26/05/52 ม นยากเก นไป.จ าไม ได.ง วงจ ง.ง บน ดนะ. IN MEDICINE IN PEDIATRIC IN GYNECOLOGY IN OBSTRATIC IN SURGERY โดย พญ. ป ทมา สายข น 21 พ.ค.

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1 โดย พญ. ป ทมา สายข น 21 พ.ค IN MEDICINE IN PEDIATRIC IN GYNECOLOGY IN OBSTRATIC IN SURGERY Acute respiratory distress syndrome ( ARDS) Cardiovascular collapse and sudden death Shock Sepsis and septic shock Acute pulmonary edema Confusion, stupor, and coma Stroke Hypoxic-ischemic encephalopathy Status epilepticus Poisoning and drug overdose Diabetic ketoacidosis and hyperosmolar coma Hypoglycemia Infectious disease emergencies Oncologic emergencies Anphylaxis Bites, venoms, stings and marine poisoning Bioterrorism ( bioweapons ) Hypothermia and frostbite ม นยากเก นไป.จ าไม ได.ง วงจ ง.ง บน ดนะ.? 1

2 1.CHEST PAIN DDx: Myocardial infarction, unstable angina, dissecting aneurysms, pulmonary embolism, pneumothorax, depressed patient with suicidal intent *** cyanosis, diaphoresis, respiration, tachycardia, hypotension, diff. BP between arms, absent breath sound, murmur : ABC, KEEP vital signs stable, iv line call EMS, o2 Slide ต อไป จดนะคะ จะได ไม ง วง อย เป นเพ อนก น acute / chronic Rx not improve severe pain mass nausea vomiting diarrhea hematemesis hematochezia melena try Rx and observe clinical not improve refer to doctor 2

3 record all treatment Rebound tenderness, fever, elevated WBC count with a left shift, severe or progressively worsening abdominal pain, abdominal distention, hypotension, shock, hematemesis, rectal bleeding Acute appendicitis Perforated viscous Intestinal obstruction Mesenteric vascular occlusion Rupture abdominal aortic aneurysm Ectopic pregnancy ABC vital sign evaluate i.v. fluid NPO pain management? Hct. Urine pregnancy test keep vital sign stable keep warm First severe headache Sub-acute worsening over days or weeks Abnormal neurological examination Fever or unexplained systemic signs Vomiting precedes headache Induce by bending, lifting, cough Disturbs sleep or presents immediately upon awakening Onset after age 55 3

4 Meningitis Intracranial hemorrhage Brain tumor Temporal arteritis glaucoma check vital signs EMS CALL NPO I.V. LINE DTX BP DECREASE? KEEP AIR WAY : HOLD O2 MASK KEEP BP BECAREFUL SEIZURE -pain worse at rest or night -prior history of cancer -Hx. Of chronic infection : pulmonary, urinary tract, skin -Hx. Of trauma -age > 50 years -intravenous drug use -glucocorticoid use -Rapid progressive neurologic deficit -unexplained weight loss or fever -failure of pain relief with bed rest -bladder or bowel dysfunction -HIV infection record note prevention neuro-injury Bed rest pain management fracture be careful 4

5 confusion hypotension seizure abnormal physical exam. : lung, heart, abdomen, neuro signs, abscess infant / old age physical cooling: sponging i.v. fluid prevention of complication seizure drugs sponging universal precaution: viral hypotension neuro-abnormal Severe anemia Cardiac arrythmia early sign of : seizure, vertigo, amnesia, concussion, migrain, hypoglycemia, drug or alcohol intoxication, coma Cause of syncope -reflex or neurally mediated -orthostatic causes: drugs, hypovolemic state -cardiac : obstructive, arrhythmia -cerebrovascular -psychiatric -unexplained vital signs Bed rest i.v. if need keep vital signs stable 5

6 - central vertigo is serious - horizontal nystagmus - associated central abnormalities : dysarthria, diplopia p, paresthesia, weakness, limb ataxia, - headache - common cause: vascular, neoplasm bed rest vestibular suppressant drugs drugs note - upper / lower motor neuron - upper = increase muscle tone, increase deep tendon reflex and Babinski sign - lower = reduce muscle tone, diminished i i d reflexes, and muscle atropy - bradykinesia, tremor, asterixis, myoclonus, dystonia, choreoathetosis,tic refer none psychiatric : schizophrenia sleep apnea syndrome depressive disorder drugs + chemical used cardiac dyspnea COPD, Asthma hyperthyroidism, menopause GERD ( gastro esophageal reflux) -behavior therapies for : anxiety,negative conditions, pharmacotherapy, good sleep hygiene - evaluate cause 6

