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If midodrine is started then remember to tell patients to sit upright and don’t give it less than 4 hours before bedtime cheap 1 mg finax. Note that this has been shown to hasten recovery but the evidence does not show a change in long term outcome finax 1mg discount. Typically patients are started on injectable medications initially owing to their lower expense, better side effect profile, and need for less frequent and less intensive monitoring. Non- diabetic patients with high blood sugars on steroids may warrant diabetes consultation (they may need insulin at home while on steroids). Take a good history, ask about tinnitus, do the Dix-Hallpike maneuver for at least a minute in each position (have an emesis bucket handy! No test perfectly distinguishes central and peripheral vertigo, but searching for neighborhood signs that localize the lesion to the brainstem is paramount. Any one of the following is concerning for a central lesion: negative head impulse, nystagmus that is vertical or variable in its direction and skew (vertical misalignment) on cross cover fixation testing. Patients with peripheral vertigo may complain of “double vision” from nystagmus, but they should not have true diplopia or disconjugate eye movements on formal testing. Common Empiric Antibiotic Dosing for Meningitis in Adults Drug Dose Notes Vancomycin 15 mg/kg Modify dosage based on renal (actual dysfunction and age (see weight) q12 Toolbook). Cefepime 2 g q8 hrs Modify dosage in patients with renal dysfunction Ampicillin 2 g q4 hrs Modify dosage in patients with renal dysfunction. If sensation is intact to cotton wisp, it is probably not “numb” - Most patients with mild isolated facial paresthesias have no acute brainstem pathology if no neighborhood findings are present - Most patients with mild isolated limb paresthesias have an entrapment or radicular lesion if no weakness is present - Bilateral arm paresthesias may signify central cord syndrome, always image the C-spine - Hugging sensations may signify a transverse myelitis - Splitting the midline with vibration can be supportive of functional overlay, but does not rule out neurological disease Pseudoseizures - Always respond to the patients with concern, but do not give Ativan if it’s not a seizure - A reasonable number of true epileptics also have pseudoseizures. The consultation is usually for assistance with determining neurologic prognosis, or to rule out seizure. It is helpful to clarify with the primary team exactly what their question is at the time the consult is called, and if neurology remains on board for any length of time, continue to have discussions with the primary team about the role of the consulting neurology team. Myoclonus and other “jerks” in Hypoxic Ischemic Injury These patients frequently develop myoclonic jerking post-arrest and non- neurologists often interpret it as seizure. We do not treat it unless it is interfering with the patient’s care or is disturbing to the patient’s family. You can use benzodiazepines for treatment; alternatively, Keppra and valproic acid have some utility for myoclonic jerking. Post-arrest patients can also develop Lance—Adams syndrome, which causes myoclonic jerks but has a much better prognosis. Significance of physical findings in coma following cardiac arrest Patients with less chance of regaining independence Initial exam No pupillary light reflex One day Motor response no better than flexor and spontaneous eye movements neither orienting nor roving conjugate Motor response no better than flexor, no spontaneous eye Three days opening Motor response not obeying commands and spontaneous eye One week movements neither orienting nor roving conjugate. Oculocephalic response not normal, not obeying commands, Two weeks no spontaneous eye opening, eye opening not improved at least 2 grades from initial examination Patients with best chance of regaining independence Pupillary light reflexes present and motor response flexor or Initial exam extensor. Remember that the guidelines for prognosis derived from the Levy criteria do not always apply to patients who are were treated with therapeutic hypothermia or patients with major metabolic or infectious aberrations. If major derangements exist, these must be corrected before any statements about prognosis can be made. Blondin et al, 2011’s review on prognosis after hypothermia suggests that loss of pupils or corneals at 72 hours is still the best predictor of poor prognosis. Again, loss of motor responses was less strong of a predictor and myoclonus during hypothermia as not a strong predictor. The metabolism and pharmacokinetic properties of certain sedating medications, including morphine, fentanyl, and propofol, are altered during therapeutic hypothermia and special care should be taken when making recommendations regarding neurologic prognosis in patients who have received sedating medications in conjunction with therapeutic hypothermia. Clinic : “Neurology Centre” 206-7-8, Sangini Complex, Near Parimal Railway Crossing, Ellisbridge, Ahmedabad - 380 006. No part of this book, including design, cover design and icons, may be reproduced or transmitted in any form, by any means (electronic, photocopying, recording or otherwise) without the prior written permission of the publisher/author. Caution: The recommendations and information in this book are appropriate in most cases; however, they are not a substitute for medical diagnosis. For specific information concerning your personal Neurological condition, I suggest that you consult a doctor. Their inclusion does not imply any endorsement, nor does the omission of any drug, alternative therapy indicate my disapproval. Chetna Sudhir Shah “Neurology Centre”, 206-7-8, Sangini Complex, Near Parimal Railway Crossing, Ellis Bridge, Ahmedabad 380006. As new research and clinical experience broaden our knowledge, changes in treatment and drug theraphy are required. The editors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the editors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this book is accurate and that changes have not been made in the recommended dosages or in the contraindications for administration. Sadly, there is not much awareness about the neurological illnesses and the patient and the family members are suddenly overcome with anxiety and apprehension, and do not know how to cope with neurological problems.

