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http://www.ucdenver.edu/academics/colleges/pharmacy/Departments/ClinicalPharmacy/DOCPFaculty/Q-Z/Pages/Paul-Reynolds,-PharmD.aspx
If left lower quadrant pressure by the examiner leads only to high cholesterol medication side effects purchase lasuna uk left-sided pain or pain on both the left and right sides cholesterol levels seafood chart purchase 60 caps lasuna with mastercard, then there may be some other pathologic etiology cholesterol kidney disease purchase online lasuna. Liver percussion to high cholesterol medication uk generic lasuna 60caps overnight delivery determine its size and identify its edges is a skill beyond the scope of a physical therapist for a screening examination. Therapists involved in visceral manipulation will be most likely to develop this advanced skill. During inspiration, the liver will move down with the diaphragm so that the lower edge may be felt below the right costal margin. Cirrhosis, metastatic cancer, infltrative leuke of one or both hands (depending on hand size) up and under the right costal border. The liver is often palpable 2 percussion test [costovertebral tenderness] of the kidney depicted to 3 cm below the costal margin in infants and young in Fig. If you come in contact with the bottom edge tucked up Palpation of the spleen is not possible unless it is distended under the rib cage, the normal liver will feel frm, smooth, and bulging below the left costal margin (Fig. A palpable hard or lumpy edge warrants spleen enlarges with mononucleosis and trauma. Some clinicians prefer to stand next to tinue to palpate an enlarged spleen because it can rupture the client near his head, facing his feet. Report to the physician immediately how far it extends in, curl the fngers over the costal margin and up under the below the left costal margin and request medical evaluation. As with other organs, the spleen is diffcult to tucked up under the liver (see Figs. The spleen is not usually pal pable unless it is distended and bulging below the left costal margin. Stand on the person’s right side and reach across the client with the left hand, placing it beneath the client over the left costovertebral angle. Using fndings from percussion, gently press fngertips inward toward the spleen Fig. To assess the kidney, position the client prone or sitting and place one hand over the rib at the costovertebral angle on the back. Reproduc tion of back and/or fank pain with this test is a red-fag sign for renal can be palpated this way. A round, fxed swelling above the umbilicus that does not move with inspiration may be a sign of acute pancreatitis or cancer in a Kidney transplants are often located in the abdomen. The kidneys are located deep in the retroperi with chronic renal disease or organ transplantation. The bladder lies below the symphysis pubis and kidney extends from approximately T12 to L3. The right is not palpable unless it becomes distended and rises above kidney is usually slightly lower than the left. Primary pain patterns for the bladder are Percussion of the kidney is accomplished using Murphy’s shown in Fig. Although this test is commonly the symphysis pubis can also be caused by abdominal gas. It may be necessary to assess for an tic score incorporating independent variables, including abdominal aneurysm, especially in the older client with back results of urinalysis, presence of costovertebral angle tender pain and/or who reports a pulsing or pounding sensation in ness and renal tenderness, as well as duration of pain, appetite the abdomen during increased activity or while in the supine level, and sex (male versus female), reached a sensitivity of position. This method com the therapist can assess the width of the aorta by using presses the kidney between your hands. The left kidney both hands (one on each side of the aorta) and pressing is usually not palpable because of its position beneath deeply. Where the aorta bifurcates (usually near the umbilicus), the width of the pulse should expand (Fig. Throbbing pain that increases with exertion and is accom panied by a sensation of a heart beat when lying down and of a palpable pulsating abdominal mass requires immediate medical attention. Remember, the presence of an abdominal bruit accompanied by risk factors for an aortic aneurysm may A be a contraindication to abdominal palpation. The therapist does not conduct a systems review such as Ribs Abdominal the medical doctor performs. The Guide uses the terminology muscles “Systems Review” to describe a brief or limited exam of the Pulsatile anatomic and physiologic status of the cardiovascular/ Iliac aorta pulmonary, integumentary, musculoskeletal, and neuromus arteries Aortic cular systems. B A more appropriate term for what the therapist does in the screening process may be a “Review of Systems. Use the stethoscope (bell) to listen for Then, the identifed cluster(s) of associated signs and bruits. Bruits are abnormal blowing or swishing sounds heard on auscultation of the arteries. Bruits with both systolic and diastolic symptoms are reviewed to search for a potential pattern that components suggest the turbulent blood fow of partial arterial will identify the underlying system involved (Box 4-19). If the renal artery is occluded as well, the client will be the therapist may fnd cause to examine just the upper quad hypertensive. B, Visualize the location of the aorta slightly to the left rant or just the lower quadrant more closely. See text (this physical assessment in a screening examination is provided chapter and Chapter 6) for discussion of normal and average pulse widths. This type of review helps bring to the therapist’s tion in physical therapy practice, ed 2, New York, 1995, Churchill attention any signs or symptoms the client has not recog Livingstone. After compil ing a list of the client’s signs and symptoms, compare those to the list in Box 4-19. Depending on the client’s answer you may want Palpitations to prompt him or her about any of the following common Limb pain during activity (claudication; cramps, signs and symptoms* associated with each system: limping) Discolored or painful feet; swelling of hands and feet General Questions Pulsating or throbbing pain anywhere, but especially in Fever, chills, sweating (constitutional symptoms) the back or abdomen Appetite loss, nausea, vomiting (constitutional Peripheral edema; nocturia symptoms) Sudden weight gain; unable to fasten waistband or belt, Fatigue, malaise, weakness (constitutional symptoms) unable to wear regular shoes Excessive, unexplained weight gain or loss Persistent cough Vital signs: blood pressure, temperature, pulse, respira Fatigue, dyspnea, orthopnea, syncope tions, pain, walking speed High or low blood pressure, unusual pulses Insomnia Differences in blood pressure from side to side with Irritability position change (10 mm Hg or more; increase or Hoarseness or change in voice, frequent or prolonged decrease/diastolic or systolic; associated symptoms: diz sore throat ziness, headache, nausea, vomiting, diaphoresis, heart Dizziness, falls palpitations, increased primary pain or symptoms) Positive fndings on auscultation Integumentary (Include Skin, Hair, and Nails) Recent rashes, nodules, or other skin changes Pulmonary Unusual hair loss or breakage Cough, hoarseness Increased hair growth (hirsutism) Sputum, hemoptysis Nail bed changes Shortness of breath (dyspnea, orthopnea); altered Itching (pruritus) breathing. Likewise, hair and nail turn to Chapter 10 for additional, pertinent screening ques changes, temperature intolerance, and unexplained excessive tions listed at the end of the chapter. The client’s answers to fatigue are cluster signs and symptoms associated with the these questions will guide the therapist in making a fnal endocrine system. Other groupings of the therapist is not responsible for identifying the specifc signs and symptoms associated with each system are listed as pathologic disease underlying the clinical signs and symp mentioned in Box 4-19. After gathering information from the Level of Lymph node Lymph node client’s history and conducting the interview, you ask him: consciousness palpation palpation • Are there any other symptoms of any kind anywhere else in Mental and Head and neck Lower limbs your body Movement patterns assessment It appears that many of the symptoms are gastrointestinal in and gait Chest and back Use of assistive (heart and lungs) nature. Since the client has mentioned unexplained sweating, devices or • Inspection but no known fevers, take the time to measure all vital signs, mobility aids • Palpation especially body temperature. Balance and • Auscultation Turn to the Special Questions to Ask at the end of Chapter coordination Clinical breast 8 and scan the list of questions for any that might be appropri Inspect skin, hair, examination ate with this client. Follow up with: • Have you ever been treated for an ulcer or internal bleeding while taking any of these pain relievers Early • What is the effect of eating or drinking on your abdominal identifcation and intervention for many medical conditions pain This does not appear to be an emergency since the client is not in acute distress. Documentation of the screening process is carefully because