Mark Corson

It is important not to duplicate or undermine the work already being done by the scheme in your area generic 5 mg frumil otc. Learning theory has shown that students need to spend as little time as possible on the passive tasks of listening and reading buy frumil 5mg low price, and as much as possible on activities and participatory exercises cheap 5mg frumil. It is good practise to keep up to date with health promotion resources and training materials. The expertise of local health promotion colleagues is very useful when planning a workshop or lesson. Health advisers are sometimes asked to show slides of different infections, such as warts and herpes to students. It has been shown that negative images just lead to denial in those seeing them and a sense of it won t happen to me. There is no advantage to this approach, as we aren t promoting self diagnosis, and symptoms are often much less extreme than those shown in medical pictures. A recent meta analysis of sex education in schools concluded: Adolescents have suggested that sex education should be more positive with less emphasis on anatomy and scare tactics; it should focus on negotiation skills in sexual 27 relationships and communication. Asking any person to talk about their own experience must be considered very carefully, as it can be 28 voyeuristic and upsetting for those listening. Reflecting on how we define health and how this affects our practise raises an ethical dilemma for health advisers. Health advisers often work with the worried well These people will present with an anxiety about illness that is overwhelming. In contrast, there are the individuals who have multiple medical problems, yet describe themselves as well and enjoy a quality of life which may surpass the worried well. This situation can be paradoxical and frustrating if health is viewed as an absence of disease. Even just listening to, and attending to, the 29 worried well is part of healthcare. However, while a demonstration of correct condom technique may be of some benefit, a holistic view of the individual and their health needs fosters consideration of the power and self esteem questions that are linked to their psychological 283 health. It can then be more helpful to explore these questions and consider that the patient may have chosen to place their psychological needs above potential physical harm. Health advisers will often choose to discuss harm minimisation or risk reduction techniques in this situation. Truth is relative Although scientific method is design to reveal facts in an empirical way by objective observation, this doesn t mean that research, even if it meets stringent scientific standards, has uncovered the truth. Popper argued that at best we can only hypothesise and we are only ever left with our own truths about our own version of the world. His theory of Falsification posits that a scientific fact is only true until it is disproved or falsified. He maintained that 30 the greater the empirical claims of any theory, the more falsifiable it is. For example the social sciences may believe that qualitative research produces useful information, but for some scientists only quantitative objective methods, such as randomised controlled trials, are 31 considered worthwhile. Talbot has helpfully summarised this debate and he points out that most scientists will reluctantly admit that there is no such thing as objective scientific knowledge. Health advisers need to keep up to date with the latest research and guidelines about sexual health. Sometimes patients will be confused by changes in protocols or regimes; cervical screening guidelines over the past few years are a good example of this. This also happens in community messages, such as advice about thicker condoms, which has failed to be endorsed by clinical research. An appreciation of the fluid and occasionally subjective nature of scientific knowledge, allows for a helpful presentation of the current facts. The latest thinking and guidelines on a subject can be summarised in an accessible way, with the aim of enabling the patient to understand the reasoning behind the advice they have been given. Medical Ethics Experts have no special prerogatives entitling them to make judgements for the rest 32 of humankind. It is reasonable to assume that for most of us, death is a negative state and we value the states of being alive and of being healthy. With this as a value base, health advisers will promote behaviours and treatments that we believe are in the best interests of our patients. While we may be motivated by beneficence, the desire to do good, our actual practice is vulnerable to paternalism. It would be impractical to belabour all the possible negative side effects of an antibiotic when discussing treatment, but is the decision not to do so pragmatic or paternalistic? We have probably all heard the argument from colleagues that they don t wish to give upsetting information to patients. For example, they may brush over asymptomatic transmission of the herpes virus, or health promotion leaflets and materials will often simply promote condoms to prevent infections such as herpes or warts, without 34 explaining that they can only partially protect against these infections. Is this motivation non-maleficence, (not doing harm) or is it again paternalistic? Thus we can be in the invidious position of the individual feeling that they are being blamed for their own misfortune, but also for the spread of infection to others. Whilst supporting people to protect themselves from infection or unwanted pregnancy, it is important to focus on their personal strategies rather than risky or dodgy sexual partners. The following chapter provides detailed protocols and guidelines for developing and implementing sexual health promotion in both clinic and community settings. Health: The foundations for achievement Chichester; John Wiley and Sons, 1986 4 Seedhouse D. Health education and the ideology of health promotion: a review of alternative approaches. Health Education Research Vol 1 1986 11 French J Boundaries and horizons: the role of health education within health promotion.

