Traditional Medicine,2007 By  Kyaw Naing Associate.Professor  M.B.B.S, M .Med .Sc (Surgery), FRCS (Edin) FRCS (Glasgow) SU...
Cervical Lymphadenopathy
Cervical Lymphadenopathy
 
 
Anatomy <ul><li>Waldeyer’s ring     palatine tonsils </li></ul><ul><li>lingual tonsil </li></ul><ul><li>adenoids </li></u...
Anatomy 2  <ul><li>Horizontal chain </li></ul><ul><ul><li>sub-mental </li></ul></ul><ul><ul><li>sub-mandibular </li></ul><...
Anatomy 3 <ul><li>Vertical chain     along the internal jugular vein </li></ul><ul><ul><li>Jugulo-digastric node </li></u...
 
 
 
 
 
Slide courtesy of Anton Pozniak
Slide courtesy of Anton Pozniak
 
APPROACH TO THE PATIENT WITH LYMPHADENOPATHY  <ul><li>Generalized immune proliferation and lymphadenopathy can occur with ...
Causes of cervical lymphadenopahty <ul><li>Inflammatory </li></ul><ul><ul><li>reactive hyperplasia </li></ul></ul><ul><li>...
Causes of cervical lymphadenopahty 2 <ul><ul><li>Viral </li></ul></ul><ul><ul><ul><li>infectious mononucleosis </li></ul><...
APPROACH TO THE PATIENT WITH LYMPHADENOPATHY  <ul><li>LYMPH NODE EVALUATION. </li></ul><ul><ul><li>a careful history   </l...
APPROACH TO THE PATIENT WITH LYMPHADENOPATHY  <ul><li>physical examination  </li></ul><ul><ul><li>localized or generalized...
APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND SPLENOMEGALY  <ul><li>METHODS OF LYMPH NODE EVALUATION </li></ul><ul><li>...
Mycobacterium <ul><li>Suspicious when antibiotic therapy fails </li></ul><ul><li>Typical presentation: preschool aged chil...
TB Lymphadenitis <ul><li>common in developing countries </li></ul><ul><li>affects children & young adults </li></ul><ul><l...
TB Lymphadenitis 2 <ul><li>limited to affected group of lymph nodes </li></ul><ul><li>matted lymph nodes due to perilympha...
TB Lymphadenitis 3 <ul><li>Investigations </li></ul><ul><ul><li>laboratory……..T & DC    lymphocytosis </li></ul></ul><ul>...
TREATMENT <ul><li>Anti-tuberculous drugs ( DOTS ) </li></ul><ul><ul><li>INH </li></ul></ul><ul><ul><li>Rifampicin </li></u...
Lymphoma <ul><li>malignant tumour arising from the lymphatic system mainly lymph nodes </li></ul><ul><li>Classification </...
Hodgkin’s Lymphoma <ul><li>types </li></ul><ul><ul><li>lymphocyte predominant </li></ul></ul><ul><ul><li>nodular sclerosis...
Non-Hodgkin’s Lymphoma <ul><li>types </li></ul><ul><ul><li>low grade </li></ul></ul><ul><ul><li>high grade </li></ul></ul>...
Presentation <ul><li>lymphadenopahty </li></ul><ul><ul><li>regional </li></ul></ul><ul><ul><li>wide spread </li></ul></ul>...
Presentation 2 <ul><li>obstructive symptoms  due to enlarged lymph nodes </li></ul><ul><ul><li>Horner’s syndrome    compr...
Histology <ul><li>Reed-Sternberg giant cells are present in Hodgkin’s lymphoma </li></ul>
Management <ul><li>history </li></ul><ul><li>thorough clinical examination </li></ul><ul><li>laboratory   CP, ESR, Urinal...
Management 2 <ul><li>treatment </li></ul><ul><ul><li>mainly chemotherapy </li></ul></ul><ul><ul><li>stage IA, IIA    Radi...
Metastatic Lymph Nodes <ul><li>from primary sites    head & neck </li></ul><ul><ul><li>nasopharynx </li></ul></ul><ul><ul...
Metastatic Lymph Nodes 2 <ul><li>Investigations </li></ul><ul><ul><li>imaging  </li></ul></ul><ul><ul><li>FNAC </li></ul><...
 
 
Anatomy <ul><li>Blood Supply  Superior and inferior  thyroid arteries </li></ul><ul><li>Venous drainage  Superior, middle ...
 
 
Overview of Method <ul><li>General Inspection Around the bed, patient </li></ul><ul><li>Hands Acropachy, sweaty palms </li...
General Inspection <ul><li>Thin / fat </li></ul><ul><li>Muscle wasting </li></ul><ul><li>Nervous / agitated </li></ul><ul>...
General Inspection <ul><li>Inspect from the front </li></ul><ul><li>BMI </li></ul><ul><li>Tremor / Restless / Agitation </...
Neck <ul><li>Inspection </li></ul><ul><li>Stand in front of pt </li></ul><ul><li>Visible? </li></ul><ul><li>Enlarged? </li...
Is   This   a   Thyroid ? <ul><li>Ask patient to stick tongue out while palpating: </li></ul><ul><li>Ask patient to swallo...
Inspection of Hands <ul><li>Temperature </li></ul><ul><li>Palmar Erythema </li></ul><ul><li>Thyroid Acropachy </li></ul><u...
Hands <ul><li>Thyroid acropachy </li></ul><ul><li>clubbing </li></ul><ul><li>digital swelling </li></ul><ul><li>periosteal...
Hands <ul><li>Sweaty palms </li></ul><ul><li>Pulse rate, rhythm </li></ul>
Eye   Disease <ul><li>Examine  from  in front </li></ul><ul><li>from  above </li></ul><ul><li>from  the side </li></ul>
Eye   Disease <ul><li>Lids </li></ul><ul><li>Lid retraction </li></ul><ul><li>Lid lag </li></ul><ul><li>Muscles </li></ul>...
Eye   Disease <ul><li>Lid retraction </li></ul><ul><li>Upper lid pulled back to expose sclera above iris </li></ul>
Eye   Disease <ul><li>Lid lag </li></ul><ul><li>On looking up or down, lid doesn’t follow eyeball </li></ul>
Eye   Signs <ul><li>Inspect from front - lid retraction </li></ul><ul><li>Inspect from side / above .... </li></ul>
Eyes  -  Graves ’  Disease <ul><li>Due to retro-orbital inflammation and lymphocyte infiltration. </li></ul>Exopthalmos Pr...
Eye   Disease
Eye   Disease <ul><li>Exophthalmos </li></ul><ul><li>Sclera visible above and below eye </li></ul>
Eye   Disease <ul><li>Ophthalmoplegia </li></ul><ul><li>Weakness of ocular muscles due to oedema & cellular infiltration o...
Eye   Disease <ul><li>Chemosis </li></ul><ul><li>Ocular injection </li></ul>
Palpation
Palpation <ul><li>Palpate from behind </li></ul><ul><li>Ask about pain! </li></ul><ul><li>Use bimanual palpation </li></ul...
Neck <ul><li>Palpation </li></ul><ul><li>Stand behind pt </li></ul><ul><li>Thumbs on occiput </li></ul><ul><li>Flex neck s...
Neck <ul><li>Palpation </li></ul><ul><li>Abnormality? Size </li></ul><ul><li>Tenderness </li></ul><ul><li>Surface </li></u...
 
