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Whenever the blood pressure is measured while taking the medication buy cytotec without a prescription treatment varicose veins, it is bound to be normal and therefore the patient may discontinue the medication due to a false sense of security discount cytotec 200mcg overnight delivery medications during labor. On discontinuing the drugs order cytotec 200 mcg with amex treatment junctional rhythm, blood pressure starts increasing again, eventually resulting in paralysis or heart attack. Along with the right treatment, the patient should be careful about his lifestyle as well as eating habits. Diet: To prevent a stroke, the fat content in the diet should be reduced to bare minimum. Instead, salads, fresh fruits and vegetables should be consumed in larger quantity. Tensions and stress should be reduced and one should learn to relax and enjoy life. Jealousy, anger, negative thinking should be avoided and everyone should live in harmony, which will always be beneficial. Use of contraceptive pills should be reduced to bare minimum and other forms of contraception should be followed. The patients who have previously suffered a stroke or a heart attack should take drugs like Aspirin, Dipyridamol, Ticlopidine, Clopidogrel, etc; to keep the blood thin, as per prescription from the doctor. With the help of these drugs the chances of a heart attack or paralysis can be reduced by about 13% to 45%. If a patient has not suffered either a heart attack ©r a brain attack, but has definite risk factors e. This recent scientific invention has revolutionized the concept of treatment of heart attacks and paralysis and has averted several angioplasties, coronary bypass surgeries and perhaps carotid surgeries. Diagnosis : Paralysis is a disease of the brain and therefore it is necessary to get proper and timely treatment from an experienced Physician or a Neurophysician. Sometimes there can be another disease with similar symptoms and a scan will diagnose the same, preventing a fatal mistake e. In addition to this, hematological tests, biochemistry (sugar, tests related to kidney etc. As observed earlier the risk factors of stroke as well as heart diseases are the same and heart disease is comparatively more prevalent than stroke. Therefore, investigations relating to heart disease are essential in patients of paralysis to prevent heart disease. According to a scientific research, number of paralytic patients dying due to heart disease is far more than the deaths caused by stroke. For young patients of paralysis, who do not have blood pressure or diabetes, special investigations like anticardiolipin test, homocysteine tests etc. The decision of the investigations required for the patient, is better left to the doctor. Details of the treatment of stroke : As soon as the symptoms of stroke or paralysis are seen, immediate treatment should be started in a hospital by an expert physician or a neurologist. If the patient gets a convulsion, it should be immediately brought under control and if he is suffering from blood pressure, diabetes etc then they should also be controlled immediately. Thrombolytic therapy : It is an undisputed fact that in case of thromboembolism, if immediate treatment is given with latest special techniques, in the first 3 to 6 hours of paralysis, then in many cases a) entire blocked artery opens up; b) the clot in the artery (thrombus) melts; c) the damage to the brain cells can be prevented or reduced. In addition, 4 to 7 % of the patients suffer from brain hemorrhage as a side effect. In foreign countries public awareness about stroke is very high and hence the person suffering from one is immediately taken to a hospital within 1 to 2 hours. We hope that the same happens in India too and the attitude of the people towards insurance changes for the better. Though our doctors are well aware of this therapy, there are many practical problems in our country. The other therapies available till now cannot cure paralysis beyond six hours after the stroke, as they can not rejuvenate the brain cells, which have died due to lack of blood and oxygen. Antithrombotic therapy : This therapy is easily available in our country and it aims to stop the clot formation in the blood vessels. It includes anticoagulant drugs like, heparin, low molecular heparin, drugs of antiplatelet group, like aspirin, dipyridamol, abciximab and drugs of fibrinolytic group, like ancrod. However, they can lead to side effects like hemorrhage and therefore they need to be administered in the right dose with proper investigations.
