Resolving within 1 hour after external compression monly bilateral (but may be lateralized to the side of is relieved usual migraine headache in those who have unilateral E erectile dysfunction caused by radiation therapy buy 20/60mg levitra with dapoxetine free shipping. Comment: the duration of headache varies with the severity and Comments: duration of the external traction erectile dysfunction urban dictionary cheap levitra with dapoxetine 40/60mg free shipping. Although headache is Studies show 80% of stabs last 3 seconds or less; rarely xylitol erectile dysfunction cheap levitra with dapoxetine online master card, maximal at the site of traction doctor's guide to erectile dysfunction order generic levitra with dapoxetine line, it often extends to other stabs last for 10?120 seconds erectile dysfunction age 25 purchase 20/60 mg levitra with dapoxetine mastercard. When stabs are strictly localized to one B?D area drugs for erectile dysfunction in nigeria order levitra with dapoxetine with a visa, structural changes at this site and in the distribu 2 impotence meme buy levitra with dapoxetine 40/60 mg otc. Brought on by and occurring only during sustained not including cranial autonomic symptoms erectile dysfunction psychological purchase levitra with dapoxetine 20/60 mg with mastercard. No cranial autonomic symptoms Ice-pick pains; jabs and jolts; needle-in-the-eye syn E. Felt exclusively in an area of the scalp, with all of hours, without characteristic associated symptoms and the following four characteristics: not attributed to other pathology. No cranial autonomic symptoms or restlessness scalp, but is usually in the parietal region. Superimposed on the back Comments: ground pain, spontaneous or triggered exacerbations 4. The pain is usually of published cases, the disorder has been chronic (pre mild to moderate, but severe pain is reported by one sent for longer than 3 months), but cases have also been? Pain is bilateral in about two-thirds of described with durations of seconds, minutes, hours cases. Felt exclusively in an area of the scalp, with three Distinction from one of the subtypes of 3. Trigeminal only of the following four characteristics: autonomic cephalalgias, especially 3. Nevertheless, patients with prior headache use; intracranial disorders must also be excluded. Tension-type headache) are not However, the presence of sleep apnoea syndrome does excluded from this diagnosis, but they should not not necessarily exclude the diagnosis of 4. Similarly, patients with prior headache should not describe exacerbation followed by medication 4. No cranial autonomic symptoms or restlessness Abortive drug use may exceed the limits de? Distinct and clearly remembered onset, with pain becoming continuous and unremitting within 24 hours Comments: C. Primary headaches associated with sexual activ acteristics and the relationship with the characteristics of ity Some observations in Indian patients. Sexual headache in young ado Headaches precipitated by cough, prolonged exercise or lescence: A case report. Incompetence of inter sexual headaches: An analysis of 72 benign and symptomatic nal jugular valve in patients with primary exertional headache: cases. Sequential benign sexual headache and Headaches precipitated by cough, prolonged exercise or exertional headache (letter. Recurrent thunderclap headache associated with Interrelationships and long term prognosis. Cephalalgia 2002; 22: headache: A prospective study of features incidence and 784?790. Idiopathic stabbing headache cium channel inhibitors a potential treatment option? Clinical and angiographic features of experimental ice cream headache (short-lived headaches. Paroxysmal stabbing headache associated with reversible intracerebral vasospasm causing in the multiple dermatomes of the head and neck: a variant of stroke. Local decrease of pressure pain threshold in nummular large survey of 8359 adolescents. Headache caused by drinking cold water is common Curr Pain Headache Rep 2007; 11: 310?312. Ice cream headache and Nummular headache with and without exacerbations: orthostatic symptoms in patients with migraine. Case series of sixteen patients characteristics of an experimental model of ?ice-cream head with nummular headache. Hypothalamic gray matter headache: Clinical and serological characteristics in a retro volume loss in hypnic headache. Neurology phadenopathy in extracranial or systemic infection: Etiology of 2004; 14: 843?847. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structure 12. Evidence of causation demonstrated by at least two 2 headache type, and at the same time develops a brain of the following : tumour, it is straightforward to conclude that headache 1. Such patients shall be given the onset of the presumed causative disorder only one headache diagnosis 7. In other disorder words, a de novo headache occurring with another dis b) headache has signi? This poral relationships between the disorder and head remains true even when the headache has the charac ache outcomes after treatment of the disorder, or teristics of a primary headache (migraine, tension-type from smaller studies using advanced scanning meth headache, cluster headache or one of the other trigem ods, blood tests or other paraclinical tests, even if inal autonomic cephalalgias. In other When a pre-existing primary headache becomes chronic words, study methods that are not useful in routine in close temporal relation to such a causative disorder, use of the diagnostic criteria may nonetheless be both the primary and the secondary diagnoses should useful for establishing general causal relationships be given. The general criteria require two separate evidential be given, provided that there is good evidence that the features to be present, and allow up to four types of disorder can cause headache. Examples are the General diagnostic criteria for secondary headaches: subtypes of 7. In evidence is accordance between the site of the head such cases, criterion D is of particular importance. General comment Numerous factors that may contribute to its develop Primary or secondary headache or both? Post-traumatic sleep dis istics of a primary headache disorder becomes chronic, turbances, mood disturbances and psychosocial stres or is made signi? The overuse of abortive close temporal relation to such trauma or injury, both headache medications may contribute to the persistence the initial headache diagnosis and a diagnosis of 5. Headache attrib Introduction uted to trauma or injury to the head and/or neck may the subtypes of 5. Headache attributed to trauma or include a previous history of headache, less severe injury to the head and/or neck are among the most injury, female gender and the presence of comorbid common secondary headache disorders. Those with injury to the head and/or neck from other headache types; pending litigation and those without are similar regard most often these resemble tension-type headache or ing headache characteristics, cognitive test results, migraine. Consequently their diagnosis is largely depen treatment responses and improvement in symptoms dent on the close temporal relation between the trauma over time. In striking the head with or the head striking an Lithuania, for example, a country in which there is object, penetration of the head by a foreign body, little expectation of developing headache after head forces generated from blasts or explosions, and injury, and a lack of insurance against personal other forces yet to be de? Headache attributed to trauma or injury to the head Comment: and/or neck is also reported in children, although less the stipulation that headache must be reported to have often than in adults. The clinical presentations of the developed within 7 days is somewhat arbitrary (see subtypes are similar in children and adults, and the Introduction. Compared with longer intervals, a 7 diagnostic criteria in children are the same. Acute headache attributed to surgical cra when the interval between injury and headache onset niotomy performed for reasons other than traumatic is greater than 7 days. Traumatic injury to the head has occurred c) post-traumatic amnesia lasting >24 hours C. Headache is reported to have developed within d) altered level of awareness for >24 hours 7 days after one of the following: e) imaging evidence of a traumatic head injury 1. Headache persists for >3 months after the injury to impaired consciousness the head b) loss of memory for events immediately before E. These include strik the diagnostic criteria for mild traumatic injury to the ing the head with or the head striking an object, head and for moderate or severe traumatic injury to the penetration of the head by a foreign body, forces head allow for substantial variability in the severity of generated from blasts or explosions, and other head injury classi? In the meantime, Appendix criteria Trauma as a result of acceleration/deceleration move for A5. Persistent headache attributed to sur when the interval between injury and headache onset is gical craniotomy performed for reasons other than greater than 7 days. Further research is needed to investigate whether shorter or longer intervals may be more appropriately adopted. Injury to the head associated with at least one of the When headache following head injury becomes persis following: tent, the possibility of 8. Whiplash, associated at the time with neck pain as the time between head injury and recovery of and/or headache, has occurred memory of current events and of those occurring C. In the majority of cases, it resolves within Note: the acute post-operative period. Exclusion of other secondary headache disorders that may occur following craniotomy is necessary prior to assigning the diagnosis of 5. Although there are numerous potential When post-whiplash headache becomes persistent, the aetiologies of headache following craniotomy, consid possibility of 8. Description: Headache of greater than 3 months? duration caused by Diagnostic criteria: surgical craniotomy. Emotional and pain-related factors in neuropsycho craniotomy logical assessment following mild traumatic brain injury. Diffusion tensor Note: imaging detects clinically important axonal damage after mild traumatic brain injury: A pilot study. Cognitive and psycholo gical patterns in post-traumatic headache following severe traumatic brain injury. Chronic daily headache in the post Comments: trauma syndrome: Relation to extent of head injury. Head or neck injury increases the risk of chronic daily headache: A popula experience 5. Is