By M. Hector. La Roche College. 2019.
Some people have a pink rash that resem- which is distortion of the sizes buy levitra toronto erectile dysfunction doctor patient uk, shapes order 10 mg levitra with visa erectile dysfunction causes in young men, and spatial bles that of measles purchase 20 mg levitra mastercard erectile dysfunction doctors kansas city. Chronic Epstein-Barr virus People with symptoms of mononucleosis should infection has an association with several types of see their health care providers as soon as possible. Mononucleosis can even lead to In particular, however, if someone experiences a death in those who are immunocompromised, sharp, sudden pain in the left upper abdomen, that but rarely in others. Children with X-linked lym- individual needs to call 911 or ask someone to take phoproliferative syndrome often contract fatal him or her immediately to a local emergency infectious mononucleosis. A rapid condition that may arise from a physical problem slide test (Monospot) uses the latex agglutination that affects either partner. The test is not accurate for children term used to refer to a woman’s inability to four years old or younger because false-negative become pregnant and a man’s inability to induce results often occur. There are many possible four, serologic testing is used to determine the causes of infertility. Infertility can result While the individual with mononucleosis has from prior pelvic inﬂammatory disease. A man an enlarged spleen, she or he should not take may have semen that lacks sufﬁcient motility or part in vigorous workouts or contact sports. Gonorrhea, which is a common recommendations for reduced activity, bed rest, cause of pelvic inﬂammatory disease in women, and avoidance of contact sports and intense exer- can also result in fertility problems in men who cise for at least one month and until the person have had the infection in the past. There are sev- has seen the doctor for follow-up to confirm that eral ways to treat infertility. A person can One of the potential solutions for infertility—in take analgesics to relieve pain and fever and gar- vitro fertilization—carries the very rare hazard of gle with salt water for sore throat. This is very unlikely, of informed consent A legal requirement that a course, but anyone who is investigating the in vitro patient must give permission for a health care pro- fertilization option should inquire about the partic- fessional to perform a treatment, surgical proce- ular facility’s policies on screening of donor sperm dure, or test. Also, some proposed treatments for mation that is not speciﬁc enough to be helpful. Seeking good, reliable information can start courtrooms; some patients had to sue to retain with a sex education class at school, a physician, a coverage when insurance companies sought to parent, a church counselor, a teacher, or another drop them after discovering their diagnosis. The education process needs to start when involved in regulating the insurance companies’ children are very young (eight or nine), as soon as practices, with the goal of ensuring fair treatment questions about sex arise and information is to all. A person expenses involved in years of treatment can be who is sexually active, however, needs valid, prac- enormous. After the insurer pays, the amount that United States has become complex and unwieldy. It is important to note, too, that or her own care (self-pay), may qualify for a state there are limits to the lifetime coverage of a policy or federal health program, or may have private and a limit on the drug coverage, so a person with health insurance coverage. Further, a patient may need to or he may have to pay all costs for treatment obtain a referral from the primary care practitioner options the insurance plan does not view as in order to see a specialist. The former employee pays the insurance pre- group plans to companies, which then offer the miums and is allowed to continue coverage for a health insurance coverage to their employees. A period of up to 18 months, at his or her own person who has an individual plan is working expense. This period begins on the date a person was instances, the coverage can last for up to 36 months. It is important to remember that law exempts, however, the District of Columbia, neither the health plan ofﬁce staff nor the employer federal employees, some church groups, and ﬁrms is required to send a notice that the premium is due, that employ fewer than 20. The employer no longer pays for vide a detailed medical history and is required to part of the premiums, and the individual also must report any existing diseases that have been diag- pay an administrative