By S. Bram. Claremont Graduate University.

Under The scaphoid may be fractured through a fall on the outstretched these circumstances the proximal scaphoid fragment may be deprived hand buy generic cephalexin 750mg line. This injury is common in young adults and must be suspected of arterial supply and undergo avascular necrosis order cephalexin 500mg online. Only the major arterial branches Flexor carpi radialis are labelled 66 Upper limb The axillary artery the artery lies on the distal radius lateral to the tendon of flexor carpi • Course: the axillary artery commences at the lateral border of the 1st radialis order 250mg cephalexin amex. It is •Asuperficial palmar branch arises at the wrist which supplies the crossed anteriorly by pectoralis minor which subdivides it into three thenar muscles and consequently anastomoses with the superficial parts: palmar branch of the ulnar artery to form the superficial palmar • First part (medial to pectoralis minor). It consequently passes over the scaphoid and trapezium • Third part (lateral to pectoralis minor)agives off the subscapular in the snuffbox and exits by passing between the two heads of artery which follows the lateral border of the scapula and gives off adductor pollicis to enter the palm and forms the deep palmar arch the circumflex scapular artery. It gives off the princeps pollicis to the thumb and the radialis indicis The brachial artery to the index finger. The brachial artery is crossed superficially by the median nerve in the mid- The ulnar artery arm from lateral to medial and hence lies between the median nerve • Course: the ulnar artery commences as the terminal bifurcation of (medial relation) and biceps tendon (lateral relation) in the cubital fossa the brachial artery at the level of the neck of the radius. At the wrist both the ulnar artery and nerve lie lateral (radial) to • Other branchesainclude a nutrient artery to the humerus and flexor carpi ulnaris and pass over the flexor retinaculum giving carpal superior and inferior ulnar collateral branches which ultimately branches which contribute to the dorsal and palmar carpal arches. The reduced arterial flow results in ischaemic necro- is completed by the superficial palmar branch of the radial artery. The common interosseous artery is the first ulnar branch to arise and it subdivides into the: The radial artery • Anterior interosseous artery: descends with the interosseous branch • Course: the radial artery arises at the level of the neck of the radius of the median nerve on the anterior surface of the interosseous from the bifurcation of the brachial artery. It predominantly supplies the flexor compartment of the don to lie firstly on supinator then descends on the radial side of the forearm. The radial artery passes sequentially runs with the deep branch of the radial nerve supplying the extensor over supinator, pronator teres, the radial head of flexor digitorum muscles of the forearm, eventually anastomosing with the anterior superficialis, flexor pollicis longus and pronator quadratus. They drain lymph from the ulnar side of the forearm As in the lower limb the venous drainage comprises interconnected and hand. From lateral, then anterolateral, aspects of the forearm and arm and this point the efferent vessels pass through the clavipectoral fascia to finally courses in the deltopectoral groove to pierce the clavipec- drain into the apical group of axillary nodes and thence centrally. If a patient • The basilic vein commences from the medial end of the dorsal presents with an infected insect bite of the thumb, the infraclavicular venous network. If, however, infection occurred on the aspects of the forearm and arm to pierce the deep fascia (in the patient’s little finger, lymphadenopathy of the supratrochlear nodes region of the mid-arm) to join with the venae comitantes of the would result. The breasts are present in both sexes and have similar characteristics • The deep veins: consist of venae comitantes (veins which accom- until puberty when, in the female, they enlarge and develop the capac- pany arteries). The breasts are essentially specialized skin The superficial veins of the upper limb are of extreme clinical import- glands comprising fat, glandular and connective tissue. It extends monly used sites are the median cubital vein in the antecubital fossa and from the 2nd to 6th ribs anteriorly and from the lateral edge of the ster- the cephalic vein in the forearm. A part of the breast, the axillary tail, extends laterally through the deep fascia beneath pectoralis to enter Lymphatic drainage of the chest wall and the axilla. The lobes are separated by fibrous Lymph from the chest wall and upper limb drains