Over 20% of UK medical students have used our exam room to revise. It's one of the most heavily utilised parts of Meducation and one of the most popular. But it's been a while since we did any work on it, something that we're about to rectify! We want to give you the opportunity to tell us how to make it even better!
What's There Already?
To recap where we're at currently. We have:
Thousands of questions (a mixture of SBAs, MCQs and EMQs) split into over 30 categories.
You can take exams of between 10 and 50 questions.
You can time your exam if you're Premium
You can compare your results in each question to the rest of the community and, if you're Premium, your medical school or year.
You can comment on questions and vote them up or down.
What Do You Want Improving?
So this is your opportunity. What does a perfect online exam revision section look like?
What features would you love? What annoys you? We want make the perfect section to help you practice for your exams, so please tell us what you want included. Post a comment below with your ideas on. If you agree with what someone else has said, please vote their comment up. Those that get voted up lots, we'll definitely try and implement!
This has been designed to show how the different components of the immune system develop individually and work together. I realised that a flowchart would be an excellent way to demonstrate this and was surprised to find that there wasn’t anything suitable on the internet that linked both the innate and adaptive systems. I know the diagram looks a bit dry but if you spend 5 minutes reading through it, I hope you'll find it useful. I'll hopefully add some images to make it more appealing at a later date.
The flowchart is based on information from lectures and several textbooks and has proven to be an excellent tool for revision and in developing a foundational understanding of the immune system for many students.
In this month’s SBMJ (May 2013) a GP called Dr Michael Ingram has written a very good article highlighting some of the problems with the modern NHS’s administrative systems, especially relating to the huge amount of GP time wasted on following up after administrative errors and failings. I personally think that it is important for people working within the NHS to write articles like this because without them then many of us would be unaware of these problems or would feel less confident in voicing our own similar thoughts.
The NHS is a fantastic idea and does provide an excellent service compared to many other health care systems around the world, but there is always room for improvement – especially on the administrative side!
The issues raised by Dr Ingram were:
Histology specimens being analysed but reports not being sent to the GP on time or with the correct information.
Histology reports not being discussed with patient’s directly when they try and contact the hospital to find out the results and instead being referred to their GP, who experiences the problem stated above.
GP’s are being left to deal with patient’s problems that have nothing to do with the GP and their job and have everything to do with an inefficient NHS bureaucracy. These problems and complaints often taking up to a third of a GP’s working day and thereby reducing the time they can spend actually treating patients.
Having to arrange new outpatient appointments for patients when their appointment letters went missing or when appointments were never made etc.
Even getting outpatient appointments in the first place and how these are often delayed well after the recommended 6 week wait.
Patients who attend outpatient appointments often have to consult their GP to get a prescription that the hospital consultant has recommended, so that the GP bares the cost and not the hospital.
My only issue with this article is that Dr Ingram highlights a number of problems with the NHS systems but then does not offer a single solution/idea on how these systems could be improved.
When medical students are taught to write articles for publication it is drummed into us that we should always finish the discussion section with a conclusion and recommendations for further work/ implications for practice. I was just thinking that if doctors, medical students, nurses and NHS staff want to complain about the NHS’s failings then at least suggest some ways of improving these problems at the same time. This then turns what is essentially a complaint/rant into helpful, potentially productive criticism.
If you (the staff) have noticed that these problems exist then you have also probably given some thought to why the problem exists, so why not just say/write how you think the issue could be resolved? If your grievances and solutions are documented and available then someone in the NHS administration might take your idea up and actually put it into practice, potentially reducing the problem (a disgustingly idealist thought I know).
A number of times I have been told during medical school lectures and at key note speeches at conferences that medical students are a valuable resource to the NHS administration because we visit different hospitals, we wander around the whole hospital, we get exposed to the good and bad practice and we do not have any particular loyalty to any one department and can therefore objective observations. So, I was thinking it might be interesting to ask as many medical students as possible for their thoughts on how to improve the systems within the NHS. So I implore any of you reading this blog: write your own blog about short comings that you have noticed, make a recommendation for how to improve it and then maybe leave a link in the comments below this blog.
If we start taking more of an interest in the NHS around us and start documenting where improvements could be made then maybe we could together work to create a more efficient and effective NHS.
