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By A. Tuwas. Morris College.

As stressed earlier buy sildenafil 100mg line erectile dysfunction icd 9 code, self-reporting is preferred and should be employed whenever appropriate order genuine sildenafil online erectile dysfunction caused by supplements. Because many factors other than pain can alter physiologic parameters purchase sildenafil now impotence beta blockers, measuring these is the least reliable way to assess pain buy 50 mg sildenafil amex intracavernosal injections erectile dysfunction. Verbal Children For children who can verbalize and are older than 4 years, self-reporting is the most reliable way to assess pain. These include (1) fear that revealing their pain will lead to additional injections and other painful procedures, (2) lack of awareness that we can help their pain go away, (3) a desire to protect their parents from the knowledge that their cancer is getting worse, and (4) a desire to please. Because the self-report may conceal pain, it can be helpful to supplement the self-report with behavioral observation (see later). Preverbal and Nonverbal Children Because preverbal and nonverbal children cannot self-report pain, a less reliable method must be used for assessment. Behavioral cues suggesting pain include vocalization (crying, whining, groaning), facial expression (grimacing, frowning, reduced affect), muscle tension, inability to be consoled, protection of body areas, and reduced activity. The biggest drawback to behavioral observation is the risk for a false- negative conclusion. That is, a child may be in pain although his or her behavior may lead the observer to conclude otherwise. Similarly, although sitting quietly might indicate comfort, it could also mean that moving and talking are painful. When behavioral observation leaves doubt about whether the child is in pain, a trial with an analgesic can help confirm the assessment. Treatment Therapy of cancer pain in children is essentially the same as in adults. As in adults, drugs are the cornerstone of treatment; nondrug therapies are used only as supplements. More invasive routes should be reserved for patients who cannot take drugs by mouth. Children generally object to rectal administration and may refuse treatment by this route. Neonates and infants are highly sensitive to drugs and hence must be treated with special caution. Because of heightened drug sensitivity, neonates and infants are at increased risk for respiratory depression from opioids. Accordingly, when opioids are given to nonventilated infants, the initial dosage should be very low (about one third the dosage employed for older children). Furthermore, use of opioids should be accompanied by intensive monitoring of respiration. Opioid Abusers When treating cancer pain in opioid abusers, we have two primary obligations: we must try to (1) relieve the pain and (2) avoid giving opioids simply because the patient wants to get high. Because of the challenge, treatment should be directed by a clinician trained in substance abuse as well as pain management. Remember, abusers feel pain like everyone else and therefore need opioids like everyone else. Clinicians must take special care not to withhold opioids because they have confused relief-seeking behavior with drug-seeking behavior. Hence, if the patient tells us that pain is persisting, adequate doses of opioids should be provided. Because of opioid tolerance, initial doses in abusers must be higher than in nonabusers. To estimate how high the initial dosage should be, we must try to estimate the existing degree of tolerance by interviewing the patient about the extent of opioid use. However, because regulations limit the dosage of methadone that drug-abuse clinics can dispense, the increased dosage required to manage pain will have to come from another source. One group of opioids—the agonist-antagonists—will precipitate withdrawal in opioid abusers and hence must never be prescribed for these patients. Patient Education Patient education is an integral part of cancer pain management. When education is successful, it can help reduce anxiety, dispel hopelessness, facilitate assessment, enhance compliance, decrease complications, provide a sense of control, and enable patients to take an active role in their care. General Issues Common sense tells us that patient education should be accurate, comprehensive, and understandable. To reinforce communication, information should be presented at least twice and in more than one way. Major topics to discuss are (1) the nature and causes of pain, (2) assessment and the importance of honest self-reporting, and (3) plans for drug and nondrug therapy. Patients should be encouraged to express their fears and concerns about cancer, cancer pain, and pain treatment—and they should be reassured that pain can be effectively controlled in most cases. To facilitate ongoing education, patients should be invited to contact care providers whenever they feel the need—be it to discuss specific concerns with treatment or simply to acquire new information. Finally, patients should know when and how to contact the prescriber to report treatment failure, serious side effects, or new pain. Drug Therapy The goal in teaching patients about analgesic drugs is to maximize pain relief and minimize harm. To help achieve this goal, patients should know the following about each drug they take: • Drug name and therapeutic category • Dosage size and dosing schedule • Route and technique of administration • Expected therapeutic response and when it should develop • Duration of treatment • Method of drug storage and disposal • Symptoms of major adverse effects and measures to minimize discomfort and harm • Major adverse drug-drug and drug-food interactions • Whom to contact in the event of therapeutic failure, severe adverse effects, or severe adverse interactions The dosing schedule should be discussed. When pain is persistent, as it is for most patients, the objective is to prevent pain from returning. Fears based on misconceptions about opioids can impair compliance and can thereby impair pain control. The misconceptions that influence compliance the most relate to tolerance, physical dependence, addiction, and side effects. To correct these misconceptions, and thereby dispel fears and improve compliance, the following topics should be discussed: • Tolerance—Some patients fear that, because of tolerance, taking opioids now will decrease their effectiveness later. Hence, to help ensure pain relief in the future, they limit opioid use now and thus suffer needless pain. These patients should be reassured that, if tolerance does develop, efficacy can be restored by increasing the dosage; tolerance does not mean that efficacy is lost. This fear is based largely on the misconception that physical dependence (which eventually develops in all patients) equals addiction. Patients should be taught that physical dependence is not the same as addiction and that physical dependence itself is nothing to fear. In addition, they should be taught that the behavior pattern that constitutes addiction rarely develops in people who take opioids in a therapeutic setting. These patients should be reassured that, when used correctly, opioids are both safe and effective. With all of the adjuvants, the objective is to complement the effects of opioid and nonopioid analgesics. Furthermore, because the drugs we use as adjuvants were originally developed to treat disorders other than pain, the rationale for prescribing specific adjuvants should be explained. For example, when imipramine is prescribed, the patient should understand that the objective is to relieve neuropathic pain and not depression, the disorder for which this drug was originally developed. Under the standards, accountability for pain management is shifted from individual practitioners to the institution as a whole. Compliance is mandatory: health care organizations that fail to meet the standards will lose accreditation. Loss of accreditation would mean loss of insurance reimbursement and would disqualify teaching hospitals from offering training programs. It should be noted that the standards are not a guideline on how to treat specific kinds of pain. Rather, they focus on (1) the rights of patients to receive appropriate assessment and management of pain and (2) ways for institutions to establish a formalized, systematic approach to pain management that involves interdisciplinary teams whose members have clearly identified responsibilities. Specific provisions include the following: • Institutions must recognize assessment and management of pain as a right of all patients. Many of the drugs considered here are discussed in other chapters, so discussion in this chapter is limited to ophthalmologic applications. Drugs for Glaucoma Glaucoma refers to a group of diseases characterized by a decrease in peripheral vision secondary to optic nerve damage. The most common forms of glaucoma are primary open-angle glaucoma and acute angle-closure glaucoma. Of the 120,000 Americans blinded each year by glaucoma, 90% could have saved their sight with timely treatment. Unfortunately, many afflicted persons are unaware of their condition: of the 4 million Americans with glaucoma, only 50% are diagnosed. From there it circulates around the iris into the anterior chamber and then exits the anterior chamber through the trabecular meshwork and canal of Schlemm. Pathophysiology and Treatment Overview P a t i e n t E d u c a t i o n Glaucoma • It is important to take the prescribed medications according to schedule. If days are skipped or if prescriptions are not refilled, loss of vision may occur. Allow at least 15 minutes to elapse between administration and insertion of the lenses. Management is usually initiated by specialists; however, primary care providers often play a role in ongoing monitoring and follow-up of patients taking these medications. Other options —cholinergic drugs and carbonic anhydrase inhibitors—are considered second- line choices. All of the antiglaucoma drugs are available for topical administration, which is the preferred route. Because all of these drugs are applied topically, systemic effects are relatively uncommon. Nonetheless, serious systemic reactions can occur if sufficient absorption takes place. Angle-Closure Glaucoma Angle-closure glaucoma is precipitated by displacement of the iris such that it covers the trabecular meshwork, thereby preventing exit of aqueous humor from the anterior chamber.

