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As blood passes through the vessels of the skin order fluticasone master card asthma definition 8 ohms, heat would be dissipated to the environment discount 250mcg fluticasone asthmatic bronchitis life expectancy, and the blood returning to your body core would be cooler. Proteins and other compounds in blood act as buffers, which thereby help to regulate the pH of body tissues. Composition of Blood You have probably had blood drawn from a superficial vein in your arm, which was then sent to a lab for analysis. Other blood tests check for the composition of the blood itself, including the quantities and types of formed elements. It is performed by spinning the blood sample in a specialized centrifuge, a process that causes the heavier elements suspended within the blood sample to separate from the lightweight, liquid plasma (Figure 18. Because the heaviest elements in blood are the erythrocytes, these settle at the very bottom of the hematocrit tube. Located above the erythrocytes is a pale, thin layer composed of the remaining formed elements of blood. This layer is referred to as the buffy coat because of its color; it normally constitutes less than 1 percent of a blood sample. Above the buffy coat is the blood plasma, normally a pale, straw- colored fluid, which constitutes the remainder of the sample. The hematocrit of any one sample can vary significantly, however, about 36–50 percent, according to gender and other factors. Normal hematocrit values for females range from 37 to 47, with a mean value of 41; for males, hematocrit ranges from 42 to 52, with a mean of 47. So the mean plasma percentage is the percent of blood that is not erythrocytes: for females, it is approximately 59 (or 100 minus 41), and for males, it is approximately 53 (or 100 minus 47). It floats at the top of the tube separated from the heaviest elements, the erythrocytes, by a buffy coat of leukocytes and platelets. Characteristics of Blood When you think about blood, the first characteristic that probably comes to mind is its color. Blood that has just taken up oxygen in the lungs is bright red, and blood that has released oxygen in the tissues is a more dusky red. This is because hemoglobin is a pigment that changes color, depending upon the degree of oxygen saturation. Viscosity is a measure of a fluid’s thickness or resistance to flow, and is influenced by the presence of the plasma proteins and formed elements within the blood. Although the surface of blood vessels is relatively smooth, as blood flows through them, it experiences some friction and resistance, especially as vessels age and lose their elasticity, thereby producing heat. Blood is therefore somewhat more basic (alkaline) on a chemical scale than pure water, which has a pH of 7. Blood Plasma Like other fluids in the body, plasma is composed primarily of water: In fact, it is about 92 percent water. There are literally hundreds of substances dissolved or suspended in the plasma, although many of them are found only in very small quantities. Serum, one of the specimen types included, refers to a sample of plasma after clotting factors have been removed. Plasma Proteins About 7 percent of the volume of plasma—nearly all that is not water—is made of proteins. These include several plasma proteins (proteins that are unique to the plasma), plus a much smaller number of regulatory proteins, including enzymes and some hormones. The three major groups of plasma proteins are as follows: • Albumin is the most abundant of the plasma proteins. Manufactured by the liver, albumin molecules serve as binding proteins—transport vehicles for fatty acids and steroid hormones. Recall that lipids are hydrophobic; however, their binding to albumin enables their transport in the watery plasma. Albumin is also the most significant contributor to the osmotic pressure of blood; that is, its presence holds water inside the blood vessels and draws water from the tissues, across blood vessel walls, and into the bloodstream. Albumin normally accounts for approximately 54 percent of the total plasma protein content, in clinical levels of 3. The alpha and beta globulins transport iron, lipids, and the fat-soluble vitamins A, D, E, and K to the cells; like albumin, they also contribute to osmotic pressure. The gamma globulins are proteins involved in immunity and are better known as an antibodies or immunoglobulins. Although other plasma proteins are produced by the liver, immunoglobulins are produced by specialized leukocytes known as plasma cells. These include various electrolytes, such as sodium, potassium, and calcium ions; dissolved gases, such as oxygen, carbon dioxide, and nitrogen; various organic nutrients, such as vitamins, lipids, glucose, and amino acids; and