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kaELECTROLYTE SOLUTIONS ELECTROLYTES

IV Soln Glu Na Cl K Ca HCO3 a) Corrected Ca = (40-lbs) x 0.02 + serCa


D5W 5mg/L b) Corrected Na = Na + RBS mg% - 100 x 1.6 / 100
D10W 100mg/L c) Na Deficit = (140 actual) (0.6 x BW)
0.9 NSS 154 154 d) K Deficit = (D-A) (0.4 x BW)
D5LR 130 109 4 3 28 D = 3.5 cardiac
D5NM 40 40 13 4.5 non-cardiac
D5NR 140 98 5 H20 Deficit = 0.6 x kg BW
D = 15 CKD
D5 0.9 50 mg/L
NaCl 18 NCKD
D5NMK 50 mg/L 40 40 30
Actual Na Desired Na / Desired Na
Soln Na Cl K HCO3 Ca Mg
ECF 142 103 4 27 5 3
D5LR 130 109 4 28 5 CUSHINGS TRIAD
D5 0.45 77 77
3% NaCl 513 513 1) Increase systolic BP
0.9 NaCl 154 154 2) Widened pulse pressure
3) Bradycardia /AbN respiratory pattern
D5W Osm = 278 a. Cheyne Stoke breathing
D5W Osm = 556
D5LR Osm = 130
NaHCO3 = 446 HEMORRHAGIC STROKE TRIAD

1) Papilledema
MECHANICAL VENTILATION 2) Headache
3) Vomiting
Indications for Intubation

1) Impending respiratory failure, apnea


2) RR >35
3) PaCO2 > 50 MEIGS SYNDROME
4) PaO2 <60
5) TV < 3-5 ml/kg 1) Pleural Effusion
6) VC < 10-15 ml/kg 2) Polycystic Ovary / Fibromatosis
7) Inspiratory force < 25 cm H20 3) Hypoalbuminemia
8) FEV < 10 ml/kg
9) Vq / Vt> 0.6
10) To deliver high FIO2
11) Absent
12) pH <7.35 GLASCOW COMA SCALE

EYE RESPONSE
VENTILATOR SETTING a) Spontaneous eye opening 4
b) Opens to verbal command 3
1) TV: 6-8 ml/kg (ARDS) 8-10 ml/kg c) Responds to painful stimuli 2
2) Pale: 6-20 d) No response 1
3) Mode: AC (Assist Control)
SIMV (Synchronized Intermittent 1 mV MOTOR
4) FIO2 a) Obeys with command 6
5) PEEP 5cm H20 b) Localizes pain 5
c) Flexion withdrawal 4
d) Decorticate / Flexion 3
INDICATIONS FOR WEANING e) Decerebrate / Extension 2
f) No response 1
1) Mental status: Awake, Alery
2) PaCO2 > 60 mmHg w/ FIO2 < 50% VERBAL
3) PEEP < 5 cm a) Oriented 5
4) PaCO2 < pH acceptable b) Disoriented 4
5) Spontaneous TV < 5mL c) Inappropriate 3
6) VC > 10 ml/kg d) Incomprehensible 2
7) MIP > 25 cm H20 e) No response 1
8) RR < 30/min
9) Rapid shallow breathing index < 100 (RBI)
10) Stable vs. Ft a 1-2 hr

Spontaneous Trial
FIO2 room air 21%
O2 via nasal prong = # lpm x 0.4 x 20
FOUR SCALE DOPAMINE COMPUTATION
- Full outline of responsiveness
Single strength = BW x desired dose / 13.3
EYE RESPONSE Double strength = BW x desired dose / 16.6
a) Eyelids open, tracking, blinking to command 4 Single strength = BW x desired dose / 16.6
b) Eyelids open but not tracking 3 Double strength = BW x desired dose / 33.2
c) Eyelids close but open to loud voice 2
d) Eyelids close but no pain 1 Cardiac Dose = 5
e) Eyelids close with pain 0 Renal Dose = 5-10

MOTOR RESPONSE
a) Thumbs up, fist or peace sign 4
b) Localizing to pain 3
c) Flexion response to pain 2 CT SCAN BLEED VOLUME
d) Extension response to pain 1
e) No response to pain or generalized myoclonus 0 Given: 58 mm ~ 5.8
23.3 mm ~ 2.3
BRAINSTEM REFLEXES
a) Pupil and Corneal reflex 4 5.8 x 2.3 = 13.34 x 5 (constant) = 66.5 x 5.2 (constant) = 34.684 -(estimated
b) One pupil wide and fixed 3 bleeding volume)
c) Pupil or corneal reflex absent 2
d) Pupil and corneal reflex absent 1
e) Absent pupil, corneal and cough reflex 0

RESPIRATION DIAGNOSTIC THORACENTESIS DUE TO HEART FAILURE


a) Not intubated, regular breathing pattern 4
b) Not intubated, cheyne-stoke breath pattern 3 1) If the effusion are not bilateral and comparable size
c) Not intubated, irregular breathing 2 2) If the patient is febrile
d) Breath above ventilation rate 1 3) If the chest has a pleuritic chest pain
e) Breath at ventilation rate, apnea 0 4) If effusion persist despite the diuretics therapy

DENGUE

GRADE I INDICATION FOR CHEST TUBE THORACOSTOMY


Fever
Non-specific symptoms 1) Pneumothorax
o Anorexia 2) Pleural effusion
o Vomiting 3) Chylothorax
o Abdominal pain 4) Empyema
(+) Torniquet test 5) Hemathorax
6) Hydrothorax
GRADE II
Grade I + spontaneous bleeding

GRADE III
Grade II + severe bleeding + circulatory failure TIMING OF TUBE REMOVAL
The timing of tube removal depends on clinical and radiological
GRADE IV evidence of complete expulsion of all contents of pleural cavity with
Grade III + irreversible shock + massive bleeding complete expansion of the lung
Minimal drainage should have occurred over the previous 24 hours
(<25 ml/kg)
When the patient coughs or performs the valsalvamaneuver no air
ABG COMPUTATION leak should ensue
The chest radiograph should confirmed complete expansion of the
I. 713 (decimal FIO2) PCO2/0.8 = I lung
II. pO2/I = II The s____ in the fluid in the tube in the underwater seal bottle
III. (Desired FIO2/II) + pCO2/0.8 should be minimal, relating to the normal negative pressured in the
________________________ x 100 chest during the phases of respiration
713

Desired FIO2 = 104 (0.43 x age)

A. 713 x FIO2 PCO2/0.8 INDICATIONS FOR CTT


B. pO2 / A Gross pus on thoracentesis
C. 02 for age / B + pC02 / 0.8 Presence of organism on gram stain of the pleural fluid
________________________________ Pleural fluid glucose < 50 mg / dL
713 Pleural fluid pH below 7.00 and 0.15 units lower than arterial pH

