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The distinctive features of erysipelas are well-defined erythema with indurated margin particularly among nasolabial fold rapid progression and intense pain flaccid bullae may develop during the second and third days of illness Treatment ¾ Penicillin is the drug of choice which is given if the lesion becomes bullous or to higher level ¾ Anti pain ¾ General skin care- cleaning the skin and applying antiseptic cream ¾ Encourage personal hygiene like regular washing hands 4 buy viagra extra dosage 120mg overnight delivery. Boil (Furuncle) Definition – Bacterial infection of hair follicles ¾ A furuncle is an infection of a hair follicle and curbancle infection of more than one hair follicle ¾ It often occurs as an extension a superficial folliculitis ¾ These infections often occur in hairy areas of the body purchase viagra extra dosage 120mg overnight delivery, especially where there is perspiration and friction discount 200 mg viagra extra dosage fast delivery. Cause Like furuncles the causative organism is generally a staphylococcus aureus/streptococcus Clinical presentation The involved area of the skin is usually red safe 150 mg viagra extra dosage, indurate purchase viagra extra dosage 200 mg without a prescription, and painful with multiple pustules and several draining points with purulent drainage. The lesion often develops a yellow gray crust at the center, which is permanent and readily visible scar. Nursing management of furuncle & carbuncle (treatment) • Control fever and pain • Teach patient to take adequate fluid, food and rest to enhance the healing process • Monitor the affected local area & the development of systemic progression • Apply warm and moist packs • Teach patient to avoid any manipulation to the infected area • Teach patient about prescribed medications • Treat with systemic antibiotics 67 4. Common sites: The exposed area of the body such as, face, hands, neck and extremities are the most frequently involved. Note: impetigo is known to be contagious and may spread to other parts of patient’s skin or to other members of the family who touch the patient or use towels that are soiled with the exudates of the lesions ¾ Although impetigo is seen at all levels of ages, it is particularly common among children living in poor hygienic conditions it also appears secondary to pediculus capitis, scabies, herpes simplex, insect bites and eczema etc. Complications ¾ Spread of infection, cellulites, erthyma ¾ Glomerulo – nephritis (Systematic reaction to streptococcal antigens) ¾ Scaring formation in deeper lesion ¾ Disfiguring and loss of asthetic appearance (Post inflammatory hypo or hyper pigmented of skin) 69 4. Involves deeper structure of skin and Characterized by erythema, edema of affected area (there will be swelling of the extremities) some times blisterma and ulceration. Rest` will decrease muscular contraction, which would force offending organism in to the circulatory system -Elevate affected limbs to reduce edema -Clean the skin apply antiseptic cream and antibiotics -Remove necrotic and dead tissue from the surface of the lesion 4. It causes nerve damage (nerve function loss) characterized by muscle weakness and hypo pigmented macula. The inflammation in the skin lesions causes redness and edema, therefore the hypopigmented macular lesion become red and raised. If this not treated early the inflammation in the peripheral nerves causes tenderness/pain/ and enlargement of the nerves, which may lead nerve damage with motor or sensory loss (muscle paralysis and loss of sensation of extremities) The nerve damage, account, for the disability and stigma in leprosy. Type1 reaction is caused by increased activity of the body is immune system in fighting the leprosy bacilli. It occur in people who have strong all mediated immunity Both paucibacillary and multibacillary get type 1 reaction and commonly seen within six months of starting treatment, but some of patients may show this reaction before starting treatment even before leprosy has been diagnosed. The most common clinical feature is inflammation in the skin patches with swelling, redness and warmth. The patches are not usually painful, but there may be some discomfort associated with swelling of the limbs or face may occur. Since these proteins/antigens are present in the blood stream, the reaction will involve the whole body causing generalized symptoms. The reactions occur most commonly during leprosy treatment and since it takes long time to clear the dead