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B Appendicitis The gastrointestinal upset and foetor oris suggests appendicitis rather than urinary tract infection discount extra super levitra 100 mg amex. She was writhing about on the bed but the pain has now subsided following a dose of morphine purchase cheap extra super levitra on-line. H Ureteric calculus The history of the pain and lack of pyrexia suggest that this is more likely to be ureteric calculus than urinary tract infection (although colic is uncommon in pregnancy because high progesterone levels relax the smooth muscle of the ureters) purchase extra super levitra 100 mg on-line. On admission, urinalysis reveals that there is a great deal of protein in her urine. E Pre-eclampsia This could be a urinary tract infection but the symptoms are more suggestive of pre-eclampsia, even at this early gestation. D Elective caesarean section at 39 weeks of gestation It is usual to offer caesarean delivery if the patient has had two previous sections because of the increased risk of scar rupture. In terms of timing, we normally choose 39 weeks of gestation because babies rarely develop transient tachypnoea of the newborn if delivery is deferred until then. Serial scans show that the baby is well grown but at 37 weeks the ultrasonographer notes that the fibroid in the lower segment has grown to 8 cm diameter and the baby is lying transversely above it. C Classical caesarean section Myomectomy does not necessarily mean that she must have a caesarean section and vaginal delivery is feasible. However, a fbroid occupying the lower segment of the uterus – especially one that is nearly as large as the baby’s head – is likely to obstruct labour. It would also make a lower segment caesarean tricky so that the best option would be to open the uterus longitudinally above the fbroid with a classical incision. We very rarely perform classical caesarean sections and there are implications for her next pregnancy, so if you know that your patient has had one before, you should take pains to point that out in your next referral letter. She is on antiretroviral medication and her viral load is extremely low at < 50 copies per ml. However, if her viral load is extremely low (as in this case) we know that the mode of delivery makes no difference to the baby. There are rules to follow that include avoiding prolonged labour and leaving the membranes intact as long as possible; therefore avoiding induction of labour is a good idea. Scan confirms that the baby is of average size and the presentation is flexed breech. I Offer external cephalic version and await spontaneous labour There are several ‘distractors’ in this question. If the presentation remains breech, this woman is likely to be offered elective caesarean; therefore the best option is to try and turn the baby. It is unnecessary to induce labour if external cephalic ver- sion is successful, as spontaneous labour is more effcient than induced. Her craniotomy wound has healed well and she is now 36 weeks of gesta- tion in her first pregnancy. A Aim for vaginal delivery but with a shortened second stage A history of previous intracranial problems such as bleeding, detached retina, and treated aneurysm make it inadvisable for a woman to be performing the Valsalva manoeuvre every couple of minutes for an hour in labour so we would plan to have an elective assisted delivery to shorten the second stage. We don’t need to consider caesarean delivery because she has had her aneurysm successfully treated. A Admit immediately to a psychiatric ‘mother and baby’ unit B Advise that depression is common and resolves after delivery C Advise that she should stop medication as it can harm the baby D Arrange specialist counselling E Ask a psychiatric liaison worker to visit at home F Continue medication and seek psychiatric advice G Recommence psychiatric medication immediately H Refer to her previous psychiatrist I Routine opinion from a specialist obstetric psychiatric clinic J Suggest that she considers short-term use of sleeping tablets K Suggest that she takes an antidepressant L Urgent opinion from a specialist obstetric psychiatric clinic 151 09:34:02. She has been off medication for many years and has been psychiatrically well since. L Urgent opinion from a specialist obstetric psychiatric clinic The chance of this woman developing a puerperal psychosis after delivery is very high (around 30 per cent) and she needs surveillance postpartum with easy recourse to urgent specialist obstetric psychiatric advice if she becomes ill. Ordinary psychiatrists sometimes do not appreciate the urgency of the problem and something drastic can happen before psychiatric admission can be organised. This message came over very clearly from the 2000–2002 maternal mortality reports (when maternal suicide was the leading cause of maternal death in the United Kingdom). D Arrange specialist counselling Although this woman does sound depressed, it is a reactive depression