By B. Reto. Barclay College.

Tumors of the brain or spinal cord : l Simple tumors like meningioma generic betoptic 5 ml amex, neuroma discount betoptic 5ml with visa, epidermoid, dermoid, tumor of the pituitary gland, and l Cancerous tumors like glioma, metastasis. Malformation) l Obstruction of the carotid artery due to Plaque formation (stenosis) and l Brain hemorrhage. Degenerative diseases of the nervous system : l Damage to the cervical or lumbar vertebrae (disc prolapse). Compression of the nerve, like carpel tunnel syndrome or nerve repair in case of the nerve trauma or nerve transplant surgery. Basic information : It is very correct to say that before going in for any such surgery absolutely accurate diagnosis is a must. It is the duty of the neurosurgeon to inform the patients and his relatives how much the patient is likely to benefit from the surgery. Though in our system the diagnosis and the decision of the need for surgery is mainly in the hands of the neurophysician, still it is necessary that before surgery, the neurophysician and the neurosurgeon discuss the case and if there is any doubt further investigations may be done to confirm the diagnosis, and surgery attempted only after full satisfaction regarding the diagnosis. However, it is not incorrect to say that the brain surgery is comparatively more dangerous than other surgeries. The brain surgeries last approximately for 2 to 4 hours, but sometimes it may also go on for 16 to 20 hours or more. After obtaining a fitness report for surgery from the physician, usually the anesthetist examines the patient to ascertain whether the patient can withstand anesthesia. However, if there is a fear of impending death and not much time is available, neurosurgeons ignore everything and perform emergency surgery in spite of the risk for the sake of humanity. For example, when there is a brain hemorrhage in a road accident and emergency operation is inevitable. If the aim is to reach only the outer membrane of the brain a hole called Burr-hole is drilled in the skull. From well-equipped operation theatres to appropriate operation tables and proper lighting arrangements are essential requirements. During surgery also, monitoring by ultra sound can pinpoint the exact location of the defect deep inside the brain. The stereotaxis instruments help in the biopsy and removal of tumors deep inside the brain and spinal cord. Without opening the skull, through a Burr-hole in the brain, using a needle and an electrode that penetrates deep into the brain, various very complicated diseases can be treated easily. Vaga1 stimulation is also a similar minor procedure in which microelectrode and a stimulator can be used to stop the electrical storms taking place in the brain with the help of computerized methods. Apart from this, if necessary major surgeries like lobectomy, hemispherectomy, corpus callosotomy etc can be done. Various other surgeries like the transaction surgery where an impulse can be prevented from passing from one neuron to another can also be done. Radio Frequency Lesion generator : This technique has been proved very effective in Trigeminal Neuralgia and other such painful diseases and also in movement disorders like Parkinson’s disease. As the name suggests, relief is obtained in the disease by using radio frequency current to block the functioning of a nerve or to cauterize it. Gamma knife and Linear Accelerator : This method is becoming increasingly popular to treat tumors or other such diseases without resorting to surgery. Endoscopic Neurosurgery : This is also a kind of minimally invasive surgery, which means that without opening the brain completely, the diseases located deep inside the brain especially tumors or aneurysms are tackled. This reduces the risk of surgery considerably but conducting the surgery from a very small opening with a microscope requires profound experience. Now-a-days our surgeons have gained expertise in conducting “Awake Craniotomy” in which no anesthesia is used and the patient is operated upon in a fully conscious state. When the disease has spread beyond limit, surgeons just remove a part of it and feel the satisfaction of having helped the patient. When it is not possible to remove the entire tumor and there is a danger that the patient may die on the operation table or surgery may paralyze a major portion of the body, it makes sense for the doctor to excise some part of the tumor so that the patient can feel better and survive a little longer. Functional Neurosurgery : In ‘this there is not much h of : excision involved but the nonfunctional parts are made to function in a different way. If necessary grafting of new cells or putting a stimulator in the brain, injecting chemicals or drugs or making newer paths through small openings can be done. In major cities like Mumbai, Delhi all types of surgeries are available and the world-renowned doctors having the best of education and expertise are available to serve the patients, and that is the pride of our nation. In majority of operations the risk factor is 2% to 4% at good centres, but if the patient is aged and suffers from diabetes or heart disease or blood pressure or the operation has had to be done in an emergency, the risk may go up to 10% to 20%. If the surgeon or the anesthetist feels that the risk is high, it is advisable to avoid surgery and treat the patient with medicines only. If the relatives of the patient insist on taking a chance, the surgeon can perform surgery on consent. Like in brain attack, if there is hemorrhage with a lot of swelling and if the prognosis is very bad, the skull can be opened so that the brain can swell outside or attempts are made to suck out the hemorrhage, so the chances of saving the patient’s life compared to certain death can be calculated as S to 25%.

