By K. Taklar. Brigham Young University Hawaii.

In fact order 10mg rizatriptan visa, acetaminophen was routinely recommended as an aspirin substitute for patients who needed a mild analgesic order rizatriptan online now. Unlike aspirin discount rizatriptan online, which promotes bleeding by inhibiting platelet aggregation, acetaminophen is believed to inhibit warfarin degradation, thereby raising warfarin levels. At this time, the interaction between acetaminophen and warfarin has not been proved. Warnings and Contraindications Like heparin, warfarin is contraindicated for patients with severe thrombocytopenia or uncontrollable bleeding and for patients undergoing lumbar puncture, regional anesthesia, or surgery of the eye, brain, or spinal cord. In addition, warfarin is contraindicated in the presence of vitamin K deficiency, liver disease, and alcoholism—conditions that can disrupt hepatic synthesis of clotting factors. Vitamin K for Warfarin Overdose1 The effects of warfarin overdose can be overcome with vitamin K1 (phytonadione). If vitamin K fails to control bleeding, levels of clotting factors can be raised quickly by infusing fresh whole blood, fresh-frozen plasma, or plasma concentrates of vitamin K–dependent clotting factors. Like medicinal vitamin K, dietary vitamin K can reduce the anticoagulant effects of warfarin. Dietary sources include mayonnaise, canola oil, soybean oil, and green leafy vegetables. Patients do not need to avoid these foods but instead should keep intake of vitamin K constant. If vitamin K intake does increase, then warfarin dosage should be increased as well. Conversely, if vitamin K intake decreases, the warfarin dosage should decrease too. Contrasts Between Warfarin and Heparin Although heparin and warfarin are both anticoagulants, they differ in important ways (Table 44. Although both drugs decrease fibrin formation, they do so by different mechanisms: heparin inactivates thrombin and factor Xa, whereas warfarin inhibits synthesis of clotting factors. Heparin and warfarin differ with respect to time course of action: effects of heparin begin and fade rapidly, whereas effects of warfarin begin slowly but persist several days. Finally, these drugs differ with respect to management of overdose: protamine is given to counteract heparin; vitamin K is given to counteract warfarin. Dosage Basic Considerations Dosage requirements for warfarin vary widely among individuals, and hence dosage must be tailored to each patient. Dosage reductions based on this information can be determined using the calculator at www. Preparations Warfarin sodium [Coumadin, Jantoven] is available in tablets (1, 2, 2. In addition, warfarin is available in a formulation for parenteral dosing, which is not commonly done. Direct Thrombin Inhibitors The anticoagulants discussed in this section work by direct inhibition of thrombin. Hence they differ from the heparin-like anticoagulants, which inhibit thrombin indirectly (by enhancing the activity of antithrombin). Dabigatran Etexilate Dabigatran etexilate [Pradaxa, Pradax ] is an oral prodrug that undergoes rapid conversion to dabigatran, a reversible, direct thrombin inhibitor. Compared with warfarin—our oldest oral anticoagulant—dabigatran has five major advantages: rapid onset; no need to monitor anticoagulation; few drug-food interactions; lower risk for major bleeding; and, because responses are predictable, the same dose can be used for all patients, regardless of age or weight. The drug binds with and inhibits thrombin that is free in the blood as well as thrombin that is bound to clots. In the United States dabigatran was first approved for prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. At the lower dabigatran dose (110 mg twice daily), the incidence of bleeding with dabigatran was less than with warfarin, but protection against stroke was less, too. By contrast, at the higher dose (150 mg twice daily), the incidence of bleeding with dabigatran equaled that with warfarin, but the incidence of stroke or embolism was significantly lower. The half-life is 13 hours in patients with normal renal function (CrCl 50 mL/min or higher) and increases to 18 hours in patients with moderate renal impairment (CrCl 30–50 mL/min). Compared with warfarin, dabigatran is safer, posing a much lower risk for hemorrhagic stroke and other major bleeds. Because dabigatran is not highly protein bound, dialysis can remove much of the drug (about 60% over 2–3 hours). Because dabigatran is eliminated primarily in the urine, maintaining adequate diuresis is important. For patients with normal renal function (CrCl 50 mL/min or higher), dosing should stop 1 or 2 days before surgery. For patients with renal impairment (CrCl below 50 mL/min), dosing should stop 3 to 5 days before surgery. Symptoms of dyspepsia can be reduced by taking dabigatran with food and by using an acid-suppressing drug (proton pump inhibitor or histamine-2 receptor blocker). Drug Interactions Dabigatran is not metabolized by hepatic P450 enzymes, nor is it an inhibitor or inducer of these enzymes. Dabigatran etexilate is a substrate for intestinal P-glycoprotein, the transporter protein that can pump dabigatran and other drugs back into the intestine. Drugs that inhibit P-glycoprotein can increase dabigatran absorption and blood levels, and drugs that induce P-glycoprotein can decrease dabigatran absorption and blood levels. Combined use with a P-glycoprotein inducer appears to be safe, even though it might reduce beneficial effects somewhat. Dabigatran etexilate [Pradaxa] is available in three strengths: 75, 110, and 150- mg capsules. If the capsules are crushed, chewed, or opened, absorption will be increased by 75%, thereby posing a risk for bleeding. However, if the missed dose cannot be taken at least 6 hours before the next scheduled dose, the missed dose should be skipped. In patients with significant renal impairment (CrCl 15–30 mL/min), the dosage is 75 mg twice a day. For patients with greater renal impairment (CrCl below 15 mL/min), no dosing recommendation can be made. To maintain efficacy, the drug must be stored in the manufacturer-supplied bottle, which has a desiccant cap. Patients should open just one bottle at a time and should not distribute dabigatran to any other container, such as a weekly pill organizer. Current labeling says that, after the bottle is opened, dabigatran should be used within 30 days.

