UilliT1ED STAITES AllMY INS1TITUlTE rn R M IlllT AIRY ISSIST1:lNICE.

..

STI31 918··

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.

, - .... ' ·1

J ' •• J. j" ••• J .' j

US ARMY SPEC A I FIRCES : '/ EDICALIAN ilB 10K

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II IIIA.ReM 1 aa2:

SPECIAL, FORCES MEDICAL HANIOOOOK

Prefac:~

• Chapters

1 8()(:1 Y System III III .., • III III III, _ • Ii II, ., " .., • " " II •• iii ••• 11 iii-

Sect-ion

I - In tegtmentar y SY',Stem iii iii .., If" • III .

I I - Musculoskeletal System 1Ii- II, iii- iii , II • II, • 01 • III -II, iii

II I - Re spi r-8tory System .. , -.' II- .. III -til 4 .. III III .. I II

IV -- Circulator y' Systa'D •• III • II II iii III __ • iii __ Ii iii " iii- •

11 - Digestive System " _ .. 11 " ..

VI - Geni tour'inary 5,sten 1Ii~,."" •• ". 4 .. t, III In .

VI I - Nierv.cttll5 System . JI II- II • JI • ~ • II 4 •• iii iii- II III ..

VI II - E'ndcer i.ne System . II t, .. ,. 01 II .. "

I X - Eye., Ear' ~ nose" .and Throat III

2 Ccmnuni.cable Diseases •• II .. III ~ .... III -t' II .. 11 .. II II II, , -- " .. • ~ .,

Section

I - Parasi tic _ .. 111 ., " II III .., • II .. 4 III -II, iii-

II - ~ot.ic (Fungal) iii .. _ • " .. -- .. Ii iii ~

III _, Bac'ter ial " .. II .. I iii- II " II, of- ....... ' • iii .. 1" II! ..... ' .... II 4 ... II, .. iii- ..

IV - Vir al, .' II! ... 'J' ,.. 'I ... -II .... _ II! III ..... " ..... " ........ t, • iii • " ...........

v - Rickettsial and Spirochetal 4o ~ .

VI --- Ver\ereail 1Ii 'I II II ••• III II, iii iii Ii II! ., • •

3. Clearing Airway [I).str·uc tionJs and CPR ..... II! • JI ... II" II- ....

4 .Pie11Jtal Vi sorder 5 III ., •• Ii iii " of. II -.' II- II .. " II- II III II III .., • _ ..

-5 N'utr i tionall Di. sea.ses and De fiC" iellc Ies .. II- .. II II III • II .. III

6 Ped,iatr ics .' .., II- • Ii III " JI III • 4 .. 11 .. _ iii iii- II ..

7 G~ol~,y II" •• .., 'J' 'I II II, .. 01 ' " II! • II III ..... iii iii II '" ..

81 <:bstetr"iC5 iii- II ' " .., .Ii. iii ., II! JI ., II! II II III

9 ~tt:1lJped ics II JI iii II, iii- II '" .. " II II III III .Iii II • " " ..

1 0 Burn s and ma.:st Injuries II! iii- 'I JI 'I • III II iii .. II I: II ...

11 Heat an~ Cold In j Lr' ies II. II Ii .., _ , 'JI II- 'I .. or •• II II 4 iii- • Ii III

1 2 Bi. te s (Snake. Insect pl and An mal) III III II • iii Ii _ • Ii -t' , .'

13 Ov-erdose and Pt)i soning -.' '" iii ' " 'I -t' 4

, , :Nuclear, BiolC@ ieal:t Chemica 1 ( NBC) II, .

1'5 Shoe k iii- Ii .. ... -- .. I] • • • II II ... II .. • 11 II. .. • .. .. .. 'I " III II • ... • III iii • • ., III .. .. .. .' ..

16 EJnergency War Stlr'B,ery II " II, .. -- II! • I' " .. II! II! III In

l1 Ane.stt1esia Ill. II _ iii " ., t, _ Ii " " ., .. If" " III II 01 ..

113 I V Therapy (Fluid sand El ee trol ytes ,I B:lsic 5) _ .. II! -II, ..

191 Dental Emer-gencies arid Treabnen t .. I' I' .. II II .. II • II ...

201 Preven ti ve ~ic me ( PH) •• II .. -I- t, or. ., ~ .. II III .. t, •• II

21 Veter inary. ~ic in@ ., ' .... II! 'I .. III , II 'I ' .. or. " II II ..

22 Primi ti ve fiedic ine II " • II II Ii III .. , .. , JI _, ' .. 'I .. I' .., III -In •

Appendixes

A .Ar1a'tomiical PI ares II -t' _ .. " ., of. • II, ., II t, II • II ., _ •

S .Bacter iolog ic al alnd Paras! tic PIa tes I' III ..

C l..aboraltory Procedures _ , III III III -I- .. II! III II ., 1m ..

D Cell ular' C'amp.Jrlent 5. of Blcod ~ Normal Value:s.1' and

Signi fi -cance 0 f m.()CI(j Te'st " .... II • iii 10 iii- .... of- .. iii ......... 'I 'I .. II ..

~ -

E HI' to . ,.... Ph ." . I 1:"' . - - r-, p' d

~ 5 I r y al'lfu. I. ySlca ~X aTlJlna tnon tJtu.ll ,e- " .. , _ " .. 01-

F Fi.~ Id Ster il i zation TechrlJ i,que s ~ II ........ " + JI t, ...

G ~'ug, 0 f Coo i e eo Cha r t ........"'........., __ 'I 'I " ~ • .. " II III iii • • • .. .. • • ..

-

l

ij i

1-,1 tOI 1-7 1--8 to i-rs 1-1~ to 1-3.~ 1-35 to 1-411 , -!l-51 to- 1-56 1-5,7 to l-62 1-0.3 to 1-70 1-7'1 to 1-73 1-1l1 to 1--,1'8 2-1 to 2-116

2- 1 tol 2-l1 2--1' to 2-lS 2-115 to 2-2fl 2-26 to 2-,33 2- 33 to 2...ij(l 2-41 to 2-~6 3~ 1 to 3-.ij; ~-l to ~-9. 5-1 to '5-51 6-1 to 6-9 1-1 to 71--15 8-1 to 8-110 9-1 to 9-112

, 0- 1 to 1 O~ 11

1 1 - 1 to 1 1-11 ~2-ll to l2-7

, 3-1 to. 13~16 1~- 1 to 1.1.5- 1 3 15-1 to 1'5-3- 16-' to 716-10 11-1 to 11'-20 1-8-l to lB-2

19-1 to 19-15

2tJ-1 tel 20-213 21-1 to 211-121 22-,1 to 221-~

A.-l to Ar-18 B-1 to B-23 C-1 to C-51

(1-1 t(] D-~ E,-1 to E-,2 r-1 to F-6 G-1 to G-5

ThIs book i s d~:signed to serve as .a read y refer'ence and re-~ iew for spec:ial Farces {SF)I med1~5 ~ It covers df seases and med ical problems tbat, SF roedic:s maly encounter in vari.ous areas of the I,«)rld.. It does oot II horwever" take the IJlace or el Un inale the need for a -c:anprel1lensi ve m-ed Lc all area stool" ~

..

Hany treabooll1ts given in this nandlbooJ.c ~uld best· ble given in .a OO_Spd.. t,iIl -..here· a Labocator y tJmldi speer al elquj pnent B!""e aw'ailaDle po and

per sonnel wi ttl ser iouls injuries air illnesses should be' evacuated to such 31 tospi tal i. fat. all possfbl.e , Know yQur 1 inn tatioo.s and d,rQl. not, e·xcee:d them .. , Be nember' the, rna>:: iJn .Ii Fi,r-st thou shall do no barm'" and seek the asst stance Olr Dlre c.cmpeten t medical authority \itJene\\"er ptls,sible ~

Sdnce we want to use as f-e'w page's as p:rssi ble in pr'esenting this infOlnna t, ion, 11 we use eomnan medlic.aLl. 3lbl)r'ev iations throughout ~ For example"

A,.,

!BE

adi

IL.IM •. BBT b,.i "Id ~ B., P'l!' BUN iii

CDC

cc: II.

all.

C. NJ"I S. OOPDI

CPR

CT C.,V~A.I

d., D&C DTR Dx

E .. , -coli e ~8-a1

f.

G~ I~

am

gr ..

gtt.,

(ill

- analysis

- acute b~terial -eTldILlC'alf'oi tlis

- up· to.

- ante meridiem

- baasll bOO'I tem.per·ature

- twic:e a day

- blood pr·e.ssure·

- bloo<:l urea n,itrog,-en

- b1i,ologic all war falr~

- Celsius IJ C!erl tigr-ade

- ccmpletel blood c:ount

- cubic centimeter

- cong,egti ve hear-t (aliI urle

- een t,imelter

- cen tral nervous, .system

-- ehron Le obstruc~ti ve

pulmonary disease

-- card iopulmlnary r esuscf.ta Li.on.

- clotting time

_, costovertebral angle; eereerov ase ul.ar aceident - d~: -daily

- dilatation and cu.rr'et::lit't-@

~I

- dee'p tendon r'eflex

- diagn.osis

- Escher icbi a c:ol i

- for ex ample

- Fahrenheit

- gastr:ointe'stinaJ

-- varni

- grall'1

- drop~

- gen i Wur in airy

Ill ...

HB Hel Her HEENT

_. hour'

- hlB11og1obin.

- hydro,chlor'ide

- hematocrli t

- head., eye ,I ear' t1 nose .&

throat,

- merc:ury

- a t, bed time·

_, hlistOIT!i

_, intr'adlenmall

- inci se & drain

-- that i.s

- i fli tr alliJscullar

- intr av'enotlS

_I international uni. t - kilQgr'all

- liter

- labaralto1ry

- jJOlUJild ( s)

- left. lower quadraJl t

-. mid claY icul ar 1 ine

- m€(j iealtian ; rnedl ic al ~

medjrc ine

- mi.ll. i@qUli val ent

- mill. ig,r-an

- masnesiLm

- myocard ia1 in farction

- merthi.olatel iodinel

fOlnnal ine soltltion - minute

- mill u iter-

- mi llimeter

- milliorl units,

H'g Ihrosa Hl. IID I&D l.e'. 1M IV 10 kg. l.~ lab Ib WJ MCL med

mEq I, mg~ Mg MI Hlf

min ml ,

om "II'

MI .. ,U ..

- . . ..........

...IAl..":"'_

N1a HOC t[;

NPN

H .. P .10 ..

o. OD oz ..

P ..

p .e ~

P .. E:.I pH

PID

PM

I

P'.MI,l., P-.M .. N ...

Pi .. 0.,

~

Eli p' D'

II· ... ,.,~ ' ...

.PJDl .. p.,r .. ,n ..

ps i. PTB p~~ 'I

q .

q d

II! I •

q., lh ..

q ~i .,d '"

.... sodi.L.ID (natriLITI}

- n ut::l-ear, b,iologic.al tl

- nasogastr Ic

- oonprolte in rti tr-ogen

- nothing by' mouth

- nausea &: vami tins

- ooj ecti ve find ing s

overdose

.... "V''I'''' I U '.' . ".

5. ehem ic all SBE

- oonc-e

- plan of treatmen t

- aftelr meal.s

- p.i1,Ysica 1 examl

- h_ydlrogen in coec entr atiofl

_I pe'lv'ic infiamnalto'T'j disease - pr"'eY'enti'Je' medicine

_, po int 0 f mal imun impulse:

- p:ll.)1m.:)r pho Ii1 uc 1 ee r- Il'"JJ e urt IrO ptl i 1

leukocytes - by' moutll

- part iall pressure D~: yg;e~l

- pulsus, per ados U~

- puri.iied protein der iv ati Lie'

- parts per ITtill ion

-- as r'eQ~i red or' as need ed

- P01undsi perl square meh

- pr imar y tubere ulost s

- through the vagina

- everly

- ever '1 day

-- every hours

III·

- fOlur tImes a day

- sUlffic'ient Q,uan t.i ty

- qtJarrt

sec sed. SLR

sp ... gr., sp_p ..

SO

51 and

stat .. srs

SIX

11.

tab .. TB t.illd. Tx

Ul ..

IJlR I

U " SI-tJ P -I VDI

US

W· ... B"C ..

W· HI O'

.. I ~ •• ,l.

14 .Iu Lv 1982

-I

- sub1jiec:t fi:nd ings

- subaeut.e bac ter'i al

endoeard i ti s - second

Ilolder 5 of' S~ 31- 91B I S(JCC i a 1 F'o r cc S !1c,d i ca 1 Ha nd book t should add to/change the text as follows:

- sedimentation

- straight le~, raise

- specific grafllity'

- species

-- 5 ubcut aneo tI S,

S - siSJil sand SyrnPltans - inned iate-ly

- serologic te~st fori

syph,ilis - 5j;1ttptms

- temperature

-- tallle,t

P1ag_e

_ ......

-

- l.n,C'Teas:e

'" - decr-ee s e

)1 - 9" rea t.e r tha n

- tuberculos,i.s

_, thr'ee' time,s B day

- trea'trnent

- un l.t

- upper' respir'atory

- fl t-

In . ee ,'lon

- ~i.teC Sta,tes Pbarmaco1peia

- vener'eal. d Lsease

- "Ii i tal slign,s

- \tl i tel 1l100d eel.I t1 whi te

blood COU'l t

- Worl-dJ Health. (8'g31lizat,i-on

- witoout

- weight

< - less t ha n

Li ne

')1 _, ,

a dd

heforc or in center and right

columns

line 11 (Breath ~ounds & voic~J} saMe as for

1 · 'JI .l.ne Il_,

-1,-21

bottom page, 2d para from bottom under Ot add .. before 1"1~ B .. C. and) before 20 J Of)n

•

- lTICrease

.... decre-ase

1-73

Li no

. ':'{_.:-,

add' before H~P.

first

_. gr-ea ter thal

mid page, last oara hefore P., 2d & 3d lines, ad.d + sign over -; S110uld read 89+:27 s 124:!f,8

-_-

..

- less tban

D-2

nara D-4c, line 3, \-1.B.C. ~I 4,50n

- ..

~I

_.

In addition to the above, users should be aware that sluper~c;cr int.c; and sub sc r i.ot s i.n t hc t ex t .. _I.'" n sam till

Ii'- . . .F"f. U.L ..... ~; : J' C-: 1 rn e 5

out of line due to mechanical error.

CHlAPTEB 1

OODY SYSTB45

Sec ti.ort I - IntegtlUentar y Systeml

•

1- 11 ... SKIN' • lough e last-i,e structure cover ing tile entire bcdJy COIlsi st.ing

of tw'o la:rer'''s:; the epider1Di s m1d the -derni 5 oi

1-2 I' nrAGHOSIS (f" SKIN orsEASES BY PHYS rca. EX1Ufl~ATIO.N ..

a II" Pr imary' lesion ..

Earl iegt changes to .appear:

smaller .'

larger .

(3} Papule'... 5)lid el evated Leston 10 nm ~ or 3In~ller ...

{5) NOd ule , Palpable so11,d lesion 5-10 [lin. II (mayor may. not be elevateC) ..

(6) Ttrmors,. larger nodules usual I y 20 DITL. or larger II-

(1') Vesicle II' Clrctlllscr ibed eleYatedl lesion 5 [fill. OT :sm~ler containing serous fluid.

(8) EUlla ~ Ci r'cumscr ibed elevated lesion 5 rmt .. , or 1 arger.

(9) Pustule ~ .super ficiaJ. elevated lesion containing pus.

(1.0)1 'Wheal. Transi,ent elevated lesion caused by l~al -edema.

b.1 Secondary lelsionls resurt frail either -evolut,ion (natural} of tlile P" imary lesion,s; or p81t.ient mmll1pulat,i,on of pr1ntLarY le:sions.,

(1 ) Sc-ales.. ije'aped up parts of epi thel iUII .. ,

(3) Erosion.. Loss of part or all 0 r the epidermi s.

(.II) Ulcer.

at least part olr dermis 4,

(5) Excoriation. linear or hollowed-out crusted area caused by 3Cratehing. rubbing ~ or picking.

(6) Lichen i f'ication. Thickeni:n8 of t~ skin with a:::centuatiofl Qf the skin marking;s ...

(7) A.tr'opby.. Thlnn ing anrl wr-'inkling of the ~~kin reselllbling cqare.t te: paper~,

1--1

(81 Sea. II

1-2

The' r'esul t of heall ing after -d E!~5tructiorl olf the

dermrs ..

1-3: ..

S~T"N O·IS· 0·· R DE· . I ·RIS

_[\.J._ ~ : jJ . . :', • - : I ._ I I . ..: 11

a, Pr-Uir i tUiS (Itching) ~

S, CexmptJ13i ve i khi.ng .ac<::ampan Les prjm}2l~'Y skin dli sease or maly' be t,he' onl. y 5 i gn sand s ympJtc.rn5 .1

O'tJ Rednelss.1 lllticarial papules Il excorialtedl papule's Ii fissures.

erust.t ng j @,tc I]

All Prulr'i tus/Prur i tus secortdar'y to skin d i.sea~' .. ,

_----

P'. fAlrrect the skin disease 11 or discantir.rue US,ingl irri.ta.t.ing substance ~ e .,S . F soap , clothlng l' ehem Ical , e·tc., Use of" miild

tr anQjuili zersl:- ValillD1, Vi,stiral a Use of rmaljor tranQruil i zers,: Thora zjne ..

Use. of an tilli stamines: Benadryl 50 lUg... t I] i ~d ~

b. Cclntac tl d,erma;ti,ti 5 i 5, d i vi.ded into two t y]Je:s,:

{ 1)1 Pr imary irrilaJI.t cont.aet (jermati tis ". Develops wi thin a few. oolurs ~ reaches peak. severity tn 241 oolurs, then disap_pelars; caused by eontact

"With a chelmical irr'itBnt ..

(: 2)1 Allerg,1c eczematous contact denmarti ti 51 ~ HB53 delayed OOsetl

of about, 18 hoursl, peaks in lIl8-1'2 hour's II and often .la:-ts 2~ 3 weeks a fter di.scontinud .. ngl e':l.J:Osure to the offending antigen", (,Polson lV~'t oak. OT SLIT\ac or allerg.Y to clothing tl etc.)

(' 3-) Symptoms varr "J from minolT i tchir1~ and rednessl to vesicles. rednes511 edema I oozing. erustfng , and scaling;; itchling is u5uall'J sharpl)l"

demarcated .'

(' III ) ~--- "'e' . f r·,a.,ol"'; 1" no .:::. L1i el"ll: 'Ir ~ .... ~ ta Ii'Ii ILJ:".:III ter· .5 0·· "'!II~ 5 .01 r

I Ii- .. 1 ru:::lrlUY .. o· ~rlU . 'ID' --e.1 ·IlJ ~ .1 U~ I. It"" "'-1;11 • ... ~ .. "Clln.. ,. .~

ccmpresses"l Blisters may be drained. but leaiVe the tops on 4, Oral cortic'Oster'ioo.s -, Prednisone J.t0-60 q_ I' Iday: x 10-1!l- days in severe -c asea, 'Topical cortic.ost-E!r Lod s are net eff'ective- in acute phase .. ,

Antihistamines - Benadryl 50 rug 4, t.1 i ... d I'

ll-!I- ~ BAeTEN III SKIN INfECT'IONS.,

.a • Impet.iSolEcthlyma or SupelT fioe ial vesiculopu5tuiar sk~n illi~ection

seen chiefl y inl c~hildren.. Ecttl;ma t.s an ulc:erati Y're rtn~1 of lmpet1g'O ..

S.. Group /Ii, B-hem.olytic stlreptoc«cus is usual cause" but· StaphyIOCOC(:U5 aureus mal'l be cULl tured allso III

O. Usually alffects amoS, legsl, al'ldi face Il with tine legs, b~'inl morel suscept.I bile to ecth~al tl1arJ Ule~polsed arealS, I] Ebth m.a-r fOl110"1 .. superficial tr.a~l O~' may' be se:comiar'y to skin d.i.sease or Insect, bi.tes Ii but it· is nOlt un~OftDl()f] COlr" it to artse OJ] no,mai. skin ..

Lelsions: var'y frcro pea-s1zed veI5i,-copust,ulle3 to large bl1zalr're cIrcinate ringwonnLlike le'sion.s that progress rapldly' f'rCJnl macuo...opapules, to vesic.opllJstules, Olr' bul.lae to eIudJaltive and then tol heavily crusted circinate le's,ioos. .. Ecthyma 1 SI char'acter i:z~ by .small, ptlr'ulefllt I .shallow ulcers

CO'Vered wi tho c. rusts. Itching is cormnon and scrat-ching ean spread the infectiOn ~

A.

Impetigolec ttJyrea ..

..

P'. SYstemic anti biotic-s are superior to topical antit"J iot.tcs ,

Penicillin is the drug of choice; .second cooice is erythrcmycin +

IJ.! Perl iCil1 in

ORAL Penicillin

Er ythramycin

Child Adult

6001 11 000 U'I- Perl G 125 nus of. -q ~ i .. (j. i 10 dalYs 1125 Dl@. qi .. i. .,<1. x 10 days

1 • 2 mil 1lJ. P.ef.l G 250 mg.. q , t Ild I] x 1 a ~ays 25{1 rng. q, II i .d II X 10 days,

In seoondary :limpe tigol., thel underl ying cause should be treated al se , 5eglec:ted inf'ection may resul.t, in. ce l I ul i ti s 11 l;mpbarn.g i ti 51, a r f'urun,cullasis in adru~,ts orl ac:ute gl001 erulonephr i tis in childretr.l.

b, frlY,s Lpel.as , A supelr flc:ial cel Iul i tis caused by Group A B-hemolytic strelltoc~ei.,

involved ..

o. lesion is \le11 dem~rc'ated:., shiny 11 red, edmlaltou.s-, and tender; ¥esi,eles and bullale often develolp,... Patches of _peripheral rOODe-55 and

regional lymJl1adlerJopathy are :seen occasionally; higb fev'e'F:I ch:ill 51! and malaise ar'e c:aJIOOn I' It m.y' be recurrl""'e'l t and IDa y resul tin. chroni e lymphedEmal. The eausat i ~'e ag,ent malY be' -d i fficult to eul turel fran the le!sion:ll burt it, may' be cul tl.l~'ed fr"Dmi t.he blood.,

AI. ErYSipelas. NOTE: Erysipelas, of the, face must be

di ff'erentiated fran herpes zoster : eontae t denma ti.ti s and ang ioneurotic. edema may al:so be mi.stalken for er ysi pel as ~

. P"I Pen UK or' erythrcm:ic in 250 rn.g., ql .. i ... -d I' x 14 days 'I- In. aeute

easels Pen G 11 .. ;2 mllll i,onl U.. IV' Q: +611,,1 X 35-48 hr'Si then start PeT.l VK ~ toeal discanfolrt. may he relieved Il't' cold packs and/or 600 Illtg, 'I- asplr in with 3(1 m@.1 cod~~ i n e III

c. Cell ullitis., HaIS the same S ami S aild is, treated the same as eryslipelas. The oni Y' di ffer'ence is ce llul i ti s involves deeper tissue I]

d"l See Chapter 2 ~ :5e~t.iOrl III!l Bacterial" for' typhoid Iel1ler.1 gas gangrene' 11 3fltt:U:-3rK:. t u 1 af"emia:t pl ag ue- ~I Ieprosy ~ and! scar 1 e t fever.

1-5. SUPERFICIAL F'UNGAL INFECTIONS ..

_ a "" ~e CliJalpter' 21 Il SectiorJ II. Mye.ot.ic~ Ii for coce idioidiOOlycosi,5 II :Nor'th . .limer learn blastanYC-tJ5i S.I and Par acocc.id ioidanyco.si:s (S:luth AmeT lean blastomyco~is)1I

. b. ~rotr'lc~oolsi,s .. A chron ic fungaJ. in fe~ t.1on caused by Sporo,thrix

.sche-::kii · It is found ~rldwide in so i.1.1 pl ants"f and t1 ecayi ng ~od .. Orgal1JI SIn. is introduced by skin tr aLfna ... usual I Y .on narldl. arm f or foot.

. . , S III and 0 II COli1llllOrll y begins wi tb a hard 11 nontender subc urtarleaus

moc:tuIe that later OOcamelsl adher'ee t to the- over l yin~, skin I ulcerates, (chancrl f'orm) ~ and ma_)! persi at for a long time. Wi tnin a few days to

1-3

1-4

weeks 11 s imi lar module::; OOJually deY el.op along the 1 ymphatics draining this ares , and the se may ul.cerate . The Ij'RlphatiC' vesser s eeccere indurated and are easily pal paille ., In fect.ion usua 11 y ceases to spread before the regional lymph rDDdles -are invaded l' and blood--bone di ssemnat ion Ls rare ..

Skin in fection m~y not. spread throlJf!.;l1 the 1 ym.P'tatic s but may appear onl y as wart y or paplJI ~ seal y lesions that malY becane pustul ar ·

Di ssemin ated s;porotricoosi 5 presents as mrul ti pl.e tJ hard subcutaneous modul.es

scatter-e(j oyer the bod::;.. These becone so ft but r ar'el y r-upture

SlXllntane:ll.l.lsl Y Ii lesions. rm91y also cevel.op in bonas , joints l' Dlusclels, and viscera.

Laborator)t findings:: Cul tures are needed to estalOl i sh d iag-nosi s ..

A ~ Sporotr ichoars ..

P. Sat'Ur'ated so 1 urt iOITl of p€Jlta..ssi L.ITl lod ine (S. S ... K ~ I IJ)I 5 drrops

in a glass of water t __ i .. d +., after roe-aJ.s I orally. in-creasing by 1 drop per dose tmtil JlO drops t .. i .d , are- being g iven , Continue unt.il signs of a~ti~e di sease ha,ve d i sappeared, Thef1 decrease the dosage- by 1 drop per dOse

un ti.l 5 drops per dose are being gi.ven:l then discontinue'. AI too ugh

51 .. , S .. f( tJ I IJ i 5 not fUcr1gi-c. ida111 i t does praoolte ralpid heal i.ng. Care mU3t be taken to rerlLlCE! the dosage if sigJ'l,s of iad ism appeer ,

Amphotericin B IV and micolla-zole hay'@ been effecti~l"'e in systemic in f'ecti,ons ..,

e , cnromamyco,si s , Helinl y a tropi.c al chronic curtan-eous infection caused bly sever al. s,pecie:s of closel'J related molds having a dark mycel ium .. Found in soil and 011 decaying vegetation.. In htl1lan s the d i.sease progresses, slowl Y:l1 occurri 11g IIOCl-st frequen tl y on t,he' 100000r' eel tremi. ties 'I but i t may occur on bands ~ arms, and e lsewher-e II

s, and O. lesi.ons b~ in as a papule or ulcer.. Over- a per iod of' month s to year.s ~ the Ies.ions enl arge to becoee vetJ.etating,

pa pi 1 1 ona to us , verrucous 1 e:l evated nodules wi ttl a, caul iflouer like appearance or widespre ad dry verT ueeus plaques. The lat ter spread peripber.ally wi th a raised II verr'ueo~s border' Il learvin@. central atror-ttic scarr ins 01 The sur fae e 0 r tile border conta ins minute abs~sses ~ Sa tell i te lesions may appear alol1g the 1 )UlPlBtic.s tJ There mlay be a foul odOIT due to .secondary bacterial iJ1 fectioo.. Sane pat i ent.s cClilpla in of i tc-hing 01 EleptJanti..aSi 3 may result if' marked fibrosi s a~d lymph stasis e:kist i.n the limb.

lab findings:: The fungus is seen as; brcll.ro.fjl" thlck-wa~lerl .. spherical~ sometbmes septate cells in pU51J

POI fl~yt.osline - 150 Ir@ .. /kg .. /d ~ arall'j or thi.aberJdazole 25-

flOg ./kg ./d. or aLlly • Surgical ex-cisioo and skin grafting may prove useful 01

d.. IRTrTkltophyte in fer=-tions 'Ringwnn)... Super floe ial infec.t-ions caused by f'ung i that invade Olnl"Y dead ti ssues 0 f the ski fl or i t.s appendages (stratLm corneun, nails. flair).

s~ tticrosp-Jrm, Tr ic:oolphyton, .and [pidenrKJlphyton are the sen.era Imst corrmornly involved.

..

o~, Same d-e~.atophyte.s produee' onl y mi ld or no in fianmation -Iu In sucll ~,ses!J the orgillllSrn. may perSist indefinitely, -cau.5ing in,termit.tent r_l~slonls ~Il~ ~.ace:tlations 0 r a grad UBIl y ex tending lesion vi ttl a

scalln~ II . ~lghtl Y . ra ~sed, eoreer , In . otller cases ~ an .ac-lJte in fection may occur typ~ealllY. caUSlrlg a suddef] veslotJlar an~ bul Ious disease of the feet I or an, 1n.~amed l:Io~y le5i,o~ or the. scal.p (Kerlon)1 may occur that. i.s due to a stro~ 1rtmm?loglC reaction to the fUnsus ; it is usually followed by reni.s.s101l or cure ..

A., 1ine·a corpar is - {RlngFilCnn of the boo,y) ~

Tinea pedf s - (Rins,\IIl'Jnll 0 f the feet) - athlete I s foct , Tinea unguiUll - {RingilJinn of the nail s) ...

Tinea capitis -- (Ringwnn of the scalp) - dandruff. Tinea cruris - C Ringl.«)1'llI of the gn)1in) - jock i tch ~ tinea barbae - (Ringaorm 0 r t,he beard .area) .. ,

TInea manuun - (Hinswnn of" the palms and sol es olf the feet) ...

Di rreren tial d 1- ::rD. ' .,'PV'\. l:IIi S· ...... I Lud .. t - -

-0.1 IV..oIf.lC oaes pi I yrlasl 5 rcsea II! discoid

eczema :f and poor iasis -to

_pre par a,tioOi -II

Confirmation can be mate with Wood Il.s 1 igbt, or KOO

.. .'. _ p~. Gr'iseofu1~'in l.is er~e:ti"e against true dermatc)phyte

lllfectlOO,s', r, but .not_ ~ga~n.st caOOld1.8s1s or tinea v-ersicollor. Adult dosage b500_1J8. b. Ld. With meals~ DJration varies _fran. 2 weeks for tinea cor~rl,.s to .6~ 12 IOOnths for- tine'a ungud.lID.. Tinac tin/MYC~)istatin are ef:fectille agamst most fungal in fections where applied b ~ Ld + to t , i.d. to Blffected areas and washed off be fcr-e reapplication.

1-6.. PWSITIC SKIN ]N~ECTI0N5.

· 8. . S::ahles. A transmissible parasi tic skin infection c~racterized

by SUperflC.lall burro\iS. inter! se pruritus. I and secondary infecti.ons tJ

. s. Ca~ loy ~he itch mite- (Sarcoptes scabiei) ~ 1he- female mite

t.~5 ~n~,the :pldlernus l~yer and clep:l3its her eggs aloog the burrow. ScabIes lStr~~TI1tted by ~to-skin. contact with an infected person. It is, not trar).!Rl tted by elothlng or beddIng ~

· . 0 ~ . f.bcturnal itcllins .. prur Itf.-c ve,sic.l@sandr'U11stu,1·e··s'in1Iir'·Ur\s.i

or 11J"'allerl"" ... all. ... t'"'... . L1, , .

· . ..,~ . '. t. _ es es,peel. . r y . on the SIdes 0 f the finger_,s and the heel of the

pa lm.s • Hi. te S Orll..a aM bl ~,b. '1 t r t!"

- .'. ..,. . t . I ... '., .~.. cos 0, .1eee's m~ be vi Sible

tn.lcroscopically ..

