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By J. Giores. Charles R. Drew University of Medicine and Science. 2018.

Clinical signs – Skin erythema purchase malegra fxt 140 mg on line erectile dysfunction medication nhs, oedema with well demarcated margins purchase malegra fxt 140mg overnight delivery erectile dysfunction treatment melbourne, warmth cheap malegra fxt 140 mg mastercard erectile dysfunction doctors, pain, usually on the lower limbs and at times the face. Treatment – In all cases: • Outline the area of erythema with a pen in order to follow the infection. The dose is expressed in amoxicillin: Children < 40 kg: 45 to 50 mg/kg/day in 2 divided doses (if using formulations in a ratio of 8:1 or 7:1) or in 3 divided doses (if using formulations in a ratio of 4:1). Children ≥ 40 kg and adults: 1500 to 2000 mg/day depending on the formulation available: 8:1 ratio: 2000 mg/day = 2 tablets of 500/62. Humans may become infected through contact of broken skin with a dead or sick animal. People at risk include livestock farmers and those that manipulate skins, wool or carcasses of infected animals. The vesicle ulcerates and becomes a painless black eschar surrounded by oedema, often associated with with lymphangitis and regional lymphadenopathy. Laboratory – From vesicular fluid : culture and susceptibility testing (rarely available) or Gram stain fora microscopic examination. Treatment Cutaneous anthrax without severity criteria – Do not excise the eschar; daily dry dressings. Change to oral treatment as soon as possible to complete 14 days of treatment with ciprofloxacin + clindamycin or amoxicillin + clindamycin as for cutaneous anthrax without severity criteria. There is no laboratory test that can distinguish between the different treponematoses. Treatment of contacts and latent cases The same treatment should be administered to all symptomatic and asymptomatic contacts and to all latent cases (asymptomatic individuals with positive serologic test for syphilis) in endemic zones. Second stage Lesions appear 3 weeks after the initial chancre, Pintids: plaques of various colours (bluish, • Mucous patches of the mouth common: occur in crops and heal spontaneously: reddish, whitish). May occur anywhere on very contagious ulcerated, round in form, • Frambesioma (papillomatous lesion, vegetal, the body. The After several years of latency: • Periostitis; painful, debilitating osteitis depigmentation is permanent, remaining after • Gummatous lesions of skin and long bones • Ulcerating and disfiguring rhinopharyngitis treatment. Leprosy is not very contagious with transmission through prolonged, close, direct contact, particularly between household members. Clinical features 4 Leprosy should be considered in any patient presenting with hypopigmented skin lesions or peripheral neuropathy. In suspect cases, conduct a thorough clinical examination: – skin and mucous membranes (patient must be undressed), – neurological examination: sensitivity to light touch, pinprick and temperature (hot-cold test), – palpation of the peripheral nerves. The Ridley-Jopling classification differentiates 5 forms based on several factors, including the bacteriological index. The Ridley-Jopling classification of leprosy Paucibacillary forms Multibacillary forms (least contagious forms) (most contagious forms)) Tuberculoid Borderline Borderline Borderline Lepromatous Tuberculoid Lepromatous T. Tuberculoid leprosy – The primary characteristic is peripheral nerve involvement: tender, infiltrated and thickened nerves; loss of thermal, then tactile and pain sensation. Lepromatous leprosy – The primary characteristic is multiple muco-cutaneous lesions: • macules, papules or infiltrated nodules on the face, ear lobes and the upper and lower limbs. Initially, there is no sensory loss; • involvement of the nasal mucosa with crusting and nose bleeds; • oedema of the lower limbs. Indeterminate leprosy (I) Form that does not fall in the Ridley-Jopling classification, frequent in children: a single well- demarcated macule, hypopigmented on dark skin, slightly erythematous on pale skin. Lesion heals spontaneously or the disease evolves towards tuberculoid or lepromatous leprosy. Lepra reactions – Reversal reactions: occur in patients with borderline leprosy, during treatment, when evolving towards tuberculoid leprosy. Acute painful neuritis (ulnar nerve) requires urgent treatment (see next page) as there is a risk of permanent sequelae. This reaction is seen exclusively in patients with lepromatous leprosy during the first year of treatment. Early antibiotic treatment prevents functional sequelae and transmission of the disease. Clinical features – Recurrent herpes labialis: tingling feeling followed by an eruption of vesicles on an erythematous base, located on the lips (‘fever blisters’) and around the mouth, they may extend onto the face. Recurrence corresponds to a reactivation of the latent virus after a primary infection. Chickenpox is the primary infection and herpes zoster the reactivation of the latent virus. Clinical features – Unilateral neuralgic pain followed by an eruption of vesicles on a erythematous base, that follow the distribution of a nerve pathway. Seborrheic dermatitis Seborrheic dermatitis is an inflammatory chronic dermatosis that can be localized on rich areas rich with sebaceous glands. Clinical features – Erythematous plaques covered by greasy yellow scales that can be localized on the scalp, the face (nose wings, eyebrows, edge of the eyelids), sternum, spine, perineum, and skin folds. Pellagra Pellagra is a dermatitis resulting from niacin and/or tryptophane deficiency (in persons whose staple food is sorghum; patients