AIDS (Acquired Immune Deficiency Syndrome)-Modes of Transmission

AIDS is a disease of the immune system that results in the development of either lifethreatening opportunistic infections or the development of unusual malignant manifestation of both.
Although AIDS is classified as an infectious disease,its transmission would seem to require sexual contact or direct entry of virus-infected blood or blood products into the circulation.There is a little evidence that AIDS is transmitted by any non-sexual form or person-to-person contact.
The first recognize case of AIDS occured in male homosexuals and this individuals constitute the main risk group(about three-quarters of reported cases occur in homosexual or bisexual males).
AIDS has been diagnosed in female sexual partners of affected males and in Africa the condition would seem to be spread predominantly by heterosexual intercorse,or by exposure to blood through insect bites or scarification.
A retrovirus known as human T-cells lympotropic virus type III(HTLV III) was identified as the probable cause of AIDS.This virus has been repeatedly isolated from the blood ,semen or saliva of affected individuals.
Although the HTLV-III virus has been identified as the probable agent causing AIDS and AIDS related illness,some individuals who have been exposed to ,or are infected by,the virus do not show an evidence of such disease.
This suggests either a long incubation period or the operation of the other factors during the incubation period,which together with the HTLV-III virus,precipitate the loss of cell-mediate immunity.
One possible factor is seminal fluid,which is thought to have a physiological role as an immunological agent after normal heterosexual intercourse.Repeated exposure to this immunosuppresive agent after intercourse,in conjunction with a virus-infected ejaculate,would certainly explain the high-risk category of homosexual or bisexual males.

Syphilis-Treatment

The specialist venerologist put the treatment for syphilis.
Local treatment is useless because the infection invade deeply and spread by vascular channels at an early stage.The best medication for early syphilis is penicillin to which the treponemes have not so far developed a resistance.The most efficient way to maintaining adequate blood levels is to inject intramuscularly aqueous procaine penicillin daily for 10 days(only after medical prescription).
Late syphilis is also treated with penicillin but the shemes of dosage and nmber of courses vary with its manifestations.Treatment should be proceded by radiological examination of the heart and aorta and by tests on the cerebrospinal fluid.
Even though apparently cured,in case of women it should be given a further course of treatment in their next pregnancy,to protect the fetus.The baby should be assesed 6 weeks and 3 months after birth.

Syphilis-Stages and Manifestation

Syphilis is caused by an organism named spirocheta pallida,and can be found in all stages:primary,secondary and tertiary.Exist an other classification too,as:early,latent,late and congenital stage.The syphilitic infection presents a risk for doctors and nurses exposed,if there is a break in their skin or mucous membrane.
Ordinarily,however,the entry of the spirochete is determinated by sexual contact whit an infected partner.This is true even when the primary stage is on the breast,in the mouth or on the lips,the last sites being determinated by genito-oal coitus rather than by kissing or by drinking from infected containers-as used to be suggested.
We will talk about syphilitic case as a result of sexual intercourse.

The primary stage is found most commonly on the labia majora,labia minora,clitoris,urethral orifice or cervix,but it may be anywhere on the lower genital tract,even the vaginal wall.The signs appears usually in 10-20 days after exposure but the incubation period can be modified by penicillin therapy for gonorrhea and can be as long as 90 days.
The first manifestation is a small papule which quickly breaks down to form an ulcer,the classical features of which are a sharply defined serpiginous outline and a brownish red colour.
In practice the signs are so slight that can pass unnoticed.Indeed,any sort of discrete relatively painless ulceration on the vulva may be a primary syphilitic sign.

The first form(primary stage) heals spontaneously in 1-8 weeks and soon afterwards the secondary stage of syphilis,which resolts from entry of the spirochaetes into the bloodstream,is manifestated by:general systemic upset with lassitude,anorexia,headache,pustular skin rashes which are typically non-irritant,occasional loss of hair,white mucous patches in the mouth and moist and necrotic warts on the vulva and around the anus.
Sometimes secondary manifestation occur before the primary heals,or they may not occur at all.
The first and second stages can last up to 2 years,and all this time the woman(and the man infected0 is a source of infection.

In untreated syphilis the tertiary stage occupies many years during which the organisms of infection attack bones,joints,eyes,blood vesels,the heart and the central nervous system.Tertiary syphilis is also characterized by the formation of localized granulomas in any part of the body.Granulomas on the genital tract are rare but,when they do occur,are most often found on the vulva.They are not painful unless secondarly infected.this late form are rarely seen nowadays.

