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By: Bertram G. Katzung MD, PhD
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Topics for specialized counseling include nutrition 10 mcg ddavp diabetes mellitus clinical manifestations, exercise buy 1mg ddavp with amex diabetes in dogs life expectancy, dental care order 1mg ddavp amex blood sugar 82, nausea and vomiting discount 1mg ddavp free shipping gestational diabetes definition rcog, vita min and mineral toxicity, teratogens, and air travel. Both fetal and maternal outcomes can be affected by maternal nutritional status during pregnancy. Dietary counseling and intervention based on special or individual needs usually are most effectively accomplished by referral to a nutritionist or registered dietitian. All women should receive information that is focused on a well-balanced, varied, nutritional food plan Preconception and Antepartum Care 133 that is consistent with the patient’s access to food and food preferences. If a patient is financially unable to meet nutritional needs, she should be referred to federal food and nutrition programs, such as the Special Supplemental Nutrition Program for Women, Infants, and Children. The recommended dietary allowances for most vitamins and minerals increase during pregnancy (Table 5-6. The National Academy of Sciences rec ommends 27 mg of iron supplementation (present in most prenatal vitamins) be given to pregnant women daily because the iron content of the standard American diet and the endogenous iron stores of many American women are not sufficient to provide for the increased iron requirements of pregnancy. Preventive Services Task Force recommends that all pregnant women be routinely screened for iron-deficiency anemia. The treatment of frank iron deficiency anemia requires dosages of 60–120 mg of elemental iron each day. Iron absorption is facilitated by or with vitamin C supplementation or ingestion between meals or at bedtime on an empty stomach. Women should supplement their diets with folic acid before and during pregnancy (see also “Preconception Nutritional Counseling” in this chapter. Recent evidence suggests that vitamin D defi ciency is common during pregnancy especially in high-risk groups, including vegetarians, women with limited sun exposure (eg, those who live in cold cli mates, reside in northern latitudes, or wear sun and winter protective clothing), and ethnic minorities, especially those with darker skin. In 2010, the Food and Nutrition Board at the Institute of Medicine of the National Academies estab lished that an adequate intake of vitamin D during pregnancy and lactation was 15 micrograms daily (or 600 international units per day) (see Table 5-6. This is the highest level of daily nutrient intake that is likely to pose no risk of adverse effects to almost all individuals in the general population. In view of the evidence linking folate intake with neural tube defects in the fetus, it is recommended that all women capable of becoming pregnant consume 400 micrograms from supple ments or fortified foods in addition to intake of food folate from a varied diet. Most prenatal vitamins typically contain 10 micrograms (400 international units) of vitamin D per tablet. For pregnant women thought to be at increased risk of vitamin D deficiency, maternal serum 25-hydroxyvitamin D levels can be considered and should be interpreted in the context of the individual clini cal circumstance. When vitamin D deficiency is identified during pregnancy, most experts agree that 25–50 micrograms (1,000–2,000 international units) per day of vitamin D is safe. Higher dose regimens used for treatment of vita min D deficiency have not been studied during pregnancy. Recommendations concerning routine vitamin D supplementation during pregnancy beyond that contained in a prenatal vitamin should await the completion of ongoing ran domized clinical trials. Increasingly, however, women are becoming pregnant when they are obese, they gain more weight than is necessary during pregnancy, and retain the weight postpartum. These same recommendations are made for adolescents, short women, and women of all racial and ethnic groups. Progress toward meeting these weight gain goals should be monitored and specific individualized counseling provided if significant devia tions are noted. The Institute of Medicine guidelines provide physicians with a basis for practice. Health care providers caring for pregnant women should determine a Preconception and Antepartum Care 137 Table 5-7. Individualized care and clinical judgment is necessary in the management of the obese and overweight woman who wishes to gain, or is gaining, less weight than