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Oxygen should be administered to all seriously and inotropes order minocycline 50 mg antibiotic antimycotic, if necessary buy minocycline 50mg mastercard yeast infection, is essential to deliver oxygen ill children via nonrebreathing face mask purchase minocycline 50 mg fast delivery antibiotic resistance latest news. Adequacy of and metabolic substrates to the brain and remove toxic ventilation should be assessed by examination and arterial metabolites buy generic minocycline 50mg on line antibiotics z pack and alcohol. Extreme hyperventilation has been associated and inappropriately treat with antiepileptic drugs. Hence, its absence must be identifed and treated appropriately, as unrecognized not be taken as a reassuring sign. Eforts should be It should not be administered round the clock and is unlikely taken to provide pain relief and sedation during painful to be efective after 48–72 hours. A neurosurgical benefts of relieving agitation outweigh the need for close consultation should be asked for. The use ){Identify and treat aggravating factors-seizures, noncon- of therapeutic hypothermia (32–34°C) may be appropriate vulsive status epilepticus, fever, pain, anxiety for children with outofhospital arrest and persistent coma ){Continuous monitoring of heart rate, respiratory rate, blood or those with ventricular fbrillation or pulseless ventricular pressure, temperature, oxygen saturations, electrocardiogram, tachycardia. T ereafter, the sugar levels should be monitored and the glucose infusion rates History (Table 3) modifed accordingly. Hyperglycemia resulting from stress is The patient’s history may hold the most important and a more common fnding in these conditions. Central nervous system benzodiazepine followed by phenytoin loading 20 mg/kg or infections, on the other hand, would present with complaints fosphenytoin) should be administered. The standard protocol evolving over a few days associated with a history of fever or 148 for the management of status epilepticus may be followed in recent illness. The presence of fever suggests an infective process (sepsis, The associated symptoms may indicate the focus of pneumonia, meningitis, encephalitis, or brain abscess); but infection. Symptoms such as headache, nausea and vomiting, may also indicate heat stroke or abnormality of hypothalamic irritability, seizures, focal defcits, rash, and joint pain temperature regulatory mechanisms. Other concurrent systemic result of fever, hypovolemic or septic shock, heart failure, or illnesses, e. Tachypnea with respiratory distress indicates lung pathology Nonaccidental trauma should always be considered in a (pneumonia, pneumothorax, empyema, or asthma). Systemic examination must be performed to look for hepatosplenomegaly (infections or Examination liver disease), pulmonary involvement such as pneumonia, pleural efusions, and empyema, skin and bone lesions and General examination (Table 4) cardiac involvement such as myocarditis or a preexisting The general examination may provide helpful etiological clues. Brainstem dysfunction is an important the level and localization of brain dysfunction. It may feature in some causes of viral encephalitis such as enterovirus also provide information about the potential causes. Respiratory pattern abnormalities signify either a metabolic derangement or a neurological insult (Table 5). Motor examination (Table 6) Pupils Assessment of muscle strength, tone, and tendon refexes Pupillary size, shape, symmetry, and response to light provide should be done for normality and symmetry. The limb position, spontaneous movements, and response to presence or absence of the pupillary reaction to light is one stimulation must be observed to look for any focal defcits of the most important diferentiating features to distinguish (suggestive of postictal Todd’s palsy or structural abnormality), between structural and metabolic disorders as metabolic and posturing (decerebrate or decorticate). Usually in Special attention should be given to posturing because it often signals a brainstem herniation syndrome. Topical administration of mydriatics must • Decerebrate posturing: Rigid extension of both arms and be avoided, but if done, should be documented to avoid legs indicative of cortical and brainstem dysfunction confusion in interpretation. Abnormalities of eye position • Opisthotonus: Neck is hyperextended and the teeth are and movement may provide some clues. Conjugate clenched; the arms are adducted and hyperextended; and lateral deviation of the eyes is a sign either of an