So I briefly just sat down and had a think earlier today about a few potential solutions for the problems highlighted in Dr Ingram’s article.
A community pathology team that handles all of the GP’s pathology specimens and referrals.
A “patient pathway co-ordinator” could be employed as additional administrative staff by GP surgeries to chase up all of the appointments and missing information that is currently using up a lot of the GP’s time and thereby freeing them to see more patients. I am sure this role is already carried out by admin staff in GP practices but perhaps in an ad hoc way, rather than that being their entire job.
Do the majority of GP practices get access to the hospitals computer systems? Surely, if GPs had access to the hospital systems this would mean a greater efficiency for booking outpatient appointments and for allowing GPs to follow up test results etc.
In the few outpatient departments I have come across outpatient appointments are often made by the administration team and then sent by letter to the patients, with the patient not being given a choice of when is good for them. Would it not be more efficient for the administrative staff to send the patients a number of appointment options for the patient to select one appropriate for them?
Eliyahu M. Goldratt was a business consultant who revolutionized manufacturing efficiency a few years ago. He wrote a number of books on his theories that are very interesting and easy to read because he tries to explain most of his points using a narrative – “The Goal” and “Critical Chain” being just tow. His business theories focussed on finding the bottle neck in an industrial process, because if that is the rate limiting step in the manufacturing process then it is the most essential part for improving efficiency of the whole process. Currently, most GPs refer patients to outpatient appointments at hospitals and this can often take weeks or months. The outpatient appointments are a bottle neck in the process of getting patients the care they require. Therefore, focussing attention on how outpatient appointments are co-ordinated and run would improve the efficiency in the “patient pathway” as a whole.
a. Run more outpatient clinics.
b. Pay consultants overtime to do more clinics, potentially in the evenings or at weekends. While a lot may not want to do this, a few may volunteer and help to reduce the back log on the waiting lists.
c. Have more patients seen by nurse specialists so that more time is freed up for the consultants to see the more urgent or serious patients.
d. An obvious, yet expensive solution, hire more consultants to help with the ever increasing workload.
e. Change the outpatient system so that it becomes more of an assembly line system with one doctor and a team of nurses handling the “new patient” appointments and another team handling the “old patient” follow up appointments rather than having them all mixed together at the same time.
I am sure that there are many criticisms of the points I have written above and I would be interested to hear them. I would also love to hear any other solutions for the problems mentioned above.
Final thought for today … Why shouldn’t medical students make criticisms of inefficiencies and point them out to the relevant administrator?
If anyone else is interested in how the NHS as a whole is run then there is a new organisation called the Faculty of Medical Leadership and Management that is keen to recruit interested student members (www.fmlm.ac.uk).
Like may of you who work for a hospital, HMO or other organized medical care, I have often been frustrated by the rigidity and dullness of administrators. Many of them go by the rules and seem to be unbending.
Once in awhile one comes across some one who does not fit into that category. A personal example will illustrate this.
After I had retired from my academic position at the University of Miami I was doing intermittent "locums" work. I had just finished a six month assignment in Okinawa, Japan and was in my traveling mode. I needed to find my next "job" and had applied to an add from Mount Edgecumbe Hospital in Sitka, Alaska. That Indian Health Service Hospital was looking for an obstetrician and gynecologist. I was interested, applied and was invited for an interview.
I liked the job and they must have liked me as I was offered a two year contact. However as a new hire they offered me only two weeks of vacation and one week of Continuing Medical Education leave. For someone with my seniority, I thought that that was insufficient and said so. I left Sitka in a sad mood as I really would have liked that job, but was not ready to accept their offer of only two weeks of vacation time. I was told that that was the Company's policy, and that they were not ready to start a precedent.
Some days later, I received a phone call from the medical director of the hospital. She started off by apologizing again that she could not offer me more vacation, as that was the Company's policy for new hires. Right away I felt discouraged, but then she added: "We really would like to have you work for us and what I can do is give you two addition weeks of unpaid leave and raise your salary by two weeks (which, by company rules she was free to do). I was elated and accepted the offer for two years. We liked it there so much that we ended up staying seven years.
I thought that this hospital administrator was using her authority to make a very creative and imaginative decision. We all benefitted.
