Singulair

Richard Webel, MD

Associate Professor of Clinical Medicine
Director, Cardiac Catheterization Laboratory
University of Missouri
Columbia, Missouri

Give 10ml/kg  Haemoglobin level has dropped by > 2g/dl below the steady-state value asthma upper or lower buy on line singulair. Exchange blood transfusion can be done manually or automatically with a red cell apheresis machine asthma zolar purchase singulair canada. Clinical Features Vary with severity but include; Anaemia asthma gerd buy singulair 4 mg overnight delivery, easy bruising/bleeding asthmatic bronchitis cure buy generic singulair line, recurrent infection; 3 asthma effects purchase 10mg singulair with amex. Diagnostic Criteria Pancytopenia asthma symptoms mucus cheap singulair 5mg on line, Bone marrow hypocellularity of < 30% hematopoietic cells for children and young adults; confirmed by trephine biopsy. Hereditary bleeding disorders includes haemophilia A and B, Von Willebrand disease  Marrow hypocellularity and pancytopenia may appear gradually after age 5yrs. Bleeding  Pallor, dyspnoe on exertion, parttens differ with age: Infants usually bleed into soft tissues or from the mouth but as  Bleeding the boy grows, characterist joint bleeding becomes more common. Occasional Note: spontaneous If there is no response to appropriate replacement therapy tests for inhibitors (an haemarthrosis inhibitor is formed when one develops antibodies against factor concentrates) Mild 5-40%of normal 5-40% of normal 1. During the process, increased platelet aggregation and coagulation factor consumption occur this does not allow time for compensatory increase in production of coagulant and anticoagulant factors. Most adult patient presents with a long history of Purpura, menorrhagia, epistaxis and gingival Note: haemorrhage are more common. During the process, increased platelet treatment of acute bleeding caused by severe thrombocytopenia need immediate platelet aggregation and coagulation factor consumption occur this does not allow time for transfusion is indicated in patient with haemorrhagic emergencies compensatory increase in production of coagulant and anticoagulant factors. Multifactor deficiency, Liver disease gives Fresh Frozen Plasma 10-15mls/kg until 3. Idiopathic thrombocytopenic Purpura is an acquired disease of children and adults and defined as isolated thrombocytopenia with no clinically apparent associated condition or other causes of thrombocytopenia. Treatment of Venous Thromboembolism Long term anticoagulation is required to prevent a frequency of symptomatic extension of thrombosis and/or recurrent venous thromboembolic events. They require immediate notification to health uuthorities as  Severe dyspnea nad tachypnea and right side heart failure required by the International Health Regulations, in order to ensure prompt and effective  Cardiovascular collapse with hypotension, syncope, and coma response to avoid further spread and prevent deaths. Treatment of Venous Thromboembolism  Immediately notifiable disease in Tanzania include Cholera, Anthrax, Plague, Long term anticoagulation is required to prevent a frequency of symptomatic extension of Viral Haemorrhagic diseases (Ebola, Lassa, and Marburg), Yellow fever, thrombosis and/or recurrent venous thromboembolic events. Human Influenza of new subtype, Small Pox, initial heparin or clexane therapy and then overlapped for 4-5days. Standard Treatment GuidelinesStandard Treatment Guidelines 3333 Note:  For confirmation at the beginning of an outbreak, rectal swab or stool specimen should be taken from first 5 to 10 suspected cases. It is of paramount importance to make correct diagnosis and administer the right treatment according to the Treatment o plan A: No dehydration, o plan B: Moderate dehydration and o plan C: Severe dehydration. It is of paramount importance to make  Ciprofloxacin was previously contraindicated to children under 12 years. Preferably, give o plan B: Moderate dehydration and antibiotics with food to minimize vomiting o plan C: Severe dehydration. If no signs of dehydration  After the initial 30 ml/kg has been administered, the radial pulse should be  Patients who have no signs of dehydration when first observed can be treated strong and blood pressure should be normal. Give an oral antibiotic to indicating other problems (eg, fever, blood in stool) patients with severe dehydration as follows: Note: Adults (Not for pregnant women) Prophylaxis of cholera contacts is not recommended. It is a zoonotic disease whereby man is infected directly through contact with infected hides or inhalation of spores in the lungs or ingestion of infected meat. Diagnostic Criteria:  Itching  A malignant pustule,  Pyrexia  Pulmonary and gastrointestinal signs. V every 6 hours until local oedema subsides then continue with A: Phenoxymethylpenicillin 250 mg 6 hourly for 7 days A: Paracetamol 15mg/kg 8 hourly for 3 days 4. Humans can be contaminated by the bite of infected fleas, through direct contact with infected materials or by inhalation. Diagnostic Criteria  Sudden onset of fever, chills, head and body aches  Weakness, vomiting and nausea. There are 3 forms of plague infection, depending on the route of infection:  Bubonic plague is the most common, caused by the bite of an infected flea. However, any person with pneumonic plague may transmit the disease via droplets to other humans. Prevention:  Inform people of the presence of zoonotic plague and advised to take precautions against flea bites 36 Standard Treatment Guidelines 4. It is a zoonotic disease whereby man is infected directly  Apply standard precautions when handling potentially infected patients through contact with infected hides or inhalation of spores in the lungs or ingestion of and while collecting specimens infected meat. Vaccination: Not recommended expect for high-risk groups (such as laboratory Diagnostic Criteria: personnel who are constantly exposed to the risk of contamination, and health care  Itching workers. Humans can  Neck stiffness, be contaminated by the bite of infected fleas, through direct contact with infected  Intense headache, nausea and vomiting, materials or by inhalation. Usually occurs through introduction of tetanus spores via the umbilical cord during  Yersinia pestis is identified by laboratory testing from a sample of pus from delivery through the use of an unclean instrument to cut the cord, or after delivery by a bubo, blood or sputum. There are 3 forms of plague infection, depending on the route of infection: Diagnostic Criteria  Bubonic plague is the most common, caused by the bite of an infected flea. This protects the mother and also her baby  Pneumonic plague is the most virulent form and is rare. However, any person with pneumonic plague may transmit the disease via droplets to  Good hygienic practices when the mother is delivering a child are also other humans. Frequency of drug administration should be titrated vs clinical condition  Airway / respiratory control o Provide mechanical ventilation. Humans typically come into contact with soft ticks when they sleep in rodent-infested cabins. A: Amoxycillin via Nasal Gastric Tube 20–30 mg/kg/day every 8 hours Without antibiotic treatment, this process can repeat several times. Postnatal age >7 days: 1200-2000 g: 15 mg/kg/day in divided doses every 12 hours >2000 g: 30 mg/kg/day in divided doses Prevention every 12 hours  Avoid sleeping in rodent-infested buildings whenever possible. Use insect repellent (on skin or clothing) or permethrin intramuscularly stat, with the dose divided into two different muscle (applied to clothing or equipment. Secondary transmission is from person to person through:  Contact with a sick person or direct contact with the blood and/or secretions or Time (hours) 0 3 6 9 1 1 1 2 2 with objects, such as needles that have been contaminated with infected 2 5 8 1 4 secretions of an infected person. Diazepam * * * * * *  Breast feeding  Sexual contact Chlorpromazine * * * the disease can spread rapidly within the health care setting. The virus enters through Phenobarbitone * * * broken skin, mucous membrane or exchange of bodily fluids or ingestion, inhalation and injection of infectious material ** these are general guidelines. Frequency of drug administration should Diagnostic Criteria be titrated vs clinical condition High grade fever and one or more of the following:  Headache, body ache, abdominal