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Gestation in weeks Estimated date of delivery Which hospital she is booked into Midwife or obstetric consultant care Complications in this pregnancy Nature of bleeding/pain/fluid loss/discharge Subjective assessment of foetal movements generic bystolic 5mg on line. It usually presents after 20 weeks discount 5 mg bystolic fast delivery, but can occur the practitioner has the requisite skills generic 2.5 mg bystolic with amex. The uterus should be palpated for tenderness, rigidity, contractions, • Severe pre-eclampsia is characterized by greatly elevated blood foetalpartsandmovements. Iftherehasbeenaspontaneousrupture pressure (>170/110 mmHg), proteinuria and one or more of of membranes the colour of the liquor should also be assessed for the following symptoms: severe headache, visual disturbance, blood or meconium staining. It generally occurs in the third Antenatal emergencies trimester, with 60% of cases reported in the intrapartum period Antepartum haemorrhage or within 48 hours after parturition. The incidence is higher Antepartum haemorrhage is vaginal bleeding after 24 completed in developing countries. The common causes are placental abruption lasting 90 seconds or less, but may be severe and recurrent. The result is Managementofseverepre-eclampsiaandeclampsiarequiresurgent bleeding from the maternal sinuses into the space between the transfer to an obstetric unit. Blood may remain concealed or left lateral position for transfer and oxygen applied if SpO2 <94%. Abruption Monitor the blood pressure en route and pre-alert the obstetric unit usually presents with severe abdominal pain and a hard, tender so that they can prepare drugs and/or theatre. Delay in presentation (up to 48 hours) is not uncommon shouldbemanagedinitiallywithbasicairwayadjucts(e. Further seizures can be prevented • Placenta praevia is when the placenta implants either completely by giving magnesium sulphate 4 g intravenously/intraosseously or partially across the cervical os. If magnesium sulphate is not available and the pregnancy because of intercourse or contractions the tearing of patient has recurrent or prolonged seizures consider parental or maternal blood vessels close to the cervical canal leads to blood rectal benzodiazepines. Emergency prehospital delivery Management of antepartum haemorrhage involves urgent Less than 1% of booked hospital deliveries are born before arrival at transfer to an obstetric unit. Neonatal consequences include a slightly higher perinatal access should be made en route and fluid resuscitation mortality rate (relative risk 5. Pre-eclampsia is a multisystem disorder consisting chiefly of elevated blood pressure (>140/90 mmHg), proteinuria with or First stage of labour The first stage of labour involves cervical effacement and dilatation to 10 cm. There will be an increase in frequency and intensity of Placental abruption Placenta previa contractions during this stage. Second stage of labour The second stage begins when the cervix is fully dilated and is completed with delivery of the baby. In the absence of a midwife able to perform a vaginal examination, the second stage will usually be recognized when the head becomes visible at the introitus (crowning). At this stage delivery is imminent and an emergency prehospital delivery should be prepared for. Allow the head to deliver with gentle support to the perineum Care of Special Groups: The Obstetric Patient 153 (a) (b) (c) Figure 28. Encouraging the mother to pant or breathe through her contractions at this stage will also help control the delivery of the head. If cord is seen around the neck it can be left alone as the body will usually deliver through the loops. The exaggerated Sim’s position should be used to transfer the patient with cord prolapse. The mother is laid on her left side with her head Third stage of labour flat and her buttocks elevated by pillows (Figure 28. The addition The third stage of labour begins with delivery of the baby and of head-down tilt may assist in relieving the pressure of the foetal ends once the placenta has been delivered. Use your fingertips to gently push the presenting of the baby the cord may be cut after it has finished pulsating part upwards and off the cord – this must be maintained during (or immediately if resuscitation is required). Alternatively, pass a urinary catheter and fill the bladder at 3 cm and 6 cm from the baby and divided between the clamps. The increase in bladder In most cases the third stage will be physiological unless Syn- size will elevate the presenting part. Any protruding cord should be tometrine (1-mL vial intramuscularly/intravenously) is available. Owing to the risk of cord rupture and uterine inversion, prehospital application of cord traction is discouraged unless the practitioner is experienced in this technique. Once deliv- Breech presentation ered the placenta should be kept for inspection by the midwife or This is where the presenting part is the feet or buttocks