In addition generic 5ml betoptic visa, patients typically present with difficulty breathing and shortness of breath (dyspnea) order betoptic 5ml online, irregular heartbeat (palpations), nausea and vomiting, sweating (diaphoresis), anxiety, and fainting (syncope), although not all of these symptoms may be present. Many of the symptoms are shared with other medical conditions, including anxiety attacks and simple indigestion, so differential diagnosis is critical. Despite its unquestioned success in treatments and use since the 1880s, the mechanism of nitroglycerine is still incompletely understood but is believed to involve the release of nitric oxide, a known vasodilator, and endothelium-derived releasing factor, which also relaxes the smooth muscle in the tunica media of coronary vessels. Longer-term treatments include injections of thrombolytic agents such as streptokinase that dissolve the clot, the anticoagulant heparin, balloon angioplasty and stents to open blocked vessels, and bypass surgery to allow blood to pass around the site of blockage. If the damage is extensive, coronary replacement with a donor heart or coronary assist device, a sophisticated mechanical device that supplements the pumping activity of the heart, may be employed. Despite the attention, development of artificial hearts to augment the severely limited supply of heart donors has proven less than satisfactory but will likely improve in the future. Coronary Veins Coronary veins drain the heart and generally parallel the large surface arteries (see Figure 19. The great cardiac vein can be seen initially on the surface of the heart following the interventricular sulcus, but it eventually flows along the coronary sulcus into the coronary sinus on the posterior surface. The great cardiac vein initially parallels the anterior interventricular artery and drains the areas supplied by this vessel. It receives several major branches, including the posterior cardiac vein, the middle cardiac vein, and the small cardiac vein. The posterior cardiac vein parallels and drains the areas supplied by the marginal artery branch of the circumflex artery. The middle cardiac vein parallels and drains the areas supplied by the posterior interventricular artery. The small cardiac vein parallels the right coronary artery and drains the blood from the posterior surfaces of the right atrium and ventricle. The coronary sinus is a large, thin-walled vein on the posterior surface of the heart lying within the atrioventricular sulcus and emptying directly into the right atrium. The anterior cardiac veins parallel the small cardiac arteries and drain the anterior surface of the right ventricle. Unlike these other cardiac veins, it bypasses the coronary sinus and drains directly into the right atrium. It occurs when the buildup of plaque—a fatty material including cholesterol, connective tissue, white blood cells, and some smooth muscle cells—within the walls of the arteries obstructs the flow of blood and decreases the flexibility or compliance of the vessels. This condition is called atherosclerosis, a hardening of the arteries that involves the accumulation of plaque. As the coronary blood vessels become occluded, the flow of blood to the tissues will be restricted, a condition called ischemia that causes the cells to receive insufficient amounts of oxygen, called hypoxia. Some individuals with coronary artery disease report pain radiating from the chest called angina pectoris, but others remain asymptomatic. Such blockages can lead to decreased blood flow (ischemia) and insufficient oxygen (hypoxia) delivered to the cardiac tissues. The disease progresses slowly and often begins in children and can be seen as fatty “streaks” in the vessels. Well-documented risk factors include smoking, family history, hypertension, obesity, diabetes, high alcohol consumption, lack of exercise, stress, and hyperlipidemia or high circulating levels of lipids in the blood. Treatments may include medication, changes to diet and exercise, angioplasty with a balloon catheter, insertion of a stent, or coronary bypass procedure. A specialized catheter with an expandable tip is inserted into a superficial vessel, normally in the leg, and then directed to the site of the occlusion. At this point, the balloon is inflated to compress the plaque material and to open the vessel to increase blood flow. A stent consisting of a specialized mesh is typically inserted at the site of 846 Chapter 19 | The Cardiovascular System: The Heart occlusion to reinforce the weakened and damaged walls. This surgical procedure grafts a replacement vessel obtained from another, less vital portion of the body to bypass the occluded area. Nor does it seem advisable in patients with stable although diminished cardiac capacity since frequently loss of mental acuity occurs following the procedure. Long-term changes to behavior, emphasizing diet and exercise plus a medicine regime tailored to lower blood pressure, lower cholesterol and lipids, and reduce clotting are equally as effective. Not the least of these exceptional properties is its ability to initiate an electrical potential at a fixed rate that spreads rapidly from cell to cell to trigger the contractile mechanism. Even though cardiac muscle has autorhythmicity, heart rate is modulated by the endocrine and nervous systems. There are two major types of cardiac muscle cells: myocardial contractile cells and myocardial conducting cells. The myocardial contractile cells constitute the bulk (99 percent) of the cells in the atria and ventricles. Contractile cells conduct impulses and are responsible for contractions that pump blood through the body. Except for Purkinje cells, they are generally much smaller than the contractile cells and have few of the myofibrils or filaments needed for contraction. Myocardial conduction cells initiate and propagate the action potential (the electrical impulse) that travels throughout the heart and triggers the contractions that propel the blood.