bacilli and remains for years after stopping the treatment. It can be few or many in number and occur on the face, trunk, and extremities The lesion appear in groups and subside spontaneously while new crops reappears. The onset may occur at any age but is most common between the ages of 10 and 40 years, but may occur at any age. A combination of specific genetic make-up and environmental stimuli may trigger the onset of the disease. Aggravating factors/ triggering factor ♦ Emotional stress ♦ Anxiety 75 ♦ Trauma ♦ Infections ♦ Seasonal and hormonal changes ♦ Cigarette smoking ♦ Alcohol consumption and drugs ♦ Non steroidal anti-inflammatory drugs. Clinical manifestation: ¾ Lesions appear as dark red, raised plaque lesion covered with silvery scales ¾ Lesions produce multiple bleeding points when the scales are scraped away ¾ These patches are not moist and mostly is not itchy ¾ When psoriasis occurs on the palms and soles, it can cause pustular lesions ¾ Lesions can be symmetrical Particular sites of the body tend to be affected ¾ Scalp ¾ The area over the elbows and knees, lower part of the back & genitalia ¾ The extensor surfaces of the arms and legs, ¾ Over the sacrum and the inter gluteal fold If nails are involved, it may be presented by - Pitting - Discoloration - Crumbling beneath the free edge and - Separation of the nail plates Complications ¾ Arthritis (the relation is not understood) ¾ Erytherodermic psoriasis (involving the whole body surface) Treatment Goal: To reduce the rapid turnover of the epidermis and to promote resolution of the psoriatic lesions 76 - Advise that the disease may persist for life with remission and exacerbation. Systemic therapy • Systemic cytotoxic preparations such as methotrexate, have been used in treating extensive psoriasis that fails to respond to other forms of therapy in specialized center Nursing management ¾ Teach patient to avoid picking or scratching the psoriatic area ¾ Teach patient to avoid any topical irritant or allergy- producing Substance ¾ Teach patient to report to physician for any infection that appears to aggravate the psoriasis ¾ Caution patient about medication because some drugs may worsen psoriasis. Acne is the most commonly encountered skin condition, affecting an estimated 85% of the population between 12 & 35 years of age. Girls develop acne 2years earlier than boys Characteristics Characterized by the presence of – closed comedones (white heads,) Open comedones (black heads) are primary lesions while Papules, Pustules, and Nodules & cysts are secondary lesions ¾ Becomes more marked at puberty ¾ Occurs when the pilosebaceous duct is plugged Clinical manifestations Closed comedones (white head) – - are formed from impacted lipids or oils and keratin that plug the dilated follicle - are small, whitish papules - may evolve in to open comedones - have minute follicular openings that can’t be seen -Open comedones (Black head) – Contents are in open communication with the external environment the blackhead is due to accumulation of lipid, bacterial & epithelial debris that obstruct the flow of sebum. Inflammation as a result of pcapionobacterum acne and leakage of content of pilosebeaceoues content 78 N. B Intradermal rupture of sebaceous gland induces an inflammatory reaction due to the leakage of follicle contents (Sebum, keratin, bacteria) in to the dermis. This inflammatory response may result from the action of certain skin bacteria, such as propoonibacterium acnes, that live in the hair follicles and break down the triglycerides of the sebum into free fatly acids and glycerin. Nursing management ¾ Inform patient that acne arises because of combination of factors ¾ Instruct patient to wash the face with mild soap and water twice a day to remove surface oils and prevent obstruction of the oil glands ¾ Caution the patient to avoid scrubbing the face constantly ¾ Hair should be kept off the face and shampooed daily if necessary ¾ Inform patient that all forms of friction and trauma should be avoided ¾ Teach patient that squeezing merely worsens the problem, this may be cause of post inflammatory hyperpigmantation ¾ Teach patient to be consistent with treatment because the problem is chronic ¾ Advise patient that cosmetics, shaving creams, and lotions can agitate acne ¾ Reassurance and emotional support, reduction of stress 79 4. The skin overlying the sacrum and hips is most commonly involved, but bed sores may also be seen over the occiput areas, elbow, heels, ankles, scapula, medial condyle of tibia and head of fibula.