ipsilateral the legs are extended with feet plantar fexed. It indicates hemisphere lesion, a contralateral hemisphere seizure focus, severe brainstem dysfunction or damage involving the contralateral pontine horizontal • The faccid patient with no response to painful stimuli gaze center (parapontine reticular formation). Lateral gaze indicates deep brainstem dysfunction palsy may signal central herniation with compression of • Monoplegia or hemiplegia, except when in postictal phase, bilateral sixth nerves. Tonic upward gaze has been associated suggests a structural disturbance of the contralateral with bilateral hemispheric damage. In younger children, Kernig’s and Brudzinski’s signs are not consistently present; especially with The various herniation syndromes can be recognized an open fontanel. The importance lies in recognition and prompt in meningitis, encephalitis, and subarachnoid hemorrhage. Treatment Neck rigidity is present in meningitis, tonsillar herniation, or of herniation involves removal of the etiologic mass and craniocervical trauma. Cranial neuropathies of the Step 3: Send Basic Investigations ocular, oculomotor, abducens, facial, and auditory nerve should be looked for. Basic Investigations Signs of increased intracranial tension in children range Basic workup like complete blood count with platelet count, from headache, vomiting to herniation. An arterial which causes direct mechanical damage as well as ischemia blood gas, chest Xray, serum ammonia, and serum lactate and hemorrhage secondary to vascular distortion. Leukopenia and syndromes, in this order (from higher to lower pressures), thrombocytopenia are noted in viral hemorrhagic fevers and signify a progression in severity. Typhoid fever and cerebral malaria may to the next, signifes progressive worsening. Serum creatinine and blood urea are helpful to Diagnosis Criteria assess the renal function and serum bilirubin, transaminases and prothrombin time are indicated if jaundice is present. In subtle changes and is likely to be more helpful in establishing patients who are not stable, a neuroimaging study should be a diagnosis by picking up characteristic pattern of gray obtained prior to the lumbar puncture (Box 3). Similar fndings may occur in tubercular meningitis information regarding prognosis in patients with anoxic or and partiallytreated pyogenic meningitis; however, the traumatic coma. Neutrophilic Magnetic resonance imaging is not needed if the etiology predominance is seen in pyogenic meningitis with high protein is clear by other investigations, e. Additional studies may be indicated if there are clinical • Decision for imaging should not delay the therapy clues suggestive of particular infections. The clinician should always be alert to the possibility diagnosis of bacterial meningitis or herpes encephalitis is of child abuse in an infant/toddler with sudden unexplained strongly suspected, as early treatment improves prognosis altered consciousness. Children mittent rhythmic delta activity are characteristic of severe beyond the neonatal group should be treated with intravenous encephalopathies. Periodic lateralized epileptiform discharges acyclovir in a dose of 10 mg/kg every 8 hours given as a 1hour suggest herpes encephalitis or infarction. Blood tandem mass spectroscopy, urine gas chromatographymass spectroscopy can detect common causes of intoxication and drug abuse, and Step 5: Send Specific specifc drug levels (suspected antiepileptic toxicity) should be Investigations and Treat the Cause obtained if specifc ingestions are suspected. In selected cases, When the etiology is not clear, other microbiological a urine toxicology screen, thyroid function tests and thyroid investigations must be obtained. These samples include urine, autoantibodies (Hashimoto’s encephalopathy), cortisol levels, throat swab, nasopharyngeal aspirate, serum, and swab from carboxyhemoglobin levels (carbon monoxide poisoning), vesicles or rash, if present. In patients having unexplained autoimmune screen (cerebral vasculitis), and coagulation 154 encephalopathy with fever and rash, testing for rickettsial studies (coagulopathy) are recommended. Visual disturbances due to chorioretinopathy After stabilization of the airway, breathing, and circulation, and peripheral amblyopia may also be seen. Myocarditis and other supportive care measures must be instituted along pulmonary edema are important complications of enteroviral with the empirical treatment as mentioned above. Subdural efusions develop in 10–30% of patients and appropriate supportive care is of paramount importance with meningitis.