For most patients wit h jaundice buy sildenafil in united states online erectile dysfunction drugs otc, it probably is more clinically useful to think about hepat ic or biliary diseases that cause conjugated (direct) hyperbilirubinemia generic sildenafil 100mg erectile dysfunction icd 9 code, because they represent the most clinically important causes of jaundice buy discount sildenafil 50mg on-line erectile dysfunction foods to eat. The term unconjugated (indirect) hyperbilirubinemia is used when the conju- gat ed (or d ir ect -r eact in g fr act ion ) d oes n ot exceed 15% of the t ot al bilir u bin sildenafil 75mg on-line impotence cream. In t hese condit ions, t he serum bilirubin level almost always is less t han 5 mg/ dL, and there are usually no other clinical signs of liver disease. In addition, there should be no bilirubinuria (only conjugated bilirubin can be filtered and renally excreted). Hemolysis usually is clinically apparent, as in sickle cell disease or aut oimmune hemolyt ic anemia. Gilbert syndrome is a ben ign condit ion caused by a deficiency of h epat ic enzymat ic conju gat ion of bilir u bin, wh ich r esu lt s in in t er m it t en t u n con ju gat ed h yp er bilir ubi- nemia. Total bilirubin is usually less than 4 g/ dL, and is often precipitated by events such as st ress, fast ing, and febrile illnesses. Conjugated (direct) hyperbilirubinemia almost always reflects either hepatocel- lu lar disease or biliar y obst r u ct ion. T h ese t wo con dit ion s can be different iat ed by the pattern of elevation of the liver enzymes. The serum alkaline phosphat ase level is elevated in cholest at ic disease as a consequence of inflammation, dest ruction, or obstruction of the intrahepat ic or extrahepatic bile ducts with relative sparing of the hepatocytes. Table 27– 1 sum- marizes the liver test patterns seen in various categories of hepatobiliary disorders. The patient discussed in this case has a pattern consistent with cholestasis, and the first diagnostic test in a patient with cholestasis usually is an ultrasound. It is noninvasive and is very sensitive for detecting stones in the gallbladder as well as int rahepat ic or ext rah epat ic biliary duct al dilat ion. The most common cause of bili- ary obstruction in the United States is gallstones, wh ich may become lodged in the i 2 _ 5 3 2 cancer) vitamin K glutamyl transpeptidase 2 1 2 _ 1 2 8 Ac u t e h e p a t o ce llu la r Bo t h fr a c t io n s m a y b e Ele v a t e d, o f t e n No rm a l t o < 3 t im e s n o rm a l No rm a l Usu a lly n o rm a l. If > 5 t im e s Ch ro n i c h e p a t o c e l l u l a r Bo t h fr a c t io n s m a y b e e le v a t e d. Ele v a t e d, b u t u s u a lly No rm a l t o < 3 t im e s n o rm a l Often Often p rolonged ; fails to d o cholestasis (obstructive Bi li r u b i n u r ia. No acute heart failure) suggests poor prognosis hepatitis, hepatotoxins, aminotransferases. H owever, obst r u ct in g st on es cau sin g jau n d ice u su ally are associ- ated with epigast ric or right upper quadrant colicky pain. Two import ant primary biliary condit ions are primary scleros- ing cholangitis and primary biliary cirrhosis. The complications of biliary obstruction include development of acute cholangi- tis as a result of ascending infection, or secondary hepatic cirrhosis, if the obstruc- tion is chronic or recurrent. The patient in this case scenario has painless jaundice, liver enzymes con sist ent wit h a ch olest at ic process, and light -colored st ools, sug- gest in g obst r u ct ion of bile flow int o the in t est in e. Becau se h e h as n o h ist or y of abdominal or biliary surgery t hat might have caused a st rict ure, malignancy is the most likely cause of his biliary obstruction. Endoscopic ultrasound with fine-needle aspiration of the pancreas is highly accurate in establishing a tissue diagnosis. Pancreatic cancer is the fifth leading cause of cancer death in the United States. Peak incidence is in the seventh decade of life, with two-thirds of cases occurring in persons older t han 65 years. Clinically apparent metastatic disease is found in 80% of patients at the time of diagnosis. For patient s without obvious met ast ases, the best hope for cure is surgical resection by pancreaticoduodenectomy (W hipple procedure), which in experienced hands has a perioperative mortality rate less than 5%. Palliative measures may include common bile duct stenting to relieve the biliary obstruction. The patient’s laboratory results show a conjugated hyperbilirubinemia wit h evidence of hepatocellular disease (hypoalbuminemia, ascites). The patient’s laboratory results show a conjugated hyperbilirubinemia con sist ent wit h an obst r u ct ive pat t er n. Sh e h as the r isk fact or s for gallst on es (middle age, female, obese) and has symptoms of postprandial abdominal pain. T h e patient ’s lab o r at o r y r esu lt s sh ow an u n co n ju gat ed h yp er b ilir u b in em ia wit hout other abnormalit y. H e is otherwise healthy wit hout symptoms of syst emic disease or hemolyt ic anemia. T h e p a t i e n t ’s l a b o r a t o r y r e s u lt s s h o w a co n ju ga t e d h yp e r b i l i r u b i n e m i a w i t h an obst ruct ive pattern. The history is consistent with inflammatory bowel disease, which is associated with primary sclerosing cholangitis. Treatment options include stenting of the larger bile duct strictures and immunosuppression to slow the progression of the disease. He first noticed swelling around his eyes 2 days ago, along with difficulty putting on his wedding ring because of swollen fingers. Addition- ally, he noticed that his urine appears reddish-brown and that he has had less urine output over the last several days. His only medication is ibuprofen that he took 2 weeks ago for fever and a sore throat, which have since resolved. On examination, he is afebrile, with heart rate 85 bpm and blood pressure 164/98 mm Hg. He has periorbital edema; his funduscopic examination is normal without arteriovenous nicking or papilledema. H e is afebrile, hypert ensive, and has periorbit al edema but a normal funduscopic examination. H is cardiac, pulmonary, and abdominal examinat ions are normal, but he does have edema of h is feet, hands, and face. Co n s i d e r a t i o n s A young man without a significant medical history now presents with new onset of hypertension, edema, and hematuria following an upper respiratory tract infection. H e has no history of renal disease, does not have manifest ations of chronic hyper- tension, and has not received any nephrotoxins. If pr esent, t h ese are sign s of in flam mat ion an d est ab - lish the diagnosis of acut e G N. Although direct visu aliz at ion of a u r in e sam p le ( gr o ss h em at u r ia) or d ip st ick exam in at ion ( p osit ive blood) can be helpful, the diagnosis of hematuria is made by microscopic confirma- tion of the presence of red blood cells (microscopic hematuria). The breakdown products of muscle cells and red blood cells (myoglobin and hemo- globin, r esp ect ively) are h em e- con t ain in g comp ou n d s cap able of t u r n in g the color of urine dark red or brown in the absence of true hematuria (red blood cells). Hematuria can be classified into two broad categories: intrarenal and extrare- nal (Table 28– 2). Laborat ory analysis and imaging st udies oft en are necessary, and considering t he pot ent ial clinical implicat ions, the etiology of hematuria