Conversely generic imipramine 50mg free shipping anxiety and alcohol, physical inactivity appears to be associated with the develop- ment of psychological disorders generic 50 mg imipramine amex anxiety symptoms pictures. Exercise compares favorably to antidepressant medications as a first-line treatment for mild to moderate depression and has also been shown to improve depressive symptoms when used as an adjunct to medications generic 75 mg imipramine overnight delivery anxiety 39 weeks pregnant. While not as extensively studied discount 25mg imipramine fast delivery anxiety symptoms in children, exercise has been shown to be an effective and cost-efficient treatment alternative for a variety of anxiety disorders. While effective, exercise has not been shown to reduce anxiety to the level achieved by psychopharmaceuticals. Depression is the leading cause of disability worldwide and is predicted to be the second largest contributor to the global burden of disease by the year 2020 . More than 30 million Americans have a lifetime history of anxiety, and anxiety disorders cost an estimated $42 billion per year in the United States [9, 10]. The most common types of anxiety disorders are generalized anxiety disorder, panic disorder, social anxiety disorder, and posttraumatic stress disorder [11-15]. Although options for pharmacologic treatment have expanded significantly in the past 20 years, between one- and two-thirds of patients will not respond to the first antidepressant prescribed, and 15 to 33% will not respond to multiple interventions [16-18]. Additionally, anxiolytic and antidepressant medications are expensive and associated with a number of serious and quality of life altering side effects. Physical activity and exercise have been recommended for the prevention and treatment of numerous diseases and medical conditions (see Table 1). Most notably, habitual physical activity prevents the development of coronary artery disease and reduces symptoms in patients with established cardiovascular disease . Evidence also supports the role of exercise in reducing the risk of other chronic diseases such as type 2 diabetes mellitus, osteoporosis, obesity, and cancer of the breast and colon. In addition, exercise and physical activity have been recommended for the treatment of depression and anxiety. Definition of Physical Activity and Exercise Physical Activity Bodily movement produced by skeletal muscles that results in energy expenditure beyond resting level. Exercise Subset of physical activity that is planned, structured, repetitive, and purposeful. Subsequently, physical activity has been shown to be associated with decreased symptoms of depression and anxiety in numerous studies [22-25]. For example, in a nationally representative sample of adults ages 1554 in the United States (n = 8,098), regular physical activity was associated with a significantly decreased prevalence of current major depression and anxiety disorders . Physical activity was not found to be significantly associated with other affective, sub- stance use, or psychotic disorders. Habitual exercise correlates to a heightened level of mental health and well- being and reduced feelings of anxiety regardless of the gender of the indi- vidual. In a group of men (n = 5,451) and women (n = 1,277), relative increases in maximal cardiorespiratory fitness and habitual physical activity are associated with lower depressive symptoms and greater emotional well-being . Ohta  noted that 30 minutes or more of walking or cycling while commuting to work may be associated with an increased perception of mental health in men. In contrast to gender, the age of the individual may affect the relationship between physical activity and mental health. Exercise has a very small but statistically insignificant effect on reducing anxiety in adolescents [31, 32]. In contrast, Fox  found that a population of European adults over the age of 70 had perceived levels of health and quality of life that were positively correlated to higher levels of physical activity. While regular physical activity appears to be related to mental well-being, physical inactivity appears to be associated with the development of psycho- logical disorders. Some cross-sectional and prospective-longitudinal clinical and epidemiological studies have shown a direct relationship between physical inactivity and symptoms of depression and anxiety . Most con- sistently associated with depression are the findings of volume loss in the hippo- campal formation [36-38]. As noted above, imaging studies have shown that depressed patients have decreased hippocampal volume . Ernst and colleagues  hypothesize that exercise similarly decreases depressive symptoms by increasing brain neurogenesis. Other possible mechanisms for exercises ability to improve mood include the association with exercise and