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Prostaglandin inhibitors Normally ductus arteriosus closes soon after birth. Vasodilatory effect of prostaglandin is what maintains to ductus arteriosus in intrauterine life. Hence in cases of delayed closure of ductus arteriosus, we can use p inhibitors to induce its closure.

Some people notice an improvement within a few days of starting treatment. However, an antidepressant often takes 2-4 weeks to build up its effect and work fully. Some people stop treatment after a week or so thinking it is not helping. It is best to wait for 3-4 weeks before deciding if an antidepressant is helping or not. If poor sleep is a symptom of the depression, it is often helped first, within a week or so. With some types of tricyclic antidepressant, the initial dose that is started is often small and is increased gradually to a full dose. (One problem that sometimes occurs is that some people remain on the initial dose which is often too low to work fully.) If you find that the treatment is helpful after 3-4 weeks, it is usual to continue. A normal course of antidepressants lasts at least six months after symptoms have eased. If you stop the medicine too soon, your symptoms may rapidly return. Some people with recurrent depression are advised to take longer courses of treatment (up to 2 years or longer)

A rash suggestive of Lyme is enough to indicate treatment. A 5-cm-wide targetshaped rash, particularly with a history of camping/hiking, is enough to indicate the need for antibiotic treatment with doxycycline. A characteristic rash is more specific than serology.

The prevention of endometritis is important. Infection prevention practices, including avoiding unnecessary caesarean section, appropriate management of prolonged labour, fewer vaginal examinations during labour, use of good sterile techniques and meticulous operative procedures during delivery, and providing appropriate prophylactic antibiotics during caesarean section should be routinely practiced. FIRST CONTACT (PRIMARY CARE LEVEL) The diagnosis of endometritis should be considered when a postpartum woman has febrile morbidity (oral temperature 38.0 or on two occasions between day 1-10 after birth) abdominal pain or foul smelling lochia. Careful physical examination to detect the source of infection is crucial. Once endometritis is diagnosed, appropriate antibiotic treatment should be started. If clindamicin is not available, or not affordable, the WHO-recommended regimen of ampicillin plus gentamicin plus metronidazole should be used. If fever is still present 72 hours after treatment, the patient should be carefully re-evaluated and the diagnosis revised. If complication(s) (such as pelvic abscess, peritonitis, septic shock, etc.) are suspected the patient should be referred to higher level of health care immediately.

References:
http://apps.who.int/rhl/pregnancy_childbirth/care_after_childbirth/ccguide/en/

Most common in Old and with usually increased WBC count and massive splenomegaly and characterized by Philadelphia (Ph) chromosome in bone marrow cells. ALL is most common in children. AML has more than 20% blasts on Bone marrow. Tip: The above patient is presented with acute Blasts crisis.

This is a wrong key. Right key should be D. CT. A case of 3rd nerve palsy. So to cause CT should be done. Red reflex is seen to diagnose cataract.

Nephropathy is a leading cause of death in diabetic patients. Diabetes may be functionally silent for 10 to 15 years. Clinically detectable diabetic nephropathy begins w development of microalbuminuria (30 to 300 mg of albumin per 24 h). The glomerular filtration may be elevated at this stage. Only after the passage of additional time will the proteinuria be (0.5 g/L) to be detectable on standard urine dipsticks.

Microalbuminuria precedes nephropathy with both non-insulin-dependent and insulin-dependent diabetes.
An increase in kidney size al the initial hyper filtration stage. Once the proteinuria becomes significant enough to be detected a steady decline in renal function occurs, with the glomerular filtration rate falling an average of minute per month. Therefore, azotemia begins about 12 years after the diagnosis of diabetes.

Inhaled corticosteroids are the most commonly used and effective preventive therapy used in adults with asthma. Corticosteroids are not the anabolic steroids misused by some athletes to enhance their performance. Rather, they are similar to naturally occurring substances produced by the adrenal gland, and play an essential role in fighting stress, injury and disease. The anti-inflammatory action of corticosteroids makes them an effective anti-asthma treatment.

Boerhaave syndrome is a full-thickness tear of the esophagus secondary to retching. The patient will have a history of severe incessant vomiting, often due to alcoholism. MI is unlikely in this patient given the subcutaneous emphysema. The other choices do not have substernal chest pain. Pancreatitis presents with abdominal pain that radiates to the back upon alcohol intake, not air in the subcutaneous space.
Biliary colic has postprandial RUQ pain. Volvulus is malrotation of the colon.

Congenital adrenal hyperplasia autosomal recessive disorder characterized by the partial or total defect of various synthetic enzyme of the adrenal cortex required for cortisol and aldosterone production Clinical Presentation - Classic presentation: vomiting, dehydration, Hyperkalemia, Hyponatremia, hypoglycemia, and fem has Ambiguous genitalia at birth.

As patient is young we should go for myomectomy. As hysteroscopic myo mainly sub mucosal fibroids we should go for abdominal myomectomy which will deal with both subserosal a fibroids.

Since the patient can cough and breathe, he should be allowed to clear the foreign object spontaneously, if possible. In the management of foreign object obstruction, if the patient can cough and breathe, it is best to initially observe and allow spontaneous resolution, since intervention may actually be damaging.

