By M. Keldron. Maryland Institute, College of Art. 2019.
Some commercially available medicines may contain excipients that may cause adverse effects or be inappropriate to use in some children generic avana 50mg amex. Liquid preparations may contain excipients such as alcohol purchase 50mg avana with visa, sorbitol cheap avana 100mg otc, propylene glycol or E-numbers buy 50mg avana overnight delivery; sugar-free medicines should be dispensed whenever possible. Parenteral products may contain benzyl alcohol or propylene glycol which can also cause adverse effects such as metabolic acidosis. In addition, there will be occasions when it will be difficult to give the dose required, because of the lack of an appropriate formulation – for example, to give 33mg when only a 100mg tablet is available. In these instances, it is advisable to contact the pharmacy department to see if a liquid preparation is available or can be prepared. If not, the doctor should be informed so that the dose can be modified, another drug can be prescribed, or another route can be used. Another problem is frequency of dosing; dosing during the day will mean doses may have to be given at school which may not always be easy or possible. Medicines may have to be changed to those that can be given once or twice daily outside school hours. Royal College of Paediatrics and Child Health and Neonatal and Paediatric Pharmacists Group. These values should only be used if a specific dose cannot be found, since they assumes the child is ‘average’. A difference of one place to the left or right could mean a 10-fold change in the dose, which could be fatal in some cases. But even so, care must be taken with the number of noughts; a wrong dose can be fatal. Drug Handling and Drug Response • Drug handling (pharmacokinetics) and drug response (pharmacodynamics) may change. General Principles • A full medication history (including over-the-counter drugs) – this should highlight any previous adverse reaction, potential interactions and any compliance issues. Various compliance aids are available, but it is important to establish that the patient can use them. This group receives 52 per cent of all prescriptions and often take a variety of drugs for several conditions. Of those aged over 75 years, 36 per cent are taking four or more drugs (polypharmacy). As a person grows older, it is almost inevitable that drug treatment will be needed. A part of the ageing process will mean that physiological changes will occur that will affect how the elderly person handles and responds to drugs. Absorption There is a reduction in gastric acid output and delay in gastric emptying with ageing. These changes do not significantly affect the absorption of the majority of drugs. Although the absorption of some drugs such as digoxin may be slower, the overall absorption is similar to that in the young. Metabolism A reduction in liver blood flow and in liver mass occurs as part of the ageing process; as a consequence, hepatic metabolism of some drugs may be altered. For those drugs eliminated primarily by liver metabolism, the capacity of the liver is reduced significantly by up to 60 per cent; resulting in decreased hepatic metabolism, increased plasma concentrations and longer half-lives, e. The nutritional status of a person can also have a marked influence on the rate of drug metabolism. In frail elderly people, drug metabolism can be reduced to a greater extent than in elderly people with normal body weight. Distribution In older people, total body mass, lean body mass and total body water decrease, but total body fat increases. The effect of these changes on drug distribution depends on whether a dug is lipid- or water-soluble. A water- soluble drug is distributed mainly in the body water and lean body tissue. Because the elderly person has relatively less water and lean tissue, more of a water-soluble drug stays in the blood, which leads to increased blood concentration levels. Drug handling in the elderly 161 Since the elderly person has a higher proportion of body fat, more of a fat-soluble drug is distributed in the body fat. This can produce misleadingly low blood levels and may cause dosage to be incorrectly increased. The fatty tissue slowly releases stored drug into the bloodstream, and this explains why a fat-soluble sedative may produce a hangover effect. A decrease in albumin results in a reduction in the plasma protein binding of some drugs (e. More non-bound drug is available to act at receptor sites and may result in toxicity. Renal excretion The most important and predictable pharmacokinetic change seen in the elderly is a reduction in renal drug clearance. Renal excretion is reduced because glomerular filtration rate, tubular secretion and renal blood flow are all reduced. Accumulation (due to increased blood levels) can occur if doses are not adjusted to account for the reduction in excretion by the kidneys. This decline in renal function can lead to an increase in adverse drug reactions, as glomerular filtration rate can decrease to around 50mL/min by the age of 80. Drugs or those with active metabolites that are mainly excreted in the urine will need to be given at lower doses, particularly those with a narrow therapeutic index (e. Tetracyclines are best avoided in the elderly because they can accumulate, causing nausea and vomiting, resulting in dehydration and further deterioration in renal