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By: John Theodore Geneczko, MD

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This leads to menopause when does it start buy lady era amex a localized inflammatory lesion breast cancer xmas ornament order lady era 100mg free shipping, which may then be followed by scarring with fibrosis and calcification women's health clinic melbourne discount lady era 100 mg overnight delivery. The autoantibodies found are usually anti-Ro antibodies pregnancy test accuracy cheap generic lady era canada, but anti-La antibodies can also be the etiologic agents. Fever, arthralgias and arthritis, and serositis can be seen in patients with drug-induced lupus. Minocycline, hydralazine, isoniazid, a-methyldopa, and chlorpromazine are also associated with drug-induced lupus, as are a variety of antithyroid medications and b-blockers. It usually resolves within 2 weeks of discontinuation of the medication, but it may last longer. A multisystem disease with fever, weight loss, and rash is often the presenting picture in a vasculitic disorder. Many different types of rashes may be seen, the more common of which are palpable purpura, urticarial vasculitis, and dermal necrosis. Central nervous system involvement, arthritis, myositis, and/or serositis may be seen. One scheme proposed by an international consensus classifies vasculitides on the basis of the size of the vessels that are predominantly affected. Conditions marked with an asterisk (*) are not uncommon in pediatric rheumatology centers. What are the conditions that are grouped under the term pulmonary-renal syndromes In two thirds of cases in children, polyarthritis and inflammatory gastrointestinal lesions occur, which can confuse the diagnosis with inflammatory bowel disease, particularly if the patient is younger than 5 years. Aseptic meningitis, sinus vein thrombosis, and other forms of deep vein thrombosis are characteristic of this disease. Edward Henoch later added the additional clinical features of gastrointestinal symptoms in 1874 and renal involvement in 1899. Thus, purists would say that, more properly, the term should be “Scho nlein-Henoch purpura. Initially, urticarial lesions predominate, and they may itch or burn; these develop into pink maculopapules (Fig. With damage to the vessel walls, there is bleeding into the skin, which results in nonthrombocytopenic petechiae and palpable purpura. This is frequently associated with nausea, vomiting, and gastrointestinal bleeding. Numerous purpuric macules and papules on the legs and feet of a child these findings may precede the skin rash with Henoch-Scho nlein purpura. Periarticular swelling of the knees, ankles, wrists, and elbows—rather than a true arthritis—is usually seen. However, up to two thirds of children who have severe crescentic glomerulonephritis documented on biopsy will develop terminal renal failure within 1 year. Of those with nephritis or nephrotic syndrome at the onset of illness, almost half may have long-term problems with hypertension or impaired renal function as adults. Coppo R, Andrulli S, Amore A, et al: Predictors of outcome in Henoch-Scho nlein purpura in children and adults, Am J Kidney Dis 47:993–1003, 2006. Kawasaki Y, Suzuki J, Sakai N, et al: Clinical and pathological features of children with Henoch Scho nlein purpura nephritis: risk factors associated with poor prognosis, Clin Nephrol 60:153–160, 2003. Steroid therapy is debated, but it should be considered for painful arthritis, abdominal pain, nephritis, edema, and scrotal swelling. Prednisone, 1 to 2 mg/kg per day (maximum: 80 mg/kg per day) for 5 to 7 days, is often used for severe intestinal symptoms and may decrease the likelihood of intussusception. Steroids do not prevent the recurrence of symptoms, and symptoms may flare when steroids are discontinued. There is a great deal of controversy surrounding whether the early use of corticosteroids (oral or intravenous pulses) in patients with renal disease improves long-term outcome, but no benefit has yet been demonstrated in randomized controlled trials. Erythematous, palpable, large purpuric lesions develop and when confluent are quite dramatic in appearance. Skin lesions are seen in the upper and lower extremities, and on the face, particularly in the ears, IgA deposition is common around the vasculitic lesions. Renal and gastrointestinal involvements are rare, and recovery is the rule in 2 to 3 weeks. See Meningitis Blastemal tumors, 607 Bacterial tracheitis (pseudomembranous croup), Bleomycin, 610 415 Blindness Bacterial vaginosis, 31, 31t, 32, 33 classification of, 77 Bacteriuria, asymptomatic, 518. Benign epilepsy with occipital focus, 544 See also Fever Berger nephropathy (immunoglobulin A [IgA] Bone age, 213–214 deficiency), 344, 490 Bone marrow failure, 302 b-agonists, 655 in