By Z. Tizgar. Bard College.
The sympathetic system has a specialized preganglionic connection to the adrenal medulla that causes epinephrine and norepinephrine to be released into the bloodstream rather than exciting a neuron that contacts an organ directly generic 500 mg amoxil free shipping antibiotic 93 1174. This hormonal component means that the sympathetic chemical signal can spread throughout the body very quickly and affect many organ systems at once buy amoxil from india antibiotics for acne for sale. Neurons from particular nuclei in the brain stem or from the lateral horn of the sacral spinal cord (preganglionic neurons) project to terminal (intramural) ganglia located close to or within the wall of target effectors buy amoxil with visa bacteria zapper for acne. Signaling molecules utilized by the autonomic nervous system are released from axons and can be considered as either neurotransmitters (when they directly interact with the effector) or as hormones (when they are released into the bloodstream). The same molecule, such as norepinephrine, could be considered either a neurotransmitter or a hormone on the basis of whether it is released from a postganglionic sympathetic axon or from the adrenal gland. The synapses in the autonomic system are not always the typical type of connection first described in the neuromuscular junction. Instead of having synaptic end bulbs at the very end of an axonal fiber, they may have swellings—called varicosities—along the length of a fiber so that it makes a network of connections within the target tissue. The central neuron projects from the spinal cord or brain stem to synapse on the ganglionic neuron that projects to the effector. The afferent branch of the somatic and visceral reflexes is very similar, as many somatic and special senses activate autonomic responses. If a visceral sensation, such as cardiac pain, is strong enough, it will rise to the level of consciousness. However, the sensory homunculus does not provide a representation of the internal structures to the same degree as the surface of the body, so visceral sensations are often experienced as referred pain, such as feelings of pain in the left shoulder and arm in connection with a heart attack. The two divisions of the autonomic system each play a role in effecting change, usually in competing directions. The sympathetic system dilates the pupil of the eye, whereas the parasympathetic system constricts the pupil. Heart rate is normally under parasympathetic tone, whereas blood pressure is normally under sympathetic tone. The heart rate is slowed by the autonomic system at rest, whereas blood vessels retain a slight constriction at rest. The sympathetic tone of blood vessels is caused by the lack of parasympathetic input to the systemic circulatory system. Only certain regions receive parasympathetic input that relaxes the smooth muscle wall of the blood vessels. The central autonomic structure is the hypothalamus, which coordinates sympathetic and parasympathetic efferent pathways to regulate activities of the organ systems of the body. The majority of hypothalamic output travels through the medial forebrain bundle and the dorsal longitudinal fasciculus to influence brain stem and spinal components of the autonomic nervous system. The medial forebrain bundle also connects the hypothalamus with higher centers of the limbic system where emotion can influence visceral responses. The amygdala is a structure within the limbic system that influences the hypothalamus in the regulation of the autonomic system, as well as the endocrine system. These higher centers have descending control of the autonomic system through brain stem centers, primarily in the medulla, such as the cardiovascular center. The solitary nucleus increases sympathetic tone of the cardiovascular system through the cardiac accelerator and vasomotor nerves. The nucleus ambiguus and the dorsal motor nucleus both contribute fibers to the vagus nerve, which exerts parasympathetic control of the heart by decreasing heart rate. These drugs affect the autonomic system by mimicking or interfering with the endogenous agents or their receptors. A survey of how different drugs affect autonomic function illustrates the role that the neurotransmitters and hormones play in autonomic function. Drugs can be thought of as chemical tools to effect changes in the system with some precision, based on where those drugs are effective. For most organ systems in the body, the competing input from the two postganglionic fibers will essentially cancel each other out. Because there is essentially no parasympathetic influence on blood pressure for the entire body, the sympathetic input is increased by nicotine, causing an increase in blood pressure. Other organs have smooth muscle or glandular tissue that is activated or inhibited by the autonomic system. The contradictory signals do not just cancel each other out, they alter the regularity of the heart rate and can cause arrhythmias. The