centrally via axillary, septa (suspensory ligaments) which pass from the deep fascia to the supratrochlear and infraclavicular lymph nodes. In its terminal por- Axillary lymph node groups tion the duct is dilated (lactiferous sinus) and thence continues to the There are approximately 30–50 lymph nodes in the axilla. Its surface is usually irregular due to • Anterior (pectoral) group: these lie along the anterior part of the multiple small tuberclesaMontgomery’s glands. They receive lymph from the upper anterior • Blood supply: is from the perforating branches of the internal part of the trunk wall and breast. From here lymph is passed to The axillary lymph nodes represent an early site of metastasis from prim- the thoracic duct (on the left) or right lymphatic trunks (see Fig. Damage to axillary lymphatics during surgical clearance of axillary nodes or resulting from radio- Lymph node groups in the arm therapy to the axilla increases the likelihood of subsequent upper limb • The supratrochlear group of nodes lie subcutaneously above the lymphoedema. The venous and lymphatic drainage of the upper limb and the breast 69 30 Nerves of the upper limb I Fig. Here it supplies the skin of the lateral forearm as far as the • Course: it passes through the quadrangular space with the posterior wrist. It provides: a motor supply to deltoid and teres minor; a sensory supply to the skin overlying deltoid; and an articu- The median nerve (C6,7,8,T1) (Fig. A short between the long and medial heads of triceps into the posterior com- distance above the wrist it emerges from the lateral side of flexor partment and down between the medial and lateral heads of triceps. It ter- eminence (but not adductor pollicis); the branches to the 1st and 2nd minates by dividing into two major nerves: lumbricals; and the cutaneous supply to the palmar skin of the thumb, • The posterior interosseous nerveapasses between the two heads index, middle and lateral half of the ring fingers. It winds under the medial epicondyle and passes between the two heads of Infraclavicular branches flexor carpi ulnaris to enter the forearm and supplies flexor cari ulnaris • Medial and lateral pectoral nerves: supply pectoralis major and and half of flexor digitorum profundus. Erb–Duchenne paralysis • The deep terminal branchasupplies the hypothenar muscles as Excessive downward traction on the upper limb during birth can result well as two lumbricals, the interossei and adductor pollicis.

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Onset is most frequent between the ages of 40 and 50 generic cephalexin 750mg visa, but people of any age can be affected purchase genuine cephalexin on-line. It is up to three times more common in smokers than non-smokers order cephalexin cheap, particularly in men, heavy smokers, and those who are rheumatoid factor positive. First-degree relatives prevalence rate is 2–3% and disease genetic concordance in monozygotic twins is approximately 15–20%. Clinical diagnosis: Rheumatoid arthritis typically manifests with signs of inflammation, with the affected joints being swollen, warm, painful and stiff, particularly early in the morning on waking or following prolonged inactivity. Increased stiffness early in the morning is often a prominent feature of the disease and typically lasts for more than an hour. Referral criteria: For further evaluation and management of cases not responding to conventional therapy. American College of Rheumatology, 2008 Annual Scientific Meeting, poster presentation. Introduction: Rickets is a softening of bones in children due to deficiency or impaired metabolism of vitamin D, phosphorus or calcium,http://en. Rickets is among the most frequent childhood diseases in many developing countries. The predominant cause is a vitamin D deficiency, but lack of adequate calcium in the diet may also lead to rickets (cases of severe diarrhea and vomiting may be the cause of the deficiency). Although it can occur in adults, the majority of cases occur in children suffering from severe malnutrition b. Sunlight, especially ultraviolet light, lets human skin cells convert Vitamin D from an inactive to active state. Children ages 6 months to 24 months are at highest risk, because their bones are rapidly growing. Mother’s milk gives adequate calcium and vitamin-D so nutritional rickets develops once breast feeding is stopped. Investigations: Alkaline Phosphatase Serum Calcium Serum Phosphorus 157 X rays of the deformed part c. Treatment: The goals of treatment are to relieve symptoms and correct the cause of the condition. Replacing calcium, phosphorus, and vitamin D, Exposure to moderate amounts of sunlight is encouraged. Others are 25 hydroxy – Vit D level 1,25 – dihydroxy- Vit D level 24 hours urinary Ca and Phosphorus levels z. In Patient : as in situation 1 and Recombinant Growth hormone therapy for Hypophosphatemic rickets ii. Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Backup attending: A backup attending is available during the day and is called at the discretion of the day attending c. Night attending: Night attending for admission, cross coverage, transport calls/consults, code team response. The role/responsibilities of the surgical fellow will vary depending on their educational goals. One of the pediatric residents should be assigned to “back-up” the subintern on each patient. Write admission orders and admission note (medical patient) or review admission orders and write admission note (surgical patient) 2. Surgical patients do not need notes on the day of transfer (except cardiac surgical patients, who transfer to the cardiology service on the ward/dncc). When gone from unit (post call, clinic, etc), communicate/sign out with resident/s who remain in the unit. Please also notify the attending that you are leaving and summarize any patient care tasks that still need to be done. Write transfer note for medical patients, communicate patient data to receiving resident. For Shriner’s discharges or home discharges, dictate admission (students should not dictate). The above caregivers will distribute patients relatively evenly, within the following guidelines a. Because of this, initially they should have fewer patients so that they can familiarize them selves with the various hospital/unit procedures. The Sub-intern should follow 1-3 patients (backed-up by one of the pediatric residents) e. Patients admitted by the cross cover residents should be divided up the following day, with attention to evening up the distribution of patients according to the above guidelines. If not all patients can be pre-rounded on, surgical patients who are expected to transfer to the floor after a one day stay should be rounded on last. If not all patients are pre-rounded, their data will be reviewed by the entire team at the time of work rounds.

The plantar reflex is commonly tested in newborn infants to establish the presence of neuromuscular function discount 500 mg cephalexin otc. To elicit this reflex order online cephalexin, an examiner brushes a stimulus purchase cephalexin pills in toronto, usually the examiner’s fingertip, along the plantar surface of the infant’s foot. An infant would present a positive Babinski sign, meaning the foot dorsiflexes and the toes extend and splay out. As a person learns to walk, the plantar reflex changes to cause curling of the toes and a moderate plantar flexion. If superficial stimulation of the sole of the foot caused extension of the foot, keeping one’s balance would be harder. The descending input of the corticospinal tract modifies the response of the plantar reflex, meaning that a negative Babinski sign is the expected response in testing the reflex. Other superficial reflexes are not commonly tested, though a series of abdominal reflexes can target function in the lower thoracic spinal segments. Testing reflexes of the trunk is not commonly performed in the neurological exam, but if findings suggest a problem with the thoracic segments of the spinal cord, a series of superficial reflexes of the abdomen can localize function to those segments. If contraction is not observed when the skin lateral to the umbilicus (belly button) is stimulated, what level of the spinal cord may be damaged? Comparison of Upper and Lower Motor Neuron Damage Many of the tests of motor function can indicate differences that will address whether damage to the motor system is in the upper or lower motor neurons. The clasp-knife response occurs when the patient initially resists movement, but then releases, and the joint will quickly flex like a pocket knife closing. Forceful trauma to the trunk may cause ribs or vertebrae to fracture, and debris can crush or section through part of the spinal cord. The full section of a spinal cord would result in paraplegia, or loss of voluntary motor control of the lower body, as well as loss of sensations from that point down. The ascending tracts in the spinal cord are segregated between the dorsal column and spinothalamic pathways. This means that the sensory deficits will be based on the particular sensory information each pathway conveys. Sensory discrimination between touch and painful stimuli will illustrate the difference in how these pathways divide these functions. On the paralyzed leg, a patient will acknowledge painful stimuli, but not fine touch or proprioceptive sensations. The reason for this is that the dorsal