Im Notes 1

ELECTROLYTE SOLUTIONS
IV Soln
D5W
D10W
0.9 NSS
D5LR
D5NM
D5NR
D5 0.9
NaCl
D5NMK
Glu
5mg/L
100mg/L
Soln
ECF
D5LR
D5 0.45
3% NaCl
0.9 NaCl
ELECTROLYTES
Na
Cl
Ca
HCO3
154
130
40
140
154
109
40
98
4
13
5
28
50 mg/L
40
40
30
Na
142
130
77
513
154
Cl
103
109
77
513
154
K
4
4
HCO3
27
28
a)
b)
c)
d)
50 mg/L
Corrected Ca = (40-lbs) x 0.02 + serCa

Corrected Na = Na + RBS mg% - 100 x 1.6 / 100
Na Deficit = (140 actual) (0.6 x BW)
K Deficit = (D-A) (0.4 x BW)
D = 3.5 cardiac
4.5 non-cardiac
H20 Deficit = 0.6 x kg BW
D = 15 CKD
18 NCKD
Actual Na Desired Na / Desired Na
Ca
5
5
D5W Osm = 278

D5W Osm = 556
D5LR Osm = 130
NaHCO3 = 446
MECHANICAL VENTILATION
Mg
3
CUSHINGS TRIAD
1)
2)
3)
Increase systolic BP
Widened pulse pressure
Bradycardia /AbN respiratory pattern
a.
Cheyne Stoke breathing
HEMORRHAGIC STROKE TRIAD

1)
2)
3)
Papilledema
Headache
Vomiting
Indication for Intubation

1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
Impending respiratory failure, apnea

RR >35
PaCO2 > 50
PaO2 <60
TV < 3-5 ml/kg
VC < 10-15 ml/kg
Inspiratory force < 25 cm H20
FEV < 10 ml/kg
Vq / Vt > 0.6
To deliver high FIO2
Absent
pH <7.35
VENTILATOR SETTING
1)
2)
3)
4)
5)
TV: 6-8 ml/kg (ARDS) 8-10 ml/kg

Pale: 6-20
Mode:
AC (Assist Control)
SIMV (Synchronized Intermittent 1 mV
FIO2
PEEP 5cm H20
INDICATIONS FOR WEANING

1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Mental status: Awake, Alery

PaCO2 > 60 mmHg w/ FIO2 < 50%
PEEP < 5 cm
PaCO2 < pH acceptable
Spontaneous TV < 5mL
VC > 10 ml/kg
MIP > 25 cm H20
RR < 30/min
Rapid shallow breathing index < 100 (RBI)
Stable vs. Ft a 1-2 hr
Spontaneous Trial
FIO2 room air 21%
O2 via nasal prong = # lpm x 0.4 x 20
MEIGS SYNDROME
1)
2)
3)
Pleural Effusion
Polycystic Ovary / Fibromatosis
Hypoalbuminemia
GLASCOW COMA SCALE

EYE RESPONSE
a) Spontaneous eye opening
b) Opens to verbal command
c)
Responds to painful stimuli
d) No response
MOTOR
a)
b)
c)
d)
e)
f)
Obeys with command

Localizes pain
Flexion withdrawal
Decorticate / Flexion
Decerebrate / Extension
No response
VERBAL
a)
b)
c)
d)
e)
Oriented
Disoriented
Inappropriate
Incomprehensible
No response
4
3
2
1
6
5
4
3
2
1
5
4
3
2
1
FOUR SCALE
Full outline of responsiveness
DOPAMINE COMPUTATION
EYE RESPONSE
a) Eyelids open, tracking, blinking to command 4
b) Eyelids open but not tracking
c)
Eyelids close but open to loud voice
d) Eyelids close but no pain
e) Eyelids close with pain
3
2
1
0
MOTOR RESPONSE
a) Thumbs up, fist or peace sign
b) Localizing to pain
c)
Flexion response to pain
d) Extension response to pain
e) No response to pain or generalized myoclonus
4
3
2
1
0
BRAINSTEM REFLEXES
a)
Pupil and Corneal reflex
b) One pupil wide and fixed
c)
Pupil or corneal reflex absent
d) Pupil and corneal reflex absent
e) Absent pupil, corneal and cough reflex
4
3
2
Single strength = BW x desired dose / 13.3

Double strength = BW x desired dose / 16.6
Single strength = BW x desired dose / 16.6
Double strength = BW x desired dose / 33.2
Cardiac Dose = 5
Renal Dose = 5-10
CT SCAN BLEED VOLUME

Given:
58 mm
~
23.3 mm ~
5.8
2.3
5.8 x 2.3 = 13.34 x 5 (constant) = 66.5 x 5.2 (constant) = 34.684 -(estimated

bleeding volume)
1
0
RESPIRATION
a) Not intubated, regular breathing pattern 4
b) Not intubated, cheyne-stoke breath pattern 3
c)
Not intubated, irregular breathing
d) Breath above ventilation rate
e) Breath at ventilation rate, apnea
0
DIAGNOSTIC THORACENTESIS DUE TO HEART FAILURE
2
1
1)
2)
3)
4)
If the effusion are not bilateral and comparable size

If the patient is febrile
If the chest has a pleuritic chest pain
If effusion persist despite the diuretics therapy
DENGUE
GRADE I
INDICATION FOR CHEST TUBE THORACOSTOMY

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

GRADE III
Grade II + severe bleeding + circulatory failure

GRADE IV
Grade III + irreversible shock + massive bleeding
ABG COMPUTATION
I.
II.
III.
713 (decimal FIO2) PCO2/0.8 = I

pO2/I = II
(Desired FIO2/II) + pCO2/0.8
________________________
713
x 100
TIMING OF TUBE REMOVAL
The timing of tube removal depends on clinical and radiological

evidence of complete expulsion of all contents of pleural cavity
with 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 valsalva maneuver no

air leak should ensue
The chest radiograph should confirmed complete expansion of

the lung
The s____ in the fluid in the tube in the underwater seal bottle
should be minimal, relating to the normal negative pressured in
the chest during the phases of respiration
Desired FIO2 = 104 (0.43 x age)