fee of up to 2 percent. The family has the responsibility to son has received medical advice or treatment notify the health plan administrator within 60 from a physician in the last five years. There are days of the event in cases of divorce, legal marital preexisting conditions that do not prevent insur- separation, or a child’s loss of independent status. Insurers can held personally liable for breaching duties, but he reject a person completely or offer to cover her or or she must have in hand the person’s correct him while excluding the coverage of all treatments mailing address. For specific information, refer to your macrophages that help regulate the immune sys- policy or contact an insurance representative. Experience has generally some states, or take advantage of insurance com- been limited to use in experimental protocols, panies’ “open enrollment” for high premiums. A viral latency and thus allow discontinuation of person who wants to apply for life insurance is antiviral drugs. The three main groups are alpha- sionals seek to make their intervention efforts interferon, beta-interferon, and gamma-interferon. It is known that involving families, one-on-one efforts, and com- interferons have antitumor activity and can stiﬂe munity programs. When people share blocked fallopian tubes or there is some other rea- their drug paraphernalia such as needles and son that the sperm and ovum cannot be united syringes, they put themselves and perhaps others successfully in the reproductive tract. Viruses can be transmitted to other people tant for a woman who is receiving donor sperm to through the contaminated blood that is still in the make sure that it has been screened and syringe or the needle. In the procedure of in vitro fertilization, the woman undergoes hormone therapy so that sev- introitus The entrance to a hollow organ or body eral ova will mature at the same time. This gravely ill patients and, in exchange, provide feed- can happen when there is an infection such as back data on the drug. The idea is to allow use of mucopurulent cervicitis, herpes, trichomoniasis, promising drugs as early as possible, in order to gonorrhea, or chlamydia. Vaginal infections and beneﬁt patients who are in need of the drug ther- pelvic inflammatory disease can also cause spot- apy. J Jarisch–Herxheimer reaction A worsening of in the blood, and this condition is called hepato- symptoms (visual and neurologic) of patients cellular jaundice. Excessive destruction of red cells with syphilis that can occur immediately after in the blood leads to hemolytic jaundice. Symptoms are sexually transmitted diseases, such as hepatitis, mild fever, malaise, headache, muscle aches, and jaundice is a symptom. Some believe that the symptoms result when killed organisms release a fever-producing enzyme. It most commonly occurs in early syphilis Johnson, Magic In 1991, the basketball great but has also been seen in all phases of syphilis Earvin “Magic” Johnson announced to the world and with therapies other than penicillin. In the years jaundice A medical condition that manifests subsequent to his startling announcement, how- itself in yellow skin and eyes, as a result of excess ever, he has gone on to live a vital life, complete bilirubin in the blood and body tissues. Clearly, not reach the intestine because of bile-duct he stands out as a prime example of the beneﬁts of obstruction is termed obstructive jaundice. Lesions occurs in the United States almost exclusively in can be treated by cryotherapy. Also, no one purple blotches proliferate and also can appear on with this sarcoma should expect the treatment for internal organs. Use of one of these involved, the disease can spread quickly to other treatments can improve the appearance of the organs and devastate the person’s health.
Immunoﬂuorescent ﬁndings and clinical overlap in two cases of follicular lichen planus discount levitra 20 mg on-line impotence herbs. Successful treatment regime for folliculitis decalvans despite uncertainty of all aetiological factors order generic levitra line erectile dysfunction pump.com. Vincent’s Hospital and Department of Medicine (Dermatology) purchase 20 mg levitra doctor for erectile dysfunction in dubai, The University of Melbourne, Melbourne, Victoria, Australia Jack Green Department of Dermatology, St. The normal hair shaft has a consistent diameter throughout its length, with the most common shape in cross section being oval. Signiﬁcant variations exist particularly in different racial groups from straight to woolly hair as well as in thickness of the hair shaft. The medulla is a normal feature of the hair shaft and is character- ized by a central