column pathway ascends ipsilateral to the sensation, so it would be damaged the same way as the lateral corticospinal tract. The spinothalamic pathway decussates immediately upon entering the spinal cord and ascends contralateral to the source; it would therefore bypass the hemisection. The motor system can indicate the loss of input to the ventral horn in the lumbar enlargement where motor neurons to the leg are found, but motor function in the trunk is less clear. The likelihood of trauma to the spinal cord resulting in a hemisection that affects one anterior column, but not the other, is very unlikely. Either the axial musculature will not be affected at all, or there will be bilateral losses in the trunk. The pain fibers on the side with motor function cross the midline in the spinal cord and ascend in the contralateral lateral column as far as the hemisection. The dorsal column will be intact ipsilateral to the source on the intact side and reach the brain for conscious perception. The trauma would be at the level just before sensory discrimination returns to normal, helping to pinpoint the trauma. That may be all that is available on the scene when moving the victim requires crucial decisions be made. There is an obvious connection to motor function based on the clinical implications of cerebellar damage. The two are not incompatible; in fact, procedural memory is motor memory, such as learning to ride a bicycle. Significant work has been performed to describe the connections within the cerebellum that result in learning. A model for this learning is classical conditioning, as shown by the famous dogs from the physiologist Ivan Pavlov’s work. This classical conditioning, which can be related to motor learning, fits with the neural connections of the cerebellum. The cerebellum is 10 percent of the mass of the brain and has varied functions that all point to a role in the motor system. The word means “bridge” and refers to the thick bundle of myelinated axons that form a bulge on its ventral surface. Those fibers are axons that project from the gray matter of the pons into the contralateral cerebellar cortex. It includes a copy of the motor commands sent from the precentral gyrus through the corticospinal tract, arising from collateral branches that synapse in the gray matter of the pons, along with input from other regions such as the visual cortex. These connections describe a circuit that compares motor commands and sensory feedback to generate a new output. The cerebellum is divided into regions that are based on the particular functions and connections involved.

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Q every 8 hours for 7-10 days • When associated with rhinitis add Xylometazoline (Otrivine) 0 generic 750mg cephalexin with visa. Predisposing risk factors - Inadequate management of otitis media - Frequent upper respiratory tract infections - Anatomic factor: Short Eustachian Tube - Poor living conditions 250 mg cephalexin with mastercard, poor housing purchase discount cephalexin online, hygiene and nutrition analphabetism - Immunosupression (e. Pharmaceutical treatment • Application of a topical antibiotics ointment to the nasal mu- cosa has been shown to be an efective treatment for recurrent epistaxis • Topical vasoconstrictor: Xylometazoline spray (otrivine) 0. It is due to intense swelling of epiglottis and surround- ing tissues with septic signs. Cardiac failure Defnition: It is the inability of the heart to deliver adequate cardiac output to meet the metabolic needs of the body. Maximum dose 8 mg/kg/day) • Supplementary Potassium if Frusemide is given for more than 5 days • Treating the underlying cause (surgical treatment): refer to a specialized centre. See section on cardiology for more details on diagnosis and treatment of cardiovascular disorders. Shock Defnition: It is an acute dramatic syndrome characterized by inadequate circulatory provision of oxygen, so that the metabolic demands of vital organs and tissues are not met. Cefotaxi- me 150-200 mg/kg/day in 3-4 divided doses per day or Cefriaxone 100 mg/kg/day given once per day) Ș If no improvement on fuid therapy ■ Give Inotropic drugs (Dopamine 5-15μg/kg/min ■ Dilution: 200 mg in 50 ml of normal saline Ș Abscess, if present should be drained • Cardiogenic shock Ș See section on management of cardiac diseases • Anaphylactic shock Ș General measures as above Ș Place patient in Tredelenberg position with head at 30 degree angle below the feet. Use one of the follow- ing solutions (in order of preference) and according to availability ■ Ringer’s lactate with 5% Glucose (dextrose) or ■ Half Normal saline with 5% Glucose (dextrose) or ■ Half-strength