การดูแลตนเองที่บ้าน โรคไข้เลือดออก

การดูแลตนเองที่บ้านไนผู้ป่วยไข้เลือดออก

• นอนพักผ่อนมากๆ

• ดื่มน้ำมากๆ อาจเป็นน้ำผลไม้ น้ำเกลือแร่ หรือน้ำข้าว(มากกว่า 5 แก้ว ในเด็กโต)

ไม่ควรดื่มแต่น้ำเปล่าอย่างเดียว เพราะจะทำให้เกลือแร่ในร่างกายผิดปกติ

• เช็ดตัวเมื่อมีไข้ ให้กินยาลดไข้ ได้ทุก 4-6 ชั่วโมง ห้ามกินยาลดไข้ แอสไพริน ยาลดไข้สูง ยาแก้ปวด เองโดยไม่ปรึกษาแพทย์ (แอสไพรินทำให้เกิดภาวะตับวาย)

• ยาปฎิชีวนะไม่มีความจำเป็นในโรคไข้เลือดออก

การสังเกตอาการที่รุนแรง

ถ้ามีอาการต่อไปนี้ควรรีบไปพบแพทย์ หรือสถานพยาบาลใกล้บ้าน•

• เลือดออก เลือดกำเดา อาเจียนเป็นเลือด เลือดออกตามไรฟัน ถ่ายดำ เลือดออกทางช่องคลอด

• อาเจียนรุนแรง บ่อย

• ปวดท้องมาก

• ซึมลง หรือเอะอะโวยวาย

• มือเท้าซีดเย็น

• หายใจลำบาก9

DENGUE

GUIDELINES FOR DIAGNOSIS,

อ้างอิงจาก Dengue Guidelines for diagnosis,treatment, prevention and control New Edition 2009 WHO edition

V’องงงงงวงง2009

Textbox G. Home care card for dengue

Severe encephalitis

http://www.soonak.com/PDF/guideline%20encephalitis%20revised.pdf

HIV Treatment Guidelines for Adults and Adolescents Updated

The Department of Health and Human Services (DHHS) Panel ในสหรัฐอเมริกา ได้ updated recommendations Antiretroviral Guidelines for Adults and Adolescents based on current evidence.

"Antiretroviral therapy (ART) for the treatment of [HIV] infection has improved steadily since the advent of potent combination therapy in 1996," the guidelines authors write. "New drugs have been approved that offer new mechanisms of action, improvements in potency and activity even against multidrug-resistant viruses, dosing convenience, and tolerability."

Topics covered in the updated and in previous guidelines have included baseline evaluation, treatment goals, indications for starting ART, choosing initial therapy in ART-naive patients, drugs or combinations to be avoided, managing adverse effects and drug interactions, managing treatment failure, and ART-related considerations directed to specific patient populations.

A new section in the updated guidelines addresses HIV diagnosis and treatment considerations in older patients with HIV infection, who often have more comorbid conditions, which complicates treatment. A new table lists the monthly average wholesale price for US Food and Drug Administration–approved brand and generic antiretroviral (ARV) drugs, including fixed-dose combination products.

Key updates to existing sections of the guidelines include the following:

• Starting ART in treatment-naive patients:
  • ART is recommended for all HIV-infected individuals, but the strength of this recommendation varies according to CD4 cell count before treatment.
  • Regardless of CD4 count, starting ART is strongly recommended for patients who are pregnant or who have a history of an AIDS-defining illness, HIV-associated nephropathy, or coinfection with hepatitis B virus.
  • ART should be offered to infected patients, particularly heterosexuals, who are at risk of transmitting HIV to sexual partners.
  • Patients starting ART should understand the benefits and risks and be willing and able to adhere to treatment. On a case-by-case basis, clinicians may decide to defer therapy because of specific clinical and/or psychosocial factors.
• HIV-infected women: The update explains the use of hormonal contraception in HIV-infected women, including interactions between combined oral contraceptives and ARV drugs and a possible association between hormonal contraceptive use and HIV acquisition or transmission.
• HIV/hepatitis C virus (HCV) coinfection: The update highlights the newly approved HCV NS3/4A protease inhibitors boceprevir and telaprevir, their interactions with ART, available evidence regarding ongoing research in HIV/HCV coinfected patients, and preliminary recommendations on administering these drugs with ART.
• Mycobacterium tuberculosis disease with HIV coinfection: The update includes recommendations about when to start ART in HIV-infected patients diagnosed with tuberculosis but not yet receiving ART. Specific recommendations are based on CD4 counts and severity of major clinical disease.
• Drug interaction tables: Based on recent pharmacokinetic data, key updates include:
  • a change in the recommendation on rifabutin dosing with HIV protease inhibitors;
  • a new recommendation not to use HIV protease inhibitors and nonnucleoside reverse transcriptase inhibitors with rifapentine;
  • additional information and recommendations on interactions of boceprevir and telaprevir with different ARV drugs; and
  • updated interactions between different ritonavir-boosted protease inhibitors and HMG-CoA reductase inhibitors.
• Prevention of secondary HIV transmission: The update describes the role of effective ART in preventing HIV transmission and evidence-based interventions to facilitate identifying and counseling patients with high-risk behaviors.

Some of the study authors report various financial relationships with Bristol-Myers Squibb, Genentech/Roche, Janssen Therapeutics (formerly Tibotec Therapeutics), Merck, Abbott, Gilead, ViiV, GlaxoSmithKline, Hoffmann-La Roche, Tobira, Sanofi Pasteur, Abbott, RAPID Pharmaceuticals, Sangamo Biosciences, MedImmune, ViroStatics, Tai-Med, Medicines Dev Ltd, Pfizer, Virionyx Corp Ltd, Avexa, Human Genome Sciences, Oncolys, Roche, Vertex, VIRxSYS, Ardea Biosciences Avexa, Monogram Biosciences, Pain Therapeutics, Serono, Teva, Argos, BMS, and/or Boehringer Ingelheim.

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents

New Guidelines for Rhinosinusitis

เนื่องจากการติดเชื้อที่ไซนัสมักจะติดเชื้อบริเวณโพรงจมูกร่วมด้วย
จึงเปลี่ยน term การวินิจฉัยจาก Sinusitis เป็น Rhinosinusitis
ทาง สมาคม โรคติดเชื้ออเมริกา (Infectious Diseases Society of America)
ได้นำเสนอ guideline สำหรับ diagnosis and management of acute bacterial rhinosinusitis (ABRS) infections โดยใช้ระบบ grading ใหม่เพื่อให้มีความชัดเจนมากขี้น( April 15, 2012, issue of Clinical Infectious Diseases.)
ความจำเป็นที่ต้องมี Guideline เกิดขึ้นเนื่องจาก

• ไม่สามารถแยกทางคลินิกได้อย่างชัดเจนว่าเป็น bacterialหรือ viral acute rhinosinusitis, ทำให้เกิดการใช้ Antibiotic มากเกินความจำเป็นและไม่เหมาะสม;
• การเลือกคนไข้ในการให้ empirical antimicrobial ที่ไม่เหมาะสมทำให้ได้ Evidence base ที่ไม่มีคุณภาพ เกิดช่องว่างต่อองค์ความรู้
  
• เกิดปัญหาเชื้อดื้อยา และปัญหาต่อ antimicrobial susceptibility profiles ของแบคทีเรียที่แยกได้จาก ABRS
• ผลของ conjugated vaccines ต่อ Streptococcus pneumoniae on the emergence of nonvaccine serotypes associated with ABRS