any tissue irregularity may be a clue to important, and the physician should be notifed appropriately malignancy. It is better to err on the side of being too quick (by phone, fax, and/or report). Medical evaluation is advised when the therapist is able to Headaches that cannot be linked to a musculoskeletal palpate a distended liver, gallbladder, or spleen. The physician must decide when this fnding is considered • Pulse increase over 20 bpm lasting more than 3 minutes “normal” physiologically. Some medications can also produce nipple dis • Persistent low-grade (or higher) fever, especially associated charge. What may be a precaution for one client may • Abrupt change in mental status, confusion or increasing be a clear contraindication for another and vice versa. The therapist conducts a screening assessment using of infammatory, infectious, and immunologic disorders appropriate portions of the physical assessment. When analyzing any signs and symptoms present, body contours, mobility, and function. Keep in mind the therapist cannot know what the risk factors or the clinical presentation raise yellow underlying pathology may be when lymph nodes are (caution) or red (warning) fags. Performing a baseline assess n Measuring vital signs is a key component of the screen ment and reporting the fndings is the important ing assessment.
After years of neglect cholesterol chicken discount lasuna 60 caps fast delivery, issues of pain assessment the undertreatment of pain is not a new prob and management have captured the attention of lem cholesterol down buy 60caps lasuna fast delivery. The Agency for Health Care Policy and both health care professionals and the public cholesterol lowering foods benecol order lasuna 60 caps on-line. The authors of this guideline acknowl pain is undertreated ldl cholesterol foods avoid generic lasuna 60 caps online, and a growing awareness of edged the prior efforts of multiple health care dis the adverse consequences of inadequately man ciplines. About 9 in 10 Americans Pain Society, International Association for the regularly suffer from pain,1 and pain is the most 13 Study of Pain) to address this situation. Sufficient knowledge and resources and complexity of the subject matter, a compre exist to manage pain in an estimated 90% of indi hensive discussion of all aspects of pain assess viduals with acute or cancer pain. Data graph emphasizes practical knowledge that from a 1999 survey suggest that only 1 in 4 indi will facilitate diagnosis and/or the selection viduals with pain receive appropriate therapy. Inadequate pain management has adverse s Controversy exists over how both pain and consequences. Poorly man graph reviews only a few of the many classi aged acute pain may cause serious medical com fication systems. Thus, undertreated pain National Pharmaceutical Council 3 Section I: Background and Significance assessment. This monograph provides an s Definitions and causes of some clinical pain overview of pain assessment, but primarily states focuses on the initial assessment. In 1968, McCaffery defined pain as “whatever Coverage of treatment issues relevant to the experiencing person says it is, existing when special populations. It also stresses that the emphasizes: 1) the major classes of drugs patient, not clinician, is the authority on the used for pain management; 2) examples and pain and that his or her self-report is the most salient features of these drugs; and 3) some 13 reliable indicator of pain. In 1979, the means of ensuring the safe, strategic, and International Association for the Study of Pain effective use of these agents. It s Transduction: the conversion of the energy also reviews a pain classification system based on from a noxious thermal, mechanical, or underlying pathophysiology. The goal is to pro chemical stimulus into electrical energy vide practical information that will facilitate (nerve impulses) by sensory receptors called pain assessment and management. A question nociceptors and-answer format is used to provide informa s Transmission: the transmission of these neu tion about the following: ral signals from the site of transduction s the definition of pain (periphery) to the spinal cord and brain s the process by which noxious stimuli gener s Perception: the appreciation of signals arriv ate neural signals and the transmission of ing in higher structures as pain these signals to higher centers (nociception) s Modulation: descending inhibitory and facili s the role of inflammatory mediators, neuro tory input from the brain that influences transmitters, and neuropeptides in these (modulates) nociceptive transmission at the