sympathetic system is affected by drugs that mimic the actions of adrenergic molecules (norepinephrine and epinephrine) and are called sympathomimetic drugs. Drugs such as phenylephrine bind to the adrenergic receptors and stimulate target organs just as sympathetic activity would. Other drugs are sympatholytic because they block adrenergic activity and cancel the sympathetic influence on the target organ. Drugs that act on the parasympathetic system also work by either enhancing the postganglionic signal or blocking it. Anticholinergic drugs block muscarinic receptors, suppressing parasympathetic interaction with the organ. When someone is said to have a rush described in this video, the nervous system has a way to of adrenaline, the image of bungee jumpers or skydivers deal with threats and stress that is separate from the usually comes to mind. The epinephrine, is an important chemical in coordinating the system comes from a time when threats were about body’s fight-or-flight response. In this video, you look survival, but in the modern age, these responses become inside the physiology of the fight-or-flight response, as part of stress and anxiety. His body’s reaction is the result autonomic system is only part of the response to threats, or of the sympathetic division of the autonomic nervous stressors. What other organ system gets involved, and what system causing system-wide changes as it prepares for part of the brain coordinates the two systems for the entire extreme responses. He undergoes endless The autonomic system, which is important for regulating tests and seeks input from multiple doctors. In the end, the homeostasis of the organ systems, is also responsible one expert, one question, and a simple blood pressure cuff for our physiological responses to emotions such as fear. Why would the heart have to beat The video summarizes the extent of the body’s reactions faster when the teenager changes his body position from and describes several effects of the autonomic system in lying down to sitting, and then to standing? As shown in this short animation, pupils As discussed in this video, movies that are shot in 3-D will constrict to limit the amount of light falling on the can cause motion sickness, which elicits the autonomic retina under bright lighting conditions. The disconnection the afferent and efferent branches of the competing reflex between the perceived motion on the screen and the lack of (dilation)? Why do you think sitting close to the screen or right in the middle of the theater makes motion sickness during a 3-D movie worse? Which of the following represents a sensory input that considered part of the sympathetic fight-or-flight response? A drug that affects both divisions of the autonomic control center for homeostasis through the autonomic and system is going to bind to, or block, which type of endocrine systems? Horner’s syndrome is a condition that presents with why would the sympathetic system not activate the changes in one eye, such as pupillary constriction and digestive system?
Stratum corneum Layer of keratin order amoxil with paypal antibiotic resistance how does it occur, most superficial layer (Horny layer) • In areas of thick skin such as the sole buy discount amoxil 500 mg infection of the blood, there is a fifth layer generic amoxil 250 mg visa can antibiotics for uti cause yeast infection, stratum lucidum, beneath the stratum corneum. This occurs in 3 main phases: a) anagen (long growing phase) b) catagen (short regressing phase) c) telogen (resting/shedding phase) • Pathology of the hair may involve: a) reduced or absent melanin pigment production e. Stages of wound healing Stages of wound healing Mechanisms Haemostasis ● Vasoconstriction and platelet aggregation ● Clot formation Inflammation ● Vasodilatation ● Migration of neutrophils and macrophages ● Phagocytosis of cellular debris and invading bacteria Proliferation ● Granulation tissue formation (synthesised by fibroblasts) and angiogenesis ● Re-epithelialisation (epidermal cell proliferation and migration) Remodelling ● Collagen fibre re-organisation ● Scar maturation 27 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Emergency Dermatology • These are rapidly progressive skin conditions and some are potentially life- threatening. Ability to recognise and describe these skin reactions: - urticaria - erythema nodosum - erythema multiforme 2. Ability to recognise these emergency presentations, discuss the causes, potential complications and provide first contact care in these emergencies: - anaphylaxis and angioedema - toxic epidermal necrolysis - Stevens-Johnson syndrome - acute meningococcaemia - erythroderma - eczema herpeticum - necrotising fasciitis 28 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Urticaria, Angioedema and Anaphylaxis Causes ● Idiopathic, food (e. A large number of inflammatory mediators (including prostaglandins, leukotrienes, and chemotactic factors) play a role but histamine derived from skin mast cells