metabolic wastes. When more than a few drops of blood are required, phlebotomists perform a venipuncture, typically of a surface vein in the arm. They perform a capillary stick on a finger, an earlobe, or the heel of an infant when only a small quantity of blood is required. After collection, the blood may be analyzed by medical laboratories or perhaps used for transfusions, donations, or research. While many allied health professionals practice phlebotomy, the American Society of Phlebotomy Technicians issues certificates to individuals passing a national examination, and some large labs and hospitals hire individuals expressly for their skill in phlebotomy. The information they provide is essential to the primary care providers in determining a diagnosis and in monitoring the course of a disease and response to treatment. Although one type of leukocyte called memory cells can survive for years, most erythrocytes, leukocytes, and platelets normally live only a few hours to a few weeks. When you donate a unit of blood during a blood drive (approximately 475 mL, or about 1 pint), your body typically replaces the donated plasma within 24 hours, but it takes about 4 to 6 weeks to replace the blood cells. The process by which this replacement occurs is called hemopoiesis, or hematopoiesis (from the Greek root haima- = “blood”; -poiesis = “production”). Sites of Hemopoiesis Prior to birth, hemopoiesis occurs in a number of tissues, beginning with the yolk sac of the developing embryo, and continuing in the fetal liver, spleen, lymphatic tissue, and eventually the red bone marrow. Following birth, most hemopoiesis occurs in the red marrow, a connective tissue within the spaces of spongy (cancellous) bone tissue. In children, hemopoiesis can occur in the medullary cavity of long bones; in adults, the process is largely restricted to the cranial and pelvic bones, the vertebrae, the sternum, and the proximal epiphyses of the femur and humerus. This process is referred to as extramedullary hemopoiesis (meaning hemopoiesis outside the medullary cavity of adult bones). When a disease such as bone cancer destroys the bone marrow, causing hemopoiesis to fail, extramedullary hemopoiesis may be initiated. Differentiation of Formed Elements from Stem Cells All formed elements arise from stem cells of the red bone marrow. Recall that stem cells undergo mitosis plus cytokinesis (cellular division) to give rise to new daughter cells: One of these remains a stem cell and the other differentiates into one of any number of diverse cell types.

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The dermis contains the blood vessels order fluticasone 250mcg mastercard asthma treatment costs in sc, nerves purchase fluticasone amex asthmatic bronchitis triggers, muscles sebaceous glands, sweat glands, hair follicles Ends of the sensory nerves (sensations like heat, cold, touch, pain) Blood vessels supply nutri­ ents and regulates the body temperature. Superficial : Only epidermis (eg) Sunburn Partial thickness : Destroys epidermis, Pain, Blister formation Full thickness : No pain sensation, skin scared. Assessing a Burn Types of Burn Causes of the burn Dry burn Flames, contact with hot objects Scald Steam, Hot liquids Electrical Burn High Voltage currents over head cables lighting strikes Frost bite Cold injury Frost bite Chemical burn Industrial chemicals, inhaled fumes and corrosive gases, chemical agents Radiation burns Sun burn, over exposure to ultra – violet rays, Expose to radio active sources. Assess for: Pain, difficulty in breathing, signs of shock Aims: (1) To stop the burning and relieve pain (2) To maintain an open airway(3)To minimize the risk of infection (4) To arrange urgent removal to hospital (5) Principles to be followed stop, drop and roll (6) Help the causality to lie down (7) Continue cooling the affected area (8) Cover the injured area with sterile/clean cloth to protect from infection. If the causalty is unconscious, make sure that the casualty is in safe area, open the causalty’s airway and check for breathing and do C. Do not approach the causalty of high voltage electricity until the current has been switched off and isolated. Chemical burn to the eye, first aider is to wash out the eye so that the chemical is diluted and dispersed. Complaints of headache, dizziness, confusion loss of appetite and nausea, sweating with pale and clammy skin, cramps in the arm, legs and abdomen, Rapid pulse and breathing. Head ache, dizziness, discomfort, restless ness, Hot & 0 0 flushed, dry skin, bounding pulse, high temperature above 104 F (40 C). Causes of Fractures: Direct Force: A bone can be fractured at the point where the force of a blow is applied. In an open fracture, one of the broken bone ends may pierce the skin surface or there may be a wound