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She says that her mouth has been dry and crestor 10 mg without a prescription, on direct questioning order crestor with visa, thinks her eyes have also felt dry cheap crestor 5 mg free shipping. There has been no disturbance of her bowels or urine although she thinks that her urine has been rather strong lately. She has taken occasional paracetamol for headaches but has been on no regular medication other than thyroxine and some vitamin tablets she buys from the chemist. Examination Her sclerae look a little yellow and she has xanthelasmata around the eyes. In the abdomen, the liver is not palpable but the spleen is felt 2 cm under the left costal margin. The symptoms and investigations are characteristic of primary biliary cirrhosis, an uncommon condition found mainly in middle-aged women. In the liver there is chronic inflammation around the small bile ducts in the portal tracts. Itching occurs because of raised levels of bile salts, and can be helped by the use of a binding agent such as cholestyramine which interferes with their reabsorption. The presence of antimitochondrial antibodies in the blood is typical of primary biliary cirrhosis. The thyroid antibodies reflect the autoimmune thyroid disease which is asso- ciated with other autoantibody-linked conditions such as primary biliary cirrhosis. This should only be carried out after an ultra- sound confirms that there is no obstruction of larger bile ducts. Ultrasound will help to rule out other causes of obstructive jaundice although the clinical picture described here is typical of primary biliary cirrhosis. Dealing with the under- lying cause, wherever possible, is preferable to symptomatic treatment. He has suffered from insulin-dependent diabetes mellitus for 18 years and his diabetic control is poor. He has had recurrent hypoglycaemic episodes, and has been treated in the emergency department on two occasions for this. His general practitioner diagnosed cellulitis and he has received two courses of oral antibiotics. This has made him feel unwell and he has complained to his wife of fatigue, anorexia and feeling thirsty. His treatment is twice-daily insulin, he checks his blood glucose irregu- larly at home. Examination He is clinically dehydrated with reduced skin turgor and poor capillary return. He has an ulcer on the third toe of his right foot and the foot looks red and feels warm. The blood glucose level is not given but the picture is likely to rep- resent hyperglycaemic ketoacidotic coma. The key clinical features on examination are dehydration and hyperventilation, and the triggering problem with the infection in the foot. A persistently high sugar level induced by his infected foot ulcer causes heavy glyco- suria triggering an osmotic diuresis. The extracellular hyperosmolality causes severe cellular dehydration, and loss of water from his brain cells is the cause of his coma. Decreased insulin activity with intracellular glucose deficiency stimulates lipolysis and the production of ketoacids. He has a high anion gap metabolic acidosis due to accumulation of ketoacids (acetoacetate and 3-hydroxybutyrate). Ketones cause a character- istically sickly sweet smell on the breath of patients with diabetic ketoacidosis (about 20 per cent of the population cannot smell the ketones). In older diabetic patients there is often evidence of infection precipitating these metabolic abnormalities, e. Salicylate poisoning may cause hyperglycaemia, hyperventilation and coma, but the metabolic picture is usually one of a dominant respiratory alkalosis and mild metabolic acidosis. The aims of management are to correct the massive fluid and electrolyte losses, hypergly- caemia and metabolic acidosis. Rapid fluid replacement with intravenous normal saline and potassium supplements should be started. Regular moni- toring of plasma potassium is essential, as it may fall very rapidly as glucose enters cells. Insulin therapy is given by intravenous infusion adjusted according to blood glucose levels. A nasogastric tube is essential to prevent aspiration of gastric contents, and a bladder catheter to measure urine production. In the longer-term it is important that this patient and his wife are educated about his diabetes and that he has regular access to diabetes services. He has had a cough with daily sputum production for the last 20 years and has become short of breath over the last 3 years. He can no longer carry his shopping back from the supermarket 180 m (200 yards) away. He worked as a warehouseman until he was 65 and has become frustrated by his inability to do what he