processes. Nociceptor activation and sensitization tor) sensitization amplifies signal transmission Nociceptors are sensory receptors that are and thereby contributes to central sensitization preferentially sensitive to tissue trauma or a 28 and clinical pain states (see I. Peripheral neuropathic pain afferent) nerve fibers distributed throughout the Not all pain that originates in the periphery is periphery (Figure 1). Some neuropathic pain is tors travel primarily along two fiber types: slowly caused by injury or dysfunction of the peripheral conducting unmyelinated C-fibers and small, nervous system. Injury to tissue causes cells to break down and release various tissue byproducts and mediators of c. The functioning of nociceptors depends upon the electrophysiological ics) block or modulate channels, thus inhibiting properties of the tissues, co-factors, and cytokines. Noxious signaling may result from either abnormal firing patterns due to damage or disease in the peripheral nerves or stimulation of nociceptors (free nerve endings due to tissue trauma). Inflammation in injured or diseased tissue sensitizes nociceptors, lowering their firing thresholds. Some clinical pain states have no peripheral origin, arising from disorders of brain function. Spinal interneurons release Nerve impulses generated in the periphery are inhibitory amino acids. Descending Signals ascend Tissue trauma to higher levels modulation of the central nervous system Posterior division Anterior root Injury signals Sympathetic ganglion enter the dorsal horn Viscera < la. Afferents Receptions in skin conveying noxious signaling from the periphery enter the Muscle dorsal horn of the spinal cord, where they synapse with dorsal spindle horn neurons. This generates nerve impulses that exit the cord ipsilaterally through motor and sympathetic efferents. A simplified schema of a spinal nerve and the different Inhibitory influences include certain spinal interneurons and types of fibers contained therein. Pain: Current Understanding of Assessment, Management, and Treatments 6 Section I: Background and Significance Figure 4. Multiple pathways of nociceptive transmission for the spinal cord to central structures. There are four major pathways the A: spinoreticular; B: spinothalamic; C: spinomesencephalic; and D: spinohypothalamic tracts. For example, opioid analgesics bind to opi other nociceptive input to the limbic system. The perception of pain is an uncomfortable awareness of some part of the body, characterized a. Descending pathways by a distinctly unpleasant sensation and negative Modulation of nociceptive transmission occurs emotion best described as threat. Melzack and contralateral somatosensory cortex39 (Figure 4), Wall’s Gate Control Theory brought this notion where input is somatotopically mapped to pre to the forefront in 1965. National Pharmaceutical Council 7 Section I: Background and Significance Multiple brain regions contribute to descend temporal summation-refers to a progressive ing inhibitory pathways. For example, some antidepressants interfere with the reuptake of manifest as: 1) an increased response to a nox serotonin and norepinephrine at synapses, ious stimulus (hyperalgesia), 2) a painful increasing their relative interstitial concentra response to a normally innocuous stimulus (allo tion (availability)52-53 and the activity of dynia), 3) prolonged pain after a transient stim endogenous pain-modulating pathways. Clinical implications Inflammatory mediators, intense, repeated, or Sensitization is likely responsible for most of prolonged noxious stimulation, or both can sensi 26,54-55 the continuing pain and hyperalgesia after an tize nociceptors. In other words, they or “abnormal” input from injured nerves or gan generate nerve impulses more readily and more glia. That is, the hyperalgesia and an important role in central sensitization and clin allodynia encourage protection of the injury dur ical pain states such as hyperalgesia (increased ing the healing phase. However, these processes response to a painful stimulus) and allodynia (pain 58-59 can persist long after healing of the injury in the caused by a normally innocuous stimulus). Central sensitization plays a key role in some chronic pain, especially pain induced by nerve injury or dysfunction. Pain: Current Understanding of Assessment, Management, and Treatments 8 Section I: Background and Significance difficult to suppress than acute pain. Pain that is classified on the basis of its pre sumed underlying pathophysiology is broadly categorized as nociceptive or neuropathic pain. Pain arising from visceral organs is called visceral