7 medication record Heart disease Airway obstruction: asthma COPD CHF bronchitis/bronchiectasis Diffuse parenchymal lung disease Pulmonary embolism Disease of chest wall or respiratory muscles Asthma / COPD : bronchodilator via oral/nb/ sc CHF : O2, I.V. diuretic drugs, bed rest, semi fowler position IHD : rest, o2, isordial SL, ASA gr. V, i.v. line Pulmonary embolism : ABC,o2, refer/ call EMS KEEP AIR WAY + CIRCURATION ว ว ฒนาการของการร กษาโรคห ด Dead Hospitalization short-acting b 2 -agonists Inh corticosteroid Combination ER visit Bronchospasm Inflammation OPD visit Loss of work Symptoms Airway Hyperresponsiveness Remodelling Smooth m hypertrophy

8 Definition of asthma Is it Asthma? Airway inflammation Recurrent episodes of wheezing Troublesome cough at night Airway hyperresponsiveness Reversible airway obstruction Symptoms (cough, wheeze, dyspnea) Cough or wheeze after exercise Cough, wheeze or chest tightness after exposure to airborne allergens or pollutants Colds go to the chest or take more than 10 days to clear Asthma Diagnosis Peak Flow meter (เคร องว ดความเร วส งส ด) PEFR = Peak Expiratory Flow Rate History and patterns of symptoms Physical examination Measurements of lung function เป าสมรรถภาพปอด หร อ Peak Flow ก อนและหล งพ นยาขยาย หลอดลม 15 นาท FEV1 เพ มข นมากกว า 12 % ถ อว าเป นโรคห ด PEFR เพ มข นมากกว า 15 % ถ อว าเป นโรคห ด Salbutamol inhaler 2 puff รอเวลา 15 นาท PEFR เพ มข น Pharmacological therapy Relievers Inhaled fastacting β 2 - agonists Controllers Inhaled corticosteroids Inhaled long-acting b 2 - agonists Oral anti-leukotrienes Oral theophyllines PEFR =300 L/min PEFR =390 L/min = 30% 8

9 Fluticaso ne Inhaled corticosteroids Budesoni de Beclomethaso Day symptoms Night symptoms PEFR Classification of asthma severity: GINA 1995 PF variability 1 Intermittent <1/wk <2/mo >80% <20% 2 Mild persistent >1/wk >2/mo >80% 20-30% 3 Moderate persistent daily >1/wk 60-80% >30% 4 Severe Persistent daily frequent <60% >30% GINA 2006 Assessing asthma control Treating to achieve asthma control Monitoring to maintain control Manage Asthma Exacerbations Day symptoms Night symptoms Reliever PEFR Exacerbation Limitation of activity 2006 Controlled Partly controlled Uncontrolled 1. B2-agonist prn 2. ICS 3. ICS (low dose) + LABA 4. ICS (high dose) + LABA 5. ICS (high dose) + LABA + prednisolone Signs of upper airway obstruction Massive hemoptysis ( > 600 ml/ day ) > 4 weeks cough : want chest x ray > 8 weeks cough : asthma / GERD / UACS ( Upper airway cough syndrome = post nasal drip) treat the cause if massive hemoptysis on i.v. fluid, keep BP stable, hct., o2, refer air born infection precaution keep airway 9

10 Central cyanosis : impair pulmonary function, anatomical vascular shunt, decrease inspired o2, abnormal hemoglobins Peripheral cyanosis : vasoconstriction, cold, shock, heart failure, peripheral vascular disease, venous hypertension cyanosis ABC + CPR O2 I.V. RESUSCITATE CALL EMS / REFER ADVISE FAMILY none เร ม cyanosis ก นแล ว. พ กก อนนะคะ pattama_suwanna@hotmail.com I want slide emer np Localized /Generalized Heart / liver / kidney Dyspnea Abnormal urine / void Murmur Lung crepitation Hepatomegaly Jaundice 10

11 diuretic drugs o2 i.v. line but no i.v. fluid except shock call EMS / REFER KEEP VITAL SIGNS STABLE Severe dehydration Pregnancy test Weight loss Mass Projectile vomiting Signs of gut obstruction Anemia / blood content evaluate cause ABC i.v. fluid prevent aspiration i cimetidine / ranitidine / plasil injection becareful! hyoscine injection / oral use no analgesic drugs : NSAIDS Tachycardia prolong fever dysphagia / anorexia change in bowel habit family hx cancer HIV risk factor 11