aplastic anemia, 302–303 b-lactamase inhibitors, 354 in Diamond-Blackfan anemia, 303 b1 receptors, 107, 107t in Kostmann syndrome, 304 b2 receptors, 107, 107t in transient erythroblastopenia of childhood, b-thalassemia, 333–334, 335, 612 303 Bicarbonate Bone scan, 634 in diabetic ketoacidosis, 204, 204t Boot-shaped heart, 89, 89f in neonatal resuscitation, 431, 432 Borrelia burgdorferi, 690. See also Lyme disease in renal tubular acidosis, 511 Bottle feedings, 274t in tumor lysis syndrome, 590 Botulism, 573–574 Biliary atresia, 266, 280 Bowleggedness (genu valgum), 637–638, 637f Bilirubin. See also Sudden cardiac death Bronze baby syndrome, 452–453 out-of-hospital, 171–172 Broviac catheter, 591 predictive factors in, 176t Brucellosis, 422t pupillary dilation in, 176 Brudzinski sign, 532 reversible causes of, 175 Brushfield spots, 290 Cardiac murmurs. See also Brain tumors gynecomastia, 38 areas of occurrence of, 602 Chest deformities, 89 classification of, 602 Chest pain, causes of, 81 incidence of, 593, 593f Chest physiotherapy, 668 key points, 602b Chest radiograph Central vertigo, 540 in bronchiolitis, 658 Cephalhematoma, 463, 464f, 464t in febrile young infant, 372 Cephalic pustulosis, neonatal, 137t in foreign-body aspiration, 665 Cephalosporins, 356–357 in pneumonia, 673 Cerebellar syndrome, 588 in wheezing patient, 654 Cerebral edema, in diabetic ketoacidosis, 206 Cheyne-Stokes breathing, 676 Cerebral palsy Chiari malformations, 581–582 Apgar scores and, 529 Chicken soup, 357 birth asphyxia and, 529 Chickenpox. See Varicella (chickenpox) versus central nervous system disorder, 525 Child abuse. Cisapride, 254 See also Hydrocephalus Cisplatin, 586 Community-associated methicillin-resistant S. See also specific defects in liver disease, 314t anomalies associated with, 90–91 management of, 309, 310 bony abnormalities in, 89 menorrhagia and, 313 with cardiomegaly, 95 physical examination findings in, 307 chest radiograph in, 89, 89f preoperative screening for, 313 with congestive heart failure, 94–95 in vitamin K deficiency, 314t cyanotic, 87–88, 88b Coarctation of the aorta, 86, 87f, 108–109 ductal-dependent, 89–90 Cobalamin (vitamin B12), 325 etiologies of, 87 Cobalamin (vitamin B12) deficiency, 325 genetic syndromes associated with, 90t Cobb method, of scoliosis assessment, 642, 642f prenatal maternal factors and, 87, 88t Cocaine, 299–300 versus pulmonary disease, 87 Coccidioidomycosis, 422t recurrence risk, 93 Coccygeal pits, 580–581 with right aortic arch, 90 “Cock-robin” deformity (torticollis), 614 Congenital hip dislocation. See also Atopic dermatitis Divorce, 70 Eczema herpeticum, 124 Dizygotic twins, 425. See Strabismus Enuresis Etanercept, 688 categorization of, 486 Ethanol ingestion, 185 diurnal, 488 Ethosuximide, 525, 526, 527t key points, 487b Ethylene glycol ingestion, 185, 186 management of, 487–488 Etoposide, 587 medical and surgical causes of, 487 Euthyroid sick syndrome, 228 nocturnal, 486–487 Ewing sarcoma, 595, 608, 609 Eosinophilia, 242, 338 Exanthem subitum (roseola infantum; sixth disease), Eosinophilic esophagitis, 231 385, 386 Eosinophilic granuloma, 601 Exanthemas of childhood, 385. See also Seizure(s); specific disorders Exophthalmos, 227 antiepileptic drugs for. See also Corticosteroids antibody production in, 339 Fluoroquinolones, 356 biophysical profile of, 435 Fluorosis, 57 causes of death in, 428 Folate, dietary sources of, 325 gestational age of, 435, 436t Folic acid deficiency, 325 heart contraction in, 436 Folk medicine, 158 immunoglobulin transport across placenta Fontan procedure, 112, 113 to, 339 Fontanel(s), 52, 53, 53f maternal infections and. See Murmurs management of, 410–411 Heart sounds, 107, 108 recurrent, 411 Heart transplantation, 112, 113 return to school following treatment of, 411 Heat emergencies, 163–164 rheumatic fever and, 411–412, 693–694 Heat exposure, from fire, 164 throat culture in, 410 Heat stroke, 163 versus viral pharyngitis, 409 Height Group A streptococcal toxic shock-like syndrome, in obese child, 18, 213 359t prediction of, 211 Group B streptococcus, intrapartum prophylaxis for, Heiner syndrome, 251 460–461 Heinz bodies, 317 Growth disorders, 215b Helicobacter pylori constitutional delay, 22, 215 in idiopathic thrombocytopenic purpura, 328 pituitary gigantism, 216 in peptic ulcer disease, 255–256 short stature. See also syndrome Hydrocephalus Hypocalcemia, 96f, 200–201, 456–457 Hydrochlorothiazide, in diabetes insipidus, 482 Hypocomplementemia, 489 Hydrocortisone, 198–199, 198t. Hypogammaglobulinemia, 347 See also Corticosteroids Hypoglycemia Hydrogen cyanide, 165 causes of, 216 Hydronephrosis, 508, 509f clinical features of, 216 Hydroxyurea, for sickle cell disease, 333 definition of, 216 Hymenal opening, 161–162 diagnosis of, 216–217, 217t Hyperacusis, 540 management of, 217–218 Hyperalimentation fluids, selenium