Most likely diagnosis: Deep surgical space infection or intra-abdominal infect ion rizatriptan 10mg sale. Need for an operation: Although his clinical course and current condition are con cer n in g discount rizatriptan 10 mg visa, h e d oes n ot h ave a clear in d icat ion for r e-explor at ion of the abd o- men at this time purchase rizatriptan uk. Operative intervention and percutaneous drainage are two import ant met hods t o achieve source cont rol in a pat ient wit h deep surgical space infect ion, if confirmed. Recognize the sources of fever in postoperative patients and become familiar with diagnostic and treatment strategies for these patients. Learn the principles of diagnosis and treatment of intra-abdominal infections in t he postoperat ive pat ient. Co n s i d e r a t i o n s When a patient fails to improve and exhibits persistent fever following definitive surgical t reat ment for an int ra-abdominal infect ious process, we must first ent er- tain the possibility that there are still untreated intra-abdominal infections. We must also consider other potential nosocomial infectious causes, as well as non- infect ious causes for h is fever. Given t he picture of persist ent ileus and fevers, t he possibility of intra-abdominal (deep surgical space) infection should be at the top of our differential diagnosis. W ith his current picture, it is not unreasonable to init iat e broad-spect rum ant imicrobial t herapy t arget ing G I t ract microbial flora. W hen identified, some intra-abdominal abscesses can be accessed and drained by percutaneous approaches (Figure 4– 1). Persistent secondary peritonitis can be the result of inappropriate or inad- equat e ant imicrobial t h erapy, wh ich can be addressed wit h addit ional ant imicrobial therapy or modification of antimicrobial regimen. Dive rt icu la r a b sce ss n o t e d b y a rro w (A) an d the n e vacu at e d b y co m p u t e r t o m o g rap h y– guided percutaneous drainage (B). They are treated primarily by wound explorat ion and drainage; systemic ant ibiot ics may be added when t here is ext en- sive surrounding cellulit is (> 2 cm from the incision margin) or if t he pat ient is immunocompromised. D eep surgical site infect ions may be a clinical manifestation of a deep surgical space infection. This type of infect ion in the sett ing of post abdominal surgery can include seconda r y per it on it is, tertiary peritonitis, an d deep surgical space abscess. Recurrence or persistence of this process can be due to insufficient ant imicrobial t herapy or insufficient cont rol of cont aminat ion process (inadequate source cont rol). Very often in these cases, low virulence or opportunist ic pathogens such as Staphylococ- cus epidermis, Enterococcus faecalis, or Candida sp ecies are id en t ified. T h e t r eat m en t for this con dit ion is somewh at un clear because most cases are relat ed t o poor h ost immune responses. T h e response produces loculat ed, infect ed inflam- matory fluid that cannot be eliminated by the host trans-lymphatic clearance pro- cess. W h en the abscesses are sizeable, su r gical or p er cut an eou s dr ain age are n eed ed to resolve this process. In t h ese sit u at ion s, the t h er apy sh ou ld be in it ially br oad an d t ar get Gram-positive and Gram-negative bacteria. The optimal therapeutic duration and end-point s of t reat ment wit h t his st rat egy remains cont roversial. In general, as t he patients improve clinically and culture results become available, de-escalation of treatment is appropriate. Severe sepsis is defined as sepsis plus sepsis-related organ dysfunction or hypoperfusion. Septic shock is defined as sepsis-induced hypotension that persists despite adequate fluid resuscitation. The Surviving Sepsis Campaign h as in t r o d u ced bundles of care for septic patients. These guidelines, based on basic science and clin ical evid en ce, were in it ially int r odu ced in 2001 an d h ave been r egu lar ly up d at ed, valid at ed, an d im p lem en t ed in t er n at io n ally. These can include infect ions related t o t he original disease and the operat ive processes, such as secondary perit onit is, int ra-abdominal abscess, and surgical sit e infec- tion. In addition, hospital-acquired infections can also occur, including urinary tract infection, pneumonia, catheter-related bacteremia, and antibiotic-associ- ated colit is. The approach to a febrile postoperative patient who has undergone abdominal surgery is to presume that there is an intra-abdominal or surgical site related infectious complication until proven otherwise. The severity of the peritoneal contamination is related to the intestinal location of the perforation, which determines the concentration and diversity 11 14 of the endogenous