SOAP NOTE

Ph Tahani Bahnasi

LAB 1
 SOAP NOTE

*Subjective
*Objective
*Assessment
*Plan

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 SOAP

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 • CASE
• “I keep running to the bathroom and I
feel awful” A 40-year-old man goes to
his general practitioner (GP)
complaining of diarrhoea that developed
suddenly 3 days ago (since 7/10/2018).
He described his motions that are slimy
and bloody and colicky abdominal pain
not relieved by spasmolytic medication
that he has taken The man has a poor
appetite and feels nauseated..

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• He smokes 10 cigarettes a day, has had DM
II for 6 years, HTN for 5 years .he is on
enalapril and metformin.the patient is allergic
to sulfa
• both parents had DMII , father died of MI at
52yo....
• On examination:blood pressure is
158/90mmHg, Pulse 80,Temp 37
• Wt: 168 lb Ht: 65”
• Stool culture was positive for amoeba
• Cardiovascular, respiratory and abdominal
examinations are unremarkable.

• Diagnosis: acute infectious diarrhea

Metronidazol 500 mg tab 1X2

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 Subjective
– Subjective data include: Patient symptoms, things that may be
observed by the patient, or information obtained from the
patient
– By its nature, subjective information is descriptive and
generally cannot be confirmed by diagnostic tests or
procedures.
• Much of the subjective data is obtained by speaking with the
patient while obtaining the following information:
• (CC) Chief Complaint : In patient’s own words.
“I keep running to the bathroom and I feel awful”
• (ROS) : review of systems:

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 (HPI) History of Present illness:
• complete description of the patient’s
symptom(s). Usually included in the HPI are:
• Date of onset (7/10/2018)
• Precise location (abdominal pain)
• Nature of onset, severity slimy and bloody, and
duration (3 days).
• Effect of any treatment was given.
(not relieved by spasmolytic medication)
• Relationship to other symptoms, bodily
functions, or activities(e.g., activity,
meals),Degree of interference with daily
activities. (poor appetite )

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(PMH) Past Medical History:( has had DM II for 6
years, HTN for 5 years )
• The past medical history includes Immunizations, serious
illnesses, surgical procedures, and injuries the patient has
experienced previously
.
(SH) Social History.. (smokes 10 cigarettes)
Familial, occupational, educational and recreational
aspects of the patient's personal life .
(FH) Family History : (both parents had DMII)
• Includes the age and health of parents, siblings, and
children
• For dead relatives, the age and cause of death are
recorded. …..
• Heritable diseases and those with a hereditary
tendency are noted (e.g., diabetes mellitus,
cardiovascular disease, malignancy, rheumatoid
arthritis, obesity). …

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 • (MH) Medication History (prior to
admission) ..
• Side effect of other medications
( antibiotic induced diarrhea),
• Non compliance .
• Allergies to drugs, food, pets, and environmental
factors (e.g., grass,dust, pollen) allergic to sulfa

• Any information you obtain from the patient or

family members about medication names,
doses, frequency, adherence, or purpose.
(enalapril and metformin).

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• Objective
• A primary source of objective information (O) is the physical
examination. Other relevant objective information includes:
• Physical Examination
• Gen (White man, appears ill, in moderate distress)
• VS (Vital signs)… blood pressure, pulse, respiratory rate,
temperature.
(PE) Physical exam findings..HEENT, CHEST,COR, ABD,
GU, RECT, EXT, NEURO, Skin.
• HEENT: Head, Eye ,Ear, Nose, Throat . COR: Cardiac
output recorder
• ABD: Abdomen GU: Genitourinary EXT: Extremities
• Results of diagnostic testing and imaging (e.g. x-ray,
Endoscopy, CT/MRI, ECG………)

• Laboratory results: serum drug concentrations (along with

the target therapeutic range for each level) ( blood test,
urine test, stool test…….)

• Risk factors that may predispose the patient to a particular

problem should also be considered for inclusion.

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 Diagnostic tests

• Angiogram: the examination of blood

vessels.
• Electrocardiogram (ECG): measures
the electrical impulses produced by
the heart.
• Electroencephalogram – EEG:
measures the electrical impulses by
the brain.
• X-rays: checking for broken bones,
diseases like pneumonia and breast
cancer.