pain, whereas that arising from nervous system injury or impairment. Common tissues such as skin, muscle, joint capsules, and causes of neuropathic pain include trauma, inflam bone is called somatic pain. Generally, there is a close corre may contribute to neuropathic pain: 1) generation of spontaneous ectopic activity, 2) loss of normal inhibitory mechanisms in the dor spondence between pain perception and stimulus sal horn. Differences in how stim nerve impulse firing and/or abnormal signal amplification. Examples and Characteristics of Nociceptive Pain Superficial Somatic Pain Deep Somatic Pain Visceral Pain Nociceptor location Skin, subcutaneous tissue, Muscles, tendons, joints, Visceral organsa and mucous membranes fasciae, and bones Potential stimuli External mechanical, Overuse strain, mechanical Organ distension, muscle spasm, chemical, or thermal events injury, cramping, ischemia, traction, ischemia, inflammation Dermatologic disorders inflammation Localization Well localized Localized or diffuse and Well or poorly localized radiating Quality Sharp, pricking, or burning Usually dull or aching, Deep aching or sharp stabbing sensation cramping pain, which is often referred to cutaneous sites Associated symptoms Cutaneous tenderness, Tenderness, reflex muscle Malaise, nausea, vomiting, and signs hyperalgesia hyperesthesia, spasm, and sympathetic sweating, tenderness, reflex muscle allodynia hyperactivityb spasm Clinical examples Sunburn, chemical or Arthritis pain, tendonitis, Colic, appendicitis, pancreatitis, thermal burns, cuts and myofascial pain peptic ulcer disease, bladder contusions of the skin distension Sources: References 22-24 and 88-89. National Pharmaceutical Council 9 Section I: Background and Significance in origin. Neuropathic pain is sometimes called “patho logic” pain because it serves no purpose. These include allodynia) or occurs when no identifiable stimu multidimensional classification systems, such as lus exists. It is associated with several types of pain, but it also may exist as a single entity. Trophic changes include thinning of the skin, abnormal hair or nail growth, and bone changes. Pain: Current Understanding of Assessment, Management, and Treatments 10 Section I: Background and Significance based on pain duration. It Even brief intervals of painful stimulation can also reviews elements of a mixed pain classifica induce suffering, neuronal remodeling, and tion system in which pain is categorized as acute chronic pain;10 associated behaviors. Therefore, increasing attention is being focused on the aggressive prevention and treat ment of acute pain to reduce complications, including progression to chronic pain states. Chronic Pain nitive, as well as sensory, features that occur in 22 Chronic pain was once defined as pain that response to tissue trauma. Acute pain is usually nociceptive, but may be Chronic pain is now recognized as pain that neuropathic. Common sources of acute pain extends beyond the period of healing, with lev include trauma, surgery, labor, medical proce els of identified pathology that often are low and dures, and acute disease states.
The barrier or base of the pouch (may) will require a hole to cholesterol medication for diabetics buy discount lasuna 60caps on line be cut for the stoma or may be sized and pre-cut test your cholesterol buy cheap lasuna 60caps line. Pouches for one and two-piece systems are drained through an opening in the bottom high density cholesterol foods discount lasuna 60caps with visa. Immediately after surgery the stoma may be swollen for approximately 6 to cholesterol levels for heart disease lasuna 60 caps free shipping 8 weeks. A measuring card may be included in boxes of pouches or you may create your own template which matches your stoma shape. The opening on the skin barrier or flange should be no more than 1/8 inch larger than the stoma size. Some persons who have ileostomies wear a belt because it makes them feel more secure or it gives support to the pouching system. If you choose to wear a belt, adjust it so that you can get two finger widths between the belt and your waist in order to avoid a deep groove or cut in the skin around the stoma. This could result in serious damage to the stoma and cause pressure ulcers on the surrounding skin. Belts should be worn so they do not ride above or below the level of the belt tabs on the pouching system. Changing the pouching system There may be a decrease in bowel activity at certain times in the day. You may find that early morning before you eat or drink is best, or allow at least one hour after a meal when peristalsis is slowed. As the discharge