A.
B.
C.
713 x FIO2 PCO2/0.8

pO2 / A
02 for age / B
+
pC02 / 0.8
________________________________
713
FIO2: 20 / 4 = L
INDICATIONS FOR CTT
Gross pus on thoracentesis
Presence of organism on gram stain of the pleural fluid
Pleural fluid glucose < 50 mg / dL
Pleural fluid pH below 7.00 and 0.15 units lower than arterial pH
LIGHTS CRITERIA
1)
2)
3)
LOCATING MYOCARDIAL DAMAGE
Pleural fluid protein / serum protein > 0.5

Pleural fluid LDH / serum LDH > 0.6
Pleural fluid LDH > 2/3 the upper limit of normal serum LDH
Anterior = V2-V4 (L) coronary, LAD

Anterolateral = I, qV1, V3 V6, LAD, circumflexes
Anteroseptal = V1-V4, LAD
TRANSUDATIVE VS EXUDATIVE FLUID

Inferior = II, III, aVF, (R) coronary artery
SG
Protein
FP / SP
LDH
FLDH/SLDH
Cholesterol
Transudative
< 1.012
< 3 g/dL
< 0.5
<60%
<0.6
<45 mg / dL
Exudative
> 1.020
>3 g / dL
>0.5
>60%
>0.6
>45 mg / dL
Lateral = I, aVL, V5, V6, circumflex brance of (L) coronary artery

Posterior = V8 V9 (R) coronary artery, circumflex artery
(R) Ventricular = V4R, V5R, V6R, (R) coronary artery
JONES CRITERIA OF RF
Major:
Carditis
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodule
Minor:
Fever
Polyarthralgia
Lab: Inc. ESR / Leukocyte count
ECG: Prolong P-R interval
Elevated anti-streptolysin O, other strep antibody
(+) throat culture
Rapid Ag test for Group A
Strep / result: Scarlet Fever
TB CLINICALLY ACTIVE
Clinical, bacteriologic, or radiographic evidence of current
disease
Criteria:
2 major/one minor and 2

(+) evidence of preceding Group A strep infection
Class 4
TB NOT CLINICALLY ACTIVE

History of episode of TB
Abnormal but stable radiographic findings
No clinical or radiographic evidence of current disease
ACUTE RESPIRATORY FAILURE
Class 5
TB SUSPECT
Diagnosis pending
TB disease should be ruled out within 3 months
CLASSIFICATION OF PTB
Class O
NO PTB EXPOSURE
Not infected
Class 1
HISTORY OF EXPOSURE
Neg. Skin test to tuberculin
Class 2
TB INFECTION
No disease
Positive reaction to tuberculin test
No clinical, bacteriologic or radiographic evidence of TB
Class 3
TYPE I or Acute Hypoxemic Respiratory Failure
Occurs when alveolar flooding and subsequent intrapulmonary

shunt physiology occurs
Alveolar flooding may be a consequence of pulmonary edema,

pneumonia or alveolar hemorrhage
Low pressure pulmonary edema
Defined by diffused bilateral airspace edema
Signs and Symptoms of TB
Fever
Night sweats
Weight loss
Anorexia
Weakness
General Malaise
TYPE II Respiratory Failure
Occurs as a result of alveolar hyperventilation and results on the

inability to eliminate CO2 effectivity
Mechanism by which this occurs are categorized by impaired CNS

drive to breath, impaired strength with failure of neuromuscular
function in the respiratory ____
Reason for diminished CNS drive to breath including drug

overdose, brainstem injury, sleep disordered breathing
RECOMMENDED DOSAGE FOR INITIAL TREATMENT OF TB
Overload Respiratory System due to:
Increase resistive loads (bronchospasms)
Reduced lung compliance (alveolar edema)
Reduced chest wall compliance (pneumothorax)
Increase minute ventilation (pulmonary embolus)
1)
2)
3)
4)
Isoniazid = 5 mg/kg, max 300 mg

Rifampicin = 10 mg/kg, max 600 mg
Pyrazinamide = 20-25 mg/kg, max 2 g
Ethambutol = 15-20 mg/kg
TYPE III Respiratory Failure
Occurs as a result of lung atelectasis
Also called perioperative respiratory failure
After general anesthesia, decreases in functional residual capacity

of dependent lung units
TYPE IV Respiratory Failure
Due to hypoperfusion of respiratory muscles in patients in shock,

due to pulmonary edema, lactic acidosis, anemic
DEFINITIONS USED TO DESCRIBE THE CONDITION OF SEPTIC PATIENTS
BRONCHIECTASIS
Is an abnormal and permanent dilatation of bronchi
Associated with destruction and inflammatory changes in the wall

of the medium sized airways often at the level of segmental or
subsegmental bronchi
The dilated airways frequently contain pools of thick purulent

material, while more peripheral airways are often occluded by
secretions or obliterated and replaced by fibrous tissue
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
pulmonary arterial circulation
Bacteremia
Presence of bacteria in blood as evidenced by positive blood

culture
Septicemia
Presence of microbes and their toxins in the blood

SIRS
Sepsis
Systemic inflammatory response syndrome

Two or more of the following conditions:
o
Fever (oral temp >38C) or hypothermia (<36C)
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
SIRS that has proven or suspected microbial etiology
Severe Sepsis
Similar to sepsis sepsis syndrome
Sepsis with one or more signs of organ dysfunction

Examples
1)
2)
3)
4)
5)
6)
Cardiovascular: Arterial systolic blood pressure <90 mmHg or

Mean Arterial Pressure 70 mmHg that responds to
administration of IV
Renal: Urine output <0.5 ml/kg/hr for 1 hour despite adequate
fluid resuscitation
Respiratory: PaO2/FIO2 <250 or if the lung is the only
dysfunctional organ 200
Hematologic: Platelet count <80,000/uL or 50% decrease in
platelet from highest value recorded over the previous 3 days
Unexplained metabolic acidosis: a pH 7.30 or a base deficit 5.0
meq/L and a plasma lactate level >1.5 times upper limit of normal
for reporting
Adequate fluid resuscitation: Pulmonary artery wedge pressure
12 mmHg or Central Venous pressure 8 mmHg
Septic Shock
Sepsis with hypotension (arterial blood pressure of 90 mmHg or