cavity, but is only present in some individuals. Its appearance can vary from a continuous cavity throughout the hair shaft to being only intermittently present. Weathering Hairs grow, on average, 1 cm per month, so the tip of a hair ﬁber that is 35 cm long has been exposed to environmental insults for approximately 3 years. These include damage to the hair cuticle leading to fraying or loss of cuticular cells from the distal hair shaft. Other features of weathering include longitudinal splits and trichorrhexis nodes (Fig. If weathering is seen in the proximal hair shaft (particularly within the ﬁrst 2 cm from the scalp) this is considered pathological and may either be present nonspeciﬁcally or be related to a characteristic hair-shaft anomaly. Examination of the Hair Shaft Most disorders (perhaps apart from disorders leading to uncombable hair, which is better diag- nosed with electron microscopy) can be diagnosed on light microscopy of hair samples. It is important to take hair samples from multiple sites as pathology can be of intermittent severity and it is helpful in noting which is the proximal end of the hair to determine if weathering changes are pathological. It is only when considering a disorder such as loose anagen syndrome that hairs need to be obtained by hair pull. Classiﬁcation of Hair-Shaft Disorders A major division of hair-shaft disorders is into those associated with hair fragility and those that do not affect the integrity of the hair shaft. Within each of these categories for each speciﬁc hair abnormality consideration should be given to whether the hair-shaft disorder is occurring as an isolated phenomenon, in association with other cutaneous or noncutaneous abnormali- ties, or as a syndrome. It is important to note that hair-shaft disorders can have signiﬁcant variations in severity from barely noticeable even subclinical anomalies to severe effects (particularly in the hair-shaft 150 Dinh et al. These variations can even occur between patients with the same genetic mutation in the same family. The condition may be present throughout the entire scalp or maybe patchy or even localized. Patients with fragility disorders usually present with short hair that breaks easily. For these patients, haircare advice is required to minimize the impact of grooming habits (Table 1). When shampooing, always use a conditioner, and leave it on the scalp for at least ﬁve minutes before rinsing. In particular do not have hair bleached, dyed, straightened, permanent waved (permed), crimped, or pleated. Protect the hair from excessive exposure to sunlight, by wearing a loose-ﬁtting hat or scarf. If a fracture occurs transversely through the node, the end of the hair resembles a small paintbrush. However an assessment of what is pathological needs to also consider the patient’s racial background. Vigorous attempts to straighten curly hair may cause nodes to occur sooner and closer to the root. In contrast, Caucasian and Asian hair is stronger than African hair and even the most vigorous abuse tends to produce distal rather than proximal acquired trichorrhexis nodosa. Trichorrhexis nodosa is the most common defect of the hair shaft leading to hair breakage (1). Treatment of trichorrhexis nodosa (congenital or acquired) involves the avoidance of mechanical or chemical injury to hair. When severe, the entire scalp is affected and patients are totally bald or more often have a sparse covering of short, twisted, broken and lusterless hairs. Hairs of the eyebrows, eyelashes, face, pubis, and legs may be involved but only rarely in the absence of scalp signs. Follicular keratosis and abnormal hairs are found most frequently on the nape and occiput but may affect the entire scalp. Occasionally there is no keratosis pilaris, suggesting that the follicular hyperkeratosis is not important in the genesis of the beaded hairs. The most pathogenic mutations in hHb6 affect either the start of the rod domain at the helix initiation motif or the end of the rod domain at the helix termination motif (2). Both these sites in the rod domain contain a sequence that is very susceptible to point mutation. In fact, patients with autosomal recessive monilethrix appear to have more severe disease than those with an autosomal dominant aetiology with more extensive alopecia and papular rash. Retinoids (4) have been used with variable success and improvement in the condition may be related to resolution of the keratosis. Minoxidil has also been used but the condition may also spontaneously improve over time. Intermittently placed nodes form and the internodes tend to be the site of transverse hair fracture. Excessive weathering of the hairs with ﬂuting and