recommended but has an appropriately growing fetus. Balancing the risks of fetal growth (both large and small), obstetric com plications, and maternal weight retention are essential until research provides evidence to further refine the recommendations for gestational weight gain. In the absence of either medical or obstetric complications, 30 min utes or more of moderate exercise per day on most, if not all, days of the week is recommended for pregnant women. Generally, participation in a wide range of recreational activities appears to be safe during pregnancy; however, each sport should be reviewed individually for its potential risk, and activities with a high risk of falling or those with a high risk of abdominal trauma should be avoided. Pregnant women also should avoid supine positions during exercise 138 Guidelines for Perinatal Care as much as possible. Recreational and competitive athletes with uncomplicated pregnancies can remain active during pregnancy and should modify their usual exercise routines as medically indicated. Women should not take up a new strenuous sport during pregnancy, and previously inactive women and those with medical or obstetric complications should be evaluated before recom mendations for physical activity participation during pregnancy are made. Additionally, a physically active woman with a history of or risk of preterm delivery or intrauterine growth restriction may be advised to reduce her activity in the second trimester and third trimester. Warning signs to terminate exercise while pregnant include the following: • Chest pain • Vaginal bleeding • Dizziness • Headache • Decreased fetal movement • Amniotic fluid leakage • Muscle weakness • Calf pain or swelling • Regular uterine contractions the following medical conditions are absolute contraindications to aerobic exercise in pregnancy: • Hemodynamically significant heart disease • Restrictive lung disease • Cervical insufficiency or cerclage • Persistent second-trimester or third-trimester bleeding • Placenta previa confirmed after 26 weeks of gestation • Current premature labor • Ruptured membranes • Preeclampsia or pregnancy-induced hypertension Dental Care. This dental care includes routine brushing and flossing, Preconception and Antepartum Care 139 scheduled cleanings, and any medically needed dental work. Caries, poor dentition, and periodontal disease may be associated with an increased risk of preterm delivery. If dental X-rays are necessary during pregnancy, the American Dental Association advises the use of a leaded apron to minimize exposure to the abdo men and the use of a leaded thyroid collar. The American Dental Association guidelines recommend timing elective dental procedures to occur during the second trimester or first half of the third trimester and postponing major surgery and reconstructive procedures until after delivery. Many dentists will require a note from the obstetrician stating that dental care requiring local anesthesia, antibiotics, or narcotic analgesia is not contraindicated in pregnancy. Nausea and vomiting of pregnancy affects more than 70% of pregnant women and can diminish the woman’s quality of life. For women with prior pregnancies complicated by nausea and vomiting, it is rea sonable to recommend preconceptional and early pregnancy use of a multivi tamin because studies show this reduces the risk of vomiting requiring medical attention.
The roof is formed by the transversalis fascia ddavp 10 mcg on-line diabetes prevention for kids, internal oblique and transversus abdominis ddavp 1 mg lowest price diabetes symptoms after eating sugar. The floor is formed by the inguinal ligament (a ‘rolled up’ portion of the external oblique aponeurosis) and thickened medially by the lacunar ligament Reference: teachmeanatomy buy 10mcg ddavp free shipping treatment diabetes pregnancy. A vagus B facial C auriculotemporal D trigeminal Answer: C C is more accurate ddavp 1 mg with amex diabetes presenting signs. Medulla oblongata C internal capsule D-Midbrain Answer: A) a hemiplegia contralateral + ataxia + (6th+7th) palsy called "Millard-Gubler syndrome". Thyroid move with swallowing b/c : A Pretracheal fascia B Carotid sheath C Prevertebral fascia Answer: A Reference: Gray’s anatomy 2nd ed, ch 8, P 950. Median nerve in supepichondile region C Median nerve in B Ulnar nerve in the medial epicondyle Answer: A Reference: Gray’s anatomy 2nd ed, ch 7, P 724. Pulled elbow is subluxation of the radial head into the annular ligament, encountered in young children (typically between 6 m 3 yrs), as a result of pulling on the arm longitudinally as in pulling a child away from something the parents would rather they not touch, or