and occurs in obstetrician. The safest means of delivering a breech baby is by caesarean section and if labour is not well established the mother should be transferred urgently to hospital. If the presenting Intrapartum emergencies part is visible at the introitus a vaginal breech delivery will be Cord prolapse required. Urgent midwifery assistance should be requested while Cord prolapse is the descent of the umbilical cord through preparing for delivery. It occurs in <1% of deliv- position and once the breech is visible at the introitus, pushing eries and may lead to foetal hypoxia. Spontaneous delivery of the limbs and trunk is preferable to deliver the head can result in brachial plexus injury and must (Figure 28. Fortunately, most can be managed with the first two ing pressure to the popliteal fossa (Pinard manoeuvre). Avoid trying to ‘pull’ the baby out as this can result in the extension and trapping • McRoberts manoeuvre (Figure 28. The arms should be delivered by sweeping them across the baby’s Hyperflex her legs against the abdomen. Assess the effectiveness face and downwards or by the Lovset manoeuvre – rotation of of the manoeuvre with routine traction (one attempt) before the baby to facilitate delivery of the arms (Figure 28. The baby’s body should be supported direction, just above the maternal symphysis pubis using the heel onyourarm. With the other hand, gentle traction should be aspect of the anterior shoulder towards the foetal chest. Again applied simultaneously to the shoulders, using two fingers to flex assess the effectiveness of the manoeuvre with routine traction the occiput, i. If each of these measures fails the mother should be asked to assume the ‘all fours’ position with her head as low as possible and her bottom elevated.

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It may be advisable to document the date of the last menstrual period on the nuclear medicine request form discount bystolic 5 mg with mastercard. A sign warning patients to tell staff if they are pregnant should be displayed in the waiting room bystolic 2.5mg online. Pregnancy is not an absolute contraindication to radionuclide studies and in many situations 5mg bystolic, such as confirmation or exclusion of pulmonary embolus, may provide essential diagnostic information. If a patient is pregnant it is imperative to discuss the indications for the study with a departmental medical officer, and the fact that the patient is pregnant must be clearly marked on the consultation form. A smaller than normal activity of radiopharmaceutical may be administered, thereby minimizing radiation to the foetus. There is little risk 99m involved with the use of Tc radiopharmaceuticals, but studies with other radionuclides should be avoided unless clinically justified. If a pregnant patient does have a nuclear medicine procedure, there are ways of calculating the radiation dose to the foetus, and tables of radiation doses. The foetal dose arises from the mother (usually from bladder activity) and from radionuclides that have crossed the placenta to the foetal circulation. Personnel monitoring All nuclear medicine staff must be routinely monitored for occupational radiation exposure. This includes nursing staff but may not need to include clerical staff, unless they are involved with patients. Records must be kept for their working lifetime, including the cumulative (running total) dose. Depending on the local regulatory requirements, it may be convenient to maintain detailed records only for the current year, and to keep yearly totals otherwise. Under the laws of many countries, the head of nuclear medicine will be held responsible for this, as well as for staff safety. Monitoring results must be reviewed regularly by an appropriate person, such as a physicist or senior technologist. The basic principle of radiation safety is to aim for the lowest feasible dose, not to allow staff to receive any regulatory dose limit. Staff who exceed this limit, on a pro rata basis (dose multipied by monitoring period in weeks/52), should be checked to ensure that their work practices are safe and that they have not been accidentally or unnecessarily exposed. If nurses are regularly involved, then they should be regularly monitored, otherwise monitoring need only be carried out for each case. Here, electronic direct reading dosimeters are advisable to allow continuous knowledge of the total dose. Routine and area monitoring Routine and area monitoring covers regular surveys of the radiation background in critical areas such as the radiopharmacy. These allow practices and safety measures to be modified before staff doses increase, particularly when new radiopharmaceuticals, radionuclides or increased activities are involved. The radiopharmacy should have a permanent area monitor (scintillation counter or ionization chamber), with an audible signal for dose rate, to allow staff to know when radioactive sources are exposed. Typically this would be a radiation safety committee with