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By D. Narkam. San Francisco Law School.

When babies are about 1 year old buy 500 mg keppra visa medicine zantac, they have quite a lot of fat under the skin of their arms keppra 500mg for sale medicine reactions. The distance around the upper arm remains almost the same between the ages of 1 and 5 years cheap 250 mg keppra with visa treatment 4 autism. By placing a special measuring strip around the upper arm one can find out whether a child between the ages of 1 and 5 is undernourished or not buy 250mg keppra treatment jellyfish sting. To use this strip: Put the strip around the mid upper arm of the child and see which colour is touched by the 0 cm end of the strip. This method of measuring the arm is useful because the health worker can identify undernutrition in a child without using a scale or knowing the child’s age. However, since it only shows large changes in a child’s nutrition, it is not suitable for determining whether the child is improving or becoming worse. The severity of these diseases varies from “subclinical” requiring little or no treatment to life threatening requiring intensive care. The diseases have been indexed alphabetically rather than by severity, incidence or mode of transmission. Two of the most important diseases, tetanus and rabies, stand alone because of their severity and widespread distribution throughout much of Europe. In addition you should be able to identify the needs of a patient requiring intensive nursing care. Such infections are spread to humans by arthropods (insects and their close relatives), especially mosquitoes, ticks and flies, which bite the human and consequently introduce the infection into the human blood stream. Such organisms are capable of surviving for long periods in hostile environments and of reactivating under suitable conditions. It environmental, seasonal, economic and social is primarily a disease of herbivorous animals, but factors. The severity of these diseases varies from it can infect all mammals including humans. The diseases such as wool, hair, hides, skins, bones, bonemeal have been indexed alphabetically rather than by and the carcasses of infected animals. There are three main modes of transmission: • direct contact with skin – infection is passed on by the handling of contaminated animal products, resulting in a cutaneous infection. Epidemiological summary Anthrax is now unusual in Western Europe but sporadic cases still occur especially in animals such as cattle. Cutaneous infection: • The bacterium enters through a cut or abrasion on the skin when handling contaminated wool, hides, leather or hair products of infected animals. Module 4 Page 99 • Within a few days a painless ulcer (1–3cm) with the typical Gram positive bacilli of Bacillus anthracis a black necrotic area in the centre develops; this is from skin lesions, respiratory secretions, blood or called an eschar. Methods of treatment Respiratory infection To be effective, treatment should be initiated as • Very difficult to diagnose early. Antibiotic therapy does not affect the cyanosis, stridor and possible subcutaneous oedema healing process or evolution of the skin lesion, but of the neck and chest can develop. If the • Death usually results soon after the onset of acute infection is spreading or if systemic symptoms are symptoms. Successful prevention • Abdominal pain, haematemisis and bloody depends upon: diarrhoea develop. Nursing care Patients with cutaneous anthrax may require dressings to prevent secondary infection of the lesions. Soiled dressings should be incinerated, autoclaved or otherwise disposed of as biohazardous waste (see Module 1). The patient is likely to be very unwell and may have an elevated pulse, respiratory rate and temperature. Although person-to-person transmission of anthrax has never been documented, universal precautions should be adopted when providing care for such patients. Most cases occur in persons involved with the • Through direct transmission, that is, through contact livestock industry, such as farmers, agricultural with blood or tissues from infected livestock. Manifestations Treatment • The incubation period following a tick bite is 1– General supportive therapy is the mainstay of 3 days. The antiviral drug Ribavirin, • The incubation period following contact with given both orally and intravenously, has been used infected blood or tissue may be 5–6 days with good results. Nursing care • Nausea, vomiting, sore