Intracerebral hemorrhage

It is usually due to hypertension. The pathologic basis for hemorrhage is probably the presence of microaneurysms that develop on perforation vessel of 100 - 300 mcm in diameter in hypertensive patients. Most frequently in the basal ganglia and less commonly in the pons, thalamus, cerebellum, and cerebral white matter. Hemorrhage may extend into the ventricular system or subarachnoid space, and signs of meningeal irritation are then found.
Symptoms and signs
Consciousness is initially lost or impaired. Vomiting occurs very frequently at the onset of bleeding, and headache is sometimes present. There is generally a rapidly evolving neurologic deficit with hemiplegia or hemiparesis. Cerebellar hemorrhage may present with equilibrium.
Imaging : CT scan is important
Laboratory: blood count, platelet count, bleeding time, prothrombine and partial thromboplastin times and liver, Renal function test.
Treatment: it is generally conservative and supportive. Such therapy may include ventilatory support, blood pressure regulation, seizure prophylaxis, control of fever, osmotherapy and nutritional supplementation. Ventricular drainage may be required in patients with intrventicular hemorrhage and acute hydrocephalus. Cerebellar hemorrhage, prompt surgical evacuation of the hematoma is appropriate, because spontaneous unpredictable deterioration may otherwise lead to a fatal outcome and because operative treatment may lead to complete resolution of the clinical deficit.

Dyspareunia

Are you sexually active?
Are you having any sexual difficultis at this time?
During the pelvic examination, the patient should be placed in a half-sitting position and given a hand-held mirror and then asked to point out the site of pain and describe the type of pain.
Etiology:
A. Vulvovaginitis
B. Vaginismus
C. Remnants of the hymen
D. Insufficient lubrication of the vagina
E. Infection, endometriosis, tumors, or the other pathologic conditions
F. Vulvodynia

Infertility

Evaluation of male factors
A. Semen Analysis
-the Semen parameters in normal fertile males may vary significantly over time, and the first response to any abnormal result should be to wait an interval of several weeks to months and repeat the test. Keeping in mind that the cycle of spermatogenesis takes about 74 days. <5 million sperm /ml warrants an endrocrinologic evaluation including FSH, LH, and testosterone, or a karyotype in selected cases.
B. DNA assays
Several tests, including sperm chromatic structure assay (SCSA), comet, and terminal dUTP nick-end labeling (TUNEL) , have been developed to quantify the damage to DNA or chromatin.
C. Other tests: Postcoital test, antibody studies , a sperm penetration assay.

Evaluation of female factors
A. Ovulatory factor
Historical: onset of menarche, cycle length, premenstrual symptoms.
Confirmation of ovulation : history of mittelschmerz and / or regular menses with molimina and mild dysmenorrhea occur at intervals of 28-32 days, the likelihood of the patient having regular ovulatory cycles is very high. Progesterone levels of >3 ng/mL in the third week of the cycle.
Pelvic ultrasonography can provide evidence for ovulation. The disappearance of, or change in, the follicle and free fluid in the cul-de-sac can document ovulation.
B. The pelvic factor
Including abnormalities of the uterus , fallopian tubes, ovaries, and adjacent pelvic structureS. History: PID, appendicitis, intrauterine devices , endometritis, and septic abortion.
C. The cervical factor
Indicated by a history of abnormal pap smears, Postcoital bleeding, cryotherapy, conization, or DES exposure in utero.

Contraception

Method of contraception
A. Traditional or folk methods
-coitus interruptus: failure may result from escape from semen before orgasm.
-postcoital douche: the sperm have been found within the cervical mucus within 90 seconds after ejaculation.
-lactational amenorrhea: suckling result in a reduction in the release of gonadotropin-releasing hormone, LH, FSH. During the first 6 months, if breastfeeding is exclussive, menses are mostly anovulatory and fertility remains low. Contraceptive method starting 3 months after delivery.
-periodic abstinence :
1. Calendar method: ovulation occurs 14 days before the first day of the next menstrual period. Fertile interval should be assumed to extend from at least 2 days before ovulation to no less than 2 days after ovulation.
2. Temperature method : temperature must be recorded before activities is undertaken.
3. Cervical mucus method : starting several days before and until just after ovulation, the mucus becomes thin and watery, whereas at other times the mucus is thick and opaque.
B. Barrier method
-condoms(male and female):
-diaphragm
-cervical cap
-vaginal sponge
-spermicides
C. Hormonal method
-oral
-inject
-implant
D. Armamentarium
-iud
-sterilization