microbes (ie, colon contents with 10 to 10 aerobic and anaerobic 2 3 microbes per gram of contents versus stomach contents with 10 to 10 aerobic microbes per gram of contents). A number of adaptive host defense responses occur following the inoculat ion of bact eria int o the perit oneal cavit y. Removal of the in fect ion occurs with translymphatic clearance of the sequestered microbes and inflamma- tory cells to help resolve the process. Several factors can influence the effectiveness of the host response, and include the following: (1) the size of the micr obial in ocu- lum; (2) the t iming of diagnosis and t reat ment ; (3) the in h ibit or y, synergist ic, or cumulat ive effect s of microbes on the growt h of ot h er microbes; (4) effect iveness of the host peritoneal defense. Tr e a t m e n t G o a l s The goals in the management of secondary peritonitis are directed toward elimi- nating the source of the microbial spillage (eg, an appendectomy for perforated appendicit is or closure of a perforated duodenal ulcer) and early init iat ion of preemptive antibiotic therapy. With appropriate and timely therapy, second- ary peritonit is resolves in most pat ient s; however, approximately 15% to 30% of the treated individuals may develop complications such as recurrent secondary peritonitis, tertiary peritonitis, or intra-abdominal abscesses. Recurrent second- ary peritonit is can be due to inappropriate ant ibiot ics or insufficient ant ibiot ic treatment duration. The initial systemic antibiotics for patients with infect ions from G I sources should include coverage of t he most likely pat hogens. Table 4– 1 cont ains some of the common ant imicrobial agent s or regimens that are used. A r upt ured appen dix wit h pur u lent drain age is n ot ed in the lower abdomen. Which of the following st at ement s is most accurat e regarding this patient’s condition? The resulting infection is a difficult problem to resolve even with appro- priate surgical treatment and antimicrobial therapy B. T h e m o st co m m o n o r gan ism s in vo lved in this in fect io n are C an d id a an d Pseudomonas C. Treatment can be effectively accomplished with appropriate surgery and a fir st -gen er at ion ceph alosp or in D. The patient should be sufficiently treated with operative removal of the appendix and copious irrigat ion of t he peritoneal cavit y E. T h ey r eq u ir e n o sp ecific t r eat m en t s b ecau se fever is an exp ect ed h o st response to surgical stress C.

Women who do not require treatment for their own health do not need to take antiretroviral therapy during pregnancy Answer [ ] 3 buy 10mg rizatriptan free shipping. Usually involves complete closure of the vaginal introitus except for a tiny hole E generic 10mg rizatriptan mastercard. Monochorionic twins are at lower risk of twin-twin transfusion syndrome than dichorionic twins C buy 10mg rizatriptan with mastercard. She should be delivered by caesarean section as there is a risk of cord entanglement E. She will not be able to have any sort of screening for Down syndrome Answer [ ] 3. She has a history of severe migraine that she has consulted you about before several times. Fundal height is irrelevant as poor growth will not be apparent at this early gestation B. If her blood pressure is 125/80 mmHg the diagnosis cannot be pre-eclampsia 38 03:11:03 06 39 C. The diagnosis cannot be pre-eclampsia because of the early gestation Answer [ ] 3. On examination it is obvious that her abdominal swelling is due to a pregnancy of about 36 weeks of gestation; fetal movements can be clearly seen and the fetal heart auscultated. She is no more likely to deliver a small-for-dates infant than mothers aged 20–30 C. You should involve the police because her pregnancy must be the result of rape Answer [ ] 3. At her 28-week checkup with the midwife she mentions that she has had a couple of minor episodes of vaginal bleeding following intercourse during the previous few weeks. Bleeding is unlikely to be caused by cervical cancer if her recent smear is normal C. She should be referred to consultant-led antenatal care for growth scans Answer [ ] 39 03:11:03 06 40 3. Her haemoglobin was 107 gm/L at booking and she takes ferrous sulphate 200 mg daily. She wishes to be absolutely reassured that the baby does not have Down syndrome as soon as possible because she feels that it would hamper her contribution to her husband’s career. She wishes to have a screening test for Down syndrome with the least false positive rate. Answer [ ] A Abruptio placentae B Appendicitis C Constipation D Pancreatitis E Pre-eclampsia F Red degeneration of a uterine fbroid G Torsion of an ovarian cyst H Ureteric calculus I Urinary tract infection J Uterine rupture These clinical scenarios relate