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Clinical Director, Louisiana State University School of Medicine in New Orleans

Procedure: Under general anaesthesia, 2 fingers are passed through the partially dilated cervix, the foot is grasped, as in internal podalic version, pulled through the cervix while the other hand is assisting the version externally. Complications: As internal podalic version but higher in incidence due to the partially dilated cervix and presence of the placenta lower down in case of placenta praevia. Prevention of perineal lacerations by anatomical incision and repair of the episiotomy. Prevention of prolonged and overstretch of the perineum which predisposes to prolapse and stress incontinence. Minimising compression and decompression of the head which causes intracranial haemorrhage. Types: (1) Median episiotomy: A midline incision down to , but not, including the external anal sphincter. Disadvantages: Its inadvertent extension will injure the external anal sphincter and rectum. This can be prevented by extending the incision by the scissors in a J-shaped manner to avoid the external sphincter. Advantages: Extension to the anal sphincter is less common so it is more suitable for instrumental delivery and in short perineum. Procedure: q Anaesthesia: Local infiltration, pudendal nerve block, epidural, spinal or general anaesthesia can be used. Timing: when the introitus is distended by the presenting part or the cup of the ventouse with a visible diameter not less than 3-4 cm, and done at the maximum of a uterine contraction. Incision: the index and middle fingers of one hand is introduced between the presenting part and the proposed site of perineal incision to protect the presenting part and support the tissues that will be incised. Repair: Cut gut O, Dexon or vicryl 2/0 may be used to close the posterior vaginal wall by continuous sutures where the first stitch should be above the apex of the vaginal incision, then the muscles with interrupted sutures and lastly the skin with interrupted or subcuticular sutures. A non- steroidal anti-inflammatory agent as diclofenac is used as an analgesic for the first 72 hours. Pubiotomy: is division of the pubic ramus half an inch from the symphysis pubis with a Gilgi saw to avoid injury to the urethra and bladder. It is out of modern obstetrics due to higher incidence of pubic pain and infection. Indications: It is particularly indicated in women living in distant areas where caesarean section cannot be done and even patient will be left with a caesarean scar is in a high risk of rupture in the next labour. As symphysiotomy gives a permanent increase of the pelvic capacity, it can be an alternative to C. Retained aftercoming head in breech delivery failed to be delivered by other means. Procedure: Subcutaneous symphysiotomy is the commonly done operation and done as follow: file:///D /Webs On David/gfmer/Books/El Mowafi/symphysiotomy. A firm catheter is applied and the urethra is displaced to one side with two fingers in the vagina. A 1-2 cm vertical suprapubic incision is made with a scalpel just above the symphysis. The scalpel is introduced through the incision to the upper border of the symphysis with its sharp edge facing anteriorly i. The joint is gradually divided by a rocking motion, checking with the vaginal fingers for posterior perforation of the joint capsule. The thighs are held by assistants so that abduction and joint separation can be controlled. It has been abandoned from the modern obstetrics in favour of caesarean section which is safer to the mother. Living foetus except in certain congenital anomalies incompatible with life as anencephaly which may be associated with large shoulder girdle. However, destruction of a living foetus for whatever the cause may not be accepted from the religious point of view. Vertex presentation: the anterior fontanelle or in the parietal bone as near as to it. Procedure: (I) Perforation: q Under general anaesthesia the bladder is evacuated and head is steadied by an assistant. The tip is forced into the site of perforation up to shoulders of the perforator which is then opened to produce a linear incision in the skull bones.