used to do. He appears to be centrally and peripherally cyanosed and has some pit- ting oedema of his ankles. Treatment with bronchodilators should be pursued looking at the effect of $2-agonists and anticholinergic agents, judging the effect from the patient s symptoms and exercise toler- ance rather than spirometry. Theophylline may sometimes be useful as a third-line ther- apy but has more side-effects. With this degree of severity, inhaled corticosteroids and long-acting bronchodilators (sal- meterol/formoterol or tiotropium) would be appropriate inhaled therapy. Blood gases should be checked to see if he might be a candidate for long-term home-oxygen therapy (known to improve survival if the pressure of arterial oxygen (paO2) in the steady-state breathing air remains! Gentle diuresis might help the oedema although oxygen would be a better approach if he is sufficiently hypoxic. Annual influenza vaccination should be recommended and Streptococcus pneumoniae vaccination should be given. If he has the motivation to continue exercising, then a pulmonary rehabilitation programme has been shown to increase exercise tolerance by around 20 per cent and to improve quality of life. Other more dramatic interventions such as lung-reduction surgery or transplantation might be considered in a younger patient. Depression is often associated with the poor exercise tolerance and social isolation, and this should be considered. However, a vig- orous approach tailored to the need of the individual patient can provide a worthwhile benefit. He noticed a sore area on the right foot 3 weeks ago and this has extended to an ulcerated lesion which is not painful. He had an inguinal hernia repaired 2 years ago and he stopped smoking then on the advice of the anaesthetist.

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By limulus amoebocyte lysate gelation test using chloroform extraction buy crestor 5mg on line, endotoxin (lipopolysacchaide) was detected in half of patients with cholera and none of patients with noncholera diarrhoea generic crestor 20mg with amex. Of 185 patients with cholers discount 20 mg crestor fast delivery, those gives tettacycline or tetracycline and berberine had considerably reduced volume and frequency of diarrhoeal stools, duration of diarrhoea, and required less intravenous and oral rehydration fluid. Analysis by factorial design equations, however, showed a reduction in diarrhoeal stools by one litre and reduction in cyclic adenosine monophosphate concentrations in stools by 77% in the groups given berberine. Considerably fewer patients given tetracycline or tetracycline and berberine excreted vibrios in stools after 24 hours than those given berberine alone. Neither tetracycline nor berberine had any benefit over placebo in 215 patients with non-cholera diarrhoea. Children who continued to be breast fed during treatment with oral rehydration solutions passed significantly fewer diarrhoeal stools. They also passed, on average, a smaller volume of diarrhoeal stools and recovered from diarrhea sooner after the start of treatment. Breast feeding exercise a beneficial effect on the course and outcome of acute diarrhea by reducing the number and volume of diarrhoeal stools. Of 185 patients with cholera, those given tetracycline or tetracycline and berberine had considerably reduced volume and frequency of diarrhoeal stools, duration of diarrhoea, and volumes of required intravenous and oral rehydration fluid. Analysis by factorial design equations, however, showed a reduction in diarrhoeal stools by one litre and a reduction in cyclic adenosine monophosphate concentrations in stools by 77% in the groups given berberine. This pattern was similar to the prevalence of acute children diarrhoea in these village children. The rate of recovery from dehydration (as demonstrated by reduction in haematocrits) were almost, identical. There was a definite seasonality for acute diarrhoea, the incidence rates during the monsoon months being significantly higher than those during the winter months. Bacterial agents, especially enterotoxigenic Escherichia coli, were the most common pathogens foracute diarrhoea during monsoon, and rotavirus was the most common pathogen detected during winter. Presumably, because of the cytopathic effect of rotavirus, children who developed diarrhoea during winter had smaller gain in body weights per month than those who developed diarrhoea during monsoon (being most commonly associated with enterotoxigenic Escherichia coli ). It is found that below age 30, the disease is rare and the peak incidence being age 51 to 60. Of 50 cases, gastric resections