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Antihypertensive remedy has been shown to scale back the danger of a extreme maternal hypertensive crisis however has not been shown to improve overall peri natal consequence medications qid best buy copegus. Experts within the United States have recommended that pregnant ladies with hypertension within the blood stress range of a hundred and fifty�a hundred and sixty/one hundred�one hundred ten mm Hg should be handled with antihypertensive remedy treatment wax discount copegus 200mg online, and that their blood stress should be stored lower than a hundred and fifty/one hundred mm Hg symptoms 0f yeast infectiion in women cheap 200 mg copegus free shipping. Based on the overall low fee of adverse results and good effi cacy treatment plan goals and objectives order copegus 200mg mastercard, labetalol is a good possibility for first-line therapy of persistent hypertension 234 Guidelines for Perinatal Care in being pregnant. Calcium channel blockers or antagonists, probably the most generally studied of which is nifedipine, also have been used in pregnant ladies with persistent hypertension. Methyldopa has been used for many years to treat hyper pressure in being pregnant, and it seems to be secure for this indication. However, its strong affiliation with vital maternal sedation at therapeutic doses is a limitation to using this medicine. Angiotensin-changing enzyme inhibitors and angiotensin receptor blockers are contraindicated in all trimesters of being pregnant. Pregnant ladies with uncomplicated delicate persistent hypertension usually are candidates for a vaginal delivery at term because most of them have good maternal and neonatal outcomes. Women with hypertension dur ing being pregnant and a previous adverse being pregnant consequence (eg, stillbirth) could also be candidates for earlier delivery after documentation of fetal lung maturity. Women with extreme persistent hypertension during being pregnant typically both give birth prematurely or need untimely delivery for fetal or maternal indications. The combination of persistent hypertension and superimposed preeclampsia, particularly whether it is preterm, represents a complicated scenario, and the clinician should contemplate consultation with a subspecialist in maternal�fetal medicine. Women with extreme hypertension might require antihypertensive drugs to treat acute elevation of blood stress. Women with persistent hypertension sophisticated by vital cardiovascular or renal disease require particular attention to fluid load and urine output because they might be susceptible to fluid overload with resul tant pulmonary edema. General anesthesia might pose a threat in pregnant ladies with extreme hypertension or superimposed preeclampsia. Intrauterine Growth Restriction Intrauterine development restriction is a term used to describe a fetus whose esti mated weight seems to be less than expected, often less than the 10th per centile. Perinatal morbidity and mortality is significantly elevated within the presence of low birth weight for gestational age, especially with weights beneath the third percentile for gestational age. Screening All pregnancies should be screened with serial fundal peak assessments, reserv ing ultrasonography for those fetuses with threat components (see Box 7-2), lagging development, or no development. Physicians should contemplate an early ultrasound examination to substantiate gestational age, as well as subsequent ultrasonography to judge sequential fetal development, in ladies with vital threat components. Diagnosis There are two essential steps concerned within the antenatal recognition of development restriction: 1) the elucidation of maternal threat components associated with development restriction (see Box 7-2) and a pair of) the medical evaluation of uterine dimension relative to gestational age. Several strategies are available for medical determination of uterine dimension, the commonest of which is the measurement of fundal peak. Serial ultrasound examinations to determine the rate of 236 Guidelines for Perinatal Care Box 7-2. Risk Factors for Intrauterine Growth Restriction ^ � Maternal medical conditions � Hypertension � Renal disease � Restrictive lung disease � Diabetes (with microvascular disease) � Cyanotic heart disease � Antiphospholipid syndrome � Collagen-vascular disease � Hemoglobinopathies � Smoking and substance use and abuse � Severe malnutrition � Primary placental disease � Multiple gestation � Infections (viral, protozoal) � Genetic disorders � Exposure