and likely to respond to simple measures. The use of antidepressants in pregnancy is rea- sonable if the benefts outweigh the risks, but there is limited information about the safety of many drugs regarding the fetus, so it is better if she can cope with nondrug therapy. F Continue medication and seek psychiatric advice Patients on lithium to stabilise their mood can become quite unwell if they stop it abruptly and in this situation the risks of stopping the lithium outweigh the ben- efts. She needs advice from her psychiatrist to decide if it is advisable to come off her medication to reduce the chances of damaging the fetus especially in the frst trimester. It is good that she has come for preconceptual counselling as it gives an opportunity to organise withdrawal before pregnancy if she is well enough. The husband reveals on the telephone that his wife has not slept since the baby was born and is making bizarre comments about the health of the baby. Her psychiatric liaison worker has left a written care plan in her obstetric notes. A Admit immediately to a psychiatric ‘mother and baby’ unit This woman appears to have developed postpartum psychosis and needs inpatient assessment done by an experienced team. If she goes into a specialised unit she can take the baby with her, which is better for bonding as she improves in the long run. If there is a written care plan it is likely that she has previous history and the plan should be accessible to everyone looking after her. She gives a history of postnatal depression that involved several months of in-patient care following her previous delivery. I Routine opinion from a specialist obstetric psychiatric clinic This woman has booked early, which provides the obstetric and psychiatric medi- cal team a great deal of time to look into her history and assess the risk for this pregnancy. The fact that she was looked after as an in-patient previously increases the likelihood of it having been a psychosis rather than an ordinary depression, but this can be investigated to confrm the previous diagnosis to work out her recur- rence risk. Initially there was some minor abdominal pain, but this has settled and there is no uter- ine activity. D Electronic cardiotocograph fetal monitoring Although the diagnosis here could be placenta praevia, therefore an ultrasound is a good idea; it is important to check that the baby is healthy before she goes to scan because another potential diagnosis is placental abruption. At some stage she will also need a speculum examination to exclude a cervical cause of the bleeding – such as chlamydial infection – but this should not be done until after the scan excludes placenta praevia. The uterus is nontender and the baby is well grown but appears to be lying transversely. There are no contractions and the condition of both the mother and the baby is stable. If she were contracting (so you haven’t much time to make the diagnosis) we would consider examining her in theatre, in case doing that makes her bleed torrentially from a low-lying placenta. D Electronic cardiotocograph fetal monitoring Recurrent antepartum haemorrhage is sometimes associated with intrauterine growth restriction. Although a Doppler is indicated here and another growth scan in 2 weeks’ time, it is important to check that the baby is healthy now before plan- ning future management.

The structures of the larynx serve two functions: to modulate expelled air to make sounds used in the production of speech and to protect the airway from food and drink passing to the esophagus buy on line extra super levitra. The larynx consists of three single cartilages (epiglottis order 100mg extra super levitra mastercard, thyroid discount extra super levitra 100 mg fast delivery, and cricoid), and three paired cartilages (arytenoid, cornicu- late, and cuneiform), for a total of nine. The thyroid cartilage resembles a partially open book, with the union of its two plates forming a laryngeal prominence (Adam’s apple) anterosuperiorly. Posterior to the thyroid cartilage is the epiglottis, a cartilaginous structure that is bound to the thyroid car- tilage by the thyroepiglottic ligament. The arytenoid cartilages rest on the superior margin of the cricoid cartilage and are held in place by capsules that surround the cricoarytenoid joint. The epiglottis attaches to the arytenoid cartilages through the quadrangular membrane. The free superior border forms the aryepiglottic fold, and the free inferior border forms the vestibular ligament (false vocal fold). The other major structure of the larynx is the conus elasticus, another broad ligament inferior to the quadrangular membrane. The free superior border also attaches to the arytenoid car- tilage and forms the vocal ligament (true vocal fold). When the rima glottidis is narrow, the expelled air will vibrate the vocal folds and produce a sound. The intrinsic musculature of the larynx is devoted mostly to fine-motor con- trol of the vocal folds to modulate pitch