should be pursued in all cases. First, examination of the cellu lar u r in e sed iment can h elp t o differ ent iat e glom er u lar from n on glom er u - lar h emat uria. Second, the urine Gram stain and culture can aid in the diagn osis of in fect iou s h emat u r ia. T h ir d, the u r in e sample sh ou ld be sent for cytologic evaluation when the diagnosis of malignancy is suspected. Glo m e r u la r Dis e a s e Glomerular disease is encountered mainly in the form of two distinct syndromes: nephritic or nephrotic (or sometimes an overlap of the two syndromes). Nephritis (nephritic syndrome) is defined as an inflammatory renal syndrome that presents as hematuria, edema, hypertension, and a low degree of proteinuria (< 1-2 g/ d). Nephrosis (or the nephrotic syndrome) is a noninflammatory (no active sediment in t he urine) glomerulopat hy t hat causes heavy proteinuria. N ephrot ic syndrome is dist inguished by four features: (1) edema, (2) hypoalbuminemia, (3) hyperlip- idemia, and (4) prot einuria (> 3 g/ d). Glomerular injury may result from a variet y of insults and presents either as the sole clinical finding in a patient (primary renal disease) or as part of a complex syndrome of a systemic disorder (secondary glo- merular disease). For the purpose of this discussion, glom er u lon ep h r i t i s includes only the inflammatory glomerulopathies. Acute kidney injury, as manifested by a decrease in urine output and azotemia, results from impaired urine produc- tion and ineffective filtration of nitrogenous waste by the glomerulus. The presence of this constellation of signs in a patient makes the diagnosis of glomerulonephritis very likely. H owever, it is impor- tant to note that often patients present with an overlap syndrome, sharing signs of both nephritis and nephrosis. T h er efor e, con fir m at ion of the p r esu mp t ive d iagn osis of acu t e glom er u lon ep h r it is r equ ir es m icr oscop ic exam in at ion of a u r in e samp le from the suspect ed pat ient. The specific diagnosis can usually be established by clinical history and serologic evaluation, and often requires a kidney biopsy (Table 28– 3). Dia g n o st ic Ap p ro a ch t o Glo m e ru lo n e p h rit is The approach to the patient with glomerular disease should be systematic and undert aken in a stepwise fashion. The history should be approached met iculously, looking for evidence of preexist ing renal disease, exposure t o neph rot oxins, and especially any underlying syst emic illness. Once the appropriate serologic tests have been reviewed, a kidney biopsy may be required. Bot h illn esses can pr esent wit h G N occurring after an upper respiratory illness. In cont rast, IgA nephropathy may present with pharyngitis and glomerulonephritis at the same time. Tr e a t m e n t o f G l o m e r u l o n e p h r i t i s Treatment depends on the diagnosis of the glomerulonephritis, whether it is a primary renal disease or secondary to a systemic illness. H e is brought t o the emergency room disorient ed aft er collapsing on t he t rack. This in dividual is suffer ing from h eat exh au st ion, wh ich can lead t o rh ab- domyolysis and release of myoglobin.

There is no vaginal bleeding or history sugges- tive of ruptured membranes and fetal movements are normal buy sildenafil 75mg overnight delivery erectile dysfunction blood pressure medications side effects. On examina- tion the uterus is irregular order sildenafil with mastercard jacksonville impotence treatment center, large for dates cheap sildenafil 50 mg erectile dysfunction causes tiredness, and tender over the fundus order sildenafil australia purchase erectile dysfunction drugs. F Red degeneration of fibroid The salient feature here is her ethnic origin; fbroids are more common in African women, and the uterus is irregular. You will know from your revision that fbroids can undergo red degeneration in pregnancy even if you’ve never seen a case. Because the pain is continuous it makes the option of preterm labour unlikely even though it is a more common condition. The pain could be due to a concealed abruption but the whole uterus would be tender and abruption usually causes fetal distress. She gives a history of losing fluid per vaginam intermittently over the preceding 3 days. The pain is described as ‘generalised’ rather than intermittent (which might suggest option G – preterm labour). The small for dates uterus would ft with oligohydramnios due to ruptured membranes. On examination her blood pressure is 170/110 mmHg, pulse 100 bpm, and she is apyrexial. On abdominal palpation the uterus is hard and tender and the fetal heart cannot be detected. C Placental abruption The salient features in this case are the severe hypertension and proteinuria sug- gesting pre-eclampsia, the lack of fetal movements, and absent fetal heart suggest- ing an intrauterine death and the hard uterus suggesting the Couvelaire uterus of a large abruption. From your revision you know that abruption is a complication of pre-eclampsia and don’t be distracted by the absence of vaginal bleeding as even large abruptions can be concealed. A Await result of fetal anomaly scan at 20 weeks of gestation B Inform the woman that Down syndrome is confrmed C Inform the woman that Down syndrome is excluded D Inform the woman that the risk for this pregnancy is low E Nuchal translucency scan at 11–13 weeks of gestation F Offer amniocentesis G Offer chorionic villus sampling H Offer Cordocentesis I Serum screening at 15–17 weeks of gestation These clinical scenarios relate to women seeking prenatal testing for Down syn- drome. The quickest result would be obtained by chorionic villus sampling because active placental cells will be dividing quickly enough to obtain a karyotype within 24–48 hours. Cordocentesis is reserved for later in pregnancy to investigate seri- ous and rare conditions like fetal anaemia. She is concerned about the risk of having a baby affected by Down syndrome and wishes to have a diagnostic test with low- est possible risk of miscarriage. F Offer amniocentesis The patient wants a diagnostic test and the one with lowest risk of pregnancy loss is amniocentesis. She has serum screening only done for Down syndrome and the result shows a 1 in 5,000 risk of the pregnancy being affected. D Inform the woman that the risk for this pregnancy is low Screening tests do not exclude Down syndrome but this low risk result is reassuring. A Delivery by caesarean section at 37 weeks of gestation is recommended B Elective caesarean section carries less fetal risks than vaginal birth C Emergency caesarean section in labour is as safe as elective section D Induction of labour is contraindicated E Induction of labour is recommended at 40 weeks of gestation F Pregnancy could continue to await spontaneous labour G The risk of scar rupture/dehiscence in labour is 10 per cent H Vaginal delivery is contraindicated for maternal reasons I Vaginal delivery is only possible if expected fetal weight is <4000 g Each of these pregnant women is seeking advice about the management of her delivery. F Pregnancy could continue to await spontaneous labour The reason for her previous section is nonrecurrent so she should be able to have a vaginal birth this time. Spontaneous labour is preferable to induced labour in this situation because the drugs we use to induce labour – prostaglandin and oxytocin – increase the risk of scar rupture. Induction is not completely