MAP > 70 mmHg
Refractory Septic Shock
Septic shock that last > 1 hour and does not respond to fluid or
pressure administration
Multi-organ Dysfunction Syndrome
Dysfunction of more than 1 organ requiring intervention to

maintain homeostasis
INDICATIONS FOR INITIATING HEMODIALYSIS
Failure of conservative management
Management to relieve
a) Pulmonary congestion (unresponsive to high dose
furosemide)
b) Severe metabolic acidosis
c)
Severe hyperkalemia
BUN >100 mg/dL or creatinine >10mg/dL
Note: For acute renal failure it is best to start dialysis early
RHEUMATIC ARTHRITIS
Require 4 out of 2 criteria:

o
Morning stiffness
o
Arteritis of 2 or more joints
o
Arteritis of hands and joints
o
Systemic arthritis
o
Rheumatoid nodule
o
Serum Rheumatoid factor
o
Radiographic changes
CHILD-PVGH CLASSIFICATION OF CIRRHOSIS

Factor
s. Bilirubin
Units
umol / L
mg / dL
g/L
g / dL
sec
INR
s. Albumin
Protime
Ascites
Hepatic
encephalopathy
1
<34
<2
>35
>3.5
0-4
<1.7
None
None
2
34-51
2-3
30-35
3.0-3.5
4-6
1.7-2.3
Easily
controlled
Minimal
Calculated by adding the score of the 5 factor and can range from
5 15
CHILD-PVGH Class is either:

A. Score of 5 6
B. Score of 7 9
C. Score of 10 or Above
Decomposition
indicate cirrhosis
N/A
CHILD PVGH Score of 7 or more

Class 8
3
>51
>3
<30
<3
>6
>2.3
Poorly
controlled
Advanced
Listing for liver transformation (accepted criteria)
Hepatic Fibrogenesis
Stellate cell activation
Collagen production
CLINICAL STAGE OF HEPATIC ENCEPHALOPATHY
Stage I
Stage II
Stage III
Stage IV
MS
Euphoria, depression, mild confusion, slurred speech,
disturbance in sleep
Lethargy, moderate confusion
Marked confusion, incoherent speech, sleeping but arousable
Coma, initially responsive to noxious stimuli, ____ response
COMPLICATIONS OF ERCP
1)
2)
3)
4)
Infection
Perforation
Pneumothorax
Bleeding
NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION

CLASS I
No limitation of physical activity

No symptoms with ordinary exertion
CLASS II
Slight limitation of physical activity

Ordinary activity causes symptoms
CLASS III
Marked limitation of physical activity
Less than ordinary activity causes symptoms
Asymptomatic at rest
CLASS IV
Inability to carry out any physical activity without discomfort
Symptomatic at rest
MUSCLE STRENGTH
O No muscular contraction
1 Trace contraction
2 Active movement with gravity eliminated
3 Active movement against gravity
4 Active movement against gravity & slight resistance
5 Against full resistance
IDEAL PEAK FLOW

Ideal peak flow: Hg (m) 100 x 5 (+) 175 (M) (+) 170 (F)
N 80%
PEFR = Peak flow reading / Ideal peak flow x 100 = _____ %
N 20%
PEFR variability: Highest reading Lower x 100 = ______ %
Highest Reading
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
FRAMINGHAM CIRTERIA FOR DIAGNOSIS OF CHF

MAJOR CRITERIA
Paroxysmal Nocturnal Dyspnea
Neck vein distention
Rales
Cardiomegaly
Acute pulmonary edema
S3 gallop
Increased venous pressure (>16 cmH20)
Positive hepatojugular reflux

MINOR CRITERIA
Extremity edema
Night cough
Dyspnea on exertion
Hepatomegaly
Pleural effusion
Vital capacity reduced by one-third from normal
Tachycardia (>120 bpm)

MAJOR OR MINOR
Weight loss of >4.5 kg over 5 days treatment
History
General data
Chief complaint
PMHx
PSHx
FMHx
OBHx
o
Menarche
o
Interval
o
Duration
o
Amount
o
Symptoms
o
Coitarche
o
Menopause
o
OCP, S/P, PAP, Intermenstrual bleeding
o
Postcoital bleeding
o
OB Score
o
LMP, EDC, AOG
o
PNCU
o
HBsAg/VDRL
o
TT/BT/MTV
o
UTI
NSVD Admitting Notes
Please admit to ROC under the service of _____
TPR q 4 hours and record
Full diet, NPO once in active labor
Labs:
o
CBC
o
HBsAg
o
Urinalysis
IVF: D5LR + 10 u oxytocin to run at 10-15 gtts/min
Meds
o
Ampicillin 2g IV ANST if PROM
SO:
o
Monitor FHB and progress of labor
o
Puboperineal shave please
o
Inform NROD
o
Will inform service consultant on deck
o
Refer prn
o
Thank you
Side notes
o
TPR
o
BP
o
Wt
o
LMP
o
EDC
o
AOG
o
FH
o
FHB
o
CD
o
Effacement
o
Station
o
BOW
o
Leopolds
Final Dx:
o
PU FT del via NSVD/1LTCS/Rpt CS in cephalic
presentation to a live Bb Girl/Boy with BW: BL: AS:
PAOG: OB score
POSTPARTUM ORDERS
Back to room/ward
Full diet once full awake
Present IVF to run at 30 gtts/min, D/C if with minimal VB
IVF to ff: D5LR + 10 u Oxy to run at30 gtts/min
Meds:
o
Antibiotics
o
MA 500 mg/cap q 8 H RTC x 24 H, then prn for pain
o
Methergin 1 tab TID x 3 days
o
Viitamins
SO:
o
o
o
o
o
o
o
o
Monitor VS q 15 min until stable