pain, diarrhoea  Airway / respiratory control  Unexplained haemorrhage may be present or not o Provide mechanical ventilation. Supportive therapy includes:  Mechanical ventilation, renal dialysis, and anti-seizure therapy may be required. The virus can be transmitted to human through;  Handling of animal tissue during slaughtering or butchering, assisting with animal births, conducting veterinary procedures. Human become viraemic; capable of infecting mosquitoes shortly before onset of fever and for the first 3–5 days of illness. The disease can  Fluid and electrolyte balance be life threatening causing hemorrhagic fever and hepatitis. Psychological support is given to patient and family Non-Pharmacological Treatment 4. This is a viral zoonosis that is primarily spread amongst animals by the bite of infected mosquitoes, transmitting the Rift Valley virus. Transmission to human is mainly through direct or indirect contact with Prevention and Control involve mosquito control and provision of Yellow Fever vaccine. The virus can be transmitted to human through;  Handling of animal tissue during slaughtering or butchering, assisting with Indication of Yellow Fever Vaccination animal births, conducting veterinary procedures. Human become viraemic; capable of infecting mosquitoes shortly before onset of fever 4. Dengue is a mosquito-borne viral infection causing by the dengue fever virus, whose full life cycle involves the role of mosquito as a transmitter (or vector) and humans as the Diagnostic Criteria main victim and source of infection. Dengue does not spread directly from person to  Acute febrile illness that does not respond to antibiotic or antimalarial person, it is only spread through the bite of an infected Aedes aegypti mosquito. B: Oxygen and manage hypoglycaemia if present Note:  No antibiotics are of proven value. Diagnostic Criteria:  Fever, Skin rashes, Conjunctivitis  Muscle and joint pain (Polyarthritis), Malaise, Headache  Minor haemorrhage, Leukopenia is common Prevention and control: Vector control:removal and modification of breeding sites and reducing contact between mosquitoes and people. Non-Pharmacological Treatment: Supportive Pharmacological Treatment  Symptomatic treatment A: Sodium Lactate Compound (Ringers Lactate) intravenously A: Give Paracetamol 15mg/kg 8 hourly for 3 days 42 Standard Treatment Guidelines  Macular or confluent blanching rash (noted during recovery period) 4. In case of ocular involvement, add  Children below 12 years require close monitoring for dangerous form. Prevention Routine measles vaccination for children combined with mass immunization campaigns Diagnostic Criteria:  Fever, Skin rashes, Conjunctivitis 4. Diagnostic Criteria:  Fever, skin rashes, conjunctivitis,  Joint pain, malaise, Headache usually mild and last for 2–7 days. Uncomplicated malaria is defined as symptomatic malaria without signs of severity or In addition, patients should receive rabies immune globulin with the 1st dose (day 0) evidence (clinical or laboratory) of vital organ dysfunction. Investigations Diagnostic Criteria: the clinical features listed above are not specific for malaria and can be found in several  Fever, skin rashes, conjunctivitis, other febrile conditions. Therefore, it is necessary to confirm malaria parasites infection  Joint pain, malaise, Headache usually mild and last for 2–7 days. Parasite-based diagnosis is recommended for all patients presenting with signs and symptoms of malaria. The  Neurological and auto-immune complications of Zika virus disease, babies born recommended investigations are: with microcephaly (Observed in northeast Brazil. A: Sodium Lactate Compound (Ringers Lactate) intravenously A: Paracetamol 15mg/kg 8 hourly for 3 days Standard Treatment GuidelinesStandard Treatment Guidelines 4545 Table 5. For more details on management of fever and pain, refer to chapter one-syndromic 46 Standard Treatment Guidelines Table 5. If effective management of severe malaria 24 hours) until symptoms resolve, usually after two days. For more details on management of fever and pain, refer to chapter one-syndromic Standard Treatment GuidelinesStandard Treatment Guidelines 4747 Pharmacological Treatment A: Parenteral artesunate Dosage: 2. For deep intra–muscular injection, add 2 ml of 5% dextrose or normal saline to obtain a artesunate concentration of 20 mg/ml. The left–over solution must be discarded within 1hr of preparation and intra–muscular injection, add 2 ml of 5% dextrose or normal saline to obtain a must not be reused artesunate concentration of 20 mg/ml. Strength 30 mg 60 mg 120 30 mg 60 mg 120 mg mg Management of complications Sodium bicarbonate 5% 0. In children, diazepam Weight Dose ml per dose strength 60mg 60mg needed** rectal route should be used. If convulsions Kg mg/kg i/v i/m* persist after 10 minutes repeat rectal diazepam treatment as above. Should 10 mg/ml 20 mg/ml convulsions continue despite a second dose, give a further dose of rectal <5 3. Where dextrose is not available, sugar water should be prepared by mixing 20 gm of sugar (4–level tea spoons) with 200 ml of clean water. Intubation /ventilation may be necessary  Acute renal failure: exclude pre–renal causes, check fluid balance and urinary sodium. Haemodialysis /hemofiltration (or if availableperitoneal dialysis) should be started early in established renal failure. Hence, early diagnosis and effective case management of malaria illness in pregnant women is crucial in preventing the progression of uncomplicated malaria to severe disease and death. Pharmacological Treatment Where dextrose is not available, sugar water should be prepared by mixing 20 the management of severe malaria in pregnant women does not differ from the gm of sugar (4–level tea spoons) with 200 ml of clean water. The aim is to prevent above mentioned complications with adverse /hemofiltration (or if availableperitoneal dialysis) should be started early in effects to both mother and fetus3 established renal failure. Dosage: Malaria is an important cause of morbidity and mortality for the pregnant woman, the. Diagnostic Criteria • Fever, diarrhoea, weight loss, skin rashes, sores, generalized pruritis, altered mental status, persistent severe headache, oral thrush or Kaposis sarcoma may be found in patients with advanced disease • Most patients, however, present with symptoms due to opportunistic infections. Mobile outreach clinics can also be used 10-15 infants infected where there are no static clinics. Therefore, 3rd line regimens, in order to have at least two or preferably three effective drugs, need to be constructed using other new classes of drugs or second generation formulations of previous drugs. Therefore, 3 line regimens, in order to have at least two or preferably three effective drugs, need to be constructed using other new classes of drugs or second generation Table 6. Provide creatinine levels; symptomatic treatment Insomnia and headache may also be experienced. Provide Immunological and clinical creatinine levels; symptomatic treatment characteristics of treatment failure Insomnia and headache develop much later after virological may also be failure. Transient rises in viral load are called viral blips and are not due to treatment failure. A diagnosis of treatment failure requires two consecutive viral load levels after >6months of treatment above 1000 copies/mL within an interval of 3 months and after adherence intensification. Genotyping will also inform possibility of recycling drugs used in previous regimens i. At each clinic visit, thorough history and physical examination should be done and recorded in the patient file. Regimens Monitoring Frequency Rationale Transient rises in viral load are called viral blips and are not due to treatment failure. Clinical Monitoring: In most cases, treatment will be associated with weight gain and reduced morbidity from opportunistic infections and improvement in the quality of life. At each clinic visit, Laboratory monitoring of patients on second line drugs thorough history and physical examination should be done and recorded in the patient the following laboratory tests are recommended for Monitoring of patients on second file. Standard Treatment GuidelinesStandard Treatment Guidelines 6363 When changing treatment, the following should be observed:  Never change a single drug in the combination if the reason for changing is treatment failure.