to teratogens American College of Obstetricians and Gynecologists. The fetus should be delivered if the danger of fetal demise exceeds that of neonatal demise, though in lots of instances these risks are troublesome to assess. Early delivery might yield an toddler with all the intense sequelae of pre maturity, whereas delaying delivery might yield a hypoxic, acidotic toddler with Obstetric and Medical Complications 237 lengthy-term neurologic sequelae. Gestational age and the findings of antenatal surveillance should be taken into consideration. The choice to ship is predicated typically on nonreassuring fetal evaluation or a complete cessation of fetal development assessed ultrasonographically over a 2�four-week interval. When extrauterine sur vival is probably going regardless of significantly abnormal antenatal testing, delivery should be seriously considered. The formation of maternal antibodies, or alloimmunization, might lead to varied degrees of transplacental passage of these antibodies into the fetal circulation. Depending on the degree of anti genicity and the quantity and kind of antibodies concerned, this transplacental passage might lead to hemolytic disease within the fetus and neonate. Undiagnosed and untreated, alloimmunization can lead to vital perinatal morbidity and mortality. Historically, a lot of the instances of Rh alloimmunization that brought on transfusion reactions or severe hemolytic disease within the fetus and new child have been the results of incompatibility with respect to the D antigen. For this cause, the designation Rh optimistic often signifies the presence of the D antigen and Rh negative signifies the absence of D antigen on erythrocytes. However, using antepartum anti-D immune globulin to stop pink cell alloimmunization has led to a relative increase within the variety of instances of non�Rh-D alloimmuniza tion, which causes fetal anemia and hemolytic disease within the new child. If the preliminary antibody titer is 1:eight or less, the affected person could also be monitored with maternal serum antibody titer evaluation every four weeks. Note that for a girl with a historical past of a beforehand affected 238 Guidelines for Perinatal Care fetus or neonate, serial titer evaluation is insufficient for surveillance of fetal anemia. Additional evaluation is required for sufferers with a important titer (rang ing from 1:eight to 1:32 at most institutions), which is associated with a major threat of extreme erythroblastosis fetalis and hydrops. Antepartum Management the preliminary administration of a being pregnant involving an alloimmunized affected person is determination of the paternal erythrocyte antigen genotype standing to assess the danger of hemolytic anemia within the fetus. However, if the daddy�s genotype is heterozygous or unknown, the fetal antigen type should be assessed by amniocentesis. Measurement of the height systolic velocity within the fetal middle cerebral artery by way of Doppler ultrasonography is used to assess the severity of erythroblastosis in utero. Moderate or extreme anemia is predicted by values of peak systolic velocity within the fetal middle cerebral artery above 1. Doppler measurements are also used to foretell extreme fetal anemia in sufferers with Kell alloimmunization. Correct approach is a important issue when determining peak systolic velocity within the fetal middle cerebral artery with Doppler ultrasonography. This procedure should be used only by those with sufficient coaching and medical experience. Intrapartum Management It is cheap to proceed with delivery by induction of labor at 37�38 weeks of gestation if the historical past and antenatal research point out only delicate fetal hemolysis. Induction could also be considered earlier if fetal pulmonary maturity is documented by amniocentesis. With severely sensitized pregnancies requiring a number of inva sive procedures, the risks of continued umbilical wire blood sampling and transfusions have to be considered and in contrast with those neonatal risks asso ciated with early delivery. Obstetric and Medical Complications 239 Multifetal Pregnancy the incidence of dual and excessive-order a number of gestations has elevated signifi cantly over the past 20 years primarily due to the provision and elevated use of ovulation induction agents and assisted reproductive know-how. There is elevated fetal, neonatal, and maternal morbidity and mortality associated with multifetal gestations. The working towards obstetrician managing these excessive-threat sufferers should be familiar with