【妇产科学】Primary-Care-in-Gynecology.ppt

Chapter 9Chapter 9Primary Care in GynecologyPrimary Care in Gynecology-Novaks Gynecology page 199230Primary Care in GynecologyPrimary Care in GynecologyEarly diagnosis and treatment of medical illnesses can have a major impact on a womans health and is a key component of primary care.Although timely referral is important for complex and advanced disorders,the gynecologist initially may treat many conditionsPrimary Care in GynecologyPrimary Care in GynecologyRespiratory InfectionsSinusitisOtitis MediaBronchitisPneumoniaCardiovascular DiseaseHypertension CholesterolEndocrinologic DiseaseDiabetes MellitusThyroid DiseaseRespiratory InfectionRespiratory InfectionSinusitisOtitis MediaBronchitisPneumoniaRespiratory InfectionRespiratory Infection Sinusitis SinusitisEtiology Infection:begin with a viral agent in the nose or nasopharynx that cause inflammation that blocks the draining ostia.Viral agents:impede the sweeping motion of cilia in the sinus and,in combination with the edema from inflammation,lead to superinfection with bacteriaBacterial agents:S.pyogenes,S.pneumoniae,H.influenzae,Staphylococcus aureus -hemolytic streptococcus species *G(-)organism:usually limited to compromised hosts in intensive care units *chronic disease:polymicrobial with mixed infections consisting of aerobic and anaerobic organisms.Respiratory InfectionRespiratory Infection Sinusitis SinusitisFactors to contributing the development of sinus disease :atmospheric pollutants,allergy,tobacco smoke,skeletal deformities,dental conditions,barotrauma from scuba diving,airline travel,neoplasm,#chronic sinusitis :systemic disease(connective tissue syndrome),malnutrition Clinical finding 1)maxillary toothache 2)poor response to nasal decongestants 3)abnormal transillumination 4)a colored nasal discharge established by history 5)a colored nasal discharge on examination -4 :the likelihood of sinusitis -none:the likelihood of sinusitis Respiratory InfectionRespiratory Infection Sinusitis SinusitisDiagnosis self-diagnosed:headache,dental pain,postnasal drainage,halitosis,dyspepsiaImaging studies :not when initial episodes,but when persistent infections occurRespiratory InfectionRespiratory Infection Sinusitis SinusitisTreatmentBroad antibiotic therapy :cover common aerobes and anaerobes patient with acute pain&purulent dischargeSystemic decongestants:pseudoephedrineTopical decongestants :25/LPF epithelial cell 10/LPF ELISA(indirect serologic test)or direct fluorescent antibody staining of organisms in the sputum :Lesionella pneumoniae cold agglutinin c appropriate clinical symptoms :Mycoplasma pneumoniaeRespiratory InfectionRespiratory Infection PneumoniaPneumoniaHospitalization OutpatientTreatmentVery ill,elderly,immunocompromised-Oxygen therapy and hydration with antibiotic therapy(same protocol for outpatient therapy except 3rd generation cephalosporin)-Chest physiotherapy#Switch to Oral antibiotics:ability to eat and drink,blood culture(-),temperature 90%on room air or patient with COPD :PO260mmHg and PCO22 lobes,respiratory rate 30breaths/minute on arrival in the health care center,severe hypoxemia(50 years:female male African Americans Whites:twice Geographic variations:higher prevalence of hypertension and stroke in the southeastern United States regardless of race Definition :blood pressure levels 140/90 when measured on two separate occasionsCardiovascular DiseaseCardiovascular DiseaseHypertensionHypertensionPrimary or essential hypertension :95%,cause unknown Secondary hypertension :5%Diagnosis -Hx and P.Ex :presence of prior elevated readings,previous use of antihypertensive agents,a family history of death from cardiovascular disease prior to age 55,excessive alcohol and sodium use