lifting the child in play. Children with a pulled elbow will hold the elbow flexed and the forearm in the prone posi tion, unwilling to supinate it. Answer: A Dorsiflexion: by Ms of the anterior leg compartment >>all innervated by deep peroneal N L4-S1 Reference: Gray’s anatomy 2nd ed, Ch 6, p 598 148-Inferior ( temporal) horn of lateral ventricle which affect A Hiccup ( I think they mean Hippocampus) B Putman C caudate nucleus Answer: C or A Roof: is formed chiefly by the inferior surface of the tapetum of the corpus callosum, but the tail of the caudate nucleus and the stria terminalis also extend forward in the roof of the temporal horn to its extremity; the tail of the caudate nucleus joins the putamen. Floor: the hippocampus, the fimbria hippocampi, the collateral eminence, and the choroid plexus. If the Q means >> Mid inguinal point: is halfway between the pubic symphysis and the anterior superior iliac spine. The external iliac A becomes the femoral A as the vessel passes under the inguinal ligament to enter the femoral triangle. There may be a tender fullness if the tendon, If the digitorum profundus tendon is damaged, the joint will not move. It is more common in soldiers, but also occurs in hikers, organists, and even those, like hospital doctors, whose duties entail much standing. March fractures most commonly occur in the sec ond and third metatarsal bones of the foot. Sensory supply: palmar aspect of the thumb, index, middle and radial half of the ring fingers. A Ant cruciate ligament B Post cruciate Answer: A Reference: Master the board step2 (surgery chapter) 162-Q Read about: -Big artery and branch what supply Reference: Guyton and Hall textbook of physiology, 12th ed, p394 6 Which system or organ will work in stress A Respiratory B Renal C Sympathetic D Parasympathetic Answer: C Reference: Guyton and Hall textbook of physiology, 12th ed, p739 7 Which cell in the stomach is responsible for production of vit B12 A Parietal cells B Chief cells C Global cells Answer: the question must be incorrect, it could be “which cell in the stomach is responsible for production of intrinsic factor that is responsible for vitamin B12 absorption Reference: Guyton and Hall textbook of physiology, 12th ed, p417 8 A boy is fighting with two boys, which system is activated Usually, reflex vasoconstriction prevents a drop in pres sure but if this is absent or the patient is fluid depleted or on vasodilating or diuretic drugs, hy potension occurs. Reference: Kumar & Clark’s Clinical Medicine, 8th ed, p676 12 Renin is secreted from Reference: Guyton and Hall textbook of physiology, 12th ed, p220 13 Which of the following increases the absorption of iron Folic acid B Vitamin C Answer: B, It helps the body absorb iron from nonheme sources. No rabies in answers A Streptococcus mutalis Answer: Pasteurella––animal bites Reference: First Aid step 1. Culture showed lactose non fermenting, gram negative motile… not the same Q but they asked about an organism!!! A) Haemophilus Influenzae B) Streptococcus pneumoniae C) Klebsiella or other gram negative bacteria D) Pseudomonas aeruginosa Answer:D Pseudomonas aeruginosa: Aerobic gram-negative rod. Ecthyma gangrenosum—rapidly progressive, necrotic cutaneous lesions caused by Pseudomonas bacteremia. Cryptococcus neoformans Answer: C the is bubble soape appearance so the answer is c Cryptococcus neoformans: Cryptococcal meningitis, cryptococcosis. Latex agglutination test detects polysaccharide capsular antigen and is more specific. Reference: First Aid step 1 5-ventilator associated pneumonia in icu patient Gram negative oxidase postive What is the organism Ecthyma gangrenosum—rapidly progressive, necrotic cutaneous lesions caused by Pseudomonas bacteremia. A 3 stool analysis in consecutive days B 3 stool analysis in separated days Answer :B Stool examination may be performed on fresh specimens or after preservation with polyvinyl alcohol or 10% formalin (with appropriate staining. Ideally, 3 specimens from different daysshould be examined because of potential variations in fecal excretion of cysts. G intestinalis is identified in 50-70% of patients after a single stool examination and in more than 90% after 3 stool examinations. Anti sperm antigen has been described as three immunoglobulin isotopes (IgG, IgA, IgM) each of which targets different part of the spermatozoa. The blood-testis barrier separates the immune system and the developing spermatozoa. The tight junction between the Sertoli cells form the blood-testis barrier but it is usually breached by physiological leakage. Not all sperms are protected by the barrier because spermatogonia and early spermatocytes are located below the junction.