post-traumatic head When headache following craniotomy becomes persis ache classifiable and does it exist? Chronic post-traumatic head ache: Clinical, psychopathological features and outcome deter needs to be considered. A prospective controlled study in the pre matic headache on the incidence and severity of headache after valence of posttraumatic headache following mild traumatic head injury. Emotional, neuropsychological, and organic factors: Kirk C, Naquib G and Abu-Arafeh I. Chronic post-traumatic Their use in the prediction of persisting postconcussion symp headache after head injury in children and adolescents. Incidence of chronic pain following trau traumatic brain injury: A systematic review. Neuropsychological deficits in symptomatic minor head Eur J Neurol 1996; 3: 424?428. Prevalence of chronic pain after traumatic for patients with mild traumatic brain injury. Posttraumatic headache: Permanency and relation A prospective controlled inception cohort study. Epidemiology and pathogenesis of posttraumatic Obermann M, Nebel K, Riegel A, et al. Headaches among Operation Automobile head restraints?Frequency of neck injury claims Iraqi Freedom/Operation Enduring Freedom veterans with in relation to the presence of head restraints. Am J Public mild traumatic brain injury associated with exposures to explo Health 1972; 62: 399?406. Proton spectroscopy in distortion in restrained car drivers: frequency, causes and patients with post-traumatic headache attributed to mild head long-term results. Emergency department assess ment of mild traumatic brain injury and the prediction of post 5. Postoperative headache: Emphasis on chronic types following mild closed pain in neurosurgery: A pilot study in brain surgery. Persistent headache after Posttraumatic headache: Biopsychosocial comparisons with supratentorial craniotomy. This remains true when the new headache has aneurysm the characteristics of any of the primary headache dis 6. The close tem cervical carotid or vertebral artery dissection poral relationship between the headache and these neuro 6. In a number of arterial disorder other conditions that can induce both headache and 6. A clue that points to an underlying vascular con symptoms or clinical or radiological signs of dition is the onset, usually sudden, of a new headache, ischaemic stroke so far unknown to the patient. For headache attributed to any of the vascular dis orders listed here, the diagnostic criteria include when ever possible: Comments: 6. A cranial or cervical vascular disorder known to be and/or alterations in consciousness, which in most cases able to cause headache has been demonstrated allows easy di? Evidence of causation demonstrated by at least two It is usually of moderate intensity, and has no speci? Rarely, an acute ischaemic stroke, the onset of the cranial or cervical vascular notably a cerebellar infarction, can present with an iso disorder lated sudden (even thunderclap) headache. It is of little practical value vascular disorder in establishing stroke aetiology except that headache is b) headache has signi? In these latter conditions, headache may be nial or cervical vascular disorder directly caused by the arterial wall lesions and may 4. Description: Diagnostic criteria: Headache caused by ischaemic stroke, usually with acute onset and associated with focal neurological A. Furthermore, positive phenomena c) localized in accordance with the site of the (e. Description: the headache is usually overshadowed by focal def Headache caused by non-traumatic intracranial hae icits or coma, but it can be the prominent early feature morrhage, with, generally, sudden (even thunderclap) of some intracerebral haemorrhages, notably cerebellar onset. Depending on the type of haemorrhage, it may haemorrhage, which may require emergency surgical be isolated or associated with focal neurological de? Reported causes include ?spontaneous? cortical artery Initial misdiagnosis occurs in one-quarter to one rupture, aneurysm rupture, arteriovenous malforma half of patients; the most common speci? The most common reasons for misdiagnosis are bral venous thrombosis and intracranial hypotension. Delayed diagnosis often of cases depending on the series and the underlying has a catastrophic outcome. Setting aside the possibi Depending on the type of malformation, the headache lity of memory biases, this suggests these headaches are may have a chronic course with recurrent attacks a result of sudden enlargement of the arterial malfor mimicking episodic primary headaches, or an acute mation (?sentinel headache?) or to mild subarachnoid and self-limited course. Moreover, the term warning leak should not be aneurysm used, because a leak indicates a subarachnoid haemor rhage. Given that at least one in three patients with Diagnostic criteria: aneurysmal subarachnoid haemorrhage is initially mis diagnosed, and given the risks of re-bleeding, patients A. Evidence of causation demonstrated by at least two b) headache has resolved after treatment of the of the following: saccular aneurysm 1. A cavernous angioma has been diagnosed morrhage and, much more rarely, migraine-like C. However, there is still no good study devoted b) headache is accompanied by ophthalmoplegia to 6. A painful pulsatile tin Coded elsewhere: nitus can be a presenting symptom, as well as headache Headache attributed to seizure secondary to Sturge with features of intracranial hypertension as a result of Weber syndrome is coded as 7. Facial angioma is present, together with neuroima Coded elsewhere: ging evidence of meningeal angioma ipsilateral to it Headache attributed to cerebral haemorrhage or sei C. Evidence of causation demonstrated by at least two zure secondary to cavernous angioma is coded as of the following: 6. Headache may be the sole symptom of giant parallel with other symptoms or clinical or radi cell arteritis, a disease most conspicuously associated ological signs of growth of the meningeal with headache, which is a result of in? Of all arteritides and collagen vascular diseases, giant cell arteritis is the disease most conspicuously asso Diagnostic criteria: ciated with headache, which is a result of in? Description: Description: Headache caused by and symptomatic of secondary Headache caused by and symptomatic of primary angiitis of the central nervous system. Evidence of causation demonstrated by either or both of the following: both of the following: 1. The pain generally has a within 1 month of its onset sudden (even thunderclap) onset. Evidence of causation demonstrated by at least two Comments: of the following: Headache with or without neck pain can be the only 1. It is by far other local signs of cervical artery disorder, or has the most frequent symptom (55?100% of cases), and led to the diagnosis of cervical artery disorder the most frequent inaugural symptom (33?86% of 2. Associated signs (of cerebral or retinal ischaemia and local signs) are common: a painful Horner?s syn drome, painful tinnitus of sudden onset or painful 6. Cervical artery dissection may be associated with Description: intracranial artery dissection, which is a potential Headache and/or pain in the face and/or neck caused cause of subarachnoid haemorrhage. Headache attributed to intracranial arterial dissection the pain is usually ipsilateral to the dissected vessel and may be present in addition to 6. It can facial or neck pain attributed to cervical arterial remain isolated or be a warning symptom preceding dissection. Several of these investigations are commonly diagnosed needed as any of them can be normal. Evidence of causation demonstrated by at least two been no randomized trials of treatment, but there is of the following: a consensus in favour of heparin followed by warfarin 1. In a small series of 53 patients, cervical pain twice a day in attacks lasting 2?3 hours occurred during balloon in? It resolves sudden (even thunderclap), or mild, and sometimes is in about 2 weeks. It Diagnostic criteria: often precedes a rise in blood pressure and the onset of seizures or neurological de? Intra-arterial carotid or vertebral angiography has early as possible and includes symptomatic treatment, been performed heparin followed by at least 6 months of oral anticoa C.
Reliever medicines in asthma Child >5yrs If not improving or condition worsens impotence aids levitra with dapoxetine 40/60mg lowest price, treat as β2 agonists erectile dysfunction doctor in miami buy cheap levitra with dapoxetine on-line. Pertussis is the only indication for antibacterial agents in the treatment of acute bronchitis erectile dysfunction treatment new york discount 40/60 mg levitra with dapoxetine with mastercard. It is also known as a chest cold impotence ruining relationship buy levitra with dapoxetine american express, is short-term inflammation of the bronchi (large and medium-sized airways) of the lungs does erectile dysfunction cause low libido discount 20/60mg levitra with dapoxetine mastercard. Diagnostic Criteria Patients with acute bronchitis present with a cough lasting more than five days (typically one to three weeks) erectile dysfunction in diabetic subjects in italy cheap 20/60mg levitra with dapoxetine amex, which may be associated with sputum production blood pressure drugs erectile dysfunction buy levitra with dapoxetine without a prescription. Pertussis is the only indication for Shortness of breath antibacterial agents in the treatment of acute bronchitis erectile dysfunction johnson city tn discount 20/60mg levitra with dapoxetine amex. Non-Pharmacological Treatment: Diagnostic Criteria Stop smoking Patients with acute bronchitis present with a cough lasting more than five days B: Give oxygen (typically one to three weeks), which may be associated with sputum Pharmacological Treatment: production. The most common It defined by a chronic productive cough for three months in each of two successive years cause is viral infection (particularly parainfluenza viruses) but may also be due to in a patient in whom other causes of chronic cough have been excluded. Standard Treatment GuidelinesStandard Treatment Guidelines 9999 Diagnostic Criteria the symptoms include paroxysmal barking cough, inspiratory stridor, fever, wheezing, hoarseness of voice and tachypnoea Such symptoms usually occur at night Respiratory failure and pneumonia are potentially fatal complications. Diagnostic Criteria Diphtheria is characterized by grayish-white membrane, composed of dead cells, fibrin, leucocytes and red blood cells as a result of inflammation due to multiplying bacteria. C: Nebulized