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 Computed tomography (CT):

• examine broken bones, Cancers,

Blood clots, Signs of heart disease,
Internal bleeding

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 Magnetic resonance imaging
(MRI):
• for examining the brain and spinal
cord. Doctor should be informed if the
patient is pregnant, has pieces of
metal or a cardiac pacemaker or a
metal artificial joint

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 Endoscopy

• is a procedure that lets the doctor to

look inside patient’s body. It uses an
endoscope, with a tiny camera
attached to a long, thin tube.
• Arthroscopy: joints
• Bronchoscopy: lungs
• Upper GI endoscopy: esophagus and
stomach
• Colonoscopy : large intestine
• ureteroscopy: urinary system

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 Pulmonary Function
Tests - PFT's

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 Pulmonary Function Tests -
PFT's
• Tidal volume (TV, Vt): Normal breathing with
approximately 500 ml of inspired and expired
gas
• Vital capacity (VC): the maximal amount of air
exhaled after a maximal inspiration.
• A forced vital capacity (FVC):
• greatest amount of air exhaled quickly and
forcefully after a deep inspiration.
• Forced expiratory volume (FEV):
• giving the total volume of exhaled air in one
second (FEV1), (FEV2), (FEV3), and (FEV4).
• Residual Volume (RV): After a maximal
expiration, the amount of air left in the lungs is
referred to as the RV.

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 Biopsies
– Remove a tissue from the
body for the purpose of
diagnosis or treatment. They
are used mainly to confirm
malignancy

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• Assessment
• The assessment (A) section outlines what the
practitioner thinks the patient's problem is,
based upon the subjective and objective
information acquired.
• This assessment often takes the form of a
diagnosis .
(Diagnosis: acute infectious diarrhea )

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• Plan
• Provide specific recommendations regarding the
treatment that is prescribed, such as medication or
other actions needed to facilitate treatment.

• Recommendations may include:

• 1- Pharmacological:
• major therapy : e.g…antibiotics to treat infection
( metronidazol)
• symptomatic therapy. e.g…analgesic , antipyretic.

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• 2- Non pharmacological
• Ordering additional diagnostic tests to rule out or confirm a
diagnosis

• Surgery.

• Dietary changes (dietary recommendations such as the DASH(

Dietary Approaches to Stop Hypertension)or TLC (Therapeutic
Lifestyle Changes )diet

• Exercise suggestions (e.g. weight bearing exercise 2-3x week)

• Lifestyle modifications (e.g. stop smoking, reduce alcohol

intake)

• Vitamin, Herbal or other OTC suggestions (e.g. 1200 mg

calcium + 800 IU vitamin daily)

• Vaccination recommendations (influenza vaccine annually)

• Educational interventions (inhaler technique training)

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• The plan should be directed toward
achieving a specific, measurable, goal
which should be clearly stated in the note.

• The plan should also outline the efficacy and

toxicity parameters that will be used to
determine whether the desired therapeutic
outcome is being achieved and to detect or
prevent drug-related adverse events.
(MONITORING)

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 The process of
rational treatment

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 Step 1:
• Define the patient's problem.
 problems may include:
- untreated disease or medication dosage
regimen errors
- side effect of drugs, contradictions
- Non-adherence to treatment
- Combinations of the above

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 Step 2:
• Specify the therapeutic Goal
What do you want to achieve with the
treatment?
Treatment /Prevention of unnecessary
drug use

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 Example

• Girl, 18 months old, slightly

undernourished. Watery diarrhea
without vomiting for three days, she
has not urinated for 24 hours. On
examination she has no fever
(36.8oC), but a rapid pulse and low
elasticity of the skin.

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 Solution Solution
diarrhea is probably caused by a viral
infection, as it is watery (not slimy or
bloody) and there is no fever. She has
signs of dehydration.

The therapeutic goal in this case is therefore to

prevent further dehydration
Advice and information: Continue breast feeding and
other regular feeding; careful observation.
Non-pharmacological treatment:
Additional fluids, (rice water, fruit juice, homemade
sugar/salt solution).
Drug treatment: Oral rehydration solution (ORS), oral
or by nasogastric tube

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 • Step 3: Verify the suitability of your PLAN-treatment:
3A Are the active substance and dosage form suitable?
Effective: Indication (drug really needed)?
Convenience (easy to handle, cost)?
Safe: Contraindications (high risk groups, other
diseases)?
Interactions (drugs, food, alcohol)?
3B Is the dosage schedule suitable?
3C Is the duration suitable?

• High risk factors groups:

• Pregnancy -Lactation
• Children- Elderly
• Renal failure -Hepatic failure
• History of drug allergy
• Other diseases /Other medication

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 EXAMPLE
• Man, 45 years, suffers from asthma, Uses
salbutamol inhaler. A few weeks ago he
was diagnosed with essential
hypertension (145/100). You advised a
low-salt diet, but blood pressure remains
high. You decide to add a drug to his
treatment, which was atenolol tablets, 50
mg a day

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 SOLUTION
• like all beta-blockers, it is relatively
contraindicated in asthma. Despite the
fact that it is a selective beta-blocker, it
can induce asthmatic problems,
especially in higher doses because
selectivity then diminishes. If the asthma
is not very severe, atenolol can be
prescribed in a low dose. In severe
asthma you should probably switch to
diuretics; almost any thiazide is a good
choice.

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 EXAMPLE
• Boy, 4 years. Cough and fever of
39.5oC. Diagnosis: pneumonia.
One of your P-drugs for pneumonia
is tetracycline tablets.