Darrow’s solution with 5% Glucose (dextrose) or if these are unavailable give Ringer’s lactate Ș Measure the pulse and breathing rate at the start and every 5–10 minutes thereafer. Recommendations - If isolated right sided heart failure: use furosemide (see dosage above) and aldactone 2mg/kg/day divided in 2 doses. Repeat the dose according to estimated fuid overload up to 8mg/kg/day • Correct arrhythmia if present with digoxin 0. Causes - Heart not removing fuid from lung circulation properly (cardio- genic pulmonary edema) - A direct injury to the lung parenchyma Signs and symptoms - Breathlessness/ Respiratory distress - Sweating - Cyanosis (decreased oxygen saturation) - Frothy blood-tinged sputum - Ronchi and crepitations/wheezes Investigations - Chest x-ray shows loss of distinct vascular margins, Kerley B lines, difuse haziness of lung felds, pleural efusion. Ofen divided into two types, non-cyanotic and cyanotic (blue discolor- ation caused by a relative lack of oxygen). Some congenital heart diseases can be treated with medication alone, while others require one or more surgeries. Cyanotic heart diseases Defnition: Cyanotic heart disease is a heart defect, present at birth (con- genital), that results in low blood oxygen levels (< 90 % even with oxygen). Acute rheumatic fever Defnition: Tis is an acute, systemic connective tissue disease in children related to an immune reaction to untreated group A Beta haemolytic strep- tococcus infection of the upper respiratory tract. Te initial attack of acute rheumatic fever occurs in most cases between the ages of 3 and 15 years. Rheumatic Heart Diseases Defnition: It is an infammatory damage of the heart valves, as a com- plication of acute rheumatic fever. Te mitral valve is the most commonly involved valve, although any valve may be afected. Types - Mitral regurgitation/stenosis - Aortic regurgitation/stenosis - Tricuspid regurgitation - Mixed regurgitation and stenosis - Multivalvular heart diseases Signs and symptoms - May be asymptomatic when minor lesions - Heart murmurs over afected valve Complications - Congestive cardiac failure with pulmonary oedema - Bacterial endocarditis. Infective endocarditis Defnition: Infection of the endothelial surface of the heart. Suspect infec- tive endocarditis in all children with persistent fever and underlying heart disease. Note: All highly suspected cases of infective endocarditis must be referred to the cardiologist where blood cultures and proper management will be done. Classifcation - Classifcation based on the predominant structural and functional abnormalities: • Dilated cardiomyopathy: primarily systolic dysfunction, • Hypertrophic cardiomyopathy: primarily diastolic dysfunc- tion, • Restrictive cardiomyopathy: primarily diastolic but ofen combined with systolic dysfunction 5. Rheumatic carditis, juvenile rheuma- toid arthritis, systemic lupus erythematosus, dermatomyositis, systemic lupus erythematosus) - Drugs toxicity (e. Restrictive cardiomyopathy Defnition: Restrictive cardiomyopathy refers to a group of disorders in which the heart chambers are unable to properly fll with blood because of stifness in the heart muscle. Pericarditis/Pericardial Efusion Defnition: Pericarditis is the infammation of the pericardium. Pericardial efusion is the abnormal build-up of excess fuid that develops between the pericardium, the lining of the heart, and the heart itself. Causes - Infection such as viral, bacterial (tuberculosis) - Infammatory disorders, such as lupus - Cancer that has spread (metastasized) to the pericardium - Kidney failure with excessive blood levels of nitrogen - Heart surgery (postpericardectomy syndrome) Signs and symptoms - Pericardial tamponade - Chest pressure or pain and signs of congestive heart failure with shock in some cases Note: Many patients with pericardial efusion have no symptoms. Te condition is ofen discovered on a chest x-ray or echocardio- gram that was performed for another reason. A sustained Blood Pressure of > 115/80 is abnormal in children between 6 weeks and 6 years of age. Convulsions Defnition: Convulsions or seizure are disturbance of neurological function caused by an abnormal or excessive neuronal discharge. Causes Causes Clinical signs/symptoms Meningitis - Very irritable - Stiff neck or bulging fontanelles - Petechial rash (meningococcal meningitis only) - Fever Cerebral malaria (only - Blood smear positive for malaria in children exposed to P. Child having 3rd convulsion Lasting < 5mins in < 2 hours* Convulsion stops by 10 minutes? Coma Defnition: It is a state of extreme unresponsiveness, in which an individual exhibits no voluntary movements or behaviour and cannot be aroused to consciousness.

