By Z. Lee. Northwestern Michigan College.

Monitoring and follow up  Inpatient  Vital signs-neurological deterioration cheap 60 mg pyridostigmine with amex, Temperature 60mg pyridostigmine free shipping, Respiratory rate Blood glucose 2hourly discount pyridostigmine 60mg, urine ketones 4 hourly  Outpatient • Blood glucose-personal glucometers discount pyridostigmine 60mg otc, • Hyperglycemia-shown by frequent micturation at night , • Urine glucose, • Glycaemic control –glycosylated Haemoglobin-(Ranges)(HbA1c), • Growth (Height and weight) every visit , • Complications, • Hypoglycaemia-management , • Continuous diabetes education-every visit Surgery Minor surgery(duration < 3h. Primary Causes:  Iodine deficiency  Congenital  Drugs; Iodine excess (contrasts media containing iodine), lithium, antithyroid drugs, p- aminosalisylic acid, interferon alfa and other cytokines, aminoglutethimide. Others are cool peripheral extremities, puffy face, hands and feet (Myxedema), diffused alopecia (hair loss), bradycardia, peripheral odema, delayed tendon reflex relaxation, carpal tunnel syndrome and serous cavity effusions. Diseases of the thyroid gland are manifested by qualitative or quantitative alterations in hormone secretion or enlargement of the thyroid gland or both. Enlargement of the thyroid gland may result in normal increased, or decreased hormone secretion. Treatment  Iodised salt may not provide sufficient iodine and should therefore not be prescribed alone  Lugol’s solution is too concentrated for daily use, and should be diluted by a factor of 30 to give 4. Treatment Age less than 45 years  First choice B: Schiller’s iodine 2 drops (460 micrograms) once daily for one year. Response may be obtained within 6 months  Second choice B: Lugol’s solution 3 drops (21mg) once each month for up to one year. Post thyroidectomy  Iodine should be given daily indefinitely to prevent recurrence, following dosing schedule give above  Physiological doses of iodine can be given even in pregnancy. It is actually necessary to provide the therapy to avoid iodine deficiency to the foetus  Patients should continue taking iodized salt indefinitely (Ref. National Policy on Nutrition) after the completion of treatment or begin giving 1 drop (7mg) at Lugol’s sol per month. It is usually due to diffuse hyperplasia and hypertrophy of the thyroid gland (Graves’ disease). Hyperthyroidism is characterized by an increased metabolic rate, which causes weight loss, increased appetite, fatigue, emotional disturbances, heat intolerance, sweating, muscle weakness and diarrhea. Treatment Graves’ disease: 241 | P a g e C: Carbimazole 40mg (O) once daily for 3 weeks then 20mg daily for 3 weeks. Maintenance dose 5mg for up to one year Toxic Nodular Goitre  Can be treated with antithyroid drugs and surgery or radio-iodine C: Carbimazole 40mg (O) once daily for 3 weeks then 20mg daily for 3 weeks. Iron deficiency is mainly due to blood loss secondary to haemorrhage, malabsoption and hookworm infections. Iron deficiency anaemia A: Ferrous sulphate200 mg (O) every 8 hours Children5 mg/kg body weight every 8 hours. Pyruvate kinase deficiency c) Haemoglobin -Abnormal haemoglobin such as HbS, C, Unstable Hb Clinical features  The disease may occur at any age and sex  Patient may present with symptom and features of Anaemia  Symptoms are usually slow in onset however rapidly developing anaemia can occur  Splenomegaly is common but no always observed  Jaundice Treatment i. Immunosuppressive drugs for the patients who fail to respond to corticosteroids and splenectomy. Symptoms may include anaemia, dactylitis, recurrent infections, impaired growth and development. Crises Three distinct types of crises develop in patients with sickle cell disease  Vaso-occlusive or painful crises are more common occurring with a frequency from almost daily to yearly. It is important to distinguish between painful crises and pain caused by another process  Aplastic crises occurs when erythropoiesis is suppressed  Sequestration crises occurs in children or occasional in adult with an enlarged spleen due to massive pooling of red cells in the spleen Treatment Guidelines Nonspecific measures A: Folic acid 5mg once daily Specific measures S: Hydroxyurea 15mg/kg/day. Maximum dose: 35mg/kg Management of Complication  Patients undergoing vascular crises should be kept warm and given adequate hydration and pain control (Inj pethedine 100mg 6hrly, Oral morphine 5mg/kg) and oxygen  Acute chest syndrome is a life threatening complication and empiric antibiotics should be given. Usually