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Chapter 9 Primary Care in Gynecology

Chapter 9 Primary Care in Gynecology

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Chapter 9 Primary Care in Gynecology

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  1. Chapter 9Primary Care in Gynecology - Novak’s Gynecology page 199~230

  2. Primary Care in Gynecology • Early diagnosis and treatment of medical illnesses can have a major impact on a woman’s health and is a key component of primary care. • Although timely referral is important for complex and advanced disorders, the gynecologist initially may treat many conditions

  3. Primary Care in Gynecology • Respiratory Infections • Sinusitis • Otitis Media • Bronchitis • Pneumonia • Cardiovascular Disease • Hypertension • Cholesterol • Endocrinologic Disease • Diabetes Mellitus • Thyroid Disease

  4. Respiratory Infection • Sinusitis • Otitis Media • Bronchitis • Pneumonia

  5. Respiratory Infection Sinusitis • Etiology Infection : begin with a viral agent in the nose or nasopharynx that cause inflammation that blocks the draining ostia. • Viral agents : impede the sweeping motion of cilia in the sinus and, in combination with the edema from inflammation, lead to superinfection with bacteria • Bacterial agents: S.pyogenes, S.pneumoniae, H. influenzae, Staphylococcus aureus α-hemolytic streptococcus species * G(-) organism : usually limited to compromised hosts in intensive care units * chronic disease : polymicrobial with mixed infections consisting of aerobic and anaerobic organisms.

  6. Respiratory Infection Sinusitis • Factors to contributing the development of sinus disease : atmospheric pollutants, allergy, tobacco smoke, skeletal deformities, dental conditions, barotrauma from scuba diving, airline travel, neoplasm, # chronic sinusitis : systemic disease (connective tissue syndrome), malnutrition • Clinical finding 1) maxillary toothache 2) poor response to nasal decongestants 3) abnormal transillumination 4) a colored nasal discharge established by history 5) a colored nasal discharge on examination - ≥4 : the likelihood of sinusitis↑ - none : the likelihoodof sinusitis↓

  7. Respiratory Infection Sinusitis • Diagnosis • self-diagnosed : headache, dental pain, postnasal drainage, halitosis, dyspepsia • Imaging studies : not when initial episodes , but when persistent infections occur

  8. Respiratory Infection Sinusitis • Treatment • Broad antibiotic therapy : cover common aerobes and anaerobes patient with acute pain & purulent discharge • Systemic decongestants: pseudoephedrine • Topical decongestants : < 3days d/t rebound vasodilation and worsening of symptoms • Mucolytic agents (guaifenesin) : help thin sinus secretions and promote drainage • Antihistamins : avoided in acute sinusitis d/t drying effects may lead to thickened secretions and poor drainage of the sinuses. • Symptomatic therapies : facial hot packs and analgesics

  9. Respiratory Infection Sinusitis • Chronic sunusitis : from repeated infection with inadequate drainage • Sx: recurrent pain in the malar area or chronic postnasal drip associated with chronic cough and laryngitis with intermittent acute infection • Treatment - directed at the underlying etiology : allergy control or aggressive management of infections - Resistant cases : CT - Endoscopic surgery : polyp remove • Complication (- untreated sinus-) : orbital cellulitis leading to orbital abscess, subperiosteal abscess formation of the facial bones, cavernous sinus thrombosis, acute meningitis, brain & dural abscess (rare)

  10. Respiratory Infection Otitis Media • Serous otitis media • Cause : 2nd to a concurrent viral infection of the upper respiratory tract • Diagnosis : reveals fluid behind the tympanic membrane • Treatment : symptomatic Tx with antihistamines, decongestants, glucorticoids but, little data exist supporting use of these medications

  11. Respiratory Infection Otitis Media • Acute otitis media • Cause : bacterial infection - Streptococcus pneumoniae, H. influenzae • Sx . : acute purulent otorrhea, fever, hearing loss, leukocytosis • P. Ex : red, bulging or perforated membrane • Treatment : Broad-spectrum antibiotics - amoxicillin-clavulanic acid, cefuroxime, trimithoprim-sulfamethoxazole * antihistamines in treatment of otitis media is unclear