supplementation neonatal, 455–456 in, 84 Hypoglycemics, oral, 211 Hyperbaric oxygen, 165 Hypohidrotic ectodermal dysplasia, 122 Hyperbilirubinemia Hypokalemia, 482, 483 breastfeeding in, 452 Hypomagnesemia, 457 key points, 453b Hyponatremia, 480–481 metalloporphyrins in, 454 Hypoparathyroidism, 200, 201 neonatal, 263t Hypopigmentation, 144, 144f phototherapy for. See Premature infant(s) palpable spleen in, 327 sense of smell development in, 60–61 Ileocolic intussusception, 279, 279f sunscreen use in, 142 Imipramine, 487 temperature measurement in, 369 Immersion burns, 159 upper gastrointestinal bleeding in, 260 Immunization(s). See also Vaccine(s) urinary tract infections in, 514–515 administration of, 380–381 Infant botulism, 573, 574 key points, 384b Infant walkers, 60 in organ transplant candidates/recipients, 338 Infantile acne, 114–115 ImmunoCap, antigen-specific IgE, 649 Infantile colic, 49–50 Immunodeficiency. See also specific syndromes Infantile cortical hyperostosis (Caffey disease), 614 diagnosis of, 352–353 Infantile esotropia, 77 in infants, 348b Infantile hemangiomas. See Hemangiomas, infantile infections in, 340b Infantile spasms, 544, 548–549 in mitochondriopathies, 351 Infantile stridor, 664 neutropenia in, 341 Infectious mononucleosis, 394 primary Inflammatory bowel disease. See Trauma Inborn errors of metabolism Inodilators, 179 clinical features of, 455 Inotropes, 179 incidence of, 454 Insensible water loss, in premature infants, 425, neonatal seizures and, 564 425t screening for, 454 Insulin urine odors associated with, 455 in diabetic ketoacidosis, 205 Inclinometer (scoliometer), 641 for hyperglycemia in newborns, 456 Incomitant strabismus, 77 pharmacokinetics of, 207t Incontinentia pigmenti, 565, 570 types of, 207t Indirect Coombs test, 317 Insulin-dependent diabetes mellitus. See Down syndrome Motor skills in fragile X syndrome, 298 delay in development of, 59, 530 Mentzer index, 323 development in twins, 60 Mercury poisoning, 189 major developmental landmarks for, 60t Mesiodentes, 56 Movement disorders, 559, 560. See also specific prevention of syndromes antibiotics for, 440 Neurocysticercosis, 402 immunoglobulin for, 440 Neurofibromatosis parenteral feeding for, 441 clinical features of, 567–568 probiotics for, 440–441 diagnostic criteria for, 566 trophic feeding for, 441 inheritance pattern in, 565, 568 rapid advance of feedings and, 442 malignancy associated with, 604 risk factors for, 439–440 mutation rate in, 285 withholding of feeding in, 440 types of, 567 Neisseria gonorrhoeae, 27–28, 27f, 161, 161t Neurogenic shock, 179–180. See Premature infant(s) risk factors for, 18 pustular lesions in, 137, 137t, 138t in children resuscitation of adult obesity and, 19 bicarbonate in, 431, 432 height and, 18, 213 carbon dioxide detectors in, 432–433 key points, 19b discontinuation of, 434 pathologic causes of, 18 epinephrine use in, 431 physical examination features in, 19 key points, 434b puberty and, 18 laryngeal mask airway use in, 432, 432f Obsessive-compulsive disorder, 67–68 room air versus 100% O2 for, 433 Obstructive shock, 178. Pityriasis rosea, 141 See also Central lines Plagiocephaly, 54, 54f, 55f Peritonitis, in nephrotic syndrome, 501 Plan B, 41–42 Peritonsillar abscess (quinsy), 412, 413 Plantar dermatosis, juvenile, 131 Periventricular leukomalacia, 465, 467 Plantar surface, characteristics by gestational age, Permanent teeth, 56 436t Permethrin 5% cream, 136 Plantar warts, 119, 119f Pernicious anemia, 325 Plaque, 114 Peroneal spastic flat foot, 622 Plastic deformation, 622 “Persian slipper” foot, 620 Platelet count, 326 Persistent vegetative state, 539 Platelet disorders/dysfunction Perthes disease. See also Corticosteroids with long-term toxic course, 181 Prednisone, 198t, 500, 501. See Congenital infection with radiopaque substances, 184 (s) salicylate, 187 hepatitis A, 365 tricyclic antidepressant, 187 hepatitis B, 365 urinary pH manipulation for, 183 human immunodeficiency virus. See also Child abuse forms of, 640–641 evidence collection in, 160 growth tracking in, 213 follow-up care for, 160 key points, 642b hymenal opening in, 161–162 in males versus females, 641 key points, 162b screening for, 641 perpetrators of, 160 Scrofula (nontuberculous mycobacterial infection), physical examination findings in, 162 393 sexually transmitted infections and, 160, Seborrheic dermatitis, 125t, 126 161, 161t Second disease (scarlet fever), 122, 385, 409–410 Sexual development. See Absence seizures human papillomavirus infection, 25–26 akinetic, 548 incidence of, 8, 24 antiepileptic drugs for. See Hypernatremia; Hyponatremia priapism in, 332 Somnolence syndrome, 587–588 screening for, 285t Somogyi phenomenon, 207 stroke prevention in, 332 Sotos syndrome, 286 Sickle cell trait, 333 Spasmodic croup, 415–416 Sigh, 676 Spastic cerebral palsy, 529.