FIO2: 20 / 4 = L
LIGHTS CRITERIA LOCATING MYOCARDIAL DAMAGE

1) Pleural fluid protein / serum protein > 0.5 Anterior = V2-V4 (L) coronary, LAD
2) Pleural fluid LDH / serum LDH > 0.6
3) Pleural fluid LDH > 2/3 the upper limit of normal serum LDH Anterolateral = I, qV1, V3 V6, LAD, circumflexes

Anteroseptal = V1-V4, LAD

TRANSUDATIVE VS EXUDATIVE FLUID Inferior = II, III, aVF, (R) coronary artery

Transudative Exudative Lateral = I, aVL, V5, V6, circumflex brance of (L) coronary
SG < 1.012 > 1.020 artery
Protein < 3 g/dL >3 g / dL
FP / SP < 0.5 >0.5 Posterior = V8 V9 (R) coronary artery, circumflex artery
LDH <60% >60%
FLDH/SLDH <0.6 >0.6 (R) Ventricular = V4R, V5R, V6R, (R) coronary artery
Cholesterol <45 mg / dL >45 mg / dL

JONES CRITERIA OF RF
CLASSIFICATIONS OF PTB
Major:
Class O Carditis
NO PTB EXPOSURE Polyarthritis
Not infected Chorea
Erythema marginatum
Class 1 Subcutaneous nodule
HISTORY OF EXPOSURE
Neg. Skin test to tuberculin Minor:
Fever
Class 2 Polyarthralgia
TB INFECTION Lab: Inc. ESR / Leukocyte count
No disease ECG: Prolong P-R interval
Positive reaction to tuberculin test Elevated anti-streptolysin O, other strep antibody
No clinical, bacteriologic or radiographic evidence of TB (+) throat culture
Rapid Ag test for Group A
Class 3 Strep / result: Scarlet Fever
TB CLINICALLY ACTIVE
Clinical, bacteriologic, or radiographic evidence of current disease Criteria:
2 major/one minor and 2
Class 4 (+) evidence of preceding Group A strep infection
TB NOT CLINICALLY ACTIVE
History of episode of TB
Abnormal but stable radiographic findings ACUTE RESPIRATORY FAILURE
No clinical or radiographic evidence of current disease
TYPE I or Acute Hypoxemic Respiratory Failure
Class 5 Occurs when alveolar flooding and subsequent intrapulmonary
TB SUSPECT shunt physiology occurs
Diagnosis pending Alveolar flooding may be a consequence of pulmonary edema,
TB disease should be ruled out within 3 months pneumonia or alveolar hemorrhage
Low pressure pulmonary edema
Signs and Symptoms of TB Defined by diffused bilateral airspace edema
Fever
Night sweats TYPE II Respiratory Failure
Weight loss Occurs as a result of alveolar hyperventilation and results on the
inability to eliminate CO2 effectivity
Anorexia
Mechanism by which this occurs are categorized by impaired CNS
Weakness
drive to breath, impaired strength with failure of neuromuscular
General Malaise
function in the respiratory ____
Reason for diminished CNS drive to breath including drug
overdose, brainstem injury, sleep disordered breathing

Overload Respiratory System due to:


RECOMMENDED DOSAGE FOR INITIAL TREATMENT OF TB
Increase resistive loads (bronchospasms)
1) Isoniazid = 5 mg/kg, max 300 mg Reduced lung compliance (alveolar edema)
2) Rifampicin = 10 mg/kg, max 600 mg Reduced chest wall compliance (pneumothorax)
3) Pyrazinamide = 20-25 mg/kg, max 2 g Increase minute ventilation (pulmonary embolus)
4) Ethambutol = 15-20 mg/kg
TYPE III Respiratory Failure BRONCHIECTASIS
Occurs as a result of lung atelectasis Is an abnormal and permanent dilatation of bronchi
Also called perioperative respiratory failure Associated with destruction and inflammatory changes in the wall
After general anesthesia, decreases in functional residual capacity of the medium sized airways often at the level of segmental or
of dependent lung units subsegmental bronchi
The dilated airways frequently contain pools of thick purulent
TYPE IV Respiratory Failure material, while more peripheral airways are often occluded by
Due to hypoperfusion of respiratory muscles in patients in shock, secretions or obliterated and replaced by fibrous tissue
due to pulmonary edema, lactic acidosis, anemic As the result of inflammation it produces airway damage,
impaired clearance of microorganism resulting to vascularity of
the bronchial wall increases with associated enlargement of the
bronchial arteries and anastomoses between the bronchial and
DEFINITIONS USED TO DESCRIBE THE CONDITION OF SEPTIC PATIENTS pulmonary arterial circulation

Bacteremia
Presence of bacteria in blood as evidenced by positive blood
culture INDICATIONS FOR INITIATING HEMODIALYSIS
Failure of conservative management
Septicemia Management to relieve
Presence of microbes and their toxins in the blood a) Pulmonary congestion (unresponsive to high dose
furosemide)
SIRS b) Severe metabolic acidosis
Systemic inflammatory response syndrome c) Severe hyperkalemia
Two or more of the following conditions: BUN >100 mg/dL or creatinine>10mg/dL
o Fever (oral temp >38C) or hypothermia (<36C) Note: For acute renal failure it is best to start dialysis early
o Tachycardia (>90 bpm)
o Tachypnea (>24 bpm)
o Leukocytosis (>12,000/uL) or Leukopenia (<4,000/uL) or
>10% bands may have a non-infectious etiology RHEUMATIC ARTHRITIS
Require 4 out of 2 criteria:
Sepsis o Morning stiffness
SIRS that has proven or suspected microbial etiology o Arteritis of 2 or more joints
o Arteritis of hands and joints
Severe Sepsis o Systemic arthritis
Similar to sepsis sepsis syndrome o Rheumatoid nodule
Sepsis with one or more signs of organ dysfunction o Serum Rheumatoid factor
o Radiographic changes
Examples:
1) Cardiovascular: Arterial systolic blood pressure <90 mmHg or
Mean Arterial Pressure 70 mmHg that responds to CHILD-PVGH CLASSIFICATION OF CIRRHOSIS
administration of IV Factor Units 1 2 3
2) Renal: Urine output <0.5 ml/kg/hr for 1 hour despite adequate s. Bilirubin umol / L <34 34-51 >51
fluid resuscitation mg / dL <2 2-3 >3
3) Respiratory: PaO2/FIO2 <250 or if the lung is the only s. Albumin g/L >35 30-35 <30
dysfunctional organ 200 g / dL >3.5 3.0-3.5 <3
4) Hematologic: Platelet count <80,000/uL or 50% decrease in Protime sec 0-4 4-6 >6
platelet from highest value recorded over the previous 3 days INR <1.7 1.7-2.3 >2.3
5) Unexplained metabolic acidosis: a pH 7.30 or a base deficit 5.0 Ascites None Easily Poorly
meq/L and a plasma lactate level >1.5 times upper limit of normal controlled controlled
for reporting Hepatic None Minimal Advanced
6) Adequate fluid resuscitation: Pulmonary artery wedge pressure encephalopathy
12 mmHg or Central Venous pressure 8 mmHg
Calculated by adding the score of the 5 factor and can range
Septic Shock
from 5 15
Sepsis with hypotension (arterial blood pressure of 90 mmHg or
MAP > 70 mmHg
CHILD-PVGH Class is either:
Refractory Septic Shock
A. Score of 5 6
Septic shock that last > 1 hour and does not respond to fluid or B. Score of 7 9
pressure administration C. Score of 10 or Above
Multi-organ Dysfunction Syndrome
Dysfunction of more than 1 organ requiring intervention to Decomposition
maintain homeostasis indicate cirrhosis
N/A
CHILD PVGH Score of 7 or more