Fibrocystic change

Essentials of diagnosis
-painful, often multiple usually bilateral mobile masses in the breast.
-rapid fluctuation in the size of the masses is common
-frequently, pain occurs or increases as does size during the premenstrual phase of the cycle.
-most common age is 30-50 years, occurrence is rare in postmenopausal women.
The term Fibrocystic disease or mammary dysplasia, is imprecise and encompasses a wide spectrum of pathologic entities.
Pain or tenderness is often the presenting symptom and calls attention to the mass. Increasing during the premenstrual phase of the cycle, at which time the cysts tend to enlarge. Multiple or bilateral masses are also common.
Treatment
Simple mastectomy or extensive removal of breast tissue is rarely if ever indicated for Fibrocystic change.
Breast pain associated with generalized fibrocystic change is best treated by avoiding trauma and by wearing a bra with adequate support.

Maternal physiology during pregnancy

Pregnancy involves a number changes in anatomy, physiology, and biochemistry, which can challenge maternal reserves
A. Cardiovascular system
-the heart rotates on its long axis in a left-upward displacement.
-the heart size increases by about 12%
-blood volume: 50% elevation in plasma volume, 30% increase in red cell mass.
-cardiac output increases approximately 40%, stroke volume increase 25-30%
-blood pressure: systemic arterial pressure declines slightly reaching a nadir at 24-28 weeks of gestation. Pulse pressure widens because the fall is greater for diastolic than for systolic pressures. Venous pressure increase in the lower extremities which can cause edema and varicosities.
-heart murmurs and rhythm can be detected in 90% or more gravidas. Its can be heard at the left sternal edge.
-peripheral vascular resistance decreases by enhancing local vasodilators(nitric oxide, prostacyclin, possibly adenosine)
-blood flow distribution: uterine blood flow can be as high as 800ml/min, breast 200ml/min.
B. Pulmonary system
-capillary dilatation leads to engorgement of the nasopharynx, larynx, trachea, and bronchi.
-diaphragma is elevated by as much as 4cm.
-dead space volume increase because of relaxation of the musculature of conducting airways.
C. Renal system
-the renal calyces and pelves are dilated
-ureters are dilated above the brim of the bony pelvis, with more prominent effects on the right.
-GFR increases 25%, renal clearence 50%
-sometimes glucosuria, protein loss <300mg
-urinary frequency increase
-bladder capacity up to 1,5L
D. Gastointestinal system
-salivation increases
-gums become hypertrophic and hyperemic
-esophageal peristalsis is decreased
-gastrin increases
-intestine motility decrease
-emptying gallbladder is slowed

Transient ischemic attacks

Essentials of diagnosis
*focal neurologic deficit of acute onset
*clinical deficit resolves completely within 24 hours
*risk factors for vascular disease often present
If the ischemia is in the carotid territory,common symptoms are weakness and heaviness of the contralateral arm, leg, or face, singly or in any combination.
Numbness or paresthesias may also occur either as the sole manifestation of the attack or in combination with the motor deficit.
Vertebrobasilar ischemic attacks may be characterized by vertigo, ataxia, diplopia, dysarthria,dimness or blurring of vision, perioral numbess and paresthesias, and weakness or sensory complaints.
There may be slowness of movement, dysphasia, or monocular visual loss in the eye contralateral to affected limbs.
Treatment is initiated with iv heparin (in a loading dose of 5000-10000 units of standard-molecular weight heparin and maintenance infusion of 1000-2000 units per hour depending on the partial thromboplastin time), while warfarIn sodium is introduced in a daily dose of 5-15mg orally depending on inr. Warfarin is more effective than aspirin in reducing the incidence of cardioembolic. Aspirin 325mg daily may be used in patients with nonrheumatic atrial fibrillation. In patients intolerant of aspirin, clopidrogel 75mg can be used instead.