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By: Katherine Schuver Garman, MD

  • Associate Professor of Medicine
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They include: • control of the mosqui to pulse blood pressure monitor purchase hytrin 5 mg line population through chloroquine arteria en ingles cheap 2 mg hytrin, Pyrimethamine-sulfadoxine arrhythmia lidocaine cheap hytrin master card, prevention of mosqui to breeding sites, indoor mefloquine, quinine and tetracyclines. Patients residual spraying and/or consistent use of with severe falciparum malaria require prompt impregnated bednets; treatment, preferably with quinine parenterally, • control of other fac to rs associated with potential depending upon the patient’s condition. The disease may manifest with a prodromal viral disease found in domestic and wild animals. Mode of transmission Rabies is transmitted to humans through close Prodromal phase contact with infected saliva, whether through a • the incubation period is usually 2–8 weeks but bite, scratch or lick on to mucous membrane or may be more than a year. It is not, in the natural sense, a disease and brain, or where large amounts of virus are of humans; rather, human cases are incidental to transmitted, result in shorter incubation periods. Epidemiological summary With the exception of Antarctica and Australia, Furious rabies animal rabies is present in all continents. It is • Initial neurological signs may include endemic in wild animals (particularly foxes) in rural hyperactivity, disorientation, hallucinations or areas of northern Europe and is found in most bizarre behaviour. Most infections biting or other bizarre behaviour, alternating with resulting from dog bites occur in the Eastern periods of calm where patients are often cooperative European countries. In an effort to further eradicate the disease followed by severe spasms of the pharynx, larynx in foxes, a campaign began in 1990 to orally and diaphragm that produces choking, gagging and immunise wildlife in European countries. Manifestations • the patient is initially relatively intact mentally, Page 115 Rabies virus infects the central nervous system, with little agitation or confusion, but the mental causing encephalopathy. Once symp to ms develop, status gradually deteriorates from confusion to there is no known cure and the disease is always disorientation, stupor and finally coma. Module 4 Page 115 • the acute neurological phase lasts 2–7 days with vigorous washing and flushing with soap and water, the longer duration in the paralytic form. Following this, apply either ethanol (700 ml/l), • Coma may last for hours to months, but in tincture or aqueous solution of iodine or povidone untreated patients, respira to ry arrest usually occurs iodine. Even if intensive care facilities are available, the infiltration of human rabies specific complications occur during the coma phase, which immunoglobulin around the wound may be result in death: hypoxia, anaemia, renal failure, indicated in high risk cases, for example, bites cardiac arrythmias, congestive cardiac failure, and sustained in a country where there is a high risk of cerebral oedema. Human rabies Those who work with animals in endemic areas, specific immunoglobulin provides immediate and anyone exposed to an animal bite or lick on passive protection. Rabies immunoglobulin is difficult to access in many areas Diagnosis and rabies vaccine can be expensive (see further No tests are currently available to diagnose rabies notes) so may not be easily available. In the clinical course of the disease, the virus can Now carry out Learning Activity 6. A corneal impression smear and skin biopsies may Nursing care show a positive result; although this will confirm Intensive care facilities can prolong life, but since a diagnosis, a negative result does not exclude death is inevitable, the most humane care for such infection. Postmortem diagnosis can be confirmed patients involves the relief of agony and suffering by examination of brain tissue. Methods of treatment Supportive care for the presenting symp to ms There is no specific treatment once the disease is includes: established. Since elimination of the rabies virus at the site of infection by chemical or physical means is the most Infection control effective mechanism of protection, immediate Rabies virus may be present in saliva, tears, urine, Page 116 Module 4 or other body fluids. Therefore, in order to prevent any possible transmission basic precautions, Universal Precautions and transmission based precautions should be taken (see Module 1). While human- to -human transmission has not been recorded, pre-exposure vaccination is recommended for those caring for, or likely to care for, a patient with rabies. Post-exposure vaccine can be given to staff found to be caring for infected patients. Prevention of spread this is dependent upon: • reduction of rabies virus in animal hosts through vaccination campaigns; and • post-exposure treatment following a potentially infected bite. Pre exposure vaccination does not rule out the need for further vaccine if exposed to the virus. Epidemiological summary • Clinical examination at this stage may also show Tetanus occurs throughout the world and is a rigidity of spinal muscles and board like firmness leading cause of death in many developing of the abdominal muscles. Countries in Europe reporting sporadic cases in • the death rate is estimated at 3 per 100 with recent years include Albania, Azerbaijan, Croatia, good hospital care. Clostridium tetani is Mode of transmission recovered from the wound in only 30% of patients. The bacterium Clostridium tetani is found in the intestinal tracts of man and animals, where it Methods of treatment remains harmless and causes no disease.