  12. Respiratory Infection Bronchitis • Acute bronchitis : inflammatory condition of the tracheobronchial tree • Causes - viral infection and occurring in winter : common cold viruses(rhinovirus and coronavirus), adenovirus, influenza virus, Mucoplasma pneumoniae (nonviral pathoen) - bacterial infections : less common and 2nd pathogens • Sx #coughning & sputum (prolonged in cigarette smokers) : m/c Sx

  13. Respiratory Infection Bronchitis • Diagnosis • P.Ex : Auscultation : coarse rhonchi (rales: not usually not auscultated ) signs of consolidation and alveolar involvement : absent. • chest x-ray : to detect the presence of parenchymal disease • sputum culture • Treatment • symptomatic relief : uncomplictated cases • antibiotics : for patients who have chest radiographic findings consistent with pneumonia • atitussives (containing either dextromethorphan or codeine) : coughing (most aggravating symptom) • expectorants : efficacy –not been proved

  14. Respiratory Infection Bronchitis • Chronic bronchitis : defined as the presence of a productive cough with excessive secretions for 3months in a year for 2 consecutive years • Prevalence : estimated to be 10-20% of the adult population • Classified as a form of chronic obstructive disease (COPD) • Causes chronic infection and environmental pathogens found in dust • Sx cardinal manifestation : incessant cough,-usually in the morning , with expectoration of sputum

  15. Sinusitis Otitis media bronchtis Pneumonia

  16. Respiratory InfectionPneumonia • Definition : Inflammation of the distal lung that includes terminal airways, alveolar spaces and the interstitium • Causes : Viral , bacterial, aspiration pneumonia • Aspiration pneumonia cause : depressed awareness commonly associated with use of drugs, alcohol or anesthesia • viral pneumonia : multiple infection - influenza A or B, parainfluenza, respiratory syncytial virus : spread by aerosolization associated with coughing, sneezing, conversation * intubation time : short, requiring only 1~3days prior to the acute onset of fever, chills, headache, fatigue and myalgia

  17. Respiratory InfectionPneumonia * pneumonia develops in only 1% of patients who have a viral syndrome - mortality rates : 30% in immunocompromised individuals and the elderly * Staphylococcal pneumoniae (2nd bacterial pneumonia) : arising from a previous viral infection, extremely lethal * vaccination : influenza, pneumococcal pneumonia amantadine : used to treat individual who have not been vaccinated (in epidemics) * Treatment : supportive care – antipyretics and fluids

  18. Respiratory InfectionPneumonia • Bacterial pneumonia • Classification : Nosocomial or community acquired - determine the prognosis and choice of antibiotic therapy • Risk factors : chronic cardiopulmonary diseases, alcoholism, DM, renal failure, malignancy, malnutrition • Signs and Symptoms : depending on the infecting organism and the patient’s immune status

  19. Respiratory InfectionPneumonia • Laboratory studies • Gram stain, sputum & blood culture * sputum collection : neutrophil > 25/LPF epithelial cell < 10/LPF • ELISA ( indirect serologic test) or direct fluorescent antibody staining of organisms in the sputum : Lesionella pneumoniae • cold agglutinin c appropriate clinical symptoms : Mycoplasma pneumoniae

  20. Respiratory InfectionPneumonia

  21. Respiratory InfectionPneumonia • Vaccination • Peumococcal vaccination - Indication : ≥ 65, heart, lung disease, alcoholism, renal failure, DM, HIV infection, cancer - repeat vaccination : recommended 5years after the 1st dose in high risk group • influenza vaccination - Indication : ≥50years, serious long term health problems like heart disease, lung disease, kidney disease, DM, immunosuppression 2nd to long-term steroid or cancer therapy, 3rd trimester of pregnancy during the flu season and anyone coming into close contact with people at risk of serious influenza (physicians, nurses, family members) * best time : October~mid November

  22. Respiratory InfectionPneumonia • poor prognosis factor : involvement >2 lobes, respiratory rate >30breaths/minute on arrival in the health care center, severe hypoxemia (<60mmHg breathing room air), hypoalbuminemia and septicemia • Complication : ARDS (mortality rate : 50~70%)