Class 8
Listing for liver transformation (accepted criteria)
Hepatic Fibrogenesis
Stellate cell activation NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION
Collagen production
CLASS I
No limitation of physical activity
CLINICAL STAGE OF HEPATIC ENCEPHALOPATHY No symptoms with ordinary exertion
MS
Stage I Euphoria, depression, mild confusion, slurred speech, CLASS II
disturbance in sleep Slight limitation of physical activity
Stage II Lethargy, moderate confusion Ordinary activity causes symptoms
Stage III Marked confusion, incoherent speech, sleeping but
arousable CLASS III
Stage IV Coma, initially responsive to noxious stimuli, ____ Marked limitation of physical activity
response Less than ordinary activity causes symptoms
Asymptomatic at rest

COMPLICATIONS OF ERCP CLASS IV


1) Infection Inability to carry out any physical activity without discomfort
2) Perforation Symptomatic at rest
3) Pneumothorax
4) Bleeding

MUSCLE STRENGTH
O No muscular contraction FRAMINGHAM CIRTERIA FOR DIAGNOSIS OF CHF
1 Trace contraction
2 Active movement with gravity eliminated MAJOR CRITERIA
3 Active movement against gravity Paroxysmal Nocturnal Dyspnea
4 Active movement against gravity & slight resistance Neck vein distention
5 Against full resistance Rales
Cardiomegaly
Acute pulmonary edema
S3 gallop
Increased venous pressure (>16 cmH20)
IDEAL PEAK FLOW Positive hepatojugular reflux

Ideal peak flow: Hg (m) 100 x 5 (+) 175 (M) (+) 170 (F) MINOR CRITERIA
Extremity edema
N 80%
Night cough
PEFR = Peak flow reading / Ideal peak flow x 100 = _____ %
Dyspnea on exertion
Hepatomegaly
N 20%
Pleural effusion
PEFR variability: Highest reading Lower x 100 = ______ %
Highest Reading Vital capacity reduced by one-third from normal
Tachycardia (>120 bpm)

MAJOR OR MINOR
Weight loss of >4.5 kg over 5 days treatment
GRADING OF MURMURS
1 Faint
2 Audible
3 Moderately Loud
4 Loud with palpable thrill
5 Loud with thrill, stet partially off
6 Loud with thrill, w/o stet