There should be more administrators like that.
Those interested in reading more about my experiences can download an e book for free from Smashword at: http://www.smashwords.com/books/view/161522 or just Google: "Crosscultural Doctoring. On and Off the Beaten Path".
This month’s case is by Barbara J. Mroz, M.D. and Robin R. Preston, Ph.D., author of Lippincott’s Illustrated Reviews: .Physiology (ISBN: 9781451175677). For more information, or to purchase your copy, visit: http://tiny.cc/PrestonLIR, with 15% off using the discount code: MEDUCATION.
The case below is followed by a choice of diagnostic tests. Select the one lettered selection that would be most helpful in diagnosing the patient’s condition.
A 54-year-old male 2 pack-per-day smoker presents to your office complaining of cough and shortness of breath (SOB). He reports chronic mild dyspnea on exertion with a daily cough productive of clear mucus. During the past week, his cough has increased in frequency and is now productive of frothy pink-tinged sputum; his dyspnea is worse and he is now short of breath sometimes even at rest. He has had difficulty breathing when lying flat in bed and has spent the past two nights sleeping upright in a recliner.
On physical examination, he is a moderately obese male with a blood pressure of 180/80 mm Hg, pulse of 98, and respiratory rate of 22. His temperature is 98.6°F. He becomes winded from climbing onto the exam table. Auscultation of the lungs reveals bilateral wheezing and crackles in the lower posterior lung fields. There is pitting edema in the lower extremities extending up to the knees.
Which if the following tests would be most helpful in confirming the correct diagnosis?
B. Arterial blood gas
C. Complete blood count
D. B-type natriuretic peptide blood test
The correct answer is B-type natriuretic peptide blood test.
Uncomfortable breathing, or feeling short of breath, is a common medical complaint with multiple causes. When approaching a patient with dyspnea, it is helpful to remember that normal breathing requires both a respiratory system that facilitates gas exchange between blood and the atmosphere, and a cardiovascular system that transports O2 and CO¬2 between the lungs and tissues. Dysfunction in either system may cause dyspnea, and wheezing (or bronchospasm) may be present in both cardiac and pulmonary disease. In this patient, the presence of lower extremity edema and orthopnea (discomfort when lying flat) are both suggestive of congestive heart failure (CHF). Elevated blood pressure (systolic of 180) and a cough productive of frothy pink sputum may also be associated symptoms. While wheezing could also be caused by COPD (chronic obstructive pulmonary disease) in the setting of chronic tobacco use, the additional exam findings of lung crackles and edema plus systolic hypertension are all more consistent with CHF.
What does the B-type natriuretic peptide blood test tell us?
When the left ventricle (LV) fails to maintain cardiac output (CO) at levels required for adequate tissue perfusion, pathways are activated to increase renal fluid retention. A rising plasma volume increases LV preload and sustains CO via the Frank-Starling mechanism. Volume loading also stimulates cardiomyocytes to release atrial- (ANP) and B-type (BNP) natriuretic peptides. BNP has a longer half-life than ANP and provides a convenient marker for volume loading. Plasma BNP levels are measured using immunoassay; levels >100 pg/mL are suggestive of overload resulting in heart failure.
How does heart failure cause dyspnea?
Increasing venous pressure increases mean capillary hydrostatic pressure and promotes fluid filtration from the vasculature. Excess filtration from pulmonary capillaries causes fluid accumulation within the alveoli (pulmonary edema) and interferes with normal gas exchange, resulting in SOB. Physical signs and symptoms caused by high volume loading include: (1) Lung crackles, caused by fluid within alveoli (2) Orthopnea. Reclining increases pulmonary capillary hydrostatic pressure through gravitational effects, worsening dyspnea when lying flat. (3) Pitting dependent edema caused by filtration from systemic capillaries, an effect also influenced by position (causing edema in the lower legs as in our ambulatory patient or in dependent areas like the sacrum in a bedridden patient).
What would an electrocardiogram show?
Heart failure can result in LV hypertrophy and manifest as a left axis deviation on an electrocardiogram (ECG), but some patients in failure show a normal ECG. An ECG is not a useful diagnostic tool for dyspnea or CHF per se.
Wouldn’t spirometry be more suitable for diagnosing the cause of dyspnea in a smoker?