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Prevention and Hygiene: See diet Follow-up Actions Return evaluation: All suspected s to arrhythmia ventricular tachycardia purchase line hytrin ne patients need to blood pressure wrist monitor purchase 5mg hytrin mastercard eventually have an abdominal film taken to blood pressure 5545 cheap hytrin line assess the presence of s to nes. For the vast majority of infections, the fluoroquinolone antibiotics are highly effective. Bladder infections (cystitis) are treated for 3 days, kidney (pyelonephritis) for 14 days and prostate (prostatitis) for 30 days. In the male, it is practical to assume that any leukoesterase positive or culture positive bacterial urinary tract infection involves the prostate so treat for 30 days. Therefore, primary treatment is different, although the fluoroquinolones are a good alternative. Objective: Signs Using Basic Tools: Fever, flank tenderness, fatigue, nausea, vomiting, suprapubic tenderness. Using Advanced Tools: Urinalysis: Pyuria (leukoesterase +) and nitrite positive indicates infection (some gram-positive organisms may be nitrite negative). Assessment: Differential Diagnosis: Cystitis burning or frequency, and leukoesterase-positive urine in a female. Pyelonephritis fever or flank pain, and leukoesterase-positive urine in a female. Microhematuria without pyuria pyelonephritis is less likely; patient may have other reasons for microhematuria (tumor, s to ne, etc. Contamination positive nitrite, negative leukoesterase and negative heme is likely skin contamination of the urine specimen. Nitrofuran to in is the safest drug in women since it is acceptable to give throughout a pregnancy. Be prepared to treat with fluconazole 150 mg po single dose or terconazole vaginal supposi to ries qd x3 days. Doxycycline 100 mg po bid Cystitis with complicating fac to rs If patient has his to ry of infections every 1-2 months, place on suppression (see below) until seen by urology. Women who are postmenopausal, especially greater than 60 years old, frequently take longer to eradicate cystitis. Pyelonephritis Moderately ill: 4-93 4-94 Fluoroquinolones (Levaquin 500 mg po qd or Cipro 500 mg po bid or Floxin 400 mg po bid) x 2 weeks. Alternative: Augmentin 875/125 mg po q12h or 500/125 mg po tid x 2 weeks or Keflex 500 mg po qid x 2 weeks. Empiric: Failure of symp to ms and urinalysis to improve suggests resistance to the antibiotic being used. Recurrence of urinary tract infection within weeks of completing the initial course of antibiotics suggests an inadequate duration of treatment or reinfection. A longer course of antibiotics, possibly with the addition of 2-3 months of suppression is indicated. Patients with cystitis that does not resolve within 3 days of initiating treatment should be referred for evaluation. The term "heel spur syndrome" refers to any to heel pain with or without a spur that typically develops from excessive repetitive strain on the plantar fascia. The plantar fascia is loaded when weight is applied (standing), causing pain along the plantar fascia, particularly where the fascia connects to the heel tubercle. This condition is often a to lerable nuisance but it may be painful enough to make ambulation difficult. More than 90% of the cases in military personnel are due to faulty foot mechanics and increased activity demands. Subjective: Symp to ms Insidious onset of heel pain, most severe in the morning or when standing up; may acutely follow an injury; pain can be bilateral. Objective: Signs Using Basis Tools: Point tenderness over medial tubercle of the calcaneus at the level of the plantar fascial attachment, which may radiate distally causing pain and swelling in the arch; more common in pronated foot type but heel pain can present in a high-arch foot type; distant symp to ms due to compensa to ry gait changes; tight Achilles tendon. Using Advanced Tools: X-rays: Spur presents 60% of the time; fracture, bone cyst or arthritic changes may be noted to explain symp to ms. Assessment: Differential Diagnosis Bursitis palpate tenderness (inflamed bursa) directly below the calcaneal tubercle.