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Dose within bone / lung cavities asthma symptoms in 1 yr old cheap singulair uk, Interface effects asthma definition trust discount singulair online amex, Electronic disequilibrium Wedge filters and their use asthma webmd order singulair 10 mg on line, Wedge angle asthma treatment algorithm buy cheap singulair online, Wedge Factors asthma treatment 2013 buy singulair 5 mg on-line, Wedge systems (External asthmatic bronchitis attack buy singulair no prescription, In-built Universal, Dynamic / Virtual), Wedge isodose curves Other beam modifying and shaping devices: Methods of compensation for patient contour variation and / or tissue inhomogeneity Bolus, Buildup material, Compensators, Merits and Demerits. Shielding of dose limiting tissue: Non-divergent and Divergent beam blocks, Independent jaws, Multileaf collimators, Merits and Demerits 1. Dose uniformity for different energies in a parallel opposed setup, Multiple fields (3 fields, 4 field box and other techniques. Plan optimization, Plan evaluation tools: Dose-Volume Histograms (Cumulative and Differential), Hard copy output, Storage and retrieval of plans. Alignment and Immobilization: External and internal reference marks, Importance of immobilization in radiotherapy, Immobilization methods (Plaster of Paris casts, Perspex casts, bite block, shells, head rests, neck rolls, Alpha-Cradles, Thermoplastic materials, polyurethane foams), Methods of beam alignment (isocentric marks, laser marks, and front/back pointers. Surface dose, percentage depth dose, beam profiles, Isodose curves and charts, Flatness and Symmetry. Suitability of measuring instruments for electron beam dosimetry Treatment planning: Energy and field size choice, air gaps, and obliquity, Tissue inhomogeneity – lung, bone, air filled cavities. Arc therapy, Use of bolus in electron beam Total Skin Electron Irradiation, Intraoperative Radiation Therapy 1. Source construction including filtration, comparative advantages of these radionuclides Historical background. Radiation and Dose units: Activity used, Exposure, Absorbed Dose, mg-hr, curie, milli-curie destroyed, milligram Radium equivalent, roentgen, rad, gray. Source strength specification, Brachytherapy Dose calibrator Techniques: Pre-loaded, Afterloading (manual and remote), Merits and Demerits. Remote afterloading machines, Detailed description of any one unit Dosage systems: Manchester System (outline only), Paris System (working knowledge) Course and Curriculum of M D Radiotherapy 273 Treatment Planning: Patient selection, Volume specification, Geometry of implant, Number, Strength and Distribution of radioactive sources, Source localization, Dose calculation, Dose rate specification, Record keeping. Need for area monitoring, Gamma Zone monitors, Survey meters Regulatory aspects: Procedural steps for installation and commissioning of a new radiotherapy facility (Teletherapy and Brachytherapy. Site plan, Layout of installation / Associated facility: Primary, Secondary barriers, leakage and scattered radiation. Introduction to factors influencing radiation response Physical factors: dose, dose quality, dose rate, temperature Chemical factors: Oxygen, radiosensitizers, radioprotectors Biological factors: type of organism, cell type and stage, cell density and configuration, age, sex. Radiobiology of low, high dose rate & pulsed brachytherapy, hyperfractionation, significance in radiotherapy. Variation of response with growth and the progression of cell through the phases of cell cycle. Chromosome aberrations in peripheral blood lymphocytes Radiation accidents: typical examples 1. Radiation Effects on Major Organs/tissues Acute & late effects on all normal organs & tissues including connective tissue, bone marrow, bones, gonads, eye, skin, lung, heart, central nervous system tissues, peripheral nerves, esophagus, intestine, kidney, liver & thyroid with special reference to treatment induced sequelae after doses employed in radiotherapy Normal tissue tolerances 1. Late effects of radiation (somatic) Sterility, cataracts and cancer Carcinogenesis: mechanisms in vitro and in vivo, oncogenes and anti oncogenes Radiation induced cancer of occupational, medical or military origin Recent controversial results for low level exposure, risk estimates 1. Late Effects of Radiation (Genetic) Mutations: definition, types, potential hazards. Low level radiation: sources, potential hazards, stochastic and deterministic (non stochastic) effects, high background areas and cancer. Biology and Radiation Response of Tumors Tumor growth; kinetics of tumor response. Volume doubling times, potential volume doubling times, repopulation, and accelerated repopulation. Causes of failure to control tumors by radiation: tumor related, host related technical/mechanical errors. Time, dose, and fractionation relationship: isoeffect curves, isoeffect relationships. Irradiation of sub-clinical disease, debulking surgery, importance of clonogen numbers. Combination Radiation -Chemotherapy Definitions of radiosensitiser, synergism, potentiation, antagonism. Hyperthermia Sources, rationale (historical examples), advantages and disadvantages, thermotolerance. Cellular damage: comparison and contrast with radiation, thermal and non-thermal effects of ultrasound, microwaves, radiofrequency, etc. Use along with radiotherapy and chemotherapy: optimum sequencing of combined modalities. Clinical trials Statistical basis for planning & interpretation Clinical Trials. Planning a trial – Establishing objectives short term and long term – Determining the appropriate criteria. Guidelines for treatment response assessment Complete Response, Partial Response, No Response, Stable disease. End points of treatment results: Loco-regional control, recurrence, metastasis, survival, quality of life. Treatment related morbidity assessment (i) Radiation morbidity (early & late) (ii) Morbidities of combined treatment (iii) Grading Systems. Chemotherapy practice & results/ toxicities in sequential & concomitant chemoradiotherapy. The principles of cell kill by chemotherapeutic agents, drug resistance, phase specific and cycle specific action. The general principles of pharmacokinetics; factors affecting drug concentration in vivo including route and timing of administration, drug activation, plasma concentration, metabolism and clearance. Early, intermediate and late genetic and somatic effects of common classes of anticancer drugs. An understanding of the mode of action and side effects of common hormonal preparations used in cancer therapy (including corticosteroids. Use of the major biological response modifiers such as interferons, interleukins and growth factors and knowledge of their side effects. Basic principles of surgical oncology, biopsy, conservation surgery, radical surgery, palliative surgery. Structured training: lectures, seminar, Journal club, Ward-round, Physics demonstration, Practical, Case Presentations (e. How to set up a Radiotherapy and Oncology department, planning of infrastructure, & equipments 5. Research Ability: He/she should also acquire elementary knowledge about research methodology, including record-keeping methods, and be able to conduct a research inquiry including making a proper analysis and writing a report on its findings. He/she should develop general humane approach to patient care with communicating ability with the patients relatives especially in emergency situation such as in causality department while dealing with cancer patients and victims of accident. Cognitive knowledge: Describe embryology, applied anatomy, physiology, pathology, clinical features, diagnostic procedures and the therapeutics including preventive methods, (medical/surgical) pertaining to musculo-skeletal system. The recent trends towards limb salvage