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The sagittal view of the fetus clearly demonstrates the presence of severe microg nathia (arrow) as early as the 13th week of gestation treatment for uti purchase 300mg combivir visa. Micrognathia is virtually never an isolated fnding medicine measurements purchase combivir 300mg on-line, being among the most common syndromic facial features the treatment 2014 order combivir 300 mg fast delivery. On the mid Trisomies 18 and 13 are among the chromosomal aber sagittal view of the fetal facial profle medicine 029 proven 300mg combivir, the micrognathia is less rations most frequently associated with micrognathia. The confrmation at autopsy is In particular, at autopsy, 70% of trisomy 18 cases show shown on the right. We report in of the nasal bones; and a second, joining the tip of the the following those most commonly encountered mentum and the anterior border of the more protrusive in the fetus, divided according to the pathogenetic lip. Again, it is safe prac syndrome [33], multiple pterygium syndrome, and tice to consider the phenotype of the parents in the NeuLaxova syndrome. In this group, micrognathia scanning room prior to defning as certainly abnormal is the consequence, as already mentioned, of masseter as the profle of the fetus that is under examination! The most severe forms of mandibular development, such as Pierre Robin anom micrognathia are often syndromic. Finally, there are the skeletal dyspla edema of the facial subcutaneous tissue, regardless of sias, in which micrognathia represents the expression the degree of micrognathia, the risk of chromosomal and of a skeletal developmental derangement. When micrognathia is diag among other signs, micrognathia are campomelic dys nosed in a fetus, a thorough anatomic scan should be plasia, the group of short-rib polydactyly syndromes, performed by an expert, in order to detect major and and thanatophoric dysplasia. It should be noted that minor anomalies, possibly leading to the disclosure of all these syndromes are severe conditions with very an underlying syndromic condition. Karyotyping is rec high perinatal mortality rates, with the exception of ommended, because of the relatively high risk of tri the primary developmental defects of the mandible somies 13 and 18. In fact, life-threatening obstruction of the upper air look for > micrognathia + diffuse joint contractures ways may occur at birth, and can lead to cerebral palsy + thoracic hypoplasia + clubfeet + ulnar deviations from neonatal hypoxia if its occurrence is not predicted of the hands + extremely reduced fetal movements and adequately managed. Prognosis basi micrognathia + diffuse joint contractures + multiple cally depends on the severity of the underlying syndrome. This parasagittal view at the level of the external ear demonstrates the abnormal preauricular appendices (arrows). The dysmorphic features of the fetus after termination of pregnancy are shown on the right: Note also the cleft lip and the hypertelorism. Definition the aim of this section is to draw the atten tion of the reader to the anomalies of the external ear. Nomograms for the diameters of the exter nal ear have been published (Appendix Table A. The external ear originates this surface-rendering reconstruction demonstrates the wrin from the first and second branchial arches. The ricular tag represents an anomalous differentiation of confrmation of the diagnosis at birth (40 weeks) is shown on these embryonic structures. Nomograms for eral anteroposterior view of the fetal head, which allows the longitudinal ear diameter (Appendix Table A. Regardless of the shape of the mainly abnormal pulmonary venous return (see external ear, it is the recognition of preauricular tags Chapter 10); that represents the poorest prognostic sign, because of Fraser syndrome [16,17]: look for > external ear the high syndromic signifcance of this fnding. These include clefting (see Chapter 10); other developmental anomalies involving anatomic struc Nager syndrome [16,35]: look for > external ear tures deriving from the frst and second branchial arches, anomalies (or tags) + ectrodactyly + micrognathia + such as micrognathia and congenital heart disease. There is a close connection to the presence of trisomy 13 and, to a lesser extent, trisomy 18. The detection of severe exter fetuses tend to have small ears, but this does not repre nal ear anomalies (tags, anotia, and small and wrinkled sent a reliable marker for suspecting trisomy 21. The prognosis lateral) + microphthalmia + clefting (see Chapter 10); depends upon the severity of the underlying syndrome. Facial profle view: oropharyngeal and cervical masses obstructing the upper airways. These anomalies become a perinatal emergency when they completely block the high airway. In this case, survival can only