disruption of the cuticle is most marked at the internodes. There are case reports of rare associations with mental and physical retardation, abnormal dentition, cataract, syndactyly and koilonychia. The beading is produced as an artifact of mounting hairs on glass slides and is of no signiﬁcance. On scanning electron microscopy, the widened beads can be seen to be an optical illusion. They merely represent art factual indentations of the shaft viewed in cross section. In the twisting hair dystrophy known as pilitori, or “corkscrew hair,” there is irregular thickening of the outer root sheath and ﬂattened hairs rotate completely through 180 degrees at irregular intervals. The twists can resemble beads on light microscopy and may be confused with monilethrix. These incomplete twists may occasionally occur in normal hair (seen in African hair and in the pubic/axillary hairs of other races). In pili torti, hair is often normal at birth, but is gradually replaced by abnormal twisted hairs that may be detected as early as the third month. Affected hairs are brittle, fracture easily, and do not grow to any considerable length. Patients present with a sparse and short coarse stubble over the entire scalp and may have a few circumscribed bald patches.
A white lacework pattern on the buccal mucosa is the most frequently observed type of lesion (Fig order levitra 10mg mastercard how does an erectile dysfunction pump work. Less com- monly purchase levitra on line amex erectile dysfunction diabetes reversible, a destructive process develops in which the nail plate is lost and the nail- forming tissue (the nail matrix) is damaged buy levitra 20 mg low cost impotence caused by medications. The scalp is sometimes affected and then localized patches of hair loss and scalp scarring occur. As lesions heal, they ﬂatten and often leave a pigmented patch, which persists for some weeks. The commonest variant is hypertrophic lichen planus, in which thickened, mauv- ish papules or nodules of irregular shape with a warty or scaling surface develop (Fig. Solitary hypertrophic lesions may appear in the course of ordinary lichen planus or develop as solitary lesions. This odd variant sometimes occurs on the male genitalia and lower abdomen, but rarely elsewhere. Lichen nitidus is a rare variant of lichen planus in which numerous tiny, pink, ﬂat-topped papules develop. Bullous lichen planus is a very rare variant in which blistering occurs on some lesions. Affected sites lose their terminal hair and develop horny spines, which project from the affected hair follicles. Amongst the inﬂammatory cell inﬁltrate are clumps of melanin pigment as a result of damage to the epidermis. Immunoﬂuorescence studies show a dense, ragged band of ﬁbrin at the dermo- epidermal junction and clumps of IgM deposit. The basic process is thought of as an immunological attack on the basal layer; the presence of inﬂammatory cells and the other epidermal alterations are believed to be secondary events. When patients are severely affected with a generalized eruption, systemic corti- costeroids are sometimes helpful, as is the oral retinoid acitretin. Summary Psoriasis ● A seronegative rheumatoid arthritis-like condition ● Psoriasis is a genetically determined, persistent occurs in 5–6 per cent of patients with psoriasis. In and/or recurring inﬂammatory dermatosis, which addition, in a few psoriatics, a distinctive occurs in 1–2 per cent of the population. It usually arthropathy affects the terminal interphalangeal starts between the ages of 15 and 25, but in some joints (arthritis mutilans) as well as other small and patients it develops in the 60s. The epidermis is ● Nail involvement occurs in many patients and is surmounted by an incompletely differentiated characterized by ‘thimble pitting’, subungual debris stratum corneum in which the nuclei are retained. Also within the stratum corneum are collections of ● Variants include guttate psoriasis with myriads of nuclei from polymorph leucocytes (Munro tiny psoriatic patches, ﬂexural psoriasis, generalized microabscesses). Polymorphs also inﬁltrate the pustular psoriasis and a localized form of pustular thickened epidermis and there is a variable degree psoriasis occurring on the palms and soles, and of lymphocytic inﬁltrate beneath the epidermis. The number of papules varies from just a few Sensitization with psoralens and radiation with to myriads. The disorder is thought inﬂammatory disorder of skin and mucosae to be autoimmune in nature. It has been estimated that 70 per cent of the population have some clinically evident acne at some stage during adolescence! They often occur over the sides of the nose and the forehead, but