throat, abdominal pain Many of these patients will develop complications and diarrhoea may present. It is therefore imperative that adequate control measures are taken to prevent this. Prevention of spread Persons living in endemic areas should be aware of the disease and how it is transmitted. Personal protective measures include: • avoiding areas where tick vectors are abundant, especially during April and September when they are active; • wearing protective clothing (long trousers, socks); • using an insect repellent, and • skin should be inspected for ticks every few hours and any ticks found should be removed immediately. Persons who work closely with livestock in endemic areas should wear gloves and protective clothing to prevent skin contact with infected tissue or blood. Vaccine Although an inactivated, mouse brain-derived vaccine has been developed and used on a small scale in eastern Europe, there is no safe and effective vaccine widely available for human use. Page 103 Page 103 Hantavirus Definition Yugoslavian army demonstrated an association Several types of hantavirus exist. While hantaviruses between outbreaks of this disease and army field found in the Far East (Korea and China) can cause exercises. Mode of transmission Diagnosis These viruses are spread in the urine and respiratory This is made by identifying specific hantavirus secretions of infected rodents, especially field mice antibodies in the blood. Treatment and nursing care Epidemiological summary There is no specific treatment for this virus, but Most cases are reported during the summer for severe cases, supportive measures and intensive especially in rural and semi-rural areas. Manifestations • Nephropathia epidemica • Initially a flu-like illness then renal failure and oliguria • Raised liver enzymes • Less than 0. Early diagnosis can be made by the detection of • Further complications include disseminated antigen in urine. Treatment Intravenous Erythromycin and/or oral Rifampicin Risk factors is the treatment of choice, substituted with oral A person’s risk of acquiring legionellosis following Erythromycin once symptoms improve. With exposure to contaminated water depends upon a appropriate antibiotic therapy the mortality of number of factors including: legionnaires disease is low in immunocompetent • The type and intensity of exposure patients. Intensive supportive care will be required Page 105 • The exposed person’s health status (those with for those who develop severe symptoms. Module 4 Page 105 Leishmaniasis Infection control Definition This disease is not contagious from person to Leishmaniasis is caused by the protozoan person, so isolation precautions are not required. Sterile water should be used to fill reservoirs of devices used for nebulization or for rinsing such Mode of transmission devices and other respiratory care equipment after Leishmaniasis is transmitted to humans by the disinfection. The sandfly bites on an animal or create aerosols should not be used unless they can human in order to obtain a blood meal to develop be sterilised or subjected to high-level disinfection. If this blood contains the leishmania parasites, these will continue to develop inside the Prevention of spread sandfly over a period of 4–25 days. When the Environmental health measures should include sandfly feeds again on a fresh source, transmission regular cleaning and maintenance of water supplies of the disease continues. Diagnosis The most accurate way to diagnose is to identify Manifestations of Visceral Leishmaniasis (also the parasite by microscopy or to culture material known as Kala-azar) on a medium that allows their growth. This type This is the most serious form of leishmaniasis, and of diagnosis will involve obtaining material from is fatal if left untreated. Page 107 Early infection • After inoculation by the biting sandfly, the Blood tests can be used to try and identify parasite may multiply locally causing a cellular antibodies, but this can give a false positive result. Their nutritional status and potential deficiencies must be addressed, and any associated bacterial infections promptly diagnosed and treated. These are given over a period of 30 days, but haematological and parasitological follow up should extend to one year to prevent any relapse. Prevention of spread This is dependant upon: • control of the sandfly population through reducing breeding sites such as dark, moist habitats (cracks in masonry, piles of rubble and the bark of dead trees.