A should be in multiple layers cheap cytotec medicine pills, using simple running or running locking stitch absorbable sutures cytotec 100mcg discount symptoms 4 months pregnant, without tension cheap 200mcg cytotec with mastercard ombrello glass treatment. Placing a Foley catheter in the bladder prior to suturing will help to outline the important anterior structures to be Rectal Lacerations avoided. Lacerations of the rectum may be closed If the laceration involves the posterior primarily with multiple layers of vaginal wall, remember that the rectum absorbable suture. The need for fecal can be within a few millimeters of the diversion should be determined by the vaginal mucosa. Local anesthetic may be Lacerations involving the lateral vaginal used but is often unnecessary if the skin walls are best sutured with good is thin and attenuated. When these lacerations are high in the After drainage of pus from the cavity, vagina, they are both more difficult loosely pack the cavity with narrow (because of exposure and lighting gauze (iodoform tape works well for problems) and more dangerous. The this), primarily to keep the incision open, ureter courses next to the cervix in the allowing continued drainage over the parametrial tissues but becomes next few days. The cut edges of the accessible to accidental vaginal suturing drainage incision may need to be sutured if the sutures are placed deep and high in for hemostasis but this is usually the vagina. Place a Foley catheter in the These draining abscesses usually resolve bladder and treat the hematoma with ice over the next few days but may return at packs. Repeat I&D can be done without surgery (the larger portion of the multiple times, although a mass is inflammatory tissue and not marsupialization procedure may blood clot), but may require several days ultimately be required. Larger to try to surgically remove an entire hematomas or expanding hematomas abscess on an emergent basis. In about half of these cases, the specific D&C bleeding point is never identified, but simple evacuation of the clot and closure In the operational setting, D&C with sutures solves the problem. These painful, unilateral vulvar masses may be treated conservatively with Under anesthesia, the bladder is antibiotics if small, but will require catheterized and a pelvic exam incision and drainage if large or performed so the surgeon can feel the persistent. Of particular the medial aspect of the mass close to importance is noting whether the cervix the introitus. If the mass is pointing, go leads directly into the uterus or whether through that area straight into the there is any angulation anterior or 6 Surgical Emergencies in Obstetrics & Gynecology posterior. Equally important is Salpingectomy determining the size of the uterus as this will guide the surgeon in inserting the Ectopic pregnancy, ruptured or instruments. Salpingectomy (removal of the cervix is grasped with a tenaculum the fallopian tube) is uniformly effective, or a ring forceps on its anterior lip. The cervix is then dilated by inserting "dilators" of gradually increasing After opening the abdomen (lower diameter until the cervix is open about 1- midline incision is fast and gives 2 cm. Fortunately, in the case of excellent exposure), identify the incomplete abortion, the cervix will fallopian tube containing the ectopic. This spreads out the mesosalpinx (the blood supply of the Polyp forceps or Ring forceps are then tube). Using hemostats, clamp across the inserted through the cervix into the mesosalpinx, starting at the fimbriated uterus to grasp and remove any large end and working toward the uterus. This is a time Clamp across the tube where it enters the when gentleness is required because it is uterus. Then remove your specimen and relatively easy to perforate the soft walls suture the clamped tissue with 0 or 2-0 of the uterus and cause damage to the Vicryl, Chromic or other such material. Then a curette is gently inserted clots (removal of all free blood from the and used to scrape any remaining tissue abdomen is both unnecessary and off the uterine walls. After an uncomplicated D&C, patients In the face of a large ectopic pregnancy are advised to rest in bed with bathroom and significant bleeding, this approach privileges for a day or two and then may of salpingectomy is probably the wisest return to their normal activities. With smaller ectopics, you may Prophylactic antibiotics may be given conserve some or all of the tube (particularly in an incomplete abortion performing a "segmental resection" in situation) as well as ergotamine 0. The since you may release clot or cellular pregnancy is extruded through the toxins into the general circulation. In incision and the tube observed for operational settings, when ovarian further bleeding. The tube may be reclosed effected tissue should be simply with very fine absorbable suture or removed. Watch for signs of metabolic acidosis during the While a linear salpingostomy may be recovery as the necrotic tissue may have preferable in some fully-equipped and released enough tissue toxins to cause fully-staffed medical facilities, there are this problem. Emergency removal of an ovarian cyst is Surgeons in these isolated settings might usually necessitated because of either be better advised to perform the severe pain or hemorrhage.