lifestyle modification is increasingly important in the therapy of hypertension -Laboratory evaluations :rule out reversible causes of hypertension(secondary hypertension)UA,CBC,S/E,Cr,fasting glucose,total cholesterol,HDL cholesterol,EKG Cardiovascular DiseaseCardiovascular DiseaseHypertensionHypertensionMeasurement of Blood Pressure -patient should be allowed to rest for 5minutes in a seated position and the right arm used for measurements (for unknown reason,the right arm has higher readings)-cuff should be applied 20mm above the bend of the elbow and the arm positioned parallel to the floor -The cuff should be inflated to 30mmHg above the disappearance of the brachial pulse or 220 mmHg -the cuff should be deflated slowly at a rate 2mmHg/sec#cuff size:important cuff hypertension:small cuffs used for obese patientsDiastolic reading:-Phase IV:Korotkoffs sounds(muffled sound)-Phase V:complete disappearance Cardiovascular DiseaseCardiovascular DiseaseHypertensionHypertensionDiagnosis and management are based on the classification of blood pressure readings Cardiovascular DiseaseCardiovascular DiseaseHypertensionHypertensionCardiovascular DiseaseHypertensionTreatment-General guidelines in assessing individuals for therapyCardiovascular DiseaseCardiovascular DiseaseHypertensionHypertensionMedicationmechanismIndication Contra IxSide effect1)DiureticsThiazides(eg.hydrochlorthiazide)Reduce plasma and ECF vol decreanse peripheral resistance,initially decrease of cardiac output then normalizem/c used medication for initial BP reduction Cr level 5:1 -predominant fractions are chylomicrons and VLDLTG:cholesterol 5:1-problem of VLDL and LDL fraction Initial classificationCardiovascular DiseaseCardiovascular DiseaseHyperlipidemiaHyperlipidemiaLaboratory testing multiple environmental causes of variation in cholesterol measurements -diet,obesity,smoking,ethanol intake,effects of exercise -clinical conditions :hypothyroidism,DM,acute or recent MI,recent weight changes -other :fasting state,position while the sample is drawn,use and duration of venous occlusion.Anticoagulant and storage and shipping conditions Cardiovascular DiseaseCardiovascular DiseaseHyperlipidemiaHyperlipidemiaIntraperson variation Age and sex 50 years,women lipid value increase d/t exogenous oral conjugated estrogensSeasional variation Diet and obesityAlcohol and cigarette smoking :moderate(defined as approximately 2ounces of absolute alcohol/day)sustained alcohol intake is noted to HDL LDL,TG -this effect is negated with higher quantitiesSmoking:LDL cholesterol and TG,HDL cholesterol (critical number:1520/day)Exercise:TG and LDL HDLCaffeine mixed effect on lipoprotein measurements,avoid in the 12hours prior to blood collection *Blood sample:collected in the morning after a 12-hour fast Cardiovascular DiseaseCardiovascular DiseaseHyperlipidemiaHyperlipidemiaDisease States and Medication Effects -Diuretics,propranolol:TG,HDL cholesterol (esp.Diuretics:total cholesterol)-DM:TG&LDL HDL cholesterol -Pregnancy :total serum cholesterol in 1st trimester,continuous increases of all fractions in 2nd3rd trimester -Hypothyroidism:total cholesterol and LDL cholesterol Cardiovascular DiseaseCardiovascular DiseaseHyperlipidemiaHyperlipidemiaManagementOnce hyperlipidemia is confirmed on at least two separate occasions,2nd causes should be diagnosed or excluded by taking a detailed medical and drug history,measuring Scr,fasting glucose level,performing thyroid,LFTobese patients:diet and weight loss(1st)Exercise and cigarette cessation Figure 9.4 Treatment decisions based on the LDL cholesterol levelFigure 9.4 Treatment decisions based on the LDL cholesterol levelCardiovascular DiseaseCardiovascular DiseaseHyperlipidemiaHyperlipidemiaMedication