Gonorrhea-Symptoms and Treatment

Gonorrhea is an infection caused by the gonococcus and in the adult woman is contracted by sexual contact with an infected male.There is usually an interval of 2-5 days between exposure and the development of symptoms,but this interval varies from 1 ti 10 days.however an asymptomatic carrier state can persist for weeks or even months and throughout this time infection can be transmitted.
The bacteria attack first those tissues of the lower genital tract.
The gonococci are also spread by anal coitus.
The initial complaints of the patient are dysuria,frequency and purulent vaginal dscharge.This discharge causes soreness but not pruritus unless there is an associated Trichomonas infection.In severe cases the whole vulva become reddened and swollen.Cyctitis and proctitis can develop.
Generally the infection remains limited to the lower genital tract.Most wemen even in the acute and subacute stages of the primary infection ,notice nothing more than slight frequency,dysuria and discharge ,so slight that they pay little attention.It is this who are responsable for the spread of the infection and they can only be found and treated by an efficient system of "contact tracing".
No matter whether it has a dramatic or quiet onset,gonorrhea persist as a chronic but contagious disease for many years.The organisms linger in the endocervix,Bartholin's glands,periurethral tubules and rectum but gives rise to no symptoms or just a vaginal discharge.
the most important and sequel to gonorrhea is tubal damage and closue which threaten future reproduction.
In the classical case the diagnosis of gonorrhea is usually suggested by the history of esposure,the acuteness of the onset of a purulent discharge,the associated urethritis and the appearance of zones of congestion around the orifices of Bartholin's ducts.
The diagnosis can only be provide by the demonstartion of gonococci in the genital tract secretions or in the lower rectum.
The woman should not have passed urine before examination and not used the shower.Having wiped its orifice clean,the urethra is milked to obtain discharge from the paraurethral glands.
the best time to performe a test is immediatly after menstruation.
Treatment:
If there is a severe systeic reaction,or if acute salpingitis is present,the patient should be put completely at rest in hospital and given intensive antibiotic therapy in divided doses.
Penicillin(injection) is the remedy of choice in gonorrhea.If for any reason penicillin is contraindicated,the next choice is ampicillin taken orally.This can be given in a repeated dose of 2g for divided doses such as 500mg,four time daily for 2-4 days.Before penicillin or ampicillin it is advisable to adminiter with 1/2-1 hour previously probenicid 1g by mouth.
Gonorrhea is diagnosed by a medical test and treated after medical advise and supervision!
Be attent with the health of your sexual life,practice a good hygiene and use condom against transmited sexual diseases!

Artificial Insemination

Artificial insemination involves the collection of semen by an emission occurring other than during coitus(usually by masturbation0 and its transfer into the upper vagina of cervical canal within 2 hours.
Intrauterine insemination is carried out with a sterilized syringe and cannula,and only a small amount of semen(0,5 ml) is injected whithout force into uterus.
The woman sometimes experiances colicky lower abdominal pain.Salpingitis is also a possible complication bacause antiseptics cannot be used in the vagina and semen is not always free from pathogenic bacteria.
for intravaginal insemination the semen is placed into tha vault around the cervix.
By either method it is often necessary to inseminate every 2 or 3 days during the fertilile period before a pregnancy results.
Higher pregnancy rates are obtained if ovulation is monitored.

Intrauterine insemination:
Several specimens of the first part of a split ejaculate,obtained at intervals,are kept in cold storage to produce semen with a resonable sperm density.The overall success rate in still poor,however,and referral for in vitro fertilization offers a greater chance of achieving pregnancy.

Intravaginal insemination:
By this method the woman can do it by herself,instilling semen into upper vagina with a pipette or placing it inside a cervical cap.
It is mainly indicated when coitus is prevented by anatomical faults in the male or by impotence.In cases of impotence,insemination is only feasible if semen can be obtained by masturbation or nocturnal emission.
Artificial insemination can also be used when the problem is retrograde ejaculation,the necessitates alkalinizing the male urine,collecting a specimen after coitus,centrifuging it for spermatozoa and then using these for insemination at the time of ovulation.
efficient technique for freezing human semen and for keeping it at temperatures which in different laboratories vary from -40 to -190 Celcius degrees are not established.Greater success rates are always obtained when fresh semen is used.

Oral contraceptive-Side Effects

Side effects of hormonal "oral" contraceptives:
-headache irritability,depression
-thromboembolic diseases like deep venous thrombosis,pulmonary embolism,cerebrovascular ischemia,myocardial infection
-hypertension
-nausea and vomiting common in 1st cycle
-impairement of liver function(cholescystitis and gall stone)
-impairement of glucose tolerance with increasing in fasting blood sugar
-increase in body weight
-breast engorgement,tenderness and enlargement
-decrease in milk production in lactating women
-water retention
-spotting-minimal bleeding during pill taking or break through bleeding(bleeding similar to menstruation)
-hypomenorrhea or amenorrhea(exces of menstrual bleeding or abscence of menstrual period)
-infections,erosions
-loss of libido
-skin pigmentation
-rarely loss of hair
-acne vulgaris may appear or improve.

Contraindication:
-migrene headache
-history of embolism,thrombosis and cerebrovascular accidents
-hypertension
-heart failure
-impaired liver function with history of iaudince
-prediabetic and diabetic
-obese women,smokers and for women over 35 years
-carcinoma of breast
-uterine fibroid

The contaceptive pill decrease therapeutic effect of:
-oral anticoagulant
-antihypertensive
-antidiabetic
-antihypercholesterolaemic.