asymptomatic but liable to haemolysis if incriminated drugs or foods are taken (e. Treatment Guidelines  Avoid incriminated agents/foods or drugs  Transfusion of packed red blood cells in severe anaemia. Most frequent haemorrhage involves joints or muscles and bleeding parttens differ with age: Infants usually bleed into soft tissues ar from the mouth but as the boy grows, characterist joint bleeding becomes more common. Frequent spontaneous haemarthrosis factor is needed several times Moderate 2-5%of normal 1Haemorrhage secondary 0. Patients present with a history of easy bruising, menorrhagea, gum bleeding and spontaneous joint bleeding in severe form. In the acute form massive activation of coagulation does not allow time for compensatory increase in production of coagulant and anticoagulant factors. Patients present with bleeding manifestation, extensive organ dysfunction, shock, renal corticle ischemia, coma, delirium and focal neurological symptoms. Clinical feature for adult thrombocytopenia appears to be more common in young women than in young men but amoung older patients, the sex incidence may be equal. Most adult patient presents with a long history of purpura, menorrhagia, epistaxis and gingival haemorrhage. Treatment of Venous Thromboembolism Long term anticoagulation is required to prevent a frequency of symptomatic extension of thrombosis and/or recurrent venous thromboembolic events. Warfarin is started with initial heparin or clexane therapy and then overlapped for 4-5days. The aim in handling major trauma is to look for life threatening complications which if missed may endanger the patient’s life. We will exclude maxillo-facial injuries and eye injuries from this discussion (Ref this to eye section). Mortality is increased if hypotension or airway/breathing problem is not adequately solved. Exclude fractures by performing appropriate X-rays Note  Referral must not be delayed by waiting for a diagnosis if treatment is logistically impossible  Closed injuries and fractures of long bones may be serious and damage blood vessels  Contamination with dirt and soil complicates the outcome of treatment I. Maximum of 4 doses per 24 hours Plus S: Cloxacillin 500mg 6 hourly for 7 days Plus B: Tetanus prophylaxis: 0. In children less than 6 months calculate dose by weight  Perform X-ray to rule out dislocations or sublaxations 2 Referral  If Severe progressive pain. Hemorrhagic shock may ensue in situations involving multiple fractures or pelvic ring fractures. Paralysis may be associated, often been brought by improper transfer of the patient to the hospital. Thus lion, tiger, leopard, hyena, bear, elephant, hippopotamus, buffalo, wolf and wild pig are examples of the wild animals that have bitten man. Clinical features of these bites arise from the pathology inflicted by teeth, tusks, claws and horns. Severe facial and eye innuries are common and pneumothorax, hemothorax, bowel perofration and compound fractures have occurred. Treatment  Emergency surgery is often needed  Replace any blood lost  Treat complications of injury e. Symptoms:Most bites and stings result in pain, swelling, redness, and itching to the affected area Treatment and Management Treatment depends on the type of reaction  Cleanse the area with soap and water to remove contaminated particlesleft behind by some insects  Refrain from scratching because this may cause the skin to break down and an infection to form  Treat itching at the site of the bite with antihistamine  Give appropriate analgesics  Where there is an anaphylactic reaction treat according to guideline. If area burnt is larger than 10% of body surface then this is extensive because of fluid loss, catabolism, anaemia and risk of secondary infection. Table 5: Rule of Nine for calculatin % of Body surface burned Body Areas Adult (%) Child % Entire head 9 18 Upper limb 9 18 Anterior or posterior surface of trunk 18 18 Lower limb 18 14 Perineum 1 1 Treatment Ensure that there is an adequate airway, adequate breathing and adequate circulation  Immerse burnt area in cold water for 10 minutes  Clean with Normal saline or Chlorhexidine – cetrimide solution  Apply Gentian Violet solution  Do not cover  Calculate fluid requirement per 24 hours: weight x % of surface burnt x 2 = quantity of fluid  Give 75% of fluid requirement as sodium lactate compound solution and 25% as 6% Dextran 70 as blood/plasma expanders. In such cases refer to secondary or tertiary level health care centre  Children give A: Paracetamol 10 mg/kg every 8 hours Plus C: Procaine Penicillin 0.