effectAdverse effect Bile acid-binding resinscholestyramine and colestipolLDLHDLConstipation,bloating,nausea,heartburnNicotinic acidTG,LDL,lipoprotein(a)HDLFlushing,pruritus,G-I distressc aspirin or ibuprofen:minimize the facial flushingFibric acid derivativesClofibrate,gemfibrozilTG,HDLLDL(some pts)HMG-CoA reductase inhibitors(-statin)Atorvastatin,fluvastatin,lovastatin,pravastatinsimvastatin Effect in cardiovascular diseaseSevere myalgias,muscle weakness c increases in creatine phosphokinase levels,rarely hhabdomyolysis leading to renal failureEndocrinologicEndocrinologic Disease DiseaseDiabetes MellitusDiabetes MellitusDefinition :chronic disorder of altered carbohydrate,protein and fat metabolism from deficiency in the secretion or function of insulin :defined by either fasting hyperglycemia or elevated plasma glucose levels after an oral glucose tolerance test(OGTT)Risk factors -age 45years -adiposity or obesity -a family history of diabets -Race and ethnicity -Hypertension(140/90)-HDL cholesterol 35mg/dL with or without a TG level 250mg/dL -History of gestational diabetes or delivery of baby 9 poundEndocrinologicEndocrinologic Disease DiseaseDiabetes MellitusDiabetes MellitusClassification Type 1 DM :The major metabolic disturbance of type 1 diabetes is the absence of insulin from destruction of cells in the pancreasType 2 DM :heterogeneous form of disbetes that commonly occurs in older age groups (40 years)and is more frequently noted to have familial tendency than type 1 diabetes.#type 1:an absence of insulin type 2:resulting in insulin resistanceEndocrinologicEndocrinologic Disease DiseaseDiabetes MellitusDiabetes MellitusDiagnosis 1.FBG(fasting blood glucose)126mg/dL 2.Random blood glucose 200mg/dL with classic signs and symptoms of diabetes (polydipsia,polyuria,polyphagia and weight loss)3.2-hour OGTT(fasting sample,60 and 120 minute samples)after a 75g load of glucose 2-hour OGTT should not be performed if the first two criteria are present.*Diagnostic criteria for imparied glucose intolerance(IGT)testing :110mg/dLFRG126mg/dL EndocrinologicEndocrinologic Disease DiseaseDiabetes MellitusDiabetes MellitusIndication of DM testing -Age 45years (repeat at 3-year intervals)-Classic signs and symptoms of diabetes (i.e.polyuria,polydipsia,polyphagia and weight loss)-Ethnic groups at high risk (Pacific Islanders,Native Americans,Africal Americans,Hispanic Americans,Asian Americans)-Obesity-First-degree relative with diabetes-Gestational diabetes or birth of a baby over 9 pound-Hypertension(140/90)-HDL cholesterol levels35mg/dL or triglyceride level 250mg/dL-Impaired glucose tolerance based on previous testing EndocrinologicEndocrinologic Disease DiseaseDiabetes MellitusDiabetes MellitusEndocrinologicEndocrinologic Disease DiseaseDiabetes MellitusDiabetes MellitusTreatmentEndocrinologicEndocrinologic Disease DiseaseDiabetes MellitusDiabetes MellitusComplication Acute complication -Diabetic ketoacidosis(DKA)-Nonketotic hyperosmolar diabetic coma(NKHC)-Hypoglycemia -LactoacidosisChronic complication -Macroangiopathy:accelerated atherosclerosis(CHD,MI,CVA)-Microangiopathy:retinopathy,nephropathy,neuropathy -Other:infection,skin lesionEndocrinologicEndocrinologic Disease DiseaseThyroid DiseaseThyroid DiseaseThyroid disorders are more common in women and some families,although the exact inheritance is unknown.In geriatric populations,the incidence 5%Thyroid function tests may be misleading in women receiving exogenous sources of estrogen because of altered binding characteristics(i.e.hormonal replacement therapy,pregnancy)HypothyroidismHyperthyoidismThyroid Nodules and cancerEndocrinologicEndocrinologic Disease Disease Hypothyroidism HypothyroidismIncidence -overt hypothyroidism:2%of women,and at