Neck <ul><li>Palpate trachea </li></ul><ul><li>?central </li></ul>
Neck / Chest <ul><li>Percussion </li></ul><ul><li>Percuss for a retrosternal goitre </li></ul><ul><li>Pemberton’s test </l...
Neck <ul><li>Auscultation </li></ul><ul><li>Auscultate for a thyroid bruit </li></ul>
Legs <ul><li>Pretibial Myxoedema </li></ul><ul><li>Quad reflexes </li></ul>
Summary Risk Factors Hypothyroidism Hyperthyroidism Family or personal hx of thyroid disease Family or personal hx of thyr...
Clinical   Findings Hypothyroidism Hyperthyroidism Fatigue Fatigue Weight gain Weight loss without change in appetite Cold...
Physical Exam: Thyroid----Related Findings Hypothyroidism Hyperthyroidism Xerosis (dry skin) Moist palms (increased perspi...
 
WOUNDS AP U Kyaw Naing SUII
Definition <ul><li>A wound can be caused by almost any injurious agent and can involve almost any tissue or structure.( du...
Classification of wound <ul><li>Tidy wound </li></ul><ul><ul><li>Inflicted by sharp instrument </li></ul></ul><ul><ul><li>...
<ul><li>Untidy wound </li></ul><ul><ul><li>Result from crushing, tearing, avulsion vascular injury or burn </li></ul></ul>...
Healthy Healing Surgical Wound
<ul><li>Wounds may be classified as  </li></ul><ul><ul><li>Clean </li></ul></ul><ul><ul><li>Potentially contaminated </li>...
Types of wound <ul><li>Incised </li></ul><ul><li>Lacerated  </li></ul><ul><li>Penetrating </li></ul><ul><li>crushed </li><...
Wound Healing <ul><li>Wound healing is the summation of a number of processed which follow injury including </li></ul><ul>...
Phase 1 : Inflammation <ul><li>Coagulation cascade </li></ul><ul><li>PMN polymorpho-nuclear leucocytes </li></ul><ul><li>3...
Phase 2 : Cell proliferation & matrix formation <ul><li>Fibroblast migrate </li></ul><ul><li>Endothelial </li></ul><ul><li...
<ul><li>Process Cell Type Mediator </li></ul><ul><li>Wounding injured cell phospholipase of  </li></ul><ul><li>  prostagla...
Healing by Primary Intention <ul><li>Haemostasis – clotting cascade </li></ul><ul><li>Pro: of inflammation </li></ul><ul><...
<ul><li>Restoration of tensile strength </li></ul><ul><ul><li>Secretion of chemoattractant </li></ul></ul><ul><ul><li>Expa...
Healing by Second Intention <ul><li>A large wound of tissue loss </li></ul><ul><li>Wound contraction </li></ul><ul><ul><li...
<ul><li>Growth factor </li></ul><ul><ul><li>Are peptides </li></ul></ul><ul><ul><li>Endocrine, paracrine, autocrine pathwa...
Stages of Bone Healing <ul><li>Haemorrhage </li></ul><ul><li>Inflammation </li></ul><ul><li>Demolition </li></ul><ul><li>G...
Factors affecting wound healing <ul><li>General factors Local factors </li></ul><ul><li>1. Age 1. Blood supply  </li></ul>...
 
Did this person jump or was he blown out of the building?
Somebody knew what was coming...
Do you think just any lawn would hold up like this after a plane crashed on it?
Not a Scratch!  Perfect Lawn!
Head injuries
 
Surgical cricothyroidotomy
Forearm Fasciotomy
Lower Limb - Fasciotomy
A  survivable airway problem
Tourniquets
Exsanguinating Pelvic Trauma
Complications <ul><li>Infection , Haemorrhage </li></ul><ul><li>Ugly scar </li></ul><ul><li>Keloid </li></ul><ul><li>Incis...
 
Tetanus
Description <ul><li>Clostridium tetani  is the bacterium that causes tetanus, and it is mainly found in the soil. </li></u...
Description <ul><li>There are four main types of tetanus </li></ul><ul><ul><ul><li>Generalized </li></ul></ul></ul><ul><ul...
The Discovery of Tetanus <ul><li>Hippocrates (right) was said to describe tetanus as far back as the 5 th  century B.C. </...
How Tetanus Was Discovered <ul><li>The bacterium  Clostridium tetani  is abundant in soil and Tetanus was produced by inje...
<ul><li>Less than 100 cases per year in the UK </li></ul><ul><li>More prevalent in developing countries </li></ul><ul><li>...
Causal organism <ul><li>Clostridium tetani  </li></ul><ul><li>Gram-positive rod with terminal spores  </li></ul><ul><li>(d...
Pathogenesis <ul><li>Spores of  Clostridium tetani  live in feces, soil, dust an on instrument. </li></ul><ul><li>The spor...
Pathology <ul><li>Clostridium tetani  usually enters the body through a wound. </li></ul><ul><li>The spores germinate, and...
Pathology <ul><li>The toxin  starts out as a polypeptide, and changes into two chains. </li></ul><ul><li>The heavy chain t...
Clinical features <ul><li>Incubation period ( time of injury to first symptom)- 7-10 days, sometimes up to years. </li></u...
<ul><li>Risus sardonicus (a grin-like posture of hypertonic facial muscles) </li></ul><ul><li>Opisthotonus (arched body wi...
Bad prognostic signs <ul><li>Short incubation period </li></ul><ul><li>Rapid progression from trismus to spasms (<48 hours...
Symptoms <ul><li>Begin about 8 days after infection. </li></ul><ul><li>“ Lockjaw” or trismus occurs, which is muscle stiff...
Symptoms <ul><li>Severe muscle spasms occur, bringing many complications: </li></ul><ul><ul><li>Fracture of spine or long ...
Diagnosis <ul><li>History of injury or presence of wound is used. </li></ul><ul><li>History of parental drug use or person...
Diagnosis <ul><li>Differential diagnosis includes: </li></ul><ul><ul><li>Painful conditions of the lower jaw is included <...
Treatment <ul><li>The treatment involves: </li></ul><ul><ul><li>Neutralizing the toxin </li></ul></ul><ul><ul><li>Removing...
Treatment <ul><li>Passive immunization with human immune globulin shortens the course of tetanus and may lesson severity. ...
Treatment <ul><li>The spasms cause by tetanus can be extremely harmful and cause many complications. </li></ul><ul><li>Sed...
Management General treatment <ul><li>Hospitalised the patient </li></ul><ul><li>Isolate the patient in quiet and comfortab...
<ul><li>Clean wounds, debride as necessary </li></ul><ul><li>Use i.v. penicillin or metronidazole for 7 days to destroy th...
<ul><li>Control fever </li></ul><ul><li>Analgesic for muscle pain </li></ul><ul><li>Fluid therapy for daily requirement </...
Specific treatment depends on severity of disease <ul><li>Stage 1. Mild case  (Tonic rigidity alone) </li></ul><ul><li>Ini...
Stage 2. A seriously ill patient <ul><li>Dysphagia and reflex spasm. </li></ul><ul><li>Sedation </li></ul><ul><li>Feeding ...
Stage 3. Dangerously ill patients <ul><li>A major cyanotic convulsion  </li></ul><ul><li>curarisation to maintain relaxati...
<ul><li>Intensive nursing care </li></ul><ul><ul><li>2 hourly position change to prevent bedsore </li></ul></ul><ul><ul><l...
Prevention Prevention of high risk group <ul><li>Pregnant mother ( ATT - first dose at 28 weeks, second dose-6weeks later,...
Prevention at the time of injury <ul><li>Thorough wound debridement </li></ul><ul><li>Penicillin to kill the  Cl. tetani <...
<ul><li>Patient with inadequate or no immunisation </li></ul><ul><ul><li>small risk wound - ATT </li></ul></ul><ul><ul><li...
Prognosis <ul><li>The death rate is high in children and the elderly. </li></ul><ul><li>The worldwide mortality rate is 50...
Prognosis <ul><li>The four types of tetanus all have different mortality rates. </li></ul><ul><ul><li>Generalized tetanus ...
Prognosis <ul><li>The amount of tetanus bound to the nerves affects prognosis, and the more toxin, the poorer the prognosi...
 