with malabsorption, or during famine). Clinical features Classically, disease of the ‘three Ds’: dermatitis, diarrhoea and dementia. In endemic areas, vitamin A deficiency and xerophthalmia affect mainly children (particularly those suffering from malnutrition or measles) and pregnant women. Disorders due to vitamin A deficiency can be prevented by the routine administration of retinol. Clinical features – The first sign is hemeralopia (crepuscular blindness): the child cannot see in dim light, may 5 bump into objects and/or show decreased mobility. Treatment It is essential to recognise and treat early symptoms to avoid the development of severe complications. Vision can be saved provided that ulcerations affect less than a third of the cornea and the pupil is spared. Even if deficiency has already led to keratomalacia and irreversible loss of sight, it is imperative to administer treatment, in order to save the other eye and the life of the patient. In addition to the immediate administration of retinol, treat or prevent secondary bacterial infections: apply 1% tetracycline eye ointment twice daily (do not apply eye drops containing corticosteroids) and protect the eye with an eye-pad after each application. Vitamin A overdose may cause raised intracranial pressure (bulging fontanelle in infants; headache, nausea, vomiting) and, in severe cases, impaired consciousness and convulsions. These adverse effects are transient; they require medical surveillance and symptomatic treatment if needed. Endemic or epidemic, conjunctivitis may be associated with measles or rhinopharyngitis in children. In the absence of hygiene and effective treatment, secondary bacterial infections may develop, affecting the cornea (keratitis) and leading to blindness. Clinical features – Clinical signs of all conjuctivites include: redness of the eye and irritation. Treatment Bacterial conjunctivitis – Clean eyes 4 to 6 times/day with boiled water or 0. The infection is bilateral in 50% of cases, highly contagious and may rapidly lead to severe corneal lesions and blindness.

More information on the European Union is available on the internet (http://europa cheap malegra fxt 140mg line erectile dysfunction 45. Tis report is available in Bulgarian order malegra fxt 140mg free shipping erectile dysfunction prevalence, Spanish buy malegra fxt 140mg on line erectile dysfunction doctors in pittsburgh, Czech, Danish, German, Estonian, Greek, English, French, Croatian, Italian, Latvian, Lithuanian, Hungarian, Dutch, Polish, Portuguese, Romanian, Slovak, Slovenian, Finnish, Swedish, Turkish and Norwegian. All translations were made by the Translation Centre for the Bodies of the European Union. Recommended citation: European Monitoring Centre for Drugs and Drug Addiction (2017), European Drug Report 2017: Trends and Developments, Publications Ofce of the European Union, Luxembourg. We ofer you a package of information and analysis that is rich and multi-layered, based on the most recent data and statistics provided by our national partners. Te 2017 report is accompanied by a new set of national overviews, in the form of 30 Country Drug Reports, presenting accessible online summaries of national drug trends and developments in policy and practice taking place in European countries. In doing so, we strive to provide the best possible evidence and contribute to realising our vision of a healthier and more secure Europe. As a top-level overview and analysis of drug-related trends and developments, we intend this report to be a useful tool for European and national policymakers and planners who wish to base their strategies and interventions on the most recent information available. In line with our objective to deliver high quality services to our stakeholders, this latest report will allow access to data that can be used for multiple purposes: as baseline and follow-up data for policy and service evaluations; to give context and help defne priorities for strategic planning; to enable comparisons to be made between national situations and datasets; and to highlight emerging threats and issues. Tis year´s report highlights some potentially worrying changes in the market for illicit opioids, the substances that continue to be associated with a high level of morbidity and mortality in Europe. We note the overall increase in opioid-related overdose deaths as well as the increasing reports of problems linked with opioid substitution medications and new synthetic opioids. As the drug phenomenon continues to evolve, so too must Europe’s response to drugs. Te framework for concerted action, set out in the European drug strategy 2013–20, allows for this. A new drug action plan for the period 2017–20 has been 5 European Drug Report 2017: Trends and Developments proposed by the European Commission and is being discussed by the European Parliament and the Council. In conclusion, we wish to thank our colleagues in the Reitox network of national focal points, who alongside national experts, provide most of the data that underpin this publication. We also acknowledge the contribution of numerous European research groups, without which this analysis would be less rich. Te report also benefts from collaboration with our European partners: the European Commission, Europol, the European Medicines Agency and the European Centre for Disease Prevention and Control. Te purpose of the current report is to prove an overview and summary of the European drug situation and responses to it. Analysis of trends is based only on those countries providing sufcient data to describe changes over the period specifed. Te reader should also be aware that monitoring patterns and trends in