfunction injection therapy. Although pharmacologic treatment cannot reverse lung changes or modif long­ term decline in lung fnction, it does reduce the severity of symptoms, decrease the fequency of exacerbations, and improve exercise tolerance and overall health. The choice of specifc agent is based on availability, individual response to therapy, and side efects. Commonly used agents in the United States are salmeterol (an inhaled �2-agonist) and tiotro­ pium (an inhaled anticholinergic). Oral methylxanthines (aminophylline, theophylline) are also options, but have narrow therapeutic windows (high toxcity) and mutple drug-drug interactions, making their use less common. The use of long-acting bron­ chodilators is more convenient and more efective than using short-acting agents, but is much more exensive and does not relace the need fr short-acting agents fr rescue therapy in exacerbations. Oxgen therapy is the only interventon that has been shown to decrease mortality and must be worn fr at least 15 h/d. Diagnoses that can cause similar symptoms (eg, pulmonary embolism, congestive heart filure, myocardial infrction, pneumonia, pneumothorax, pleural efusion) must be excluded so that appropriate therapy can occur. The severity of the exacerbation should be evaluated by history, examination, assessment ofoxygenation using a pulse oximetry, and fcused testing. The fllow­ ing questions fom the medical history may help to assist in assessing the exacerba­ tion: number of previous episodes and hospitalizations, other chronic conditions, current treatment regimen, history ofintubation/mechanical ventilation, and dura­ tion and new symptoms. Physical examination signs of severity include the use of respiratory muscles, worsening or new cyanosis, unstable blood pressure and heart rate, altered mental status, and peripheral edema. Oxygen should be given with a target saturation of88% to 92% or Pa02 levels at about 60 mm Hg. Patients with more severe symptoms, comorbidities, altered mental status, an inability to care fr themselves at home, or whose symptoms fil to respond promptly to ofce or emergency room treatments should be hospitalized. Ifhospi­ talized, a baseline arterial blood gas should be ordered to evaluate fr hypercapnia, hypoxemia, and respiratory acidosis. Ventilatory support with either noninvasive (nasal or fce mask) or invasive ventilation (intubation) should be considered in deteriorating or critical patients. Combinations of short-acting agents with diferent mechanisms of action (ie, �-agonist and anticholinergic) can be used until symptoms improve. A steroid dose of40 mgprednisolone (or equivalent) fr 10 to 14 days is recommended. Exacerbations associated with increased amounts of sputum or with purulent sputum should be treated with antibiotics. Pneumococcus, Haemophilus injluenzae, and Moraxella catarrhalis are the most com­ mon bacteria implicated. In milder exacerbations, treatment with oral agents directed against these pathogens is appropriate. In severe exacerbations, gram-negative bac­ teria (Klebsiella, Pseudomonas) can also play a role, so antibiotic coverage needs to be broader. The number of annual exacerbations can be reduced by receiving appropriate vaccinations (influenza and pneumococcal), smoking cessa­ tion counseling, education about current medications and their proper use. Patients should be encouraged to discuss social concerns, psychiatric problems (such as anxi­ ety), and proper nutrition and exercise with their physician. She has never smoked cigarettes, has no known passive smoke expo­ sure, and does not have any occupational exosure to chemicals. Pulmonary fnction testing shows obstructive lung disease that does not respond to bron­ chodilators. In counseling him about the benefts of smoking cessation, which of the fllowing statements is most accurate? By quitting, his current pulmonary fnction will be unchanged, but the rate of pulmonary fnction decline will slow. By quitting, his current pulmonary fnction and the rate of decline are unchanged, but there are cardiovascular benefts. By quitting, his pulmonary fnction will approach that of a nonsmoker of the same age. The air­ way obstruction of asthma would be at least partially reversible on testing with a bronchodilator. Smoking cessation will not result in reversal of the lung damage that has already occurred, but can result in a slowing in the rate of decline of pulmonary fnction. In fct, smoking cessation can result in the rate of decline returning to that of a nonsmoker. He is best treated by a long-acting bronchodilator (eg, tiotropium) and an inhaled steroid (eg, fluticasone) used regularly, along with an inhaled, short-acting bronchodi­ lator on an as-needed basis. Right heart failure causes increased right atrial pressures and right ventricular end-diastolic pressures, which then lead to liver congestion, jugular venous distension, and lower extremity edema. He says that the pain started suddenly afer dinner and was severe within a span of 3 hours. On examination, his temperature is 98°F, his pulse is 90 beats/min, his respi­ rations are 22 breaths/min, and his blood pressure is 129/88 mm Hg. The patient is reluctant to flex the lef knee, wincing in pain at touch, and has passive range of motion. There is pain to movement and touch of the lef knee, with evident edema, erythema, and warmth of the joint. Have a diferential diagnosis fr nontraumatic joint pain, based on clinical presentation. Be fmiliar with the most common diagnostic tests fr the above conditions, and have a rationale when ordering these tests. Considerations This 45-year-old man presents with the sudden onset of monoarticular joint pain. A joint becomes septic by blood inoculation, by contiguous infction (such as fom bone or sof tissue), or fom direct inoculation fom trauma or surgery. Exclusion of an infc­ tious etiology is paramount as cartilage can be destroyed within the frst 24 hours of infction. There are several additional pieces of infrmation that guide the diagnosis in this case. Most gout attacks occur between the ages of 30 and 50 in men and in postmenopausal women (50-70 years of age). Premenopausal women are less likely to sufer fom gout due to the increased level of female sex hormones, which aid in the urinary excretion of uric acid. Other fctors that may also increase the risk of a gout attack include trauma, surgery, or a large meal (especially one high in purines such as red meat, liver, nuts, or seafod) that induces hyperuricemia. Other medications that increase the risk of a gout attack include loop diuretics and chemotherapeutic agents.