appears to be the major mediator. Local mediator release from mast cells can be induced by immunological or non-immunological mechanisms. Stevens-Johnson syndrome may have features overlapping with toxic epidermal necrolysis including a prodromal illness. Herpes zoster (shingles) infection due to varicella-zoster virus affecting the distribution of the ophthalmic division of the fifth cranial (trigeminal) nerve Note: Examination for eye involvement is important Learning outcomes: Ability to describe the presentation, investigation and management of: - cellulitis and erysipelas - staphylococcal scalded skin syndrome - superficial fungal infections 36 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Erysipelas and Cellulitis Description ● Spreading bacterial infection of the skin ● Cellulitis involves the deep subcutaneous tissue ● Erysipelas is an acute superficial form of cellulitis and involves the dermis and upper subcutaneous tissue Causes ● Streptococcus pyogenes and Staphylococcus aureus ● Risk factors include immunosuppression, wounds, leg ulcers, toeweb intertrigo, and minor skin injury Presentation ● Most common in the lower limbs ● Local signs of inflammation – swelling (tumor), erythema (rubor), warmth (calor), pain (dolor); may be associated with lymphangitis ● Systemically unwell with fever, malaise or rigors, particularly with erysipelas ● Erysipelas is distinguished from cellulitis by a well-defined, red raised border Management ● Antibiotics (e. Ability to recognise: - Bullous pemphigoid - Pemphigus vulgaris 52 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Bullous pemphigoid Description ● A blistering skin disorder which usually affects the elderly Cause ● Autoantibodies against antigens between the epidermis and dermis causing a sub-epidermal split in the skin Presentation ● Tense, fluid-filled blisters on an erythematous base ● Lesions are often itchy ● May be preceded by a non-specific itchy rash ● Usually affects the trunk and limbs (mucosal involvement less common) Management ● General measures – wound dressings where required, monitor for signs of infection ● Topical therapies for localised disease - topical steroids ● Oral therapies for widespread disease – oral steroids, combination of oral tetracycline and nicotinamide, immunosuppressive agents (e. Learning objectives: Ability to formulate a differential diagnosis, describe the investigation and discuss the management in patients with: - chronic leg ulcers - itchy eruption - a changing pigmented lesion - purpuric eruption - a red swollen leg 55 Dermatology: Handbook for medical students & junior doctors 56 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors 57 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors 58 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors 59 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors 60 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors 61 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors 62 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors 63 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors 64 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Management Management and therapeutics • Treatment modalities for skin disease can be broadly categorised into medical therapy (topical and systemic treatments) and physical therapy (e. They consist of active constituents which are transported into the skin by a base (also known as a ‘vehicle’). The common forms of base are lotion (liquid), cream (oil in water), gel (organic polymers in liquid, transparent), ointment (oil with little or no water) and paste (powder in ointment). Learning objectives: Ability to describe the principles of use of the following drugs: - emollients - topical/oral corticosteroids - oral aciclovir - oral antihistamines - topical/oral antibiotics - topical antiseptics 65 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Emollients Examples ● Aqueous cream, emulsifying ointment, liquid paraffin and white soft paraffin in equal parts (50:50) Quantity ● 500 grams per tub Indications ● To rehydrate skin and re-establish the surface lipid layer ● Useful for dry, scaling conditions and as soap substitutes Side effects ● Reactions may be irritant or allergic (e. Ability to perform the following tasks: - explain how to use an emollient or a topical corticosteroid - make a referral - write a discharge letter - write a prescription for emollient - take a skin swab - take a skin scrape - measure the ankle-brachial pressure index and interpret the result 2. Describe the principles of prevention in: - pressure sores - sun damage and skin cancer 68 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Patient education How to use emollients ● Apply liberally and regularly How to use topical corticosteroids ● Apply thinly and only for short-term use (often 1 or 2 weeks only) ● Only use 1% hydrocortisone or equivalent strength on the face ● Fingertip unit (advised on packaging) – strip of cream the length of a fingertip Preventing pressure sores ● Pressure sores are due to ischaemia resulting from localised damage to the skin caused by sustained pressure, friction and moisture, particularly over bony prominences. Taking a skin scrape • Skin scrapes are taken from scaly lesions by gentle use of a scalpel in suspected fungal infection (to show evidence of fungal hyphae and/or spores) and from burrows in scabies (see page 59). Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education. Important Guidelines for Printing and Photocopying Limited permission is granted free of charge to print or photocopy all pages of this publication for educational, not-for-profit use by health care workers, students or faculty. Under no circumstances is it permissible to sell or distribute on a commercial basis, or to claim authorship of, copies of material reproduced from this publication. Except as expressly provided above, no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission of the author or authors. This material is intended for educational use only by practicing health care workers or students and faculty in a health care field. We could like to extend our gratitude to our university /Health Science College/ for keeping the atmosphere conductive for the preparation of this module. Finally, it is our pleasure to acknowledge all those, who have directly and/or indirectly provided us with administrative and logistic support that ultimately facilitated the development and preparation of the module. What are the salient features in the clinical evaluation of a patient suspected to have diabetes that aid you in labeling him/her as having type 1 or type 2 diabetes mellitus? What should the first step be in managing a known diabetic when he /she presents with loss of consciousness in the absence of a laboratory facility that could help you determine the random blood sugar? One of the following is not the site for subcutaneous injection during management of diabetes mellitus. He should have a snack, such as cheese, sandwich and a glass of milk, an hour before the play and should carry a fast acting source of glucose 3 B. He should not go on to play because the possible side effects of extraordinary activates are just unpredictable C. It is known that majority of lower extremity amputation are performed in a diabetic patient like Ato kebede. Why is there a discrepancy between the whole blood glucose concentration and the plasma glucose concentration? In a person with normal glucose metabolism, the blood glucose level usually increases rapidly after carbohydrates are ingested, but returns to a normal level after A. Which of the following organs uses glucose from digested carbohydrates and stores it as glycogen for later use as a source of immediate energy by the muscles? The health officer on duty examined him and the findings were an acutely sick looking boy who was conscious and in respiratory distress. On further questioning it was found out that he lives in a one room thatched roofed house with his seven siblings and parents. There is no window in the house; the cattle are kept in the same room and firewood is burned in the same room. He comes from a rural village 15Km far from the health center and had to be carried all the way to the health center by his relatives. Epidemiology The prevalence of diabetes mellitus has risen dramatically in the past two decades; it is also projected that the number of individuals with diabetes mellitus will continue to increase in the near future. The prevalence of diabetes mellitus is reaching epidemic proportions, in large part because of obesity and sedentary life style in both adults and children The incidence and prevalence of diabetes mellitus in the general Ethiopian population are unknown. A population based study done near Gondar on 2381 individuals using glycosuria screening with blood glucose confirmation showed glucose intolerance in 12 only 0. Patient education, dietary management and exercise play a central role in managing diabetic patients in addition to pharmacologic therapy. Patient Education • It should be viewed as a continuing process with regular visits for reinforcement and not just a one-time affair. The majority of these individuals are obese, and weight loss is strongly encouraged and should remain an important goal • Food intake must be spread evenly throughout the waking hours and taken at regular times in relation to the insulin dose. Despite its benefits, exercise presents several challenges for individuals with diabetes mellitus because they lack the normal glucoregulatory mechanisms. If the insulin level is too low, the rise in catecholamines may increase the plasma glucose excessively, promote ketone body formation, and possibly lead to ketoacidosis. To avoid exercise-related hyper- or hypoglycemia, individuals with type 1 diabetes should • monitor blood glucose before, during, and after exercise • delay exercise if blood glucose is > 250 mg/dL, <100 mg/d), or if ketones are present • eat a meal 1 to 