In paucibacillary leprosy buy minocycline 50 mg on line yeast infection, • The nerve and limb complications that lead to defor- clinical surveillance once in a year is required for at least mity are not inevitable; they are the result of neglect purchase 50mg minocycline mastercard bacteria 1 in urinalysis. In multibacillary leprosy minocycline 50 mg amex ear infection 8 month old, clinical and • Leprosy can be cured even at an advanced stage discount 50mg minocycline with visa treatment for dogs ear infection, 268 bacteriological surveillance is required once in a year though it may not be possible to correct all the for at least 5 years. Leprosy – A tingling or “ant-crawling” sensation along the control is no exception. These aspects – Early detection are discussed in detail under the National Leprosy – Early intervention Eradication Program described later. Proper evaluation of a health program is necessary to check whether the desired results are being achieved Rehabilitation and whether any program modifications are needed. The indicators for evaluation are of two types- All cured cases should be provided suitable jobs through 10 operational and epidemiological. Modern plastic and indicators relate to case finding, treatment, relapse and orthopedic surgery and physiotherapy should be used disabilities. Examples of such indicators are: to treat disfiguration and deformities and to restore • Case detection ratio (the ratio of leprosy cases appearance and function. Burnt out cases with marked registered to the estimated number of cases) deformities may be kept in special rehabilitation centers. The last is a good indicator of the has to be viewed from this viewpoint and its success or efficacy of the drug regimen. Institutional rehabilitation Epidemiological indicators relate to the effectiveness is costly and time-consuming. These include age, sex and of leprosy patients given rehabilitation training in area wise incidence and prevalence rates. According to the Director, Gandhi Memorial Leprosy Foundation, Wardha, two studies There are many voluntary organizations working in the conducted there showed that more than half patients field of leprosy in India. These include: discharged from leprosy rehabilitation centres were just • Leprosy Mission: This was the first voluntary orga- not traceable at the address given, most having taken to nization for leprosy work in India. Of those traced, none was earning his livelihood 1874 by Bailey in Chamba, Himachal Pradesh. Continue dapsone Severe skin complication Extensive scaling, itching, ulcers in the mouth and stop dapsone. Refer to hospital (Exfoliative dermatitis) eyes, jaundice and reduced urine output immediately. Never restart Abdominal symptoms Abdominal pain, nausea, and vomiting on high symptomatic treatment. Refer to hospital (Nephritis) Reduced urine output Rifam picin No significance Redish coloration of urine, saliva and sweat Reassure the patient Hepatitis (Liver damage) Jaundice (yellow color of skin, eyeballs and urine) Stop rifampicin. Refer to hospital Loss of appetite and vomiting Restart after the jaundice subsides Flu like illness Fever, malaise and bodyache Symptomatic treatment Allergy Skin rash Stop rifampicin Clofazim ine No significance Brownish-red discoloration of Reassure the patient, it will skin, urine, and body fluids go after completion of treatment Ichthyosis Dryness and thickening of Apply oil to the skin. However this drug is also not recommended for use in pregnant women and children below five years of age. The government started the National Leprosy Control 270 Two other important organizations active in the field Program in 1955. The objective was “to control the of leprosy are the Jalma Central Institute of Leprosy spread of disease and to render modern treatment faci- lities to patients”. Remarks the goal set was “to achieve arrest of the disease activity existing in all the known leprosy cases in the country by the Leprosy One per 4. The program receives 100 percent Survey, One per 25,000 5744 In low endemic education and population areas, attached to a financial support from the Center government. At the district Survey: This is done house to house, at schools, by level, the District Leprosy Officer is responsible for imple- family visits, and through health educational approaches, mentation and supervision of the Program. At the voluntary reporting, contact examinations and referral peripheral level, the Medical Officer Incharge of Leprosy services. Diagnosis is confirmed by the doctor and, Control Unit/Center and the Medical Officer in the sometimes, in the absence of a doctor, by the Primary Health Center, to which a Survey, Education nonmedical supervisor. The mass media like radio, The program has the following four strategies: television, newspapers and journals are used. Treatment: The line of treatment is indicated by the • Provide services through mobile leprosy treatment doctor or the nonmedical supervisor. Treatment is units with the help of primary health care staff in delivered by the leprosy paramedical worker who holds moderate and low endemic districts. Domiciliary treatment is also given through and the community to increase awareness and to the network of outdoor clinics. The new multidrug regimen is implemented under the close supervision of the doctor. Learning Material on Leprosy for Capacity Building – Genital scabies of Medical Officers. Delhi: many countries, especially among females between 15 Hind Kustha Nivarak Sangh, Delhi Branch, 1985. Delhi: Arnold world, the trend being towards more and earlier sexual