Labor Pains

Labor pains may be:

1) True Term Labor: more than or equal to 37 weeks, Cervical dilatation and effacement, Ruptured membranes.
2) True Preterm Labor: less than 37 weeks, Cervical dilatation and effacement, Ruptured membranes.
3) False Labor: less than 37 weeks, NO cervical dilatation or effacement, NO ruptured membranes.

True Preterm Labor is managed as follows:

Mother and fetus stable: Bed rest, Fluids, Cervical Culture, Steroids if less than 34 weeks , Antibiotics if ruptured membranes occurred more than 18 hrs ago.
Mother and/or fetus are unstable: terminate.

ABORTION

Abortion may be:

1) THREATENED ABORTION:
the patient has lower abdominal cramps, minimal vaginal spotting, closed cervix, DO an US to check fetal life activity (fetus is alive in threatened abortion). This is to differentiate it from missed abortion which presents with the same presentation but US will show a dead fetus. MANAGE conservatively with home bed rest and follow up with US after one week of diagnosis.

2) MISSED ABORTION:
the patient says that she doesn't feel fetal kicks. Uterus no longer grows, brownish vaginal discharge, milk secretion, closed cervix. DO an US (it shows dead fetus with no cardiac activity). Screen for DIC. If gestational age is less than 16 weeks, do D&C. If gestational age is more than 16 weeks, we can do vaginal delivery with oxytcoin. IMMEDIATELY search for a cause to prevent recurrence of fetal death in next pregnancies.

3) INEVITABLE ABORTION:
the patient presents with lower abdominal cramps, vaginal bleeding, open cervix, concepus is totally INTRAUTERINE. The patient doesn't claim any tissue that dropped down. Do suction & curettage.

4) INCOMPLETE ABORTION:
the same as for inevitable abortion but some of the conceptus is outside the uterus and the remainder is retained inside. Do suction & curettage.

5) COMPLETE ABORTION:
the patient has dropped out all parts of conceptus outside the uterus and the cervix closed. NOTHING is needed EXCEPT a follow up with B-hCG not to miss intrauterine parts.

ATTENTION

ALL patients who are Rh negative and not sensitized MUST receive Anti-Rh (RhoGAM) after each type of abortion

Pain With Pregnancy

Causes of abdominal pain with pregnancy:

1) Placental abruption:

The patient presents with severe abdominal pain with (revealed PA) or without (concealed PA) vaginal hemorrhage. The uterus is typically HYPERTONIC. Do an US. usually think about DIC and Hemorrhagic shock as complications. risk factors include: maternal hypertension, cocaine abuse, trauma, folate deficiency, short cord, sudden amnios decompression. If the mother and fetus are stable and fetus is at term, deliver immediately usually C.section. If not, stabilize the patient, if not stabilized, terminate.

2) Uterine rupture:

The patient presents with severe abdominal pain after which she feels reliefed. The most important risks are trauma and vertical uterine scar. The patients feels giving way. The fetal parts can no longer be felt. vaginal hemorrhage may be present. The treatment is according the patient's need for further fertility. If she doesn't seek fertility, TAH is indicated. If she needs to preserve her uterus, surgical repair is the treatment of choice.

3) Ectopic pregnancy:

The patients has abdominal pain, hemorrhage, amenorrhoea, adnexal mass, BhCH fail to double after 24 hr, do a TVUS and BhCG.

Patient is unstable: laparotomy.

Stable and no containdication for methotrexate (see later), give IM methotrexate.

Stable and there are contraindication for mthx: laparoscopic procedures involving the tube

Indication for methotrexate use:

nonviable nonruptured sac <>

contraindication for methotrexate use:

viable ruptured bleeding sac > 3cm, B-hCG >3000.

4) Abortion

5) Labor

Parkinsonism Treatment Strategy

Patients with Parkinsonism typically present with triad of rigidity, static tremors, bradykinesia. Important other signs: mask like face, shuffling short stepping gait, lewy-body dementia. The treatment of parkinson disease depends greatly on the extent of functional ability and age of the patient:

The patient has limited life activity due to his disease:

Mainly with bradykinesia

                Old patients: L-dopa

                Young patients: Bromocrptine

Mainly with tremors and/or rigidity: 

                Benzotrpine

The patient has normal life activity:

Amantadine or nothing.

To prevent the progression of the disease:

selegine.