and intonation during speech. Perhaps the most important muscles are the posterior cricoarytenoids, which are the only muscles used to abduct the vocal folds and are necessary to widen the rima glot- tidis for breathing. All of the other muscles function to adduct the rima glottidis or modulate the tension of the vocal chords. The transverse and oblique arytenoid muscles bring the two arytenoid cartilages together, which indirectly act to close the posterior portion of the rima glottidis. The cricothyroids lengthen and tighten the vocal fold, whereas the thy- roarytenoid relaxes it. The vocalis muscle runs under the vocal fold and produces local modulations in tightness (e. Several structures protect the trachea from food or liquid traveling to the esoph- agus. The first of these is the epiglottis, which deflects food laterally around the quadrangular membrane to the piriform recess and into the esophagus. The epi- glottis itself does not apply sufficient force to completely close off the laryngeal inlet. During swallowing, the suprahyoid muscles contract and, through the thyro- hyoid membrane, lift the larynx up against the epiglottis. The infrahyoid muscles attached to the external face of the thyroid cartilage help to return the larynx to its resting position. The only exception is the crico- thyroid, which is innervated by the external branch of the superior laryngeal nerve, also a branch of the vagus. Thus, damage to the superior laryngeal nerve will affect voice quality, particularly the ability to reach high tones. More significantly, damage to the recurrent laryngeal nerve will impair the ability to abduct the vocal folds, possibly leading to respiratory distress if the injury is bilateral. Unilateral damage to the recurrent laryngeal nerve will result in inability to tightly adduct the two vocal folds, resulting in hoarseness. In addition, the protective function of the rima glottidis may be lost, and food or liquid that does not go down the esophagus may flow into the trachea and cause a choking response. In the supraglottic region (above the vocal fold), the mucosa is innervated by the internal branch of the superior laryngeal nerve. In the infraglottic region (below the fold), the mucosa is innervated by the recurrent laryngeal nerve. Thus, damage to the superior and recurrent laryngeal nerves may also have deficits in reflex behaviors that depend on sensory input from the larynx. Which of the following nerves is responsible for carrying the sensa- tion for this pain? The posterior cricoarytenoid muscles are the only muscles that abduct the vocal folds and are necessary to widen the rima glottidis for breathing. Injury to the recurrent laryngeal nerve is common during thyroid surgery and may lead to the inability to tightly adduct the two vocal folds, resulting in hoarseness. In addition, the protective function of the rima glottidis may be lost, and food or liquid that does not go down the esophagus may flow into the trachea and cause a choking response. The laryngeal mucosa above the vocal cords is innervated by the superior laryngeal nerve, whereas mucosa below the vocal cords is innervated by the recurrent laryngeal nerve. On examination, he has a blood pressure of 150/90 mmHg and a normal body temperature. If the deficits were to resolve before 24 h, it would be called a transient ischemic attack. If the deficits were to continue beyond 24 h, it would be called a cerebrovas- cular accident, or stroke. Differentiating between the two is important because fibrinolytic therapy (medication that dissolves blood clots) would be contraindicated with hemorrhagic strokes. In this patient, the bruits identified on the carotid arteries are likely due to increased rate and tur- bulence of blood flow through the stenotic vessels. Immediate management of this patient would include administration of an antiplatelet medication such as aspirin and/or clopidogrel. After stabilization of the patient, carotid endarterectomy surgery may be indicated. Be able to review the somatotopic organization of sensory and motor regions in the brain 2. Be able to list the branches of the common carotid artery and the vascular sup- ply to the brain and identify the sites most susceptible to formation of athero- sclerotic plaques 3. The cerebrum is involved in the major functions of sensory perception, motor control, and the associational processing that integrates the two. The surface or cortex of the cerebrum is folded into a number of ridges (gyri) separated by valleys (sulci) of different depths. The brain is divided into lobes named for the overlying cranial bones: frontal, temporal, parietal, and occipital. The precentral gyrus controls voluntary motion, whereas the postcentral gyrus is the site of somatosensory perception. The sensory and motor areas are arranged according to a somatotopic organi- zation. The lower extremity is represented medially along the gyrus; the upper extremity, more laterally; and the head and neck, most laterally.