be assured if the obstructing mass is removed or bypassed (tracheotomy). These anomalies include laryngeal atresia (see Chapter 6), tracheal atresia, obstructing laryngeal cysts, obstructing tumors of the oropharynx and the cervical region, large thoracic masses such as cystic adenomatoid malformations of the lung, and rare cases of diaphragmatic hernia. This group of anomalies is responsi ble for a partial or total obstruction of the upper air ways at various levels. If these masses are very large, they can compromise swallowing of amniotic fluid relatively Pierre Robin anomaly: this condition has already early in the course of the third trimester, causing severe been described among the primary developmental polyhydramnios. It is mentioned here because re-establish the patency of the upper airways in order it can cause clinically signifcant obstruction of the to ensure normal ventilation [3840]. This is very low, from the sphenoid bone or from the soft tissues because these lesions are primarily tumor masses. This is low, except echogenic mass located in front of the mouth and for the Pierre Robin anomaly, for which the associa nose of the fetus. Of these, the syndromes potentially detectable case of a dramatically fast-growing mass, the early in the fetus are diastrophic dysplasia (see Chapter 9), compression can lead to developmental anomalies BeckwithWiedemann syndrome (see Chapter 10), and of the nose and the mouth (micrognathia and cleft campomelic dysplasia (see Chapter 9). The perinatal the oral cavity, is an extremely rare location for management of these conditions is complex and mul a tumor. As already mentioned, upper-airway lymphangiomatous origin [41] or solid and hyper obstruction represents a neonatal emergency. Amniorrhexis is then performed of mass causing the obstruction, the tumor is removed and the fetal head and neck are exposed. Throughout this procedure, fetal cedure depends mainly on the type of lesion causing well-being is monitored with oximetry and umbilical the obstruction. If extremely severe conditions such as laryngeal atresia or intubation fails, due to severe obstruction, then either primary pulmonary hypoplasia [3840]. Midsagittal view of the fetal profle; axial view of the thyroid region: anterior neck masses (mesenchymal tumors, goiter). Definition Although cystic hygromas account for most Associations with other malformations. This is extremely low, cally show a prevalence of neuronal cells of ectodermal as for all tumor masses. Goiter consists of hypertrophic and hyper additional risk of chromosomal anomalies. This is extremely fetal goiter are represented by maternal hyperthyroid low, as for all tumor masses. Goiters also do not show ism or, much more rarely, by maternal therapy with any association with nonchromosomal syndromes. As with most tumors, cervi diagnosed in a fetus, the occurrence of concurrent polyhy cal teratomas are sporadic lesions. If polyhydramnios is absent, opera is extended, allowing the anterior neck region to be tive delivery by Cesarean section is indicated due to the seen, and on the axial view of the thyroid, which allows common occurrence of anomalous presentation and/or direct assessment of the origin and the relationships mechanical dystocia due to the neck hyperextension. The final treatment of neck tumors partly cystic, with possible calcified spots (Figure 3. However, it should Goiters appear as solid well-defined areas continuous be noted that a significant percentage of mesenchymal with the thyroid gland, with which they share a weakly tumors tend to regress after birth. The concurrent occurrence of ital wryneck, sternocleidomastoid muscle hypoplasia, evident polyhydramnios indicates the likely presence etc. More than hyperextension of the fetal head is a consequence of one tumor has macroscopically disappeared or dramat very large neck tumors. Surgery have claimed that the regression observed in the neona is indicated in the rare cases in which significant esoph tal period for numerous mesenchymal benign tumors is ageal compression occurs. As usually good for both conditions, and quality of life soon as this hormonal storm ceases, with delivery, the is not affected in the absence of mechanical sequelae growth of the tumor is no longer stimulated and the due to these masses. Goiters can also undergo (wryneck), temporomandibular joint anomalies, den the same dramatic changes (partial or complete regres tal malocclusion, etc. The diagnosis is made on the midsagittal view of the profile but virtually all views of the fetal face are abnormal, due to the complete dis tortion of the facial anatomy. Definition Otocephaly is characterized by agenesis or severe hypogenesis of the mandible (agnathia). Risk is not known, temporal bones are juxtaposed and the external ears but presumably extremely low, or absent.