procedures and the advances in chemotherapy need to be familiar to him. In any type of posting after qualification the orthopaedic surgeon would be exposed to all varieties of acute trauma. Hence, it is his responsibility to be able to recognize, assess and manage it including the medico legal aspects. Sports medicine not only encompasses diagnostic and therapeutic aspects of athletic injuries but also their prevention, training schedules of personnel & their selection. Adequate exposure in the workshop manufacturing orthotics and prosthetics is mandatory, as is the assessment of the orthopedically handicapped. In addition the student learns about implants in orthopaedics and their metallurgy. Research: Develop ability to conduct a research enquiry on clinical materials available in Hospital and in the community. Patient doctor relation: Develop ability to communicate with the patient and his/her relatives pertaining to the disease condition, its severity and options available for the treatment/therapy. Preventive Aspect: Acquire knowledge about prevention of some conditions especially in children Course and Curriculum of M S Orthopaedics 283 such as poliomyelitis, congenital deformities, cerebral palsy and common orthopaedic malignancies. Identification of a special areas within the subject: To further develop higher skills within the specialty in a specialized are such as Arthroplasty, Neurology, Arthroscopy oncology, spine surgery, hand surgery and Rheumatology, identify some area of interest during the residency and do fellowship/ senior residency programme in one of such areas. Presentation of Seminar/paper: Should develop public speaking ability and should be able to make presentation on disease-conditions/research topics to fellow colleagues in a Seminar/meeting/ conference using audiovisual aids. Research writing: Should be capable to write case-reports and research papers for publication in scientific journals. Degree course is expected to perform major and minor surgical procedures independently as well as under supervision of a faculty member/senior resident. Research methology / reporting on research: Learns the basics in research methodology and make the thesis protocol with the 4 months of admission. Course and Curriculum of M S Orthopaedics 285 – Humanity/Ethics: – Lectures on humanity including personality development, team spirit and ethical issues in patient care and human relationship including, public relations, by Psychologist and public relation officers are to be arranged by the department/college. Presentation for the Thesis work: (a) Selection of thesis topic: Subject of thesis will be selected by the candidate under guidance of faculty, which will be approved by the departmental guide and other faculty. The candidate will be asked to submit the protocol within 4 (Four) month of admission after it is scrutinized by departmental faculty. It is to be approved by the central thesis committee of the institute/college if such committee does exist, and the ethical considerations are also discussed in such Research Programme Committee. At the discretion of director/thesis committee one month extension may be given to a candidate for submission of the protocol and the final thesis for any valid reason for the delay. Teaching Methods: the following learning methods are to be used for the teaching of the postgraduate students: 1. Journal club: 1 hrs duration –Paper presentation/discussion – once per week (Afternoon. Lecture/discussion: Lectures on newer topics by faculty, in place of seminar/as per need. Case presentation in the ward and the afternoon special clinics (such as scoliosis/Hand clinics. Case Conference Residents one expected to work-up one long case and three short cases and present the same to a faculty member and discuss the management in its entirety on every Monday afternoon. X-Ray Classes Held twice weekly in morning in which the radiologic features of various problems are discussed. Surgicopathological Conference: Special emphasis is made on the surgical pathology and the radiological aspect of the case in the pathology department such exercises help the ortopaedics/ Pathology/Radiology Residents. Combined Round/Grand Round: these exercises are to be done for the hospital once/wk or twice/ month involving presentation of usual or difficult patients. Presentations of cases in clinical combined Round and a clinical series/research data on clinical materials for benefit of all clinicians/Pathologists/ other related disciplines once in week or forthrightly in the Grand round. Community camps: For rural exposure and also for experiences in preventive aspect in rural situation/ hospital/school, patient care camps are to be arranged 2-3/ year, involving residents/junior faculty. Residents work up the cases of spinal deformity and present them to a faculty member and management plan recorded in case file. All the cases of hand disorders are referred to the clinic and discussed in detail. Polio Clinic Held once a week, Various braces & Calipers are prescribed and surgical management planned. Besides clinical training for patient care management and for bed side manners: Daily for ½ to one hours during ward round with faculty and 1-2 hours in the evening by senior resident/faculty on emergency duty, bed side patient care discussions are to be made. Clinical interaction with physiotherapist: Clinical interaction with physiotherapist pertaining to management of the patients in post-op mobilization. Research Methodology: Course and Lectures are to be arranged for the residents for language proficiency by humanity teachers besides few lectures on human values and ethical issues in patient care. Writing Thesis: Thesis progress is presented once in 3 months and discussion made in the department. Guides/co guides are to hear the problems of the candidate; can provide assistance to the student. Progress made or any failure of the candidate may be brought to the notice of college Dean/Principal. Final Examination & Examiners: the oral, clinical and Practical Examination: One or 2 centers depending on local university rules. Results of the examination will be declared as pass/failed/pass with distinction (Grade/marks may also be given if necessary as per University Rules. While doing so, both, formative and summative assessment will be taken into consideration. One of the internal examiners will be the Head of Department and he she shall be chairman/Convener. The second internal examiner shall be next senior most member of faculty of the department provided he/she is eligible for such duty. The necessity of an external examiner is to maintain the standard of the examination at the National level. Hony teacher with previous full time experience (of 10 years standing) may only be made examiners if there does not exist nay a full time qualified faculty under the same university/ college. There will be 2 external examiners from a different university so that the number of questions available, will be double the which will be given to the student in the moderate papers. The Chief internal examiner or Chairman/Convener will moderate it and finally make two sets of question paper, containing 8-10 shorts questions. He/she shall send both sets of such papers to the university and university will decide to give one of the sets to the students. In presence of the external examiners, the Chairman and the internal examiner shall make the necessary arrangements for conducting the final examination. For different College/Institution, separate examination center/examiners may be arranged/appointed for convenience and proper administration of the final examination. While preparing the final results, formative assessment of the students shall be taken into consideration and the results will be sent to the university under seal cover.