Incease side effects of the contraceptive pill:
-tabacco smoking
-antifibrionlytic aminocaproic acid.

Other uses of contracetive pill:
-pregnancy test(2 pills daily for 5 days)
-suppression of lactation
-postpone menstruation
-dysmenorrhea
-dysfunctional uterine bleeding
-endometriosis.

House fly-Transmission of disease

Characteristics of the house fly:

Is a medium size fly about 1cm in length,greyish colour.The head carries:2 big compound eyes(close in male,apart in female)and 3 simple eyes in between;2 antennae,mouth parts adapted for sucking.

The life cycle:
Has a complete metamorphosis,the cycle takes one week.female deposits eggs in batches(50-100 at a time0 on organic decayed matter,garbage.The eggs are banana shaped with 2 longitudinal riges,creamy withe in colour,1 mm in length and hatches in 10 hours.

Habits:
-live in contacts with man
-active in daytime and rest at night(corners of rooms,ceilling)
-prevalent all the year round in tropics while in temperate zones the number falls strongly or may even dissapear in cold weather.
-feed usually on liquid or semi-liquid substances beside solid material which has been softened by saliva or vomit.

The importance role of house fly in transmitting diseases to man is due to:
-their habits of standing and feeding on human excretions and human food,
-their high intake of food with constant vomiting and deposition of faeces.

MEDICAL IMPORTANCE:
Transmission of diseases:
-bacterial diseases:enteric fevers,cholera,bacillary dysentery,wound infection.
-viral diseases:poliomyelitis,hepatitis,tranchoma.
-parasitic diseases.
The mechanism of transmission;mechanical transmismission along the mouth parts,hairs covering the body and legs and faeces.

Control:
-screening of windows and doors
-covering the food
-fly paper,traps and mechanical knocking down
-insectocides
-proper disposal of garbage
-sanitary disposal of excreta
-insecticides specially for heaps of manure,garbage,animal stables
-health education.

Gastritis

Gastritis is an inflammation of the gastric mucosa.
Types of gastritis:
1.Acute
2.Chronic
3.Special(allergic,viral,parasitic,etc)

1.Acute gastritis:is erosive or haemorrhagic.
Causes:
-heavy use of drugs as nonsteroidal anti-inflamamatory drugs,cytotoxic drugs and cortisone.
-alcoholism
-cigarette smoking
-uraemia
-systemic infection(salmonellosis)
-severe stress,ischemic and shock
-chemical irritation by strong alkalias and acids
-mechanical trauma as during endoscopic examination

2.Chronic gastritis:Chronic mucosal inflammatory changes leading eventually to mucosal atrophy and ephithelial metaplasia or dysplasia which may be complicated by carcinoma.
Causes:
-immunologic associated with pernicious anemia
-alcoholism and cigarettes smoking
-chronic Helicobacter pylori infection
-irradiation
-post-operative

Sexual contact during and after pregnancy

Although it is often suggested that the sexual contact to be discontinued during the first 3 months and during the last 2 months of pregnancy,is no contraindication of the sexual contact at any stage in normal pregnancy.
The alleged riscks are abortion,premature labour and the introduction of bacteria to cause subsequent puerperal sepsis.
These are theoretical and few women come to harm.
Coitus need be banned for a period of time when the women has threatened to abort or is an habitual aborter.
During pregnancy,however the woman rarely has much sexual desire and a dominant progesterone may play a part in this too.
The possible dengers are puerperal infection and injury to the soft and vascular vaginal walls.There is little risk of either after the fourteenth day and some authorities go so far as to advice intercourse from that time onwards,arguing that it assists involtion and restores muscle tone.
A more resonable view is that if the couple are desirous,sexual contact may be resumed 4 weeks after delivery-provided that the lochial discharge has ceased and that vaginal and perineal tears have healed and are not tender.

Anomalies of Breast Development

As anomalies of breast development and function are known:

1.Hypoplasia:
Varying of degrees underdevelopment of the breast are seen and young wemen may seek medical advice on this type of problems.The size of the breast depend on fat as much as on glandular tissue and the development of the nipple is the best guide to the latter.
Causes of hypoplasia:
-deficiencyof ovarian hormons:in this case there is always other evidence of the deficiency such as amenorrhea(absence of a menstrual period) and genital underdevelopment.
-intrinsic defects in the gland itself:the gland may be absent,rudimentary or insensitive to hormone stimuli.This is always the case when ovarian function is normal and when the woman is not wasted.
Treatment:
-By oestrogen.If the case is clearly a deficiency of ovarian hormones,then breast development can be complete by administreting oestrogen and progesteron for several months.If the menstrual and ovarian functions are normal,there is no pont in administreting oestrogen becose the supply is already adequate and it is the breast which are at fault.
-By diet:Encourage the thin patient to increase her weight.
-By physiotherapy:Local massage,exercises for the prctoral muscle and measures designed to improve blood supply are of limited value.
-By plastic surgery.The placing of protheses deep to the breast can give satisfactory results.