3 hours before exercise and take supplemental carbohydrate feedings at least every 30 min during vigorous or prolonged exercise • decrease insulin doses (based on previous experience) before exercise and inject insulin into a nonexercising area. Insulin formulations are available as U-100 (1ml of solution equivalent to 100 units) or U-40 (1ml of solution equivalent to 40units). It is very important that one designs and implements an insulin regimen that mimics physiologic insulin secretions. Twice daily administration of a short acting and intermediate acting insulin, given in combination before breakfast and the evening meal, is the simplest and most commonly used regimen. Therapy is initiated with one class of agent, depending on patient characteristics and a second agent is added if adequate glycemic control is not achieved. Many patients with type 2 diabetes mellitus have one or more of diabetes mellitus related complications at diagnosis.
Day Care k) Referral criteria: Surgically treated patients may be referred back to secondary hospitals for physiotherapy buy 500mg amoxil overnight delivery xcell antimicrobial dressing, and care of back buy discount amoxil 250 mg line antibiotics for uti price, bladder and bowel purchase 250 mg amoxil with mastercard antimicrobial vinyl. Doctor Primary assessment and resuscitation Clinical diagonosis Ordering and interpretation of investigations Clinical decision making Surgical procedures b. Nurse Primary resuscitation can be performed by a nurse Prevention of bed sores Maintenance of inventory(drugs,consumables etc. In advanced trauma life support for doctors’ student course th manual; 8 edition: Chicago; American college of surgeon: 2008:269-76 7. Pathogenesis and pharmacological strategies for mitigating secondary damage in acute spinal cord injury. Incidence of the condition Due to intensive pulse polio immunization along with routine immunization has reduced its incidence to negligible and it almost near eradication in our country. But there are still a reasonable number of patients of residual paresis who need some sort of surgical correction either for proper fitting of orthosis or for the proper use of the extremity. Differential diagnosis The cases of cerebral palsy, myopathies and the neuropathies like motor neuron disease, Gullain-Barre syndrome etc need to be differentiated from poliomyelitis. Clinical features Three types of cases occur: Inapparent infections (95% cases), non-paralytic infections (about 5%) and paralytic cases 0. The non-paralytic infection is manifested by fever, sore throat, headache, nausea, vomiting, diarrhea and rigidity of the neck and back lasting for 2-10 days. The paralytic attack is manifested by acute flaccid paralysis of the muscles of the limb or the trunk and face followed by maximum recovery within 6 months. Broadly and conventionally these are acute attack and the residual paresis and paralysis. One should recognize the features of flaccid or lower motor neuron level disorder and its residual effects. Following can be done at this level: Prescription of orthosis/calipers and its fitting; -corrective cast application; -Simple corrective procedures like- tenotomy for the tight tendo-achillis; lengthening of tendon etc -arrangement of polio corrective surgery camps ( but the team of surgeons from teaching Medical Institute/College should evaluate the cases and supervise the surgeries). Criteria for referral: The cases who need investigations like nerve conduction studies and electromyographies. Those who need tendon transfers, correction of deformity at multiple joints and in different planes. Any case where the non metro level surgeon is in doubt in decision making of the type of surgery should be referred. Then all surgeries for the correction of deformity -by tendon transfer (dynamic) -the osteotomies/tenodesis, -tendon lengthening, - tenotomies, capsulotomies and arthrodesis as per the indication and after the careful evaluation of the individual. The goal of the treatment is focused on the independent walking (for lower limb) or the proper use of the upper extremity with/without orthosis. The lower extremity should be with planti-grade foot with no or minimal residual deformity at various joints and the limb should be suitable for fitting of the orthosis/calipers. The upper extremity should be made for the independent usage with/without support. Various common surgical procedures include: Tendo-achillis lengthening-for equinus correction, Jone’s Teno-suspension- for dropped first metatarsal and sub-luxed st 1 metatraso-phalangeal joint, Tibialis posterior tendon transfer- for foot drop, Dorsal bony wedge resection (Japa’s) and Steindler’ release for cavus foot deformity correction, Osteotomy for deformity correction (e. Definition: Cerebral palsy is defined as the non-progressive motor impairment (motor neurological deficit) due to the insult to the developing brain; affecting the movements and posture, however, no sensory impairment. The involvement