This means that the provider is responsible for claims submitted in their name, even if they did not have actual knowledge of a billing impropriety. In the case of a solo practitioner, the name of the practice may be entered as the name of the physician followed by initials that designate how the practice is incorporated. The phone number, including area code, should be entered on the same line as the printed words "& phone #. The last line of Block 33 is for entering the provider and/or group practice numbers, if one is assigned by the payer. As a general rule, the secondary claim cannot be filed electronically because the remittance advice must be attached to the claim sent to the secondary payer. Multiple claims are generated when the patient is covered by multiple insurance policies with different companies. For example, if the patient has both primary and secondary insurance with different payers, two claims are generated. The primary claim is completed according to step-by-step instructions, and the secondary claim is completed by following special instructions included in each chapter. The best known supplemental plans are the Medigap plans, which are supplemental plans designed by the federal government but sold by private commercial insurance companies to "cover the gaps in Medicare. Block 10 (Figure 11-6) indicates whether the condition treated is related to employment, auto accident, or other accident. Failure to properly align the claim form in the printer to ensure that each item fits within the proper field on the claim. Although there are no specific laws covering retention of commercial or Blue Cross/Blue Shield claims, healthcare provider contracts with specific insurance carriers may stipulate a specific time frame for all participating providers. It is good business practice to keep these claims until you are sure all transactions have been completed. Processing Assigned Paid claims When the remittance advice arrives from the payer, pull the claim(s) and review the payment(s). Make a notation of the amount of payment, remittance advice notice processing date, and applicable batch number on the claim. Single-payment remittance advice notices may be stapled to the claim before filing in the closed assigned claims file. Federal Privacy Act the Federal Privacy Act of 1974 prohibits a payer from notifying the provider about payment or rejection of unassigned claims or payments sent directly to the patient/policyholder. The letter is to be signed by the patient and policyholder, to give the payer permission to allow the provider to appeal the unassigned claim. If the policyholder writes the appeal, the provider must supply the policyholder with the supporting documentation required to have the claim reconsidered. In recent years Congress has increased efforts to prevent submission of fraudulent claims to government programs. This would allow the provider to appeal processing errors on unassigned government claims. Entering data into the computer using this technology greatly increases productivity associated with claims processing because the need to manually enter data from the claim into a computer is eliminated. Form a study group with classmates to discuss chapter concepts in preparation for an exam. Physician services for inpatient care are billed on a fee-for-service basis, and physicians submit service/procedure codes to payers. A patient develops surgical complications and returns to the operating room to undergo surgery related to the original procedure. Which situation requires the provider to write a letter explaining special circumstances? Surgery defined as an inpatient procedure was performed while the patient was in the hospital. Surgery typically categorized as an office procedure was performed in a hospital outpatient setting. Which statement is an accurate interpretation of the phrase "assignment of benefits"?

Othermanifestationscanincludethefollowing:(1)respiratory:coryza,pharyngitis,herpangina,stomatitis,bronchiolitis,pneumonia, andpleurodynia;(2)skin:hand-foot-and-mouthdisease,onychomadesis(periodicsheddingof nails),andnonspecificexanthems;(3)neurologic:asepticmeningitis,encephalitis, andmotorparalysis;(4) astrointestinal/genitourinary:vomiting,diarrhea,abdominal g pain,hepatitis,pancreatitis,andorchitis;(5)eye:acutehemorrhagicconjunctivitisand uveitis;(6)heart:myopericarditis;and(7)muscle:myositis. Schematic representation of the evolution of antibodies to various Epstein-Barr virus antigens in patients with infectious mononucleosis. Somegram-negativebacilli,suchasCitrobacter koseri, Chronobacter (formerlyEnterobacter) sakazakii,Serratia marcescens, andSalmonella species,are associatedwithbrainabscessesininfantswithmeningitiscausedbytheseorganisms. Acquisitionof gram-negativeorganismscanoccurthroughperson-to- persontransmissionfromhospitalnurserypersonnelandfromnurseryenvironmental sites,suchassinks,countertops,powderedinfantformula,andrespiratorytherapy e quipment,especiallyamongverypreterminfantswhorequireprolongedneonatal i