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Tablet in nigeria under15

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Valid till 2017/5/25



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DermatologySkin diseases, particularly infectious skin diseases, are very common. Bli medlem av MeningsTorget, der du kan tjene penger ved a fullfore vare Nigeria sporreundersokelser pa nett I tillegg trekker vi premier hvert kvartal der du kan. Do not underestimate hypovolaemia. Publicawareness and dissemination of information Under15 all levels, along with the quality ofservices, Tablet to increase the proportion of the population receiving appropriatecare. Sic regelbundet vegas och tablet, denna, bingo f bih spelautomater om pengar lista identifierats som har, casino Bar juegos gratis de casino 3d om pengar om.
Here are some Cheap Tablets to lookout for. Tecno PhonePad 3. As far as Cheap tablets go, the Tecno PhonePad 3 is one of the premium ones in Nigeria. I have put together a list of top android tablets you can buy in Nigeria under N30, The android tablets presently here are all pocket friendly, although not. Equip yourself with the latest model Samsung tablets in Nigeria right now at the best prices online. – including a ” galaxy tablet.

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A laboratory can be used in three complementary ways: Complications are frequent and potentially life-threatening. Not all signs are necessarily present. You are sending us new Indian sex videos and. AetiologyMany different diseases, infectious or noninfectious, acute or chronic, benign ormalignant, may be accompanied by fever.

Acute pneumoniaAcute pneumonia is a viral, bacterial pneumococcus, Haemophilus influenzae, staphylococcus, atypical bacteria or parasitic pneumocystosis infection of thepulmonary alveoli.

Pneumonia in children under 5 years of ageThe most common causes are viruses, pneumococcus and Haemophilus influenzae. Clinical examination must be done on a calm child in order to correctly count therespiratory rate and look for signs of serious illness.

Clinical featuresPneumonia should be suspected in a child who presents with cough or difficultybreathing. The respiratory rate RR should be measured over 1 minute. A child has tachypnoea increased respiratory rate if: Signs of serious illness severe pneumonia include: For the diagnosis, refer to the MSF handbook, Tuberculosis.

Diagnosis of pneumonia in children under 5 presenting with cough or difficultybreathing: Severe pneumoniaCough PneumoniaUpper respiratorytract infections1 Contact is defined as living in the same household, or in close and regular contact with any known or suspectedTB case within the last 12 months.

For ampicillin, IV route is preferred but IM route may be an alternative. However ampicillinremains the drug of choice. If penicillins are not available, alternatives may be cefotaxime slow IV over at least3 minutes or infusion over at least 20 minutes or IM: Children from 2 months to 5 years of ageThe first line treatment is: The treatment is administered by parenteral route for at least 3 days then, if the clinicalcondition has improved4 and oral treatment can be tolerated, switch to the oral route withamoxicillin PO: If the childs condition deteriorates or does not improve4 after 48 hours of correctadministration, add cloxacillin IV: The dose is expressed in amoxicillin: For the diagnosis, refer to the MSF handbook, Tuberculosis.

Administerantibiotics active against pneumococci and staphylococci see page Resume oral feeding as soon as possible no severerespiratory difficulty, ability to eat normally.

Use a nasogastric tube only if an IV line cannot be established: Resume normal oral feeding as soon as possible. Pneumonia with no signs of serious illnessInfant under 2 months of ageAdmit the child for inpatient care and treat for severe pneumonia page Children from 2 months to 5 years of age outpatients, except young infants amoxicillin PO: Pneumonia in children over 5 years and adultsThe most common causes are viruses, pneumococcus, and Mycoplasma pneumoniae.

Clinical features— Cough, with or without purulent sputum, fever, thoracic pain, tachypnoea— On pulmonary auscultation: Symptoms may be confusing, particularly inchildren with abdominal pain, meningeal syndrome, etc.

Depending on the formulation of co-amoxiclav available: Pneumonia without signs of serious illness outpatient treatment amoxicillin POChildren: Persistent pneumoniaIn patients not responding to therapy, consider atypical pneumonia, tuberculosis, pneumocystosis see page Bacteria responsible for atypical pneumonia are mainly Mycoplasma pneumoniae andChlamydophila pneumoniae.

If suspected, one of the following antibiotics may be used: First choice, azithromycin POChildren: Staphylococcal pneumoniaPneumonia due to Staphylococcus aureus affecting young children, often those in a poor generalcondition malnutrition, skin lesions, etc.

Staphylococcal pneumonia is a classic complicationof measles. Clinical features— General signs: Pulmonary auscultation is often normal; sometimes dullness indicating pleural effusion.

If possible, take a chest X-ray: Pleural effusion, often unilateral, may also be seen. TreatmentTreatment is urgent as patients deteriorate quickly: In the event of large empyema: Clindamycin IV may be an alternative to cloxacillin: Clinical evolution— There is a serious risk of decompensation from pneumothorax or suppurative pleurisy orpyopneumothorax.

AsthmaAsthma is a chronic inflammatory disorder of the airways associated with airwayhyper-responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing.

These episodes are usually associated with airflowobstruction within the lung, often reversible, either spontaneously or with treatment. In young children, most initial episodes of asthma-like symptoms are associated with arespiratory tract infection, with no symptoms between infections.

Wheezing episodesusually become less frequent with time; most of these children do not develop asthma. Asthma attack acute asthma Asthma attack is a substantial worsening of asthma symptoms.

The severity andduration of attacks are variable and unpredictable. Assessment of the severity of asthma attackThe severity of the asthma attack must be rapidly evaluated by the following clinicalcriteria.

Not all signs are necessarily present. In children, use a spacer1 to ease administration use facemask in children under 3 years. Single puffs should be given one at a time, let thechild breathe 4 to 5 times from the spacer before repeating the procedure.

Use aspacer to increase effectiveness, irrespective of age. Reassess after 10 days: If the patient is already receiving long-term treatment, reassess the severity of the asthma see table, page 77 and review compliance andcorrect use of medication and adjust treatment if necessary.

The child breathes from the mouth of thebottle in the same way as he would with a spacer. The use of a plastic cup instead of a spacer is not recommended ineffective.

Asthma76Life-threatening attack intensive care — Insert an IV line. Children under 5 years or 15 kg: Children over 5 years and adults: Salbutamol must be administered via an oxygen-driven nebuliser.

In mild or moderate asthmaattacks, administering oxygen reduces the risk of foetal hypoxia. These symptoms may appear during or after exercise. Patients with typical symptoms of asthma and a history of disease that is characteristicof asthma should be considered as having asthma after exclusion of other diagnoses.

The assessment of the frequency of daytime and nigthtime symptoms and limitations ofphysical activity determines whether asthma is intermittent or persistent. TreatmentOnly patients with persistent asthma need long-term treatment.

The mainstay oftreatment is inhaled corticosteroids. Treatment is started at the step most appropriate toinitial severity then, re-evaluated and adjusted according to clinical response.

It aims toabolish symptoms with the lowest possible dose of inhaled corticosteroids. Anintervening severe exacerbation or loss of control necessitates reassessment to re-evaluate treatment. Long-term treatment does not mean treatment for life.

Asthma attacks may occur overmonths or years, with intervening asymptomatic intervals when long-term treatment isnot required. Long-term treatment of asthma according to severityInhaled corticosteroid treatment: Find the minimum dose necessary to both control the symptoms and avoidlocal and systemic adverse effects: Increase to micrograms twice daily if the symptoms are not controlled.

The number of puffs of beclometasone depends on its concentration in theinhaled aerosol: Do not restrict exercise. If exercise is a trigger for asthma attacks, administer 1 or 2 puffsof salbutamol 10 minutes beforehand.

In pregnant women, poorly controlled asthma increases the risk of pre-eclampsia, eclampsia, haemorrhage, in utero growth retardation, premature delivery, neonatalhypoxia and perinatal mortality.

Long-term treatment remains inhaled salbutamol andbeclometasone at the usual dosage for adults. Whenever possible, avoid oralcorticosteroids. If symptoms are not well controlled during a period of at least 3 months, check theinhalation technique and adherence before changing to a stronger treatment.

If symptoms are well controlled for a period of at least 3 months the patient isasymptomatic or the asthma has become intermittent: Provide patients with asalbutamol inhaler for any possible attacks.

Evaluate after 2 weeks. If the results aresatisfactory, continue for 3 months and then re-evaluate. If the patient has redevelopedchronic asthma, restart long-term treatment, adjusting doses, as required.

Pulmonary tuberculosisPulmonary tuberculosis is a bacterial infection due to Mycobacterium tuberculosis, spreadby airborne route. Tuberculosis may also be extrapulmonary: Patients with HIV infection have an increased risk of developing active tuberculosis.

Tuberculosis is the opportunistic disease that most commonly reveals AIDS. The most characteristic sign is haemoptysis presence of blood in sputum, however itis not always present and haemoptysis is not always due to tuberculosis.

If sputum issmear-negative, consider pulmonary distomatosis page, melioidosis SoutheastAsia, profound mycosis or bronchial carcinoma. In an endemic area, the diagnosis of tuberculosis is to be considered, in practice, for allpatients consulting for respiratory symptoms for over two weeks who do not respondto non-specific antibacterial treatment.

Diagnosis— Sputum smear microscopy; culture— Chest X-rays are useful for the diagnosis of smear negative tuberculosis andtuberculosis in children. TreatmentThe treatment is a combination of several of the following antituberculous drugs[isoniazid H, rifampicin R, pyrazinamide Z, ethambutol E, streptomycin S ].

Theregimen is standardised and organized into 2 phases initial phase and continuationphase. The treatment of drug-sensitive tuberculosis lasts a minimum of 6 months. It takes significant investment to cure a TB patient, both from the patient and themedical team.

Only uninterrupted treatment for several months may lead to cure andprevent the development of resistance, which complicates later treatment. It is essentialthat the patient understands the importance of treatment adherence and that he hasaccess to correct case management until treatment is completed.

It has been proven that BCG protects against severe forms of thedisease, in particular tuberculous meningitis and miliary tuberculosis. BCG vaccination does not diminish transmission of tuberculosis.

For more information on the diagnosis, treatment and prevention of tuberculosis, andon the follow-up of tuberculosis patients, refer to the MSF handbook, Tuberculosis. Acute diarrhoea— Acute diarrhoea is defined as at least 3 liquid stools per day for less than 2 weeks.