Simple spirometry will readily identify the presence of airflow limitation (obstruction) as a cause of dyspnea. It's a valuable test to perform in any smoker and can establish a diagnosis of chronic obstructive pulmonary disease (COPD) if abnormal. While this wheezing patient is an active smoker who could have airflow obstruction, the additional exam findings above point more to a diagnosis of CHF.
What would an arterial blood gas show?
An arterial blood gas measures arterial pH, PaCO¬2, and PaO2. While both CHF and COPD could cause derangements in the values measured, these abnormalities would not necessarily be diagnostic (e.g., a low PaO2 could be seen in both conditions, as could an elevated PaCO¬2).
Would a complete blood count provide useful information?
A complete blood count could prove useful if anemia is a suspected cause of dyspnea.
BNP was elevated (842 pg/mL), consistent with CHF. Diuretic treatment was initiated to help reduce volume overload and an afterload reducing agent was started to lower blood pressure and improve systolic function.
This is an excerpt from "Fluids and Electrolytes Made Incredibly Easy! 1st UK Edition" by William N. Scott. For more information, or to purchase your copy, visit: http://tiny.cc/Fande. Save 15% (and get free P&P) on this, and a whole host of other LWW titles at lww.co.uk when you use the code MEDUCATION when you check out!
The chemical reactions that sustain life depend on a delicate balance – or homeostasis – between acids and bases in the body. Even a slight imbalance can profoundly affect metabolism and essential body functions. Several conditions, such as infection or trauma, and certain medications can affect acid-base balance. However, to understand this balance, you need to understand some basic chemistry.
Understanding acids and bases requires an understanding of pH, a calculation based on the concentration of hydrogen ions in a solution. It may also be defi ned as the amount of acid or base within a solution.
Acids consist of molecules that can give up, or donate, hydrogen ions to other molecules. Carbonic acid is an acid that occurs naturally in the body. Bases consist of molecules that can accept hydrogen ions; bicarbonate is one example of a base.
A solution that contains more base than acid has fewer hydrogen ions, so it has a higher pH. A solution with a pH above 7 is a base, or alkaline.
A solution that contains more acid than base has more hydrogen ions, so it has a lower pH. A solution with a pH below 7 is an acid, or acidotic.
Getting your PhD in pH
A patient’s acid-base balance can be assessed if the pH of their blood is known. Because arterial blood is usually used to measure pH, this discussion focuses on arterial samples.
Arterial blood is normally slightly alkaline, ranging from 7.35 to 7.45. A pH level within that range represents a balance between the concentration of hydrogen ions and bicarbonate ions. The pH of blood is generally maintained in a ratio of 20 parts bicarbonate to 1 part carbonic acid. A pH below 6.8 or above 7.8 is usually fatal.
Under certain conditions, the pH of arterial blood may deviate significantly from its normal narrow range. If the blood’s hydrogen ion concentration increases or bicarbonate level decreases, pH may decrease. In either case, a decrease in pH below 7.35 signals acidosis.
If the blood’s bicarbonate level increases or hydrogen ion concentration decreases, pH may rise. In either case, an increase in pH above 7.45 signals alkalosis.
Regulating acids and bases
A person’s well-being depends on their ability to maintain a normal pH. A deviation in pH can compromise essential body processes, including electrolyte balance, activity of critical enzymes, muscle contraction and basic cellular function. The body normally maintains pH within a narrow range by carefully balancing acidic and alkaline elements. When one aspect of that balancing act breaks down, the body can’t maintain a healthy pH as easily, and problems arise.
Metaphors and analogies have long been used to turn complex medical concepts into everyday ones, albeit with fancy terminology. Having been involved with many 3D animations on the topics of Blood Pressure, arteriosclerosis, cholesterol and the like, we find that often a metaphor goes a long way to building understanding, credibility and even compliance with patients. One of my favorite analogies is what we call the arterial highway. Much like their tarmacked counterparts, arteries act as conduits for all the parts that make your body go. A city typically uses highways, gas lines, water pipes, railways and other infrastructure to distribute important materials to its people. Your body is much the same, except that it does it all in one system, the cardiovascular system. This is used to deliver nutrients, extract waste, transport and deliver oxygen and even to maintain the temperature!