can occur anywhere (Fig. Comedones are follicular plugs composed 149 Acne, rosacea and similar disorders Figure 10. They have pigmented tips from the melanin pigment deposited by the follicular epithelium at this level (Fig. Accompanying the visible comedones are numerous invisible comedones, many of which do not have pigmented tips. These are often quite tender to the touch and may be set quite deep within the skin (Fig. Sometimes they develop pus at their tips (pustules), but these may also arise inde- pendently. In a few patients, some of the papules become quite large and persist for long periods – they are then referred to as nodules. In severely affected patients, the nodules liquefy centrally so that ﬂuctuant cysts are formed. This type of severe acne is known as cystic or nodulocystic acne and can be very disabling and disﬁguring. When the large nodules and cysts eventually subside, they leave in their wake ﬁrm, ﬁbrotic, nodular scars, which sometimes become hypertrophic or even keloidal (Fig. Even the smaller inﬂamed papules can cause scars and these tend to be pock-like or are triangular indentations (‘ice-pick scars’: Fig. There is a very rare and severe type of cystic acne known as acne fulminans in which the acne lesions quite suddenly become very inﬂamed. At the same time the affected individual is unwell and develops fever and arthralgia. The cause of this disorder is not clear, although it has been suggested that it is due to the presence of a vasculitis that is somehow precipitated as a result of the underlying acne. These acne-prone areas tend to have hair follicles with small terminal hairs and larger sebaceous glands (sebaceous follicles). The face and particularly the skin of the cheeks, lower jaw, chin, nose and forehead are usually affected. The scalp is not involved, but the back of the neck, front of the chest, the back and shoulders are all ‘favoured areas’ for the development of lesions. In patients with severe acne, it is quite common for other areas to be affected, including the outer aspects of the upper arms, the buttocks and thighs. For the unfortunate few, the condition is a disaster, as it is disﬁguring, disabling and persistent, with wave after wave of new lesions. Although the natural tendency is for resolution, it is difﬁcult to know in any indi- vidual patient when the condition will improve. The majority have lost their acne by the age of 25 years, but some tend to have the occasional lesion for very much longer. In some women there is a pronounced premenstrual ﬂare of their acne some 7–10 days before the menses begin. Acne improves in the summertime and sun exposure seems to improve the condition of many patients. However, the heat does not produce improvement and, indeed, can make it much worse. Soldiers with acne in hot, humid climates often become disabled by it suddenly worsening, with large areas of skin covered by inﬂamed and exuding acne lesions, and have to be evacuated home or to a cooler climate. This proportion varies in different parts of the world, depending on the racial mixture, the afﬂuence and the sophis- tication of medical services.
Bacteria in diarrheal stools of infected persons can be passed from one person to another if hygiene or handwashing habits are inadequate generic levitra 20 mg with visa new erectile dysfunction drugs 2011. Family members and playmates of these children are at high risk of becoming infected discount levitra 20mg on-line erectile dysfunction 20 years old. Young children typically shed the organism in their feces for a week or two after their illness resolves order levitra no prescription erectile dysfunction causes alcohol. In some persons, particularly children under 5 years of age and the elderly, the infection can also cause a complication called hemolytic uremic syndrome, in which the red blood cells are destroyed and the kidneys fail. In the United States, hemolytic uremic syndrome is the principal cause of acute kidney failure in children, and most cases of hemolytic uremic syndrome are caused by E. All persons who suddenly have diarrhea with blood should get their stool tested for E. Most persons recover without antibiotics or other specific treatment in 5-10 days. There is no evidence that antibiotics improve the course of disease, and it is thought that treatment with some antibiotics may precipitate kidney complications. Hemolytic uremic syndrome is a life- threatening condition usually treated in an intensive care unit. Waterborne Diseases ©6/1/2018 148 (866) 557-1746 What are the long-term consequences of infection? About one-third of persons with hemolytic uremic syndrome have abnormal kidney function many years later, and