Adrenaline 400 mcg/kg every 2 hours if effective; repeat after 30 min if necessary. Children between 1–5 years of age are most susceptible although non-immune adults are also at risk. Non-Pharmacological Treatment Place the child head down and prone, or on the side, to prevent any inhaling of Diagnostic Criteria vomitus and to aid expectoration of secretions. Diphtheria is characterized by grayish-white membrane, composed of dead cells, fibrin, Care for the airway but avoid, as far as possible, any procedure that could leucocytes and red blood cells as a result of inflammation due to multiplying bacteria. It is characterized by high fever, breathlessness, cough productive of large amounts of this does not shorten the illness but reduces the period of infectiousness foul-smelling sputum and haemoptysis. Diagnostic Criteria the diagnosis is usually established clinically on the basis of chronic daily cough with viscid sputum production, and radiographically by the presence of bronchial wall thickening and luminal dilatation on chest x-rays. The infection is primarily acquired through ingestion of contaminated food and water and occasionally can be acquired through oral-anal sexual practices. Giardiasis acquired through ingestion of contaminated food and water and occasionally can be It is the infestation of the upper small intestine caused by the flagellate protozoan Giardia acquired through oral-anal sexual practices. It is most common infestation in children and it is acquired through ingestion of Tender and enlarged liver contaminated food and water. Note: Give treatment for 10 days in case of disseminated/super infestation Diagnostic Criteria 10. Human infestation is through contamination of food or water causing visceral cysts (Hydatid Cyst Disease) particularly in the liver and lungs and is usually asymptomatic in susceptible host. Diagnostic Criteria Upper abdominal discomfort and pain, poor appetite, Upper abdominal mass swelling with enlarged liver. Diagnostic Criteria Schistosoma mansoni: Swimmers itch or katayama fevers in acute infection phase. Human infestation is through contamination of food or water causing visceral cysts (Hydatid Cyst Disease) particularly in the liver and lungs and is usually Pharmacological Treatment asymptomatic in susceptible host. Infection is acquired through ingestion of Cough with features of acute hypersensitivity reaction. Shigella organisms are a group of gram-negative, facultative intracellular bacteria Diagnostic Criteria pathogens. They are grouped into 4 species: Shigella dysenteriae, Shigella flexneri, Shigella Schistosoma mansoni: boydii, and Shigella sonnei, also known as groups A, B, C, and D respectively. Diagnostic Criteria Dyspeptic symptoms present for last 3 months and onset at least months prior to diagnosis and must include one or more of the following 6 Bothersome post prandial fullness. The inflammation may involve the entire stomach (pangastritis) or a region of the stomach (antral gastritis) while the severity of inflammation may be erosive or non erosive. It is a chronic recurrent dyspeptic disorder characterized by epigastrtic pain syndrome and post prandial distress syndrome without any organic, systemic or metabolic disease 10. Plus supportive therapies such as: section note above High fibre diet and eating a healthy diet. Pharmacological Treatment Principles of management include supportive therapies. Common risk factors which trigger the acute episode are presence of gallstones hyperglycaemia. Treatment Pharmacological Treatment Depends on severity of the disease Principles of management include supportive therapies. Pharmacological Treatment: Refer unstable cases to next level of care with adequate expertise and facility. Diagnostic Criteria Severe sharp pain during and after defecation with/out bright red bleeding. Diagnostic Criteria Fever, anorexia, malaise, jaundice and abdominal pain Enlarged and tender liver Altered consciousness, coma (hepatic encephalopathy), and bleeding stigmata (in fulminant cases. Young and middle aged adults most Fulminant cases may require specific antiviral medications commonly affected. Passage of hard stools is a common predisposition to primary expertise and facility for proper management and disposal. Chronic viral Hepatitis Diagnostic Criteria this is a chronic inflammatory reaction that on going beyond 6months from the acute Severe sharp pain during and after defecation with/out bright red bleeding. Non-Pharmacological Treatment Diagnostic Criteria Ensure high fluid intake Usually asymptomatic Use non stimulant osmotic laxatives Right upper quadrant abdominal pains. This is high blood pressure in the hepatic portal system which includes the portal veins and its branches which drains from most of the intestines to the liver. It is indicated when the hepatic venous pressure gradient exceeds 7mmHg, while liver cirrhosis remains the Standard Treatment GuidelinesStandard Treatment Guidelines 119119 most common cause which in our local setting is commonly caused by chronic viral hepatitis followed by heavy alcohol intake. Cholestasis is a pathologic state of reduced bile formation or flow which can be hepatocellular (Intrahepatic), where an impairment of bile formation occurs or ductular Pharmacological Treatment (extra hepatic), where impedance to bile flow occurs after it is formed. Extrahepatic causes include resolves choledocholithiasis, carcinoma, and ascariasis of the biliary tree. S: Inj sclerotherapy (Histo Acryl Glue Inj 5%; Ethanolamine oleate 5%); given 2mls -5mls per varix up to 20mls per session. Bleeding can sometimes be a sign of something serious, therefore it is important to know the possible causes and take adequate measures. Abortion It is a spontaneous loss of a fetus before it is viable (has the potential to survive outside the womb. Bleeding can Severe lower abdominal pain sometimes be a sign of something serious, therefore it is important to know the possible Significant draining of liquor if membranes have ruptured or the membranes causes and take adequate measures. It is a spontaneous loss of a fetus before it is viable (has the potential to survive outside Fundal height may correspond with gestational age the womb. If no response with the above antibiotics within 3 days; Adjust according to culture and sensitivity results. Standard Treatment GuidelinesStandard Treatment Guidelines 127127 Diagnostic criteria Unruptured ectopic pregnancy Sporting in early pregnancy Abdominal and pelvic pain Ruptured ectopic pregnancy Acute abdominal and pelvic pain Hypotension Fast and weak pulse Abdominal distension and tenderness Shoulder tip pain Investigations Perform ultrasonography Hb level Grouping and cross-matching Referral Ectopic pregnancy is a medical emergency; refer the patient immediately. Diagnostic criteria Sudden onset of bright red fresh painless bleeding after 28 weeks of gestation Management If asymptomatic – Bed rest and follow up every 2 weeks If complete placenta praevia o Admit for fetal lung maturation ≥ 24 weeks of gestation o Deliver by Cesarean section at 37–38 weeks of gestation o 30–60mg of elemental iron and 400µg (0. Investigations Prevention Ultrasound for fetal wellbeing, amount of liquor and gestation age. Iron deficiency anemia during pregnancy has been associated with an increased risk of low birth weight, preterm delivery and perinatal mortality. Severe anaemia with maternal hemoglobin levels less than 6 g/dL has been associated with abnormal fetal oxygenation resulting in non-reassuring fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral vasodilatation and fetal death. Iron deficiency anemia during pregnancy has been Referral associated with an increased risk of low birth weight, preterm delivery and perinatal Refer and transfuse in case of signs of severe anemia. Severe anaemia with maternal hemoglobin levels less than 6 g/dL has been associated with abnormal fetal oxygenation resulting in non-reassuring fetal heart rate 11. Most women with chronic Dizziness, faintness, headache hypertension are asymptomatic. New onset chronic hypertension should have further Intermittent claudication (ache, cramp, numbness or sense of fatigue) evaluation to find underlying cause. It is common in Urea, creatinine, electrolytes, liver function test and uric acid nonwhite nulliparous women from low socioeconomic status. Monitor respiratory rate (> 16 breaths/min), urine output, consciousness, deep tendon reflexes and magnesium sulfate serum levels (where possible) Obstetrical management Patients with eclampsia should be delivered within 12 hours after the onset of seizures, even if the foetus is premature. It is an autoimmune disease characterized by the presence of maternal circulation of one or more auto antibodies against membrane phospholipids. In general, treatment should begin as soon as Note: Contra–indications of magnesium sulfate are; myasthenia, respiratory insufficiency, pregnancy is confirmed. Obstetrical management Patients with eclampsia should be delivered within 12 hours after the onset of seizures, Recurrent Pregnancy loss even if the foetus is premature. Referral Diagnostic Criteria Immediate referral to a health facility where monitoring of the treatment through lab Pain tests is available is recommended Swelling or redness of the calf or thigh Homans sign (pain in the calf in response to dorsiflexion of the foot) 11. It is blockage, usually a blood clot, prevents oxygen from reaching the tissues of the lungs; Monitor electrolytes for 24hrs it can be life-threatening Counselling Reassurance Diagnostic Criteria Emotional support Acute onset of shortness of breath (dyspnea) Rest Pleuritic chest pain Life style adjustment Cough and/or hemoptysis Ensure adequate hydration Low grade fever Frequent small carbohydrate meal Tachypnea Standard Treatment GuidelinesStandard Treatment Guidelines 139139 Pharmacological Treatment A: Ringers Lactate with Normal Saline according to daily needs and severity. It is caused by some of the hormonal and physical changes in pregnant women Management Pregnant women should avoid: Food and beverages that cause gastrointestinal distress Tobacco and alcohol Do not eat big meals, instead eat several small meals throughout the day Drinking large quantities of fluids during meals Do not eat close to bedtime, they should give themselves 2–3 hours to digest food before they lie down Sleep propped up with several pillows or a wedge. Oxytocics are indicated for:– Augmentation of labour Induction of labour 140 Standard Treatment Guidelines Pharmacological Treatment