. '. t... ..Sca.b .. des, e ; Co~f, inll. by demonstrating the para~,ite in scra~in"'.·'ls

ta~en from a burro th 11 n I'" tOl

. . .,.. I·W., m~1 WII, arJV cJ.ear .uid , 3tld exain@ micro~picallly ..

nee ' P.. Disin ~estatioo wi til. gaTIna Xwell 11 er"eao base awl ied fr-an

ne:o ~ ~d repeated in ?De week ~ (WARNING: tllere is a po ten tial of toXl.Clty Crom use- on Infants and from overuse on adults .. ) Treatlnent

1-5

1--b

should be aimed at all infected per'sonnel. In cases of severe secoec ary in fec:tions, treatment should be- SI LJPIO 1. em en ted wi th s)"stemic. atild topical 8f1tibiotic.5 ..

b. Pedicu1.osis (Lice) ~ A parasitic inf"estaltio.n of thE skin ... - scalp, trt.l"lk!l or pubic ar-eals--that usual.I y occur's irl overcrowded dW!elllings ~

S.. Head and pubic lice cen be found on the, head ald irI the pubic area. B:xty lice are seldcrn foun.d Of] the body as the insects. only cOOle to the skin to fe:ed; )"OU must look for them in the 5eatlS of clothing,..

o. Pruri tis with exeor iation :I nits (oval) on h.air- shafts. li-ce on skin or -clothing !I occasionally sky-Ibl LIe maeul es {macul ae caeruleae) on the i.nner ttJigbs OT on the- lower abdanen in pubic 1 ice inf'estaticns. You may

a 1 so se e secont1 ar 'i in f" ec t lOI"1 S ..

A,. Pediculo5is, pubis (Crabs - Phtbirus pubis). Infestation of cmogeni tal regioo. Pedi<::tllosis bunanus-vlar corpor'Ls (bod Y' louse) .. Dif'f'erential d iagnosi s :se.lborrlleic dennati ti S:fl sc ab ies t anoseni tal prur i tis 'P and eezena ...

P. Cure is rapid with garr.ma Kvell 11 q .. d. x 2 days ~ Repeat after' 1-0 day's to destroy the ni ts; pr actic e goOOd person al hygiene.., I f the in f'estati-on is widespread t1 wash all clothing and bedd ing in hot water wi th a strang detergent and dust; the area with lindooe lXl,wder.,

c , !)ee Ch~pter 2, Section 1:1 Parasi tic. for Afri-can tr)!paI1osomiasisl (sleeping .sickn-eIs.3)1 F Almer ir:-an trypaoolsan.iasi 5 t Chaga 5, Ii di sease) J and cutaneous arnd m~ocutan-eoU5, lei man Laai.s •

1-1 • VI RAt.. INFECTIONS OF THE SKIN I'

a, Her-pelS s1m.plex. (: o)!ldll feveT sore) , An acute v,ir al in fee tion.,

S·.. (1 in.ical outbreaks 11 which m.a y be recurren t i.n the' .!3IJe locat,i.,on for years tJ are. provoked by fever f SUflburn.. ind igest ion 11 fatigue l' vindrblurn. F mE!fl-5.trualtion II or ne r vous ten sian .,

0.. Recurrent l' smaJ.l... grouped ilesic:l es on an -erythematous ba.se ~ aspect alII y around the oral and gen i tal area tl last.ing approxira.etely 1-2 weeks. Regional lym~ nodes may be sr.r«>llen and tender ~ Blrning and stinging = neur algta m~ y precede and aeccmp'any at tacks.. The le-sion s con si st, of small" grouped vesicle's tbat may occur atl yvhere I but most oftEn oceur on the Ii ps , mouth, aJld gent tals .

A.. Her-pes s,implex. Di ffe-ren t.ial d Iagnosd.s : Di st inguish fnlm other 'Ie sictJla~ Iestons , espec iall y: herpes zoster aJ1d impetigo I. in th,e geni tal ar-ea, s),philis" 1 ymjtlogr'anulana venereun fJ and chane ro id ..

CCMFLICATIONlS: XaPJ.si Ii 3 1J aricell i form erupt ion 5 (ee l.emal her peticun or

di ssem.in ated berpes simplex). en~e'phal i ti s 1- ker ati ti 5:1 and pertlap.s c-erv ic al cance r arnd other- nee p.l.asti C" .cj i. s@alses I'

p" E1 im ifl.ate' prec ipi tating agen. ts lNhen p:J,ss.ibl-e. Appl y a moi stened st,yptic. perlei 1 sever-all times da il y to abort lesions. Dus,t vesicles. twice d ail y wi th bi.smurttJ fO!1EJic iod idle or use gtta ke lotions or CaDlpOOlr spirit.. Epinellhr tne 1: 1 t1 000 appl ied It1Call y b. i I'd.. may al SO be used Ii If there is asso-c iated eellul i ti:5 and 1 )'mphaden i ti S j apply cool

canJ:resses. Tr'eat stCfilBti tis wi th mi.ld sal ine rno1lth!'Wasn ..

D .. ~rpes wister ~ (Shingles) ~ An acute \fesicul ar' erupt ion due to a

virl!JS that 1.5 nttorphcloS,lcally iden tical wi ttl the Y. ar Ieel.La virus. ·

...

S. Usuall Y OCCtlf."' s in adults with or wi thotlt a hi stor y olf chlc~.P01. d~ring -chi Idhaod andl j, s pro'b.abl y a f"eac ti.vatton of a 'var icella 11 ilrus 10 feet 100 t.~t ha s been occult fa r many year.5.. Per sons in anergi,c state~ (Hodgkin' sd i,sea~. 1. rmp,~aS"fl or thrJ:se taking ifimlunosuppressi ve drugs) are at gr'eateli- r i.ak Il and ll.fe-threatening di.sSE!l1inatiolfi (~aricella) may occur .. ,

, ., 0.., Pa~n along the -course .. 0 r a, nerve follo'We:d bly pa infu[ groops

of veSIcular lesIons"" Invol vemen tIs tal ilateral aed per ai st s for

appfox imatel y 2-3: weeks. Lesions are usual 1 y on the face and trunk ..

Swel~ ~I]g a f reg iona 1 1 )mph node's may OC<:1Jr'., Pain LJ5uall y precedes

erupt zons by 48 holJrs or more and ma_y per si st and actually increase in interJsit.y after the lesions harwe disaJppear'ed.

~.. . . Herpes zoster.... Dl fferer1 tial diiagnosis: Poi son ivy 11 poison Qak dermatl,~l s , anti ~eT pes SIl.mp1ex:t which is usual l J Ie.ss pain ful .. a:tIFLIClTIOflS: Per.:51 stent netlralg La fJ anestilelslia 0 f the alffe-eted area following heal ing fJ rae ial or -at,her nerve paralysis, 3ild ene~jph.al i tt.s may OCCqr ..

_ P II- _ Barbi tur ates may help con;trol ten ston and nervousness

as.soc~ated Wl til neur algi,; . A.s.pirirl with Qr without cede ine (30 mg ... ) usually control s the pain.. A sing II! injecti.onl of tr iam~ inolone .acetonidle (Ken al og) 5~pension. (~O .mB:. int~aglute.ally) may give prcmpt relief. . PredniSOlle ~a 11:£. dad 'I ~or .q days arid then continued in declirl ing doses may also be used. Cal gnlne lot ion. or other shake lotions are 0 ften or-

val tie: appl y 1 ilber-ally and cover wi th a protec ti.,e- 1 alrer 0 r co' two n 00'" U'IVr

USE GREASES 4 ," ....• 0 ~ !~Ul

.'. . . .~. . ~ Chapter- 2. Section IV ~ Viral, 1"or measles t smallpox. d«.!gue,

COlorado. tick feverl• and herpes genitalis II .

d • seel Ch.apt@'T 6 'I Pedia tr'ic 5 111 far -chickenp:>.K ..

~ -~ ., I~CXETTSUL 1}~u.:>f.S. See Chapter 2. Section V', Rickettsi.al arxI ..:~tal, fo,r, epl.demlC loooe-~ne typhus.. endem~c f1e~bonJe typhus. t ,.POtted, fev~ s . (Aoc,kll' rtluntal.t1 spot ted fever. lb eke tt sial pox , scrul)

.yphus t t~nch fel1l'er I] Q f"ever').,

1-9 II SPIROCHETAL DISEASES.

See Cnapter 2 t Section VI t1 Venerelal for syphil is ..

... . II:! ~ See Chapter 2", Sec tioo Y I Rickettsi at and Spirochetal,. for

trePJnemall. infection.! (ya'ws a-- ...... Eml'!' ~ "11 - )

o 0·:., .:;:n,u t c .sy~IJ . .l SI, plnta ..

i2!1.

1-1

}-8

Section II - MUsculoskeletal System

{6) N~urol-ogic .. , The str'ength of the aff'ecte-d muse Les and! the quail 1 ty 0 r. the . :9upe~fic ial and. de7Ptendofi re fl exes s~uld be nt?t~ ~ I Also the integrIty of cutaneous sensatdon sholild be determined ~n ind icated .. ,

1-10.. GENERAL.

1-11 • HHEUHATOiD ARTHR 11 IS... Cl1ron ic systemic di sease 0 f LJf1koown etiol~~

... usuall y inw'olll in! the ;synovial membrarle.s a f multi ple' jOlintSi t teI1dons:t or

bursae ...

;iii .. The hi.story, of a musculoskeletal d isordler is moctl 1 ike an~ othe-r history.. A concise .story' of specific ccnplaint.s will help the rned1C best detennin-e~ the extent, of the disorder., Q.J.estions should inreludle chronological sequence, manner 0 f onset, duration of s;mptcm5., previous ro.,SbarY!M IpiTogres5 of the ecmplaint IJ ex tent of di sabi 1 i ty" spec iflc . canpl ain t of ~'i8ht bearing tl unotion 0 f the par't!l weather chanses ~ wtlat aggrav ates the canpl atnt , wh.a t rel, ieves it I vbether it has eyer been

treatE!d 11 and, i r so , whet wer'e.' the effects 0 r trea bneTlt •

b , The physical -eXaDlination should incl udle ~ g~ler al, po.st~e and! al iemeJl t 0 f the bod 'J a s a whole. Ev 3~ua te . the pa tu~1'l t r s body at t.i tud-e wile standing and wilking. The relatlOl'1shlP of the feet t.o the legs and

of the hips to the pe lvis should be noted; also the relati~.ship of" the arms to the 3houldler girdle and to the upper' trtm k. Ne'xt the general contour' of the spine and its relation to the shoulde'T girdle:t thorax.. and ~lv.isl should De' noted. The local phy'sical eXaffi,ination should inclooe:

( l ) Inspec tion ~ Con tour Il appear ance tJ color ~ de -fonni t-y l' and its general reI ationlstlill to the body.

C 2) Palpation., Jenderness I .sWl!lling tJ muscle spasm:t Ioeal temperature changes:l and gross al terat ions ·

(3} .Range of mot ton, MJtion i 5, measuredl in degrees of a cir~le as illustrated below. Merl ic should -CQTIpare affec: te~ area with uninvolvll:'U

oppllsi tes or wi ttl his own joints I'

S.. and 0. Cbmmon in ~es 25;-50; wv.men are affe<: ted three times as often as mefl.. Abrupt onset with symmetrical swelling of joints in the bands and feet F reg ional atrQph:y of bone and muscle fl 1 imited joint motion 'I the' skin of the ex tremi tiel5 may tie :snoottl:t glossy,. arid a trophic" Other signs and S)'IIlptoms inc 1 ude e-levate~ temperature... tach,:ycarrJ ia .. general i zed 1 ~pbad-enopathy :t -m.taln.utri t ion , body' WBs;ting] f ml')rning sti ffn~s.s,. and detression. Syoov ial fluid is cl cudl' and sterile tJ reduced 11 i scosi, ty .. PoI).!TIDY- _phonlJJc.lear leLJ.koc:yte s t ypi-c'ally p edcninate.. Hi story should rule aut other types of art.hr i tis.

A. Ht1eLlTlatoid ar thr i tis.

P. Rest, aspirin in high doses (look out for- ulcer), corticosteroids 11 ei ther' systemically al'ld/olT ill tra-,arti.cular injection,... Severe. rebound may fOllow steroid withdrawal. Heat and physical therapy to maintain jOlint r-ooetion~

1-12,. (6TEOAHTHRITIS. A -degen.erative joint disease usually affee.tin.g large weig.ht-bear ing joint;s p. folder- ind i viduals:t, cauJSlng, deter ioration of articular cartilage.

90{l

s. and O~ Cm.set is gradual and localized to a fe'w joil1ts ~ 60 .... 10- year age bracket = wcmen affected 10 timEs. as often as men; distal

interpllal ang-eal joints of the f'Lnger s frequentl y show mOO 111 1 at.ioa 11 obesd. tyl; palin is made wor'se by exere i se , The c-er-rl'ic al and ll.lDhar spine:l hill II a.nd knee are most often inval ved I' Hi story 1J ~ysicall, laboratory find ings wi 11 show minlimal aboormal i ties .. ,

A_". Osteoartilr'itis 11

P. Rest ~ weight reduction p neat t occasional brace sUp]:Crt:l aspirit:J I analgesicsi F and physical tllerapy ..

1-13. SEPTIC ARTHRITIS .. Jio A<!ute disease proc-eS5 involving a single joint and is, .secondar y to a bacter i.a1 in fee t[cn 1M-

s... an4 o~ Previously neal thy Il case. of gonorrhea usually in, MDer.lI Ii c'oncurrent bac:ter1al infection;tJ rever 11 rash P"J.3sibily. acute joint pa~ and stiffness, joint is warn. tender, swl.len... leukoeytosi S]l arthrocet1 tesis wi 11 st'i:Jw color' to be VaT table , ViSC:05,it,y variable., clari.tly

opaque, culture of'ten :positi¥ell Gr-i:DIl,s stain:l' W .. B .. C .. greater than 10,.000.

A II" Septic arthr1 t1s.,

(1.1.) Joint posi tiol'l. Posi tion of function is the. p:tsi tion that gilles tne joint its malillu.m strengtll andl e~f1ciency .~sttlon of cc;-fort is the posd, tlon tn which the jOlin t feels the most camfo:t.8ble + Pat1ent~. will alwalY~ tr y to assune the posi tion 0 r camfort. It.ls up to ~b7 med ae to il1sure that the. arCe:cted joints are always supp:1rted in a fX)Sll.tIon of

function.

t'5)1 fi4ea3lrement .. A.tropny Olr hyptlrtr'Olphy maYI De detennlined by .e8SUT ins and ccmp'a.rlng with minvol'lled oppo:!Ji. te ...

. ,. " P.. Evacuate if J)Dssible; the joint may be destroyed i r not

prc.ptly treated. Treat witll arlltibiotics acco1rding to infectious orgaliSll ...

1- ~otJ _ ([JUlY AR:mRIIIS. Re<::urret'lt metabolic ~ise'ase u~ually' causing

arthrl tis in peripherial joint.9 due to hyper~ icenia t.hat leaves .. ate erystala wdthin the jOint space~

1-9

1.-10

s. aoo Ol~ Mino~ tr-am3l maYI start: orVer'indulS,enc1f\1 in pork or alcQholl: cl.assacal.l y the joi:nt of' tile 10 ig toe 1 SI ialffected; inflarmati.on 11 , pain ,I :Sl.-!lellillg" fever F chills 11 tachycali-dl1a; ur ate salts; maYI pree ilPi talte in a c:ollection c3111e-d a tophus that ma)" be' rnisblkenl y 1r~lXlr,ted as

calei ficartion.. These tolphi may' be found il1 thel muse le- 5Iuf"rolt.D1ding thel joinlt. 11 the tendons ,lor the wall 3, of the bur sae' a usuai I y made' b,y', hi.s~ry and] phys,ical.. Synov ial fl ud..d wi.II ha.\fe fJ eedle-.shalpedi urate' c:rystaJ..s. that are free in the fl uid ~

.acI h!!'S ions ~

1-11 II A RllI[ROCOO E'S IS ... Find the effu5ion... Mark the~ st te fOT erltr'y It' So rub

withl :Be,tadine or iodline I' Anesthetize· t,he skin 1:1 I 'idocaine ~ Asplirate with 2O-Sage need:le': insllr-e need Ie is 1 eng enough, Record the val one':I

'II; vi.soasLitlY 11 color 11 and clarri.ty o,r synoyial fltlid.. IrrIlled.iately pilace (I~-S mI •. ill ster ile' tnae far culture, wi ttl Thayesr-Mar tin men i [.I'D II P~ac'e a .. 5 mil.. 0 f syrlovial flui~1 in aJ hepar ini zed t.ube for- leukoc yte comt.. Use' 0,. 31 sal ine sc"lution as dll uent for w. B ... C t< Pre'pare' smears COlr' Wright rl sand Gr.en· s Sltain. Pr@par·e \let ~'ar' by pll ac= ing drop 0 f syr\Q'V1 ial flu id on sl idel., cover wi ttl cover slip". and seal ~8e-5 with na il pol ishl ..

A... GbutYI arthrit.i..s"1

Pi ~ -Tenminate the ac:ute attacks by the use 0 r an anti-,inflanIHi.ato,ry· drug II prophylax.is by daily use of c:oI chic ine ,I and

preverl t,ion 0 f further deposits of urate cr'ystal s by loltler ing uric ae id _ level s vi th, Ben.enid or allapttr'i~roI.... Cctdeine may be neooed] to corrtrol pa m ..

~1-1 51 ~ CBTECM1El.IT IS. ArI in fee t.ion 0 f the bane arid bonle marrowl dtte to septi.e-emia or blact~renia ..

S·.. and 0,,1 Infected tonst 15, l)oi1511 abscessed teethl ~ or upl_per' respira:tory inf'ect ion S IDa y! cause the .septicemia.. Dd..rec:t con tatlination m~y resuu..t froml open triac tur-e or war WOJundl... Ge.rnreral s)'rmpt-omsi are' those' 0 f an acute toa(: Lc illne'5s with shar prise in temperature" Localll y the itjrYol y'-ed area may be s,wollen 11 warm" and ver'y tender to touch to There m:ay be a severe. constant Ii pul sating pa i.rI Il usual.I Y sw ava ted by mot ion I' Thediagnosis olr acute oste-omyel i tis i.dl-e~al.ly requires the identlficat.ion of" thel causative' agent... StaphylOCCtCC1l5 aureta~ i SI the' rmcJst oCOfTItI()n 11 a~oounting for 65-10 per'cen t. of tile cases., ProlteUS l' pseudanonas:t salmonella l' stre'ptococ-c:u.s:p Be id-fa st, tJ.acilll ~ fLmgi. and r iCKet tsiae can also be the eause . Blood test wl11 usually show' an el.evated leukocyte count anti tll-ood cuI tur'e may be p:llsi tive II

,

Etl50W"

I I

n_":J, ,II i.,- E~::"~L '

1-11

J------ , a" n f_ r,:,,=- r ~~ml,;' ~jl.i Ll ],

La =[ (~. r ~ ~

., aplp["oa.ch

A.. Osteomyelitis~

P' ~ The' suc'ce'ssflJl treatment, is c(]Ii]pletel''l d ependen t upon estalblish,ing an e'alrly -clinicall and bacterial diagnosis,. Jlrltibliotics are star ted. as soon as, diagoosi.s i. S suspected and may tie all ter-edl af'ter the re'sults 0 f thie' eul ture anc senst ti v'i t yl are koo,wI.. lP~ic i.11 in. G with dose's of 12-2:01 mill ion LJni its dali 1 y and 1-81 g,r am SI of methic ill in: da il Y' 5! de·pend iflg on pati erJl t 1.s age, For patient s t: halt are alIlerg ic to pen i.-c i 11 in :I ceP1alospor'in ~I e'r'ythronl~cin:l a r 1 ineomlY'c~ifl may be 8 i yen. '" llnti b·ioltics soould! be con ti.nued for 8- 12 weelks aft€:T al.L signs al1d 5ympt~S: di sappear .. The a f'fected bone should be irnrTloblil i.zed LIi1 t.i 1 all sigr!s ·01 r aet.iee irl-fectiorl

. -

have dli s,appearedllt, Aspiraltion 0 f aDSI'C€'5s ma yl all so bel necessary. ChrDfi lC

oster:Jmye-l i ti s r'eq~ilres surger y wi ttl r adl ic all -detlr Id ement of tbe bon~' wi th exci 51'Dln 0 f all sinuses t dead bone , so car tissue ,I and neerot.Ic tt.ssue ~

- -

~ li~ J e ( t :u IIJlIIl

~ -11 a. _ TlJE SHO~l.DIER~" Sttoulder pa i n may -ari se fraE .a prGlblefll prl imlaril y in t~ JOInt orl it mlalY be referr'ed pa.in In lielfelr'red pa in mlay' be due to cerv ieal .spl~n~ ~is()rde[f'.s, card iac d ioolrners. tJ gallbladder- di seases , olr dli sease-s In,vQll"Ylng. the' mediaJsti~ltnl or dialP1ragml. ieferre(l palin will less likely have Iocat t.enderness , infl,amnation:l and limited range of motion ..

1-11 bl., BU~SIT'lS. Inn afrloatioln of tbe bursa. Bursae' are 1 uhr ic at ing

dey ices that d imin Lsh the fr ie ti.Qlr:li -0 r movement.... The y are fa undo benealth the skin 1;' blenealthl tendons, and O~ erl yinlEl jOli.n tSI.. In f1 amm.atioEl m.a.y be due to traLmaJ:I e·x ten stye UI5e" infection. 11 gout 11 Olr' rneL.l1lato idl arthr it i 50 ~ Due to the stimuillJ5 0 f in fl anmation tJ the 1 in ing memllrane pr'oo.ooes excess fluid causing d i sten s Ion 0 f the bur sa sec , The n tI id may be blood y or in the case of gout T' tbere may. be ur altel c:rysta 1 s .. , Treat.rDent COIilSi. st s 0 f local

inj ect i.o~ S olf corticosteroids in tol the' i,nflarrmed blE'sa.. Jreatmrent of' eooic:e i 5, 20-110 rngl. h,ydr<>coITti sclne' following in fi 1 tr .atioll1 Qlf 1 'II procaine .. Ph61 ylbutazoQ1e 3G3 m~,,, for 2- J d ay's f{)lllowed ~y '100 mgl II fOt*' 10 dalYs i oS also e.ffecti LJe-. Ear-'l y dJeti v@ movement i n,hi,b tts; dleye'lopDE:nt 0 f. 1 im i ting

}-12

Ac r'om i OC'l a.vicular

Gleno!lurmera 1

L

'OJ

-

.. I

! :'1

1-1911] DiE KNEE II

a ~ Collatelr all. liganent r uptlJre te,st I, Wi th t:he knee p.arti ailly flexed ,I an abnorma.l opening of the medial aspect of t,ne' knee indieates daJIaee to, the moo iBl collateral 1 ig;ament I' If the lateral col later al I igallent has been inljurled ttlere vli.II be an opentng on the la,terlal a15~ t. of the LaiJeel ..

D + (roc iate 1 igament r u.pturle test , Wi ttl botb knees f1 exed , the- med Ic gr'a~:ps the leg just, below t,he knee lrith both hands and pulls the tibia f-orwar'd ~ For best resul t.s the medic stlould placel his hip on thel patien:t~l.s foolt .. Abnormal forlw3lr-d ID:]lt.i-on 0 f ttle t.iblia suggest dia!lase to the an ter-'iar crue iate 1 igamen ts... Ahl1olnn,al bac k'W'ard motion of th~ ti bIa suggests damage to the ~5ter ior Clrluc'iate 1 igaments ..

C r. ]t.I£fa\!rlray Il s te st for torn men iSCUlS .. The pa t,ierl 1. shoul.d be 1 ying in

tile supine po si tion with t.he knee full ~ fl,ex ed .. The fro·t is fore it-I y rotated outwarl-d to t.ts full capacity.. \tti.le the foot iSI helld outward! in the rota ted p.J5i tion:fJ the knee is slorwl y ex tended. If' a. palnful c1 Ick Ls

fel t., this i~d it: ales .a tear of the rned ial mef1 i.sc~us,... If thel pain ful c l ick

is reI t -...hen ttlel foo lis roltated inward!. the tear i SI In the lateral mer11SC us ~

.. ..

I

I-

t-201-- LOW BACK PAIN., A thorolugh knolwle.dge of thel an;:!lttlmy 0 f the spine 11

par t icul ari y 0 f the 1 Lmb'l)saer'a 1 area" i s e.sserJ ti,al to the d i-agnosi.s am treatment 0 flow bsc k pain. Low bac k pain may' be d LIe to congen i tal dioorders'l ttlIlOrs, trauna.1 Tine,tabolic dt.sorder s ,I innaunat()ry diseases f degmerati ve d i se a ses , in felctions:I ntecllaan ical causes 11 0 r ps yeooneurotic

(j t sorcers .. Thi s doe s not end the 1 i st t; 1r'aLm~ i 5 the most eeemon cause of back pain. A study of the presented dlisorder.s wil.l help' the medic in his differlelltial diagnosis",- GeI'leral treatment consists of bed rest l' heating

'II

;::

II

pads, firml mattresS-I] massage 11 and possibly a local anesthetic intil tratioln to tr tgser' points ...

a ... Thel mal ingeref"" .. Hal mgerer-s ex i.st , blurt elyery patien t shoul-d be treated a s al trUE- pa tien t· tI"l t,i 1 ot he rl ev Idence e~ i st.s ~

....

(1) Havel the patient. S1 t in a ehatr and tr-y to toooh the fioor; a pa tiel'lt wi.th a sever e d1i sc bern ialtion c an usuaf l Y' per form while the

mal Ingerer eannot oil]

~ 2) Place the patie:n t in the supine po s,i tioli1 ~ fult one hand under the heel and r'af se the opposi te Ieg , A malli~lerer will u5uall'j lin hi 5 heel .out. a f the mecilic IJ 5· hand ~ i 1 ethel leg i timate patient will pr'ess r-urttler into the hand II·

(3}1 Tl'1e rnal ingering patient ~su.al1y exhitlits a marked, wi.thdrawal resJKln.se when thel med te _p~l pates an y: par't of bi s b<ldY.I Squee zing the sacroil iac join ts bly c-onpression from both sides usual I y -e I Ic its palin ('ran the patient wOOl Ls faking and not franl the trlE pa.tierlt .. ,

(:.q) M..ilscle weakrle.ss in the in jured side' is usually too obviolU5i and di spropoIJ,tionate to the nreurologic:al find ings in thel mal inger'er ~ The tlest- course- of action is to tell the patient thalt n01 OTg3l'l ic cause coo be fOUl']d far the patient I s 3ymptan~ ~

1-1J

1-14

Section I I I - aESlPir atolr y System]

TIle T@slpir-ator y system include's the nasal pharynx:, g i TItI.ge'5 -.' trachea II bronc-htal tree:t 1 ungs f pleuf""aJ 1 -d i aphr an l' and the chest ~al1 ..

The upper port.ion of the respiratory system Le cover-ed in Ctlapter 1.1 Section IX. EE1JT ..

l-21 .. PN'EUMOTHORAX::: The pr'-esen£e of air in the pl.eur all carv i ty' resul t ing

in partiall or total col.Lapse of th,e lung ..

S.. Clo~ed pneumothcralX: No direct c.mmunication lletween pleural cavit,y and the atmosphere ..

( 1 ) Spontaneous pn.eumothorax: Due to rupture of a blleb a~t the surface Olr the 1 ung lining.. 1ft)15 t c-()[l'll1Oln. in ottler'wi se heal thy' male s between 20-301 years 0 f a.ge 11 Sudden onset r of prog resst -ve d,y's.pnea is the mXJist ccmnon cCIllIP1aint ~ Ches:t palin olf variable quallit.y {but'usually

pleur i tic) is, frequentl y assoe i 31t&l.. The rupture 0 ften oeeur.s d ur i.ng

e:terc. i.se, coughing ~ sneezinlg,:r {}Jr' stra tn ing 11 and the pat.i.en t can utSllJally' pin~ in.t the onset of -dy.spnre~ to· the second, The pr'Ggression is usually r~.pld 1" and the pat, ien t rm.a J find himsel f in sever-e respir'31tolr Y' d.i str'eS5 in mInutes:. The course, hosever , may be 1 es s acute' and th.e pat Lent, may nDte only slowily inc.reasiJJg d ~3P'lea on exert.Ion for d a-:;s pT ior' tOI On.SEt of frank dyslpneal at rest, The chest, palin is, usus l Ly Local.ized to the affected side I,

, .( 2) Ten s ion pne'll.ITlQlthorax: DtJe to r'IUlpt\Jre 0'[ a small

br~ij']c:hlul5 'I bronchiole" or al veell us , Thf s resul t.s in the format.Ion of a one-way v'al ve that allows inspired at r to enter but pre'len t,s, i t.s, esca]le ~ The progrelssi ve' incr-ease in pressure from ttle trapped air' btli Idup PUSDe'5 th: heart to .. the oPJ:l'site side and eCOllpres,se.s the- univalv'ed lung and great veIns resul tlng. in. a decreased card i.ac aut put . Thel S}roilptomlS are the same as ., spontaneous pnreLlT1Othorax. but fair ox)re- rapid ill1 progr-essdon . The chest paln us ua 1 I 'i Ioeat i'les well t~)i the affected side- ~ in i.tiall 'I' tl burt mCliy become more diffuse- aSI the' C.GrJ tral,a ter a 1 llJ~~, is inv·ol ved .,

. ; ~ , 0.. ~ Gen.e'ral : The pa ti.ecnt is, l;suall y anx tous and tach.Yprleic ...

Slgns 0 f varyIng degrees ~)f shock may be presen t depend ing on tile t :;pe and elxtent of the pne'l..ITlothar'ax:. The same carl be sa id for c yanosi 5 ..

Vi tal Sign5; Temperature is us,ually normal but may be subnormal if' severe t1egree of' shock is present. Pul se is LI~uall Y' inc re'ased and feeble.. Re.spir'ation. i.'s tachlypne,ic 11

'. B~ P .. : A postural drop may be noted wi th sig,nifi.calilt.

card 1.011 asc ular campratli se ; al per st sten tl J law olr fall Ing supine 8 .. P... will be seen 81S shock. beccmes mrre developed ~

Chest Exam!

Spontaneous

or' aE.sen~ on alf'fect-ed side greater tbaf]

un involvedl s,1dfe r wtLich may al.so

dernons:trate poor expansion)

CheSt ex panS;lon

, , or' absent on arrectea side"

....

!nv'ol vee 3ide>tll'\in~lol ved side

lfesonooce '\0 per'culSslon -

Invol ved side}' ull,invol1Jedi sid@'

Biealtb 'soL:.l"1ds & voice soundsl

III':

, or absent.' on ilfll"olll'oo. side

or' absent on in:'IIollljJle-D side

'A'tisent.

Fremitus

Absent

1lt'lefl' present,.. is awalj' fran affected .s ide ..

rr·,aCheal' dlev iation

•

When present" is

;away' fran

affected .side.

USiuall Y' OOfle

Irae hea I', PI .. M •• IriswingUI (a pendulluml type motion of the heart -& tr~hea during e3(piration and insplir'atiolJ"l is often

seen i,n pnetmlOthorax)1 "

Insp: Toward involve..u side'

Ex pd.r : Away f'rOBl inrvo'lv'ed side

In SPI : Away ft'oml tnvol vedl

side

~xp: Toward inr-

vol ved side

Subcurtaneous eRlptr~serna: f\ili in tile sube utan eous t.Lssues about the neck, and chest usually int1 teates an LZlder-1 y1.n8, pneL.lT1Othorax ..

