java barcode generator library Clinical Findings in Objective-C

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Clinical Findings
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A Symptoms and Signs
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An acute attack of malaria typically begins with a prodrome of headache and fatigue, followed by fever A classic malarial paroxysm includes chills, high fever, and then sweats Patients may appear to be remarkably well between febrile episodes Fevers are usually irregular, especially early in the illness, but without therapy may become regular, with 48-hour cycles (P vivax and P ovale) or 72-hour cycles (P malariae), especially with non-falciparum disease Headache, malaise, myalgias, arthralgias, cough, chest pain, abdominal pain, anorexia, nausea, vomiting, and diarrhea are common Seizures may represent simple febrile convulsions or evidence of severe neurologic disease Physical findings may be absent or include signs of anemia, jaundice, splenomegaly, and mild hepatomegaly Rash and lymphadenopathy are not typical in malaria, and thus suggestive of another cause of fever When treated appropriately, uncomplicated malaria generally responds well, with a mortality of about 01% Because malaria diagnoses are often delayed in the developed world, it is imperative that all persons with suggestive symptoms, in particular fever, who have traveled in an endemic area be evaluated for malaria The risk for falciparum malaria is greatest within 2 months of return from travel; other species may cause disease many months and occasionally more than a year after return from an endemic area
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B Laboratory Findings
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Giemsa-stained blood smears remain the mainstay of diagnosis, although other routine stains (eg, Wright stain) will also demonstrate parasites Thick smears provide efficient evaluation of large volumes of blood, but thin smears are simpler for inexperienced personnel and better for discrimination of parasite species Single smears are usually positive in infected individuals, although parasitemias may be very low in nonimmune individuals If illness is suspected, repeating smears in 8- to 24-hour intervals is appropriate The severity of malaria correlates only loosely with the quantity of infecting parasites, but high parasitemias (especially > 10 20% of erythrocytes infected or > 200,000 500,000 parasites/mcL) or the presence of malarial pigment (a breakdown product of hemoglobin) in > 5% of neutrophils are associated with a particularly poor prognosis A second means of diagnosis is rapid diagnostic tests, which have been developed recently to identify circulating
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Protozoal & Helminthic Infections
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plasmodial antigens with a simple dipstick format These tests are not yet well standardized but are increasingly available around the world At best, they offer sensitivity and specificity near that of high-quality blood smear analysis and are simpler to perform Serologic tests indicate history of disease but are not useful for diagnosis of acute infection PCR is highly sensitive but not available for routine diagnosis In immune populations, highly sensitive tests, such as PCR, have limited value because subclinical infections, which are of uncertain significance and not routinely treated, are common Other diagnostic findings with uncomplicated malaria include thrombocytopenia, anemia, leukocytosis or leukopenia, liver function abnormalities, and hepatosplenomegaly Severe malaria can present with the laboratory abnormalities expected for the advanced end-organ dysfunction discussed above
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CMDT 2008
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A Uncomplicated Falciparum Malaria
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Most doses of antimalarial drugs are for uncomplicated malaria Although this disease is not usually rapidly lifethreatening, inappropriate therapy places individuals at increased risk for progression to severe malaria, and on a population level can impact greatly on malarial morbidity and mortality Decisions about how to treat malaria are affected by the potential for drug resistance, especially with P falciparum, the high cost of newer agents for developing world populations, and potential toxicity The drug sensitivity of individual strains can be studied in laboratory settings, but such testing is slow and not useful clinically Rather, therapeutic decisions are made based on the infecting species and geography P falciparum is now commonly resistant to older drugs, notably chloroquine and sulfadoxine-pyrimethamine, in most areas, with the principal exception of Central America west of the Panama Canal and Hispaniola Falciparum malaria from other areas should not be treated with these older drugs, and decisions regarding appropriate chemoprophylaxis should follow the same geographic considerations In the developing world, malaria is often treated with suboptimal regimens due to the high cost and limited supplies of newer agents In particular, chloroquine is still widely used in Africa, and its poor efficacy may be underappreciated due to its antipyretic properties, the ability of some immune individuals to recover from acute malaria without effective therapy, and the fact that recrudescences may not lead to symptoms until weeks after partially effective therapy Some countries have changed their first-line therapy for falciparum malaria from chloroquine to sulfadoxine-pyrimethamine, but
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