Active management of third stage of labour. Referral: Depends on the status of the patient, refer to a hospital if vomiting is intractable and if there is a need for high volume replacement. Pre-induction assessment Health care providers should assess the cervix (using the Bishop score) to 11. Pregnant women should avoid: Food and beverages that cause gastrointestinal distress Post-dates induction Tobacco and alcohol Women should be offered induction of labour between 41+0 and 42+0 weeks as Do not eat big meals, instead eat several small meals throughout the day this intervention may reduce perinatal mortality and meconium aspiration Drinking large quantities of fluids during meals syndrome without increasing the Caesarean section rate Do not eat close to bedtime, they should give themselves 2–3 hours to digest Women who chose to delay induction >41+0 weeks should undergo twice food before they lie down weekly assessment for fetal wellbeing Sleep propped up with several pillows or a wedge. All these complications are discussed under specific disease chapters misoprostol 11. When 4U are not enough to cause maintained contractions, and it is first pregnancy, the dose can be increased to 16, 32 then 64U in liter of Normal Saline each time increasing the delivery rate through 15, 30 and 60 drops per minute. Augmentation of labour If labour progress is not optimum labour augmentation is necessary. If membranes are already ruptured and no labour progress the steps above should be followed; rule out obstruction before augmenting labour with oxytocin. Incompatibility between an infants blood type and that of its mother, resulting in When 4U are not enough to cause maintained contractions, and it is first pregnancy, destruction of the infants red blood cells (hemolytic anemia) during pregnancy and after the dose can be increased to 16, 32 then 64U in liter of Normal Saline each time birth by antibodies from its mothers blood. Investigation Augmentation of labour Test to detect antibody If labour progress is not optimum labour augmentation is necessary. If an individual cannot feed the baby more frequently, expressing the milk more often can be helpful. If an individual cannot feed the baby more A: Ibuprofen (200–400 mg)1–2 tablets before or at beginning of menses, then 1 frequently, expressing the milk more often can be helpful. There Anatomic are 2 types of dysmenorrhea: Fibroids, polyps, or adenomyosis Often heavy bleeding, pain Primary (no organic cause. Typically, in primary dysmenorrhea pain occurs on the first Uterus might be enlarged day of menses, usually about the time the flow begins, but it may not be present until the second day. Treat the underlying condition if known Standard Treatment GuidelinesStandard Treatment Guidelines 145145 Note: For primary dysmenorrhea patients may be advised to start taking ibuprofen one or two days before menses and continue for three to four days during menses to minimize painful menstruation 11. The recommended oral contraceptives are: A: Ethinyloestradiol + Norgestrel Tablets 0. Avoid use in women with severe hypertension and women without proven fertility Post-coital contraception ( morning-after pill) the method is applicable mostly after rape and unprotected sexual intercourse where pregnancy is not desired. They guide the provider through a series of decisions and actions that need to be made. Each decision or action is enclosed in a box, with one or two routes prolactin leading out of it to another box, with another decision or action. Upon learning a patients symptoms and signs, the service provider turns to the flow chart for the relevant Treatment will depend on the underlying cause syndrome and works through the decisions and suggestions it guides to manage the client Non-pharmacological treatment accordingly. After taking the history and examining the along with fertility drugs) patient you should have the necessary information to choose Yes or No accurately. Hyperprolactinemia Depending on your choice, there may be further decision boxes and action B: Bromocriptine 2. In syndromic management, treatment of a patient Referral with urethral discharge should adequately cover these two organisms. If none is seen per inspection, the urethra should be gently milked from the ventral part of the penis towards the meatus. Standard Treatment GuidelinesStandard Treatment Guidelines 149149 Delayed or inadequate treatment may result into orchitis, epididymitis, urethral stricture and/or infertility. The clinical detection of cervical infection is difficult because a large proportion of women with gonococcal or chlamydia infections are asymptomatic. Sometimes it is accompanied by diarrhea and it may occur as a toxic side effect of oral administration of certain broad spectrum antibiotics. Standard Treatment GuidelinesStandard Treatment Guidelines 151151 Ano-rectal syndrome may include a number of presentation. Anyone whose immune system is impaired is at increased risk of developing proctitis, particularly from infections caused by the herpes simplex virus or cytomegalovirus, or from reactivation of an earlier infection. Antibiotics that destroy normal intestinal bacteria and allow other bacteria to grow in their place may also cause proctitis. Proctitis typically causes painless bleeding or the passage of mucus (sometimes mistaken for diarrhoea) from the rectum. There may also be ineffectual straining to defecate ( tenesmus), sometimes mistakenly described as constipation by patients. The anus and rectum may be intensely painful, with external and internal ulceration, when the cause is gonorrhoea, herpes, or cytomegalovirus infection. A proctoscopic examination (which should be done, if feasible) will reveal rectal pus, bleeding or ulceration. The discharge can occur for many reasons, including anal fissure, anal fistula (an abnormal connection between two organs) or abscess, other infections including sexually transmitted diseases, or chronic inflammatory diseases. Other symptoms might occur with rectal discharge includes gastrointestinal symptoms which vary depending on the underlying disease, disorder or condition. These may include: Abdominal pain or cramping, abdominal swelling, distention or bloating; bloody stool (blood may be red, black, or tarry in texture), burning feeling, change in bowel habits, constipation, diarrhea; fecal incontinence (inability to control stools), flatulence; pain, which may be severe, in the abdomen, pelvis, or lower 152 Standard Treatment Guidelines Ano-rectal syndrome may include a number of presentation. The most common back, urgent need to pass stool and watery diarrhea including multiple include proctitis and rectal discharge. Antibiotics that destroy normal be more difficult to clear than urethral infections. It is recommended that whenever a patient is suffering from colitis or Crohns disease. Proctitis typically causes painless bleeding or the significant pharyngitis, and a history of unprotected oral sex makes pharyngeal passage of mucus (sometimes mistaken for diarrhoea) from the rectum. There gonococcal or chlamydial infection a likely risk, the patient should be treated may also be ineffectual straining to defecate ( tenesmus), sometimes syndromically. The anus and rectum may be intensely painful, with external and internal ulceration, when the cause is Treatment for sexually-transmitted Pharyngitis gonorrhoea, herpes, or cytomegalovirus infection. Symptoms of diarrhoea, bloody stools, abdominal cramping, nausea, and/or bloating may indicate giardia infection or amoebic dysentery. In many parts of Tanzania, genital herpes is another observed: frequent cause of genital ulcer disease. Clinical differential diagnosis of genital ulcers is inaccurate, Anal fissure, Fecal impaction, Food intolerance, Gastroenteritis (bacterial and viral), particularly in settings where several etiologies are common Inflammatory bowel disease (includes Crohns disease and ulcerative colitis), Neurological damage, and Perirectal or perianal abscess. They are frequently associated with lymphogranuloma venereum and chancroid caused by Chlamydia trachomatis and Haemophilus ducreyi respectively. In many cases of chancroid an associated genital ulcer is visible, but occasionally may not be. Balanoposthitis, while other some conditions which are transmitted through close sexual intimacy may not affect genital parts only. Early Syphilis: this refers to primary, secondary or latent syphilis of not more than two years duration. Syphilis in Pregnancy Pregnant women should be regarded as a separate group requiring close surveillance, in particular, to detect possible re-infection after treatment has been given. However, others are not related to sexual transmission but they affect genital parts. Balanoposthitis, while other some conditions which are Genital Warts (Venereal Warts) transmitted through close sexual intimacy may not affect genital parts only. Recommended Early Syphilis: this refers to primary, secondary or latent syphilis of not more than two regimens for venereal warts are as follows: years duration. M single dose given as two injections at each Chemical Treatment (High level Health Facility Management) buttock. The treatment area should be washed this refers to Syphilis infection of more than 2 years. Note: the safety of both podophyllotoxin and imiquimod during pregnancy has Syphilis in Pregnancy not been established. Pregnant women should be regarded as a separate group requiring close surveillance, in particular, to detect possible re-infection after treatment has been given. D: Podophyllin 10–25% in compound tincture of benzoin, applied carefully to A: Benzathine Benzyl Penicillin 2. External genital and perianal warts In case of late syphilis 3 doses of Benzathine Benzyl Penicillin should be should be washed thoroughly 4–6 hours after the application of provided. Podophyllin applied to warts on vaginal or anal epithelial surfaces should be allowed to dry before removing the speculum or Congenital Syphilis anoscope. Treatment regimens for early congenital normal tissue, followed by powdering of the treated area with talc or syphilis (up to 2 years of age), and Infants with abnormal cerebrospinal fluid: sodium bicarbonate (baking soda) to remove unreacted acid.