increased levels of endocannabinoids, which are associated with analgesia, anxiolysis, and a sense of well-being . Finally, exercise improves self-concept in depressed patients, possibly leading to decreased depressive symptoms . The National Guideline Clearinghouse states in a consensus-based recommendation that exercise is recommended as an adjunctive treatment to antidepressants or psychotherapy . Multiple studies exist that suggest that exercise is an effective treatment for depression. A Cochrane meta-analysis of 25 randomized controlled trials com- paring exercise and placebo or a control intervention found that the exercise groups had a significant improvement in depressive symptoms when compared to the placebo or control group . Only three trials with sufficient allocation concealment, intention to treat analysis, and blinded outcome assessment were found (see Table 2). When these three trials were analyzed together, the effect size was not significant. Blumenthal  conducted a randomized controlled trial in which they assigned 156 adults over age 50 to either aerobic exercise, sertraline, or both. After 4 months, all three groups had a statistically significant improvement in their depressive symptoms with no statistically sig- nificant difference between the groups. The medication group did have a faster response to treatment in the first 4 weeks. The differences between the intervention and placebo groups were not statistically different. Exercise has also been shown to improve depressive symptoms when used as an adjunct to medications. Exercise significantly improved symptoms when added to an antidepressant in a group of older patients with depression that had not responded to 6 weeks of antidepressant medication alone . Unlike its benefit as an adjunct to antidepressive medications, exercise in addition to cog- nitive therapy was found to be no better than either alone . A dose-response effect with exercise in the treatment for depression has been noted. In one study, high intensity weight training was more effective than low intensity weight training in treating depression . Low intensity weight training and general practitioner care were found to have nearly the same improvement in depression that is consistent with the widely accepted number of the 30% placebo effect in depression treatment. With aerobic exercise, intensity equaling the energy expenditure in public health recommendations was more effective than a program of guided movements of low intensity that had a reduction in depressive symptoms equal to the placebo group . While more research is needed on the type of exercise needed for depression treatment, available research indicates that the type of exercise is not as impor- tant as having the physical activity reach a sufficient intensity. For example, both running and weight lifting were found to significantly decrease depressive symptoms with no significant difference found between these two forms of physical activity and the decrease in symptoms . In general, aerobic exercise has been shown to be an effective and cost-efficient treatment alternative for a variety of anxiety disorders . Several studies have indicated that aerobic exercise may be as effective in reducing generalized anxiety as cognitive behavioral therapy . Exercising at 70%90% of maximum heart rate for 20 minutes three times a week has been shown to significantly reduce anxiety sensitivity . Self- reported fears of anxiety sensations, fears of respiratory and cardiovascular symp- toms, publicly observable anxiety symptoms, and cognitive dyscontrol decrease following a prescribed exercise program .
Aspiration pneumonia: This occurs when large amount of oropharyngeal or gastric contents are aspirated into the lower respiratory tract buy 75mg imipramine visa anxiety kids. Aspiration occurs more frequently in patients with: Decreased level of consciousness (alcoholism buy imipramine 75 mg on line anxiety 54321, seizure order 25mg imipramine anxiety symptoms wikipedia, strokes or general anesthesia) Neurologic dysfunction of oropharynx and swallowing disorders buy 75mg imipramine with mastercard anxiety quitting smoking. Common Etiologic agents of Aspiration pneumonia: It is often polymicrobial o Anerobic organisms in the oral cavity o Enterobateriacae o S. Hospital-acquired pneumonia: a patient is said to have hospital acquired pneumonia if the symptoms begin 48 hours after hospital admission and not incubating at the time of admission. Common organisms that cause hospital-acquired pneumonia are:- o Gram-negative bacilli including Pseudomonas aeroginosa, K. Clinical Presentation of community acquired pneumonia Community acquired pneumonia can have typical or atypical presentations. The typical Community acquired pneumonia: is characterized by:- Sudden onset with a single shaking chill. Some viruses like