The rise a permanent checklist in order that obvious following should be considered by the causes are not omitted cheap 5mg frumil with amex. Cerebrospinal Fluid History A rise or fall from normal of the cerebrospinal Often the history is the total disease in the uid pressure is associated with headache frumil 5mg overnight delivery. When the acutely raised cheap frumil 5 mg fast delivery, a severe headache may ensue, rise of intracranial pressure is caused by a accompanied by blurring of vision. Any adults space-occupying lesion, signs of focal brain with headaches should have their blood pres- damage can also be present. Another form of headache associated with abnormality of the blood Blood Vessels vessels is that caused by an intracranial aneurysm of the internal carotid artery or one A variety of diseases involving the blood vessels of its branches. The commonest is prob- throbbing in nature and there might be other ably migraine. Classical migraine is thought to signs of a space-occupying lesion at the apex of be caused by an initial spasm followed by dilata- the orbit, for example a cranial nerve palsy or a tion of the meningeal arteries. In the case of a family history of the same problem showing elderly patients, the possibility of giant cell dominant inheritance, and attacks can some- arteritis must always be kept in mind. This is an times be precipitated by stress or taking certain inammation of the walls of many of the foods, such as cheese. Before the headache medium-sized arteries in the body, but it tends begins, there is usually a visual aura charac- to affect the temporal arteries preferentially. The that is centred above the eye and is described headache is made particularly bad by brushing as a boring pain. The headache lasts for any time the hair and other systemic symptoms include between 1 h and 24 h and then disperses. Migraine can begin quite early in childhood and continue at regular inter- vals for many years. Migraines are more common in women and tend to improve at the time of the menopause. The visual aura might appear by itself or the migraine attack might be accompanied by gastrointestinal symptoms or by ophthalmople- gia. The attack might be preceded by oliguria and uid retention and be followed by a diuresis. Cross-section of the temporal artery from patient the original diagnosis must be reviewed care- with temporal arteritis. Of some importance is the fact that a the large number of giant cells (with acknowledgement to history of migraine increases the risk of devel- Dr J. Headache 73 importance of this type of headache rests on the merges with cluster headache, being described fact that the eye is involved in about 60% of as severe ocular pain associated with meiosis cases and the patient can suddenly go blind in and ptosis. Trigeminal neuralgia can be easily one eye and then a short time later go blind in distinguished from these other forms of the other. A touching a part of the cheek or by chewing and temporal artery biopsy is helpful in specic sit- swallowing. The pain is so severe that the patient uations to assist with the diagnosis, particularly can become suicidal,and surgical division of the in those with indeterminate clinical ndings. Steroid people after an attack of trigeminal herpes treatment is effective in preventing blindness zoster. The pain seems to be more severe in the and is required usually for a 12 18-month elderly and it can persist for many years. Once instituted, the response to treat- cause of the headache is usually evident when ment and the side effects should be very care- one inspects the skin of the forehead, which is fully monitored, preferably in co-operation with slightly whitened and scarred from the previous a general physician with regular measurement attack of herpes zoster. It is easy to forget that Bones anaemic patients often have headaches, which can be cured by treating the anaemia. Likewise, In Paget s disease of bone, the bones of the head patients with polycythaemia might also com- enlarge and grow abnormally, the abnormal plain of headache. Hypoglycaemia is another growth being associated with headache and, recognised cause; here, the symptoms occur incidentally, an increase in hat size. The eyes after strenuous exercise or insulin excess in a themselves might show optic atrophy, and close diabetic patient. Oxycephaly is a congenital defect of the skull caused by premature closure of the In many respects, cluster headache resembles sutures; patients sometimes complain of migraine,although it is more common in men in headache, as well as visual loss because of optic the third or fourth decade. Multiple myeloma is the refers to the timing of the attacks, which can be name given to a malignant proliferation of repeated several times over a few weeks, fol- plasma cells within the bone marrow. There is lowed by a period of remission for several also an excessive production of immunoglobu- months. There is conjunctival congestion the skull, and headache can be an accompani- and constriction of the pupil on the affected ment. Tenderness over the affected side of nosis is made by examining the urine for the face and nasal discharge are also features. Bence Jones proteins and the serum for abnor- Raeder s paratrigeminal neuralgia probably mal immunoglobulins. Disease of the cervical 74 Common Eye Diseases and their Management vertebrae is another cause of headache, because commonly in adults aged 30 40 years who are of the effect of spasm of the neck muscles. Relief beginning to have difculty in accommodating of the pain by neck manipulation has been through their long-sightedness. For reasons of claimed, but the exact diagnosis must be made vanity, patients might have been deliberately before embarking on such treatment. In the patient with no refractive error, the onset of It is presumed that the pain and headache that presbyopia can be accompanied by headache, accompany meningitis or encephalitis are which is sometimes delayed until the morning mediated through the sensory nerve supply to the after prolonged reading. The pain-sensitive structures in the person aged 45 years should be suspected of middle and anterior cranial fossa are supplied by having presbyopic headaches. Uncorrected the fth cranial nerve, and inammation can myopes do not usually complain of headaches.