เนื่องจาก Acute Rhinosinusitis พบได้บ่อยมาก โดยพบ 1 ใน 7 ราย ของผู้ใหญ่ แต่เป็น ABRS 2-10 %ของผู้ป่วยที่อาการเข้าได้กับ Acute Rhinosinusitis การพิจารณาให้ Antibiotic ทาง clinician ต้องพิจารณาจาก clinical presentation เพื่อแยก bacterial จาก viral rhinosinusitis. guideline ข้างล่างถ้ามีข้อใดข้อหนึ่ง ควรให้การรักษาแบบ bacteria ดังนี้

• symptoms or signs compatible with acute rhinosinusitis lasting for ≥ 10 days without any evidence of clinical improvement;
• Onset with severe symptoms or signs of high fever (≥ 39°C or 102°F) and purulent nasal discharge or facial pain lasting for at least 3-4 consecutive days at the beginning of an illness; or
• Onset with worsening symptoms or signs characterized by new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection that lasted 5-6 days and initially improved ("double-sickening").

• Antibiotic Treatment for Rhinosinusitis

  First-line therapy:

  amoxicillin-clavulanate, which has better coverage than amoxicillin.เนื่องจาก

• Increasing prevalence of Haemophilus influenzaeใน respiratory tract infections in children since the introduction of the pneumococcal vaccines; and
• High prevalence of beta-lactamase-producing respiratory pathogens in ABRS among recent respiratory tract isolates, particularly H influenzae.

Second-line therapy:

• Doxycycline may be used as an alternate regimen in adults;
• The following are not recommended because of resistance issues: macrolides, such as clarithromycin and azithromycin; trimethoprim-sulfamethoxazole; and second- and third-generation oral cephalosporins;
• Combination therapy with a third-generation oral cephalosporin plus clindamycin may be used in children with non-type-1 penicillin allergy or who are from geographic regions with high endemic rates of penicillin-nonsusceptible S pneumoniae. Levofloxacin is recommended for children with type-1 penicillin allergy; and
• Respiratory fluoroquinolones may be used in patients in whom first-line therapy failed or who have risk factors for antibiotic resistance.

Length of therapy:

• Adults: 5-7 days for uncomplicated ABRS
• Children: 10-14 days

Adjunct therapy:

• Intranasal saline irrigations with physiologic or hypertonic saline may be helpful in adults but are less likely to be tolerated in children;
• Intranasal corticosteroids are recommended in persons with a history of allergic rhinitis; and
• Topical and oral decongestants and antihistamines are not recommended.

Parotid gland enlargement

1. Unilateral Salivary enlargement
   1. Salivary Gland Tumor
   2. Bacterial Sialadenitis
   3. Chronic Sialadenitis
   4. Sialolithiasis
2. Bilateral Salivary enlargement with hypofunction
   1. Viral Sialadenitis
   2. Sjogren's Syndrome
   3. Human Immunodeficiency Virus (HIV Infection or AIDS)
   4. Chronic granulomatous disease
      1. Sarcoidosis
      2. Tuberculosis
      3. Leprosy
3. Sialadenosis (asymptomatic parotid enlargement)
   1. Eating disorder (Anorexia, Bulimia)
   2. Cirrhosis
   3. Chronic Pancreatitis
   4. Endocrine Disorder
      1. Acromegaly
      2. Diabetes Mellitus
      3. Gonadal hypofunction

Oral mucosal lesions in children(virus)