BLOOD TRANSFUSION
CP status assessed
VS checked
Please transfuse available _____ unit of patients blood type after
proper cross matching
Run BT @ 5-10 gtts/min for 30 mins then to titrate @ 15-20 gtts/min
with no BT reactions
Mainline to KVO while on BT
Monitor VS q15 mins while on BT
Refer for any BT reactions such as fever, chills, dyspnea, hypotension
and pruritus
Refer accordingly
POSTPARTUM ORDERS
History Back to room/ward
General data Full diet once full awake
Chief complaint Present IVF to run at 30 gtts/min, D/C if with minimal VB
PMHx IVF to ff: D5LR + 10 u Oxy to run at30 gtts/min
PSHx Meds:
FMHx Antibiotics
OBHx MA 500 mg/cap q 8 H RTC x 24 H, then prn for pain
o Menarche Methergin 1 tab TID x 3 days
o Interval Viitamins
o Duration SO:
o Amount Monitor VS q 15 min until stable
o Symptoms Massage uterus prn
o Coitarche Ice pack on hypogastrium
o Menopause Perilight x 15 min OD
o OCP, S/P, PAP, Intermenstrual bleeding Routine perineal care
o Postcoital bleeding Watch out for profuse vaginal bleeding
o OB Score Refer accordingly
o LMP, EDC, AOG Thank you
o PNCU
o HBsAg/VDRL
o TT/BT/MTV
o UTI DISCHARGE ORDERS (Normal OB)
MGH
Home Meds
NSVD Admitting Notes OPD ff-up on Sat @ OB service clinic with photocopy of D/S
Please admit to ROC under the service of _____ Discharge IE and summary c/o ___
TPR q 4 hours and record TCB anytime if with profuse VB, HA, blurring of vision, U2W ssx
Full diet, NPO once in active labor
Labs:
CBC
HBsAg CS ADMITTING NOTES
Urinalysis Please admit to ROC under the service of _____
IVF: D5LR + 10 u oxytocin to run at 10-15 gtts/min TPR q 4 hours and record
Meds Full diet, NPO post midnight
Ampicillin 2g IV ANST if PROM Labs:
SO: CBC, APC
Monitor FHB and progress of labor CT, BT, PT
Puboperineal shave please Urinalysis
Inform NROD Venoclysis
Will inform service consultant on deck Meds:
Refer prn Cefazolin 500mg IVTT q8H x 3 doses then shift to Co-Amox
Thank you 625mg/tab, 1 tab BID
Side notes Famotidine 20mg IVTT q8H x 3 doses
TPR Ketomed 30mg IVTT q8H x 3 doses
BP Ketomed 10mg q8H to start if px is on soft diet
Wt Tramadol 50mg IVTT q6H prn
LMP Inform OR
EDC Secure signed consent
AOG Abdominoperineal prep please
FH Request 500cc FWB of patients blood type as standby
FHB Dr. ___ for anesthesia
CD Inform NROD
Effacement Refer accordingly
Station Thank you
BOW
Leopolds
Final Dx:
PU FT del via NSVD/1LTCS/Rpt CS in cephalic presentation to a
live Bb Girl/Boy with BW: BL: AS: PAOG: OB score
POST-OP ORDERS POST OP ORDERS (TAHBSO)
To RR To RR
Monitor VS q15 mins until stable Monitor VS q 15 min, until stable
NPO x 6 H, then may have sips of CL Flat on bed x 6 H, then may turn to side
O2 at 2-3 LPM via nasal prong NPO x 6 H then may have sips of CL
Run present IVF @ 30 gtts/min Present IVF x 30 gtts/min
IVF to ff: IVF to ff:
o D5LR o D5LR
+ 10 u oxytocin x 8 H + 10 u oxytocin x 8 H
o D5NM o D5NM
o D5LR x 8 H o D5LR x 8 H
Meds: Meds:
Antibiotics SO:
Ranitidine (Zantac) 50mg IVTT q8H x 3 doses MIO q H and record
SO: Refer if UO is <30cc/H
Attach px to O2 at 2-3 LPM via nasal prong May return blood
Attach pc to pulse ox Remove FC @ ___
MIO q H and record Apply abdominal binder
Refer if UO is <30cc/H Refer PRN
Remove FC 24H post op Thank you
Standby available blood
Apply abdominal binder
Morphine precaution please
Specimen for histopathology PELVIC EXAM
Watch out for profuse vaginal bleeding, hypotension, tachycardia or Inspection
any untoward s/sx o Grossly N external genitalia
Refer PRN o Masses, discharges, bleeding
Thank you Speculum
o Cervix hyperemic/nonhyperremic; fish mouth deformity/ping
pong
IE
TRANS-OUT o Cervical dilatation
Side notes the ff: o Cervical effacement
Stable VS o Station
Able to flex both legs o BOW (intact/leaking)
(-) vomiting o Amniotic membrane PROM x days/hours
Blurring of vision o Presenting part
Orders Clinical pelvimetry
May refer back to room o Inlet
D/C O2 and pulse oximeter o Midplane
Monitor V/S q 15 min until stable Ischial spines
MIO q Hly(+ FC) or shift (- FC) and refer if UO <30 cc/H Sacrum
Watch out for profuse vaginal bleeding, hypotension, tachycardia or Sidewalls
any untoward s/sx o Outlet
Refer accordingly EFW
Thank you BME
o I (introitus) - admits 2 fingers with ease/snugly
o C (cervix) open/closed,; firm, doughy
o U (uterus) level of umbilicus
ADMITTING ORDERS (Abdomen) o A (adnexae) firm/fullness; w/ adnexal masses
Please admit to ROC under the service of Dr. ____ o D (discharges) (+) (-); scanty or minimal bleeding
TPR q shift and record o E (episiotomy) with blood/well coaptated wound
NPO RVE
Labs: o Intact rectovaginal septum
CBC (save serum) o Good sphincter tone
Serum pregnancy test Abdomen
Urinalysis o Inspection: globular/gravid; lineanigra, striae
IVF: D5LR + 10 u oxytocin x 30 gtts/min o Auscultation: NABS
SO: o Palpation: Leopolds
For completion curettage on call o FH, FHB R/L
Secure consent Final Dx:
Pad count at bedside
Save specimen passed out
Please prescribe the ff: Nubain, Benadryl, Dormicum
Refer for profuse bleeding and other untoward ssx
Thank you
NON-STRESS TEST Hypertension etiology(Williams)
Test of fetal condition Exposed chorionic villi
REACTIVE when: Twin pregnancy (Multiple gestation)
At least 2 accelerations of the FHR occurs for at least 15 bpm, lasting for Vascular dses
15 sec w/in 20 min period of observation Famhx
NONREACTIVE
May imply that the fetus is acidotic, asleep, or drugs was administered
to the mother
A. EARLY DECELERATION THREATENED ABORTION
Head compression Bloody vaginal discharge or bleeding appears
B. LATE DECELERATION Closed vaginal os
Utero-placental insufficiency Low abdominal pain
C. VARIABLE DECELERATION Bleeding first, cramping follows
Cord compression ; Fetal distress
Most common ; Most ominous INEVITABLE ABORTION
Gross rupture of membrane
Leaking amniotic fluid
CONTRACTION STRESS TEST/OCYTOCIN CHALLENGE TEST Cervical dilatation
A measure of utero-placental function
Contraction induced by using IV oxytocin COMPLETE ABORTION
Record FHB Complete detachment
POSITIVE Int. cervical os closes
Consistent and persistent late deceleration (50%) of the FHB in
the absence of uterine hypertonus or supine hypotension INCOMPLETE ABORTION
NEGATIVE Int. cervical os opens and allows passage of blood
@ least 3 contractions in 10 mins, each lasting 40 secs, w/o late
deceleration
SUSPICIOUS
Inconstant late deceleration patterns Mullerian Anomalies
HYPERSTIMULATION Segmented mullerianagenensis or hyperplasia
Uterine contractions occur more frequent than every 2 mins, or Unicornuate uterus
lasting longer than 90 secs, or presence of hypertonus Bicornuate uterus
UNSATISFACTORY Septate uterus
Frequency of contractions is <3 per minute Uterus with internal ___? Changes

Induction of labor
Oxy drip but not in labor

HYPERTENSION Augmentation of Labor


140/90MMhG Oxy drip however in labor
Proteinuria
>300mg/24H urine sample
> 1000mg/random sample 6H apart
1+ = mild proteinuria
2+ to 4+ = heavy proteinuruia PRENATAL CHECK-UPS
*Edema DOES NOT validate Preeclampsia 0-27 wks q4wks
28 wks q 2wks
GESTATIONAL HPN 29-35 wks q2wks
HPN w/o Proteinuria (after 20 weeks gestation) 36 wksand beyond q week
Confirm 12 wks Postpartum

PREECLAMPSIA TETANUS TOXOID


(+) HPN, (+) Proteinuria after 20th week 0 20 wks AOG
1 1 month
ECLAMPSIA 2 6 months
(+) convulsions, (+) Preeclampsia 3 1 year
4 1 year
CHRONIC HPN 5
140/90mmHg
STEROIDS
SUPERIMPOSED PREECLAMPSIA 1 dose 28-32 wks
Inc diastole and systole 3 doses q 2 wks
Proteinuria OGTT at 24-28wks
S/Sx of end organ damage

