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This revised manual is the result of considerable collective effort of senior clinicians from the Ministry of Health, the University of Nairobi and the Kenyatta National Hospital. Efforts have been made to include the most recent recommendation of the Ministry of Health specialised disease programmes and the World Health 3 Organisation. On behalf of the Ministry of Health many thanks are accorded to all contributors, reviewers and the editors who have worked so hard to make the Guidelines a reality. The regular use of the Guidelines by clinicians countrywide will improve and encourage the rational use of available drugs and thus contribute albeit in a modest way towards the realisation of the health sector vision of "creating an enabling environment for the provision of sustainable quality health care that is acceptable, affordable and accessible to all Kenyans". Although it was not possible to meet the big demand for the guidelines by health workers countrywide, most public, mission and private health institutions received copies which have been and continue to be put to good use. A wide cross section of users provided useful feedback on areas needing revision and expansion through twoday Provincial user/reviewers workshops. The Editors have put in many hours to review, correct and edit the material for publication. Users of the guidelines are advised to keep updated on the management of these diseases since their treatment is rapidly evolving and changing. New material includes a section on orthopaedics, sickle cell anaemia and disaster management. Access to drugs for the treatment of lifelong conditions such as diabetes, asthma, hypertension, epilepsy and psychiatric illness has been increased. Some of these drugs have been made available at dispensaries and health centres to facilitate filling of prescriptions at less costs. While the use of these guidelines will to some extent standardise the approach to rational drag use all health workers are encouraged to be aware and observe the existing national laws, regulations and guidelines that govern the registration, procurement, marketing prescribing and use of pharmaceuticals. Health professionals owe it to Kenyans and the world at large to eliminate the existing practice of making nearly all drugs available (with or without prescription) often on considerations that are nonmedical: and unethical. Health professionals must accept, perform and take responsibility for the roles they are qualified, registered and licensed to perform. If demand so dictates printing and distribution of more copies will depend on sales of copies even at subsidised costs. Finally, the Editors wish to extend their sincere appreciation to all those colleagues who have contributed in any way to the preparation and publishing of this 2nd edition of the Guidelines. The crosssection of health workers who used the Guidelines and provided useful inputs and suggestions for the revision and update of the Guidelines. The health professionals who provided materials and technical inputs to revise and rewrite the Guidelines. The secretariat team which provided administrative and logistical support at all stages of the preparation of the Guidelines. Vomitus and secretions should be aspirated or removed with fingers or handkerchief. Abdominal Trauma Abdominal injuries(to spleen, liver, bladder, gut) can follow fairly minor trauma. If a patient has multiple injuries assume abdomen is involved until this is ruled out. The evolution of the injury could be slow leading to symptoms and signs developing late. Unexplained shock in trauma patient should point towards an intraabdominal bleed 8 Clinical Features Of important value are the vital signs (Pulse rate, blood pressure, respiratory rate and temperature). Pain, localised tenderness or rigidity of the abdominal wall indicate the most likely site of injury. Abdominal distension could either be due to gas leaking from a ruptured viscus or from blood from injured solid organ(s) or torn blood vessels: this is a serious sign. Absent bowel sounds and sustained shock despite resuscitation mandate urgent surgical intervention.