Antibiotics for MENINGITIS..

Any patient who presents with symptoms/signs of meningitis should undergo a lumbar puncture (LP) and immediately begin empirical antibiotic therapy while pending LP results for culture and examination. However, A CT scan is mandatory before LP if there's a history of focal signs, altered sensorium, seizures or intracranial mass to avoid herniation. 

Empirical AB therapy is as follows:

-Neonates: cefotaxime + ampicillin

-Older children & adults: ceftriaxone + vancomycin

-Immunosuppressed: ceftriaxone + vancomycin + ampicillin

-Post-neurosurgery,  hospital acquired meningitis, head injury &

  CSF shunt: ceftazidime + vancomycin

Once results are obtained:

-Streptococcal: ceftriaxone +  vancomycin

-Meningococcal: penicillin G, ceftriaxone, rifampicin

-H.influenza: ceftriaxone, cefotaxime

-Staphylococcal: Methicillin-sensitive: naficillin or oxacillin. MRSA/S.epidermidis: vancomycin

-Cryptococcal: IV Amphotericin B for 14 days and oral fluconazole in HIV for life

-TB: Rif+INH+PTB+ETB or STM for 2 months and then Rif+INH for the next 4 months. 

-Viral meningoencephalitis: IV Aciclovir for 10 days.

STEROIDS are important in H.flu, children, TB meningitis & TB serositis.

Ampicillin is added whenever possible to cover Listeria which is common in neonates, elderly & immunocompromised persons.

Penicillin-allergic patients can take chloramphenicol.

TUBERCULIN TEST (PPD)

Tuberculin test is used as a tool to screen for high risk patients susceptible to TB. It's done by intradermal injection of purified protein derivative of the M.tuberculosis (PPD is another name of the test) that enhances the cell-mediated immunity and results in both induration & erythema. The result of the test are recorded according to the diameter of induration after injection not erythema. The test is said to be positive (i.e. the patient is of a high risk to acquire TB) if the induration diameter is:

1- More than or equal to 5 mm in:

Persons who are close contacts to TB patients.

Persons with CXR suggestive of lung fibrosis.

Patients with HIV-AIDS.

Patients under immunsuppression: Chronic steroid therapy, Chemotherapy, Blood malignancy, Rheumatoid arthritis, Crohn's disease.

2-More than or equal to 10 mm in:

Immigrant persons from endemic areas.

Patients with Selicosis.

Patients with comorbid disorders: Diabetes Mellitus, COPD, Heart Failure, Renal Impairment... 

Health care workers: doctors, nurses, cleansing workers.

3-More than or equal to 15 mm in:

Normal individuals.

Negative test means the diameter of induration is less than 2 mm.

All patients with a positive PPD should have a CXR.

If the CXR is normal, so the patient may have 'latent' TB. The patient should receive a 9 months course of INH + Vit B6. If the CXR is abnormal, get 3 successive sputum samples if positive, give AntiTB medications (rifampicin, INH, Pyrizenamide, ETB for 2 months and then 4 months only with rifampicin and INH). If negative treat as latent TB.

Don't forget: Vit B6 is essential with INH to prevent peripheral neuropathy.

PNEUMOMEDIASTINUM

A CXR showing Pneumomediastinum: note the air around the heart.

This patient had severe episodes of vomiting that have been complicated with hematemesis after binging a lot of alcohol cans (Mallory-Weiss Syndrome). As a result of these vigorous vomiting episodes, the esophagus ruptured (Boerhaave Syndrome). The most usual CXR finding of this case is left-sided pleural effusion however, pneumomediastinum may happen due to air tracking in the mediastinum (as in this case). Other cause of pneumomediastinum are trauma, pneumothorax, rupture of bronchi. It may be associated with subcutaneous emphysema in which air trackles in the subcutaneous tissue and is usually conservatively treated unless due to perforated airway in which fiberoptic bronchoscope is indicated.

DON'T forget: Stabilizing the patient and ABC are the most important initial lines of management. Treatment of rupture esophagus is basically surgical.

COMPARTMENTAL SYNDROME (CS).

Typical presentation of the COMPARTMENTAL SYNDROME (CS):

The patient presents with severe pain out of proportion to tenderness that increases with passive extension of the wrist & fingers , parasthesia, pulselessness, blistering and gangrene. Usually, loss of pulse is the latest sign to happen. Pain on passive extension of the wrist is almost diagnostic of CS. 