Triad for Severe Preeclampsia


Hemolysis
Elevated Liver Enzyme
Low Platelet Count
MAGNESIUM SULFATE DOSES
Loading dose:
4gms slow IV BISHOP SCORE
5gms each buttocks deep IM 0 1 2 3
Maintenance dose:5gmsIM/IV q 6hrs Dilatation 0 1-2cm 3-4cm 5-6cm
Monitor BP, U/O, DTRs-hyporeflexia Effacement 0-30% 31-50% 51-70% >70%
Monitor RR Station -5/-3 -2 -1 +1/+2
MgSO4 drip: Cervical Posterior Midline Anterior -----
1-2gms/hr Position
1L = 10gm given 100cc/hr Cervical firm medium soft -----
10meq/L(about 12mg/dL) Consistency
>respiratory depression *Scoring: 3-8 difficult induction
12meq/L 9-favorable induction
>respiratory paralysis and arrest
Antidote: Calcium gluconate 1g iV
MYOMA
Causes soft tissue dystocia
Etiology: unopposed estrogen stimulation
FETAL DEATH Types: Subserous, Intramural,Submucous
1. Tobacco-stained amniotic fluid ROT-right occiput transverse
2. Spaldingssign Montevideo Units- 200 units or pressure of > 60
o significant overlapping of fetal skull bones Depoprovera- injectable CP is G1 to HPN patients
3. Roberts sign
o Demonstration of gas bubbles in the fetus
4. Exaggeration of fetal spinal curvature
EXCISION OF BARTHOLINS CYST
BIOPHYSICAL SCORING PARAMETERS Hyperplasia (uterus) Provera
1. Fetal Breathing Movements
Endocervical
2. Gross Body Movement For Functional Curettage
Endometrial
3. Fetal Tone
Endometrial for D & C
4. Reactive FHR
5. Amniotic Fluid
AUGMENTATION OF LABOR
*Perfect Score is 10/10 or 8/8
amniotic fluid
CBC repeated at 28-32 AOG
HbsAg last trimester Oligohydramnios (causes)
Alpha fetoprotein 16-18 wks AOG o Cord compression
o Macrosomia
o Deformations
PLASMA GLUCOSE RESULTS: o Fetal distress
(Blood Glucose testing performed at 24-28wks AOG)
Time NDDG Coustan&Capenter(mg/dL)
HYOSCINE N-BUTYL BROMIDE (Buscopan) for softening of the cervix
Fasting 105 95
1stHr 190 180 NST: Fetal condition 7 days
2ndHr 165 155
3rdHr 145 140 CST: Uteroplacental contraction

DELIVERY OF PLACENTA
LEOPOLDS MANEUVER
L1 (Fundal Grip) SHULTZE MECHANISM
What fetal pole occupies the fundus Peripheral
L2 (Umbilcal grip) Shiny portion
Fetal back DUNCAN MECHANISM
L3 (Pawlicks grip) Central
(+) engagement of head or (-) engagement Dirty part
L4 (Pelvic grip) DEFINE:
Side of cephalic prominence Placenta increta invades
Placenta percreta penetrates
Placenta accrete attaches
FUNDIC HEIGHT Normal Rotation of Umbilical Cord:
12wks- 1st felt; above the symphysis pubis Counter clockwise or Left-handed maneuver
16wks- bet. Symphysis and umbilicus
20wks- umbilicus
36wks- below ensiform cartilage