function. Disease states such as diabetes and heart failure can worsen renal function, as can an acute illness such as a chest infection that leads to dehydration. Pharmacodynamics The elderly appear to exhibit altered responses to drugs; in general, they have an increased sensitivity to drugs. When receptor changes are investigated in the elderly, beta-adrenergic receptors show a reduction in function and sensitivity, so agonist drugs such as salbutamol will have a reduced effect; propranolol (an antagonist) will also have a reduced effect. Orthostatic blood pressure control (control of blood pressure at rest and movement) is already impaired in the elderly, so they are more likely to suffer drug- induced hypotension, which can lead to dizziness and falls. The thermoregulatory mechanisms may become impaired, which may lead to some degree of hypothermia, particularly drug-induced. This includes drugs that produce sedation, impaired subjective awareness of temperature, decreased mobility and muscular activity, and vasodilation. Commonly implicated drugs include phenothiazines, benzodiazepines, tricyclic antidepressants, opioids and alcohol, either on its own or with other drugs. Anticholinergic drugs, opiates, tricyclic antidepressants and antihistamines are more likely to cause constipation in the elderly. Urological problems Anticholinergic drugs may cause urinary retention in elderly men, especially those who have prostatic hypertrophy. Bladder instability is common in the elderly and urethral dysfunction more prevalent in elderly women. Psychotropic drugs Hypnotics with long half-lives are a significant problem and can cause daytime drowsiness, unsteadiness from impaired balance, and confusion. Short-acting ones may also be problematic and should only be used for short periods if essential. The elderly are more sensitive to benzodiazepines than the young; the mechanism of this increased sensitivity is not known – smaller doses should be used. Tricyclic antidepressants can cause postural hypotension and confusion in the elderly. Warfarin The elderly are more sensitive to warfarin; doses can be about 25 per cent less than in younger people. Digoxin The elderly appear to be more sensitive to the adverse effects of digoxin, but not to the cardiac effects. Factors include potassium loss (which increases cell sensitivity to digoxin) due to diuretics and reduced renal excretion. General principles 163 Diuretics The elderly can easily lose too much fluid and become dehydrated and this can affect treatment of hypotension. Diurectics can also cause extra potassium loss (hypokalaemia) which may increase the effects of digoxin and hence contribute to digoxin toxicity. The elderly can be more prone to gout because of diuretics’ side effect of uric acid retention (hyperuricaemia). Compliance Compliance can be a problem in the elderly as complicated drug regimes may be difficult for them to follow; they may stop taking the drugs or take wrong doses at the wrong time. Dispensing drugs for elderly and confused people can be made easier by using various compliance aids. These are devices in which medication is dispensed for patients who experience difficulty in taking their medicines, particularly those who have difficulty in co-ordinating their medication regime or have large number of medicines to take. They have compartments for each day of the week and each compartment is divided into four sections, i. They do not provide benefit to all types of patients and are not useful for patients who have visual impairment, dexterity problems or severe cognitive impairment. Adverse reactions An adverse reaction to a drug is likely to be two or three times more common in the elderly than in other patients. There are several reasons for this: • Elderly patients often need several drugs at the same time and there is a close relationship between the number of drugs taken and the incidence of adverse reactions. In addition, people who are confused, depressed or have poor memories may have difficulty in taking medicines. The following general principles may be helpful: 164 The elderly and medicines • A full medication history (including over-the-counter drugs) – this should highlight any previous adverse reaction, potential interactions and any compliance issues.
The group has low confdence in the estimate of effect and considers that further research is Low very likely to have an important impact on their confdence and is likely to change the estimate discount avana 200 mg with mastercard. Recommendations were formulated after considering the quality of the evidence cheap 50 mg avana free shipping, the balance of benefts and harm and the feasibility of the intervention based on the four core principles listed in the executive summary generic 50 mg avana overnight delivery. Although cost is a critical factor in setting national antimalarial treatment policies generic avana 200 mg overnight delivery, cost was not formally considered. The dose recommendations were designed to ensure equivalent exposure of all patient groups to the drug. A revised dose regimen was recommended when there was suffcient evidence that the dose should be changed in order to achieve the target exposure. The Guideline Development Group discussed both the proposed wording of the recommendations and the rating of its strength. Areas of disagreement were resolved through extensive discussions at the