A bruit and pulsatile abdominal mass are hallmark signs of an abdominal aortic aneurysm (AAA). The fact that the medical student was palpating the area and the patient passed out was a coincidence; however,

syncope in the setting of the AAA is rupture until proven otherwise. Ruptured peptic ulcer would have more severe and sharp abdominal pain. Hemorrhagic gastritis could cause syncope, but the bleeding would cause emesis, and the patient is supine, so orthostasis is not of concern. Narcolepsy would not have hypotension. This patient's abdominal pain was from the AAA beginning to rupture and was dull and gradual in onset.

A person with expressive aphasia will exhibit halting and effortful speech. Speech m important content words. Word comprehension is preserved. The person may still be understood, but sentence grammatical.
This contrasts with receptive or Wernicke's aphasia, which is distinguished by a patient's inability comprehend language or speak with appropriately meaningful words though fluency, may be preserved.

A SSRIs are the initial antidepressants of choice for uncomplicated depression because of their minimal anti-cholinergic effects

Antihypertensive therapy has been shown to reduce morbidity and mortality in older patients with elevated systolic or diastolic blood pressures. This benefit appears to persist in patients older than 80 years, but less than one third of older patients have adequate blood pressure control. Systolic blood pressure is the most important predictor of cardiovascular disease. Blood pressure measurement in older persons should include an evaluation for orthostatic hypotension. Low-dose thiazide diuretics remain first-line therapy for older patients. Beta blockers, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and calcium channel blockers are second-line medications that should be selected based on comorbidities and risk factors.

Colonoscopy is indicated in all patients > 50 simply as routine screening. Hence, in this case, the patient needs colonoscopy anyway, regardless of what the stool tests show. Another reason to go straight to colonoscopy is the presence of microcytic anemia. Unexplained microcytic anemia in a patient above 50 is most likely caused by colon cancer. Sigmoidoscopy will do nothing to evaluate the right side of the colon and would miss nearly 40 percent of cancers. No matter what a sigmoidoscopy showed, you would need to inspect the right side of the colon. Capsule endoscopy is done to evaluate bleeding when the upper and lower endoscopy are normal and the source of bleeding is likely to be in the small bowel.

Autoimmune hepatitis. Definitive investigation is liver biopsy Steroid [start with high dose prednisolone].
Azathioprine is commonly added with steroid to reduce its dose as more side effects than azathioprine.

Most secondary hemorrhage occurs due to infection which erodes a vessel. S be admitted for IV antibiotics.

Indirect inguinal hernia. [Swelling in the groin; mass just above and lateral to the pubic tubercle mea hernia. It is reducible. On applying pressure on the internal ring there is no cough impulse; it means the
hernia through deep ring, and enters scrotum passing through the Superficial ring. That means it is indirect inguinal hernia.

It has a neutral act on lipid profile so is suitable for those in whom hyperlipidemia

Rheumatoid arthritis has the lowest glucose level of all the causes of pleural effusion described here.

Anxiety is the most common cause of erectile dysfunction postinfarction. Although beta blockers may be the most common medication associated with erectile dysfunction, anxiety is still a more common cause of erectile dysfunction than beta blockers.

Antihypertensive therapy has been shown to reduce morbidity and mortality in older patients with elevated systolic or diastolic blood pressures. This benefit appears to persist in patients older than 80 years, but less than one third of older patients have adequate blood pressure control. Systolic blood pressure is the most important predictor of cardiovascular disease. Blood pressure measurement in older persons should include an evaluation for orthostatic hypotension. Low-dose thiazide diuretics remain first-line therapy for older patients. Beta blockers, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and calcium channel blockers are second-line medications that should be selected based on comorbidities and risk factors.

References:
http://www.aafp.org/afp/2005/0201/p469.html

Bone marrow examination is essential to confirm the diagnosis Chronic lymphatic leukaemia (CLL) is characterized by accumulation of small mature lymphocytes in the bone marrow and peripheral blood. The presenting features are persistent lymphocytosis, lymphadenopathy and hepatosplenomegaly.
Hypogammaglobulinemia is often present at the time of the diagnosis. Autoimmune hemolytic anemia occurs in 25% of cases. The diagnosis is usually confirmed on peripheral blood examination; bone marrow
examination is rarely needed. Evolution in to a more aggressive disease such as diffuse large cell lymphoma (Richter's syndrome) can occur.

The risk of miscarriage resulting from chromosomal abnormalities of the embryo increases with advancing maternal age. However, it is important to note that as the number of miscarriages increases, the risk of
euploid pregnancy loss increases.

The relatively slow elimination of fluoxetine (elimination half-life of 1 to 3 days after acute administration and 4 to 6 days after chronic administration) and its active metabolite, nor fluoxetine (elimination half-life of 4 to 16 days after acute and chronic administration), leads to significant accumulation of these active species in chronic use. After 30 days of dosing at 40 mg/day, plasma concentrations of fluoxetine in the range of 91 to 302 ng/mL and nor fluoxetine in the range of 72 to 258 ng/mL have been observed. Plasma concentrations of fluoxetine were higher than those predicted by single dose studies, presumably because fluoxetine's metabolism is not proportional to dose. Nor fluoxetine, however, appears to have linear pharmacokinetics. Its mean terminal half-life after a single dose was 8.6 days and after multiple dosing was 9.3 days.

The diagnosis is glaucoma (headache and haloes especially at night). In glaucoma the vision.