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The sympathetic system includes the adrenal medulla order extra super levitra 100 mg with visa, which releases norepinephrine and epinephrine into the blood purchase cheap extra super levitra online. Nitric oxide is an impor­ somatic nervous systems are acetylcholine and norepineph- tant neurotransmitter that produces vasodilatation in many rine (see Fig purchase extra super levitra visa. Acetylcholine is the transmitter at all autonomic ganglia, Receptors for Acetylcholine, Norepinephrine, at parasympathetic neuroeffector junctions, and at somatic and Epinephrine neuromuscular junctions. It is also the transmitter at a The acetylcholine receptors have been divided into two few sympathetic neuroeffector junctions, including the types, based on their selective activation by one of two plant junctions of nerves in sweat glands and vasodilator fbers alkaloids. The presence of acetylcholine in line receptors activated by muscarine, are primarily located several types of autonomic and somatic synapses contributes at parasympathetic neuroeffector junctions. Nicotinic to the lack of specifcity of drugs acting on acetylcholine receptors are acetylcholine receptors activated by nicotine. They are found in all autonomic ganglia, at somatic neuro­ Although norepinephrine (noradrenaline) is the primary muscular junctions, and in the brain. Muscarinic receptors neurotransmitter at most sympathetic postganglionic neu­ are subdivided based on molecular and pharmacologic crite­ roeffector junctions, epinephrine (adrenaline) is the princi­ ria. Activation of the M3 receptor produces smooth muscle pal catecholamine released from the adrenal medulla in contraction (except sphincters) and gland secretion. Sympathetic effects are mediated by α­adrenoceptors (α), β­adrenoceptors (β), or muscarinic receptors (M). The two types of adrenoceptors, called α- adrenoceptors produces cardiac stimulation. The α1­adrenoceptors Cholinergic and adrenergic neurotransmission have many mediate smooth muscle contraction, whereasβ2­adrenoceptors basic similarities. Postjunctional acetylcholine receptors are activated or blocked by acetylcholine receptor agonists or antagonists, respectively. Postsynaptic adrenoceptors are activated or blocked by adrenoceptor agonists or antagonists, respectively. After the neurotransmitter activates postjunc­ mechanisms of action are listed in Table 5­1. Various drugs exert their effects at specifc steps in Acetylcholine is synthesized from choline and acetate in the the process. When parasympathetic nerve is stimu­ This group of drugs includes muscarinic receptor antago- lated, the action potential induces calcium infux into the nists such as atropine and nicotinic receptor antagonists neuron, and calcium mediates release of the neurotrans­ such as atracurium that act at the skeletal neuromuscular mitter by a process called exocytosis. Choline is recycled through the process of reuptake Norepinephrine is synthesized via the following steps: tyro­ by the presynaptic neuron. Acetylcholine can also activate presynaptic autoreceptors, First, the amino acid tyrosine is converted to dopa which inhibits further release of the neurotransmitter from (dihydroxyphenylalanine) by tyrosine hydroxylase, the rate­ the neuron. Dopa is then converted to dopamine by l­aromatic amino acid decarboxylase Drugs Affecting Cholinergic Neurotransmission (dopa decarboxylase). At this point, dopamine is accumu­ Figure 5­3A shows the sites of various agents that affect lated by neuronal storage vesicles. Inside the vesicles, cholinergic neurotransmission, including substances affect­ dopamine is converted to norepinephrine by dopamine ing acetylcholine synthesis (hemicholinium) and storage β­hydroxylase. Once in the synapse, norepinephrine acti­ Black widow spider venom containing α-latrotoxin stimu­ vates postjunctional α­ and β­adrenoceptors. It also activates lates vesicular release of acetylcholine, producing excessive prejunctional autoreceptors that exert negative feedback and activation of acetylcholine receptors. Salivation, lacrimation, sweating, neuronal reuptake via a transport protein known as the and changes in heart rate and blood pressure can occur but catecholamine transporter located in the neuronal membrane. Administration of analgesic and antiinfammatory synaptic and postsynaptic receptor activation and enables the medication is usually the only treatment required. Botulinum toxin A, which is produced by Clostridium Once inside the neuron, norepinephrine is sequestered in botulinum, blocks the exocytotic release of acetylcholine and storage vesicles. Botulinum toxin has also Drugs Affecting Adrenergic Neurotransmission been used to treat excessive sweating (hyperhidrosis) of the Figure 5­3B shows the sites of various agents that affect palms and soles, and irrigation of the urinary bladder with adrenergic neurotransmission, including the neuronal block­ botulinum toxin may provide long­lasting relief of bladder ing agents such as reserpine and bretylium that are used in spasm. The most common side effects of botulinum toxin pharmacology research but no longer have any clinical use. The synthesis of norepinephrine is inhibited by metyro- After acetylcholine is released, it can activate postsyn­ sine, which is a competitive inhibitor of tyrosine hydroxy­ aptic muscarinic or nicotinic receptors. Metyrosine is used to inhibit norepinephrine and pilocarpine mimic the effect of acetylcholine at these epinephrine synthesis in persons with