a hidden and stigmatised behaviour such as drug use is both practically and methodologically challenging. For this reason, multiple sources of data are used for the purposes of analysis in this report. Although considerable improvements can be noted, both nationally and in respect to what is possible to achieve in a European level analysis, the methodological difculties in this area must be acknowledged. Caution is therefore required in interpretation, in particular when countries are compared on any single measure. Caveats and qualifcations relating to the data are to be found in the online version of this report and in the Statistical Bulletin, where detailed information on methodology, qualifcations on analysis and comments on the limitations in the information set available can be found. Information is also available on the methods and data used for European level estimates, where interpolation may be used. Reitox national focal points Reitox is the European information network on drugs and drug addiction. For two important topics, overview of the drug market, drug use cannabis use among young people and and harms and responses forms the changes in the opioid market, the body of this report. Tis is accompanied current European situation and its by 30 complementary national reports evolution is compared and contrasted as well as extensive online data and with that in North America, and notable methodological information. Tis introductory section features a short analytical comment on some of the key themes emerging from this year’s data. Tese helpful, as it allows comparisons to be made between developments have been quite diverse, and there is a need patterns of cannabis and other substance use among to wait for robust evaluations before the relative costs and European and American students. Encouragingly, in both benefts of difering cannabis policy approaches can be regions, the most recent data show a decline in use of assessed. Furthermore, the extent to which developments tobacco and, albeit to a lesser extent, alcohol; though occurring elsewhere can be directly transferable to the trends in cannabis use appear more stable. Levels of alcohol consumption also medical conditions, of growing interest in some countries. It is possible that some of these relative infuence of the social, contextual and regulatory developments will impact on consumption patterns in factors on the choices made by young people. Europe, underlining the importance of behavioural Understanding, for example, what has led to the reductions monitoring in this area and the need to evaluate the in cigarette smoking observed in both the United States potential health implications of any changes in future and Europe may ofer insights for addressing the use of consumption patterns. It is also important to remember that diferences exist in how substances are Te European cannabis market has already changed consumed. In Europe, for example, in contrast to the considerably in recent years, in part driven by a move to United States, cannabis is often smoked in combination more domestic production. Te historically high overall with tobacco, and this is likely to have implications for potency levels of both resin and herbal cannabis available public health policies. Te drug also continues to be associated with health problems, and is responsible for the greatest share of reported new entrants to drug treatment in Europe. For all these reasons, understanding trends in cannabis use and related harms is important to the debate on what constitutes the most appropriate policy responses to this drug. Tis sector of the illicit drug market has l for public health policies grown in complexity, with the ready availability of new stimulants including cathinones and phenethylamines. Tis does not mean, however, that concerns have seizures, and price and purity data, suggest that the disappeared in this area. Tis drug has historically been the most two decades, this still represents a signifcant public health commonly used illicit stimulant in a number of countries, problem. Moreover, there have been recent outbreaks in mainly located in the south and west of Europe. New data some vulnerable populations and among users who are reported here supports this, with increasing seizures noted injecting stimulants and new psychoactive substances. In contrast, in northern Tere is also evidence that blood-borne infections are and central Europe, amphetamine and, to a lesser extent, often diagnosed relatively late among people who inject methamphetamine play a more signifcant role in the drug drugs, compared with other groups, thereby reducing the market than cocaine. Good clinical practice In the past few years, the possibilities for the treatment of together with an understanding of how prescription viral hepatitis have improved greatly, with the arrival of a opioids are diverted from their legitimate use, and how to new generation of medicines, which are highly efective. Highly potent synthetic opioids: a growing health l e changing nature of the opioid problem l threat Comparison with developments in North America is also In both Europe and North America, the recent emergence relevant to an analysis of Europe’s opioid drug problem. A of highly potent new synthetic opioids, mostly fentanyl review of the data presented in this report suggests that, derivatives, is causing considerable concern. Tese substances have been sold Te latest data show that heroin use still accounts for the on online markets, and also on the illicit market. Tey have majority, around 80 %, of new opioid-related treatment sometimes been sold as, or mixed with, heroin, other illicit demands in Europe.