For example order viagra extra dosage 150 mg on-line, the level of glucose purchase viagra extra dosage 200mg with mastercard, a simple sugar generic viagra extra dosage 150 mg mastercard, 248 Human Anatomy and Physiology is maintained at a remarkably constant level of about on tenth of a 1% solution viagra extra dosage 200mg fast delivery. Proteins are the principal constituents of cytoplasm and are essential to the growth and the rebuilding of body tissues buy discount viagra extra dosage 150 mg. Albumin, the most abundant protein in plasma, is important for maintaining the osmotic pressure of the blood. A system of enzymes made of several proteins, collectively known as complement, helps antibodies in their fight against pathogens. The principal form of carbohydrate found in the plasma is glucose, which is absorbed by the capillaries of the intestine following digestion. The 249 Human Anatomy and Physiology mineral salts in the plasma appear primarily as chloride, carbonate, or phosphate salts of sodium, potassium, and magnesium. These salts have a variety of functions, including the formation of bone (calcium and phosphorus), the production of hormones by certain glands (iodine for the production of thyroid hormone), the transportation of the gases oxygen and carbon dioxide (iron), and the maintenance of the acid base balance (sodium and potassium carbonates and phosphates). The Formed Elements Erythrocytes Erythrocytes, the red cells, are tiny, disk-shaped bodies with a central area that is thinner than the edges. They are different from other cells in that the mature form found in the circulating blood does not have a nucleus. These cells, like almost all the blood cells, live a much shorter time (120 days) than most other cells in the body, some of which last a lifetime. Haemoglobin that has given up its oxygen is able to carry hydrogen ions; in this way, haemoglobin acts as a buffer and plays an important role in acid-base balance. The red cells also carry a small amount of carbon dioxide from the tissues to the lings for elimination in exhalation. It displaces the oxygen that is normally carried by the haemoglobin and reduces the oxygen-carrying ability of the blood. Carbon monoxide may be produced by the incomplete burning of various fuels, such as gasoline, coal, wood, and other carbon containing materials. Leukocytes The leukocytes, or white blood cells, are very different from the erythrocytes in appearance, quantity, and function. They contain 251 Human Anatomy and Physiology nuclei of varying shapes and sizes; the cells themselves are round. Leukocytes are outnumbered by red cells by 700 to 1, numbering 5,000 to 10,000 per cubic millimetre of blood. The different types of white blood cells are identified by their size, the shape of the nucleus, and the appearance of granules in the cytoplasm when the cells are stained, usually with Wright’s blood stain. Granulocytes include neutrophils, which show lavender granules; eosinophils, which have beadlike, bright pink granules; and basophils, which have large, dark blue granules that often obscure the nucleus. Because the nuclei of the nuclei of the neutrophils are of various shapes, they are also called polymorphs (meaning “many forms”) or simply polys. The agranulocytes, so named because they lack easily visible granules, are the lymphocytes and monocytes. The ratio of the different types of leukocytes is often a valuable clue in arriving at a diagnosis (see Figure 9-1). Whenever pathogens enter the tissues, as through a wound, certain white blood cells (neutrophils and monocytes) are attracted to that area. The Lymphocytes destroy foreign invaders by attacking the cells directly or by producing antibodies that circulate in the blood and help destroy the cells. Platelets Of all the formed elements, the blood platelets (thrombocytes) are the smallest (Figure 9-1). The number of platelets in the circulating blood has been estimated at 200, 000 to 400,000 per cubic millimeter. When, as a result of injury, blood comes in contact with any tissue other than the lining of the blood vessels, the platelets stick together and form a plug that seals the wound. They then release chemicals that take part in a series of reactions that eventually results in the formation of a clot. The last step in these reactions is the conversion of 253 Human Anatomy and Physiology a plasma protein called fibrinogen into solid threads of fibrin, which form the clot. Blood Clotting Blood clotting, or coagulation, is a protective device that prevents blood loss when a blood vessel is ruptured by an injury. A balance is maintained between compounds that promote clotting, known as procoagulants, and those that prevent clotting known as anticoagulants. Thromboplastin reacts with certain protein factors and calcium ions to form prothrombin activator, which in turn reacts with calcium ions to convert the prothrombin to thrombin. Thromboplastin Ca++ Prothrombin Thrombin Fibrinogen Fibrin threads + Blood cells and plasm a Clot Blood Typing and Transfusions Blood Groups If for some reason the amount of blood in the body is severely reduced, through haemorrhage or disease, the body cells suffer from lack of oxygen and food.