Standard precautions medications and mothers milk 2014 order combivir 300 mg amex, especially good hand washing after diaper changes medicine you can overdose on combivir 300mg mastercard, is particularly important for pregnant personnel medications osteoarthritis pain buy generic combivir 300mg online. Most infections (80%) are acquired in the intrapartum period as ascending infections with ruptured membranes (4-6 h is considered a critical period for this to medications lexapro order cheapest combivir occur) or by delivery through an infected cervix or vagina. The usual portals of entry for the virus are the skin, eyes, mouth, and respiratory tract. Once colonization occurs, the virus may spread by contiguity or via a hematogenous route. The risk of genital herpes infection may vary with maternal age, socioeconomic status, and number of sexual partners. Only ~25-33% of cases have signs or symptoms of genital herpes at the time of labor and delivery despite having active infection. More than 20% of infants with disseminated disease and 30-40% of infants with encephalitis will never have skin vesicles. Localized infections involving the skin, eyes, or oral cavity usually manifest at 10-11 days of age and account for ~40% of neonatal herpes. Skin lesions vary from discrete vesicles to large bullous lesions and occasionally denude the skin. Even with treatment, there is still a risk of neurologic sequelae, usually manifested between 6 and 12 months of age. Disseminated disease carries the worst prognosis with respect to mortality and long-term sequelae. Approximately one half of these cases also have localized disease as described previously. Presentation with bleeding and cardiovascular collapse may be sudden and rapidly fatal. Without antiviral therapy, 80% or more die, and most go on to have serious neurologic sequelae. The mortality rate remains as high as 55%, even with appropriate treatment; however, 40-55% of survivors suffer long-term neurologic impairment. Clinical manifestations of encephalitis include seizures (focal and generalized), lethargy, irritability, tremors, poor feeding, temperature instability, a bulging fontanelle, and pyramidal tract signs. These infants usually present at 15-17 days of age (30-40% will have no herpetic skin lesions), and the mortality rate is ~17%; however, it may be as high as 50% in untreated patients. Of survivors, 40% have long term neurologic sequelae, such as psychomotor retardation. Surface cultures obtained before 24-48 h of life may indicate exposure without infection. Recovery of virus from spinal fluid and characteristic lesions indicates infection regardless of the age of the infant. Cytologic examination of the base of skin vesicles is with a Giemsa or Wright stain, looking for characteristic but nonspecific giant cells and eosinophilic intranuclear inclusions. This is only about 50% sensitive and is plagued with false-positive results as well. Most infants with neonatal herpes are delivered to women with no history of infection and no lesions at the time of delivery. If there are no visible lesions at the onset of labor or prodromal symptoms, vaginal delivery is acceptable. These studies, especially including evaluation of the efficacy, safety, and cost of acyclovir prophylaxis administration to mothers in late pregnancy, may change the current recommended delivery route. If it is a known recurrent lesion and the infant is asymptomatic, the infection rate is 1-3%. If maternal infection is primary, the risk to the infant is 33-50%; therefore, most clinicians recommend empiric acyclovir at birth after cultures have been obtained. Some support no treatment initially if the infant is asymptomatic, and obtain cultures at 24 48 h. The second choice being vidarabine (which requires 12-h infusion with a large volume of fluid). The infant may breast-feed as long as no breast lesions are present on the mother, and the mother should be instructed in good hand-washing technique. Parents with orolabial herpes should wear a mask when handling the newborn and should not kiss or nuzzle the infant. Typically, viral hepatitis refers to several clinically similar diseases that differ in cause and epidemiology. To date, perinatal transmission of hepatitis D and E has not been well documented. It is unlikely that hepatitis A or E will prove to be a problem because they are not characterized by a chronic carrier state. Table 68-1 outlines various hepatitis panel tests useful in the management of this disease. A high concentration of virus is found in stools of infected persons, especially during the late incubation and early symptomatic phases (and ceases before the onset of jaundice); it has not been found in urine or other body fluids. Although it appears to be a very rare occurrence, one case report documented intrauterine transmission of hepatitis A. The risk of