Massage uterus prn
Ice pack on hypogastrium
Perilight x 15 min OD
Routine perineal care
Watch out for profuse vaginal bleeding
Refer accordingly
Thank you
DISCHARGE ORDERS (Normal OB)
MGH
Home Meds
OPD ff-up on Sat @ OB service clinic with photocopy of D/S
Discharge IE and summary c/o ___
TCB anytime if with profuse VB, HA, blurring of vision, U2W ssx
CS ADMITTING NOTES
Please admit to ROC under the service of _____
Full diet, NPO post midnight
Labs:
o
CBC, APC
o
CT, BT, PT
o
Urinalysis
Venoclysis
Meds:
o
Cefazolin 500mg IVTT q8H x 3 doses then shift to CoAmox 625mg/tab, 1 tab BID
o
Famotidine 20mg IVTT q8H x 3 doses
o
Ketomed 30mg IVTT q8H x 3 doses
o
Ketomed 10mg q8H to start if px is on soft diet
o
Tramadol 50mg IVTT q6H prn
Inform OR
Secure signed consent
Abdominoperineal prep please
Request 500cc FWB of patients blood type as standby
Dr. ___ for anesthesia
Inform NROD
Refer accordingly
Thank you
POST-OP ORDERS
To RR
Monitor VS q15 mins until stable
NPO x 6 H, then may have sips of CL
O2 at 2-3 LPM via nasal prong
Run present IVF @ 30 gtts/min
IVF to ff:
o
D5LR
+ 10 u oxytocin x 8 H
o
D5NM
o
D5LR x 8 H
Meds:
o
Antibiotics
o
Ranitidine (Zantac) 50mg IVTT q8H x 3 doses
SO:
o
Attach px to O2 at 2-3 LPM via nasal prong
o
Attach pc to pulse ox
o
MIO q H and record
o
Refer if UO is <30cc/H
o
Remove FC 24H post op
o
Standby available blood
o
Apply abdominal binder
o
Morphine precaution please
o
Specimen for histopathology
o
Watch out for profuse vaginal bleeding, hypotension,
tachycardia or any untoward s/sx
o
Refer PRN
o
Thank you

TRANS-OUT
Side notes the ff:
Stable VS
Able to flex both legs
(-) vomiting
Blurring of vision
Orders
May refer back to room
D/C O2 and pulse oximeter
Monitor V/S q 15 min until stable
MIO q Hly (+ FC) or shift (- FC) and refer if UO <30 cc/H
Watch out for profuse vaginal bleeding, hypotension, tachycardia

or any untoward s/sx
Refer accordingly
Thank you
ADMITTING ORDERS (Abdomen)
Please admit to ROC under the service of Dr. ____
TPR q shift and record
NPO
Labs:
o
CBC (save serum)
o
Serum pregnancy test
o
Urinalysis
IVF: D5LR + 10 u oxytocin x 30 gtts/min
SO:
o
For completion curettage on call
o
Secure consent
o
Pad count at bedside
o
Save specimen passed out
o
Please prescribe the ff: Nubain, Benadryl, Dormicum
o
Refer for profuse bleeding and other untoward ssx
o
Thank you
POST OP ORDERS (TAHBSO)
To RR
Monitor VS q 15 min, until stable
Flat on bed x 6 H, then may turn to side
NPO x 6 H then may have sips of CL
Present IVF x 30 gtts/min
IVF to ff:
o
D5LR
+ 10 u oxytocin x 8 H
o
D5NM
o
D5LR x 8 H
Meds:
SO:
o
MIO q H and record
o
Refer if UO is <30cc/H
o
May return blood
o
Remove FC @ ___
o
Apply abdominal binder
o
Refer PRN
o
Thank you
PELVIC EXAM
Inspection
o
Grossly N external genitalia
o
Masses, discharges, bleeding
Speculum
o
Cervix hyperemic/nonhyperremic; fish mouth
deformity/ping pong
IE
o
Cervical dilatation
o
Cervical effacement
o
Station
o
BOW (intact/leaking)
o
Amniotic membrane PROM x days/hours
o
Presenting part
Clinical pelvimetry
o
Inlet
o
Midplane
Ischial spines
Sacrum
Sidewalls
o
Outlet
EFW
BME
o
I (introitus) - admits 2 fingers with ease/snugly
o
C (cervix) open/closed,; firm, doughy
o
U (uterus) level of umbilicus
o
A (adnexae) firm/fullness; w/ adnexal masses
o
D (discharges) (+) (-); scanty or minimal bleeding
o
E (episiotomy) with blood/well coaptated wound
RVE
o
Intact rectovaginal septum
o
Good sphincter tone
Abdomen
o
Inspection: globular/gravid; linea nigra, striae
o
Auscultation: NABS
o
Palpation: Leopolds
o
FH, FHB R/L
Final Dx:
NON-STRESS TEST
Test of fetal condition

REACTIVE when:
At least 2 accelerations of the FHR occurs for at least 15 bpm,

lasting for 15 sec w/in 20 min period of observation
NONREACTIVE
May imply that the fetus is acidotic, asleep, or drugs was

administered to the mother
A. EARLY DECELERATION
Head compression
B. LATE DECELERATION
Utero-placental insufficiency
C. VARIABLE DECELERATION
Cord compression ; Fetal distress
Most common ; Most ominous
CONTRACTION STRESS TEST/OCYTOCIN CHALLENGE TEST
A measure of utero-placental function
Contraction induced by using IV oxytocin
Record FHB
POSITIVE
Consistent and persistent late deceleration (50%) of the FHB in

the absence of uterine hypertonus or supine hypotension
NEGATIVE
@ least 3 contractions in 10 mins, each lasting 40 secs, w/o late

deceleration
SUSPICIOUS
Inconstant late deceleration patterns

HYPERSTIMULATION
Uterine contractions occur more frequent than every 2 mins, or

lasting longer than 90 secs, or presence of hypertonus
UNSATISFACTORY
Frequency of contractions is <3 per minute
HYPERTENSION
140/90MMhG
Proteinuria
>300mg/24H urine sample
> 1000mg/random sample 6H apart
1+ = mild proteinuria
2+ to 4+ = heavy proteinuruia
*Edema DOES NOT validate Preeclampsia
GESTATIONAL HPN
HPN w/o Proteinuria (after 20 weeks gestation)
Confirm 12 wks Postpartum

PREECLAMPSIA
(+) HPN, (+) Proteinuria after 20th week

ECLAMPSIA
(+) convulsions, (+) Preeclampsia

CHRONIC HPN
140/90mmHg
SUPERIMPOSED PREECLAMPSIA
Inc diastole and systole
Proteinuria
S/Sx of end organ damage

