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Program Director, Palm Beach Medical College

The girl told her mom that it also happened several times in the past but he told her not to symptoms 3 days after conception generic zyprexa 5mg online tell medications kidney damage purchase zyprexa 10 mg visa. The anus can enlarge to medications given during labor trusted 2.5 mg zyprexa large diameters to pass bowel movements, and thus penetrating injuries to the anus are common. Which of the following is true when interviewing a child about the alleged sexual abuse: A. The child should be interviewed many times to make sure there are no variations in his story. Screen for Chlamydia trachomatis, Neisseria gonorrhoeae, syphilis, and trichomonas. With frequent delays in disclosure of sexual abuse, injuries that may have been present at the time of the abuse will often be healed by the time the child undergoes a physical examination. Genital tissues are elastic in nature making them less prone, not more prone to injury. The anus can enlarge to large diameters to pass bowel movements, and thus penetrating injuries to the anus are rare, not common. Accidental straddle injuries on playground equipment, toys, furniture, etc often result in physical injuries. Key in discerning such injuries from sexual abuse is that straddle injuries typically include injury to the clitoris, clitoral hood, mons pubis, and labia. Also important to note is that straddle injuries are usually asymmetric and do not involve the hymen. Conversely, the posterior fourchette, fossa navicularis, and posterior hymen are the structures/area that are injured with penetrating sexual abuse. The yield from such evidence collection does significantly drop off when greater than 24 hours has passed and when the patient has bathed or changed clothes, but it should still be done with penetrating sexual abuse. The requests of the family and patient should not factor into the decision to collect forensic evidence. When there is concern for internal injuries a pediatric surgeon should be consulted to perform an exam and repair if needed in the operating room under anesthesia. Admitting the child until the bleeding resolves or sending the child home to be rechecked in 24 hours are not acceptable as there may be significant ongoing blood loss and/or injuries that need immediate surgical repair. The history taken from the child is often the most important part of the overall evaluation. The child may find repetitive questioning unpleasant or threatening, may infer that he or she is not believed, or may modify his or her history in response to repetitive questioning. However, "Why" questions should be avoided because they may imply blame to the child. If possible, it is recommended that children with a developmental age of 3 or older should be interviewed alone. Having the family leave the room for the interview will often allow the child to open up more without the fear of upsetting the family or getting into trouble. The identification of an abused child is challenging because the history provided is typically inaccurate, physical finding are nonspecific, and the physician fails to include abuse in the differential diagnosis. A careful and complete medical exam and detailed documentation is important in cases of suspected abuse. This chapter delineates the types of abuse most commonly seen in the emergency department, describes historical and physical indicators to help differentiate inflicted from noninflicted injuries, describes diagnostic studies useful in the medical evaluation, and discusses the legal obligations to report suspected abuse and neglect. It is vital that emergency medical care providers recognize, evaluate, and report suspected child abuse and neglect in order to facilitate the safety and well-being of children. The history of the injury must be carefully correlated with the observed pattern of injury, burn depth, and wound appearance. Hematologic disorders Vitamin K deficiency (hemorrhagic disease of the newborn) Hemophilia 3.

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Thick smears are more likely to medicine 10 day 2 times a day chart purchase 10mg zyprexa overnight delivery reveal parasites than thin smears by a factor of approximately 10:1 treatment 3 nail fungus purchase zyprexa 7.5 mg visa. Even though it had been treated in the past symptoms liver cancer buy zyprexa 20 mg with mastercard, it is quite likely that the parasites were not completely eradicated. The most common presentation for malaria is a nonspecific flu-like syndrome with high fever. Laboratory studies frequently show moderately elevated liver functions with hyperbilirubinemia. Yellow fever is an arboviral infection which is transmitted by the A aegypti mosquito. The more common intestinal protozoa, G lamblia and E histolytica, do not cause eosinophila. Thrombocytopenia and hemoconcentration are indicators of worsening disease in dengue fever. Dengue fever may progress to a hemorrhagic state with oozing and bleeding, but a positive stool guaiac test alone is not an indication of worsening disease. The American Academy of Pediatrics still recommends against the use of loperamide or other antimotility agents for the management of diarrhea in children, whether travel-related or not. The routine use of antibiotics for the treatment of diarrhea in children who have not travelled out of the is not recommended. Salmonella infections which are transmitted from animals such as turtles and poultry are caused by other serotypes such as S typhimuirium or S enteritidis. It may be reasonable to obtain a stool culture in this patient, but antibiotics would not be indicated at this point. In children that are otherwise healthy, salmonella enteritis tends to be a self-limited disease and treatment with antibiotics is usually not indicated. Burkholderia mallei Burkholderia pseudomallei Alphaviruses (Venezuelan equine, eastern equine, western equine encephalomyelitis viruses) Rickettsia prowazekii Toxins. Cutaneous has less than 1% mortality if treated, but about 20% mortality if untreated. There can be a large release of anthrax bacilli into the blood stream causing septicemia. The hallmark of cutaneous disease is a single lesion or a few lesions that are painless. Several days later, this progresses to a black depressed eschar at the base of the ulcer. Bacillus anthracis spores are highly stable and highly infectious upon inhalation. Illness resulting from an aerosolized release of anthrax spores is associated with an incubation period of 1 to 60 days, followed by fever, myalgias, cough, and chest pain. Children, particularly infants and toddlers, present with nonspecific symptom complexes primarily limited to fever, vomiting, cough, and dyspnea. Children with inhalational anthrax have abnormal chest roentgenograms; however, children with other forms of anthrax usually have normal roentgenograms. With inhalational anthrax there is abrupt onset of sepsis, hypotension, and death within 24 to 36 hours. Chest radiograph findings include mediastinal widening from lymphadenitis with pulmonary infiltrates or effusions. Hemorrhagic meningitis is expected in 50% of cases with a high overall case fatality rate. Hallmarks of the illness include gram-positive bacilli on tissue biopsy and blood smear or spinal fluid. Early antibiotic administration is likely to be the most important determinant of outcome in the setting of anthrax infection.