Signs Reduced Visual Acuity A reduction in visual acuity can buy cheap frumil 5 mg on line, of course cheap frumil 5 mg on-line, be an early sign of cataract formation but this is not always the case discount frumil 5 mg. Opaque areas in the lens can be seen clearly the effect on visual acuity as measured by the against the red reex. The function of the peripheral retina can be clarity of the fundus and the visual acuity of usefully assessed by performing the light pro- the patient, some other pathology might be sus- jection test. Checking the pupil and misleading in this respect and this applies par- the light projection test take a brief moment to ticularly to those seen in highly myopic patients. A number of other more tion of the fundus while the disc and macula sophisticated tests are available, for exam- can be seen quite clearly. Findings on Slit-lamp Microscopy Sometimes, at least an area of the peripheral retina can be seen when the pupils have been A detailed view of any cataract can be obtained dilated, and all cataract patients should be with the slit-lamp. By adjusting the angle and examined in this way before one embarks on size of the slit beam, various optical sections of more complex tests. A search for the signs of the lens can be examined, revealing the exact cataract thus involves a full routine eye exami- morphology of the cataract. The presence of nation, including a measurement of the best small vesicles under the anterior lens capsule spectacle correction. Cataracts secondary to uveitis or to drugs might rst appear as an opacity in the posterior sub- Management capsular region. For optical reasons, an opacity in this region tends to interfere with reading At the present time, there is no effective medical vision at an early stage. Opacities in the lens treatment for cataract in spite of a number of can appear in a wide range of curious shapes claims over the years. A recent report has sug- and sizes, and earlier in the last century there gested that oral aspirin can delay the progress of was a vogue for classifying them with Latin cataract in female diabetics. Such a might be expected to have some effect on classication is of some help in deciding the theoretical grounds, any benet is probably cause of the cataract, although it can sometimes marginal. Congenital cataracts are usually cataracts seem to have cleared, but such uc- quite easily identied by their morphology, as tuation in density of the lens opacities has not are some traumatic cataracts. Cataract is, therefore, essentially a surgical Other Important Signs problem, and the management of a patient with cataract depends on deciding at what point Certain other important signs need to be care- the visual impairment of the patient justies fully elicited in a patient with cataracts. The cataract pupil reaction is a particularly useful index of operation itself has been practiced since retinal function and it is not impaired by the pre-Christian times,and developments in recent densest of cataracts. A poor reaction might lead years have made it safe and effective in a large one to suspect age-related macular degeneration proportion of cases. The operation entails or chronic glaucoma, but a brisk pupil with a removal of all the opaque lens bres from mature cataract might be described as a within the lens capsule and replacing them with surgeon s delight because it indicates the a clear plastic lens. Cataract 87 In the early part of the last century the tech- a visual acuity of 6/9, whereas others with less nical side of cataract surgery necessitated visual demands might be quite happy with a waiting for the cataract to become ripe. Early surgery might be days no such waiting is needed and it is needed to keep a joiner or bus driver at work for theoretically possible to remove a clear lens. Modern Age of the Patient cataract surgery can restore the vision in