Directorate of Technical Education
KERALA (Government of Kerala)



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By: T. Asam, M.A., Ph.D.

Associate Professor, George Washington University Medical School

Surgical rium nucleatum can be isolated from oropha- debridement of necrotic tissue may be neces- ryngeal specimens in healthy people antibiotic resistance causes best purchase zitrofar, are sary for patients who do not respond to anti- frequent components of human dental plaque infection treatment buy zitrofar master card, microbial therapy antibiotic ointment for eyes order zitrofar 500 mg mastercard. Invasive associated with Lemierre disease have evidence disease attributable to Fusobacterium species of thrombophilia at diagnosis. Tese fndings has been associated with otitis media, tonsil- ofen resolve over several months and can indi- litis, gingivitis, and oropharyngeal trauma, cate response to the infammatory, prothrom- including dental surgery. Ten percent of cases botic process associated with infection rather of invasive Fusobacterium infections are than an underlying hypercoagulable state. Human infec- Invasive infection with Fusobacterium species tion usually results from F necrophorum subsp can lead to life-threatening disease. Patients with classic Lemierre dis- Fusobacterium species can be isolated using ease have a sepsis syndrome with multiple conventional liquid anaerobic blood culture organ dysfunction. The accurate activity against microaerophilic streptococci identifcation of anaerobes to the species level that can coinfect some patients. Clindamycin has become important with the increasing inci- is generally an efective agent. Fusobacterium dence of microorganisms that are resistant to species are intrinsically resistant to gentamicin, multiple drugs. Up to anaerobic bacteria to the genus or taxonomic 50% of F nucleatum and 20% of F necrophorum group level and, frequently, to the species level. Anaerobic polymicrobial, broad-spectrum therapy fre- blood culture in addition to aerobic blood cul- quently is necessary. Terapy has been advo- ture should be performed to detect invasive cated with a penicillin-?-lactamase inhibitor Fusobacterium species infection. Duration of antimicrobial therapy metronidazole, clindamycin, chloramphenicol, depends on the anatomic location and severity carbapenems (meropenem or imipenem), of infection but is usually several weeks. Resistance to anti- intervention involving debridement or incision microbial agents has increased in anaerobic and drainage of abscesses may be necessary. Metronidazole is the treat- sis, anticoagulation therapy may decrease the ment preferred by many experts but lacks risk of clot extension and shorten recovery time. Courtesy of Centers for anaerobic bacteria including Fusobacterium, Disease Control and Prevention. Fusobacterium fusiforme is a spindle- bacteria that are normal inhabiters of the oral shaped gram-negative bacteria that colonizes cavity, intestine, and female genital tract. Most Giardia intestinalis community-wide epidemics have resulted ( formerly Giardia lamblia from a contaminated drinking water supply; outbreaks associated with recreational water and Giardia duodenalis) have also been reported.

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Intrapartum transmission has also been with IgM antibodies not appearing until 2 to documented when the mother was viremic 3 weeks afer onset of illness and neutralizing around the time of delivery antibiotic basics for clinicians purchase zitrofar in united states online. Immunization history antibiotics for uti urinary tract infection generic 100 mg zitrofar fast delivery, date of symptom onset bacteria 37 degrees celsius order genuine zitrofar line, and information on other arboviruses known Incubation Period to circulate in the geographic area that may Typical range, 2 to 15 days. Longer incubation cross-react in serologic assays should be con- periods can occur in immunocompromised sidered when interpreting results. Acute-phase Colorado tick fever, dengue, and yellow fever serum specimens should be tested for virus- viruses. Immunohistochemical predictive value, but cross-reaction with staining can detect specifc viral antigen in related arboviruses from the same viral family fxed tissue. For most arboviral infections, IgM Antibody testing for common domestic arbo- is detectable 3 to 8 days afer onset of illness viral diseases is performed in most state public and persists for 30 to 90 days, but longer per- health laboratories and many commercial sistence has been documented. Serum collected within 10 days immunohistochemical staining, and testing of illness onset may not have detectable IgM, for less common domestic and international and the test should be repeated on a convales- arboviruses are performed at the Centers for cent sample. A plaque-reduction neutralization test Treatment can be performed to measure virus-specifc The primary treatment for all arboviral disease neutralizing antibodies and to discriminate is supportive. Although various therapies have between cross-reacting antibodies in primary been evaluated for several arboviral diseases, arboviral infections. She was admitted to the hospital with fever, multiple seizures, and a widespread rash; chikungunya virus was detected in her plasma. A, Little fnger of the left hand; B, index fnger of the right hand; C, 4 toes on the right foot. Courtesy of Centers for Disease Control and Prevention/Emerging Infectious Diseases. Courtesy of Centers for Disease Control and Prevention/Emerging Infectious Diseases and Patrick Hochedez. Fortunately, most infected patients improve and their symptoms disappear after 3 to 4 days. About half of the patients who enter the second phase die within 10 to 14 days; the rest recover. Courtesy of Centers for Disease Control and Prevention/Fred murphy, mD, and Sylvia Whitfeld. The epidemiologic importance of C tarsalis lies in its ability to spread western equine encephalomyelitis, St. Louis encephalitis, and California encephalitis and is currently the main vector of West Nile virus in the western united States. Japanese encephalitis is the most common vaccine-preventable cause of encephalitis in Asia. However, about 1 in 200 infections results in severe disease characterized by rapid onset of high fever, headache, neck stiffness, disorientation, coma, seizures, spastic paralysis, and death. Severe disease occurs almost exclusively among people who are immuno- Arcanobacterium compromised. Pharyngitis occurs primarily haemolyticum Infections in adolescents and young adults and is very unusual in young children. Rash is associated primarily with cases hemolysis, and may not be visible for 48 to presenting with pharyngitis and typically 72 hours. Detection is enhanced by culture on develops 1 to 4 days afer onset of sore throat, rabbit or human blood agar rather than sheep although cases have been reported with rash blood agar because of larger colony size and preceding pharyngitis. Presence of 5% car- tions that mimic diphtheria, including mem- bon dioxide also enhances growth.