The Medical Examiner the Federal Motor Carrier Safety Regulations identify a person who can be a medical examiner by two criteria: professional licensure and scope of practice that includes performing physical examinations erectile dysfunction treatment by homeopathy levitra with dapoxetine 20/60mg discount. Medical examiner means a person who is licensed erectile dysfunction 60 year old man order levitra with dapoxetine 20/60mg on-line, certified impotence at 18 generic 40/60 mg levitra with dapoxetine fast delivery, and/or registered erectile dysfunction of diabetes safe 20/60 mg levitra with dapoxetine, in accordance with applicable State laws and regulations being overweight causes erectile dysfunction generic 40/60 mg levitra with dapoxetine, to perform physical examinations icd 9 code for erectile dysfunction due to medication purchase on line levitra with dapoxetine. The medical examiner is responsible for certifying only drivers who meet the physical qualification standards erectile dysfunction statin drugs buy levitra with dapoxetine 40/60mg visa. The Federal Vision and Diabetes Exemption Programs require annual medical certification erectile dysfunction vegan buy genuine levitra with dapoxetine online. There are potential subtle interpretations that can cause significant problems for the medical examiner. What information must or can be turned over to the carrier is a legal issue, and if in doubt, the examiner should obtain a legal opinion. Medical Examination Report Form Although the Federal Motor Carrier Safety Regulations do not require the medical examiner to give a copy of the Medical Examination Report form to the employer, the Federal Motor Carrier Safety Administration does not prohibit employers from obtaining copies of the Medical Examination Report form. Medical examiners should have a release form signed by the driver if the employer wishes to obtain a copy of the Medical Examination Report form. Employers must comply with applicable State and Federal laws regarding the privacy and maintenance of employee medical information. For information about the provisions of the Standards for Privacy of Individually Identifiable Health Information (the Privacy Rule) contact the U. If the medical examiner finds that the driver is physically qualified to drive a commercial motor vehicle in accordance with ?391. The motor carrier is required to keep a copy of the certificate in the driver qualification file. The driver may request a replacement copy of the certificate from the medical examiner or get a copy of the certificate from the motor carrier. It is divided into 50 titles that represent broad areas subject to Federal regulation. Each title is divided into chapters, which usually bear the name of the issuing agency. When the title is understood, the citation may just include the part and section (e. When the certification decision does not conform to the recommendations, the reason(s) for not following the medical guidelines should be included in the documentation. Four of the standards: vision, hearing, epilepsy, and diabetes mellitus have objective disqualifiers that do not depend on medical examiner clinical interpretation. For the other nine "discretionary" standards, the medical examiner makes a clinical judgment in accordance with the physical qualification requirements for driver certification. Table 1 Medical Regulations Summary Table To view the regulations in the Medical Regulations Summary Table, visit: http://www. The role of the medical examiner is to determine if the driver is "otherwise qualified. Both Federal exemptions require the driver to have an annual medical examination for maintenance and renewal of the exemption. Important Definitions Regulation Definitions the medical examiner should become familiar with frequently used terms in the context of the Federal Motor Carrier Safety Regulations and the medical examiner role. Has a gross vehicle weight rating or gross combination weight rating, or gross vehicle weight or gross combination weight, of 4,536 kg (10,001 pounds) or more, whichever is greater; or 2. Is designed or used to transport more than 8 passengers (including the driver) for compensation; or 3. Is designed or used to transport more than 15 passengers, including the driver, and is not used to transport passengers for compensation; or 4. Is used in transporting material found by the Secretary of Transportation to be hazardous under 49 U. Interstate Commerce: Interstate commerce means trade, traffic, or transportation in the United States: 1. Between a place in a State and a place outside of such State (including a place outside of the United States); Page 14 of 260 2. Between two places in a State through another State or a place outside of the United States; or 3. Between two places in a State as part of trade, traffic, or transportation originating or terminating outside the State or the United States. Intrastate Commerce: Intrastate commerce means any trade, traffic, or transportation in any State which is not described in the term "interstate commerce. The term includes, but is not limited to , doctors of medicine and osteopathy, advanced practice nurses, physician assistants and chiropractors. Motor Carrier: Motor carrier means a for-hire motor carrier or a private motor carrier. For purposes of subchapter B, this definition includes the terms "employer" and "exempt motor carrier. The Omnibus Transportation Employee Testing Act of 1991 requires drug and alcohol testing of safety sensitive transportation employees in aviation, trucking, railroads, mass transit, pipelines, and other transportation industries. There are times when a medical examiner may have interactions with healthcare professionals who perform services in the drug and alcohol testing program. A safety risk in any one or more of these commercial operations components can endanger the safety and health of the public. Thus, an estimated 3 to 4 million physical examinations must be performed annually, with the demand increasing every year. Commercial driver medical fitness for duty records must include all Federal physical qualification requirements found on the Medical Examination Report form. Truck and bus companies may also have additional medical requirements, such as a minimum lifting capability. Stat Regulations States regulate intrastate commerce and commercial drivers who are not subject to Federal regulations. They are required, at a minimum, to adopt Federal physical qualification requirements and may even have additional, different, or more stringent requirements. Medical examiners are responsible for knowing the driver regulations for the State or States in which they practice. As a medical examiner, you should be knowledgeable regarding the physical qualification requirements of the driver specified in Subpart E Physical qualifications and examinations. You are responsible for ensuring that only the driver who meets the Federal physical qualification requirements is issued a Medical Examiner?s Certificate. When you issue a Medical Examiner?s Certificate, you are certifying that the driver is medically fit for duty and can perform the driver role that is described in the Medical Examination Form. You may also, at any time, certify the driver for less than 2 years when examination indicates more frequent monitoring is required to ensure medical fitness for duty. The Average Driver the driver population exhibits characteristics similar to the general population, including an aging work force. Aging means a higher risk exists for chronic diseases, fixed deficits, gradual or sudden incapacitation, and the likelihood of comorbidity. All of these can interfere with the ability to drive safely, thus endangering the safety and health of the driver and the public. The Job of Commercial Driving Stress Factors Associated with Commercial Driving Many factors contribute to making commercial driving a stressful occupation. A long relay route requires driving 9 to 11 hours, followed by at least a 10-hour, off-duty period. With a straight through haul or cross-country route, the driver may spend a month on the road, dispatched from one load to the next. The driver usually sleeps in the truck and returns home for only 4 or 5 days before leaving for another extended period on the road. In team operation, drivers share the driving by alternating 5-hour driving periods with 5-hour rest periods. Long hours and extended time away from family and friends may result in a lack of social support. The driver may encounter adverse road, weather, and traffic conditions that cause unavoidable delays. Transporting hazardous materials, including explosives, flammables, and toxics, increases the risk of injury and property damage extending beyond the accident site. Stay alert when driving this demands sustained mental alertness and physical endurance that is not compromised by fatigue or sudden, incapacitating symptoms. Required cognitive skills include problem solving, communication, judgment, and appropriate behavior in both normal and emergency situations. Driving requires the ability to judge the maximum speed at which vehicle control can be maintained under changing traffic, road, and weather conditions. Use side mirrors Mirrors on both sides of the vehicle are used to monitor traffic that can move into the blind spot of the driver. The act of steering can be simulated by offering resistance, while having the driver imitate the motion pattern necessary to turn a 24-inch steering wheel. Use of these components requires adequate reach, prehension, and touch sensation in hands and fingers. This requires the driver to repeatedly perform reciprocal movements of both legs coordinated with right arm and hand movements. Physical demands include grip strength, upper body strength, range of motion, balance, and flexibility. Vision and hearing are used to identify and interpret changes in vehicle performance. When a fatal crash involves at least one large truck, regardless of the cause, the occupants of passenger vehicles are more likely to sustain serious injury or die than the occupants of the large truck. The answer is found in basic physics: injury severity equals relative velocity change. The crash of a vehicle having twice the mass with a lighter vehicle equals a six-fold risk of death Page 21 of 260 to persons in the lighter vehicle. In addition to the grievous toll in human life and survivor suffering, the economic cost of these crashes is exceedingly high. As a medical examiner, your fundamental obligation is to establish whether a driver has a disease, disorder, or injury resulting in a higher than acceptable likelihood for gradual or sudden incapacitation or sudden death, thus endangering public safety. As a medical examiner, any time you answer ?yes? to this question, you should not certify the driver as medically fit for duty. Public Safety