Triad for Sever Preeclampsia
Hemolysis
Elevated Liver Enzyme
Low Platelet Count

Hypertension etiology(Williams)
Exposed chorionic villi
Twin pregnancy (Multiple gestation)
Vascular dses
Fam hx
THREATENED ABORTION
Bloody vaginal discharge or bleeding appears
Closed vaginal os
Low abdominal pain
Bleeding first, cramping follows

INEVITABLE ABORTION
Gross rupture of membrane
Leaking amniotic fluid
Cervical dilatation
COMPLETE ABORTION
Complete detachment
Int. cervical os closes

INCOMPLETE ABORTION
Int. cervical os opens and allows passage of blood

Mullerian Anomalies
Segmented mullerian agenensis or hyperplasia
Unicornuate uterus
Bicornuate uterus
Septate uterus
Uterus with internal ___? Changes

Induction of labor
Oxy drip but not in labor

Augmentation of Labor
Oxy drip however in labor
PRENATAL CHECK-UPS
0-27 wks
28 wks
29-35 wks
36 wksand beyond
TETANUS TOXOID
0
1
2
3
4
q4wks
q 2wks
q2wks
q week
20 wks AOG
1 month
6 months
1 year
1 year
STEROIDS
1 dose
3 doses
OGTT at 24-28wks
28-32 wks
q 2 wks
MAGNESIUM SULFATE DOSES

Loading dose:
4gms slow IV
5gms each buttocks deep IM
Maintenance dose:5gmsIM/IV q 6hrs
Monitor BP, U/O, DTRs-hyporeflexia
Monitor RR
MgSO4 drip:
1-2gms/hr
1L = 10gm
given 100cc/hr
10meq/L(about 12mg/dL)
>respiratory depression
12meq/L
>respiratory paralysis and arrest
Antidote: Calcium gluconate 1g iV
FETAL DEATH
1.
2.
3.
4.
Tobacco-stained amniotic fluid

Spaldingssign
o
significant overlapping of fetal skull bones
Roberts sign
o
Demonstration of gas bubbles in the fetus
Exaggeration of fetal spinal curvature
BIOPHYSICAL SCORING PARAMETERS

1. Fetal Breathing Movements
2. Gross Body Movement
3. Fetal Tone
4. Reactive FHR
5. Amniotic Fluid
*Perfect Score is 10/10 or 8/8
CBC repeated at 28-32 AOG
HbsAg
last trimester
Alpha fetoprotein
16-18 wks AOG
PLASMA GLUCOSE RESULTS:
(Blood Glucose testing performed at 24-28wks AOG)
Time
NDDG
Coustan & Capenter(mg/dL)
Fasting
105
95
1st Hr
190
180
2nd Hr
165
155
3rd Hr
145
140
LEOPOLDS MANEUVER
L1 (Fundal Grip)
What fetal pole occupies the fundus
L2 (Umbilcal grip)
Fetal back
L3 (Pawlicks grip)
(+) engagement of head or (-) engagement
L4 (Pelvic grip)
Side of cephalic prominence
FUNDIC HEIGHT
12wks-1st felt; above the symphysis pubis
16wks- bet. Symphysis and umbilicus
20wks- umbilicus
36wks- below ensiform cartilage
FHB Monitoring
Every 30mins= low risk
Every 15mins= high risk
BISHOP SCORE
0
1
1-2cm
31-50%
-2
Midline
Dilatation
0
Effacement
0-30%
Station
-5/-3
Cervical
Posterior
Position
Cervical
firm
medium
Consistency
*Scoring: 3-8 difficult induction
9-favorable induction
2
3-4cm
51-70%
-1
Anterior
3
5-6cm
>70%
+1/+2
-----
soft
-----
MYOMA
causes soft tissue dystocia
etiology: unopposed estrogen stimulation
types: Subserous, Intramural, Submucous
ROT-right occiput transverse
Montevideo Units- 200 units or pressure of > 60
Depoprovera- injectable CP is G1 to HPN patients
EXCISION OF BARTHOLINS CYST
Hyperplasia (uterus) provera
Endocervical
For Functional Curettage
Endometrial
Endometrial for D & C
AUGMENTATION OF LABOR
amniotic fluid
Oligohydramnios (causes)
o
Cord compression
o
Macrosomia
o
Deformations
o
Fetal distress
HYOSCINE N-BUTYL BROMIDE (Buscopan) for softening of the cervix
NST: Fetal condition 7 days
CST: Uteroplacental contraction
DELIVERY OF PLACENTA
SHULTZE MECHANISM
Peripheral
Shiny portion
DUNCAN MECHANISM
Central
Dirty part
DEFINE:
Placenta increta invades
Placenta percreta penetrates
Placenta accrete attaches

Normal Rotation of Umbilical Cord:
Counter clockwise or Left-handed maneuver

PLACENTA PREVIA
Types:
o
o
o
Totalis placenta covers cervical os completely

Partialis internal os partially covered by placenta
Marginal edge of the placenta is at margin of
internal os
Etiology: (P2ALM2)
o
Previous CS
o
Puerperal Endometritis
o
Advancing age
o
Multiparity
o
Multiple induced abortions
Diagnosis:
o
Painless third trimester bleeding
o
UTZ for placental localization
Placental Migration (placenta close to the internal os

during 2nd trimester migrate to fundus as pregnancy
advances
PLACENTA ABRUPTION
premature separation of the normally implanted placenta after

the 20th week of pregnancy and before birth of fetus
Etiology: (PECSS)
o
Pre-eclampsia
o
External trauma
o
Chronic hypertension
o
Short umbilical cord
o
Sudden uterine decompression
LACERATIONS
1st Degree
o
Fourchette, perineal skin, vaginal mucosa but not the
underlying fascia and muscle
2nd Degree
o
Fascia and muscles of the perineal body but not the
anal sphincter
3rd Degree
o
Extend from vaginal mucosa, perineal skin and fascia
up to anal sphincter but not the rectal mucosa
4th Degree
o
Encompasses extension up to rectal mucosa
BRAXTON HICKS CONTRACTION
The uterus undergoes palpable but originally painless contractions

at irregular intervals from the early stages of gestation
SIGNS OF PLACENTAL SEPARATION
Calkins Sign (uterus becomes globular and firmer from discoid)
Sudden gush of blood
Uterus rises in the abdomen as the detached placenta drops to