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 SOLUTION

• Tetracycline is not a good drug

for children below 12 years of
age, because it can cause
discolouration of the teeth. The
drug may interact with milk and
the child may have problems
swallowing the large tablets. The
drug and, if possible, the dosage
form, will therefore have to be
changed.

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 EXAMPLE

Woman, 22 years, 2 months

pregnant. Large abscess on her right
forearm. You conclude that she will
need surgery fast, but in the
meantime you want to relieve the
pain. Your P-drug for common pain is
acetylsalicylic acid (aspirin) tablets.

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 SOLUTION

• This patient is pregnant and will soon

be operated on. In this case
acetylsalicylic acid is contraindicated
as it affects the blood clotting
mechanism and also passes the
placenta. You should switch to another
drug that does not interfere with
clotting. Paracetamol is a good choice
for a short time.

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• Step 4: Start the treatment: The advice should
be given first, with an explanation of why it is
important.
• Step 5: Give information, instructions and
warnings
• The six points listed below summarize the
minimum information that should be given to the
patient:
• 1. Effects of the drug
• 2. Side effects
• 3. Instructions
• 4. Warnings
• 5. Future consultations
• 6. Everything clear?

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 Step 6
Monitor (stop) the treatment
Passive monitoring :explain to the patient what
to do if the
treatment is not effective, is inconvenient or if too
many side effects occur.
In this case monitoring is done by the patient.

Active monitoring: the physician makes an

appointment to determine whether the
treatment has been effective.

The purpose of monitoring is to check whether

the treatment has solved the patient's problem.

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 Thank you

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UPPER RESPIRATORY TRACT INFECTIONS
Ph Tahani Bahnasi
 Otitis media
Otitis media, or middle ear inflammation, is the most
common childhood illness treated with antibiotics. It
usually results from a nasopharyngeal viral infection and
can be sub-classified as:
 Acute Otitis Media (AOM) is a rapid, symptomatic
infection with effusion, or fluid, in the middle ear
 Otitis Media with Effusion (OME). fluid in the middle ear,
but no signs of acute infection.
 Chronic otitis media; persists for 3 or more months on
examination OR tympanic membrane has perforated
 Pathophysiology
• Viral URIs impair Eustachian tube function and cause
mucosal inflammation, impairing mucociliary
clearance and promoting bacterial proliferation and
infection.

 Common bacterial pathogens;

 S.pneumoniae, Non typeable Haemophilus Influenza
and moraxella catarrhalis.
• Children are predisposed because they have
shorter, more flaccid, and more horizontal
Eustachian tubes than adults, which are less
functional for middle ear drainage and
protection.

• AOM occurs in all ages but is most common

between 6 and 18 months of age.
 CASE STUDY (1)
A 13-month-old boy presents to the pediatric clinic with
2 days of fever ( temperature of 39.3°C [102.7°F]),
rhinorrhea, and fussiness. His mother reports that he was
rubbing his left ear throughout the day yesterday. She
states that he is irritable and he was crying throughout
the last night. Furthermore he has not eaten much today.
He attends daycare 3 days a week and has a 5-year-old
sister who recently had a cold. The boy is bottle fed and
use pacifier, both parents are smokers
 CASE STUDY (1)
Meds: Acetaminophen drops 120 mg orally every 4 to 6
hours as needed for fever
ROS: (+) rhinorrhea and fever, (–) vomiting, diarrhea, or
cough
Gen: Irritable child but consolable
VS: BP 100/64 mm Hg, P 130 beats/min, RR 22
breaths/min,
T 39.1°C (102.4°F)
HEENT: Erythema and severe bulging of the left tympanic
membrane with the presence of middle ear fluid.
 Diagnostic certainty
AOM should be diagnosed if any of the following is met:
 Moderate to severe bulging of TM (usually with impaired
mobility as assessed by pneumatic otoscopy)

 Mild bulging of TM and recent onset (< 48 hours) of

otalgia (or ear rubbing/tugging in nonverbal child) or
intense erythema of TM.
 New onset otorrhea not caused by acute otitis externa.

• Severe AOM: Moderate to severe otalgia or otalgia for at

least 48 hours or T of 39.0°C (102.2°F) or greater
 What clinical features are suggestive of acute otitis
media (AOM)?
Patients with AOM usually have: cold symptoms,
(rhinorrhea, cough, or nasal congestion, before or at diagnosis).
Symptoms
Young children: ear tugging or rubbing, irritable, poor sleeping and eating.
Older patients: ear pain(otalgia), ear fullness, hearing impairment
Signs
• Fever: not common in older children; often in younger children
• Middle ear effusion
• Otorrhea with tympanic membrane perforation
• Bulging tympanic membrane
• Limited or absent mobility of tympanic membrane
• Distinct erythema of tympanic membrane
• Opaque tympanic membrane that obscures middle ear visibility
What risk factors does this child have for AOM?
 Is there any additional information you need to know
before recommending a treatment plan?