Consider Safety Implications As you conduct the physical examination to determine if the driver is medically fit to perform the job of commercial driving, you must consider:. Physical condition o Symptoms Does a benign underlying condition with an excellent prognosis have symptoms that interfere with the ability to drive (e. Is the onset of incapacitating symptoms so gradual that the driver is unaware of diminished capabilities, thus adversely impacting safe driving? Nonetheless, you have a responsibility to educate and refer the driver for Page 24 of 260 further evaluation if you suspect an undiagnosed or worsening medical problem. Medical Examination Report Form Overview As a medical examiner, you must perform the driver physical examination and record the findings in accordance with the instructions on the Medical Examination Report form. The purpose of this overview is to familiarize you with the sections and data elements on the Medical Examination Report form, including, but not limited to:. You are encouraged to have a copy of the Medical Examination Report form for reference as you review the remaining topics. As a medical examiner, you are responsible for determining medical fitness for duty and driver certification status. Health History the Driver completes and signs section 2, and the Medical Examiner reviews and adds comments: Figure 5 Medical Examination Report Form: Health History Health History Driver Instructions the driver is instructed to indicate either an affirmative or negative history for each statement in the health history by checking either the "Yes" or "No" box. The driver is also instructed to provide additional information for "Yes" responses, including:. Health History Driver Signature Verify that the Driver signs Medical Examination Report Form: Figure 6 Medical Examination Report Form: Driver Signature Page 27 of 260 By signing the Medical Examination Report form, the driver:. Regulations You must review and discuss with the driver any "Yes" answers For each "Yes" answer:. As needed, you should also educate the driver regarding drug interactions with other prescription and nonprescription drugs and alcohol. Page 28 of 260 Health History (Column 1) Overview In addition to the guidance provided in the section above, directions specific to each category in Column 1 for each "Yes" answer are listed below. Any illness or injury in the last 5 years A driver must report any condition for which he/she is currently under treatment. The driver is also asked to report any illness/injury he/she has sustained within the last 5 years, whether or not currently under treatment. Seizures, epilepsy Ask questions to ascertain whether the driver has a diagnosis of epilepsy (two or more unprovoked seizures), or whether the driver has had one seizure. Gather information regarding type of seizure, duration, frequency of seizure activity, and date of last seizure. Eye disorders or impaired vision (except corrective lenses) Ask about changes in vision, diagnosis of eye disorder, and diagnoses commonly associated with secondary eye changes that interfere with driving. Complaints of glare or near-crashes are driver responses that may be the first warning signs of an eye disorder that interferes with safe driving. Ear disorders, loss of hearing or balance Ask about changes in hearing, ringing in the ears, difficulties with balance, or dizziness. Loss of balance while performing nondriving tasks can lead to serious injury of the driver. Obtain heart surgery information, including such pertinent operative reports as copies of the original cardiac catheterization report, Page 29 of 260 stress tests, worksheets, and original tracings, as needed, to adequately assess medical fitness for duty. High blood pressure Ask about the history, diagnosis, and treatment of hypertension. In addition, talk with the driver about his/her response to prescribed medications. The likelihood increases, however, when there is target organ damage, particularly cerebral vascular disease. As a medical examiner, though, you are concerned with the blood pressure response to treatment, and whether the driver is free of any effects or side effects that could impair job performance. Muscular disease Ask the driver about history, diagnosis, and treatment of musculoskeletal conditions, such as rheumatic, arthritic, orthopedic, and neuromuscular diseases. Does the diagnosis indicate that the driver is at risk for sudden, incapacitating episodes of muscle weakness, ataxia, paresthesia, hypotonia, or pain? However, most commercial drivers are not short of breath while driving their vehicles. Health History (Column 2) Overview In addition to the guidance provided in the section above, directions specific to each category in Column 2 are listed below for each "Yes" answer. Feel free to ask other questions to help you gather sufficient information to make your qualification/disqualification decision. Lung disease, emphysema, asthma, chronic bronchitis Ask about emergency room visits, hospitalizations, supplemental use of oxygen, use of inhalers and other medications, risk of exposure to allergens, etc. Even the slightest impairment in respiratory function under emergency conditions (when greater oxygen supply is necessary for performance) may be detrimental to safe driving. Page 30 of 260 Kidney disease, dialysis Ask about the degree and stability of renal impairment, ability to maintain treatment schedules, and the presence and status of any co-existing diseases. Digestive problems Refer to the guidance found in Regulations You must review and discuss with the driver any "Yes" answers. Diabetes or elevated blood glucose controlled by diet, pills, or insulin Ask about treatment, whether by diet, oral medications, Byetta, or insulin. To do so, the medical examiner must complete the examination and check the following boxes:. Meets standards but periodic monitoring required due to (write in: insulin treatment. Loss of or altered consciousness Loss of consciousness while driving endangers the driver and the public. Your discussion with the driver should include cause, duration, initial treatment, and any evidence of recurrence or prior episodes of loss of or altered consciousness. You may, on a case-by-case basis, obtain additional tests and/or consultation to adequately assess driver medical fitness for duty. Health History (Column 3) Overview In addition to the guidance provided in the section above, directions specific to each category in Column 3 are listed below for each "Yes" answer. Fainting, dizziness Note whether the driver checked ?Yes? due to fainting or dizziness. Ask about episode characteristics, including frequency, factors leading to and surrounding an episode, and any associated neurologic symptoms (e. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring Ask the driver about sleep disorders. Also ask about such symptoms as daytime sleepiness, loud snoring, or pauses in breathing while asleep. Page 31 of 260 Stroke or paralysis Note any residual paresthesia, sensory deficit, or weakness as a result of stroke and consider both time and risk for seizure. Missing or impaired hand, arm, foot, leg, finger, toe Determine whether the missing limb affects driver power grasping, prehension, or ability to perform normal tasks, such as braking, clutching, accelerating, etc. Spinal injury or disease Refer to the guidance found in Regulations You must review and discuss with the driver any "Yes" answers. How does the pain affect the ability of the driver to perform driving and nondriving tasks? You should refer the driver who shows signs of a current alcoholic illness to a specialist. Narcotic or habit-forming drug use Explore the use of the medication, whether or not it is prescribed, and the medication?s effect on driver reaction time, ability to focus, and concentration. Health History Medical Examiner Comments Overview At a minimum, your comments should include:. Include a copy of any supplementary medical reports obtained to complete the health history. Page 32 of 260 Vision the Medical Examiner completes section 3: Figure 7 Medical Examination Report Form: Vision Vision Medical Examiner Instructions To meet the Federal vision standard, the driver must meet the qualification requirements for vision with both eyes. Use of contact lenses when one lens corrects distant visual acuity and the other lens corrects near visual acuity.
It is therefore erectile dysfunction injection buy 20/60mg levitra with dapoxetine mastercard, a key tool which should effectively be used to promote access to essential medicines to achieve maximum therapeutic benefit and optimize patient outcomes male impotence 30s buy levitra with dapoxetine 20/60 mg low price. I am confident that all prescribers and dispensers will find these guidelines very useful erectile dysfunction newsletter 20/60 mg levitra with dapoxetine sale. However impotence of organic nature generic levitra with dapoxetine 40/60mg on-line, comments and suggestions that may help us to improve the treatment guidelines will be appreciated in order to ensure that these guidelines continue to advance and remain adapted to the reality of the field injections for erectile dysfunction treatment order generic levitra with dapoxetine on-line. It helps the clinicians to identify those clinical patterns impotence underwear buy levitra with dapoxetine 20/60 mg overnight delivery, which indicate what disease the patients may have and when they can treat it and when they must be referred to higher level health facilities erectile dysfunction and zantac 20/60 mg levitra with dapoxetine for sale. It is an unpleasant sensation or emotional experience associated with actual or potential tissue damage diabetes and erectile dysfunction health buy generic levitra with dapoxetine 20/60mg. Other pains may include: Generalized body ache Joint pain Pain due to local infections Pains due to injury Standard Treatment GuidelinesStandard Treatment Guidelines 3 3 Eye pains Ear pains Non-Pharmacological and Pharmacological Treatments For generalized pain give analgesics as in section 1. Referral: Refer patients to Regional and Tertiary care for: Children with moderate and acute severe pain No response to oral pain control Uncertain diagnosis All acute abdominal pain accompanied by vomiting and no passing of stool Pain requiring definitive treatment for the underlying disease Pain requiring strong opioids 1. It is characterized by an elevation of body temperature above the normal range of 36. Advise the patient to rest and Children: 15mg/kg 6 hourly when