at the fracture site. Complicated fractures: They occur when the jagged ends of the bone fragments damage blood ves­ sels, nerves or a joint, broken bones in the chest may penetrate the lung, heart or liver. Depressed fractures: These occur in the skull when the broken ends of the bones are pressed in­ wards. Pathological Fractures: These occur when the bone is weakened by loss of calcium, infection or cancer. In old age the bones are more brittle, and may break spontaneously due to calcium loss which is part of the ageing process. People who are drowned may not be able to call for help because they expend all their energy to breathe or to keep the head over water. The drowning sequence: Begins with panic or struggle followed by submersion with breath holding, then water swallowing before passing out, within 3 minutes of being under water, loss of consciousness, within 5 minutes, brain suffers damage, then the heart goes into irregular rhythm before it stops breath­ ing. Additional Care Measures : (1) When you can place him on a firm surface, check breathing and pulse and continue resuscitation if necessary (2) As soon as the casualty begins breathing, place in recovery position. Effects of hemorrhage: The loss of red blood cells causes a lack of oxygen to the tissues of the body. Direct pressure: Place your hand directly over the wound and apply pressure, firm and steady until the bleeding stops. Elevation: Elevate the bleeding part of the body above the level of the heart so that the flow of blood will slow down in that part and blood clothing take place. Pressure Points: Applying pressure over the pressure points pressing over the underlying bone pres­ sure points on the arms (brachial pressure point) on the groin (femoral pressure point). Applying a tourniquet: A standard tourniquet is a piece of web belting about 36" long with a buckle device to hold it tightly in place when applied. Management: Apply direct pressure over the wound with your fingers and palms, with clean pad/cloth you can ask the casuality to apply direct pressure herself. If you suspect the casuality is going into shock, raise and support her legs so that they are above the level of her heart. Dial for an ambulance and transport the casuality to hospital till then the first aider should not leave the casuality until taken over by doctor or nurse. Advise her not to speak, swallow, cough spit because she may disturb the blood clots that have formed in the nose. The nervous system is affected and later if the condition of shock continues, the circulation of blood gradually fails and the patient dies. Prompt first aid treatment is needed to prevent shock increasing, and to help the patient to recover from the primary shock. And look pale, or he may collapse with signs and symptoms as follows: (1) He feels faint, weak and giddy. If shock is severe, raise the lower part of the body unless is injury to the head nor chest 3) Loosens tight clothing, but do not remove clothing 4) If he feels cold, cover him with the blanket, but do not try to warm him by any means 5) Offer him a warm sweat drink, e. Avoid causing pain 7) If there are severe injuries, or shock increases, get the causality to the health center or hospital without delay. Aims of first aid treatment: 1) Have the source of electricity switched off 2) Check breathing, and give artificial respiration immediately if he is not breathing. To bandage a limb, work from below upwards, and from inside towards the outside over the front of the limb. Finish in front, not over the wound, and fix the end with a safety pin, sticking plaster, stitching, or by tearing the end into two tails and tying. The completed bandage should be comfortable, look neat and fulfil its purpose with no restriction of circulation. Choosing the Correct Size :Before applying a roller bandage, check suitable width for the injured area Applying a Roller Bandage: Keep the roller part of the bandage (Head) upper most as your work (the unrolled part) is called the “tail”. Stand in front of the casualty except in cape line (Head bandaging and eye bandage are applied standing behind the client). Splinting:Splints can be made out of wood, card board, iron rods used to support the fractured part and for immoblization. To make two bandages, take a 1 metre square piece of strong cotton cloth, cut in across from corner, and hem the edges. The long side is called the ‘base’, and the corner opposite to it the ‘point’, The bandages may be applied opened out or it can be folded into a ‘broad’ or ‘narrow’ bandages. Three types of slings are used: Large Arm sling: This is used in cases of simple rib fracture and for fracture of the forearm. With the casualty’s forearm flexed and fingers touching the opposite shoulder, a clove hitch, made from a narrow bandage, is