their particular antepartum and intrapartum prob lems, and consultation with maternal�fetal medicine specialists could also be essential. Antepartum Management Antepartum administration of multifetal pregnancies requires particular contemplate ations within the areas of vitamin, prenatal prognosis, antepartum surveillance, ultrasonography, and within the prognosis and therapy of generally related being pregnant problems. It is recommended that maternal dietary intake in a a number of gestation be elevated by approximately 300 kcal more per day than that for a singleton being pregnant. The optimal weight achieve for ladies with a number of gestations has not been determined. The ordinary indications for prenatal prognosis and counsel ing in a singleton being pregnant apply to twin and excessive-order a number of gesta tions (see additionally �Antepartum Genetic Screening and Diagnosis� in Chapter 5. The presence of a number of fetuses increases the mathematical chance that a number of fetuses might be affected and, thus, leads to a higher threat for the being pregnant than that attributed to maternal age alone. Amniocentesis or chorionic villous sampling could also be technically troublesome to accomplish in sufferers with a number of gestations, and only skilled physicians should perform these procedures in excessive-order a number of gestations. Technical issues unique to excessive-order a number of gestation embrace the need to traverse another fetus� sac to reach a special fetus for sampling, incorrect 240 Guidelines for Perinatal Care fetal karyotype caused by cross contamination with different sacs, issue in accurately mapping the fetuses and determining which fetus is being sampled, issue in accurately determining whether any of the fetuses are monochori onic twins, and issue in locating and lowering only the affected fetus within the occasion an aneuploidy is identified and termination chosen. Ultrasonography can be helpful in both prenatal prognosis and surveillance of a number of gestations. Early ultrasonography should be used for evaluation of chorionicity, given its importance regarding prognosis and threat of certain problems. Beginning at viability, serial estimations of fetal development by ultrasonography (every four�6 weeks after viability, or more intently spaced should indications come up) are a prudent measure because physical exami nation is less reliable. Complications associated with a number of gestations embrace ges tational diabetes, hypertension and preeclampsia, untimely delivery, development restriction, discordant development, demise of one fetus, and twin�twin transfu sion syndrome.

Continuous presence of a help individual seems to scale back the probability of medicine for pain reduction medications and mothers milk 2014 order copegus 200 mg amex, operative vaginal delivery medicine you can overdose on copegus 200mg mastercard, cesarean delivery medications osteoarthritis pain buy generic copegus 200mg online, and 5-minute Apgar scores lower than 7 medications lexapro order cheapest copegus. The judgment of the obstetric employees, the individual obstetrician, the anesthe siologist, and pediatric help personnel, as well as the policies of the hospital, determines whether or not help individuals could also be present at a cesarean delivery. Postpartum Maternal Care Immediate Postpartum Maternal Care Monitoring of maternal standing postpartum is dictated partly by the occasions of the delivery course of, the type of anesthesia or analgesia used, and the complica tions recognized. Postanesthesia pain administration must be guided by protocols established by the anesthesiologists and obstetricians in live performance. Blood stress ranges and pulse must be monitored a minimum of every 15 minutes for two hours, and extra regularly and for longer length if complications are encountered. The girl�s temperature must be taken a minimum of every 4 hours for the first eight hours after delivery, then a minimum of every eight hours subsequently. Discharge from the delivery room, which can involve recovery from an anesthetic, must be on the discretion of the doctor or certified nurse�midwife or the anesthesiologist in cost. Policy ought to ensure that a doctor is available in the facility, or a minimum of is close by, to manage anesthetic complications and provide cardiopul monary resuscitation for patients in the postanesthesia care unit. The affected person must be discharged from the recovery area solely on the discretion of, and after communication between, the attending doctor or a licensed