  23. Cardiovascular Disease • Hypertesion • Hyperlipidemia

  24. Cardiovascular Disease Risk factors

  25. Cardiovascular DiseaseHypertension • Epidemiology -In U.S. : 15% of the population between the ages of 18 and 74 years • Incidence : increases with age and varies with race >50 years : female > male African Americans > Whites : twice Geographic variations : higher prevalence of hypertension and stroke in the southeastern United States regardless of race • Definition : blood pressure levels ≥140/90 when measured on two separate occasions

  26. Cardiovascular DiseaseHypertension • Primary or essential hypertension : >95%, cause unknown • Secondary hypertension : <5% • Diagnosis - Hx and P.Ex : presence of prior elevated readings, previous use of antihypertensive agents, a family history of death from cardiovascular disease prior to age 55, excessive alcohol and sodium use → lifestyle modification is increasingly important in the therapy of hypertension - Laboratory evaluations : rule out reversible causes of hypertension (secondary hypertension) UA, CBC, S/E, Cr, fasting glucose, total cholesterol, HDL cholesterol, EKG …

  27. Cardiovascular DiseaseHypertension • Measurement of Blood Pressure <Protocols for measurement> - patient should be allowed to rest for 5minutes in a seated position and the right arm used for measurements (for unknown reason, the right arm has higher readings) - cuff should be applied 20mm above the bend of the elbow and the arm positioned parallel to the floor - The cuff should be inflated to 30mmHg above the disappearance of the brachial pulse or 220 mmHg - the cuff should be deflated slowly at a rate ≤ 2mmHg/sec # cuff size : important cuff hypertension : small cuffs used for obese patients • Diastolic reading : - Phase IV : Korotkoff’s sounds (muffled sound) - Phase V : complete disappearance

  28. Cardiovascular DiseaseHypertension Diagnosis and management are based on the classification of blood pressure readings

  29. Cardiovascular DiseaseHypertension

  30. Cardiovascular DiseaseHypertension • Treatment - General guidelines in assessing individuals for therapy

  31. Cardiovascular DiseaseHypertension

  32. Cardiovascular DiseaseHypertension • Choice of drugs • migraine headache : β-blockers or CCB • DM : ACEi • MI : β-blockers • African Americans: diuretics + CCB • Monitoring Therapy • Lifestyle modification (slightly elevated BP) - Interval : 1~2 week • With other disease (i.e.cardiovascular or renal) - lifestyle modification alone is successful : close monitoring - interval 3~6month - lifestyle modification is unsuccessful: medication

  33. Cardiovascular DiseaseHyperlipidemia Cholesterol : esterized form with various proteins and glycerides that chrarcterize the stage of metabolism • Important lipid particles in cholesterol metabolism • Chylomicrons : large lipoprotein particles - dietary triglycerides + cholesterol secreted in the intestinal lumen, absorbed in the lymph, and then passed into general circulation adhered to binding sites on the capillary wall and are metabolized for energy production. (in adipose tissue and skeletal muscle ) • Lipoprotein Particle : consisted three major component - core : consists of nonpolar lipids (triglycerides & cholesterol ester) - surface coat of phospholipids : made of apoproteins & structural proteins • Apoprotein : attached to all lipoprotein particles have specific receptors and demarcate the stage of cholesterol metabolism

  34. Cardiovascular DiseaseHyperlipidemia • Lipoprotein classes :determined by the separation of lipids in an electrophoretic field • Prehepatic metabolites : CM and Remnants • Posthepatic metabolites : VLDL , IDL, LDL., HDL • Metabolism

  35. Cardiovascular DiseaseHyperlipidemia • Hyperlipoproteinemia • TG:choesterol > 5:1 - predominant fractions are chylomicrons and VLDL • TG : cholesterol < 5:1 - problem of VLDL and LDL fraction • Initial classification

  36. Cardiovascular DiseaseHyperlipidemia • Laboratory testing multiple environmental causes of variation in cholesterol measurements < major sources of variation > - diet, obesity, smoking, ethanol intake, effects of exercise - clinical conditions : hypothyroidism, DM, acute or recent MI, recent weight changes - other : fasting state, position while the sample is drawn, use and duration of venous occlusion . Anticoagulant and storage and shipping conditions