the responsibility for overseeing radiation safety practices in the hospital, and advising the administration on radiation safety issues. Repre- sentation from the nuclear medicine section is very important and should be mandatory. Often, the nuclear medicine physician or physicist is the only person who can provide expert advice on internal radionuclide dosimetry, and in investigation of radiation incidents where unsealed radionuclides are involved. The committee should have among its responsibilities the following: —Review of staff radiation dose records, especially abnormally high doses; —Review of radiation safety protocols; —Approval of applications for licences under radiation legislation; 520 8. The hospital should also appoint an appropriately qualified and experienced person as the radiation safety officer. Nuclear medicine physicists, physicians or technologists are usually good candidates for this role. While this is common to all medical specialties, it is particularly true for nuclear medicine because of its relationship to, and dependence on, high technology advances. Rapidly developing areas such as electronics, physics, computer sciences, radio- pharmacy and radiochemistry, as well as molecular biology, are closely related to nuclear medicine so that this medical science not only follows developments in such areas but also provides feedback to them. Some particular areas regarding recently achieved advances or future potential ones in nuclear medicine are worth highlighting. The range and benefits of these procedures, both diagnostic and therapeutic, are gaining in both recognition and appreciation. Their role in medical decision making, as part of standard patient care, helps fulfil an otherwise unmet need. The centralization of nuclear medicine and radiopharmaceutical services is leading to a hub and spoke concept. This means that patients may be studied in a peripheral hospital according to the agreed protocols set out in this manual, and the data transferred to a central point for analysis and reporting. This in turn enables nuclear medicine physicians to assist colleagues who work in new centres or in remote areas. Simple telenuclear medicine practice requires an image acquisition site coupled with an image interpretation site. In advanced telenuclear medicine networks, different sites should have the same system configurations to ensure basic compatibility and interoperability, enabling image acquisition, data analysis and data interpretation. It is important, however, to ensure the confidentiality of patient data at all times. The Internet has provided many new opportunities for education in nuclear medicine through distance learning. Universities, scientific societies and international organizations can place a range of teaching resources — slide shows, multimedia teaching packages, relevant textbooks and documents, and digital case study files — on the Internet, for easy access and downloading. Teaching materials on the Internet can be used for both education and on-the- job training in nuclear medicine. Staff members can tailor these materials and design their own purpose made teaching packages. This is particularly useful when there is no Internet connection available or telephone links are too slow for image file transfer. Advances in telecommunications have opened a new horizon for the promotion of nuclear medicine around the world.

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Excessive stress and a sense of helplessness have been postulated purchase bystolic 2.5 mg without a prescription, but not proven buy discount bystolic 5 mg on line, to promote cancer growth discount 5 mg bystolic mastercard. It was generally held that relapse was more likely in breast cancer patients in the presence of severely threatening live events and difficulties, but a prospective study did not bear this out. It is the commonest lethal inheritable disease of Caucasians (autosomal recessive). Carcinoma of the lung (16% of cases), ovary and stomach can cause brain syndromes in the absence of metastases. Children educated about their cancers have good psychological outcomes if they happen to survive. Despite undoubted medical progress, parents of children with leukaemia may have great difficulty accepting the diagnosis, the children often develop behaviour problems, and leukaemic children may feel that they have a foreshortened future. Diagnostic and therapeutic procedures, as well as frequent hospital admissions can be emotionally challenging. Cognitive problems are associated with irradiation of meninges and intrathecal methotrexate. According to Massie (2004) rates of depression vary with cancer type: oropharynx (22-57%), pancreas (33-50%), and lung (11-44%) have high rates; lower rates are associated with colon (13-25%) and lymphoma (8-19%). Venlafaxine may help reduce hot flushes in survivors of breast cancer,(Loprinzi ea, 2000) as may citalopram and paroxetine. Some felt less emotionally stable, felt more stressed with reduced