Tennison in 1952 described technique for unilateral cleft the main disadvantage of this procedure is the visible lip; wherein he applied the principles of transferring transverse scar on the lower part of the lip asthmatic bronchitis dangerous order singulair overnight delivery, where it is visible tissue from lateral element to medial side in the form of a 15 as it transgresses the philtral column acute asthmatic bronchitis icd 10 code discount 4 mg singulair with mastercard. Care was taken to recreate the natural features of the lip asthma symptoms after pneumonia order singulair with mastercard, especially a balanced Cupid?s bow asthma treatment 1940s cheap singulair 10 mg amex. Revision lip surgery asthma quick reference buy 10mg singulair amex, if required later asthma symptoms gina purchase 10 mg singulair with visa, is also more difficult Muscle approximation and pouting of lower lip were given with this technique. Sawhney further modified the triangular flap adding measurements and effectively reduced the size of to mathematical precision. Sawhney17 from Chandigarh India described the to the midline as the anatomical abnormality exists only on the side of cleft and the noncleft side is essentially normal. The triangular method is used to this day by many surgeons Principle in India with considerable effect. A backcut in the form of a transverse incision is placed immediately above the Cupid?s bow point to the midline on Triple Wedge Technique the cleft side on the medial lip element to bring it down to the level of its counterpart on the noncleft side. Balakrishnan of Nagpur, and later, Chandigarh, devised a a triangular defect that is closed by raising a geometrically Triple wedge technique, a form of multiple triangular flaps designed perfect isosceles triangular flap from the lateral lip repair that was evolved independently of the triangular element. Unfortunately, Balakrishnan did not publish side is shorter and the sides of the triangle are equal to the his work. This consisted of three wedges Advantages one at the alar base, one above the vermillion, and one at the Since the measurements are done to perfection at the vermilion (Fig. It is easy to bring down the Cupid?s bow as the transverse the advantage is the ease of planning and execution. Postoperative triangles are small, hence the scar transgressing the philtral scar contraction and secondary deformity are minimal as column is not obvious and has the advantage of avoiding a the triangular flap breaks the straight line scar. The patient is evalu? Principles of Cleft Lip Repair ated for orthognathic surgery at 17 years. Lip repair was ??Achieving accurate skin, muscle, and mucous performed at 3 months in two centers, 3 to 5 months in membrane union. One center used Musgrave and Garrett also emphasize preservation of the primary bone grafting at 6 to 9 months. Thus, Agrawal K resorted to cleft palate repair at 6 Goals of Treatment to 9 months, and then the cleft lip repair at 3 to 6 months later. There are centers even in India that perform cleft lip repair in the immediate neonatal period. One is that the fetal growth factor favors ??The Cupid?s bow, the most visible part of the lip, should almost scarless healing. However, these are very rapidly be symmetrical with the apices of the bow at the same replaced by the adult growth factor and hence unless the level on both sides. There should be a natural looking seen the most intense bonding between mothers of children philtral dimple. Most of the children in developing nations attain the ??Reconstruction of a fistula free nostril floor and optimal weight of 10 lbs or 5 to 6 kg only by then. When the cleft of the primary followed at the authors? center for the past five decades and palate is wide with gross alveolar disparity, lip adhesion we shall describe this technique in detail along with certain was widely used to narrow the cleft and to bring the alveolar refinements that have been incorporated in to this technique segment in better alignment. Johansson is credited with by the senior author to overcome some shortcomings with performing the first lip adhesion. The technique of lip adhesion used varies from a mere paring along the mucocutaneous edges and turning Markings the mucosa over and closure in three layers, to a nasolabial 20 We make our skin markings with a marker pen using adhesion as practiced by Chen et al using a mucosal C flap, Bonney?s Blue (Fig. The most vital points on the Cupid?s buccal mucosal flap, and an inferior turbinate flap. The important landmarks that are marked are: Advantages ??The apex of the Cupid?s bow. The benefits of lip adhesion are that the wide cleft is ??The high point of the Cupid?s bow on the noncleft side. There is at present no evidence to mucocutaneous junction and this is the point that is indicate that lip adhesion improves the outcome in terms of to be sutured to the Cupid?s bow point that has been the lip or the nose. These are still used by to the red line of Noordhoff (widest part of the dry many surgeons today. C Flap these measurements are extrapolated onto the cleft side at the lateral point as shown in the figure. The the lateral point has also been mentioned as the point authors always use it for the columella. Thus, the very fact that there are so many different ways the mucosal lining of the inferior turbinate has been used of marking this point amply attests to the fact that this is in the reconstruction of the nasal floor. A superiorly based often an ambiguous point and that none of the methods are rectangular flap is marked and raised and used for the nasal accurate all the time. It aids in avoiding excess narrowing of the dry mucosa3 and the distance from the oral commissure4 are nostril. Very often one needs to use Rotation Flap one?s experience in judging the point and should not go by measurements alone. This ascends up to the base of the Infiltrations columella with a gentle convexity facing the cleft. It hugs Adrenaline in Saline 1: 200,000 solution is infiltrated sub? the base of the columella for about two?thirds of its distance periosteally over the buccal surfaces and also under the and ends with a backcut that is made perpendicular to the mucoperichondrium of the septum and under the muco? incisions. This backcut should stop short of the noncleft periosteum of the lateral shelf of the maxilla. If not, it will lengthen the noncleft side also infiltrate into the lip tissue itself. But the authors avoid as well and the discrepancy in the heights of the sides of it as it is felt that it may distort the lip anatomy. Incisions the backcut is necessary to bring about adequate rotation the cleft edges are pared, using Beaver No. The attachment of the frenum tethers believe, as did Millard, that it is necessary in all patients the lip and only after it is released can one accurately to bring about adequate rotation. These have been used to assist in the closure of the vermillion is then undertaken at the tattooed point Unilateral Cleft Lip 47 a b c d Fig. The entire bulk of Primary closed nasal correction and septal repositioning orbicularis oris marginalis at this level is preserved. This have been performed from the early 1970s in India almost is to avoid muscle deficiency which is a possible cause of a simultaneously by Dr. The incision Primary Alar Cartilage Dissection commences from the base of the ala to the previously Primary alar cartilage dissection and stabilization of the tattooed lateral point. The dissection may be Millard recommended that an additional 2 mm in height through a closed approach or open, as performed by C could be obtained by moving the lateral point out by a mm Thomas and Mishra26 and Trottet and Mohan. Undermining of the skin and mucosa is performed cartilage dissection; the alar cartilages