11.. PneLmOtoor ax ~ Oi ffer'ential d iagr-losis: p.tIa y mimic many acute thoraxic: ellents inclooing; _ptJlmonary etiTi1bolus and MI. The specifi-c features of demon.3tr-atlle hyperresonanc:e wi ttl asSQC ialted poor ex-pans. i011l a f' one side of the! chest will u~ually differentiate' a pnelLmOtoorax. ~n~thele'5S t1 a quic.k ru~e a f other- possi,ble causes should be done ..

, 1 ) Spctntaneous - Tube tOOr-8COStClTlY wi tb df"'alinage:

{a} At tile 3rd or ~tl1 intercostal space just medial tal the anter ior' axillar'Y 1 ine.1 mske .a shor·t skin inci sian just above and rough! 't parallel to the infe'T iOlr rib of the' interspace! II-

(b)1 USe large' hemostats to separate th.e mu~cles and puncture t,he' pleura~,

'.. (C)I With the hemostats t1 introdiooe a large bore' Foley

c.atheter Into the pleural space witn the tip polinting sUiperiolrly (if a. chest tube' Is d\!lIallable. use it)I~.

(d) The tube slt~]Julld be in s@rted: 112 to 3/ll of its

I e ngt hi and the balloon i.nflatedl.. The catheter i:s then silowl y pulled outward unti 1 the inflated bal.loon IIi1 c'altcheslfl on the inner chest wall. [Urintg this time the patient should be' urged to' cough anti str-a in to allow TeDIOrVal OIC pleural fllJid... (i]ce the cathelter catches: ~ i t, Ls secured with sutures. A vertical mattress sut,ur'l! -wrapt;:ed around the tube is preferrerl ..

1-,15

1-16.

The wound 1" tOOl" is rl t.ightenedn wi th sutures:l a01Q. petr'o,ledOO gauze. overlaid wi ttl dr'y dressing is pI aced ewer tru: en trance. Secure the edges of the dressing out to 6 inches, wi ttl t ape, tightly'.. 00 NCIT secur-e Wi tho circLmferen tial wrapls around the chest"

To ~--'.-- ....

',,--=:-' _ ....... To suet ton (i f

iii va i 1 d bl e }

ma~ leaye Dpen if no suet ion dll.:! ; lldtd e but mus.t be kept be~ow

• I 1 e ve 1 0 f

patient

(e} If the, tube' does not h-aILJ€:' a OTle-w3ly vial ve I] one can be improvised by tying a finger cot !I a finger cut out of a rubber glove-:r or a condom ~er t~e end of the tube and cutting a s~ll hole in it. A rubber Penrose dra in sl, ipped over the end (with a few -een=timeter's 111eft daflgl Ing") will aeconpl.Lsh the sa e {i 'I e .. " preven tali r reflLB into. the ches~)... The water' bowl seal cain be used for th~ same plurpose II See 111 u~tr'atlOln,s, below.

To

Twa-bottl e water seal tT ap fOT prlelmOthor-ax-l'

patient

(2) Tension PneUTJOt,oor'ax: Because of the rapid progr-ess.ion of derangements and their consequences (i ... e. 1" sboe k). heroic steps may have to be taken to buy time for tube plac-ement and defini ti VE! management II

-----..-#.'

(a} I f a tension pnelDJothor.ax. is suspec ted .and the palt,ient is cY'anot,ic or manifests an y signs 0 r card Iovaseul ar- ccmprcmis@

(e , g":f postural drop in E ... P., fr anI-:: tlypotension; col d ~ -cl antnty skin t etc.). a 118 or '16 needle sbould be in. tr(j(j]uced into the ctle:st to deccmpress, the pleural space , The need Ie shoul.::l be introduced slowly in the 2d or 3rd inte'rc.ostal space .MrCL III til the "his.51·~ o fair can 'be heard (~ .... get yoUr' ear doW'] there' and listen ~ !) esc api TIS .. Avoid the underside of the super ior r Ib (see 1-27. Pleural Effusions).

W'ater bOWl} seal bowl must tie kept below !el1lel of paltient ..

palient

P-enro-se d ra i n

(b} When th,e in i tiall l:Il ast, of adT ceases, remove the needle and in std turte tulle thoracostc.my arnd drain age .a s outlined above I'

(3) Gener'al car'€' after' closed thoraco5tomy - tube drainage:

- .-

Improvi sed one-wa y vall ve ..

(a) r'oni tor" patient for sign s of continued improvement (or deter ioration). 1M Have the patient cough occasional I y" and check for s:igns of air movement in tile tube or w~ter trap. system... If patient e->!aT1 is conSistent wi ttl susta ined ex pansdon and no air leak is noted fOlr' 2.11 hours ~ the tube may be -clamped.. In an uncoapl Iea ted spon t.at1eo~ plE!tIllOthorax, the tube may be wi. thdrarwn after another 2l1. hour s 0 f cantin ued s,tabi 1 i ty .. The mattress sLlture is. drawn tig,ht. and closure effected as the tlJbe is pul1-ed clear.. Pull ing the tube in the field is 1" oowever,. strongl f -d i scour aged in s~ntarLeous pne-tmOthor'aJx a 00, absolutel Y contr-a Ind icalted in open. or tension Prteurnothor-ax"

(f) If a water seal device is available or can be improyi,sedl' it La preferable.. A" simple 2-bottle wBter trapl suction s,y-stem is illustrated below.

. (Il) If the _pneLmothorax persists wi th evidence of good

arr drainage (large leak in to th,e pleural space) or wi thoJUt ev idenc.e of

gOOd air -drainage (ob,structed or pJo'Tly' p()sitioned tubel) a secorc tube

1-17

1-18

should be' placed nearby to facil i talte d rainage ~ If.a si8ll i ficanlt, hemo-toorax is, pre'ser1t (open ctlesit trauaa:l etc.) a second tubel should be' placed in the 61th. or' 7th in.teli-costal. space in the mid or ;poster'ior a(Xillary' linE! ~ Th.e pIIe:serJce of fluid there should first be confi rmed tJ "I ne@(jle

· t· aspara ':,lon~1

(-c.) Tetanus prophylaxis is given and all dr'ainagerorutin-elly Gr .am-,stained for ev i.denc~e of' infecti.on ..

.

1-22 .. , ASPI RA TIOlr.

a , DefltJitioln: In:spi,ratory sucking into the airrwaysl of fluid or other for'eign m~terial... Tw types:

( 1 ) !ott ve aspirati.on: Thel patient tJ.s airway' defensel mec-hani.sms C:COugJl" gag,~ etc .. ) are over..tIelmed by the sud~en coll~ti,on of matter in the p()ster-lor' pharynx.., Thi s u.sually happens as al resul t of v'ami tills but -c-an happen with: rapid hemor'TtJarge thalt drains into the area (1, Fe'",,, mexillo faciaJ. tr aunal:r servere nose bleeds) Ii Drowning is al so a type' of active aspdrat ion ...

(2) Pa~y'e aspi,Ii'ation: Orolilaryngeal secret ions pool in the

,posterior pharynx and passiv'ely tlilealkIII into the trachea I' Alnros,t alwalYs

oceues in the presence of 51 uggi sh or ablSent airway defen,se. m.echafl isms ( Qbltundat,ioo. Il c-cm.a" eltc .. )I ...

ttl II- Patttology'.. Three major- events may' occur:

(1)1 Asphyxiation (U5trBnglin~tll): C)ccurs when large volone's are aspirated resulting in ex tens i,vel airwalY obstr~tion ..

{2) As,piraltion ]l11ellDOn i.al: Occurs as a Irl@'sult olr a5plir'ating ortJlpnar'yngeal sec.retions tha:t contain mmerous po ten, tially _p.altt:KJlogical org;.anisms Ii

(3) O1E!11lical _pneLDoni t-1,;5: :tt::Iy resul t, f"ran aspir'al.ion of' t1ighly acid stomac·h secretions; .. , It is a type 0 f noneard iac- pUlmoniaf" y edema II

S. The actual event (v(Xllli ting Pl choking 11 etc _,.,) may' harle been wi tne!ssed 11 but ~ tis li kely tba:t, the' lJ: ictim of aet.I ve asptra t.ion will be f ound c·yall1olti.c ".and in se v ere, r'-e sp ira tor y: d i.5. t re S3 II The' tI s ual, hi sto r _y 0' f passave alspir'at.ion is the onset '')If fever and progresaive relsplir.atory d.j.st,r·ess a ft.el_r or during a bout olf Qbtundation.

. . Any rec'oot Hx ·Qlf abttlr:lIJat ion in a patieIJt, with resp-iratory

d1stress sbould alert th:e eX,(Illlin.erl for aspir-at.ion , Illy' Hz of' cond i tions ttlat malY produce uncone Iousness (al-cohal ism ~ sei zuee d i.snlrder)1 has the sane significa.nce.

o. General a~pear'anclf!" : With mass.lve a~i)i r'atiofl, vani tus air ather mat·ter m.ay be seen abf)lut the· nose and motlttl '" The pati-ent may be cyanotic wi th var ying, states of cone tousness (raJlgi.ng, front alert to fran,k CCJDla) depend ing 011 d~sree o r obstruct.ioe , time oo,structiofl presel'1t II and naturle of' assoerated inj urie~5.

US: TeIli1perature mlaJ)' be e l ev ated if pnetmCri ial or cbem i.c al

p1eUD:lni t,i.s has. dle1J-eloped II . ftllse. is . u~ual1 y Lncr-ea sed .. , ~Ii. is. usual.I y increased and Labored. B ... P. may' be decreased or rea)" -eXh,lb It :post,ural dir{)Jp if shock is pr'esen t or iTl'llil inent ~,

....

PnetmOfl i ti s

Pnetlnonia

Use 0 f accessor-y muscles may be pr'QnIlinen.t un.ti 1 near t.he end.

use elf accessory mruscles ..

Use -of accessory mUlScles

UrJiUSUIa 1 Dr' unti 1 adiv anced stage-Sin

Poor br'eattl sound! o¥er large areG5 may be noted; coar se rhonchi ,

The' f'i nd ings of pulmonar y edema (rales 11 rhon-ehi. pl wt"Ie-ezing l'

ete ... ) ..

R"esem h 1 e' s find! ings, in

other'

J.1i1 etlUOfl i C!I s (i. . e! .. ,I S igns

Olf eon 501-, idation}l ..

Labl: W .. BI .. C .. : HaIJ have Leukoe ytosi s wi ttl le·ft shift:l espec iailly if

P1eumon i.a is present t'

~nurtLID ex ami: Many W D C" • ml; "'led] f'L

I.o.IJ:o' . . . i .',... D.. .• 'to . .u,._"': '. ... I or al __

A,,, The most impor'tan t· clue tOI d Lagno sd s is the presence 1f1 the f.b[ of a suspect setting II

P.. < 1 ) Cl @'ar the airwa:t' by man usl extr ac:tion of f~J.ireign matter II Ulse Sluction if avafl.abl,e , The He-iml Lch maneuver m.ay be' neces.sar y to clear' the 3Iirwa,y.

{ 2) If p :altient i 5 CO.III"'II·II~-r--.l'!".-O. :U·S. . and C· .. , ......... 1Ii"'Ii I" crl"'iiug.... ~ ..... ~1· I:"'ii 1-' ster ul

.II.IJ~ .;;:II 't.I awJ I .''..P .blll 11 ~lJIUJI.I-l I ~......::- .' reg ~.. ar

chest, P@r:'"clJssion and drainage. If the' patien t. 15, unconsc iotlSI, he should be

intubated and secretions J"'eaK}"ij'led bl_)" suction ..

. (3) P4ed :: Ox:ygen!" if ava il able 11 should tie acbnini stered II

Ant,ibiolties ar-e the prefer'red fIlelttxxis: Tobran.y-c in or g,entamyc in -B{] mg , IV

or' 1M b , i -llJd. i Pen ic ill in G t,wo' mill iQ~ uni tSI IV q .. 6h. Bronc hod] ila tors may'

be of' benefit.., AminoptLy'lline t as per astbma) tJ .

, I . C • General ccns iderat.icns Ii The best trEatmen t. is pr el'll~n.tion +.

Sev'erely debil i tatedl or obt.unded PB tients should not have food or 1 iqui{i,s

U~ rQ~edfll. "UllCfn tbem, Their' head s should be kept. at, a 30~-4i50 angJe.. 1 f a ~tlent has ~o gag r~nex 1 cannot cough or gargle .a smatll amoun t 0 f wate'r

Wl.t,oo~rt cbokfng II he should be considered a high r'isK for aspiration -III We't j

gurgling noises on in.spi ration and ex piralti.-onl m,ay represent imp.end]ing passl 'lie aspiraltion in the obtuflderl paltient ~ He 5haul-d he ilTlTloo iatel y suc'tioned or his airwalY ev'acuateti by postural methods ...

li-?3: HEJIllPTYSIS'I1 Spi t,ting: or coughing up blood: of respfrator y: tract. OrIgIn II] Mas.sive hemoptysis: hremorrhage exceeds 200 cc .. in 2'.ij-hr period.

. .... ' _ . al ~.. Pathol~: The bleed ing rea y cane fram .a lesion anywher'e in the respll raroory, tr ac:t II- HemoptYSis can be (jeadl y ~ Few patients Illbleed tol

death.·" rattler d~atl1 is almost allways (j ue to aspiraltion asphyx ialtioli'l (i .. -e _,., ,

1-19

A. Pn~1nococcal pneunonia ~ Di rfer'ential (1 iagnc)sl:s:: other bacterial _pne'LlTlonias ~

P... Perl i-cill in G is the drug of cOOlie~e + Gi ve 600,10001 un its Q 01, 1121 h .. , IHI ror :mod et'alte' eases ~ Seveli'e cases wi 11 :requir'e UPI to 1101 mi.ll ion

.. 111 i tsl2lJi hrs DY IV· infusion II An ad e qual te BiTwalY mus.t be maintainedl tl i.f

necessary', byl .. tr·ac~he'al :suct;on!l ~tr acheal tube t or tractleo,stanlY -In 02' must be .sup_pll.ed to an,y paltlent WI. th severe _pnlellTlonia. e. yano.si,s; jll or markedl

d:,splea + frealt .shock Pi ... 1'" .n -.' as outl itlied in cilalpter 15 III, To.x Ic deli:r ium

OCCIlr s in MY severe p1etmorl ial and may be els_peciall J d i fficull t to managel irl alcoholics. It, is best controlled b,y prcnalzi.nel 50-100 mg '" ~M q. .111., p ... r. nil" Anxiety and relstle'SSl'lels5 .. mlay be treated wi th p,enobarbi tall I) 11- 3;{)1 :mg ~ q, + Jihl. O1e-ten,th. gr'anJl phenobarhl tal h ,s , helps insur'e adequate rest IJ Foree nUlid to malin talin a daily' ur inlar" y output of at least 1,,500 CC II Li.quid Q,iet int,ially then oolnnal diet. when pat.iE!l,t can tolerate it.. E1H with code-ine t 1 tsp q '" ~h. Pl. r .n, Mild pleur i tic pain may be' controlled, bl)r 5,praying

the area of grea test, pelf) with etflylchlor ide x 1 m.ill 11 then along the long a.i,s of the bOO yl through the entire area of' paifl, SOl that, aline! of frost about 1 inch, wide i 3, fbnned. Codei.ne 1-5-]0 mg. or meper idine 50-1001 :mg III, may be used fOlr .sever'e pain ..

they ~r'drO'WnJ"l in the 1r:" OWTl blood).,

b , Causes:- Lung abscess/TS/sane heart disease s {rni.tr'al

:sterlosi s) fer-'usbi ng, penetr .ating or eoneussa ve chest, tr8LJn.a/penetr ating neck inj ur Les II"

-

S~ QuestiOfl for evidence of dJi sease states out.Lined above! ""

TralJ..l1]aJ :she u Id be obv'i O~5 F

01. General appe.ar'aliJc!e: Se'.arch, CO!""' signs of passitlle respir'atory

cQIlap5e1 C:ey'a.oosis., lethargYI ,I etc .. )I.. In severe states., use 0 f' neek .

.accessory muscles and retrBC,tions, olf the chest may be seen. t\!111nress and poo~ e.Kp~n3ion. IDa Y' be noted on the sid~ where tlleed ing 1,5, or iginating (i r emling, from .a ILmg).. Rhonchi, ralesll and ~eezes may be be'ar-dill" Decreased Olf"" absen t brealth .sound 5 may be hear(j oyer the· s id e fIOOlst inr'loll ¥'ed •

J\., HemnJlt,ysi s should be obvious ~ but. take care to dis,tingui stJ from G .. I. bleed ing ..

, I. . P II ( 1 ) Clear the airttG)l· Ij Chelst perc us.sioln and drainagle ~ If

the bleedi ng is too br-I.sk or the p.atien tis; in severe re.spirJ'altor"J distress, 11 intub~itlo~. .soolulld bel -carried out -wi,th 111 ig,orotls suction.. tol not in.tlllb.alte if suction nOlt, 3v'alilable, unlelss, the patient i So unconsedous ..

(2:) Klebsiella _pnetmo~1aI.. Occur s pr imar ily i rt person .q,~O year 5 of sse wi ttl a hi story 0 f' al.eoholi sm QIIi deb il i tatlng di.seases II" The causati vie org.ani.sml is JUebsiella P1eumoni,ae. which occur's as floTlllal1 bacterial n,ora in the re.sp1r'ator'y tr'act, or' gut.

f2') Hassiv'e hemopt.ysis, or any hemoptysis assooiated with se:vere, respfra tory dli stress is an emerrgen.c J 'tJl~ t cannot be' adeQuatel y managed in the, field -to Evacuate! ASA,P!! The measure's clutl ined abclVe are temporar y supportive mealSUlr'es only ..

, _. s. .sudden o~set. of etJi ll~ II f·ever d ys~ea f. c~yano..si s , and profoLmd 't?X,:lCl,ty'... 'The SlpurtLD 15 often red (··currant jell Jtli)l, mOOD id f. .sticky I a.ndl dIfficult to expectoratel ...

l-2~·., ~EUM()NIA. An inlflaon)fltion olf the 1ll1g palr-enenymlal to include the avecl i and smaller airways I' Thougll title inn amnat iOln may be secondary tal anlY fltDber olr processes. 11 the telnn, as used in this d i.sC;1lJ3,sion will apply to inlfectiolu~ processes III

o. .ftJ.,ysical findings andl W ~ B. c: ~ are- v ariaille., Diagoolsis is based on flndi,rlg, short I @l'lcalp5llJla ted gr'alD-negati ve Oac:ter La a 9, t·he pr-edminate organi9mJ in .sput 1.10 :sme-ars, ..

a, Bacterial. pnellROni.a "" M acute infec.tion of the ailleol ar spaces a r tile lung. Org.ani sms causing _pne'LITKlni a in~ludle pneU1lOCocc:i, .staphYl~occ ~. Group A hemal ytic streptococci l' Klebsiella pleuoon ia 'I Haremophll us lnfl uenzae , and! f'ra[]c~i sella ttll arensi s 'I-

A ~ Klebsiella pneumorJ ia 4, Di ffer@nti al d j,agnoSi s: PneQl1OCoceal ~nia (YOUI must have- a good, -weIll. stairledi smear) II

(1 ) PnelDOcl{)Ccal pn-e'tIOOTI ia ~ The pnelJDOCoc-eu.s accoam ts for 60-801 pereen t of pr irnar 'i baeter i.al pneunolnl i.a, AmoflS oondi t.ions whic~h pred iSp:l.se to p1€1t1TtOni.a are- vir.81 respirr'atory diseases 1- mal nurtr' i t.ion 11 exposur'e WI

cokd , noxtous gases t alcohol" drugs:t and card rae fa il ure 0+. •

Pl. Kananycin 0.5 p 1M q , 6-Bh ... (15 mg .. ,/kg./tllay'): ce-pbalothin 6-1101 gill IV oil Antib'iotic tt-aerapf' Imust be' c.ootir.rue·d for' at least, three weeks. Generlal supPlrtive care is tbel .same' as fClr pne'LlD:OCoccall pleU1Klnfa·.·

.. (3)1 Sta~lulococ~.:"!lIi.··1 pn ... ·I~I WftJI"'\ ... : .·n, ·11-~.' .. D..... ., edl b

,... »x IIi:iII 'lj;:L.AI~ ~ r-ueuno1118 callS··.. ::Y

StalilJ,llacOCCUISI aureus oceus s as, a sequell tOI v ir'al il1.fectiOrliS 0 r the

r~8r:>lT.atory ~r'ac~, {e~g .. 7 inlfluenza) and!. in debilitatedl (e.g •• POIst8Illrgic'al)1 pat~,~t~ or hoSPl tallzedl inr-ants II espec~iailly after ant1rDlic~rOO ial drug adl11nlstratlQn~

S I' Sudden onset 0 f' snakingl -ellill s , fever" rli stablbing;'~ chest pa in .1 high f~'er' (10' -1 050F F ), t prodlucti.'1 e cough wi ttl ·~ruLSt.y·1 sputllTl" and occa:s~,o~lall_y' van i ting F A history 0 f reeeJ'l t respir ator·y illness Call often ~, ellc1ted ""

, '., . . 0., .. The pa t ient aippears acurtel y tll wi. ttl mlarked ta[!"hypnea

(30~O"mlnute)i" but flO orthopnea. Re'splirations a["'e sruntiflg 11 nare's

n,ar ing f. .and] the patier.n t. olfteln 1 ie.5 Q'TI the affec.ted .si.de in an at tempt tol

5pll in t. tbe cbelst ~ Sig~ s' Olf consol i-d a tion may be lack in8; dJtJr'ill~ the first fe!w hour's:l but fin e ralles and suppresse<l tlrealth solundls are soon h:earl1 over the involved area III Frank -canSOll idation, involvi,nJg; par"t olf a lobe or sever.al lobes:l. is found l.ater".. A ple'uF"al fric ticln: rub is olften heard in the earl y stages.. leulkoc'ytosi s, olr 2[)~ 35 toolU3.3ndl/ctllJ mnl.. i.s tile rule .. Grcm--s,taine.a sputL.lTt showsl man y R .. B t, C ~ 11 W. B .. C .. , arnd pnell11Ococc i t'

ten, . o. 'I't1erella~ be ear 1 ysigns 0 r pleural effusion" empyema, or

. .. slon PleUfX]lthor ax W .. B,," c. us,uall:y' 2(11,. O{K) CU., [lID.. Gr"i:lD-sta ied sputtm

~eveals massesl or 11 IJ B. C. 1':! an~ sranr--posi ti 'lie cocci !I many 0 f which ar@

l.nl tr ace 11 Ull a F .'

l. Staphylococcal pnelmOl1lia. 1-:21

1-22

P... Ini t.ia 1 ther'a:py (based 00 sp.urtml smear" -C011.si sts. a f rull~ .

systenic doses 0 r a celph~losJ:Mllr in. a pen ici lltna~e-resi st.ant . pen icillrn tJ orvancanycin. The doses are as follows; -c-ephalotlrt. 8-1~ ~/d~y IV;

methic ill in jl 8-16 gm/dalY; IV: ¥al1cc:mycln II 2 gm/day IV: na~c llll~:r 6-12 p/day IV. If empyema devel.ops , €:I rainage must be- est~bll:shed. If pleLmOtoorax develolp5. treat as described in chapter 16" Emergeoc,Y War Sur'gery ...

(~) Streptococcal p:JetmOl'l i.a, Usually occurs a s a seQuel to viral inf-ectioln 0 f t,he respirator y: tract:t e'speci all y influenza or measles or In persons with underlying puilmonary dise.a.S@' ..

S. The p.atients are u.suall.)" sev'eral}' t~ic and cyanotic.

0.. PllCltJrall effusion develops fr~uentl"f and early and pr~re~:se5 to emp:feHIa in orJ.f:--lhircl a f intreated patients.. Diagnosis rests in find lng

larg;e nuober of ~t~reptoc:ocei. in GraID-st.a Ined .sput LID :smears Ii

A. Streptococeal pneLll'lOnia.

P'" Treat same as penmococcal pnellTl.onia Ii

Viral ooeUD:lnia II

L

s. Relati¥'ely slow pr'ogres.si.ve symptoms" Cough may DE! hacking and dr y or produce SIIall aftOlilts of nonpurulen to muco id or water y SplurtLln.

Rar-el f d YSpleic~ IU Usually 3.ssoci.ated signs of y ira! sy~drome {e'.g.,. .."

rn¥alg iasl I .sore throat.. ralsnes IJ rlZ'lny nose l' conjuct.I v'i tiS " . etc .. } ... ~leur1 tIC pain may be' ~e5ent but is usually much less severe than l.n bacterIal _pneLDDnia (spl inting is rare)-to

0... UsuaJ.ly, only mild.ly febr-ile ira tall.. f):)es not appear Iltox.icf.1 as a rule. :No chest f'indings 0 f 00 n 001 ida tioo " Coarse breath Slmds and sometimes. sparse rales may be heard '"_ W ... B ... Co. is usually normal but may Teach 12:r000 or above with slight left. :shift (early) or rigtJt shift (late in course)... Gra:staineC sputum: :No orgar..isms; or few mix ed o'rganisnm •

A.. Vir-alii

P.. Therapy: Symptoraatic treatment.

c... Mty-copl a sma 1. pnelllloni.a.

S,,, Resembles 'rJ ir.al pnetmon.ia in sympt-QlllQ!ogy but wi th 31 ightl Y

more acurte- on se t and more severe =xpre ss'ion of symptcms. G:lugh is usually more productive but sputun is similar in cllalracter. Mala ise and my.al_gias m'i31Y he more prontnen t,. May occur in 1 imi ted r. sma'l _! group epidemics (cemps , school:s 1,' etc .. )I.,

o. Pa tien t may appear m lid ly toxic. ~e-·.rer ntay be high tlut is usually lClw' grade.. Signs of consolidation in the chest. LeuKccytosis (up to 15:1 000) seen in olnly 25 percent of cases ~ ~utllrr appeer's similar to .,ir.a1 sputun,

A tJ Mycopl asma, Ili fferen tial diagoosi s.: (nliDyd ia- and rickettsia ..

Pol' 1belrapy: Tetracycline P .. OI ... 500 mg. -q.4h. 0 .... erythrany'ciT1 '500 III!.. ...10.. Treatmell tis sane for chl.amycl ia and r i.ckett.sia ..

1-25... CHPl~IC IBRCf.ICHIITISI A~[I EMftr:tSB1:'A '"

....

a , Chronic bronchitis:- A chronic airway di sorder char acteri:zed by JrOduetlon of thickened secret~orJs 1.' r-~ ur'r-en~ bouts a r in fe'oQ ti,on ., . and lliUCOsal edema-broncOOSp831l. AIrway obstr-oct ion devetops as the dl.sease

WJrsens"l

b.. fm(llysema: "!be term .appl ied to disten tion and tii stortion of the alv'eol i, or tennlinal bronchioles.

S, Chronic bronchi ti s Ls character i:zed by .a cough that is

per sister.L t or recur's dai 1 Y' for at. least 3 mnths a ~ear for alt least 2 suecesst ve years Ii The typical cough is usually wr.se in the morning; the patien t continues; to cough until tbe urge is r-elieved b'f couglhing up tile pla-l or I'I'lUOOllS that has collected d ur Ing the night. A var iahle degree of ches.t tiglr.ltness. and. occas.ional.I y sane wheezing may be oolt,ed in the morniJ1g:p WE tbi s too is, r"el iellled somelnhat once the, chest has been t1ooug;hed clear." As the disease becaDes more advanced, the cougtJ I.rIJrsen.s in severity and duration. and sputtRI production increases" A significan t smoking hi.stor}, is ahx>st alwa~3 present.. In the majority of eases it is a sU5;)erirn_posed !lout olr r-e.sp'i,r atary infeo t,ion. tb.e t blringls the p.a tient to see y'otJ II Lulr ing, ttli.:5 time he usu.ally note s a charnge in th;e color {green" brown or grey) !I cllaracter {thickened} or volume f increased) "of" sputwn product ioe., The ooUgIl may nave beci:me painfUl.. 1llOugFL.a fever Cusu.aU-j law grade) may be p-esent, siglJifican t degrees of dys. pnea at rest are rare unl @'s·s chronic oostTucti ve flulmonar y di.sea se (CGPD) was present ..

Wi th the hi story of ehron ie cough and the morning distress, the patient may 31 so note a decrea se in exerc t se tol erance secondary to shormelss 0-( b:reattJ.. The grealter the ex ercise intollerance the more .advarred the disease II

fimp,ysem..a: In the majority of' cases. it will be assec iated with chronic bronchitis :I it s sign S 0800 :symPltc:ms. The rare case 0 f pure EmPlysema usuall yl pre-sen ts wi ttl d Y3ple'.a an exer t ion , Cough is usually not pn::minent un til COPD dev el.ops and , :..I.hen present PJ is prodoc ti ve 0 f olilly snaIl ;:mounts, of water'y mucoid sput.un Ii Li ke-wi se , repeated reg,pliraltor'y infection,s are UW!COIDllOTI ..

Ev idet1ce (I f T igbt~ sided heart failure is imp-Jrtant. 111 em~Y5ema it s appear-arlee represent s the onset 0 f tile termin al phase ,.her.re.as in

ctu-Ofl Ic bronchi. tic 5, right-s,i-ded he'ar't fa il ure may. be wI er .a ted fO'T same time ..

0.. In the early stages the findings on physieal e1xa:n .are nonspec i,fic II] Iodeed , many ex t:I!\.S wi 11 reveal no aboonnal it ie s to ex plain the respiratory aboonnal i ties 1-

. Olronic Bronchi tis; So at tered .a irway coar seness {rooJ1cbi)

~lear ing wi tn coegn is the rwst const stent find ing... OccasionallY!I whee zes may be he'ar-d l' blut they are lJery rnil-d and also clear some'_"at witb cough"

As the di sease progresses in seli-eri t:;,,_ SCIl1e hyper'ex_p.an.sioln 0 f th,e chest .andl prolongationl of tile €xpir a tor ~ phase rnaly be' noted ...

Emphysema::: Airwa y coar seness usual.I y not as prxm inent .. 1-2)

1-24

~her'wi se the find ings ar e .similar ..

.Lab: The only lab sttKIly' or- any potentiall Ibeflelfi t i.n the field

will bel Gram-,stalined SPlutum~ This soolUildi be done to suppor't a di.ag,r1OSis of inf"ectl.oln,1I }bough _pr1leLlDOnia terldls to occur morel fr-equently i.n these patietllt,S. tile most. eaunon in fectioln in ttli:; group i:s bout 5, olf . ac ute

bronchi ti 51. Gr ant's .stain usual 1 y shows moo ~ V .. H,., C"," (' 'S!' 000- 3,0,1000) F mal)" epit,helial cells:t. and, mixed f'Ior-a ..

{C)I ArC ut.e bronchi ti ::- · .::,putLlll gr'~ sita in -+5 non spec i fic '~ft 01 ... ~ixeti ilor"'al)l; arftJ_Pli-c i 11 in or tetr acycl ine 500 DIg" P., 0.. q I,oh IJ x: lO

.... .Ii- III!":;: "" tJ

days IJ SplJtL7.l sh,ows ~redcmdnate 01 rg 3.:11 ism: Treat, al:5 Lnd.icated (:.see

plelJ1OC)r1l i a) •

{~l Se!llerel brQlrlchi ti s or emph jfSem,;3 .,

A" Di ff'erentiating, chronic bronehi. t.is from Bsthna may prorvedi fficul t blut, certad n dli ff@rences are tiel pful ·

Chrofl Ic lBIron£hi ti,,5

Asttma

(a) Stabl-e : The same gener all t herapeut ic pr'ogr alE aSI outlined abo¥'-e is; i,ni ti.ated but wi ttl nli}ire ur'genc Y ~ U: er c i.se progr .emSI 'J as, such" sholllld not be a.ttempted; rather the patient should be -eneourag,ed to dol as, much for himself as jJOssibl e ..