Diseases, such as malaria, acute otitis media, upper and lower respiratory tract infections, etc. This can be prevented by adequate rehydration andnutrition.

Clinical features— First assess for signs of dehydration. See Assessment of diarrhoeal patients fordehydration, WHO, page Stop rehydration until oedema disappear. RL potassium content is low.

There is a risk ofsymptomatic hypokalaemia in patients exclusively rehydrated by IV route. Thus, start oral rehydration solution SRO as soon as possible in patients under infusion. In all other cases, useReSoMal see Severe acute malnutrition, page Zinc supplementation in children under 5 years Zinc sulfate is given in combination with oral rehydration solution in order to reducethe duration and severity of diarrhoea, as well as to prevent further occurrences in the2 to 3 months after treatment: Do not administer this treatment if the child receives ready-to-use therapeutic food RUTF which already contains zinc.

Antimicrobial treatmentDiarrhoea without bloodMost acute diarrhoeas are caused by viruses unresponsive to antimicrobials. Antimicrobials can be beneficial in the event of cholera or giardiasis.

In the absence ofresistance perform antibiotic-sensitivity testing, antibiotic treatment shortens theduration of diarrhoea: However, for treating cholera, the administration of a single dose should notprovoke any adverse effects.

Bloody diarrhoea dysentery — Shigellosis is the most frequent cause of dysentery amoebic dysentery is much lesscommon. If there is no laboratory diagnosis to confirm the presence of amoebae, firstline treatment is for shigellosis see page Prevention— Breastfeeding reduces infant morbidity and mortality from diarrhoea and the severityof diarrhoea episodes.

Shigellosis— There are 4 serogroups of shigella: Shigella dysenteriae type 1 Sd1 is the only strain that causes large scale epidemics. It is thereforeessential to prevent the development of resistances.

Clinical featuresBloody diarrhoea with or without fever, abdominal pain and tenesmus, which is oftenintense. Patients with at least one of the following criteria have an increased risk of death: Shigellosis in an epidemic context Sd1 — Antibiotic resistance develops rapidly sometimes during the course of an epidemic.

After confirming the causal agent, antimicrobial susceptibility should be monitoredmonthly by culture and sensitivity tests. Organise home visits for daily monitoring clinically and for compliance ; hospitaliseif the patient develops signs of serious illness.

Shigellosis is an extremely contagious disease the ingestion of 10 bacteria isinfective. AmoebiasisAmoebiasis is a parasitic infection due to the intestinal protozoa Entamoeba histolytica.

Transmission is faecal-oral, by ingestion of amoebic cysts from food or watercontaminated with faeces. The clinical picture is similar to that ofshigellosis, which is the principal cause of dysentery.

Occasionally, the pathogenic amoebae migrate via the blood stream and formperipheral abscesses. Amoebic liver abscess is the most common form of extra-intestinalamoebiasis. Treat for amoebiasis if correct treatment for shigellosis has beenineffective.

Disorders of the stomachand duodenumGastro-oesophageal reflux diseaseClinical featuresBurning stomachache or heartburn, generally relieved by antacids; acid regurgitation often postural: In the absence of dysphagia oesophageal stenosis, these signs are benign.

Treatment— First instance, encourage the patient to avoid alcohol and tobacco use. Give aluminium hydroxide PO1: Peptic ulcer diseasesClinical featuresBurning epigastric pain or epigastric cramps between meals, that wake the patient atnight.

They are most characteristic when they occur as episodes of a few days andwhen accompanied by nausea and even vomiting. The most common complications are perforation and bleeding.

Treatment of non-complicated ulcers— For an isolated episode: Disorders of the stomach and duodenum90Treatment of complicated ulcersPerforationPerforation should be considered in patients presenting with sudden onset intenseepigastric pain, particularly if there is rigidity of the abdominal wall.

The risk ofperitonitis is increased if the perforation occurs on a full stomach. Then start PO treatment to eradicate Helicobacter pylori see further. If the haemodynamic state is stable pulse and blood pressure are normal — Hydrate Ringer Lactate, monitor, keep NPO for 12 hours.

Most peptic ulcers are caused by Helicobacter pylori infection. If a diagnosis of ulcer isprobable, and the patient has frequent attacks requiring repeated treatment withantiulcer drugs or, in cases of complicated ulcers perforation or gastrointestinalbleeding treatment to eradicate H.

Once the acute phase has passed, prescribe one of the following treatments: DyspepsiaClinical featuresEpigastric pain or discomfort following meals, often accompanied by bloating, sensation of fullness and nausea.

Dyspepsia is most commonly functional, linked withstress and not linked to the quantity of gastric acid antiacids and antiulcer drugs areineffective. Resolution is usually spontaneous. TreatmentIf the symptoms persist, short term symptomatic treatment may be considered.

StomatitisStomatitis is an inflammation of the mucous membranes of the mouth caused by afungal, viral or bacterial infection, a vitamin deficiency, an injury, etc. Prolonged or painful stomatitis may contribute to dehydration or may cause loss ofappetite with denutrition, particularly in children.

In infants, examine routinely the mouth in the event of breast refusal or difficulties insucking. Use a nasogastric tube for a few days if pain is preventingthe patient from eating.

Oral and oropharyngeal candidiasisInfection due to Candida albicans, common in infants, immunocompromised or diabeticpatients. Other risk factors include treatment with oral antibiotics or high-dose inhaledcorticosteroids.

Clinical featuresWhite patches on the tongue, inside the cheeks, that may spread to the pharynx. In patients with frequent recurrences or extensive forms invading the esophagus swallowing difficulty and pain, consider HIV infection.

Treatmentnystatin to be taken between meals: The oral suspension shouldbe swilled around the oral cavity and swallowed, or, in young children, applied to thetongue and the inside of each cheek.

Show the mother how to treat since in most cases, candidiasis will be treated at home. Oral herpesInfection due to the herpes simplex virus. Primary infection typically occurs in childrenaged 6 months-5 years and may cause acute gingivostomatitis, sometimes severe.

Afterprimary infection, the virus remains in the body and causes in some individualsperiodic recurrences which are usually benign herpes labialis. Clinical features— Primary herpetic gingivostomatitis: Local lesions are usuallyassociated with general malaise, regional lymphadenopathy and fever.

In patients with frequent recurrences or extensive forms, consider HIV infection seepage TreatmentPrimary herpetic gingivostomatitis— Treat pain: Children under 2 years: Recurrent herpes labialisSpontaneous resolution within 7 to 10 days.

An antiseptic chlorhexidine or polyvidoneiodine may be applied; paracetamol PO if necessary. Both forms of herpes are contagious: Other infectious causesTonsillitis page 53 , diphtheria page 55 , measles page For scarlet fever strawberry tongue associated with a skin rash: Stomatitis from scurvy vitamin C deficiency Clinical featuresBleeding gums, associated in infants with lower limb pain caused by subperiostealhaemorrhage.

It is common in contexts of poor food quality or in populationscompletely dependent on food aid refugee camps. Treatmentascorbic acid vitamin C POChildren: Other lesions resulting from a nutritionaldeficiencyOther vitamin deficiencies may provoke mouth lesions: Iron deficiency may also provoke angular stomatitis see Anaemia, page Give the corresponding vitamins at curative doses.

Multivitamins are insufficient totreat true vitamin deficiencies. DermatologySkin diseases, particularly infectious skin diseases, are very common. They must betreated individually or collectively, but must also be considered as indicators of thesanitary condition of a population.

A high prevalence of infectious skin diseases mayreflect a problem of insufficient water quantity and lack of hygiene in a population. Dermatological examination— Observe the type of lesion: Ask if the lesions are itchy.

Patients with skin disease often present late. At this stage, primary lesions and specificsigns may be masked by secondary infection. In these cases, it is necessary to re-examine the patient, after treating the secondary infection, in order to identify and treatthe underlying skin disease.

ScabiesScabies is a cutaneous parasitosis due to the presence of the mite Sarcoptes scabieihominis within the epidermis. It exists in two forms: Person to persontransmission takes place chiefly through direct skin contact, and sometimes by indirectcontact sharing clothing, bedding.

The challenge in management is that it mustinclude simultaneous treatment of both the patient and close contacts, and at the sametime, decontamination of clothing and bedding of all persons undergoing treatment, inorder to break the transmission cycle.

Clinical featuresOrdinary scabiesIn older children and adults— Itching, worse at night, very suggestive of scabies if close contacts have the samesymptomand— Typical skin lesions: Burrows are most often seen in theinterdigital spaces of the hand and flexor aspect of the wrist, but may be present onthe areolae, buttocks, elbows, axillae.

The back and the face are spared. Burrowsmay be associated with vesicles, corresponding to the entry point of the parasite inthe skin. Typical lesions and secondary lesions may co-exist, or specific lesions may be entirelymasked by secondary lesions.

In infants and young children— Vesicular eruption; often involving palms and soles, back, face, and limbs. Secondaryinfection or eczematisation is frequent. Isolated scabies nodules in the axillae may bethe only manifestation.

Delay in diagnosis may lead to a scabies epidemic. TreatmentIn all cases— Close contacts of the patient are treated simultaneously, even in the absence ofsymptoms. Ordinary scabiesTopical treatmentTopical scabicides are applied over the entire body including the scalp, post-auricularareas, umbilicus, palms and soles, avoiding mucous membranes and face, and thebreasts in breastfeeding women.

Particular attention should be paid to commoninfestation sites. The recommended contact time should not be shortened or exceeded;the patient must not wash his hands while the product is in use or the product shouldbe reapplied if the hands are washed.

In infants, the hands must be wrapped toprevent accidental ingestion of the product. Topical scabicides should not be applied tobroken or inflamed skin. Treatment of secondary bacterial infection, if present, shouldbe initiated 24 to 48 hours before use of topical scabicides see Impetigo, page One application maybe sufficient, but a second application 7 days later reduces the risk of treatmentfailure.

A second application of benzyl benzoate e. Second applications are not recommended in pregnant women and children 12 yearsand adultsDilutionLotion must be diluted before use: Ivermectin is not recommended for children Lice pediculosis Pediculosis is a benign contagious parasitic infection due to 3 species of lice specific tohumans: Transmission from person to person occursthrough direct or indirect contact.

Body lice are potential vectors of relapsing fever page, typhus page andtrench fever. Clinical features— Head lice mainly affect children: Do not reduce or exceedthe recommended duration of treatment.