contraindicated, just less safe but you could induce if there were good maternal reasons, for example, pre-eclampsia. She is anxious because scan confirms a breech presentation and she refuses to consider external cephalic version. B Elective caesarean section carries less fetal risks than vaginal birth The best option is external cephalic version because it reduces the incidence of breech presentation at term. If she won’t accept this, then the ‘Term Breech Trial’ showed that section is safer for the breech baby than vaginal delivery. F Pregnancy could continue to await spontaneous labour Although this woman has had diffculty getting pregnant, she should now be treated like any other mother. A Anorexia nervosa The distracter is pregnancy, which is the most common cause of secondary amen- orrhoea in teenagers, but the normal examination makes this less likely. I Pregnancy The mass could be an ovarian cyst but a granulosa cell tumour of the ovary is more likely to cause irregular bleeding than amenorrhoea and in any case they are extremely rare. Haematocolpos can also present with a lower abdominal mass, but the patient would have primary amenorrhoea, not secondary. You note that she has been admitted to hospi- tal twice already during the previous 3 months with pain and suspect that she is avoiding school as exams are imminent. Her younger sister also has frequent episodes of pain but attained menarche recently at the age of 14 years. D Haematocolpos Imperforate hymen can cause cyclical pain as the haematocolpos gets bigger and it is not unusual to fnd a couple of hospital admissions have occurred before the diagnosis is reached. Many teenagers have anovulatory cycles but this causes irregular periods and menorrhagia rather than primary amenorrhoea. She sees a poster about chickenpox in pregnancy on the surgery wall and realises that she was exposed to a tod- dler with chickenpox 6 weeks ago at a birthday party. F Reassurance that no action necessary The incubation period for varicella is 1 to 3 weeks so she would have developed it herself by now. A personal history of chicken- pox is 99 per cent predictive of the presence of serum varicella antibodies, so this woman does not even need testing for zoster IgG levels. She did have some routine screening tests when she started her job 6 months ago but was not given any results. It is still not recommended as part of a national screening programme to check antibody status and vaccinate all women in the United Kingdom like we do for rubella, but some occupational health departments do undertake this in high- risk groups such as teachers. If a woman contracts varicella in pregnancy she can become very ill with serious problems such as pneumonia and, of course, we worry about fetal varicella syndrome and infection of the newborn. For each patient pick the most appropriate investigation given the clinical information provided. She is not yet sexually active and her mother had similar problems before starting a family. C Diagnostic laparoscopy If she is not sexually active she will not have pelvic infammatory disease so the most likely diagnosis here is endometriosis, especially as it can run in families. Laparoscopy is the gold standard investigation as scan will not show up small deposits of endometriosis. She mentions that she has experienced severe deep dyspareunia for several weeks and wishes to stop using Depo- Provera® as she has read that it can cause low estrogen levels, which she thinks is responsible for her problem. J Triple swabs It is more likely that she is suffering from pelvic infammatory disease as a cause of her symptoms rather than vaginal atrophy so triple swabs would be the frst investigation, especially as speculum examination would allow you to reas- sure her about the state of her vaginal skin at the same time. She does not need scan or laparoscopy unless her pain becomes chronic and a defnite diagnosis is necessary. Her symptoms have not responded to mebeverine, which one of your colleagues has prescribed recently. The next step is ultrasound, although there are many other conditions 264 09:38:04. A thorough history and examination is recommended to avoid missing other pathology such as infam- matory bowel disease. Select the most appropriate management plan for each woman based on the clinical information given. She tells you she is delighted to have discovered that she is about 8 weeks pregnant. Colposcopy within 4 weeks Although this woman will have to wait until after she has delivered for treatment, someone must look at her cervix urgently to make sure that she is not one of the women with severe dyskaryosis who has cervical cancer already. She has been recently assessed at the colposcopy clinic because of her second smear showed mild dyskaryosis. Urine or endocervical swab for chlamydia trachomatis screen One of the most common causes of postcoital bleeding in young women is chla- mydia. As her cervix has recently been inspected at colposcopy, the smear history is irrelevant. Routine smear for liquid-based cytology The family history is not relevant as cervical cancer is not genetic. However, this woman has reached the age at which she should be enrolled on the screen- ing programme and this seems like a good opportunity. Select the most appropriate investigation based on the clinical information given. J Urodynamics The diagnosis is likely to be either detrusor instability or genuine stress inconti- nence and urodynamics will help you differentiate between them. She is at risk of losing her job as she cannot continue to work in the fields on account of her symptoms. She is still menstruating regularly but wonders if she is menopausal because she has night sweats. C Flexible cystoscopy Smoking is a risk factor for transitional cell carcinoma of the bladder, which should be excluded frst before the incontinence is addressed, especially in view of the haematuria. A Arrange to see the woman on her own to ask her about domestic abuse B Arrange an independent translator and ask about domestic abuse C Ask the relatives if she is experiencing domestic abuse D Ask the community midwife to visit her at home E Contact the adult safeguarding team F Contact the police G Discuss child protection issues with the on-call social work team H Encourage the woman to confde in a close relative if she is being abused I Give the woman a card with contact numbers of agencies and refuges J Offer immediate admission to hospital You are concerned about the possibility of domestic violence in each of these women who are attending the hospital for antenatal care. Her 25-year-old boyfriend is also present to watch the scan and when she is asked questions (such as her address and date of birth) he supplies the answers. A Arrange to see the woman on her own to ask her about domestic violence 29 At 02. Speculum examination reveals a tear in the posterior vaginal fornix which is not actively bleeding and the cervix is healthy. J Offer immediate admission to hospital 30 A 26-year-old immigrant woman attends antenatal clinic at 34 weeks with her sister-in-law who translates for her, as she speaks no English at all. This is her first pregnancy and she is having growth scans on account of recur- rent ante-partum haemorrhage. The growth of the baby is fine, but when you are auscultating the fetal heart you notice some circular lesions on the maternal abdomen that look like cigarette burns.