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They are organised in such a manner that a postgraduate should possess the following qualities and knowledge on qualification. Patient Care the candidates need to be trained in the following: (i) Basic Sciences: He should possess basic knowledge of (1) the structure, function and development of the human body as related to Rehabilitation Medicine. He should be able to practice and handle independently most day to day problems as encountered in Rehabilitation Medicine. He should be able to integrate the preventive and promotive methods with the curative and rehabilitative measures in the treatment of diseases. He should be familier with the common problems occuring in rural areas and deal with them effectively. Given an opportunity to participate in surveys and camps, the students should be able to: (a) organise and conduct surveys in rural, urban and industrial communities and in specified groups of population; (b) organise and conduct camps for disability prevention and rehabilitation of disabled persons. Teaching He should be able to plan educational programs in Rehabilitation Medicine in association with his senior colleagues and be familiar with the modern methods of teaching and evaluation. The candidate should be able to: (a) To deliver lectures to undergraduates and hold clinical demonstrations for them. Structure of the course: There would be no division of the course into sections/ semesters. Course content: the course content would include the following: (1) Philosophy, history, scope and need of Rehabilitation Medicine. These are considered necessary in view of an inadequate exposure to rehabilitation medicine in the undergraduate curriculum. The topics of the symposia would be given to the residents with the dates for presentation. Leprosy Rehabilitation (iii) Clinical: the Residents would be attached to a faculty member to be able to pick up methods of history taking and examination in rehabilitation practice. During this period the resident would also be oriented to the common problems that come to the Department after 6 months, the resident would be allotted new and old cases, he would work up these cases including prescription writing. Following journals have been chosen for discussions: (a) Indian Journal of Physical Medicine and Rehabilitation. The contributions made by the article in furtherance of the scientific knowledge are highlighted. He would also be given exposure to partake in the research prijects going on to learn their planning, methodology and execution to learn various aspects of research. Written papers, which would consist of 4 Theory Papers List of Papers Paper I: Basic Sciences as applied to Rehabilitation Medicine. Clinical posting Course and Curriculum of M D Physiology 239 Physiology: Theory & Practical the theory and practical syllabus is completed in four semesters. The department conducts the semester wise programme in a cyclic fashion so that no matter at what point a student joins the programme, he completes the course in two years. General & Cellular Physiology Cell as the living unit of the body the internal environment Homeostasis Control systems Organization of a cell Physical structure of a cell Transport across cell membranes Functional systems in the cells Genetic code, its expression, and regulation of gene expression Cell cycle and its regulation b. Cardio-vascular Physiology Properties of cardiac muscle Cardiac cycle Heart as a pump Cardiac output Nutrition & metabolism of heart Course and Curriculum of M D Physiology 241 Specialized tissues of the heart Generation & conduction of cardiac impulse Control of excitation & conduction Electrocardiogram Arrhythmias Principles of Hemodynamics Neurohumoral regulation of cardiovascular function Microcirculation & lymphatic system Regional circulations Cardiac failure Circulatory shock b. Respiration Functional anatomy of respiratory system Pulmonary ventilation Alveolar ventilation Mechanics of respiration Pulmonary circulation Pleural fluid Lung edema Principles of gas exchange Oxygen & carbon-dioxide transport Regulation of respiration Hypoxia Oxygen therapy & toxicity Artificial respiration Environmental Physiology c. General, Sensory & Motor Physiology General design of nervous system Interneuronal communication Classification of somatic senses Sensory receptors Sensory transduction Information processing Dorsal column & medial lemniscal system Thalamus Somatosensory cortex Somatosensory association areas Pain Organization of spinal cord for motor function Reflexes & reflex arc Brain stem & cortical control of motor function Cerebellum Basal ganglia Maintenance of posture and equilibrium Motor cortex c. Special Senses Optics of vision Receptors & neural functions of retina Colour vision Perimetry Visual pathways Cortical visual function Functions of external and middle ear Cochlea Semicircular canals Auditory pathways Cortical auditory function Deafness & hearing aids Primary taste sensations Taste buds Course and Curriculum of M D Physiology 243 Transduction & transmission of taste signals Perception of taste Peripheral olfactory mechanisms Olfactory pathways Olfactory perception d. Nutrition & Metabolism Carbohydrates Fats Proteins Minerals Vitamins Dietary fibre Recommended Dietary Allowances Balanced diet Diet for infants, children, pregnant & lactating mothers, and the elderly Energy metabolism Obesity & Starvation b.