2.Breast asymmetry:
The breasts are similar to most paired organs in that they are rarely equally developed.Even if they look the same,their function is unequal when they lactate and the baby prefers one to the other becouse it obtains more milk more easily from it.
Often the breasts are obviously different in size and since both are subject to the same hormone stimulus the fault is always inherent in the target tissue.
Endocrine treatment is valueless but plastic surgery can offer reduction in size of the larger breast and sometimes enlargement of the smaller.

3.Retracted nipples:
Acquired retraction of the nipple developing in later life a sign of cancer.Here we shall consider retraction only as a developmental anomaly caused by fibrous bands fixing the base of the niplle to the underlying fascia.
Plastic operations for this condition are unsatisfactory and more hope lies in regular manipulation or suction.
Pregnancy itself often brings about considerable improvement in the anatomy.

4.Accesory breast and nipples:
Is known as the axillary tail of Spencer and is well developed in some wemen and may result in axillary pain and swalling premenstrually or during lactation.Sometimes there are accesory breast but more commonly there are accesory nipples only.
These are usually found on the nipple line which extends from the anterior fold on the axilla to the pubic spine.small papillomas or pigmentated moles on this line are nearly always accesory nipples,are extremely common and not always recognize for what they are.
No treatment is necessary as a rule.

5.Hyperprophy of the breast:
True hyperprophy of the breast is not common.It affects the glandular tissue and not the nipples.The cause is unknown.
It is nearly always bilateral and often first appears at puberty.the breast enlarge progressively and weight as much as 6-13 kg each.
As treatment the plastic surgery after the age 20 years is necessary.

6.Pendulous breast:
After childbearing and lactation,and with advancing age and obesity ,the breast loses it is firmness and shape.The treatment immediatly after lactation is to support the breast and to do pectoral exercises.A plastic surgery gives good result.

7.Neonatal mastitis:
The breast of male and female babies sometimes become enlarged and hard 3 or 4 days after birth.
The condition is associated with congestion and activity of the primitive ducts and it is related to the withdrawal of the influence of maternal oestrogen.The baby is attempting to lactate at he same time at it is the mother.
No treatment than reassurance of the mother is required.

8.Adolescent mastitis:
A nodular painful enlargement of the breast sometimes occurs at puberty in both boys and girls.

Health of the Elderly-Help and Support for aging persons

Geriatric health-health of the elderly(aging persons) who form a vulnerable group that needs special care.
Onset of aging cannot be precisely given.It may be considerated 60 years but the recent trend is 65-70 years.
The elderly can be classified according to magnitude of health problems into 2 age groups:65-79 and plus 80 yeras.
The elderly are exposed to morbidity,injuries and disability that are responsable for physical,mental and social complications.
1.Morbidity(disease):
cardiovascular is the common form of morbidity(atherosclerosis,hypertension and complications,varicosity).
2.Nervous;
-cerebrovascular disease
-involved sensory and motor nerves
psychoneurosis.
3.Dental:
Problems on teeth and gums that may interfere with proper feeding.
4.Bone and joints:
-osteorthritis(a common disorder) and back and joint aches
-osteoporosis(the common metabolic disease of bone).
5.Malnutrition and Deficiency:
A common problem due to;
-anorexia,oral disease and missing teeth and impaired digestion,absorption and metabolism
-low income or living alone and doesn't exist nobody to take care of their food.
6.Disorders of Special senses:
-presbycusis:impaired hearing whit aging and deafness that is sensorineural,usually bilateral and symmetrical.
-senile macular degeneration and cataract and other visual disorders.
-diminished speech.
7.Respiratory:chronic bronchitis.
8.Others:diabetes,neoplasms.

Injuries:
The elderly are exposed to accidents that cause injuries of varied severity and sequele.Fractures,specially fracture neck femur are particularly important.

Disability:
Morbidity of aging and injuries may interfere with physical activity or mental psychologic behaviour.

Elderly Heath Program
Objectives:
Is needed organized elderly health programs to provide preventive and curative services of primary health care for:
-maintenance of health to keep the aging person in good health
-prevention of health complications associated with the aging process
-control of health complications,some of complications may be inevitable and more or less incurable.
-management of disability and rehabilitation if is necessary.
Is necessary teaching and counseling the elderly for principles of healthful lifetstyle by personal aproach and mass media.
we can help elderly by socioeconomic promotion:satisfactory income and social study to solve their problems and provide support when they needed.
The aging persons need periodic medical examination for early cases-finding and management.

