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Monica chesbrough purchase silagra 100 mg with amex, District laboratory practice in Tropical countries order silagra 50mg mastercard, part I, Cambrige university press, 1998. First edition 2009 Revised first edition 2009 Second edition 2014 For comments and feedback, please contact the author at chiangyizhen@gmail. Dr Chiang is to be congratulated for her exceptional industry and enthusiasm in converting an idea into a reality. Julian Verbov Professor of Dermatology Liverpool 2009 Preface to the 2nd edition Nicole and I are gratifed by the response to this Handbook which clearly fulfils its purpose. The positive feedback we have received has encouraged us to slightly expand the text and allowed us to update where necessary. Julian Verbov Professor of Dermatology Liverpool 2014 5 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Foreword to First edition There is a real need for appropriate information to meet the educational needs of doctors at all levels. The hard work of those who produce the curricula on which teaching is based can be undermined if the available teaching and learning materials are not of a standard that matches the developed content. Any handbook must meet the challenges of being comprehensive, but brief, well illustrated, and focused to clinical presentations as well as disease groups. It should find a home in the pocket of students and doctors in training, and will be rapidly worn out. I wish it had been available when I was in need, I am sure that you will all use it well in the pursuit of excellent clinical dermatology! Dr Mark Goodfield President of the British Association of Dermatologists 6 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors What is dermatology? Ability to examine skin, hair, nails and mucous membranes systematically showing respect for the patient 5. Ability to record findings accurately in patient’s records Taking a dermatological history • Using the standard structure of history taking, below are the important points to consider when taking a history from a patient with a skin problem (Table 1). Taking a dermatological history Main headings Key questions Presenting complaint Nature, site and duration of problem History of presenting complaint Initial appearance and evolution of lesion* Symptoms (particularly itch and pain)* Aggravating and relieving factors Previous and current treatments (effective or not) Recent contact, stressful events, illness and travel History of sunburn and use of tanning machines* Skin type (see page 70)* Past medical history History of atopy i. General terms Terms Meaning Pruritus Itching Lesion An area of altered skin Rash An eruption Naevus A localised malformation of tissue structures Example: (Picture Source: D@nderm) Pigmented melanocytic naevus (mole) Comedone A plug in a sebaceous follicle containing altered sebum, bacteria and cellular debris; can present as either open (blackheads) or closed (whiteheads) Example: Open comedones (left) and closed comedones (right) in acne 10 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Table 4. Distribution (the pattern of spread of lesions) Terms Meaning Generalised All over the body Widespread Extensive Localised Restricted to one area of skin only Flexural Body folds i. Configuration (the pattern or shape of grouped lesions) Terms Meaning Discrete Individual lesions separated from each other Confluent Lesions merging together Linear In a line Target Concentric rings (like a dartboard) Example: Erythema multiforme Annular Like a circle or ring Example: Tinea corporis (‘ringworm’) Discoid / A coin-shaped/round lesion Nummular Example: Discoid eczema 12 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Table 6. Colour Terms Meaning Erythema Redness (due to inflammation and vasodilatation) which blanches on pressure Example: Palmar erythema Purpura Red or purple colour (due to bleeding into the skin or mucous membrane) which does not blanch on pressure – petechiae (small pinpoint macules) and ecchymoses (larger bruise-like patches) Example: Henoch-Schönlein purpura (palpable small vessel vasculitis) 13 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Hypo- Area(s) of paler skin pigmentation Example: Pityriasis versicolor (a superficial fungus infection) De- White skin due to absence of melanin pigmentation Example: Vitiligo (loss of skin melanocytes) Hyper- Darker skin which may be due to various causes (e. Morphology (the structure of a lesion) – Primary lesions Terms Meaning Macule A flat area of altered colour Example: Freckles Patch Larger flat area of altered colour or texture Example: Vascular malformation (naevus flammeus / ‘port wine stain’) Papule Solid raised lesion < 0. Morphology - Secondary lesions (lesions that evolve from primary lesions) Terms Meaning Excoriation Loss of epidermis following trauma Example: Excoriations in eczema Lichenification Well-defined roughening of skin with accentuation of skin markings Example: Lichenification due to chronic rubbing in eczema Scales Flakes of stratum corneum Example: Psoriasis (showing silvery scales) 18 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Crust Rough surface consisting of dried serum, blood, bacteria