12 supportive treatment refer for evaluate cause Take medication record Orpharyngeal dysphagia Esophageal dysphagia Gall stone GERD Esophageal motility disorders Esophageal infection / inflammation Scleroderma Drugs pill-related esophagitis : doxy, tetra,asa, NSIADS,KCL,FBC, ect. threat by cause shock wt. loss abdominal mass high h fever / prolong fever distended abdomen severe abdominal pain previous abdominal surgery supportive rx. i.v. resuscitate NPO if need no hyoscine! no laxative drug if think gut obstruction 12

13 be careful : shock, ischemic / rupture bowel Hemolytic Obstructive Infection / inflammation Cancer? Drugs? NO = PLEASE REFER NPO if need for investigation - Azotemia = the retention of nitrogenous waste products by the kidney - impaired renal = volume overload, hyper k, hypo cal, hyper phos, met. Acidosis i, hormonal disturbances( insulin resist., functional vit D deficiency ) severe uremia - uremia = anorexia, lethargy, confusion, Pleuritis, pericarditis, enteritis, pruritis, sleep and test disturbance, nitrogenous fetor Abnormal urine volume - oliguria = < 400 ml / day - polyuria = > 3,000 ml / day Abnormal urine volume - proteinuria i = > 500 mg / 24 hours - Hematuria = > 1-2 rbc / hpf - pyuria = infection / non infection - try threat cause - refer for investigation - check underlining disease - i.v. line but no fluid - drugs toxicity 13

14 Male = Hb < 13 g/dl, Hct < 39 % female = Hb < 12 g/dl, Hct < 37 % - Acute anemia = blood loss, hemolysis - moderate anemia = < 8 g/dl fatigue, loss of strength, breathlessness, tachycardia, more frequency + severity if pt. underlying IHD / ANGINA - severe anemia = CHF, hypotension, dizziness, edema Evaluate cause check vital signs ask kfor abnormal clinical i l FBC supplement, folate, vit B 12? blood transfusion? keep vital sign stable i.v. fluid? hct. o2 High fever Petiche/ ecchymosis / epistaxis Hx. Mass, malignancy HIV infection severe pain anemia huge size LN Clinical of obstruction ATB? pain management look for abnormal signs, take note and refer -Minor trauma / FB -Infection -Inflammation: autoimmune -Acute Angle-Closure Glaucoma : rare but important, red painful,rise intraocular pressure,headache, n/v, blurred vision -Glaucoma - Macular degeneration - Diabetic retinopathy 14

15 check FB eye irrigate bacterial infection prevention ophthalmoscope hh? pain management look for others complication refer if not improve severe visual loss / blurred vision eye pad pus per ear high fever neuro-deficit FB severe vertigo ear mass trauma / bleeding, REFERAL PREPRARATION be careful ear drop drugs look for FB ATB pain management look for associated disease : URI, Allergic RNA virus!!! Gives advance warning of the pattern of spread around the world - Influenza : H1N1 - bird flu : H5N1 - SARS Dyspnea, hypotension, very poor intake, Chronic sinusitis, aware ear infection, oral infection, deep neck infection -> abscess / Ludwig s angina air born precaution / hand hygiene ATB smart use look for sign upper air way obstruction treat dehydration d 15

16 call for notify if it severe viral infection Anaphylaxis / angioedema Anaphylasis / angioedema: 1. Adrenaline inj. 1:1000 = 0.01 ML / KG 2. CPM i.v. / i.m. 3. steroid injection i i.v. /i.m. 4. take i.v. fluid when shock / dyspnea 5. take salbutamal NB when very dyspnea or poor air entry be careful airway obstruction keep vital sign stable DOCTOR STYLE REFERAL SYSTEM EMS SYSTEM CALL SYSTEM Polite words Firstly do no harm Early response to worse changes condition Empathy Aware Same same case may be harmful case Step advise to family 16

17 ช าง ควาย ไก ย งลาย = ช ค นก นยา = ช ค ก ย มาหาเราเร วกว า, ไข ส งเร วกว า ระยะไข ส นกว า 2 ว น, DHF 4 ว น TT + ve น อยกว า ไม พบ convalescent petechial rash ท ม ล กษณะเป นวงขาว พบ maculopapular rash + conjunctival infection ได บ อยกว าในDHF พบ myalgia / arthalgia ได บ อยกว าในDHF พบการช กร วมก บไข ส งได ถ ง 15% > DHF 3 เท า Question? อ นความกร ณาปราณ จะม ใครบ งค บก หาไม. หล งมาเองเหม อนฝนอ นช นใจ. จากฟากฟ าส ราล ย. ส แดนด น THANK YOU FOR YOUR ATTENTION 17