J"""'-Ilffl.:-.I \.IU~~l

Dcminant feature"1 occur's chNllnical1 f' .,

Oc.curs usuafL Y! in association wi thl attaek ( e "K. wheezing I

dl yspnea F etc ... ) I'

(b) t, fcealkt!lown/Ifi is m,arked DY a -sudrd en ItO,.. sen ing in

re'.spiratof'IY status (i .. e .. 1:. i nereased dys prlea t, f-a t.igue, etc II ) -.' TOl prevent FO£resslion to re'sp1ir.aior·y failure ,I .same ·[)if the measure-s must be ex.ecuted r .apidly arid simrul taneousl y '"

Wheezing

Mi Idl t1 most notable in A,. M·III! or' dlur ing infection;.

clears SaDe'wt\at. with cougJ1, ..

1 III! M IV should be started and IV aminophylline aOnill'lister-ed .a s descr ibed in the a sttIJJa .se:c t.iM . Ra te should not exceed , 21) ce IJ/mrn III!

Usually on exertioln. SlJb.ac u te in on set "I'

At rest ..

Usuall y acute In onset ,

2 III! Terburtal Ine 2 ~ 5-5 mlg,.. may be, given SQ.

:ttt of snDking

Almost al 'Ways (present.

Rare.,

.3 .. An t:: ibiot ic s shc., ldi he- gi \fen .. Treat vi th ampic ill. in

or' tetr ac~line as d-e'·sc:ri!bed ..

As both disorders, progress through. the years 11 the cl inieal pictures bec:ane less d ist,ine:ui sharble"ll' Ebttll bO~lIIer 11 terminate in a ehron ic cb.structi,ve lU11g di sease with r fghrt he'.arlt probl~s. The

II! iffererltCes at th151 point. I oo~'¥"er! are a:cadlemlic because treatmen,t and l-ong-,term Mmagemet1t wi 11 be t,he sane regard!le'5s, olr the -courses Ii

~.. Ox ~gen may be g i Vefl CAREFlILL"Y if arv ailable ., Cn! Y'

LOIia! flow o:c: ygen snot.llt1 be .adminisLered (2 I i.ter slmin)., Hi.gh a,l ygen conce!1ltr at ions ean cause suddLetl r-espi r aJtolr'y ar·re'.st· in the patient ~

P"II' Jmllag,ement of Less a.dvi:I'lcad case 5 of chronic bronchi ti 5 and enJll Y SE!II a gOO utI d be c arr i edl 0 III t as 0 u tl ill ed ~

Sill! During the therap~ ttJF.::' patient m!J5t tie- encouraged] to COughl and clear as· mueh secretion as pJISS.i bile ..

( 1 ) HaJI t, progression of the di sease process.

(a)1 St..o Pi smoking;; b'l far' ~ the singl·e most impartant r·actor..,

6 III! Right- sided heart fa tl ure that is second ar:y to the

Img disease wi,lI. onY·y res_pond to :itmprov'em.~nt in pulmonary st.atus , Dig,ooo:in

will not help., Di ure,tics may pr'ec i.pi tate shock ,. hence Il soouldl be avo id.ed in the field ..

(b) Avolid. areas wtlere nox Ious fUmes or l1igh concen trati.olns of' par-tlcula te rna tter (e ~g .. T smoke.. dust. I] fib.ers, etc 11") are preseI1t.

1 . :NeY'elf" 81 ve narcotics air sedla.ti ve·:s that mlight decre·ase r'e3pirator y (jr i ve .'

(c:) Ole.st, perc u5sion anrd. _pc...stur al drainage in the' morn in@: and. as needed th~ougl1 the day'. The pat.i.etnt should. be en 001 ur .aged to mainta,in l1ydratiotl (2-3 liter's of \later per day) Il

1-26.. PUlMORA,RY' EH]OOLISM

(21) furnctional rehab il i lation:. Prqr'essi ve e-xerci se pr'Og;r~'5I1s increase tolera1ce. &toe patients r-espclnd to broncbod ilators so ttli 51 ther'a_Ply is probabl.y w:n-'th a try.. AlmiooPL:i11 ine 200-~ 00 ntJ! to t , i. .d .. -q IIli .d , or- tbeophyll tne 1]=OO\-20~) mg.. t .. i .d .. -q .. i ... d, may be g i y'E!f} • Terburtal Ine 2.,5-5 1UgI.to toll i .. d .. -q_. i .. d _, may Il@ aonllfji5t~red. with -e'i ther ~ ino (ily 11 in e olr theop,.yllin-e. :x:.me inhal ants (e .,S .. 11 Isupre-l ~ may also be 0 f .some ben,efi t, especially when a:an,in.ister-edl ~'ior to a c.hest per"cussion an~ drainage

a 1111 fu lmon a r- y em b<)l. i Slnl oe C IlJ r s lIilen a thrClnh us ( t) I ood c.l 0 t} or' fa rE:' il,gn. matter lodge So in the pulmxJr'Jary vascul.ar bed (the· ~Ullmonar'Y arteries or their brBJ1£h~s} ..

. . b , EtioloJ2::Y. The rmJIst CatmOli1 ty~~ olf' embolu5 is a blood clot fOlmed

an SQ'ne part Ol:f the' systemic venous eirculat.ioln (usually deep leg y·eins) ,. ~atl breaks, Loose to tr-avel, to and .subsequently l-odlge in tile pulmonary

C lreulatioo. Ii Fat g.Lobul.es and anniot i-c fl uid may all 001 arb 01 i Z'f!1 to the

lUl£, -- Death is usual 1 Y" t,he result 0 f .stloc:k.

{" 3)1 In feetion rnanag~ent II

S.. Chief oC<ITlpla int: Su-dden onset· of unexpla ined dyspneal is the 1-251

1-26

most CmlttOri can.pl airtt.. Thi s may' or may fiOlt be assoc 1ated wi til chest. palin: usual1 y pleuri tic (i ... e .. , sharp II lac ali zed, .aggr av al ted bly deep inspiration. or- couetling}1 but m~y resemble zhat o:f MI. Hemclptysls ma~ be a feature and is usual.I y .seenl when pulmon:ar y in-rarction has resul ted~. Syncope maly

.sometime s be the presenting .symptom.. By far" the most eonsi steflt of these

symptans is, dyspnea.. lbis camplaint, also has sone prog.oost.i-C value., as .severe p1"alonge€:i dyspnea is tlsluall y associated wi th LJ er "i 1 arge ewbol i an-d a

.

poor prosJJOsl..s ..

D.Jllness." e)a c!hange with decreased breath sound ma y be pr esen t if a pleural effusion is pre.s61t +

card ioY ascul a.r"' III Kussmaul' S .s igrl. C:"fa i 1 ure- of the j ugul, ar ve in s to

~ collapse on :irI:s:pirat~ ) IDa Y be not~ . Wit It 1 arge 6I1ooli, sign S 0 f acute risht ventr icull,ar' ('all ure{ see card 1011 ase ul ar sec tton) may be saen , SearloC hi for signs of -veOO1US in5uf'fic ieocy or t~r~rtlophlebi tj s in thel lQwer

ex tremities (: the chief source of efr.boll JI •

Presel1 t· Ax: Sin.ce- 80-901 I;)eTCer1 t, of pulroonar y emboli are blood el.ot.s , the pati.ent should be quest,ioned about any pred i,spDls:ing conditions. These ~oodi t.i.ons alre L1SUall J mlarked by' stasi 3; of" venous blloodl flow wi th sebsequee t clot formation _, Que.stion e are fu11 y for SympltcmS 0 f deep vein ttu:cmbophl eb i ti s in the 1 egs (by flar' thel me-st ccmmon source ot emboli) . Pre-exi sting cOrlt5estive tteart failure; shock state 50 (' tralmBti-c tJ cardfae 11 and septic)' ~ prolonged irurobil ization!" e'i tber gel1erlal C: i .,e ... tJ pallal y:si s , bed confinement... etc It} or 0 f al'1 ecXtr'-emi t y (i ... e .. " paral,ysi.s." east , tlrac tiOlTI)I;; and post.-cp states are all assoctated wi th al uggi sh venous blood now. In pregnlalt ~n .clot 5 me f farm in thel pelv i.e ve ins , Sev'er'e celllll i tis or ganSTeI1e of an ex tremi ty m-ay cause clot formation In larg,"! veins i r these vein s are inyol ved in the prloces~.

A.. Even with the aid! of X rays afidl Lao ract l i.t ies , the diagn.osis

of' pulmonary embol i zi:lltion rna:,' ~e el us.i,ve; pulmonar y! -embol} i sm maYI mimic. ~

OI!yocaniial infar:ctiOrl I pneLJTlOr'1 1 a J asthma, S pori tan E!1?tlS pneLJllOthor.ax. card lBiIC tarDp)nade. or vlrltual1yl anyl acute or subacute eard iac or pulmona~ly ev·ent .. The·l'I1()st consister1t· fin.ding (tach,ycardia) is nonspeciflc aM the ot.her findings are so inconst st.ent as to make .fOlnTlulatioln of anyl t ype of rleliablel sympt-cm-sign cCJnplel:( im~.s.si ble , The so-cal.Led 11 classic tr iad~ll a f d ~Sf.'leal ,I pll..,euri tic cbest pain, and t.aehycard i.a is- n eli thel'"' spec ific nor regtJl ar in oecurr-ence. Pubnon ary enhol i sml must first be thoU8h,t of before it e an be diagoolsed an~d iII: :shaul.d be considered in all.,' pataen t. that delVelops soold.en I] .unexpla.ined ~'el.s prra tory d Lstre.ss in a suspect set t.ing , In the field l' t,he diagnosis will be 91 f'ooc ti-Olrl 0 f three factor s : ( 1! } hi swric,al and physical flndi1ngs; {2}1 tile set t i ng_ in \til ic h the event Qccurred (e Ilg .. tl thrcmbophl eb i ti SI... prolonged i9TIobli 1 i za t.ion f et~ .. }i; and ~ 3) title excl uston of olther poss ibl,e reason s for the :j i str-ess {e "I~ .!I sudden on se t of -d YSJWlea ami tach)fc~ar-dlia in ~ 22--year-oldJ troop.elf L-klo has hadl a fractured leg

iDmobil i..zed fair 31 days is unl, i kel y to be hafll ing .a m:i(}C ard i.al infarc:tion)1 aSI rapidly and! pr .actic.al as. JXllssibl e ..

Past Hx: A tenden.c Ii' towrd r:"'ecurrenc~1 has been noted in many

eases of pulmonlar y embol iSMI. A palst. HI of' ptJlm:lnar'y embolli:sm or

trJexplained s.ignsl and :symptoms .suslplicious 0 f pulmonary embol ism .are Ilel'pful~

(kCUPIi3 tio(J1al f.k: A t1 igh inc idlence· has been noted. in civil iafl occupatdons wi th lOlng per i.od S of inI'Doblili za tiolrl C:e .,S ~. cab &- truck dri,vers). It is likely that. s:im1larl mlilltarlY occepat tons mlight car'r"l wi.ttl therm SOOIe. pred is po:s:i t ion tolw.ar{j clot formation a.rn:ll .sublseq.uen t, embol i zat.Icn ,

p", Iher a:plY : In the field 11 once embol. Lzat ion is sluspected ~ very li ttlel shor t. of glener'al suppor t.iv e ~a.stlre3 (e. g .. IJ Olxygen" vetlltllator'j'

as sj.. sta nee T eltc .. )1 can. be- done to rerned y the effects of tne embol us II Large orl at-ensive embol i zat.ion pro:luci ngl more t,ha.n 70-80 percent 0 r t.hepulmonary c ircua.ation (depend ing on prev' ious re.spi r a.-torYI status and: over al.I heal til) will usual l y ki 11 reg.ar-dle ss of suppor'ti ve measures. ~aller emboJ.i.ZBtion (the! major'i ty) will beg in "to re·.soll vie wi thin the first:. few

days t1 tha~1 signi ficarl t impror\femren t in the _p8ltien t 11 S sta te rna y be noted

wi thin the fi rst ootJt:'s.. SJ.nce @yen small emllol1. mlay produce very prOOLi.n ent signs and s)'Ilptan's ind tia:llY.1 it is im~5siblel to preict ttle severi.tyl of the obstructicrn i.n the first i'lf)ur s after embol i zation ~ Vi,gorQu:3 -5t1pp.1rti ve IDeas~e.s must b@ in sti t,uted to give the p8ltie.nt f s bod y a 5 moo h time as p:ls31ble fof" resol ut ion."

0'.. Ftlysical find in8,SI are tneonsf.stent; and oftenl absent wi ttl small emboli"" Generally t,hrel largelr the embolus 11 the greater the pulmonary a.nld hemodlynamie. consequenc.e.s 11 hence the mi]re prr.xminenlt the P ",I E ~ find inlg S ~ The pat-lent i 3 usuallly Ij,\'ler'Y anx iOIUiS and in mOO er al tel tol serll e Irll!'splir awry

d istrles!!i .. "Hel m,ay grimac~e on inspiration (.secondlar),1 tOI p1,eulr i,tie pa in:} and. h,aY'e orle or' both hands pI aced ov'er t,h'e area where pain is, greatest as i r

WJurldiedl there... He may be pall el and e!ami1Y if obstruction i SI glrelat enoush to

proooce' sc.me degreel olr .shock III

'V'i tal Signs: Temperlaturle is o·ftefl sltgntl y to mode-r -Bltel yl

el evalted {38- 39PC .. ) but, rna Y' be s,ubno;nnal if shrx::k i.s _pr'esent II TactJyear-dlia. is the moISt cansi stent PillE:. find inc of the sl)'M.,r'atie andl h~s, the same prognostic impll ications Q f d ySplea. Note al.sa p:lstlUT al char.rgles (see a tJ P ... ) ~ Respirlations are uSluall Y f:""apidl and, olften :some"'.a t, shallow (seeono.ary to

3:p1 in ti.ng, because or pain) otJ B. P. rna y; be nomal.... Thel pre'seli1Ce ofl

signi ficant post-u.ral dro,p in systol ic B .. P II may ind1c ate al high degree of ooatruc,tion wi th jXXl-r card:1 ac output.. A. low systol i-c: B. P. may be SeerJ when frank: stlock has developed II Use of arcce.srory muscles of' respiration IS usually seen only whenl the gnbollls has triggered di (fuse .severe b1roncmlspasrn < r'ar-e). .. Jugular' venous d istet1ltioTl may' be noted C see

c an:t iova.scULlar below) II As yrrlarte'tr' teal exp~s1on bet-ween the two slde.s 0 f the

thorax may be seen .secondary' to pain (i .. e,. 11 splinting") ... In tile Img.s a patcb y area ot e)a charlse or b1ronchovesi-cullar (tubuilar) brE!attl soumis and rales may be discovered if some 11.118; collapse' (:atelec,tas1s) halS oocurrled.

Whee-zing IE J be detected i r th2' anbollJls ha 5 tr tgg-eredl blrocoospal9T1l ", A

:pleur'al fT icti.-on rub may be heard if pUlmOrllBO'" y infarctIon has re.sul ted ...

Hepar ifll theraIP:f' i 3 instituted to, pr"ellent fiUr'ther clot fomlalti.on,.

It dOes not "'mel t ~I tile c-lot alread y loogoo, in the ,Pu:lmonarljl c i rCUIlation CthOlJgh n:- does alssi.st re50JI urtion ~at). Hepa.r in ma)! cause fatal b~E!OOing if tile dosages given a~el too high or tthe patierll has another

d lse.ase pro,ce-s:s: or injtlr Y' (e "'~ .... .ee ti ve pept i.e uleer, h,emorrlhag ic or

in namnaltor-y per icardi tis" iJll ternall injuri.es:I etc .. ) frOOJJ Mr1 ie-hi t.I1controllable bleed ingl may occur ..

. .. Gi vlen Hepar in::: An in i ti.al boluSI of 1'5" 0001 to 2Q t 000 uri its IV'

.roll()~l by 7 tJ 50~] un its SQ q .. 6h.. ar 10. 0001 units SQ q. atllt HeparlifJ theF'"lap~

:oo_ ~ moni toredl ; in the field. c10ttintg time is the 001)' pT actieal

1-2.1

1-:28

Cl at ti.ng: Time: A stopwatch 1 s started when I) ee _ of y'erlOU~ blood] is drawn tn to a glass syr inge . COe ml I, a f blood is pi aced in each 0 f three dry gl t'I5S test tulles -I- After' 3 minurte.s the tubes ar'e til ted ever-'y 3CI sec' ootil the tubes can be i.nverted wi thout bloed s;pi lling oue , The e'lalpsed times are note-d in the 3 tubes and averaged to gi vie the clot ting, t· i.~ {C!) I'

The test fllust bel dcne as close to 370 C. as, jl()s:silble ~ Thi 5 rma:r be

aecanlpli:shed by talping the tubes to the:· abdClillen 0 r a vol onteer .1 HafY.p him.

st t ~rect. 0"1 thel g;ro1uOOI wi ttl outstretched Iegs and reel ine ~ gr ad.uall"'i ~ black:

OD hlS elbows e\ller'y 30· sec to check bllood movlement in the tubes I, In warn. wealtner the tubes MIa y bel hand warmedlll 'Nolrm~l c:r is betlHeen ~-- ~I [] m.inurtes" b,ut. your moni. tor ing should be- based on a bas.e'l ine· mre'.a5ur en en t {e .. g .. , a C:r done pr'io,r- to hepar in Rx).., S,ibsequell t Level.s soould be drawn just pr ior' 'bD adIm in istr ati.olrl 0 f eaeh lnterm i ttefl t dose II The' goal should be' 001 maintain a

c,r of appro,ximaltely twice the basel Ine meaI5ur'ementof." Rei par in . a~oses, SOOLJ1Q'

c:e·~aliSea- or'QrweF"'ed~oITdinglY! I] If on a given dose the CT srelem.s to

stabi l i.ze wiler'e' you want i t (for thre!e corrsec ut,i ve reed ings)· 1" YOIU nf!ted only obtain thi 5 meals;urlement once or: twice dlai 1 Y' ..

Lab: Pleur'aJ. fllJlid. sooluld bel ex ~ined and the· following te st.s per-formed:

( l} WI II B, C _. (!olunt and d ifferen tial:: R. Boo (:.. count ,

(21 } Gram '" s sta in ....

(3) Glucose me·asurenJ~t {dextrosti x) of fl ui.d and bl.ood ,

Other fin:d]i.ng.9 related] to t,he specific causes of ttle effusion may be present.

IIsually right-sidle.;: may' be 10 i1 ater al . W. B .. C ~ < 1 ~nOO/IllTl. 3/g1 ocose equals ~LD glucose .

R. e. C; <: 1 01 f OOQ/mm ~ 3. other ev Idenee of CHf II]

Cirr'hosis

As above but, with, el1l idence a f liver dt.sea se.,

kterial or viral pnetmJrlia

Same side as in fection.. Ma y pr-ecede other

e"V idenc.-e' of ]lt1.e'UinOJ"J 1alli Wi. 6·1' C II >1 OOO/nn ~ 3 with >50flP ~ "M,,).I.,. s-/gl ocose{sertIJI glooose orgarLi-Sms (bact.er ia) mal)" be seen on Gm- am Ii 5 sta in (rare) II

Hepar in therlalplYI should be cant inued until tt-.re patient ~ s car"diopulmonar),' st.a tUSi has improved ~ Ch£-e' thi s oc-cur's t t.hel he~par in .may be tapered overl !l8 oolur 51 tOI 5! {too tll'1i ts 501 erver:t' 12 hours ..

Tuberculosis

Same side as in fect.iolrt ~ other ev idence 0 f PTIl _. Bolle. >1 p,ODOlmlnl .. 3 wit,h >50rI lymphocyte~s.

Progress;i vie anbUilatior:li" blefore' taper ing, thel hepar j,n 11 5h~ulldl be -encouraged .. Ace wrap·s sb:)'uld be employed on tile legs d1ur-ing thi, s tintel II

Pulmonary infarction

May be bloody. R. B.,C~ }l ° ,.QOOfnm Ii 3

W IS C >1 000· .. /1 3

I I J t. I . / - - l ..

• I. III I . I! r- ' :11 ' unl. .

The paltient should be main tained on 5." OOttl un its .so -erwery 112 hours fori .Ql-6 -wt!eks I! Thlis dose- (often referr'ed was· 'limin.i-doserlJ helpar i 1'1) wi 11 not a ffeet e Iot tlng time·s 11 S() none need be doee , Thi s 1 ~w dose does 11 however-. affo,rd sane reststanee to fut .... e p:J-ssible, clot format.ion.,

SJb~enie absc~ess

W.B .. C.)1 11000IlIDDl~3. (us,ually} evid]ence of intraabdcmin.al infection 'Ill

Olest tr-auna

frequentl y blood., Hx of trlalJT1a usual I f ofltalin able.

F'alt ernbol Lza t.ion: Should! be suspected if sudden tI]e~iPl.a:ined dys,_pneal ,I tachypn,e~:t, t.aehycard ta IJ and ne'urol()S ical deter-iOl'latioll {e.,g .. !

de~ iriLm I cana'l1 etc ~ ) . develop 12-36 hoW'" s a fter' bone fracture {especial 1 y a maJor long bone- or pel 11 10 fracture)l.. Treatment is suppor ti ye ·

1-27 ... PLEUHAL, EFfUSIONS. The preSEnce o-f fl uid (inc} ud ing blo-od and pus) in the plelural cavit,y ..

Leakage througtJ a 5ubcl.aru"ian line

Fluid has cha[racterist.i-c of IV fluid used gluoo~}serlill glucose (: i f DS was camlXlnent. of fl ulds) •

Usuali y unrenarkabLLe- burt ms)' have W .. , BIoi C ~ lr:1Crealse ..

.. Pattology:: The presence a f fl uid di s'p1 aces and restricts tbe Illflg on tbe lrlrvolw'ed aide .. hlndlering, respdrat ien . The mcu'''el fluid .. the, mor-'e restriction., Flurld can arise fromJ .se'yeral processes t see b~low) .

P .. Thor acentesi.s : Because of t,he' d.anger 0 f ind ue ir:ag a pnellnOltbor ax jl -ervacua, t,ion of the fl uid (tberr .ape,urtic thc)racentesi 511 should D-el

re·served fo~ oond i taons where' severe res p'i.rator Y' distress is pre,serlt II A

.small sampllnJg elf f1 ui.d m~ay be oblta in-ed for st·udlies {~iagoostic

thorac~en tesig} relalti v'ei y safely III .

S. and 01., PTQ;ressi I.J e or I.rtDr.sen ins d ySplea is the! frost consistent finding 11 The rapidity of fluid acctm'lulation as well as the amount of fl uid present will cont.r ibute to the prorrtin_enc~e of t,hi.s 5)!Dptam. Sl ow-tl Y' detl"elop,i n~ effusions may not prod lJ:;e signi ficaln t -dyspnea un ttl large "ijIlOll.l'l\e5 h~ve! acc'l.m'ul ated 'WI1ere a r aptdl. y devete pi ng ef'f'us ion will prod uce dyspnea at smaller V·OlLlll@'S. other .symptoms of pleural erfu~i.on will bel related to t·he specific causes ... , Del'lli-atioltl of' tile trachea a'Way from the affected side may be seen , Poor mOlVement 0 r the involved si die 0 f the ctL st mayl be noted.. rAJll:ne.s.s to pe-n::u~sian: will be rioted i rt the! upr ight.

p;:a.si tion . The' e~te':n t of dlullness (me.als,ur'ed to the in tercostall space were' -dull ness d i sappe ar'Sj)1 sooluld be· mark:ed o,ff. Sanetime.s an CIlrea of nyperre,solnanrce will be noted just .a~ove:· the fluliri level., fremljt~~ is

albsef1t .. Dec:re~ sedl tOI ab'sen. t breath s:)u~ji is-the r ule' II but i,o~ tubul ar

hlreath Sl:Jiundis may a ften be present of. AI,SOI whi spered souna~ .... ~ 3}" ~I~_' ab.sp.n t Olr

leas. ccmnonl y increase.,

The mla(jlor' their Blpeut ic e'ffor,t should be dl ir-ected at resoll v ing the prtlCess r-e'5'ponsible! fori the e·ffusion., ftJlSlt effusion will resorb once ttJi s is diane.

1-)0

rl-ecogn i z-ed, i s usua 11 y prlDgre:ss.i ve. I3ecalu~e! 'the sensat.Ion of shortness, of breath is subject to modi fici3ltiot1 D lj factor-s not d ir-ect.I y the resul t -of the pathophysiologyl (: i .. e ~ t anx ietY:I il11to>: ication 1 II the' diegree of apparent. dyspile a doe s no t cOlrlr'elate well with the sever it '1 of alirway obstroc tioo ; benee i.t should not be usee as a CODe rete c'ltn ical guide to therapy Dlr the pat i.en tis responee to ther apYI .. C:OtJgh is usually' presen t and may' be

prod.1.1C ti vel of a thick I' teln ac ious tJ gr-ely-whi.te, sputun I] This sput LIm most.ly canrsi st.s 0 f bronchl al. secre t ion s that bave ·l1dr ied out III scure-wihat (i .. eli" too wate'r is evaporated off' bly a ir rlo,.,,1 leaving behi.nd the' thick mlUCOUiS coaponen t of the secr''e'tt-DLns,) amd can reach the! consistency of gelatin. ..

This: inspt ssaten ~llJCOLJ.S c an plug airways T thUlS increasing air-wa'i oostruction II] Hence a drYI cough in em alsthmatic durinlR an attack may indicatel a, reverie degree olr ol)s'truction dlue to the '~muco~s, pI ugg ing" phenanen.a ~ 'Wheezing rna y olr' ma y' no t. be pelrc€:'pt,ible to tile pati-et11 It- and! Ls defined: further bel o'w "- The d ulrlation between. onset. olf symptoos and presentaltion should be oblt.ain-ed as thte rapirl.ity with which a ~tient approache-si a given at1()unt 0 f d istre3S 'as obta tned f'ran hi story a.fld ~ysical) may _prove 8 valuable- indel( to the severit"j of the api sode ,

the relspirlat.ions should be n.o,ted .. , Bee ause in spi r at ion has. mor-e rnulscul ar assi.st, "tn,an el piration, a i r e an be fOlrcled t.brough par t iall" obs trux..: ted airwayS" but ba s con si j er abl"!l ~or'e d i ffi~ LJ 1 t Y getting out , Th i s resUil t.s in .a prolonged ex pira t= 'i pna~" thel 1 ength 0 f ,,-wan ich par all e l.s r~o-UE'~hl, 'i the degree of atlstrlJctlon.. Fur·th.er' f as the pat.rerrt b:r'eaths 1a~te.r1 [be~a!jlSe of hyplJlxi.a" bi s it1spir at ion 3- b~g in be f()re the 310wer e:(:pi rat 1.om; s C]; e

canpletedi tJ hence airl i So t.r apped ann the chest beccme..s prog1relssi lJely

byperex panded • As hyperre)( pans ion i ncrel;3 ses., the Emoun t D f a ir the pa t Lent is abl-el to, for-ce fUill y i.aspi re d ecr'eases , H~ c crnpelTI sate So bl}' breatJhi rig st.i 11 faster·... Pore air is trapped and a 1Jiciotls cycle ensues , For t~;ese reasons a lorw re'spirator y r.ate w1 th mar kedl y prolonged ex pi F ator y phase

{exhalt.Jst.iOlTI) or a ralpid sbal Iou rate in the presenc e ·of marked

hyper in n artion are preltermlinal ev.len ts in the asthmatiC' ....... secono 5 COUll t .,

Past hist-orlY: ~5t· asthnatics alre' v'er'y farnili,ar wi th their' .sta.te and rna'i tell you both wha t usual L y tT igger:",s an at t.ac~k and wflat tberap,y the"!f usually resp:lnd to ~

B .. P .. : When the! SII P'I] is. mlarlkedllj elevated (>160l}100) caution shoul {j he used in too admin istr atio,n of elp.ine;:fllf" ine , The drugs should! p!""obabljf be witl1hrelld 311together' in ttle o-Lder patient with elevated 13., P-., eSlpeciall Y' if there- i SI a hi.stalr y of heart d Lsease o Ii' st.roke , The sever i ly of t he elevaltion and the pat Lent I 5 overall state must, be -weighed t..aget.her"' ..

There ar'e no hard and fas:t ru} es .1 AA abnorma 1 d e~ree of pulsus par adcx us,

(PiP} sblJiuld be searched fOT".. }lben_ the cuff is in fl a ted 'I SLCWL y{ def'Late j, t (1 tml.. Jig; every 2 .see 5)1 and note alt wh,a t po int thE syst-ol ie ton-es ~egif'] ~ 1 f pulsus parlooox'us is pr-esent ~ t.hese tones will disappear during inspiratiof]

and reappear on ex pir ation ., C~)Jnt.inILJe to de fl ate, the c:Ulff 51 owl y and note

the rangle aver ~1 ic h tni s ['1 nd i.ng per s.i sts .. If t.he find in.g per st st.s ever a rang:e greater than 1 ~ ,,-l~':1 there 1S an abnol'llJlal degr'e~ of paradox _present. !hi s sign corr'efa tes well wi th the d.egree OJ f obstruction {tht?, greater the range ,I the- Mar-Ie' sever'e the obstr'ue ti.Qn) aand usualll y r ef'l.ee t.s tr'-end.s in the pat.Ient, ~:s st.atuaS before they c-an. be' full'i a ppr ec iated in otherl a.sJJects 0 f the ptryslic.al ..

~d ieations;: Moany attacks prohabll y r esul t flr-om Loss of mea iea1 corrtro'l , rete:rmine what med.ieat.Ions t, i r any 'I the pSlti,ent uses for asthma ..

If' h··· ,... i . , tl ~. '·d th dJ .. termi .." """ ' .' .' . '11 ,.. t· h· .' " ' .. ,. . edl r I t.1·· 'I' • ·d· I

.' I e u13can .lnue, I . em II 'e.· mme wuen. genlerr.a . Y :I I e more rm .. lea.Ul n s· .an

tbe higher the dosages , the' more .se1lere his di.sea se ., Stero ids ar-e the ''''b1ig g:LI'lSlrl of astbma theralp:; and the a~thrrlatic requi r"ing them for control has severe' disease ~

A11.ergie-s: .&::me ast~ati{! s gli'llE aI h.isto ry a f y ar iou.s and sunrdr'y allerg ic resp:tn.ses (hi veSI•1 r'tlini tis, etc ... ) to sp~ i flc substances.. These, patients are e.spec iall 't' prone to anaphylac~tic reacti,on.s ~ so spec ial attent.iofl should be Sli ven to ttli 3 segmen. t of Q~:st,iDning., t.Fote nere that certa in drugs can prec i,pl, tate' orr irJOlrS€n an alsthma attack. II] The most notable be ing sal ),cil:ate5 and! other nonsteroidal anti- in.fl-rurma tory agents (e I'S II Ind~ in ~ ~tT in ~ e te t,1 as veIl as proprlCH10101 (ltlder3l) Ij

The degr'ee of pul, sus p8lr'adox U~ should be- no ted through l he treatment unti 1 nonnal an~ recarde<l wi th rrequent1'1 COllI ec tedl 11 i tal signs. II1 mOr'e severe degreel5 ~ t.he pUll sus- par adl(Jx us mlay be noted in tilel per l.pher'al. pulses, where i t mani rests a s am in ~ plir a tor y d i. sappear anc e or weaken i[JE. 0 f' the pUI!se... Thi.s find ing is an in ~ 81 tklbl e .a i.-d t·a estimating the sEver'i t 'i 0 f oblstruction aU'ld tile adequac~~ {ar in.adeiltlac y) Q f therlapy when arter j . .a 1 b.J oill; 8aJses an_(j other' 12bs a:-'e not i3vail~ble or' ~ot practicable.. A note of caurt.iOfl her-I·e: A decrease in PP may be noted as, t,he pat i~l t beg i~.s t~ succ.umb to e~xhalJ.Stion or approac-he s thel stalt-e of max imal hyper in fiatio~ .. Like, an y' other phys:ic.al sigrl j PP m.tJst be interlpreted in 1 iRhit 0 f the' ger;l~rail elirl ical pi.c tur'e i ye,t here- ~ any clhange is a f sign ific.aft-ce ..