The preferred localization modality varies based on local expertise and technologi- cal availabilit y buy sildenafil 100 mg visa importance of being earnest. When patients have biochemi- cally d ocu ment ed pr im ar y h yp er par at h yr oidism an d n on localized pat h ology by preoperative imaging buy sildenafil australia erectile dysfunction drugs without side effects, there is a higher probability parathyroid hyperplasia exists generic sildenafil 100mg fast delivery erectile dysfunction treatments herbal. These individuals may require more extensive parathyroid explorations buy 75mg sildenafil overnight delivery erectile dysfunction psychological causes, subtotal parathyroidectomy, and have a lower chance of cure. It is important to have more ext ensive discussions of risks and benefit s prior t o t he planning surgery in t hese patients. With unilateral parathyroid exploration or the minimally invasive approach, int raoperat ive parat hyroid h ormone assay is generally used t o verify removal of the parathyroid gland responsible for hyperparathyroidism. Published results show that a greater than 95% cure rate can be expected for primary hyperparathyroidism wh en parat hyroid explorat ion is performed by an experienced surgeon aft er obt ain- ing appropriat e preoperat ive evaluat ions and localizat ion studies. W hich of the following serum tests is most likely to establish the cause of her hypercalcemia? E n - b lo c left p ar at h yr o id ect o m y an d t h yr o id lo b ect o m y wit h r em o val of adjacent soft t issue C. A sestimibi scan is a localizat ion st udy most useful t o localize the parat h yroid adenoma prior t o operative resection. Malignancy is the most common cause of hypercalcemia encountered in patients in the in-patient setting, particularly when hyperparathyroidism is ruled out. Familial hypocalciuric hypercalcemia, medications, and sarcoidosis are all less common causes of hypercalcemia. N ephrogenic diabetes insipi- dus is not a cause of hypercalcemia but can be seen in patients with hyper- parathyroidism, as increased serum calcium inhibits the kidneys’response to ant idiuret ic hormone. Kidney stones are the most common metabolic complication associated wit h hyperparathyroidism, occurring in 15% to 20% of pat ient s wit h t he disease. Hyperparathyroidism is associated with a high secretion of calcium in urine (hypercalcinuria), low serum phosphate, high serum chloride, and low serum bicarbonate levels. Increased serum creat inine is generally not seen in pat ient s wit h primary hyperparat hyroidism unless t h ere is damage t o t he kidneys from long-standing nephrocalcinosis. Elevated creatinine or chronic renal insufficiency causes increased serum phosphorous and lead to the increase in P T H levels (secondary hyperparat hyroidism). This patient with nonlocalized primary hyperparathyroidism likely has parathyroid hyperplasia. The procedures of choice are subtotal parathyroid- ect omy (3½ gland removal) or t ot al parat hyroidect omy wit h forearm reim- plantation of ½ of a gland to prevent postoperat ive hypoparathyroidism. Surgical treatment involves unilateral parathyroidectomy, and thyroid lobec- tomy with en-bloc resection of adjacent lymph nodes and soft tissue to pre- ven t r ecu r r en ce. The best treatment fo r p rim a r y h yp e rp a ra t h yro id ism is su rg ica l p a ra t h yro id e c t o m y. Th i s s u r v i v a l a d v a n t a g e i s m o s t n o t a b l e i n y o u n g e r p a t i e n t s ( a g e < 5 0 ). Surgery or surveillance for mild asymptomatic primary hyper- parathyroidism: a prospective, randomized clinical trial. G u id elin es for the m an agem ent of asympt om at ic pr im ar y hyperparathyroidism: statement from the fourth international workshop. What symptom improvements can be expected after operation for primary hyperparathyroidism? Her symptoms are worse in the morning and at the end of her work shifts, but seem to improve after eating. The results of her physical examination are unremarkable, but she has an isolated serum glucose of 44 mg/dL. Most likely diagnosis: In su lin oma is ver y likely wit h this con st ellat ion of symp - toms that worsens with fasting and improves with ingestion of glucose. Confirmation of diagnosis: 72-hour fasting glucose levels demonstrate low blood sugars with onset of symptoms. Recognize the constellation of clinical signs and symptoms of functional pan- creat ic endocrine neoplasms. Understand the diagnosis and management principles of pancreatic endocrine neoplasms. Co n s i d e r a t i o n s T his 37-year-old nurse has symptoms of hypoglycemia, which is confirmed with a markedly low serum glucose level. Because of the numerous nonspecific symptoms cau sed by low blood su gar, man y pat ient s are in cor r ect ly clin ically d iagn osed wit h hypoglycemia. The signs and symptoms include shakiness, nervousness, irritabil- it y, hunger, diaph oresis, clumsiness, light h eadedness, weakness, and confusion. Sequelae of hypoglycemia can be severe and may result in seizures, coma, and death. Once hypoglycemia has been confirmed, etiologies should be determined to facilitate immediat e t herapy. The most common cause is t he use of oral diabet es mellitus medications such as sulfonylureas. Among the many causes of low blood sugar, exogenous administ rat ion of insulin must be ruled out in t he workup of a low- serum glucose. The diagnosis of an insulinoma is confirmed through biochemical workup wh ich may require a 72-h our fast. Result s reveal a blood glucose below 50 mg/ dL in t he sett ing of elevat ed insulin and C-pept ide levels. Elevat ed insulin wit h nor- mal C-peptide levels indicate exogenous use of insulin, and patients should be ch ecked for u se of or al h yp oglycem ic agent s wh ich can r esu lt in h igh in su lin levels and low serum glucose. Following confirmat ion of t he diagnosis of an insulinoma, localizat ion and st aging are performed t o det ermine the mult idisciplinar y t reat - ment plan. The majorit y are located in t he gast rinoma t riangle ( junct ion of the cyst ic duct and common bile duct, 2nd t o 3rd port ion of the duodenum, junct ion of head and neck of pancreas). Clinical manifestations include diabetes, cholelithiasis, steatorrhea, hypochlorhydria, and obstructive jaundice. In this t riad, a pat ient must demonst rat e (1) symptoms consistent with hypoglycemia, (2) low plasma glucose measured at the time of symptoms, and (3) resolution of symptoms when glucose levels are cor r ect ed. Dia g n o sis Pancreatic endocrine neoplasms present primarily as incidental findings on imag- ing, as an obst ruct ive pancreat ic mass, or by a const ellat ion of sympt oms associ- ated wit h t he pancreat ic endocrine overproduct ion. D iagnoses are generally obt ained by combinat ion of characteris- tic clinical syndromes and detection of hormone elevations. Wo r k u p Preoperative imaging has become an integral component of the workup and man- agement of pancreat ic endocrine neoplasms. Although there is no single best modality for the various types of lesions, the preferred initial imaging technique is a high-resolut ion comput ed t omography scan. Alternative techniques include magnetic resonance imaging, somatostatin receptor scintigraphy, endoscopic and intraopera- tive ultrasound, or venous sampling. Multimodality treatment includes the use of surgery, ablative procedures, chemotherapy, and