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Prolonged weakness may occur when corticosteroids are used concurrently with non- depolarizing neuromuscular blocking agents buy cheap finax 1mg line. Higher doses may be required if administered through a ventilator due to loss of drug in the circuit discount finax 1mg overnight delivery. Titrate dose to effect and/or adverse effects (tachycardia, tremor and hypokalemia). For most patients metered dose inhalers with a spacer device are the preferred method of drug delivery. Some patients, particularly those receiving opiates may require higher doses and/or more frequent administration. Use lower doses if there is no significant bleeding and patient will require warfarin in the future. They were developed taking into consideration services provided at different levels within the health system and resources available. These guidelines are intended to standardize care at both tertiary and secondary levels of service delivery across different socio- economic stratifcations of our society. The clinical conditions included in this manual were selected based on facility reports of high volume and high risk conditions treated in each specialty area. The guidelines were developed through extensive consultative work sessions, which included health experts and clinicians from different specialties. The work group brought together current evidence-based knowledge in an effort to provide the highest quality of healthcare to the public. It is my strong hope that the use of these guidelines will greatly contribute to improved diagnosis, management and treatment of patients. And, it is my sincere expectation that service providers will adhere to these guidelines/protocols. The Ministry of Health is grateful for the efforts of all those who contributed in various ways to the development, review and validation of the National Clinical Treatment Guidelines. We would like to thank our colleagues from district, referral and university teaching hospitals, and specialized departments within the Ministry of Health, our partners and private health practitioners. We also thank the Rwanda Professional Societies in their relevant areas of specialty for their contribution and technical review, which enriched the content of this document. Finally, we wish to express thanks to all those who contribute to improving the quality of health care of the Rwanda population. Weak / absent breathing Circulation Cold Hands with any of: Immediate transfer to emergency area: 1. Classifcation of pain severity - Self-reporting: use of number or faces scale - Observational: based on behaviors (crying, shaking, etc. Acute Gastroenteritis Defnition: Gastroenteritis is an infammation of the stomach and intestines that causes diarrhea, vomiting, nausea and other symptoms of digestive upset. Causes - Viral gastroenteritis: Rotaviruses are the most likely cause of infec- tious diarrhea in children under the age of 5 - Bacterial gastroenteritis : Campylobacter, Salmonella or E. Persistent Diarrhea Defnition: Persistent diarrhea is a diarrhea, with or without blood, which begins acutely and lasts for 14 days or longer. Bloody Diarrhea Defnition: Frequent (>3/day) passage of blood and/or mucus in the stool Causes - Amoebic dysentery is the most common serious cause in children - Bacterial infections (e. Peptic Ulcer Disease Defnition: Tis refers to ulceration of gastric or duodenal mucosa that tends to be chronic and/or recurrent Causes - Helicobacter pylori (H. Te symptoms associated with peptic ulcers are not sensitive or specifc and the diferential diagnosis is broad. Causes - Foods : Some mushrooms, polluted drinking water, certain im- properly prepared or handled food - Drugs : Sometimes drugs may be toxic and even deadly when taken in excess e. B It is ofen not possible to distinguish viral pneumonia from disease caused by bacterial pathogens. Wheezing child Defnition: A wheeze is a musical and continuous sound that originates from oscillations in narrowed airways. Wheezing is heard mostly in expira- tion as a result of critical airway obstruction. Causes/ diferential diagnosis - Bronchiolitis - Asthma - Oesophageal foreign bodies - Aspiration Syndrome (gastro-oesophageal refux diseases) 3. Acute Bronchiolitis Defnition: Bronchiolitis is an infammation of the bronchiole tubes due to viral organism resulting in wheezing. If bronchodilators to be used, closely monitor efect as it might worsen respiratory distress. Asthma Defnition: Asthma is a chronic infammatory condition of the lung air- ways resulting in episodic airfow obstruction. Note: Kilopascals are also used internationally; conversion would be appropriate in this regard. Asthma attack requires prompt treatment • Bronchodilators Ș Salbutamol: begin with 2-4 pufs/20 min frst hour then depending on severity: ■ Mild: 2-4 pufs/3 hours ■ Moderate: up to 10 pufs / hour ■ Alternatively (especially in severe cases), use nebuli- zation of Salbutamol 2. Te clinician must monitor the patient’s response in terms of clinical control and adjust the dose accordingly. Once control of asthma is achieved, the dose of medication should be carefully titrated to the minimum dose required to maintain control, thus reducing the potential for adverse efects.