are approached both for a few mm more than on the noncleft side. Although lining as the cartilage is densely adherent to the lining at Millard?s incision originally went all around the ala, this has this level and closed dissection is nearly impossible. The original bolster avoid this incision altogether, while the author uses a limited 28 sutures were described by McComb and had to be tied over perialar incision as it also provides easy access for the alar pledgets on the skin. Once these were removed, there was a dissection and enables direct visualization of the paranasal 29 slumping of the cartilage once again. Dissection proceeds in a sub?periosteal plane and extends superiorly till the infra Primary Septal Repositioning orbital foramen with its neurovascular bundle, laterally this has not yet gained wide acceptance. However, this has till the zygomatic prominence and medially to the edge of been performed at our center from the early 1970s with no the nasal process of the maxilla. The orbicularis oris muscle is undermined from the conclusion from long?term studies published after 35 years of follow?up by Anderl et al32and 10 years follow?up by mucosa and from the skin. Primary Nasal Correction There is a residual bow stringing that is neutralized by the nose in a patient with a unilateral cleft lip has some transverse and longitudinal scoring incisions on the noncleft characteristic deformities. A sliver of cartilage is excised from its inferior border by Huffmann and Lierle2 as we have discussed earlier. Though there was an initial apprehension that primary the released, straightened septal cartilage is then fixed. Some in the unilateral cleft lip child, there is no such anchoring form of primary nasal correction is now performed almost point available. Published reports of nasal correction include sutured to the just reconstructed cleft side nasal floor. Columella Hemicolumellar lengthening is obtained using the C flap as mentioned above. Closure of the Anterior (Hard) Palate at the Time of Cleft Lip Repair Conventionally, the anterior palate has been closed along with the cleft lip repair. Initial surgeons used an inferiorly based nasal septal and vomerine flap from the medial aspect and the mucoperiosteum from the lateral shelf. This has been the preferred method First the nasal floor is reconstructed by suturing the septal of the authors. We suture the hard palate till its junction mucoperiosteum with the maxillary mucoperiosteum. The orbicularis oris muscle on either side of the cleft is Two layered closure has been used by some surgeons. The Millard cinch Campbell34 used a septal turn over flap, Muir used a labial suture anchors the perialar muscle on the cleft side to mucosal flap for the second layer. In addition to the Millard cinch suture, the of lip repair, the extent of the cleft that needs to be closed senior author has introduced another sill cinch suture that at the time of palate repair is much less. However, early goes through the subcutaneous tissue medially and dermis Unilateral Cleft Lip 51 laterally and can provide a better control of nostril shape. Arm restraints have been traditionally the orbicularis oris muscle is then brought together across used to prevent injury to the recently repaired lip. Pictures of patients operated with this technique are Postoperative Care presented, with only primary lip and nose correction A tongue stitch placed deep and adequately posteriorly on (Fig. Mid?philtral point is marked at the lowest point of Cupid?s bow in the midline corresponding to the philtral tubercle. The lateral columellar base is marked on two sides at the point where the philtral column meets the columella base (Fig. A vertical line is drawn from lateral columellar base point to the lateral philtral point on noncleft side indicating the height of lip. Another vertical line is drawn in the midline from mid?columella point to mid?philtral point at the lowest point of the Cupid?s bow. A horizontal line is drawn from the cleft side lateral philtral point bisecting the midline and philtral column. This is the most important line as it decides the difference in the height between cleft and noncleft side. Markings on the Lateral Element of the Lip Medial side markings are used for marking the triangle on the lateral element of the lip. Lateral philtral point is marked Randall-Tennison-Sawhney Triangular at the point where the white line starts thinning. The alar base point is marked medial to the alar base on the nostril Flap Technique of Unilateral Cleft sill (Fig. Lip Repair Castroviejo caliper is used to design the triangular flap using the dimensions from the medial element. The present height of cleft side is used for making an arc from alar base Marking point. Another arc is marked from the lateral philtral point Geometrical designing of the incision line and precise to bisect the previous arc using the difference between marking are soul of this technique. The distance Markings on the Medial Element of Lip between this point to lateral philtral point makes the base of Lateral philtral point is marked as the highest point of Cupid?s the triangle (Fig. Corresponding lateral philtral point lateral philtral point to the midline on the medial element is marked on cleft side at the point where white line starts is measured. Markings on lateral element: A??Proposed lateral philtral point, where the white line starts thinning; B??Alar base point which is supposed to meet point a B? on the medial side. A??H? forms the base of the isosceles triangle which will fit in the future backcut on the medial element. With Castroviejo caliper, two arcs are drawn from points A? and H? on its medial side over the skin area. The arcs cut each other at point O? which is the apex of the triangle and will form an isosceles triangle. Vermilion incisions are drawn from points A and A? so as to create equal size vermilion for suturing. On medial element, the line is drawn obliquely toward vermilion tubercle to point V and on lateral element the line is perpendicular to the white line to point V? over redline and the markings are made over the dry?wet vermilion junction (red line. Muscle is sutured aligning the corresponding points starting from the nostril sill. Special attention to be paid to white line, red line, and h nostril sill approximation. These two arcs bisect each other to make the the incision on the lateral element follows the line apex of the triangle (Fig. Care is taken to tattoo all from alar base point to the base of triangle and down to the points especially the key points on white line, columella lateral philtral point crossing the white line to the redline and alar bases, vermilion points, and apex and sides of the of vermilion. The lateral and medial elements are dissected off the Full?thickness incisions are made along the markings on maxilla sub? or supraperiosteal based on ones? choice. The tissue toward the cleft edges was earlier extent of the dissection varies depending upon the degree discarded. These flaps are used orbicularis oris muscle is dissected from skin and mucosa for second layer of anterior palate repair or for deepening laterally as well as medially. Through medial incision, the cartilaginous septum philtral column in the upper part, and in the lower part, a is dissected. The septoplasty is performed by dislocating the back?up cut is made from the lateral point horizontally upto cartilaginous septum from the maxillary crest. It opens up the lip to the level of highest point of dissection is essentially surgeons? choice. Unilateral Cleft Lip 55 Anterior Palate Repair ?l? flap is the marginal tissue from lateral element of the lip. This is based on alveolar margin or on the lateral wall In case of alveolar cleft and cleft lip and palate, the anterior of the nose.