influenza virus, Varicella zoster virus and cytomegalovirus may cause atypical pneumonia. Complications: Local: Parapneumonic effusion or pus in the pleural space (empyema). Diagnosis: Pneumonia should be suspected in patients with acute febrile illness, associated with chest pain, dyspnea and cough. Response In mildly ill patients who are treated early, fever subsides in 24 to 48 hrs. Treatment: Acutely ill patients who have suspected bacterial infections are often treated with antibiotics selected on the basis of probabilities and the findings with sputum gram stain and culture. Later treatment is adjusted on the basis of more definitive diagnostic evaluation. Bronchial Asthma Learning Objective: At the end of this unit the student will be able to 1. Definition: Bronchial asthma is defined as chronic inflammatory disease of airways characterized by increased responsiveness of the tracheobronchial tree to a multiplicity of stimuli. It is associated with widespread airway obstruction that is reversible (but not completely in some patients), either spontaneously or with treatment Epidemiology: Asthma is a common disease The prevalence of asthma is rising in different parts of the world. About 50% of patients develop asthma before the age of 10 and another 35% before the age of 40. Most cases of asthma are associated with personal or family history of allergic disease such as eczema, rhinitis and urticaria. Etiology Asthma is a heterogeneous disease and genetic ( atopic ) and environmental factors such as viruses, occupational exposure and allegens contribute to its initiation and continuance. In general asthma which has its onset early in life tends to have strong allergic component, where as asthma that develops late in life tends to be nonallergic or to have mixed etiology. The cells thought to play important part in the inflammatory response are mast cells, eosinophils, lymphocytes and airway epithelial cells. These cells release inflammatory mediators which may result Bronchoconstriction (spasm of airways smooth muscles ) Vascular congestion and edema of airways mucosa Increased mucus production Injury and desquamation of the airways epithelium and impaired muco-ciliary transport Symptom and Signs The symptoms of each asthmatic patient differ greatly in frequency and degree. Psychological factors particularly those associated with crying, screaming or hard laughing may precipitate symptoms. On physical examination Varying degrees of respiratory distress tachypnea, tachycardia, and audible wheezes are often present. However, low grade wheezing maybe heard at any time in some patients, even when they claim to be completely asymptomatic. Complications during an Acute Attack of Asthma Pneumothorax: It may present as sudden worsening of respiratory distress, accompanied by sharp chest pain and on examination, hyperresonant lung with a shift of mediastinum. A family history of allergy, rhinitis or asthma can be elicited in most asthmatics. Physical examination should search for heart failure and signs of chronic hypoxemia (clubbing). Treatment General principles Assessing the severity of the attack is paramount in deciding management Bronchodilators should be used in orderly progression Decide when to start corticosteroids Treatment of the Acute Attack Mild acute asthmatic attack: Most patients can be managed as an outpatient st Salbutamol aerosol (Ventolin) two puffs every 20 minutes for three doses is the 1 line of treatment. However, over hydration may cause pulmonary edema and one should be cautious in fluid administration. However this can be overcome when underlying hypoxia and feeling of asphyxiation is treated. Maintenance Therapy for Asthma (Chronic Treatment) Goal of Therapy: To achieve a stable, asymptomatic state with the best pulmonary function, using the list amount of medication. Step wise approach for managing Asthma in adults Severity Symptoms Medication Alternative day/night treatment in resource limited setting Mild 2 days/wk and 2 No daily medication intermittent nights /month needed Treat when there is acute exacerbation Mild > 2days /week but < Low dose inhaled steroids Theophedrine tablets Persistent 1 per day and > 2 or or Salbutamol tabs nights/month Cromolyn Moderate Daily symptoms and Low-medium does inhaled Theophylline Persistent more than 1 night /wk steroid and long acting B- sustained release agonist inhaler Salbutamol Tabs Prednisolone tablets (low dose Sever Continual daily High dose inhaled steroid Theophylline Persistent symptoms and and long acting inhaled B- sustained release 183 Internal Medicine frequent night agonists and Oral steroids Salbutamol Tabs symptoms (if needed ) Prednisolone tablets (high dose) or Celestamine tabs References: 1) Kasper L. Both these diseases occur together in the same individual in a variable proportion but the manifestations of