FHB Monitoring
Every 30mins= low risk
Every 15mins= high risk
PLACENTA PREVIA INDICATIONS FOR CESAREAN SECTION
Types: Prior CS
o Totalis placenta covers cervical os completely Labor dystocia (most frequent indication for 1 CS)
o Partialis internal os partially covered by placenta Fetal distress
o Marginal edge of the placenta is at margin of internal os Breech presentation
Etiology: (P2ALM2)
o Previous CS POST OP COMPLICATIONS OF CS DELIVERY
o Puerperal Endometritis Hysterectomy
o Advancing age Operative injury to pelvic structures
o Multiparity Infection
o Multiple induced abortions Puerperal fever
Diagnosis: Transfusion
o Painless third trimester bleeding
o UTZ for placental localization
o Placental Migration (placenta close to the internal os during
2nd trimester migrate to fundus as pregnancy advances
STAGES OF LABOR
I: Active labor to full cervical dilatation (4-10 cm)
PLACENTAL ABRUPTION II: Full cervical dilatation to delivery of baby
premature separation of the normally implanted placenta after the 20th II: Delivery of baby to expulsion of placenta
week of pregnancy and before birth of fetus IV: Delivery of placenta to 1 hour after
Etiology: (PECSS)
o Pre-eclampsia CARDINAL MOVEMENTS
o External trauma Engagement
o Chronic hypertension
Descent
o Short umbilical cord
Flexion
o Sudden uterine decompression
Internal rotation
Extension
External rotation
LACERATIONS Expulsion
1st Degree
o Fourchette, perineal skin, vaginal mucosa but not the ASYNCLITISM such lateral deflection of the head to a more anterior or
underlying fascia and muscle posterior position of the pelvis
2nd Degree
o Fascia and muscles of the perineal body but not the anal
sphincter
ANTERIOR COLPORRHAPY
3rd Degree
1. Induction of anesthesia.
o Extend from vaginal mucosa, perineal skin and fascia up to
2. Patient is placed in dorsal lithotomy position.
anal sphincter but not the rectal mucosa
3. Asepsis/Antisepsis
4th Degree
4. Drapings done leaving the operative site exposed
o Encompasses extension up to rectal mucosa
5. Evacuation of urine using straight catheter.
6. The lateral edges of the vaginal cuff are held with Allis. Several
Allis clamps are placed 3-4 cm apart up the midline of anterior
vaginal wall.
BRAXTON HICKS CONTRACTION
7. The vaginal mucosa is undermined for approximately 3-4 cm up
The uterus undergoes palpable but originally painless contractions
to first Allis clamps placed in midline.
at irregular intervals from the early stages of gestation
8. The vaginal mucosa is dissected off the pubovesical cervical fascia
and opened with scissors in the midline. The vaginal mucosa is
SIGNS OF PLACENTAL SEPARATION
opened in midline up to next Allis clamp. This is continued until
Calkins Sign (uterus becomes globular and firmer from discoid) the vagina is opened to within 1 cm of urethral meatus.
Sudden gush of blood 9. The PVC fascia is separated from the vaginal mucosa. The
Uterus rises in the abdomen as the detached placenta drops to dissection is continued until bladder and urethra are separated
the lower segment and vagina from the vaginal mucosa and clearly identified and urethral vesical
Lengthening of the cord angle has been ascertained.
10. Kelly plication done with chromic 2-0. The anterior repair is
AMONIOTIC FLUID INDEX started by placing suture in PVC fascia, starting at the level of
Normal: 6-24 cm first Kelly placation suture
Oligohydramnios: <5 cm 11. The edges of vaginal mucosa retracted laterally with Allis clamps
Low normal: 9-10 and remaining PVC fascia is plicated in midline with multiple
Polyhydramnios: >24 interrupted mattress sutures. The edge of vaginal mucosa are
held in tension and excessive mucosa trimmed.
12. The vaginal mucosa is sutured in midline down to previously
incised site by continuous interlocking suture.
13. Perineal wash done
14. End of procedure.
POSTERIOR COLPORRHAPY REPEAT LOW TRANSVERSE CESAREAN SECTION
1. Induction of spinal anesthesia. 1. Induction of spinal anesthesia.
2. Patient is placed in dorsal lithotomy position. 2. Patient in supine position.
3. Asepsis/Antisepsis 3. Insertion of foley catheter.
4. Drapings done leaving the operative site exposed 4. Asepsis/Antisepsis
5. Allis clamps are applied at the posterior vaginal mucosa, elevated 5. Drapings done, exposing operative site.
creating a triangle. 6. Old scar removed. Vertical incision done from 2 FB above the
6. A transverse incision made at the posterior fourchette. A portion symphysis pubis up to 3 FB below the umbilicus. Incision
of the posterior vaginal mucosa is elevated using an Allis clamp deepened to subcutaneous tissues and transversalis fascia,
and an index finger covered with gauze is inserted upward and rectus muscle split, peritoneum cut longitudinally.
laterally, dissecting the posterior vaginal mucosa of the 7. Bleeders clamped and ligated as encountered
perirecteal fascia. 8. Retractors applied exposing pelvic structures.
7. Vertical incision in posterior vaginal mucosa made. Perirectal 9. Vesico-uterine folds identified, lifted out and cut 1 cm above the
fascia dissected off the posterior vaginal mucosa. The apex of bladder.
triangle held with Allis clamp. The dissection of perirectal fascia 10. Bladder pushed downward and a curvilinear incision is done on
off the vaginal mucosa is started with scalpel but is completed the lower uterine segment using bandage scissors.
with blunt dissection. 11. Rupture of membranes.
8. Kelly plication sutures with vicryl 2-0 through the margins of 12. Amniotic fluid suctioned and fetal head exposed.
levatorani muscles from apex down to posterior fourchette is 13. Delivery of baby boy in left occiput transverse position.
done and progressively tied. 14. Umbilical cord doubly clamped and cut.
9. The excess posterior vaginal mucosa trimmed. 15. Manual extraction of placenta.
10. The perineal fascia closed with interrupted vicryl 2-0 16. Closure of incision site done layer by layer
11. Vicryl 2-0 suture is placed at the apex of vaginal mucosa using a. First (endometrial) layer closed by continuous interlocking
continuous interlocking stitches to posterior fourchette. stitches using Chromic 1.
12. Vaginal packing done with 1 os. b. Second (myometrial) layer closed by continuous interlocking
13. Perineal wash done. stitches using Chromic 1.
14. End of procedure. c. Third (Vesico-uterine folds) closed by simple continuous
stitches using chromic 2-0.
17. Suction of blood and amniotic fluid and sponge done.
1 LOW TRANSVERSE CESAREAN SECTION 18. Inspection of the ovaries, fallopian tubes and ligaments
1. Induction of spinal anesthesia. 19. Parietal peritoneum closed with continuous suture using
2. Patient in supine position. chromic 2-0
3. Insertion of foley catheter. 20. Transversalis fascia sutured with continuous interlocking stitches
4. Asepsis/Antisepsis using Vicryl 1-0
5. Drapings done, exposing operative site. 21. Subcutaneous tissue sutured simple interrupted stitches using
6. Vertical incision done from 2 FB above the symphysis pubis up to Plain 2-0
3 FB below the umbilicus. Incision deepened to subcutaneous 22. Skin closed by subcuticular stitches using Monocryl 4-0.
tissues and transversalis fascia, rectus muscle split, peritoneum 23. Incision site painted with betadine
cut longitudinally. 24. Top dressing applied.
7. Bleeders clamped and ligated as encountered 25. End of procedure.
8. Retractors applied exposing pelvic structures.
9. Vesico-uterine folds identified, lifted out and cut 1 cm above the
bladder.
10. Bladder pushed downward and a curvilinear incision is done on ENDOCERVICAL POLYPECTOMY
the lower uterine segment using bandage scissors, bag of water 1. Induction of labor.
ruptured. 2. Sepsis/Antisepsis/drapings done leaving operative site exposed.
11. Rupture of membranes. 3. Insertion of straight catheter to empty the urinary bladder.
12. Amniotic fluid suctioned and fetal head exposed. 4. Posterior vaginal retractor positioned, endocervix identified.
13. Delivery of baby boy in left occiput transverse position. 5. Anterior lip of the cervix grasped with tenaculum forceps.
14. Umbilical cord doubly clamped and cut. 6. Endocervical polyp found.
15. Manual extraction of placenta. 7. Polyp grasped, twisted, and removed using an ovum forcep.
16. Closure of incision site done layer by layer 8. Vaginal packing inserted.
a. First (endometrial) layer closed by continuous interlocking 9. End of procedure.
stitches using Chromic 1.
b. Second (myometrial) layer closed by continuous interlocking
stitches using Chromic 1.
c. Third (Vesico-uterine folds) closed by simple continuous
stitches using chromic 2-0.
17. Suction of blood and amniotic fluid and sponge done.
18. Inspection of the ovaries, fallopian tubes and ligaments
19. Parietal peritoneum closed with continuous suture using
chromic 2-0
20. Transversalis fascia sutured with continuous interlocking stitches
using Vicryl 1-0
21. Subcutaneous tissue sutured simple interrupted stitches using
Plain 2-0
22. Skin closed by subcuticular stitches using Vicryl 4-0.
23. Incision site painted with betadine
24. Top dressing applied.
25. End of procedure.
1 LOW TRANSVERSE CESAREAN SECTION (PFANNENSTIEL) TAHBSO
1. Induction of spinal anesthesia. 1. Induction of spinal/epidural anesthesia
2. Patient in supine position. 2. Patient in supine position.
3. Insertion of foley catheter. 3. Insertion of foley catheter done.
4. Asepsis/Antisepsis 4. Asepsis/Antisepsis
5. Drapings done, exposing operative site. 5. Drapings done leaving operative site exposed.
6. Curvilinear incision done from 2 FB above the symphysis pubis 6. Midline incision done from symphysis pubis up to 2 FB below the
up to 3 FB below the umbilicus. Incision deepened to umbilicus cutting through skin, subcutaneous tissue and fascia,
subcutaneous tissues and transversalis fascia, rectus muscle rectus muscle split and peritoneum incised.
split, peritoneum cut longitudinally. 7. Bleeders clamped and ligated as encountered.
7. Bleeders clamped and ligated as encountered 8. Self retaining and bladder retractors were applied to expose
8. Retractors applied exposing pelvic structures. pelvic structures.
9. Vesico-uterine folds identified, lifted out and cut 1 cm above the 9. Moist pack applied.
bladder. 10. Inspection of the pelvic structures done.
10. Bladder pushed downward and a curvilinear incision is done on 11. Abdominopelvic structures examined revealed that the uterus