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Long-term treatment of asthma according to severity Categories Treatment Intermittent asthma No long term treatment • Intermittent symptoms (< once/week) Inhaled salbutamol when symptomatic • Night time symptoms < twice/month • Normal physical activity Mild persistent asthma Continuous treatment with inhaled beclometasone • Symptoms > once/week cheap 60mg pyridostigmine visa, but < once/day + • Night time symptoms > twice/month Inhaled salbutamol when symptomatic • Symptoms may affect activity Moderate persistent asthma Continuous treatment with inhaled beclometasone • Daily symptoms + • Symptoms affect activity Inhaled salbutamol (1 puff 4 times/day) • Night time symptoms > once/week • Daily use of salbutamol Severe persistent asthma Continuous treatment with inhaled beclometasone • Daily symptoms + • Frequent night time symptoms Inhaled salbutamol (1-2 puff/s 4 to 6 times/day) • Physical activity limited by symptoms Inhaled corticosteroid treatment: beclometasone dose varies according to the severity of asthma discount pyridostigmine 60mg with amex. Find the minimum dose necessary to both control the symptoms and avoid local and systemic adverse effects: Children: 50 to 100 micrograms twice daily depending on the severity pyridostigmine 60mg visa. In patients with severe chronic asthma the dosage may be as high as 800 micrograms/day pyridostigmine 60 mg with mastercard. Adults: start with 250 to 500 micrograms twice daily depending on to the severity. If a total dosage of 1000 micrograms/day (in 2 to 4 divided doses) is ineffective, the dosage may be increased to 1500 micrograms/day, but the benefits are limited. The number of puffs of beclometasone depends on its concentration in the inhaled aerosol: 50, 100 or 250 micrograms/puff. If exercise is a trigger for asthma attacks, administer 1 or 2 puffs of salbutamol 10 minutes beforehand. In pregnant women, poorly controlled asthma increases the risk of pre-eclampsia, eclampsia, haemorrhage, in utero growth retardation, premature delivery, neonatal hypoxia and perinatal mortality. Long-term treatment remains inhaled salbutamol and beclometasone at the usual dosage for adults. If symptoms are not well controlled during a period of at least 3 months, check the inhalation technique and adherence before changing to a stronger treatment. If symptoms are well controlled for a period of at least 3 months (the patient is asymptomatic or the asthma has become intermittent): try a step-wise reduction in medication, finally discontinuing treatment, if it seems possible. If the patient has redeveloped chronic asthma, restart long-term treatment, adjusting doses, as required. In immunocompetent patients, the pulmonary lesion heals in 90% of cases, but in 10%, patients develop active tuberculosis. Tuberculosis may also be extrapulmonary: tuberculous meningitis, disseminated tuberculosis, lymph node tuberculosis, spinal tuberculosis, etc. Clinical features Prolonged cough (> two weeks), sputum production, chest pain, weight loss, anorexia, fatigue, moderate fever, and night sweats. The most characteristic sign is haemoptysis (presence of blood in sputum), however it is not always present and haemoptysis is not always due to tuberculosis. If sputum is smear-negative, consider pulmonary distomatosis (Flukes, Chapter 6), melioidosis (Southeast Asia), profound mycosis or bronchial carcinoma. In an endemic area, the diagnosis of tuberculosis is to be considered, in practice, for all patients consulting for respiratory symptoms for over two weeks who do not respond to non-specific antibacterial treatment. Treatment The treatment is a combination of several of the following antituberculous drugs [isoniazid (H), rifampicin (R), pyrazinamide (Z), ethambutol (E), streptomycin (S)]. The regimen is standardised and organized into 2 phases (initial phase and continuation phase). Only uninterrupted treatment for several months may lead to cure and prevent the development of resistance, which complicates later treatment. It is essential that the patient understands the importance of treatment adherence and that he has access to correct case management until treatment is completed. Diseases, such as malaria, acute otitis media, upper and lower respiratory tract infections, etc. Treatment General principles: – Prevent or treat dehydration: rehydration consists of prompt replacement of fluid and electrolyte losses as required, until the diarrhoea stops. However, for treating cholera, the administration of a single dose should not provoke any adverse effects. Bloody diarrhoea (dysentery) – Shigellosis is the most frequent cause of dysentery (amoebic dysentery is much less common). If there is no laboratory diagnosis to confirm the presence of amoebae, first line treatment is for shigellosis. Prevention – Breastfeeding reduces infant morbidity and mortality from diarrhoea and the severity of diarrhoea episodes. Shigella dysenteriae type 1 (Sd1) is the only strain that causes large scale epidemics. Clinical features Bloody diarrhoea with or without fever, abdominal pain and tenesmus, which is often intense. Patients with at least one of the following criteria have an increased risk of death: – Signs of serious illness: • fever > 38. After confirming the causal agent, antimicrobial susceptibility should be monitored monthly by culture and sensitivity tests. Organise home visits for daily monitoring (clinically and for compliance); hospitalise if the patient develops signs