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By: K. Deckard, M.A.S., M.D.

Assistant Professor, Oregon Health & Science University School of Medicine

Examination for chest injury the chest examination in blunt injury should be approached systematically to blood pressure 3rd trimester purchase coreg 12.5 mg fast delivery ensure injuries are adequately identified heart attack songs videos discount 6.25mg coreg with amex. An efficient physical exam begins with a quick visual inspection of the neck and chest in the cephalad to how quickly should blood pressure medication work order 12.5 mg coreg with amex caudad direction. The trachea is checked for midline position and the internal jugular veins are inspected for distention. Any abrasions, 294 contusions, or lacerations are noted as visual surveillance is carried down the chest for obvious signs of external injury. In addition, the chest wall motion is observed for asymmetric chest rise or paradoxical movement with respirations. The exam should then proceed with auscultation of the chest for symmetrical, bilateral breath sounds. Absent or decreased breath sounds are suggestive of a hemothorax or pneumothorax and immediate drainage with tube thoracostomy is indicated if the patient has cardiopulmonary instability. Auscultation is followed by palpation of the neck, clavicles, sternum, and chest wall to assess for any tenderness, skeletal instability, or crepitance. Finally, percussion of the chest for dullness or hyperresonance completes the chest examination. Abnormalities in the chest exam should prompt further investigation with radiological studies for intrathoracic injuries. For penetrating injuries, particular attention should be directed to Zone I of the neck, which is bordered by the cricoid cartilage superiorly and the clavicles inferiorly. This location is the thoracic outlet and is densely occupied by significant structures that may be potentially injured, including the carotid artery, internal jugular vein, trachea, and esophagus. As visual inspection descends down the chest, the number, location, and character of open wounds should be noted. Sucking chest wounds should be addressed immediately with a three-sided dressing to prevent precipitation of a tension pneumothorax. In cases of missile injury, the wounds should be marked with a radiopaque marker, prior to chest X-ray. Lastly, the neck and chest are palpated for 295 tenderness and subcutaneous emphysema. There is increased risk of intrathoracic damage with penetrating injuries, particularly hemothorax and pneumothorax. There should be a low threshold to perform chest tube thoracostomy, if the clinical situation warrants. The boundaries of the box are the clavicles superiorly, the nipples laterally, and the costal margin inferiorly. As part of the physical exam, the patient should be examined for signs of cardiac tamponade. Additionally, pulsus paradoxus, or a drop in 10mm Hg of arterial pressure with inspiration, may be seen. Sonographic examination should also be done at the bedside to assess for pericardial effusion. Confirmation of cardiac injury or hemodynamic instability warrants emergent thoracotomy. In cases of severe tamponade, pericardiocentesis may be done as a temporizing measure prior to the operating room. Physical exam findings may be non-specific for injuries in this area of the cardiac box. Patients may present with hoarseness, chest wall crepitance, or substernal tenderness. However, the location of the penetration wound and knowledge of the cardiac box may be the only clue to 296 intrathoracic injury. Concern for injuries in this area, regardless of physical exam findings, merits further endoscopic or radiographic evaluation.