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  • Atypical tuberculosis Atypical tuberculosis (TB). Atypical TB, or nontuberculous mycobacteria infections, are well known to cause cervicofacial lymphadenopathy in children. Infections occur predominantly in children between the ages of 2 and 5 and are rare after the age of 12. Although there are many members of this group of bacteria, clinically, infections caused by the MAIS complex ( Mycobacterium avium-intracellulare and Mycobacterium scrofulaceum ) and Mycobacterium kansaii are the most predominant. The significance of these organisms lies in the fact that in previously healthy children under the age of 5 years, the most prevalent cause of chronic lymphadenitis is now nontuberculous mycobacteria. Children most often present with a painless cervical mass that has not responded to antibiotics. Constitutional signs and systemic manifestations of the disease in immunocompetent children are rare. Although all nodes in the cervical region may be affected, the nodes most commonly affected are those in the anterior cervical chain and in the submandibular region. The infection may also commonly involve major salivary glands, especially the parotid. The mass usually begins as a firm, painless, and discrete nodule that fails to respond to conventional antibiotic therapy. As the disease progresses, the mass enlarges and becomes fluctuant. The overlying skin discolors and develops characteristic violaceous changes, eventually leading to skin breakdown with discharge. In the face and neck, the portal of entry is thought to be through the oral and pharyngeal mucosa, skin, conjunctivae, and salivary glands. The treatment for nontuberculous adenopathy is surgery; antituberculous therapy is rarely effective. If caught early before granulomatous liquefaction and skin necrosis have occurred, a trial of a macrolide antibiotic such as clarithromycin or azithromycin may be beneficial. Because of the low recurrence rate, surgical excision of involved nodes (as opposed to incision and drainage, or curettage) is recommended. Taken from: Papsin B, James A, Friedberg J, Forte V, Crysdale W. Atlas of Pediatrics . Edited by Ronald Laxer, Ronald M. Laxer, Elizabeth Lee N. Ford-Jones, Jeremy N. Friedman, J. Ted Gerstle. ©2005 Current Medicine, Inc .
  • Insert picture of thyroid anatomy
  • Add picture of thyroid embryology
  • Papillary ca female pt
  • Symptoms are diplopia, opthalmoplegia (esp in upward gaze), eye discomfort and protrusion. Optic nerve compression may occur - look for a decrease in colour vision. Also look for chemosis and injection in Graves’. For proptosis look from above.
  • The thyroid isthmus lies over tracheal cartilage 2-3.
  • Traditional medicine 2007 by ap u kyaw naing