one often predominates the clinical picture. Etiology Emphysema: Any factor leading to chronic alveolar inflammation would encourage development of an emphysematous lesion. Congenital enzyme defects such as 1- antitrypsin deficiency are also risk factors for the disease. In developing countries household smoke from fire wood is said to be a major contributing factor. Nowadays, the incidence of this disease in females is increasing because of the increasing smoking habit. Pathological changes and pathophysiology Chronic bronchitis is characterized by hypertrophy of mucus glands in both large and small airways with thickening of walls and accompanying excess production of mucus and narrowing of airway lumen. This leads to abnormal V/Q (arteriovenous shunt) and patients usually suffer from hypoxemia (manifested with cyanosis) and acidosis, which causes pulmonary hypertension and right heart failure in the long term. Moreover, emphysema causes mucus production and airway narrowing with accompanying reduction in ventilation. This leads to retention of carbon dioxide in the blood and severe dyspnea from reduced tissue perfusion. However, these patients dont suffer from hypoxia and acidosis, and have less chance of development of pulmonary hypertension and cor-pulmonale. However, patients usually have a mixed picture of emphysema and chronic bronchitis. In patients with chronic bronchitis, severe hypoxemia may be noted relatively early. The course can be repeated at the first sign of recurrence of bronchial infection. Oxygen should be given in such patients with hypoxia, and in severe cases a portable oxygen therapy ( 16 hrs /day) for home use is recommended. Antidepressants may be necessary but they should be used cautiously to avoid sedation. If sputum becomes purulent, a course of broad-spectrum antibiotics should be given. Phlebotomy 189 Internal Medicine should be done when the hematocrit level is very high (above 55%) and patients are symptomatic. Design appropriate methods of prevention of bronchiectasis Definition: It is a pathologic, irreversible destruction and dilatation of the wall of bronchi and bronchioles, usually resulting from suppurative infection in an obstructed bronchus. Etiology and pathogenesis: Small bronchi of children are susceptible to recurrent infections and obstruction by foreign body, lymph node, or impacted secretions, all of which lead to persistent infection and the development of bronchiectasis. Clinical features Chronic cough productive of copious and offensive purulent sputum is the cardinal feature of bronchiectasis. The sputum typically forms three layers when collected in a glass container: the upper layer is foam (mucus), the middle one is liquid and the lower one is sediment. Obtaining a history of recurrent pulmonary infections ultimately followed by chronic recurrent cough and production of copious purulent sputum may suggest a diagnosis of bronchiectasis. Additional findings like cyanosis, clubbing and signs of right heart failure appear late.
Cholecystectomy is also considered in The functions of the liver are carried out by the hepa- younger patients with asymptomatic gallstones in or- tocytes effective 25 mg imipramine anxiety symptoms 7 year old, which have a special architectural arrangement 75mg imipramine with amex anxiety zone ms fears. Blood enters the liver through the portal tracts best 50mg imipramine anxiety symptoms ringing in ears, which Carcinoma of the gallbladder is treated by wider resec- contain the triad of hepatic artery imipramine 75 mg with visa anxiety urinary frequency, portal vein and bile tion, including neighbouring segments of the liver and duct. The lobule is classically used to Open cholecystectomy is usually performed through describe the histology of the liver (see Fig. Cholangiography may be used to The hepatocytes in zone 1 of the acinus receive well- visualise the duct system. The gallbladder is removed oxygenated blood from the portal triads, whereas the with ligation and division of the cystic duct and artery. The liver has multiple functions, which may be im- Aetiology paired or disrupted by liver disease: The causes of acute hepatitis: r Carbohydrate metabolism: The liver is one of the ma- r Acute viral hepatitis may be caused by the hepa- jor organs in glucose homeostasis under the control totrophic viruses (A, B and E) or other viruses such as of pancreatic insulin. Excess glucose following a meal EpsteinBarr virus, cytomegalovirus and yellow fever is converted to glycogen and stored within the liver. The liver is also involved in the breakdown of amino acids producing ammonia, which is converted Pathophysiology to urea and excreted by the kidneys. Cellular damage results in impairment of normal liver r Fat: The liver is involved in synthesis of lipoproteins function: bilirubin is not excreted properly resulting