• Laboratory Tests
• Gram stain, culture, and sensitivities of ear fluid if draining
spontaneously or obtained via tympanocentesis.

(Pneumatic otoscopy)
 What are the goals of therapy for this patient?

 Alleviate ear pain and fever, if present.

 Eradicate infection.
 Prevent complications.
 Avoid unnecessary antibiotic use.
 Management approaches

• Children with recurrent AOM or chronic OME with impaired

hearing or speech may benefit from surgery (tympanostomy
tube placement)
• Watchful waiting and “safety-net” antibiotic prescriptions.
(prescription given to the patient but only filled if symptoms
persist or worsen within 48–72 hours after diagnosis) attenuate
microbial resistance /avoid unnecessary antibiotic adverse
events.
Watchful waiting is only an option when follow-up can be
ensured and antimicrobial agents started if symptoms persist or
worsen.
 Criteria used to identify a patient as not a
candidate for Watchful Waiting :
• Temperature >38.6°C within the past 48 hours
• Symptoms suggestive of AOM for >48 hours
• The TM of the infected ear was not intact
• The pt is immunocompromised
• Another episode of AOM within the past 3
months
• The infected ear has signs perforation
• A coexisting bacterial infection exists
Treatment algorithm for initial antibiotics or observation in
children 6 months to 12 years of age with uncomplicated AOM .
Treatment algorithm for uncomplicated AOM in
children 6 months to 12 years of age.
 Pharmacological Therapy
• Amoxicillin is the drug of choice in most patients.
High dose amoxicillin-clavulanate is preferred for:
 Children who received amoxicillin in the previous 30 days.
 Have concurrent purulent conjunctivitis
Patients with otitis conjunctivitis syndrome are more likely to be
infected with H. influenzae, hence the need for a β-lactamase
inhibitor (such as clavulanate)

 Have a history of recurrent AOM unresponsive to amoxicillin

 Recurrent OM; at least 3 episodes in 6 months or at least 4
episodes in 1 year with 1 episode in the preceding 6 months .

Patients with penicillin allergies require alternative therapy.

Notably, clindamycin lacks efficacy against H. influenzae, whereas macrolides

lack efficacy against both H. influenzae and S. pneumoniae; therefore, macrolides
are not recommended.
 Adjunctive Therapy
 Acetaminophen and ibuprofen for mild to moderate
pain.
 Ibuprofen should be avoided in children younger
than 6 months (increased toxicity concerns).
 Topical anesthetic drops ..pain relief within 30
minutes.
 Decongestants, antihistamines, and corticosteroids
have no role in AOM treatment and can prolong
effusion duration.
 Case 2
A mother brings her five-year-old son to clinic because
her child show signs of impaired speech, inattention
and a decrease of his academic performance. The child
complains of fullness and a sensation that the ear is
popping .On examination: fluid behind a non-
erythematous right tympanic membrane.
 What is the most probable diagnosis?

 What is the most probable management for this

patient?
 What are the complications of otitis media?

• Infectious: mastoiditis, meningitis,

osteomyelitis, intracranial abscess
• Structural: perforated eardrum, cholesteatoma

• Hearing and/or speech impairment

 Pharyngitis
(sore throat)
 Pharyngitis
(Sore throat)
Pharyngitis is an inflammation of the throat often caused by
infection.
Although viral causes are most common, Streptococcus
pyogenes (Group A streptococci) is the most common bacterial
cause. group A β-hemolytic Streptococcus (GABHS, also known as S. pyogenes)

Proper diagnosis is important to minimize unnecessary

antibiotic use for viral pharyngitis and prevent complications of
untreated streptococcal infection.

Antibiotic should be used only in cases of lab documented

streptococcal pharyngitis with symptoms.

late treatment till 9 days can still prevent complications

 Case study (3)
5-year-old girl presents to the pediatrician with a sore
throat and fever of 39.1°C (102.4°F) for the past 12
hours. She has pain while swallowing, so she is unable
to eat or drink as much as usual. She also complains of
a “belly ache.” She has no other symptoms and takes
no medications. She has type 1 penicillin allergy. Her
mother reports that two children in her daughter’s
class had “strep throat” recently.
Physical examination reveals halitosis, pharyngeal and
tonsillar erythema with exudates, and cervical
lymphadenopathy
 Does this child have streptococcal pharyngitis?
Signs and Symptoms of Streptococcal Pharyngitis
 Sudden sore throat with severe pain while swallowing
 Fever
 Headache, abd pain, nausea, or vomiting (especially children)
 Tonsillopharyngeal erythema with or without exudates
 Tender, anterior cervical lymphadenitis
 Swollen red uvula and Soft palate petechiae
 Halitosis ( bad breath)

 Scarlat-iniform rash (caused by pyrogenic exotoxin-producing

S.pyogenes.
 Centor criteria

Signs Suggestive of Viral Origin for Pharyngitis

 Conjunctivitis
 Coryza (Runny nose, sneezing)
 Cough
 Diagnosis
 Tests should be performed only when there is clinical
suspicion for streptococcal pharyngitis.