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The patient usually describes the frequent passage of small volumes of s to blood pressure chart lower number generic 5 mg hytrin visa ol rather than true diarrhoea arteria3d mayan city pack buy hytrin in india. The frequency of bowel action is also variable as the diarrhoea may alternate with constipation prehypertension in 30s cheap hytrin 5mg without a prescription. Often the bowels are open several times in the morning before the patient leaves for work. The condition is more likely to occur at times of stress, it may be associated with anxiety and occasionally it may be triggered by a bowel infection. It is possible that certain foods can irritate the bowel, but this is difficult to prove. The latter is more likely with increasing age (from middle age onwards) and is likely to be associated with a prolonged change in bowel habit; in this case diarrhoea might sometimes alternate with constipation. Medication Medicines already tried the pharmacist should establish the identity of any medication that has already been taken to treat the symp to ms in order to assess its appropriateness. Management Oral rehydration therapy the risk of dehydration from diarrhoea is greatest in babies, and rehydration therapy is considered to be the standard treatment for acute diarrhoea in babies and young children. Oral rehydration sachets may be used with antidiarrhoeals in older children and adults. Sachets of powder for reconstitution are available; these contain sodium as chloride and bicarbonate, glucose and potassium. It is essential that appropriate advice be given by the pharmacist about how the powder should be reconstituted. Patients should be reminded that only water should be used to make the solution (never fruit or fizzy drinks) and that boiled and cooled water should be used for children younger than 1 year. Boiling water should not be used, as it would cause the liberation of carbon dioxide. Fizzy, sugary drinks should never be used to make rehydration fluids, as they will produce a hyperosmolar solution that may exacerbate the problem. Special measuring spoons are available; their correct use would produce a more acceptable solution, but their use should be reserved for the treatment of adults, where electrolyte concentration is less crucial. Quantities Parents sometimes ask how much rehydration fluid should be given to children. The following simple rules can be used for guidance; the amount of solution offered to the patient is based on the number of watery s to ols that are passed. Other therapy Loperamide Loperamide is an effective antidiarrhoeal treatment for use in older children and adults. When recommending loperamide the pharmacist should remind patients to drink plenty of extra fluids. The latter has not been shown to be true and the usefulness of the former is questionable. The use of kaolin-based preparations has largely been superseded by oral rehydration therapy, although patients continue to ask for various products containing kaolin. Morphine Morphine, in various forms, has been included in antidiarrhoeal rem edies for many years. Kaolin and morphine mixture remains a popular choice for some patients, despite the lack of evidence of its effective ness. Practical points 1 Patients with diarrhoea should be advised to drink plenty of clear, non-milky fluids, such as water and diluted squash. The severity and dur ation of diarrhoea are not affected by whether milk feeds are con tinued. A well-nourished child should be the aim, particularly where the infant is poorly nourished to begin with and where the withhold ing of milk feeds may be more detrimental than in a well-nourished infant, where temporary withdrawal is unimportant. Some doc to rs continue nevertheless to advise the discontinuation of milk, especially bottle, during the acute phase of infection. Temporary lac to se in to lerance can therefore be produced, which makes the diarrhoea worse. Diarrhoea in practice Case 1 Mrs Robinson asks what you can recommend for diarrhoea. Her son David, aged 11, has diarrhoea and she is worried that her other two children, Natalie, aged 4, and Tom, aged just over 1 year, may also get it. David’s diarrhoea started yesterday; he went to the to ilet about five times and was sick once, but has not been sick since. Yesterday he had pie and chips from the local takeaway during his lunch break at school.

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Eye drops that contain a vasoconstric to heart attack burger discount hytrin 1 mg online r should not be used in patients who have glaucoma or who wear soft contact lenses hypertension 4011 buy hytrin 5mg cheap. Steroid nasal sprays Beclometasone nasal spray (aqueous pump rather than aerosol version) hypertension yoga poses buy cheap hytrin 1 mg line, fluticasone metered nasal spray and triamcinolone aqueous nasal spray can be used for the treatment of seasonal allergic rhinitis. A steroid nasal spray is the treatment of choice for moderate to severe nasal symp to ms that are continuous. The steroid acts to reduce inflammation that has occurred as a result of the allergen’s action. Regular use is essential for full benefit to be obtained and treatment should be continued throughout the hay fever season. If symp to ms of hay fever are already present, the patient needs to know that it is likely to take several days before the full treatment effect is reached. Dryness and irritation of the nose and throat, and nosebleeds have occasionally been reported; otherwise side-effects are rare. Beclome tasone, fluticasone and triamcinolone nasal sprays can be used in patients over 18 years of age for up to 3 months. Patients are sometimes alarmed by the term ‘steroid’, associating it with potent oral steroids and possible side-effects. Therefore the pharmacist needs to take account of these concerns in explanations about the drug and how it works. It should be started at least 1 week before the hay fever season is likely to begin and then used continuously. There seem to be no significant side-effects, although nasal irritation may occasionally occur. Cromoglicate eye drops are effective for the treatment of eye symp to ms that are not controlled by antihistamines. The eye drops contain the preservative benzalk onium chloride and should not be used by wearers of soft contact lenses. Topical antihistamines Nasal treatments Azelastine and levocabastine are used in allergic rhinitis. Azelastine can be used in adults and children over 5 years of age; levocabastine can be used in adults and children over 12 years of age. Advise the patient to keep the head upright during use to prevent the liquid trickling in to the throat and causing an unpleasant taste. Eye treatments Levocabastine eye drops can be used in children over 12 years of age and adults for the treatment of seasonal allergic conjunctivitis. Special vacuum cleaners are now on sale that are claimed to be particularly effective. His eyes have been itching a little and are slightly watery, and he has been sneezing for a few days. He will not be driving, but is a student at the local sixth-form college and has exams coming up next week. The pharmacist’s view this young man is experiencing the classic symp to ms of hay fever for the first time. The nasal symp to ms are causing the most discomfort; he has had rhinorrhoea and now has congestion so it would be reason able to recommend a corticosteroid nasal spray providing he is aged 18 or over. If he is under 18, an oral or to pical antihistamine could be recommended, bearing in mind that he is sitting for exams soon and so any preparation that might cause drowsiness is best avoided. You know that he is not taking any other medicines, so you could recommend acrivastine, loratadine or cetirizine. Even though they are generally non sedating they can cause drowsiness in some patients. He may benefit from sodium cromoglicate eye drops if his eye symp to ms are not fully controlled by the antihistamine. It is often worthwhile trying an older antihistamine as an alternative because some people are unaffected by the sedative properties, or an alternative non-sedating one such as fexofenadine. She tells you that she has hay fever and a blocked nose and is finding it difficult to breathe. You find out that she has had the symp to ms for a few days; they have gradually got worse.

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