    1. 1. Traditional Medicine,2007 By Kyaw Naing Associate.Professor M.B.B.S, M .Med .Sc (Surgery), FRCS (Edin) FRCS (Glasgow) SU II,MGH
    2. 2. Cervical Lymphadenopathy
    3. 3. Cervical Lymphadenopathy
    4. 6. Anatomy <ul><li>Waldeyer’s ring  palatine tonsils </li></ul><ul><li>lingual tonsil </li></ul><ul><li>adenoids </li></ul><ul><li>lymphoid tissue around the eustachian tube </li></ul>
    5. 7. Anatomy 2 <ul><li>Horizontal chain </li></ul><ul><ul><li>sub-mental </li></ul></ul><ul><ul><li>sub-mandibular </li></ul></ul><ul><ul><li>pre-auricular </li></ul></ul><ul><ul><li>post-auricular </li></ul></ul><ul><ul><li>occipital </li></ul></ul>
    6. 8. Anatomy 3 <ul><li>Vertical chain  along the internal jugular vein </li></ul><ul><ul><li>Jugulo-digastric node </li></ul></ul><ul><ul><li>Jugulo-omohyoid node </li></ul></ul><ul><ul><li>lymph nodes in the posterior triangle of the neck </li></ul></ul>
    7. 14. Slide courtesy of Anton Pozniak
    8. 15. Slide courtesy of Anton Pozniak
    9. 17. APPROACH TO THE PATIENT WITH LYMPHADENOPATHY <ul><li>Generalized immune proliferation and lymphadenopathy can occur with a </li></ul><ul><ul><ul><li>systemic disorder of the immune system, </li></ul></ul></ul><ul><ul><ul><li>disseminated infection, or </li></ul></ul></ul><ul><ul><ul><li>disseminated neoplasia. </li></ul></ul></ul><ul><li>Malignancies of the immune system might be manifested as : </li></ul><ul><ul><li>localized or </li></ul></ul><ul><ul><li>disseminated lymphadenopathy. </li></ul></ul>
    10. 18. Causes of cervical lymphadenopahty <ul><li>Inflammatory </li></ul><ul><ul><li>reactive hyperplasia </li></ul></ul><ul><li>Infective </li></ul><ul><ul><li>Bacterial </li></ul></ul><ul><ul><ul><li>staphylococcal </li></ul></ul></ul><ul><ul><ul><li>streptococcal </li></ul></ul></ul><ul><ul><ul><li>actinomycosis </li></ul></ul></ul><ul><ul><ul><li>TB & brucellosis </li></ul></ul></ul>
    11. 19. Causes of cervical lymphadenopahty 2 <ul><ul><li>Viral </li></ul></ul><ul><ul><ul><li>infectious mononucleosis </li></ul></ul></ul><ul><ul><ul><li>HIV </li></ul></ul></ul><ul><ul><li>Protozoal </li></ul></ul><ul><ul><ul><li>toxoplasmosis </li></ul></ul></ul><ul><ul><li>Neoplastic </li></ul></ul><ul><ul><ul><li>primary  lymphoma </li></ul></ul></ul><ul><ul><ul><li>secondary  known primary  SCC </li></ul></ul></ul><ul><ul><ul><li>unknown primary </li></ul></ul></ul>
    12. 20. APPROACH TO THE PATIENT WITH LYMPHADENOPATHY <ul><li>LYMPH NODE EVALUATION. </li></ul><ul><ul><li>a careful history </li></ul></ul><ul><ul><li>a thorough physical examination </li></ul></ul><ul><ul><li>laboratory tests </li></ul></ul><ul><ul><li>imaging studies to determine the extent and </li></ul></ul><ul><ul><li>character of the lymphadenopathy </li></ul></ul><ul><ul><li>age of the patient </li></ul></ul><ul><ul><li>The occurrence of fever, sweats, or weight loss </li></ul></ul><ul><ul><li>of a site of infection, a particular medication, a travel history, or a previous malignancy. </li></ul></ul>
    13. 21. APPROACH TO THE PATIENT WITH LYMPHADENOPATHY <ul><li>physical examination </li></ul><ul><ul><li>localized or generalized </li></ul></ul><ul><ul><li>size of nodes </li></ul></ul><ul><ul><li>Texture </li></ul></ul><ul><ul><li>presence or absence of nodal tenderness </li></ul></ul><ul><ul><li>signs of inflammation over the node </li></ul></ul><ul><ul><li>skin lesions </li></ul></ul><ul><ul><li>splenomegaly . </li></ul></ul>
    14. 22. APPROACH TO THE PATIENT WITH LYMPHADENOPATHY AND SPLENOMEGALY <ul><li>METHODS OF LYMPH NODE EVALUATION </li></ul><ul><li>Physical examination </li></ul><ul><li>Imaging </li></ul><ul><ul><li>Chest radiography </li></ul></ul><ul><ul><li>Lymphangiography </li></ul></ul><ul><ul><li>Ultrasonography </li></ul></ul><ul><ul><li>Computed tomography </li></ul></ul><ul><ul><li>Magnetic resonance imaging </li></ul></ul><ul><ul><li>Gallium scanning </li></ul></ul><ul><ul><li>Positron emission tomography </li></ul></ul><ul><li>Sampling </li></ul><ul><ul><li>Needle aspiration </li></ul></ul><ul><ul><li>Cutting needle biopsy </li></ul></ul><ul><ul><li>Excisional biopsy </li></ul></ul>
    15. 23. Mycobacterium <ul><li>Suspicious when antibiotic therapy fails </li></ul><ul><li>Typical presentation: preschool aged child, upper cervical or submandibular mass with overlying violaceous skin. </li></ul><ul><li>Infected nodes may suppurate, and lead to persistent sinus drainage </li></ul><ul><li>PPD will help TB vs NTB </li></ul><ul><li>Treatment: complete excision if possible vs. long term medical management </li></ul>
    16. 24. TB Lymphadenitis <ul><li>common in developing countries </li></ul><ul><li>affects children & young adults </li></ul><ul><li>deep upper cervical nodes are commonly affected </li></ul><ul><li>human strain of Mycobacterium tuberculosis > bovine strain </li></ul><ul><li>atypical mycobacteria in HIV patients </li></ul><ul><li>direct entry from tonsils </li></ul><ul><li>haematogenous spread </li></ul>
    17. 25. TB Lymphadenitis 2 <ul><li>limited to affected group of lymph nodes </li></ul><ul><li>matted lymph nodes due to perilymphadenitis </li></ul><ul><li>natural resistance  calcification </li></ul><ul><li>if failed  cold abscess </li></ul><ul><li>collar stud abscess </li></ul><ul><li>discharging sinus </li></ul>
    18. 26. TB Lymphadenitis 3 <ul><li>Investigations </li></ul><ul><ul><li>laboratory……..T & DC  lymphocytosis </li></ul></ul><ul><ul><li>ESR  high </li></ul></ul><ul><ul><li>Tuberculin test </li></ul></ul><ul><ul><li>Sputum for AFB </li></ul></ul><ul><ul><li>Imaging……….. CXR ( PA ) </li></ul></ul><ul><ul><li>Excisional biopsy  for confirmation by histology & microbiology </li></ul></ul>
    19. 27. TREATMENT <ul><li>Anti-tuberculous drugs ( DOTS ) </li></ul><ul><ul><li>INH </li></ul></ul><ul><ul><li>Rifampicin </li></ul></ul><ul><ul><li>Ethambutol </li></ul></ul><ul><ul><li>Pyrazinamide </li></ul></ul><ul><li>Antibiotics according to C & S </li></ul><ul><li>Multi-drug resistant tuberculosis </li></ul><ul><li>Nutrition </li></ul>
    20. 28. Lymphoma <ul><li>malignant tumour arising from the lymphatic system mainly lymph nodes </li></ul><ul><li>Classification </li></ul><ul><ul><li>Hodgkin’s lymphoma </li></ul></ul><ul><ul><li>Non-Hodgkin’s lymphoma </li></ul></ul>