biotherapeutics. H er fast ing blood glucose is 42 mg/ dL, C-peptide and urine sulfonyl- ureas are normal. H er stool sample is negative for ova and parasites, but her chemistry reveals a low potassium. This h ealt h car e wor ker h as a fact it iou s d isor d er, an d sh e h as b een in ject - ing insulin. The normal C-pept ide indicates an exogenous source of insulin rather than an insulinoma. U p t o 7 5 % of en d o cr in e n eo p lasm s d evelo p m et ast ases t o the liver d ep en d - ing on t ype. Surgical resect ion is t he t reat ment of choice when feasible but is not indicated with extensive bilobar disease. Radiofrequency ablat ion of liver lesions provides sympt omat ic relief in a large percent age of pat ient s wit h adequate survival. Gastrinoma or Zollinger-Ellison syndrome frequently presents with diarrhea and refractory peptic ulcer disease. Failure to improve despite sur- gical ant iu lcer su r ger y sh ou ld pr ompt wor kup. G ast r in levels gr eat er t h an 1000 pg/ mL or a rise of over 200 pg/ mL above the basal level on secretin st imulat ion t est support a diagnosis of gast rinoma. The steatorrhea, diabetes, and cholelithiasis suggest a somatostatinoma and the overall slowing of gastrointest inal function. Necrolytic migratory erythema, diabetes, anemia, stomatitis, and weight loss are the classic present at ion of a glucagonoma. The pathologic classification of neuroendocrine tumors: a review of nomenclature, grading, and staging systems. The patient has n o kn o wn m e d ica l p ro b le m s, a n d sh e d e n ie s re sp ira t o ry o r g a st ro in t e st in a l symptoms. On examination, she is found to have mild bilateral ptosis and n o n e ck m a sse s. Th e re su lt s o f the ca rd io p u lm o n a ry e xa m in at io n a re u n re - markable, and there is no generalized lymphadenopathy. The neurologic e xa m in at io n re ve a ls n o rm a l se n sa t io n a n d d im in ish e d m u scle st re n g t h in all of her extremities with repetitive motion against resistance. Most likely diagnosis: An incidentally identified thymoma in a patient with class I I A M G. Co n s i d e r a t i o n s This patient presents with an incidentally discovered anterior mediastinal mass. Other symptoms may include ptosis, diplopia, dysarthria, dysphagia, and respiratory fatigue. The diagnoses can be tent at ively made on t he basis of history and physical examinat ion, and t he diagnosis can be confirmed by provocative testing (Edrophonium-Tensilon test). Becau se of the mu lt iple op t ion s available for the t r eat m en t of M G, it is imp or- tant that these patients be managed in a multidisciplinary fashion, where manage- ment decisions take into consideration the severity of the baseline illness, severity of the flare-ups (crisis), benefit s of thymectomy, and the medical management of the patient in the perioperative period.

After an effective regimen has been established purchase sildenafil 100mg on line erectile dysfunction doctor in los angeles, dosing just once or twice daily should be tried order sildenafil 100mg otc erectile dysfunction treatment massage. Adherence can be promoted by giving positive reinforcement when therapeutic goals are achieved generic sildenafil 25mg on-line vascular erectile dysfunction treatment. Also 50 mg sildenafil with mastercard erectile dysfunction pump infomercial, adherence can be promoted by scheduling office visits at convenient times and by following up when appointments are missed. For many patients, antihypertensive therapy represents a significant economic burden; devising a regimen that is effective but inexpensive will help. Drugs for Hypertensive Disorders of Pregnancy Hypertension is the most common complication of pregnancy, with an incidence of about 10%. When hypertension develops, it is essential to distinguish between chronic hypertension and preeclampsia. Chronic hypertension is relatively benign, whereas preeclampsia can lead to life-threatening complications for the patient and the fetus. Chronic Hypertension Chronic hypertension, seen in 5% of pregnancies, is defined as hypertension that was present before pregnancy or that developed before the 20th week of gestation. Potential adverse outcomes include placental abruption, maternal cardiac decompensation, premature birth, fetal growth delay, central nervous system hemorrhage, and renal failure. The goal of treatment is to minimize the risk for hypertension to the patient and fetus while avoiding drug-induced harm to the fetus. When drug therapy is initiated during pregnancy, methyldopa and labetalol are the traditional agents of choice. These drugs have limited effects on uteroplacental and fetal hemodynamics and do not adversely affect the fetus or neonate. In contrast, there is little evidence that treating mild hypertension offers significant benefit. Patients who have chronic hypertension during pregnancy are at increased risk for developing preeclampsia (see later). Risk factors for preeclampsia include black race, chronic hypertension, diabetes, collagen vascular disorders, and previous preeclampsia. Risks for the fetus include intrauterine growth restriction, premature birth, and even death. The mother is at risk for seizures (eclampsia), renal failure, pulmonary edema, stroke, and death. Management of preeclampsia is based on the severity of the disease, the status of mother and fetus, and the length of gestation. The objective is to preserve the health of the mother and deliver an infant who will not require intensive and prolonged neonatal care. Management of mild preeclampsia is controversial and depends on the duration of gestation. If preeclampsia develops near term, and if fetal maturity is certain, induction of labor is advised. However, if mild preeclampsia develops earlier in gestation, experts disagree about what to do. Suggested measures include bed rest, prolonged hospitalization, treatment with antihypertensive drugs, and prophylaxis with an anticonvulsant. Studies to evaluate these strategies have generally failed to demonstrate benefits from any of them, including treatment with antihypertensive drugs. Because preeclampsia can deteriorate rapidly, with grave consequences for the patient and fetus, immediate delivery is recommended. However, if the fetus is not sufficiently mature, immediate delivery could threaten its life. Do we deliver the fetus immediately, which would eliminate risk for the patient but present a serious risk for the fetus—or do we postpone delivery, which would reduce risk for the fetus but greatly increase risk for the patient? Because severe preeclampsia can be life threatening, treatment must be done in a tertiary care center to permit close monitoring. Because severe preeclampsia can evolve into eclampsia, an antiseizure drug may be given for prophylaxis. In one study, prophylaxis with magnesium sulfate reduced the risk for eclampsia by 58% and the risk for death by 45%. If eclampsia develops, magnesium sulfate is the preferred drug for seizure control. To ensure therapeutic effects and prevent toxicity, blood levels of magnesium, as well as presence of patellar reflex, should be monitored. The target range for serum magnesium is 4 to 7 mEq/L (the normal range for magnesium is 1. When started before 16 weeks of gestation, low-dose aspirin reduces the risk for preeclampsia by about 50%. By contrast, several other preparations— magnesium, zinc, vitamin