 The likelihood of having streptococcal infection increases

with the number of Centor criteria that are present.
 Diagnosis
 Rapid antigen detection test (RADT): 70% to 90%
sensitivity;
 Throat culture: “gold standard”; results(24- 48 hr)Should
be performed after all negative RADTs.

 Only those with a positive test for GABHS require Abx

(Group A beta-hemolytic streptococci)
 What are the complications of pharyngitis ?
• Non-suppurative:
 Acute rheumatic fever. inflammation in the heart, joints, skin or
..
CNS can cause permanent damage to the heart, including damaged heart
valves and heart failure.

 Scarlet fever.

 Streptococcal toxic shock syndrome.

 Glomerulonephritis or reactive arthritis.
 Pediatric autoimmune neuropsychiatric disorder
associated with group A streptococci (PANDAS).
 What are the complications of pharyngitis?

• Suppurative:
Peritonsillar abscesses
Retropharyngeal abscesses,
Cervical lymphadenitis,
 Otitis media,
Sinusitis,
Necrotizing fasciitis
(hemolytic streptococcal gangrene)
 Pharmacological therapy

Symptomatic relief:
1)Antipyretics and analgesics :
paracetamol(acetaminophen),NSAID
Acetaminophen is a better option because there is some
concern that NSAIDs may increase the risk for necrotizing
fasciitis/toxic shock syndrome.

2)Lozenges and spray containing menthol and topical anesthetic

3)Antibiotics
 Is antibiotic therapy indicated? If so, what agent should be
initiated and for how long?

Azithromycin dose for pediatric :

12mg/kg (maximum 500 mg) on day one followed by 6 mg/Kg
(maximum 250 mg) once daily on day 2 through 5.

Antibiotics relieve symptoms of streptococcal pharyngitis within 3

to 5 days, and patients can return to work or school if improved
after the first 24 hours of therapy.

Lack of improvement or worsening after 72 hours of therapy

requires reevaluation.
Follow-up throat cultures are recommended if symptoms persist
or recur.
Recurrent symptoms following an appropriate treatment course
should prompt reevaluation for possible retreatment
Sinusitis
 Case study
A 35-year-old female presents to clinic complaining of
purulent postnasal discharge, nasal congestion,
headache, and fatigue. She reports that her symptoms
began 6 days ago and have worsened over the past 2 days.
Her “head hurts” when she bends forward, her upper
molars ache when she eats or brushes her teeth. she tried
acetaminophen but no relief.. Her last course of antibiotics
was 1 month ago when she received penicillin for
streptococcal pharyngitis.
 Case study
Meds: acetaminophen 500 mg PO, PRN; VS: BP 132/74
mm Hg, P 88 beats/min, RR 14 breaths/min,
T 39°C , Wt 95.5 kg
HEENT: Thick, purulent brown postnasal discharge; nasal
mucosal edema; right maxillary facial pain and right upper
molar hypersensitivity upon tapping; no oral lesions;
erythematous pharynx with mild tonsillar hypertrophy
 Case
• What information is suggestive of acute bacterial
rhinosinusitis (ABRS)?
• ………………………………………………………………
• ……………………………………………………………..

• What risk factors are present?

• ……………………………………………………………….
• What is the management?
• …………………………………………………………………
 Rhinosinusitis
 Acute rhinosinusitis :symptoms persist for up to 4 weeks
With complete resolution of symptoms.
 Chronic rhinosinusitis: lasts for more than 12 weeks.
With persistence symptoms.
 It is caused mainly by respiratory viruses, triggered by
allergies or environmental irritants or anatomic defects.
 Viral rhinosinusitis can be complicated by secondary
bacterial infection
 Same organisms (S. pneumoniae and H.influenzae) which
cause otitis media.
 Signs and Symptoms (ABRS)

 Nasal congestion or obstruction

 Purulent nasal or postnasal discharge
 Facial pain or pressure
 Diminished sense of smell
 Fever
 Cough
 Maxillary tooth pain,
 Fatigue, ear fullness or pain.
 Mouth breathing, persistent cough,
 Periorbital edema or facial swelling
(particularly in children)
RISK FACTORS
• Goals of treatment
• Relieve symptoms
• Promote sinus drainage( ostia….)
• Use antibiotics when appropriate that minimize resistance
• Prevent development of chronic disease or complications

• Complications:
• Orbital cellulitis or abscess, periorbital cellulitis,
meningitis, cavernous sinus thrombosis, ethmoid or
frontal sinus erosion, chronic sinusitis, and exacerbation
of asthma or bronchitis
 Approach to Treatment
• It is important to differentiate between viral sinusitis and ABRS
to avoid inappropriate antibiotic use.
• Viral rhinosinusitis typically improves in 7 to 10 days.
• Antibiotics should be prescribed only when ABRS is most
likely:
 Persistent symptoms for greater than 10 days with no improvement;