Some patients experience health problems as a result of the normal decline in hormones that can accompany aging cheap 750 mg cephalexin with visa. These patients can consult with an endocrinologist to weigh the risks and benefits of hormone replacement therapy intended to boost their natural levels of reproductive hormones 750mg cephalexin otc. In addition to treating patients buy 750mg cephalexin with amex, endocrinologists may be involved in research to improve the understanding of endocrine system disorders and develop new treatments for these diseases. Once the hormone binds to the receptor, a chain of events is initiated that leads to the target cell’s response. Hormones play a critical role in the regulation of physiological processes because of the target cell responses they regulate. These responses contribute to human reproduction, growth and development of body tissues, metabolism, fluid, and electrolyte balance, sleep, and many other body functions. These chemical groups affect a hormone’s distribution, the type of receptors it binds to, and other aspects of its function. An example of a hormone derived from tryptophan is melatonin, which is secreted by the pineal gland and helps regulate circadian rhythm. Tyrosine derivatives include the metabolism-regulating thyroid hormones, as well as the catecholamines, such as epinephrine, norepinephrine, 738 Chapter 17 | The Endocrine System and dopamine. Epinephrine and norepinephrine are secreted by the adrenal medulla and play a role in the fight-or-flight response, whereas dopamine is secreted by the hypothalamus and inhibits the release of certain anterior pituitary hormones. Peptide and Protein Hormones Whereas the amine hormones are derived from a single amino acid, peptide and protein hormones consist of multiple amino acids that link to form an amino acid chain. Peptide hormones consist of short chains of amino acids, whereas protein hormones are longer polypeptides. For example, the reproductive hormones testosterone and the estrogens—which are produced by the gonads (testes and ovaries)—are steroid hormones. The adrenal glands produce the steroid hormone aldosterone, which is involved in osmoregulation, and cortisol, which plays a role in metabolism. Because blood is water-based, lipid- derived hormones must travel to their target cell bound to a transport protein. This more complex structure extends the half-life of steroid hormones much longer than that of hormones derived from amino acids. Pathways of Hormone Action The message a hormone sends is received by a hormone receptor, a protein located either inside the cell or within the cell membrane. The receptor will process the message by initiating other signaling events or cellular mechanisms that result in the target cell’s response. Hormone receptors recognize molecules with specific shapes and side groups, and respond only to those hormones that are recognized. The same type of receptor may be located on cells in different body tissues, and trigger somewhat different responses. Thus, the response triggered by a hormone depends not only on the hormone, but also on the target cell. The response may include the stimulation of protein synthesis, activation or deactivation of enzymes, alteration in the permeability of the cell membrane, altered rates of mitosis and cell growth, and stimulation of the secretion of products. Pathways Involving Intracellular Hormone Receptors Intracellular hormone receptors are located inside the cell. Steroid hormones are derived from cholesterol and therefore can readily diffuse through the lipid bilayer of the cell membrane to reach the intracellular receptor (Figure 17. Thyroid hormones, which contain benzene rings studded with iodine, are also lipid-soluble and can enter the cell. The location of steroid and thyroid hormone binding differs slightly: a steroid hormone may bind to its receptor within the cytosol or within the nucleus. Pathways Involving Cell Membrane Hormone Receptors Hydrophilic, or water-soluble, hormones are unable to diffuse through the lipid bilayer of the cell membrane and must therefore pass on their message to a receptor located at the surface of the cell. Except for thyroid hormones, which are lipid-soluble, all amino acid–derived hormones bind to cell membrane receptors that are located, at least in part, on the extracellular surface of the cell membrane. Therefore, they do not directly affect the transcription of target genes, but instead initiate a signaling cascade that is carried out by a molecule called a second messenger. This receptor is associated with an intracellular component called a G protein, and binding of the hormone activates the G- protein component (Step 2). Activated protein kinases initiate a phosphorylation cascade, in which multiple protein kinases phosphorylate (add a phosphate group to) numerous and various cellular proteins, including other enzymes (Step 6). The phosphorylation of cellular proteins can trigger a wide variety of effects, from nutrient metabolism to the synthesis of different hormones and other products. The effects vary according to the type of target cell, the G proteins and kinases involved, and the phosphorylation of proteins. The calcium ions then act as second messengers in two ways: they can influence enzymatic and other cellular activities directly, or they can bind to calcium-binding proteins, the most common of which is calmodulin. For example, the presence of a significant level of a hormone circulating in the bloodstream can cause its target cells to decrease their number of receptors for that hormone. This process is called downregulation, and it allows cells to become less reactive to the excessive hormone levels.