transmission is limited because the period of viremia is short and fecal contamination does not occur at the time of delivery. In most cases it becomes detectable 5-10 days after exposure and can persist for up to 6 months after infection. Hepatitis A vaccines are now available; however, effectiveness in postexposure prophylaxis is unknown; therefore, they are currently not recommended. In the fetus and neonate, transmission has been suggested by the following mechanisms: A. Transplacental transmission either during pregnancy or at the time of delivery secondary to placental leaks. Postnatal transmission by fecal-oral spread, blood transfusion, or other mechanisms. Maternal acute hepatitis in the third trimester or immediately postpartum (70% attack rate). Maternal hepatitis B infection has not been associated with abortion, stillbirth, or congenital malformations. The infants are rarely ill and usually asymptomatic; jaundice appears <3% of the time. Liver biopsy is occasionally indicated to differentiate biliary atresia from neonatal hepatitis. Most infants demonstrate antigenemia by 6 months of age, with peak acquisition at 3-4 months. Cord blood is not a reliable indicator of neonatal infection (1) because contamination could have occurred with antigen-positive maternal blood or vaginal secretions and (2) because of the possibility of noninfectious antigenemia from the mother. For preterm infants weighing <2 kg, this initial dose of vaccine should not be counted in the required 3-dose schedule, and the subsequent 3 doses should be initiated when the infant weighs 2 kg. One Taiwan study showed no difference in infection rates between bottle and breast-fed infants. In option 1, these are at birth, 1-2 months, and at 6-18 months; in option 2, doses should be given at 1-2 months, 4 months, and 6-18 months. Hepatitis C is transmitted primarily by parenteral and percutaneous means (eg, tattooing). The average incubation period is generally 6-7 weeks, with a range of 2 26 weeks. Infants with acute hepatitis C typically are asymptomatic or have a mild clinical illness. Approximately 65-70% of patients experience chronic hepatitis, 20% cirrhosis, and 1-5% hepatocellular carcinoma. If the mother was infected during the last trimester, the risk of transmission to the infant is highest. It does not appear that a vaccine against hepatitis C will be available for at least another several years. Advise mothers that transmission of virus is possible; however, currently it is not believed to be a contraindication to breast-feeding.

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The effect of 50 Hz external electrical interference on implanted cardiac pacemakers treatment yeast infection male generic 300 mg combivir otc. The effect of electromagnetic fields on blood coagulation and fibrinolysis in humans medicine 219 buy combivir 300 mg cheap. Electrokinetic lithotripsy: safety symptoms adhd order 300 mg combivir free shipping, efficacy and limitations of a new form of ballistic lithotripsy treatment zone guiseley discount combivir 300mg without a prescription. Exposure to magnetic field harmonics in the vicinity of indoor distribution substations. Adenosine-induced atrioventricular block: a rapid and reliable method to assess surgical and radiofrequency catheter ablation of accessory atrioventricular pathways. The effect of extremely low frequency magnetic field on the conjunctiva and goblet cells. Assessment of radiofrequency/microwave radiation emitted by the antennas of rooftop-mounted mobile phone base stations. Effects of radiofrequency electromagnetic wave exposure from cellular phones on the reproductive pattern in male Wistar rats. Biophysical evaluation of radiofrequency electromagnetic field effects on male reproductive pattern. The effects of an electromagnetic field on the boundary tissue of the seminiferous tubules of the rat: A light and transmission electron microscope study. Exposure to radio frequency electromagnetic fields from wireless computer networks: duty factors of Wi-Fi devices operating in schools. Safety of pacemakers and defibrillators in electromagnetic navigation bronchoscopy. A pilot study on the reproductive risks of maternal exposure to magnetic fields from electronic article surveillance systems. A pooled analysis of extremely low-frequency magnetic fields and childhood brain tumors. Future needs of occupational epidemiology of extremely low frequency electric and magnetic fields: review and recommendations. Epidemiologic study of residential proximity to transmission lines and childhood cancer in California: description of design, epidemiologic methods and study population. Comment concerning "Childhood leukemia and residential magnetic fields: are pooled analyses more valid than the original studies Occupational electric and magnetic field exposure and brain cancer: a