the lower segment and vagina
Lengthening of the cord

AMONIOTIC FLUID INDEX
Normal: 6-24 cm
Oligohydramnios: <5 cm
Low normal: 9-10
Polyhydramnios: >24
INDICATIONS FOR CESAREAN SECTION
Prior CS
Labor dystocia (most frequent indication for 1 CS)
Fetal distress
Breech presentation
POST OP COMPLICATIONS OF CS DELIVERY
Hysterectomy
Operative injury to pelvic structures
Infection
Puerperal fever
Transfusion
STAGES OF LABOR
I: Active labor to full cervical dilatation (4-10 cm)
II: Full cervical dilatation to delivery of baby
II: Delivery of baby to expulsion of placenta
IV: Delivery of placenta to 1 hour after
CARDINAL MOVEMENTS
Engagement
Descent
Flexion
Internal rotation
Extension
External rotation
Expulsion
ASYNCLITISM such lateral deflection of the head to a more anterior or
posterior position of the pelvis
ANTERIOR COLPORRHAPY
1. Induction of anesthesia.
2. Patient is placed in dorsal lithotomy position.
3. Asepsis/Antisepsis
4. Drapings done leaving the operative site exposed
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.
7. The vaginal mucosa is undermined for approximately 3-4 cm up
to first Allis clamps placed in midline.
8. The vaginal mucosa is dissected off the pubovesical cervical fascia
and opened with scissors in the midline. The vaginal mucosa is
opened in midline up to next Allis clamp. This is continued until
the vagina is opened to within 1 cm of urethral meatus.
9. The PVC fascia is separated from the vaginal mucosa. The
dissection is continued until bladder and urethra are separated
from the vaginal mucosa and clearly identified and urethral vesical
angle has been ascertained.
10. Kelly plication done with chromic 2-0. The anterior repair is
started by placing suture in PVC fascia, starting at the level of first
Kelly placation suture
11. The edges of vaginal mucosa retracted laterally with Allis clamps
and remaining PVC fascia is plicated in midline with multiple
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
1. Induction of spinal anesthesia.
5. Allis clamps are applied at the posterior vaginal mucosa, elevated
creating a triangle.
6. A transverse incision made at the posterior fourchette. A portion
of the posterior vaginal mucosa is elevated using an Allis clamp
and an index finger covered with gauze is inserted upward and
laterally, dissecting the posterior vaginal mucosa of the
perirecteal fascia.
7. Vertical incision in posterior vaginal mucosa made. Perirectal
fascia dissected off the posterior vaginal mucosa. The apex of
triangle held with Allis clamp. The dissection of perirectal fascia
off the vaginal mucosa is started with scalpel but is completed
with blunt dissection.
8. Kelly plication sutures with vicryl 2-0 through the margins of
levator ani muscles from apex down to posterior fourchette is
done and progressively tied.
9. The excess posterior vaginal mucosa trimmed.
10. The perineal fascia closed with interrupted vicryl 2-0
11. Vicryl 2-0 suture is placed at the apex of vaginal mucosa using
continuous interlocking stitches to posterior fourchette.
12. Vaginal packing done with 1 os.
13. Perineal wash done.
1 LOW TRANSVERSE CESAREAN SECTION

2. Patient in supine position.
3. Insertion of foley catheter.
5. Drapings done, exposing operative site.
6. Vertical incision done from 2 FB above the symphysis pubis up to
3 FB below the umbilicus. Incision deepened to subcutaneous
tissues and transversalis fascia, rectus muscle split, peritoneum
cut longitudinally.
7. Bleeders clamped and ligated as encountered
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
the lower uterine segment using bandage scissors, bag of water
ruptured.
11. Rupture of membranes.
12. Amniotic fluid suctioned and fetal head exposed.
13. Delivery of baby boy in left occiput transverse position.
14. Umbilical cord doubly clamped and cut.
15. Manual extraction of placenta.
16. Closure of incision site done layer by layer
a.
First (endometrial) layer closed by continuous
interlocking stitches using Chromic 1.
b. Second (myometrial) layer closed by continuous
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.
REPEAT LOW TRANSVERSE CESAREAN SECTION
6. Old scar removed. Vertical incision done from 2 FB above the
symphysis pubis up to 3 FB below the umbilicus. Incision
deepened to subcutaneous tissues and transversalis fascia, rectus
muscle split, peritoneum cut longitudinally.
bladder.
the lower uterine segment using bandage scissors.
13. Delivery of baby boy in left occiput transverse position.
a.
c.

2-0
using Vicryl 1-0
Plain 2-0
22. Skin closed by subcuticular stitches using Monocryl 4-0.
ENDOCERVICAL POLYPECTOMY
1. Induction of labor.
2. Sepsis/Antisepsis/drapings done leaving operative site exposed.
3. Insertion of straight catheter to empty the urinary bladder.
4. Posterior vaginal retractor positioned, endocervix identified.
5. Anterior lip of the cervix grasped with tenaculum forceps.
6. Endocervical polyp found.
7. Polyp grasped, twisted, and removed using an ovum forcep.
8. Vaginal packing inserted.
1 LOW TRANSVERSE CESAREAN SECTION (PFANNENSTIEL)
6. Curvilinear incision done from 2 FB above the symphysis pubis up
to 3 FB below the umbilicus. Incision deepened to subcutaneous
tissues and transversalis fascia, rectus muscle split, peritoneum
cut longitudinally.
bladder.
the lower uterine segment using bandage scissors
13. Delivery of live full term baby boy in left occiput transverse
position.
a.
c.
2-0
using Vicryl 1-0
Plain 2-0
22. Skin closed by subcuticular stitches using Vicryl 4-0.
TAHBSO
1.
2.
3.
4.
5.
Induction of spinal/epidural anesthesia