0... Gelil er'al appear"arnce. Asthmat i.e s appear' arlX iQUS d urling ani

at tack t1 and the expf;""e:s.sio~ of fe air OJ} the ir faces is ev ident .across a r"'-oom_ .. They in hrue through olpen mouth soften throwing t.he irl heats bac k as the 'j' do., E:K:tmlatiot1l may be through pur sed 1 ips a9ild the paitient may lean fOE"'W8lrd as: if str-ain i.ng to de fecate ~ Astt-.cta t ic 3 in rnoo.erate to sevier e di stress prlef-er' t/)J s.i t .a s- max: imal. mechanical ad IJ antage of the respit"'atory mU:5)(:les are! obtained i,n this lX'sitiQr... When an asthmalti-c i,n this type of distrelss nllalYs dOlwnt~ on YO;nJ, it mlay i;nd i.e ate he is tir ing,; he~rl{!e:! you must movel quickl,! to

BEENT - Illr Y' mucous membrane s should b€ 1111 terpreted (as an. indiication Olr p:..ssihle debydratio[]~ ~ ttl c'aurtion alSo there is invarr"'ia~j_y sane drying secoooar Y' to the prlan.inen t motlth breat.hing ..

Vi tal slg;ns;: Shou:d be Dbta in ed pr lor' to an y theT .apy ..

Neck _I Uise of the' .a~ces5nry mlu5C~le,.5 (] f re.spir ation" oS pe~j, fi -c ally tile anter ior and an terolater al neck mllscles ,I haiile been SOOI-wtjJ to c10rrel a te rOllKhly wi th the degree of obst.ruction... StJ\[3 in ing of these muscles, ..J.1: inlslpiliati-DITI i 5 seel1 in moderate to severel d egr·-ee.s a f -obstruction and! the ir use will decrease anrd -event.ually disappear' a5 obstruct-i·on is reli.efi/ed .. Ranemlber, however'. that, use 0 f these mus(!les, wi 11 aJ.,so b~ane less pr'aDlinlerlt as tl1e pa It:i.-eJ1 t becOOJe3 ex ha1Jsted ., II ~mon i't:.lr the lJHOl.E patient!:

Temperattlre t ~ f ~lel~atetj, m~~ itldicate prese~nce of a eon(:(11111 t~nt infection -

Pu 1se is LJslJall y r a:plid and r€gullar; s1 O~ olr irreg uil arr pul $e' may ind ica te se~-ere h ypox if] are idolsi 5 - Pul sus _par adlax UIS should he se.ar-ched f-rJr

, ~.~.B [[j Pi 'I

~ .... ~~ .D.J IF. j • i •

Chest - In the field 11 probatJ.l y the' 18)S t val uable' 1nd iC31tions of the adequ~cy a f venti ratiO!'M a rei the magn i tude .and nature Qlf chest.

D)()V EIDen t 5 .. ,

1-32

fOIT al I pr-actic able purlJX)ses if ther'e is no Chestl expel'!] ston, the pat.ier! t, is not mov ing .a ir' .. All tne other parameter s used to moni tor the .a stm~tic in the field 'e ",g .. :t' changes in PP;; presence 0 r absenfQ.el of weezes.; use of' accessor y rmusclels 11 etc II) smlLJld bel in terweted in light 0 f chest expansion. (oodl to a 1 esser €'x tent onl the· presence or ablsenee 0 f b're'.ath scunds) ~

By the mec:bani.sm pr ev iOUiSly out l Ined ,I the ctlelst. m3YI blec.(1'Df;· ~r11ocked in·" a prog resst viel y increasing state of ex pansfon bly a ir trappIng and be unable' to relax to its prleinspiTaoor "i posi.t.icn. Sitjce the chest wall can onl y elE pondi so far, the arnoun t olr a Lr ttJalt. can be for ced in Ilrngresisi vel yl decreases ~ SiRn s of hyr.erex: pan,sion i:nclLXIe· increlased or' illcre.aslifllg anter"ior-fJ:l,ster ior chest diameter {best noted at, the end of

ex pi.r'a t.iof:l); decreasing res ptr ator y exctlr'sionsl; increasing chest bY]lerrelsonance to pe~rc. usston wi tb 10s3 of eard Lac area d ul.Lness and wi.deflect in terco,stal spaces . In severe instances {appro,ac:hi ng, max mal

hyperiJ1 nation} ai:r fDQlIE!merl t· decreases to tl1e po in t tl1alt brealttl sounds and wheeze::; begin to fade and dt.sappear . Ex:pir.crtL)ir·y movemmt: As ;stated pr-evi.oulSly 11 the degr-ee of" explir.crtolry phase 'pr'olongaltion shou.ld be nOlted .. ,

Lungs - Er'-e.ath. SOtlOO.S ma y be helard in mild to' moderate states t, but usually llec-anel ob3Cured by \iheeziflS in mare sev ere- cases .. , Wheezing is· a h~llrnark of parr t.ial a iFwa ys obstruction. 1 "The' sound is prod uced b I.j air'

IJI ~istl ing'~ through parti ally obstructed charmel.s t; Ebth inspiratory and expiratory wheezEsl are' bearrd in astrma thougb. elx'plir'atory wheezes are mf)Te prClMlinent and may be the only type present in m:ild epi sodea, As obstruction is r-el. ieved, w1tee:zing will dimi,ni sh and clearl breath sounds

wi ttl improrved respi r"atorly ex cur:sion:s wi.ll be notoo. Since the production of wheezes depend s al so Of] air' flow, theYI will al so dimin ish or vani sll when "'ienti lation fall I 50 (e .. g. l' h.igh degrees of hypelrelxpan sion or patient e~haustion} .. ' Her-e no br-'e.atl1 sounds will be bedIrdi. and cheat expansion will be min im~l to oorlexi,stent.

EgophOa1Y' C: II el)a 'I ctJal1ges) may be nroted in patchy arelas over' all

1 ung fields.. In. till s C81se' ~ the finding is problablly secondary to co11apsel o,f small areas olf lUlE, bee aU5e1 their airwys halvel been c-ompJ..etely

obstruc ted -In I f the finding is vier y prtlTlinen t, over a fairl yl largel.1 well dlemerlcalted area 11 then ani als.sociated PleUlJO~.ia Qlr collapse of a Ioog segJiT1ent.. l-cbe '" or en:tire' 1 uliJg (depending on ex tent of the are'a) secQndar'y tol obstruction {Jlr a bronchus by a large mfIJCous pilUS; must be consider-'ed ~

Lab : AA elevalted W II B. C.. coun t af.ldlolrl left.ward stliftl inl the

di ffelr-entiatl,on ma:y indli.calte an associated in,fection ~ If' tbi s test i 51 to be per for med '-" it, sbould be! done be forel amJllini stration. olr eplinephr inll! aSI thris agent will i tsell f increase W Ii B; C III eoent in the, lertwr-ti direction .. This errec-t maly persist for 2ll- hours. Ex ami 01,- tile SlllJJt,LIIIl may rleveal t.iflY muc:ous pI ugs thilt t1a~e· been d islodged :fr~ the :sm.aller' airways (eal.Ied Cur.sctrnann" s spirals) II Eosinophils may all SOl bel present in lalrge I'IlllDbersllI 1he prelseru:::e of many nronr-eo:sinoPlilic pDIIllTlorphonoc 1 ea r' cells shaul·d :raise suspde ian of a pa.ssi.bile a 5500 iated pletDJOn i,a or bronchi tis ~I In general. ho-wev'er,_ most olf tile above provirdel merel y :supPllrti'Ve ev'idence" and since more sophi stir=alted 1 aha will not be aiL/a 11 abllel• the d iag;ooISi. 5 and rnanl3Hentent of the asthmatic inl the field wi 11 depen~ on your ablili ties to obltain and ifl ter'pretl cl inicall, flndi,tl8$ II

A~ Asthna.

P. Management:: 1herlapJ 1 s aimed at rever sing thel patooPly.s.iolog ie fac:tors 'Wh.il e correc: t.in!; the· der'angenents (e. g ... hypJ~ La !III

dehydration:! etc .. ) they neve produced , The treatment is staged to oolrrespond to the cIa s ses 0 r sever i t y preil i-ousl y out 1 ined ..

Mi.ld

II.

D~1r'Ii I!"'I.' ~ ....... S n:;:I . .srm :: []I VIIJ .... ·[-.J ·r .....

.1 3- .. '5cc' • 1 ~ 1001 sol urt Ion of'

ep i ne'pbrine! SC

re't)e a-E ~ q .~L()m i n :( 3 0 r

unti 1. wheezes clear'ed

Admin i st.er epinephr ine

as sehed ule(f-~ti.uf~i ~ed iatelYI a f't.er fir.st iflj ec t.Ion

.admin i.ster' ami nOI ph yll me as follows ::

If no il1JlP!'"OV emen t noted -Qlr pat i en t 'hOr"'sens during Tx

Aminophylline .tlOO mg .. in 250 cc _ Drs 11/2 MS run

in IV QIJ erl 11 SI min. FolloWJed b"i an I \r' -aafmlinli 5tered

so.lut.ion of aninophylline 200 mgl.. in IjrOo ce - D5 /1/2 NS at rate of '50-200 cc _/hr until cleaJredll

If" 001 inlfl~'mren t noted at 2 hr s or pa t.ien t \K)rsensl,

ccnt inue infusion and 'I

Gi,ve' ter"b utal me 0 t, 25-0 .. 51 mg , SQI" I f no impr ov emeJt in 11 Ilr or pat ient- WOT.sen 5 0011 t.inue- in fu.s ion and , . .

Gi lie Soltl-Medrol (methYll predn i50lane)

1 8JTI I V push fallowed by 1 PJIII IV push q .. 6ft.. un ti.l clear- . Sol u-Cor lef (h~dlr(l.CQrti.sone)

ma y bel substi tuted ~ An

.irn t i al. '0 gJm is given IV push and! .511bsequen tl y: q .. 6h Ii there-a fter U'1 til clear ..

Eehrydrra t in n :.

P'. 01.., hydration (for<:e fl utds )1 is usuall "i

edequate

H_ydr at ion t s aretmpl i stled with] thel aminophylline

sol UltiOf] • OS /11/21 is _pr'eferlr'"-edl but ~S or Ri.nger I s

sal Ult ion will 5uffi-ce.. (DI5WI in extr ernE emergency).

02" i r at all attainable! ml1$t be emlpl'oyed pr'-elfelr'ably

by mask: (because of mouttl brealthingJ

~:ssatedsecretions: Are. thinned by tlydr.atioo and released by relief .of

.. .. chcJ,.spa311 tol be e'ffectively cou.ghe·d] up:' and c:le~r·edl ..

General therapeutic COIl sideratioos : Many I.I1Uld view tbi s out! ill ed 1'1 aJl of

managen~t aSI .aE8res~i 'lie' ~ HtJwelllerl ,I in the field 11 removedl fTCID

SQl~lstl.caterl diag;no'st,ic-rooni tor inlR rae iIi t.ies ~ mechan ic.a 1 venti latolry

alSSl stance. and most p.robatJly oxyglen. tilel only OOII1=E the astmati.c has i 51 an

1-]]

t~.l4J

approach tha t r-el, ieves hi s obstruction A5A P! The 01 d adage of .", push it

( CIn inc phyl1 ine} till t.he y puke" nnE 1 be quite necessar y In field pr act.Ice to assure adlequat-e- blood levels.. It. mu.st be' remembered that it Ls irnJl~)s.sible to r~liably pr'edic:t which epd sode s will respand to lo,w€r do sage s or legs 'JIigoro~s man a~;emrent and tba t as t-hel attac k progresses )flour chances of retrieval d imi.ni.sh !by large factors II] In these instances ~ you can expect fflOrta 1 Lt y: rates approaching 20 times tbese of a ho spi tal emerg,enre'1' roam ~

Spec i a 1 wn s ider-at.ions :

Exhaust, ion: {lose moni taring 1.s nece asar y to head off cooplete respiratory collapse II If the patient SOOIWS, signs of Irlgiving it up" (i lie ~ tJ Wf2.akened respI. r a.wry' -e ffort man i fe st.ed h~ a d ecreased or er r .atic res,pira:tory rate Qlr decreased! ins pir-ator y: exc LJr s ion s as.soc i.ated with. a pliDg ressi ve dec rease in breath so und Si---or' wh·eezes in the absence (I f breath sounds=- and a ietharg,ic fatigued over a l l appearance) , therapy sboul.d be :ste'p.Ped =up by pr'og,ressing, d i r set, 1 y to st.ero id adm if1l i st.r at.ion ~ 1'al k to the pat.ierrt and eneour age him to hang in th.ere'~ Slap ~Iim or p.inch h.im if :fOIU ha\l' e to b~~t tr y tOI buy' any' add i tio nal t iene you can . If he does n.Olt an ~r eoher'en tl y, and con tinue 50 to 'I: 51 i p awa.jt,. If 10 Ui MljiS- t intuba t~ and b.agl him

W1 til the'r apy be~ ins to t.a ke effec t and he cain breath on hi So o,~ ~

Cyanu si s ; Sl ight d i scol.or a t i.on rna y be noted at t.he na i I bed s a~ snoul d. b~1 ~ an aged bY' Q)[ ygern and con ti:J [Jed br,oMctl-ud ilation ther'ap~., Wh.en i t ocr ur.s in the set tirlfi.: Q f impend i.ng ex naust.ron (above}l, i tis an lrJd rcat ion for imm~d i a t.e irrtubat io~ and venti 1 ato r"'j a s.si stanc-e II]

Hyper In flation : }Jig tL degr ee 50 (t,r hylper in f1 at.ion a ssoc ialtedi wi th je(~ reasi rig ex c ur'sions are an i~(j teat i Onl to ste Pi up t.her .apy as 0 ut:! inee

Rlr.: ~r. .. r~, • ;~rl::':E' the chest; b~cane s .1 f'Lx ed" at dl high 1 evel 0 f ex p·a~ s ion '"

~OWt~V er.. V'erllt i i ato r~ a ssi st~lnce c i3!'l. u_stJ~l ill:" f8 ree no mOire air in t.haln lne

,Z ~

pa ti er: t. ccaJ_l.-d.. It sholL)" 1d rn)neth~ less b1e -3 t tecpted s ioc-e som.e. degr ece· (}If

eJ: haust i~:)n is U5:uta 11::; acti \re II]

[~lr~.e mllC(tUS pll~ s : ~'ay' blel reI i-eved wi th h yd.r2;til:.}Ul ="

b rol;}n:::-:r.().j ~ 1 a 7.or S',I and c·he st perc Llss,ion.. T") per r~ rm p€rc us,s ion! t h-e pat i ent. is pl~ ed in OJ :1 dn.n er to p";) si tii]li1 tb~e a ffee telo s i de' [J~ • .ar.::d i~l a he'adl ... dlo~ ~ il t ;:)~. 3IPP;QX i1!altel y 302., :he are ~ "i. So br i..s~_;_): s13 pped wi th eupped. p~lm 5 a~1d the· pa tie'nt is a sked to i riC ~ease e:.:.. pJl r 3 t8ry' e ffo r t ~I if prJssi,bl e I (t·r coup;h ..

!r'u tubl;:[t iOln : (nee in tub.3lted. thel p~ t i -en t "s own e ffectl iJI€

me<: hari i ~5 fo r' c :ear ing, secretion s (ccU~hi) ~r'e rern·oved.. f re-qtu~n t

soc ~ i-~.}r1 i:1,g i~i a :must. tlel'J e,_r' 1 -e.a1.J e a tube~ i.rt p1.aee in an as.t.~lati~ tin 1 €SS ,OUI arc' ·~!e~tilat.inft ~im r

;:_nc e th~' pa:'ient ba S Ie 1 -eared, n€ shu wId be pi.ae:ed Din theoph j lline 1 OJ ... 300 r~l5. t of. i .. d . -q " i . d.. dlepefl~rl i filE; on .sel1er.1 t y a f the ep.~ sode I-

T€rbut~ll i.r:0f2 2 .. :.r-51 rug" p" Q.. t .. i .. d . -q .. i . d.. ;n.a y a 1 so be given r.,ri th thi s .

Tho se patie~l t -s tha t roe qtl ire s t~~Q- i 11 ~ her rip 'iJ should ~e pl.ac-ed .-_)rI pred r. i saane ~Q mg I P .. 0" tr.,e fir st dlay rll fter thel epi sode and the :j ose r-edluc edl by L") mg ..

eax.; h da 'Y ~ n~rea fte'r' (e' " g 11 !I 3~i" mg II the 2nd dia~r ~ 301 mg.. lhe 3rd ~ etc .. )1 unti 1

th·' b ed -5. 0' d Th 4- .'.L_ d - d ed ""II 1

··e v -r.'"lla· ","e" 'eornl t"':1rYCi~"" ... """ I, 1 I mg·' '-::IiIlq I I~-t;:".c p. '..;.1.' -. £:linT S ".:II,"'" in.o ~.J!.

' " ~ ., I' 1(' , '~;o;;;ll i "r:i:t'"'-......II . ~ -" ",'.. ,Col I' ., .;:;; ~ ,'~ Il.o......... ....' a:.lli L,' i' .._. " ' of;.I .

"'Sever e case s sJnould be ev acua ted as soo:; as p::J ss ibl.e for fur tl1er'" evaluation ..

11-29 II The e i rcula tor'y sys tern is cenposec of th-e he.art· t1 ~lood vessels 1 IllDPlactic system and the'ir eon lained f'Iurd 5-11 hlood, anc 1 ymph, ..

..

a .. Arter fal hi y' per'ten s ion, El eva ti~)in 0 f s~stoll it and/or d iastol ic blood pressure'! e i the:- primary' (esselntial h_yp€rtension) or .seccfl(Jar"'j .. ,

Al ttX)ugtJ the etic-l og Y' e f essent t 911 h!y'pertension i s unkr:}".]~n 1 the ram ii y history is lJSLJa 11}" .s uggesti ye' of n}?pertelTI s ion t str-oke , S Lidden deatb , hear t fa ilure l . Secondar y h.y'pertensi.o~ Ls assoc La ted }.IIi tho .kidne y di.sea se (e IIS~· ~ chron i-c glomerul onephr i t i s or pye 1 onephr i ti s) 11 0 r occI us Ion 0 f one or more of the renal ar ter ie 5 or the i r branches (r'eno~'asctll ar hypertension)1 ~ An til tr'ealted hyr;>er ten st.ve patient is a t great r i.sk 0 f developing fa tal hear t. fa i1 ere II brain hemorr'hage', or kidn~y failtJr1f2 ~

S.. Pr imar y n yper tension is. .a symJltOO1at.i~ un ti 1 can pI tc ation.s ari se , COOlpl ication s inc! ude Ie ft ven tr ic-u1.ar fa i 1 ur-e'; at.beroscl.ero t.i-c helart disease; retinal hemcr'rhages ~ ex udates , and vase ul ar accidents; cerebral va scul ar insuffic ieoc y;; an-j r~n.al fa i.l, ure ~ Hypertensi iJe enceph,alopatby due to c:er'etlral v .a so SpaSJl1 and ed€fliJ3J i 5 char acter tst.te ·of hypert-ension .'

0.. ConS1 st.ent d i asco 1 ic pr-essure ) 1 DO tun IJ Hg in patients }6a

years of age ; diast.ol i c pressure >90 em , Hg in pat.Lent.s (50 years of age; or .systol tc pr essur e ) 11 ~.J-DI n"n. Hg regaruless a f a~e.. Retinal changes wi.ll range froml minimal arte'r :luI ar nar rowi rig anc i rregul ar i ty to f1' ank bemorrt:lages and papi 11 edemal f i"€'.!1 e Levat.Lon 0 f the 0 _ptic d i sk or bl urrirlg of the· disk marg in 5· ..

A 11 A D~ a r h,~per tension is no t ~arT'an ted in a pa t.Len t tinder 5.0 year S 01 age- un.Leas the· B .. P... exceeds ~ 401 90 nJfi ~ .Hg Of] at 1~.a st three separalte cccastons a fter- the pa t i.en t hL8 s r'est.ed for 20 min ut.es or mOire in q,llJie t and f.E.l1li 1 iar surrourad ings _ Secot1dar'_y c;,:mpl ieat ions wi 11 pr'esent 5yrnprtornato log,y OJ f the' u targ-et o,·rgan s1t' irJlV'ol ~"ed :::

(1) Calrdliarc inl,olIvement often le.ads to nocturnal dyspnea Dr carrdiac astmla (irlspir .aw'ry' a~d e)[ pi.ratoT'Y whee zing)l.. Ang ina pec:tnr is or" myocat:d i,a} in farc. t i~)n may develop II

(2)1 Benal invQI1. vemrent m.ay proo uce r.-oc-turi a and nernatur 1a ~ The pa t ien t may have a uOf'emi-c odo~r" Kidne._y s may be enl alrged and pal pahle .

(3.l Cer eo r al in vol ~'emrent -wi 11 d ancnstr ate n euro log ie'al signs F' an@: ing fr-om. a _polsi t i lie Han it1I~~i or ~ io f [man re flex to pa~'.31 ysi s, ..

{.lJ.) Per ipher.a 1 arte'r i811 d ise-ar5~ causes i nterm it tent clatJaication (l.i~pi~g).. If the tenninal oo-rt.a is invcJ~'ed tl _pain in tr.L€

Ilut tccks and: lG~1 back - 1 ~ .. " ~l - .

:' I, ,.', .• pa In appear 0 n Wi] ,AI ng a~::"1 men D eC(1!'JI!;:" l~PJ ten t _

PI' Trea t mi 1. d hyper tension t d i a.slto 1 ic press ure g\.'] trD 11 J' rfll]. Ug) wi th an oral d i.ur-e-t ie ~uc h as ch 1 orothi a zi de {Ji ur i1} 'SlOG r:Jg., ~ Il i .. Ij] • If tile dliure'ti,c doe-s n~t oontrol t~e ~~fJpe!rten3iDr. ~ ~thyldo~a (Aldlcmet) 25C mg.. b .. i ~d. ta sao mg. q_ .. i .. d .':! OJ r' (: lonid i.n e (' Ca :epr~5 ) :J r r- 2..ser ~ i n eO .. 25 to o. 5 mg .. ida:." sJhc:ul dl t>.€ ad~ed. J~1e't!"i:f 1d0 pL3 i ~ pre f erred bleca~se' t ts s ~d e effects are better to I €'r ated .. for DJloder'ate ~_~~e r te-r: s 1. Cilt~ (dl i a stol ic

pre55ur'e iletwee!ll ' 111 '-r.~ 12,ilC ~ U.:.1' .... I..:::: t, ~IIF'" t t hrl"l;r·' ""'~.' ,; '_~l' tli.-. "':l.,1l""Ii ...... ·r ~ -.1 "'1:." l' 'ii Ir· ..0.' t l' If"

,.' I 'ICI IrJi.J I ' ,..J" II" ~ i I ~ L~ j .... a. I " I, I ~1C. ICI j.li l' ..... 1, II I a ~ I r;J' r:J" ... ..Ii <...Ii ~ I .......

and a sympetheTr~ d ' , " t, (. tL. 1" - ~' ..... -

, . ',~. "., ' I 'I ' ..... l.~ ". epressan I , e .. g .... :Tt€ I]Y, acpa, .:: .~ orr lu ~ ::€:! reser pI :1 e! or

propr anralol )., For s,ever-e hyper t-ens io r1 (jl i~st(:l jc ore 5: -~:-'e ) 1251 r!Jr.. Hg}

b , ThraMaphl-ebi t.Is , P'arti.al or eanl'pllet,e occtustcn of a v'ein b,y' a thrcxmbus wi til a seconder Y' in fl tl'rll'lator'y react ion i~ the, wall of ell vein "- It occurs most f~ecqrUen tl y: in t.he, deep ve'in.5. a r the' 1 eg s alnd pel vi s in

postooer ati ve and p.:l.stparttm patients dur ing the four th to fourteenth d,;:JIY', arnd in :Patient s wi th rr aetures or other trallJia t cardLac d i sease , or stroke t espee ially if pr'oloogerl bed rest is involved,.. Deep yeOOU5 thr(:lT1ooL5i s is usual I y ben ign tllJt occasion a;l.l y t.erminates in lethal. plullnuonar y emboli SIR, or cbrordo VetflOUSI insuf'fic Ienc y ~ .Super f'ic i.al Iillebi t.i.s aLone is usoolly'

sell f-1 imi ting arid wi. t 001 urt ser ious c!cmpl icat ions ; ag ing, 'I mal ign anc-Y:t, shock; dehydr'.atiofi:l anem ia , obeai t.y" and chronic infection are predisp:)sing

f'ae 001 r .s "

clotting de,fe>e t} .. Prior to i!l i It. i at.ton 0 f hepar in therap~., a base l me clott.ing time must be e.stab-li shed ., (Normal Lee-W'hi te clot tinE; time' is 6-,115 minu.tes) ... The- dose snoul j be adj ust.ed to pro~ ide 2- 3 times the, base 1 in e pret~eal~eI1 t IJ alue.. I C·~l1Jtin OOUl5 "IV il1J~'u5.iGn is. thel pr'efeT'red rolute .. Give a

II. loadIngl dose as, an IV bolus (21,,000 \J111ts,} prtor to starting const.ant

infusion at .a, rat~ 0 f 2ppr-0)l ima tel. Y: 1,!)DC uni ts/b:)ur- fo,r the arver'age-si zed adult" Remember that the' ultimate' rate mUlst be established on the lJasi.s of clotting time!s 00 t..ained q , 2- 3h. frQim an ar:rn OOlt bernlE,l,nfu~ed, and veri fred . '6~" at least 2 s~cess,~ ve cl ott.i ng t imes i ~I the therapeut.Ic r ange ,

Subsequent clottIng t l~S ar e relpeated q. £- 11 Cll .1 The requir'edi dosage will

usually d,ecre~~ wi th ti,me"" If ani infus,ion pUililp is not avai l abt e give deep SQ Q] ... 6~1 .. (use small needle aandi inject slowly} .. , Starrt dose in the range-olf !.I 0001.-9 .. {JOOl un i t.s for an .a~ er age~,si zed adtll t. -lbta in cl.ot ting time 30' mlln.utes ~efore eaeh pI anned dose and adj ust tOI me in ta in therapeut i c range... Thel reQ]LI lred dose shoul.d drop to ~ t1 0001.-(}1 ~ -000 un i t.s a f't.er a day or tw of therapy -al Ther apy soo,uld bel cont in LI~ un ti 1 the pati en t i SI as)IIlptomartic and the dal'lger 0 f embol i 9111 has passed {Il()irmall y 2-3 weeks). The d,iagnosi:5 01 f thramoo ptnl ebi.ti s i.s di f'f'i.cul t wi too-ut the ULSe of

~phi s~,ic~ated -d,iagno.st.ic aids that normal Ly ar-e not alvalilable (_phll-ebog_r- aP1,Y 1 sotol'pll,C- scan, etc.); there fore , max lrfJJLm use IiIlUS,t be made of pa st and current t.Jistory. and the mos.t thorough P. E. possibl~. The dangers of leth.al pu.lrrlJna:ry' ,anbollSIOO must. be c'arefully ~ighed against t.he danglers of mc~rl:trol1edl hetm.orrhage, and eacb dee:i ston is mad e on a sound asseasment. of all fac~tor's inr~olved t;

1~36

ther'ap,y should be- started wi ttl an Olr.al dl iur-e,tic- and guaflethid ine (110 mg; ~ tOI '50 rng .. /dalY in a s i.ngle dose) simul tan eclJsly ~ Methyldopa should be add,ed if need ed ~ Patients wi th ae ute severe hyper ten ston (di a stol, ic pressure )1'50 nI11 .. Hg) or with _pr'-essures s..r::mewhat lOlwer blurt with, comDanding SlynlP-tans of head aehe , v tsual d istu:rbafices:I scmnol.ence or' other sign.s 0 f c.erebr.a1:t card tac , or renal i,nvol yemen t or acute ,Pulmonary edema shou'ld be pI aced on str-ict bed rest (s@liDi-Fbw'ler posi tiofl)l and parenteral therapy ins.t i.tuted irrme.ri iateo ly ... Diawxi.d e (By'per stat) is the drug of c he i-ce; 300 mg.l· IV pusb wi.ll rcij oce 18 .. P... to normal val ues wi thin '5 mi~tltes II The drug shoul.d be used 01111 y for shfJr t per tods and c-omb ined wi ttl .a p:t-te1'1 t -di uret ie 3UC:tl as f'urosem ide (Las.i.x ) ~a to 8'31 mg. IV.. Vi tal signs m,uslt be mont tared

cantin UOLJsJ.y .. Be pre~pared to tre~ t hy'_poten.sio n (see Chapter 5, Shrek:) ",

Di scent i n ue if allY sign of bear ing impa trment leyelops... When B .. P.. has been brought under cont.rod , camlb,inlat.icfl s of or 811 an ti hy'pertensi ve agent s can be ooded as parenteral drugs are tapered off over a period of 21-3 days.