The possibility that topical tretinoin could be responsible for fetal malformations after usage for acne has been extensively investigated best keppra 500 mg symptoms 8 dpo bfp, but discounted because insufficient is absorbed through the skin purchase 500mg keppra fast delivery treatment 2nd degree burn. Fortunately buy generic keppra 500 mg online medications errors, this applies to most of the routine topical agents used for psoriasis 250 mg keppra with visa treatment goals and objectives, eczema and acne – providing the affected area does not amount to 10 per cent or more of the body surface area. Effects of intercurrent maternal disease on the fetus The fetus is occasionally affected by skin disorders in the mother. This is obvious with dominant disorders such as some of the ichthyoses (see page 246). This may be the case in lupus erythematosus and, in one rare variety of this condition, congenital heart block can be induced in the child. In most of these cases, the fetal skin disorders only last as long as the transplacentally transmitted antibodies in the newborn child’s circulation. Syphilis may still be a problem if undiag- nosed and then transmitted congenitally. Other infective skin disorders that may be passed from mother to fetus include chickenpox, herpes simplex, candidiasis and warts, although the last two are better classified as ‘intranatal’ infections, as they are caught from the birth passages. Their causes are unknown, they are transient, remitting spontaneously before delivery or, at worst, shortly afterwards, and they produce much discom- fort. The rash mostly occurs over the abdomen and flanks, but also appears on the upper limbs. The lesions are mainly micropapules, but in some patients red, urticaria-like plaques develop (Fig. Case 15 Charlotte, aged 24, is 7 months pregnant with her first child and has suddenly developed an itching, red rash on her abdomen, buttocks and thighs. Apart from striae and midline pigmentation, there are only a few nondescript papules to see. This is the common maculopapular rash of pregnancy, which will quickly subside when she has been delivered and will obtain some relief from simple emollients. The eruption starts on the flanks or over the abdomen with itchy urticarial papules and vesicles and blisters (Fig. The blistering is subepidermal and is quite similar to that seen in senile pemphigoid (see page 88). There is often a circulating antibody directed to the dermoepidermal junctional area, although this is present in ‘low titre’. The rash usually remits shortly after birth, but may recur in subsequent preg- nancies or even after taking oral contraceptives. Great care should be after delivery but may recur in subsequent taken to ensure that the developing fetus is not pregnancies. In this process, which takes about 14 days, plump, cuboidal or spheroidal, hydrated, highly meta- bolically active cells gradually become tough, hardened, biochemically inactive, thin, shield-like structures that are programmed to desquamate off the skin sur- face (Fig. This process is biochemically complex and it is not surprising that it is subject to genetically determined errors. During keratinization, a tough, chemically resistant, cross-linked protein band is laid down just inside the plasma membrane and the whole cell flattens to a thin disc (corneocyte, Fig. The corneocyte’s water content is reduced from the usual 70 per cent to 30 per cent and most of the cellular organelles, including its nucleus, are eliminated. The ker- atinous tonofilaments become organized in bundles and are spatially orientated. A further characteristic feature of the normal stratum corneum is the presence of an intercellular cement material that contains non-polar lipid and glycoprotein. It also pro- vides some mechanical protection and prevents penetration by microbes. Thus, regardless of the particular metabolic fault ultimately respon- sible, the final common pathogenetic pathway is a failure in the normal loss of intercorneocyte binding forces (cohesion) in the superficial portion of the stra- tum corneum. The term ichthyosis is used to describe generalized, non-inflammatory disorders of keratinization and implies a congenital origin. There is a primitive revulsion at a disordered skin surface, which results in significant isolation and social and emotional deprivation. Patients with chronic 244 Xeroderma skin disorders often become severely depressed. Also, it is not often appreciated just how severely physically disabled some patients with skin disease are. The abnormal scaling and hyperkeratotic skin does not have the normally excellent extensibility and compliance, so that movements are limited. The term derives from the Greek xeros, meaning dry, and xeroderma just means dry skin. Because the appearance of scaling transiently disappears if the abnormal skin is hydrated, it has mistakenly been believed that scaling is the manifestation of water deficiency. Ageing tends to make the surface of the skin feel ‘drier’ and this seems to be associated with prur- itus in susceptible individuals. A low relative humidity aggravates the problem, as does repeated vigorous washing, especially in hot water with some soaps and cleansing agents. Presumably, the toilet procedures leach out important sub- stances that are vital to the integrity of the stratum corneum. Xeroderma tends to be worse in the wintertime and, when accompanied by itching, is known, logically enough, as ‘winter itch’. It has been sug- gested that this is a manifestation of