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These children may present with failure to thrive, lymphadenopathy, neurologic disease, hepatomegaly, or with an opportunistic infection. Incidentally, acyclovir seems to be an ineffective treatment, despite the fact that this virus is a member of the Herpesviridae family. Under these circumstances, infants experience intrauterine growth retardation, cataracts, microcephaly, and vesicular rash. The virus can be transmitted vertically if a pregnant woman acquires the virus and develops viremia. Although a third of patients are asymptomatic and many develop a self-limited febrile illness, others may experience symptoms of an aseptic meningitis: fever, headache, nuchal rigidity, photophobia, and malaise. Other members of the enterovirus (non-poliovirus) family include group A coxsackie viruses, group B coxsackie viruses, echoviruses, and other unclassified enteroviruses. The illness is more common in children, and often the patients have a mild pharyngitis or other respiratory symptoms. Headache, seizures, meningeal signs, neuropsychiatric symptoms, visual loss, and ataxia are common symptoms. T multiceps is a canine tapeworm that results in symptoms similar to cysticercosis with more pronounced ophthalmic involvement. In addition, aerobic organisms, such as members of the genera Staphylococcus, Streptococcus, and Haemophilus, have been isolated as have Gram-negative enterics. The causal organism depends on the underlying condition: head injury, postoperative infection, chronic otitis media, and cardiac disease. Erythematous nodule of the check of a 9-year-old girl at the site of the cat scratch. She states that she feels fine for the first 10-15 minutes but after that seems to fatigue. In addition, during routine practices, she falls approximately 10-12 times per session. She has to rest after 2 flights and cannot climb without holding on to the railing. In addition to soccer, the patient runs competitively, stating she used to be able to run 400 meters in 65 seconds. She denies any history of muscle pain, myoglobinuria, or previous infectious illness. On review of her past medical history, she was born at full term without complications. She has a history of bifrontal headaches associated with photophobia and phonophobia. However, on prolonged upward gaze, she developed moderate bilateral ptosis after 20 seconds. When asked to abduct her left arm repetitively, she developed left deltoid weakness after 45 attempts. An important study to obtain in the management of this patient is which of the following In counseling this patient, you warn her that certain common medications may make her condition worse. From the following list of medications, which will potentially exacerbate her condition A 4-year-old boy comes to your clinic with the chief complaint of muscle weakness. Which of the following statements is true regarding the genetics of Becker muscular dystrophy Which of the following statements is true regarding the genetics of myotonic dystrophy Children with congenital muscular dystrophy are deficient in which of the following proteins Shortly after birth, he developed respiratory distress requiring mechanical ventilation.

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Other teachers may stop instruction to adopt a more accepting, encouraging tone, and apply and wait patiently for the student to redirect his the psychodynamic techniques mentioned previously. Here the Contingency-based approaches are primarily based teacher employs two or more of the basic inter on behavioral methods. This teacher may develop a contract with the student, idea was presented originally by Barrish & usually with the assistance of the school coun colleagues (1969), and is called the Good selor or school psychologist. Rathvon (1999) discusses ifies both a requirement to reduce targeted numerous variations on this approach. Parental a signaling device to prompt independent and administrative involvement may be neces small-group work at the elementary level. At the most serious level, the students were off-task the teacher stopped the student may be suspended for a period of time, stopwatch until students were back on task. The either to home or to some area of the school longer they were off task, the less free time they reserved for in-school suspension purposes. When school personnel sense that certain behavior Behavioral contracting with students is a method problems are becoming widespread among their of establishing a formal statement of behavioral students, they may wish to generate programs expectations and possible reinforcers for meeting that are implemented consistently by all teach those expectations. Hall students with emotional and behavioral disor and Hall (1999) and Lassman and colleagues (1999) ders is the Franklin-Jefferson Program (Schloss give specific suggestions for developing behavioral & colleagues, 1988). A variation on the whole-class reinforcer idea consists of establishing teams in the classroom Some of these behaviors may be associated with that essentially compete against each other for accepted categories of disability. In any event, school personnel recognize these ment for either appropriate behavior or acade reasons for poor behavior and, increasingly, are devel mic achievement. An interdependent group sometimes confusing array of social expec oriented contingency system for improving academic tations are directly taught, practiced, and then performance. Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (2nd ed. Anger management programs focus on giving game: Effects on individual contingencies for group conse students the skills to recognize anger in them quences on disruptive behavior in a classroom. Psychological per by either social skills or anger management spectives on intervention. How to negotiate a behavioral Curriculum, where problem-solving skills are contract (2nd ed. Collaborative consultation in the students are taught to be mediators who assist schools (2nd ed.

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