meetings, e-mail and teleconferencing. The fnal draft was circulated to the Guideline Development Group and external peer reviewers. The external comments were addressed where possible and incorporated into the revised guidelines. Consensus was reached on all the recommendations, strength of evidence and the wording of the guidelines. Factor considered Rationale The more the expected benefts outweigh the expected risks, the more likely it is that Balance of benefts a strong recommendation will be made. If the recommendation is likely to be Values and preferences widely accepted or highly valued, a strong recommendation is more likely. If an intervention is achievable in the settings Feasibility in which the greatest impact is expected, a strong recommendation is more likely. These recommendations were made when the panel considered there to be such limited evidence available on alternatives to current practice that they could do little but recommend the status quo pending further research. These statements are made to re-emphasize the basic principles of good care, or good management practice with implementation, such as quality assurance of antimalarial medicines. Substantial The majority debate should Be prepared to of people in be conducted help individuals your situation at national in making a would want the Conditional level, with the decision that is recommended involvement consistent with course of action, of various their own values. No external source of funding either from bilateral technical partners or from industry was solicited or used. No case necessitated the exclusion of any of the Guideline Development Group member or an external peer reviewer. The members of the guideline development group and a summary of declaration of interest listed in Annex 1. There will also be dissemination through regional, sub-regional and country meetings. Member States will be supported to adapt and implement these guidelines (further details on national adaptation and implementation provided in Chapter 14). A mechanism will be established for periodic monitoring and evaluation of use of the treatment guidelines in countries. The frst symptoms of malaria are nonspecifc and similar to those of a minor systemic viral illness. They comprise headache, lassitude, fatigue, abdominal discomfort and muscle and joint aches, usually followed by fever, chills, perspiration, anorexia, vomiting and worsening malaise. In young children, malaria may also present with lethargy, poor feeding and cough. At this early stage of disease progression, with no evidence of vital organ dysfunction, a rapid, full recovery is expected, provided prompt, effective antimalarial treatment is given. If ineffective or poor-quality medicines are given or if treatment is delayed, particularly in P. Disease progression to severe malaria may take days but can occur within a few hours. Severe malaria usually manifests with one or more of the following: coma (cerebral malaria), metabolic acidosis, severe anaemia, hypoglycaemia, acute renal failure or acute pulmonary oedema. The pattern of acquired immunity is similar across the sub-Sahel region, where malaria transmission is intense only during the 3- or 4-month rainy season and relatively low at other times. In both these situations, clinical disease is confned mainly to 4 High transmission area: hyperendemic or holoendemic area in which the prevalence rate of P. In these areas, virtually all exposed individuals have been infected by late infancy or early childhood. Malaria infection and disease may occur at a similarly low frequency at any age, as little immunity develops. In contrast, in these settings adolescents and adults are partially immune and seldom suffer clinical disease, although they often continue to have low blood-parasite densities. Immunity is modifed in pregnancy, and it is gradually lost, at least partially, when individuals move out of the endemic areas for long periods (usually many years). In areas of unstable malaria transmission, which prevail in much of Asia and Latin America and the remaining parts of the world where malaria is endemic, the intensity of malaria transmission fuctuates widely by season and year and over relatively small distances. The entomological inoculation rate is usually < 5/year and often < 1/year, although there are usually small foci of higher transmission in areas in which asymptomatic parasitaemia is common. The generally low transmission retards acquisition of immunity, so that people of all ages—adults and children alike—suffer from acute clinical malaria, with a signifcant risk for progression to severe malaria if it is untreated. Epidemics may occur in areas of unstable malaria transmission when the inoculation rate increases rapidly because of a sudden increase in vectorial capacity. Epidemics manifest as a very high incidence of malaria in all age groups and can overwhelm health services. In epidemics, severe malaria is common if prompt, effective treatment is not widely available. Non-immune travellers to a malaria endemic area are at particularly high risk for severe malaria if their infections are not detected promptly and treated effectively. This will be followed in time by a corresponding change in the clinical epidemiology of malaria in the area and an increasing risk for an epidemic if control measures are not sustained (see Annex 2). Good practice statement Prompt, accurate