ichthyosis, but there is more evidence in favour of the disorder being the result of the eczematous process itself. Xeroderma is also seen during the course of severe wasting diseases such as carcinomatosis, intestinal malabsorption and chronic renal failure, but should not be confused with acquired ichthyosis (Table 16. It is seen in ‘ordinary xeroderma’, in autosomal dominant ichthyosis, and sometimes in normal young women for no apparent reason. If the patient lives in centrally heated rooms, humidifiers should be employed to raise the rela- tive humidity. Emollients act for a short time only – up to 2–3 hours at most – and need to be frequently applied. Their action can be supplemented by bath oils, which deposit a film of lipid on the skin surface. It spares the flexures and is most notice- able over the extensor aspects of the limbs and trunk, being most noticeable over the back, the lateral aspects of the upper arms, the anterolateral thighs and par- ticularly the shins (Fig. Keratosis pilaris may be seen over the outer aspects of the upper arms in a few subjects. The condition is hardly noticeable in most people, but is quite marked and disabling in a few. It has been estimated that the gene occurs with a frequency of 246 Sex-linked ichthyosis Figure 16. Histologically, the only abnormality detectable is a much diminished granular cell layer (Fig. Ultrastructurally and biochemically, there is decreased content of a basic histidine- rich protein known as filaggrin, which is important in the orientation of the keratin tonofilaments. Patients who have very severe scaling may be helped by the use of topical keratolytic agents, including preparations containing urea (10–15 per cent) and salicylic acid (1–6 per cent). The latter is particularly effective in encouraging desquamation, but may not be used on large body areas for any length of time, as salicylic acid preparations when applied to abnormal skin may cause salicylate intoxication (sal- icylism). The reason for this appears to be a pla- cental deficiency of the steroid sulphatase and a consequent failure of the usual splitting of circulating maternal oestrone sulphate in the last trimester of pregnancy. The free oestrone is thought to have a role in priming the uterus to oxytoxic stimuli. It is also more marked over the extensor aspects of the body surface, but does not always spare the flexures and often affects the sides of the neck and even the face. The scales are often quite large, particularly over the shins and have a dark-brownish discoloration. Patients with sex-linked ichthyosis may be signifi- cantly disabled by their disorder.

They may also need to use a feeding pump at night and for emergency feedings should their blood sugar drop dangerously low buy 500 mg keppra mastercard treatment for ringworm. Cornstarch is digested slowly and therefore releases its glucose gradually cheap keppra 250 mg line medicine sans frontiers, helping to safely extend the time between meals generic keppra 500mg on-line medications borderline personality disorder. Without close monitoring of the diet however buy 500mg keppra overnight delivery medicine cabinets with lights, extremely low blood sugar can be fatal. Long- term complications can include kidney damage, brittle bones (osteoporosis), benign cysts on the ovaries (in women), and benign tumors of the liver (adenomas). Detection Population Rate* 45% African American 45% Ashkenazi Jewish 45% Eastern Asia 45% Finland 45% French Canadian or Cajun 45% Hispanic 45% Middle East 45% Native American 45% Northwestern Europe 45% Oceania 45% South Asia 45% Southeast Asia 45% Southern Europe * Detection rates shown are for genotyping. The lack of this enzyme means the body cannot properly break down glycogen, a stored form of sugar. As a result, glycogen cannot properly be used to energize the body and glycogen molecules accumulate in the body. This enlargement usually subsides with puberty, although there may be long term liver damage. Children with the disease may experience delayed growth, but usually reach normal adult height. A minority of people with the disease also have a mildly enlarged heart, though its function is usually normal. The onset of the disease may occur in adulthood, which typically corresponds with milder symptoms. This disease is much more common in Israeli Jews of North African descent, where 1 in 35 are carriers and 1 in 5,400 babies has the disease. The highest rate is found among people on the Faroe Islands of the North Atlantic, where 1 in 30 is a carrier and 1 in 3,600 babies is afected. Physicians will monitor the liver, heart, and muscles in afected people and recommend physical therapy when necessary to promote better movement. Physicians may recommend consuming corn starch, which breaks down slowly into simple sugars and may alleviate symptoms of low blood sugar between meals. Parents of infants should be particularly careful to monitor the child’s diet to avoid hypoglycemic seizures. The Counsyl Family Prep Screen - Disease Reference Book Page 122 of 287 Glycogen Storage Disease Type V Available Methodologies: targeted genotyping and sequencing. Detection Population Rate* <10% African American 80% Ashkenazi Jewish 64% Eastern Asia 80% Finland 80% French Canadian or Cajun <10% Hispanic <10% Middle East <10% Native American 80% Northwestern Europe <10% Oceania <10% South Asia <10% Southeast Asia 80% Southern Europe * Detection rates shown are for genotyping. This defciency prevents an afected person from turning glycogen, a