nurse midwife, anesthesiologist, or certified registered nurse anesthetist in cost. Vital signs and additional signs or occasions must be monitored and recorded as they happen. Subsequent Postpartum Care the medical and nursing employees ought to cooperatively establish specific postpar tum policies and procedures. In the postpartum period, employees ought to assist the girl discover ways to take care of her personal basic wants and people of her neonate, and may identify potential issues associated to her basic well being. The obstetric caregiver ought to observe postpartum orders on the affected person�s medical record (see also �Postpartum Form� in Appendix A. If routine submit partum orders are used, they should be printed or written in the medical record, reviewed and modified as necessary for the actual affected person, and signed by the obstetric caregiver earlier than the affected person is transferred to the postpartum unit. When a labor, delivery, and recovery room is used, the same guidelines ought to apply. Bed Rest, Ambulation, and Diet It is essential for the brand new mom to sleep, regain her power, and get well from the results of any analgesic or anesthetic brokers that she may have received throughout labor. In the absence of complications, she may have an everyday food plan as soon as she wishes. Because early ambulation has been shown to decrease the incidence of subsequent thrombophlebitis, the mom must be encouraged to walk as soon as she feels ready to do so. If blood loss is greater than ordinary, the affected person�s hematocrit also must be assessed earlier than discontinuing intravenous access. Urogenital Care Traditional teaching contains that the affected person must be taught to cleanse the vulva from anterior vulva to perineum and anus quite than in the reverse direc tion. Application of an ice pack to the perineum in the course of the first 24 hours after delivery may assist scale back pain and swelling that have resulted from stress of the neonate�s head. Orally administered analgesics often are required and usually are adequate for reduction of discomfort from episiotomy or repaired lac erations. Beginning 24 hours after delivery, moist heat in the type of a warm sitz bathtub may scale back native discomfort and promote healing. Often ladies have difficulty voiding instantly after delivery, probably because of trauma to the bladder throughout labor and delivery, regional anesthesia, or vulvar�perineal pain and swelling. In addition, the diuresis that always follows delivery can distend the bladder earlier than the affected person is aware of a sensation of a full bladder. To ensure adequate emptying of the bladder, the affected person must be checked regularly in the course of the first 24 hours after delivery, with specific atten tion to displacement of the uterine fundus and any indication of the presence of a fluid-crammed bladder above the symphysis. Although every effort must be made to assist the affected person void spontaneously, catheterization could also be necessary. If the affected person continues to find voiding troublesome, use of an indwelling catheter is preferable to repeated catheterization. Care of the Breasts the girl�s choice about breastfeeding determines the suitable care of the breasts. During the stage of engorgement, the breasts may become painful and must be supported with a nicely-fitting brassiere. This is best addressed by administering the drugs on an as-wanted foundation according to postpartum orders. Most mothers experience appreciable pain in the first 24 hours after cesarean delivery. Although at one time pain most often was handled by intramuscular injections of narcotics, newer methods, similar to spinal or epidural opiates, affected person-controlled epidural or intravenous analgesia, and potent oral analgesics, present better pain reduction and higher affected person satisfaction. Regardless of the route of administration, opioids potentially can cause respiratory melancholy and reduce intestinal motility. Therefore, adequate supervision and monitoring must be ensured for all submit partum patients receiving these drugs. Postpartum Immunizations Attention must be given to maternal immunizations earlier than hospital discharge. No further administration of anti-D immune globulin is important when the infants of Rh D-unfavorable ladies are also Rh D-unfavorable. When the doctor and the mom desire a shortened hospital keep, the following minimal criteria must be met: � the mom is afebrile, with pulse and respirations of regular price and