diagnosis of malaria is part of effective disease management. Correct diagnosis in malaria-endemic areas is particularly important for the most vulnerable population groups, such as young children and non-immune populations, in whom falciparum malaria can be rapidly fatal. High specifcity will reduce unnecessary treatment with antimalarial drugs and improve the diagnosis of other febrile illnesses in all settings. Malaria is suspected clinically primarily on the basis of fever or a history of fever. There is no combination of signs or symptoms that reliably distinguishes malaria from other causes of fever; diagnosis based only on clinical features has very low specifcity and results in overtreatment. Other possible causes of fever and whether alternative or additional treatment is required must always be carefully considered. The focus of malaria diagnosis should be to identify patients who truly have malaria, to guide rational use of antimalarial medicines. In malaria-endemic areas, malaria should be suspected in any patient presenting with a history of fever or temperature ≥ 37. In areas in which malaria transmission is stable (or during the high-transmission period of seasonal malaria), malaria should also be suspected in children with palmar pallor or a haemoglobin concentration of < 8 g/dL. High-transmission settings include many parts of sub-Saharan Africa and some parts of Oceania. In settings where the incidence of malaria is very low, parasitological diagnosis of all cases of fever may result in considerable expenditure to detect only a few patients with malaria. In these settings, health workers should be trained to identify patients who may have been exposed to malaria (e. The results of parasitological diagnosis should be available within a short time (< 2 h) of the patient presenting. In settings where parasitological diagnosis is not possible, a decision to provide antimalarial treatment must be based on the probability that the illness is malaria. The latter detect parasite-specifc antigens or enzymes that are either genus or species specifc. Antimalarial treatment should be limited to cases with positive tests, and patients with negative results should be reassessed for other common causes of fever and treated appropriately. In nearly all cases of symptomatic malaria, examination of thick and thin blood flms by a competent microscopist will reveal malaria parasites. This is particularly likely if the patient received a recent dose of an artemisinin derivative. At present, molecular diagnostic tools based on nucleic-acid amplifcation techniques (e. Strong recommendation, high-quality evidence Revised dose recommendation for dihydroartemisinin + piperaquine in young children Children weighing <25kg treated with dihydroartemisinin + piperaquine should receive a minimum of 2. The public health objectives of treatment are to prevent onward transmission of the infection to others and to prevent the emergence and spread of resistance to antimalarial drugs. Other considerations The guideline development group decided to recommend a menu of approved combinations, from which countries can select frst- and second-line treatment. Dihydroartemisinin-piperaquine for treating uncomplicated Plasmodium falciparum malaria. The artemisinin component rapidly clears parasites from the blood (reducing parasite numbers by a factor of approximately 10 000 in each 48-h asexual cycle) and is also active against the sexual stages of parasite that mediate onward transmission to mosquitos. The longer-acting partner drug clears the remaining parasites and provides protection against development of resistance to the artemisinin derivative. Partner drugs with longer elimination half-lives also provide a period of post-treatment prophylaxis. Other considerations The guideline development group considered that 3 days of artemisinin derivative are necessary to provide suffcient effcacy, promote good adherence and minimize the risk of drug resistance resulting from incomplete treatment. Shorter courses (1–2 days) are therefore not recommended, as they are less effective, have less effect on gametocytes and provide less protection for the slowly eliminated partner drug. It is essential to achieve effective antimalarial drug concentrations for a suffcient time (exposure) in all target populations in order to ensure high cure rates.
For example cheap avana 100 mg with visa, you may request a patient with newly diagnosed hypertension to come back in two weeks so that you can monitor blood pressure and any side effects of the treatment 100mg avana amex. As you get to know the patient better you could extend the monitoring interval avana 100 mg without a prescription, say order avana 50 mg overnight delivery, to one month. Three months should be about the maximum monitoring interval for drug treatment of a chronic disease. Summary How to select a P-drug i Define the diagnosis (pathophysiology) ii Specify the therapeutic objective iii Make an inventory of effective groups iv Choose a group according to criteria efficacy safety suitability cost Group 1 Group 2 Group 3 v Choose a P-drug efficacy safety suitability cost Drug 1 Drug 2 Drug 3 Conclusion: Active substance, dosage form: Standard dosage schedule: Standard duration: 36 Chapter 5 P-drug versus P-treatment C hapter 5 P-drug and P-treatment Not all health problems need treatment with drugs. As explained in Chapter