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This not only makes the spine straighter but of the instrumentation has its limitations in very kyphotic also longer ddavp 1mg fast delivery early signs diabetes feet. Back of a 2-year old child with severe congenital scoliosis with fused ribs on the left order ddavp 1 mg online diabetes mellitus patient teaching. The follow ing are required a pediatric spinal surgeon order 1mg ddavp the new diabetes diet joyce schneider, a pediatric surgeon buy generic ddavp 1 mg diabetes mellitus is a disorder caused by malfunction of the, a pediatric chest physician, a pediatric anesthetist, a pediatric intensive care unit, facilities for intraoperative motor and sensory spinal cord monitoring in very small children. The monitoring only works if there is excellent coordina tion with the anesthetist as most anesthetics affect the signals. The thoracostomy procedure has rendered almost all other surgical treatments for congenital abnormali Fig. We believe that there are no level and contralateral unilateral unsegmented bar and pronounced longer any indications for stiffening or growth-retarding progression of the scoliosis. The purpose of these operations was always vertebrectomy from a ventral and dorsal approach and insertion of a to keep the spine as straight as possible, while the prob compression rod on the convex side lem of the small thoracic volume was ignored, and even deteriorated, in many cases. Hemivertebrectomy is indicated for hemivertebrae that cause decompensation of the spine or that are lo cated posteriorly. The operation can be performed either exclusively from the posterior side or simultaneously from the anterior and posterior sides. The correction can then be performed from the posterior side using compression instrumentation. The surgeon should be careful to avoid constricting the nerve roots on the side to be compressed ( Fig. A hemivertebrectomy in the area of the cervical spine is particularly hazardous as the presence of the vertebral artery constitutes an additional complication ( Fig. Congenital spon a b dylolysis/spondyloptosis can also pose a problem in this procedure ( Fig. Conventional tomograms of the cervical spine of an 11-year old girl with Klippel-Feil syndrome with multiple deformities! Before carrying out a hemivertebrectomy in the and pronounced tilting of the head. We have since operated on around 200 patients with congenital scolio Complication risks sis (out of approx. One transient paraplegia, although this is almost never caused by direct paraparesis occurred as a result of compression of the injury to the spinal cord. The exis compression rod produced a partial recovery even during tence of an intraspinal anomaly (which occurs in approx. Full remission was subsequently achieved 16% of cases [1, 2]) can lead to tension being exerted on after the operation. Another complication associated with posterior spon dylodeses in very young patients is what is known as the these principles are highly simplified, and numerous crankshaft phenomenon , which involves the progres factors must be taken into account in each individual sion of the scoliosis, including rotation, as a result of the case, including the extent of the curvature, pro continuing growth of the vertebral bodies anteriorly. For gression, sagittal profile, rotation, the extent of the this reason, a posterior spondylodesis should never be countercurve, compensation options, alignment, etc. Brouwer I, van Dusseldorp M, Thomas C, van der Put N, Gaytant M, in congenital scoliosis: a preliminary report. J Pediatr Orthop 11: Eskes T, Hautvast J, Steegers-Theunissen R (2000) Homocysteine 527–32 metabolism and effects of folic acid supplementation in patients affected with spina bifida. Campbell R, Smith M, Mayes T, Mangos J, Willey-Courand D, Kose N, Pinero R, Alder M, Duong H, Surber J (2003) the characteristics 3. J Bone Jt Surg (Am) 85: 409–20 mastoid muscle with inclination of the head towards the 6. Am J Med torticollis was caused by birth trauma during delivery Genet 27: 419–24 from a breech presentation. J Bone Joint Surg (Am) 68: section is generally performed for this intrauterine posi 424–9 tion. J Bone Joint Surg (Am) 66: 588–601 treatment revealed any form of hemosiderin deposits  13. Poussa M, Merikanto J, Ryoppy S, Marttinen E, Kaitila I (1991) the such as would be expected after a pulled muscle. Purkiss S, Driscoll B, Cole W, Alman B (2002) Idiopathic scoliosis in families of children with congenital scoliosis. Clin Orthop with a breech presentation, it has probably nothing to do 401:27–31 with the birth process. Microscopic examination reveals a fibrosis of the children, the sternocleidomastoid muscle is palpable as a muscles that is sometimes seen after necrosis . An ab tough cord, and it usually easy to detect whether the cla normal intrauterine posture may be a contributory factor vicular part, the sternal part or both parts are shortened. The A clicking sound is also occasionally elicited by a stretch occurrence of torticollis in families has been observed . Imaging is not usually necessary 3 Ocular causes are not infrequently involved . X-rays of the cervical spine Congenital muscular torticollis is relatively common, al are often difficult to interpret in patients with muscular though corresponding epidemiological figures are not torticollis since the bony structures are distorted and the available. In a study in Japan involving 7,000 infants, the vertebral bodies are not shown in the standard projection. The facial asymmetry is not just present as a primary sign, but can also develop secondarily or become Clinical features, diagnosis exacerbated if the torticollis persists for a prolonged Congenital muscular torticollis can be diagnosed on the period. On palpation of the con accustomed to the oblique position, which is even tracted sternocleidomastoid muscle, the doctor can fre tually sensed as »straight« by the child itself. In such quently feel a lump or a kind of tumor, generally in the cases, the corrected, objectively straight, position is distal part of this muscle. The infant’s head is inclined towards the side of the contracted muscle, turned towards the opposite side and almost in Differential diagnosis variably shows asymmetry of varying degree, otherwise the most important differential diagnosis is the Klippel known as plagiocephaly.