thickens, you will be in a better position to determine the best time for changing your system. When you go out, always take supplies with you that you would need to change your pouch. These include weather, skin condition, scars, weight changes, diet, activity, body shape near the stoma and the nature of the ileostomy output. Body heat, in addition to outside temperature, will cause skin barriers to loosen more quickly than usual. Swimming, very strenuous sports or work that causes perspiration may shorten wearing time. Emptying the Pouch Emptying the pouch when it is 1/3 full will prevent bulging and possibility of a leak. Some pouching systems have an integrated closure (follow manufacturer’s suggestions) Ostomy Supplies For the sake of convenience, keep all your equipment together on a shelf, in a drawer or in a small box away from hot or cold temperatures. It is a good idea to order supplies several weeks before you expect to run out, thus allowing enough time for delivery. It is best to avoid stockpiling of supplies because they may be influenced by changes in temperatures. To order additional pouches, wafers and other ostomy products, you will need the manufacturer’s name and product numbers. Supplies may be ordered from a mail order company or from a medical supply or pharmacy in your town. For information and help in ordering, you may contact a local ostomy nurse, the product manufacturer, telephone directory business pages or the internet (search words: ostomy supplies). An opening that is too small can cut or injure the stoma and may cause it to swell. In both cases, change the pouch or skin barrier and replace with one that is properly fitted. They can develop weeks, months or even years after use of a product since the body can become gradually sensitized. But, if you want to rinse, use slightly soapy water and a large irrigating syringe or baster to flush out the pouch. Cleaning around the stoma as you change the pouch or skin barrier may cause slight bleeding. The blood vessels in the tissues of 14 the stoma are very delicate at the surface and are easily disturbed. Removing hair under the pouch Excessive hair around the stoma area can interfere with the skin barrier and may be painful when removing. A straight razor should not be used to shave this area, if you must use a razor an electric is the best choice. Flatulence (Gas) Immediately after surgery, it may seem that you have excessive gas almost all the time. Most abdominal surgery is followed by this uncomfortable, embarrassing, yet harmless symptom. Although drinking from a straw, chewing gum, sodas and certain foods may cause intestinal gas: eggs, cabbage, onions, fish, baked beans, milk, cheese and alcohol. Skipping meals to avoid gas or discharge is unwise because your small intestine will be more active and more gas and watery discharge might result. Odor Many things, such as foods, normal bacterial action in your intestine, illness, different medicines and vitamins can cause odor. The odor of ileal contents is not the same as that of a normal stool because the bacteria that cause food breakdown (and odor) in the colon are not present in the small intestine. Check with your physician or ostomy nurse about the suitability of these products and recommended dosage. Among those that many have found effective are chlorophyll tablets, Devrom (bismuth subgallate), and bismuth subcarbonate. If you have (a large) an irritated, moist area with skin missing, you will need to adjust your skin preparation until the skin heals. Apply stoma powder and then brush off the excess with a tissue or piece of gauze 3. If you have itching and a rash, they may prescribe topical medication such as Mycostatin powder or Kenalog spray. If using Mycostatin, apply a thin dusting and seal with no sting skin prep as noted above. For deep pressure ulcers caused by a very tight belt, loosen or remove the belt and call your physician or ostomy nurse immediately, treatment is needed. Obstruction/Blockage There are occasions when the ileostomy does not function for short periods of time. However, if the stoma is not active for 4 to 6 hours and is accompanied by cramps and/or nausea, the intestine could be obstructed. An obstruction (or blockage) may be partial; that is, some liquid may pass through. Sometimes a change in body position, such as assuming a knee to chest position, may encourage movement of the bolus of food. Diarrhea • When diarrhea occurs, the intestinal contents pass through the small intestine too quickly for the absorption of fluids and electrolytes to take place and may cause excessive loss of fluids and electrolytes. You must