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The dose of intermediate acting insulin is 2/3 of the total daily soluble insulin requirement buy nasonex nasal spray 18gm on line. Alternative strategy is to base control on two doses of intermediate acting insulin 2/3 in the morning and 1/3 before supper buy discount nasonex nasal spray 18gm online. Clinical features include intense polydipsia, abdominal pain, vomiting, dehydration, acidotic breathing or coma. Investigations • Urinalysis; − Ketonuria and glycosuria 85 • Blood sugar − hyperglycaemia. Most patients with Type 1 need hospitalization and are best managed with divided doses of intermediate acting insulin 2/3 lente A. Continue intravenous fluids until fluid losses have been corrected and ketonuria has disappeared. Potassium replacement should commence immediately after the first dose of insulin and 1 litre of fluids. Treat with broad spectrum bactericidal antibiotic while awaiting results of cultures where applicable. Take blood for glucose and give 20 ml of 50% dextrose immediately • All diabetics with complications such as diabetic foot should be admitted Patient Education • Teach patients on how to avoid foot injury. Hospital occupational therapist should advice patients on foot care • Patients with any injury, however minor, should seek medical advice • Patients should eat regularly • Patients should carry sweets or glucose and chew them if they experience any symptoms of hypoglycaemia • Patients should always carry "Diabetic Alert" card with them • Patients should join any branch of the Kenya Diabetic Association for support and "Continuing Education. Usually caused by lack of iodine or defects in synthesis of thyroxine hormone • Toxic goitre; diffuse or nodular. Produces excess thyroxine (T3, T4) and manifests with signs and symptoms of thyrotoxicosis • Neoplastic goitre; benign or malignant • Thyroiditis e. In hyperthyroid patients weight loss, diarrhoea, heat intolerance, sweating, tachycardia, tremors, lid lag, exophthalmos, menstrual disorders may occur. Non−toxic goitre • Pressure symptoms − dysphagia, venous obstruction, dyspnoea • Cosmetic • Suspicious histology e. Complications of thyroidectomy • Haemorrhage and haematoma • Dyspnoea − can be due to oedema haematoma or neurological • Nerve palsy − recurrent laryngeal mainly tends to recover, if "paresis" • Hypoparathyrodism − leading to tetany and convulsions • Hypothyroidism − give thyroxine. Refer If • Increase in size of the goitre • Suspicion of malignancy • Pressure symptoms • Large goitres for cosmetic reasons • Thyrotoxic patients who fail to respond to medical treatment • Goitres in children and male adults. Classification • Congenital failure of thyroid development (complete or partial) • Endemic cretinism • Iatrogenic − (after, thyroidectomy, radio−iodine therapy, pituitary ablation, drug induced) • Auto−immune thyroiditis • Goitrogens e. Diagnosis The deficiency ranges from mild with minimal or unrecognised clinical manifestation to severe mental retardation (cretinism). Diagnosis should be based on neonatal screening tests and not abnormal physical signs. Clinical Features Prolonged jaundice, feeding difficulty, lethargy and somnolence, apnoeic attacks, constipation, large abdomen, umbilical hernia, macroglossia, failure to thrive, delayed physical and mental development. Adult Hypothyroidism Clinical Features 91 Myxoedema is a very advanced form of hypothyroidism and this is not applicable to the more common milder degrees seen after thyroidectomy or autoimmune thyroiditis. Early symptoms include; tiredness, cold intolerance, menstrual disturbances, carpal tunnel syndrome. The physical signs include; slow pulse rate, dry skin, sparse and dry hair, periorbital puffiness, hoarse voice. Common Eye Conditions It is important to note that over 75% of all blindness in Kenya is either preventable or treatable. Most of the patients who come to clinics with eye complaints can be successfully treated by non−specialist medical workers. Important causes of blindness in Kenya are: Cataract 42%, trachoma 19%, glaucoma 9%, others include trauma, vitamin A deficiency. The table below shows some of the common eye diseases and the recommended management. Eye injuries include: Corneal and conjunctival foreign bodies and abrasions, burns (dry heat and chemical burns), blunt trauma (contusions), penetrating injuries to the eyeball (perforations), injuries to the eyelids, orbital injuries and cranial nerve injuries. Management − General • Check vision of all eye patients 92 • Use topical local anaesthesia for examination (not treatment) of a painful injured eye • Good lighting and magnifying lens make eye examination easier. Trachoma with Inturned upper lids with eyelashes Surgery: Refer to eye clinic entropion and trichiasis scratching cornea Prevention: Good hygiene 2(a). Asthenopia (eye Normal vision and complaint of pain Reassurance; if persistent refer to eye strain) when reading clinic Majority also anxious 4. Allergic conjunctivitis Red itching eyes Commonest in 0 5% zinc sulphate × 7 days children Usually recur on and off with or without treatment Refer If no Improvement 5. Conjunctivitis of the Bilateral copious pus in the eyes of Careful, constant cleaning of eyes newborn (ophthalmia newborn Local and systematic antibiotics. May be confused with cataract, could be glaucoma, retinal or optic nerve disorders.