C, vitamin E, fish oil, and diuretics—appear to offer no protection at all. Treatment guidelines have been released by several organizations, including the American Society of Hypertension, the Canadian Hypertension Education Program, the European Society of Hypertension in conjunction with the European Society of Cardiology, and the World Health Organization in conjunction with the International Society of Hypertension. The disease affects nearly 5 million Americans and, every year, is responsible for 12 to 15 million office visits, 6. With improved evaluation and care, many hospitalizations could be prevented, quality of life could be improved, and life expectancy could be extended. However, because many patients do not have signs of pulmonary or systemic congestion, the term heart failure is now preferred. The syndrome is characterized by signs of inadequate tissue perfusion (fatigue, shortness of breath, exercise intolerance) and/or signs of volume overload (venous distention, peripheral and pulmonary edema). Other causes include valvular heart disease, coronary artery disease, congenital heart disease, dysrhythmias, and aging of the myocardium. As cardiac performance declines further, blood backs up behind the failing ventricles, causing venous distention, peripheral edema, and pulmonary edema. Cardiac Remodeling In the initial phase of failure, the heart undergoes remodeling, a process in which the ventricles dilate, hypertrophy, and become more spherical. Remodeling occurs in response to cardiac injury, brought on by infarction and other causes. In addition to promoting remodeling, neurohormonal factors promote cardiac fibrosis and myocyte death. The net result of these pathologic changes— remodeling, fibrosis, and cell death—is progressive decline in cardiac output. As a rule, cardiac remodeling precedes development of symptoms and continues after they appear. Physiologic Adaptations to Reduced Cardiac Output In response to reductions in cardiac pumping ability, the body undergoes several adaptive changes. Cardiac dilation results from a combination of increased venous pressure (see later) and reduced contractile force. Reduced contractility lowers the amount of blood ejected during systole, causing end-systolic volume to rise. The increase in venous pressure increases diastolic filling, which causes the heart to expand even further. That is, as the heart fails and its volume expands, contractile force increases, causing a corresponding increase in stroke volume. However, please note that the maximal contractile force that can be developed by the failing heart is considerably lower than the maximal force of the healthy heart. In the normal heart and the failing heart, increased fiber length produces increased contractile force. However, for any given fiber length, contractile force in the failing heart is much less than in the healthy heart. By increasing cardiac contractility, digoxin shifts the relationship between fiber length and stroke volume in the failing heart toward that in the normal heart. If cardiac dilation is insufficient to maintain cardiac output, other factors come into play. In response, the baroreceptor reflex increases sympathetic output to the heart, veins, and arterioles. Acceleration of heart rate increases cardiac output, thereby helping improve tissue perfusion. However, if heart rate increases too much, there will be insufficient time for complete ventricular filling, and cardiac output will fall. Increased myocardial contractility has the obvious benefit of increasing cardiac output. Elevation of venous tone increases venous pressure and thereby increases ventricular filling. Unfortunately, if venous pressure is excessive, blood will back up behind the failing ventricles, thereby aggravating pulmonary and peripheral edema. Furthermore, excessive filling pressure can dilate the heart so much that stroke volume will begin to decline. Elevation of arteriolar tone increases arterial pressure, thereby increasing perfusion of vital organs. Unfortunately, increased arterial pressure also means the heart must pump against greater resistance. Water Retention and Increased Blood Volume Mechanisms Water retention results from two mechanisms. Activation occurs in response to reduced blood pressure and reduced renal blood flow. Aldosterone acts directly on the kidneys to promote retention of sodium and water. Increased blood volume increases venous pressure and thereby increases venous return. However, as noted, if venous pressure is too high, edema of the lungs and periphery may result.

The use of oral suppressive antiviral therapy at 36 weeks for women who have had a recurrence or first episode during pregnancy has been shown to decrease vir al sh ed d in g an d the fr equ en cy of ou t b r eaks at t er m order line sildenafil icd 9 code erectile dysfunction neurogenic, an d d ecr ease the n eed for cesar ean d eliver y purchase sildenafil online from canada erectile dysfunction drugs uk. It is u n clear wh et h er this pr oph ylaxis is u sefu l for t h ose wit h out a recurrence during pregnancy cheap sildenafil 75mg line most popular erectile dysfunction pills, yet many practitioners will recommend prophylaxis order cheapest sildenafil severe erectile dysfunction causes. Use of acyclovir for suppression has also been found t o be safe in breastfeeding mot hers. At t his t ime, rout ine screening for ant ibodies and suppressive t herapy for seroposit ive part ners is not recommended. The obstetrician counsels the patient about the possibility of needing cesarean when she goes into labor. H ist o r y of lesio n s n o t ed o n the vagin a 1 m o n t h p r evio u sly, n ow n o t visib le C. Which of the followingstatements is most accurate in the counseling of this patient? D ecr ease the lik elih o o d of t r an sp lacen t al t r an sm issio n t o the fet u s C. The lesions h ave ragged edges, a necrot ic base, and t h ere is adenopat h y not ed on the right inguinal region. W hich of t he following is the most likely scenario of infect ion to t his infant? W h en t h er e are n o lesio n s o r p r o d r o m al sym p t o m s, the patient should be counseled that she is at low risk for viral shedding and has an unknown risk of neonatal herpes infection; typically, the patient will opt for vaginal delivery. The posterior thigh is unlikely to inoculate the baby during delivery, and is not an indication for cesarean delivery. Lesions on the ch est wall con sist ent wit h h er p es zost er would n ot n ecessit at e cesar ean d eliv- ery; however, t he baby should st ill not come in cont act wit h t hese lesions, and breast feeding should be avoided. The rationale for oral acyclovir therapy at the primary outbreak is to decrease viral shedding and the duration of infection. The acyclovir does not affect t he likelih ood of fut ure recurrence and does not change t he pat ient ’s immune response. O ral suppressive ant iviral t h erapy beginning at 36 weeks should also be considered in t his pat ient t o reduce t he chance of viral shed- ding and recurrence near the time of delivery. There is no evidence that oral acyclovir alt ers t ransplacent al t ransmission t o t he fetus, alt hough reducing t he vir em ia m ay h elp. Chancroid is a rare cause of infectious vulvar ulcers in the United States, alt hough worldwide it is quit e common; t hus, cases occurring in t he United St ates are related to port