Herpes simplex infectionเกิดจากการติดเชื้อ herpes simplex type 1 ผู้ป่วยที่ได้รับเชื้อครั้งแรกอาจจะไม่มีอาการหรือเกิดตุ่มใส เชื้อนั้นจะไปยังปมประสาทและอยู่โดยไม่มีการแบ่งตัว จนมีภาวะแวดล้อมเหมาะสมเชื้อจะแบ่งตัวและทำให้เกิดตุ่มใสที่ปากลักษณะเป็นกลุ่มของตุ่มน้ำใส แสบและคันเล็กน้อย ตุ่มน้ำใสนี้จะแตกออกง่ายแล้วตกสะเก็ด หายไปในเวลาประมาณ 7-8 วัน ก่อนจะเกิดตุ่มน้ำใส อาจมีอาการตึงๆ ร้อนวูบวาบบริเวณริมฝีปากนำมาก่อนได้ในผู้ป่วย บางรายอาการครั้งแรกจะรุนแรง มีแผลตุ่มน้ำจำนวนมาก มีไข้ ต่อมน้ำเหลืองโตได้ หลังจากอาการหายแล้ว เชื้อไวรัสจะหลบซ่อนภายในปมประสาท ต่อมาเมื่อร่างกายอ่อนแอลง มีอารมณ์เครียด ถูกแสงแดด ฯลฯ เชื้อไวรัสนี้จะออกจากปมประสาทมายังบริเวณที่เคยมีอาการติดเชื้อครั้งแรก ทำให้โรคเป็นๆ หายๆ อยู่บ่อยๆ โดยทั่วไปการติดเชื้อเริมมักจะไม่รุนแรง แต่ในคนที่มีภูต้านทานต่ำกว่าปกติ เช่น คนที่กำลังได้รับยารักษาโรคมะเร็งหรือกำลังได้รับการฉายรังสี เป็นต้น อาการที่เป็นอาจรุนแรงได้

พบบ่อย ติดต่อง่าย ลักษณะ lesionอาจเป็น cutaneous หรือ mucocutaneous.เด็กเล็กต่ำกว่า 4 เดือน พบน้อย มีอาการแสบร้อนบวมบริเวณที่เป็น ตามมาด้วย grouped vesicles on an erythematous base ซึ่งจะแตกและ heal ภายใน 2-3 วันแต่อาจจะนานกว่านั้นถ้ามีแบคทีเรียแทรก

Secondary herpetic stomatitis พบค่อนข้างบ่อยมักมี ไข้ stressหรือติดเชื้อ HIV เป็นตัวprecipitated ส่วนใหญ่มักเป็นที่ริมฝีปาก รอบปาก เพดานปาก และเหงือก โดยลักษณะ lesion เป็น vesicleเล็ก อยู่เป็น cluster (Fig.)ซึ่ง vesicle จะแตกภายในเวลาอันสั้นเกิดเป็น ulcer ซึ่งจะ heal เองภานใน 6–10 วัน, มักมีอาการแสบร้อนคันแดงเจ็บแดง อาจมีไข้ร่วมกับ

generalized regional lymphadenopathy รักษาตามอาการ

Common Superficial Oral Lesions

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Condition	Clinical presentation	Treatment	Comments
Candidiasis4–9	Pseudomembranous: adherent white plaques that may be wiped off	Topical antifungals (e.g., nystatin [Mycostatin] suspension or troches, clotrimazole [Mycelex] troches, fluconazole [Diflucan] suspension, or systemic antifungals (e.g., fluconazole, ketoconazole [Nizoral], itraconazole [Sporanox])	Can confirm diagnosis with oral exfoliative cytology (stained with periodic acid-Schiff or potassium hydroxide), biopsy, or culture
	Erythematous: red macular lesions, often with a burning sensation
	Perlèche (angular cheilitis): erythematous, scaling fissures at the corners of the mouth
Recurrent herpes labialis10–14	Prodrome (itching, burning, tingling) lasts approximately 12 to 36 hours, followed by eruption of clustered vesicles along the vermilion border that subsequently rupture, ulcerate, and crust	Immunocompetent patients usually do not require treatment	Reactivation triggers: ultraviolet light, trauma, fatigue, stress, menstruation
		Topical agents include 1% penciclovir cream (Denavir)
		Systemic agents (e.g., acyclovir [Zovirax], valacyclovir [Valtrex], famciclovir [Famvir]) are most effective if initiated during prodrome or as prophylaxis
Recurrent aphthous stomatitis15–17	Ulcers surfaced by a yellowish-white pseudomembrane surrounded by erythematous halo	Mild cases do not require treatment	—
		Fluocinonide gel (Lidex) or triamcinolone acetonide (Kenalog in Orabase), amlexanox paste (Aphthasol), chlorhexidine gluconate (Peridex) mouthwash
Erythema migrans18	Migrating lesions with central erythema surrounded by white-to-yellow elevated borders; typically on tongue	Asymptomatic cases do not require treatment	—
		Symptomatic cases may be treated with topical corticosteroids, zinc supplements, or topical anesthetic rinses
Hairy tongue19–21	Elongated filiform papillae	Regular tongue brushing or scraping; avoidance of predisposing factors	Predisposing factors include smoking and poor oral hygiene as well as antibiotics and psychotropics
Lichen planus22	Reticular: white, lacy striae	Asymptomatic cases do not require treatment	Buccal lesions typical in reticular form; other sites (e.g., tongue, gingiva) may be involved
	Erosive: erythema and ulcers with peripheral radiating striae, erythematous and ulcerated gingiva	Symptomatic cases may be treated with a topical corticosteroid gel or mouth rinse