of serious illness. Shigellosis is an extremely contagious disease (the ingestion of 10 bacteria is infective). Note: over the past few years, Sd1 epidemics of smaller scale and with lower case fatality rates (less than 1%) have been observed. Transmission is faecal-oral, by ingestion of amoebic cysts from food or water contaminated with faeces. Usually, ingested cysts release non-pathogenic amoebae and 90% of carriers are asymptomatic. In 10% of infected patients, pathogenic amoebae penetrate the mucous of the colon: this is the intestinal amoebiasis (amoebic dysentery). The clinical picture is similar to that of shigellosis, which is the principal cause of dysentery. Occasionally, the pathogenic amoebae migrate via the blood stream and form peripheral abscesses. Clinical features – Amoebic dysentery • diarrhoea containing red blood and mucus • abdominal pain, tenesmus • no fever or moderate fever • possibly signs of dehydration – Amoebic liver abscess • painful hepatomegaly; mild jaundice may be present • anorexia, weight loss, nausea, vomiting • intermittent fever, sweating, chills; change in overall condition Laboratory – Amoebic dysentery: identification of mobile trophozoites (E. Treatment – First instance, encourage the patient to avoid alcohol and tobacco use. Gastric and duodenal ulcers in adults Clinical features Burning epigastric pain or epigastric cramps between meals, that wake the patient at night. They are most characteristic when they occur as episodes of a few days and when accompanied by nausea and even vomiting. Gastrointestinal bleeding Passing of black stool (maelena) and/or vomiting blood (haematemesis). Gastric lavage with cold water is not essential, but may help evaluate persistence of bleeding. If a diagnosis of ulcer is probable, and the patient has frequent attacks requiring repeated treatment with antiulcer drugs or, in cases of complicated ulcers (perforation or gastrointestinal bleeding) treatment to eradicate H. Dyspepsia is most commonly functional, linked with stress and not linked to the quantity of gastric acid (antiacids and antiulcer drugs are ineffective). Treatment If the symptoms persist, short term symptomatic treatment may be considered.

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As part of the clinical encounter order pyridostigmine 60 mg free shipping, health and clinical experts reviewed the draft recommendations trusted pyridostigmine 60 mg. More any new sex partners you’ve had since your last visit purchase 60 mg pyridostigmine overnight delivery,” and comprehensive 60 mg pyridostigmine mastercard, annotated discussions of such evidence “What has your experience with using condoms been like? For infections with more a sexual history is one strategy for eliciting information than one recommended regimen, listed regimens have similar concerning five key areas of interest (Box 1). For additional efficacy and similar rates of intolerance or toxicity unless information about gaining cultural competency when working otherwise specified. Partners prevention section and sections on chlamydia, gonorrhea, • “Do you have sex with men, women, or both? Prevention of pregnancy which can be resource intensive, is directed at a person’s risk, • “What are you doing to prevent pregnancy? Other approaches use motivational interviewing to move • “Is there anything else about your sexual practices that clients toward achievable risk-reduction goals. A recent federal guideline mutually monogamous relationship with a partner known to recommends that clinical and nonclinical providers assess be uninfected. Rates of breakage and • Ensure adequate lubrication during vaginal and anal sex, slippage may be slightly higher during anal intercourse (33,34). Users should check the firmly against the base of the penis during withdrawal, expiration or manufacture date on the box or individual and withdraw while the penis is still erect. Latex condoms should not be used beyond their Additional information about male condoms is available at expiration date or more than 5 years after the manufacturing http://www. Male condoms made of materials other than latex are Female Condoms available in the United States and can be classified in two general categories: 1) polyurethane and other synthetic and Several condoms for females are globally available, including 2) natural membrane. The effectiveness of other synthetic prevention method, and the newer versions may be acceptable male condoms to prevent sexually transmitted infections to both men and women. Additional Natural membrane condoms (frequently called “natural skin” information about the female condom is available at http:// condoms or [incorrectly] “lambskin” condoms) are made from www. Spermicides containing N-9 might • Carefully handle the condom to avoid damaging it with disrupt genital or rectal epithelium and have been associated fingernails, teeth, or other sharp objects. Condoms with N-9 • Put the condom on after the penis is erect and before any are no more effective than condoms without N-9; therefore, genital, oral, or anal contact with the partner. N-9 use has also been associated with an AquaLube, and glycerin) with latex condoms. Oil-based increased risk for bacterial urinary tract infections in women lubricants (e. Sexually be available to families that desire it, as the benefits of the active women who use hormonal contraception (i. Studies examining the association potential benefit of male circumcision for this population (62). Three randomized, controlled