pheochromocytoma, receptors and are called direct-acting acetylcholine recep- an adrenal medullary tumor that secretes large amounts tor agonists. These include phentol- called indirect-acting acetylcholine receptor agonists (see amine, which selectively blocks α­adrenoceptors; propran- Chapter 6). These drugs are described transmission are the acetylcholine receptor antagonists. A, Increased arterial pressure activates stretch receptors in the aortic arch and carotid sinus. Drugs that reduce blood pressure attenuate this response and cause refex tachycardia. In this case, the effect on the heart rate is known as direct-acting adrenoceptor agonists and include called refex tachycardia. These drugs • The sympathetic and parasympathetic divisions of the and their mechanisms of action are explained more fully in autonomic nervous system have opposing effects in Chapter 8. In the autonomic nervous system there are Drugs Modulating the Baroreceptor Refex several nonadrenergic-noncholinergic neurotransmit- In addition to exerting their primary pharmacologic actions, ters, including peptides, nitric oxide, and serotonin. Activation of muscarinic sure, this activates stretch receptors (mechanoreceptors) and α-adrenoceptors produces smooth muscle located in the aortic arch and in the carotid sinus at the contraction, whereas activation of β-adrenoceptors bifurcation of the carotid artery. Receptor activation initiates produces smooth muscle relaxation and cardiac impulses that travel via afferent nerves to the brain stem stimulation. Stimulation of the vagal motor nucleus • Some drugs have effects on neurotransmitter synthe- (via nerves from the solitary tract nucleus) leads to an sis, storage, release, or metabolism. These are called increase in vagal (parasympathetic) outfow, a decrease in indirect-acting drugs. The effect on the heart rate is a neurotransmitter at synapses, by inhibiting transmit- called refex bradycardia. Which the release of acetylcholine from cholinergic neurons, and side effect is most likely to occur in this patient? The drug may also inhibit acetylcholine (B) urinary incontinence release from parasympathetic nerves and cause dry mouth (C) dry mouth and dysphagia, particularly when it is administered to the (D) diarrhea head and neck. Bradycardia, urinary incontinence, diar­ (E) constriction of the pupils rhea, and miosis are effects that would be caused by 2. A man receives an injection of epinephrine to treat an increased release of acetylcholine from parasympathetic allergic reaction to a bee sting. Epinephrine does not (D) increased formation of glycogen increase glucose absorption (answer A), glucose uptake (E) increased conversion of glucose to fat (answer C), glycogen formation (answer D), or conver­ 3. Which property is characteristic of the sympathetic sion of glucose to fat (answer E). Norepinephrine activates α1­ (C) involuntary muscle contractions adrenoceptors in the iris dilator muscle, thereby causing (D) fushing of the skin muscle contraction and pupillary dilation. Excessive (E) sedation sweating (answer A) would result from activation of mus­ 5. A woman with acute high blood pressure is given a drug carinic receptors in sweat glands, whereas involuntary that inhibits formation of dihydroxyphenylalanine.

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Waterbirth Cord prolapse is an obstetric emergency necessitating immediate delivery and is more likely where the presenting part is either not in the pelvis (e order cheapest extra super levitra and extra super levitra. Undiagnosed antepartum haemorrhage Urinary tract infection is not an indication for induction generic extra super levitra 100 mg without a prescription, and active infection in the pelvis during labour may increase the chances of septic complications purchase generic extra super levitra on-line. There is no evidence that inducing labour is benefcial to patients with symphysis pubis dysfunction although they usually request induction (or even caesarean). Although antepartum haemorrhage is an indication for induction of labour it is important to exclude placenta praevia before planning induction. Although it is not ideal for a woman who did not manage a normal delivery last time or does not get on well with her midwife to plan a home birth she is still likely to be able to deliver without medical intervention. A grand multip is more likely to have a postpartum haemorrhage and therefore should be advised to plan delivery in a consultant-led unit. A primigravid woman whose baby is in the occipito-posterior position at the start of labour B. A woman with an otherwise uncomplicated pregnancy who has had a successful external cephalic version E. The main issue for the rhesus disease mother is going to be the baby’s haemoglobin and bilirubin levels, and as long as the midwife can obtain blood samples from the cord after delivery, labouring in the birthing pool should be safe. The anaesthetist will check the level of the block and get ready to intubate her should the spinal rise any higher. Previous third-degree tear Mothers who are pushing actively are performing the Valsalva manoeu- vre frequently, which is probably not a good idea if she has cardiac problems. Instrumental delivery is associated with an increased risk of third-degree tear so should only be used if there is failure to progress or fetal compromise in women with a previous third-degree tear. The woman refuses to give consent for the operation and the midwife looking after her thinks that she may be confused on