stored form of sugar, into glucose, which can be used for energy. The severity of the symptoms can vary, but in many people symptoms do not get signifcantly worse over time. About a third of The Counsyl Family Prep Screen - Disease Reference Book Page 123 of 287 adults with the disease experience progressive muscle weakening later in life. One study showed the disease incidence to be 1 in 100,000 in the Dallas-Fort Worth area of Texas in the United States. Too much physical exertion will result in muscle breakdown and severe kidney problems. Detection Population Rate* <10% African American <10% Ashkenazi Jewish <10% Eastern Asia >99% Finland <10% French Canadian or Cajun <10% Hispanic <10% Middle East <10% Native American <10% Northwestern Europe <10% Oceania <10% South Asia <10% Southeast Asia <10% Southern Europe * Detection rates shown are for genotyping. Iron overload The body does not metabolize iron properly, leading to excess levels, particularly in the liver. Lactic acidosis Lactic acid builds up in the body, causing the blood to become too acidic. Here, researchers estimate that 1 in 47,000 babies are afected, meaning that roughly 1 in 110 Finnish people are carriers of the genetic mutation. There have been reports of several infants in the United Kingdom and Turkey with similar but not identical symptoms. Experimental treatments to reduce acidity and/or iron levels in the infants’ blood have not been shown to extend life beyond several months. The Counsyl Family Prep Screen - Disease Reference Book Page 126 of 287 Hb Beta Chain-Related Hemoglobinopathy Including Beta Thalassemia and Sickle Cell Disease Available Methodologies: targeted genotyping and sequencing. Detection Population Rate* 78% African American 83% Ashkenazi Jewish 86% Eastern Asia 83% Finland 83% French Canadian or Cajun <10% Hispanic 72% Middle East <10% Native American 83% Northwestern Europe <10% Oceania 86% South Asia 86% Southeast Asia 93% Southern Europe * Detection rates shown are for genotyping. Hb beta chain-related hemoglobinopathies are a group of inherited blood disorders that afect hemoglobin, the major component of red blood cells which carries oxygen throughout the body. People with Hb beta chain-related thalassemia do not produce enough beta protein—and in some cases do not produce it at all—resulting in a shortage of red blood cells (anemia). Without sufcient numbers of properly functioning red blood cells, the organs of the body do not receive enough oxygen. There are The Counsyl Family Prep Screen - Disease Reference Book Page 127 of 287 three main types of beta thalassemia. The lack of oxygen can cause him or her to be pale, listless, tired, and irritable. Without frequent blood transfusions, the condition can be life-threatening at an early age. Beta thalassemia intermedia, a less severe form of the condition, causes mild to moderate anemia and a wide spectrum of possible health problems. The types of symptoms are the same as with thalassemia major, including bone deformities and an enlarged spleen, though these are typically not as severe. People with thalassemia intermedia require fewer blood transfusions and use them to improve the quality of their lives. Sickle cell disease is a type of hemoglobinopathy caused by two Hb S mutations, or one copy of the Hb S mutation along with a beta thalassemia mutation. The sickled blood cells die prematurely, causing a person to feel weak and tired, a condition known as anemia. People with sickle cell anemia develop symptoms including anemia, repeated infections, shortness of breath, fatigue, jaundice, and bone pain starting in early childhood. These sickled cells also get stuck in small blood vessels, blocking blood fow and causing serious medical complications such as blood-starved organs or tissue deterioration. The most recognizable symptom is episodes of acute back, chest, or abdominal pain called "crises. Interactions between beta globin proteins and these mutations can alleviate or exacerbate the efects of the individual variants. Thalassemias are most common in people of Mediterranean descent, especially in those from Sardinia and Cyprus. In Cyprus, 1 in 7 people are carriers of beta thalassemia, a rate which prompted a successful government-run disease prevention program. The Counsyl Family Prep Screen - Disease Reference Book Page 128 of 287 Sickle cell disease is common in people from Africa, the Mediterranean, the Arabian Peninsula, India, South America, and Central America. In the African American population, approximately 1/10 people are carriers of sickle cell. Ethnic Group Carrier Rate Afected Rate Cypriot 1 in 7 1 in 170 Sardinian 1 in 8 1 in 240 Italian 1 in 31 1 in 3,700 Middle Eastern 1 in 34 1 in 4,500 Southeast Asian 1 in 35 1 in 4,800 East Asian 1 in 62 1 in 15,000 Indian 1 in 64 1 in 16,000 How is Hb Beta Chain-Related Hemoglobinopathy treated? The most common treatment for beta thalassemia is blood transfusions, which provide a temporary supply of healthy red blood cells to bring oxygen to the body. Among people with thalassemia major, transfusions may take place every two to three weeks. While these transfusions can be life-saving and life- enhancing, they result in a toxic buildup of iron in the blood. To counteract this side-efect, people with beta thalassemia require a procedure called chelation therapy in which a medication is taken to eliminate excess iron from the body. These individuals require frequent monitoring by a physician to assess the efcacy of transfusion/chelation therapy.