 Sudden worsening of symptoms (fever, headache, or increase in

nasal discharge) within 5 to 10 days of initial improvement

 Severe signs or symptoms (high fever (≥39°C [102°F]) and purulent

nasal discharge or facial pain) for 3 to 4 days at illness onset.

patients with mild persistent illness for at least 10 days, observation for
another 3 days can be employed if there is adequate follow-up
 Nonpharmacologic Therapy

• Humidifiers and saline nasal sprays or drops or

irrigation:
 Moisturize the nasal canal
 Impair crusting of secretions
 Promote ciliary function
especially in patients with recurrent or chronic sinusitis
 Adjunctive Therapy
1.Analgesics/antipyretics should be used to treat facial
pain and fever.

2.Nasal decongestant sprays that reduce inflammation by

vasoconstriction, such as phenylephrine and oxymetazoline.
Use should be limited to no more than 3 days to prevent
the development of tolerance and/or rebound congestion.
Oral decongestants relieve congestion but should be
avoided in children younger than 4 years and patients
with ischemic heart disease or uncontrolled hypertension
 Adjunctive Therapy
3.Mucolytics : guaifenesin, decrease the viscosity of nasal
secretions.

 Avoid antihistamines because they thicken mucus and

impair clearance…can dry mucosa..useful for allergic
rhinitis or chronic sinusitis.

 Intranasal corticosteroids usually are reserved for

patients with allergies or chronic sinusitis.
Antibiotic Therapy
 Risk for Abx resistance
• Geographic region with 10% PRSP(penicillin-resistant
Streptococcus pneumoniae)
• Severe infection (eg, temperature > 39°C, toxic
• appearance) and threat of complications
• Daycare attendance
• Age < 2 years or > 65 years
• Recent hospitalization
• Antibiotic use in past month
• Immunocompromised state
 Allergic sinusitis
Common in early childhood, is a reaction to exposure to
dust, pollen, smoke and animal dander.
Sinusitis can be acute, lasting less then 4 weeks or chronic,
lasting longer than 8 weeks.
Symptoms:
Allergic sinusitis symptoms vary with the season and may
include:
Nasal congestion (sneezing, runny nose) and post nasal
drip that persists for more then two weeks
Itchy eyes, nose and throat.
Headache, pain, tenderness, swelling and pressure around
the forehead, cheeks, nose and between eyes.
fatigue. Reduced sense of smell and taste.
 Allergic sinusitis management
For mild seasonal allergies and allergies to pet dander,
avoidance is the most effective course of action.
 Saline nasal sprays
 Inhaling steam may reduce nasal congestion.
 Decongestants
 Corticosteroid nasal sprays may reduce inflammation.
 Desensitization through allergy shots (exposure to the
allergen) may benefit children with pollen sensitive
allergies.
 Analgesics can provide relief
 Balloon Sinuplasty
 Surgery
HYPERTENSION IN PREGNANCY
Preeclampsia and eclampsia

ph: Tahani Bahnasi

Classification of hypertensive disorder in pregnancy
1-Gestantional hypertension (pregnancy induced hypertension)
 Detected for the first time after 20 weeks’ gestation
 Absence of proteinuria ( no protein in urine)
 Blood pressure : >140 / >90mmHg
 Resolve within 3 months after birth

2- Chronic hypertension
Present before pregnancy or before 20 weeks’ of gestation
Could be essential (no under laying disease) or secondary

T. Bahnasi
3- Preeclampsia and eclampsia (toxemia of pregnancy)
 Detected for the first time: after 20 weeks of gestation
 Protein in urine ≥ 300 mg /day Or ≥ 1+ on dipstick
 Bp : >140/>90 mmHg
Eclampsia :convulsive condition associated with pre-eclampsia. occurrence of
seizures superimposed on the symptoms of preeclampsia, an acute and life-threatening
complication of pregnancy.

4- Superimposed preeclampsia
 Refer to women with chronic HTN (secondary or primary) who develop
preeclampsia ..new onset proteinuria ≥ 300 mg /day before 20 weeks’
gestation

T. Bahnasi
Although the exact pathophysiologic mechanism is not clearly understood,

preeclampsia is disorder of placental dysfunction (placental insufficiency with

diffuse placental thrombosis) narrower than normal blood vessels that react
differently to hormonal signaling.

a syndrome of endothelial dysfunction with associated vasospasm.

dysfunction of multiple organ systems, including the central nervous, hepatic,
renal, pulmonary and hematologic systems,

endothelial damage leads to pathologic capillary leak that can present in the mother
as rapid weight gain, nondependent edema (face or hands), pulmonary edema.
CASE (1)

40 years old lady was admitted to the labor clinic at 32 weeks' gestation
complaining of sever headache ,light sensitivity, flashing vision. On
examination she looked generally unwell, irritable, epigastric pain, nausea
& blood pressure was 170/110 pulse 90/m, wt 100 kg, with lower limb and
abdominal wall and face edema . Uterus was small for date with a viable
twins . Urine analysis showed protein urea.