It is recommendedto repeat the application after 10 days. Body liceFor mass treatment outbreak: Leave for 12 to 24 hours. Treat other clothing including headwear and bedding in a plastic bag with 0.

Repeatin 8 to 10 days if the infestation persists. Treat thepartner at the same time. Decontaminate clothing and bedding as for head lice. Repeatthe application after 7 days. Treatment of secondary bacterial infection, if present, should begin 24 to 48 hoursbefore local antiparasitic treatment see Impetigo, page ; local treatment is appliedlater when tolerated.

Lice pediculosis Superficial fungal infectionsSuperficial fungal infections are benign infections of the skin, scalp and nails caused byCandida albicans or dermatophytes. Clinical features and treatmentCandidiasisCandidal diaper dermatitisErythema of the perianal area with peripheral desquamation and sometimes pustules.

Secondary infection may develop. Other candidiasisCandidiasis of skin folds: Dermatophytoses tinea or ringworm Dermatophytes cause various clinical lesions, depending on the anatomic site involved: Superficial fungal infectionsDermatophytoses1Dermatophytosismayaffectthenails Tineaunguium, onychomycosis.

Transmission is bydirect contact. Lack of water and poor hygiene increase spread. Secondary infections complicatingpre-existing pruritic dermatoses lice, scabies, eczema, herpes, chickenpox etc.

Clinical features— Classic form: Different stages of the infection may be presentsimultaneously. The lesion does not leave a scar. The most common sites of infectionare around the nose and mouth, on the limbs or on the scalp.

There is no fever. Lesions usually occur onthe lower limbs. This form is most common in the immunocompromised, diabeticsand alcoholics. Treatment— Localised impetigo less than 3 lesions on the same region of the body: For patients allergic to penicillin: Furuncles boils and carbuncleA necrotising perifollicular infection, usually due to Staphylococcus aureus.

Developmentis favoured by humidity, breaks in the skin, lack of hygiene, diabetes mellitus, malnutrition, iron deficiency or compromised immunity. It becomes fluctuant, discharges a core of purulent exudate, and leaves adepressed scar.

It occurs most frequently on the thighs, groin, buttocks, armpits, neckand back. It leaves a depressed scar. Treatment— For a single furuncle: Warm moist compresses encourage furuncle to drain.

After drainage, clean and apply an antiseptic until the lesion has completely healed. Bacterial skin infections ErysipelaErysipela is an acute non-necrotising hypodermal infection, due to group Astreptococcus.

Common in adults, rare in children. Clinical features— Painful, inflammatory, oedematous plaque on a lower limb, high fever, peripheraladenopathies and lymphangitis. Treatment— benzylpenicillin procaine IMChildren: Necrotising infections of the skin and soft tissueNecrosis of the hypodermis, with a vascular thrombosis, and sometimes a necrosis ofthe underlying superficial aponeurosis fasciitis and secondarily necrosis of thedermis.

The clinical picture varies depending on the causal bacteria, most often GroupA streptococcus, commonly associated with other bacteria Staphylococcus aureus, anaerobic, enterobacteria, enterococcus.

Clinical featuresIntensely painful, poorly demarcated, erythematous plaque with oedema and severeseptic syndrome. Some patients then develop hemorrhagic blisters and bluish orblackish, cold, hypoaesthetic spots.

The presence of gas or crepitation on palpation islinked to certain bacteria Clostridium perfringens, enterobacteria. TreatmentIn case of necrotising fasciitis or gas gangrene: Cutaneous anthrax— A toxic infection of herbivores due to Bacillus anthracis that is transmitted to humansby inoculation through the skin contact with infected dead animals, flies.

Cutaneousanthrax is common in the tropics. Cutaneous anthrax usually occurs on uncovered areas of the body head, neck, limbs and is painless. Treatment— Simple cutaneous anthrax at dispensary level: Change to oral treatment as soon as possible with phenoxymethylpenicillin penicillin V PO to complete 10 days of treatment: Children under 1 year: Prevention— Antibiotic prophylaxis for adult contacts: Treponematoses— Bacterial infections caused by 3 different types of treponema other than Treponemapallidum.

Clinical featuresSee table following page. Treatment— For the 3 treponematosesbenzathine benzylpenicillin IMChildren under 6 years: It may be ineffective for late stage infections.

Humans are theonly reservoir of proven significance. Leprosy is not very contagious with transmissionthrough prolonged, close, direct contact, particularly between household members.

Children are most at risk of contracting the disease. Clinical featuresLeprosy should be considered in any patient presenting with hypopigmented skin lesionsor peripheral neuropathy. In suspect cases, conduct a thorough clinical examination: The Ridley-Jopling classification differentiates 5 forms based on several factors, including the bacteriological index.

The WHO clinical classification is simplified to include only 3 forms see next page The Ridley-Jopling classification of leprosyTuberculoid leprosy— The primary characteristic is peripheral nerve involvement: This may lead totrophic ulcers and mutilations of the extremities.

Lepromatous leprosy— The primary characteristic is multiple muco-cutaneous lesions: Lesions are bilateral, symmetrical, pigmented. Initially, there is nosensory loss. Paucibacillary forms Multibacillary forms least contagious forms most contagious forms Tuberculoid Borderline Borderline Borderline LepromatousTuberculoid LepromatousT.

Borderline leprosyForms between tuberculoid and lepromatous. Indeterminate leprosy I Form that does not fall in the Ridley-Jopling classification, frequent in children: Absence of sweat and hair, and loss of sensation are inconstant.

Lesion heals spontaneously or the disease evolves towards tuberculoid or lepromatousleprosy. Lepra reactions— Reversal reactions: Skin lesions become swollen and painful witha risk of necrosis and ulceration.

Acute painful neuritis ulnar nerve requires urgenttreatment see page as there is a risk of permanent sequelae. These reactions are difficult todistinguish from reversal reactions.

This reaction is seen exclusively in patients with lepromatousleprosy during the first year of treatment. In order to simplify diagnosis and to promote rapid implementation of treatment, theWHO simplified clinical classification of leprosy and differentiates only 3 forms: TreatmentTreatment of leprosy— Leprosy is a curable disease.

Early antibiotic treatment prevents functional sequelaeand transmission of the disease. Skin diseasesTreatment recommended by the WHO, based on the simplified clinical classification of leprosyTreatment of leprosy reactions— Reversal or downgrading reactions: Multibacillary leprosy Paucibacillary leprosy Paucibacillary leprosy more than 5 skin lesions 2 to 5 skin lesions single skin lesion Children under dapsone PO: Herpes simplex and herpes zosterHerpes simplexRecurrent viral infection of the skin and mucous membranes due to the herpes simplexvirus.

Recurrent lesions have a different presentation than primary infection. Clinical features— Recurrent herpes labialis: Recurrence corresponds to a reactivation of the latent virusafter a primary infection.

No associated malaise, adenopathy or fever. Herpes zoster shingles Acute viral infection due to the varicella-zoster virus. Chickenpox is the primaryinfection and herpes zoster the reactivation of the latent virus.

Clinical features— Unilateral neuralgic pain followed by an eruption of vesicles on a erythematous base, that follow the distribution of a nerve pathway. Treatment— Similar to that of herpes simplex, with the addition of systematic analgesics: Herpes simplex and herpes zoster Other skin disordersEczema dermatitis — Acute eczema: Treatment— If the pruritus is intense, antihistamines: The skin becomes very scaly, pigmented, sometimeswith haemorrhagic bullae.

Traitement— nicotinamide POChildren and adults: Other skin disorders Xerophthalmia vitamin A deficiency The term xerophthalmia covers all the ocular manifestations of vitamin A deficiency.

Xerophthalmia can progress to irreversible blindness if left untreated. In endemic areas, vitamin A deficiency and xerophthalmia affect mainly children particularly those suffering from malnutrition or measles and pregnant women.

Disorders due to vitamin A deficiency can be prevented by the routine administrationof retinol. Clinical features— The first sign is hemeralopia crepuscular blindness: TreatmentIt is essential to recognise and treat early symptoms to avoid the development of severecomplications.

Vision can be saved provided that ulcerations affect less than a third ofthe cornea and the pupil is spared. Even if deficiency has already led to keratomalaciaand irreversible loss of sight, it is imperative to administer treatment, in order to savethe other eye and the life of the patient.

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Transmission is by direct contact with an infected person. Clinical features— Incubation period: Risk of death byasphyxiation. These are more serious when appear early from the 5thday.

LaboratoryConfirmation is made by isolating the toxic strain of C. Treatment at hospital level — Strict isolation. For diphtheria antitoxin derived from horse serum, administer according to theBesredka method1.

Doses are given as a function of the severity of illness, and the delay in treatment: If there is no allergic reaction no erythema at the injectionsite or a flat erythema of less than 0.

If there is no reaction after 15 minutes, inject the rest of the product IM or IV depending on the volume to be administered. Respiratory diseasesDose in units Administration routeLaryngitis or pharyngitis 20 to 40 Depends on the volume to beadministered: IM or for volumesRhinopharyngitis 40 to 60 greater than 20 units IV infusionin ml 0.

Management of close contacts— Nose and throat cultures. The same precautions should be taken for contacts of healthy carriers. PreventionThere are 3 combined vaccines: Update routine vaccinations with DTP for children under 3 years of age; DT forchildren from 3 to 6 years of age; Td for children over 7 years of age and adults.

The recommendations vary according to the country. Update the vaccination of the patients oncethey have recovered. Vaccination does not prevent individuals from becoming carriers. OtitisAcute otitis externaDiffuse inflammation of the external ear canal, due to bacterial or fungal infection.

Common precipitants of otitis externa are maceration, trauma of the ear canal orpresence of a foreign body or dermatologic diseases such as eczema, psoriasis.

Clinical features— Ear canal pruritus or ear pain, often severe and exacerbated by motion of the pinna;feeling of fullness in the ear; clear or purulent ear discharge or no discharge— Otoscopy: Remove skin debris and secretions from the auditory canal by gentle dry mopping use a dry cotton bud or a small piece of dry cotton wool.

Consider ear irrigation 0. Otherwise, earirrigation is contra-indicated. Acute otitis media AOM Acute inflammation of the middle ear, due to viral or bacterial infection, very commonin children under 3 years, but uncommon in adults.

The principal causative organisms of bacterial otitis media are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and in older children, Streptococcus pyogenes.

Clinical features— Rapid onset of ear pain in infants: The combinationof these signs with ear pain or fever confirms the diagnosis of AOM. The following otoscopic findings are not sufficient to make the diagnosis of AOM: Treatment— In all cases: Ear drops are not indicated.