and cellular debris that has exuded through an eroded epidermis (e. Hair Terms Meaning Alopecia Loss of hair Example: Alopecia areata (well-defined patch of complete hair loss) Hirsutism Androgen-dependent hair growth in a female Example: Hirsutism Hypertrichosis Non-androgen dependent pattern of excessive hair growth (e. Nails Terms Meaning Clubbing Loss of angle between the posterior nail fold and nail plate (associations include suppurative lung disease, cyanotic heart disease, inflammatory bowel disease and idiopathic) Example: (Picture source: D@nderm) Clubbing Koilonychia Spoon-shaped depression of the nail plate (associations include iron-deficiency anaemia, congenital and idiopathic) Example: (Picture source: D@nderm) Koilonychia Onycholysis Separation of the distal end of the nail plate from nail bed (associations include trauma, psoriasis, fungal nail infection and hyperthyroidism) Example: (Picture source: D@nderm) Onycholysis Pitting Punctate depressions of the nail plate (associations include psoriasis, eczema and alopecia areata) Example: (Picture source: D@nderm) Pitting 22 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Background Knowledge • This section covers the basic knowledge of normal skin structure and function required to help understand how skin diseases occur. Ability to describe the difficulties, physical and psychological, that may be experienced by people with chronic skin disease Functions of normal skin • These include: i) Protective barrier against environmental insults ii) Temperature regulation iii) Sensation iv) Vitamin D synthesis v) Immunosurveillance vi) Appearance/cosmesis Structure of normal skin and the skin appendages • The skin is the largest organ in the human body. The skin appendages (structures formed by skin-derived cells) are hair, nails, sebaceous glands and sweat glands. The average epidermal turnover time (migration of cells from the basal cell layer to the horny layer) is about 30 days. Composition of each epidermal layer Epidermal layers Composition Stratum basale Actively dividing cells, deepest layer (Basal cell layer) Stratum spinosum Differentiating cells (Prickle cell layer) Stratum granulosum So-called because cells lose their nuclei and contain (Granular cell layer) granules of keratohyaline. Stratum corneum Layer of keratin, most superficial layer (Horny layer) • In areas of thick skin such as the sole, there is a fifth layer, stratum lucidum, beneath the stratum corneum. This occurs in 3 main phases: a) anagen (long growing phase) b) catagen (short regressing phase) c) telogen (resting/shedding phase) • Pathology of the hair may involve: a) reduced or absent melanin pigment production e. Stages of wound healing Stages of wound healing Mechanisms Haemostasis ● Vasoconstriction and platelet aggregation ● Clot formation Inflammation ● Vasodilatation ● Migration of neutrophils and macrophages ● Phagocytosis of cellular debris and invading bacteria Proliferation ● Granulation tissue formation (synthesised by fibroblasts) and angiogenesis ● Re-epithelialisation (epidermal cell proliferation and migration) Remodelling ● Collagen fibre re-organisation ● Scar maturation 27 British Association of Dermatologists Dermatology: Handbook for medical students & junior doctors Emergency Dermatology • These are rapidly progressive skin conditions and some are potentially life- threatening.

Medical interventions Non-medical interventions Other interventions The use of various interdental cleaning aids such as dental floss cheap silagra 50mg line, interdental brush buy silagra 50 mg on-line, water pik, etc. Use of an electronic fluorides • Proper methods of accessible and toothbrush in children and persons with decreased m anual • Use of pit and maintaining oral hygiene affordable dexterity is recom m ended. These should be used on prescription of a restorations and ·antiseptic mouth washes • Include oral health dental surgeon. Increase the intake of fibrous food • Using sugar substitutes such as saccharine, xylitol, to stimulate salivary flow, which is protective against caries. Stim ulate salivary flow with sugar- • M aking toothbrushes and fluoridated toothpaste available free chewing gum. Regular use of fluoridated chewing gum , if chewed between m eals, produces an anti- toothpaste is proven to reduce the incidence of dental caries effect by stim ulating salivary flow. Preventive interventions35–43 Table 2 summarizes the prevention and treatment strate- 35,36 gies for dental caries. The use of pit and fissure sealants and application of fluoride varnish37,38 help in slowing down the developm ent References of caries. Dental caries in the rat in relation to Treatm ent com prises rem oval of decay by operative pro- the chem ical com position of the teeth and diet. Variations in the cedures and restoration with appropriate m aterials such diet of the Ca/P ratio obtained by changes in the phosphorus content. In advanced rat in relation to the chem ical com position of the teeth and of the cases, where the pulp of the tooth is involved, endodontic diet. Dental caries after radiotherapy of the oral • Prevention of prem ature loss of deciduous teeth regions. Dem onstration of the etiologic role of • Restoration of m issing perm anent teeth by prostheses streptococci in experim ental caries in the ham ster. Causal relation between m alocclusion and of a 6-year oral health education program m e for prim ary caries. Im pact of socio-dem ographic variables, varnishes— a review of their clinical use, cariostatic m echanism , oral hygiene practices, oral habits and diet on dental caries efficacy and safety. W orldwide, the average prevalence of m alocclusion in the • Congenital: These include cleft lip and palate, and 10–12 years’ age group is reported to be 30% –35%. Causes of dentofacial anomalies and malocclusion Direct Indirect Distant • Hereditary/congenital • Environmental factors • Poor nutritional status·deficiency of • Abnormal pressure habits and functional ·prenatal causes such as trauma, vitamin D, calcium and phosphates aberrations maternal diet and metabolism, • Endocrine imbalance such as hypothyroidism ·abnormal suckling German measles, certain drugs, • Metabolic disturbances and muscular dystrophies ·mouth breathing and position in utero • Infectious diseases such as poliomyelitis ·thumb and finger sucking ·postnatal causes such as birth injury, • Functional aberrations ·tongue thrusting and sucking cerebral palsy, temporomandibular ·psychogenic tics and bruxism ·abnormal swallowing joint injury ·posture • Trauma and accidents • Local factors ·abnormalities of number (supernumerary teeth, missing teeth) ·abnormalities of tooth size and shape ·abnormal labial frenum and mucosal barriers ·premature tooth loss ·prolonged retention of deciduous teeth ·delayed eruption of permanent teeth ·abnormal eruptive path ·untreated dental caries and improper dental restorations, especially on the proximal surfaces • Local factors: These include abnorm alities of num ber Factors responsible for causing dentofacial anom alies such as supernum erary and m issing teeth, abnorm alities and m alocclusion are sum m arized in Table 3. Strategies for the prevention and treatment of dentofacial joint injury anomalies and malocclusion Medical interventions Non-medical interventions Distant causes 26,27 • Habit-breaking appliances • Control harmful oral habits • Endocrine im balance: H ypothroidism is related to an • Serial extractions • Prenatal and perinatal care abnorm al resorption pattern, delayed eruption and • Space-maintainers and -regainers • Genetic counselling • Functional appliances in developing gingival disturbances. Etiological and predisposing factors Secondary prevention related to traum atic injuries to perm anent teeth. The N orthcroft tions, space maintainers/regainers, and functional appliances lecture, 1985 presented to the British Society for the Study of to correct jaw relations are other m odalities. Genetic and epigenetic regulation of craniofacial craniofacial growth patterns in patients with orofacial clefts: developm ent. Gingival and inadequate plaque rem oval, can also cause gingival periodontal diseases affect 90% of the population. Distant causes19–25 Aetiology 11111–66666 These include low socioeconomic and literacy level, difficult Direct causes access to an oral health care facility, poor oral health These include poor oral hygiene leading to accum ulation awareness, and lack of oral health insurance. O ral health such as puberty, pregnancy, menopause, and pathological education is required for the m aintenance of oral hygiene causes such as hyperthyroidism , hyperparathyroidism (brushing, flossing, rinsing, etc. Interventions for the prevention and • Blood disorders such as acute m onocytic leukaem ia and treatm ent of periodontal diseases are given in Table 6. Prevention and treatment of periodontal diseases Medical interventions Non-medical interventions Other interventions • Scaling and polishing of teeth • Oral health education • Make oral health care more accessible • Oral and systemic antibiotics • Nutrition and diet and affordable • Use of mouth washes • Proper methods of oral hygiene maintenance • Improve the socioeconomic and literacy • Gingival and periodontal surgery ·use of toothpaste and tooth brush level of the population ·gingivoplasty, gingivectomy, flap surgery, ·use of inter-proximal cleaning devices such as • Include oral health care in general health mucogingival surgeries, guided tissue interdental brushes, dental floss and water pik, etc. Periodontal m anifestations of system ic in com m unity settings for people with special needs: Preface. It is the m ost com m on cancer in cancers are diagnosed at a very late stage, when treatm ent m en and the fourth m ost com m on cancer in wom en, and not only becom es m ore expensive, but the m orbidity and constitutes 13% –16% of all cancers. The 5- Aetiology year survival rate is 75% for local lesions but only 17% for Direct causes those with distant m etastasis. Since the oral cavity is easily • Tobacco— M any form s of tobacco are used in India— accessible for examination and the cancer is always preceded sm oking (78% ); chewing of betel quid, paan m asala, by som e pre-cancerous lesion or condition such as a white gutka, etc. Increased incidence of • Bacterial infections such as syphilis, and fungal (candi- 8–10 m outh cavity, pharyngeal and laryngeal carcinom as.