  37. Cardiovascular DiseaseHyperlipidemia • Intraperson variation • Age and sex < 50years, in women lower lipid values than men > 50 years, women lipid value increase d/t exogenous oral conjugated estrogens • Seasional variation • Diet and obesity • Alcohol and cigarette smoking : moderate (defined as approximately 2ounces of absolute alcohol/day) sustained alcohol intake is noted to HDL ↑ LDL ↓, TG ↑ - this effect is negated with higher quantities • Smoking : LDL cholesterol and TG ↑, HDL cholesterol ↓ (critical number : 15~20 / day) • Exercise : TG and LDL↓ HDL↑ • Caffeine mixed effect on lipoprotein measurements, avoid in the 12hours prior to blood collection • * Blood sample : collected in the morning after a 12-hour fast

  38. Cardiovascular DiseaseHyperlipidemia • Disease States and Medication Effects - Diuretics, propranolol: TG↑, HDL cholesterol↓ (esp. Diuretics : total cholesterol ↑) - DM : TG & LDL↑ HDL cholesterol↓ - Pregnancy : total serum cholesterol ↓in 1st trimester, continuous increases of all fractions in 2nd~3rd trimester - Hypothyroidism : total cholesterol and LDL cholesterol ↑

  39. Cardiovascular DiseaseHyperlipidemia • Management • Once hyperlipidemia is confirmed on at least two separate occasions, 2nd causes should be diagnosed or excluded by taking a detailed medical and drug history, measuring Scr, fasting glucose level, performing thyroid, LFT • obese patients : diet and weight loss (1st) • Exercise and cigarette cessation

  40. Figure 9.4 Treatment decisions based on the LDL cholesterol level

  41. Cardiovascular DiseaseHyperlipidemia

  42. Endocrinologic DiseaseDiabetes Mellitus • Definition : chronic disorder of altered carbohydrate, protein and fat metabolism from deficiency in the secretion or function of insulin : defined by either fasting hyperglycemia or elevated plasma glucose levels after an oral glucose tolerance test (OGTT) • Risk factors - age >45years - adiposity or obesity - a family history of diabets - Race and ethnicity - Hypertension (≥140/90) - HDL cholesterol ≤35mg/dL with or without a TG level ≥ 250mg/dL - History of gestational diabetes or delivery of baby >9 pound

  43. Endocrinologic DiseaseDiabetes Mellitus • Classification • Type 1 DM : The major metabolic disturbance of type 1 diabetes is the absence of insulin from destruction of β cells in the pancreas • Type 2 DM : heterogeneous form of disbetes that commonly occurs in older age groups (>40 years) and is more frequently noted to have familial tendency than type 1 diabetes. # type 1 : an absence of insulin type 2 : resulting in insulin resistance

  44. Endocrinologic DiseaseDiabetes Mellitus • Diagnosis 1. FBG (fasting blood glucose) ≥ 126mg/dL 2. Random blood glucose ≥200mg/dL with classic signs and symptoms of diabetes (polydipsia, polyuria, polyphagia and weight loss) 3. 2-hour OGTT (fasting sample, 60 and 120 minute samples) after a 75g load of glucose → 2-hour OGTT should not be performed if the first two criteria are present. * Diagnostic criteria for imparied glucose intolerance (IGT)testing : 110mg/dL≤FRG<126mg/dL

  45. Endocrinologic DiseaseDiabetes Mellitus • Indication of DM testing - Age ≥45years (repeat at 3-year intervals) - Classic signs and symptoms of diabetes (i.e. polyuria, polydipsia, polyphagia and weight loss) - Ethnic groups at high risk (Pacific Islanders, Native Americans, Africal Americans, Hispanic Americans, Asian Americans) - Obesity - First-degree relative with diabetes - Gestational diabetes or birth of a baby over 9 pound - Hypertension (≥ 140/90) - HDL cholesterol levels≥35mg/dL or triglyceride level ≥250mg/dL - Impaired glucose tolerance based on previous testing

  46. Endocrinologic DiseaseDiabetes Mellitus

  47. Endocrinologic DiseaseDiabetes Mellitus • Treatment

  48. Endocrinologic DiseaseDiabetes Mellitus • Complication • Acute complication - Diabetic ketoacidosis (DKA) - Nonketotic hyperosmolar diabetic coma (NKHC) - Hypoglycemia - Lactoacidosis • Chronic complication - Macroangiopathy: accelerated atherosclerosis (CHD, MI, CVA…) - Microangiopathy : retinopathy, nephropathy, neuropathy - Other : infection, skin lesion