account of her high temperature. Use the Mental Health Act to justify proceeding with caesarean delivery If the woman is judged to have capacity to process information and make sound decisions, you cannot force her to have a caesarean even if her baby dies as a result. The baby has no rights in law until it is born and the interests of the mother take precedence. If an epidural is inserted in the presence of this condition, there is an increased risk of a haematoma in the restricted space within the spinal canal which could lead to paralysis. Halfway through the first stage of labour the patient has become increasingly distressed and is complaining of severe abdominal pain. The pain continues between contractions, which are occurring every 3 minutes and the midwife has noticed that the uterus is tender and hard on palpation. Uterine rupture Fresh vaginal bleeding is suggestive of abruption or uterine rupture. Rupture is uncommon – unless oxytocin (or prostaglandins) are being used to stimulate contractions – but if the uterus ruptures the contractions usually cease. The inexperienced student midwife hands you a selection of drugs to choose from to try and stop the uterine bleeding. Oxytocin Atosiban is used to stop contractions in the management of preterm labour. Unstable lie The risk of placenta praevia increases with increasing number of sections and the chance of that low-lying placenta invading the myometrium and becoming accreta increases markedly with each subsequent caesarean. This is one of the main reasons for trying to keep the caesarean section rate down. Several patients – whose stories are described in the triennial mater- nal mortality reports – died because their blood pressure was signifcantly raised by third-stage administration of syntometrine, and they subsequently died from massive intracranial bleeding. Which of the following pregnant women does not need a cannula when she is admitted? For any of these rea- sons, she could need a cannula and a ‘group and save’ blood test doing when she is labouring. The only woman on the preceding list who is not in this situation is the woman who needed a forceps delivery last time. Inadequate transfusion The pulmonary oedema with a low oxygen saturation is the key to this diagnosis, although the some of the clinical information given would also ft sepsis. The obstetric anaesthetist is keen for her to have an epi- dural inserted thereby avoiding a general anaesthetic if emergency delivery becomes necessary later. Epidural can lower her blood pressure and improve placental perfusion 162 09:34:41. This leads to a high chance of a pregnant woman aspirating during induction of anaesthesia and developing pneumonitis. Before the widespread use of regional anaesthesia by trained obstetric anaesthetists, this was a common cause of maternal death. Epidural may lower her blood pressure but this will reduce rather than improve placental perfusion, so it is important to make sure that the baby is not hypoxic before she has her epidural. The midwife is more easily able to support the mother’s legs The main reason is to improve placental perfusion by preventing the weight of the gravid uterus compressing the inferior vena cava thereby reduced venous return. Which of the following procedures may help the birth attendants deliver the baby in this life-threatening situation? If you want to relieve the situation by delivering an arm, it is the posterior arm that may be accessible as the anterior one is stuck in the abdomen. Mauriceau- Smellie-Veit and Lovsett’s manoeuvres are for delivering a breech baby. We do not do fundal pressure because of the risk of rupturing the uterus (although this is 163 09:34:41. This risk is increased if there is an element of infection that may be the case after prolonged labour. Extended Matching Questions A Amniotomy B Elective caesarean section C Electronic fetal monitoring D Emergency caesarean section E Intermittent auscultation F Request a clotting screen G Routine elective episiotomy H Titrated synthetic Oxytocin infusion I Vaginal examination in theatre with the operating team standing by J Ventouse delivery The following clinical scenarios apply to women delivering in a hospital obstet- ric unit. Her membranes have just ruptured spontaneously and fresh meconium is seen in the liquor. C Electronic fetal monitoring Meconium in the liquor becomes more likely as gestation advances, especially in postmature babies. It is, however, sometimes a sign of hypoxia especially if the pregnancy has not reached term, so in any labour where meconium is noted it 164 09:34:41. D Emergency caesarean section This is a cord prolapse, so delivery of the baby must be expedited. As the cervix is not fully dilated the delivery must be by emergency caesarean section, with a birth attendant lifting the presenting part off the cord until the operator can get the baby out. The uterus is nontender and the baby is well grown with a cephalic presentation, four-fifths palpable. The condition of both mother and baby is stable, but she is contracting strongly every 3 minutes and the blood continues to trickle from the vagina. I Vaginal examination in theatre with the operating team standing by The baby’s head should be engaged after 37 weeks in a primiparous woman, so that the fact that it is four-ffths palpable makes you wonder why and in this situation in which there is vaginal bleeding a low-lying placenta is likely. She mobilises in her labour room using nitrous oxide for analgesia and 4 hours later the cervix is 7c m dilated.