The arteries can do all these things because of their smart three-layered structure. Our arteries consist of a muscular tube lined by smooth tissue. They have three layers named – the Adventitia, Media and Intima. Each is designed with a specific function and through the magic of evolution has developed to perform its function perfectly.
The first is the Tunica Adventitia, or just adventitia. It is a strong outer covering over the arteries and veins. It has special tissues that are fibrous. The fibers let the arteries flex, expanding and contracting to accommodate changes in blood pressure as the blood flows past it. Unlike a steel pipe, arteries pulsate and so must be at once be flexible, and strong.
Tunica Media - the middle layer of the walls of arteries and veins is made up of a smooth muscle with some elasticity built in. This layer expands and contracts in a rhythmic fashion, much like a Wave at a baseball game, as blood moves along it.
The media layer is thicker in arteries than in veins, and importantly so, as arteries carry blood at a higher pressure than veins.
The innermost layer of arteries and veins is the Tunica Intima. In arteries, this layer is composed of an elastic lining and smooth endothelium - a thin sheet of cells that form a type of skin over the surface. The elastic tissue present in the artery can stretch and return, allowing the arteries to adapt to changes in flow and blood pressure. The intima is also a very smoothe, slick layer so that blood can easily flow past it.
Every layer of the artery has developed evolutionary traits that help your arterial system to maintain flexibility, strength and promote blood flow. Diseases and conditions like high cholesterol or high blood pressure, diabetes and others prevent the arteries from doing their function well by creating blockages or increasing the stress on one or more of the layers. For example, high blood pressure causes rips in the smooth lining of the Intima. Anybody who has experienced a pipe burst in a house knows that the damage can be extreme and can never fully be restored.
Understanding the delicate functions of the arterial structure gives good incentive to treat them better. Conditions like high blood pressure, high cholesterol and lifestyle diseases such as diabetes create tears, holes, blockages, and can disrupt the functions of one or more layers. Getting patients to visualize the effect of bad eating habits on their anatomy helps to increase patient compliance. In modern society, the concept of highways goes hand in hand with the concept of traffic jams. Patients understand that the arterial highway is one that can never be jammed.
As a hospital doctor, surgeon or GP we encounter death frequently. We quickly learn to cope. It helps when we know that we have done everything within our power to prevent death. When death is close we have the ability, medication and specialists services to make the process as 'comfortable' as possible. In the final moments it is rare that the patient is alone; whether in the company of family, friends or health care professionals.
When an individual dies on expedition it may have been avoidable, you have very little kit to prevent it, they may be alone and they probably were your friend.
No one prepares you for the potential of a client dying. But it happens.
First of all, I am not trying to put you off doing an expedition. I love expedition medicine and have dedicated the last five years of my life to it. But I was not prepared for my first near death experience and I want to make sure you are.
During an expedition injuries, near misses and deaths are sometimes avoidable. There may have been a faulty bit of kit, medication which wasn't packed or route marker that fell down ... Hindsight is a wonderful thing. You, the team and the organisers work within what is feasible and normal health and safety don't and can't apply. I am NOT saying it is ok to be negligent, but a degree of pragmatism is need. What you need to remember is the competitors/ clients are aware of the dangers and, as medics, we should be too.
Many medics are shocked by the lack of kit taken on expedition. But you need to think about the environment you are in and then think rationally. If your nearest decompression chamber is 3 days away by boat, is there much point taking oxygen on a diving expedition? If you are on expedition in the middle of the jungle is there any point taking a defib if any client in need of a defib is unlikely to survive extrication. You have to work within the limits of your environment and with the kit you have. As the medic you need to be aware of the nearest hospital and their facilities, the nearest large hospital with surgical and ITU facilities and the casevac plan.
During expeditions the clients often become good friends. You will experience their highs and lows and share incredible experiences. This makes it especially hard when unfortunate events occur. At this point our role as medic often broadens to counsellor and bereavement officer. The other clients, organisers and medics need support during this time. Try to start this process whilst you are out there.
Even with near misses, the psychological effect on people can be huge. Signs and symptoms are generally easy to spot, but screen for them at clinics. Be aware during race events that grief may manifest though clients pulling out, loss of performance and increased injuries due to lack of sleep, low mood or poor concentration.