l, the treatment can consist of advice and information, non-drug therapy, drug treatments, referral for treatment, or combinations of these. Making an inventory of effective treatment alternatives is especially important in order not to forget that non-drug treatment is often possible and desirable. As with selecting your P-drugs, the criteria of efficacy, safety, suitability and cost should be used when comparing treatment alternatives. Exercise Make a list of possible effective and safe treatments for the following common patient problems: constipation, acute diarrhoea with mild dehydration in a child, and a superficial open wound. Constipation Constipation is usually defined as a failure to pass stools for at least a week. Because of tolerance, laxatives are only effective for a short period and may then lead to abuse and eventually even to electrolyte disturbances. The first treatment plan, your P-treatment, should therefore be advice; not drugs! Acute watery diarrhoea with mild dehydration in a child 37 Guide to Good Prescribing In acute diarrhoea with mild dehydration in a child, the main objective of the treatment is to prevent further dehydration and to rehydrate; the goal is not to cure the infection! The inventory of possible effective treatments is therefore: Advice and information: Continue breast feeding and other regular feeding; careful observation. Non-drug treatment: Additional fluids (rice water, fruit juice, homemade sugar/salt solution). Metronidazole and antibiotics, such as cotrimoxazole or ampicillin, are not listed in the inventory because these are not effective in treating watery diarrhoea. Antibiotics are only indicated for persistent bloody and/or slimy diarrhoea, which is much less common than watery diarrhoea; metronidazole is mainly used for proven amoebiasis. Antidiarrhoeal drugs, such as loperamide and diphenoxylate, are not indicated, especially for children, as they mask the continuing loss of body fluids into the intestines and may give the false impression that ‘something is being done’. Superficial open wound The therapeutic objective in the treatment of an open wound is to promote healing and to prevent infection. The inventory of possible treatments is: Advice and information: Regularly inspect the wound; return in case of wound infection or fever. The wound should be cleaned and dressed, and tetanus prophylaxis should probably be given. All patients with an open wound should be warned about possible signs of infection, and to return immediately if these occur. Local antibiotics are never indicated in wound infections because of their low penetration and the risk of sensibilization. Systemic antibiotics are rarely indicated for prophylactic purposes, except in some defined cases such as intestinal surgery. They will not prevent infection, as permeability into the 38 Chapter 5 P-drug versus P-treatment wound tissue is low, but they can have serious side effects (allergy, diarrhoea) and may cause resistance. Your P-treatment for a superficial open wound is therefore to clean and dress the wound, give antitetanus prophylaxis, and advice on regular wound inspection. Advice, fluids and rehydration are essential in the treatment of acute watery diarrhoea, rather than antidiarrhoeals or antibiotics. Practical examples illustrate how to select, prescribe and monitor the treatment, and how to communicate effectively with your patients. When you have gone through this material you are ready to put into practice what you have learned. It is obvious that making the right diagnosis is a crucial step in starting the correct treatment. Making the right diagnosis is based on integrating many pieces of information: the complaint as described by the patient; a detailed history; physical examination; laboratory tests; X-rays and other investigations. In the next sections on (drug) treatment we shall therefore assume that the diagnosis has been made correctly. Complains of a sore throat but is also very tired and has enlarged lymph nodes in her neck. She is a little shy and has never consulted you before for such a minor complaint. Very sore throat, caused by a severe bacterial infection, despite penicillin prescribed last week. Her problem is completely different from the previous case, as the sore throat is a symptom of underlying disease. Patient 5 (sore throat) You noticed that she was rather shy and remembered that she had never consulted you before for such a minor complaint. You ask her gently what the real trouble is, and after some hesitation she tells you that she is 3 months overdue. Patient 6 (sore throat) In this case, information from the patient’s medical record is essential for a correct understanding of the problem. His sore throat is probably caused by the loperamide he takes for his chronic diarrhoea. Patient 7 (sore throat) A careful history of patient 7, whose bacterial infection persists despite the penicillin, reveals that she stopped taking the drugs after three days because she felt much better. These examples illustrate that one complaint may be related to many different problems: a need for reassurance; a sign of underlying disease; a hidden request for assistance in solving another problem; a side effect of drug treatment; and non-adherence to treatment. He may suffer from a heart condition, from asthma and from his stomach, but he definitely has one other problem: polypharmacy! Think of all the