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Settings: Of all trials identified order betoptic 5 ml, only one was not set in Europe or North America safe 5 ml betoptic. Across all trials, Asian patients represented a minor fraction of patients studied. Consideration of risks and benefits of treatment therefore shifts, from an expectation that adverse events may accompany effective treatments to an appreciation that adverse effects of treatment may be worse than the disease itself. We did not find high strength evidence for differences in effectiveness or adverse effects in any treatment comparison. We did find high strength and moderate strength evidence for comparable effectiveness of several treatments for several outcomes, low strength evidence for superiority of two treatments for two outcomes, and moderate strength evidence for the avoidance of insomnia. For example, although conclusions of comparable effectiveness may suggest that differential costs of treatments are unwarranted, lack of evidence to evaluate comparative harms of these treatments prohibits full assessment of their risk-benefit profiles. For clinical decisionmaking, conclusions of comparable effectiveness suggest that patient preferences and priorities can contribute significantly to treatment choice. When considering the balance between effectiveness and harms in relatively healthy individuals, potential harms may 144 acquire greater weight. Limitations of the Comparative Effectiveness Review Process To narrow the scope of this project to a manageable size, we made several decisions at the start that had downstream consequences. Given the current state of transition between classification schemes for allergic rhinitis, use of the original scheme may have excluded some trials. We decided to pick one disease to study and then find studies similar enough to compare results. Introducing studies of allergic rhinitis classified according to the newer scheme may have added to the variability of included studies. It is hoped that we selected, and found evidence to assess, comparisons that are meaningful to users of this report. We excluded trials of one drug versus a placebo and focused on direct comparisons only. This decision was based on feasibility concerns given the large scope of the project and 200 time constraints. Harms assessment was limited by the absence of placebo groups, which can inform adverse event reporting particularly. For the comparison of oral selective antihistamine to oral nonselective antihistamine in particular, this significantly reduced the number of included trials. Our minimum 2-week duration excluded examination of other treatment features that may be important to patients, e. Trials less than 2 weeks’ duration often did not replicate natural methods of exposure to airborne allergens (i. Data from trials that used variations on these reporting scales could not be incorporated into the report. As a consequence of this approach, individual drug comparisons were beyond the scope of this report. Also, for comparisons with trials studying a small proportion of the drugs in a class, we were limited in our ability to make conclusions about entire pharmacologic classes, particularly for larger classes such as intranasal corticosteroids and oral nonselective antihistamines. Limitations in the quality of trial reporting impacted directly the conclusions that could be drawn and strength of evidence ratings. For example, insufficient group-level data reporting prevented equivalence assessments. It is hoped that continued implementation of guidelines for trial reporting will address such difficulties. Additionally, evidence for efficacy and harms in patients with mild disease was lacking due to enrollment of patients primarily with moderate/severe disease. In fact, standard definitions of mild, moderate, and severe disease in terms of symptom scales do not currently exist. A 4-point scale may be divided into terciles (0-1 mild, 1-2 moderate, 2-3 severe), but this is an empirical division. We could not incorporate several trials that reported only total symptom scores, comprising nasal, eye, ear, and palate symptoms. Examples include: Reporting the results of statistical testing for only two arms of a three-arm trial Not reporting variance estimates for group-level treatment effects Not reporting results for all identified outcomes Missing baseline symptom or quality of life scores Partial accounting of patient flow through the trial Adverse event reporting was consistently incomplete. Severity of adverse events was sometimes mentioned, but, as above, lack of standard definitions of severity or a standard adverse event scale currently limits the usefulness of severity descriptions. That is, the proportion of patients experiencing adverse events was at times reported without any description of the adverse events experienced. We excluded several trials that did not report results by age groups or that formed age groups using non-standard cut points.