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What are the risks and benefits of mood stabilisers and antipsychotics in the prophylaxis and management of postpartum psychosis hypertension 80 mg purchase coreg with paypal, and the management of bipolar disorder in pregnancy What evidence exists concerning the benefits of specific elements of service design and delivery for patients with antenatal and postnatal mental health disorders Management of Women with Mental Health Issues during Pregnancy andandthe Postnatal Period blood pressure medication dosages purchase genuine coreg on line. Adapted from Glasgow Perinatal Mental Health Service Lithium is a mood stabilising drug heart attack exo xoxo 25 mg coreg fast delivery, used in the management of bipolar affective disorder. It is rarely used in pregnancy, because of teratogenicity and neonatal complications. It has a narrow therapeutic to toxic ratio and must be monitored regularly by blood sampling. Dose range to achieve therapeutic blood levels is usually between 400 mg and 1,200 mg/day, but this is less important than the blood level. The dose required to achieve therapeutic levels may increase from mid-pregnancy, but high levels at delivery can be associated with toxicity in the mother and neonate. Any woman taking lithium in pregnancy should have an individualised psychiatric care plan for lithium management throughout pregnancy and the peripartum. Toxicity can be precipitated by: y dehydration y impaired renal function y sodium-restricted diet y overdose y drug interactions. Pregnancy-related conditions that increase the risk of lithium toxicity include: y fluid loss at delivery y hyperemesis y pre-eclampsia Remember: If lithium toxicity is suspected, take a lithium level, noting the time when the sample was taken, and the time and amount of the last dose, and seek medical/psychiatric advice. Prospective study of postpartum depression in an Israeli cohort: prevalence, incidence and demographic risk factors. Paternal and nonpostpartum depression: Clinical presentation, psychiatric maternal depressed mood during the transition to parenthood. Postpartum North Staffordshire Maternity Hospital prospective study and nonpostpartum depression: differences in presentation of pregnancy-associated depression. J Abnorm Psychol Post-natal depression in an urban area of Portugal: comparison 1991;100(4):594-9. Effects of postnatal depression on infant screening accuracy, and screening outcomes. Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, of postnatal psychiatric morbidity in mothers and fathers. Estimating psychiatric morbidity by of depressed mood during pregnancy and after childbirth. Social support, life events, and depression depression predicts depression in adolescent offspring: during pregnancy and the puerperium. Screening for postnatal depression in of postpartum depression on maternal mood and infant a population-based Swedish sample. Puerperal psychosis: Identifying and of maternal postnatal depression on cognitive development of caring for women at risk. Murray L, Sinclair D, Cooper P, Ducournau P, Turner P, Stein treatment of postnatal depression. Br J of the short and long-term effect of psychological treatment Psychiatry 2005;186:258-9. Safety concerns associated with the use of serotonin reuptake inhibitors and other serotonergic/noradrenergic 38. Clin Ther postpartum exposure to maternal depression: different effects 2009;31(Pt 1):1426-53. Pharmacopsychiatry 2009;42(3):95 development of 5-year-old children of postnatally depressed 100. The Association and Royal Pharmaceutical Society of Great Britain; course of anxiety and depression through pregnancy and 2011.

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Follow up of multiple pregnancies should be arranged in accordance to hypertension 38 weeks pregnant buy generic coreg 6.25 mg on line local guidelines and clinical practices blood pressure quit drinking buy coreg 12.5mg on line. All these characteristics can be visualized at the time of the head measurements and when the brain is evaluated for anatomic integrity (Figure 2) (40) blood pressure zanidip purchase coreg 25mg overnight delivery. Shape: the skull normally has an oval shape without focal protrusions or defects and interrupted only by narrow echolucent sutures. Rarely, brain tissue can extrude through defects of the frontal or occipital bones although cephaloceles may occur at other sites as well. Density: Normal skull density is manifested as a continuous echogenic structure that is interrupted only by cranial sutures in specific anatomical locations. The absence of this whiteness or extreme visibility of the fetal brain should raise suspicion of poor mineralization. Poor mineralization is also suggested when the skull becomes easily depressed as a result of manual pressure from transducer placement against the maternal abdominal wall. Two axial planes permit visualization of the cerebral structures relevant to the anatomic integrity of the brain. These planes are commonly referred to as the transventricular and transthalamic planes (Figure 2). If 12 technically feasible, a median facial profile view can be obtained (Figure 3c). Both lungs should appear homogenous and without evidence for mediastinal shift or masses. The diaphragmatic interface can often be visualized as a hypoechoic dividing line between the thoracic and abdominal content. A single acoustic focal zone and relatively narrow image field of view can help to maximize frame rates. Images should be magnified until the heart fills at least a third to one half of the display screen. The heart 13 should be located in the left chest (same side as the fetal stomach) if the situs is normal. A normal heart is usually no larger than one-third the area of the chest and without pericardial effusion. Additional views to the basic examination are more likely to identify conotruncal anomalies such as tetralogy of Fallot, transposition of the great arteries, double outlet right ventricle, and truncus arteriosus. Normal great vessels are approximately equal in size and should cross each other as they exit from their respective ventricular chambers. Bowel should be contained within the abdomen and the umbilical cord should insert into an intact abdominal wall. Aside from the left-sided stomach, a fetal gallbladder may be seen in the right upper quadrant next to the liver although this latter finding is not a minimum requirement of the 14 basic scan. Any other cystic structures seen in the abdomen should be referred for a more detailed scan. The fetal umbilical cord insertion (Figure 5a) site should be examined for evidence of a ventral wall defect such as omphalocele or gastroschisis. Cord vessels may also be counted using gray-scale imaging as an optional component of the routine anatomic survey. If either the bladder or renal pelvis appears enlarged, a measurement should be documented. Persistent failure to visualize the bladder should prompt a referral for a more detailed assessment. Complete evaluation of the fetal spine from every projection is not a part of the basic examination although transverse and sagittal views are usually informative.