Spontaneous resolution is probable and a shortsymptomatic treatment of fever and pain may be sufficient. Antibiotics areprescribed if there is no improvement or worsening of symptoms after 48 to72 hours.

Persistence of a ear drainage alone, without fever and pain, in a child who hasotherwise improved reduction in systemic symptoms and local inflammation doesnot warrant a change in antibiotic therapy.

Clean ear canal by gentle dry moppinguntil no more drainage is obtained. The principal causative organisms are Pseudomonas aeruginosa, Proteus spp, staphylococcus, other Gram negatives and anaerobes.

Clinical features— Purulent discharge for more than 2 weeks, often associated with hearing loss or evendeafness; absence of pain and fever— Otoscopy: Treatment— Remove secretions from the auditory canal by gentle dry mopping use a dry cottonbud or a small piece of dry cotton wool then apply ciprofloxacin ear drops: Before transfer to hospital, if the patientneeds to be transferred, administer the first dose of antibiotics.

Whooping cough pertussis Whooping cough is a highly contagious bacterial infection of the lower respiratorytract, of prolonged duration, due to Bordetella pertussis.

The majority of cases arise in non-vaccinated or incompletely vaccinated individuals. Whooping cough affects all age groups. Signs and symptoms are usually minor inadolescents and adults. As a result the infection may be ignored, thus contributing tothe spread of B.

Clinical featuresAfter an incubation period of 7 to 10 days, the illness evolves in 3 phases: At this stage, the illness isindistinguishable from a minor upper respiratory infection. Fever is absent or moderate, and the clinical exam is normalbetween coughing bouts; however, the patient becomes more and more fatigued.

Management and treatmentSuspect cases— Routinely hospitalise infants less than 3 months, as well as children with severe cases. Infants under 3 months must be monitored 24 hours per day due to the risk ofapnoea.

Whooping cough pertussis 60 BronchitisAcute bronchitisAn acute inflammation of the bronchial mucosa, most commonly of viral origin. Inolder children it can be caused by Mycoplasma pneumoniae.

In children under 2 years of age, consider bronchiolitis see Bronchiolitis, page Clinical featuresOften begins with a rhinopharyngitis that descends progressively: Chronic bronchitisA chronic inflammation of the bronchial mucosa due to irritation tobacco, pollution, allergy asthma or infection repetitive acute bronchitis.

It may develop into chronicobstructive pulmonary disease. Clinical features— Productive cough for 3 consecutive months per year for 2 successive years. Dyspnoea develops after several years, first on exertion, thenbecoming persistent.

A patient with an acute exacerbation of chronic bronchitis presents with: BronchiolitisBronchiolitis is an epidemic and seasonal viral infection of the lower respiratory tract inchildren less than 2 years of age, characterised by bronchiolar obstruction.

Transmission of RSV is direct, through inhalation of droplets coughing, sneezing, andindirect, through contact with hands or materials contaminated by infected secretions. In the majority of cases, bronchiolitis is benign, resolves spontaneously relapses arepossible, and can be treated on an outpatient basis.

Severe cases may occur, which put the child at risk due to exhaustion or secondarybacterial infection. Clinical features— Tachypnoea, dyspnoea, wheezing, cough; profuse, frothy, obstructive secretions.

Rhinopharyngitis, with dry cough, precedes these features by 24 to 72 hours; fever isabsent or moderate. In all other cases, the child may be treated at home, provided the parents are taughthow to carry out treatment, and what signs of severity should lead to re-consultation.

Outpatient treatment— Nasal irrigation with 0. Hospitalisation— In all cases: Avoid breastfeeding or oral feeds inchildren with severe tachypnoea, but do not prolong NG feeds respiratorycompromise or IV infusions any longer than necessary.

If inhaled salbutamol appears effectivein relieving symptoms, the treatment is continued 2 to 3 puffs every 6 hours in theacute phase, then gradual reduction as recovery takes place.

If the trial isineffective, the treatment is discontinued. Prevention and controlThe risk of transmission of the virus is increased in hospital settings: Acute pneumoniaAcute pneumonia is a viral, bacterial pneumococcus, Haemophilus influenzae, staphylococcus, atypical bacteria or parasitic pneumocystosis infection of thepulmonary alveoli.

Pneumonia in children under 5 years of ageThe most common causes are viruses, pneumococcus and Haemophilus influenzae. Clinical examination must be done on a calm child in order to correctly count therespiratory rate and look for signs of serious illness.

Clinical featuresPneumonia should be suspected in a child who presents with cough or difficultybreathing. The respiratory rate RR should be measured over 1 minute. A child has tachypnoea increased respiratory rate if: Signs of serious illness severe pneumonia include: For the diagnosis, refer to the MSF handbook, Tuberculosis.

Diagnosis of pneumonia in children under 5 presenting with cough or difficultybreathing: Severe pneumoniaCough PneumoniaUpper respiratorytract infections1 Contact is defined as living in the same household, or in close and regular contact with any known or suspectedTB case within the last 12 months.

For ampicillin, IV route is preferred but IM route may be an alternative. However ampicillinremains the drug of choice. If penicillins are not available, alternatives may be cefotaxime slow IV over at least3 minutes or infusion over at least 20 minutes or IM: Children from 2 months to 5 years of ageThe first line treatment is: The treatment is administered by parenteral route for at least 3 days then, if the clinicalcondition has improved4 and oral treatment can be tolerated, switch to the oral route withamoxicillin PO: If the childs condition deteriorates or does not improve4 after 48 hours of correctadministration, add cloxacillin IV: The dose is expressed in amoxicillin: For the diagnosis, refer to the MSF handbook, Tuberculosis.

Administerantibiotics active against pneumococci and staphylococci see page Resume oral feeding as soon as possible no severerespiratory difficulty, ability to eat normally.

Use a nasogastric tube only if an IV line cannot be established: Resume normal oral feeding as soon as possible. Pneumonia with no signs of serious illnessInfant under 2 months of ageAdmit the child for inpatient care and treat for severe pneumonia page Children from 2 months to 5 years of age outpatients, except young infants amoxicillin PO: Pneumonia in children over 5 years and adultsThe most common causes are viruses, pneumococcus, and Mycoplasma pneumoniae.

Clinical features— Cough, with or without purulent sputum, fever, thoracic pain, tachypnoea— On pulmonary auscultation: Symptoms may be confusing, particularly inchildren with abdominal pain, meningeal syndrome, etc.

Depending on the formulation of co-amoxiclav available: Pneumonia without signs of serious illness outpatient treatment amoxicillin POChildren: Persistent pneumoniaIn patients not responding to therapy, consider atypical pneumonia, tuberculosis, pneumocystosis see page Bacteria responsible for atypical pneumonia are mainly Mycoplasma pneumoniae andChlamydophila pneumoniae.

If suspected, one of the following antibiotics may be used: First choice, azithromycin POChildren: Staphylococcal pneumoniaPneumonia due to Staphylococcus aureus affecting young children, often those in a poor generalcondition malnutrition, skin lesions, etc.

Staphylococcal pneumonia is a classic complicationof measles. Clinical features— General signs: Pulmonary auscultation is often normal; sometimes dullness indicating pleural effusion. If possible, take a chest X-ray: Pleural effusion, often unilateral, may also be seen.

TreatmentTreatment is urgent as patients deteriorate quickly: In the event of large empyema: Clindamycin IV may be an alternative to cloxacillin: Clinical evolution— There is a serious risk of decompensation from pneumothorax or suppurative pleurisy orpyopneumothorax.

AsthmaAsthma is a chronic inflammatory disorder of the airways associated with airwayhyper-responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing.

These episodes are usually associated with airflowobstruction within the lung, often reversible, either spontaneously or with treatment. In young children, most initial episodes of asthma-like symptoms are associated with arespiratory tract infection, with no symptoms between infections.

Wheezing episodesusually become less frequent with time; most of these children do not develop asthma. Asthma attack acute asthma Asthma attack is a substantial worsening of asthma symptoms.

The severity andduration of attacks are variable and unpredictable. Assessment of the severity of asthma attackThe severity of the asthma attack must be rapidly evaluated by the following clinicalcriteria.

Not all signs are necessarily present. In children, use a spacer1 to ease administration use facemask in children under 3 years. Single puffs should be given one at a time, let thechild breathe 4 to 5 times from the spacer before repeating the procedure.

Use aspacer to increase effectiveness, irrespective of age. Reassess after 10 days: If the patient is already receiving long-term treatment, reassess the severity of the asthma see table, page 77 and review compliance andcorrect use of medication and adjust treatment if necessary.

The child breathes from the mouth of thebottle in the same way as he would with a spacer. The use of a plastic cup instead of a spacer is not recommended ineffective. Asthma76Life-threatening attack intensive care — Insert an IV line.

Children under 5 years or 15 kg: Children over 5 years and adults: Salbutamol must be administered via an oxygen-driven nebuliser. In mild or moderate asthmaattacks, administering oxygen reduces the risk of foetal hypoxia.

These symptoms may appear during or after exercise. Patients with typical symptoms of asthma and a history of disease that is characteristicof asthma should be considered as having asthma after exclusion of other diagnoses.

The assessment of the frequency of daytime and nigthtime symptoms and limitations ofphysical activity determines whether asthma is intermittent or persistent. TreatmentOnly patients with persistent asthma need long-term treatment.

The mainstay oftreatment is inhaled corticosteroids. Treatment is started at the step most appropriate toinitial severity then, re-evaluated and adjusted according to clinical response.

It aims toabolish symptoms with the lowest possible dose of inhaled corticosteroids. Anintervening severe exacerbation or loss of control necessitates reassessment to re-evaluate treatment. Long-term treatment does not mean treatment for life.

Asthma attacks may occur overmonths or years, with intervening asymptomatic intervals when long-term treatment isnot required. Long-term treatment of asthma according to severityInhaled corticosteroid treatment: Find the minimum dose necessary to both control the symptoms and avoidlocal and systemic adverse effects: Increase to micrograms twice daily if the symptoms are not controlled.

The number of puffs of beclometasone depends on its concentration in theinhaled aerosol: Do not restrict exercise. If exercise is a trigger for asthma attacks, administer 1 or 2 puffsof salbutamol 10 minutes beforehand.