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The lesions are more common in young women purchase 18gm nasonex nasal spray mastercard, usually persist with variable severity for months or years generic nasonex nasal spray 18 gm without a prescription, and may cause cosmetic problems. Usage subject to terms and conditions of license 348 Lip Lesions Contact Cheilitis Definition Contact cheilitis is an acute inflammatory disorder of the lips. Clinical features It is characterized by mild edema and erythema, followed by irritation and thick scaling (Fig. Actinic Cheilitis Definition Actinic cheilitis is a chronic degenerative disorder of the lower lip. Clinical features In the early stage, mild erythema and edema fol- lowed by dryness and fine scaling of the lower lip vermilion border are the presenting signs. As the lesion progresses, the epitheliumbe- comes thin and smooth, with small whitish-gray areas intermingled with red regions and scaly formations (Fig. Differential diagnosis Leukoplakia, lichen planus, lupus erythemato- sus, early squamous-cell carcinoma, cheilitis due to radiation. Usage subject to terms and conditions of license 350 Lip Lesions Angular Cheilitis Definition Angular cheilitis, or perlèche, is a common disorder of the angles of the mouth. Etiology Reduced vertical dimension, mechanical trauma, Candida al- bicans, staphylococci, streptococci, iron-deficiency anemia, riboflavin de- ficiency. Clinical features The condition is characterized by erythema, macer- ation, fissuring, erosions, and crusting at the commissures (Figs. Treatment Correction of the occlusal vertical dimension, topical ste- roids, and antifungal ointments. Usage subject to terms and conditions of license 352 Lip Lesions Lip-Licking Dermatitis Definition Lip-licking dermatitis is an irritant contact condition that most commonly occurs in children. Clinical features The lips and the perioral skin are erythematous, associated with scaling, crusting, and fissuring of variable severity (Fig. Median Lip Fissure Definition Median lip fissure is a relatively rare disorder that may appear in the lower or upper lip. Clinical features It presents as a deep, inflammatory, persistent verti- cal fissure at the middle of the lip, usually infected by Candida albicans and bacteria (Fig. Usage subject to terms and conditions of license 354 Lip Lesions Angioneurotic Edema Definition Angioneurotic edema is a relatively common allergic dis- order. Clinical features It characteristically has a sudden onset, and lasts for 24–48 hours. Lymphedema due to Radiation Radiation therapy for oral and other head and neck malignancies is common. The side effects on the oral mucosa after radiation mainly depend on the dose and duration of the treatment. Usage subject to terms and conditions of license 356 Lip Lesions Systemic Diseases Some systemic diseases with oral manifestations may produce lip swel- ling. Crohn disease, sarcoidosis, tuberculosis, and cystic fibrosis are the more common conditions in this group. Crohn disease is a chronic inflammatory, probably immunologically mediated, condition primarily involving the ileum and other parts of the gastrointestinal tract. Nodular or diffuse soft swelling, a cobblestone appearance of the mucosa, mucosal tag lesions, ulcers, angular cheilitis, and aphthouslike ulcerations may also occur. Sarcoidosis is a systemic granulomatous disease affecting the lungs, lymph nodes, spleen, liver, central nervous system, bones, oral mucosa, and salivary glands (see also p. Usage subject to terms and conditions of license 358 Lip Lesions Cystic fibrosis is a relatively common multisystemic, life-threatening, inherited disorder (one in 2000 births) caused by a defective gene on chromosome 7. The disease is characterized by dysfunction of the exo- crine glands (pancreas, branchial, tracheal, gastrointestinal tract, and sweat glands). The principal manifestations are chronic pulmonary infections, pancreatic insufficiency, cirrhosis, malabsorption, abdominal pain, skeletal disor- ders, skin wrinkling, and sweating with characteristic salty taste. Laboratory tests Increased chloride and sodiumion levels in sweat, absence of pancreatic enzymes in the intestinal fluid, chest radiography, and histopathological examination of the minor salivary glands. Differential diagnosis Lipoid proteinosis, mucopolysaccharidosis, cheilitis granulomatosa, cheilitis glandularis. The first deals with clinical conditions, diseases and syndromes under the various organ systems. For each of these, causative agents, diagnosis, treatment and, where appropriate, prophylaxis, prevention and control are given, together with some general notes. Recommended treatments are current consensus opinions from a variety of authoritative sources but may not be the most suitable in all situations. Practitioners should always be guided by individual circumstances and local patterns and should always verify dosages and precautions from package inserts. References are not included, since these would have required a book as large as the existing work. I freely acknowledge my debt to the thousands of colleagues who have directly or indirectly contributed. It is a common symptom of upper respiratory infections, occurring in 81% of patients with influenza A, in parainfluenza, rhinovirus infections and rotaviral respiratory tract infection.