Diseases

Renal dysplasia limb defects
Leucinosis
Fascioliasis
Transposition of great vessels
Sondheimer syndrome
Microcephaly with normal intelligence, immunodeficiency
Birt Hogg Dub? syndrome
Birnstad syndrome
Pseudohermaphroditism male with gynecomastia

Explain procedures asthma definition 9 amendment order singulair without a prescription, providing opportunity for questions and Accurate information allows client to deal more effectively with honest answers asthmatic bronchitis mucinex singulair 10 mg line. Stay with client during anxiety-producing reality of situation asthma symptoms throwing up cheap singulair 4mg visa, thereby reducing anxiety and fear of the procedures and consultations asthma 2014 soundtrack order singulair master card. May help reduce anxiety by fostering therapeutic relationship and facilitating continuity of care asthmatic bronchitis that wont go away purchase singulair overnight delivery. Be alert to signs of denial or depression asthma definition kingdom discount 5 mg singulair with mastercard, such as withdrawal Client may use defense mechanism of denial and express hope and anger or making inappropriate remarks. Feelings of guilt, spiritual dis presence of suicidal ideation and assess potential on a scale tress, physical symptoms, or lack of cure may cause the of 1 to 10. Encourage and foster client interaction with support systems, Reduces feelings of isolation. If family support systems are not including counselors, spiritual leader, and local cancer available, outside sources may be needed immediately. Collaborative Administer anti-anxiety medications, such as lorazepam (Ativan) May be useful for brief periods of time to help client handle or alprazolam (Xanax), as indicated. Continue normal life activities, looking toward and planning for the future, one day at a time. Use therapeutic Promotes and encourages realistic dialogue about feelings and communication skills of active-listening, acknowledgment, concerns. Encourage verbalization of thoughts and concerns, accepting Client may feel supported in expression of feelings by the un expressions of sadness, anger, and rejection. Be aware of mood swings, evidence of conflict, expressions of May be clients way of expressing or dealing with feelings of anger or hostility, and other acting-out behavior. Set limits despair and spiritual distress, reflecting ineffective coping on inappropriate behavior and redirect negative thinking. Preventing destruc tive actions enables client to maintain control and sense of self-esteem. Ask client direct questions Studies show that clients with physical illnesses are at higher about state of mind. Listen for statements of despair, guilt, risk for suicide (Taur et al, 2013; Aiello-Laws, 2010. Honest answers Be honest; do not give false hope while providing emotional promote trust and provide reassurance that correct informa support. Opportunity to identify skills that may help individuals cope with grief of current situation more effectively. Possibility of remission and slow progression of disease and/or new therapies can offer hope for the future. Having a part in problem-solving and planning can provide a Encourage setting of realistic goals. Refer to appropriate counselor as needed, such as psychiatric Can help alleviate distress or palliate feelings of grief to facilitate clinical nurse specialist, social worker, hospice counselor, coping and foster growth. Collaborative Refer to visiting nurse, home health agency as needed, or Provides support in meeting physical and emotional needs of hospice program, if appropriate. Demonstrate adaptation to changes and events that have occurred as evidenced by setting of realistic goals and active participation in work, play, and personal relationships, as appropriate. Encourage discussion of and problem-solve concerns about May help reduce problems that interfere with acceptance of effects of cancer or cancer treatments on role as homemaker, treatment or aggravate progression of disease. Give infor Validates reality of clients feelings and gives permission to mation that counseling is often necessary and important in take whatever measures are necessary to cope with what is the adaptation process. Use touch during interactions, if acceptable to client, and Affirmation of individuality and acceptance is important in maintain eye contact. Pain of more than 6 months or verbal rating scale—no pain to excruciating pain—and duration constitutes chronic pain, which may affect thera relief measures used. Recurrent episodes of acute pain can occur within chronic pain, requiring increased level of interven tion. Note: the pain experience is an individualized one composed of both physical and emotional responses. Determine timing and precipitants of breakthrough pain Pain may occur near the end of the dose interval, indicating when using around-the-clock agents, whether oral, intra need for higher dose or shorter dose interval. Evaluate painful effects of particular therapies, such as surgery, A wide range of discomforts are common, such as incisional radiation, chemotherapy, or biotherapy. Provide nonpharmacological comfort measures, such as mas Promotes relaxation and helps refocus attention. Encourage use of stress management skills and complemen Enables client to participate actively in nondrug treatment of tary therapies, such as relaxation techniques, visualization, pain and enhances sense of control. Pain produces stress guided imagery, biofeedback, laughter, music, aromather and, in conjunction with muscle tension and internal stres apy, and Therapeutic Touch. Provide cutaneous stimulation, such as heat and cold packs, or May decrease inflammation, muscle spasms, reducing associ massage. Be aware of barriers to cancer pain management related to Clients may be reluctant to report pain for reasons such as client as well as to the healthcare system. Health care system problems include factors such as inadequate assessment of pain, concern about controlled substances or client addiction, inadequate reimbursement, and cost of treatment modalities. Adjust medication Goal is maximum pain control with minimum interference regimen as necessary. Collaborative Discuss use of alternative or complementary therapies, such as May provide reduction or relief of pain without drug-related acupuncture, if client desires. Develop individualized pain-management plan with the client An organized plan beginning with the simplest dosage sched and physician. Administer analgesics, as indicated, for example: A wide range of analgesics and associated agents may be em ployed around the clock to manage pain. Fentanyl citrate (Oralet) is avail able as a transmucosal agent that is absorbed through the mucosa of the inner cheek. Corticosteroids, such as dexamethasone (Decadron) or May be effective in controlling pain associated with inflamma prednisone tory process including metastatic bone pain, acute spinal cord compression, and neuropathic pain. Anticonvulsants, such as phenytoin (Dilantin), valproic Useful for peripheral pain syndromes associated with neuro acid (Depakote), clonazepam (Klonopin), gabapentin pathic pain, especially shooting pain, postherpetic neuralgia. Antihistamines, such as hydroxyzine (Atarax, Vistaril) Mild anxiolytic agent with sedative and analgesic properties. May produce additive analgesia with therapeutic doses of opioids and may be beneficial in limiting opioid-induced nausea or vomiting. Bisphosphonates, such as Pamidronate (Aredia) or zoledronic Specific inhibitors of osteoclastic activity that treat hypercal acid (Zometa) cemia and reduce bone pain and fractures especially in multiple myeloma, breast, and prostate cancers. Provides for timely drug administration, preventing fluctua tions in intensity of pain, often at lower total dosage than would be given by conventional methods. Prepare for and assist with