quality. The medical and nursing employees must be sensitive to potential issues related to shortened hospital stays and may develop mechanisms to 200 Guidelines for Perinatal Care tackle affected person questions that come up after discharge. With a shortened hospital keep, a house visit or comply with-up telephone convention by a well being care provider, similar to a lactation nurse, inside 48 hours of discharge is inspired. When a pregnancy, labor, or delivery is sophisticated by medical or obstetric problems, the mom�s readiness for discharge could also be based on the aforemen tioned criteria, as modified by the individual judgment of the obstetric care provider. The stability of the girl�s medical condition, the need for contin ued inpatient statement, and therapy and dangers of complications must be taken into consideration. Postpartum Nutritional Guidelines Postnatal dietary guidelines are much like those established throughout pregnancy (see also Chapter 5. The minimal caloric requirement for adequate milk production in a lady of common dimension is 1,800 kcal per day. In basic, an additional 500 kcal of vitality every day is recommended all through lactation. A balanced, nutritious food plan will ensure each the quality and the quantity of the milk produced without depletion of maternal stores. Fluid consumption by the mom is ruled by thirst (see also �Breastfeeding� in Chapter eight. Mothers at nutri tional risk must be given a multivitamin complement with specific emphasis on calcium and vitamin B12 and vitamin D (see also Chapter 5. Maternal postpartum weight reduction can happen at a price of two lb per 30 days without affecting lactation. On common, a lady will retain 2 lb more than her prepregnancy weight at 1 year postpartum. Aging, quite than parity, is the most important determinant of increases in a lady�s weight over time. Residual postpartum retention of weight gained throughout pregnancy that ends in obesity is a concern. Special attention to lifestyle, together with exercise and eating habits, will assist these ladies return to a standard physique mass index. Postpartum Considerations ^ Before discharge, the mom ought to receive information about the following regular postpartum occasions: � Changes in lochia pattern anticipated in the first few weeks � Range of actions that she may moderately undertake � Care of the breasts, perineum, and bladder Intrapartum and Postpartum Care of the Mother 201 � Dietary wants, notably if she is breastfeeding � Recommended quantity of exercise � Emotional responses, and risk of postpartum melancholy � Signs of complications (eg, temperature elevation, chills, leg pains, episiotomy or wound drainage, or elevated vaginal bleeding) the size of convalescence that the affected person can expect, based on the type of delivery, also must be mentioned. The earliest time at which coitus could also be resumed safely after childbirth is unknown. Therefore, sexual activity can resume after healing of the perineum and when bleeding has decreased, depending on resolution of contraceptive administration and, most significantly, on the affected person�s need and comfort. Sexual difficulties which might be common in the early months after childbirth must be mentioned. Healing on the episiotomy site can cause the girl some discomfort throughout intercourse throughout the first year following delivery. Furthermore, the calls for of the new child�s care alter the couple�s capability to find time for physical intimacy. At the time of discharge, the household must be given the title of the individual to contact if questions or issues come up for both the mom or the new child. Arrangements must be made for a comply with-up examination and specific instruc tions conveyed to the girl, together with when contact is advisable.

Depressed temper (or may be irritable temper in children and adolescents) for most of the day treatment centers cheap copegus 200 mg on-line, more days than not treatment urinary tract infection buy 200 mg copegus free shipping, as indicated both by subjective account or remark by others treatment 4 burns discount copegus 200mg with amex, for at least two years (one yr for youngsters and adolescents) B medicine wheel native american purchase copegus 200 mg visa. During a two-yr period (one-yr for youngsters and adolescents) of the disturbance, by no means with out the signs in A for greater than two months at a time. No evidence of an unequivocal Major Depressive Episode through the first two years (one yr for youngsters and adolescents) of the disturbance. Not