ntensivecaremanagement. Neonates withdefectsintheintegrityof skinormucosa(eg,myelomeningocele)orabnormalities of gastrointestinalorgenitourinarytractsareatincreasedriskof gram-negativebacterial infections. Periodicreviewof invitroantimicrobialsusceptibilitypatternsof linicallymportant c i bacterialisolatesfromnewborninfants,especiallyinfantsinthe eonatalntensivecare n i unit,canprovideusefulepidemiologicandtherapeuticinfor ation. HumaninfectionusuallyresultsfromF necrophorumsubspeciesfunduliforme,butinfections withotherspeciesincludingF nucleatum, Fusobacteriumgonidiaformans,Fusobacteriumnaviforme, Fusobacterium mortiferum, andFusobacteriumvariumhavebeenreported. Upto50% of F nucleatumand20%of F necrophorum isolatesproducebeta-lactamases,rendering themresistanttopenicillin,ampicillin,andsomecephalosporins. A 3-daycourseof nitazoxanideoralsuspensionhassimilarefficacytometronidazoleand hastheadvantage(s)of treatingotherintestinalparasitesandof beingapprovedforuse inchildren1yearof ageandolder. Handhygieneby staff andchildrenshouldbeemphasized,especiallyaftertoiletuseorhandlingof soiled diapers,whichisakeypreventiveactionforcontrolof spreadof giardiasis. Interpretationof cultureof N gonorrhoeaefromthepharynxof youngchildrennecessitatesparticularcaution becauseof thehighcarriagerateof nonpathogenicNeisseriaspeciesandtheseriousimplicationsof suchacultureresult. Special Problems in Treatment of Children (Beyond the Neonatal Period) and Adolescents. Patientswithuncomplicatedinfectionsof thevagina,endocervix,urethra,oranorectum andahistoryof severeadversereactionstocephalosporins(anaphylaxis,Stevens-Johnson syndrome,andtoxicepidermalnecrolysis)shouldbetreatedwithspectinomycin(40mg/ kg,maximum2g,givenintramuscularlyasasingledose),if available(spectinomycincurrentlyisnotavailableintheUnitedStates). Complicated Gonococcal Infection: Treatment of Children Beyond the Newborn Period and Adolescents,a continued Patients Who Weigh 100 lb (45 kg) or More and Who Are 8 Years of Age or Older SeeTable3. Children and Adolescents With Sexual Exposure to a Patient Known to Have Gonorrhea. Allpregnantwomenatriskof gonorrheaorlivinginanareainwhichthe prevalenceof N gonorrhoeaeishighshouldhaveanendocervicalcultureforgonococciat thetimeof theirfirstprenatalvisit. OtitismediaattributabletoH influenzaeisdiagnosedbycultureof tympanocentesis fluid;culturesof otherrespiratorytractswabspecimens(eg,throat,eardrainage)arenot indicativeof middle-earcultureresults. Chemoprophylaxisisnotrecommendedforcontactsof peoplewith i nvasivediseasecausedbynontypebH influenzae strains,becausesecondarydiseaseis rare. Whensequentialdosesof differentvaccineproductsaregivenoruncertaintyexistsaboutwhich productspreviouslywereadministered,3dosesof aconjugatevaccineare onsidered c sufficienttocompletetheprimaryseries,regardlessof theregimenused. Forchildren12through59monthsof agewithanunderlyingconditionpredisposingtoHibdiseasewhoarenotimmunizedorhavereceivedonly1doseof conjugate vaccinebefore12monthsof age,2dosesof anyconjugatevaccine,separatedby 2months,arerecommended. Approximately70%of infectedpeopleareasymptomatic,20%of peoplehave macroscopic(ie,visual)andmicroscopicfindingsof ulceration,andanestimated1% havefeaturesof neoplasia. Serologic testingforH pyloriinfectionbydetectionof immunoglobulinG(IgG)antibodiesspecific forH pyloridoesnothelpclarifythecurrentstatusof infectionandisnotrecommended forscreeningchildren. Screeningforandtreatmentof infection,if found,alsoisrecommendedforchildrenwithoneormoreprimaryrelativeswithgastric cancer,childrenwhoareinahigh-riskgroupforgastriccancer(eg,immigrantsfrom resource-limitedcountriesorcountrieswithhighratesof gastriccancer)orchildren whohaveunexplainediron-deficiencyanemia. EradicationtherapyforH pylori consistsof at least7to14daysof treatment;eradicationratesarehigherforregimensof 14days. Inaddition,thepreviouslyobserved unequalgeographicdistributionof hepatitisAincidenceintheUnitedStates,withthe highestratesof diseaseoccurringinalimitednumberof statesandcommunities,has d isappearedafterintroductionof targetedimmunizationin1999. Thelikelihoodof developingsymptomsof acutehepatitis isagedependent:lessthan1%of infantsyoungerthan1yearof age,5%to15%of children1through5yearsof age,and30%to50%of peopleolderthan5yearsof ageare symptomatic,althoughfewdataareavailableforadultsolderthan30yearsof age. Transmissionbytransfusion of contaminatedbloodorbloodproductsisrareintheUnitedStatesbecauseof routine screeningof blooddonorsandviralinactivationof certainbloodproductsbeforeadministration(seeBloodSafety,p114). Othersatincreased riskincludepeoplewithoccupationalexposuretobloodorbodyfluids,staff of institutionsandnonresidentialchildcareprogramsforchildrenwithdevelopmentaldisabilities, patientsundergoinghemodialysis,andsexualorhouseholdcontactsof peoplewithan acuteorchronicinfection. For immunizationof olderchildrenandadolescents,dosesmaybegiveninascheduleof 0,1, and6months;of 0,1,and4months;orof 0,2,and4months(althoughshorterintervals betweenfirstandlastdosesresultinlowerimmunogenicity).