procedures such as nerve blocks, May be used in severe, intractable pain unresponsive to other cordotomy, commissural myelotomy, or radiation therapy. Note: Radiation is especially useful for bone metastasis and may provide fast onset of pain relief even with only one treatment. Refer to structured support group, psychiatric clinical nurse May be necessary to reduce anxiety and enhance clients specialist, psychologist, or spiritual advisor for counseling, coping skills, decreasing level of pain. Participate in specific interventions to stimulate appetite and increase dietary intake. Measure height, weight, and skinfold thickness or other anthro If these measurements fall below minimum standards, clients pometric measurements, as appropriate. Assess skin and mucous membranes for pallor, delayed wound Helps in identification of protein-calorie malnutrition, especially healing, and enlarged parotid glands. Encourage client to eat high-calorie, nutrient-rich diet, with Hypermetabolic state and treatment requires increased nutri adequate fluid intake. Encourage use of supplements and ents and fluids to promote healing and elimination of tox frequent, smaller meals spaced throughout the day. Supplements can play an important role in maintaining adequate caloric and protein intake. Note: Early studies re garding eating-related distress indicates there is currently no evidence that people with advanced cancer can improve their survival or quality of life by changing what they eat. Therefore, the goal of psychosocial intervention may need to change from optimizing nutritional intake to mitigating weight and eating-related distress when the focus of treat ment and care shifts from achieving cure to optimizing qual ity of life (Hopkinson et al, 2006; Brown, 2002. Create pleasant dining atmosphere; encourage client to share Makes mealtime more enjoyable, which may enhance intake. Control environmental factors, such as strong or noxious odors Can trigger nausea and vomiting response. Encourage use of relaxation techniques, visualization, guided May prevent onset or reduce severity of nausea, decrease imagery, and moderate exercise before meals. Identify the client who experiences anticipatory nausea or Psychogenic nausea and vomiting occurring before chemother vomiting, and take appropriate measures. Change of treatment environment or client routine on treatment day may be effective. Collaborative Review laboratory studies, as indicated, such as total lympho Helps identify the degree of biochemical imbalance or malnu cyte count, serum transferrin, and albumin or prealbumin. Note: Anticancer treatments can also alter nutrition studies, so all results must be correlated with the clients clinical status. These medications phenothiazines, such as prochlorperazine (Compazine) are often prescribed routinely before, during, and after and thiethylperazine (Torecan); antidopaminergics, such chemotherapy to prevent nausea and vomiting. Note: Some med ical providers recommend avoiding such antioxidants as E and C because they may interfere with chemotherapy and radiation. Antacids and/or proton pump inhibitors, such as esomepra Minimizes gastric irritation, decreases nausea, and reduces risk zole (Nexium), lansoprazole (Prevacid), or pantoprazole of mucosal ulceration. For many clients, mitigation of distress is likely to be achieved by supporting them in optimizing their nutritional intake within the confines of their small appetite and other obstacles to eating (considered to be a psychoso cial intervention) (Hopkinson, 2002. Provides for specific dietary plan to meet individual needs and reduce problems associated with protein or calorie malnu trition and micronutrient deficiencies. Include all Continued negative fluid balance, decreasing renal output, and output sources, such as emesis, diarrhea, or draining wounds. Encourage increased fluid intake as individually appropriate Assists in maintenance of fluid requirements and reduces risk and tolerated. Observe for bleeding tendencies, such as oozing from mucous Early identification of problems that may occur as a result of membranes or puncture sites and presence of ecchymosis cancer and/or therapies allows for prompt intervention. Given for general hydration and to dilute antineoplastic drugs and reduce adverse side effects—nausea, vomiting, or nephrotoxicity. Note: Malnutrition and effects of decreased albumin levels potentiates fluid shifts or edema formation. Platelets Thrombocytopenia may occur as a side effect of chemotherapy, radiation, or cancer process, increasing the risk of bleeding from mucous membranes and other body sites. Avoid use of aspirin, gastric irritants, platelet inhibitors, or these substances can negatively affect clotting mechanism herbs such as ginseng, green tea, garlic, ginger, ginkgo, or and/or potentiate risk of bleeding. Frequent rest periods and/or naps are needed to conserve and Schedule activities for periods when client has most energy. Encourage client to do whatever possible, such as self-bathing, Enhances strength and stamina and enables client to become sitting up in chair, and walking. Encourage aerobic exercise, as client is able, with goal of Aerobic exercise minimizes fatigue, increases strength and 30 minutes per day. Presence of anemia or hypoxemia reduces O2 available for cellular uptake and contributes to fatigue. Protects client from sources of infection, such as visitors and Screen and limit visitors who may have infections. Temperature elevation may occur, if not masked by cortico steroids or anti-inflammatory drugs, because of various fac tors, including chemotherapy side effects, disease process, or infection. Early identification of infectious process enables appropriate therapy to be started promptly. Limits fatigue, yet encourages sufficient movement to prevent stasis complications—pneumonia, decubitus ulcers, or throm bus formation. Adhere to Reduces risk of contamination and limits portal of entry for in aseptic techniques. Note: the nadir is usually seen 7 to 10 days after administration of chemotherapy. Provide antibiotics within May be used to treat identified infection or given prophylacti 1 hour, as ordered for neutropenic sepsis (Davis, 2013. Identifies prophylactic treatment needs before initiation of chemotherapy or radiation and provides baseline data of current oral hygiene for future comparison. Encourage client to assess oral cavity daily, noting changes in Stomatitis generally occurs 7 to 14 days after treatment be mucous membrane integrity. Note reports of burning in the gins, but signs may be seen as early as day 3 or 4, espe mouth, changes in voice quality, ability to swallow, sense of cially if there are any preexisting oral problems. Discuss with client areas needing improvement and demonstrate Good care is critical during treatment to control stomatitis methods for good oral care. Initiate and recommend oral hygiene program to include the following: Avoidance of commercial mouthwashes and lemon or Products containing alcohol or phenol may exacerbate mucous glycerin swabs membrane dryness or irritation. Use of mouthwash made from warm water with salt and May be soothing to the membranes. Rinsing before meals may baking soda; dilute solution of hydrogen peroxide may improve the clients sense of taste. Rinsing after meals and be used for bleeding or infected tissue at bedtime dilutes oral acids and relieves xerostomia. Brushing with soft toothbrush or foam swab Prevents trauma to delicate, fragile tissues. Flossing gently or use WaterPik cautiously Removes food particles that can promote bacterial growth. Note: Water under pressure has the potential to injure gums and force bacteria under gum line. Keeping lips moist with lip gloss or balm, K-Y Jelly, Promotes comfort and prevents drying and cracking of tissues.

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