s of ent ry. G en it al h er- pes can cause recurrent painful genital sores, and herpes infection can become severe in people who are immunosuppressed. Syphilis t yp ically p r esen t s d u r in g the first stage of the disease as a small, round, and painless chancre in the area of the body exposed to the spirochete. The Bartholin glands, responsible for vagin al secr et io n s, are lo cat ed at the en t r an ce of the vagin a ; they m ay en lar ge into painless abscesses when they become clogged and infect ed. Vulvar car- cin oma t ypically is n ont en d er, u lcer at ive, an d is m or e com mon in p ost men o- pausal women. Th e s e a r e u s u a l l y d u e t o p r i m a r y o r n o n p r i m a r y f i r s t e p i s o d e i n fe c t i o n s. The patient states that 4 weeks previously, after she had engaged in sexual intercourse, she experienced some vaginal spotting. Fo u r week s p r evio u sly, sh e exp er ien ced so m e p o st co it al vagin al spotting. Long- term management : Expectant management as long as the bleeding is not excessive. Cesarean delivery at 34 weeks’ gest at ion (see new reference lat er in this case). Understand that the ultrasound examination is a good method for assessing placental location. Co n s i d e r a t i o n s T his patient is experiencing antepartum vaginal bleeding (bleeding after 20 weeks’ gest at ion ). Becau se of the p ain less n at u r e of the bleed in g an d lack of r isk fact or s for placent al abr upt ion, this case is more likely t o be placent a previa, d efin ed as the placenta overlying the internal os of the cervix. Placental abruption (premature separat ion of t he placent a) usually is associated wit h painful uterine cont ract ions or excess uterine tone. The history of postcoital spotting earlier during the preg- nancy is consistent with previa because vaginal intercourse may induce bleeding. The ultrasound examination is performed before a vaginal examination because vagin al m an ip u lat io n ( even a sp ecu lu m exam in at io n ) m ay in d u ce b leed in g. Becau se the patient is hemodynamically stable, and the fetal heart tones are normal, expect- ant management is t he best t herapy at 32 weeks’gest at ion (due to the prematurit y risks). If the same patient were at 35 to 36 weeks’ gestation, delivery by cesarean sect ion would be prudent. Completeplacentaprevia(A), m a rg in a l p la ce n t a p re via (B), and low-lying placentation (C) a re d e p ict e d. T h e t wo m ost com m on cau ses of sign ifican t an t ep ar t u m bleed in g are placental abruption an d placenta previa ( Tab le 1 0 – 1 ). T h e m ain d iffer en t iat or b ased on a patient’s history is that the vaginal bleeding is painless in a previa and painful in an abrupt ion secondary to cont ract ions. When the patient complains of antepartum hemorrhage, the physician should first rule out placenta previa by ultrasound even before a speculum or digital examina- tion, since these maneuvers may induce bleeding. At times, transabdominal sonography may not be able t o visualize the placent a, and t ransvaginal ult rasound is necessary and is more reliable for visualizing the internal cervical os. The natural history of placenta previa is such that the first episode of bleeding does not usually cause sufficient concern as to necessitate delivery. H ence, a woman wit h a preterm gest at ion and placent a previa is usually observed on bed rest and complet e p elvic r est in an effor t t o pr olon g gest at ion an d avoid mor bidit y of fet al prematurity. The bleeding from previa rarely leads to coagulopathy, as opposed to that of placen- tal abruption. Because the lower uterine segment is poorly contractile, postpartum bleeding may ensue. Several risk factors have been cited including parity, increased maternal age, smoking, multiple gestations, prior curettage, and prior cesarean delivery. Of note, placenta accreta (invasion of the placent a int o the ut er us) is more com mon wit h placent a pr evia, par t icu lar ly in the pr esen ce of a ut er in e scar su ch as aft er a cesarean delivery. T iming of delivery depends on clinical circumst ances for placenta previa and placenta accreta. The N ational Institutes of H ealth con- clu d ed that elect ive d eliver y is id eal at 36-37 complet ed weeks for t h ese pat ient s, but practices still vary. T here is no demonst rated benefit to performing amniocen- tesis for fetal lung maturity prior to delivery at any gestational age. An u lt r asoun d is per for med revealin g that the placent a is cover in g the int er n al os of the cer vix. Which of the followin g is a r isk fact or for this pat ient ’s con dit ion? U lt r aso u n d exam in at io n, d igit al exam in at io n, sp ecu lu m exam in at io n C. S ch ed u le an am n io cen t esis at 3 4 week s an d d eliver b y cesar ean if the fet al lungs are mat ure C. Multiple gestation, with the increased surface area of placentation, is a risk factor for placenta previa. H ypertension is not a risk factor for placenta previa; however, it is one of the main risk factors for placental abruption. Polyhydram- nios, due to the excess amount of amniotic fluid in the amniotic sac, is also a risk factor for placenta abruption. Salpingitis involves inflammation and infection of the fallopian tubes and over time may lead to permanent scarring of the tubes. Since this particular process is limited to the tubes, there is not an increased risk of placenta previa; rather there is an increased risk of ectopic pregnancy. Unlike placenta abruption, placenta previa is not commonly associ- ated with coagulopathy, painful bleeding, or having a profuse first episode of bleeding. The main distinguishing factor between a previa and abruption is the presence or absence of pain. With abruption, painful uterine contractions are t ypically t he chief complaint, whereas previa is painless. There is no need to place the patient at risk for hemorrhage when the fetus’ lungs are mature enough for life outside the womb; therefore, expectant management would not be the best choice for this scenario. A patient with a scheduled cesar ean d eliver y d oes n ot n eed t o be in du ced for labor, n or d oes sh e n eed tocolysis since the status of the patient’s labor is typically insignificant in a cesar ean d eliver y. A pat ient wit h pr evia sh ou ld n ot d eliver vagin ally sin ce the lower ut erine segment is poorly cont ract ile, and post part um bleeding may ensue. An int raut erine t ransfusion is also not indicat ed for this pat ient because the baby is going to be delivered and will be independent of the mother’s blood supply. Even in the setting of an Rh– mother with an Rh+ fetus, an intrauter- ine t ransfusion before delivery would pose a significant ly great er risk t o the mother and baby than waiting to evaluate the situation after birth. U lt rasound sh ould be performed first t o r ule out previa, speculum exami- nation second to assess the cervix and look for lacerat ions, and finally digit al examinat ion. Performing eit her a speculum examinat ion or digit al examina- tion before evaluating the patient with ultrasound puts the patient at risk for hemorrhage. In the setting of a previa, the lower uterine segment and cervix are highly vascularized, and varices of t he cervix may be visualized on specu- lum examination in some situations; however, the speculum it self may cause trauma to these varices and induce bleeding.