Clinical Features Presents with characteristic dermatitis keppra 250 mg with mastercard medicine 44 159, diarrhoea generic keppra 500 mg line treatment nausea, dementia and death if not treated cheap 500 mg keppra medicine bg. Weight loss order keppra 250 mg with mastercard symptoms ms, 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. It is an infiltration into the dermo−epidemial junction by mono−nuclear cells leading to vesicle, generally found in the extremities, palms and soles in the mild form of disease. Refer to ophthalmologist • Mouth care − antiseptic wash • Keep patient warm • Cradle nursing. Serious, life threatening reaction pattern of the skin characterised by generalised and confluent redness with scaling associated systemic toxicity, generalised lymphadenopathy and fever. Constitutional symptoms − fatigue, weakness, anorexia, weight loss, malaise, feeling cold (shivering) clinically skin is red, thickened and scaly, commonly without any recognizable borders. Prognosis: Guarded and therefore a medical problem that should be dealt with using modern inpatient dermatology facility and personnel. Management Bath soaking • Bland emollients: Liquid paraffin, Emulsifying ointment • Nursing care − single room, keep warm etc. History i) A thorough history must be taken (this should include a history of chronic illnesses, a drug history and history of previous surgical encounters). Examination i) A thorough physical examination and in particular check for: − anaemia 295 − jaundice − level of hydration − fever − lymph node enlargement. For any major operation a check chart need be kept for at least 24 hours before surgery. Management − Supportive before surgery Correction of conditions that are identified in the evaluation is necessary and critical: • Correction of volume and electrolyte imbalance • Control of blood pressure • Control of thyrotoxicosis • Control of diabetes mellitus (and any other metabolic disease) • Correction of anaemia and malnutrition • Prophylactic antibiotics where indicated [see appropriate section for details]. A pint of blood is removed every 7 days prior to surgery and is re−transfused at the time of surgery. It is important to liaise with the blood donor bank to ensure that the patient gets his own blood • Do not correct post−operative anaemia with transfusion if there is no active bleeding or shock. The administration of antibiotic agents to prevent infection cannot be substituted for either sound surgical judgement or strict aseptic technique. Other highly contaminated wounds involve operations on the large intestines and severe burns. Other high risk factors include: • Development of infection because of malnutrition, impoverished blood supply, obesity, old age and immunodeficiency states • Treatment− specific factors such as use of steroids, anticancer agents and radiotherapy • Operative procedures of long duration such as cardiac and vascular procedures, orthopaedic and in neurosurgery • Insertion of a prosthesis or graft. Management • Prophylactic use of antibiotics should be distinguished in dosage and duration from their therapeutic use. To achieve the above, the surgeon must give legible, concise and clear post−operative instructions. Transit from theatre to ward • Keep airway clear to avoid upper airway obstruction and aspiration pneumonitis. Titrate against state of hydration • Watch for airway obstruction, reactionary bleeding, etc. Post−operative period 72 hrs−7 days • Mobilise out of bed about 18−72 hrs to avoid static pneumonia and deep vein thrombosis • Encourage independence e. It is critical in these patients that a variety of diagnosis be suspected and diagnosed or clearly excluded before definitive management. Clinical Features Meticulous history and physical examination is very important in establishing diagnosis. Abdominal pain, distension, guarding, rigidity, altered bowel sounds, alteration of bowel habits. In adults suspect bowel obstruction if, there is constipation, abdominal distension, fever (if advanced obstruction is present), features of dehydration exist, altered bowel sounds, abdominal pain, vomiting. Management • Correct fluid and electrolyte imbalance • Group and cross match blood • Deflate