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Care should be taken to choose lesions for scraping or biopsy that have not been excoriated by repeated scratching generic nasonex nasal spray 18gm mastercard. Prior application of mineral oil facilitates collecting the scrapings and examining them under a cover slip discount nasonex nasal spray 18gm visa. Past epidemics were attributed to pov- erty, poor sanitation and crowding due to war, movement of refugees and economic crises. Reservoir—Humans; Sarcoptes species and other animal mites can live on humans but do not reproduce on them. Mode of transmission—Transfer of parasites commonly occurs through prolonged direct contact with infested skin and also during sexual contact. Transfer from undergarments and bedclothes occurs only if these have been contaminated by infested people immediately beforehand. Persons with the Norwegian scabies syndrome are highly contagious because of the large number of mites present in the exfoliating scales. Incubation period—In people without previous exposure, 2–6 weeks before onset of itching. People who have been previously infested develop symptoms 1–4 days after reexposure. Period of communicability—Until mites and eggs are destroyed by treatment, ordinarily after 1 or occasionally 2 courses of treatment, a week apart. Susceptibility—Some resistance is suggested; fewer mites succeed in establishing themselves on people previously infested than on those with no prior exposure but immunologically compromised people are susceptible to hyperinfestation. Preventive measures: Educate the public and medical com- munity on mode of transmission, early diagnosis and treatment of infested patients and contacts. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Official report not ordinarily justifiable, Class 5 (see Reporting). For hospitalized patients, contact isolation for 24 hours after start of effective treat- ment. Laundering bedding and clothing is important for patients with Norwegian scabies because potential for fomites transmission is high. Treat prophylactically those who have had skin-to- skin contact with infested people (including family members and sexual contacts). Alternatively, topical applications of 1% gamma benzene hexachloride (lindane is contraindicated in premature neonates and must be used with caution in children under 1 and pregnant women); chromatin; tetra- ethylthiuram monosulfide in 5% solution twice daily; or an emulsion of benzyl benzoate to the whole body except head and neck. On the following day, a cleansing bath is taken and a change made to fresh clothing and bedclothes. Itching may persist for 1–2 weeks; this should not be regarded as a sign of drug failure or reinfestation. Overtreatment is common and should be avoided because of toxicity of some of these agents, espe- cially gamma benzene hexachloride. In about 5% of cases, a repeat course of treatment may be necessary after 7–10 days if eggs survived the initial treatment. Epidemic measures: 1) Provide treatment and educate infested individuals and oth- ers at risk. Identification—A blood fluke (trematode) infection with adult male and female worms living within mesenteric or vesical veins of the host over a life span of many years. Eggs produce minute granulomata and scars in organs where they lodge or are deposited. Symptoms are related to the number and location of the eggs in the human host: Schistosoma mansoni and S. The most important effects are the late complications that arise from chronic infection: liver fibrosis, portal hypertension and its sequelae and possibly colorectal malignancy in the intestinal forms; obstructive uropa- thy, superimposed bacterial infection, infertility and bladder cancer in the urinary form of schistosomiasis. Eggs can be deposited at ectopic sites, including the brain, spinal cord, skin, pelvis and vulvovaginal areas. The larvae of certain schistosomes of birds and mammals may penetrate the human skin and cause a dermatitis, sometimes known as “swimmer’s itch”; these schistosomes do not mature in humans. Such infections may be prevalent among bathers in lakes in many parts of the world. However, the clinical entity of “seabather’s eruption”, a pruritic dermatitis that appears principally where the bathing suit has been worn has been shown to be caused by the larval stage of some jellyfish species. Definitive diagnosis of schistosomiasis depends on demonstration of eggs in biopsy specimens, or in the stool by direct smear or on a Kato thick smear, or in urine by the examination of a urine sediment or Nuclepore® filtration. More recently, various assays developed to detect schistosome antigens directly in serum or urine have proved useful in detecting current infection and in assessing cure after treatment. People, dogs, cats, pigs, cattle, water buffalo and wild rodents are potential hosts of S. Epidemiological persis- tence of the parasite depends on the presence of an appropriate snail as intermediate host, i. Mode of transmission—Infection is acquired from water contain- ing free-swimming larval forms (cercariae) that have developed in snails.

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