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When a person’s body is in correct alignment cheap silagra 50mg with amex, all the muscles work together for the safest and most efficient movement buy generic silagra 100mg, without muscle strain. Again the head is erect, the back is straight, and the abdomen is in (remember that the client in bed should be in approximately the same position as if he/she were standing). Positioning the client Encouraging clients to move in bed, get out of bed, or walk serves several positive purposes. Prolonged immobility can cause a number of disorders, among which are pressure ulcer, constipation, and muscle weakness, pneumonia and joint deformities. By assisting clients to maintain or regain mobility, you promote self-care practices and help to prevent deformities. Moving and Positioning Clients Moving and positioning promote comfort, restore body function, prevent deformities, relieving pressure, prevent muscle strain, and stimulate proper respiration and circulation. Purpose: o To increase muscle strength and social mobility o To prevent some potential problems of immobility o To stimulate circulation 171 Basic Clinical Nursing Skills o To increase the patient sense of independence and self- esteem o To assist a patient who is unable to move by himself o To prevent fatigue and injury o To maintain good body alignment Practice Guideline - Maintain functional client body alignment. Adjust the client’s arms (a) Shift his or her lower shoulder to ward you slightly (b) Support his or her upper arm on a pillow 10. The limit of the joint’s range is between the points of resistance at which the joint will neither open nor close any further. Abduct and adduct the hip by moving the client’s straightened leg toward you and then back to median position. Some of the reasons include promoting comfort, restoring body function, preventing deformities, relieving pressure, preventing muscle strain, restoring proper respiration and circulation and giving nursing treatment. C aution:Thispositionm aybeuncom fortable forapersonwith abackproblem F igure3HorizontalR ecum bentposition 2. K eep the clientcovered as m uch aspossible F igure4D orsalrecum bentposition 180 Basic ClinicalN ursing Skills 3. Caution:U nconscious clients, pregnantwom en,clients with abdom inalincisions,and clients with breathing difficulties cannot lie in this position. The rightknee is flexed againstthe abdom en,the leftknee is flexed slightly,the leftarm is behind the body,and the rightarm is in a com fortableposition. Caution: The clientwith leg injuries or arthritis often cannotassum ethisposition F igure6Sim ’sposition 181 Basic ClinicalN ursing Skills 5. K nee-ch estPosition:-is used forrectal andvaginalexam inationsandastreatm enttobring the uterus into norm alposition. The clientis onthe knees with the chestresting on the bed and the elbow rested on the bed,orwith the arm s above the head,the client’s head is turned to the side. Itis sim ilarto dorsal recum bentposition,exceptthatthe client’s legs are wellseparatedandthekneesareacutelyflexed. F igure9 L ithotom yposition 183 Basic Clinical Nursing Skills Crutch Walking Crutches: - are walking aids made of wood or metal in the form of a shaft. Application of Nursing Process Assessment - Assess physical ability to use crutches and strength of the client’s arm back, and leg muscle. Implementation/Procedure - Teaching muscle- strengthening exercises - Measuring client for crutches 184 Basic Clinical Nursing Skills - Teaching crutch walking: Four-point gait, Three-point gait, two-point gait. Four-Point Gait Equipment - Properly fitted crutches - Regular, hard soled street shoes - Safety belt, if needed Procedure 1. Three-Point Gait The Equipment is Similar with Four Gait 186 Basic Clinical Nursing Skills Procedure 1. The gait can be performed when the client can bear little or no weight on one leg or when the client has only one leg. Put weight on the crutch handles and transfers unaffected extremity to the step where crutches are placed. Document the following points: - Time and distance of ambulation on crutches - Balance - Problems noted with technique - Remedial teaching - Client’s perception on the procedure Helping the client into Wheelchair or Chair Supplies and Equipment - Wheelchair - Slippers or shoes (non-skid soles) - Robe - Transfer self (optional) 191 Basic Clinical Nursing Skills Procedure 1. Obtain help from another person if the client is immobile, heavy, or connected to multiple pieces of equipment. Fluid & Electrolyte Balance Normal body function depends on a relatively constant volume of water and definite concentration of chemical compounds (electrolyte). Electrolyte – is a compound that dissociate in a solution to break up in to separate electrically charged particles (ions) – cation, anions Distribution of Body Water in Adult Body water is contained with in two major physiological reservoirs (compartments). Extra cellular fluid about 20% of body weight (20 liters) in which: a) 5 liter in intra vassal b) 15 liter interstissual – tissue space the space between blood and the cells. A part from this the extra cellular fluid contains other fluids, which are usually negligible, considering their concentration in the body.