superimposed on a chronic psychotic dysfunction, similar to Schizophrenia or Delusional Disorder. Anxiety + weight lack of 10 kg: A main despair B secondary despair Answer: these are the only signs How to stop chlamydia trachomatis infection� Primary prevention of chlamydia may be accomplished in two common ways. A Compression take a look at Answer: A Explanation: the carpal compression take a look at : � this take a look at includes making use of agency stress directly over the carpal tunnel, often with the thumbs, for as much as 30 seconds to breed signs. A Close the eye and isolate yourself to scale back the unfold of the virus Answer:A Explanation: Patients should be instructed to take contagion and isolation precautions for at least 2 weeks or as long as their eyes are pink and weeping. In specific, they need to keep away from contact with infants, aged individuals, people taking immunosuppressive or chemotherapeutic brokers, and immunocompromised sufferers. A Nausea and vomiting B Dizziness Answer: Perioral numbness should be in the selections. Explanation: Manifestations of native anesthetic toxicity typically seem 1-5 minutes after the injection, but onset might range from 30 seconds to as long as 60 minutes. Treatment of carpal tunnel syndrome A Thumb splint B Wrist splint Answer: B Explanation: Splint the wrist in a neutral position at night and through the day if possible. Scenario describe Torsion of appendix testis (blue dots on the upper scrotum) Ask about prognosis 150. Answer: anterior to masseter insertion on the mandible degree Explanation: External maxillary artery is outdated name. The course of this artery on the face may be indicated by a line ranging from the lower border of the mandible on the anterior margin of the Masseter, and operating at first forward and upward to a point 1 cm. Treatment of orbital pseudotumor A Systemic steroids Answer: a Explanation: Orbital pseudotumor is an idiopathic autoimmune inflammation of the orbit. Orbital inflammatory disease (pseudotumor) often is treated medically with systemic steroids. Prostate most cancers metastases to� A Vertebra Answer: A Explanation: Breast, prostate and lung most cancers are responsible for greater than eighty% of instances of metastatic bone disease. Prostate most cancers metastasizes often to the lumbar-sacral spine and pelvis, as a result of it drains by way of the pelvic plexus in the lumbar region. Ulnar nerve palsy will result in A Complete claw hand B Partial claw hand Answer: b Reference: gradestack. Case of Osteoarthritis and on medical physical examination you find enlargement on both side of distal interphalangeal joint What does it referred to as Examples include corneal or epithelial disease (eg, dry eye), superficial corneal harm or ocular injuries (eg, those due to foreign bodies), and make contact with lens put on (eg, every day disposable delicate lenses, extended-put on delicate lenses, gas-permeable lenses, hard polymethylmethacrylate lenses. Spontaneous corneal abrasions may be associated with map-dot-fingerprint dystrophy or recurrent corneal erosion syndrome. Definitive trigger for tonsillectomy: A-retro pharyngeal abscess B-sleep apnea C-alloplasia D-non symptomatic enlargement Answer: B Explanation: Absolute Indications of tonsillectomy: � Most common indication: sleep-disordered respiratory � 2nd commonest indication: recurrent throat infections � Tonsillar hypertrophy inflicting upper airway obstruction, obstructive sleep apnea, severe dysphagia, or cardiopulmonary complications similar to cor pulmonale � Suspicion of malignancy (e. Old age eighty dull pain with bilateral renal hydroneohrosis no urinary signs dx A Prostate enlargement B Bladder most cancers Answer: incomplete Q. Median by no means Answer: a Explanation: the median nerve then passes between the superficial (humeral) head and deep (ulnar) head of the pronator teres in the proximal third of the forearm. Purulent Mucopurulent Answer: A Explanation: In neonates, in whom bilateral conjunctivitis (ophthalmia neonatorum) often follows vaginal supply from an untreated mother with a gonococcal infection, signs of gonococcal conjunctivitis include the following: Eye pain Redness Purulent discharge Reference: emedicine. Explanation: Etomidate and Benzodiazepines (midazolam) have the lowest doses> Reference: Toronto notes 2017/ web page A16 Anesthesia 173. A Fentanyl Answer: A Explanation: Transdermal fentanyl isapproximately eighty times as potent as morphine. Case of rheumatoid arthritis with swelling in the 2nd to 5th fingers bilaterally, what