self-esteem, had unsatisfactory sex lives and felt less feminine. In other work, women who regretted prophylactic mastectomy felt that the decision to operate had come from the surgeon. In males, the storage of sperm should be considered when chemotherapy is given with curative intent. They should, however, individualise information and find out what the patient is really asking. The patient should be given the information requested but not bombarded with facts. There is some evidence that doctors may try to keep the patient alive or to cure cancer to too great an extent. There may be more pressing indications for a greater emphasis on the care and comfort of the terminal cancer patient, with more use of analgesics and psychoactive drugs and less use of radiotherapy and chemotherapy. Imparting bad news 2239 Problems in the doctor – untrained (how and where to tell and how to answer questions), uncertain (of patient’s reaction or if the therapeutic relationship will suffer), and unsure (if patient will be upset) Preparation – consider patient’s prior knowledge and supports/resources, likely questions and types of reaction and appropriate responses, knowledge of patient’s previous responses to adversity When to tell – this is based on a consideration of many issues, e. Imagework,(Kearney, 1992) where the patient focuses on mental images in his mind and asks himself questions that allegedly helps him to work through repressed material, has been advocated for pain, including cancer pain, that is inadequately responsive to physical interventions and which is considered to have a significant emotional component. About one in four patients receiving combined chemotherapy develop nausea and vomiting if reminded of the treatment (Watson ea, 1992) and this response may lead to treatment avoidance. Involvement of the spinal cord can lead to various inflammatory disorders, stiff person syndrome, amyotrophic lateral sclerosis, or sensory (dorsal root) neuronopathy. Other potentially affected areas Peripheral nerve - various neuropathies 2242 Neuromuscular junction - Lambert-Eaton myasthenic syndrome , myasthenia gravis Muscle - polymyositis, dermatomyositis, necrotising myopathy, myotonia Neurological disorder usually precedes overt malignancy by months, even years. Spinal cord injury Migliorini ea (2008) examined mental health status in cross-section among 443 community-based adults with injured spinal cords. Most patients with spinal cord injury fail to ejaculate, or if they do, it is either non-orgasmic or with only an awareness of some altered feeling. Most male paraplegics with spinal cord injury put resumption of sexual function at the top of their wish list. Patients with spinal cord injury often say that they develop an area of arousal lying superior to the level of the lesion leading to sexual satisfaction (‘phantom orgasm’) from tactile experiences such as caressing. This is due to lack of sensory information from the environment and from immobilisation. It is better to observe such cases for about four weeks than to rush in with antidepressants. The spinal cord-injured patient who still feels (but does not believe) as if he/she is in/on the vehicle in which the trauma occurred may think he is losing his mind. He/she needs to be reassured that such persisting perceptions are a recognised complication of cord injury. Vermiform appendicitis Patients with a normal appendix at laparotomy have been found to have experienced more severely threatening life events in the weeks before the onset of abdominal pain than did those found to have an acutely inflamed appendix. Patients with a normal appendix at laparotomy are at increased risk of future hospital visits, particularly for self harm and for been seen by the liaison psychiatrist. Those amputees who realistically appraise their situation and who work hard with rehabilitative measures do best. It seems to take some amputees many months before they appear as such in their dreams, although the dream content and changes therein varies widely between individuals. Phantom and supernumerary limbs Experience of possessing a limb that does not exist - in the first case the limb was amputated whereas in the second instance an extra limb is experienced Phantom limb Described in 1649 by Ambrose Paré Tactile (often painful) rather than visual phenomenon, usually disappearing a matter of days after 2244 amputation Usually the ‘limb’ is ‘absorbed’ or telescoped into the body, although some patients have a permanent phantom Very young children rarely experience phantoms Congenital limb absence may occasionally be associated with replacement phantoms Preoperative anaesthetic block does not reduce the likelihood of phantom limb pain (Bach ea, 1988; Birbaumer ea, 1997; Flor, 2002) Supernumerary limb Experiencing an extra hand, fingers or limb, the number and site of such extra parts varies between patients May occur with anosognosia for a left-sided hemiplegia Usually there is retained insight Looking at the limb may cause the extra