required make a follow-up. Aspirin is not recommended in children and young adult, under 16 years due to risk of Reyes syndrome6 Referral: Refer patients to Regional and Tertiary care for: Children with moderate and acute severe pain Referral: No response to oral pain control Refer the patient to the next facility with adequate expertise and facilities. A cough can be caused by several conditions both temporary and characterized by an elevation of body temperature above the normal range of 36. Differential Diagnoses Special concerns includes body twitching, body spasms, jerking limbs, head spasms, fits, bladder incontinence, bowel incontinence, loss of consciousness and sleeping after convulsion. Diagnostic Criteria Trauma Epilepsy Intracranial haemorrhage Alcohol or medication withdrawal Drug induced seizures etc. Referral: Refer the patient to next facility with adequate expertise and facilities if: Fits do not stop Eclampsia Other complications 1. Adherence to evidence-based care of the specific causes of shock can enhance a patients chances of surviving7. Type of shock Description Additional symptoms Diagnostic Criteria Hypovolemic Most common type of shock Weak thread pulse, cold Trauma Primary cause is loss of fluid from and clammy skin. Investigations: Septic shock Caused by an overwhelming infection, Elevated body Some investigations must be ordered: leading to vasodilatation. Adherence to evidence-based care of the specific causes Treatment depends on the type of shock. Intravenous fluid therapy is important in the of shock can enhance a patients chances of surviving7. Ringer Lactate, within 48 hours of administering ceftriaxone Contra-indicated in neonatal jaundice Annotate dose and route of administration on referral letter. Persons at greatest risk for dehydration include persons with diarrhoea, vomiting, fever, diabetes or infections, impaired level status. Repeat bolus until Blood chemistry (to check electrolytes, especially sodium, potassium, and blood pressure is improved. In more severe cases, correction of a dehydrated state is accomplished by the replenishment of necessary water and electrolytes. Persons at greatest risk for dehydration include persons with diarrhoea, Note: If the underlying disease condition is diagnosed; treat as per specific condition in vomiting, fever, diabetes or infections, impaired level status. It is usually induced for the purpose of facilitating surgery and other therapeutic or diagnostic procedures. It is a continuum of clinical services that range from monitored anesthetic care, sedation to deep general anesthesia or it can be regional anesthesia alone or combined with light general anesthesia. Thus anesthetic services include the use of medicines for premedication, induction of anesthesia, maintenance of anesthesia, reversal or recovery from anesthesia and post-operative care. It is a Antimuscarinics continuum of clinical services that range from monitored anesthetic care, sedation to deep general anesthesia or it can be regional anesthesia alone or combined with light If there is bradycardia, salivary secretion or other muscarinic side effects give general anesthesia. Not more than 30 minutes pre– whenever general anesthesia, regional anesthesia or sedation is administered. The addition of glucose produces 20–45 minutes after initial dose for maintenance or infusion at 0. Ephedrine: Used frequently for hypotension in obstetric anesthesia as it may maintain Maximum dose of morphine 0. Administer intravenously after dilution to at least 1 mg/ ml 10 Antagonists of Opioids ml. Continue repeated administration until cardiac and respiratory symptoms stabilize. Others: A: Magnesium sulphate: for prevention and control of seizure caused by pre– eclampsia or eclampsia, Severe Tetanus. Dexmedetomidine has demonstrated to be an efficacious and safe anaesthetic adjuvant Dose: Hydrochloride Injection, 1µg/kg S: Clonidine: (hydrochloride injection 500µg/ml) used as an adjuvant in regional anesthesia with proved effect of prolonging the duration of the analgesic effect of local anaesthetics. This procedural sedation and analgesia is commonly used in emergency units, radiological /diagnostic units, dentistry and for certain endoscopic and gynaecological procedures. General Measures Procedural sedation is a continuum, ranging from minimal sedation (anxiolysis), moderate sedation (conscious sedation), and deep sedation (anesthesia. They should have a detailed understanding of the risks and A: Adrenaline 1–2µg/kg, nebulised to reduce symptoms associated with acute benefits of the medicines used, and should be competent in resuscitation, upper airway obstruction, post–intubation swelling and infectious croup airway management and assisted ventilation. D: Dobutamine: in Critical Care practice a combination of noradrenaline and Appropriate sedation protocols and guidelines for patient care from dobutamine is often preferred to adrenaline alone, giving greater control preparation to discharge should be available and implemented. Dexmedetomidine has demonstrated to be an Oral sedation may be appropriate for certain procedures efficacious and safe anaesthetic adjuvant Medicines for moderate sedation & analgesia Dose: Hydrochloride Injection, 1µg/kg If analgesia is required, one of the above is usually combined with an opiate. However, ketamine has analgesic activity and can be used on its own, or combined with a S: Clonidine: (hydrochloride injection 500µg/ml) used as an adjuvant in benzodiazepine. But it is more likely to cause myoclonus Standard Treatment GuidelinesStandard Treatment Guidelines 1515 Medicines for Deep Sedation & Analgesia this is usually achieved with either higher doses of medications used for moderate sedation, or by combining an opiate, a benzodiazepine, and either Propofol or Etomidate. Supplemental Analgesia: Simple analgesics can be given before or after the procedure: A: Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24 hours. Diabetes leads to increased surgical morbidity, mortality and length of hospital stay. Perioperative Hyperglycemia is associated with increased risk of infection, Supplemental Analgesia: Simple analgesics can be given before or after the procedure: medical complications and death and Hypoglycemia is associated with increased risk of A: Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses death. Diagnostic Criteria Pallor, depression, hair loss, pins and needles, numbness in hands or feet, tremors and palsies, mildly jaundiced (lemon yellow tint), beefy tongue, darkening of palms and ataxic gait. Acquired haemolytic anaemias: this is a condition whereby the bone marrow usually produces large, structurally a. Immune abnormal, immature red blood cells (megaloblasts) often due to inadequate intake or Autoimmune (warm antibody type, cold antibody) malabsorption of vitamin B12 or folate. Pyruvate kinase deficiency o Haemoglobin -Abnormal haemoglobin such as Hb S, C, Unstable Hb Clinical Features: the disease may occur at any age and sex Patient may present with symptom and features of Anaemia Symptoms are usually slow in onset however rapidly developing anaemia can occur Splenomegaly is common but no always observed Jaundice General Treatment: i. Plasmapheresis Note: After supportive treatment refer to higher health facility with adequate expertise and facilities Pharmacological Management Immunosuppressants C: Prednisolone 1–1. Hereditary spherocytosis including acute pain in any part of the body, anaemia, acute neurological symptoms, and 2. Pyruvate kinase deficiency o Haemoglobin Vaso-occlusive crisis: painful crisis usually presenting as back pain, pain in the -Abnormal haemoglobin such as Hb S, C, Unstable Hb upper/lower limbs, joint pain, abdominal pain, chest pain. Clinical Features: Hemolytic crisis: presents with features of anemia, jaundice, may have dark the disease may occur at any age and sex urine signifying intravascular hemolysis Patient may present with symptom and features of Anaemia Sequestration crisis: sudden massive enlargement of the liver and spleen Symptoms are usually slow in onset however rapidly developing accompanied with a fall in hematocrit anaemia can occur Aplastic Crisis: Where the bone marrow ceases to function reflected by a Splenomegaly is common but no always observed worsening of anemia in the absence of reticulocytosis. Remove the underlying cause death if not diagnosed and managed in a timely manner ii. If the child has not previously received this vaccine, then at least one dose should be given between 6–18 years. Screening o From the age of 10 years, screen for renal disease (proteinuria by urine dipstick) and retinopathy annually o Annual screening for risk of stroke by transcranial Doppler from the age of 2 years to 16 years. Exchange Blood Transfusion Venesection to reduce the proportion of HbS red cells with transfusion of normal HbA blood is often beneficial in the treatment or prevention of life-threatening and other manifestations of sickle cell disease 5. Relative Indications for Exchange Blood Transfusion Intractable or very frequent severe crises Major priapism unresponsive to other therapy. Give 10ml/kg Haemoglobin level has dropped by > 2g/dl below the steady-state value. Exchange blood transfusion can be done manually or automatically with a red cell apheresis machine. Clinical Features Vary with severity but include; Anaemia, easy bruising/bleeding, recurrent infection; 3. Diagnostic Criteria Pancytopenia, Bone marrow hypocellularity of < 30% hematopoietic cells for children and young adults; confirmed by trephine biopsy. Hereditary bleeding disorders includes haemophilia A and B, Von Willebrand disease Marrow hypocellularity and pancytopenia may appear gradually after age 5yrs. Bleeding Pallor, dyspnoe on exertion, parttens differ with age: Infants usually bleed into soft tissues or from the mouth but as Bleeding the boy grows, characterist joint bleeding becomes more common. Occasional Note: spontaneous If there is no response to appropriate replacement therapy tests for inhibitors (an haemarthrosis inhibitor is formed when one develops antibodies against factor concentrates) Mild 5-40%of normal 5-40% of normal 1. During the process, increased platelet aggregation and coagulation factor consumption occur this does not allow time for compensatory increase in production of coagulant and anticoagulant factors. Most adult patient presents with a long history of Purpura, menorrhagia, epistaxis and gingival Note: haemorrhage are more common. During the process, increased platelet treatment of acute