are these A Bouchard nodules B Heberden nodules C Synovial swilling (my reply) D Subcutaneous nodules 175. Answer: Levothyroxin Explanation: the mainstay in the therapy of congenital hypothyroidism is early prognosis and thyroid hormone alternative. Optimal care might contains prognosis earlier than age 10-thirteen days and normalization of thyroid hormone blood levels by age 3 weeks. Antidiuretic Hormone secreted half in pituitary gland is: A Pars tuberalis B Infundibulum C Pars intermedia D Neurohypophysis Answer: D Explanation: Posterior pituitary = neurohypophysis. Embryological origin of Rt Atrium A Right horn of sinus venousus Answer: Depends on which part of proper atrium. Microbiology pathogen description of pseudomonas, Gram-negative lactose non ferments greenish producing discharge. Loss of sensation in medial hand palm and dorsum and medial 1 & half finger� which nerve injured Inguinal canal relation of sac to the wire A Antromedial B Posreiomedial Answer: A Explanation: I assume they had been requested about oblique inguinal hernia which consists of a sac of peritoneum extending by way of the internal ring, antero-medial to the spermatic wire in males (or round ligament in females. Explanation: the harm occurs iatrogenically throughout intramuscular injection to upper medial gluteal region. Clear case of gout, what enzyme should inhibited by a drugs used in acute at tack A: Xanthene oxidase Answer: Cyclooxygenase. Explanation: Acute gout Rx: Indomethacin (Cyclooxygenase inhibitor), Phenylbutazone (Cyclooxygenase inhibitor), and Colchicine (inhibit microtubule polymerization. Chronic gout Rx: Allopurinol (xanthine oxidase inhibitor), Febuxostat (xanthine oxidase inhibitor), Pegloticase ( catalyzes metabolism of uric acid to allantoin), Probenecid (Inhibits reabsorption of uric acid in proximal convoluted tubule. C terminal single Answer: not sure, but most probably C Explanation: Proteins to be degraded need to enter the small channel in the 20S core fashioned by the subunits. However, the entrance is often blocked by the N-termini of the -subunits, which collectively kind a gate to regulate entry and stop indiscriminate protein degradation. The parietal pleura is innervated by somatic nerves that sense pain when the parietal pleura is infected. The phrenic nerve supplies innervations to the central part of every hemidiaphragm; when these fibers are activated, the feeling of pain is referred to the ipsilateral neck or shoulder Intercostal nerves provide outer rib cage and lateral side of each hemidiaphragm: when these fibers are activated, the feeling of pain is referred to thoraco-stomach wall. Atypical hyperplasia -What is commonest serious chronic infection present in expatriates coming to Saudi Arabia A urine catacholamins B dexamethasone stress take a look at **I assume pheochromocytoma -twisted ankle What is the most typical ligament Anterior talofibular ligament ** in inversion sprain. A Sickle cell anemia B Thalassmia C Spherocitosi s D B12 **Functional hyposplenism is a situation accompanying many ailments similar to 1-sickle celiac disease 2-alcoholic liver disease 3-hepatic cirrhosis 4-lymphomas 5-autoimmune disorders. Pneumonea Mycoplasma pneumonea Others 2 77 yo male with early onset of dyspnea whin shifting 50 meters, has left apical heave and loud audible systolic murmur most intenst to listen to in hight sternal border. Sever mitral regurgitate Calcified aortic stenosis 3 Gram -ve lactose non fermenting oxidase +ve. Vancomycin ( metronidazole not in the selections) 6 Women with excessive heels fall in a bizarre means with outward (eversion) of foot. Fentenyl (not sure) 21 Case of rheumatoid arthritis with swilling in the 2nd to 5th fingers bilaterally, what are these Bouchard nodules Heberden nodules Synovial swilling (my reply) Subcutaneous nodules 22 Case of hematoma underneath nail after door Closed over finger, management Observation Evacuation of hematoma 23 Village with excessive nomber of cretinism , first thing to do is Levothyroxin (my answe) 24 Psoriasis ( silver scale) involving 15% of skin therapy. Give anti tetanus 72 h earlier than supply Vaccinate the mother throughout her pregnancy (my reply) 29 17 yo boy with Audiogram exhibits conductive listening to loss in the left ear. No part of this publication may be reproduced or transmitted in any kind or by any means, digital or mechanical, including photocopying, recording, or any info storage and retrieval system, with out permission in writing from the publisher.

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