in (lipid protein complexes), triglycerides and choles- jaundice and conjugated bilirubin in the urine, which terol. Swelling of the liver results in stretching of the liver capsule which may result in pain. However,itissometimesdiagnosed may be an enlarged, tender liver, pale stools and dark earlier than this. Stigmata of chronic liver disease should be looked for to exclude acute on chronic liver disease. Aetiology The main causes of chronic hepatitis: Microscopy r Viral hepatitis: Hepatitis B virus (+/ hepatitis D), Acute viral hepatitis has a histological appearance which hepatitis C virus. Complications Clinical features Fulminant liver failure, chronic hepatitis, and cirrhosis. Patients may present with non-specic symptoms (malaise, anorexia and weight loss) or with the compli- Investigations r cations of cirrhosis such as portal hypertension (bleed- Serum bilirubin and transaminases (aspartate ing oesophageal varices, ascites, encephalopathy). Asymp- Ultrasound may be needed to exclude obstructive tomatic patients with chronic viral hepatitis may be de- jaundice, if applicable. This includes careful uid balance, which is likely to progress rapidly to cirrhosis with adequate nutrition and anti-emetics. Where possible re- chronic inammatory cells inltrating the portal moval of the causative agent, e. Patients require se- to central veins or central veins to each other (bridging rial liver function tests (including clotting) to follow the necrosis). Pathophysiology Complications All the liver functions are impaired (bilirubin meta- Cirrhosis is the most common complication. Femini- Investigations sation in males and amenorrhea in females are common Chronic hepatitis is diagnosed by a combination of per- in alcoholic liver disease and haemochromatosis due to sistently abnormal liver function tests and the ndings alterations in the hypothalamicpituitarygonadal axis. Other investigations are aimed at diag- Reduced immune competence and increased suscepti- nosing the underlying cause and providing a prediction bility to infection also occur. Patients may present with complications such as bleed- ingfromoesophagealvaricesorencephalopathy. Patients Management withactivechronichepatitismaypresentwithfeaturesof r Symptomatic management includes adequate nutri- chronic liver disease before cirrhosis is established. The liver is usually enlarged, rm and irregular, but is shrunken Aetiology in late disease. The spleen may be enlarged due to Cirrhosis results from continued hepatocellular necro- portal hypertension. The cut surface shows nodules of liver tissue, r Alcohol accounts for more than 80% of cirrhosis in separatedbyneorcoarsebrousstrands. Other rare but impor- Grading system 1 2 3 tant drug-induced causes are halothane, isoniazid and rifampicin. Hepatic time (seconds encephalopathy is thought to be due to failure of the over control) liver to metabolise toxins. Serum amino acid levels rise ChildPugh grade A = score of 56; ChildPugh grade B = score affectingthebalanceofcerebralneurotransmitters. Hep- of 79; ChildPugh grade C = score of 1015 atic dysfunction also results in renal failure (hepatorenal syndrome). Investigations Aimed at diagnosis of underlying cause and assessment of severity/degree of reversible liver injury. The severity Clinical features of liver disease may be graded AC by means of a mod- Patients may have altered behaviour, euphoria or se- ied ChildPugh grading system (see Table 5. On examination patients are jaundiced, there may be Management fetor hepaticus (sickly sweet odour on breath), apping Treatment is largely supportive. Withdrawal from alco- tremor, slurred speech, difculty in writing and copy- hol is essential in all patients. Malnutrition is common ing simple diagrams (constructional apraxia) and gen- and may require nutritional support. Prognosis Complications Cirrhosis is an irreversible, progressive condition which r Central nervous system: Cerebral oedema in 80% oftencontinuestoend-stageliverfailuredespitethewith- causing raised intracranial pressure. The higher the Child r Cardiovascular system: Hypotension, arrhythmias Pugh grade, the worse the prognosis, particularly for due to hypokalaemia including cardiac arrest. Specic tests depend on the sus- Complications of chronic pected underlying cause, e. Denition Management Raised portal venous pressure is usually caused by in- Treatment is supportive as the liver failure may resolve: creased resistance to portal venous blood ow and is a r Specialisthepatologyinputisessential,ideallypatients common sequel of cirrhosis. Position- pressure is consistently above 25 cm H2O, serious com- ing at a 20 head up tilt can help ameliorate the ef- plications may develop. Aetiology Whilst adequate nutrition is essential the protein in- By far the most common cause in the United Kingdom take should be restricted to 0. Causes