S II] Approx imately' hal f of patden l.s wi tb thrombophlebli t.i 51 ar-el

as ~ptanatic: : Ctther So ma yl canpla in 0 f a] dull ache II tigh,tne'ss II or fr ank paIn] in the cal f or thel whcIl e 1 eg ~ espec Lal.Ly when val king .. , A fe!el ing of

a nx Let y i.s not UncOOlOOa1 II

., ~evention: The best cure for postoper ati 'VIe thranbophlebi t.i.s is

Its _preverJtl.on.. Assur'e that c Ireul.at.ton is rnai,ntained by' .active and paSSl.ve exere ise . ..tJ.i lepa tieflts are bedridden. Avoid tigtlt clothing. Elev-alt~ legs or'., foot ~f bed 15-30 degrees", Flex kl1ees. Eru:::our-age deep breatt.tl.n~ exe:r'cl se , ~bulate pa tien t i::IlS soon as p:J-3si bile (walking.. OOlt

.stand Ing) IF. _ [)ex tr an II 5~) mI. IV during surger'i af.ldJ repe,,ate;:l on fir'st

~tope~atlve, day 11 appea~5 to have a prophylactic: elffect~ as does ASA t gml

dbe', D.i.IIY.I/' P'.O. NOTE: ASA 1.5 conltraindicalted once aJ1tiooagulatiofi theraplu has-

Idl~ ~

.'0 .. 1•

011 S1 ight :S~ lling in the involved cal f (measure); blui sh

di sc:oloration or pran in,enclf2 0 f thel super fic i.el veins: warmt h Olf affec:ted leg ~,en both leg s .erie e:x: poised to rocm temperature; teflderne55 and in(1ura:tion or spasm in the cal f' muscle,s:t with or wi ttl-out, pain if] the calf prodluc:ed hy dorsi fl e>l: i-Cln of tOeI foolt (Homan:> r sign). Wi ttl deep thrOOltX)phlebitis involv'ing the P"JPliteal!l fem,~)irall!l and! iliac: segrnel'lts., there IIJaly be terndernres.s and d, tlaF"'d cord may be palpable over the irrvo-l -vedl vein in] the felJ]t]ral triangle in tine groin" th,e medial thigh.1 or ~pli,te'al Space i :SJ. i.ght fertler and tac:hycard ia may be present.. The, .skin may be cyanot ic i r venous ob5tr~t ion is servere:t, or- pale anrl cool if a reflex ar'ter ial -spasm is .super imp,t):sed II

c..Hetioorrooidis., Va1f'"i~osi.ties of the v'eins of the hernorrooidal f.!a~ I . oneil .. <:cmpl iea ted b 'i ~ n~tion •. thrxmbosis ~ a~ti bl e«iing . May

1i'. ,ex),ternal (dl.5tal to ano'rec tal lIne} or lnternal t prO:': Im.al to anorectall ne. .1 .,

A... lbrombophleb i,tis ~ Di ffer entia! diagoolsis.: Cal f mUGCle-

stra in orl contusion", NaTE: Palinl -d1Jle to muscular" ca.,uses is ab.sen tori

min irnal on (jar.si flex ion -Olf the ankle wi th the laIee flexed and maoo imall -Qcrl dlOf"'s:i fl~~;t iDn (J f the an kl e' -wi t,h the kI'lee eJ::tendedl 0 r dur ins SLfts (H!msns IJ

sign.); cellul i ti:s; lymphalt.i-c obstroc tion; arc urte a.rter ial ocel usian (distal puisesl are absent and there is 001 swelling); bilateral leg edena due to heart, kidney t or 1 i veT di :sease F

, .' .' " ' ~j'.. . SnaIl, round,ed. purpI ish .skin-cover'ed masses that ar'e SCtlft

and, seldon ~Il" ftll unless t tllr (Ynoo, ,: I,' _1-..-11 _, ~,' ]1DIi"'Ii. I' t h ......-!l-. - ed he

.r... ... ~ ""II ..i)'C\I ~ n[:Jo;;;~.. ] 'Ir ..... IIlU'US • ':... t,. '.: y - are halrdi am

o~ ~n extremel yl pa infull lrArlen palpi tated ~

A ~ HErD:l'Tr' ho-i d: s (in tern all 0 rex tern all) • Per'ianal ab

," I ,cess .. rec:tal neapl a~s 11 olr eol i tIs ..

Di. ff@renti3JI d iagno.sis :

Pi... Treatmen t: Str'ict tloo. rest; elevate 1 eg.s 15-20 degreel5.. f\ce band age ft"'OOl toe:3- t~~] just bela w the kne-es;: rocttst healt ~ Anticoagulation tiler apl_Y wi th hepar in should Del in i ti.a ted if' ther'e' arel nOI contraindl ic-ation.s

tol its use ((!:ontraindication.s ariel pepti c tile er:l signi ric~aJ'jt kidney or- 1 i ver' -d iseal5e; ~ x 0 f cer-ebr(Jrv a.sc ull aT hem~ Ii"' rttage'" reo e n t be'ad tr allll a tJ olr krl a 'WT1]

mi. . . . p ~ Use .stool 50 ftljer.s or nanirr 1 tating I lO:ati ve3 sue h as

~er,:! 011. tJ . an-n 501ft ~ ie t to.'. pre\l'.ie. n t bard stools and str a~ il1t& ~ Sttall

an~~ icat@dhenorrho'·'ldcoar",B:_s'11elfl"--nd'

.t"'IiQ' 11'1 .. " .. . • .',., ,.',.' I' '~ . .,;;;;; u' ,u,a 1 Y S.' , I _I 1ml tItlg a i I reSt"Y"100 well to

"Ioo1:115e.rvatl \U! or .,.:.,.' .. 1 t ". ' .' , ,', ' . ~

warm :s - t ' b, .. '; to.. m Ull~a. ,Ir~arbnerlt. ~,~e looal p.a in andl in fe~ tiOln wi th,

1 a,atllS .and, ln~..ol""itlO'¥"Ii of a 500·" 'thIng an 1 ..... '...... b .. '... ' .. d

.A,void tbl! u • ,.,' .. , "i~ll. , • 'IIH , •. • ,.. , , ..•. ': I., . I I : I . . lal ,SUPplsJ.. wr y :1 .. 1. .. 'L.I .. - t -Ill 1 .. I ..

se of benDO<:alln-e and o,tkol!!<li" t~s' of si' 11'" . t.m t I-.

pVS&ble to : 'I '., .. , ,.' '.,', ••• '"r"=1 ,'],,'r-II. ' .. 'm' 1 ~ o:rl I,en, oS as, rmUClloi as

t .. i.d . ..Precl.ooe senSI hung the patient, Use hot. utz baths

.. -q.1. ~d II to redluce thromboGed bemo,rr'tlO id,S,. If thd.s i,oS unsoo(:e~sftll or

1~]3

patien t. is in ex tr eee d i SC'()!1 f(H-t tJ exc ise the thrambtl3 llJOO er 1" 1 idocaine local; pac k. 1 ightly wi th iodoform gau ze aot ti all y and cover with dr y ste'Til~ dr'esgin~,. Chang,+! dressing daily .. , f..ontinlJE w.arm st t.z b-aths. Instroct - pat i ent to allJl()dd trallJ1a Mlen, clean sing the an al are a a fter b01wel moVerrlerJt.s. by p.at ti!'lg wi th damp ti ssue rather- than. r:ubbing. In struc t

patien t not to at tempt t.o -de fecate un less there is a r-e al. urge and to avoid str-ai,n ing at stools.

1-30. DISEASES OF THE HEART 01

a . M~Jr'acard ial if] f'arction {MI}. Lsebemfe myocard iall nee rOSl S us llJall)! r·e,sl.Jl t ing fran a sudden reduc t iO':1 in blood flow to a sect.ion a f the myocardiLln -d l.Ie to occl usioJ1 of a coroner y ar t.ery ..

S.. Sudden. onset 0 f in tense 1 c ru.shi ng suost.ernal or preco rdi al pain, often Tad iating to the left shoul.der , arm , 0 r jaw. Pat ien t.s br'eak out in a cold s,weat., r~ 1 weak and ;:1:pprehensive,. and move about see king a ~sli tion of COOl fort t' They prefer oot to 1 ie quietl y .. Ligbtheadedne.ss f syncope t d I'spnea., ortllopnea, ~ougil1' wheezing, nause a and voni ti ng, or abdawinal bloati~g may al.so be present I singly or in ccmbiriatdon , The pain is- oot r-el ieved by n i,tragl y'cer in ..

0.. Pat.i.en t may be cyanotic and the skin is usuall y coo'l , The pul se may be thready a 00. the blood presser e v'ar iaDle .. ~.st sb:lw .sOOlE degreel of hypertension unless card i..og,en ie sbock i s de~ eloping {inciden~e' about 8--14 perc€fl t).. In a severe at.tack , the first and second heart solJrlds are faint and cften Indi st inguf shab Le • Arr-h:fthmia is c-ommonol Rales may be heard on a uscul tat ion and the nee k lJleifiS .ar e 0 fte·n distended. Fe\I'ler is absent at the onset, but usually rise s to , OO~ 10]0' F".. wi thin 24 hours ,

V., B~ C.. will be elevated with a silt ft to the Le ft b ~ t he second -day.. 1lle sedim,el1 tation rate is normal at onse t and wi 11 ri S~ a n the secoed or tt1i rd day.

A.. Ac ute myoc.ard ial in farct.Lon of- D1i ffer enti al -d iagna si s: A.n~ iJ1.-1.

pee wr is 11 ac ute per icard i tis, acute p\Jmn.ary embol ism. r-efiul: esoplnagi ti S t ac:ut-e parncreati ti s ~ acute chQll ecysti tis, s pont.i3nOOU5 pnetrrJOlth)ra]( tJ

.

prlleUOCJfl la .

FI.. ~ alert far cardiac ar-rest, particularly dlur'ing the first

fewl hf.)ur s .a fter on set {50 percen t of all ~l death s rxcur dur i =ng thi s

period) -I- H?- preparerl to in i tiate CPR immedi.a tell ~l' if patient does ar rest

(:'lee Cha pter 31 t.mergency !fIesusc i tao tinT]) •. fo'b:r_:- phin'iE' SQ.!J.. 2-5 Iq!;. s~ow IV •. stat ~ repeat q .. , 1-.5 mIn. p .. r .. nl ~ unless, T'eSp1.T atlon fa lIs tJelow 121mll'l.. Shoc.k

.' .. t - 011' 1"1. (do not use p:)s.i ti ve-- p~-e ~5t1r e-) " Cid.oca ine in i tiaI blolu5

_gqsl. ,1·, I , \..12 , . ,_ , .

:,0- , 00 mg.. (1 :ng ot I kg .. ) IV., then I"lr drip a t 1-~ mg. pe'r m In urte . H:lSPl tall ze

'With st:ri c t bed rest and canp.l-e te r! ~r :sing c.ar-e f~lr a t least 6 w,eeks.

Sedate with 172 ~ phenobarbi.tal t .. i .d., low SQdlilln~ low fat" low protein diet" ttJn i ta-r Y i tal s igo s constan t.l 'j " Be a 1 er t Cor sign s of l.e ft-sid-ed he'art fa i 1 ur e (see p.ara e" Congest i" e he.ar t fa i 1 ure) ~ hYJ)Oltension:! and

card iogeJ1 ie sltCJCk (see Chaprel"' 15 l' Shock 1; ev'ac uate' \When feasible.

b.. Acute m:yocard i ti s . A roc a1 -or d. i fftl5e infllInl11ation 0 f tile myccardiuli--occurrmg duril1g or afte'r m~I"i Yiral. rickettsial'l spiroch.etal" fmgal, l=.ll1di p.ar'.3si t.ic diseases or adm in i str at ion 0 f var io,'Us drugs. Severe ml)'oc.ardi tis, occurs ~5t camicnly in acute rhetnatic f-ever III diphtheria t' :scrub t~phus. and Chagas II d i se'ase IJ

S.. Fever"J malai se. arthr aiJ!,i.as 1 -c he st pal in II dys pte.a r and

..

palpli tatiOIlS., _ Th~ pati en t . may ~a'Ule. assoc Iated per icard i tis I wi th c he.st paitl cha~2I7ter 1 st i.c or. per icard ~ a 1 , 1 nvul "II Em en t . (se.e par a f, _ Ac ute. . pericard1t,ls) · The chest pa in 15 fr-equent.I y YagtJ€:' and nond lagnost.:tc .

0., Tacfl:iCard i a out 0 f prop::.rt iO·U1 to the an.o Uri t 0 f fever II The'

8. Pili s usually normal , Ausc ul.at.Ion may roe\' eal a tic- tac rhytll:o. and systol ic murmur ~ Acute c i rcul.ator y col.Ia pse ,I embol i ,I and sudden deat h ma1"

occur •

A... Acute myoeard i tis · ill. fferential d iagnosi. s: Vi rail .

protozoan tor tlac-ter-ial in fec~ ions m:rst be d isti~ui .shed (rom ac~te tox ie myocarditis due to drugs -rJlr d l~ tner ~a and from myocard it is assoe ia ted with .acute rhematic reve,f and acut.e glcm-erulon.epl1ri tis by a caref'ul anal yst s of each I'li st.ory and cl in ic a1 picture as i t pr esen t:s '"

P Direct treatment toward underl ying cause i f kn~~)WI1. In all cases Ylen my'oc ardi tis is suspec ted or appa ren t 1 can:pi e1te bed rest- and sedation plus cont.inued tner apy 0 f the unci er 1 y ing d i sea se are need-ed ..

Qc ygen is ind ic ated tlhen cyanosi s or d yspn e.a occur s , Colt\ t.Lnue bed rest Ul til all -ev idence 0 f cardiac involllenJerl t d i sa ppea,.s ..

e .. Baeter ial endocard i ti s , R3cter i.al in fee t.ion 0 f tine 1 in irig msnbr'ane o_f the be art. Jk: iJte bac ter ial endoc-ard i ti 5 (A,B[;) beg in s abr u_p-tl V aIld P'"-ogre~s rapidly. The usual, cause is sta;:in:r1tlCocc-i and oc--c.a.sianall_y plell1WJC.OCClll It malY follo w po stancrt.at pel V'i~ in fee t io~ t surger "9' on

in fected ti . ssue 11 or unster i 1 e in tr av enous tre~hn i ques _ Sulbac ute bac teri.al endocardi tis (SHE) is us. ua l I y -d ue to al pha-nencl i t ic us S tre pt.ococc i and frequentl. Y' follo~, a -d en tal pr{}C-ed ur e . The disease is fa tal if un treated.

R S. Fever is uaual.I y. presen t tru t a reID!'"" i l.e per i.od s r:1e f eccur ,

light sw:ats, chi ~ l s , mal ai se ~ . f":"tigue-, _ 8~Ore)[ ta ~ weight 1855-; my a 19ia ; arthT al~l.a, IJ 0: r~flJe~s and swe 111 ~g ~f" JOInts; sudden vis uc:: dli st urbances ; palr~.1 J:S~.s ! ,p·aln In the abdamen:l c he st. for' fl a ks ; nose -~ Leed 5: e'asy

brw sablll ty; and. SymPltcmS 0 f hear t r.a i1 UlE e rna'i al so ocr ur ~

... . I _ O. . findil'lgs in SBE Lnc l ud:e tachyC!"ardia, s-plenomega }1; petechiae

of ~lhe- .skln:! RlJUCOUS mEfTlbr an es rand oc ul air fundi tJ or beneath the na i 1 s as Spllt.rteT hemor'Th.a~e:s ; ('1 Llhb ing of the f .inger 5 and t;)es; pallor 0 r a yellO~sh-blrown tIn t 0 f thel s.k in; neUlralog ic r-es.id Uial of ffer~t s of eerebr al ~b~li; ~nd tender finger and toe pads. In ABE s y:nptorns and Signs are .sllllll_l~ to those of SEI[ f but the COlli se i:;; more rapid 1 Sus pec-t ABE if an

O~Wil se . heal thy irtrd i v idual wi tt: a foc al in fee lion suddenl'1 d evel op5 ~~lS;, hIgh f~er ~ a~ p~gtratior:. ~ _ ~afllaine~ f.e-\l'er in patient wi ttl

. I artlDiLrmlr IS lndlcatne of endocardlh5. Merna ~ ~arJ<e.dly elevated .sed:nta~1on rate.. 'J ar iable leukoc ytosis ~ In ic ro.sco .pte !1ematur ia 2

pro. lnur .la:p and casts are- canmonl y pr -esen t in SSE arid ABE.

.. l. Infective -end~.aTd i ti g due to 01

Dltferential d l~ ao0051- • II L ,. ~, . t·h· ~~yto ..

.'. '. ..' '. .. ~.' L.oI IJ ymtA",anaIS!I Ircmu~- ,'pen Ie pur ptJr-a. 1 eukernia :I

acute rheLlllatlC. fever 1111' I!lr+ I-..._."&, t .. ., J

~cr·· . .' .' '. .. . .. l . ~pU5 er J" .... 11 ierne ~SUS:l :sep,lCem1. a 'IJ, rna Y' be the

. erllZlner) I UR Is .

da!1 ... P. . ~dO:aNitis due to streptococcus: Penicillin G 20-"-10 M.Il.

, . y" or all n 1 C 1.111 n t:. 12 d -1 · - . .

q ~,hh: .. • tt". .. , u-' .. ' gm ,.a 1 !i l.n d 1 v lded doses as bal us .in)· ections

.c:-. I.., Into .an IV 'f' . .. .

~'-'dInl""""" .'. I ,1. n . usion -. .Prob~nec ld 0 ~ t: am ~ 0 .,.. l~ d' .,. JI~_5' '1....=1. lDi!e·I~,'."

IIl!Wr ....... ~yc 111 1 . 1 J t:t'. r ...... " ... 11' . II .... ~ .... . II1'II'':=' ~ "

1It~ 111!.t.n.· ,". .• 8m day;. kanamyc in 15 nat7 .. /l,n • /day· 0 r gentan,icin 5·,

.~ "" .' --.s per da' b - u~ ~ 11 . . .

8taPh1~ I Y ~ ~.d ~-~ • i. dI · . in d ~ v Wed d~~. fnaoc arni t~;5 due t-o

us (perlleill.l~a resultant). na.fcIl1.lrJ • .8-12 gm t:i.:uly as a bolus

1-39

1-401

ql .. ;?h"1 tn an rv injlJ~ion. If pa t.i. en t, i:5 hyper senst li ye tol peme ill in tl desen si.ti ze Or' use Llan~cmy>c in 2-3 g;m IV dlail y in ell i.y ided dose's q. IlIh .. continue Tx x 5;-6 w,eeks -J. Complete nur'sing, care , rtlni tor for" 518115 of f]etJrolto~ic it 'I aJ1d thranoophlebi ti s , Chang,e inj ec:t ion si te q .. 1Il8h., and k«p scrupul.ous.l ~ c Lean , Ev aeua te if at all feasibl e,

re.stlessoress, and .ar1X iety' wd th a sense- of" .suffoc:at.i on, Right v~ tr ieul ~ . failure presents lIi ~h i.ncrea~i~g fat igue I ., .i3waren.esls, of fullness In the neck. and abdarten II aoolreXl~:t blloi:ltlng ~ or, ~~rtlonal RIJQ pa in ~ 01 igUF ia is p"eSEftt in Ute da y tune; polyur~a at n Ight ·

'Ir; 01111 Signs 0 f' le,ft. ventr icul ar fa il ure inclooe red-uced carotid

pul satioo, tJ di r~use., a pi-e:aI impulse 11 palpable a~d ,a~i.ble t~lird, and! fourth heart sooodst 1I'lSp1.raoolry' r'ale.s 11 and pleural e-rfu510ITI.. With acute

pullrnol1~ry ed,emiJ tile pu~ se may be thread ~ .an~ t~' B .. ~.. di ffieul t. to , ~bta ~nl ~ Respili'ationsar~ gruntlrlS, and loo?red WI ttLl Insp-~T at.ton ~ and ex plr-atlon I ,loS pro 1 0 Ilgled .. Exp'lrator y r ales .. can b~, hea~d ~yer, bath Lungs , ,~r'e may be ntar-ked 'bronc:hosp.a.smJ or lfIleezlng; t. H,ypoxla 1S severe and cyaoo31 s d-eep- t'

.Pati.ents; wi. ttl rigl1t ventr ic:ular fa illre show sig~ 5, of venaus hyper tension, an I!Illarged and tender 1 i ver l' munntJrs:I and pi tting -edama 0 f t,he lo.-.er e~:trEmi ties.. (Be and sed , rate are' normall in. uncClmpl tcated left hear-t failur'e a Urinal ysi soften sflOW5 signi fic.ant pll'""Olt@in UIr' i.a and g F anul.ar casts a

dllJ Arlgilila pee tori s " A. ct inic.al S)!OO rxme dtJe' U) myocard ial ischemia prOOuci.ng a sensation of precordi al. d i scoefor-t , preISSUF€", Q'r a straJlgling sen sat ion ,I char act.er i stieally prec:i pli tated, b:y exertion afld reli.eLJed b,:."" rest orl TI i tr-ogl yeer'in I,

S.. Squecezi ng art pressurel i.ke pain" retrolstern,al or 51 ightly to the le ft 11 that appear's .qu ie kl y dur ing exer·tion and! incr'e,a ses Iri:llpidl y in i.nten.si t"jl un til the pa t.ien t i Si e:Dmlpell1 edl to .stop arnd rest.. Thel

dt str ibutiol11 0 f the di str-ess lELa Y' V: ar'y wide l:l in dli ffer-'en t. pa t.ient:s, but is allwa~s the same for each indliyjdlual oat.tent II] The attaeks us,ually' last Less

~ I-~ ...l

than 3 mif:1~te5 unle.s.s fol!awtng al heavy ~'al Clr preci,pli tater! by angl-er j In

lflli -ch ease the y may' last 15,-20 min ut.es, The d i strless. of arngina Ls never a sh,arpl Y;' loc:.al i zee d artdng pa in. tba t cain bel po.in ted to with one fililg;er" If th.e! patiefJt po ints wi th one fingler to the area 0 f the api.cal, impulse as the onl y st.te 0 f pa in t1 an~ ina ma'i almost cer ta inl y be rul ed out· ...

A.. ec.ngest i v'e helart fa ilure- d lie to "I Di ffer-ential

diagno,sis: Per-ieard ial. e ffulSlion 11 const;r ictive per'icarditis... pulman.ar yl disease I earc iru:>m,Cl of t,he 1 LIrlg IJ anemias 11 and rebomd edema following the use of' dliureti-cs..,

0... The' d iagoosi S of ang ina pee tori 51 de!pend,s almclst enti rely t.lpclln ttle hi :story:! and i t. i:s; olf utmost imp:lrtalTlce that the pat ien t bel allo..:oo to deser ibe hi.5 S.YnIptOOIs to the ex amliner ~ The d iagnosi s i . .5 str'Ongly supported ~ ') if" 0 .. bj mg. ni tragi yc:er in ii.ny arl i abl 'i shortens an attac:k and (2) i f that, clTlQUn t taken: i!'l'l1'Led iaul 'i 'be fOlre hand Lnv ar iabl 'i permi.ts g reater e)[ertion b·@fol:re on se tar an attaek or prevents i t entirel y .. E~am ina lion. -d ur ing an at tack frequently T'evelal s el ell a ted 8 .. P -;: occasional.Ly , gallop r-tlyttmi i,5 prelsent dUl""l ing pali n clnly ~

Pi.. Bed rest {Fowler olr' semi-Folw~er' pctlsi,tion) 11 sedat.i cn "With nK)rphine or ph.eno.llar-bi tall; f"reque.n t. (-'I-6} .31ili::lll1 fi til and , low e alcr ie , low' rest d lIel 11 sod i 1.111 res tr i C: ted melal s wi t h v i tarn in S uppl emen t s . [I i ur e tic s s IUC' h as hl.ydlroc.hLlolrothia zide 501 mg .. ,I day or cblolrothiaJzidie 500 mg. da il y or b· ~ i .. .d · alr'e essentiall tol man agenent of chronic hear,t fai lure. Increase daily ingestioln 0 f fooas wi,th a h.igh pJtassit.lT1 ron. tent c: bananas 11 or enge .juice)

for p:t,tass.itDJ repl.aeenen t, Adm in i S.te'IT °21 P II r II n II fOI!"" respi.rato ry dl istre-55 and hlypQx ia., Acute· pulmonary edemalisgraY.::mledicalemer.geliJc:y demanding prompt am effectiveT'x... Uhlessln' 3hock~ the~ patient. 'should' sit upright.

wi. thl legs darngling ~ Gi,ve' n.ig,h COlnCef1 tr'ations of' 02 IJ Y' mask or nasa~l cannula ~ 'MDlf']IDine' SOIll- -J-' 01 :n1g1 a lV or-' 1M.. Staib 1 ingual ni taro.glycer in [) ~ Ili-D 111 6, !!Ig;. q.10 miinl for .several dbse's ma.j!" bel irrJnediately effecti\l'le. If severe 11 apply Bit. P ~ c uf"f's (or -S~)lft Ir'ublber tour n iquets) to, three· I imrb.s .and in fl alte OT tighten sUlff'iciently to oostruct venOllJjS return (:rfti-dway' hetweer1 systol ic and diastoll i,(: pressure)1 but. not arterial flow.. Rota,te Q] ... liS min II NOTE:: [)J not· appl y to a I imb in whic:tJ an IV is l'Iunn ing. 1 f I Vis runn ing IJ aJeflate

q ~ 15-20 md.n but do not ro,tate,.. Gi \\"e a rapd.d -actinlgl d iuret.ic- tJ e ~g .. to l.asi :c: (furosemdJje} !lO-BO DIg ~ IV' or Edlecrin 25-50 mJgI. IV., Aminophylline" 0.25-0.5 JIll sJ.ow IV or' aninopt:ry II ine sUIPp:l,si tories"t o~ 25-0 t,5 wn ~a~' be 0 f nel p "-

Ralpid digi talizatl,orJ i5 0 f y allue;. I'lowever tJ i t must, ble E""'emember-ed It hat .all dligi taIls prepa(f' atiOIfJ.3 are tax i,e 'and the d i -rferene:e between the ther-aptJtic anD toCli.C 1 e'llel is small. D~) not, use digital. i.5 i r there' i.s an Y' i ndi,catiolfl of Ir'edal failure. I:f renal f.m,e t.ion is normal. I the fol1OO ng .schedule mal:; be: used: Digol in 0 II 25 rng.. IV' or P .. 0... stat. IJ then 0111251 mg. q. 6h ~ x 2: dalYs. and 0 ... 25 mg.. (I aily thereafter ~ NOTE: Dig i tal iSI maintenance may be requir'ed ft'}r t,he ranalinder of t,M patiel1t1's 1i fe. \then stable, the patient should be carefull y rnon.i wrledl for: ( 'I) Status; 0 f Q r iginal slymptomS.1 {2} ~'W 8JD1ptcms or signs'll (3) weight. chang,es IJ ("lJ,}1 illi tal signs"t (5)1 evidence of Pllebolthrombosi.s ~ E:y'aclJ8ite as .ooon ~s fealsi,bl e.

A,. Angina pec~tolr is II Di ff:erential d j,ag,no.si 31: Mtlsculosketal dioorders, 11 eoolecysti ti5, re nux: e S~JiPMgi tis" peptic ulcer- 'I myocard ial io farct lOin ..

Pi.. Nli troglyc-er i.fI 0 .. 3 mg. subl ing-uall y i 5: the' dirt« of' cooice ... lrlC'reasE! dose to 0.11-0.6 It@., if SR!lal.l er:" -dose i 5 i,nelffec,ti ve'. Cl'le em)"l nitrite' ampule cru.slled and i.nh.aled will act in about 10 s~.onds.. The patient should sta[l'1d] still or 1 i.e doltlrJ as soon a 5 the pa i.,n begins arnd

:remain qui et until the .at tack lS oV"'er'lI- P.a tien ts should be warned not to

tf" 'J to kClrk: the- at t.ac-k orf ..

e .. Conge's.ti v.e heart fi:llil ur'l~'. A c lin ieal synd rr.::ne in -..t1 ieh the- heart fa il 31 to rna in ta in an adequate outptlt Ii rel5ul t ing i.n d imi.n ished blood flow to the t.issue s a.nd in congest iDn in. thel ptJlm;orlarYI and/or Siysternic c ir-cullati,on .. The left or right ventri.cle alone may fail in.i tially (usu,al.ly' the fomer) 11 but, ·ul timlate 1 y ccmoined fa illITe 1,5 the rule" Thel basic causes 0 f

ventr ic:ul air fai lurel .are: C 1) Mryoc.ard ial -weakmess O'T in fla:lcltlation (e ~g • ,

ml)'OC ar'dli.ti s, i scbemia)1 f (2) Excess, ~rkl oad {e' .. g .,,. hype'rtefl sion1:t aortic ins1uffi.ciency anemia,. pr'eg~a~~ ~ etc- ... ) ..

s. Ear'! yl marl i fe'stations of 1 eft yen tr ic ul ar falil ur'e in~ I ude ,

uootJrE!:' tach )"calrd ial. fi::lltigU:e' wi t h elxer tiofl f dsypnela: wli t.h mi.ld exe'rc,i se, am i.ntoler'ance to cold;: p.~n-'QlxySfli]aJ. nocturnal dyspnleal an~ coug_h,.. In advanced f'a 11 ur'e se\\,ler'e' c~lugh i.s prominen.t.·- '-me- -sputum malyi be tinged] r UlSt y or

brol~ .. Fir an k hemtOpt ysi sis r are but Carl oC(!:'ur II Acute pulmo~~~r ~ edema i.s a ser'iolJ s life th.r-ea teni ng mlani fe.sta t ion 0 f left 'len tr i.e ull ar fad lu~€ . The paltient pre.sen ts wi th ex.trsne d:;s pnei::IJ r -c yaoosi s ~ tachyrpnea tl hyper'pi'lea ,I

" • ' ~I ~ .'. AeUlte per ieardii ti s " Inf} arrroatian 0 f the peric.ard i LIiTI. It may

result from t'l!'li r' 'f" tr , I d 1-..... t·

••. .'.'., ill' auma 1" In,' e-c;: . lon II or neop a.srm or se-c.ocr1' lar y t;V .5 ys lem lC

d"l:ge'a.ses s·linih 'he t- f h ~d hr· t" -

' , " ,'."',, ' .• ~ I' as r, · :L.mii : ,1:C I e'Jer:l r, eLmatol • art "I, '1 ;13, II or uremIa"

S., fleuli'i tie: or pe'r 5i st i.ng subste1rn.al or preeordi ial palin

1~2:

raiiating to the nee k , shoulder:p or' back , fain may' be aggrBrVatedi bly tmracic root,ion, OOll8h 11 and r-e5-p~ration.. It. is relieved by s.i tting, up and

leaf] ing fOlr-..erd.and may be acc~ntlJated by swaillowing II Tact\,,.Vpnea 'I

oonproou:ct iv e [!ougb. fever, chi I1s1 11 ~kne's5!t and anx_t.et yare carmon.,

Q. Au.scul tation rewleals to and fr'o fr'i.c tion souads (: nr'ic~tion rlub) over 4th (L) intercostal space near sterrnm, Inspection and palpation ..oometimes reveal a diffuse apex beat IJ Wi ttl purulent e fflls ion may' pr-e'.5en t, wi th high, irregulalr fever II sweatls 'I chills t arnd progre ss ive pallor 01

ftlllg ins of the precordi.lll11l Increased dullness to perc usston 11 and edem~ of the pr-ecornium may also be (Jr''esent.. Leukocytosi.s and elevated sed ~ r'ate wi II be present. at the Qnselt ..

A" Ironl defic terre y an-em La due to II Dj rfer'en tial

~ diagnosis:. ~r h y~brOOlic ~emta s . ~ anemra~so --,- TnTeetion, t hala sse'"d a ~ etc ... ) perfllic lOIUS aneml..3 j a pl.asa.i.c anaJl La •

P. ( 1 ) Treat under 1 yi.ng, cause ..

A. Acute' per-icard i tis. due -to F

diagnosis: A-c ute :MIl l' pleur 1.31 II- ------

(2) Or al FeS(l~. {JI .. 2 gm t ... i lid. p cc I, Contir1luel fOT 3. months alfter Hbl returns to normal.. If t,ner'e is bleeding if'] excess of 500 mllJ/wk

over a sus;ta ined period Il iron tiler ap~ wi 11 not \io.fOJr-k LJfI til the c suse 0 f

bll eeding: is carr-ected ~ ~OTE:: Iron C:i3 uses a color ebange in the' stool (d~rk green or bl ac~) .. Adv.' tse patient not to be al.armred i.r tlli S occ ur s ..