Heinemann, 1984;138-50. A striking increase in the incidence of sexually transmitted diseases, especially “gonorrhea”, has been observed since 1960. In some countries the reported Sexually Transmitted Diseases or incidence for persons below 17 years of age doubled Venereal Diseases for boys and tripled for girls between 1966 and 1971. The adjective venereal is derived from Venus, the The age group 16 to 17 years showed a fifty to eighty- Goddess of love. Venereal diseases are transmitted fold increase over the age group below 15 years, through sexual intercourse. Rarely, transmission may be indicating the start of sexual activity by a large group of high-risk adolescents at that point. Acquired syphilis manifests the following three stages: Secondary Stage Prim ary Stage It lasts four weeks to six months after the appearance A small red spot is noticed on the penis 3 to 4 weeks of chancre. It is painless and develops skin rashes, enlargement of glands and pain and gradually into a well defined hard sore or hard chancre swelling in bones and joints. The untreated sore heals in 6 to 8 are seen on the moist surfaces like anus, vulva and the weeks. Ulcer in throat and white mucous another fortnight, the glands in neck, axilla and patches inside the cheeks may also occur. Tertiary Stage Diagnosis: Serous exudate from the sore is positive The characteristic feature here is the formation of for the causative agent. Serological tests become positive gummata (nodules), which may suppurate and form 6 to 8 weeks after sexual intercourse and remain so in ulcers on the skin. The tests depend on two classes of antibodies and in internal organs like liver, spleen, testes and lungs. It becomes positive condylomata and mucous patches in the second stage, during the primary stage, reaches its maximum when saliva and urine may also contain the germs. Congenital syphilis is transmitted to the child Secondary syphilis: Contacts during preceding six from the mother through placenta. The patient remains infective as long as primary sore, Late and late latent syphilis: Marital partners and children condylomata, mucous patches or ulcerating gummata of infected mothers. Some patients may be intermittently Specific Teatment1,11 infective for 2 to 4 years.
Syndromes
- Lack of interactive play
- Bone pain or tenderness
- You may breathe some of these germs directly into your lungs.
- You have pain with swelling of the scrotum.
- Chronic disease
- Eye drops
- Hernia (usually a soft, large bulge in the groin on one or both sides)
Secondary health care: This refers to an Primary Health Care is equally valid for all countries purchase minocycline 50mg with amex treatment for frequent uti, intermediate level of health care where specialist though the problems addressed at this level would differ facilities are available to deal with the complex between the developing and developed countries minocycline 50 mg on-line virus 911. The Primary Health Care is concerned with the main health community health centers and the district hospitals problems of the community buy minocycline 50 mg lowest price bacteria que se come la carne, providing promotive generic 50mg minocycline with amex antibiotic resistance video, represent the secondary health care level. Tertiary health care is available at medical college hospitals and at regional or All India • It is essential health care which is based on practical, Hospitals and Institutions. Health for All basically meant • Its availability should be at a cost which the that individuals should attain a level of health which would community and country can afford to maintain at enable them to earn their livelihood and lead a socially every stage of their development in a spirit of self- congenial life. A perusal of these appendices will • Maternal and child health care, including family be very helpful for a full understanding of the concept planning of Primary Health Care. It constitutes ment, especially agriculture, animal husbandry, food, the first element of a continuing health care process. The Primary Health Care should be sustained by inte- component of people’s participation needs to be grated, functional and mutually supportive referral sys- 533 specially emphasized. A 2,500 bedded district health unit at the district visualized as a passive one-way approach. The patient head quarter to provide cover to 10 to 30 lakh should always continue to remain under care of his population was envisaged. The specialists should also endea- The above three types of health units were to be vor to move down the referral ladder so that services connected by telephone and ambulance. This is approximately twice the present number Care relies heavily on services of health workers and of 4. Village Health guides and be mentioned that in a neighboring country, Mongolia, trained ‘Dais’ are the peripheral workers providing there are 10. The staff included resources and the particular health problems and needs two medical officers, five nurses, 4 midwives, 4 trained of the people, with initial emphasis on underserved dais, two sanitary inspectors and other support areas. Suitable strengthening participation is the process by which individuals and of the existing district hospital was also suggested. This enables them independence had to wait for some years due to many to become agents of their own development, instead reasons, the main reason being shortage of funds and of remaining passive beneficiaries. The Central Council of Health, at its A series of indicators of progress towards the goal firstmeeting held in January, 1953, fully endorsed