meta-analysis. Comparative analyses of the studies of magnetic fields and cancer in electric utility workers: studies from France, Canada, and the United States. Leukemia risk and occupational electric field exposure in Los Angeles County, California. Change settings for visual analyzer of child users of mobile communication: longitudinal study. Changes in the parameters of the simple auditory-motor response in children users of mobile communication: longitudinal study. Some immunological responses of common carp (Cyprinus carpio) fingerling to acute extremely low-frequency electromagnetic fields (50Hz). Combined effect of noise and electromagnetic fields of industrial frequency (experimental study). Guide for the protection of occupationally-exposed personnel in hyperthermia treatment from the potential hazards to health. Temperature elevation in the fetus from electromagnetic exposure during magnetic resonance imaging. Evaluation of radiofrequency exposure levels from multiple wireless installations in population dense areas in Korea. Origins of electromagnetic hypersensitivity to 60 Hz magnetic fields: A provocation study. Lower face lifting and contouring with a novel internal real-time thermosensing monopolar radiofrequency. Objective evaluation of the clinical efficacy of fractional radiofrequency treatment for acne scars and enlarged pores in Asian skin. Radiofrequency ablation for the treatment of primary intrahepatic cholangiocarcinoma. Risk factors, health risks, and risk management for aircraft personnel and frequent flyers. Risk perception and public concerns of electromagnetic waves from cellular phones in Korea. Time-multiplexed two-channel capacitive radiofrequency hyperthermia with nanoparticle mediation. Efficacy of fractional microneedle radiofrequency device in the treatment of primary axillary hyperhidrosis: a pilot study. Estimation of relative exposure levels for cellular phone users using a neural network. Toxicity bioassay in Sprague-Dawley rats exposed to 20 kHz triangular magnetic field for 90 days. Use of a controlled subdermal radio frequency thermistor for treating the aging neck: Consensus recommendations. Design of a magnetic field generator for experiments on magnetic effects in cell cultures. Gene expression profiles in white blood cells of volunteers exposed to a 50 Hz electromagnetic field. Contralesional repetitive transcranial magnetic stimulation for chronic hemiparesis in subcortical paediatric stroke: a randomised trial. Chronic exposure to an extremely low-frequency magnetic field induces depression-like behavior and corticosterone secretion without enhancement of the hypothalamic-pituitary adrenal axis in mice. Re: "Fetal loss associated with two seasonal sources of electromagnetic field exposure". Status of immunological reactivity of the organism under the effect of some noxious industrial factors. Are children living near high-voltage power lines at increased risk of acute lymphoblastic leukemia Aviakosmicheskaia i ekologicheskaia meditsina = Aerospace and environmental medicine. The effect of weak electromagnetic fields on the stability of a computer monitor image: the possible consequences for the operator. Follow-up of radio and telegraph operators with exposure to electromagnetic fields and risk of breast cancer. Residential and occupational exposures to 50 Hz magnetic fields and breast cancer in women: a population-based study. Incidence of breast cancer in a Norwegian cohort of women with potential workplace exposure to 50 Hz magnetic fields. Increase in the mitotic recombination frequency in Drosophila melanogaster by magnetic field exposure and its suppression by vitamin E supplement. Epidemiology and aetiological factors of male breast cancer: a ten years retrospective study in eastern Turkey. Methods of the physical medicine therapy in prevention of heterotopic ossification after total hip arthroplasty. Multiphysics and Thermal Response Models to Improve Accuracy of Local Temperature Estimation in Rat Cortex under Microwave Exposure. Occupational extremely low-frequency magnetic field exposure and selected cancer outcomes in a prospective Dutch cohort. Cancer cluster among young Indian adults living near power transmission lines in Bom Jesus do Tocantins, Para, brazil. The progeny of male rats subjected to chronic exposure to a permanent magnetic field. Do airport metal detectors interfere with implantable pacemakers or cardioverter defibrillators Incidence of electromagnetic interference in implantable cardioverter defibrillators. Effect of mobile phone electromagnetic emission on characteristics of cerebral blood circulation and neurohumoral regulations in humans. Health problems among operators of plastic welding machines and exposure to radiofrequency electromagnetic fields. The problem area of biological effects of technical electromagnetic energy fields.