When oral intake is restricted purchase cytotec 200 mcg mastercard medicine interaction checker, regular Insulin may be given 4-6hrs to control hyperglycemia generic 200mcg cytotec overnight delivery treatment associates. Screen for complication that may affect surgical risk: Nephropathy cheap cytotec 200mcg with visa medicine 031, cardiac disease, proliferative retinopathy. Regular (Soluble) insulin given pre-meals for the main meals (Breakfast, Lunch and supper), long acting insulin at bedtime Table 5: Insulin Regimens Regimen 1 Breakfast Intermediate/long acting(2/3) + Short acting (1/3) 2/3 of daily dose Supper Intermediate/Long acting (2/3) + Short acting (1/3) 1/3 of daily dose Regimen 2 Breakfast Intermediate/long acting + Short acting 2/3 of total daily dose Supper Short acting Bedtime Intermediate/long actin + short acting 1/3 of total daily dose Regimen 3 Breakfast Short acting 20% of daily dose Lunch Short acting 20% of daily dose Supper Short acting 20% of daily dose Bedtime Intermediate/long acting 40% of daily dose Table 6: Insulin adjustment (how to adjust insulin) Blood glucose-High/Low Insulin dose to adjust-/ Twice daily injection regimen Before breakfast or overnight Evening intermediate-acting Before lunch Morning short acting Before dinner Morning intermediate Before bed Evening short acting Three-times daily Before breakfast or overnight Evening intermediate- acting Morning short-acting injection regimen Before lunch Morning intermediate-acting Evening short-acting Before dinner 233 | P a g e Before bed Before breakfast or overnight Evening intermediate acting Basal-bolus Before Lunch Morning short acting (multiple Before Dinner Lunchtime short acting injection) Before Bed Evening short acting regimen Give education on — What is diabetes? U/kg/hr patients circulation has When pump not available- separate low dose insulin been restored ( 1-2hrs infusion should be used [Soluble Insulin 50 units in after rehydration) Normal Saline 500ml (ie 1 unit Insulin per 10ml Saline)] may be given at a rate of 0. Insulin Dilutions A solution of Soluble Insulin 1 unit / ml made up in Normal Saline. Dilute 50 units soluble (regular) insulin in 50ml normal saline-1unit=1ml) When syringe pumps are not available a separate low dose insulin infusion [Soluble Insulin 50 units in Normal Saline 500ml (ie 1 unit Insulin per 10ml Saline)] may be given at a rate of 0. Vigilant observations throughout the 24 hours must not diminish — In many cases warning signs/symptoms occur which should prompt the emergency administration of Mannitol Warning signs/symptoms of cerebral edema — Headache — Slow heart rate — Change in neurological status ( restlessness, irritability, increased drowsiness, incontinence, specific neurological signs (eg. Monitoring and follow up Inpatient Vital signs-neurological deterioration, Temperature, Respiratory rate Blood glucose 2hourly, urine ketones 4 hourly Outpatient • Blood glucose-personal glucometers, • Hyperglycemia-shown by frequent micturation at night, • Urine glucose, • Glycaemic control –glycosylated Haemoglobin-(Ranges)(HbA1c), • Growth (Height and weight) every visit, • Complications, • Hypoglycaemia-management, • Continuous diabetes education-every visit Surgery Minor surgery(duration < 3h. Primary Causes: Iodine deficiency Congenital Drugs; Iodine excess (contrasts media containing iodine), lithium, antithyroid drugs, p- aminosalisylic acid, interferon alfa and other cytokines, aminoglutethimide. Others are cool peripheral extremities, puffy face, hands and feet (Myxedema), diffused alopecia (hair loss), bradycardia, peripheral odema, delayed tendon reflex relaxation, carpal tunnel syndrome and serous cavity effusions. Diseases of the thyroid gland are manifested by qualitative or quantitative alterations in hormone secretion or enlargement of the thyroid gland or both. Enlargement of the thyroid gland may result in normal increased, or decreased hormone secretion. Treatment Iodised salt may not provide sufficient iodine and should therefore not be prescribed alone Lugol’s solution is too concentrated for daily use, and should be diluted by a factor of 30 to give 4. Treatment Age less than 45 years First choice B: Schiller’s iodine 2 drops (460 micrograms) once daily for one year. Response may be obtained within 6 months Second choice B: Lugol’s solution 3 drops (21mg) once each month for up to one year. Post thyroidectomy Iodine should be given daily indefinitely to prevent recurrence, following dosing schedule give above Physiological doses of iodine can be given even in pregnancy. It is actually necessary to provide the therapy to avoid iodine deficiency to the foetus Patients should continue taking iodized salt indefinitely (Ref. National Policy on Nutrition) after the completion of treatment or begin giving 1 drop (7mg) at Lugol’s sol per month. It is usually due to diffuse hyperplasia and hypertrophy of the thyroid gland (Graves’ disease). Hyperthyroidism is characterized by an increased metabolic rate, which causes weight loss, increased appetite, fatigue, emotional disturbances, heat intolerance, sweating, muscle weakness