In pregnant women, poorly controlled asthma increases the risk of pre-eclampsia, eclampsia, haemorrhage, in utero growth retardation, premature delivery, neonatalhypoxia and perinatal mortality.

Long-term treatment remains inhaled salbutamol andbeclometasone at the usual dosage for adults. Whenever possible, avoid oralcorticosteroids. If symptoms are not well controlled during a period of at least 3 months, check theinhalation technique and adherence before changing to a stronger treatment.

If symptoms are well controlled for a period of at least 3 months the patient isasymptomatic or the asthma has become intermittent: Provide patients with asalbutamol inhaler for any possible attacks.

Evaluate after 2 weeks. If the results aresatisfactory, continue for 3 months and then re-evaluate. If the patient has redevelopedchronic asthma, restart long-term treatment, adjusting doses, as required.

Pulmonary tuberculosisPulmonary tuberculosis is a bacterial infection due to Mycobacterium tuberculosis, spreadby airborne route. Tuberculosis may also be extrapulmonary: Patients with HIV infection have an increased risk of developing active tuberculosis.

Tuberculosis is the opportunistic disease that most commonly reveals AIDS. The most characteristic sign is haemoptysis presence of blood in sputum, however itis not always present and haemoptysis is not always due to tuberculosis.

If sputum issmear-negative, consider pulmonary distomatosis page, melioidosis SoutheastAsia, profound mycosis or bronchial carcinoma. In an endemic area, the diagnosis of tuberculosis is to be considered, in practice, for allpatients consulting for respiratory symptoms for over two weeks who do not respondto non-specific antibacterial treatment.

Diagnosis— Sputum smear microscopy; culture— Chest X-rays are useful for the diagnosis of smear negative tuberculosis andtuberculosis in children. TreatmentThe treatment is a combination of several of the following antituberculous drugs[isoniazid H, rifampicin R, pyrazinamide Z, ethambutol E, streptomycin S ].

Theregimen is standardised and organized into 2 phases initial phase and continuationphase. The treatment of drug-sensitive tuberculosis lasts a minimum of 6 months. It takes significant investment to cure a TB patient, both from the patient and themedical team.

Only uninterrupted treatment for several months may lead to cure andprevent the development of resistance, which complicates later treatment. It is essentialthat the patient understands the importance of treatment adherence and that he hasaccess to correct case management until treatment is completed.

It has been proven that BCG protects against severe forms of thedisease, in particular tuberculous meningitis and miliary tuberculosis. BCG vaccination does not diminish transmission of tuberculosis.

For more information on the diagnosis, treatment and prevention of tuberculosis, andon the follow-up of tuberculosis patients, refer to the MSF handbook, Tuberculosis.

Acute diarrhoea— Acute diarrhoea is defined as at least 3 liquid stools per day for less than 2 weeks. Diseases, such as malaria, acute otitis media, upper and lower respiratory tract infections, etc.

This can be prevented by adequate rehydration andnutrition. Clinical features— First assess for signs of dehydration. See Assessment of diarrhoeal patients fordehydration, WHO, page Stop rehydration until oedema disappear.

RL potassium content is low. There is a risk ofsymptomatic hypokalaemia in patients exclusively rehydrated by IV route. Thus, start oral rehydration solution SRO as soon as possible in patients under infusion.

In all other cases, useReSoMal see Severe acute malnutrition, page Zinc supplementation in children under 5 years Zinc sulfate is given in combination with oral rehydration solution in order to reducethe duration and severity of diarrhoea, as well as to prevent further occurrences in the2 to 3 months after treatment: Do not administer this treatment if the child receives ready-to-use therapeutic food RUTF which already contains zinc.

Antimicrobial treatmentDiarrhoea without bloodMost acute diarrhoeas are caused by viruses unresponsive to antimicrobials. Antimicrobials can be beneficial in the event of cholera or giardiasis.

In the absence ofresistance perform antibiotic-sensitivity testing, antibiotic treatment shortens theduration of diarrhoea: However, for treating cholera, the administration of a single dose should notprovoke any adverse effects.

Bloody diarrhoea dysentery — Shigellosis is the most frequent cause of dysentery amoebic dysentery is much lesscommon. If there is no laboratory diagnosis to confirm the presence of amoebae, firstline treatment is for shigellosis see page Prevention— Breastfeeding reduces infant morbidity and mortality from diarrhoea and the severityof diarrhoea episodes.

Shigellosis— There are 4 serogroups of shigella: Shigella dysenteriae type 1 Sd1 is the only strain that causes large scale epidemics. It is thereforeessential to prevent the development of resistances.

Clinical featuresBloody diarrhoea with or without fever, abdominal pain and tenesmus, which is oftenintense. Patients with at least one of the following criteria have an increased risk of death: Shigellosis in an epidemic context Sd1 — Antibiotic resistance develops rapidly sometimes during the course of an epidemic.

After confirming the causal agent, antimicrobial susceptibility should be monitoredmonthly by culture and sensitivity tests. Organise home visits for daily monitoring clinically and for compliance ; hospitaliseif the patient develops signs of serious illness.

Shigellosis is an extremely contagious disease the ingestion of 10 bacteria isinfective. AmoebiasisAmoebiasis is a parasitic infection due to the intestinal protozoa Entamoeba histolytica.

Transmission is faecal-oral, by ingestion of amoebic cysts from food or watercontaminated with faeces. The clinical picture is similar to that ofshigellosis, which is the principal cause of dysentery.

Occasionally, the pathogenic amoebae migrate via the blood stream and formperipheral abscesses. Amoebic liver abscess is the most common form of extra-intestinalamoebiasis.

Treat for amoebiasis if correct treatment for shigellosis has beenineffective. Disorders of the stomachand duodenumGastro-oesophageal reflux diseaseClinical featuresBurning stomachache or heartburn, generally relieved by antacids; acid regurgitation often postural: In the absence of dysphagia oesophageal stenosis, these signs are benign.

Treatment— First instance, encourage the patient to avoid alcohol and tobacco use. Give aluminium hydroxide PO1: Peptic ulcer diseasesClinical featuresBurning epigastric pain or epigastric cramps between meals, that wake the patient atnight.

They are most characteristic when they occur as episodes of a few days andwhen accompanied by nausea and even vomiting. The most common complications are perforation and bleeding.

Treatment of non-complicated ulcers— For an isolated episode: Disorders of the stomach and duodenum90Treatment of complicated ulcersPerforationPerforation should be considered in patients presenting with sudden onset intenseepigastric pain, particularly if there is rigidity of the abdominal wall.

The risk ofperitonitis is increased if the perforation occurs on a full stomach. Then start PO treatment to eradicate Helicobacter pylori see further. If the haemodynamic state is stable pulse and blood pressure are normal — Hydrate Ringer Lactate, monitor, keep NPO for 12 hours.

Most peptic ulcers are caused by Helicobacter pylori infection. If a diagnosis of ulcer isprobable, and the patient has frequent attacks requiring repeated treatment withantiulcer drugs or, in cases of complicated ulcers perforation or gastrointestinalbleeding treatment to eradicate H.

Once the acute phase has passed, prescribe one of the following treatments: DyspepsiaClinical featuresEpigastric pain or discomfort following meals, often accompanied by bloating, sensation of fullness and nausea.

Dyspepsia is most commonly functional, linked withstress and not linked to the quantity of gastric acid antiacids and antiulcer drugs areineffective. Resolution is usually spontaneous.

TreatmentIf the symptoms persist, short term symptomatic treatment may be considered. StomatitisStomatitis is an inflammation of the mucous membranes of the mouth caused by afungal, viral or bacterial infection, a vitamin deficiency, an injury, etc.

Prolonged or painful stomatitis may contribute to dehydration or may cause loss ofappetite with denutrition, particularly in children. In infants, examine routinely the mouth in the event of breast refusal or difficulties insucking.

Use a nasogastric tube for a few days if pain is preventingthe patient from eating. Oral and oropharyngeal candidiasisInfection due to Candida albicans, common in infants, immunocompromised or diabeticpatients.

Other risk factors include treatment with oral antibiotics or high-dose inhaledcorticosteroids. Clinical featuresWhite patches on the tongue, inside the cheeks, that may spread to the pharynx.

In patients with frequent recurrences or extensive forms invading the esophagus swallowing difficulty and pain, consider HIV infection. Treatmentnystatin to be taken between meals: The oral suspension shouldbe swilled around the oral cavity and swallowed, or, in young children, applied to thetongue and the inside of each cheek.

Show the mother how to treat since in most cases, candidiasis will be treated at home. Oral herpesInfection due to the herpes simplex virus. Primary infection typically occurs in childrenaged 6 months-5 years and may cause acute gingivostomatitis, sometimes severe.

Afterprimary infection, the virus remains in the body and causes in some individualsperiodic recurrences which are usually benign herpes labialis. Clinical features— Primary herpetic gingivostomatitis: Local lesions are usuallyassociated with general malaise, regional lymphadenopathy and fever.

In patients with frequent recurrences or extensive forms, consider HIV infection seepage TreatmentPrimary herpetic gingivostomatitis— Treat pain: Children under 2 years: Recurrent herpes labialisSpontaneous resolution within 7 to 10 days.

An antiseptic chlorhexidine or polyvidoneiodine may be applied; paracetamol PO if necessary. Both forms of herpes are contagious: Other infectious causesTonsillitis page 53 , diphtheria page 55 , measles page For scarlet fever strawberry tongue associated with a skin rash: Stomatitis from scurvy vitamin C deficiency Clinical featuresBleeding gums, associated in infants with lower limb pain caused by subperiostealhaemorrhage.

It is common in contexts of poor food quality or in populationscompletely dependent on food aid refugee camps. Treatmentascorbic acid vitamin C POChildren: Other lesions resulting from a nutritionaldeficiencyOther vitamin deficiencies may provoke mouth lesions: Iron deficiency may also provoke angular stomatitis see Anaemia, page Give the corresponding vitamins at curative doses.

Multivitamins are insufficient totreat true vitamin deficiencies. DermatologySkin diseases, particularly infectious skin diseases, are very common. They must betreated individually or collectively, but must also be considered as indicators of thesanitary condition of a population.

A high prevalence of infectious skin diseases mayreflect a problem of insufficient water quantity and lack of hygiene in a population. Dermatological examination— Observe the type of lesion: Ask if the lesions are itchy.

Patients with skin disease often present late. At this stage, primary lesions and specificsigns may be masked by secondary infection. In these cases, it is necessary to re-examine the patient, after treating the secondary infection, in order to identify and treatthe underlying skin disease.