may be divided into those tulose and phosphate enemas may be used to empty due to obstruction of blood ow, and rare cases due to the bowel and minimise the absorption of nitroge- increased blood ow (see Fig. Venous blood from the gastrointestinal tract, spleen and r Complications should be anticipated and avoided pancreas (and a small amount from the skin via the pa- wherever possible. Regular monitoring of blood glu- raumbilical veins) enters the liver via the portal vein. As cose and 10% dextrose infusions are used to avoid the portal vein becomes congested, the pressure within hypoglycaemia. Other electrolyte imbalances should it rises and the veins that drain into the portal vein be- be corrected. If the portal pressure continues to rise travenous vitamin K (although this may not be effec- the ow in these vessels reverses and blood bypasses the tive due to poor synthetic liver function), fresh frozen liver through the porto-systemic anastamoses (paraum- plasma should be avoided unless active bleeding is bilical,oesophageal,rectal). Thisportosystemicshunting present or prior to invasive procedures as it can pre- eventually results in encephalopathy. H2 antagonists or proton pump inhibitors may reduce Clinical features the risk of gastrointestinal haemorrhage. Renal sup- The presenting symptoms and signs may be those of port may be necessary. Complications Prognosis Oesophageal varices can cause acute, massive gastroin- Outcome is dependent on the degree of encephalopa- testinal bleeding in approximately 40% of patients with thy. Surgical shunting may exacerbate por- 1 -blockers, in particular propranolol, cause splanch- tosystemic encephalopathy.
The nodules may enlarge and ulcerate with erythematous raised border and overlying crust which may spontaneously heal over months to years imipramine 25mg without prescription anxiety symptoms how to stop it. Different clinical patterns are described depending on the etiologic agents as follows:- 60 Internal Medicine Table I- 3 order imipramine 75mg fast delivery anxiety 6th sense. Investigation for Diagnosis Giemsa staining of smear from a split skin: This demonstrates leishmania in 80% of cases Culture followed by smear 61 Internal Medicine Leishmanin skin test is positive in over 90% of cases although it is negative in diffuse cutaneous leishmaniasis buy discount imipramine 75 mg online anxiety 6 weeks postpartum. However large lesions or those on cosmetically important sites require treatment either 0 Locally - by surgery purchase 50mg imipramine visa anxiety essential oils, curettage, cryotherapy or hyperthermia (40-42 c) or Systemic therapy: with drugs like Pentostam. Treatment is less successful than visceral leishmaniasis as antimonials are poorly concentrated in the skin L. Bolivia, Uruguay and Northern Argentina) In the early stage it affects the skin, but in secondary stage of the disease it involves the upper respiratory mucosa. This leads to nasal obstruction, ulceration, septal perforations and destruction of the nasal cartilage called Espundia. Death usually occurs from secondary bacterial infection 62 Internal Medicine References: th 1. Tuberculosis Learning Objective: At the end of this unit the student will be able to 1. Understand the different treatment categories of Tuberculosis be able to categorize any type of Tuberculosis 11. Refer complicated cases of Tuberculosis diseases to hospitals for better management 14. Design appropriate methods of prevention and control of Tuberculosis Definition: Tuberculosis is a Chronic necrotizing disease caused by Mycobacterium tuberculosis complex. The rate of clinical disease is highest during late adolescence and early adulthood, but the reasons are not clear. Activated alveolar macrophages ingest the bacilli; after which they release chemicals to activate other immune system components and try to control the infection or multiplication of bacilli. These activated cells aggregate around the lesion and the center becomes necrotic, soft cheese like material called caseous necrosis. But if the bacteria inside the macrophage multiply rapidly, they will kill the macrophage and are released but to be taken up 66 Internal Medicine by other macrophages again. Clinical Manifestations Pulmonary Tuberculosis: - This can be classified as primary or post primary (Secondary). Primary disease: Clinical illness directly after infection is called primary tuberculosis; this is common in children <4 years of age. Post primary disease: -If no clinical disease is developed after the primary infection, dormant bacilli may persist for years or decades before being reactivated, when this happens, it is called secondary (or post primary) tuberculosis. Most patients have cough, which may be dry at first, but later becomes productive of whitish sputum; it is frequently blood streaked. Chest x-ray findings are