a remarkable way and patients often say that they By itself, the age of the patient need have little have not seen so well for many years. Many many patients have quite reasonable vision people over the age of 100 years have had their without glasses but this cannot be guaranteed cataracts successfully removed. The general and, because the plastic lens implant gives a health of the patient must be taken into account xed focus, glasses will inevitably be needed for and this can inuence one s decision in unex- some distances. Occasionally, one is presented with can happen after the operation is infection a patient who has difculty with balancing, leading to endophthalmitis and loss of the sight perhaps as a result of Mnire s disease or some of the eye. The patient asks for cataract one out of a thousand cases, the patient con- surgery in the hope that this will cure the templating cataract surgery needs to be aware of problem. Sometimes routine to measure the length of the eye and the cataract surgery is requested in a nearly blind, corneal curvature. Knowing these two measure- demented patient on the grounds that the ments, one can assess the strength of lens dementia will improve with improvement of the implant that is needed. Although this occasionally happens, strength of implant, it is necessary to consider often the patient s mental state is made worse the other eye. This raises some eyes optically similar because patients nd it interesting ethical problems for the surgeon difcult to tolerate two different eyes. In the case of the child with congenital When to Operate cataracts, the indications for surgery depend largely on the degree of opacication of the lens. Even though the decision to operate on a An incomplete cataract might permit a visual cataract must be made by the ophthalmic acuity of 6/12 or 6/18 and yet the child could be surgeon, optometrists and the nonspecialist able to read small print by exercising the large general practitioner need to understand the rea- amount of available focusing power. Elderly patients child could undergo normal schooling, and tend to forget what they have been told in the cataract surgery might never be required. A clinic and might not, for example, understand complete cataract in both eyes demands early why cataract surgery is being delayed when surgery and this can be undertaken during the macular degeneration is the main cause of visual rst few months of life. An operation is usually not required if the one eye could become amblyopic in these young patient has not noticed any problem, although patients, even after cataract surgery. The require- Traumatic Cataract ments of the patient need to be considered; those of the chairbound arthritic 80-year-old subject This is usually a unilateral problem in a younger who can still read small print quite easily are dif- patient and sometimes the nature of the damage ferent from the younger business person who to the eye prevents the insertion of an intra- needs to be able to see a car number plate at ocular lens. Some patients Vision can be restored by a strong convex who have marked glare might need surgery with spectacle lens but the difference between the 88 Common Eye Diseases and their Management two eyes makes it impossible to wear glasses. This is partly because everything looks much bigger with the corrected aphakic eye; the image on the retina is abnormally large. By wearing a contact lens on the cornea, the optical problems might be solved,but it is an unfortunate fact that patients with traumatic cataracts usually have working conditions that are unsuited to the wearing of a contact lens. It is an example of a classical pro- ferent designs to suit different surgical techniques. This entailed pushing the lens back into the vitreous, where it was complete lens within its capsule and, by this allowed to sink back into the fundus of the eye.