part/phantom to disappear Disorders of body schema Abnormal awareness of spatial characteristics of the person’s own body Partially paralysed limb may feel excessively heavy or large (hyperschemazia) – found in multiple sclerosis, vascular disease, spinal cord lesions, toxic states, conversion states, hypochondriasis, dreaming, and in states of depersonalisation Aschemazia and hyposchemazia (part of body seems smaller or absent respectively) may occur when the cord is divided, with parietal lobe lesions (e. Executive dysfunction is common after stroke, an outcome that may be ameliorated by antidepressant drug therapy. The infarct is either so small or in an area of brain that allows its effects to go unnoticed. It could mean that there are no discernible physical signs (see strategic infarct in box). However, such cases can be psychiatrically ‘noisy’ and present in a 2246 manner ranging from delirium to a pseudo-‘functional’ psychosis. Higher doses used in America and methodological flaws may have partly led to this finding. A meta-analysis (Antithrombotic Trialists’ Collaboration, 2002) found low dose (75-150 mg/day) aspirin reduced the risk of vascular events (at least 150 mg/day in acute setting) but that adding dipyridamole to aspirin did not significantly improve outcome. Olanzapine and aripiprazole are ‘contraindicated’ in elderly patients with dementia-related psychosis and/or behavioural disturbance because of evidence for an association with an increased mortality rate and a 2247 greater likelihood of stroke. Also, there is also evidence against an association between stroke and atypicals in elderly subjects with dementia! People who are born deaf have no increase in psychiatric illness, although they may be prone to behaviour problems. The latter may stem from parental over-protection, separation in institutions, adverse reactions of third parties, excess emphasis in teaching on speech at the expense of sign language, or associated brain damage. High frequency hearing loss is common in early middle age in Down’s syndrome patients and may account for apparent deterioration in cooperativeness. Whilst persecutory states are the classical psychiatric problem in the elderly with hearing impairment depression is more common in practice.

Some o f these commentators order bystolic 2.5mg with amex, such as Leonard bystolic 5 mg line, have gone on to the second argum ent—that a new epoch is em erging trusted 2.5mg bystolic, or at least that we are on its threshold. It has become less and less easy to dismiss these voices as millenarian, rustic, nonscientific, or even crazy. Sociocultural innovation is impoverished, and economic and political structures are variations on a common and empty theme. Revolutions and revolts, each chasing on the heels o f its predecessor, disap­ pear one into another in a dreary uniform ity—the op­ pressed become the oppressors, and so on. In The Struggle Against History, Ronald Segal, a socialist critic and writer, recognizes this when he says of the two dom inant political and economic systems: “While the two. Remedial pro­ grams utilizing still m ore technology are ultimately self- defeating. Moreover, there may be fixed and im m u­ table limits to growth, even though we do not know when we shall reach them. Robert Theobald puts it this way in Habit and Habitat: 146 The Climate for Medicine All o th er species w ork w ithin th e existing habitat. T h e ir success o r failure d ep en d s u p o n th eir ability to ad ap t to th e conditions in w hich they find them selves. T h eir survival d ep en d s u p o n a com plex, in terrelated ecosystem o f w hich they fo rm a sm all p a rt an d over w hich they have very lim ited control. M an alone has tried to deny his relationship to th e total ecosys­ tem o f w hich he form s p a rt by continuously ignoring and cutting o ff feedback w hich he finds undesirable. H e has d e­ veloped th e habit o f seeing his habitat as totally flexible accord­ ing to his ow n wishes and desires. Prevailing paradigm s springing from materialistic and mechanistic bases are blurring at the edges. Although the behavioral sciences continue to rely largely on traditional interpretations, the physical sciences are striding into mysti­ cism. Hence, to assume that a linear developm ent of current scientific knowledge will subsume the usable knowledge of the future is to fall into what Richard H. Bube, a professor of material sciences and electrical engineering at Stanford University, has labeled “one of the most pernicious false­ hoods ever to be almost universally accepted. W hen taken together, the similar strands woven through existing mythic, religious, and scientific accounts suggest a “lost” historical record. These provocative strands are found in the records o f the Sumerian culture and the ancient cultures o f Central America, particularly Mexico. We are all familiar to one degree or another with the recrudescence of the occult. Freedland traced the revival in The Occult Explosion,8 and Colin