No matter what happens when you are on expedition my advice is; you can only work within your skill set and with the equipment you have. As a foundation doctor, if you’re faced with an unresponsive client - you are not expected to perform RSI and intubate. Work through your ABCDE and work within your limitations.
If you would like to suggest any other blog topics or have any questions please post below.
This month’s case is by David R Bell PhD, co-author of Medical Physiology: Principles for Clinical Medicine, 3e (ISBN: 9781451110395) For more information, or to purchase your copy, visit: http://tiny.cc/Rhoades4e, with 15% off using the discount code: MEDUCATION.
The case below is followed by a quiz question, allowing you a choice of diagnoses. Select the one letter section that best describes the patient’s condition.
A 28-year old woman has an unremarkable pregnancy through her first 28 weeks of gestation, with normal weight gain and no serious complications. She has no previous history of diabetes, hypertension of other systemic disease before or during her current pregnancy. During her 30-week checkup, her blood pressure measures 128/85, and she complains about feeling slightly more “bloated” than usual with swelling in her legs that seems to get more uncomfortable as the day goes on. Her obsterician recommends that she get more bed rest, stay off her feet as much as possible and return for evaluation in one week.
At the one-week follow-up, the patient presents with noticable”puffiness” in her face, and a blood pressure of 145/95. She complains she has been developing headaches, sporadic blurred vision, right-sided discomfort and some shortness of breath. She has gained more than 10 lb (4.5kg) in the past week. A urinalysis on the patient revelas no glucose but a 3+ reading for protein. Her obstetrician decides to admit her immediately to a local tertiary care hospital for further evaluation. Over the next 24 hours, the patient’s urine output is recorded as 500mL and contains 6.8 grams of protein.
Her plasma albumin level is 3.1 g/dl, hemacrit 48%, indirect bilirubin 1.5mg/dl and blood platelets=77000/uL, respectively. Her blood pressure is now 190/100.
It is decided to try to deliver the foetus. The expelled placenta is small and shows signs of widespread ischmic damage. Within a week of delivery, the mother’s blood pressure returns to normal, and her oedema subsides. One month later, the mother shows no ill effects of thos later-term syndrome.
What is the clinical diagnosis of this patient’s condition and its underlying pathophysiology?
A. Gestational Hypertension
C. Gestational Diabetes
D. Compression of the Inferior Vena Cava
The correct answer is "B. Preeclampsia".
The patient’s symptoms and laboratory findings are consistent with a diagnosis of Preeclampsia, which is a condition occurring in some pregnancies that causes life-threatening organ and whole body regulatory malfunctions. The patient’s negative urine glucose is inconsistent with gestational diabetes. Gestational hypertension or vena caval compression cannot explain all of the patient findings. The patient has three major abnormal findings- generalised oedema, hypertension and proteinuria which are all common in preeclampsia. Although sequalae of a normal pregnancy can include water and salt retention, bloating, modest hypertension and leg swelling (secondary to capillary fluid loss from increased lower limb capillary hydrostatic pressure due to compression of the inferior vena cava by the growing foetus/uterus), oedema in the head and upper extremities, a rapid 10 pound weight gain and shortness of breath suggests a generalized and serious oedematous state. The patient did not have hypertension before or within 20 weeks gestation (primary hypertension) and did not develop hypertension after the 20th week of pregnancy with no other abnormal findings (gestational hypertension). Hypertension with proteinuria occurring beyond the 20th week of pregnancy however is a hallmark of preeclampsia. In addition, the patient has hemolysis (elevated bilirubin and LDH levels), elevated liver enzyme levels and thrombocytopenia. This is called the HELLP syndrome (HELLP = Hemolysis, Elevated Liver enzymes and Low Platelets.), and is considered evidence of serious patient deterioration in preeclampsia.