Begin feeding a high-quality milk replacer on day 4 at 10% body weight: Coccidiosis Minimum 22% protein most or all of milk origin if possible Etiology Minimum 20% fat Coccidiosis has become one of the most serious prob- Minimal crude ber lems encountered in raising dairy calves when the 4 cheap frumil 5mg fast delivery. After the rst week cheap 5mg frumil with visa, quantity can gradually be in- calves are grouped and housed in mini free stall barns creased to maintain 10% to 12% body weight intake buy generic frumil 5 mg on line. Be sure dilution factors for milk replacer are correct ment currently is very popular because it decreases la- to mimic the total solids of milk. All calves should have fresh water and a high-quality Although up to 20 species of Eimeria may infect cat- calf starter available at all times. Sporulated oocysts that are infective enough that the starter does not spoil in the feeder. Feces collected immediately after onset of diarrhea to diagnostic two or three consecutive affected calves lab on at least two or three consecutive affected calves A. Whenever possible, more than one calf should be sampled before blaming the whole herd problem on a single isolate. If patient older than 2 weeks, consider poor replacer rather than infectious diseases. Therefore calves remain viable for more than 1 year in favorable condi- exposed to coccidia oocysts and simultaneously sub- tions that include moisture and absence of temperature jected to stress, poor nutrition, exogenous corticoste- extremes. Rectal pro- calves licking themselves and ingesting feces or fecal- lapse may occur secondary to proctitis and prolonged stained hair, or from browsing on a contaminated bed- tenesmus. Affected calves appear dehydrated, thin, ded pack under the roofed area of the housing unit. Milder cases merely show Coccidia are quite host-specic intracellular para- mild diarrhea without systemic signs and many cases sites that complete both the asexual and sexual phases are subclinical. Feces stain the (meronts) that release merozoites that then infect epi- perineum, tail, and hocks of typical cases. Second-generation calves in the group are infected, only those with severe schizonts then form in these cells and subsequently infection show dramatic signs. Coccidiosis is a perfect release merozoites that begin the sexual phase of the example of the weak sister law in parasitology this law reproductive cycle by invading yet another host epithe- states that when a group of animals are parasitized, the lial cell and become microgamonts (male) or macro- most seriously affected bring attention to the problem gamonts (female). Microgamonts release microgametes and act as a signal that the entire group needs treatment. Invasion of cells and subse- the patient from concentrating on eating or drinking. The magnitude of enteric pathology appears to be related to the dose of oocysts ingested. Small doses of ingested oocysts may result in inapparent infection and eventual induction of immu- nity. Oocysts are observed in feces (patent infection) ap- proximately 17 to 20 days following infection with E. The numbers of oocysts in the feces do not always correspond with the degree of enteric pathology or clinical signs because even asymptomatic animals may shed fairly large num- bers of oocysts. Some of the counts may be relatively low despite the serious pathol- calves are well grown and have normal hair coats, ogy present in the large intestine. Factors that have a than normal for their diet, and the hindquarters are negative inuence on the calves immune competence stained by loose feces. Heifers raised in connement groups elevate oocyst counts as they traverse the intestinal require prophylactic treatment for coccidiosis, or tract. Theoretically it is possible In general, oocyst counts of 5000/g of feces are that calves will show signs by 3 weeks of age based on considered signicant when coupled with clinical signs. Fortunately this Several calves should be sampled to conrm the diagno- seldom occurs unless newborn calves are put in con- sis because severely affected groups of calves tend to taminated environments such as group housing arrange- show higher oocyst counts as a population. Weaning and grouping of when response to treatment for coccidiosis fails to correct calves that were previously housed individually induce the problem. Occasional out- Calves that die from acute, severe coccidiosis may or breaks have been observed in 12- to 18-month-old may not have gross pathologic lesions in the cecum and heifers as well and rarely in milking age animals. Severe infections may cause a diphtheritic mem- would be assumed that older animals showing signs brane from sloughed mucosa, blood, and brin. Whole of coccidiosis had never developed resistance to the blood clots occasionally are found in the colon, and Eimeria sp. Small white spots (schizonts) may be appa- fected animals remain subclinical or show mild signs. Microscopic lesions mainly reect colonic damage vere oocyst loads exist, or if concurrent disease affects secondary to second-generation schizonts and sexual the coccidiosis patients. Inammation, sloughing of epithelial cells, cel- Nervous coccidiosis has been well described in Canada lular inltrates, and alteration of the appearance of in- and the northern United States. Although this form has fected epithelial cells to a less columnar shape may be been observed primarily in beef calves, it may occur in observed. Affected calves can show a variety of neurologic signs, including (but not limited to) severe Treatment and Prevention tremors, nystagmus, and recumbency. Opisthotonos may Treatment and prevention of coccidiosis in calves en- be observed and confuse the diagnosis with that of polio- tail orally administered coccidiostatic or coccidiocidal encephalomalacia. The mortality rate is high for calves agents, some of which also are used as prophylactic with nervous coccidiosis. Amprolium, monensin, lasalocid, and decoqui- Diagnosis nate are the drugs used most commonly to treat Clinical signs coupled with fecal otation to conrm groups of affected or at-risk calves. Diarrhea may precede the highest oocyst counts by continuously in many calf-raising operations where a few days in acute cases because merozoite damage coccidiosis is known to exist; the same is true for deco- to the colonic epithelium may cause diarrhea before quinate.