possible side effects and interactions between so many different drugs: hypokalemia by furosemide leading to digoxin intoxication is only one example. Careful analysis and monitoring will reveal whether the patient really needs all these drugs. Isosorbide dinitrate should be changed to sublingual glyceryl trinitrate tablets, only to be used when needed. You can probably stop the furosemide (which is rarely indicated for maintenance treatment), or change it to a milder diuretic such as hydrochloro-thiazide. Salbutamol tablets could be changed to an inhaler, to reduce the side effects associated with continuous use. Cimetidine may have been prescribed for suspected stomach ulcer, whereas the stomach ache was probably caused by the prednisolone, for which the dose can probably be reduced anyway. So you first have to diagnose whether he has an ulcer or not, and if not, stop the cimetidine. And finally, the large quantity of amoxicillin has probably been prescribed as a prevention against respiratory tract infections. However, most micro-organisms in his body will now be resistant to it and it should be stopped. If his respiratory problems become acute, a short course of antibiotics should be sufficient. Box 5: Patient demand A patient may demand a treatment, or even a specific drug, and this can give you a hard time. Some patients are difficult to convince that a disease is self-limiting or may not be willing to put up with even minor physical discomfort. In some cases it may be difficult to stop the treatment because psychological or physical dependence on the drugs has been created. Patient demand for specific drugs occurs most frequently with pain killers, sleeping pills and other psychotropic drugs, antibiotics, nasal decongestants, cough and cold preparations, and eye/ear medicines. The personal characteristics and attitudes of your patients play a very important role. So a prescription is written because the physician thinks that the patient thinks. It may also fulfill the need that something be done, and 46 Chapter 7 Step 2: Specify the therapeutic objective symbolize the care of the physician. It is important to realize that the demand for a drug is much more than a demand for a chemical substance. There are no absolute rules about how to deal with patient demand, with the exception of one: ensure that there is a real dialogue with the patient and give a careful explanation. Never forget that patients are partners in therapy; always take their point of view seriously and discuss the rationale of your treatment choice. Valid arguments are usually convincing, provided they are described in understandable terms. All may be related to different problems: a need for reassurance; a sign of underlying disease; a hidden request for assistance in solving another problem; a side effect of drug treatment; non-adherence to treatment; or (psychological) dependence on drugs. Your definition (your working diagnosis) may differ from how the patient perceives the problem. Exercise: patients 9-12 For each of these patients try to define the therapeutic objective. Sleeplessness during six months, and comes for a refill of diazepam tablets, 5 mg, 1 tablet before sleeping. Consulted you 3 weeks ago, complaining of constant tiredness after delivery of her second child. She has now returned because the tiredness persists and a friend told her that a vitamin injection would do her good. Patient 9 (diarrhoea) In this patient the diarrhoea is probably caused by a viral infection, as it is watery (not slimy or bloody) and there is no fever. She has signs of dehydration (listlessness, little urine and decreased skin turgor).
Diagnosis Pain typically occurs once or twice daily and last for 30 to 90 minutes Attacks tend to occur at about the same time every day The pain typically is excruciating and located around or behind one eye generic 50 mg avana with mastercard. The affected eye may become red avana 50 mg overnight delivery, inflamed generic 50 mg avana visa, and watery Note: Cluster headaches are much more common in men than women discount avana 100 mg with visa. Stopping smoking and minimizing alcohol may prevent future episodes of cluster headache. Early diagnosis and treatment is essential if damage is to be limited Examples of Secondary headache: Head and neck trauma Blood vessel problems in the head and neck 1. Temporal arteritis (inflammation of the temporal artery) Non-blood vessel problems of the brain 6 | P a g e 1. Idiopathic intracranial hypertension, once named pseudo tumor cerebri, Medications and drugs (including withdrawal from those drugs) Infection 1. Systemic infections Diagnosis If there is time, the diagnosis of secondary headache begins with a complete patient history followed by a physical examination and laboratory and radiology tests as appropriate However, some patients present in crisis with a decreased level of consciousness or unstable vital signs. In these situations, the health care practitioner may decide to treat a specific cause without waiting for tests to confirm the diagnosis 3. Infections are the most common cause of fevers, however as the temperature rises other causes become more general. Note: Hyperpyrexia is considered a medical emergency as it may indicate a serious underlying conditions. Where causative/precipitating factors cannot be detected, the following treatments may be offered: For Non-productive irritating cough