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On occasion administering medications 7th edition buy combivir toronto, the depressed newborn may be very premature medicine 027 order combivir online from canada, and the decision to medications used to treat anxiety trusted 300mg combivir be made will be whether to medicine guide discount generic combivir uk initiate resuscitation. On other occasions, after resuscitation has already been initiated, continuing or discontinuing resuscitation may become an issue if the depressed newborn infant has multiple congenital malformations or is very premature. In such instances, it may become necessary to seek guidance, since there may be a conflict between initiation and continuation of resuscitation on the one hand and the duty to do no harm on the other. Maternal age (very young and very old mothers) Key Objectives 2 Identify non-reassuring fetal status by interpreting information such as antepartum risk factors and fetal monitoring during labor. Objectives 2 Through efficient, focused, data gathering: Identify historical. The physician requires a framework of knowledge in order to assess abnormal sensation, consider the likely site of origin, and recognise the implications. Objectives 2 Through efficient, focused, data gathering: Determine the portion of the neural axis likely causing the symptoms: restricted to distribution of peripheral nerve, nerve root, stocking-glove, both sides of body, half of body, or cape distribution, face involved on same side or opposite side of rest of body, cranial nerve involvement. Outline the anatomy of the sensory system from perception of a somatic sensation by receptors to transmission to the central nervous system. In contrast, chronic pain (>6 weeks or lasting beyond the ordinary duration of time that an injury needs to heal) serves no physiologic role and is itself a disease state. Although control of pain/discomfort is a crucial endpoint of medical care, the degree of analgesia provided is often inadequate, and may lead to complications. Physicians should recognise the development and progression of pain, and develop strategies for its control. Neuroma formation Key Objectives 2 Because some conditions are so painful that rapid and effective analgesia is essential. Physicians may have an inflated perception of the risk of addiction by treating pain with opioids. Outline the neural basis of pain including the specialized nociceptors that are the nerve terminals of primary afferent fibers (myelinated A-delta fibers and unmyelinated C fibers). Contrast the first immediate sharp pain of A fibers to the delayed dull pain of C fibers, and the visceral afferents that travel with sympathetic and parasympathetic fibers. Along with a group of similar conditions, fibromyalgia is controversial because obvious sign and laboratory/radiological abnormalities are lacking. Polymyalgia rheumatica, a rheumatic condition frequently linked to giant cell (temporal) arteritis, is a relatively common disorder (prevalence of about 700/100,000 persons over 50 years of age). Clencher syndrome Key Objectives 2 Differentiate between articular and non-articular pain. Objectives 2 Through efficient, focused, data gathering: Diagnose fibromyalgia, 10 times more common in women, from history of chronic pain, fatigue, and sleep/mood disturbances; examine for multiple tender points (11/18 pre-defined sites). Medical problems (nerve entrapment, diaphragmatic irritation, hepatic capsule distension, myocardial ischemia) 2. Objectives 2 Through efficient, focused, data gathering: Differentiate between various causes of upper extremity pain. The knee, the most intricate joint in the body, has the greatest susceptibility to pain. Patellar (patella-femoral syndrome, patellar tendonitis, pre-patellar bursitis, Osgood Schlatter disease) c. Other (muscle strain/tear, arterial/venous insufficiency/phlebitis/lymphangitis) Key Objectives 2 Determine whether the pain is articular or non-articular and related to exertion or not (constant, night pain suggests inflammatory/neoplastic process). Objectives 2 Through efficient, focused, data gathering: Differentiate between different causes of lower extremity pain by eliciting essential information. As the proportion of our population in old age rises, osteoporosis becomes an important cause of painful fractures, deformity, loss of mobility and independence, and even death. Although less common in men, the incidence of fractures increases exponentially with ageing, albeit 5 10 years later. For unknown reasons, the mortality associated with fractures is higher in men than in women. Disuse (lack of weight-bearing activity/inactivity/prolonged bed rest/paralysis/paresis/weightlessness in space) ii. Neoplasms (myeloma/lymphoma) Key Objectives 2 Define osteoporosis as a metabolic bone disease with decreased density (mass/unit volume; bone is abnormally porous and thin) which weakens the mechanical strength of the bone, thus making it much more likely to break, often with little or no trauma. Objectives 2 Through efficient, focused, data gathering: In a patient with spinal compression, vertebral, or other fractures, determine extent of trauma or whether the fracture occurred at rest or routine activity; there is no other clinical manifestation. This prevalence is similar to low back pain, but few patients lose time from work and the development of neurologic deficits is<1 %. Meningitis Key Objectives 2 Determine whether the pain is caused by conditions that are intrinsic to the cervical spine or its musculature, systemic conditions or by referred pain from elsewhere. Objectives 2 Through efficient, focused, data gathering: Elicit a history including age, occupation, trauma, radiation of pain (if not correlated with neuro-anatomic pathways, consider myofascial pain or fibromyalgia). Outline the anatomy of the cervical spine, identify C4 C7 as the sites of greatest wear and tear, with the nerve roots of C5, 6, and 7 passing through these foramina. Since the diaphragm is innervated by C3 C5, respiratory paralysis may be present with injuries above C4. Most frequently it is associated with vocations that involve lifting, twisting, bending, and reaching. In individuals suffering from chronic back pain, 5% will have an underlying serious disease. Gastrointestinal (pancreatitis, cholecystitis, penetrating ulcer) Key Objectives 2 Determine whether pain is unremitting and constant at night or abnormal physical exam indicative of systemic disease (fever, weight loss, etc. Nociceptive Key Objectives 2 In diabetics, differentiate neuropathic pain from vascular pain by determining site of pain (feet>calves), quality (sharp, burning, tingling>deep ache), effect of rest/walking, and whether worse in bed. Objectives 2 Through efficient, focused, data gathering: Determine how the pain is characterized (sharp, shooting, or burning). Although the cause is often benign, occasionally it may indicate the presence of a serious underlying problem. Atrial flutter/Fibrillation (ischemic/hypertensive, valvular, thyrotoxic, electrolyte disorders, drugs) ii. Metabolic (hypoglycemia, thyrotoxic, pheochromocytoma) Key Objectives 2 Select patients in need of urgent treatment; differentiate palpitations due to intrinsic heart disease from those that are a manifestation of anxiety, exercise, or other systemic disease (differentiate from sinus tachycardia). Objectives 2 Through efficient, focused, data gathering: Contrast benign palpitations to those associated with serious disease; identify risk factors. Describe the role of the autonomic system (parasympathetic and sympathetic) in the development of arrhythmias. Relate the electrophysiologic events above to the various waves and segments of an electrocardiogram. Although such patients may present with discrete episodes of intense fear, more commonly they complain of one or more physical symptoms. A minority of such patients present to mental health settings, whereas 1/3 present to their family physician and another 1/3 to emergency departments. Generalized anxiety disorder, characterized by excessive worry and anxiety that are difficult to control, tends to develop secondary to other psychiatric conditions. Generalized anxiety disorder Key Objectives 2 In patients with many other medical complaints and/or excessive utilisation of medical health care, determine whether anxiety co-exists. Objectives 2 Through efficient, focused, data gathering: Review various physical symptoms briefly; elicit history of other non-psychiatric illness, intake of alcohol and caffeine, and a brief history of any major life stresses. Explain that although the pathophysiology of panic disorder/attacks is incompletely understood, the amygdala, locus ceruleus, and hippocampus along with several neurotransmitters have been the focus of attention. Causal Conditions (Causes for abnormal Pap smears, other than papilloma virus, are unknown. False positive or negative Key Objectives 2 Select patients who are in need of a referral for further investigation after the Pap smear report becomes available. Objectives 2 Through efficient, focused, data gathering: Determine whether the patient is at high risk for developing cervical dysplasia or invasive disease. Environmental emergencies (hypothermia/heat stroke) Key Objectives 2 Describe the differences between pediatric and adult airways and their effect on airway management; describe the difference between pediatric and adult response to hypovolemia. Objectives 2 Through efficient, focused, data gathering: Elicit symptoms and signs in a focused fashion for the assessment of an infant/child in an urgent/emergent situation.

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