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A 24-year-old gravida 3 para 1 is

admitted to the hospital at 29 weeks


gestation with a high fever, flank pain,
and an abnormal urinalysis. You order
blood and urine cultures, a CBC,
electrolyte levels, and a serum
creatinine level. You also start her on
intravenous fluids and intravenous
gentamycin plus ampicillin. After 24
hours of antibiotic treatment she is
clinically improved but continues to
have fever spikes.
Appropriate management at this time
would be to:

a) Continue current management


b) Change her antibiotics, as her
infection is likely due to a resistant
organism
c) Order a plain abdominal
radiograph to rule out a renal stone
d) Order modified intravenous
pyelography to rule out urinary
tract obstruction
e) Order renal ultrasonography to
rule out a perinephric abscess

Explanation: The correct answer is a)


Pyelonephritis is the most common serious
medical problem that complicates pregnancy.
Infection is more common after midpregnancy,
and is usually caused by bacteria ascending from
the lower tract. Escheria coli is the offending
bacteria in approximately 75% of cases. About
15% of women with acute pyelonephritis are
bacteremic. A common finding is
thermoregulatory instability, with very high
spiking fevers sometimes followed by
hypothermia. Almost 95% of women will be
afebrile by 72 hours. However, it is common to
see continued fever spikes up until that time.
Thus, further evaluation is not indicated unless
clinical improvement at 48-71 hours is lacking. If
this is the case, the patient should be evaluated
for urinary tract obstruction, urinary calculi and an
intrarenal or perinephric abcess. Ultrasonography,

A 32 year old white female comes to see you because of


moderately severe pelvic pain that has been present for
several years and is worse with menses. She describes the
pain as bilateral, deep in the pelvis, and intermittently
cramping and steady. She has never been pregnant, although
she has not been using any contraception during the 6 years
she has been married. She is not interested in fertility at this
time. She has no history of previous sexually transmitted
disease, IUD use, or abdominal or pelvic surgery. She
currently uses ibuprofen, 600 mg 3-4 times a day as needed,
with moderate pain relief. She is a nonsmoker.
Physical examination reveals a blood pressure of 120/70 mm
Hg and normal findings on examination of the heart, lungs,
and abdomen. The vagina and cervix are normal in
appearance. Bimanual examination reveals a normal-sized
uterus and adnexa with no masses, but mild tenderness on
palpation of the posterior uterus and posterior cul-de-sac.
Recent screening laboratory work was normal, including a
CBC, thyroid function tests, lipid levels, and liver function
tests. What is the most appropriate management at this time?

a) Referral for
hysterosalpinography
b) Prescribing a COX-2 inhibitor
such as rofecoxib (Vioxx) or
celecoxib (Celebrex) to be used
instead of ibuprofen
c) Starting her on an oral
contraceptive containing both
estrogen and progesterone
d) Starting her on a danazol
(Danocrine), 600 mg/day

The correct answer is c)


Explanation:
This patient most likely has endometriosis with
chronic, cyclical pelvic pain. Since she is not
interested in fertility, the next reasonable step is
to induce a hormonal pseudopregnancy using
combination oral contraceptives.

A 34-year-old white female visits your office with a


chief complaint of pelvic pain that intensifies with
her menstrual period. She has a history of pain
during intercourse, which started in her midtwenties and has gradually become worse. She
reports recently missing some work during her
menstrual period due to the pain. She has had
two uneventful deliveries and the pain was absent
during and after each pregnancy, but gradually
returned. She and her husband do not wish to
have any more children and her husband has had
a vasectomy.
The patient denies vaginal discharge or fever and
a review of systems is negative. A complete
physical examination is normal except for
moderate non-specific tenderness on pelvic
examination. In addition, her uterus is moderately
retroverted and has decreased mobility.
Which one of the following would be the most

A) start her on a combination of oral


contraceptives
B) Admit her immediately and go for a
complete hysterectomy
C) Admit her immediately and go for a
complete oophorectomy
D) Explain her consequences related to
surgery and post. Op. lifestyle changes.
E) As she doesnt want any more child
ask her to go for vasectomy.

The correct answer is b)


Explanation:
This patient has endometriosis. Combination oral
contraceptives should be first-line therapy for
women with endometriosis who do not wish to
become pregnant. Conjugated estrogens is not a
treatment for endometriosis. Depot
medroxyprogesterone acetate and danazol are
accepted treatments, but each has undesirable
side effects. A complete hysterectomy and
bilateral oophorectomy is considered a radical
surgical approach, and is reserved for more
difficult endometriosis cases.

An 80 ,year-old man is admitted to the


hospital with a massive intracranial bleed.
He has been placed on a ventilator because
of the respiratory failure associated with
intracranial herniation, When you try to
remove the ventilato5 there are no
respirations. The patient makes no purposeful
movements. There is no pupillary reaction
when you shine a light in his eyes. There is no
nystagmus on cold caloric question testing.
Oculocephalic and corneal reflexes are
absent. He left no specific wishes for his care.
Which of the following is the most appropriate
action regarding this patent:

a) Remove the ventilator.


b) Make the patient DNR.
c) Place a nasogastric tube to prevent
aspiration.
d) Get a court order authorizing you to
remove the ventilator.
e) Do an EEG (electroencephalogram)
three times separated by six hours each
time.

(a) Remove the ventilator.


The patient meets the criteria for brain death.These are:
negative corneal reflex, no nystagmus in response to caloric
stimulation of the tympanic membranes, negative pupillary
and oculocephalic reflexes, and the absence of
sponontaneous respiration
when the ventilator is held. If there are no brainsten reflexes
and the patient will not spontaneously breathe, then the
patient is brain dead. There is no hope of recovery in this
circumstance. An EEG is not necessary because the clinical
presentation is consistent with brain death. Brain death is the
legal definition of death. When a patient is brain dead, you
do not
Need to seek court order prior to stopping all therapy. When
a pt. is brain dead u donot need to place nasogastric tube to
feed or hydrate him.
Remember, although you have legal right to turn off
the ventilator immediately on a person who is brain
dead, you should talk to the family first. Discuss the
matter with the pt. family first prior to removing the
endotracheal tube.