quickly replace these electrolytes to avoid becoming ill from dehydration and mineral deficiency. Raw fruits and vegetables, milk, fruit juice, prune juice or contaminated drinking water are examples. Some people with ileostomies may always have “watery discharge” and this is normal for them. Diarrhea has these characteristics: • the intestine discharges great quantities of watery stool. Diarrhea can be caused by: • Intestinal flu which may be accompanied by fever and vomiting. Then replace fluids by taking one cup of sweetened, clear tea or one glass of orange juice followed the next hour by one cup of salty broth. Electrolyte Balance Electrolyte balance (especially potassium and sodium) is important. When the colon (large intestine) is removed, a greater risk for electrolyte imbalance can occur. Dehydration is a common concern with symptoms of increased thirst, dry mouth, decreased urine output and fatigue. Increase any type of fluids such as Pedialyte which is high in potassium and sodium.
For health facilities without laboratory services total cholesterol hdl ratio diabetes generic lasuna 60caps with visa, one must treat on clinical grounds i cholesterol medication harmful buy cheap lasuna 60caps. In syndromic approach clinical syndromes are identified followed by syndrome specific treatment targeting all causative agents which can cause the syndrome cholesterol medication triplex generic lasuna 60 caps on-line. First line therapy is recommended when the patient makes his/her first contact with the health care facility Second line therapy is administered when first line therapy has failed and reinfection has been excluded cholesterol lowering diet plan mayo clinic lasuna 60 caps mastercard. Third line Therapy should only be used when expert attention and adequate laboratory facilities are available, and where results of treatment can be monitored. The use of inadequate doses of antibiotics encourages the growth of resistant organisms which will then be very difficult to treat. There is increasing evidence (clinical and now laboratory confirmation) that some of the first line drugs in these treatment protocols are below acceptable levels of effectiveness. New drugs have been introduced for these conditions, but are currently advised as second line and third line. Support Scrotal to take weight off spermatic cord, worn for a month, except when in bed. Genital Warts: Carefully apply either 317 | P a g e C:Podophyllin 10-25% to the warts, and wash off in 6 hours, drying thoroughly. Non-itchy rashes on the body or non-tender swollen lymph glands at several sites-Yes; treat for secondary syphilis with Benzathine penicillin 2. Note:The tradition of norfloxacin (a quinoline antibiotic) is specifically for the second line treatment of gonorrhoea. Norfloxacin is contraindicated in pregnancy and age less than 16 years (damage caused to the joints in animal studies) unless advised by a specialist for compelling situations. Treatment First line A: Co-trimoxazole (O) 960 mg twice daily for 10 days Second line A: Erythromycin (O) 500 mg 6 hourly for 10 days Third line A: Ciprofloxacin (O) 250 mg 8 hourly for 7 days 6. The main clinical features include swollen and tender epididymis, severe pain of one or both testes and reddened oedematous scrotum. Causative organisms include filarial worms, Chlamydia trachomatis, Neisseria gonorrhea, E. Doxycycline is added to the first line treatment for urethral discharge in men and women (See Syndromic treatment flow chart). It can be acquired mainly through sexual intercourse or congenitally when the mother transfers it to the fetus. Also seen are gumma and osteitis Treatment guidelines For primary and secondary syphilis: B: Benzathine penicillin 2. The common sites affected by warts include genital region (condylomata acuminata) hands and legs. In the genital region, lesions are often finger like and increase in number and size with time. Treatment C: Podophyllin10-25% to the warts, and wash off in 6 hours, drying thoroughly. Alternatively S:5% Imiquimod cream with a finger at bedtime, left on overnight, 3 times a week for as long as 16 weeks. The treatment area should be washed with soap and water 6-10 hours after application. Most expert advice against the use of podophyllin for cervical warts; therefore apply imiquimod cream as above. Meatal and urethral warts Accessible meatal warts may be treated with podophyllin or povidone-iodine solution. Great care is needed to ensure that the treated area is dried before contact with normal, opposing epithealial surface is allowed. It causes inflammation of vagina and cervix in females and inflammation of urethra