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Different dopamine agonists have been created that bind to different dopamine receptors with varying strengths order malegra fxt 140 mg line erectile dysfunction drugs online. Dopamine agonists have longer half-lives (longer duration of action) than levodopa and for that reason can be helpful in reducing the intensity of the “wearing-off” reaction or to generally enhance the effect of levodopa cheap malegra fxt 140mg free shipping erectile dysfunction treatment in kuwait. However purchase 140mg malegra fxt fast delivery erectile dysfunction kit, certain side effects, such as excessive daytime sleepiness, visual hallucinations, confusion and swelling of the legs, occur more commonly with the use of dopamine agonists than with levodopa. This may be partly due to a higher likelihood of other illnesses (also known as comorbidities) and the greater risk of undesirable interactions between Parkinson’s drugs and drugs taken for other purposes. One possible adverse effect of dopamine agonists is the occurrence of drug-induced compulsive behaviors, such as uncontrolled eating, shopping, gambling and sexual urges. The underlying physiology is likely related to over- -)(11#$ 0 stimulation of dopamine receptors in the part of the brain responsible for instant gratification. Dopamine Agonist Started Stopped 2% 2% The Parkinson’s Outcomes Project is the largest clinical study of Parkinson’s in the world. This chart shows the percentage of people using and not using dopamine Used 38% agonists at each of the more than 19,000 visits tracked Not Used in the study as of May 2015. Frequency surveys have shown that these abnormal behaviors are more common with dopamine agonists but can also be seen with carbidopa/levodopa. Those at greatest risk include patients with a family history of gambling and those who are younger, unmarried, and/or cigarette smokers. Additional study will likely provide more insight into the true risk associated with the addition of these dopaminergic medications, as the newer questionnaire may be more likely to pick up such behaviors. Remember also that the people suffering from impulse control issues may not have insight into the behavioral problems, and this lack of insight underscores the importance of involving caregivers in any proactive monitoring plan. Neither of these dopamine agonists is ergot- derived, nor have they been associated with abnormalities of the heart valves. The side effects are similar, with the addition of usually mild local skin irritation under the patch in up to 40% of patients. Fewer than 5% of those studied in the clinical trials discontinued its use due to skin irritation. The initial formulation of the patch was removed from the market worldwide in 2008 because of technical problems with the delivery system. The original patches had a tendency to show a crystallized substance on their surface after they were stored in pharmacies and in patient medicine cabinets for weeks. Neupro® was redesigned and returned in 2012 with dosing available in 1, 2, 3, 4, 6 and 8 mg daily. Its short half-life (average 40 minutes) and chemical structure make it difficult, if not impossible, to take by mouth. In the person affected by severe “off” reactions, during which disabling bradykinesia and rigidity interfere with function, a self-injected dose of Apokyn® can reverse the “off” period within minutes and bridge the gap of one to two hours until the next dose of levodopa takes effect. An anti-nausea medication (usually trimethobenzamide or Tigan®) is required prior to injection in the early phase of treatment but can be discontinued after the first week or two. Selegiline was shown to delay the need for levodopa by nine months, suggesting neuroprotection, but this benefit may simply have been from the antiparkinson symptom effect of selegiline. Selegiline is available in two formulations: standard oral (Eldepryl®, l-deprenyl) and orally- disintegrating (Zelapar®). Standard oral selegiline is converted to an amphetamine like by-product which may contribute to side effects of jitteriness and confusion. Conversely, Zelapar® is dissolved in the mouth and absorbed directly into the bloodstream (no byproduct) without these side effects. Because of Zelapar®’s absorption in the mouth, it may be preferred for convenience or out of necessity for the person who has difficulty swallowing. Clinical trials of Azilect® as monotherapy or adjunctive therapy showed mild but definite efficacy, and there was also an unproven hint of slowing disease progression. A worldwide, multi-institutional clinical trial of rasagiline’s potential for neuroprotection was published in 2008 and follow-up data from the original studies has also been examined closely. A study was published in 2011 that fortunately found no cases of dangerous blood pressure shifts in 18 Parkinson’s Disease: Medications over 2000 patients taking rasagiline in combination with many of the anti-depressant medications on the market today. Additional side effects include confusion, hallucinations, discoloration of urine (reddish-brown or rust-colored) and diarrhea. Entacapone is prescribed with each dose of levodopa, whereas tolcapone is taken three times a day, no matter how many doses of levodopa are prescribed. Tolcapone was removed from the American market in the early 2000s because of a few instances of liver toxicity in people who used it. Tolcapone is currently available with the condition that blood tests of liver function be conducted every two to