Di fferential

-C:. Perr.. ic tous anemJia.. Miami a due to impa ired ab,sorption of I.J i tamin

IP .. ( 1 ) Treat ooder-lying conditiOln'l-

B12-11

(21} ASA 600 mg. P.o .. t codeinel 15-6~) mJglI Pl. 0'01:1 me per id inel 501-100 fig ... PI.,OI~ orr 1M: .. or mOTptline 10-15 mg_I' ~l q.!ih tJ for palin. .Selja:tel

wi th pheoobarbd;, tal 15-301 mg ~ P 11 0 It t I' i It.d .. , -q .. i ... d _.,; 100-2'00 mg. pt_u!no.barbi tall. malY be gi -V~n h 1,5. f'or insomn La, Prednis):ne- 201 tOI 60 mg,.. dlail yl in d.i 11 ided do ses t. i .,rj 10 --q .. i .d -a, m.ay be r-elq[Ulired to control pain" fever , arnd e,ffuslion. 1be dose sttould be red ueed grladiually and, dl Lscont.Inoed aver 3] pe!:r-ioo. of 7 -,1~, days;"Il I f the per'ieam i. ti s t s dille B plyog;en Lc inf'ect ion 'I surgical dir:-'ainage' of the per icard iall sac may be ind lc!ated II

51. Same as iron (j ef'i -c iency ~ In add i tian the pa t.i.en t may

eanpla in 0 f a IIIbiurll ing of t.he, tongue'"; constant , symnetr'ic nLJr.ltlness 0 f ttJe feet; liar iOlu!S G 111 I... dl isturbanc.es (anorex La , con:st ipet.ion ,I dl iarr'hea, vague alxlani"nall pa in); tr enstent parestbesfas 0 f the IJPper ex. tremi ties; and severe' we ighrt 1053.. Thelr'e may be' mentall disturbance's r arJg irlg franl mild deP'"ession tOI del ir iU1l and! parana ial 10

o. Pallor wi.th i:I: trace Olf jalLmldice: 105S of' vibrato·rLl sensat.ion in the. lower ex tremli ties l' loss 0 f p.:ts.i tional .sen 5e1 11 loss a f eoord ination ;; tl.ypelracti y'el deepl tendon Irene·xes and posi, ti ~e' Bae in SIi(t Il {kc:alslionall.

splencmegal yl and bepatonegal Y' DiE Y' be pre sent 111 Of ffer-en ti.al smear will

denonstrate largle ov.a1 R .. B.{:. witb a fe'w smal11 m.i5stl.ape11 R· ... BI~ CII Will S .. ell is usually lei SI s; than 5 f 000 ~ The' gr anul.ecytes tend to be hyper segmen t~ It

a .. Anemia (: gener-aLl)1 ... A eond i tion in ~ i.eh therel is Ii redlllC I1i.Orl ifJ ttJe- Ii1t1lilber of c il'l~ u~ ating: R: .. HI .. C .. s a ru:l/·or' Hb itl t,hrel bloodl" FundltD:entaLlly', all anemias ar-e o alused by one of the following oond i tion:s:

{ 1 ) Increased 1055 of ft.., B. C ~ due tor

A.. Perlnie i011J,S anen,ial... Di ff@lrenti.al d iaglno.si:s: All emia due to

follc ac id defic iency .. NOlTE: The- DIU.a 1 shape olf the' R .. HI .. C. and

hypelT .sesmentation olf the W -al B.I 1:. are nat chair acter i.st i.c of fOil ic Be id d~fi,clenc~' anemia ..

(a) H~morrhage.

(tI) Incr-eased rate of R .. B'II C... destruction (hemolyt,ic

. .. P. Gi ve lOO mg.. vitamin 812 I[J( stat .. 11 t.hen II DO mg -0- 3 times per

week until blood picture returo S to oonn~lll If anema t, s severe 11 gi li'-e

transfusion (aft.eT" type and X-mat-c hJ of pac ked red cell S 51 owly II

anenias) .

{2}1 Dec reased prodl..l!tion of R ~ B .. C.. dtJe tol-:

(a) ~ficjen~iegl.

(b} Pone marlrov suppresston.

d .. Hemal,tic tr a.nsfus.ioln r'-e'ac lions ., Hemnllysi s olf tbe Ir'€{!'i pi en t f.s or dOOOlr" II 51 R .. IB ... C ~ (: usuall_y t·he 1 atte'f' ) dUl""l ing or f·ollo\rlng the adrmin istration ?f solutions, plasma Ii t.10Dd1, or blood ccmponellts;... Idemolytic reactions -v aryl l~ seY'erit,y depending on the dlegr'ee of inccnJpatibi.li,ty ~ the aflount of bloOO gl,¥en I a 00, the ra te of admtn i stra lion II The most, sev ere re act ion occurs whe~ ~.onor· R~B ... C .. are hemol ized instantanoously 1)'1 .ant.ibooy in therecl.p1enlt ~:s pl.asna, These reac,tion.s con sti tLJte a gr av'e nted iC-aJl emergency' ..

b .. Iron-defic Lenc y anemia. Chronic ooem.i.a char acteri led by .srmall ~ p:Ill e H .. B., C~. and t1.e-PI} et.ion of iron stores, In.ad ul t.s it i 3 almost all ways due tol occul t til oed 10 s s- tG, .. I. bleed ing ~ e-xces.si.ve met1.str u~l., excessive' s311icylate intalke'tJ etc .. }.

s.. ~sy fa tigab il i ty. dl ).!spt11eal II pal pi ta t.ion 11 arnglna tJ and

tach ycardl ia. Inall i.l i..t Y' u) swallow or di ff'icult 'i in 3-w~lla'Wing may ex i.st in advallced case So.. !her e often ex ist.s .a (l:1r'aJiI ina fOlr' strange foOO stuff's (dir t., chalk ,I pa int ,I e~t-c -0-) ~

lIS. Suddielr.l 01'lset of chills and fever and _pain in the vein at the OCa . inj@C:t.ion .si te or' i.n th.e Ilack f che st" Dr-' aMomen. Anx iet y 'I 8ppreherJsiOl1, and headache .are Ccmmrl. lII'Ider gene'!" <31 anesti1esi a ..Sp:tllltaneous bleed ing rna y be- the onJ. y sign 0 r a tr'ansfUision reac ti-Orrl ..

'.r' •... ', " : - o .. ,Evide~e of shock (see. Chapt~!!" . 15, F _ Shock). {1~ ig,l:ll'" ia , _ an W" ia F ia:r~S:~ng, to ,tlt'"eJll.a. Ir,.3 han~l yt 1C ,react l~ .1 S S~3pecterl" l~ed l~telY 1:!1. '. . . ~ '. sample fr~ tile pat lent and, cen~r 1 fuge It. Hernul Y515 w.lIl be early YI S-lhle a s a pInk to dark red. cola r ln the 5ertlll ..

011 Skin arnd =ntICOIJJS- membranes ar'e usuall y pale.. In adv anced cases the ski n ~na.y harve' al w~x; y appelarr anoce; the ha i:r and na il.s .are bri, ttle Il

long i tudinal r i(j~.in~ wi thi progressi ve ~·oncay 1 ty (s_pno:n ing 1 may' i3:P_pelar' OIR the fingern.a ils... The tongue may be 3i1i1OOth ~ and the 1 ips inflamed and

l-~·]

1 ... 44

AI! Hemolytic tran.sfu.sion reaction.. Differential diagoolsi,s:Hioor aller'gic reactions;.. (Serum will remalif.l el.ear v )

Section V - Disesti ve System

( 2 ) Treat fori shlcck ..

1-33.. GEHER·lll.... The. d ige,st i.~e ,:sys~e!iTil cover s ttle entire al imerl t.ary tract (.,uth fl e:9Cph~8US:l .. storna:h ~ In test lfiJeS" eol.on, afld rrectLDI) a~ .all organs that .a,idi in dlsestlon (11 ~€r, gall bladder IJ and panereas) • D(l seases 0 f ttle mooth are cQver""ed in the denta 1. sect-ion. Diseases, of' the esoptlagu1S are either minor' or oj .5U'C h .a nature that we can onl,y tr'ea.t them: symptanartically ..

p ~ ( 11 ) STOP tBANSf us 10111 STAr~,

(3) To prevent- renal failure':l gIve lUi m~nlni tol S()l ut.ian IV' infusion at al rate Ole 10-15 ml ... /min mltil 11,0001 ml I' have been g i v-en ~I If dli uresi s occurs 11 contanue the manni tol In Fuston, lI'"J ttl serltrnl and ur fne are c 1 e'alr'l I!

, - 32 ... IDISEASES OF !tiE tIMPHA TIC SYSTEM ...

1-34 I' ACUTE: AJ~OOMEN .. , Ulsuailly man i fested bly pain ti aeorex i.a 11 nau~ea tl

V01li ting t1 and fever ~ Rl )lisical ex::am shows: tenderness" musel E!~ s pal sm , and: manges in per'i stall ai s. Colrreet di agnosf.s depends an the pree tston and c'areitl taking history and! doing physical e:€~s, J.

a.. Lympharlenli t.i.s , Inflallnatioli1 0 f one alrl ID)re I ~pf:l nedes , Us,u~lly secoooary to a pr'imary' in fection else-wher'e il1"0,1 v'ing the skirt or subcutaneous tl sstJe II

.a .' History.,

( , ) Hbd:e of onset of abljom.inal pa m ,

SI.. Enlarg,ed, teoo.er 11 often actltellt pa infull l)"ll*! nodes , Systemic symptc.ms malY be minimal or sever'''! II

(a) Patient is, well one moment and .seized wi.ttl agol1izing (el.plosi vel} pain the nex t; "1Jist probalble d iagno.si 31 is fr'ee' rupture 0 f a hollow1 viscus or vaseular acefdent . Renal and bi 1 iary CQI Ic may be very sudden in onset burt are not 1 ikel y tOI cause sev e rei and prostr-at ing, pain ~

01• Pr imar y focus 0 f' in fection in thel regJon of the affected nod,e(.s.)1 • Ce llul i ti 51 Pi suppuration wi til abce's,s, fO,nDaltion may occur 4· low grade· orr ~hronic in fec~tion:s may prodtIC>e _firm, nontender nodes that, per.si st indefinitely (:e,~.g ~ 11 18 and rtingal infections,)", TheIJ may fOlrTnl cold, abcesses or @l'"'C(ie through the .sur face' to c rea tel dr"ain ing, SIn uses ...

(b) If pail1 i:s I""'alpid in on:set---mOOer'ately severe at first 2Id beoomd.ng rapidly worse--coosi.der acute pane reaJti.ti 5, mresenter Ic thranbosls: ~ or strangulation of the' .srmall bowel ...

A.. Lymphadeniti,;s secondary 001 ... Differential

diagoos,is : Lymlphed-ema seeondar "i to blockage of t,ne' lymph channel 51 ..

III!

(c) Gr adua 1 onsat Q·f slowl y progresai 'ate- palin is character'i stic of" per:i to ne al, in fE!et.ion or in fl arnmBltioo ... Appendici ti 5 and dj,tjertieull tis often star't thi s way' ..

P • Treat pr'imar-y in reet.ton. Ap_ply' moi st, bea t to local 1. z@ in fecti-on. An algestcs for' pa in . 1&0 abcessea,

r 2') Character of the pain ..

b II Lympnarngi tis .. Ac~ute or c hron ic in n,arranation of the SupeT fici.al or dee'p I ym_j11atic- channel s , Ul5U~11 Y c aus;ed (by streptc~occi or staphy Ioeoeet ...

(al) Excru~ i.ating pa in not rel.ievec by oar-cot iC3 iOO tcates a vasc:u1.ar· lesion such as ma.ssi.ve' in ra~tion of the inte'stine- or rupture of iEI1 abdOnin a 1 an e ur -y sm I!

s. Fever ~ 102 to 1050 F -to ) T chi.II s 1 malai se , general i zed. ac'hing, and he ad.ac: he ..

(b) Ver'y severe pa in readily controlled by' med icati-on more typi.call 0 f' aelJte panc:reati ti s or the peri toni tis assoe Lated with BI rlupttJ("'-ed]

viSCUSI" Cb3tructive appendii-citis, an-d tnearcerated small bo~l without exten,s1ve lli1lfarction occ a s ion a 11 yl produce' the same' type of pain 111 l3il iar'y' or renall, col ic is usual Iy promptl'i alleviated by' med icatiolillJ

Q.. Patchy' ar'e'a5 a f in n a'mlation along the path of a 1 ~Iphati c c:naflnel re3eJlbl mg cell uili tis. lyrnpnangi ti S oceurr ins: a 50 the r@5ull., t. 0 f hand or fbet in.feetion presents as irregul ar pink 11 tender" 1 inear str-eaks eJ:. tend ing toward the r'eg,iofl all 1 )1mphJ nodes., L,ymlphadeni tis u1Suall)' fol1oW5 ... Leukocytosi s (: WI .. , B-&, C ~ 15:1 000-]0,(00) wi ttl sb ift to thel left.

A.... Ac ute 1 ~paljlR.i ti 3 due to

diagoosi s: Acute thrallp:l phlebi tas , ce11ul i,"Ei s ...

..

b~ ffererl ti.al

( c ) Dl..J11:l v'aguel tJ and poor 1 y local Lzed pain usual.I yl gr acual

in onset strongl Y susgests an in fiMm.ato'ry process 0 r l-oIW grade in fee t.ion, e' .g... .all~ndiei t,is ~

P .. Treat the or ig inal in feet ion" blut, alvolid al.L undue, surgical

msn ipul at ion of tile WOUld I! Use .same- antibiotic therapy' as for:'" acute

c~elltlli tis {Chap l' fJ Sec I).. AIltibiotics should be continued until the temlperature has been normal f{}lr 12 bour:s. and in n,anmation has subsided I!

. . .. {d) Nrc .abd(xnlinal pain but cClft_plalins 0 f' feel ing of fullness

t~t mllght. be reI i evedl h Ii' a 00 we I 1DOf'iJ'anent, enema pro\!'ide s no reI i.ef" (Ugals stoppage 5ignU). Thi.:s m~y be pre'sen t when al'1lj" in f1 mvnatory lesion i:5 walled Qlrf frem free pelT itoneal cBvi ty .1

. . (e}l Intermittent pain witb cramp.s and! E"'UlSbeS c~cmmnly ;seen

in g~.str-oenteri tis t, The per i.st.al tic rushes have 11 t,tle air no r'elat ion 001

a~~if.lal cr-ERIps in gastroenter i t.is + If the palin canes in r e@:ul ar cycles: l' ~Sing . in CF"esc:ndo fashion. syru:::tJrooOU5 wi th the pa in and thEil! SlJbsid ing

a pain-free Interv'a11 small bcl-wel obstruct iOITI i SI v'er-)l' 1 ike ly ..

1-46

(f), Radli.a t iOlTI or fa shi ft in. I eeat izatian 0 f pa in: "" Pa inl in thel, soolul-de'r" f?lllo\lIS dialphliap;natic irritatio,n diue' to .air ~ perttoneal fluid, or hlood. , , Btl 1 ~alr-y' p~ in i s ~ft-en referred to the rl ight so apul.a aildl r'ar-e'l't t;o th~ left eplg;astr'lum and left shoulder, simulating angJnaJ _pec·toris .. ClasS1Cal1'i II append.ic i ti So beg ins in the' eprgast.r itm and settles in the! right lower q,lJa.drant... A .shift or spr-ead of .abd.minal pain often tndi.cates spreading per iton i t.is .'

bacterial inf~tiot.i 01'" toltins (,~ .g. ~ .starn}'l?Coceal food po i.soning , s,carlE:t fever. ~e~nla}I., V 1 r al. .11'] fee t 100 S, (e , g •• VI r a 1 _ g.astroen terl t.i s , measles. I)epaJti tIS IJ 11'1f1 uen za) -r and al1ergly {e! .. g .. ,I shell f1 sn) ...

S.. Aoorex i.a is allwa:i'S presen t arid ma'i be the onl, Y' S,ympt-nm .. usuall'1 'I patient campI a ins of epigast.r ic fJUll ness and pr'esisurel and nausea and vorni t,i,ng. II D1ialrrne.a, col ic " ma1ai se ~ fever , c nill s 1 he adac he:l a[]d ml1Scle craDp5 ar e ccmmot1J wi.th toxins or infections ..

(g)1 An.orex La ~ nausea 11 and. v~i t.ing ~ The time a f onset. of the~e S}'Dlpt~~ is imp:tlrtarlt; i r they precede th,€, onset 0 f' pa in ~ gastroenterlt15 Qr' .5OmE- systemic illness is much more likel~ the diagnosis tt_l;Jn acute abdon in al disorder requir' i ng ;31n em:ergenc y operati,Qfl. The most 11~e 1 y poss i btl i.ties are gast roen teri t i.s j all::urte ga.stri tis 'to acute

p~l1er'eati tis, coomon duct stone , a.nd hig,h intestinal .obstruction.. In ]OOJst otlJer acute surg ic al -em ergene Ies l' nausea and \remi ting, ar-e not dcminaWi t symp-tans looug.h the y: m~ 'i be present ...

O. The pataent may be prostrated aJnd dehy~rated" EJ[amination shows mild episastr ic ten_dernre''s5., Hemorrhage' is frequent wi th: chemical irritants te lig .. 1 salicy;lates):.. This m~y be found usfng al guad ac test .. ma~ show a leukocyt~]si.s or in Vii r al. in feoct ion s 11 a 1 e!UlkDlpen i.a ...

esc

It.. Acute simpl e gastri t is caused b 'J

Di (fer et.I t i.a 1 d i agno s i 51 : Inc 1 Lid! e s pe pt i c U 1 eer s-al~n;a=-I -, .a~P-lpe-.' -.n-I~ d~i l-:--~ ~ i tis; ..

...

_ ,{:h1 Diarrhea t c-oost,ipat,ian J and otlstipatiolf]., Some

211 ter at ion of vowel function is CrnmlrJ in. !1iK)S;t ea sea of acute abdcnin.al

~r"genC' i€,s ., Di ar rh~'a is the cl ass ic ma~ ifes.tation of gastr'center' i tis J but

1 tmaJ~ . ~1 so ~e' a dom:]'1 a~lt 5ynJiptomi of pe Iv i.e: append lei tis" Bloody and r·epet.l t1 ve- d i arr'ne'B lnd i,c ates ul ce("'at.i-on 0 r ttle colon -.- but you should consider bac.i ll.ary or a11ebic dlysenter y fir.st _,

P . Treat the speei f'ic infe.ct ion or prob Ien , Correct flui-d and! eilectrollyte' di stllEtlance .. PI ace patient N" P ... D II unlti 1 3(: ut.e s.~ptoms a f' pa in and nausea barve subided ~ then start g i v.ing cl.eae' 1 i.q:u i,(j SI ano prlOS€"ess t-o .a :soft -diet .astole:ratedl .. , Sedat ives 11 Lompa2ine, or 0 p,i ates m,a-y be used as

indlicalted II S~~tCl1lS last fr'{)ffll 11-7 -d a 'is ..

( 11 ) Genef"al in s pe-c t ilf)In (' pat i.ernt :stand.ing)l-I

{2)i CCHJgh tenderness.. Exa:mine herni al rings .and m,a 1 el gen i tals .

b , Food po Lson i.ng and aeut.e ~a5troen ter-i t iSI.. Food po i.son ing is a general term appl, i.ed to t.ne s ~n~ rome of acute anerex i a, f nausea , vt:mi t i ng , 8ld/or diarr'hea that is at tr- ibuted to food ir.ltake ,I espec i al.Ly if i t aJffects. 81 group of people who ate the' same foods , There 3lf€ n wnerou s causa t i \Fe agents .and! organ isms, tha l h~vle s im i.l air s igns and! symptoms to a ~rea ter or' lesse~' degree . The onI Y pos.it i Ye' way' ~Jif di fferen tiatillg between these .agent.s or organ isms is tI'i c ul t.ur i.ng, the .sus,pee ted food and stOG Is 0 r the affected i.nd i'lidual.s II M'Jst formsi of food po i son ing are seL f -1 imi t.ing a.oo r~l!Jire symptomatic tr-eatment ~ such as repl acemen t of f1 ui.ds anc elec:trolyte.s j control of di alfrhea with LCIT;~)til tl and controll 0 f nause.a and vani.ti.ng, wi tin CCRlpa zi ne.. V'er'y r arell 'i patient,3 may' d.evelop hypovol€fr. ic s~k .,and ~espir'atary: embarrassmen.t· r and this wi.ll have t£ll be m,anaged. ~tl.lc:ablal drugs should not be g i veJ1 urn 1 ess the spec i fic org~n i 3m oe-an be ldent1,Cle,d , a 5 ~hey may aggr a"U"ate the anorex ia .and di arrhea and p rOil 0 ngl the OOUf"~ olf the Illness Il The'exce-p·tion to the rul e is if you su sJlect BOtULISM.; then polyvalent antitQ~in must b'E! arllli3nister'ed. The following

chart Will 1-.-1 ., . d . f .

:' 1 '.,'. '., " • _ 1I.r: P ].11 1;, entl · :,rlng the Y: ar ioulS types air focd poi soning and

theIr .specl fiC treatnolents ..

(i ) Chi 11 s and fever ~ fiepe'ated houts of chi lis and fe't€r are cnaeae ter i . .st i e signs 0 f pyl ephl etl i t.i S and bact.eremi.a, Chi,113 and rever

are c~~. in in fectio~~" o~ ~he ~ i 1. iar-y' or renal tr-act . Acute el1a1 angi t is and! p,y~ll tl s prels€n.t. W1 th 1 n tenn It tent chill sand fever , In appel1~ ici tis,

~e~er 1 s not tlS~fall ~J ver'f hi.gb and there are usual 1 y no chi 1103 un1 ess you h~ve a ~r" for at ion " In .a woman wi til nOI appar'en t general systemlic ill ness , ~v~ry , 11 ~g;h fe:~er wi t~ _per"i tone-al s igns is. char .ac:ter i st Lc of' acute pel vi 'C Infl.annator Y' d1. sease (, FID)I ..

bl - ~OUlt irJIe for:- phys ical e:at::an of the ac ute abd<xnen""

(3) feel fOT spasm ..

(rganism,

Inc ub.atiot] Per-iod (Hours)

EpidBI'.JJiology

[1 in leal Features

'lI)' ~ f

\ \AI je- . inge'J" pa lpa t i.~)n ..

StaJphylococculS

1-18

St.aphylococc], grOWl in ri1fe'.ats,

~.a iry 11 and ba.ker y' products and

prod oce enterQ-, toxin ..

A.br·up1t OJl set r. intense v'(oli t ing for up to 2~ hour.s =" r egul ar T'ecover yin :?4-li e hours. 02curs in

pe-r sons eati!'lg t h.e

oS arne f 0001 .. N'o

treatment usually;

n ecessar y except WI r'es t-~)r€ fluid sand electro,11Ite.s ""

( 7 ) !1~€ bo un dl te nfd ef"TI of -S.5 ..

(8) Ausc[Jl t.ation ~

( 9 ) Rec t.al and! pel iJ i.e e-xaJnination of.

a ,_ Ac ute 3 imple gastr i tis _ Th i 5 is probab 1 'J th.e !1X)St C()?'f]lO(:]

d i st uT'blatnce 0 f t he st~aC'h a:11~ is freqLrentl y! aC-C{)i1ilparl iedi by gener a1 ]_ zen ent,e,r i ti s . [all~e5 are ch~mlic'al i rr i t.ants (e ~ R _! a 1 roool1 sa 1 lcylate-s) tl

1-4}

Clo.str j,di lInl per fringerl 5,

Clo:str idi UflBl botulinllBl

Escher i,ch,iB col.t (some stralin.s }l

Vibr io par.ahaem.olyti.cus

6-96

J'

Vibrio -choler1ae

(mlild eases}

2~-12

~,-4,g

Clo,gt,r idi a grow i.n r -e' w.anned meat d ishas and proouc-e' enterotcx in 11

Clo.str i.,dia grow i.n aJ'j a e roll i c fOOd.s arnd produce 00)[ in t-

Org;aJ1 i.sms: grolw

i f1l S urt an dJ pr adl uc-e

to-:tin Il :May also

i,nvade

super f'i,c ial

e'pli thel i un II

Q - .

rg_,anl sn.s grow In

sea food amdl in gut and Ilrodu~e to:( in ..

O· "

rgam sns grow 1 n

g,ut and proc uce tax in ...

Ablrupt, onset o,r p~ofllse diarrhea; YOlIi,ting occasionally' 01 Recover'i usual

wi, tboUit trealtment

in 1 ~ days IJ Many clostr idl i.a in culture S- of foodl .aoo feces 0 f' patients ..

Shigella S.PIl· {mild cases}

Dipil.,opia, dysphag,ia t dyspholni.a"l r·e.spir·ator ~

ernb~r'r'a5sment .. Treatment requires clear a i.r w;ay Ii ventilati,oo t1 and intra'Ier1Ous: pol ~y'alen t

an ti, WI>: in .' Toxin presen tin food and! serlEl .. , rtJlrtali t.y r1ate high 'I

Sabmnella sPP II

Usuell yl abrupt.

onset 0 f d ialrrhe1a ; vomiting Tar~. A serious in fectiof1 in neonates;. In adtJl t.s ! t1trayeler 1i.3 d iarrbea:""~ i 5 tlS1ULall Y' self-l

limi ted in 11-3 days. Use' {j i.pheflox ylate

( Lant)i t, i 1.) D IJ t no

to-~' b- I

an Imlcro' Jia s ..

Oostr i-d ign dif"ficile

Abrupt onset 0'" diarr'rhea in groups. cOrl5tmifllg tile .sane Toodl II espec i.ally cr-abs and other sea-'

fcOOl " R'ecOfll'er y i 3-

usually compllete in 1- 3- dalYs., F'oOO aool stool elll t·ul""'e:s are p:lsitive ..

-

Canpylobac:ter retus

AtilrlllJlt. onset of

1 i,quid -d iarrtrea in end erm i e ar e a 01- Need s pr-ompt r-eplacBTilent of fl uidls and eteetrolytes IV or or all Y' • Tetraeyl--

cl, mes sbor ten excr'et ian of vibr'io's.,

Stoo 1 C 1111 t,ure Sl

JX)si.ti ve! ..

Yersinial

er.ter· 11

. . "

I I .". , , .

.. <leOI. tlcal

211-12

Organi sm.s grow in sUlper"fic i a1 gut epith-elill!1J and BlJlt 1 Lmen and

!iii r· . odi I..Ii' e' : t a " 1" n

It'" .··.x 1 ...

Orlgani sns grow' in gut. CO nat

prooi uce to >I i n .,

?

...

Dr Ulg1 in ta ke ,

e .. g_ I clin~amy~in tJ

?

..

Organism grows in. j e j t8'l LITL an dl i 1 e LITlI ..

?

•

Fecal-oral tr·an~i.5sion ., FcOO-borne.? In I""W::t.t~

~ .~.I

1-49

Ahrup1t onset 0 f

d tarr-hea, often wi til b-lood and fJUS in s,toolS; cramps;

tenesmus; and lethal"8,Y. Stool

cuI t{J~lels are

positive.. Give ampic ill in 11 chlor'aJllpnell icol "

Dr .sul f.amethoxa zo'l.e with trimethoprim (co-tr unoxa zol-e1) in sever-e cases . Often mild and sel.r-

I imi ted Il Iftes:tore flui-ds.l

Gr adual or abrupt onset of d i.a1i1rhea and low·-g,.- ade feyer II No .antimlicrob ial s un 1 ess systemi.c

di.ssesninat i.on is suspected. St..ool

c:ul tl1lres are

post t ive .1 frolong1edl earr' Lsge is,

frequent ...

Especd.al.I y after' albdaminal SlJl""'gerr'''j ,I abrupt hloody d i,ar' ___

F"hea and fever. Tb.xin in stool .. Oral varrc<m:ycin useful in ttlerapy.,

Fever 11 diarrhea;:

PI .. M .. N'. 1 S and frelstl blood in stool:t especial] Y'

in children ..

Usuall y .sel r-

limi t.ed ~ Spec~i al

med ia neefjed for

cul ture .. ErythrD-'

myc in in severe cases

wi th invi:llsion ..

Sevl ere B bd aD ill a-l.

.P~ in f diarrheal. reviler; P .. Hl.. ~ .. Ii s arxi

blood in stool; polyarthritisl1 erythema nooo.sml, espec iailly in

c!hi ldlr-en .. If severe IJ tetracycline' or

1-5{]

t ' ~,

, ' , " """, I '

gen am,lC In .,

..".k wi 11 show occul.t, bl-ood in the stool .and .anleinia in c.hronic ulcer's. :oefini be diagno.si s depend s 0)1 x- r a y and endoscojric examination ~

c .. Bac i 11 ar '! d y'.se:n ter y (stl i ge l.Ios.Ls )- . Shige llosi sis a comon, oft,en m ildl and! se 1 f -,} im i ti.!'l,g di sease that occaai.onal Ly is ser iou.s ., It, i.s usual L y: found in canjJJ.JrlC lion wi ttl poor sam tary cond i t ions ..

NOTE.: Compl ications LncI ude sey'ere hernor'rnage dUE to ulc.er'atiolrl in to a vein or artery or ev·e'TI. bleeding from SIr'rululat.ion ti s>5.ue'; per fora ti;on. into

.. the per i ton e all e~IU' i ty calu15ing per i Win it is.; puretr at.aon into, sur round ing, Oirg;ans II usually mto the! pancr-eas -t but th,e- liver j bi l iary trac:t or ga5tro11epat~c cmrentLmI may bel i nvol. ved .. In 2'0 to 2S percent. of untr-eated patien~s.1 m~nor d'7&rees a f pyl.or ic LJ al v'e Obs,tFu~t ion occur 11 but majo r or caupl-ete obstr'uc t ions are rare ...

S.. Abrupt. onset of di.ar rhea (often with blood ood mlucus)" lower a!xlomlin 811 er aTlPS" and t.enesmus , Thi, sis usual I y accc:mpan ied by felijer.1

chi lls ~ anorexi.a 1 mal.a i se , head ache" I etharsy Pl clouded ment.al CQIj(j it 10;' , a~dl in the mo.st, severe' cases men ingi,smu5 (S and S of met'] ingeal irri tation wi thout .actual in fe-eti.en) ~ cerna I' andl COO vu 1 stons , As the illness progresses, the pat i.ee t becomes weaker" and more dehydrated ..

.1\., Pept.ic ulc.er dli:ease' doodenal ul-cer'_ Differential diagnosis: functional gas:trointe5tlnal d i sease j ga.str i ti s '" gastr ic c arc-i nerna., and

1 r r"i tabll e col en 3 yn-d. raTJ e ..

01... T'em pe r' a tu r e u Pi to 1 0 ~CI F..:! te'TI dl e r' a bd{)rften 11 and blood fl m oc us ~ and pu s in the stoo'l , Stan 1 culture' is posf t i ve f~)r shigell ae ·

P.. 2- 3. ~eHS rest fron! Lyork if posz i bl,e .. He 1. lev e ·or .av'oid anx ietf when,ev'er' jlC1s,si,ble~, forbid alcotbol., Di soon t in ue or avo.id drtrgs that aggravalte ~ ulcers (e 'I g .. ~ pherJ]_Y 1 but.azone 1 i ndoonethac: in p' and Large amWl,ts of sal~c_ylates).. Place patient 011 a -dietar~ rnanag,S[leflt pr'ogram.,

(a} In the acute phase" sitart full 1 'i quid diet· wi ttl hatlrly' 3fltac ids I itler ali zed rapid 1 y to .a reglul.ar d iel.

A.. Sac illar y d ys-e'nter 'f 'stJigellosis)l... Di ffelrenti al, d iagnosi s:

Arnebi e (j ysen. tery 11 salmonella" gastroen teri tis t1 E. CQl i , viral di arrheal t1 and ulcer ati ve col, i ti s ..

