By X. Ali. Union College.
A history of trauma precipitating acute (or chronic) neck pain necessitates ruling out the possibility of a fracture with X-ray and/or computed tomography evaluation in most cases generic triamterene 75 mg with visa. Most patients with Z-joint disease can recall some history of trauma (even if it was 60 years ago and did not immediately precipitate their symptoms) buy triamterene 75mg low cost. Patients with radicular symptoms caused by a herniated disc may be more likely to have worsening symptoms with neck flexion (which increases intradiscal pressure). Patients with radicular symptoms caused by foraminal stenosis may be more likely to have increased symptoms with neck oblique extension (such as looking back over the shoulder) because this position increases pressure on the foramen. Patients with Z-joint disease may have increased pain with neck extension because this position increases pressure on the Z-joints. This question is most helpful for deciding which imaging studies (if any) to order and how to treat your patient. If the answer to any of these questions is “yes,” then you should consider an underlying infection or malignancy. Progressive neurological injury is an indication for surgery and the patient should have spinal cord compromise ruled out. Physical Exam Having completed the history portion of your exam, you have deter- mined whether or not your patient has symptoms of axial neck pain or radicular, and you have begun to narrow your differential diagnosis. To help differentiate C7 from T1, have the patient laterally rotate the head as you simultaneously palpate the spinous processes of C7 and T1. C7 will move slightly with lateral rotation but T1 is fixed and will not rotate. Palpate the paraspinal cervical muscles for any muscle spasms, tender points, or trigger points. Trigger points are dif- ferentiated from tender points because in addition to being tender, trig- ger points have referral pain patterns when palpated. Then have the patient rotate the head slowly from side to side (as if shaking the head “no”). Instruct the patient to laterally flex the neck (as if attempting to touch the ear to the ipsilat- eral shoulder).
It is not order triamterene 75 mg line, therefore discount triamterene 75mg mastercard, appropriate to use chronological age alone as a guide to the level of explanation but instead an assessment of the apparent developmental age displayed by the child needs to be made. Taking time to explain the procedure is essential if maximum co-operation is to be achieved and the use of physical restraints minimised. The explanation should, if possible, be made in a neutral environment such as the waiting area and, as the age at which comprehension begins is uncertain, it should be worded in such a way as to be understandable to both adult and child, including children as young as 12 months of age (Fig. An effective explanation, although apparently time consuming, will in fact result in a more efﬁcient examination as improved child and guardian co- operation will reduce actual examination time and, if the explanation can be undertaken outside of the imaging room, will reduce patient waiting times. Invite guardian to be present Family centred care (see Chapter 1) is the major ethos of children’s healthcare today and working in partnership with guardians is seen as essential if high- quality care is to be provided and maintained. The presence of a guardian within 14 Paediatric Radiography Fig. A guardian will be able to comfort and divert a child more effectively if they understand what is happening Emphasise the child’s role is to remain still throughout the examination and repeat this role at several intervals during the explanation Provide the child with choices to emphasise their control of the situation (e. Guardians are also able to comfort the child in a famil- iar manner and often instinctively implement appropriate distraction techniques that can reduce the child’s fear and anxiety, increase the child’s co-operation and minimise the need for restraining devices. Position child in a comforting manner Lying supine within an unfamiliar environment increases the feeling of help- lessness and loss of control in adults and children alike and increases patient anxiety. Radiographers need to be more creative in their imaging strategies when examining children and work with what is presented rather than ‘forcing’ the Consent, immobilisation and health care law 15 child to adopt a position routinely used in the imaging of adults. The need for ‘cuddles’ and comfort throughout an imaging examination is not restricted to very young children and children as old as 7 or 8 years will prefer to sit across a guardian’s lap or next to a guardian to gain comfort from their presence (Figs 2. Maintain a calm, positive atmosphere If you talk to a screaming child quietly and positively then eventually they will calm down. Anxiety levels in children and adults increase with the level of surrounding noise and therefore focusing on a calm and quiet voice can help reduce this anxiety. Distraction tools The use of distraction techniques within health care is growing greater in promi- nence and the experts in the use of distraction and play are play specialists. Play specialists are not generally employed within imaging departments but instead tend to work mainly on children’s wards and outpatient clinics. However, most play specialists would welcome the opportunity to discuss child-friendly envi- ronments and distraction techniques with other health care professionals and (b) (a) Fig. Alternatively, various pieces of equipment designed to distract children are available but care must be taken before purchase to ensure that they are easy to use and operate (Fig.
It is very important to splint the hand and digits in the intrinsic plus 266 Go´mez-Cıa´ and Ortega-Martınez´ position buy triamterene 75mg free shipping, with the thumb in flexion order triamterene 75 mg amex, opposition, and abduction. Some authors suggest placing the hand in fist position when placing the graft because they believe that the amount of graft material needed can be better estimated [15,16]. When the digital extensors, ligamentous apparatus, or joints have been damaged, we use internal splinting of the affected segment using K-wires until the wound has healed. We examine laminar grafts of the hands 24 hours after surgery to eliminate seromas and hematomas, which may accumulate beneath the graft, and to apply a new nonadherent bandage. Grafted hands should be elevated with respect to the position of the patient’s body by placing them on a pillow or by elastic traction above the patient, and splinted in the position described previously. Occasionally, skeletal traction may be useful alone or in association with devices such as the ukelele, horseshoe, or others. Once the graft is secure, the patient should then begin active and passive mobilization of the joints of the digits, hand, and wrist. A splint is used to maintain the correct position of the hand while the patient is resting. If deep structures are exposed, such as tendon lacking a peritenon, bone lacking periosteum, joints, or nerves, after burn debridement, cutaneous grafts are not indicated. In such cases, it is necessary to use local flaps, distal flaps, or occasionally free flaps. In addition to the classic flaps, based on a proximal, random, or axial vascular pedicle, proximal cutaneous regions based on distal vascular pedi- cles using inverse flow are also useful. Cutaneous losses in the pulp of the long digits occurs frequently with low- voltage electrical burns in children. When bone is not exposed and the injury is less than 1 cm2, it is justifiable, in our opinion, to take a conservative approach and allow the wound to close by spontaneous scarring. If the injury is greater than 1 cm2, it may be covered with full-thickness skin graft.