least an additional 5%develop subclinical hypothyroidism (subclinical hypothyroidism:defined as an elevated serum TSH concentration with a normal serum free T4 level)EndocrinologicEndocrinologic Disease Disease Hypothyroidism HypothyroidismCauses -Autoimmune thyroiditis(Hashimotos thyroiditis)-incidence increases with age -associated with other endocrine(e.g.type 1DM,primary ovarian failure,adrenal insufficiency and hypoparathyroidism)and nonendocrine disorders(e.g.vitiligo and pernicious anemia)-Familial predisposition (specific genetics or environmental trigger is unknown)-Iatrogenic cause:after surgical removal or radioactive iodine therapy for hyperthyroidism of thyroid cancer -Secondary to pituitary or hypothalamic diseases from TSH or TRH deficiencyEndocrinologicEndocrinologic Disease Disease Hypothyroidism HypothyroidismClinical Features -Fatigue,lethargy,cold intolerance,nightmares,dry skim,hair loss,constipation,periorbital carotene deposition(causing a yellow discoloration),carpal tunnel syndrome and weight gain(510kg)menstrual dysfunction(menorrhagia or amenorrhea -Infertility(d/t anovulation):exogenous thyroid hormone is not useful for women who are anovulatory and euthyroid -Neuropsychiatric symptoms :depression,irritability,impaired memory and dementia in the elderly -Not cause of premenstrual syndrome(PMS),but worsening PMS may be a subtle manifestation of hypothyroidism -Precocious or delayed pubertyEndocrinologicEndocrinologic Disease Disease Hypothyroidism HypothyroidismDiagnosis :confirmed with laboratory studies -Serum TSH,s-T4 or free T4 index,-Autoimmune thyroiditis :confirmed by the presence of serum antithyroid peroxidase(antimicrosomal)antibodies *Central hypothyroidism :low or low-normal serum free T4 with either a low or inappropriately normal serum TSH concentrationEndocrinologicEndocrinologic Disease Disease Hypothyroidism HypothyroidismTreatment -L-thyroxine(T4),levothyroxine(Synthroid of Levothroid):absorption may be poor when taken in combination with aluminum hydroxide(common in antacids),cholestyramine,ferrous sulfate or sucralfate because of binding or chelation -Normal daily dosage:0.10.15mg (maintain TSH levels within the normal range)EndocrinologicEndocrinologic Disease DiseaseHyperthyroidismHyperthyroidismIncidence :affects 2%of women during their lifetimes most often during their childbearing years *Graves disease represents the most common disorderCauses -Graves disease -Transient thyrotoxicosis :result of unregulated grandular release of thyroid hormone in postparum(painless,silent or lymphocytic)thyroiditis and subacute(painful)thyroiditis -Other :hCG-secreting choriocarcinoma,TSH-secreting pituitary adenoma,and struma ovarii -Factitious ingestion or iatrogenic overprescribingEndocrinologicEndocrinologic Disease DiseaseHyperthyroidismHyperthyroidismClinical feature-Fatigue,diarrhea,heat intolerance,palpitations,dyspnea,nervousness,and weight loss.(In young patients:paradoxical weight gain from an increased appetite)-Vomiting in pregnant women-confused with hyperemesis gravidarum-P/Ex)Tachycardia,lid lag,tremor,proximal m.weakness and warm,moist skin-Dramatic physical change:ophthalmologic and lid retraction,periorbital edema and proptosis,:1/3 of women-In elderly adults:symptoms are often more subtle with presentations of unexplained weight loss,atrial fibrillation or new-onset angina pectoris-Menstrual abnormalities :regular menses,light flow,anovulatory menses and associated infertilityEndocrinologicEndocrinologic Disease DiseaseHyperthyroidismHyperthyroidism -Goiter:in younger women(m/c)c Graves disease -Toxic nodular goiter is associated with nonhomogeneous glandular enlargement while in subacute thyroiditis the gland is tender,hard and enlargedDi