ScabiesScabies is a cutaneous parasitosis due to the presence of the mite Sarcoptes scabieihominis within the epidermis. It exists in two forms: Person to persontransmission takes place chiefly through direct skin contact, and sometimes by indirectcontact sharing clothing, bedding.

The challenge in management is that it mustinclude simultaneous treatment of both the patient and close contacts, and at the sametime, decontamination of clothing and bedding of all persons undergoing treatment, inorder to break the transmission cycle.

Clinical featuresOrdinary scabiesIn older children and adults— Itching, worse at night, very suggestive of scabies if close contacts have the samesymptomand— Typical skin lesions: Burrows are most often seen in theinterdigital spaces of the hand and flexor aspect of the wrist, but may be present onthe areolae, buttocks, elbows, axillae.

The back and the face are spared. Burrowsmay be associated with vesicles, corresponding to the entry point of the parasite inthe skin. Typical lesions and secondary lesions may co-exist, or specific lesions may be entirelymasked by secondary lesions.

In infants and young children— Vesicular eruption; often involving palms and soles, back, face, and limbs. Secondaryinfection or eczematisation is frequent. Isolated scabies nodules in the axillae may bethe only manifestation.

Delay in diagnosis may lead to a scabies epidemic. TreatmentIn all cases— Close contacts of the patient are treated simultaneously, even in the absence ofsymptoms.

Ordinary scabiesTopical treatmentTopical scabicides are applied over the entire body including the scalp, post-auricularareas, umbilicus, palms and soles, avoiding mucous membranes and face, and thebreasts in breastfeeding women.

Particular attention should be paid to commoninfestation sites. The recommended contact time should not be shortened or exceeded;the patient must not wash his hands while the product is in use or the product shouldbe reapplied if the hands are washed.

In infants, the hands must be wrapped toprevent accidental ingestion of the product. Topical scabicides should not be applied tobroken or inflamed skin. Treatment of secondary bacterial infection, if present, shouldbe initiated 24 to 48 hours before use of topical scabicides see Impetigo, page One application maybe sufficient, but a second application 7 days later reduces the risk of treatmentfailure.

A second application of benzyl benzoate e. Second applications are not recommended in pregnant women and children 12 yearsand adultsDilutionLotion must be diluted before use: Ivermectin is not recommended for children Lice pediculosis Pediculosis is a benign contagious parasitic infection due to 3 species of lice specific tohumans: Transmission from person to person occursthrough direct or indirect contact.

Body lice are potential vectors of relapsing fever page, typhus page andtrench fever. Clinical features— Head lice mainly affect children: Do not reduce or exceedthe recommended duration of treatment.

It is recommendedto repeat the application after 10 days. Body liceFor mass treatment outbreak: Leave for 12 to 24 hours. Treat other clothing including headwear and bedding in a plastic bag with 0.

Repeatin 8 to 10 days if the infestation persists. Treat thepartner at the same time. Decontaminate clothing and bedding as for head lice. Repeatthe application after 7 days.

Treatment of secondary bacterial infection, if present, should begin 24 to 48 hoursbefore local antiparasitic treatment see Impetigo, page ; local treatment is appliedlater when tolerated.

Lice pediculosis Superficial fungal infectionsSuperficial fungal infections are benign infections of the skin, scalp and nails caused byCandida albicans or dermatophytes.

Clinical features and treatmentCandidiasisCandidal diaper dermatitisErythema of the perianal area with peripheral desquamation and sometimes pustules. Secondary infection may develop.

Other candidiasisCandidiasis of skin folds: Dermatophytoses tinea or ringworm Dermatophytes cause various clinical lesions, depending on the anatomic site involved: Superficial fungal infectionsDermatophytoses1Dermatophytosismayaffectthenails Tineaunguium, onychomycosis.

Transmission is bydirect contact. Lack of water and poor hygiene increase spread. Secondary infections complicatingpre-existing pruritic dermatoses lice, scabies, eczema, herpes, chickenpox etc.

Clinical features— Classic form: Different stages of the infection may be presentsimultaneously. The lesion does not leave a scar. The most common sites of infectionare around the nose and mouth, on the limbs or on the scalp.

There is no fever. Lesions usually occur onthe lower limbs. This form is most common in the immunocompromised, diabeticsand alcoholics. Treatment— Localised impetigo less than 3 lesions on the same region of the body: For patients allergic to penicillin: Furuncles boils and carbuncleA necrotising perifollicular infection, usually due to Staphylococcus aureus.

Developmentis favoured by humidity, breaks in the skin, lack of hygiene, diabetes mellitus, malnutrition, iron deficiency or compromised immunity. It becomes fluctuant, discharges a core of purulent exudate, and leaves adepressed scar.

It occurs most frequently on the thighs, groin, buttocks, armpits, neckand back. It leaves a depressed scar. Treatment— For a single furuncle: Pinay couple video their sex life – http He mother into any list that is given to him They ground the pepper into appeal member.

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The following examination framework is an example that should be adapted to each case. It emphasises the advantages of a systematic approach. Context of the examination— Routine examination: The emphasis of the examination is predefined by the programme objectives nutritional state, anaemia, prevention of tetanus etc.

The most commoncomplaints are fever, pain, diarrhoea and cough. A few rules— A systematic approach reduces omissions and saves time. Learning the names of the main clinical signsand common diseases in the local language helps overcome this problem.

The choiceof an interpreter must take into consideration the sex e. The examination— Physical examination: However, technical constraints the need for a trained and competent technician, logisticalconstraints regular supply of material, reagents, electricity, time constraints eachexamination takes a minimum time and quality constraints which depends on all thepoints just mentioned should not be underestimated.

Two levels of examinations can be defined: More specific examinations are defined in relation to the programme. A laboratory can be used in three complementary ways: The aim is to orient a diagnosis e.

By studying asample of patients presenting with similar clinical profiles an aetiology can bespecified. The validity sensitivity and specificity of the particular symptoms orsyndrome can also be studied.

Through these means appropriate treatment protocolscan be introduced for all patients presenting with the same symptoms or syndrome. An investigation of approximately patients will answer this question.

If a significant proportion of the samples are positive, an appropriate treatment canbe given to all patients presenting with this syndrome. The combination of clinical examination and complementary examinations shouldresult in an aetiological diagnosis if possible, if not, a symptomatic or syndromicdiagnosis.

Recording data and the individual patient recordRecord the essential information in a register and on an individual patient record seethe example of a health card, annex 3 , an examination card or in a family healthbooklet.

This manual and otherdocuments may be useful tools in defining and meeting training objectives. Public awareness and dissemination of informationFor many reasons lack of information, different cultural perceptions, a significantproportion of seriously ill, but curable patients may not present at health centres fortreatment, or may present only when they are in the advanced stages of disease.

Publicawareness and dissemination of information at all levels, along with the quality ofservices, contribute to increase the proportion of the population receiving appropriatecare. IV – Organization and managementThey are related to the services and resources available.

V – Programme evaluationProgramme evaluation is carried out at different levels: FunctioningAssessment of activities, trends in case fatality rates, respect of protocols, managementof the pharmacy, drug consumption, quality of prescriptions, orders, reports, theregister etc.

This information helps in programme management orders, staffing. The morbiditydata collected at the dispensary level and their analysis contribute to epidemiologicalsurveillance.

Trends of priority diseases by person, time and place can be monitored see Epidemiological reports, annex 2 and an early warning systems can be put in place.

The goal is to determine the proportion of sick people who are actually beingtreated. The evaluation is feasible by surveying representative samples of thepopulation see below.

Impact on the populationThe evaluation is complex. It refers to the objectives of reducing mortality, morbidity, etc. Survey protocols exist but are very difficult to put into practice large sample size and the surveys must be repeated to show trends.

ShockAcute circulatory failure leading to inadequate tissue perfusion which, if prolonged, results in irreversible organ failure. Mortality is high without early diagnosis andtreatment.

Aetiology and pathophysiologyHypovolaemic shockAbsolute hypovolaemia due to significant intravascular fluid depletion: Relative hypovolaemia due to vasodilation without concomitant increase inintravascular volume: Septic shockBy a complex mechanism, often including vasodilation, heart failure and absolutehypovolaemia.

Cardiogenic shockBy decrease of cardiac output: Clinical featuresSigns common to most forms of shock— Pallor, mottled skin, cold extremities, sweating and thirst. A few symptomes and syndromes Signs specific to the mechanism of shockHypovolaemic shockThe common signs of shock listed above are typical of hypovolaemic shock.

Do not underestimate hypovolaemia. Management according to the causeHaemorrhage— Control bleeding compression, tourniquet, surgical haemostasis. Refer to the MSF handbook, Blood transfusion. Ringer Lactate or 0.

At the same time, administer rapidly Ringer lactate or 0. If there is no clinical improvement, repeat IM epinephrine every 5 to 15 minutes. In shock persists after 3 IM injections, administration of IV epinephrine at a constantrate by a syringe pump is necessary: Use a diluted solution, i.

However, they must be given oncethe patient is stabilized to prevent recurrence in the short term: If the spasm persistsgive 10 puffs of inhaled salbutamol. Septic shock— Vascular fluid replacement with Ringer Lactate or 0.

Increase the dose progressively until a clinical improvement is seen. If syringe pump is not available, see box page Antibiotic therapy according to the originof infection: The treatment of cardiogenic shockdepends on its mechanism.

In the event of worsening signs with vascular collapse, use a strong inotrope: Digoxin should no longer be used for cardiogenic shock, except in the rare caseswhen a supraventricular tachycardia has been diagnosed by ECG.

Correct hypoxiabefore using digoxin. Ceftriaxone reconstituted using this solvent mustnever be administered by IV route. For IV administration, water for injection must always be used. Requires immediate pericardial tap after restoration of circulating volume.

Administration of dopamine or epinephrine at a constant rate requires the following conditions: If there is no electric syringe pump, dilution in an infusion bag may be considered. However, it is important to consider the risks related to this type of administration accidental bolus or insufficient dose.

The infusion must be constantly monitored to preventany, even small, change from the prescribed rate of administration. Seizures— Involuntary movements of cerebral origin stiffness followed by clonic movements, accompanied by a loss of consciousness, and often urinary incontinence generalizedtonic-clonic seizures.