A: Cough syrup/Linctus (O) 5-10 ml every 6 hours Expectorants may be used to liquefy viscid secretions. A: Cough expectorants (O) 5-10 ml every 6 hours Note: Antibiotics should never be used routinely in the treatment of cough 5. Some investigations must be ordered: Serum glucose level Serum electrolyte Pregnancy test for women of child bearing age. Therefore, the following are primarily assessed in children: Prolonged capillary filling (more than 3 seconds) Decreased pulse volume (weak thread pulse) Increased heart rate (>160/minute in infants, > 120 in children) Decreased level of consciousness (poor eye contact) Rapid breathing Decreased blood pressure and decreased urine output are late signs and while they can be monitored the above signs are more sensitive in detecting shock before irreversible. Table 2: Types of Shock Type of Shock Explanation Additional symptoms Hypovolemic Most common type of shock Weak thread pulse, cold Primary cause is loss of fluid from circulation due and clammy skin. Cardiogenic Caused by the failure of heart to pump Distended neck veins, shock effectively e. Septic shock Caused by an overwhelming infection, leading to Elevated body vasodilatation. Anaphylactic Caused by severe allergic reaction to an allergen, Bronchospasm, shock or drug. Intravenous fluid therapy is important in the treatment of all types of shock except for cardiogenic shock. Ringer-lactate, within 48 hours of administering ceftriaxone Contra-indicated in neonatal jaundice Annotate dose and route of administration on referral letter. There are three types of dehydration: hypotonic or hyponatremic (primarily a loss of electrolytes, sodium in particular), hypertonic or hypernatremic (primarily a loss of water), and isotonic or isonatremic (equal loss of water and electrolytes). In humans, the most commonly seen type of dehydration by far is isotonic (isonatraemic) dehydration which effectively equates with Hypovolemic, but the distinction of isotonic from hypotonic or hypertonic dehydration may be important when treating people who become dehydrated. Physiologically, dehydration, despite the name, does not simply mean loss of water, as water and solutes (mainly sodium) are usually lost in roughly equal quantities to how they exist in blood plasma. In hypotonic dehydration, intravascular water shifts to the extra vascular space, exaggerating intravascular volume depletion for a given amount of total body water loss. The former can lead to seizures, while the latter can lead to osmotic cerebral edema upon rapid rehydration. It defines water deficiency only in terms of volume rather than specifically water. Signs and symptoms Symptoms may include headaches similar to what is experienced during a hangover, a sudden episode of visual snow, and dizziness or fainting when standing up due to orthostatic hypotension. Untreated dehydration generally results in delirium, unconsciousness, swelling of the tongue and, in extreme cases, death. In the presence of normal renal function dehydration is associated usually with a urine output of less than 0. Differential diagnosis 12 | P a g e In humans, dehydration can be caused by a wide range of diseases and states that impair water homeostasis in the body. These include: External or stress-related causes o Prolonged physical activity with sweating without consuming adequate water, especially in a hot and/or dry environment o Prolonged exposure to dry air, e. Treatment For some dehydration oral fluid is the most effective to replenish fluid deficit. For severe cases of dehydration where fainting, unconsciousness, or other severely inhibiting symptom is present (the patient is incapable of standing or thinking clearly), emergency attention is required. Fluids containing a proper balance of replacement electrolytes are given intravenously with continuing assessment of electrolyte status. Reversal or improvement of symptoms or problems when the glucose is restored to normal Symptoms of hypoglycemia usually do not occur until the blood sugar is in the level of 2. The precise level of glucose considered low enough to define hypoglycemia is dependent on (1) the measurement method, (2) the age of the person, (3) presence or absence of effects, and (4) the purpose of the definition. Signs and symptoms Hypoglycemic symptoms and manifestations can be divided into those produced by the counter regulatory hormones (epinephrine/adrenaline and glucagon) triggered by the falling glucose, and the neuroglycopenic effects produced by the reduced brain sugar. Adrenergic manifestations Shakiness, anxiety, nervousness Palpitations, tachycardia Sweating, feeling of warmth (although sweat glands have muscarinic receptors, thus "adrenergic manifestations" is not entirely accurate) Pallor, coldness, clamminess Dilated pupils (mydriasis) 14 | P a g e Feeling of numbness "pins and needles" (paresthesia) Glucagon manifestations Hunger, borborygmus Nausea, vomiting, abdominal discomfort Headache Neuroglycopenic manifestations Abnormal mentation, impaired judgment Personality change, emotional liability Fatigue, weakness, apathy, lethargy, daydreaming, sleep Confusion, amnesia, dizziness, delirium Stupor, coma, abnormal breathing Generalized or focal seizures Causes The circumstances of hypoglycemia provide most of the clues to diagnosis. Circumstances include the age of the patient, time of day, time since last meal, previous episodes, nutritional