the distended stomach with nasogastric suction. This is more effective for small bowel than in large bowel obstruction • High enema may be effective for faecal impaction only • Remove the cause of the obstruction usually by surgery. The aseptic type is usually due to chemical irritants like bile, gastric juices, etc. Peritonitis usually ends up producing adhesions that may cause future bowel obstructions of varying degrees. Clinical Features Presentation is with an acute tender abdomen, abdominal distension, altered bowel sounds, guarding, rigidity, rebound tenderness and fever. These are usually disturbed by movement of fluid and electrolytes into the third space. The disturbance could arise or be made worse by vomiting and/or diarrhoea • Nasogastric suction is usually necessary because of organ hypotonia and dilatation • Antibiotics to cover a broad spectrum of bacteria should be used. The pain may be relieved briefly after perforation but is accentuated by the ensuing diffuse peritonitis. There is rebound tenderness, muscle guarding, cutaneous hyperaesthesia: Pelvic tenderness in the right iliac fossa on rectal examination. There is no great advantage of differentiating indirect from direct inguinal hernia, pre−operatively. Management • Surgical repair is necessary for all inguinal hernias • In strangulation, with obstruction of viscus, especially bowel the usual resuscitative measures are carried out before and after surgery. Complications • Obstruction This occurs when a hollow viscus goes through a ring of variable size and cannot be reduced. This if not corrected culminates in ischaemia of the viscus supplied by the involved blood vessels. Sudden change from reducible to irreducible status especially if discolouration of tissues over the area is present is an ominous sign. Management • Treatment involves incision and drainage • Indications that an abscess needs incision and drainage include; incomplete pus discharge, throbbing pain, a localised swelling that is tender, hot, usually with a shiny skin and with fluctuation. Technique involves: • Preparing the area by cleaning and draping • If not under general anaesthesia, spraying the area with spray anaesthetic (ethyl chloride) • Test needle aspirate if not already done • Incision into the soft part of abscess. Leave a wick of gauze (Vaseline) to facilitate drainage • Breast abscess may require counter incisions leaving in a corrugated drain for about 24 hours • Leave the wounds to heal by granulation • Hands and feet abscesses will require multiple incisions with counter incisions in some areas and elevation of the limbs • Peri−anal and ischio−rectal abscesses (together with hand abscesses) require general anaesthesia. Ask the patients to add 1 to 2 teaspoons of salt into the water • Recurrent peri−anal and ischio−rectal abscesses necessitate procto−sigmoidoscopy to rule out anal fissures or fistulae. Other abscesses may or may not need antibiotics depending on the presence or absence of local cellulitis. Bleeding Painless bleeding is commonly due to haemorrhoids but may be due to colorectal carcinoma. Perianal mass The patient complains of feeling a mass (usually prolapsed haemorrhoids or anal tags). Trauma (obstetric, operative, accidental), the sphincters and anorectal ring are injured. Anorectal disease (rectal prolapse, third degree haemorrhoids and anorectal cancer). Common in children and elderly (especially females 85% of adults) but may occur at any age. Clinical Features Clinically three types of prolapse are recognized: 1° − prolapse with spontaneous reduction 2° − prolapse with manual reduction 3° − prolapse which is irreducible Most patients will present with reducible prolapse, otherwise: prolapse during defaecation associated with discomfort, bleeding and mucus discharge. Ask the patient to bear down and strain; prolapse will usually occur Check for Patulous anus. Complications Irreducibility with ulceration, bleeding, gangrene with rupture of bowel. Clinical Features More common in females in their midlife, and uncommon in the elderly. Digital examination and proctoscopy is painful, and can be performed after application of 5% xylocaine gel.

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