to the emergency presentation of a pregnant woman with abdominal pain. At 32 weeks of gestation she is admitted to the obstetric unit with increasing pain in her abdomen for 3 days, which only responds to opiate analgesia. She was writhing about on the bed but the pain has now subsided following a dose of morphine. On admission, urinalysis reveals that there is a great deal of protein in her urine. Answer [ ] A Aim for vaginal delivery but with a shortened second stage B Await spontaneous labour and aim for vaginal delivery C Classical caesarean section D Elective caesarean section at 39 weeks of gestation E Elective caesarean section at 39 weeks of gestation and sterilisation F Elective caesarean section at 40 weeks of gestation G Emergency caesarean section H Induction of labour at 38 weeks of gestation and aim for vaginal delivery I Offer external cephalic version and await spontaneous labour J Offer external cephalic version and, if successful, induce labour 42 03:11:03 06 43 The following scenarios relate to a woman with a complicated pregnancy or underlying medical condition. Serial scans show that the baby is well grown but at 37 weeks the ultrasonographer notes that the fibroid in the lower segment has grown to 8 cm diameter and the baby is lying transversely above it. She is on antiretroviral medication and her viral load is extremely low at < 50 copies per ml. Scan confirms that the baby is of average size and the presentation is flexed breech. Her craniotomy wound has healed well and she is now 36 weeks of gesta- tion in her first pregnancy. Answer [ ] A Admit immediately to a psychiatric ‘mother and baby’ unit B Advise that depression is common and resolves after delivery C Advise that she should stop medication as it can harm the baby D Arrange specialist counselling E Ask a psychiatric liaison worker to visit at home F Continue medication and seek psychiatric advice G Recommence psychiatric medication immediately H Refer back to her previous psychiatrist I Routine opinion from a specialist obstetric psychiatric clinic J Suggest that she considers short-term use of sleeping tablets K Suggest that she takes an antidepressant L Urgent opinion from a specialist obstetric psychiatric clinic 43 03:11:03 06 44 The following scenarios relate to psychiatric problems in pregnant women. She has been off medication for many years and has been psychiatrically well since. The husband reveals on the telephone that his wife has not slept since the baby was born and is making bizarre comments about the health of the baby. Her psychiatric liaison worker has left a written care plan in her obstetric notes. She gives a history of postnatal depression that involved several months of in-patient care following her previous delivery. Initially there was some minor abdominal pain, but this has settled and there is no uterine activity. The uterus is nontender and the baby is well grown but appears to be lying transversely. There are no contractions and the condi- tion of both the mother and the baby is stable. An ultrasound scan confirms that the baby’s abdominal circumfer- ence is on the tenth centile of the growth chart and the liquor volume is less than expected. Answer [ ] A Candida albicans B Chlamydia trachomatis C Escherichia coli D Gardnerella vaginalis E Gonococcus F Group B streptococcus 45 03:11:03 06 46 G Listeria monocytogenes H Parvovirus B19 I Rubella J Streptococcus faecalis K Toxoplasma gondii The clinical scenarios that follow relate to women with infectious diseases in pregnancy. The community midwife refers her to hospital for an ultrasound scan, which shows polyhydramnios and fetal hydrops. On examination she is flushed, has a tachycardia of 100 bpm, and has a tem- perature of 38°C. Speculum examination reveals a florid ectropion with contact bleeding on taking swabs. On speculum examination there is a thick, white discharge adherent to the vaginal walls. Several children in her class have ‘slapped cheek syndrome’ at the start of term and when she comes to hospital for her routine anomaly scan her baby is found to be hydropic. Answer [ ] 46 03:11:03 06 47 Curriculum Module 4 Management of Labour and Delivery Syllabus You will be expected to have the knowledge, understanding, and judge- ment to be capable of initial management of intrapartum problems in a hospital and in a community setting. You will need to demonstrate appropriate knowledge of regional anaesthesia, analgesia, and operative delivery including caesarean section. This part of the exam will be much easier if you have worked on a labour ward since you were a medical student. In the last pregnancy she had a very slow first stage of labour and got stuck at 9 cm dilatation.

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