a few require long-term dialysis. Another 8% of persons with hemolytic uremic syndrome have other lifelong complications, such as high blood pressure, seizures, blindness, paralysis, and the effects of having part of their bowel removed. Preventive measures may reduce the number of cattle that carry it and the contamination of meat during slaughter and grinding. Because ground beef can turn brown before disease-causing bacteria are killed, use a digital instant-read meat thermometer to ensure thorough cooking. Ground beef should be cooked until a thermometer inserted into several parts of the patty, including the thickest part, reads at least 160º F. Persons who cook ground beef without using a thermometer can decrease their risk of illness by not eating ground beef patties that are still pink in the middle. If you are served an undercooked hamburger or other ground beef product in a restaurant, send it back for further cooking. Wash hands, counters, and utensils with hot soapy water after they touch raw meat. Never place cooked hamburgers or ground beef on the unwashed plate that held raw patties. Children under 5 years of age, immunocompromised persons, and the elderly should avoid eating alfalfa sprouts until their safety can be assured. Drink municipal water that has been treated with chlorine or other effective disinfectants. Make sure that persons with diarrhea, especially children, wash their hands carefully with soap after bowel movements to reduce the risk of spreading infection, and that persons wash hands after changing soiled diapers. Anyone with a diarrheal illness should avoid swimming in public pools or lakes, sharing baths with others, and preparing food for others. Waterborne Diseases ©6/1/2018 149 (866) 557-1746 Chapter References Buchanan, Robert L. Foodborne Disease Significance of Escherichia coli 0157:H7 and other Entrohemorrhagic E. Impact of Changing Consumer Lifestyles on the Emergence /Reemergence of Foodborne Pathogens. Identification of Enteric Bacteria by Using Metabolic Characteristics: An Excerpt from a Bulletin Published by the Centers for Disease Control. Although most strains are harmless and live in the intestines of healthy humans and animals, this strain produces a powerful toxin and can cause severe illness. An estimated 73,000 cases of infection and 61 deaths occur in the United States each year. The combination of letters and numbers in the name of the __________________ refers to the specific markers found on its surface and distinguishes it from other types of E. They usually live in human or animal intestinal tracts, and their presence in drinking water is a strong indication of recent sewage or animal waste contamination. The water can be treated using __________________, ultra-violet light, or ozone, all of which act to kill or inactivate E. Systems using surface water sources are required to disinfect to ensure that all bacterial contamination is inactivated, such as E. Systems using ground water sources are not required to disinfect, although many of them do. Systems analyze first for total coliform, because this test is faster to produce results. Any time that a sample is positive for total coliform, the same sample must be analyzed for either fecal coliform or E. The largest public water systems (serving millions of people) must take at least 50 samples per month. Smaller systems must take at least 20 samples a month unless the state has conducted a sanitary survey – a survey in which a state inspector examines system components and ensures they will protect public health – at the system within the last year. Some states reduce this frequency to quarterly for ground water systems if a recent sanitary survey shows that the system is free of sanitary defects. Systems using surface water, rather than ground water, are required to take extra steps to protect against bacterial contamination because surface water sources are more vulnerable to such contamination. A Waterborne Diseases ©6/1/2018 155 (866) 557-1746 Waterborne Diseases Name Causative organism Source of organism Disease Viral Rotavirus (mostly in young Human feces Diarrhea gastroenteritis children) or vomiting Norwalk Agent Noroviruses (genus Norovirus, Human feces; also, Diarrhea and family Caliciviridae) *1 shellfish; lives in polluted vomiting waters Salmonellosis Salmonella (bacterium) Animal or human feces Diarrhea or vomiting Gastroenteritis -- E. The covert release of a biologic agent may not have an immediate impact because of the delay between exposure and illness onset, and outbreaks associated with intentional releases might closely resemble naturally occurring outbreaks. Indications of intentional release