Upper vesicourethral part forms the mucous persists as vestibule women's health clinic lismore generic lady era 100 mg without a prescription, into which the urethra and the membrane of the bladder except the trigonal vagina open women's health center of lansdale generic lady era 100 mg visa. It also contributes to menstruation cycle pregnancy purchase online lady era the major part of side and lateral to breast cancer 3rd stage discount lady era online american express the genital fold is called labioscrotal female urethra. Middle pelvic part of urogenital sinus: It the genital folds meet at the cephalic end of the receives the united caudal end of the two para cloacal membrane to form an elevation. The duct forms one on tion is known as genital tubercle, which ultimately each side as an ingrowth of coelomic epithelium in differentiates into the clitoris. If the gonads become ovaries, the external genitalia While it grows downwards, it has developed three will attain the female characteristics (Table 3. The cervix Each paramesonephric duct passes ventral to the is differentiated from the corpus by 10th week. The corresponding mesonephric duct and then meets its intervening septum disappears during the 5th counterpart from the opposite side in the midline month of intrauterine life. The lower vertical parts of the two and the glands of the uterus and cervix are developed paramesonephric (Mullerian) ducts pass caudal wards from the coelomic epithelium. Around endometrial stroma are developed from the meso 9th week, the solid caudal tip of the fused vertical parts derm of the paramesonephric ducts. When the Mullerian ducts approach each other in the paramesonephric ducts shortly undergo the midline, a broad transverse fold is established. It fusion with each other and the partition between extends from the lateral side of the fused Mullerian them disappears. The united lower vertical parts ducts up to the lateral pelvic walls, which is named form the uterovaginal canal and the fused Mullerian as Broad ligament. The endodermal cells from the dorsal wall of the urogenital sinus proliferate and form the sinovaginal Vagina is developed mainly from the Mullerian ducts and partly from the urogenital sinus. These endodermal cells further proliferate and extend cranially into the central axis Upper three-ffth above the hymen develop from to form a solid plate, called vaginal plate. The upper end of the canal forms the vaginal the hymen is developed from the junction of fornices and communicates with the cervical canal the mullerian tubercle (mesodermal) and the and uterine cavity. Central cells of the Mullerian eminence disinte Lower one-ffth below the hymen is developed grate, so that the vaginal canal now opens into entirely from the endoderm of the urogenital sinus. The tissue at the Vaginal introitus is developed from the ectoderm periphery persists as hymen. It is lined by sinus of the genital folds after rupture of the bilaminar epithelium (endodermal origin) on either side with a urogenital membrane. Finally, the urogenital membrane ruptures and the Site genital folds persist as the labia minora. This ridge is formed in a four-week these are surrounded by flat cells (granulosa cells) embryo between the dorsal mesentery (medially) and and are called primordial follicles. At birth, there is no the mesonephric ridge (laterally) by the multiplication more mitotic division and all the oogonia are replaced of the coelomic epithelium along with condensation by primary oocytes. Sources Indifferent or Primitive Gonad the cortex and the covering epithelium are developed Initially, the gonads do not acquire male or female from the coelomic epithelium and the medulla from morphological characteristics until the seventh week the mesenchyme. They migrate from the yolk sac to the cells, the coelomic epithelium of the genital ridge genital ridge along the dorsal mesentery by ameboid proliferates. These undergo a number of rapid mitotic divisions and cords of cells surround the primordial germ cells and differentiate into oogonia. It reaches its maximum at 20th week numbering is difficult at this stage to differentiate between an about 7 million. In the fourth month, these cords split an ovary about two weeks later than testicular into clusters of cells, which surround the germ cells. Thus, a basic Genetic control is of prime importance for differentiation unit of a follicle is completed. The cranial part of the genital ridge becomes the the surface becomes thicker and continues to infundibulopelvic ligament (Fig. It sends down secondary pole of the ovary, genital ligament (gubernaculum) 40 textbook of GyneColoGy is formed, which is attached to the genital swelling the Mullerian attachment is the ovarian ligament (labial). The and the part between the cornu of the uterus to genital ligament gets an intermediate attachment the end is the round ligament. The ovaries descend as it comes close to Mullerian ducts (angle of the during the seventh to ninth months, and at birth, developing uterus). The cortex and the covering epithelium are developed from the coelomic epithelium and the medulla from the mesenchyme. The germ cells are endodermal in origin and migrate from the yolk sac to the genital ridge. The part between the cornu of the uterus (Mullerian attachment) to the end (external genitalia) is the round ligament. The mesonephric duct in male gives rise to epididymis, vas deferens and seminal vesicles. The sinovaginal bulbs, which grow out from the posterior aspect of the urogenital sinus, differentiates into vagina. Partial nephrectomy and ureterectomy may be indicated or From the embryological considerations, the following implantation of the ectopic ureter into the bladder facts can be deduced. Dyspareunia may be the first complaint, or it may be detected during investigation of infertility. The anal opening Gross hymenal abnormality of significance is situated either close to the posterior end