are performed on 19 patients (38 percent), gastrojejunostomy (palliative by-pass procedure) on 24 patients (48 percent) and on 7 patients (14 percent) neither resection or palliative by-pass could be done, laprotomy and biopsy only could be done. The common clinical presentations are vague abdominal pain (mainly in epigastrium) not relieved by antacids, dyspesia and presence of clinically palpable epigastric lump. It is found that the presence of palpable epigastric lump lessens the resectability rate. In this study, of 19 cases of gastric resection, 12 patients (64 percent) have no clinically palpable epigastric lumps. It is found in the study that those who have their time-lapse over four months, the gastric resection rates are much reduced. In this study 80 percent of the growths are found situated in the pyloric antrum and the rest in the body and fundus. In this study, of 19 cases resected, 11 acses (56 percent) have local spread and 8 cases (42 percent) have intra-abdominal spread. Surgeons of consultant level have the greater skill than their first assistants to perform gastric resections. When keeping controls with the same type of spread of the disease and the same sizes of growth, the resection rates are still higher in the consultant level group than those in their junior colleagues. These neonates also lost more sodium in their stools than their non diarrhoeic counterparts. On the other hand, the diarrhoeic newborns lost less potassium in stools in the first few days. In the process of making these sweets, there are many ways by which they can get contaminated. The percentage isolation of enteric bacteriae was the highest in the sweet-damp types and during the hot-wet season. The enteric bacteriaea were isolated more in tamarinds and the plums and the least in marian group. The Myanmar fruit sweets may be one of the potentially important vehicle to transmit diarrhoeal pathogens during the hot-wet season in Myanmar. Improvements in the personal and environmental hygiene are needed to prevent contamination during their production. From the morning meals and stored drinking water of 208 randomly selected children, 775 food and 113 water samples were collected and were cultured using standard methods. Enterotoxigenic Escherichia coli, salmonella spp, shigella spp, and non-O1 Vibrio cholera were isolated from fly pools in animal pens (88. The gastroenteritis caused by these bacteria is caused by these bacteria is accompanied by pain in abdomen, nausea and vomiting, fever and a mild degree of dehydration. This is the first report indicating the frequency and importance of Aeromonas and Plesiomonas species in causing gastroenteritis in Myanmar. It is anticipated to facilitate the epidemiological study in order to provide an effective control of the disease. The latter group received boiled-rice to supply at least 55kcal/kg/d (about 150g boiled-rice per feed, given four times daily). However, the children fed boiled rice absorbed and retained 176ml more fluid, and had gain in body weight comparable to that observed in children who were not fed during the first 24h of hospitalization. Anthropometric measurements were made every 3 mo and growth rates were calculated. By limulus amoebocyte lysate gelation test using chloroform extraction, "endotoxin" (lipopolysaccharide) was detected in half of patients with cholera and none of patients with non-cholera diarrhoea. Gastric biosy in 154 cases of gastric ulcer confirmed the benign nature of the lesion. Therapeutic endoscopy (prophylactic injection sclerotherapy of oesophageal varices) was done in 132 cases of cirrhosis who had at least one but of variceal haemorrhage. Discrepancy between radiological and detecting endoscopic findings was found in 87 cases (17. Fibre endoscopy is advantageous in detectiong mucosal lesions, tissue diagnosis and assessment of ulcer healing. This was administered orally and the results showed that the test drug could purge worms in 57% of the moderately worm-infested subjects. The overall anthelminthic efficacy of the Indigenous Drug-03 is 16% when compared to the efficacy of the classical levotetramisole. Occupation of the patients revealed the majority of patients were of labourer class. The main presenting signs and symptoms were, passing of blood and mucus in their stool, abdominal pain and tenesmus, with duration of a few days to more than 4 weeks. Stool examination revealed (either from fresh specimen or from protosigmoidoscopic aspirates and scraping) haematophagus active trophozoites in 30 of the cases. Stool culture showed positive for pathogenic strains of Shigellosis in 5 of the cases.