Impotence

Male impotence is much more common that is generally supposed.It may be constant or occasional and it seen in varying degrees.Some men find themselves impotent with one woman and not with another.Most impotent men have good spermatogenesis and are potentially fertile.
Clinical types:
-absence of sexual desire and consequently of erection
-failure to obtain an erection
-weak and fleeting erection which subsides before penetration is complete
-normal erection and penetration but failure to emit semen.This condition of partial impotence is difficult to diagnose and the couple are ofthen unaware of it themselves.
Causes:
Ofthe there is more then one factor operating and in nearly all cases a vicious cicle is quickly established.
Impotence resuts in loss of self-esteem and this in turn causes impotence.The more a man fails the more likely he is to fail.
Impotence slightly low levels of testosterone in the plasma.The administartion of testosterone in this case never restores potency so is just a theory.There is little evidence to support this or the idea that a hormone deficiency plays any part in impotence which is not caused by an endocrine disorder.
Impotence is physiological before puberty and with advancing years.Too-frequent coitus at any age temporarily diminishes desire and capacity.Sexual capacity in the male is usually quite strong up to the age of 50 years but thereafter slowly weakens.But a man of 80 years and more can be surprisingly potent.
Some men have minimal sex drive and some may even be completely unresponsive sexually.A man with minimal or no sex drive is not necessarily timis and undersized,he is often physically well built and handsome.
From overexcitement or anxiety coitus may fail.The stress on any problem creates inhibition which prevent ejaculation despite normal penetration or erection loss.
Organic causes:
These account for only 5% of cases of male impotence:
-general ill health,debility.physical and mental exhaustion
-castration(even this does not always cause impotence)
-hypoplasia of the testes
-complete testicular failure
-an endocrine disease(for exemple diabetes)
-depression
-generalized vascular disease.

Drugs which sometimes destroy libido and encourage impotence include certain hypotensive agents and narcotics,depressants and tranquillizers.

Treatment:
This must be proceded by diagnosis and this means clinic hystory,examination and investigation to exclude an organic cause.If nocturnal erection occur an organic cause is excluded.If is not an organic problem than the man need psychiatric treatment and support.
An hormone therapy is used too.Androgens by mouth,by injection or by implant are indicated only when there is clear evidence of hormone deficiency and sometimes are useful in agening men.

Congenital Heart Disease

The incidence may be up to 1% of live births and the mortality is low,becouse is readily preventable trough maternal care.
Causes:
Exposure of the embryo to adverse genetic and intrauterinefactors that interfere with development of the heart.They cause congenital malformation that involve different sites of heart and blood vessels.
Exposure during the first trimester of pregnancy is particularily important,due to rapid embryogenesis during this period:the heart develops between the 3td and 7th week.
1.Genetic factor:chromosomal abnormalities are associated with Down's Syndrome with high incidence of heart disease,specially coartation of aorta.
2.Exposure to adverse intrauterine invironment:
-Viral infection of the pregnant during first trimester(rubella for exemple).Congenital anomalies of viral infection may involve the heart causing persistent ductus arteriosus,aortic stenosis,pulmonarystenosis and others.
-Teratogenic drugs
-Inhalationof chemical pollutanta in air:
-isecticides and cigarette smoke(pasive smoking0-they are teratogenic.
-carbone monoxide,occasionally.
-Cigarette smoking and alcohol consumption during pregnancy.

Manifestations:some cases only are suspected at birth,while the other nonfatal cases are detected later,on heart appraisal(at school entry for exemple).

Prevention:
-family hystory
-genetic examination and counseling
-family planning service
-avoiding exposure to infection
-immunization
-avoid cigarette smoking and passive smoking,alcohol consumption,any drug without medical prescription and supervision,insecticide application at home.
-no exposure to radiation
prevention and control of air pollution.

Management of screened cases:
-surgical repair
-medical care:treatment to manage manifestations and prevent complications.prophylaxis to prevent infective endocarditis if is necessary.
-general measures for case:health promotion,specially adequate nutrition,guidelines for healtful lifestyle.

Menstruation-Disturbances associated with Menstruation

The menarche is a late feature of puberty.The first period may be short or long,thereafter the cycle is often irregular,periods occuring sometimes every few month,sometimes too frequently.A more or less regular rhythm is usually established within 2-3 years.
During active reproductive era menstruation occurs at approximately 28-day interdals.Each woman tends to have her own rhythm although it may change after marriage or chieldbearing.Any regular cycle of 3-5 weeks is arbitrarily accepted as normal.
There are wide variations in the duration and amount of blood loss.The duration is the most often from 3 to 5 days.
The menstrual flow is called menses.It begins as a pink discharge consisting of cervical mucus and blood and is rich in leucocytes.It is havier in the second and third days when it is dark red in colour and consists of blood,endometrial and cervical secretion,endometrial debris and bacteria.
The discharge has a chracteristic odour caused partly by bacterial action and degeneration,and partly by accompanying secretions of sebaceous and apocrine glands on the vulva.
The total loss of blood varies from 5 to 60 or 80 ml.Small clots are noticed occasionally by 50% of women.