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Of the five antibody classes cheap finax 1mg amex, notice that only two can function as the antigen receptor for naïve B cells: IgM and IgD (Figure 21 finax 1 mg free shipping. Mature B cells that leave the bone marrow express both IgM and IgD, but both antibodies have the same antigen specificity. It is excellent at binding complement proteins and activating the complement cascade, consistent with its role in promoting chemotaxis, opsonization, and cell lysis. Thus, it is a very effective antibody against bacteria at early stages of a primary antibody response. As the primary response proceeds, the antibody produced in a B cell can change to IgG, IgA, or IgE by the process known as class switching. Thus, the antibodies made are still specific to the pathogen that stimulated the initial IgM response. IgG is a major antibody of late primary responses and the main antibody of secondary responses in the blood. IgG is a monomeric antibody that clears pathogens from the blood and can activate complement proteins (although not as well as IgM), taking advantage of its antibacterial activities. Furthermore, this class of antibody is the one that crosses the placenta to protect the developing fetus from disease exits the blood to the interstitial fluid to fight extracellular pathogens. IgA exists in two forms, a four-chain monomer in the blood and an eight-chain structure, or dimer, in exocrine gland secretions of the mucous membranes, including mucus, saliva, and tears. IgA is also of importance to newborns, because this antibody is present in mother’s breast milk (colostrum), which serves to protect the infant from disease. It is present in the lowest concentration in the blood, because its Fc region binds strongly to an IgE-specific Fc receptor on the surfaces of mast cells. IgE makes mast cell degranulation very specific, such that if a person is allergic to peanuts, there will be peanut-specific IgE bound to his or her mast cells. In this person, eating peanuts will cause the mast cells to degranulate, sometimes causing severe allergic reactions, including anaphylaxis, a severe, systemic allergic response that can cause death. Clonal Selection of B Cells Clonal selection and expansion work much the same way in B cells as in T cells. Eventually, the plasma cells secrete antibodies with antigenic specificity identical to those that were on the surfaces of the selected B cells. These memory cells lead to the differentiation of more plasma cells and memory B cells during secondary responses. Primary versus Secondary B Cell Responses Primary and secondary responses as they relate to T cells were discussed earlier. Because antibodies are easily obtained from blood samples, they are easy to follow and graph (Figure 21. As you will see from the figure, the primary response to an antigen (representing a pathogen) is delayed by several days. The second time a person encounters the same antigen, there is no time delay, and the amount of antibody made is much higher. Thus, the secondary antibody response overwhelms the pathogens quickly and, in most situations, no symptoms are felt. When a different antigen is used, another primary response is made with its low antibody levels and time delay. Active versus Passive Immunity Immunity to pathogens, and the ability to control pathogen growth so that damage to the tissues of the body is limited, can be acquired by (1) the active development of an immune response in the infected individual or (2) the passive transfer of immune components from an immune individual to a nonimmune one. Active immunity is the resistance to pathogens acquired during an adaptive immune response within an individual (Table 21. A vaccine is a killed or weakened pathogen or its components that, when administered to a healthy individual, leads to the development of immunological memory (a weakened primary immune response) without causing much in the way of symptoms. Thus, with the use of vaccines, one can avoid the damage from disease that results from the first exposure to the pathogen, yet reap the benefits of protection from immunological memory. The advent of vaccines was one of the major medical advances of the twentieth century and led to the eradication of smallpox and the control of many infectious diseases, including polio, measles, and whooping cough. Active versus Passive Immunity Natural Artificial Active Adaptive immune response Vaccine response Passive Trans-placental antibodies/breastfeeding Immune globulin injections Table 21. IgG is transferred from the maternal circulation to the fetus via the placenta, protecting the fetus from infection and protecting the newborn for the first few months of its life. As already stated, a newborn benefits from the IgA antibodies it obtains from milk during breastfeeding. The fetus and newborn thus benefit from the immunological memory of the mother to the pathogens to which she has been exposed. In medicine, artificially acquired passive immunity usually involves injections of immunoglobulins, taken from animals previously exposed to a specific pathogen. This treatment is a fast-acting method of temporarily protecting an individual who was possibly exposed to a pathogen. The downside to both types of passive immunity is the lack of the development of immunological memory.

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