four weeks for the first six months after beginning treatment, then periodically thereafter. It works by providing relief for the motor symptoms as well as reducing “off” time. By combining the two drugs into one tablet, the manufacturer has made pill-taking a little more convenient compared with carbidopa/ levodopa + entacapone taken separately. In addition, there are more dosing options (see table) to better tailor the medication needs to an individual patient. Its mechanisms of action are not fully known, but it is likely that it interacts with multiple receptors at various sites in the brain to achieve its positive effect. Amantadine is cleared from the body by the kidneys, so a person with kidney problems may require a lower dose. Amantadine is most commonly available as a 100 mg capsule, although liquid and tablet forms can also be obtained. The most frequent side effects of Amantadine are nausea, dry mouth, lightheadedness, insomnia, confusion and hallucinations. Stopping the drug will resolve this adverse effect, although if the drug is providing good benefit there is no harm in continuing it. It is believed that acetylcholine and dopamine maintain a delicate equilibrium in the normal brain, which is upset by the depletion of dopamine and the degeneration of dopamine-producing cells. The common antihistamine and sleeping agent diphenhydramine (Benadryl®) also has anti- tremor properties. Ethopropazine, an anticholinergic and an antihistamine, may have fewer side effects but is not available in most U. Although he didn’t differentiate motor from non-motor symptoms, he observed that his patients experienced symptoms of fatigue, confusion, sleep disturbances, constipation, drooling and disturbances of speech and swallowing. Speech, swallowing and drooling are included among non-motor symptoms although the root cause is in part motor: decreased coordination of the muscles of the mouth and throat. Make sure your healthcare provider is aware of any non-motor symptoms you are experiencing! Unfortunately, it has also been shown that physicians and healthcare team members do not recognize these symptoms in their patients up to 50% of the time. Just as physicians assess complaints of slowness, stiffness or tremor, they should also address issues related to sleep, memory, mood, etc. The definitive cause is not completely understood but it is likely related to an imbalance of chemicals in the brain (including dopamine, serotonin and norepinephrine).

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Most chapters start with a title cheap malegra fxt 140mg with amex erectile dysfunction age factor, a brief description of the topic generic malegra fxt 140 mg on line impotence risk factors, common clinical signs and symptoms of each disease purchase malegra fxt 140 mg with mastercard erectile dysfunction treatment without drugs, the diagnosis and differentials, investigations, treatments and supportive care. The medicines will be used to treat the majority of public health problems and they should be available to health facilities at all time. The guideline also makes provision for referral of patients to higher health facilities. The indices for all medicines used are found at the back of the guide book, together with the information on how to report the adverse drug reactions. The guideline also, makes provision for referral of patients to higher health facilities see the referral form. The last pages of the guideline contain annexes, references as well as the Essential Medicines List. Comments that aim to improve these treatment guidelines will be appreciated all the time and the form for that purpose is appended. Any pain of moderate or higher intensity is accompanied by anxiety and the urge to escape or terminate the feeling. In non- or pre verbal children, facial expression is the most valid indicator of pain; therefore use faces pain scale to assess severity. Children A: Paracetamol 15 mg/kg/dose 4–6 hourly when required to a maximum of 4 doses per 24 hours; 1|P a g e 1 | P a g e 1. They have the broadest range of efficacy, providing the most reliable and effective method for rapid pain relief. Adults : C: Tramadol tablets or injection 50-100mg every 6 hours or until pain is controlled. Drug Treatment Mild Pain Adult: A: Paracetamol 1000 mg (O) 6 hourly until pain subsides Pain Associated with Trauma or Inflammation See under Trauma and Injuries section Moderate pain (Including neuropathy) Adults: If still no relief to simple analgesics as above, add C: Tramadol 50 mg (O) 4–6 hourly as a starting dose May be increased to a maximum of 400 mg daily Adjuvant therapy Adults: In addition to analgesia as above add antidepressants; C: Amitriptyline 25 mg (O) at night; Maximum dose: 75mg. Referral  Pain requiring strong opioids  Pain requiring definitive treatment for the underlying disease  All children 1. Therefore, before embarking on opioid therapy, other options should be explored, and the limitations and risks of opioids should be explained to the patient (For detailed information, refer to Malignant Disease chapter). There are three major categories of headaches:  Primary headaches,  Secondary headaches, and  Cranial neuralgias, facial pain, and other headaches Assessment of headache should be comprehensive for example to include  Age at onset  Presence or absence of aura and prodrome 3 | P a g e  Frequency, intensity and duration of attack  Number of headache days per month  Quality, site, and radiation of pain  Associated symptoms and abnormalities 2. It is more common