of the is imperforate hymen. Rarely, it is situated disintegration of the central cells of the Mullerian in the vagina (congenital rectovaginal fistula). The eminence that projects into the urogenital sinus opening is usually sufficiently big and continence is (see p. Depending upon the amount of is to be done bringing the anal end to the anal pit with blood so accumulated, it first distends the vagina prior colostomy. Note the elongaton of the urethra hematocolpos in a girl with imperforate hymen due to distension of the vagina by blood clinical features: the girl is aged about 14–16 years. Abdominal examination reveals a suprapubic Pressure from above should not be given. The residual pathology, if any, may be detected Vulval inspection reveals a tense bulging membrane by internal examination after the next period is over. Ultrasonography can make the diagnosis of Common variations of vaginal maldevelopments hematometra and hematocolpos (Fig. The secretion Failure of lateral fusion chapter 4 conGeniTal MalforMaTion of feMale GeniTal orGans 43 Fig. The principles of surgical polygenic, multifactorial, teratogens, or environmental. Incision of a complete (imperforate) Pathology of Mullerian malformation: It may be septum becomes easy when the upper vagina is due to failure of formation of the vaginal plate or due distended. This reduces the risk of injury to adjacent to its failure of canalization or cavitation. Otherwise abdominovaginal approach (see Vertical fusion defects result in failure of fusion of p. It may Longitudinal septum of the vagina may be present also be due to incomplete or segmental canalization when the distal parts of the Mullerian ducts fail to of the vagina. It may be associated with double Disorders of lateral fusion are also due to failure uterus and double cervix. Results of surgery are good Transverse vaginal septa are due to faulty fusion or in terms of achieving pregnancy. About 45% occur in the upper vagina, 40% in mid vagina and 15% in the lower vagina. Vesicovaginal fstula is formed when the Mullerian always satisfactory though successful pregnancy and eminence ruptures into the vesicourethral part live birth have been reported. When hysterectomy of the cloaca instead of the pelvic part of the is considered, ovaries should be conserved. Rectovaginal fistula when the Mullerian reproductive technology would be the option, when eminence opens in the dorsal segment of the desired, using a surrogate uterus. Persistent urogenital sinus with various irregularities of urethral and vaginal orifces in Complete agenesis of the vagina is almost always the sinus. The entity is often associated Uterine anomalies are often associated with vaginal with urinary tract (40%) and skeletal (12%) maldevelopment. Nonsurgical method: Repeated use of graduated Incidence of Mullerian abnormalities: It varies vaginal dilators for a period of 6–12 months. The incidence is found to be high Presence of a vaginal dimple (1 cm) is often in women suffering from recurrent miscarriage or seen.

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Trauma varied by site: tears should not influence their testimony regarding the appeared most often on the posterior fourchette validity of the rape since most rape victims do not and fossa navicularis; abrasions appeared on the experience genital injury as a result of the rape labia; and ecchymosis was seen on the hymen menstrual knitting purchase generic lady era from india. In one study sepia 9ch menopause buy lady era visa, vaginal They also found that all women with tears re injuries represented only 19 percent of the total ported vaginal bleeding menopause sexual dysfunction cheap lady era 100 mg overnight delivery. The colposcopic exam is especially Researchers also concluded that timing of the exam important as a part of the pediatric protocol was crucial because beyond 24 hours womens health 6 week boot camp order 100mg lady era visa, the likeli (Soderstrom: 94). At followup examination, which occurred W ith gross visualization alone, positive genital beyond 4 days (average of 25 days), all injury was findings occur in only 10 percent to 30 percent resolved and there was no scarring and no evidence of the cases (Cartwright et al. W ith colposcopic examination, the exception of hymenal tears, which were nearly genital trauma has been identified in 87 percent four times more common in adolescent victims, (N= 114) of sexual assault cases (Slaughter & injury was not related to age. When a colposcope is used, the magnification must always be documented, the the literature also suggests that colposcopic pictures or video must be well focused and clear, examination to magnify genital tissue is an impor standard positions for examination should be used tant asset to the identification of genital trauma and documented, and a method of measurement (Frank: 96; Slaughter & Brown: 92; Slaughter et should be used (Soderstrom: 94). W ith the use of a colposcope, the number of cases increased by 8 In a study of genital trauma in a consenting percent because three or more genital injuries were population using the colposcope, 11 (61%) of 18 identified as compared to identification with the volunteers, who had consenting sex within 6 hours, naked eye (O’Brien: 97). This trauma both still and video, can be easily attached for was not visualized with gross visualization but forensic documentation. In one study, 28 percent required the use of the colposcope (Norvell, of 440 rape victims had genital trauma, however, Benrubi & Thompson: 84). In the legal arena, the use of genital injuries compared with gross visualization the colposcope is well documented as an accepted alone. It has also been found useful in particularly valuable for examination of young or sexual assault examinations to detect perineal lacerations and abrasions. Since it is spermicidal, the literature consistently suggests it should only be Genital Trauma Evidence used after all