The midline is composed of the vermis and the flocculonodular lobe cheap 130mg viagra extra dosage overnight delivery, and the hemispheres are the lateral regions purchase viagra extra dosage 150 mg with visa. Coordination and Alternating Movement Testing for cerebellar function is the basis of the coordination exam discount 120mg viagra extra dosage free shipping. The subtests target appendicular musculature purchase viagra extra dosage 200mg line, controlling the limbs order viagra extra dosage 200mg with visa, and axial musculature for posture and gait. The assessment of cerebellar function will depend on the normal functioning of other systems addressed in previous sections of the neurological exam. Motor control from the cerebrum, as well as sensory input from somatic, visual, and vestibular senses, are important to cerebellar function. The subtests that address appendicular musculature, and therefore the lateral regions of the cerebellum, begin with a check for tremor. The examiner watches for the presence of tremors that would not be present if the muscles are relaxed. By pushing down on the arms in this position, the examiner can check for the rebound response, which is when the arms are automatically brought back to the extended position. The extension of the arms is an ongoing motor process, and the tap or push on the arms presents a change in the proprioceptive feedback. The cerebellum compares the cerebral motor command with the proprioceptive feedback and adjusts the descending input to correct. The check reflex depends on cerebellar input to keep increased contraction from continuing after the removal of resistance. When the examiner releases the arm, the patient should be able to stop the increased contraction and keep the arm from moving. A similar response would be seen if you try to pick up a coffee mug that you believe to be full but turns out to be empty. Without checking the contraction, the mug would be thrown from the overexertion of the muscles expecting to lift a heavier object. Several subtests of the cerebellum assess the ability to alternate movements, or switch between muscle groups that may be antagonistic to each other. In the finger-to-nose test, the patient touches their finger to the examiner’s finger and then to their nose, and then back to the examiner’s finger, and back to the nose. A similar test for the lower extremities has the patient touch their toe to a moving target, such as the examiner’s finger. Both of these tests involve flexion and extension around a joint—the elbow or the knee and the shoulder or hip—as well as movements of the wrist and ankle. The patient must switch between the opposing muscles, like the biceps and triceps brachii, to move their finger from the target to their nose. Coordinating these movements involves the motor cortex communicating with the cerebellum through the pons and feedback through the thalamus to plan the movements. Visual cortex information is also part of the processing that occurs in the cerebrocerebellum while it is involved in guiding movements of the finger or toe. The patient is asked to touch each finger to their thumb, or to pat the palm of one hand on the back of the other, and then flip that hand over and alternate back-and- forth. To test similar function in the lower extremities, the patient touches their heel to their shin near the knee and slides it down toward the ankle, and then back again, repetitively. A patient is asked to repeat the nonsense consonants “lah-kah-pah” to alternate movements of the tongue, lips, and palate. All 720 Chapter 16 | The Neurological Exam of these rapid alternations require planning from the cerebrocerebellum to coordinate movement commands that control the coordination. Posture and Gait Gait can either be considered a separate part of the neurological exam or a subtest of the coordination exam that addresses walking and balance. Testing posture and gait addresses functions of the spinocerebellum and the vestibulocerebellum because both are part of these activities. A subtest called station begins with the patient standing in a normal position to check for the placement of the feet and balance. The patient is asked to hop on one foot to assess the ability to maintain balance and posture during movement.