and prostate gland in males. Patient may be asymptomatic or may present with a frothy green/yellowish discharge, itchness, erosion of cervix. In pregnancy treatment with metronidazole should be delayed until after first trimester. Vulvae-vaginal Candidiasis is common in women on the pill, in pregnancy and diabetics and in people on prolonged antibiotic courses. Vulvae vaginal candidiasis is characterized by pruritic, curd-like vaginal discharge, dysuria and dyspareunia. Disseminated Candidiasis; resulted from complications of the above, presents with fever and toxicity. Give: Ciprofloxacin tabs Provide Health 500mg orally stat,plus Doxycycline tabs appropriate/flow Education 100mg b. Appointment in 7 days Improvement 3rd Take history & Examine Discharge from Visit Clinic No Improvement Refer for Laboratory Analysis 324 | P a g e 12. D 14/7 Appointment in 7 days Note 3rd Visit Take Histroy & Examine Mother should be examined and treated as per flow chart on vaginal discharge Continue Discharge Altenative regimen where ceftriaxone is not available is Spectinomycin injection 25mg/kg i. Infection by the human immunodeficiency virus leads to gradual and progressive destruction of the cell mediated immune system. Diagnosis Fever, diarrhoea, weight loss, skin rashes, sores, generalized pruritis, altered mental status, persistent severe headache, oral thrush or Kaposi’s sarcoma may be found in patients with advanced disease Most patients, however, present with symptoms due to opportunistic infections. Followed by a complete blood count, renal and hepatic chemical function tests, urine pregnancy test and viral load where applicable should be done at baseline. Initiation of treatment should be based on the extent of clinical disease progression. General orientation of the patient and family members should include: Who to call and where to get refills Who to call and where to go when clinical problems arise Who to call/where to go for assistance on social, spiritual and legal problems that might interfere with adherence to treatment 1. It is important to remember that there is no single combination that is best for every patient and/or that can be tolerated by all patients. Regimens should be recommended on the basis of a patient’s clinical condition, lifestyle, and ability to tolerate the regimen. In the first two weeks of treatment only half of the required daily dose of Nevirapine should be given, and a full dose if there are no side effects such as skin rash or hepatic toxicity. Renal function should be monitored through routine urine testing for the occurrence of proteinuria and if available serum creatinine. Second category: Symptoms are somewhat more severe and often respond to some medical intervention. They include more severe gastric upset with nausea and vomiting, more severe headaches and mild peripheral neuropathy that does not incapacitate or interfere with a patient’s lifestyle. These symptoms can often be successfully treated with anti-emetics, anti diarrhoea medicines, analgesics, neuroleptics. The rash can occur in up to 20 % of patients and usually occurs in the first 6-8 weeks of therapy. Note: If a mild drug-reaction type rash occurs, patients will continue treatment with caution and careful monitoring. This rash will be treated with patient assurance, antihistamines and close follow up until resolved. Hypersensitivity symptoms include: flu symptoms, shortness of breath, cough, fever, aches and pains, a general ill feeling, fatigue/tiredness, swelling, abdominal pain, diarrhoea, nausea, muscle or joint aches, numbness, sore throat or rash. Patients may benefit from assurance that these symptoms are common and will decrease over time. Stavudine (d4T) Side effects Peripheral neuropathy is a common side effect with the use of Stavudine and occurrence of lactic acidosis has been reported. Cumulative exposure to d4T has the potential to cause disfiguring, painful and lifethreatening side-effects, such as lipodystrophy and lactic acidosis; for 336 | P a g e patients who are still on d4T; prescribe 30 mg every 12 hours for all individuals, irrespective of body weight. It results from failure to suppress viral replication with the development of viral resistance. In Tanzania, immunological and clinical parameters are used to identify treatment failure. However, in light of declining costs of performing viral load measurements, along with the simplification of processes, where available, viral load parameters should also be applied. Each of the above scenarios could result in sub-therapeutic drug levels and poor clinical response.
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