স্পেশাল বিসিএস (স্বাস্থ্য) - লং কোর্স

  Signs
ØCoated tongue
ØRelative bradycardia
ØSplenomegaly ( Just Palpable)
ØCaecal gurgling

Blood culture establishes the diagnosis  and multiple cultures increase the yield
^{Stool cultures are often positive in  the  second and third weeks}
The Widal test detects antibodies to the O  and H antigens but is not specific

Dengue virus, which has 4 distinct  serotypes, i.e. DENV-1, DENV-2, DENV-3,  DENV-4 is transmitted by Aedes aegypti  and Aedes albopictus to human

Evidence of Plasma Leakage (key differentiating point between Dengue and Dengue Haemorrhagic Fever)
Rise in Hct.: 20% (eg. In children 35 → 42 and in adults 40→48)
• Circulatory failure: Cold/cold clammy skin, CRFT>2 Sec, tachycardia, weak pulse, narrow pulse pressure <20, hypotension.
• Fluid accumulation - Ascites/ Pleural effusions
• Albumin <3.5 gm/dl

Dengue Shock Syndrome
Clinical Signs of Dengue Shock Syndrome:
• Cool extremities, delayed capillary refill time
• Lethargy or restlessness (which may be a sign of reduced brain perfusion)
• Tachypnoea or Kussmaul's breathing
• Tachycardia, weak pulse
• Narrow pulse pressure: Pulse pressure ≤20 mmHg with increased diastolic pressure, e.g. 100/80 mmHg •
Hypotension by age, defined as systolic pressure <80 mmHg for those aged <5 years or 80 to 90 mmHg for older children and adults

Investigations
1 to 5 days of fever : CBC, NS1 antigen, SGOT and SGPT (Not mandatory but helpful)
• After day7: IgM and IgG Antibodies (Day 5-7 window period)
• Follow up testing may be done on 1st afebrile day, but should be done daily when DHF is suspected
Haematocrit:
-A regular haematocrit is more important for management than the thrombocytopenia
-In severe dengue especially with shock hourly haematocrit is crucial for management

Warning Signs
• No clinical improvement or worsening of the situation just before or during the transition to afebrile phase or as the disease progresses.
• Persistent vomiting.
• Severe abdominal pain.
Lethargy and/or restlessness, sudden behavioural changes.
• Bleeding: Epistaxis , black stool, haematemesis, excessive menstrual bleeding, dark colored urine (haemoglobinuria) or haematuria.
Giddiness.
• Pale, cold and clammy hands and feet.
• Less/no urine output for 4-6 hours
• Liver enlargement > 2cm • Haematocrit >20%

Indications of Colloid in Dengue
• Patients with massive plasma leakage
• Patients with shock with rising Hct.
• Those not responding to the maximum volume of crystalloid
• Those with pulse pressure < 10 mm Hg, who need urgent restore BP

•Pancytopenia is common.
•Moderate to severe anaemia develops  rapidly and can cause cardiac failure.
•Thrombocytopenia, often compounded by  hepatic dysfunction, may result in bleeding  from the retina, gastrointestinal tract and  nose.
•In advanced illness, hypoalbuminemia may  manifest as pedal oedema, ascites and  anasarca (gross generalized oedema and  swelling).

The diagnosis of Kala-azar will be based on the  following criteria in a symptomatic case.

History of fever for more than 2 weeks
Residing/ traveling in endemic areas
Any one of the following symptoms and signs:
1.Splenomegaly
2.Weight loss
3.Anemia
And ‘rk39’ test (+) positive.

P. vivax and P. ovale may persist in liver cells as  dormant form hypnozoites capable of developing  into merozoites months or years later
Thus the first attack of clinical malaria may occur  long after the patient has left the endemic area, and  the disease may relapse after treatment with drugs  that only kill the erythrocytic stage of the parasite
P. falciparum, P. knowlesi and P. malariae have no  persistent exoerythrocytic phase but recrudescence  of fever may result from multiplication of parasites  in red cells that have not been eliminated by  treatment and immune processes

Red cells infected with malaria undergo haemolysis  which is most severe with P. falciparum that  invades red cells of all ages.
P. vivax and P. ovale preferentially invade younger  cells, and P. malariae normoblasts

Mild falciparum malaria
Preferred therapy
• Co-artemether (CoArtem or Riamet); contains artemether and lumefantrine (4 tablets orally at 0, 8, 24, 36, 48 and 60 hrs)
Alternative therapy
• Quinine (600 mg of quinine salt 3 times daily orally for 5-7 days), together with or followed by doxycycline (200 mg once daily orally for 7 days)
Use clindamycin not doxycycline if the patient is a pregnant woman or young child
or
• Atovaquone-proguanil (Malarone, 4 tablets orally once daily for 3 days)
Pregnancy
• Co-artemether but avoid in early pregnancy
• If not using co-artemether, use quinine plus clindamycin (450 mg 3 times daily orally for 7 days)
Other regimens
• Artesunate (200 mg orally daily for 3 days) and mefloquine (1 g orally on day 2 and 500 mg orally on day 3)

Tools
CBC
Sputum smear examination
Radiological (X-ray) examination of the lungs
Culture of TB bacilli
Rapid Molecular Diagnostic Tests (RMDT)
Gene Xpert
Line Probe Assay (LPA)
FNAC, Biopsy and Histopathology for EP TB
IGRA

Diethylcarbamazine (DEC)—6 mg/kg in three divided doses for 2 weeks

An increased discharge without any itch or irritation accompanied by an unpleasant or fishy odour, worse after sexual intercourse and during menstruation, indicates the possibility of BV

Leprosy, also known as Hansen's disease, is a chronic infectious disease caused by Mycobacterium leprae. The disease affects the skin, the peripheral nerves, mucosal surfaces of the upper respiratory tract and the eyes.

Mode of Transmission-Sexually from partner, Neonate  exposed to infected secretions in birth canal

Chancroid usually starts as a small papule that rapidly becomes pustular and eventually ulcerates. The ulcer enlarges, develops ragged undermined borders, and is surrounded by a rim of erythema. Unlike syphilis, lesions are tender and the border of the ulcer is not indurated

Vaginal discharge from endocervicitis is the most common presenting symptom of gonorrhea and is usually described as thin, purulent, and mildly odorous. Many patients have minimal or no symptoms from gonococcal cervicitis. Dysuria or a scant urethral discharge may be due to urethritis accompanying cervicitis.

In tuberculoid leprosy, ulnar and common peroneal nerves are typically affected.