placed round his wrist. The ends of the bandages are taken around the neck and tied in the hollow just above the collar bone, on the injured side. First place the open bandage across the chest with the point beyond the elbow and one end over the hand. Take the end behind the elbow across the back and tie to the first end with the knot just in front of the shoulder, on the uninjured side. Improvised Slings : The lower edge of the casualty’s coat or shirt may be turned up and pinned to support the arm, or the hand may be passed inside a buttoned up coat. Fold a narrow hem at the base, place it just above the eyebrows, then take the two ends backwards, cross them below the occiput with the point underneath, then back to the forehead where they are tied. Signs and Symptoms: Headache, dizziness, discomfort, restless ness, Hot & flushed, dry skin, bounding 0 0 pulse, high temperature above 104 F (40 C), rapid unconsciousness First aid: 1) Remove the patient to dry and shady place, loosening his collar, and other tight clothings. First aid: 1) Replace the sodium with salt tablets or an electrolyte solution 2) Adding salt in the diet will prevent heat cramps Points to prevent heat injury: 1) Limiting the strenuous activities in the hot weather 2) Stay indoors and wear a minimum of clothing’s during heat waves.

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At the end of the course order cheapest fluticasone and fluticasone asthma with acute exacerbation, students are expected to differentiate self limiting condition from sight threatening conditions order fluticasone 250 mcg visa asthma 504 plan example; and to act early. If they are neglected and mismanaged they will complicate to the extent of sight threatening condition. Those patients who will not have improvement in less than 48 hrs need referral to a better center for better management. Epidemiology The prevalence of each is different in pediatric and adult population. The vast majority of pediatric cases are bacteria, while in adult’s bacterial and viral causes are equally common. Bacterial conjunctivitis • Commonly caused by staphylococcus aureus, streptococcus pneumonia, Hemophilic influenza, and moraxella catarrhalis • S. Symptoms:- • Patients typically complain of redness and discharge in one eye; although it can also be bilateral. Sign: - • On examination, patients will typically have purulent discharge at the lid margins and in the corners of the eye. More purulent discharge appears within minutes of wiping the lids • Red eye – due to dilatation of superficial blood vessels as apart of inflammation 36 • Edema of the conjunctiva (chemosis) and eyelids swelling • Cornea is mostly clear; but if it is involved, there will be different degree of corneal opacity it is common special in untreated and delayed patients (see color plate14) Diagnosis - Mostly clinical - Gram stains Course - It lasts for 1 - 2 weeks and then it usually resolves spontaneously. Symptoms _ Red eye _ Severe and persistent itching of both eyes _ Mucoid eye discharge _ No visual reduction Signs _V/A is normal _ papillary reaction to hypertrophy on tarsal conjunctiva Treatment _ Cold compress _Vasoconstrictor-antihistamine like cromolyn sodium _ Topical steroid -Terracortril eye suspension Neonatal Conjunctivitis (Ophthalmia Neonatorum) Defn: is conjunctivitis in a newborn (in the first 28 days of life) Etiology Gonococcus and Chlamydia are the commonest cause of which gonococcal is most serious Symptoms - profuse thin to thick purulent eye discharge Sign - purulent eye discharge, eye lids are swollen - If cornea is involved, ulcer, scarring, lately cornea will shrink. Treatment - It is sight threatening condition that needs systemic antibiotic and close follow up in better ophthalmic center - Start with tetracycline eye ointment 3-4 times a day - Urgent referral to ophthalmic center for further evaluation and management 38 Prevention - The eye lids should be cleaned with saline swabs as soon as the head was born and before the infant‘s eyes opened. The diagnosis of such diseases need experienced ophthalmic worker, appropriate instruments and especial diagnostic tests and procedures. Their visual out come highly depends on the time interval between onset of the disease and initiation of treatment and subsequent close follow up. Symptoms - Painful red eye - Sudden reduction of vision - Rapid progressive visual impairment. Symptoms - Painful disorder-typically a constant severe boring pain that worsens at night or in the early morning hours and radiates to the face and 42 periorbital region. To give a general over view on the burden of blindness on global and country levels 2. To give a clear idea on the disease that have been launched by vision 2020 to control disease 4. The hope is that by the year 2020 most