    21. 29. Hodgkin’s Lymphoma <ul><li>types </li></ul><ul><ul><li>lymphocyte predominant </li></ul></ul><ul><ul><li>nodular sclerosis </li></ul></ul><ul><ul><li>mixed cellularity </li></ul></ul><ul><ul><li>lymphocyte depleted </li></ul></ul>
    22. 30. Non-Hodgkin’s Lymphoma <ul><li>types </li></ul><ul><ul><li>low grade </li></ul></ul><ul><ul><li>high grade </li></ul></ul><ul><ul><li>intermediate </li></ul></ul>
    23. 31. Presentation <ul><li>lymphadenopahty </li></ul><ul><ul><li>regional </li></ul></ul><ul><ul><li>wide spread </li></ul></ul><ul><li>enlarged lymph nodes are rubbery & discrete  bilateral cervical lymphadenopathy </li></ul><ul><li>constitutional symptoms </li></ul><ul><ul><li>intermittent fever, malaise, aches & pain, wt loss </li></ul></ul><ul><ul><li>pruritus </li></ul></ul><ul><ul><li>alcohol induced pain </li></ul></ul>
    24. 32. Presentation 2 <ul><li>obstructive symptoms due to enlarged lymph nodes </li></ul><ul><ul><li>Horner’s syndrome  compression on the sympathetic ganglion </li></ul></ul><ul><ul><li>mediastinal obstruction </li></ul></ul><ul><ul><li>intestinal obstruction </li></ul></ul><ul><ul><li>renal failure </li></ul></ul><ul><li>Hepatosplenomegaly </li></ul>
    25. 33. Histology <ul><li>Reed-Sternberg giant cells are present in Hodgkin’s lymphoma </li></ul>
    26. 34. Management <ul><li>history </li></ul><ul><li>thorough clinical examination </li></ul><ul><li>laboratory  CP, ESR, Urinalysis </li></ul><ul><li>imaging  CXR, USG abdomen </li></ul><ul><li>CT </li></ul><ul><li>Lymphangiogram </li></ul><ul><li>Bone marrow aspiration </li></ul><ul><li>Lymph node biopsy </li></ul>
    27. 35. Management 2 <ul><li>treatment </li></ul><ul><ul><li>mainly chemotherapy </li></ul></ul><ul><ul><li>stage IA, IIA  Radiotherapy….90% survival </li></ul></ul><ul><ul><li>stage IIIA, IIIB  Chemoradiation </li></ul></ul><ul><ul><li>CHOP  cyclophosphamide </li></ul></ul><ul><ul><li>doxorubicin </li></ul></ul><ul><ul><li>oncovin( vincristine ) </li></ul></ul><ul><ul><li>prednisolone </li></ul></ul><ul><ul><li>extensive extra-nodal d/s  poor prognosis </li></ul></ul>
    28. 36. Metastatic Lymph Nodes <ul><li>from primary sites  head & neck </li></ul><ul><ul><li>nasopharynx </li></ul></ul><ul><ul><li>tonsil </li></ul></ul><ul><ul><li>tongue </li></ul></ul><ul><ul><li>pyriform fossa </li></ul></ul><ul><ul><li>supraglottic larynx </li></ul></ul><ul><li>history & clinical examination to find out the primary lesions </li></ul>
    29. 37. Metastatic Lymph Nodes 2 <ul><li>Investigations </li></ul><ul><ul><li>imaging </li></ul></ul><ul><ul><li>FNAC </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>surgery for primary lesion is required & node > 3 cm  en bloc dissection </li></ul></ul><ul><ul><li>--radiotherapy  advanced tumours </li></ul></ul>
    30. 40. Anatomy <ul><li>Blood Supply Superior and inferior thyroid arteries </li></ul><ul><li>Venous drainage Superior, middle and inferior thyroid veins </li></ul>
    31. 43. Overview of Method <ul><li>General Inspection Around the bed, patient </li></ul><ul><li>Hands Acropachy, sweaty palms </li></ul><ul><li>tremor </li></ul><ul><li>Pulse </li></ul><ul><li>Face Peaches and cream complexion </li></ul><ul><li>Eyes Eye disease </li></ul><ul><li>Neck Thyroid, trachea, and lymph nodes </li></ul><ul><li>Legs Pretibial myxoedema </li></ul><ul><li>Reflexes </li></ul>
    32. 44. General Inspection <ul><li>Thin / fat </li></ul><ul><li>Muscle wasting </li></ul><ul><li>Nervous / agitated </li></ul><ul><li>Under-clothed and sweaty </li></ul><ul><li>Overdressed but cold </li></ul><ul><li>Hoarse ( RLN ) / fatiguable voice ( ELN ) </li></ul><ul><li>Stridor </li></ul>
    33. 45. General Inspection <ul><li>Inspect from the front </li></ul><ul><li>BMI </li></ul><ul><li>Tremor / Restless / Agitation </li></ul><ul><li>Eyes </li></ul><ul><li>Hair and Eyebrows </li></ul><ul><li>SCARS </li></ul>
    34. 46. Neck <ul><li>Inspection </li></ul><ul><li>Stand in front of pt </li></ul><ul><li>Visible? </li></ul><ul><li>Enlarged? </li></ul><ul><li>Symmetrical? </li></ul>
    35. 47. Is This a Thyroid ? <ul><li>Ask patient to stick tongue out while palpating: </li></ul><ul><li>Ask patient to swallow water: </li></ul>Should NOT move Should move
    36. 48. Inspection of Hands <ul><li>Temperature </li></ul><ul><li>Palmar Erythema </li></ul><ul><li>Thyroid Acropachy </li></ul><ul><li>Tremor </li></ul><ul><li>Pulse (AF / Tachy) </li></ul>
    37. 49. Hands <ul><li>Thyroid acropachy </li></ul><ul><li>clubbing </li></ul><ul><li>digital swelling </li></ul><ul><li>periosteal new bone </li></ul>
    38. 50. Hands <ul><li>Sweaty palms </li></ul><ul><li>Pulse rate, rhythm </li></ul>
    39. 51. Eye Disease <ul><li>Examine from in front </li></ul><ul><li>from above </li></ul><ul><li>from the side </li></ul>
    40. 52. Eye Disease <ul><li>Lids </li></ul><ul><li>Lid retraction </li></ul><ul><li>Lid lag </li></ul><ul><li>Muscles </li></ul><ul><li>Exophthalmos </li></ul><ul><li>Proptosis </li></ul><ul><li>Ophthalmoplegia </li></ul><ul><li>Periorbital swelling </li></ul><ul><li>Conjunctivae </li></ul><ul><li>Chemosis </li></ul><ul><li>Occular injection </li></ul><ul><li>Optic Nerve </li></ul><ul><li>Optic neuropathy </li></ul>
    41. 53. Eye Disease <ul><li>Lid retraction </li></ul><ul><li>Upper lid pulled back to expose sclera above iris </li></ul>
    42. 54. Eye Disease <ul><li>Lid lag </li></ul><ul><li>On looking up or down, lid doesn’t follow eyeball </li></ul>
    43. 55. Eye Signs <ul><li>Inspect from front - lid retraction </li></ul><ul><li>Inspect from side / above .... </li></ul>
    44. 56. Eyes - Graves ’ Disease <ul><li>Due to retro-orbital inflammation and lymphocyte infiltration. </li></ul>Exopthalmos Proptosis
    45. 57. Eye Disease
    46. 58. Eye Disease <ul><li>Exophthalmos </li></ul><ul><li>Sclera visible above and below eye </li></ul>
    47. 59. Eye Disease <ul><li>Ophthalmoplegia </li></ul><ul><li>Weakness of ocular muscles due to oedema & cellular infiltration of these muscles. </li></ul><ul><li>Superior & Lateral rectus and inferior oblique muscles are affected mostly. </li></ul><ul><li>Paralysis of these muscles prevents the patient looking upwards & outwards. </li></ul>