The drug cocktail is effective but frequently causes unwanted side effects including mitochondrial dysfunction resulting in myopathy or pancreatitis or lipodystrophy (esthetically displeasing changes in the distribution of subcutaneous fat) purchase viagra extra dosage 150mg overnight delivery. This is not a question of popping two pills a day purchase viagra extra dosage 120 mg without a prescription; therapy protocol is complex order viagra extra dosage 130mg on line, requiring the patient to take medications at exact time points distributed over the entire day buy generic viagra extra dosage 200 mg. If this is paired with intermittent selective pressure by therapy best viagra extra dosage 120mg, resistant strains will emerge rapidly. The countries needing these medications most, especially in sub-Saharan Africa, are the ones least able to pay for them. Despite some programs to equip these countries at reduced prices, this discrepancy remains largely unsolved. By this process of "co-evolution", many pathogens developed strategies to elude host defense mechanisms. The difference between these types is mainly in capsular antigens, represented by polysaccharide patterns and branch points. Antibodies against one serotype are of no use against another serotype, although it is always the same organism, coming in a different disguise. A shift in outer appearance to evade immune mechanisms is even better exemplified by the influenza virus. Via the first, hemagglutinin (H), it binds to human cells; the second, neuraminidase (N), is required for the release of new virus particles from a producing cell and possibly also to enter a cell. There are at least 18 different variants of H and 9 of N, which are used to name different isolates, together with location and time of isolation. As soon as these mutations interfere with antibody binding, the slightly altered virus variant has a selective advantage over its peers and quickly spreads in a previously protected human population, causing a new wave of infections. The H-N-type is maintained: for example, isolate A/Syndey/1977/H3N2 drifts to reinvent itself as A/Moscow/1999/H3N2. At the first influenza infection, a child produces antibodies against all antigenic domains of this specific virus subtype. In the event of later infections, efficient antibody responses are only induced against domains that were already part of the first virus. The probable reason is that memory cells stemming from the first encounter with influenza are activated so quickly that the immune system is not able –or does not need to— activate new naive cells. In addition, influenza A viruses are not restricted to humans, but also infect pigs and fowl (chickens, ducks, swans, etc. Some subtypes of influenza A virus circulate mainly in humans, but many others are best adapted to fowl. The danger is a coinfection, be it in a human or a bird, with two influenza virus subtypes that leads to an exchange of genetic material. If that happens, a novel, human-adapted subtype may emerge against which nobody has any useful antibodies, leading to one of the dreaded pandemics. Such a pandemic during the period 1918-1920 took the lives of approximately 30 million people (out of a world population of 1. During the last ten years, the biggest perceived threat was the fowl-adapted influenza A subtype H5N1. First in Hong Kong in 1997, and several times later on in other places, it infected singular human individuals. A H5N1 epidemic in birds spread and reached western Europe in 2005, exposing more and more humans to the virus. Infected individuals contracted H5N1 from massive contact with infected fowl, and in all but a handful of cases did not transmit the virus to other humans. However, the latest pandemic was unexpectedly caused by a different virus which started to spread from Mexico in 2009. Here, the antigen shift mechanism had reassorted genome segments of swine-adapted influenza virus strains with human-adapted segments. The virus was of the H1N1-Type, yet the specific variants of H1 and N1 differed from those which had been around previously. In these young adults, the 1918 H1N1 caused an especially strong inflammatory response; lung alveoli quickly filled with exsudate, causing respiratory failure). Herpes simplex virus first replicates in the epithelial cells of the oral cavity, then infects the afferent neurons of the trigeminal nerve. Cytotoxic T cells quickly eliminate infected epithelial cells in a painful immune reaction, but some viruses go into hiding in the cell bodies of neurons in the trigeminal ganglion.

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