Patient in supine position.
Insertion of foley catheter done.
Asepsis/Antisepsis
Drapings done leaving operative site exposed.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
Midline incision done from symphysis pubis up to 2 FB below the

umbilicus cutting through skin, subcutaneous tissue and fascia,
rectus muscle split and peritoneum incised.
Bleeders clamped and ligated as encountered.
Self retaining and bladder retractors were applied to expose
pelvic structures.
Moist pack applied.
Inspection of the pelvic structures done.
Abdominopelvic structures examined revealed that the uterus
measures 8x7cms with smooth serosa. Both ovaries grossly
normal .Both measures 3x2 cm. Left fallopian tube dilated to 7x3
cm and its ampullary area containing serous fluid. Right fallopian
tube with small cystic paratubal masses ~1x1cm.
Right round ligament is doubly clamped, then cut and ligated with
Chromic 1. The same procedure is done on the opposite side.
Anterior and posterior leaves of the broad ligament opened.
Anterior leaf of the broad ligament incised to the point of bladder
reflection.
Infundibulopelvic ligament triply clamped, cut and doubly ligated
using Chromic 1-0.
Vesicouterine folds cut transversely
Bladder dissected by blunt and sharp dissection.
Uterine arteries triply clamped, cut and doubly ligated with
Chromic 1-0 on both sides.
Pubovesical fascia incised and pushed down with use of sponge
Cardinal ligaments clamped, cut and suture ligated with Chromic
1-0.
Amputation of cervix at level of cervical os.
Betadinized OS inserted to the vaginal stump.
Closure of vaginal stump with continuous interlocking suture using
Vicryl 1-0. Stump angles are anchored to the cardinal ligaments on
both sides with figure of eight stitches using Vicryl 1-0.
Bleeders clamped and ligated as encountered.
Parietal peritoneum closed with continuous stitches using chromic
2-0.
Transversalis fascia sutured with continuous stitches using vicryl 10.
Subcutaneous tissue closed with simple interrupted stitches with
Plain 2-0.
Skin closed by subcuticular stitches using Monocryl 3-0.
Operative site painted with betadine
Top dressing done.
Specimen sent for Histopath.
End of procedure.
VAGINAL HYSTERECTOMY
5. Evacuation of urine using straight catheter
6. Vaginal mucosa is incised with a scalpel around the entire cervix.
7. Downward traction is applied using tenacula, Metzenbaum used
to dissect the bladder off the anterior lower uterine segment.
8. A sponge covered finger dissects the bladder all the way up to the
vesicouterine fold, facilitates entry to anterior cul de sac.
9. Right angle retractor is placed under the vaginal mucosa and
bladder, elevating the bladder. Strong downward traction is
applied to the tenacula on the cervix, and the peritoneal
vesicouterine fold is grasped with Allis clamps and incised with
sharp curved mayo scissors.
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-sac
12. The posterior vaginal retractor is removed. The broad ligament is
exposed from the uterosacral ligaments to the tuboovarian
ligament. A finger is placed in the posterior cul-de-sac and moved
laterally revealing the uterosacral ligament as it attaches to the
lower uterine cervix.
13. With the cervix on upward and lateral retraction using the
tenacula, a clamp is placed in the posterior cul-de-sac with one
blade underneath the uterosacral ligament, and the opposite
blade over the uterosacral ligament. This is done to prevent
possible ureteral damage from clamping the ligaments in lateral
position.
14. Uterosacral ligament is cut using the mayo scissors.
15. Chromic 1-0 suture is used to suture ligate the uterosacral
ligament.
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.
18. Cardinal ligaments is sutured ligated with Chromic 1-0 suture.
Suture is held with a Kelly clamp for traction
19. The remaining portion of the broad ligament attached to lower
uterine cervix segment containing the uterine artery is clamped
and ligated.
20. With all the ligaments on both sides, clamped and ligated, cervix is
retracted upward in midline with the tenacula. Posterior uterine
wall is grasped, the fundus is delivered posteriorly.
21. Two cochers clamps are applied to the tubo ovarian round
ligaments, incised close to the fundus.
22. Infundibulo-pelvic ligament is tied twice using Vicryl 1.0. Second
suture ligation is tied in a fixation stitch, placing the suture in the
mid portion of its pedicle.
23. The anterior and posterior clamps right angle retractors are
removed, and the weighted posterior retractor is placed in the
vagina. Any bleeding from any pedicle is clamped.
24. Cardinal ligaments, uterosacral ligaments and utero ovarian
ligaments anchored at the posterior vaginal mucosa.
25. Reperitonealization of the pelvis, carried out with purse string
sutures.
26. Perineal wash done.
EVACUATION CURETTAGE
2. Patient in dorsal lithotomy position.
3. Asepsis/Antisepsis.
4. Drapings done leaving the operative site exposed.
5. Straight Catheterization done.
6. Right angle retractor applied to expose cervix.
7. Anterior cervical lip grasped with tenaculum forceps at 12 0clock
position.
8. Hysterometer inserted.
9. Pre-curettage uterine depth measured 9 cms.
10. Sharp and dull curettage done in a clockwise manner, evacuated
cup of products of conception and placental tissues.
11. Post curettage uterine depth was not measured.
12. Perineal washing done.
13. Specimen for histopathology.
DIAGNOSTIC CURETTAGE
2. Patient in dorsal lithotomy position
4. Drapings done leaving operative site exposed
5. Straight catheter was inserted.
6. Cervix dilated with Goodells dilator
7. Retractor applied at posterior & anterior vaginal wall
8. Application of tenaculum forceps at 12 oclock position of cervical
lip.
9. Insertion of hysterometer to measure pre-curettage uterine depth
of 3 inches.
10. Blunt curette done in a clockwise manner. Evacuated scanty
endometrial scrapings.
12. Specimen sent for histopath
FRACTIONAL CURETTAGE
2. Patient in dorsal lithotomy position.
3. Asepsis/Antisepsis.
4. Drapings done leaving operative site exposed.
5. Straight catheterization done.
6. Weight-bearing retractor applied at posterior vaginal wall. Cervix
smooth with no erosions.
lip.
8. Endocervical curettage done, evacuated minimal endocervical
scrapings.
9. Hysterometer inserted. Pre-curettage uterine depth measured
9cm.
10. Endometrial curettage done. Evacuated teaspoon of
endometrial scrapings/tissues and placental tissues.
11. Post curettage uterine depth measured, approximately 8 cm.
12. Tenaculum and retractors removed.
14. Specimen sent for histopath.
COMPLETION CURETTAGE
2. Patient in dorsal lithotomy position
4. Drapings done leaving operative site exposed
5. Insertion of straight catheter.
6. Speculum applied at posterior vaginal wall
lip.
8. Sharp/blunt curette done. Evacuated 1 tablespoon cup of
products of conception.
9. Betadine wash done.
11. Specimen sent for histopathology.
VAGINAL BIRTH AFTER A CESAREAN SECTION (VBAC)
Allow a trial of labor under double set-up for all previous cesarean
of one low segment incision after excluding an inadequate pelvis
and unless a new indication arises
Selection Criteria:
o
1 or 2 prior low-transverse cesarean section delivery
o
Clinically adequate pelvic
o
No other uterine scars or previous rupture
o
Physicians immediately available throughout active
labor capable of monitoring labor and performing an
emergency cesarean section delivery
o
Availability of anesthesiologist and personnel for
emergency cesarean section delivery
CRITERIA FOR TIMING OF ELECTIVE REPEAT CS DELIVERY (At least 1):
Fetal heart sounds documented for 20 weeks by non-electronic