bleeding caused by severe thrombocytopenia need immediate platelet aggregation and coagulation factor consumption occur this does not allow time for transfusion is indicated in patient with haemorrhagic emergencies compensatory increase in production of coagulant and anticoagulant factors. Multifactor deficiency, Liver disease gives Fresh Frozen Plasma 10-15mls/kg until 3. Idiopathic thrombocytopenic Purpura is an acquired disease of children and adults and defined as isolated thrombocytopenia with no clinically apparent associated condition or other causes of thrombocytopenia. Treatment of Venous Thromboembolism Long term anticoagulation is required to prevent a frequency of symptomatic extension of thrombosis and/or recurrent venous thromboembolic events. They require immediate notification to health uuthorities as Severe dyspnea nad tachypnea and right side heart failure required by the International Health Regulations, in order to ensure prompt and effective Cardiovascular collapse with hypotension, syncope, and coma response to avoid further spread and prevent deaths. Treatment of Venous Thromboembolism Immediately notifiable disease in Tanzania include Cholera, Anthrax, Plague, Long term anticoagulation is required to prevent a frequency of symptomatic extension of Viral Haemorrhagic diseases (Ebola, Lassa, and Marburg), Yellow fever, thrombosis and/or recurrent venous thromboembolic events. Human Influenza of new subtype, Small Pox, initial heparin or clexane therapy and then overlapped for 4-5days. Standard Treatment GuidelinesStandard Treatment Guidelines 3333 Note: For confirmation at the beginning of an outbreak, rectal swab or stool specimen should be taken from first 5 to 10 suspected cases. It is of paramount importance to make correct diagnosis and administer the right treatment according to the Treatment o plan A: No dehydration, o plan B: Moderate dehydration and o plan C: Severe dehydration. It is of paramount importance to make Ciprofloxacin was previously contraindicated to children under 12 years. Preferably, give o plan B: Moderate dehydration and antibiotics with food to minimize vomiting o plan C: Severe dehydration. If no signs of dehydration After the initial 30 ml/kg has been administered, the radial pulse should be Patients who have no signs of dehydration when first observed can be treated strong and blood pressure should be normal. Give an oral antibiotic to indicating other problems (eg, fever, blood in stool) patients with severe dehydration as follows: Note: Adults (Not for pregnant women) Prophylaxis of cholera contacts is not recommended. It is a zoonotic disease whereby man is infected directly through contact with infected hides or inhalation of spores in the lungs or ingestion of infected meat. Diagnostic Criteria: Itching A malignant pustule, Pyrexia Pulmonary and gastrointestinal signs. V every 6 hours until local oedema subsides then continue with A: Phenoxymethylpenicillin 250 mg 6 hourly for 7 days A: Paracetamol 15mg/kg 8 hourly for 3 days 4. Humans can be contaminated by the bite of infected fleas, through direct contact with infected materials or by inhalation. Diagnostic Criteria Sudden onset of fever, chills, head and body aches Weakness, vomiting and nausea. There are 3 forms of plague infection, depending on the route of infection: Bubonic plague is the most common, caused by the bite of an infected flea. However, any person with pneumonic plague may transmit the disease via droplets to other humans. Prevention: Inform people of the presence of zoonotic plague and advised to take precautions against flea bites 36 Standard Treatment Guidelines 4. It is a zoonotic disease whereby man is infected directly Apply standard precautions when handling potentially infected patients through contact with infected hides or inhalation of spores in the lungs or ingestion of and while collecting specimens infected meat. Vaccination: Not recommended expect for high-risk groups (such as laboratory Diagnostic Criteria: personnel who are constantly exposed to the risk of contamination, and health care Itching workers. Humans can Neck stiffness, be contaminated by the bite of infected fleas, through direct contact with infected Intense headache, nausea and vomiting, materials or by inhalation. Usually occurs through introduction of tetanus spores via the umbilical cord during Yersinia pestis is identified by laboratory testing from a sample of pus from delivery through the use of an unclean instrument to cut the cord, or after delivery by a bubo, blood or sputum. There are 3 forms of plague infection, depending on the route of infection: Diagnostic Criteria Bubonic plague is the most common, caused by the bite of an infected flea. This protects the mother and also her baby Pneumonic plague is the most virulent form and is rare. However, any person with pneumonic plague may transmit the disease via droplets to Good hygienic practices when the mother is delivering a child are also other humans. Frequency of drug administration should be titrated vs clinical condition Airway / respiratory control o Provide mechanical ventilation. Humans typically come into contact with soft ticks when they sleep in rodent-infested cabins. A: Amoxycillin via Nasal Gastric Tube 20–30 mg/kg/day every 8 hours Without antibiotic treatment, this process can repeat several times. Postnatal age >7 days: 1200-2000 g: 15 mg/kg/day in divided doses every 12 hours >2000 g: 30 mg/kg/day in divided doses Prevention every 12 hours Avoid sleeping in rodent-infested buildings whenever possible. Use insect repellent (on skin or clothing) or permethrin intramuscularly stat, with the dose divided into two different muscle (applied to clothing or equipment. Secondary transmission is from person to person through: Contact with a sick person or direct contact with the blood and/or secretions or Time (hours) 0 3 6 9 1 1 1 2 2 with objects, such as needles that have been contaminated with infected 2 5 8 1 4 secretions of an infected person. Diazepam * * * * * * Breast feeding Sexual contact Chlorpromazine * * * the disease can spread rapidly within the health care setting. The virus enters through Phenobarbitone * * * broken skin, mucous membrane or exchange of bodily fluids or ingestion, inhalation and injection of infectious material ** these are general guidelines. Frequency of drug administration should Diagnostic Criteria be titrated vs clinical condition High grade fever and one or more of the following: Headache, body ache, abdominal pain, diarrhoea Airway / respiratory control Unexplained haemorrhage may be present or not o Provide mechanical ventilation. Supportive therapy includes: Mechanical ventilation, renal dialysis, and anti-seizure therapy may be required. The virus can be transmitted to human through; Handling of animal tissue during slaughtering or butchering, assisting with animal births, conducting veterinary procedures. Human become viraemic; capable of infecting mosquitoes shortly before onset of fever and for the first 3–5 days of illness. The disease can Fluid and electrolyte balance be life threatening causing hemorrhagic fever and hepatitis. Psychological support is given to patient and family Non-Pharmacological Treatment 4. This is a viral zoonosis that is primarily spread amongst animals by the bite of infected mosquitoes, transmitting the Rift Valley virus. Transmission to human is mainly through direct or indirect contact with Prevention and Control involve mosquito control and provision of Yellow Fever vaccine. The virus can be transmitted to human through; Handling of animal tissue during slaughtering or butchering, assisting with Indication of Yellow Fever Vaccination animal births, conducting veterinary procedures. Human become viraemic; capable of infecting mosquitoes shortly before onset of fever 4. Dengue is a mosquito-borne viral infection causing by the dengue fever virus, whose full life cycle involves the role of mosquito as a transmitter (or vector) and humans as the Diagnostic Criteria main victim and source of infection. Dengue does not spread directly from person to Acute febrile illness that does not respond to antibiotic or antimalarial person, it is only spread through the bite of an infected Aedes aegypti mosquito. B: Oxygen and manage hypoglycaemia if present Note: No antibiotics are of proven value. Diagnostic Criteria: Fever, Skin rashes, Conjunctivitis Muscle and joint pain (Polyarthritis), Malaise, Headache Minor haemorrhage, Leukopenia is common Prevention and control: Vector control:removal and modification of breeding sites and reducing contact between mosquitoes and people. Non-Pharmacological Treatment: Supportive Pharmacological Treatment Symptomatic treatment A: Sodium Lactate Compound (Ringers Lactate) intravenously A: Give Paracetamol 15mg/kg 8 hourly for 3 days 42 Standard Treatment Guidelines Macular or confluent blanching rash (noted during recovery period) 4. In case of ocular involvement, add Children below 12 years require close monitoring for dangerous form. Prevention Routine measles vaccination for children combined with mass immunization campaigns Diagnostic Criteria: Fever, Skin rashes, Conjunctivitis 4. Diagnostic Criteria: Fever, skin rashes, conjunctivitis, Joint pain, malaise, Headache usually mild and last for 2–7 days. Uncomplicated malaria is defined as symptomatic malaria without signs of severity or In addition, patients should receive rabies immune globulin with the 1st dose (day 0) evidence (clinical or laboratory) of vital organ dysfunction. Investigations Diagnostic Criteria: the clinical features listed above are not specific for malaria and can be found in several Fever, skin rashes, conjunctivitis, other febrile conditions. Therefore, it is necessary to confirm malaria parasites infection Joint pain, malaise, Headache usually mild and last for 2–7 days. Parasite-based diagnosis is recommended for all patients presenting with signs and symptoms of malaria. The Neurological and auto-immune complications of Zika virus disease, babies born recommended investigations are: with microcephaly (Observed in northeast Brazil. A: Sodium Lactate Compound (Ringers Lactate) intravenously A: Paracetamol 15mg/kg 8 hourly for 3 days Standard Treatment GuidelinesStandard Treatment Guidelines 4545 Table 5. For more details on management of fever and pain, refer to chapter one-syndromic 46 Standard Treatment Guidelines Table 5. If effective management of severe malaria 24 hours) until symptoms resolve, usually after two days.
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