status, physical and mental development, drugs or toxins (especially insulin or other diabetes drugs), diseases of other organ systems, family history, and response to treatment. When hypoglycemia occurs repeatedly, a record or "diary" of the spells over several months, noting the circumstances of each spell (time of day, relation to last meal, nature of last meal, response to carbohydrate, and so forth) may be useful in recognizing the nature and cause of the hypoglycemia. Glucose requirements above 10 mg/kg/minute in infants, or 6 mg/kg/minute in children and adults are strong evidence for hyperinsulinism. Finally, the blood glucose response to glucagon given when the glucose is low can also help distinguish among various types of hypoglycemia. For patients who have recurrent hypoglycemia’s the following tests might be needed depending on the history and physical examination: insulin, cortisol, and electrolytes, with C-peptide and drug screen for adults and growth hormone in children. Treatment Management of hypoglycemia involves immediately raising the blood sugar to normal, determining the cause, and taking measures to hopefully prevent future episodes. The blood glucose can be raised to normal within minutes by taking 10-20 grams of carbohydrate. This amount of carbohydrate is contained in about 100-120 ml of orange juice or non-diet soda. Starch is quickly digested to glucose (unless the person is taking acarbose), but adding fat or protein retards digestion. Symptoms should begin to improve within 5 minutes, though full 15 | P a g e recovery may take 10–20 minutes. Overfeeding does not speed recovery and if the person has diabetes will simply produce hyperglycemia afterwards. One situation where starch may be less effective than glucose or sucrose is when a person is taking acarbose. Since acarbose and other alpha-glucosidase inhibitors prevents starch and other sugars from being broken down into monosaccharide’s that can be absorbed by the body, patients taking these medications should consume monosaccharide-containing foods such as glucose powder, honey, or juice to reverse hypoglycemia. The lesions affecting the maxillofacial region (perioral, jaws and face) are also considered here but for a more detail a relevant text book or manual need to be referred. The clinician should be able tqo identify conditions requiring immediate attention by the dentist, do the preliminary urgent and life saving measures where possible before referring the patient to a centre with a dentist/dental surgeon. There are some cases which will need the attention of a specialist dental surgeon (like oral and maxillofacial surgeon, orthodontist e. Diagnostic criteria: Inflammation of the gingival which is initially seen as discrete colour and texture changes of the marginal tissues. Prevention Instructions for proper oral hygiene care Treatment Removal of accumulated plaque and oral hygiene instructions on tooth brushing and other adjuvant means of oral hygiene (dental flossing, use of mouth washes) 1. The damage of the periodontal membrane, periodontal ligaments and eventually alveolar bone leads to formation of pockets which eventually favours more bacterial growth. Note: Tetracycline should not be given to pregnant and lactating mothers to avoid tetracycline stains in for their babies. Patients usually present with soreness and bleeding of the gums and foul test (fetor-ex ore). Contact stomatitis (a counterpart of contact dermatitis) also can occur due to allergy. Choline salycilate, Benzalkonium chloride and Lignocaine hydrochloride) Note: Mouth washes should not be used at the same time with the gel. Start slowly with white spots later developing to black/brown spot and cavities in enamel, dentine and eventually the pulp. Dental caries is caused by bacteria of the dental plaque which feed on sugary food substrates producing acid as by-products which dissolve the minerals of the tooth surface. Note: The Susceptible sites are those areas where plaque accumulation can occur and be hidden to escape active and passive cleansing mechanisms e. Prevention Proper instruction to avoid frequent use of sugary foods and drinks Use fluoridated toothpaste to brush teeth at least once a day Non-pharmacological measures Early lesions presenting as a spot on enamel without cavitation and softening, observe and adhering to preventive measures. The condition may be acute and diffuse or chronic with fistula or localized and circumscribed. Adult: Paracetamol (O) 500mg – 1g, 4-6 hourly for 3 days, Child: Paracetamol (O) 10-15 mg/kg 4-6 hourly For anterior teeth (incisors, canine and premolars: Extraction is carried out only when root canal treatment is not possible. Give antibiotics: Adult A: Amoxicillin (O) 500mg, 8 hourly for 5-7 days; Children, Amoxicillin (O) 25 mg/kg in 3 divided doses for 5 days. Plus A: Metronidazole (O); Adult 400mg 8 hourly for 5-7 days 21 | P a g e Children 7-10 years, 100mg every 8 hour Note: Periodontal abscess is located in the coronal aspect of the supporting bone associated with a periodontal pocket. Diagnostic criteria Severe painful socket 2-4 days after tooth extraction Fever Necrotic blood clot in the socket Swollen gingiva around the socket Sometimes there may be lymphodenopathy and trismus (Inability to open the mouth) Treatment Under local anesthesia with Lignocaine 2% socket debridement and irrigation with nd rd Hydrogen peroxide 3%.