the lower uterine segment using bandage scissors measures 8x7cms with smooth serosa. Both ovaries grossly
11. Rupture of membranes. normal .Both measures 3x2 cm. Left fallopian tube dilated to 7x3
12. Amniotic fluid suctioned and fetal head exposed. cm and its ampullary area containing serous fluid. Right fallopian
13. Delivery of live full term baby boy in left occiput transverse tube with small cystic paratubal masses ~1x1cm.
position. 12. Right round ligament is doubly clamped, then cut and ligated
14. Umbilical cord doubly clamped and cut. with Chromic 1. The same procedure is done on the opposite
15. Manual extraction of placenta. side.
16. Closure of incision site done layer by layer 13. Anterior and posterior leaves of the broad ligament opened.
a. First (endometrial) layer closed by continuous interlocking Anterior leaf of the broad ligament incised to the point of
stitches using Chromic 1. bladder reflection.
b. Second (myometrial) layer closed by continuous interlocking 14. Infundibulopelvic ligament triply clamped, cut and doubly ligated
stitches using Chromic 1. using Chromic 1-0.
c. Third (Vesico-uterine folds) closed by simple continuous 15. Vesicouterine folds cut transversely
stitches using chromic 2-0. 16. Bladder dissected by blunt and sharp dissection.
17. Suction of blood and amniotic fluid and sponge done. 17. Uterine arteries triply clamped, cut and doubly ligated with
18. Inspection of the ovaries, fallopian tubes and ligaments Chromic 1-0 on both sides.
19. Parietal peritoneum closed with continuous suture using 18. Pubovesical fascia incised and pushed down with use of sponge
chromic 2-0 19. Cardinal ligaments clamped, cut and suture ligated with Chromic
20. Transversalis fascia sutured with continuous interlocking stitches 1-0.
using Vicryl 1-0 20. Amputation of cervix at level of cervical os.
21. Subcutaneous tissue sutured simple interrupted stitches using 21. Betadinized OS inserted to the vaginal stump.
Plain 2-0 22. Closure of vaginal stump with continuous interlocking suture
22. Skin closed by subcuticular stitches using Vicryl 4-0. using Vicryl 1-0. Stump angles are anchored to the cardinal
23. Incision site painted with betadine ligaments on both sides with figure of eight stitches using Vicryl
24. Top dressing applied. 1-0.
25. End of procedure. 23. Bleeders clamped and ligated as encountered.
24. Parietal peritoneum closed with continuous stitches using
chromic 2-0.
25. Transversalis fascia sutured with continuous stitches using vicryl
1-0.
26. Subcutaneous tissue closed with simple interrupted stitches with
Plain 2-0.
27. Skin closed by subcuticular stitches using Monocryl 3-0.
28. Operative site painted with betadine
29. Top dressing done.
30. Specimen sent for Histopath.
31. End of procedure.
VAGINAL HYSTERECTOMY EVACUATION CURETTAGE
1. Induction of anesthesia. 1. Induction of spinal anesthesia.
2. Patient is placed in dorsal lithotomy position. 2. Patient in dorsal lithotomy position.
3. Asepsis/Antisepsis 3. Asepsis/Antisepsis.
4. Drapings done leaving the operative site exposed 4. Drapings done leaving the operative site exposed.
5. Evacuation of urine using straight catheter 5. Straight Catheterization done.
6. Vaginal mucosa is incised with a scalpel around the entire cervix. 6. Right angle retractor applied to expose cervix.
7. Downward traction is applied using tenacula, Metzenbaum used 7. Anterior cervical lip grasped with tenaculum forceps at 12
to dissect the bladder off the anterior lower uterine segment. 0clock position.
8. A sponge covered finger dissects the bladder all the way up to 8. Hysterometer inserted.
the vesicouterine fold, facilitates entry to anterior cul de sac. 9. Pre-curettage uterine depth measured 9 cms.
9. Right angle retractor is placed under the vaginal mucosa and 10. Sharp and dull curettage done in a clockwise manner, evacuated
bladder, elevating the bladder. Strong downward traction is cup of products of conception and placental tissues.
applied to the tenacula on the cervix, and the peritoneal 11. Post curettage uterine depth was not measured.
vesicouterine fold is grasped with Allis clamps and incised with 12. Perineal washing done.
sharp curved mayo scissors. 13. Specimen for histopathology.
10. Elevating the peritoneal vesicouterine fold with Allis clamps,
definite hole can be seen. Finger is inserted in the hole.
11. Tenacula are brought acutely up toward the pubic symphysis,
exposing the cul- de-sac, second right angle at posterior cul-de- DIAGNOSTIC CURETTAGE
sac 1. Induction of anesthesia.
12. The posterior vaginal retractor is removed. The broad ligament is 2. Patient in dorsal lithotomy position
exposed from the uterosacral ligaments to the tuboovarian 3. Asepsis/Antisepsis
ligament. A finger is placed in the posterior cul-de-sac and 4. Drapings done leaving operative site exposed
moved laterally revealing the uterosacral ligament as it attaches 5. Straight catheter was inserted.
to the lower uterine cervix. 6. Cervix dilated with Goodells dilator
13. With the cervix on upward and lateral retraction using the 7. Retractor applied at posterior & anterior vaginal wall
tenacula, a clamp is placed in the posterior cul-de-sac with one 8. Application of tenaculum forceps at 12 oclock position of
blade underneath the uterosacralligament, and the opposite cervical lip.
blade over the uterosacral ligament. This is done to prevent 9. Insertion of hysterometer to measure pre-curettage uterine
possible ureteral damage from clamping the ligaments in lateral depth of 3 inches.
position. 10. Blunt curette done in a clockwise manner. Evacuated scanty
14. Uterosacral ligament is cut using the mayo scissors. endometrial scrapings.
15. Chromic 1-0 suture is used to suture ligate the uterosacral 11. Perineal wash done
ligament. 12. Specimen sent for histopath
16. When tied, the suture is held with a Kelly clamp for traction.
17. With uterus on upward and lateral retraction using the tenacula
on the cervix, cardinal ligaments is clamped adjacent to the
lower uterine segment and incised. FRACTIONAL CURETTAGE
18. Cardinal ligaments is sutured ligated with Chromic 1-0 suture. 1. Induction of anesthesia.
Suture is held with a Kelly clamp for traction 2. Patient in dorsal lithotomy position.
19. The remaining portion of the broad ligament attached to lower 3. Asepsis/Antisepsis.
uterine cervix segment containing the uterine artery is clamped 4. Drapings done leaving operative site exposed.
and ligated. 5. Straight catheterization done.
20. With all the ligaments on both sides, clamped and ligated, cervix 6. Weight-bearing retractor applied at posterior vaginal wall. Cervix
is retracted upward in midline with the tenacula. Posterior smooth with no erosions.
uterine wall is grasped, the fundus is delivered posteriorly. 7. Application of tenaculum forceps at 12 oclock position of
21. Two cochers clamps are applied to the tubo ovarian round cervical lip.
ligaments, incised close to the fundus. 8. Endocervical curettage done, evacuated minimal endocervical
22. Infundibulo-pelvic ligament is tied twice using Vicryl 1.0. Second scrapings.
suture ligation is tied in a fixation stitch, placing the suture in the 9. Hysterometer inserted. Pre-curettage uterine depth measured
mid portion of its pedicle. 9cm.
23. The anterior and posterior clamps right angle retractors are 10. Endometrial curettage done. Evacuated teaspoon of
removed, and the weighted posterior retractor is placed in the endometrial scrapings/tissues and placental tissues.
vagina. Any bleeding from any pedicle is clamped. 11. Post curettage uterine depth measured, approximately 8 cm.
24. Cardinal ligaments, uterosacral ligaments and utero ovarian 12. Tenaculum and retractors removed.
ligaments anchored at the posterior vaginal mucosa. 13. Perineal wash done
25. Reperitonealization of the pelvis, carried out with purse string 14. Specimen sent for histopath.
sutures. 15. End of procedure.
26. Perineal wash done.
27. End of procedure.
COMPLETION CURETTAGE ADMITTING NOTES (Ectopic Pregnancy)
1. Induction of anesthesia. Cc:
2. Patient in dorsal lithotomy position Imp:
3. Asepsis/Antisepsis Please admit pc to ROC under the service of Dr. ___
4. Drapings done leaving operative site exposed TPR q 4 hours and record
5. Insertion of straight catheter. NPO temporarily
6. Speculum applied at posterior vaginal wall Labs:
7. Application of tenaculum forceps at 12 oclock position of o CBC, APC
cervical lip. o CT, BT, PT
8. Sharp/blunt curette done. Evacuated 1 tablespoon cup of o BT w/ Rh
products of conception. o U/A
9. Betadine wash done. o S. Preg test
10. End of procedure. IVF: D5LR 1L X 8 Hrs
11. Specimen sent for histopathology. Meds: None temporarily
SO:
Monitor VS, abdominal status hourly
Refer once lab result is in
VAGINAL BIRTH AFTER A CESAREAN SECTION (VBAC) Dr. ___ seen px at ER
Allow a trial of labor under double set-up for all previous cesarean Watch out for any untoward s/sx
of one low segment incision after excluding an inadequate pelvis Refer prn
and unless a new indication arises
Selection Criteria:
o 1 or 2 prior low-transverse cesarean section delivery
o Clinically adequate pelvic ANESTHESIA
o No other uterine scars or previous rupture Pre-meds:
o Physicians immediately available throughout active labor Cefuroxime (Zegen) 1.5 gms IV
capable of monitoring labor and performing an emergency Omeprazole 20mg IV
cesarean section delivery Metoclopramide (Plasil) 10mg IV
o Availability of anesthesiologist and personnel for emergency Anesthetic Agent: Bupivacaine 15mg + MgSO4 16mg
cesarean section delivery Detailed Technique: RA-SAB
X-LLDP, SAS
LA w/ 2% Lidocain
LP at L3 L4
CRITERIA FOR TIMING OF ELECTIVE REPEAT CS DELIVERY (At least 1): CSF clear and free flowing
Fetal heart sounds documented for 20 weeks by non-electronic Intrathecal administration of anesthetic
fetoscope or for 30 weeks by Doppler
It has been 36 weeks since a (+) serum/urine hCG pregnancy test
was performed by a reliable laboratory
An UTZ measurement of the CRL obtained at 6-11 weeks supports SIGNS OF MALIGNANCY UTZ:
a gestational age at least 39 weeks Septations
UTZ obtained at 12-20 weeks confirms the gestational age of at Internal echoes
least 39 weeks determined by clinical history and PE Ascites
Multiple daughter cysts
<5 cm cyst in postmenopausal women expectant management