non-specific; infiltrations, consolidation or cavitory lesions may be present. Pleural tuberculosis:- Pleural involvement may be asymptomatic or patients could have fever, pleuritic chest pain and dyspnea. Patients may present with swelling and pain on the back with or without paraparesis or paraplegia due to cord compression. Patients present with progressive joint swelling, usually with pain and limitation of movement. Gastro Intestinal Tuberculosis:- Tuberculosis can affect anywhere from the mouth to the anus. Patients usually present with abdominal swelling and pain, weight loss, fever and night sweating. Milliary tuberculosis:- This is secondary to hematogenous dissemination of the bacilli. Patients who have suggestive symptoms and signs for tuberculosis should undergo further tests. If all 3 sputum smears are negative and the patient has suggestive clinical and chest x-ray findings, first the patient should be treated with broad spectrum antibiotics to rule out other bacterial causes. However the bacillus is slowly multiplying and it takes several weeks to grow the bacilli in a culture media. Although any radiographic finding is possible, typically there will be nodular infiltrates and cavities in the upper lobe; pleural effusion is also common. This group includes cases without smear result, which should be exceptional in adults but are relatively more frequent in children. A patient who returns to treatment, positive bacteriologically, following interruption of treatment for 2 months or more. This group includes Chronic case, a patient who is sputum-positive at the end of a re-treatment 4. Involvement of an anatomical site results in classification as severe disease if there is a significant acute threat to life (e. This categorization helps in prioritizing patients and in selecting the type regime to be used in a patient. This is to decrease the bacterial load and make the patient non-infectious rapidly. During the continuation phase, the drugs must be collected every month and self-administered by the patient. If sputum is negative at the end of 8 weeks, the continuation phase can be started. The reasons being rectal mucosa is thin and fragile and there are susceptible cells ( Langerhans cells ) in the rectal mucosa Vaginal sex is also an effective from of transmission. Currently the risk is very minimal as blood and blood products are screened carefully using antibody and p24 antigen testing to identify donors in the widow period. There may be a risk of transmission from one patient to another or from an infected patient to health care provider 3. They mainly coordinate the Cell mediated immune system and also assist the antibody mediated immune system. Viral replication is continuous in all stages (early infection, during the long period of clinical latency, and in advanced stage. Account for 15 % of all patients Normal Progressors: After the initial primary infection patients remain health for 6- 8 years before they start having overt clinical manifestations: account for 80 % of all patients Long term survivors: Patients who remain alive for 10-15 years after initial infection. In most the diseases might have progressed and there may be evidences of immunodeficiency. Asymptomatic stage Clinical latency In most ( 90 ) of patients, primary infection with or without the acute syndrome is followed by a prolonged period of clinical latency 91 Internal Medicine The length of time from initial infection to the development of clinical disease varies greatly (median is 7-10 years. Oral thrush: o Appears as a white, cheesy exudates, often on an erythematous mucosa (most commonly seen on the soft palate) which gives an erythematous or bleeding surface on scraping o When it involves the esophagus, patients complain of difficulty and/or pain on swallowing o Is due to Candida infection o Confirmatory diagnosis is by direct examination of a scraping for pseudohyphal elements o Treatment - Apply 0. Oral hairy leukoplakia: o Appears as a filamentous white lesion, generally along the lateral borders of the tongue. Dyspnea and fever are cardinal symptoms Cough with scanty sputum in > 2/3 of cases Signs: Findings on physical examination are minimal, and the usual findings for pneumonia may not be noted. Respiratory distress Cyanosis Little abnormality on chest examination rhonchi or wheeze may be heard, especially in patients with some other underlying pulmonary disease, findings of consolidation are usually absent. A higher dose of fansidar (2 tab/day) has been found to be associated with frequent incidence of fatal hemorrhage. Palliative measures : to decrease the size of the lesion and associated edema Radiotherapy Glucocorticoides : Cervical cancer There is a five-fold risk of developing cervical c. Sexually transmitted Infections Learning objectives: At the end of this lesson students are expected to 1.