and diarrhea. Treatment Graves’ disease: 241 | P a g e C: Carbimazole 40mg (O) once daily for 3 weeks then 20mg daily for 3 weeks. Maintenance dose 5mg for up to one year Toxic Nodular Goitre Can be treated with antithyroid drugs and surgery or radio-iodine C: Carbimazole 40mg (O) once daily for 3 weeks then 20mg daily for 3 weeks. Iron deficiency is mainly due to blood loss secondary to haemorrhage, malabsoption and hookworm infections. Iron deficiency anaemia A: Ferrous sulphate200 mg (O) every 8 hours Children5 mg/kg body weight every 8 hours. Pyruvate kinase deficiency c) Haemoglobin -Abnormal haemoglobin such as HbS, C, Unstable Hb Clinical features the disease may occur at any age and sex Patient may present with symptom and features of Anaemia Symptoms are usually slow in onset however rapidly developing anaemia can occur Splenomegaly is common but no always observed Jaundice Treatment i. Immunosuppressive drugs for the patients who fail to respond to corticosteroids and splenectomy. Symptoms may include anaemia, dactylitis, recurrent infections, impaired growth and development. Crises Three distinct types of crises develop in patients with sickle cell disease Vaso-occlusive or painful crises are more common occurring with a frequency from almost daily to yearly.
Heparin: • contains a repeating unit of D-glucuronic and D-gluconsamine proven cytotec 200mcg symptoms lead poisoning, with sulfate groups on some of the hydroxyl and aminx-groups • It is an important anticoagualtn cheap cytotec online visa treatment broken toe, prevents the clotting of blood by inhiginting the conversion of prothrombin to throbin purchase cytotec 200 mcg on-line treatment depression. Thrombin is an enzyme that acts on the conversion of plasma fibrinogen into the fibrin. Glycoproteins (Mucoproteins) Glycoprotiens are proteins to which oligosaccharides are covalently attached. They differ from the glycosaminoglycans in that the length of the glycoproteins carbohydrate chain is relatively short (usually two to ten sugar residues in length, although they can be longer), whereas it can be very long in the glycosaminoglycans. The glycoprotein carbohydrate chains are often branched instead of linear and may or may not be negatively charged. It also contains disaccharides: sucrose, lactose, maltose and in small amounts monosaccharides like fructose and pentoses. Liquid food materials like milk, soup, fruit juice escape digestion in mouth as they are swallowed, but solid foodstuffs are masticated thoroughly before they are swallowed. Digestion in Mouth Digestion of carbohydrates starts at the mouth, where they come in contact with saliva during mastication. Saliva contains a carbohydrate splitting enzyme called salivary amylase (ptyalin). Action of ptyalin (salivary amylase) - It is ? - amylase, requires Cl ion for activation and optimum pH 6-7. The enzyme hydrolyzes (1,4) glycosidic linkage at random, from molecules like starch, glycogen and dextrins, producing smaller molecules maltose, glucose and disaccharides maltotriose. Digestion in Stomach No carbohydrate splitting enzymes are available in gastric juice. Digestion in Duodenum Food reaches the duodenum from stomach where it meets the pancreatic juice. The enzyme hydrolyzes (1,4) glycosidic linkage situated well inside polysaccharide molecule. Such patients suffer from watery diarrhea, abnormal intestinal flow and chloeic pain. Maltase the enzyme hydrolyzes the ? -(1,4) glycosidic linkage between glucose units in maltose molecule liberating two glucose molecules. Sucrase Sucrose Glucose + fructose 34 Absorption of Carbohydrates Products of digestion of dietary carbohydrates are practically completely absorbed almost entirely from the small intestine. It is also proved that some disaccharides, which escape digestion, may enter the cells of the intestinal lumen by “pinocytosis” and are hydrolyzed within these cells. No carbohydrates higher than the monosaccharides can be absorbed directly in to the blood stream. Simple Diffusion This is dependent on sugar concentration gradients between the intestinal lumen. All the monosaccharides are probably absorbed to some extent by simple ‘passive’ diffusion. Hence fructose is not absorbed by simple diffusion alone and it is suggested that some mechanism facilitates its transport, called as” facilitated transport”. This pathway is unique in the sense that it can utilize O2 if available (‘aerobic’) and it can function in absence of O2 also (‘anaerobic’) 35 Fig 2. Hence, to provide a given amount of energy, more glucose must undergo glycolysis under anaerobic as compared to aerobic. For discussion and proper understanding, the various reactions can be arbitrarily divided in to four stages. Uptake of Glucose by Cells and its phosphorylation Glucose is freely permeable to Liver cells. In Intestinal mucosa and kidney tubules, glucose is taken up by ‘active’ transport. In other tissues, like skeletal muscle, cardiac muscle, diaphragm, adipose tissue etc. The reaction is catalyzed by the specific enzyme glucokinase in liver cells and by nonspecific Hexokinase in liver and extrahepatic tissues.