The posterior oro-pharynx should be medication is a beta agonist inhaler antibiotic for pink eye generic 500 mg zitrofar amex, such as albuterol infection on x ray buy zitrofar 100 mg line. Although there is no single diagnostic test for asthma efficacy of antibiotics for acne discount zitrofar on line, albuterol is required more than a few times a week, a spirometry with bronchodilator responsiveness is a controller medication should be initiated. Most patients patients, this means a steroid inhaler, although some with asthma will have normal pulmonary function patients respond well to leukotriene modi?ers as ?rst- when not having an exacerbation, so this ?nding does line therapy. If the patient is symptom- higher-dose steroid inhalers or the addition of a long- atic, the spirometry should show an obstructive pattern acting beta agonist can be considered. An alternative way to demon- measurements with thresholds for increasing therapy strate this is with ambulatory peak ?ow monitoring. National Asthma Education and Prevention Project: Update on selected topics, 2002. A complete history and physical examination are crucial birefringent crystals, whereas rhomboid-shaped, posi- and are the most useful tools for making the correct tively birefringent crystals indicate calcium pyrophos- diagnosis. In patients 60 years of age, consider screening ligaments, tendons, bursae, or soft tissues. Pain may also for associated disorders such as hemochromatosis, hy- be referred from a neuropathic condition or pathology perparathyroidism, and hypothyroidism. Monarthritis of acute onset (hours to calcium hydroxyapatite crystals is more dif?cult be- days) usually indicates trauma, infection, or a crystal- cause it requires electron microscopy or Alizarin Red induced process. If analysis of synovial ?uid does not reveal the diagno- condition such as atypical infection, osteoarthritis, sis, radiographs of the affected joints and contralat- tumor, or systemic in?ammatory disease. Aspiration of the affected joint for synovial ?uid analy- include osteoarthritis and chondrocalcinosis (suggest- sis is always indicated to evaluate monarthritis. Repeat synovial ?uid analy- tests do not generally improve diagnostic sensitivity. In endemic areas, a measurement to separate nonin?ammatory from in- Lyme titer should be sent, especially if there is a his- ?ammatory processes. With appropriate clinical corre- tory of rash, tick bite, or appropriate exposure. Polymorphonuclear detecting a systemic in?ammatory disease such as an leukocyte-predominant effusions ( 75% cell count) atypical presentation of rheumatoid arthritis or sys- also indicate an acute in?ammatory process. If the diagnosis is still not clear, close observation is rapid treatment is warranted to prevent irreversible warranted. Alternatively, additional axial or peripheral may be divided into nongonococcal and gonococcal arthritic symptoms may develop to suggest evolution causes. Gram-positive organisms, particularly Staphylo- into a systemic in?ammatory disease. Nongonococcal in- sis, synovial biopsy should be considered to diagnose fection is often associated with a primary focus of infec- tuberculous or fungal infections, amyloid, pigmented tion elsewhere. Nonin?ammatory, nonbloody effusions should prompt tion should be presumed to represent septic arthritis. Neuropathic arthropathy is most ing macules, pustules, and vesicles, may also be pres- commonly associated with diabetes but may occur in a ent. In such cases, synovial biopsy is there is a history of trauma with persistent clicking, lock- warranted for further diagnosis. A thorough history and physical examination are re- inside the ears, gluteal cleft, lateral margins of the quired for the evaluation of polyarthritis. Historical feet), nail pitting, dactylitis (sausage digit), diarrhea features of interest include duration of symptoms; prior or abdominal pain, urethritis, pyoderma gangreno- episodes of arthritis; and distribution, presence, and sum, uveitis, or keratoderma blennorrhagica.