---

Information from references 4 through 22.

Herpes infection is characterized by an acute eruption of grouped vesicles upon an erythematous base most frequently on the mucocutaneous junction. The symptoms may be very mild attacks or very severe even fatal in newborn.

Infection may be primary in individuals who have no specific neutralizing antibodies or recurrent which is exceedingly common in individuals who posses specific antibodies.

This is a very common viral infection in young children between the age of 2-5 years , in older children and young adults . The condition begins with fever and the sudden development of painful oral lesions, which ulcerate. These may be misdiagnosed as Vincent‘s angina, aphthous stomatitis or other ulcerating bullous diseases. The mucous membrane becomes red, swollen and painful with ulceration. These are considered very important cardinal signs of herpetic infection of the mucous membranes .

Extensive involvement of the mucous membrane of the mouth, tongue and pharynx may interfere with feeding and the child becomes debilitated and seriously ill .

The lesions show shallow ulcers on an erythematous base covered with whitish exudate, which bleeds when removed.

Blood tinged saliva in severe cases causes dribbling in young children.

ไข้ในทารกแรกเกิด

Fever in the infant and toddler is one of the most common problems and greatest challenges faced by those caring for them

Next Section: Young Infants

Neonates

Neonates with fever who are aged 28 days or younger may have few clues on history and physical examination to guide therapy. Therefore, a high index of suspicion is necessary in order to detect the febrile neonate with a serious bacterial infection. Obtaining the pertinent medical history from the mother regarding the pregnancy, delivery, and early neonatal life of the febrile neonate is essential. Typically, infections that occur in the first week of life are secondary to vertical transmission, and those infections occurring after the first week are usually community acquired or hospital acquired.

Definitive identification of a serious bacterial infection requires laboratory investigation; a full sepsis evaluation; and a positive result in blood culture, cerebrospinal fluid (CSF), and/or urine. Bacterial meningitis is more common in the first month of life than at any other time. An estimated 5-10% of neonates with early onset group B streptococcal (GBS) sepsis have concurrent meningitis.^[1]

Previous

Next Section: Young Infants

Previous

Next Section: Young Infants

Prenatal history

A review of the prenatal history, including maternal history of sexually transmitted infections (human immunodeficiency virus [HIV], hepatitis B and hepatitis C, syphilis, gonorrhea, chlamydia, herpes simplex), maternal group B Streptococcus (GBS) status and prophylaxis, mode of delivery, prolonged rupture of membranes, and history of maternal fever should be noted.

A birth weight of less than 2500 g, rupture of membranes before the onset of labor, septic or traumatic delivery, fetal hypoxia, maternal peripartum infection, and galactosemia are all risk factors for a serious bacterial infection in the neonate. Gestational age should be determined, because premature infants are at increased risk for serious bacterial infections.