specimens are collected. One study 30% 28% examined 22 women after being sexually assaulted 25% within the previous 48 hours. Forty percent were found to have vaginal lacerations when examined 20% 16% using Toluidine blue. Of these, 70 percent (N=7) 15% of the positives were nulliparas (Laufer & Souma: 82). Another study found that 14 of 24 (58%) 10% cases were positive for genital trauma using Tolui 5% dine blue (M cCauley et al. The prison for anyone who uses a controlled substance colposcope is however, the preferred method for to commit a crime of violence, including sexual better genital trauma documentation (O’Brien: 97; assault (U. Once In addition, it is recommended that an additional approved by the regulatory agencies, the new tube of blood routinely be drawn for blood and Rohypnol tablets dissolve more slowly and they alcohol analysis should this become an issue later release a bright blue color as they dissolve. Victims drug-facilitated rape, and if she is seen within 72 may report a history of having only a couple of hours of the assault, a urine specimen should be alcoholic beverages but quickly becoming ex collected for drug analysis. She should herself undressed, or partially dressed, with vaginal complete the form and return it with a urine or rectal soreness making her believe she has been specimen by Fedex to the independent laboratory raped. The victim can often remember very little of with whom Hoffmann LaRoche Laboratories have the incident prior to awakening, other than flashes. If mately 2 weeks for the complete drug analysis of the victim calls prior to coming to the hospital or the urine to be Faxed back (Ledray: 96c). In those cases where genital trauma was identified, Flunitrazepam has been used for sleep disorders in a followup exam may strengthen the evidence of Europe, M exico, and Asia since its initial release in genital trauma. It is used legally in 80 countries and is the time of the followup exam to document the widely and easily available, but it has not been healing of the genital injuries for comparison approved for use in the United States. Others specify the use of not only indicate a pre-existing infection, but also water for this purpose (Ledray: 92b). W hile until after the assailant is convicted of the rape and testing can begin as early as 6 weeks after exposure, a court order is obtained for testing. This usually 3 months or even 6 months is more often recom takes more than the 6 months necessary for the mended to avoid multiple testing (Gostin, victim to seroconvert if she is going to do so, and Lazzarini, Alexander, Brandt, M ayer & Silverman: in some cases it may take a full year or more to 94). W hile victims still want this informa other routes of exposure such as needle sticks, tion for their own peace of mind, the time delay needle sharing, mother to infant, or transfusions. Pregnancy resulting this will provide clear documentation of why the from rape is indeed the cause of great concern and medication (Ovral) is or is not given. M ost would be the typical informed consent of possible programs offer pregnancy prevention or intercep complications with agreement to take the medica tion for the woman at risk of becoming pregnant, tion. Some tubal ligation) pregnancy prevention is not recom times referred to as “the morning-after pill, ” oral mended for me. This will reduce all were aware of the pregnancy (Tucker, Ledray & the risk of pregnancy by 60 percent to 90 percent. Fortunately, at least one If a low dosage ethinyl estradiol contraceptive, study found pregnant women were less likely to be such as Lo-Ovral, Nordene, Levlen, Triphasil, or physically injured during a rape, and the rape had Trilevlen, is used, a dose equivalent to 100ug of little immediate effect on the pregnancy. No estrogen, 4 tablets, should be provided for each spontaneous abortions or deliveries occurred dose (Yuzpe, Smith & Rademaker: 82). A low birth rate (24%) programs operating at a Catholic hospital went as and preterm deliveries (16%) were common, far as to get special permission from the diocese to however (Satin, Hemsell, Stone, Theriot, & administer Ovral (Frank: 96; O’Brien: 97). The risk of pregnancy from a rape is the same as If the victim chooses to take medication for the risk of pregnancy from a one time sexual pregnancy interception, it is also important to encounter. This is estimated to be 2 percent to 5 inform her about the effect on her next period. Up percent (Yuzpe, Smith & Rademaker: 82; Holmes, to 98 percent of patients will menstruate within 21 Resnick, Kilpatrick & Best: 96). In 90 percent of the cases, found that the majority of these pregnancies menses will be of normal duration for that patient. Unfortu onset of menstrual bleeding may be 3 to 7 days nately, only 11 percent of these victims received earlier than expected. Fifty ovulation, the onset of bleeding may be on time or percent decided to terminate the pregnancy later. A review of 10 rape, it is possible that more of these pregnancies studies found an overall effectiveness rate of at least and abortions could have been prevented. It means that if 100 women Maintaining have intercourse in the middle 2 weeks of their Chain-of-Evidence cycle, approximately 8 (8%) would become pregnant without postcoital interception. W ith M aintaining proper chain-of-evidence is as impor interception only 2 (2%), representing a 75 tant as collecting the proper evidence. If the victim has not had and must include the signature of everyone who a period within 21 days she should be advised to had possession of the evidence from the individual have a pregnancy test. If this Crisis Intervention and Counseling proper chain-of-evidence is not maintained, the evidence will be inadmissible (Ledray: 93b). M aintain clinic or refer to a local rape center, social service, ing chain-of-evidence is critical to prevent any or to the hospital chaplain for followup counseling possibility of evidence tampering