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The visceral surface of the liver comes into contact with several viscera that are as follows (28 antibiotic journal articles discount 250mg zitrofar with amex. A strip along the inferior margin of the liver comes in contact with the transverse colon bacteria pilorica order zitrofar 250mg online. The oesophagus comes in contact with a depression to the left of the upper end of the fssure for the ligamentum venosum antibiotics for dogs cephalexin side effects buy zitrofar online. The part of the visceral surface to the left of the fssure for the ligamentum venosum and the ligamentum teres comes in contact with the stomach, and with the lesser omentum. The area for the stomach is in the form of a shallow depression called the gastric impression. The frst part of the duodenum crosses the upper part of the gall bladder, while the superior duodenal fexure comes into contact with an area immediately to the right of the upper part of the gall bladder. To the right of the area for the superior duodenal fexure, and above the area for the transverse colon, the visceral surface bears a large impression for the right kidney. The liver comes in contact with the right suprarenal gland above and medial to the impression for the kidney. The suprarenal produces a depression on the bare area immediately to the right of the lower part of the inferior vena cava. The liver has been traditionally divided into right and left lobes using certain surface features. On the anterior and superior parts of the diaphragmatic surface, the line of demarcation is the attachment of the falciform ligament. On the posterior part of the diaphragmatic surface, the line of demarcation is the fssure for the ligamentum venosum. On the visceral surface, the demarcation is by the fssure for the ligamentum teres. According to this plan of division, the caudate and quadrate lobes form part of the right lobe. The liver is drained by two hepatic ducts, right and left which join to form the common hepatic duct. It is rational to regard the territory drained by the right hepatic duct as the true right lobe and that drained by the left hepatic duct as the true left lobe. On the visceral surface, the line of demarcation between these territories lies roughly along the fossa for the gall bladder. On the posterior part of the liver, the line lies along the groove for the inferior vena cava. On the anterosuperior part of the diaphragmatic surface, the line is not marked by any surface feature. It can be represented roughly by a line joining the fundus of the gall bladder and the upper end of the inferior vena cava (red lines in 28. Note that the caudate and quadrate lobes lie in the territory drained by the left hepatic duct. Each lobe, thus defned is divisible into a number of segments based on the branching pattern of the hepatic ducts within the liver. On the visceral surface it corresponds to the quadrate lobe, and the caudate lobe. The medial and lateral parts of the left lobe are each divided into superior and inferior segments.

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When these two Dorsal rami of cervical (lower half) bone on back of mastoid muscles of both sides nerves 2 antibiotic kinds zitrofar 500 mg discount. Vertebral spines C7 process and occipital contract the head is to T3 bone below lateral 1/3 of pulled backwards superior nuchal line) 2 antibiotics for sinus infection online purchase zitrofar 500mg amex. When muscles of one Splenius cervicis Vertebral spines T3 to T6 Vertebrate C1 antimicrobial resins purchase cheapest zitrofar and zitrofar, C2, C3(? Extensor and lateral Dorsal rami of cervical U-shaped three main parts: fexor of vertebral nerves tendon. Slightly rotates face tebrae, and vertebra C7 superior and inferior opposite side to opposite side 2. This is a group of small muscles placed in the uppermost part of the back of the neck, deep to the semispinalis capitis. The anterior triangle is further divided into four smaller triangles by the digastric and the omohyoid muscles as follows: a. The space between the anterior bellies of the digastric muscles of the two sides is the submental triangle. Collectively, these Dorsal ramus of posterior minor part of area below inferior muscles maintain frst cervical nuchal line) position of the head nerve Rectus capitis Axis vertebra (from spine) Occipital bone (lateral 2. The two recti and the posterior major part of area below inferior superior oblique extend nuchal line) the head (against gravity) 3. The obliquus capitis Obliquus capitis Axis vertebra (from spine) Atlas vertebra (transverse inferior rotates the head inferior process) turning the face to its Obliquus capitis Atlas vertebra (transverse Occipital bone (lateral part own side superior process) of area between superior 4. The rectus capitis and inferior nuchal posterior major can also lines) produce slight rotation to its own side 5. In addition to the above, the suboccipital triangle is present deep in the upper part of the back of the neck, and is bounded by the suboccipital muscles. The lower part of the posterior triangle is crossed by the inferior belly of the omohyoid muscle that divides the triangle into: a. The muscles forming the foor are covered by the prevertebral layer of deep cervical fascia. The roof of the posterior triangle is formed by the investing layer of deep cervical fascia. Superfcial to the deep cervical fascia the posterior triangle is covered by superfcial fascia and skin. Several nerves and vessels are present in relation to the roof of the posterior triangle. Cutaneous branches of the cervical plexus (supraclavicular, lesser occipital, great auricular and transverse cutaneous) enter the posterior triangle by piercing the fascia over its foor, and run for some distance between the foor and roof, before piercing the latter to become subcutaneous. Muscular branches arising from the cervical plexus for the levator scapulae and trapezius run deep to the fascia of the foor. The spinal accessory nerve runs downwards and laterally across the triangle lying between the two layers of the fascia forming the roof. The subclavian artery (surrounded by the axillary sheath) runs across the lowest part of the posterior triangle. The transverse cervical artery runs backwards a little above the posterior belly of the omohyoid muscle. Above and laterally, this triangle is bounded on each side (right and left) by the anterior belly of the digas- tric muscle. The only contents of the triangle are the submental lymph nodes, and some small blood vessels. Skin, superfcial fascia (containing the platysma, the cervical branch of the facial nerve and some cutaneous nerves).

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