General disturbances associated with menstruation:
Menstruation is frequently accompanieted by minor physical and nervous disturbances.It is estimated that only 20% of wemen are completely free from disconfort.general manifestations mainly occur premenstrually and include a feeling of lethargy and tiredness,malaise,depression,excitability and irritability,headache,fullness and tenderness of the breasts,inability to concentrate and impairment of efficiency and both mental and physical activities.
Other changes:tendency to constipation(with abdominal distention) premenstrually and more frequent motion during menstruation.Nausea and vomiting may occur.Skin changes include shadows under the eyes and few acne spots on the face,back or chest.
One-third of women temporarily gain 1,4kg or more in weight premenstrually.

Management of normal menstruation:
The menstrual discharge is contained either by menas of sanitary pad applied to the vulva or by an absorbant tampon placed within the vagina.In either case regular and frequent chanfge are necessary.
Intravaginal tampons are popular becose they are confortable.It is said that they shorten the apparent duration of the period by 24 hours becose the last day of the flow ordinarily consists only of drainage from the vagina.Their disavantages are:
-they cannot be used unless the hymen is torn or streched
-they are inefficient if the flow is heavy
-you can do toxic shock syndrome(TSS).it can be reduced by using pads at night.
Vaginal douching with deodorant powders or sprays as a hygienic measure at the end of a period,or at any other time,is unnecessary and potentially hurmful becose is washed away the natural protective discharges.The vagina can take care of itself.

Rheumatic Heart Disease

Rheumatic Heart Disease involves the heart after rheumatic fever that causes cartidis.

Rheumatic fever:
Rheumatic fever is a systemic sequela of streptoccocal infection.It may be acute severe(occasionally0 or subacute(commomnly) and may become chronic.
Causes:
Rheumatic fever is a clinical syndrome that fallows Streptococcus Pyogenes infection,after a latent period of 2-3 weeks.It is autoimmune disease that represents hypersensitivity reaction to streptococcal infection.
Incidence:Rheumatic fever is commonly a problem of children and adolescents of 5-15 years,with varied incidence.

Predisposing factors:
-Insanitary environment:poor housing,slum areas,with high crowdness index,crowded badly ventilated classrooms.bedroos and other confined places,faulty habits that favour spred of infection
-Frequent exposure to streptococcal pharyngitis since causative organism has a big number of serptypes.
-Cases of sterptococcal pharyngitis not or improperly given chemotheraphy.
-Host factors:poor living conditions,inheritance.

Characteristics:
-sudden onset of fever,anorexia,epistaxis and precordial and abdominal pain.
-inflammtory involvement of different parts of the body
-case eventually subsides but is more susceptible to repeated attacks of rheumatic fever on repeated streptococcal infection and development of rheumatical heart disease.

Prevention of Rheumatic Fever:
I.Primary prevention:
1.General mesasures:
-community and socioeconomic development with sanitary housing and living conditions
-health promotion,including adequate nutrition.
2.Prevention of streptococcal infection,specially in confined groups of children and adolescents,in schools,institutes and camps.
3.Control of streptococcal disease,specially pharyngitis.

II.Secondary prevention;
Those who have suffered an attack of rheumatic fever must be protected by chemoprophylaxis,against streptococcal infection and recurrent rheumatic fever(given later).

Blood Transfusion Complications

Blood transfusion is lifesaving emergency service,that may be needed for surgical,obstetric,first aid and other purposes.
Transfusion however may be associated with health complications that may arise from:
-body reaction to given blood
-infectious agents from blood donor

Potential Complications of transfusion:
-infection when the donor is infected with hepatitis viruses,ciclomegalo virus,HIV.syphilis,malaria.
-blood incompatibility:when ABO blood type group of donor,other then the O differs from that of recipient
-agglutination and hemolysis of red blood cells
-haemolytic jaundice
-kidney injury:tulbular necrosis'-shock in severe cases
-sensitization of Rh negative female when given Rh positive trasfusion.When married to Rh positive husband,the first infant,supposed not to be affected,would not escape ,since mother is already sensitized by past Rh positive transfusion.
-mild fever,do to presence of pyrogens.

Prevention of Transfusion Complications;
1.Precautions with blood donors-must be healthy,and no addicts,must be free of infection.
blood group ABO and Rh to be registrated in identity and blood donation card
2.Precautions with blood recipients:
-blood grouping ABO and Rh is not determinated before and registrated in identity card
-if the blood grouping is not available and no time or facilities for pretransfusion grouping:group blood O Rh negative blood for females is used.
-supervision of case during and after process of transfusion,for any reaction.