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

a gestational age at least 39 weeks
UTZ obtained at 12-20 weeks confirms the gestational age of at

least 39 weeks determined by clinical history and PE
CP STATUS
CP status assessed
Pls. transfuse available ___ u PRBC of px blood after proper

crossmatching
BT to run initially @ 5-10 gtts/min x 30min then to 15-20

gtts/min if with no BT rxn
Maintain IVF x KVO while on BT
BT precautions please
Watch for any untoward s/sx such as DOB, pruritus, fever
Refer prn
Thank you.
ADMITTING NOTES (Ectopic Pregnancy)
Cc:
Imp:
Please admit pc to ROC under the service of Dr. ___
NPO temporarily
Labs:
o
CBC, APC
o
CT, BT, PT
o
BT w/ Rh
o
U/A
o
S. Preg test
IVF: D5LR 1L X 8 Hrs
Meds: None temporarily
SO:
o
Monitor VS, abdominal status hourly
o
Refer once lab result is in
o
Dr. ___ seen px at ER
o
Watch out for any untoward s/sx
o
Refer prn
ANESTHESIA
Pre-meds:
Cefuroxime (Zegen) 1.5 gms IV
Omeprazole 20mg IV
Metoclopramide (Plasil) 10mg IV

Anesthetic Agent: Bupivacaine 15mg + MgSO4 16mg
Detailed Technique: RA-SAB
X-LLDP, SAS
LA w/ 2% Lidocain
LP at L3 L4
CSF clear and free flowing
Intrathecal administration of anesthetic

SIGNS OF MALIGNANCY UTZ:
Septations
Internal echoes
Ascites
Multiple daughter cysts

<5 cm cyst in postmenopausal women expectant management
PIPERACILLIN TAZOBACTAM
Mode of Action:
Highly active against piperacillin-sensitive microorganisms as wells

as B-lactamase-producing piperacillin-resistant microorganisms
Indication:
For UTI, lower resp tract, intraabdominal & skin infections &
septicemia
Side effects:
Upset stomach, vomiting, unpleasant or abnormal taste, diarrhea,

gas, headache, constipation, insomnia, rash, itching skin, swelling,
shortness of breath, unusual bruising or bleeding
CaMg (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, hemolytic anemia, 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 ( objective signs 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

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ELECTROLYTE SOLUTIONS

Corrected Ca = (40-lbs) x 0.02 + serCa

D5W Osm = 278

HEMORRHAGIC STROKE TRIAD

Indication for Intubation

Impending respiratory failure, apnea

TV: 6-8 ml/kg (ARDS) 8-10 ml/kg

INDICATIONS FOR WEANING

Mental status: Awake, Alery

GLASCOW COMA SCALE

Obeys with command

Single strength = BW x desired dose / 13.3

CT SCAN BLEED VOLUME

5.8 x 2.3 = 13.34 x 5 (constant) = 66.5 x 5.2 (constant) = 34.684 -(estimated

DIAGNOSTIC THORACENTESIS DUE TO HEART FAILURE

If the effusion are not bilateral and comparable size

INDICATION FOR CHEST TUBE THORACOSTOMY

Grade I + spontaneous bleeding

Grade II + severe bleeding + circulatory failure

Grade III + irreversible shock + massive bleeding

713 (decimal FIO2) PCO2/0.8 = I

TIMING OF TUBE REMOVAL

The timing of tube removal depends on clinical and radiological

Minimal drainage should have occurred over the previous 24

When the patient coughs or performs the valsalva maneuver no

The chest radiograph should confirmed complete expansion of

Desired FIO2 = 104 (0.43 x age)

713 x FIO2 PCO2/0.8

INDICATIONS FOR CTT

Gross pus on thoracentesis

Presence of organism on gram stain of the pleural fluid

Pleural fluid glucose < 50 mg / dL

LOCATING MYOCARDIAL DAMAGE

Pleural fluid protein / serum protein > 0.5

Anterior = V2-V4 (L) coronary, LAD

TRANSUDATIVE VS EXUDATIVE FLUID

Lateral = I, aVL, V5, V6, circumflex brance of (L) coronary artery

2 major/one minor and 2

TB NOT CLINICALLY ACTIVE

ACUTE RESPIRATORY FAILURE

TYPE I or Acute Hypoxemic Respiratory Failure

Occurs when alveolar flooding and subsequent intrapulmonary

Alveolar flooding may be a consequence of pulmonary edema,

Low pressure pulmonary edema

Defined by diffused bilateral airspace edema

Signs and Symptoms of TB

TYPE II Respiratory Failure

Occurs as a result of alveolar hyperventilation and results on the

Mechanism by which this occurs are categorized by impaired CNS

Reason for diminished CNS drive to breath including drug

RECOMMENDED DOSAGE FOR INITIAL TREATMENT OF TB

Overload Respiratory System due to:

Increase resistive loads (bronchospasms)

Reduced lung compliance (alveolar edema)

Reduced chest wall compliance (pneumothorax)

Increase minute ventilation (pulmonary embolus)

Isoniazid = 5 mg/kg, max 300 mg

TYPE III Respiratory Failure

Occurs as a result of lung atelectasis

Also called perioperative respiratory failure

After general anesthesia, decreases in functional residual capacity

Due to hypoperfusion of respiratory muscles in patients in shock,

DEFINITIONS USED TO DESCRIBE THE CONDITION OF SEPTIC PATIENTS