through advance prescription or supply from providers trials performed in regions of sub-Saharan Africa where (64,65). It is also Retesting several months after diagnosis of chlamydia, recommended that health departments provide partner services gonorrhea, or trichomoniasis can detect repeat infection for persons who might have cephalosporin-resistant gonorrhea. Clinicians should positive for trichomonas, should be rescreened 3 months familiarize themselves with public health practices in their after treatment. Any person who receives a syphilis diagnosis area, but in most instances, providers should understand should undergo follow-up serologic syphilis testing per current that responsibility for ensuring the treatment of partners of recommendations (see Syphilis). Clinical evaluation, counseling, diagnostic testing, and treatment providers are unlikely to participate directly in internet partner designed to increase the number of infected persons brought notification. Internet sites allowing patients to send anonymous to treatment and to disrupt transmission networks. The term via the internet is considered better than no notification at all “public health partner services” refers to efforts by public and might be an option in some instances. However, because health departments to identify the sex- and needle-sharing the extent to which these sites affect partner notification and partners of infected persons to assure their medical evaluation treatment is uncertain, patients should be encouraged either and treatment. Patients then provide partners with these their sex partners and urge them to seek medical evaluation and therapies without the health-care provider having examined the treatment. Unless prohibited by of notifying partners is associated with improved notification law or other regulations, medical providers should routinely outcomes (88). Although this approach can be effective for a If the patient has not had sex in the 60 days before diagnosis, main partner (89,90), it might not be feasible approach for providers should attempt to treat a patient’s most recent sex additional sex partners. However, providers should patients with written information to share with sex partners visit http://www. Testing pregnant women and treating those in accordance with state and local statutory requirements. Women who are at high risk for syphilis or chlamydia also should be retested during the third live in areas of high syphilis morbidity should be screened trimester to prevent maternal postnatal complications and again early in the third trimester (at approximately chlamydial infection in the neonate. Some states require found to have chlamydial infection should have a test-of- all women to be screened at delivery. Any woman who delivers a stillborn infant should be adverse effects of chlamydia during pregnancy, but tested for syphilis. Women who were not screened prenatally, those concurrent partners, or a sex partner who has a sexually who engage in behaviors that put them at high risk for transmitted infection) should be screened for N. Preventive Services Task Force July 1992, receipt of an unregulated tattoo, having been Recommendation Statement (111). Symptomatic women should be evaluated sequential sexual partnerships of limited duration, failing to use and treated (see Bacterial Vaginosis). Women who report symptoms should be evaluated and All 50 states and the District of Columbia explicitly allow treated appropriately (see Trichomonas). Preventive Services Task Force health insurance plans, presents multiple problems. In addition, federal Viral Hepatitis in Pregnancy (114); Hepatitis B Virus: A laws obligate notices to beneficiaries when claims are denied, Comprehensive Strategy for Eliminating Transmission in the including alerting beneficiaries who need to pay for care until United States — Recommendations of the Immunization Practices the allowable deductible is reached. Vaccination is also recommended for females recommended for all sexually active females aged <25 years aged 13–26 years who have not yet received all doses or (108). However, 11 and 12 years and also can be administered beginning screening of sexually active young males should be at 9 years of age (16). This recommendation is based on the low consistent and correct condom use and reduction in the number of sex partners). Detection behavioral counseling for all sexually active adolescents and treatment of early syphilis in correctional facilities might (7) to prevent sexually transmitted infections. However, because of the mobility of cooperation between clinicians, laboratorians, and child- incarcerated populations in and out of the community, the protection authorities. Official investigations, when indicated, impact of screening in correctional facilities on the prevalence should be initiated promptly. For example, in jurisdictions with comprehensive, targeted jail screening, more chlamydial Syphilis Screening infections among females (and males if screened) are detected Universal screening should be conducted on the basis of and subsequently treated in the correctional setting than any the local area and institutional prevalence of early (primary, other single reporting source (118,129) and might represent secondary, and early latent) infectious syphilis. Syphilis seroprevalence rates, which can a heterogeneous group of men who have varied behaviors, identities, and health-care needs (138).

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