in females than in males often there is a family history of migraine. In severe attack give: C: Ergotamine tartrate 1-2 mg, maximum 4mg in 24hours, not to be repeated at intervals less than 4 days. Referral  Patient with additional neurological signs or additional risk factors for an alternate diagnosis, such as immune deficiency. These patients require brain imaging  Sudden onset of a first severe headache may indicate serious organic pathology, such as subarachnoid hemorrhage  Acute migraine, not responding to treatment  Recurrent migraine not controlled with prophylactic therapy Tension headaches While tension headaches are the most frequently occurring type of headache, the cause is most likely contraction of the muscles that cover the skull. Common sites include the base of the skull, the 4 | P a g e temple and the forehead. Tension headaches occur because of physical or emotional stress placed on the body. Diagnosis  The pain begins in the back of the head and upper neck and is described as a band-like tightness or pressure. Note:  The key to making the diagnosis of any headache is the history given by the patient  If the health care practitioner finds an abnormality, then the diagnosis of tension headache would not be considered until the potential for other types of headaches have been investigated. Treatment Tension headaches are painful, and patients may be upset that the diagnosis is "only" a tension headache. Even though it is not life-threatening, a tension headache can affect the activities of daily life. Thus, the headache becomes a symptom of the withdrawal of medication (rebound headache). Cluster headaches Cluster headaches are headaches that come in groups (clusters) lasting weeks or months, separated by pain-free periods of months or years. Some evidence shows that brain scans performed on patients who are in the midst of a cluster headache, shows abnormal activity in the hypothalamus. Cluster headaches:  May tend to run in families and this suggests that there may be a genetic role  May be triggered by changes in sleep patterns  May be triggered by medications (for example, nitroglycerin) 5 | P a g e If an individual is in a susceptible period for cluster headache, cigarette smoking, alcohol, and some foods (for example, chocolate) also can be potential causes for headache. Diagnosis  Pain typically occurs once or twice daily and last for 30 to 90 minutes  Attacks tend to occur at about the same time every day  The pain typically is excruciating and located around or behind one eye. The affected eye may become red, inflamed, and watery Note: Cluster headaches are much more common in men than women. Stopping smoking and minimizing alcohol may prevent future episodes of cluster headache. Early diagnosis and treatment is essential if damage is to be limited Examples of Secondary headache:  Head and neck trauma  Blood vessel problems in the head and neck 1. Temporal arteritis (inflammation of the temporal artery)  Non-blood vessel problems of the brain 6 | P a g e 1. Idiopathic intracranial hypertension, once named pseudo tumor cerebri,  Medications and drugs (including withdrawal from those drugs) Infection 1. Systemic infections Diagnosis  If there is time, the diagnosis of secondary headache begins with a complete patient history followed by a physical examination and laboratory and radiology tests as appropriate  However, some patients present in crisis with a decreased level of consciousness or unstable vital signs. In these situations, the health care practitioner may decide to treat a specific cause without waiting for tests to confirm the diagnosis 3. Infections are the most common cause of fevers, however as the temperature rises other causes become more general. Note: Hyperpyrexia is considered a medical emergency as it may indicate a serious underlying conditions. Where causative/precipitating factors cannot be detected, the following treatments may be offered: For Non-productive irritating cough A: Cough syrup/Linctus (O) 5-10 ml every 6 hours Expectorants may be used to liquefy viscid secretions. A: Cough expectorants (O) 5-10 ml every 6 hours Note: Antibiotics should never be used routinely in the treatment of cough 5. Some investigations must be ordered:  Serum glucose level  Serum electrolyte  Pregnancy test for women of child bearing age. Therefore, the following are primarily assessed in children:  Prolonged capillary filling (more than 3 seconds)  Decreased pulse volume (weak thread pulse)  Increased heart rate (>160/minute in infants, > 120 in children)  Decreased level of consciousness (poor eye contact)  Rapid breathing  Decreased blood pressure and decreased urine output are late signs and while they can be monitored the above signs are more sensitive in detecting shock before irreversible. Table 2: Types of Shock Type of Shock Explanation Additional symptoms Hypovolemic Most common type of shock Weak thread pulse, cold Primary cause is loss of fluid from circulation due and clammy skin. Cardiogenic Caused by the failure of heart to pump Distended neck veins, shock effectively e. Septic shock Caused by an overwhelming infection, leading to Elevated body vasodilatation. Anaphylactic Caused by severe allergic reaction to an allergen, Bronchospasm, shock or drug. Intravenous fluid therapy is important in the treatment of all types of shock except for cardiogenic shock. Ringer-lactate, within 48 hours of administering ceftriaxone  Contra-indicated in neonatal jaundice  Annotate dose and route of administration on referral letter.