PMH: DM.

T. Bahnasi
What is the diagnosis?
Preeclampsia
What are the symptoms for preeclampsia?
 Severe or rapid edema ( swelling of legs ,face and hands)
 Severe headache
 Sudden nausea and vomiting
 Upper right abdominal pain or stomach pain
 Rapid weight gain
 Sensations of flashing lights, auras, light sensitivity, or blurry vision or spots
 Difficulty breathing

T. Bahnasi
What are the risk factors for preeclampsia?
Pregnancy history:
 First pregnancy. Low risk
 Multiple gestation: twins, triplets, or a greater number of multiples
 Assisted reproduction (in vitro fertilization)
 Family or own history of pre-eclampsia (or intrauterine growth restriction, placental abruption)
Medical conditions
 Obesity (Body Mass Index ≥30)
 Chronic diseases (HTN, kidney diseases or diabetes)
 Autoimmune diseases (for example; systemic lupus erythematosus)
 Abnormal uterine artery Doppler scan.
Demographic factors:
 Age <18 years or >40 years. Ethnicity (black women)
How to reduce the risk of hypertensive disorders in pregnancy?
Preventative interventions may be best started before 16 weeks’ gestation
(when most of the physiologic transformation of uterine spiral arteries occurs), or even
before pregnancy.

WOMEN AT ‘LOW RISK’ WOMEN AT ‘HIGH RISK

Aspirin (81 mg/d at bedtime) ’ ((60–162 mg/d at bedtime) or
Aspirin

Oral calcium supplement of 1 g/d Low molecular weight heparin

Folate-containing multivitamins Oral calcium supplement of 1 –2.5 g/d

Exercise regularly Folate-containing multivitamins

Weight loss if overweight Home rest

Reduction of workload or stress
What is the Management of preeclampsia?

Definitive treatment of preeclampsia is delivery.

Even after delivery, symptoms of preeclampsia can last 1 to 6 weeks or more.

Delivery is indicated if frank eclampsia is present. .

Otherwise, if no eclampsia: management consists of:
 If fetus is fully developed usually by 37 weeks or later:
 Induce labor or do a cesarean section to avoid further complications
 Antihypertensives are used prior to induction of labor if the DBP>105
mm Hg, with a target DBP of 95 -105 mm Hg.
 If fetus is not fully developed, less than 37 weeks:
 If the preeclampsia is not severe, it may be possible to wait to deliver.
To help prevent further complications:
 Bed rest
 Blood pressure lowering agent (e.g. methyldopa)
• Close monitoring of the woman and her fetus will be needed: Tests for woman
may include platelet counts, liver enzymes, kidney function, and urinary
protein levels,
• Tests for the fetus might include ultrasound, heart rate monitoring, assessment
of fetal growth, and amniotic fluid assessment.

T. Bahnasi
 If fetus is not fully developed, less than 37 weeks, severe preeclampsia:
 Admission to the hospital so she can be monitored closely and
continuously.
 Treatment in the hospital: IV medication to control Bp and prevent seizures
or other complications, as well as steroid injections to help speed up the
development of the fetus's lungs.

 If the pregnancy is at 34 weeks or later, severe preeclampsia:

Preterm delivery may be necessary, even if that means likely
complications for the infant, because of the risk of severe maternal
complications
T. Bahnasi
Preeclampsia management approaches

 Antihypertensive therapy
 Severe (blood pressure ≥160/110 mmHg)
Hydralazine IV/ Labetalol IV
 Non-severe hypertension
Methyldopa PO / Labetalol PO

 MgSO4: Eclampsia convulsions treatment and prevention, Fetal

neuroprotection

 Corticosteroids: Antenatal only, for fetal pulmonary maturity when delivery is

anticipated within the next 7 days and at <34 weeks, and for HELLP
syndrome

 Platelet transfusion for HELLP syndrome

T. Bahnasi
CASE (2)

A 36 year old obese lady at 38 weeks of gestation in her first pregnancy presents
to ER her blood pressure is found to be 170/110 mmHg with a pulse rate of
85/min, the patient complains of sever headache, dizziness, and vision
disturbances.