The loss of the windlass mechanism may result in the following clinical pathologies: • Joint laxity of the metatarsals • Metatarsalgia • Formation of hallux valgus 46 order ddavp 10mcg otc diabetes specialist nurse definition. The claw toe results from muscle imbalance in which the active extrinsics are stronger than the deep intrinsics (lumbricals proven ddavp 10mcg diabetes in dogs what are the symptoms, interosseus) and may indicate a neurologic disorder order 1 mg ddavp with amex diabetes mellitus. Stretching purchase ddavp 10mcg fast delivery diabetes type 1 feeling sick, as with the hammertoe, is often successful with flexible deformities, and shoes should avoid unnecessary pressure. The medial digital plantar nerve also runs in close proximity to the medial sesamoid and can be irritated. The differential diagnosis should include fracture of the sesamoid and bipartite medial sesamoid. Metatarsalgia refers to an acute or chronic pain syndrome involving the metatarsal heads. The various causes include overuse, anatomic misalignment, foot deformity, and degenerative changes. A cavus foot, which places more weight on the distal end, is commonly seen with this disorder. Neuromas are found most commonly in the third web space between the third and fourth metatarsals. Patients complain of deep 616 the Foot and Ankle burning pain and may have paresthesia extending into the toe. The main symptom is pain in the plantar aspect of the foot, which is increased by walking and relieved by rest. The neuroma is secondary to irritation of the intermetatarsal plantar digital nerve as it travels under the metatarsal ligament. Palpation in the interspace as opposed to over the joint should provoke the patient’s pain. A positive Mulder’s sign is also indicative of a neuroma; this test is positive when pain is reproduced or a click or pop is heard. The metatarsal squeeze test can also indicate the presence of a neuroma; in this test, compression of the foot from the medial and lateral directions while palpating the plantar aspect often reproduces the pain. Traditional treatment includes shoe modication (specically a wider toe box), use of metatarsal pads, steroid injection, and, in chronic unrelenting cases, referral for surgical neurectomy. Neurodynamics also should be assessed and treated because the nerve may be compressed more proximally as well as locally. The Semmes-Weinstein microlament test is a simple, inexpensive, and effective method for assessing sensory neuropathy in patients at risk for developing foot ulcers. Patients unable to feel the nylon lament with a 10-gram bending force are diagnosed with loss of protective sensation. Bibliography Alfredson H et al: Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis, Am J Sports Med 26:360-366, 1998. The location of muscles in the leg in relation to symptoms, J Bone Joint Surg 76A:1057-1061, 1994. Bonnin M, Tavernier T, Bouysset M: Split lesions of the peroneus brevis tendon in chronic ankle laxity, Am J Sports Med 25:699-703, 1997. Cetti R et al: Operative versus nonoperative treatment of Achilles tendon rupture: a prospective randomized study and review of the literature, Am J Sports Med 21:791-799, 1993. Kulig K et al: Selective activation of tibialis posterior: evaluation by magnetic resonance imaging, Med Sci Sports Exercise 36:862-867, 2004. Lentell G et al: the contributions of proprioceptive decits, muscle function, and anatomic laxity to functional instability of the ankle, J Orthop Sports Phys Ther 21:206-215, 1995. Part 1: Etiology, pathoanatomy, histopathogenesis, and diagnosis, Med Sci Sports Exercise 31:S429-S437, 1999. Ankle fractures are described by the number of malleoli involved: • Single malleolar fracture is a lateral or medial malleolar fracture. Fractures are classied in order to dictate treatment, simplify communication between medical personnel treating the fracture, and predict outcome. Part 1: Etiology, pathoanatomy, histopathogenesis, and diagnosis, Med Sci Sports Exercise 31:S429-S437, 1999. Ankle fractures are described by the number of malleoli involved: • Single malleolar fracture is a lateral or medial malleolar fracture. Fractures are classied in order to dictate treatment, simplify communication between medical personnel treating the fracture, and predict outcome. The ankle is a hinge joint in which the malleoli are connected to the talus through the collateral ligaments. A bular fracture combined with a deltoid ligament tear is a bimalleolar equivalent fracture and also requires surgery. Ankle fractures that involve only one malleolar disruption and do not disturb the stability of the ankle mortise are treated nonoperatively; the patient wears a short-leg walking cast or fracture boot for 4 to 6 weeks. Describe the radiographic views and alignment guides used in assessing ankle fractures. Talar neck fractures usually result from hyperdorsiflexion injury, as in a motor vehicle accident or fall from a height. Treatment is usually surgical in light of problems with late displacement and prolonged immobilization. The radiograph is taken with the foot in maximal plantar flexion and pronated at 15 degrees; the x-ray tube is directed 15 degrees cephalad to the vertical. Surgical treatment generally provides better outcomes than nonoperative treatment.