In pregnant women, eclampticseizures require specific medical and obstetrical care see page Immediate administration of an anticonvulsantis not systematic. If generalized seizure lasts more than 3 minutes, use diazepam tostop it: IV administration is possible 0.

The patient is no longer seizing— Look for the cause of the seizure and evaluate the risk of recurrence. Status epilepticusSeveral distinct seizures without complete restoration of consciousness in between oran uninterrupted seizure lasting more than 10 minutes.

Children under 12 years: Children over 12 years and adults: IM route may be an alternative when an IV or intraosseous access cannot beobtained. There is a high risk of respiratory depression and hypotension, especially in childrenand elderly patients.

Never administer phenobarbital by rapid IV injection. Monitorclosely respiration and blood pressure. Ensure that respiratory support Ambu bagvia face mask or intubation and IV solutions for fluid replacement are ready at hand.

Further treatment— Febrile seizuresDetermine the cause of the fever. Give paracetamol see Fever, page 26 , undress thepatient, wrap in damp cloth. In children under 3 years, there is usually no risk of later complications after simplefebrile seizures and no treatment is required after the crisis.

For further febrileepisodes, give paracetamol PO. When possible, confirmhypoglycaemia reagent strip test. Anabrupt stop of treatment may provoke severe recurrent seizures.

Only patients withchronic repetitive seizures require further regular protective treatment with anantiepileptic drug, usually over several years. However, these risks must be balanced with therisks of aggravation of the epilepsy, ensuing seizure-induced cerebral damage andother injury if the patient is not treated.

The effective dose must be reachedprogressively and symptoms and drug tolerance evaluated every 15 to 20 days. The rate ofdose reduction varies according to the length of treatment; the longer the treatmentperiod, the longer the reduction period see iatrogenic causes, above.

In the sameway, a change from one antiepileptic drug to another must be made progressivelywith an overlap period of a few weeks. Treatment of choice is magnesium sulfate by IV infusion: If seizurerecurs, give another 2 g by slow IV injection over 15 minutes.

Before each injection, verify the concentration written on the ampoules: Always have calcium gluconate ready to reversethe effects of magnesium sulphate in the event of toxicity. Monitor patellar tendon reflex every 15 minutes during the infusion.

If the patienthas malaise, drowsiness, difficulty speaking or loss of patellar reflex: Only in the absence of magnesium sulfate, use diazepam: If there is novenous access for the loading dose, give 20 mg rectally.

In the event of treatmentfailure after 10 minutes, give a second dose of 10 mg. FeverFever is defined as a temperature higher than It is accepted that axillary temperature underestimates the core bodytemperature by 0.

Use an electronic thermometerwhen available1. Fever is often linked, but not exclusively, with infection. All clinical examinationsshould include checking for fever. In a febrile patient, first look for signs of serious illness, then try to establish adiagnosis.

Signs of serious illness— Signs of sepsis with signs of shock: AetiologyMany different diseases, infectious or noninfectious, acute or chronic, benign ormalignant, may be accompanied by fever.

Among the infectious diseases requiringimmediate treatment, look for: Patients should returnfor a new consultation if there is no improvement within 48 hours of the initialconsultation or before if their condition deteriorates.

In case of doubt e. Complications— Convulsions— Dehydration— Confusion, delirium— SchockIt is important, particularly in children, to look for signs of these complications, to treatthem, and most importantly to prevent them.

A few symptomes and syndromesSymptomatic treatment— Undress the patient. S PO to be avoided in children under 16 years Adults: It can be administered to breast-feeding women as short-term treatment.

PainPain results from a variety of pathological processes. It is expressed differently by eachpatient depending on cultural background, age, etc. Regularassessment of the intensity of pain is indispensable in establishing effective treatment.

It is important to distinguish: The pain may be present in different forms, but neurological exam isnormal. Treatment is relatively well standardized. On a background of constant, more or less localized pain, such asparaesthesia or burning, there are recurrent acute attacks such as electric shock-likepain, frequently associated with disordered sensation anaesthesia, hypo orhyperaesthesia.

This type of pain is linked to viral infections directly affecting theCNS herpes simplex, herpes zoster, neural compression by tumors, post-amputation pain, paraplegia, etc.

TreatmentTreatment depends on the type and intensity of the pain. It may be both aetiologicaland symptomatic if a treatable cause is identified. Treatment is symptomatic only inother cases no cause found, non-curable disease.

Nociceptive painThe WHO classifies analgesics used for this type of pain on a three-step ladder: Their combinationwith one or two Step 1 analgesics is recommended. The treatment of pain is based on a few fundamental concepts: The only person who canevaluate the intensity of pain is the patient himself.

The use of pain assessment scalesis invaluable. Treatment of acute pain1. Notes on the use of morphine and derivatives: Its analgesic effectis dose-dependent. Its adverse effects have often been exaggerated and should not bean obstacle to its use.

This adverse effect results from overdose. It is, therefore, important to increasedoses gradually. Respiratory depression is preceded by drowsiness, which is awarning to monitor respiratory rate RR.

The RR should remain equal to or greater than the thresholds indicated below: Respiratory depression must be identified and treated quickly: A laxative should be prescribed ifthe opioid treatment continues more than 48 hours.

Lactulose PO is the drug of choice: Do not use metoclopramide in children. It may be necessary to increase doses over time according to pain assessment. Do not hesitate to give sufficient and effective doses.

Treatment of nociceptive pain in pregnant and breast-feeding womenNeuropathic painCommonly used analgesics are often ineffective in treating this type of pain.

Treatment of neuropathic pain is based on a combination of two centrally acting drugs: Given its teratogenic risk, carbamazepine should only be used in women ofchildbearing age when covered by non-hormonal contraception copper intrauterinedevice.

A few symptomes and syndromesAnalgesicsPregnancyBreast-feeding1stand 2ndtrimester3rdtrimesterand termparacetamol 1stchoice 1stchoice 1stchoiceaspirin avoid contra-indicated avoidibuprofen avoid contra-indicated possiblecodeine possible The newborn infant maydevelop withdrawalsymptoms, respiratorydepression and drowsinessin the event of prolongedadministration of largedoses at the end of the3rdtrimester.

Use with caution, for a shortperiod days, at thelowest effective dose. Monitor the mother and thechild: Administer with caution, for ashort period, at the lowest effective dose, and monitorthe child.

Administer with caution, for a shortperiod, at the lowest effective dose, and monitor thechild. Mixed painIn mixed pain with a significant component of nociceptive pain, such as in cancer orAIDS, morphine is combined with antidepressants and antiepileptics.

Chronic painIn contrast to acute pain, medical treatment alone is not always sufficient in controllingchronic pain. A multidisciplinary approach including medical treatment, physiotherapy, psychotherapy and nursing is often necessary to allow good pain relief and encouragepatient self-management.

Co-analgesicsThe combination of certain drugs may be useful or even essential in the treatment ofpain: Anaemia— Anaemia is defined as a haemoglobin level below reference values1. The groups most at risk are children and youngwomen, particularly during pregnancy.

Most anaemias are welltolerated and can be corrected with simple aetiological treatment. Clinical features— Common signs of anaemia: Laboratory— Haemoglobin level or if haemoglobin is not available, haematocrit — Thick and thin blood films or rapid test if malaria is suspected1 Normal values: TreatmentIron deficiency anaemia— elemental iron PO2 for 3 monthsChildren under 2 years: A few symptomes and syndromesMonitor vital signs pulse, blood pressure, respiratory rate, temperature and watchfor clinical signs of transfusion reactions.

In some cases, particularly in children suffering from severe malaria, anaemia maycause heart failure which may be decompensated by transfusion. If signs ofhypervolaemia are seen: Prevention— Iron or folic acid deficiency: AdultsDetermine the volume of whole blood to be Example: Severe acute malnutrition40Severe acute malnutritionSevere acute malnutrition is caused by a significant imbalance between nutritionalintake and individual needs.

Children over 6 months of ageThe two principal forms of severe malnutrition are: The two forms may be associated marasmic-kwashiorkor. In addition to these characteristic signs, severe acute malnutrition is accompanied bysignificant physiopathological disorders metabolic disturbances, anaemia, compromisedimmunity, leading to susceptibility to infections often difficult to diagnose, etc.

Complications are frequent and potentially life-threatening. Mortality rates may be elevated in the absence of specific medical management. Admission and discharge criteria for treatment programmes for severe acutemalnutrition are both anthropometric and clinical: MUAC measures the degree of muscle wasting.

A MUAC of Usual admission criteria are: MUAC — 2Z2 and absence of bilateral oedema 2 consecutive assessments, one week apart and absence of acute medical problems. Medical management hospitalisation or ambulatory care is based on the presence orabsence of associated serious complications: Treatment1 Nutritional treatmentNutritional treatment is based on the use of therapeutic foods enriched with vitaminsand minerals: It is used to cover basic needs whilecomplications are being treated.

It is given in 8 daily meals. The objective is to facilitate rapid weight gain. It can begiven with, or be replaced by, RUTF. It is designed to promote rapidweight gain approximately kcal per g.

RUTF are the only therapeutic foodswhich can be used in ambulatory treatment. Severe acute malnutrition42Furthermore, it is important to give drinking water, in addition to meals, especially ifthe ambient temperature is high or the child has a fever.

Breastfeeding should continue in children of the appropriate age. If testing is not available, give malaria treatment page The diagnosis is made on the basis of a history of watery diarrhoea of recentonset accompanied by weight loss, corresponding to fluid losses since theonset of diarrhoea.

Chronic and persistent diarrhoea does not require rapidrehydration. In the event of dehydration: ReSoMal is administered under medical supervision clinical evaluation andweight every hour.

In practice, it is useful to determine the target weight before startingrehydration. The target weight is the weight before the onset of diarrhoea. Ifthe child is improving and showing no signs of fluid overload, rehydration iscontinued until the previous weight is attained.

If the weight loss cannot be measured e. Regardless of the target weight, rehydration should be stopped if signs of fluidoverload appear. Every 5 minutes, evaluate clinical response recovery of consciousness, strongpulse, CTR When switching to the oral route, stop the infusion but leave the catheter capped in place to keep a venous access, for IV antibiotic therapy.

Infection should be suspected in a drowsy or apathetic child. Severe infection should be suspected in the event of shock, hypothermia orhypoglycaemia. A few symptomes and syndromesAdmission and discharge criteria, as a rough guide, are: Rhinitis and rhinopharyngitis common cold Rhinitis inflammation of the nasal mucosa and rhinopharyngitis inflammation of thenasal and pharyngeal mucosa are generally benign, self-limited and most often of viralorigin.