Give an extra meal per day and continue until 1 month after diarrhoea has stopped buy cheap cytotec on-line symptoms 6 days before period due. Food hygiene • Ensure that all food consumed by the whole household is prepared and stored hygienically order cheap cytotec medicine search. Environmental sanitation • Ensure proper disposal of wastes (human and household) in the homes and communal areas generic 100 mcg cytotec with visa symptoms 6 weeks pregnant. Managing food handlers • Require regular examination of food handlers, especially in schools. Fever accompanies a wide variety of illnesses and does not always need to be treated on its own. In general, the cause should be ascertained as far as possible before therapy is started. Clinical Features History should take into account the duration, place of residence or travel to areas of high malaria transmission, pain on passing urine, pain in the ears, and whether there is a rash or not. Management – Specific Identification of the cause is the key to management and helps to prevent overuse of specific drugs, e. This includes not only the use of the appropriate antimalarial, but also the use of other methods to control fever. The patients should be taken immediately to a health facility if there are any features of severity as described in the section on severe malaria below. Malaria Malaria parasites are usually transmitted by the bite of an infected female anopheles mosquito. Plasmodium falciparum is the commonest type in Kenya and is associated with significant morbidity and mortality. Other features include: Malaise Headache Myalgia Joint pains Refusal to feed Nausea Vomiting Abdominal discomfort Diarrhoea 20. In low malaria endemic areas, any child with fever or history of fever in the absence of measles, running nose, or any other identifiable cause of fever should be presumptively classified and treated as having malaria. Where cerebral malaria is suspected appropriate therapy must be instituted promptly. On the other hand, a positive blood smear may be coincidental – up to 30% of the population in high endemic malaria parts of the country have parasitaemia without features of malaria. In children below 5kg (under 2 months of age), malaria is not a common cause of fever. Emphasize that all 6 doses must be taken over 3 days even if patient feels better after few doses. Advise patients to return immediately to the nearest health facility if their condition deteriorates at any time, or if symptoms have not resolved after 3 days. Encourage adequate fluids and nutrition: Caregivers should be encouraged to give extra fluids and where applicable to continue breastfeeding. Feeds and fluid should be administered as small quantities in frequent intervals, especially when the child is still very sick. Treatment failure may result from poor adherence to treatment, unusual pharmacokinetic properties in that individual, or drug resistance. Treatment failure could also arise because of a wrong diagnosis and thus initiating the wrong treatment. In evaluating a patient with treatment failure, it is important to determine from the patient’s history whether they vomited previous treatment or did not complete a full treatment course. Treatment failures should be suspected if patient deteriorates clinically at any time or if symptoms persists 3–14 days after initiating drug therapy in accordance with the recommended treatment regimen. Development of symptoms 14 days after initiation of therapy where there has been prior clearance of symptoms should be considered as a new infection and be treated with the first line drug. A fever that does not respond to adequate antimalarials may be due to other causes. This is administered as a daily dose of 30mg/kg in 3 divided doses of 10mg/kg for 7 days (refer to Table 20. Repeat test if unreliable and there is fever, assume child has malaria and give oral concern remains.
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