of a biologic agent include 1) an unusual temporal or geographic clustering of illness (e. Agents of highest concern are Bacillus anthracis (anthrax), Yersinia pestis (plague), variola major (smallpox), Clostridium botulinum toxin (botulism), Francisella tularensis (tularemia), filoviruses (Ebola hemorrhagic fever, Marburg hemorrhagic fever); and arenaviruses (Lassa [Lassa fever], Junin [Argentine hemorrhagic fever], and related viruses). Approximately 2--4 days after initial symptoms, sometimes after a brief period of improvement, respiratory failure and hemodynamic collapse ensue. Inhalational anthrax also might include thoracic edema and a widened mediastinum on chest radiograph. Gram-positive bacilli can grow on blood culture, usually 2--3 days after onset of illness. Cutaneous anthrax follows deposition of the organism onto the skin, occurring particularly on exposed areas of the hands, arms, or face. An area of local edema becomes a pruritic macule or papule, which enlarges and ulcerates after 1--2 days.
This definition will exclude common short self−limiting infections and those which have been investigated and diagnosed within 3 weeks levitra 20mg on-line erectile dysfunction treatment heart disease. Sites like kidneys and tubo−ovarian region raise diagnostic difficulties • Specific bacterial infections without distinctive localising signs generic levitra 20mg without a prescription erectile dysfunction in diabetes ppt. The commonest here are salmonellosis and brucellosis • Deep seated bacterial abscesses e buy levitra with amex crestor causes erectile dysfunction. Reactivated old osteomyelitis should be considered as well • Infective endocarditis especially due to atypical organisms e. Diagnosis may be difficult if lesions are deep seated retroperitoneal nodes • Leukaemia Contrary to common belief, it is extremely rare for leukaemia to present with fever only. The common ones are: Rheumatoid arthritis, systemic lupus erythematosus, polyarthritis nodosa, rheumatic fever, cranial arteritis/polymyalgia in the old. Usually young adult female with imperfect thermoregulation • Cause may remain unknown in 10−20% of the children Temperature rarely exceeds 37. Do the following • Repeated history taking and examination may detect: − new clinical features that give a clue − old clinical signs previously missed or overlooked • New tests: − immunological: rheumatoid factor (Rh. Refer If • Patient deteriorates rapidly • New tests described above are not available in your centre • Invasive procedure is required. The liver size should be described as centimetres below costal margin and below xiphisternum. Since splenomegaly is an extremely common sign and commonly related to malaria, probably splenomegaly smaller than grade 3 Hacket will not cause major concern. If tests normal, treat as idiopathic splenomegaly syndrome, proguanil 50 mg daily below 3 yrs, 100 mg in older children for ½ yr or until spleen is definitely smaller. In general terms, hyperbilirubinaemia may be pre− hepatic, hepatic and post−hepatic. Clinical Features Meticulous history and physical examination are important before ordering investigations. History should include: exposure to hepatotoxic drugs; known haematological disorder; history of anorexia, nausea and aversion to smoking suggestive of viral hepatitis); history of dark urine, pale stool and pruritus suggest obstructive jaundice. Physical examination should include observation for presence of spider naevi, gynaecomastia, loss of axillary hair, parotid gland enlargement and ascites suggestive of cirrhosis; splenomegaly indicative parenchymal liver disease or haemolytic jaundice. Sickle cells may be seen in the peripheral blood smear • Reticulocyte count − Increased reticulocyte count indicates a haemolytic anaemia. Protein content >3 gm% is found in tuberculosis, peritoneal tumours, peritoneal infection or hepatic venous obstruction. Blood stained ascites usually indicates a malignant disease − cytology is mandatory. Management • Patients with history and physical findings suggestive of viral hepatitis can be managed as out−patients requiring advice on bed rest, avoidance of alcohol. Consider hepatic encephalopathy in any patient who has jaundice and mental complain. Clinical Features • It presents as painless jaundice, pruritus which can be severe, and the jaundice progresses steadily • Distended gall bladder is present in 60% of Ca. Head pancreas • Anorexia is usually present • Diarrhoea is present and trouble−some with foul smelling − pale stool • Dark urine, history of flatulence, dyspepsia in fat females point to gall stones. Onset usually in the first 2−3 months of life and usually occurs in first