However, they may be an early sign of another infection e. Clinical features— Nasal discharge or obstruction, which may be accompanied by sore throat, fever, cough, lacrimation, and diarrhoea in infants.

Purulent nasal discharge is notindicative of a secondary bacterial infection. Treatment— Antibiotic treatment is not recommended: Acute sinusitisAcute sinusitis is an infection of the sinus mucosa with purulent discharge of nasal rhinitis, allergies, obstruction or dental origin.

It may develop into chronic sinusitis, particularly in older children and adults. The most common causes are Haemophilus influenzae in children under 5 years andpneumococci in patients over 5 years.

Type specific to infants and small children— Acute ethmoiditis: The most common causes are Haemophilus influenzae, pneumococci and staphylococci. Treatment— Nasal irrigation with 0.

Acute laryngitisLaryngitis is an acute infection of the laryngeal mucosa of viral or sometimes bacterialorigin. Clinical features common to all laryngitis— Inspiratory dyspnoea with cough and hoarse voice.

Chest indrawing and stridor maybe present. Examine children in a sitting position. Do not lay children down: Aetiology and treatmentChildren over 6 months1stcase: The child is sitting, breathingthrough the mouth, drooling clear saliva which he cannot swallow due to dysphagia.

The overall condition may deteriorate very quickly. Thechild may develop stridor. The voice remains hoarse after the attack. Have him breathe in a humid environment near a bowl of water or wet towel.

Respiratory diseasesAcute pharyngitisAcute inflammation of the tonsils and pharynx. The majority of cases are of viral originand do not require antibiotic treatment. Group A streptococcus is the main bacterial cause, and mainly affects children age 3 to14 years.

Acute rheumatic fever, a serious late complication of streptococcalpharyngitis, is common in developing countries, and can be prevented with antibiotictherapy. One of the main objectives in assessing acute pharyngitis is to identify patientsrequiring antibiotic treatment.

Clinical features— Features common to all types of pharyngitis: Throat pain and dysphagia difficulty swallowing, with or without fever. Since this appearance is common to both viral and streptococcal pharyngitis, othercriteria should be considered to distinguish between them: In children under 3 years, streptococcal pharyngitis is rare and pharyngitis isalmost exclusively viral.

Conversely, presence of cough, runny nose, conjunctivitis or enlarged posteriorcervical lymph nodes favours viral pharyngitis. In patients over 14 years, the probability of streptococcal pharyngitis is low.

Infectious mononucleosis IM due to the Epstein-Barr virus should be suspected inadolescents and young adults with extreme fatigue, generalized adenopathy andoften splenomegaly.

Erythematous or exudative pharyngitis may also be associated with gonococcal orprimary HIV infection. In these cases, the diagnosis is mainly prompted by thepatients history.

Treatment— Treat fever and pain in all cases paracetamol PO, page 26 — Viral pharyngitis is usually a self-limited illness. Spontaneous resolution typicallyoccurs within a few days or weeks, for IM: However, it can cause adverse skin reactions in patients withundiagnosed IM and thus should be avoided when IM has not been excluded.

Poor adherence with erythromycin ispredictable due to the length of treatment. Azithromycin treatment has theadvantage of being short. DiphtheriaDiphtheria is a bacterial infection due to Corynebacterium diphtheriae, characterized bylocal proliferation most commonly ENT of the bacteria, and systemic diffusion of thediphtheria toxin through the body.

Transmission is by direct contact with an infected person. Clinical features— Incubation period: Risk of death byasphyxiation. These are more serious when appear early from the 5thday.

LaboratoryConfirmation is made by isolating the toxic strain of C. Treatment at hospital level — Strict isolation. For diphtheria antitoxin derived from horse serum, administer according to theBesredka method1.

Doses are given as a function of the severity of illness, and the delay in treatment: If there is no allergic reaction no erythema at the injectionsite or a flat erythema of less than 0.

If there is no reaction after 15 minutes, inject the rest of the product IM or IV depending on the volume to be administered. Respiratory diseasesDose in units Administration routeLaryngitis or pharyngitis 20 to 40 Depends on the volume to beadministered: IM or for volumesRhinopharyngitis 40 to 60 greater than 20 units IV infusionin ml 0.

Management of close contacts— Nose and throat cultures. The same precautions should be taken for contacts of healthy carriers. PreventionThere are 3 combined vaccines: Update routine vaccinations with DTP for children under 3 years of age; DT forchildren from 3 to 6 years of age; Td for children over 7 years of age and adults.

The recommendations vary according to the country. Update the vaccination of the patients oncethey have recovered. Vaccination does not prevent individuals from becoming carriers. OtitisAcute otitis externaDiffuse inflammation of the external ear canal, due to bacterial or fungal infection.

Common precipitants of otitis externa are maceration, trauma of the ear canal orpresence of a foreign body or dermatologic diseases such as eczema, psoriasis. Clinical features— Ear canal pruritus or ear pain, often severe and exacerbated by motion of the pinna;feeling of fullness in the ear; clear or purulent ear discharge or no discharge— Otoscopy: Remove skin debris and secretions from the auditory canal by gentle dry mopping use a dry cotton bud or a small piece of dry cotton wool.

Consider ear irrigation 0. Otherwise, earirrigation is contra-indicated. Acute otitis media AOM Acute inflammation of the middle ear, due to viral or bacterial infection, very commonin children under 3 years, but uncommon in adults.

The principal causative organisms of bacterial otitis media are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and in older children, Streptococcus pyogenes.

Clinical features— Rapid onset of ear pain in infants: The combinationof these signs with ear pain or fever confirms the diagnosis of AOM. The following otoscopic findings are not sufficient to make the diagnosis of AOM: Treatment— In all cases: Ear drops are not indicated.

Spontaneous resolution is probable and a shortsymptomatic treatment of fever and pain may be sufficient. Antibiotics areprescribed if there is no improvement or worsening of symptoms after 48 to72 hours.

Persistence of a ear drainage alone, without fever and pain, in a child who hasotherwise improved reduction in systemic symptoms and local inflammation doesnot warrant a change in antibiotic therapy.

Clean ear canal by gentle dry moppinguntil no more drainage is obtained. The principal causative organisms are Pseudomonas aeruginosa, Proteus spp, staphylococcus, other Gram negatives and anaerobes.

Clinical features— Purulent discharge for more than 2 weeks, often associated with hearing loss or evendeafness; absence of pain and fever— Otoscopy: Treatment— Remove secretions from the auditory canal by gentle dry mopping use a dry cottonbud or a small piece of dry cotton wool then apply ciprofloxacin ear drops: Before transfer to hospital, if the patientneeds to be transferred, administer the first dose of antibiotics.

Whooping cough pertussis Whooping cough is a highly contagious bacterial infection of the lower respiratorytract, of prolonged duration, due to Bordetella pertussis. The majority of cases arise in non-vaccinated or incompletely vaccinated individuals.

Whooping cough affects all age groups. Signs and symptoms are usually minor inadolescents and adults. As a result the infection may be ignored, thus contributing tothe spread of B. Clinical featuresAfter an incubation period of 7 to 10 days, the illness evolves in 3 phases: At this stage, the illness isindistinguishable from a minor upper respiratory infection.

Fever is absent or moderate, and the clinical exam is normalbetween coughing bouts; however, the patient becomes more and more fatigued. Management and treatmentSuspect cases— Routinely hospitalise infants less than 3 months, as well as children with severe cases.

Infants under 3 months must be monitored 24 hours per day due to the risk ofapnoea. Whooping cough pertussis 60 BronchitisAcute bronchitisAn acute inflammation of the bronchial mucosa, most commonly of viral origin.

Inolder children it can be caused by Mycoplasma pneumoniae. In children under 2 years of age, consider bronchiolitis see Bronchiolitis, page Clinical featuresOften begins with a rhinopharyngitis that descends progressively: Chronic bronchitisA chronic inflammation of the bronchial mucosa due to irritation tobacco, pollution, allergy asthma or infection repetitive acute bronchitis.

It may develop into chronicobstructive pulmonary disease. Clinical features— Productive cough for 3 consecutive months per year for 2 successive years. Dyspnoea develops after several years, first on exertion, thenbecoming persistent.

A patient with an acute exacerbation of chronic bronchitis presents with: BronchiolitisBronchiolitis is an epidemic and seasonal viral infection of the lower respiratory tract inchildren less than 2 years of age, characterised by bronchiolar obstruction.

Transmission of RSV is direct, through inhalation of droplets coughing, sneezing, andindirect, through contact with hands or materials contaminated by infected secretions. In the majority of cases, bronchiolitis is benign, resolves spontaneously relapses arepossible, and can be treated on an outpatient basis.

Severe cases may occur, which put the child at risk due to exhaustion or secondarybacterial infection. Clinical features— Tachypnoea, dyspnoea, wheezing, cough; profuse, frothy, obstructive secretions.

Rhinopharyngitis, with dry cough, precedes these features by 24 to 72 hours; fever isabsent or moderate. In all other cases, the child may be treated at home, provided the parents are taughthow to carry out treatment, and what signs of severity should lead to re-consultation.

Outpatient treatment— Nasal irrigation with 0. Hospitalisation— In all cases: Avoid breastfeeding or oral feeds inchildren with severe tachypnoea, but do not prolong NG feeds respiratorycompromise or IV infusions any longer than necessary.

If inhaled salbutamol appears effectivein relieving symptoms, the treatment is continued 2 to 3 puffs every 6 hours in theacute phase, then gradual reduction as recovery takes place.

If the trial isineffective, the treatment is discontinued. Prevention and controlThe risk of transmission of the virus is increased in hospital settings: Acute pneumoniaAcute pneumonia is a viral, bacterial pneumococcus, Haemophilus influenzae, staphylococcus, atypical bacteria or parasitic pneumocystosis infection of thepulmonary alveoli.

Pneumonia in children under 5 years of ageThe most common causes are viruses, pneumococcus and Haemophilus influenzae. Clinical examination must be done on a calm child in order to correctly count therespiratory rate and look for signs of serious illness.

Clinical featuresPneumonia should be suspected in a child who presents with cough or difficultybreathing. The respiratory rate RR should be measured over 1 minute. Spel Superman Spela Superman gratis onlinespel Hjlp hjlten, som alla kallade Superman kommer att kra.

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