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Encouraging acceptance of the mass drug administration programme is an important health education message that you can deliver in affected communities order 10mg crestor amex. It is also known as elephantiasis because of its effects on the legs of infected people discount crestor 5 mg fast delivery. Though the disease is not fatal purchase generic crestor pills, it is responsible for considerable disability and distress, causing social stigma among men, women and children. You will learn more about the social consequences of lymphatic lariasis and a non-infectious cause of swelling in the legs (podoconiosis) in Study Session 39. After mating, the females lay millions of eggs which develop into microlaria, completing the lifecycle. The overall effect is to disrupt the lymphatic system, which normally collects tissue uids draining from the body s cells and returns the uid to the blood stream. If the lymphatic drainage is blocked, the lower limbs and sometimes also the genitals become hugely swollen with uid a condition called lymphoedema (pronounced limf-ee-deem-ah ). Infection of the swollen skin folds by bacteria is a frequent cause of very painful attacks. Therefore, if you live in an endemic area and you suspect a case of lymphatic lariasis, you should refer the patient to the nearest health centre for further testing and treatment. Education in the community about the causes and modes of transmission of lymphatic lariasis, and ways to protect themselves from mosquito bites. Encouraging acceptance of the mass drug administration programme is an important health education message that you can deliver if your community is affected. You also have a key role in educating patients about how to prevent and alleviate disabilities and pain due to lymphatic lariasis, as described in the nal part of this study session. You infectious elephantiasis, Study should educate them to wash the affected parts carefully every day, especially Session 39). Advise the patient to exercise the limbs any time and anywhere, as often as possible, to help the uid to exit from their swollen limbs. It is common in communities living near rivers, lakes and streams, where infected people shed Schistosoma eggs when they urinate or defaecate into the water. Schistosoma haematobium affects blood vessels in the bladder and causes pain during urination and bloody urine. Three other Leishmania species cause cutaneous leishmaniasis, which manifests as ulcers in exposed areas of skin. The microscopic microlaria cause skin nodules and can migrate to the eye, causing blindness. The worms block the lymphatic system, causing swelling of the limbs and sometimes the genitals, resulting in severe pain, disability and bacterial infection of thickened skin folds. In this study session, we turn to two communicable diseases found in Ethiopia in which a non-human warm- Taeniasis is pronounced blooded animal transmits the infectious agent to humans. Zoonotic is rabies transmitted to humans by dogs, and taeniasis (or tapeworm disease) pronounced zoo-nott-ik. Diseases in which a warm-blooded animal transmits the infectious agents to humans are known as zoonotic diseases (or zoonoses). Zoonotic diseases are difcult to control because the non-human animal acts as a reservoir of infection that can be passed on to humans. The infectious agent of rabies is a virus in the rhabdovirus family, which attacks the nervous system. Image Library, image 8319) The rabies virus exists in the saliva of the infected animal (as well as in its nervous system) and is transmitted to a person through a bite. Transmission can also be if an infected animal licks a fresh break in the person sskinor mucus membranes, e. Person-to-person transmission is theoretically possible if someone with advanced rabies bites another human, but this is not known to have occurred. After an incubation period usually lasting one to three months, but sometimes even up to one year after the bite, the patient develops symptoms that are similar to many other illnesses fever, headache and general weakness. The speed of progression is faster if the original site of infection was in an area of the body that is close to the spinal cord or brain, e. A dog s saliva travels along the characteristic sign of late-stage rabies in some patients is hydrophobia (fear of nerves to the person sbrain. This form of the disease (known as furious rabies) prevents the patient from drinking and speeds the arrival of death within a few days. There are no tests to conrm rabies with absolute certainty while the patient is still alive. Viruses can be detected by laboratory investigation of the patient s brain after death, but this test is not usually carried