Orthostatic hypotension can be minimized by moving slowly when changing from a supine or seated position to an upright posture buy extra super levitra with a mastercard. Primary risk factors are renal impairment purchase 100 mg extra super levitra free shipping, preexisting cognitive impairment cheap extra super levitra 100 mg overnight delivery, and prolonged, high- dose opioid use. Adjuvant Analgesics Adjuvant analgesics are used to complement the effects of opioids. Accordingly, these drugs are employed in combination with opioids—not as substitutes. Adjuvant analgesics can (1) enhance analgesia from opioids, (2) help manage concurrent symptoms that exacerbate pain, and (3) treat side effects caused by opioids. The adjuvant analgesics differ from opioids in that pain relief is limited and less predictable and often develops slowly. The adjuvants are interesting in that, although they can relieve pain, all of them were developed to treat other conditions (e. Accordingly, it is important to reassure patients that the adjuvant is being used to alleviate pain, and not for its original purpose. Important adverse effects are orthostatic hypotension, sedation, anticholinergic effects (dry mouth, urinary retention, constipation), and weight gain (secondary to improved appetite). Dosing at bedtime takes advantage of sedative effects and minimizes hypotension during the day. Other Antidepressants In addition to the tricyclic agents, certain other antidepressants (e. Acute pain (sharp, darting pain) is especially responsive, although other forms of neuropathic pain (cramping pain, aching pain, burning pain) also respond. Of the available antiseizure drugs, carbamazepine [Tegretol] has been used most widely. Because carbamazepine is myelosuppressive, it must be used with caution in patients receiving anticancer drugs that suppress bone marrow function. As discussed in Chapter 19, caution is also needed in patients of Asian descent, owing to an increased risk for severe dermatologic reactions. Another drug—gabapentin [Neurontin]—is also very effective and causes fewer side effects than carbamazepine. Dosage should be low initially (100 mg once a day) and then gradually increased; dosages as high as 1200 mg 3 times a day have been employed. Local Anesthetics/Antidysrhythmics Lidocaine (a local anesthetic and antidysrhythmic) and mexiletine (an antidysrhythmic related to lidocaine) are considered second-line agents for neuropathic pain. Antihistamines Hydroxyzine [Vistaril], an antihistamine, promotes drowsiness and reduces anxiety. Drawbacks include worsening of constipation, urinary retention, and cognitive impairment. Glucocorticoids Although glucocorticoids lack direct analgesic actions, they can help manage painful cancer-related conditions. Because glucocorticoids can reduce cerebral and spinal edema, they are essential for the emergency management of elevated intracranial pressure and epidural spinal cord compression. Similarly, glucocorticoids are part of the standard therapy for tumor-induced spinal cord compression. In addition to these benefits, glucocorticoids can improve appetite and impart a general sense of well-being; both actions help in managing anorexia and cachexia-associated with terminal illness. Glucocorticoids are very safe when used short term (even in high doses) and very dangerous when used long term (even in low doses). In particular, long- term therapy can cause adrenal insufficiency, osteoporosis, glucose intolerance (hyperglycemia), increased vulnerability to infection, thinning of the skin, and, possibly, peptic ulcer disease. The risk for osteoporosis can be reduced by giving calcium supplements and vitamin D along with calcitonin or a bisphosphonate (e. Bisphosphonates Bisphosphonates, such as etidronate [Didronel] and pamidronate, can reduce cancer-related bone pain in some patients. The cause of pain may be tumor-induced bone resorption, which can also cause hypercalcemia, osteoporosis, and related fractures. Bisphosphonates inhibit bone resorption and are approved for treating hypercalcemia of malignancy and bone metastases in breast cancer—but not bone pain itself. However, when these drugs are given to treat hypercalcemia, many patients report a reduction in bone pain, although others do not. Hence, although these drugs appear promising, their use for management of bone pain is still considered investigational. Nondrug Therapy Neurolytic Nerve Block The goal of this procedure is to destroy neurons that transmit pain from a limited area, thereby providing permanent pain relief. Nerve destruction is accomplished through local injection of a neurolytic (neurotoxic) substance, typically alcohol or phenol. To ensure that the correct nerves are destroyed, reversible nerve block is done first, using a local anesthetic. If the local anesthetic relieves the pain, a neurolytic agent is then applied to the same site. However, even if pain relief is only partial, the procedure can still permit some reduction in opioid dosage and can thereby decrease side effects, such as sedation and constipation. When nerve block is successful and opioids are discontinued, opioid dosage should be tapered gradually to avoid withdrawal. Potential complications include hypotension, paresis (slight paralysis), paralysis, and disruption of bowel and bladder function (e. Palliative treatment can be directed at primary tumors and at metastases anywhere in the body. With brachytherapy, cell kill is limited to the immediate area of the implanted pellets; hence the technique is suited only for localized tumors. With teletherapy, cell kill can be localized or widespread, depending on the size of the beam employed; hence the technique can be used for both localized tumors and metastases. Radiofrequency ablation uses a thin, needle-like probe inserted into a tumor through an incision in the skin. The probe extends electrodes that emit high-frequency electrical current, producing heat to destroy cancer cells; hence the technique is best suited for localized tumors. With radiation therapy, as with chemotherapy, damage to normal tissue is dose limiting. Therefore the challenge is to deliver a dose of radiation that is large enough to kill cancer cells, but not so large that it causes intolerable damage to healthy tissue. Fortunately, in the regimens employed for palliation, these acute effects are generally mild. The most common late reaction is fibrosis, which occurs mainly in tissues that have a limited ability to regenerate (e. Late reactions are of limited concern, however, because most patients die of their cancer before late reactions can develop. Pain Management in Special Populations Older Adults In older-adult patients, two issues are of special concern: (1) undertreatment of pain and (2) increased risk for adverse effects. Paradoxically, a third issue— heightened drug sensitivity—contributes to both problems. Heightened Drug Sensitivity Older adults are more sensitive to drugs than are younger adults, owing largely to a decline in organ function.