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There is a loss of scalp and body hair purchase 5ml betoptic, the nails become thickened and separated from the nail bed (onycholysis) 5 ml betoptic amex, and there may be hyperpigmentation or patchy loss of pigment in patients whose normal skin color is brown or black. The most frequent preexisting skin disorders are (in order of frequency) psoriasis, eczematous dermatitis (atopic, allergic contact, seborrheic), adverse cutaneous drug reaction, lymphoma, and pityriasis rubra pilaris. Drugs most commonly implicated in erythroderma are found In 10 to 20% of patients it is not possible to identify the cause by history or histology. Large amounts of warm blood are present in the skin due to the dilatation of capillaries, and there is considerable heat dissipation through insensible fluid loss and by convection. Also, there may be high output cardiac failure; the loss of scales through exfoliation can be considerable, up to 9 g/m2 of body surface per day, and this may contribute to the reduction in serum albumin and the edema of the lower extremities so often noted in these patients. Thickening leads to exaggerated skin folds; scaling may be fine and branny, and may be barely perceptible or large, up to 5 cm, and lamellar. Palms and Soles Usually involved, with massive hyperkeratosis and deep fissures in pityriasisrubra pilaris, Sézary’s syndrome, and psoriasis. General Examination Lymph nodes generalized, rubbery, and usually small; enlarged in Sézary’s syndrome. Despite the best attention to all details, patients may succumb to infections or, if they have cardiac problems, to cardiac failure (“high output” failure) or to the effects of the prolonged glucocorticoid therapy that may be required. Management This is an important medical problem that should be dealt with in a modern inpatient dermatology facility with experienced personnel. The patient should be hospitalized in a single room, at least for the beginning workup and during the development of a therapeutic program. The hospital room conditions (heat and cold) should be adjusted to the patient’s needs; most often these patients need a warm room with many blankets. Presenting with atypical presentation, more disseminated disease, or being resistant to conventional therapies and patient having related disorders eg candidiasis, H. The eruption, which is characterized by widespread inflammatory and hyperkeratotic lesions in seborrhoeic areas, may progress to erythroderma in some patients. In some instances, pre-existing psoriasis may become more severe with disseminated plaques and pustules. It manifests as small, itchy, red or skin-colored papules on the head, the neck, and the upper part of the trunk. Oral hairy leukoplakia has no malignant potential, but it may be the initial sign of progressive immunosuppression. Systemic coccidioidomycosis may disseminate to the skin, usually as hemorrhagic papules or nodules Cutaneous drug eruptions 10% Sulfonamides may cause urticaria; erythema multiforme; toxic epidermal necrolysis; and systemic reactions, including fever, leukopenia, thrombocytopenia, hepatitis, and 59 nephritis. B: Regarding Leprosy you are advised to refer the Manual prepared by disease prevention and control department, Ministry of Health, Ethiopia, 2002. Purpose and use of this satellite module This module is intended to be used by midlevel Nurses and is believed to equip them with basic and adequate information that are not discussed in the core module. Besides, it helps the health worker to appreciate common skin infectious disease by focusing on bacterial, fungal, viral and parasitic skin problems including non- infectious skin disease 4. All are possible causes of skin diseases, except a) Chemical agent b) Physical agent c) Irritant substances d) None of the above 5. All can be practical measures to prevent skin disease except a) By keeping cleanliness of the skin b) By early identification c) By removing the predisposing factors d) By treating all skin diseases with antibiotics 6. It is the disease associated with poor personal hygiene and low living condition a) Scabies b) Acne c) Carbuncle d) Leprosy 8. Nurse can manage a disease called scabies in the health center by ordering a) Benzyl benzoate lotion b) White filed ointment c) Procaine penicillin 600. All are true statements about cutaneous Leshimaniasis except, a) Single or multiple lesion that can be changed to ulcer b) Mucocutaneous lesion will involve in nasopharyngeal tissue c) Animals are consider as source of infection d) All of the above e) None of the above 12. The role of nurse who is working in primary health care unit, for the patient who is admitted and developed bedsore will be all, except a) Clean and dress the wound b) Encourage the patient to take balanced diet c) Maintain skin integrity d) Refer the patient to nearest hospital e) None of the above 64 4. 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. 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, especially where there is perspiration and friction. Cause Like furuncles the causative organism is generally a staphylococcus aureus/streptococcus Clinical presentation The involved area of the skin is usually red, indurate, 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.

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