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Albendazole 400 mg daily for 5 days may Albendazole 200 mg po once daily for 5 be effective days for children up to 2 years of age order cheap cephalexin online; for children 2 years and older purchase 500mg cephalexin overnight delivery, similar dose as for adults 7 Ascariasis Piperazine citrate 3 purchase 500 mg cephalexin otc. Pyrantel pamoate 10 mg /kg po stat Pyrantel pamoate 10 mg /kg po stat (maximum 1 gram base) (maximum 1 gram base) May be repeated in 2-3 weeks if May be repeated in 2-3 weeks if required. These requirements should be observable and measurable, using such factors as time, temperature and sensory measures. Types of Hazards Types of Hazards Microbiological Examples Biological Bacteria Clostridium botulinum Salmonella choleraesuis Salmonella paratyphic A-C Shigella dysenteriae Vibrio cholerae Salmonella spp. Campylobacter jejuni Clostridium perfringens Staphylococcus aureus Vibrio parahemolyticus Aeromonas hydrophila Viruses Norwalk and Norwalk-like viruses Rotavirus Hepatitis A virus Parasites Anisikiasis simplex Ameba Giardia Taenia spp. Trichinella spiralis Chemical Raw materials Heavy metals Pesticide/Insecticide residues Antibiotic residues Histamine Toxins In the process Refrigerants Lubricants/Hydrocarbons from the process Pest control agents Sanitizing agents Water additive Paints From packaging materials Plasticizers Printing code inks Adhesives Lubricants Physical Natural materials Bone Skin Connective tissue Contaminating ingredients Foreign bodies Insect infestation Glass Metal Plastic Wood paper 160 C. The Center for Disease Control and Prevention, Diagnosis and Management of Food-borne Diseases, February 2004, (www. Drug Adminsitration and Control Authority of Ethiopia, Standard Treatment Guidelines for the District Hospital, 2004 25. 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. Nuclear family is defined as ‘’ a family consisting of a married couples and their children; the children can be born or adopted’’. For practical reasons, it may be sound to distinguish: ♦ The childbearing unit, nuclear or one parent family, where the genetic factors are prominent. It could be defined as: A quality of life, which involves social, mental and biological fitness on the part of the individual, which results from adaptations to the environment. The summary of different views conceptualises health to be multidimensional and inclusive of many components and many different aspects of one’s life. We can consider health as a quality of life that is a function of at least social, mental, emotional, spiritual and physical health. Justification Knowledge acquired in the past few decades has clarified the biological and social bases underlying the health and health care of families. This represents the image of a healthy family – the only real basis for the self-realization of all its members. This approach also takes account of the patterns of intra-family relationships in regard to disease prevention, health education and health care. The cause and factors to maternal morbidity and mortality could be: Medical Factors ♦ Anaemia of pregnancy ♦ Obstructed labour ♦ Infections ♦ Hypertension 9 Family Health Health delivery system factors ♦ Inadequate action taken by health personnel ♦ Lack of essential supply and trained staff. The fertilized ovum gradually grows and develops in the uterus of the woman and transforms itself into a foetus. Antenatal service is the provision of counselling and health service to a pregnant woman by a health professional from the time of conception to delivery. The medical check up made during pregnancy helps mothers to get advices during pregnancy and post delivery periods. The following are the activities that would be undertaken during first antenatal visit: Registration of age, height, weight, last day of menstruation. Other information that would be collected from the mother are, number of children born, where they were born, previous health problems, information whether she ever taken vaccination or not. After these and other information are collected, and when there are some indications for risks during pregnancy and delivery, the mother should be educated about the need for her to go to the next higher 13 Family Health level of health facility. Unless these illnesses are known on time and the necessary care is taken, the illnesses can lead to life threatening risks. The signs of such illness are the following: - Puffiness/ oedema of the face especially around the eye. When the following signs are observed, the woman should be immediately referred to a health facility since this will lead her to dangerous situations. She needs to regularly and attentively feed herself with cereals, vegetables, fruits, milk, meat, pulses, butter, and cereals with fat contents. If she cannot get these food items, she should be educated on the use of other food items that replace those ones. Regular antenatal follow up It is proposed that there should be: ♦ Nine visits for the healthy nulliparous ♦ Seven visits for the healthy parous Actual visit is – Once per month up to 28 weeks (that is four times) • Twice per week up to 32 weeks (four times) • Then once per week till delivery.