Nursery course

The neonate’s nursery course should be noted, including the age at which the patient went home from the nursery, whether or not a male neonate has been circumcised, and the use of peripartum or antepartum antibiotics. Any underlying diseases or conditions, as well as the use of medications that may increase the risk of infection, should be ascertained. Diet (ie, quantity and description of milk consumed; breast milk vs formula; and, if pertinent, the method the caregiver uses for preparing and storing the formula) and sleep histories should be obtained, because decreased oral intake or an acute change in sleep patterns may be clues to an invasive infection.

Household contacts

Any ill contacts in the household should also be noted. Exposure to any animals inside the home of the caregiver or outside the home (eg, in daycare facility) should be determined. The vaccination status of household members should be determined. A history of maternal fetal loss or death due to an infectious disease in a previous infant increases the suspicion of congenital anomalies and primary immunodeficiencies.

Identifying who is in the neonate’s household, who is the primary caregiver, contact with recent immigrants, and exposure to homelessness and poverty all impact the care the neonate receives.

Review of systems and physical examination

A thorough review of systems must be obtained to identify any other symptoms associated with the fever. A complete physical examination including vital signs (temperature 38°C = 100.4°F), pulse oximetry, and growth parameters with percentiles is necessary. General appearance should be noted for activity level, color, tone, and irritability. Signs of localized infection should be identified via a thorough examination of the skin, mucous membrane, ear, and extremities.

The presence of an umbilical stump after age 4 weeks should be noted, because it is a potential clue to leukocyte adhesion deficiency, and the lack of a circumcision in males should be noted, because it increases the risk for a urinary tract infection (UTI). In addition to fever, the most common clinical features of a UTI in a neonate include failure to thrive, jaundice (typically secondary to conjugated hyperbilirubinemia from cholestasis), and vomiting. Irritability, inconsolability, poor perfusion, poor tone, decreased activity, and lethargy can be signs of a serious infection in this age group.

Most neonates with bacterial meningitis have a full fontanelle with normal neck flexion at the time of presentation. Remember that neonates younger than 28 days with significant bacterial infections can appear to be at low risk when analyzing history, physical examination findings, and laboratory values; thus, a high index of suspicion must be maintained.

Diagnostic Considerations

Clinicians must maintain a high index of suspicion for serious bacterial and/or viral infections in febrile infants and toddlers. The diagnostic approach consists of a targeted medical history, a complete physical examination, and the judicious use of the laboratory tests.

Differentials

• Bacteremia
• Neonatal Sepsis
• Pediatric Bacterial Meningitis
• Pediatric Escherichia Coli Infections
• Pediatric Haemophilus Influenzae Infection
• Pediatric Meningitis and Encephalitis
• Pediatric Pneumococcal Bacteremia
• Pediatric Urinary Tract Infection
• Staphylococcus Aureus Infection
• Streptococcus Group B Infections

  Approach Considerations

  The clinical management of infants and toddlers with fever is based on their age groups.

  Neonates and young infants should be hospitalized with intravenous antibiotics pending results of laboratory tests and cultures.

  For the most part, management should be individualized based on risk factors, clinical appearance, and clinical judgment. Ill-appearing children with poor capillary refill and children who have clinical signs and symptoms suggestive of meningitis need to be managed in hospital and perhaps in the critical care setting. Children with focal infections such as sinusitis and pneumonia need to be managed with appropriate antimicrobial therapy.

  With the widespread use of pneumococcal vaccine in young children, the incidence of occult bacteremia in febrile children aged 3 months to 3 years has fallen from 4.6% to less than 1%.^{[5, 16]} As such, the evaluation has become more extensive to prevent overtreatment. In the absence of focal findings, any child in the target age group who appears ill or has excessive fever, vomiting, or tachypnea with retractions should be evaluated further.

  Parents and medical professionals who want to supplement physical measures with medication in order to maximize the time that children spend without fever should use ibuprofen first and weigh the use of paracetamol plus ibuprofen over 24 hours.^[17]

• Medication Summary

  Antibiotics are used to treat occult bacterial infection. Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens for the patient's age range and in the clinical setting. Whenever feasible, select antibiotics based upon blood culture sensitivity.