A urine output of 500 ml in 24 hours is 1/2 to 1/4 of normal output in a hydrated female and indicates renal insufficiency. Protein should never be found in the urine and indicates loss of capillaries integrity in glomeruli which normally are not permeable to proteins. The patient has substantial 24 urine protein loss and hypoalbuminemia. However, generally plasma albumin levels must drop below 2.5 gm/dl to decrease plasma oncotic pressure enough to cause general oedema. The patient’s total urinary protein loss was insufficient in this regard. Capillary hyperpermeability occurs with preeclampsia and, along with hypertension, could facilitate capillary water efflux and generalized oedema. However myogenic constriction of pre-capillary arterioles could reduce the effect of high blood pressure on capillary water efflux. An early increase in hematocrit in this patient suggests hemoconcentration which could be caused by capillary fluid loss but the patient’s value of 48 is unremarkable and of little diagnostic value because increased hematocrit occurs in both preeclampsia and normal pregnancy.
PGI2, PGE2 and NO, produced during normal pregnancy, cause vasorelaxation and luminal expansion of uterine arteries, which supports placental blood flow and development. Current theory suggests that over production of endothelin, thromboxane and oxygen radicals in preeclampsia antagonize vasorelaxation while stimulating platelet aggregation, microthrombi formation and endothelial destruction. These could cause oedema, hypertension, renal/hepatic deterioration and placental ischemia with release of vasotoxic factors. The patient’s right-sided pain is consistent with liver pathology (secondary to hepatic DIC or oedematous distention).
Severe hypertension in preeclampsia can lead to maternal end organ damage, stroke, and death. Oedematous distension of the liver can cause hepatic rupture and internal hemorrhagic shock. Having this patient carry the baby to term markedly risks the life of the mother and is not considered current acceptable clinical practice. Delivery of the foetus and termination of the pregnancy is the only certain way to end preeclampsia.
This case is by David R Bell PhD, co-author of Medical Physiology: Principles for Clinical Medicine, 3e (ISBN: 9781451110395)
For more information, or to purchase your copy, visit: http://tiny.cc/Rhoades4e.
Save 15% (and get free P&P) on this, and a whole host of other LWW titles at (lww.co.uk)[http://lww.co.uk] when you use the code MEDUCATION when you check out!
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I'm student of University of Debrecen - one of Hungary’s five research-elite universities. It offers the widest choice of majors in the country for over 32,000 students. It has 1500 lecturers of 15 faculties endeavour to live up to the elite university status and to provide high quality education for those choosing the University of Debrecen every day.
The University of Debrecen is a dynamically expanding institution.
I believe in power of social media and I'm so glad my University has embraced it too. It has an official Facebook page where they post newest education or sport news (they have 18.863 followers, which is not too bad). For the fastest information you can follow their Twitter page. If you like videos or simply you missed some events, you can catch up on their official Youtube channel. In other universities (e.g. Cardiff University) these tools are evident, but, unfortunately not all universities in Hungary understand the value of them.
The University of Debrecen tries to keep up with revolution of social media. Encourage your university to do the same!
It's been a while since I've added any thoughts to this blog. In that time I have finished my Obs/Gynae placement, I have spent a week on labour ward, and done my first week of my 4th year surgical placement. All the while cramming in revision between various activities and general staying alive measures. This, I feel, is how most people who are sitting their final written exams are spending their time, so I don't feel so alone.
I just want to bring to the attention one amazing incident that happened on my labour ward week. I was on a night shift, there wasn't a lot going on. Absolutely everyone was knackered, the registrar who'd been on nights for the past week was just chatting to me. I have never seen someone look so tired. The emergency alarm went off and a lady had a cord prolapse, which is an obstetric emergency with a high foetal mortality rate. Now I think it's amazing that the doctor went from nearly falling asleep to switched on 'surgical-mode' in an instant, successfully performed the C-section, delivering the baby in about a minute, then went back to being absolutely knackered and let the SHO close up the wound.
It just really impressed me and I felt it was something worth sharing. Actually I was incredibly surprised that I enjoyed Obs/Gynae. Women's health was a placement I was dreading, it was my last major knowledge gap and I didn't have a clue what it was going to be like. If my tutor for the block does read this, thank you for all your help and getting me involved in everything. I would encourage other students who are going into it and feeling any level of apprehension to just throw yourselves into it and give 110% effort. It is a great placement for practicing transferable skills (this is important to remember, especially if you don't have any desire to go into it you CAN transfer and practice skills from elsewhere!) and getting heavily involved in patient care.
Also I'd like to point out the Mother and Baby were fine :)