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Analytical factors The laboratory is more able to control the analytical factors purchase 100 mg silagra visa, which depend heavily on instrumentation and reagents A silagra 50 mg generic. Instrumentation - Instrument function checks that are to be routinely performed should be detailed in procedure manual and their performance should be documented B. Post analytical factors The post analytical factors consist of the recording and reporting of patient data to the physician with in the appropriate time interval Post test Go back to the pretest questions & do them carefully 104 3. Direction for using this module Before reading this satellite module be sure that you have completed the pre- test and studied the core module 2. But today literature and statistical data clearly depicted that these cases of diabetes are getting high with alarming incidence rate even in developing nations. And Ethiopia is one of the developing countries where by the prevalence is increasing from time to time. Numerous environmental events have been proposed to trigger the autoimmune process in genetically susceptible individuals; however, none has been conclusively linked to diabetes. For this new change of the pattern of prevalence of diabetes many factors were considered as the culprit. Among the factors that aid the increment of the prevalence diabetes even in the developing, countries the following are some: 1. Most people are living in very hectic environment where by the housing condition is predominated with substandard housing condition that doesn’t usually meet the physiological and psychological requirement of the dwellers. People are more ignorant about the healthy style of nutrition at the family and community level in particular and at large respectively. Many jobs are becoming sedentary rather than exercise/movement demanding and in turn these furnish the ground for the people to become more obese. Physical exercise is not taken as a routine life activity among the people especially living in developing country where the living places are not comfortable to make exercises at continual basis. Diabetes in Africa: some of the factors related to the development of diabetes in Africa include: • Genetic Factors: Family history • Environmental Factors: such as infection, dietary changes. The environmental health officers will take great share of tasks of advocacy on proper nutrition so that obesity can be attacked. Construction of standard housing with local materials will be advocated and technically commented and regularly inspected by environmental Health officers. Thus the requirements of physiological and psychological health of the dwellers will be met and this consequently will alleviate the potential stressful environment. Environmental health officers technically suggest comments and follow its implementation to make the working places more comfortable. The environmental health officers are most needed here to apply their expertise knowledge of housing and institutional sanitation, nutrition and food hygiene and safety, environmental chemistry. Post – test First try to look and do the pretest again, then keep on attempting the following questions. Thus, today there has been a strong commitment from the government side to realize the policy and protects the public health. It is one part of the strategies of national health policy to train the health extension workers as a front line community health personnel in the regional health institutions with the intent that after the end of their training they will go near to the community that is rural areas and they fight with the nation public health challenges together with their professional colleagues in the interdisciplinary approach. It provides basic information on different aspects of diabetes so that they participate in early case detection, case management and prevention of complications as front line health workers. Directions for using the module Before starting to read this module, please follow the instruction given below. Self- Monitoring of glucose Many patients (especially those with type 1(insulin- dependent diabetes mellitus)) now regularly monitor their own blood glucose concentrations on the advice of their health care provider, using reagent test strips and reflectance meter. Several companies manufacture reagent test strips for monitoring blood glucose, and most of these companies make reflectance meters to be used to electronically read the test result. The strips used for these tests are impregnated with the enzyme glucose oxidase, enzyme peroxidase and an indicator to give a color change that is detectable. Urine Glucose determinations Chemical screening tests for glucose (dextrose) are generally included in every routine urinalysis. The occurrence of glucose in the urine indicates that the metabolic disorder diabetes mellitus should be suspected, although several other conditions result in glycosuria (glucosuria).

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