out in countries with few resources. The wound should not be sutured (stitched) unless this is essential to stop heavy bleeding. If stitches are required, the wound should not be sutured until after post-exposure prophylaxis has occurred. Post-exposure prophylaxis for rabies If a person is bitten by a dog in countries where rabies is endemic, there is no way of being certain that the animal is free from rabies. The bitten person should be given post-exposure prophylaxis (details of the regimen are described below) as soon as possible after the bite. Every year, around 15 million people receive this treatment worldwide, preventing an estimated 327,000 human deaths from rabies. Details of the vaccines and rabies immunoglobulin mentioned in the table will be described below. Contact category Action Category I: touching or feeding the None animal, licks on intact skin (i. The newer type of vaccine is made from virus-infected cells grown (cultured) in the laboratory and is safer and more effective. The intradermal route has been shown to be as safe and effective as the traditional intramuscular route, and is cheaper because it requires less vaccine. If you are referring someone to a health centre for rabies post- exposure prophylaxis, you should tell the patient and their family that it is essential to return at xed intervals for repeat vaccinations in order to prevent rabies if they have been infected by the bite. The term immunoglobulin refers to a preparation of antibodies made either in humans or in horses who have been vaccinated against rabies. Antibodies from their blood which attack the rabies viruses are harvested and stabilised in an injectable liquid. As much as possible of the dose of rabies immunoglobulin is given into, or as near as possible to, the site of the bite. If there is any remaining in the syringe, it is injected at a different site to elicit active immunity. The main prevention measures against rabies are aimed at controlling the animals that transmit the virus, educating the community on how to protect themselves from dog bites, and what action to take if they are bitten. Your roles as a Health Extension Practitioner are to contribute to a comprehensive rabies control programme by carrying out the following activities:. Educate the owners of dogs and the public on the importance of restricting the activity of their dogs. People should be educated that they must be careful handling or approaching strange-acting dogs and other canines.

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Initially prolapse only occurs on defecation with sponta- neous return; however order crestor 10 mg visa, with time the prolapse becomes Clinical features more permanent crestor 5mg mastercard. Thesentinelpilemaybevis- Clinical features ible on examination order crestor once a day, rectal examination is very painful There is often discomfort on passing stool possibly with and often impossible. Examination under anaesthesia bleeding and mucus due to inammation of the pro- (proctoscopy/sigmoidoscopy) allows diagnosis. Patients often present with an abscess, the incision of which completes the stula. Patients with a completed Management stula present with a discharging sinus that causes lo- Primaryanalssuresmayhealspontaneously. An incision is made into the perianal skin on one side of the anal canal Investigations and the internal sphincter is divided without entering Proctoscopy may reveal the internal opening with a exi- the lumen. Fistula-in-ano Management Denition Primary stulas are laid open to granulate and epithe- A stula is an abnormal communication between one lialise. Associations include inammatory bowel disease, tuberculosis and Denition carcinoma of the rectum. A sinus of the natal cleft containing hair that often be- 1 Low anal stula is the commonest form with a com- comes infected. Aetiology/pathophysiology 2 High anal stulas have a track which extends above It is thought that sinuses arise from penetration of hairs the pectinate line below the anorectal ring. A post anal cle bres of the internal and external anal sphincter pilonidal sinus typically occurs around 2 cm posterior surround the rectum. In both low and high stulas to the anus and extends superiorly and subcutaneously the track of the stula may pass through the bres for about 2 5 cm. Pathophysiology Goodsall s rule states that if the stula lies in the anterior Anorectal abscess half of the anal area then it opens directly into the anal canal, while if a stula lies in the posterior half of the Denition canal then it tracks around the anus laterally and opens Anorectal abscesses may occur as perianal, ischiorectal into the midline posteriorly. Sex Management 2M : 1F Perianal and ischiorectal abscesses are