    48. 60. Eye Disease <ul><li>Chemosis </li></ul><ul><li>Ocular injection </li></ul>
    49. 61. Palpation
    50. 62. Palpation <ul><li>Palpate from behind </li></ul><ul><li>Ask about pain! </li></ul><ul><li>Use bimanual palpation </li></ul><ul><li>Note character of swelling (one lump / multiple lumps / diffuse enlargement) </li></ul>
    51. 63. Neck <ul><li>Palpation </li></ul><ul><li>Stand behind pt </li></ul><ul><li>Thumbs on occiput </li></ul><ul><li>Flex neck slightly </li></ul><ul><li>Palpate </li></ul>
    52. 64. Neck <ul><li>Palpation </li></ul><ul><li>Abnormality? Size </li></ul><ul><li>Tenderness </li></ul><ul><li>Surface </li></ul><ul><li>Consistency </li></ul><ul><li>Discrete nodules </li></ul><ul><li>Moves on swallowing? </li></ul>
    53. 66. Neck <ul><li>Palpate trachea </li></ul><ul><li>?central </li></ul>
    54. 67. Neck / Chest <ul><li>Percussion </li></ul><ul><li>Percuss for a retrosternal goitre </li></ul><ul><li>Pemberton’s test </li></ul>
    55. 68. Neck <ul><li>Auscultation </li></ul><ul><li>Auscultate for a thyroid bruit </li></ul>
    56. 69. Legs <ul><li>Pretibial Myxoedema </li></ul><ul><li>Quad reflexes </li></ul>
    57. 70. Summary Risk Factors Hypothyroidism Hyperthyroidism Family or personal hx of thyroid disease Family or personal hx of thyroid disease Goiter or hx of goiter Goiter or hx of goiter Prior or current thyroid use Prior or current thyroid use Hx of other autoimmune disease Hx of other autoimmune disease   Recent iodine exposure
    58. 71. Clinical Findings Hypothyroidism Hyperthyroidism Fatigue Fatigue Weight gain Weight loss without change in appetite Cold intolerance Heat intolerance Depression or memory impairment Depression or nervousness, irritablility, anxiety or agitation Menstural irregularities (menorrhagia), infertility Menstural irregularities (oligomenorrhea) Weakness, muscle cramps, joint pains Weakness, tremor   Palpitations   Exertional dyspena Constipation Hyperdefecation Hoarseness Anterior neck pain Hypersomnolence Insomnia
    59. 72. Physical Exam: Thyroid----Related Findings Hypothyroidism Hyperthyroidism Xerosis (dry skin) Moist palms (increased perspiration)   Thickening of skin, especially pre-tibial Preorbital puffiness Bulging eyes (lid retraction or proptosis ), unblinking stare   Eye irritation, periorbital edema, diploplia, change in visual acuity ** Delayed relaxation phase, deep tendon reflex Hyperreflexia Dry Coarse hair or alopecia   Bradycardia Tachycardia, atrial fibrillation Non-pitting edema  
    60. 74. WOUNDS AP U Kyaw Naing SUII
    61. 75. Definition <ul><li>A wound can be caused by almost any injurious agent and can involve almost any tissue or structure.( due to trauma) </li></ul><ul><li>A wound is a breach in continuity of epithelium due to trauma . </li></ul><ul><li>An ulcer is a breach in continuity of epithelium. </li></ul>
    62. 76. Classification of wound <ul><li>Tidy wound </li></ul><ul><ul><li>Inflicted by sharp instrument </li></ul></ul><ul><ul><li>Contain no devitalized tissue </li></ul></ul><ul><ul><li>Can be closed primarily with exception of P’ healing . Eg. Surgical wound, cut from glass and knife. </li></ul></ul><ul><ul><li>Clean </li></ul></ul><ul><ul><li>Repair is possible. </li></ul></ul>
    63. 77. <ul><li>Untidy wound </li></ul><ul><ul><li>Result from crushing, tearing, avulsion vascular injury or burn </li></ul></ul><ul><ul><li>Contained devitalised tissue </li></ul></ul><ul><ul><li>Irregular </li></ul></ul><ul><ul><li>Must not be closed primarily </li></ul></ul><ul><ul><li>T – wound excision </li></ul></ul>
    64. 78. Healthy Healing Surgical Wound
    65. 79. <ul><li>Wounds may be classified as </li></ul><ul><ul><li>Clean </li></ul></ul><ul><ul><li>Potentially contaminated </li></ul></ul><ul><ul><li>Contaminated – eg. Bowel perforation </li></ul></ul><ul><ul><li>Dirty – eg. fecal contamination </li></ul></ul>
    66. 80. Types of wound <ul><li>Incised </li></ul><ul><li>Lacerated </li></ul><ul><li>Penetrating </li></ul><ul><li>crushed </li></ul>
    67. 81. Wound Healing <ul><li>Wound healing is the summation of a number of processed which follow injury including </li></ul><ul><ul><li>Phase 1 : inflmmation </li></ul></ul><ul><ul><li>Phase 2 : cell proliferation & matrix formation </li></ul></ul><ul><ul><li>Phase 3 : matrix remodelling </li></ul></ul>
    68. 82. Phase 1 : Inflammation <ul><li>Coagulation cascade </li></ul><ul><li>PMN polymorpho-nuclear leucocytes </li></ul><ul><li>3 – 4 days </li></ul>
    69. 83. Phase 2 : Cell proliferation & matrix formation <ul><li>Fibroblast migrate </li></ul><ul><li>Endothelial </li></ul><ul><li>New capillary & matrix systhesis </li></ul><ul><li>Collagen, proteoglycan & glycoprotein </li></ul><ul><li>Granulation tissue </li></ul><ul><li>Phase 3 : Matrix remodelling </li></ul><ul><li>Reorientation of collagen fibrils </li></ul>
    70. 84. <ul><li>Process Cell Type Mediator </li></ul><ul><li>Wounding injured cell phospholipase of </li></ul><ul><li> prostaglandin </li></ul><ul><li>Coagulation platelets IL-1, PDGF, TGF-B </li></ul><ul><li>Inflammation L FGF </li></ul><ul><li>M </li></ul><ul><li>Angiogenesis Gr TGF-B </li></ul><ul><li>Proteoglycan Syn Fibroblast </li></ul><ul><li>Collagen deposition </li></ul><ul><li>Epithelialisation Epithelial cell EGF </li></ul><ul><li>Remodelling Fibroblast </li></ul><ul><li>( Biological Process in wound repair ) </li></ul>
    71. 85. Healing by Primary Intention <ul><li>Haemostasis – clotting cascade </li></ul><ul><li>Pro: of inflammation </li></ul><ul><li>Cell proliferation and migration </li></ul><ul><li>Epidermal event </li></ul><ul><ul><li>Epidermal cell migration - covering </li></ul></ul><ul><li>Dermal event </li></ul><ul><ul><li>Arrival of neutrophil and macrophage </li></ul></ul><ul><ul><li>Demolition and removal of exudate and debris </li></ul></ul>