year in 60% of patients. It commonly presents with the following skin lesions−erythema, papules, scaling, excoriations and crusting. Pruritus is the cardinal feature of eczema and the constant scratching leads to a vicious cycle of itch−scratch−rash−itch. Management • Parents should be educated on the disease and its natural history and be advised to avoid any precipitating factors eg − Avoid synthetic clothing − Avoid any food substance that seriously aggravates the eczema − Avoid letting the skin to dry excessively e. No need to use medicated soaps 288 − Avoid any of the petroleum jelly products on those who react (Vaseline, ballet, valon, ideal etc. As with other atopic conditions stress may aggravate eczema and thus older children should be encouraged to avoid stress. Allergic contact dermatitis Topical drugs, plants, shoes, clothing, metal compounds, dyes and cosmetics. Sensitivity to latex in gloves is a particular problem for many health worker and sensitivity to latex condoms may preclude their use by some men. Lesions may be acute vesicles or weeping subacute erythema, dry scaly with papules or chronic − lichenified (thickened) excoriated and hyper pigmented. The lesions may take the shape of offending item − shoes, watch, gloves, etc but may be asymmetric or oddly shaped. Management • Identify and remove causative agent • Drain large blisters but do not remove tops (roofs) • Apply gauze or thin cloths dipped in water or normal saline • Topical 1% hydrocortisone ointment for dry lesions and cream for wet lesions. Commonly associated with poor hygiene, crowded living conditions and neglected minor trauma. Causes large bullae containing pus and clear serum, which rupture easily leaving raw−areas. Admit If • Patient is toxic with suspected of septicaemia Patient Education • Spreads easily in schools • Isolate and treat infected individuals • Separate towels and bath facilities. Severity varies from localised form (bullous impetigo) to generalised form of epidermolysis. Clinical Features • Vesicles which are flaccid, gentle lateral pressure causes shearing off leaving raw areas • Focus of infection may be found in the nose, umbilical stump, purulent conjunctivitis, otitis media, nasopharyngeal infection Investigations • Pus swab for C&S is essential. Change antibiotics according to culture and sensitivity results • Skin care: 290 − topical care baths with normal saline − if widespread and weeping lesions are present treat like burns [see 1. Sources of infection include other persons, animals such as puppies or kittens and more rarely the soil. Tinea pedis (athletes foot) Scaling or maceration between toes particularly the fourth interspace. Tinea cruris An erythematous and scaly rash with distinct margin extending from groin to upper thighs or scrotum. Tinea corporis (body ringworm) Characteristically annular plaque with raised edge and central clearing scaling and itching variable. Tinea capitis (scalp ringworm) Mainly disease of children and spontaneous recovery at puberty normal. Tinea anguum Involves the nails and presents with nail discolouration and subungual hyperkeratosis (friable debris) Investigations • Direct microscopy of skin scale in 20% potassium hydroxide mounted on a slide to demonstrate hyphae. Transmission via beddings or clothing is infrequent (the mites do not survive for a day without host contact) Clinical Features • Intense itching worse at night or after hot shower • Burrows occur predominantly on the finger webs, the wrists flexor surfaces, elbow an axillary folds, and around the areolar of the breasts in females, the genitals especially male, along the belt line and buttocks. Day three bathe and apply • Other drugs: 5−10% sulfur ointment • Nonspecific: − personal hygiene − antihistamines for pruritus − treat the whole family and personal contacts • Treat secondary bacterial infection − cloxacillin in severe cases. Clinical Features Presents with characteristic dermatitis, diarrhoea, dementia and death if not treated. Weight loss, anorexia, fatigue, malaise, pruritus burning, dysphagia, nausea diarrhoea vomiting, impaired memory, confusion and paranoid psychosis. Clinical Features Symptoms develop gradually as: • Dry or greasy diffuse scaling of scalp (dandruff) with pruritus • Yellow− red scaling papules in severe cases found along the hairline, external auditory canal, the eye brows, conjunctivitis and in naso−labial folds. Management • Control scaling by 2% salicylic acid in olive oil • Shampoos containing selenium sulfide, sulfur and salicylic acid, or tar shampoos daily till dandruff is controlled (more recently ketaconazole shampoo is excellent) • Topical steroids − use mild lotion (e.