and to prevent (Antognoli-Toland: 85). Continued police officer to be in the exam room when the fear and anxiety resulting from the rape can evidence is collected to maintain proper chain-of significantly affect the victim’s life, including her evidence. The police can leave the area, and the work, school, and relationships with others far into nurse can call them when the exam is completed, the future (Ledray: 96a). Burgess summarized and the evidence in a locked storage area, preferably a labeled the psychological impact Rape Trauma refrigerator with limited access, and when the Syndrome (Burgess and Holmstrom: 74). Self-help police do return, any available nurse can sign that books, such as Recovering From Rape (Ledray: 94), she removed the evidence from the refrigerator and are available for the large majority of rape victims gave it to the police officer (Ledray: 93b). The Assistance League, a Maintaining Evidence national organization that for several years has Integrity provided clothing for rape victims after the eviden tiary exam, began providing in October 1997 the W hile it is suggested that the specimen be refriger book Recovering From Rape to sexual assault victims ated for long-term storage to prevent deterioration at the time of the evidentiary exam throughout the of the specimens, it is essential that the evidence be State of M innesota and in parts of California kept in an area of less than 75 degrees Fahrenheit (M aggie Trenkmann. This tool was developed to provide a systematic guide for collecting information about s If a condom was used. It includes detailed s Activities of the victim that may have destroyed investigative information about the victim and evidence, such as bathing, douching, bowel offender as well as victim forensic data and data movement, use of tampon. Other authors caution against collecting this detailed investigative information and suggest that s Allergies. Details reported by the nurse Sources: (Osborn & Neff: 89; Antognoli-Toland: 85; that differ from the police report may be used by Ledray: 92b; Slaughter & Brown: 92). The only documentation required is It is important not to be afraid to include the name information necessary to guide the exam and treat of the assailant, just be sure to use qualifying the victim (Smith: 87). All statements, tent with the victim’s account of the assault” procedures, and actions must be accurately, com (Sheridan: 93). It is important to accurately and completely assess There is disagreement over the use of the term and document the emotional state of the victim “alleged” in medical documentation of a sexual and quote important statements made by the assault. Ninety seven percent of the guilty pleas resulted from plea After the Exam bargains (Tintinalli & Hoelzer: 85). They often provide her with a change of of the initial exam is the best preparation. The Assis prior to testimony to be better informed about the tance League, a national charitable organization, significant issues involved and the defense that will provides these services to rape victims in many likely be used to properly prepare her testimony in States throughout the country.

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Symptoms and Signs Patient education topics include the importance of regular eye examinations, smoking cessation, and routine monitor Patients with acute angle-closure glaucoma typically present ing for central vision changes. Its use is described at report seeing halos around light sources and complain of. Physical examination shows a mid-dilated pupil, conjunctival injec Prognosis tion, and lid edema. Patients may notice a patients will develop advancing disease and further loss of gradual loss of peripheral vision. More accurate tools include tono-pen, Goldmann applanation tonometry, and pneumotonometry (puff test). Patients with significant risk factors or physical findings that raise concern for glaucoma should be referred to an oph thalmologist for further evaluation and confirmation of General Considerations diagnosis. Additional possible risk factors include diabetes diagnosis of glaucoma, it has been shown that reduction of mellitus, hypertension, and myopia. Topical miotics and epinephrine compounds are also complain of a decrease in color perception and even now infrequently used. Oral medications include carbonic note “second sight, ” which is an improvement in near vision anhydrase inhibitors such as acetazolamide. Examination of the eye reveals the coma agents have varying degrees of systemic absorption and opacification of the lens. Cataracts may be easier to see with are capable of producing systemic side effects and drug-drug dilation of the eye and a direct ophthalmoscope at +5 diopters interactions. Patients should be educated on the importance setting held 6 in from the patient’s eye. Surgical intervention—When medical management is unsuccessful, surgical intervention is considered. Factors influencing the timing of surgery include life expectancy, current level of disability, status of Untreated glaucoma can result in blindness. Rapid treatment other medical illnesses, family and social situations, and of acute angle-closure glaucoma may preserve vision. Treatment of primary open-angle glaucoma can prevent fur Family physicians may aid patients in understanding the ther loss of vision, but typically does not restore lost vision. Routine use of labora Burr J et al: Medical versus surgical interventions for open angle glaucoma. Individuals should receive a history and phys ical examination prior to undergoing surgery. Prognosis General Considerations Cataracts do not resolve and may progress without treat ment. The prognosis with surgical treatment is excellent, and Any opacification of the lens is termed a cataract. Diet and vitamins do not play a role in development or progression of the disease. Physicians should use steroids at as low a dose as is therapeutic and discontinue them when