of the avoidable blindness in the world should be eliminated, so that everyone in the world except those with untreatable and unavoidable disease should have a visual acuity of 20/20 by the year 2020. The three main components (priorities) of Vision 2020 are 1-human resources development 2- Infrastructure and appropriate technology 3- Disease control (cataract, trachoma, onchocercaisis, childhood blindness, refractive error glaucoma and low vision). The result of these two factors means that the population aged over 60 years will double during the next 20 yrs from approximately 400 million now, to around 800 million in 2020. This increase in the elderly population will result in a greater number of the people with visual loss and blindness from cataract that will need eye services. A figure of 1000 new blind people from cataract per million populations per year is used for planning purpose in developing countries. Progress of the disease Some patient develops mature cataract only in a few months after a sign of opacity in the lens, others with early opacity may persist in the lens for many years without obvious progress at all. Signs - Reduced V/A - Whitish opacity seen through the pupil(see color plate3) Complication of unoperated cataract ™ Dislocation or sublaxation of lens ™ Glaucoma ™ Uveitis Operable cataract eyes The term is used to define a cataract where the patient and the surgeon agree to proceed with cataract surgery. It is a Greek word meaning ‘rough’ which describes the surface appearance of the conjunctiva. Trachoma tends to be found in dry rural areas, where lack of water and bad living conditions may facilitate the spread of the disease. Trachmatos inflammation becomes increasingly intense in children up to the age of six to eight years. Scars on the inside of the eye lids, caused by trachoma, can be found in children from the age of four years. Scarring is increasingly common in older children, but the serious complication of inturned eye lashes and corneal scarring do not usually appear before adult age. Trachoma in the community The severity of trachoma can vary from one community to another because of differences in the eases of spread of infection. Children are the main reservoir of Trachomatous infection, as they are commonly and heavily infected. Compared to men, women tend to have more severe trachoma, including inturned eyelashes and blindness, probably re infected by children for whom they care. Central and sufficiently dense to obscure the part of pupil Aims of simplified trachoma grading 1. To facilitate all health workers the recognition of the signs of trachoma and its complications 2. To enable health workers to assist in undertaking simple surveys to identify communities in need of measures to control blindness from trachoma. To allow for easy evaluation, by health workers, of results of trachoma control efforts in identified communities. Other terms, commonly used in older classification of trachoma, can be related to the present scheme. The number of people with Trichiasis (1%or more); this indicates the immediate need to provide surgical services for lid correction 5. Doxycycline 100mg po/d for 21 days, don’t give for children below 7 years, pregnant and lactating mother B. For community treatment of trachoma, mass distribution of tetracycline ointment is carried out especially during epidemics of conjunctivitis at intervals for five consecutive days per month for six months. The eye acts as a convex lens and parallel rays of light are focused on the retina. For this reason during distance vision testing the patient is seated 6 meters from the test chart. Most of the refraction in the eye is done by the cornea (2/3) the rest being by the lens (1/3) Fig 5. Refraction in a normal eye Accommodation Rays of light from an object close to the eye is divergent and will be focused behind the retina. The eye adjusts the image by: -Contraction of ciliary muscles thereby loosens the suspensory ligaments so that the lens will be more spherical and strong. Myopia (short sightedness) In myopic eye the refractive power is so high that parallel rays of light focused in front of the retina. Refraction in myopic eye Symptom -Poor distant vision Treatment - Spectacle- concave or negative lens 2. Hypermetropia (long-sightedness) In hypermetropia rays of light are focused behind the retina because the power of the optical system is too low for the length of the eye. Refraction in hypermetropic eye Symptoms -Complain about near vision tasks -In advanced state they will have poor distant vision Treatment - Convex lens or positive lens 3. Astigmatism In astigmatism the rays of light coming to the eye are focused differently in different meridians or has two focal points.

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