NOTE: the typical hand position: flexion of the wrist and interphalangeal joints with extension of the metacarpophalangeal ones with the forearm in supination.

EMERGENCY: the CS is a surgical emergency that must be treated immediately with fasciotomy.

DIVERTICULOSIS.

NOTE: the small outpouchings of the colonic wall. 3 important clinical presentations are on the board:

1) Painful Diverticulosis: simple pain and discomfort in the left lower quadrant (LLQ).

 The patient is completely normal. Barium enema can be performed but colonoscopy is the imaging tool of choice. Treated with high fiber diet (bran).

2) Mild Acute Diverticulitis: acute pain in the LLQ with mild tenderness. Still there is no fever or leukocytosis. Managed the same way as for painful diverticulosis.

3) Severe Acute Diverticulitis: severe acute pain in the LLQ with marked tenderness. The patient is feverish, toxic and has a high leukocytic count. Stool may be positive for blood. CT is the investigation of choise (colonoscopy & Barium enema are CI due to high risk of perforation). Treated at hospital with IV antibiotics (Augmentin, Ticarcillin, Imipenems, 3rd generation CS, Quinolones..)

PRE-ECLAMPSIA.

Two important clinical categories of pre-eclampsia are defined:

(A) Mild Pre-eclampsia: the only pertinent physical findings are BP<160/110>(B) Severe Pre-eclampsia: A more severe form in which BP equals or exceeds 160/110 mmHg. Symptoms of severity are usually present e.g. headaches, blurred vision, abdominal pain and marked LL edema. In severe cases HELLP syndrome may be seen (hemolysis, elevated liver enzymes, low platelets). Renal impairment also maybe present. Before anything to do, try to stabilize the patient with bed-rest and IV antihypertensive drugs (hydralazine), If the patient responded well and the blood pressure goes down, do the same as for mild pre-eclampsia. If not, prompt vaginal delivery is a must unless CS is indicated for other causes.

As regard MgSO4, in the mild form: it's given only intrapartum and for 24 hrs after delivery. In the severe form: it's given from the moment of admission till 24 hrs after delivery.

As regard the mode of delivery in patients with mild or severe pre-eclampsia, vaginal delivery is the role unless C.section is obstetrically indicated.

ME

Mehmet II Kaphoury

Also Muhammad Al-Kaphoury. Mehmet II Kaphoury.. is the second person carrying the name of Muhammad in his paternal family "Al-Kaphoury's". Born in Al-Mataryyia, Cairo, Egypt on Tuesday, 9th of November 1982. He has graduated from Ain Shams Medical School in December 2006 and works as a resident doctor in the radiodiagnosis department of Ain Shams Medical School Hospitals. 

Early Life

Kaphoury was born in Al-Mataryyia district of Cairo, the major city and capital of Egypt. He was born on Tuesday, the ninth of November, 1982. It has been postulated that Al-Kaphoury's aren't originally Egyptians however some of the early ancestors of that Family were descendants of Moroccan origin. Some other postulations assure that this family has some Indian or Pakistani descendece. 

In The Preliminary School

Mehmet stayed a period of 5 years in Refaa Al-Tahtawi Preliminary School which he considers not to be the happiest period of his life. He ascertains that "he didn't love to go to kindergarten or school" because he actually " didn't find the environment he ever dreamed of." Mehmet was not that excellent student at school. Because he hated this environment he couldn't cope up with it and thus couldn't do a much big business. Mehmet had also some educative problems that was attributed to his being not interested in his school not because of some mental illness. He tends to be alone always and have a few intimate friends. He said with humor "I think I had some kind of autism once a day but I could never know that until I had it in my psychiatric lessons. However, people with autistic disorder suffer a little bit of mental problems that I have never got.". In this period specifically, Kaphoury was almost exclusively fond of drawing. He has been well known for his beautiful and amazing works for an age he was. He was also fond of Islamic architecture especially mosques. The first mosque he drew was Muhammad Ali's Mosque (the Citadel mosque) which he depicted from a 20 Egyptian pounds paper.  

In The Preparatory School

Kaphoury stayed 3 years in the preparatory stage. One year in Al-Shahid Atif Al-Askari School for Boys and the next 2 years in Maysara Preparatory School for Boys. He has been moving between schools even in the Secondary school.