possible. Topics to review with patients risk, and severe depending on the severity and extent of include the importance of an annual, comprehensive eye exam neovascularization. Prevention Prognosis Patients with diabetes mellitus type 2 should have a compre Early diagnosis and treatment, as well as tight glycemic con hensive eye examination by an ophthalmologist shortly after trol, improve prognosis. Preventing and managing visual disability in progression of retinopathy in all patients with diabetes. Others may report decreased vision that has occurred slowly or suddenly, unilaterally or Lighthouse International (health information on vision disorders, treatment, and rehabilitation services): bilaterally. In addition, Surgeon General, called attention to a largely overlooked epi one-third of persons of all ages have untreated decay, 8% demic of oral diseases that is disproportionately shared by of adults older than 20 years of age have lost at least one Americans: this epidemic strikes in particular the poor, permanent tooth to dental caries, and many older adults young, and elderly. The report called for improved Pathogenesis education about oral health, for a renewed understanding of Dental caries is a multifactorial, infectious, communicable the relationship between oral health and overall health, and disease caused by the demineralization of tooth enamel in for an interdisciplinary approach to oral health that would the presence of a sugar substrate and of acid-forming car involve primary care providers. The ectoderm forms the Additionally, when plaque is not regularly removed, it may dental enamel and the mesoderm forms the pulp and dentin. The adult dentition is composed of 32 permanent that involves an imbalance between demineralization and teeth. Table 45-1 outlines the eruption pattern caused by environmental factors such as low pH or inade of the teeth. Symptoms and Signs Dental caries (tooth decay) is the single most common chronic childhood disease, five times more common than When enamel is repeatedly exposed to the acid formed by the asthma and seven times more common than hayfever among fermentation of sugars in plaque, demineralized areas children 5-7 years of age. Minority and low-income children develop on the tooth surfaces, between teeth, and on pits and are disproportionately affected. If infection is allowed to progress, a cavity forms that can spread to and through the dentin (the component of the tooth located below the enamel) and to the pulp (com posed of nerves and blood vessels; an infection of the pulp is called pulpitis), causing pain, necrosis, and, perhaps, an Periodontal abscess. Diagnosis Cementum Carious lesions progress at various rates and occur at many different locations on the tooth, including the sites of previ ous restorations. Demineralized lesions (white or brown spots) generally occur at the margins of the gingiva and can be detected visually; they may not be seen on radiographs. Advanced carious lesions such as those spread through Alveolar bone dentin can be detected clinically or, if they occur between the teeth, by radiographs. Root caries, commonly seen in older adults, occur in areas from which the gingiva has receded. Dental professionals use a dental explorer to detect early caries in the grooves and fissures of posterior teeth. Anatomy of the tooth and supporting diagnose secondary caries (caries formed at the site of restora structures. Risk factors for caries devel Mandibular central incisors 6 y opment are shown in Table 45-2. Maxillary lateral incisors 8 y the risk factors for adult caries are similar to those for Mandibular canines 9 y 10 y childhood caries, including those listed in Table 45-2. Maxillary first premolars Mandibular first premolars 11 y Maxillary second premolars 11 y Prevention & Treatment Mandibular second premolars 11 y 11 y Fluoride, the ionic form of the element fluorine, is widely Maxillary canines 12 y accepted as a safe and effective practice for the primary Mandibular second molars 12 y prevention of dental caries. To learn more about fluoride supplements (tablets, drops, lozenges) are recom fluoride varnish application visit the Smiles for Life Web site, mended for children older than 6 months who are at high Natural sources fluoridated or who have diseases that produce a decrease in of fluoride include well water exposed to fluorite minerals, salivary flow, receding gums, or mental or physical disabil certain fruits and vegetables grown in soil irrigated with ities. A supplemental fluoride dosage schedule is shown in fluoridated water, and foods such as meats or poultry which Table 45-3. Topical fluoride supplements such as gels and may contain 6%-7% of total dietary fluoride. Although fluo varnishes are highly concentrated fluoride products that are ride supplementation is not recommended for persons who professionally applied by a dental health provider or a live in communities whose water is optimally fluoridated parent (for gels). Parents and care givers should be educated about the benefits of fluoride and the possible side effects of too much fluoride, a condition called fluorosis. Sealants prevent decay from developing in the pits and obtained from any source when the permanent tooth is fissures of teeth. Thirty-two percent of children and combination with topical fluorides (Figure 45-7). The benefits and side effects of fluoride use should be sumption of drinks and snack foods containing sugars. Before the teeth erupt, a parent may use a Council on Clinical Affairs, American Academy of Pediatric washcloth or cotton gauze to clean an infant’s mouth and to Dentistry: Clinical guidelines on baby bottle tooth decay/early transition the child to tooth brushing. Parents should super childhood caries/breastfeeding: unique challenges and treat vise brushing and should discourage children younger than ment options. A pea-sized amount of toothpaste is recommended for Available at: consensus.