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The Arnold-Chiari malformation 503 504 Pathology consists of herniation of the cerebellum and fourth ventricle into the foramen magnum medications list generic 7.5mg zyprexa free shipping, flattening of the base of the skull symptoms gestational diabetes buy generic zyprexa 5mg online, and spina bifida with meningomyelocele medications in pregnancy cheap zyprexa 5mg overnight delivery. Newborns with this disorder are at risk of developing hydrocephalus within the first few days of delivery secondary to stenosis of the cerebral aqueduct. In contrast, severe hypoplasia or absence of the cerebellar vermis occurs in the Dandy-Walker malformation. There is cystic distention of the roof of the fourth ventricle, hydrocephalus, and possibly agenesis of the corpus callosum. Tuberous sclerosis may show characteristic firm, white nodules (tubers) in the cortex and subependymal nodules of gliosis protruding into the ventricles ("candle drippings"). Other signs of tuberous sclerosis include the triad of seizures, mental retardation, and congenital white spots or macules (leukoderma). In von Hippel-Lindau disease, multiple benign and malignant neoplasms occur, including hemangioblastomas of the retina, cerebellum, and medulla oblongata; angiomas of the kidney and liver; and renal cell carcinomas. Patients with Sturge-Weber syndrome, a nonfamilial congenital disorder, display angiomas of the brain, leptomeninges, and ipsilateral face, which are called port-wine stains (nevus flammeus). There are several disorders in this group of developmental abnormalities that have varying degrees of severity. Spina bifida occulta is the mildest form and is characterized by failure of vertebral fusion only. In spina bifida occulta the defect in the closure of the neural tube is covered by skin and dermis, with only a pinpoint sinus or hair-covered depression marking the site. Bacterial meningitis, or meningomyelitis, is the major potential risk in these patients. Because the cord is in its normal location, there are minimal neurologic deficits. Next in severity is spina bifida with a myelomeningocele, which is characterized by herniation of the cord and a meningeal sac through the vertebral defect. This abnormality is often associated with severe neurologic defects in the lower extremities, bladder, and rectum. The most severe form of spina bifida, spina Nervous System Answers 505 bifida aperta or myeloschisis, results from complete failure of fusion of the caudal end of the neural plate, which lies open on the skin surface. This abnormality also results in severe neurologic defects in the legs, bladder, and rectum. These hemorrhages result from severe trauma that typically causes a skull fracture. The hemorrhage results from rupture of one of the meningeal arteries, as these arteries supply the dura and run between the dura and the skull. The artery involved is usually the middle meningeal artery, which is a branch of the maxillary artery, as the skull fracture is usually in the temporal area. Since the bleeding is of arterial origin (high pressure), it is rapid and the symptoms are rapid in onset, although the patient may be normal for several hours (lucid interval). Bleeding causes increased intracranial pressure and can lead to tentorial herniation and death. Berry aneurysms are saccular aneurysms that result from congenital defects in the media of arteries. Instead, berry aneurysms are called congenital, although the aneurysm itself is not present at birth. Berry aneurysms are most commonly found in the circle of Willis, typically either at the junction of the anterior communicating artery with the anterior cerebral artery or at the junction of the middle cerebral artery and the posterior communicating artery. The chance of rupture of berry aneurysms increases with age (rupture is rare in childhood). Rupture causes marked bleeding into the subarachnoid space and produces severe headaches, typically described as the "worst headache ever. Global ischemia results from generalized decreased blood flow, such as with shock, cardiac arrest, or hypoxic episodes. Global hypoxia results in watershed (border zone) infarcts, which typically occur at the border of areas supplied by the anterior and middle cerebral arteries, and laminar necrosis, which is related to the short, penetrating vessels originating from pial arteries. Atherosclerosis, which predisposes to vascular thrombi and emboli, is related to regional ischemia. Hypertension damages parenchymal arteries and arterioles, producing small ischemic lesions (lacunar infarcts). Fat emboli, related to trauma of long bones, lodge in small capillaries to form petechiae.

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