Bronchial Asthma

Bronchial Asthma arises from spasm of the intrapulmonary bronchi.
It is characterized by wheezing and dyspnoea(shortness of breath).
Spasmodic attack of asthma varies in severity,but is usually temporary for short time,then clears up.
The subject is exposed to recurrent attacks at varied intervals.
Exist 2 types of causes:
1.Extrinsic causes:attack of asthma fallows inhalation of external antigenic substances(allergens).Atopic individuals are at-risk of developing asthma,due to hypersensitivity,usually to more than one,and rarely only one,antigen.
Allergenic substances provoking asthma attack:
-Dust:house dust,organic dust in industry.
-Pollen grains,animal hair and fur,bird feathers
-Some drugs as aspirin for exemple.
2.Intrinsic Causes:no history of hypersensitivity,no skin sensitivity reaction is given.So no apparent allergen can ba accused.
Intrinsic causes differs from extrinsic by:
-later age of onset
-more persistent attacks
-less response to bronchodilator drugs

Aggravation factors of asthma:
1.Allergenic substances that provoke extrinsic asthma attacks.
2.Nonspecific factors that may:
-precipitate asthma attack
-increase severity of existing attack(upper respiratory infection,inhalation of respiratory irritants as smoke,tobacco smoke,dust;physical exertion,muscular activity and exercise,emotional disorders as anxiety and anger.
3.Sometimes no obvious precipitating factor is found.

Prevention:
Primary prevention cannot be achieved,due to:
-causative agent is unknown in many cases,specially of intrinsic asthma.
-provoking/precipitating factors of asthmatic attack are not always practically available.
Preventive measures:
-sanitary,clean,plluation-free environment
-healthful lifestyle and open-air recreation
-avoiding exposure to provoking factors.No:smoking or passive smoking,exposure to polluted air,muscular exertion,emotional disturbance,drug abuse.

Megaloblastic Anaemia

Megaloblastic Anaemia is a group of anaemia caused by deficiency of vit.12 or/and folic acid and characterised by the presence ob abnormal red cell precursors in megaloblasts.

Vitamin B12:
-is required 1 mcgm/day
-as sources are;animal foods as liver,kidney and meat.Vegetables contain no vitamin B12.
-parietal cells of the stomach secrete a glycoprotein called the intrinsic factor which combines with vitamin B12.On reaching the terminal ileum specific receptors on the mucosa bind the vitamin B12-intrinsic factor complex thus enabling vitamin B12 to be absorbed.
-2 mg are stored in the liver.This is sufficient to give to body its needs for at least 2 years.
-vitamin B12 is essential for hemopoietic system,gastrointestinal and nervous system.

Folic Acid:
-is required less than 1 mg/day
-as sources are:vegetables and food of animal source.cooking destroys 50-90% folic acid in food
is absorbed from duodenum and jejunum
-is essential for hemopoiesis and gastrointestinal integrity.

Causes of Megaloblastic Anaemia:
1.Vitamin B12 deficiency
-intestinal desease(cause general malabsorption)
-increase demand(infancy and pregnancy)
-adviced liver disease
2.Folic Acid deficiency:
-deficient intake for exemple alcoholics
-malabsorption from upper intestine
-increase demand as vitamin B12
-drugs

Characteristics of Megaloblastic Anaemia:
1.In vitamin B12 deficiency:
-anaemia
-gastrointestinal manifestations:dyspepsia,aorexia,nausea,vomiting and diarrhea,beefy tongue(red,glazed tongue),hepato-splenomegaly.
-nervous manifestations.
2.In folic acid deficiency:anaemia and gastrointestinal manifestations.

Treatment:
For folic acid deficiency:folic acid 5 mg.
For vitamin B12 deficiency:if there are no nervous manifestations 100 mcgm twice weekly untill the red blood cells reach normal then 100 mcgm every month for life.If there are nervous manifestations:1000 mcgm/2 days fro 6 doses,the 100 mcgm/week for 6 months,the 100 mcgm every month for life.
Folic Acid is never given alone for B12 deficiency anaemia as it will increase the nervous manifestations.

Management of Diabetes

The diabete can be managed by:
1.DIET:
-The patient must fix the time and amount of daily food to allow matching of insulin regim to diet.
-Specify the caloric need to maintain desired body weight(for obese patients 1000-1500 kcal/day;for elderly patients 1500-2000 kcal/day;faor young active patient 2000-3000 kcal/day).
-adjust proporton of food elements to avoid atherosclerosis(5% of calories from carbohydrates,20% of calories from fats,30% calories from proteins).
-Reduce the rate of carbohydrate absorption to avoid glycemia peaks(avoid simple sugars,they are rapidly absorbed;carbohydrates should be taken as starches and other complex sugar;consumption of fibre-rich foods causes slowing of sugar absorption;use food with low glycemic index).
-Advice frequent,relatively small meals to avoid hyperglycemia peaks(for exemple 3 meals and 3 sneaks inbetween meals).
The alcohol consumption has many effects on diabetes!

2.ORAL HYPOGLICEMIA DRUGS:(Only by doctor prescription after an examination and blood test)
-Suplhonylures stimulate the release of insulin from pancreas and decrease insulin resistance
-Biguanides reduce glucose absorption from the gut,reduce the appetite,promote anaerobic glycolysis and increase insulin sensitivity.Is contrandicated in case of severe liver and renal disease and pregnancy.