The postganglionic fibers of either division release neurotransmitters onto the smooth muscles of the iris to cause changes in the pupillary size purchase cheap cephalexin online. It is a homeostatic reflex mechanism that keeps the activation of photoreceptors within certain limits discount cephalexin 500mg mastercard. In the context of avoiding a threat like the lioness on the savannah trusted 500 mg cephalexin, the sympathetic response for fight or flight will increase pupillary diameter so that more light hits the retina and more visual information is available for running away. Likewise, the parasympathetic response of rest reduces the amount of light reaching the retina, allowing the photoreceptors to cycle through bleaching and be regenerated for further visual perception; this is what the homeostatic process is attempting to maintain. The pupillary light reflex involves sensory input through the optic nerve and motor response through the oculomotor nerve to the ciliary ganglion, which projects to the circular fibers of the iris. As shown in this short animation, pupils will constrict to limit the amount of light falling on the retina under bright lighting conditions. Autonomic Tone Organ systems are balanced between the input from the sympathetic and parasympathetic divisions. When something upsets that balance, the homeostatic mechanisms strive to return it to its regular state. For each organ system, there may be more of a sympathetic or parasympathetic tendency to the resting state, which is known as the autonomic tone of the system. Because the resting heart rate is the result of the parasympathetic system slowing the heart down from its intrinsic rate of 100 bpm, the heart can be said to be in parasympathetic tone. In a similar fashion, another aspect of the cardiovascular system is primarily under sympathetic control. Blood pressure is partially determined by the contraction of smooth muscle in the walls of blood vessels. These tissues have adrenergic receptors that respond to the release of norepinephrine from postganglionic sympathetic fibers by constricting and increasing blood pressure. The hormones released from the adrenal medulla—epinephrine and norepinephrine—will also bind to these receptors. Those hormones travel through the bloodstream where they can easily interact with the receptors in the vessel walls. The parasympathetic system has no significant input to the systemic blood vessels, so the sympathetic system determines their tone. It does not have an overall effect on blood pressure to alter the tone of the vessels, but rather allows for blood flow to increase for those skeletal muscles that will be active in the fight-or-flight response. The blood vessels that have a parasympathetic projection are limited to those in the erectile tissue of the reproductive organs. Acetylcholine released by these postganglionic parasympathetic fibers cause the vessels to dilate, leading to the engorgement of the erectile tissue. This is because, for one reason or another, blood is not getting to your brain so it is briefly deprived of oxygen. When you change position from sitting or lying down to standing, your cardiovascular system has to adjust for a new challenge, keeping blood pumping up into the head while gravity is pulling more and more blood down into the legs. The reason for this is a sympathetic reflex that maintains the output of the heart in response to postural change. Both changes will make it possible for the cardiovascular system to maintain the rate of blood delivery to the brain. Blood is being pumped superiorly through the internal branch of the carotid arteries into the brain, against the force of gravity. Gravity is not increasing while standing, but blood is more likely to flow down into the legs as they are extended for standing. This sympathetic reflex keeps the brain well oxygenated so that cognitive and other neural processes are not interrupted. If the sympathetic system cannot increase cardiac output, then blood pressure into the brain will decrease, and a brief neurological loss can be felt. This can be brief, as a slight “wooziness” when standing up too quickly, or a loss of balance and neurological impairment for a period of time. The name for this is orthostatic hypotension, which means that blood pressure goes below the homeostatic set point when standing. It can be the result of standing up faster than the reflex can occur, which may be referred to as a benign “head rush,” or it may be the result of an underlying cause. This hypovolemia may be the result of dehydration or medications that affect fluid balance, such as diuretics or vasodilators. Both of these medications are meant to lower blood pressure, which may be necessary in the case of systemic hypertension, and regulation of the medications may alleviate the problem. The disorders range from diabetes to multiple system atrophy (a loss of control over many systems in the body), and addressing the underlying condition can improve the hypotension. For example, with diabetes, peripheral nerve damage can occur, which would affect the postganglionic sympathetic fibers. Getting blood glucose levels under control can improve neurological deficits associated with diabetes.

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