CP STATUS PIPERACILLIN TAZOBACTAM


CP status assessed Mode of Action:
Pls. transfuse available ___ u PRBC of px blood after proper Highly active against piperacillin-sensitive microorganisms as wells
crossmatching as B-lactamase-producing piperacillin-resistant microorganisms
BT to run initially @ 5-10 gtts/min x 30min then to 15-20 Indication:
gtts/min if with no BT rxn For UTI, lower resp tract, intraabdominal& skin infections
Maintain IVF x KVO while on BT &septicemia
BT precautions please Side effects:
Watch for any untoward s/sx such as DOB, pruritus, fever
Upset stomach, vomiting, unpleasant or abnormal taste, diarrhea,
Refer prn
gas, headache, constipation, insomnia, rash, itching skin, swelling,
Thank you.
shortness of breath, unusual bruising or bleeding

CgMg (CALMAG)
Mode of action:

Indication:
Calcium deficiency, nutritional supplement to prevent
osteoporosis
Side effects:

ISOXUPRINE HCl (Duvadilan)
Mode of Action:

Indication:
Treatment of circulatory disorders and uterine hypermotility
Side effects:
Transient palpitations, fall in BP, dizziness

DYDROGESTERONE (Duphaston)
Mode of Action:
Orally active progesterone
Promotes pregnancy in case of luteal insufficiency for maintaining
pregnancy in threatened and habitual abortions
Indications:
Dysfunctional uterine bleeding, irregular cycles, threatened and
habitual abortion, infertility, premenstrual syndrome,
endometriosis, dysmenorrheal
Side effects:
Breakthrough bleedings, hemolyticanemia, edema, asthenia or
malaise, jaundice and abdominal pain

METOCLOPRAMIDE (Plasil)
Mode of Action:
Stimulates motility of the upper GIT w/o stimulating gastric,
biliary or pancreatic secretions
Sensitization of tissues to action of acetylcholine
Indications:
For disturbances of GIT motility, GERD, diabetic gastroporesis,
nausea, vomiting, migraine HA
Side effects:
Restlessness, drowsiness, fatigue, lassitude

Ransons Criteria ( objectivesigns of severity of acute pancreatitis)


On Admission:
Age > 55 y.o
Glucose > 200mg/dl
WBC > 16,000/cumm
LDH > 350 IU/L
AST > 250 U/L

After Initial 48 hrs


Serum Ca++ < 8mg/dl
Arterial PO2 < 60mmHg
Base Deficit > 4meq/L
BUN Increase > 5mg/dl
Hematocrit fall > 10%
Fluid Sequestration > 6,000ml