The infection is usually polymicrobial and necessitates the use of combined drugs generic malegra fxt 140 mg otc erectile dysfunction pump uk. Clinical types are recognized according to findings when the patient is first seen malegra fxt 140mg with amex erectile dysfunction essential oil. These include: Threatened abortion cheap malegra fxt 140 mg line icd 9 code of erectile dysfunction, inevitable abortion, incomplete abortion, complete abortion and missed abortion. Diagnosis  Clinical features will depend on the types of abortion  Viginal bleeding which may be very heavy in incomplete abortion, intermittent pain which ceases when abortion is complete and cervical dilation in inevitable abortion  In missed abortion, dead ovum retained for several weeks while sympoms and signs of pregnancy disappear  When infected (septic abortion) patient presents with fever tachycardia, offensive vaginal discharge, pelvic and abdominal pain. Puerperal/Post abortal Sepsis Pyrexia in women who has delivered or miscarried in the previous 6 weeks may be due to puerperal or abortal sepsis and should be managed actively. The uterus may need evacuation however parenteral antibiotics must be administered before evacuation. V)1gm start Plus A: Metronidazole 500mg Plus A: Gentamycin 80mg stat Patient should continue with the following oral antibiotics after evacuation for 5 to 7days For Mild/moderate A: Amoxycillin (O) 500mg every 8 hours for 10 days Plus A: Metronidozole (O)400 mg every 8 hours for 10 days Plus A: Doxycycline (O)100 mg every12hrs for 10 days Treatment Guidelines for severe cases 0  Body temperature higher than (38 C)  Marked abdominal tenderness are signs of severe post abortal sepsis Drug of Choice: A: Benzylpenicillin (I. V) 500mg every 6 hours Plus A: Metronidazole 500mg 8hrly for 5 days For urgent Delivery irrespective of gestational age A: Benzylpenicillin (I. Continue with antibiotics after delivery for 3-5 days Note: Use of antibiotics for prophylaxis during surgery, should be evaluated from situation to situation and not generalized 5. Management  If vomiting is not excessive, advise to take small but frequent meals and drinks  If persistent, vomiting cases, search for other reasons e. General measures  Admit in the hospital Give B: Normal saline Plus C: Nifedipine 10-20 mg 12 hrly; Plus C: Hydralazine 10 mg (I. High blood sugar levels in the mother’s body are passed through the placenta to the developing baby. Gestational diabetes usually begins in the second half of pregnancy and goes away after the baby is born. Management Pregnant women should avoid:  Food and beverages that cause gastrointestinal distress  Tobacco and alcohol  Eating big meals; should eat several small meals throughout the day  Drinking large quantities of fluids during meals  Eat close to bedtime; they should give themselves two to three hours to digest food before they lie down  Sleep propped up with several pillows or a wedge. Elevating upper body will help keep the stomach acids where they belong and will aid food digestion. Major causes are;  Uterine atony  Tears of the vagina/vulva  Retained products of conception  Rarely rupture of the uterus  Bleeding disorder (e. This involves the injection of an oxytocic after the delivery of the foetus followed by controlled cord traction and uterine massage. Recommended methods  Routine Dilation and curettage - up to 7 weeks since last menstrual period  Suction termination – Between 7-12 weeks since the last menstrual period  Prostaglandin termination – after 12 weeks since the last menstrual period. The infection can happen as an ascending infection from the vagina, after delivery (puerperal sepsis), after an abortion (septic abortion), postmenstrual or after Dilation and Curettage (D&C) operation. The common causative organisms are Neisseria gonorrhea, Chlamydia trachomatis and Mycoplasma hominis. Diagnosis The main clinical features are lower abdominal pain, backache, vomiting, vaginal discharge, menstrual disturbance, dyspareunia, fever, infertility and tender pelvic masses. It may also be used in treatment of dysfunctional uterine bleeding, dysmenorrhea or endometriosis. The goal of therapy in the use of these products for contraception is to provide optional prevention of pregnancy while minimizing the symptoms and long term risks associated with excess or deficiency of the oestrogen and progestogen components. The eligibility for hormonal contraception can be obtained from nearest family planning clinic or unit. This type is suitable for lactating mothers or women with mild or moderate hypertension. Management Follow up:  Instruct women always to inform the doctor or nurse that they are on contraceptives while attending clinic or hospital. Contraindications for Norplant  Severe hypertension  Thromboembolism  Active liver disease  Sickle cell anaemia  Undiagnosed genital bleeding  Severe headaches 16. If