    72. 86. <ul><li>Restoration of tensile strength </li></ul><ul><ul><li>Secretion of chemoattractant </li></ul></ul><ul><ul><li>Expansion of fibroblast </li></ul></ul><ul><ul><li>Stimulation of fibroblast to secrete extracellular connective tissue </li></ul></ul><ul><li>Angiogenesis </li></ul><ul><li>Granulation tissue </li></ul><ul><li>Collagen-tensile strength </li></ul><ul><li>scar </li></ul>
    73. 87. Healing by Second Intention <ul><li>A large wound of tissue loss </li></ul><ul><li>Wound contraction </li></ul><ul><ul><li>Movement of wound margin </li></ul></ul><ul><ul><li>Contraction – myofibroblast fibronectin </li></ul></ul>
    74. 88. <ul><li>Growth factor </li></ul><ul><ul><li>Are peptides </li></ul></ul><ul><ul><li>Endocrine, paracrine, autocrine pathway </li></ul></ul><ul><ul><li>PDGF, EGF, TGF@ and B </li></ul></ul><ul><li>Cytokines </li></ul><ul><ul><li>IL1, TNF-@ </li></ul></ul>
    75. 89. Stages of Bone Healing <ul><li>Haemorrhage </li></ul><ul><li>Inflammation </li></ul><ul><li>Demolition </li></ul><ul><li>Granulation tissue </li></ul><ul><li>Callus </li></ul><ul><li>Woven bone formation </li></ul><ul><li>remodelling </li></ul>
    76. 90. Factors affecting wound healing <ul><li>General factors Local factors </li></ul><ul><li>1. Age 1. Blood supply </li></ul><ul><li>2. Vitamin – C, Zinx 2. Infection </li></ul><ul><li>3. Diabetic 3. Haematoma </li></ul><ul><li>4. Jaundice & Uraemia 4. Faulty technique </li></ul><ul><li>5. Cytotoxic drug 5. Tension </li></ul><ul><li>6. Malignancy 6. Steriod </li></ul><ul><li>7. Infection – pus 7. Oxygen </li></ul><ul><li>8. Immunocompromised Pt </li></ul>
    77. 92. Did this person jump or was he blown out of the building?
    78. 93. Somebody knew what was coming...
    79. 94. Do you think just any lawn would hold up like this after a plane crashed on it?
    80. 95. Not a Scratch! Perfect Lawn!
    81. 96. Head injuries
    82. 98. Surgical cricothyroidotomy
    83. 99. Forearm Fasciotomy
    84. 100. Lower Limb - Fasciotomy
    85. 101. A survivable airway problem
    86. 102. Tourniquets
    87. 103. Exsanguinating Pelvic Trauma
    88. 104. Complications <ul><li>Infection , Haemorrhage </li></ul><ul><li>Ugly scar </li></ul><ul><li>Keloid </li></ul><ul><li>Incisional hernia </li></ul><ul><li>Pigmentation </li></ul><ul><li>Marjolin’s ulcer </li></ul>
    89. 106. Tetanus
    90. 107. Description <ul><li>Clostridium tetani is the bacterium that causes tetanus, and it is mainly found in the soil. </li></ul><ul><li>In developed countries, most cases occur in older adults. </li></ul><ul><li>In developing countries, about half of the cases of tetanus are found in neonates. </li></ul>
    91. 108. Description <ul><li>There are four main types of tetanus </li></ul><ul><ul><ul><li>Generalized </li></ul></ul></ul><ul><ul><ul><li>Local </li></ul></ul></ul><ul><ul><ul><li>Neonatal </li></ul></ul></ul><ul><ul><ul><li>Cephalic </li></ul></ul></ul><ul><li>Symptoms of tetanus are cause by disinhibition of the nervous system. </li></ul><ul><li>The source of a tetanus infection is a wound, where Clostridium tetani enters the body. </li></ul>
    92. 109. The Discovery of Tetanus <ul><li>Hippocrates (right) was said to describe tetanus as far back as the 5 th century B.C. </li></ul><ul><li>Nicolaier first produced tetanus in animal specimens. </li></ul><ul><li>Kitasato isolated the organism from a human victim and neutralized the toxin. </li></ul>
    93. 110. How Tetanus Was Discovered <ul><li>The bacterium Clostridium tetani is abundant in soil and Tetanus was produced by injecting soil specimens in animals. </li></ul>
    94. 111. <ul><li>Less than 100 cases per year in the UK </li></ul><ul><li>More prevalent in developing countries </li></ul><ul><li>Following deep or penetrating wound in relatively avascular areas </li></ul>
    95. 112. Causal organism <ul><li>Clostridium tetani </li></ul><ul><li>Gram-positive rod with terminal spores </li></ul><ul><li>(drum stick appearance). </li></ul><ul><li>A strict anaerobe </li></ul><ul><li>Produce powerful exotoxin. </li></ul><ul><li>Exotoxin causes muscle spasms and rigidity </li></ul>
    96. 113. Pathogenesis <ul><li>Spores of Clostridium tetani live in feces, soil, dust an on instrument. </li></ul><ul><li>The spores enter through tiniest breach in skin and mucous membrane </li></ul><ul><li>They may then germinate and produce exotoxin. </li></ul><ul><li>This travel up peripheral nerves and interferes with inhibitory synapse. </li></ul><ul><li>Reduces the release of inhibitory neurotransmitters </li></ul><ul><li>Excess activity of motor neurones produces muscle spasm </li></ul>
    97. 114. Pathology <ul><li>Clostridium tetani usually enters the body through a wound. </li></ul><ul><li>The spores germinate, and two toxins are produced: </li></ul><ul><ul><ul><li>Tetanospasmin </li></ul></ul></ul><ul><ul><ul><li>Tetanolysin </li></ul></ul></ul>
    98. 115. Pathology <ul><li>The toxin starts out as a polypeptide, and changes into two chains. </li></ul><ul><li>The heavy chain travels to the central nervous system, which activates the light chain. </li></ul><ul><li>The light chain releases an inhibitor which causes muscle spasms to occur. </li></ul>
    99. 116. Clinical features <ul><li>Incubation period ( time of injury to first symptom)- 7-10 days, sometimes up to years. </li></ul><ul><li>Period of onset (first symptom to first reflex spasm) - 5-7 days </li></ul><ul><li>Prodromal symptoms (fever, malaise, headache) </li></ul><ul><li>Trismus (patient can not open his mouth) </li></ul>
    100. 117. <ul><li>Risus sardonicus (a grin-like posture of hypertonic facial muscles) </li></ul><ul><li>Opisthotonus (arched body with hyperextended neck) </li></ul><ul><li>spasms (at first may be induced by stimulus but later are spontaneous) </li></ul><ul><li>Dysphagia and respiratory arrest </li></ul><ul><li>autonomic dysfunction (arrythmias, wide fluctuation in BP) </li></ul>
    101. 118. Bad prognostic signs <ul><li>Short incubation period </li></ul><ul><li>Rapid progression from trismus to spasms (<48 hours) </li></ul><ul><li>Tetanus in neonates and old age </li></ul>
    102. 119. Symptoms <ul><li>Begin about 8 days after infection. </li></ul><ul><li>“ Lockjaw” or trismus occurs, which is muscle stiffness in the jaw. </li></ul><ul><li>Autonomic dysfunction. </li></ul><ul><li>Respiration difficulty. </li></ul>