Wilson rendered its histor­ ical sweep in The Occult,9 Moreover, new religious move­ ments are springing up. Edgar Cayce has been more widely read than nearly any other author in recent years. T he anthropological lore of Carlos Cas­ taneda is perhaps the best single statem ent. Sartre touches on this in his tetralogy, The Roads to Freedom,12 when he depicts M athieu’s w onderm ent at the pulsing life of a tree. George Leonard in The Transformation picks up the them e this way: For a b rief m om ent I ex perienced th e tree ’s being, th en I am th ru st back firm ly to m y separate existence, capable o f seeing th e tree at a distance, touching it, cutting it dow n, analyzing it. I have been given nam es fo r each o f its constituent parts, term s for its processes, an d ways for relating it w ith th e o th er ele­ m ents o f the biosphere. B ut som ething is w rong with this m ode o f perceiving and being, even in strictly scientific term s. T h e physicists have tau g h t m e th at th e tree, so substantial a n d im penetrable, actu ­ ally is m ostly “em pty space”; if we conceive the subatom ic elem ents o f w hich it is m ade as particles. T h ere fo re, the tree ap p ears im penetrable to m y physical body, a handy cor­ respondence. Physics an d m athem atics have provided us a respectable way o f acknow ledging w hat prim itive peoples have always know n: T h e tree is not really solid. Related to the issue of reality is the anthropocentri- cism of our science, which persists in classifying hom o sa­ piens as a wholly independent variable in the cosmos. Much of the cosmic literature is sensationalized; Hal Lindsey’s The Late, Great Planet Earth is an exam ple. Many argue that the dom inant culture of consum p­ tion and competition m ust yield to an em ergent culture characterized by self-restraint, cooperation, and communal- ity. These views have not found their way into politics, but they may form the foundation for the future social ex­ perim entation. In ways that are not entirely clear, there are signs of an evolving “consciousness” am ong an increasing, largely youthful, but still small num ber of people. T here is general agreem ent that there is a move­ m ent to build a better, m ore hum ane society, but observers disagree on the causes, breadth, and specific aims o f the movement. In an article in Saturday Review, “T he New Naturalism ,” Daniel Yankelovich argues that the new naturalism means, am ong other things: T o push th e D arw inian version o f n a tu re as “survival o f the fittest” into the background, an d to em phasize instead the in terd ep en d en ce o f all things and species in natu re; T o place sensory experience ah ead o f conceptual know ledge; T o live physically close to n atu re, in th e open, o ff th e land; An Emerging Zeitgeist 149 T o live in g ro u p s (tribes, com m unes) ra th e r th an in such “artificial” social units as th e nuclear fam ily; T o de-em phasize aspects o f n a tu re illum ined by science; in ­ stead, to celebrate all th e unknow n, th e m ystical, an d the m ys­ terious elem ents o f natu re; T o stress cooperation ra th e r th an com petition; T o devalue detach m en t, objectivity, a n d noninvolvem ent as m ethods fo r finding tru th ; to arrive at tru th , instead, by direct experience, participation an d involvem ent; T o reject m astery over n atu re; T o em phasize the com m unity ra th e r th an th e individual; and T o preserve th e en v iro n m en t at the expense o f econom ic grow th an d technology. But if the m ovement gains m om entum over the next three de­ cades, new values will be established upon which future decisions m ust be based. If so, some of the prob­ lems associated with growth, such as pollution, resource depletion, and the spread of concrete might be checked. If it is true that attitudes engendered in youth survive into old age, many o f those who govern at the end of this century will have been acculturated differently from those who govern today. A lthough the countercultural rev­ olution may turn out to be ephem eral, it is still likely to have some effect on political and social change over the next 30 years. With that integration has come a steady inflation of the role o f the federal government. T he passage of a national health insurance plan will swell the federal role even more. But at the same time, some communities may seek to assume 150 The Climate for Medicine more, not less, of the obligation to provide their care. In addition, consum er dem ands for more personalized care are likely to increase; ironically at a time when manpower shortages and the institutionalization in the medical care system frustrates this dem and. It is doubt­ ful that this will be widespread, but communities may try to treat “their own” using indigenous folk practices. T he demise of folk medicine was associated with the disin­ tegration of viable insular com m unities. Profes­ sionalism is incompatible with the idea of community and the egalitarianism that accompanies it.