3.INSULIN.
Available insulins:Actrapid and Humalin S(with short acting),Monotard and Humalin M(intermediate),Ultratard and Humalin Zn(long acting).
Methoda of administration;
-injection by syringes
-pen injection device(zinc insulin cannot be ussed)
-infusion devices(using soluble insuline only)
-artificial pancreas(using soluble insulin only).

Management of Diabetes during pregnancy:
The patient should perform daily home blood glucose levels.Urine test are not useful as renal threshould falls in pregnancy.
The patient has to be seen in the outclinic by obstetrician and physician every 2 weeks.
The fundus examination and urine testing for protein should be done when the patient is first seen,at 28 weeks and before delivery,as retinopathy may deteriorate during pregnancy.
Diet control may be enought in mild cases and pregnancy diabetes.If diet control is not enought the control by insulin is needed.Oral agents should be avoided as they cross the placenta,so there is a potential risk for the baby.

Anaemias-Definition,Classification and Manifestations

The anaemia is defined as reduction in number of red blood cells and haemoglobin content of blood with a corresponding reduction in the oxygen carrying capacity of blood.

Classification:

I.Aetiological Calssification:
1.Dyshaemopoietic anaemia:due to deficiency of factors essential for erythropoiesis.
-iron deficiency anaemia
-megaloblastic anaemia:due to B12 or folic deficiency
-anaemia of renal disease:due to erythropoietin deficiency
-anaemia of endocrinal disease:due to pituitary thyroid or suprarenal deficiency
-vitamin C and pyroidoxine deficiency anaemia(very rare0
2.Aplastic anaemia:due of failure of Bore marrow to carry on erythropoiesis.
3.Haemolytic:due to excessive of distruction of red blood cells.
4.Haemorrhagic anaemia:
-acute haemorrhagic anemia:occurs after severe hemorrhage and gives the characteristic of shock
-chronic hemorrhagic aneamia:occurs after repeated slight bleeding and gives the characteristic of iron deficiency anaemia.

II.Morphological Classification;
1.Microcytic-hypochronic anaemia
-iron deficiency anaemia
-anaemia not caused by iron deficiency(sideroblastic anaemia,thalassemia,chronic lead poisoning).
2.Nermocytic-nonmochromic anaemia:
-aplastic anaemia
-hemolytic anaemia
-hemolytic anaemia
-acute hemorrhagic anaemia
-anaemia associated with infection and chronic systemic diseases.
3.Macrocytic-nonchromic anaemia;
-megaloblastic anaemia
-non-megaloblastic anaemia.

General manifestations of anaemia:
1.Skeletal:tiredness,lassitude and easy fatiguability
2.Neurological:lack of concentration,drowziness and may be faintness,headache,tinnitus and black spots before the eyes,may be numbness and tingling in feet and hands.
3.Pallor;this is the most prominent and characteristic sign.It is seen in the face,palm of hand,nail bed and mucus membranes of mouth and conjunctiva.
4.Cardio-vascular:dyspnoea of exertion,palpitation and may be angina,manifestation of hyperdynamic circulation,heart failure may occur in severe cases and sligh oedema of lower limb may occur without heart failure due to increased capillary permeability.
5.Gastro-intestinal:anorexia,flatulence and may be constipation of diarrhea.
6.Genital;menstrual disturbance.
7.renal:slight proteinuria may occur.

Hypothyroidism

Hypothyroidism is presented in two modes:cretinism(during infancy and myxoedema after puberty).

Causes of CRETINISM:
-congenital absence or hypoplasia of thyroid gland
-congenital defect in the enzymes converting iodide into nascent iodine or entering into formation of di-ioothyroisine
-endemic cretinism(due to iodine deficiency)
-an amount use of antithyroid drugs or rasioactive iodine during pregnancy.

Characteristics:
1.General features:
Face:
-puffness of eye lids and depressed nasal bridge
-big lips and large protruding tongue
-delayed dentition and teeth are small
Hands:
-square sharped whit short tapering fingers
-dorsal pad of fat
Disproportionate dwarfsm(the height is more than the span).
Walking is delayed and the gait is waddling due to dysgenesis of the femur head and muscle weakness.
Subnormal body temperature.
2.Skin manifestation;
-dry,rough,scaly.cold skin
-hair is scanty,coarse and britte
-deposition of subcutaneus myxoedematous tissue,particularly on the dorsum of hands,face and suclavian region
3.Nervous Manifestations:
-mental retardation
-slow speaking and thinking and hoarse cry
4.Cardiovascular Manifestations:bradycardia and electrocardiogramma shows low voltage
5.Muscle weakness:together with constipation lead to pot belly abdomen and the umbelical hernia is common.

The treatment in case of hypothyroidism should be started before the elapse of the first year of life to prevent mental retardation.And after the medical prescription Thyroxin is started by 0,025mg/day and gradually increase up to 0.2 mg/day for life.