a major placental separation has occurred, emergency delivery to minimize the possibility of disseminated  Intravascular coagulation 100 | P a g e  Give blood when indicated. Typically, in primary dysmenorrhoea pain occurs on the first day of menses, usually about the time the flow begins, but it may not be present until the second day. Treatment  Allow bed rest  Give Analgesics such as A: Ibuprofen 200-600 mg every 8 hours (maximum 2. It is classified as primary when there has never been a history of pregnancy or it is secondary when there is previous history of at least one conception. Treatment Treatment in all cases depends upon correction of the underlying disorder(s) suspected of causing infertility whether primary or secondary. Alpha-haemolytic streptococci are the most common causes of native valve endocarditis but Staphylococcus aureus is more likely if the disease is rapidly progressive with high fever, or is related to a prosthetic valve (Staphylococcus epidermidis) Diagnosis: Use Modified Dukes Criteria below and consult microbiologist where possible. One-hour peak concentration should not exceed 10mg/l and trough concentration (2 hour pre- dose) should be less than 2mg/l. At any stage, treatment may have to be modified according to:  detailed antibiotic sensitivity tests  adverse reactions  allergy  failure of response Endocarditis leading to significant cardiac failure or failure to respond to antibiotics may well require cardiac surgery. In these cases replace clindamycin with Vancomycin iv [Specialist-only drug] 1g over at least 100 minutes 1-2 hours before procedure. Pharmacological treatment Treatment of acute attack for eradication of streptococci in throat: Regardless of the presence or absence of pharyngitis at the time of diagnosis. Children > 10years 500mg, 5-10 years 250mg, < 5years 125mg two to three times daily for 10 days orally If allergic to Penicillin A: Erythromycin 500mg or 40mg/kg 4 times per day for 10 days orally Treatment of acute Arthritis and Carditis: A: Aspirin orally 25mg/kg* 4 times a day as required. Then reviewsGradual reduction and discontinuation of prednisolone may be started after 3-4 weeks when there has been a substantial reduction in clinical disease. Referral: Ideally all patients should be referred to specialized care  where surgery is contemplated  management of intractable heart failure or other non-responding complications  pregnancy Antibiotic prophylaxis after rheumatic fever: Prophylaxis should be given to all patients with a history of acute rheumatic fever and to those with rheumatic heart valve lesions. The optimum duration of prophylaxis is controversial, but should be continued up to at least 21 years of age. Congenital Heart Disease It is a congenital chamber defects or vessel wall anomalies Valvular Heart Disease and Congenital structural Heart Disease may be complicated by:  Heart failure  Infective endocarditis 107 | P a g e  Atrial fibrillation  Systemic embolism eg Stroke General measures  Advise all patients with a heart murmur with regard to the need for prophylaxis treatment prior to undergoing certain medical and dental procedures  Advise patients to inform health care providers of the presence of the heart murmur when reporting for medical or dental treatment Referral  All patients with heart murmurs for assessment  All patients with heart murmurs not on a chronic management plan  Development of cardiac signs and symptoms  Worsening of clinical signs and symptoms of heart disease  Any newly developing medical condition, e. Lower doses are needed  Recommended an alternative contraceptive method for women using oestrogen 108 | P a g e Containing oral contraceptive  Evidence of end organ damage, i. Potassium Sparing Diuretics Spirinolactone 25mg once daily Eplerenone 25mg once daily 04. Central Adrenergic Inhibotor Methylodopa 250mg 12hrly 112 | P a g e Clonidine 50µg 8hrly 05. Beta Blockers  Non selective Propranolol 80mg 12 hrly  Selective Atenolol 50 – 100mg once daily Metoprolol 100mg 12hrly  Alpha& Beta blockers Carvedilol 12. Referrals are indicated when:  Resistant (Refractory) Hypertension  All cases where secondary hypertension is suspected  Complicated hypertensive urgency/emergencies  Hypertension with Heart Failure  When patients are young (<30 years) or blood pressure is severe or refractory to treatment. Resistant (Refractory) Hypertension Hypertension that remain >140/90mmHgdespite the use of 3 antihypertensive drugs in a rational combination at full doses and including a diuretic. Important adverse effects are dry cough, hypotension, renal insufficiency, hyperkaelamia, and angioedema. Monitor digoxin level - trough blood levels (before the morning dose) should be maintained between 0. Drug Management Adjunctive therapy Control cardiac pain C: Glyceryl trinitrate sub-lingual/ spray 0.

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