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See therapeutic hypothermia toxin-induced liver failure, 245-249, theophylline, for asthmatic exacerbation, 252-254 128 toxins. See vancomycin-intermediate zanamivir (Relenza), 395 Staphylococcus aureus Zithromax. See azithromycin vital signs zone of coagulation, 322 critical illness awareness using, 18-21, zone ofhyperemia, 322 22t, 24 zone ofstasis, 322. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the beneft of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they have been printed with initial caps. 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This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise. Toshi Nikaidoh, who led by example, always beyond the call of duty, and along the way, taught so many of us about so many important things about life. As a surgeon-to-be, he tutored fellow lower-level medical students on not only how to master the challenges of gross anatomy but also how to develop the skillful art of dissection and respect for the human body. As a spiritual leader, he taught his youth group not only the meaning of good fellowship by recalling good times spent on missionary travels abroad, but also the value of good worship by sharing his faith along the way. As a physician, he taught patients not only to hope when all hope is lost but also to have faith through which peace can be found. And as a friend, son, brother, or just that smiling doctor in the hallway with the bow tie, he taught us how truly possible it is for one person to make a world of difference. Toshi’s dedication to academics and education, his compassion for the sick and less fortunate, and his tireless devotion to his faith, family, and friends have all continued to touch and change lives of all who knew him, and even of all who only knew of him. Joseph Medical Center Ob/Gyn Resident Written on behalf of Toshi’s many friends, classmates, fellow residents, staff, and faculty at University of Texas Medical School at Houston and St. Hitoshi Nikaidoh, who demonstrated unselfshness, love for his fellow man, and compassion for everyone around him. He is the best example of the physician healer, and we were blessed to have known him. Your positive reception has been an incredible encouragement, especially in light of the short life of the Case Files® series. In this third edition of Case Files®: Anatomy, the basic format of the book has been retained. New cases include hydrocephalus, knee injury, peritoneal irritation, rotator cuff injury, and thoracic outlet syndrome. We reviewed the clinical scenarios with the intent of improving them; however, their “real-life” presentations patterned after actual clinical experience were accurate and instructive. Through this third edition, we hope that the reader will continue to enjoy learning diagnosis and management through the simulated clinical cases. It certainly is a privilege to be teachers for so many students, and it is with humility that we present this edition. The Authors ix acknowLedgments The inspiration for this basic science series occurred at an educational retreat led by Dr. Buja served as Dean of the University of Texas Medical School at Houston from 1995 to 2003 before being appointed Executive Vice President for Academic Affairs. Lawrence Ross, who is a brilliant anato- mist and teacher, and my new scientist author Dr. Sitting side by side during the writing process as they precisely described the anatomical structures was academically fulfilling, but more so, made me a better surgeon. Cristo Papasakelariou, a dear friend, scientist, leader, and the fin- est gynecological laparoscopic surgeon I know. I would like to thank McGraw-Hill for believing in the concept of teaching by clinical cases. I owe a great debt to Catherine Johnson, who has been a fantastically encouraging and enthusiastic edi- tor. It has been amazing to work together with my daughter Allison, who is a senior nursing student at the Scott and White School of Nursing; she is an astute manu- script reviewer and already early in her career she has a good clinical acumen and a clear writing style. Ross would like to acknowledge the figure drawings from the University of Texas Medical School at Houston originally published in Philo et al. Joseph Medical Center, I would like to recognize our outstanding administrators: Pat Mathews and Paula Efird. Konrad Harms, Priti Schachel, Gizelle Brooks-Carter, John McBride, and Russell Edwards, this manuscript could not have been written. Most importantly, I am humbled by the love, affection, and encour- agement from my lovely wife, Terri, and our children, Andy and his wife Anna, Michael, Allison, and Christina.