    103. 120. Symptoms <ul><li>Severe muscle spasms occur, bringing many complications: </li></ul><ul><ul><li>Fracture of spine or long bones </li></ul></ul><ul><ul><li>Abnormal heartbeats </li></ul></ul><ul><ul><li>Flexion of arms and legs </li></ul></ul><ul><ul><li>Laryngospam </li></ul></ul>
    104. 121. Diagnosis <ul><li>History of injury or presence of wound is used. </li></ul><ul><li>History of parental drug use or personal IV drug use strengthens diagnosis. </li></ul>
    105. 122. Diagnosis <ul><li>Differential diagnosis includes: </li></ul><ul><ul><li>Painful conditions of the lower jaw is included </li></ul></ul><ul><ul><li>Abnormalities in the peripheral nervous system </li></ul></ul><ul><ul><li>Meningitis </li></ul></ul><ul><ul><li>Bell’s palsy </li></ul></ul><ul><ul><li>Stiffman’s syndrome </li></ul></ul><ul><li>Appropriate history and physical examination can differentiate most of these. </li></ul>
    106. 123. Treatment <ul><li>The treatment involves: </li></ul><ul><ul><li>Neutralizing the toxin </li></ul></ul><ul><ul><li>Removing the source of the toxin </li></ul></ul><ul><ul><li>Supportive care for muscle spasms, respiration, and autonomic instability </li></ul></ul><ul><li>Recovered patients must receive a tetanus immunization series, due to the fact that survivors of tetanus have a greater risk of getting it again. </li></ul>
    107. 124. Treatment <ul><li>Passive immunization with human immune globulin shortens the course of tetanus and may lesson severity. </li></ul><ul><li>Penicillin and metronidazole are the antibiotics commonly used. </li></ul>
    108. 125. Treatment <ul><li>The spasms cause by tetanus can be extremely harmful and cause many complications. </li></ul><ul><li>Sedatives can be used to control spasms. </li></ul><ul><li>Neuromuscular blocking agents are used to relax muscles. </li></ul><ul><li>Metronidazole, diazepam, and benzodiazepine and most commonly used to control spasms. </li></ul>
    109. 126. Management General treatment <ul><li>Hospitalised the patient </li></ul><ul><li>Isolate the patient in quiet and comfortable place with dim lighting. </li></ul><ul><li>Change the position to prevent pressure sore </li></ul>
    110. 127. <ul><li>Clean wounds, debride as necessary </li></ul><ul><li>Use i.v. penicillin or metronidazole for 7 days to destroy the bacteria </li></ul><ul><li>Human tetanus immune globulin (HTIG) 500 U i.m. to neutralise free toxin </li></ul><ul><li>Antitetanus toxoid to get active ammunity </li></ul>
    111. 128. <ul><li>Control fever </li></ul><ul><li>Analgesic for muscle pain </li></ul><ul><li>Fluid therapy for daily requirement </li></ul><ul><li>Care and maintenance of airway during cyanotic convulsion </li></ul>
    112. 129. Specific treatment depends on severity of disease <ul><li>Stage 1. Mild case (Tonic rigidity alone) </li></ul><ul><li>Initial sedation, relaxation by drugs </li></ul><ul><ul><li>promazine up to 200 mg. and a barbiturate or diazepan. </li></ul></ul><ul><li>Feeding orally +/- IV fluid </li></ul>
    113. 130. Stage 2. A seriously ill patient <ul><li>Dysphagia and reflex spasm. </li></ul><ul><li>Sedation </li></ul><ul><li>Feeding by nasogastric tube or total parenteral nutrition </li></ul><ul><li>Tracheostomy should be considered if the patients has any difficulty in breathing. </li></ul>
    114. 131. Stage 3. Dangerously ill patients <ul><li>A major cyanotic convulsion </li></ul><ul><li>curarisation to maintain relaxation. </li></ul><ul><li>Intermittent positive-pressure ventilation should be provided. </li></ul><ul><li>Increasing sedation </li></ul><ul><li>Feeding - total parenteral nutrition, IV fluid </li></ul>
    115. 132. <ul><li>Intensive nursing care </li></ul><ul><ul><li>2 hourly position change to prevent bedsore </li></ul></ul><ul><ul><li>Indwelling urinary catheter change </li></ul></ul><ul><ul><li>Mouth attendance </li></ul></ul><ul><ul><li>Care of tracheostomy, parenteral feeding and feeding line </li></ul></ul><ul><li>If recovery takes place, the patient can be weaned from ventilator. </li></ul>
    116. 133. Prevention Prevention of high risk group <ul><li>Pregnant mother ( ATT - first dose at 28 weeks, second dose-6weeks later, third dose-6 weeks after delivery) </li></ul><ul><li>Infant - ATT 3 doses during infancy and booster dose at 5 years. </li></ul><ul><li>Farmers, labourers - ATT - 3 doses( 6 weeks after first and 6 months after second) . Booster dose for ever 5 years or at the time of injury. </li></ul>
    117. 134. Prevention at the time of injury <ul><li>Thorough wound debridement </li></ul><ul><li>Penicillin to kill the Cl. tetani </li></ul><ul><li>Patient with adequate immunisation </li></ul><ul><ul><li>booster dose of ATT </li></ul></ul>
    118. 135. <ul><li>Patient with inadequate or no immunisation </li></ul><ul><ul><li>small risk wound - ATT </li></ul></ul><ul><ul><li>High risk wound - ATT plus human antitetanus globulin </li></ul></ul><ul><ul><li>followed by second and third dose of ATT at 6 weeks and 6 months interval </li></ul></ul>
    119. 136. Prognosis <ul><li>The death rate is high in children and the elderly. </li></ul><ul><li>The worldwide mortality rate is 50%, and it is 30% in the United States. </li></ul><ul><li>Drug users have a high rate of death because of complications due to the drug. </li></ul><ul><li>Untreated tetanus is usually fatal within a few weeks. </li></ul>
    120. 137. Prognosis <ul><li>The four types of tetanus all have different mortality rates. </li></ul><ul><ul><li>Generalized tetanus has a 50% mortality rate. </li></ul></ul><ul><ul><li>Local tetanus has a 1% mortality rate. </li></ul></ul><ul><ul><li>Neonatal tetanus has a 70% mortality rate. </li></ul></ul><ul><ul><li>Cepahic tetanus has a 15-30% mortality rate. </li></ul></ul>
    121. 138. Prognosis <ul><li>The amount of tetanus bound to the nerves affects prognosis, and the more toxin, the poorer the prognosis. </li></ul><ul><li>Surgical removal of damaged tissue and medical treatment improve prognosis. </li></ul>
    122. 140. Thank You !

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