of the brain most commonly occurs between the time of conception and the age 2 years (the time of major motor development). After 8 years of the age, the development of the immature brain is almost complete; its affection is just like adults. Types: As per the time of affection of the brain this is categorized as prenatal, perinatal and post natal. Most common is prenatal and only less than 10% cases are affected during the delivery time i. Management For the management, the complete and proper evaluation of the individual as whole and the affected part is mandatory. Some times in the situation of spasticity it is difficult to judge the muscle power and the treatment can be worsening rather than improving the functions and there can also be recurrence of the deformity. Therefore, whenever in doubt, the peripheral surgeon can refer the patient to the medical institute or to the metro hospital for the treatment after evaluation. The treatment of the some rare types of cerebral palsy is really difficult and very much demanding even at the level of the medical institute or the metro hospital. At the metro hospital the team approach involving the peaediatrician, the orthopedic surgeon, psychiatrist, physiotherapist and psycho-social workers is required for the better outcome in such patients. Following can be done at this level: - Prescription of orthosis/calipers and its fitting; -corrective cast application; -Simple corrective procedures like- tenotmy for the tight tendo-achillis; lengthening of tendon and adductor tenotomy etc. They can be issued the disability certificates for their financial benefits from various schemes run by the Government. Those who need tendon transfers, correction of deformity at multiple joints and in different planes; and need care of multiple specialists under one roof. Any case where the non metro level surgeon is in doubt in decision making of the type of surgery should be referred. Then all surgeries for the correction of deformity -by tendon transfer -the osteotomies/tenodesis, -tendon lengthening, -tenotomies, capsulotomies and arthrodesis as per the indication and after the careful evaluation of the individual. The goal of the treatment is focused on the independent walking (for lower limb) or the proper use of the upper extremity with/without orthosis. The lower extremity should be with planti-grade foot with no or minimal residual deformity at various joints and the limb should suitable for fitting of the orthosis/calipers and if feasible for independent walking. The upper extremity should be made suitable for fitting of orthosis and for the use in daily day to day routine like self eating, bathing; cleansing after toilet etc. Various common surgical procedures include: Tendo-achillis lengthening-for equinus correction, Adductor tenotomy – to correct scissoring gait Split tibialis anterior transfer for inversion foot Tibialis posterior tendon transfer- for foot drop, Egger’s operation/Fractional release of hamstrings (Tendon lengthening/tenotomies and capsulotomies)-for knee contracture release, Tripple arthrodesis for talipes equino-varus correction in mature feet. Flexor pronator release and transfer of flexor carpi ulnaris to the wrist dorsiflexors for contracture of flexor and pronator muscle group. Sever’s and Fairbank operation and derotation osteotomy of humerus- for internal rotation contracture at shoulder etc All the surgeries should be performed by the experienced surgeon and standard text book on the subject should be available in the operation theatre for the reference. Introduction: A form of spondyloarthritis, is a chronic, inflammatory arthritis and autoimmune disease. It mainly affects joints in the spine and the sacroiliac joint in the pelvis, and can cause eventual fusion of the spine. Case Definition: The typical patient is a young male, aged 20–40, however the condition also presents in females. These first symptoms are typically chronic pain and stiffness in the middle part of the spine or sometimes the entire spine, often with pain referred to one or other buttock or the back of thigh from the sacroiliac joint. Patient needs to be counselled regarding the chronic nature of the disease and need for regular treatment, possible complications and possible treatment options and chances of improvement. Clinical diagnosis: 111 chronic pain and stiffness in the middle part of the spine or sometimes the entire spine, often with pain referred to one or other buttock or the back of thigh from the sacroiliac joint. In 40% of cases, ankylosing spondylitis is associated with an inflammation of the eye (iritis and uveitis), causing redness, eye pain, vision loss, floaters and photophobia. Any 2 out of first four criteria strongly indicate presence of Ankylosing Spondylitis even in the absence of xray and lab investigations. Physical Therapy – Patients to be encouraged to undertake active and passive range of motion exercises for all joints to maintain and prevent the progression of loss of mobility.