drained under general anaesthetic and de-roofed by making a cruci- Aetiology ate incision and excising the resultant 4 triangles of skin. In the majority of patients there is no apparent cause for 25% of abscesses recur. Vascular disease of the bowel Pathophysiology Infection of an anal gland may cause a tracking down Intestinal ischaemia to form a perianal abscess, or tracking out to form a Intestinal ischaemia results from a failure of the blood ischiorectal abscess, or upwards to produce a high inter- supply to the bowel. Three underlying patholo- gies are in operation resulting in a number of clinical Clinical features r entities all with three possible outcomes (see Fig. Perianal abscess is common and presents in well pa- tients with an acute tender swelling at the anal verge. Patients Localised bowel pathology may result in focal area of have signicant systemic upset. These are conrmed twists on itself usually around a brous peritoneal band on barium studies and require resection. Investigations Pathophysiology A barium enema can be used to show oedema or mu- The ischaemia results from venous infarction due to cosal sloughing. Mesenteric angiography will external pressure resulting in venous congestion and demonstrate the stenosis or occlusion. Management The condition generally is self-limiting within a few days Clinical features/management with uncomplicated cases managed conservatively. If blood ow is not restored, a progression to in- farction and necrosis necessitates bowel resection. Chronic intestinal ischaemia Denition Slow progressive ischaemia of the gut due to atheroma Ischaemic colitis generally occurring in the elderly. Denition Ischaemia of the colon due to interruption of its blood Aetiology supply. Risk factors: r Fixed: Age, sex, positive family history, familial hyper- Aetiology In most cases the underlying cause is thrombosis of the lipidaemia. Pathophysiology In around half the ischaemia is transient with damage Pathophysiology connedtothemucosaandsubmucosa. Thesplenicex- Progressive atheroma occludes the lumen of the vessels ure is most often affected due to the territories of the causing reduced blood ow. If the blood supply is not depends on the position and degree of occlusion and the restored, ischaemia progresses to gangrenous ischaemic presence of collateral blood supply. Clinical features Patients describe pain occurring after food, weight loss, Clinical features malabsorption and signs of vascular disease. The patient presents with lower abdominal pain, nausea, vomiting and bloody diarrhoea. There is lower abdom- Investigations inal tenderness and guarding in the lower abdomen. Microscopy Management There is ischaemic loss of mucosa, ulceration and later Surgical revascularisation depends on the results of an- healing with oedema and inammatory inltrate. Denition Complete necrosis and gangrene of the midgut resulting Aetiology from cessation of blood ow in the superior mesenteric r Squamous carcinoma accounts for more than 90% of artery. These usually occur in the middle third of the oesophagus although the lower third may also be af- Clinical features fected. Aetiological factors include high alcohol con- There may be a preceding history of non-specic symp- sumption, smoking and chewing betel nuts. Signs of acute intestinal failure include ab- affects the lower third of the oesophagus particularly dominal tenderness, guarding, loss of bowel sounds and the gastrooesophageal junction possibly following ep- rigidity, due to perforation. Calcication within the abdominal aorta may be evident r Familial forms have been noted. Gas lled, thickened, dilated bowel loops and free gas within the peritoneal cavity due to Pathophysiology perforation may also be seen. Following adequate resuscitation laparotomy and resec- tion(whichmaybemassive)arerequired. Patients may present with progressive dysphagia, but of- Asecond look laparotomy can be performed 24 hours tenpresent late with weight loss, anaemia and malaise. If Barium swallow demonstrates an apple core defect or the patient survives they have considerable malabsorp- stricture without proximal dilatation. In the absence of metastases endoscopic ultrasound is useful to assess operability. Management r Wherever possible surgical resection is the primary Age treatment with those occurring in the lower third Rare below the age of 40 years. Neoadjuvant Denition chemotherapy with cisplatin and 5-uorouracil (5- Malignant tumour of the stomach. Sex Prognosis 2M > 1F Surgical resection carries an operative mortality of up to 20%. Benign gastric tumours Aetiology Denition Pre-malignant conditions include chronic atrophic gas- Benign tumours and polyps of the stomach.

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