On examination the cardiovascular examination and chest examinations are

otherwise unremarkable, (+) edema was noticed, and urine analysis showed a
proteinurea ,while the pt was at ER she experienced two generalized seizures

T. Bahnasi
What is the difference between pre-eclampsia and eclampsia ?
Eclampsia with seizures, (emergency case)
What is the appropriate management for her eclampsia?
The definitive treatment is delivery of the fetus.
 Steroid Inj is given to help speed up development of fetus lungs.)
 Either intramuscular (IM) dexamethasone or IM betamethasone (total 24 mg in divided doses)
12 mg betamethasone X2 given IM (24 hours apart),
or 6 mg dexamethasone X 4 given IM (12 hours apart)

 Magnesium sulphate for seizures

 Diazepam, phenytoins are not effective as magnesium sulphate

 Manage high blood pressure:

 Hydralazine IV
 Labetalol IV
T. Bahnasi
 Intravenous hydralazine,
( repeat dose: 5-10 mg every 20 minutes -Duration: 3-8 hrs)
Continuos infusion 0.5–10 mg/h IV (max dosage 45 mg)
Side effects: headache, flushing, tachycardia, lupus like symptoms
 Intravenous Labetalol,
(20 mg IV over 2 min then if needed, 40 mg then 80 mg each over 2 min q 30 min- duration 4 hrs)
Continuos infusion1–2 mg/min (max dosage 300 mg)
parenteral labetalol may cause neonatal bradycardia

Labetalol should be avoided in women who have asthma heart failure /diabetes
Atenolol is not given will cause fetal growth restriction.
ACE↓,ARBs, are contraindicated in pregnancy
postpartum preeclampsia and eclampsia
In some women, preeclampsia develops between 48 hours and 6 weeks
after they deliver their baby (postpartum preeclampsia)

If a woman has seizures within 72 hours of delivery, she may have

postpartum eclampsia. It is important to recognize and treat postpartum
preeclampsia and eclampsia because the risk of complications may be
higher than if the conditions had occurred during pregnancy. Postpartum
preeclampsia and eclampsia can progress very quickly if not treated and
may lead to stroke or death.
T. Bahnasi
 Complications of preeclampsia
 Lack of blood flow to the placenta.
If the placenta doesn't get enough blood, the fetus may receive less O2
and fewer nutrients. lead to slow growth, low birth weight or preterm birth.
Prematurity can lead to breathing problems for the baby.

T. Bahnasi
 Complications of preeclampsia

 Placental abruption. the placenta

separates from the inner wall of the uterus
before delivery. This can lead to stillbirth

Severe abruption can cause heavy vaginal

bleeding and damage to the placenta, which
can be life-threatening for mother and her
baby.

T. Bahnasi
 Complications of preeclampsia may include:

 HELLP syndrome. HELLP — which stands for hemolysis (the destruction

of red blood cells), elevated liver enzymes and low platelet count —
syndrome can rapidly become life-threatening for both mother and her
fetus. Symptoms of HELLP syndrome include nausea and vomiting, headache, and
upper right abdominal pain

 Eclampsia. When preeclampsia isn't controlled, eclampsia — which is

essentially preeclampsia plus seizures — can develop

T. Bahnasi
CASE (3)

38-year-old lady, 19 wks gestation, was transferred to hospital/High Risk

Pregnancy for management of acute hypertension (systolic >200 mm
Hg). Her pressures were stabilized with hydralazine and labetolol. After
approx. 48 hrs, severe fetal bradycardia occurred.

PMH – HTN, Anxiety, Depression

ROS –blurry vision, RUQ/epigastric pain, ankle swelling

Urine analysis showed proteinurea

What is the diagnosis?
………………………………………………..
Management of pregnancy with chronic hypertension
 Encourage women with chronic hypertension to keep their dietary sodium intake
low.
 In pregnant women with uncomplicated chronic hypertension aim to keep blood
pressure lower than 150/100 mmHg.
 In pregnant women with target-organ damage secondary to chronic
hypertension, the aim of keeping blood pressure lower than 140/90 mmHg.
 Methyldopa is still considered the drug of choice.
 B-Blockers, labetalol and CCBs are also reasonable alternatives.

 Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers

are contraindicated in pregnancy.

T. Bahnasi
CASE 4

26 years old lady was seen at clinic at 32 weeks gestation for routine check
up. On examination she looked generally well, blood pressure was 150/95
pulse 80/m with . Uterus was appropriate for date with a viable fetus. Urine
analysis showed (-) protien

What type of hypertension the pt has?

………………………………………………

T. Bahnasi
Management of pregnancy with gestational hypertension
Mention the monitoring parameters for hypertension in
pregnancy?
o Consider reducing antihypertensive treatment if their blood pressure falls
below 140/90 mmHg
o For women with gestational hypertension who did not take antihypertensive
treatment and have given birth, start antihypertensive treatment if their blood
pressure is higher than 149/99 mmHg.
o Women who have had gestational hypertension should have a medical
review at the postnatal review (6–8 weeks after the birth).

T. Bahnasi
 References
1-The FIGO Textbook of Pregnancy Hypertension An
evidence-based guide to monitoring, prevention
and management, 2016
2-Clinical pharmacy and therapeutics 6th edition ,
2019