the of Health for All have been developed as already principle of integrated community development and mentioned. A primary health center was intended to Rural Primary Health Care provide health care, both curative and preventive, and Background to serve as a focus from which health services radiate into the area covered by the Community Development The Bhore Committee7 recommended that an integrated Block. This service should provide all facilities of medical and Evolution of Primary Health Centers health care including ambulance, hospitals, laboratories and various specialists. The staff included an adminis- 1,00,000 population trative officer and full time heads of departments of • Establishment of one subcenter for every 10,000 medicine, surgery, maternity, tuberculosis and pathology. Level, and would be provided training for a period of • Establishing functional referral linkages. The Ninth Plan targets that personnel and community health level workers in the gaps will be completely filled by 2002. Population served: 30,000 (20,000 in tribal, hilly and backward • Implementing the National Health Programs. Total 3 Records of all cases should be maintained and diseases 535 Population served: 6,000 (3,000 in tribal, hilly and backward areas). The efforts in this direction include education, guidance He also has to attend to school health program, check and help to the community as regards the following: the records and performance of the Health Assistant • Provision of safe and wholesome water supply by or Sanitary Inspector, and visit villages for specific construction of new sanitary wells and tanks, repair tasks. The Medical Officer has a vehicle to move in the of the old ones, maintenance of hand-pumps and area and to shift maternity and other cases to the periodical disinfection of water by the use of referral hospital. Handflush water-seal various duties which include, in addition to the above, latrine is considered to be the best but aqua privy, taking care of the indoor patients, which may be either septic tank and trench latrines may also be indicated maternity cases or general emergency cases. Antenatal and natal services were traditionally provided Unfortunately, various states have not accepted the by untrained dais. Both are of crucial importance for Communicable diseases still form the most important the health and welfare of the family. Details about school health service are given in tuberculosis, diphtheria, whooping cough, tetanus and Chapter 32. The sanitary inspector, health He supervises and guides the work of other members inspectors and health assistants should check the village of the staff. He visits subcenters and other villages for registers and find omissions of births by comparing them this purpose. They should help He coordinates and cooperates with other health the village registrars (e. Sarpanch, Panchayat Secretary, agencies and voluntary organizations working in the Village Munsif, Police Patel, etc. He enlists cooperation of other departments such tration, keeping of records and making reports. Registers as revenue, agriculture, education and Public Health on epidemic disease should be checked and properly Engineering for promotion of health and prevention of maintained. A large number of national programs have been • All matters relating to management of personnel. The more • Reporting the progress of activities under all pro- important among these are the Family Welfare Program, grams to the Chief Medical Officer. This staff is stationed mostly health program at the headquarter while some members are posted at • Training to untrained dais. At the end of the training, the health guides are given a certificate, a manual and The Rural Health Scheme emerged out of the recom- a kit. The manual tells them in simple words what to mendations of the Shrivastav Committee and was intro- do and what not to do in the situations they might face. It is based on a 4-tier system of services The kit contains common medicines (modern as well provided at the level of the village, the subcenter, the as indigenous) needed in the community. As The health guide is to be selected by the Gram per the provisional totals of the 2001 census, the literacy 10 Panchayat. In these ones, which are referred to the concerned Medical conditions, it is not surprising that health facilities are Officer. It is not possible for a physician population (500 in case of tribal, hilly or remote areas). One of these should be a envisaged to enlist local people in the health service set- woman, and one should be from a Scheduled Caste/ up. The health guide cannot administer injections and cannot prescribe Village Health Guides outside the list of drugs provided to him. He should not On October 2, 1977 the Community Health Workers treat any case for more than 2 days if there is no Scheme was launched in India to provide health services improvement. This scheme is in homes, unattended by a doctor or a properly trained operation in all states and Union Territories except in health functionary. The high maternal mortality rate and four states where alternative rural health schemes are in progress. These states and their schemes are as neonatal tetanus mortality rates are largely due to lack follows: Jammu and Kashmir (Rehbar-e-Sehat), of proper antenatal, natal and postnatal care. This is the idea behind the within the community who provides primary health care dai training scheme. During the one month • He or she should have had formal education up to training, the dai has to conduct at least 2 deliveries under at least sixth standard.