, .. pi: IV flulidl and el.ec tr-ol yte repl acem.erllt t1 place· pa tient NI. P, 0 11 ;

ant,lspBlsmoolcs (e.g.,., tincture of bel Ladonna) are htelpful whe'TI cramps are

severe ., Avoid LQ.mo~t~i !:__~!:_J)alre~8r Le ; they mla-y imlpr'9.fiJe' the gener-al S')m1ptoms but prolong fever l' -d.iar'r hea , an-d excre'tion of shigella in feces 4· (ffee t.i ve stool, i 30 18ltiorli and d i.spo sal shoul-d be ini t.iated . OTug Olr coo ice is ~picillin 250 mg. q, fih., x 51--1' days; second choice is; tetracycline 2150 DIg~, q ~ 6h.. x 5-7' davs , After' bowel has been at rest fot:"", a short time:t star't pat.rent on clear fl uids for 2-3 dalYs j thren sa ft d Let and gr-adual I y: bui.Id ,

c: b) Avoid iIllil k as, therapy'.

hours) •

(c) Avoid inter-val feed ing {eating SJlall meals ever y .few

{dJ Nutriliou~ diel~

tl , Ameb ic d,Ysente'r y: ~ see Cha pter 2 f Section I ~ Par .asi t.ie Di.se.ases,) ..

eel Regular meals.

f ..

Choler-al (, see ," C' ,'~:!:!I,I l,n,l, ,'''I, e 'r 2., 111 C'~, et i 0" ,'''''1 I'. I' 1'.1 CI.... te ~ 1 Di" ~ }

.J"Il.. J] IYr~ "..::lIC...... ~J ". ~c ,·T la ' 1 se.a.seS) •

( f} Restr i.ct, coffee tJ tea P' arnd col a bever ages, "

~ g} I\\"oid food s thalt ar'e knOiHfl] to- prod uee ur1lplea sant s;,mptons, in a g iven individuall t,

Antacids ~ . in _ order to be effective, must be taken fr equen tl '1 • pha.,se 11,antac Ids should be gi ven ooLlIFI y.. The sched ul.e rnay then to a f)Jll dose 1 and 3 bour .s a fte'r meals .and at bedtime ..

In the .acute' be cfJlangedl

e , Typhoi.cJ felJ€:r (see' ehLa pter 2", Sect.Ion I I I 1" B.acteriaJ.. Di seases 1 ..

h. Pept.ic ulcer' d Lsease , ArI ac ut.e or chrcndc bell ign ulcer .ati,Qn In a por'tion of the diges:tive' tr'sct exposed to g~.5tric :secretions.

(:, l DtJodenal ul.cer-. ~st -ccmmon type of ulcer, four to f'Lve t.imes, mnre prevalent than gastr ic ulcer.

ulcer.

(2) Ga atr ic ul.cer . In man y r'es pect sit is sim.i] ar to duodenal,

S.. Symptoms, mlay be lJague or .ab3e:ll t .. In a typical case p.a in is descr ibed as gnalwil1'lg; f burn ing, C:T ~pli ke 'to ac h,ing.1 or a s. heartburn; i tis usually mild to moderatel Pl 1 ~ated near tile midline and near the xiphoid process.. Pad n. may ("'ad ii:llte' below' the ribs in to the bac k or o[!casionall'i to thel right shoulder. Patient may halVe rl aruse~a an-d may \!"ClEi t small qua.n t i t.ies of highl y aci-d gastra'i c: juice's with 1 it tl e or no food.. lJ5u~11 y occur's .ij51-60 mlinurtes .a ft-er meal s;: absent in the morning ~Iforel bre~akfast a.nd gets progressi vel Y 'K)rse as; thel day' passes.. :Me'i be D)st server e be't.we~n midnight

.and OQOO.. Pa in is. r'e 1 ievedl b~ food.... mil k, antacids F and vamiting wi thin

5-]0 minutes. Ulcer's can 'spontaneolJlsl_y get bettelr Or' -wor'3e.. Causati"le facto r S mlay be- unkoDIiIfl blurt I!JlaJ)' incloce ~ :;s:ical. olr emotion.al d istres3, tralllll.a" or in feetions .. , '

Pa..,' "~. There, m,' :a)" be r:JrQ s')nptoms or 11 .aCiU~ and at-up, :ic ~l II::!! vn1li'tl om' ,oC!"

lIn 1 s ep' i1Ji ' ,t -', ," " " OIl ' , ,01!;1 ~ ,Ji-IJ,IIfi'" ", .._:II •

'n , '" .'+b.as T H~ , ~nrJ dlescr lbed as gnaving ~ burning ~ ;a~hing: ~ or' hlJtliger

~g~ .• r-efe~red at tllTleS ~ len: subcostal area _ Usually occur oS ~5-&O ~~te5.aft~T ~als and IS, ~elleved by food ~ antacids-t or varti ting _ \\!eight 'I canst lp;3 t lon:t. .and fa t l.gue are COl'lTtOll ~

the 0111'1 f~~dlr~P.jp_;alsI;tf::jt~'~~ tendh'erness. o,r vOlltmtary musrele guarding is ~slJla11y'

" ,,' :' ,I: I 'iLg.. "I '·J·~re 'as been. bl eedlin.:r , a (Ii u~ l' ~ te t -, 11 1,1...

OCcuo._ t 101000.. b" ' .r"_t, ~ '1;In"., "IS', Wl. ' . S.dQW

NOn:

, 0.. E'xarninaltion .shows supe'r fj-c i.al and! deep e pligastric tenrd:erness!1

volll1 tary muscle guard it;jlS ,I and un ila:teri al spasm orV'er' duodenal bulb~, L,abl

~ena1 uf · Pel.:ltie. ulcer dl sease T ga stl" ic ulcer. Di ffereJ1 tia 1 d i agnosi 5-:

" , '" cer '" lrr 1 tabl e colon tl rune tiolnal gastro intest ina! d i stres,s" and

1-51

gastr'i tis ...

51. Append Lc i ti S us,uall:l begins wi t,n gerrer' al i zed peri LI11bil. i.cal or e"p,iga stric pain and 11 QIT 21 ept sodes 0 f V-Qnlli t i ng .. Wi tbin 2-117 hour s, t,ne

pa in sru ft:5 to r ign t lower' quadran t where L t per si st s a SI a stead'i sorenessl .ag~;raf\f ated by weI king or c:o.oughirllg +, Pa t.i.en t C:Cin usual.Ly pl ace a finger' on a

speca fie p:.-.,int II Anorex i.3 ~ mal a i se , .31 ignt fever tl and constipation are

usuaf , but d i.ar rbeli:IJ OC:C"Ur'S oceasronal I y •

WATER LE'In

• ...p! ",J

... II!

It! .. III III! .... J .I~ •

... .. ..

Ii •

p ~ TreaLllent is thel same as, fOIl'" duodenal ul~eli' tJ Fai Lure tel respond in 3-.l.I1 weelKs i s ind ieation for sur-g,er'f",

G.astr Ic ulce~'s tend to be recurrent. RE!'C urrent, ooccrnpl icated uCLcer s usual.l J heal faste:r than the prev ious tllc,er "-

•

.. II

i .. ~ute organdc ill test Lnal, obstr-oe t.icln. Ulsuailly involves the small inteslt.inel.5 11 part ic'ul a 1'"i Y' the ileLmI. :Maj;Olr' causes are ecter-nal heTn ra and posto_perali ve adhesions., less cammon causes are galll.stone:S:r n-eo pI asas ,I foreignl bOO ies" intu5suseept.ion"l gr anul.anaoous processes 'I internal hernia II andl vQVulus "-

GLASSI TUBl

...

II otJ

.. ~ J'

III"

..

to

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II

..

.. ..

I .• LEVINTUBE".:

.. I.

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'II

Ii

S I' Col icky abdCdlin.a1 pain in per'illTlbi 1. leal area beccming more eonst.an t and di ffuse! as di.stent Ion developsl"- Vomd. ting assoe iated wi t.h, waves of p.ain. If" obstruction is. of the distal bo~l:l voniting becom.e's fecal in n.atttre "- l.olud stCl1D3ch g,TOwl ing II unrmanag,e.a.IlI e cOrlsti patian • ~aknes.s Ii -5'Weatlng tJ and anI iety are often present, II!

•

:w.---- ....... RUBBER TU.

O. Pa ti.en tis r'esltle'55:t 0 ften Ln shookli ke .sta Ite wi ttl t.achy'Cardla and dehydration ,I t,ender d Lstended albdamen (can be l-ocali.zed but u1Suall y gerl€:r al i zed) wi thout per i toneal irr'i tation -to AOO i hIe .and \\"is:i b,le per istal:si So! hli~h pi lched tinkle's f. and _pa in. reI a ted, to per istal tie: rushe's IDa yl be present IC Tetllperatur·e i s normal or 51 igtltl y elevated """ A tenc,er herni a may be presen t "- W .. B. C-.. is normal Olr' al ightly elevated.

R~UBBER STOPPER

-tI
~
"II
III
..
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iii
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iii
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, III!
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• A. ArC ut.e o-rgal1 ic inltest in al OOstruction., Di fferr'el'] tial

diiagnosis : R~nal col, Lc ,I gall bladder col ie 11 a r meseoter ic v ascul ar d.i sease Il

....... ,ClAMIP

P.. Pl ace pat i.ent R. P _ 0 II] Deccmpr'ess in te.stinal trac t b,y

nasrJgastric suet.Ion (see illu1Strai1iQln on next page) II! Rep13ce fluids and!

el ee trol y'tel5 tI y 1 V .. Treat, t,he ca use 0 f the oblstrllC t ion . Star t brotadl-spectr urn am t i.b.iok.i.c theT apy if needed ..

STOMACH

j I' Append ic i ti s , liJl€ of thle DTIO,st frequent causes of acute abdomen., Sig:n s alndl syrnptDmls usua 11 Y' f'ol. low a fa ir-l Y' :ste'reoltype-d pelt tern tl but i t earl d i.spfa y: man 'i d i fferen t OOafi i. festaltians that. sb[}luld be cons.ider'ed in the

d ifferell tial d ialR,nosi 31 of every easel of .abdmlif1al sepsi s and pa in. ..

s· ,

B01TLE 3:

NASO GASTIC SUCTION

BOmE2

0.. Rebol.Jlnd telTIdiernesls, and spa SrrI of the over 1 ying aJbdaninal

musc l es _ Ree:tal tefiderness t s c.crnrnv.(]: per' istal st sis d.imlinistie-d or absen t .. 51 ight t~) oooolerate fe·~ler.. Pa i ~l ] oc ali z-ed in :r ig,ht 1 orwerl quadran t. W II B. C ..

1 0-2(} t ooe wi th a!l inc r ease in n e'ut.ro'pbi 1 s ~

.NOTE: COO1I)I rcat.ton s inci udel per fora tion lead ing t.o g,ener-al i zed ~ritonit.is t appendiceal absce.ss , pylephlebitis II and intestinail obstruc,tiort "

I-54

A... Append Lc i tis.. Dri f"ferent i al d i.sgnost a : A~ ut.e

gast.roen t.er i ti s , IDe.-sen ter" i.c adeni tis t- :Meeke 1 .. s dl i ver t ieu1i tis.1 region al enter i tis t, aI11eti iasi, S Ii per'fo,ratedl d urJ(j en.al ulcer, tlreter.al col ie, Ttlllt,ured -ec:topic pregnancy Il and twis,ted ovar Lan cyst may at times mimic

append ic i tis .,

L,I!ltil peris,taLlsi SI r~lturn s . ~rnd pa ti~n.t . b~ins passing fl 3ltu,S ~.. Pl ace pat.Ient :N .. P~O. unt,ilafter~G s,uctlOf.l. J.~ .dll~ontlnued 11 tMn 51~)wly re~~e oral ifltalke.1 IV for ~uld etectro.l ~e ther apy ~ and paren te~all feed lng ar~1 re4ulred"I.Hareo,tloCs and 5~~t~'i~~ .Ul~€d .11beral1y. to .lnsure rest and cGlfort, II .Broad---spect~~ ~ ~:Lb iot ic therapy tOI ~Ir'ellent an.dcontrol

.. jnree~tions should tie lfll,tl.ated:. B(lood transfUSIons as needed , Watch patient. (OF" signs a f "tax. ic sboc k arJd treat as requir'ed ..

1... ACLIte Pancre-ati t.ts , A, severe .atx:lan ina 1. dli sease prod uced by ae:ute Inflalrn.atlon in the pancreas and al5soeiated II! escape" of pancreatic enzymes, :into ttle surround ing tiSSUES., The exae t cause is not koo'\mJ ~ but more tbanl 80 elinic:a1 cause's have been r elated to de ute parlcreat i ti s , everyttJifl8 fraMI alcohDliSTl to drugs II

Pol Place patient under observatdon f·ar diagoosi.s withi.n the

first 8-121 hours , Bed rest ~ N' ... P .. 0 .. II st.sr t main t.a ining IV t' avo i,d narcotic m.e.c ication as i t might mask s ~ptom3 necessar y: f'a i proper diagt1osis ... Abd011ifl all and r'ectal eXaJll I' white lllcodl calm t. Pl and di fferentiaJ., COUll tare repeated per iodical1 y' ..

C· 1). OtJ1ce d i.agnosi sis made, an appendectomy shoul.e be per fonned as soon as fl uidl Imbal ance 5, and ather sy'stemic' d.i st.urbance 5 are controlled ..

S.. Epigastr Ic pa in gefierall'J abrupt in -DIn set is stead y and severe" made 1tCIr-s-e DY' 1 Y'ing dawn; and bette r IJ y st.t t.ing up Ie an i.ng fOlrward.1 Pain uSlually radiates to, the' back but malY radiate right Olr left.. :Nauseal:l vani t,ing" and eonst.i pat ion are present, and sever-e prostr-at.ton , .swe'.a ting, a'ld anx.iety· ar'e tlsuell y fOlund., There may be a hi story 0 f .alcohol intake or a heaIYY meal imned iatel Y' befor'e the attack .. ,

(: 21), Al1ti brot ie 5 stlould be admlin istered in thel presence of mar k~ systemic' r-eact ion with se'Vere' to:€icity arld high fever ..

(3-) rmerge~c:y nortsurg icall tre'at.otnent when stlrgieal fa£ il tties; are' oot elY'a! Labke ; tr-eat as for acute peri toni tis., Aet.lte append lei ti s ma y subside and crnlpl Lcat ions will be mlin imi zed •

01.. Tender' abdi~rel11 ma inl y in upper abdonen Pl usual.Ly wi t.hout, 8rUardling., r igidi ty." or' r'ebaund.. Abdlcmen me y be' d Lst.ended anti 00 we 1. SO\Jnd s ma,YI be absent .. Temperature of 101 tJ 1- 1 02 .. 20f II ~ t.achyc.ard ia, pallolr" hypotension 1" and a cool. e lau.DIY' skin are often present ..

k _ Actlte per i toni t i s , Localized or generalized per-'i to~li ti 9. is the moist important cOOilpl teat.ion of ntmer'oulS acute abdcminall d Lsord er 5 .. Ma y' be caused b-; infe-cti.oln or chernlic:al irri.tatiorl.

s. ~1~1 ai se , prostr ae ion , 11 ausea, vani tIng IJ feve'r, de'pend] Ing on ext.en t 0 f ifll':trol V eD] en t local i.zed -Dr gener-al i zed, pa in and tenderness"t. abdcmin.al pai:n on caug,hing ..

Mild jartmd ieee' is ecmmon., Uplper' 8vd(.1JgJinal mass ma~y be presen t .. Ac:urte renal "allure IE Y" occur earl y: inl the cour se 0 f the dli :;ease .. W .. B .. C.. 11 fl-·3 0 ,aOD ... Urinal..ysi s stH:Jws- prote intlr' i a , casts in 25 percee t of the c ases , and glooosuria in 10--20 percen t 0 f tile cases, ...

o. Eleva teod W III Bile., rebound tendern.ess re ferred WI .are!i:IJ of

per i ton i ti s , and t enderneas to 1 tgh.t percuss ion over t.he arrea... Pe 1 vic

per i tori i ti:s i 3, assoc iated wi th r'ec tal and vagir).al tenderness., Spastic mu.scles over dire a of in f'Laemat.ton ., Wh~n 1Jer"'i toni ti 8, is generali zed'! there will be marked ri~idi ty' of the ent.i.re .ab(J-cminal wall.. This rigi-dity is freqllen tl"'1 d innJi,f)] i shed or abseJl tin the 1 ate stages 0 f per: i toni t.iS'.1 in. severe toxen La I and when the abdcminal wall is weak" fl abby I a r obese, Dimiti Lshee to absent peri st.al si s and] progressive abdlOOilinal di sten t ion is found. Vom i ting occur 3,,, -d ue to p-Jol i fie of gastroin test i~,al secret.iclr\s, and gas ~ W ~ B~ C. will. increase tD 10-20 'I OOG ~,

A ~ Acute pat1ic:realt.i ti s , Di ffererlti al. d iagnosi s : Pancre-ati,ti 5,

Ls hard to tell ft:'-om: COOIOOlrl duct stone or per'faralted peptic ulcer. 1 t rmU1S·t also be differenltiated from_ ac ut.e me.seJ1telric thr-ombosi.s t1 renal eol Ic -p' ae ute cholec.y:sti t.i s II and ac ut.e int-est inal ob'str oct ion ~

~L _!tcurte per i tan i tis ., Di ffe,rential dl iagnosi 5: Per'i tond tis may

pres-en tat. ig,hl. Y Ii ar i ablle cl in ical picturre' and. mUlst be di ffer-entiat-ed f'rom .acute i r1 testinal .::.bstr uct,lrJO" ::tc urte chf)l-ec yst-i ti:S:l renal cal ic ,

ga.st,ro in. te stin al h€tOCJlrrllage! lOlNer 1 abor' pneumo~ i.a, p?rph.yl""' ia I' per iod ic feve'r!t h.yster 103, .3r.Jld centr al ner~ct.ls .system disorders ..

, . P., E'"nergelle}~ measures for impend i ng shock: Place- pat.ren t i'J. P. 01•

If oovel sound s ar'e absent 1- ini tiate nascgast.r Lc soc tion .. Pat i.ent should be . placed at be<i rest and given 100-1 50 mg_~, dlemerol SQ as necessary fot"" relief' of pain" Atrop,ine- may be given .as an antispa.snooic 011]-4,-0",01 mg .. , SQ. start, IV to repl ace fl uidls and mon i tor ur in.ary Otltput., !Use .sho~ k drug,s if ~lece.ssary; -c-al ci wn g IlJConate must be gillen IV' if there is ev i-den.ce o,f hY.POC'aleemia wi th te tall y .. In i ti ate prol_phyl ac:tie anti bliotic th~T'apy onJ.y if fevler e~ceeds ,aeolF ~ Pat i ent should bel con stantl y atteoo,ed anrd vi tal signs

chec.ked .. -ever "i 15J- 3:01 mi unute.s .. C~C arnd ur'in.al ysi S soolU11d be dOfle freqJuen tly and] IOODl tared .,

p .. ~rred trnB1 t. is gener all 'i .appl icabl € as sUlp},:Or-ti vel tr'€atment in RKlst acute abdCff, i~.a 1 d i.s-nrder So.. Tbe' ob jec.t i ve's .a re : Contr'o I. i nfection ~ mirtimi:ze the e ffeet s of par-'al yt ic ile-Ll~;: cor'r ect flu ia I' eo leetrol y'te II a~ld nutr it ion al d i SOlrders I

(1) Follow-up ear-e: Patient sllould be kept N~ P .. Q .. fOlr .ll.8-12 tours II Ex amine frequen tl y and C" l05el y fo,r ev idlence 0 f contintJedi

In.Oall .. ation 0 f tne pen~ reas -or reI ated str uctures . Conduc t per ioo ic me

-::n urinalysis.. . ~yper feEdl. the . pat~ ent P;=37e!1 ter ~l~ y for ~i r st f.l8-12 hours!

. •. grajuall'j lntroduce oral feed lng: ~ ~n c llrLlC.al €v'ldenc-e 0-£ pan,CTeati ti s has c:lear ed t plaL! ~ thel _patien t on a 10 w fa t diet.,

( 1 )I Spec i fic measurres: Identi r-:t and treat the cau5.e; tlli 3 u.suall y en tai 1 s s,urger Y' t-o remove' sources 0 f in fee t ion sue h aiS

.append i.e i tis ,I gar.g renous bowl"" ab ~cesses for' perfor atedJ ulcer s ..

(21) Pr-ogfJosi s : Hee urr'ence is COOInOJlIF. SUFger'y is ind icated -only ~. d iagnosi sis i n -dQ"lJ~t. i f ?-on s.er ... at i '.Ie- treatmen. t ~-S not w;::.rking J or in presence, a f am assoc: 1 a ted j] lsordelr such ~ 50 stones 1 n b i ! i.ary tr Be t ..

(2) GCt]eral: Bed rest in medium Fowler P'Jsi tiaTI (semi-.sittin~).

Na:sog.ast r if!: { .NG )J suetion to plte'lJent abd{)M i.n al -d i sten tion -anc cont in ued

11-'5-5

1-5£

m-, Acute Cholec),sti tis,.. Choler:ysti ti,5 is, asscct.ated with gallstones, in over 90 pereen t. 0 r cases ~ It is caused by a p.arti al or eonnl.e te cystic doct obstr-uet.ton . If the, obstructiofl is not, r'e 1 ieved, pr-essure trll1i Ids UPI witbin ttle gallbladder. Pr'im~ril'1 as a re!sUllt. of isch€fmi-c changes secondary to distention !I gangrene may develop with, res,ulting perforation IThis. may ca use gE11eral i zed peri toni ti 5 but U~ u~ll yl r'eme ins local i zed and. forms a chronic we-ll-ci,r-c LITl.5C r i.b-e:d abscess. c a~1 i ty ..

S. Usually fa 11aw.s al 1 arge or fatty mJeaLi., Relati,v e 1 'J sudden Of1.Se·t of :severe ~ min imaJ.. 1. yl f1 uct.uat.ing pa in local i ze~ in ttle e pligastr i tim or right upper quadrant frequentl Y' radl La tin.g to in fr.a scapular area" In th,eU1c~cmpl icated easel IJ the' palin mlay grad uaI1 y sub·si -d e over a 121-18 t]()ur

per ioo 10 V'aDli ting oceurs in 15 percen t 0 f easels and 50 percent 0 f these get variable relief Ie

0... Right upper Q}nJa(j ran t abdClJlitl all, tenderness , guard ins; and! .

rebound pa in. About 15 percen t ·of" cases have a pal palll e galllJl adder- and 25 percen t of cases naye j aJunrd.,ice.. fever is usual.L 'I present , W • B. C... is usual.Iy 121- i15, 000.,

l.. Acute c hal ec )"5t i ti s , Di ffer-ential d iagoosi s : Per'foralted. peptic: ulcer, acute pancrealti.tis'l appendici tis:I hepaititis ,I and p1E!umlnia with pleur isy on the r ighrt side +

P .1 Place patient N· .. P .. 0.. Ini tiate IV far malin.tenance and

feed ing. Start Ilrophylac tic antibiotic tner-a ply .' Gi vel .i3fI allg-e'sic5 as needed (nr:n""phline aT meper idine) .' &nooth, mlusel e reI alX:an t.s I such as- 1MI altropine air problClnth,in.e- 11 should be used. Pi3:t.ien t stxluld tie watched closely. W + BI. C '" sooUildi be done .se'Veral times a d al)" ~ Treatmen tis continued 00 til symptams slubsid~. en.al ecysltectan 'J 1.5 usually required lOut not, .a SI emerg:ency :surger'y mle!ss the!re' i 3 ertl idence of glangrene or per fora..tiorl .

Sec ti,on. V'I - Gen i tour i n arl y Sys,tern

1- 36 . The gen i to~d[Jar 1 systein. is. made up.-o r the fl]al e <IDOl female sexual orlans 11 the urethr a II t.he bladder 1 the ur-eter s ~ and the ki d neys ..

..

~ _ 37 ~. GEN ITOUR INlARY T'RAJJMA I-

a", Kidney tr'auma.. MOst canmonl ~ c aused by b I untel: te rnal force such as bloWS I ~ icks 11 falls I et-c ~ tJ in the' fl an k area. Other' cause s are ~undl.s SUC!h as gLllshot.1 stabs tl et-c .. ; i tis very rarel yl caused by 5 poertaneous Ir'upture of a di se a sed kidn.~~ ..

S.. Pain at si tel a,r injur ~J wi tJl a bOr""inl& OT tear Ing sensa t ion

tel t in loin Of"' uppe'r 3lbdlmren.

01.. Swell i.nlR, and prCi~ ressi ve r igidi it y' olf a f'fected side .. If t.nere is a tear in the reoa 1 caps ulle III there i s usual I Y d Ir'apidl y expafidl i ng, rna S5 in the flank. Fran mild to gross hematul""' i a. is presen t jj_ n 90 percen t o·f the cases.. Shock occur SI in var., ing degreels... -tlill 81 .. c: '" e ley-a tes rapidl)! to 2101 tJ 000

and: higber ..

P'. Conser'velrvlati vie tl""'ealtmen t wi 11 u~ually pr'OIi ide sat i sfac tory ~esrUll,tsl in most cases ldlere ther'e is, no penet.rat Lng ItOtioo. Bed rest for" at least 21 weeks.1 un til ur irte is c l ear . Shoe k and pa in measures as required ~ Mlr.I i tor urinary {}lurtput clo,sel 'i . Pat iefl t, mu~t f~Jitrce flu i-d s to insure urinary' output of ;?5-~O ml .. lhr. In ser-Ious cases, an indwelling catbet.er slK:tuld be in:s ta 11 ed and t hi ro ug_' I V t h er a P 'i p1""101U'1 id el a UIr in am-., out p Ul t -01 f 25-J1O mll./hr. An t.ib io,tic ther a_p,y .sooUild bel in it iated in .a 11 cases as a prollfllylarxis. I f an in feetion is allowed to d:e"U'elop· , it wi 11 cause .scar tissue and rUT tiler cctnlp11 ications , If at all p:1ssible 11 med evae all penetratingl wuoos and ser"iolJs cases ...

b. Bladder' tratDla. Causes. include' crushing InjUry from bl.ous I seatbelt.s I etc II!':I p.ar'ticul air 1., if the injury _ ace Ur'5 when the III adder is Cull;., gm:shot or staib WLI1ds.; or ben}" fragJDents, fran fractured pelvis .. ,

S II Severe pa i rt in lower- abdonen , Slow1 and painful uri' Inat Win due to mlJ8Cle .spasm, after Ln jury ..

01111 'Hern-aJtur ia 11 often onl y a few drops Qlr bloodJ -1" Prosressi Ye' s,JI1lp't.ags of peri toM ti, s depend ing on the e.x:ten t of III addler rupture __

A.. B1.adder tr'aJLITla"

•

P., Flat. in bed , Treat for sboek: install inA.1 well ins eatbeter, Proiitylaetie antihiotic treatment.. Treat related, problems C:fracture Pl WCLl'ld e'tc"

. t 1 '" J ~

d ot_ e , External gen i tall ia tradDa. Usual causes, are heavy Dlow.s!l cuts ,I , .IlrE!e·t injury ,I pel vic: fr acture, or atr atijle inj uryl •

S., Intense to, ex crooiating pain,. s'fIe'll ing , and ralp1id developnent Q,e a large tJematana~,

b .. I. . 0., V'ar It wtth the sever i tyl of thel cond i tion l1ut will censt 51. of

BDatW"ia I spa.smod Lc COrl tr ac-ti,Qn.:s 0 f the lle:sicl e :sphioc ter with pain 1" and

1-57

~-'SR

persistent desire to empt1 tile hladder wi t.h involuntary' in.elffe'Ctual strai,ning e,ffbr-ts and shock ,

A ~ Ex ternal gen i tal. trr3llliTla.,

P _ Indwell mg cat heter j <::0 l.d pa~ ks , scrotal support, pa in medication ~ and, treat rei ated probl ems (shoe k , tlound" elt<!) ~

11- 38 -t, GE1J ITOUR I:NAB Y TRACT INlFLAK~A1]O~.,

.a ... Renal cal cul i I' Caused by' a COf.JrC entration 0 f miner'all sa 1 ts and crystal s tba tare fonned in the Call 'Ix 0 f the kidlne'~. The se k:idn.e'y' stones var y froo SfIilla,ll send 1 ike par t ic Les tal large oval or branchi TIS t st.agborn) stone s that ma Ii' fi 11 the en tire r en ail pel'l/'i s .. Man y f'actor So are'

eontr ibutof"'Y such 8.3 in feet ion ~ obscrue t.ions , d elh:;dration" and be,redi tarYI

tend ency .'

S.. Sey'ere in term i tteln t col icky pa in:! r ad Lat.ing to pel \r' i 51 j

te sti cl.e I'. .andllor inner aspect 0 f the' thigh.. wttil e the stone is in the kidney!p' ~ he pa in i 51 dul I and inlLensi f i.ed t) y mot ion, Wiler1J the stone' enter's

the. oreter , a sudden st.ab 0 f excr uc Ia t.ing pal i fI is reI t.. I r sborre is in the bl adder 1 the pa t Lent may bel .able to iJo.lid on1 y in the hori zon.tal posi t.ioln •

0.. Usuall yl aecompan ied tI y e hills 'I fever t1 v i,ol en t rROFwl"ements ~ sLNeating" al1dl shock, a s the stone- ~lules thratl~b tne urete'T.. Frequenrc yl 'I urgency !Ii 01 igur' i.a (ILL imli~i shed anatm t Dr ur 'ine fOT!1i1ation)l., dysUI!""' i.a (pa mf'ul or difficult ur'illaJt.to1n)! hematuria" and ;p:)ssibl!Y' p~ria (P;.tJSI in the urine') ar-'f! con tr ibultOIr' y find i ngs., If arruri al t carnplete ur in ar 1 5Ulppreggion)

develops, tJ it is i nd ic at.i ve of r'en.al fail ur'e ..

A., Renal ealc~li.

P. Pe Li.eve pairl {morphine 11/4, g:r ~ q 112-3nr) ., Relax ureteral spa sms with PTo-Banthine, 11/100-'/1 50 gr' tJ atropme F or 1/100 gr ..

1'\1 trog] ycerin ~ Fore e fl ui.ds and keep close recOlrrl, of in take arnd out put · Str a in all ur me for scones ; these should paas wi t.hin 2~ - 36 hour S I' At the fi r st sisn of anur ia th,i s becomes a!:l ac ut.e emerg,enc-y and patient .should. be

evacuated to a defini tive tre'.atment f.ac-ili.t~' ..

b . Acute _pye Ionephri tis", An ae ut.e i,n feet ion of the kidney usually

fl ue tol an ascend ing i.nf-eetion (frlD", b1ad{1 er thirougjl ureters to k.idney) but malY start fr'iJm] a systemlie b,acter i a 1 in fec-tion .,

S.. Sudden onset with chi lIs, fever l' sooe muse: ular' rl igidi t Y t' freq,uel1c 'i ~ urgenc Y!p. and d ys,ur ia ..

0.. Pain on perCtiSSliOifl of the ~ack with radiation to eosto'll'ertelbral angles. and alon~: the' courrse of the ur'-eter'sll Urinalysi.s .shows albU1len T' pus cells 11 casts., R _ E .. [ .. '" s, W.I 8 ... C .• 1 S ~ arldi bacter ia.. V. B .. C. in e'xces,s- of 20., anf).

A.

II

Di fferent i al -d iagnosi 5. : Cyst i ti s -

Acute pyelon-e'phr i ti So.

Pi .1 Bed res.t ~ f·arce fluids!" and. soft diet., E1 irminate irr i tants such as al caooll or cocoa. An:tib iot i -c tJJe'r .aPY' using Gantri sin f

tet.r-ac ycl irle T Olr' pelil ie ill inJ streptmtye. in .. Symptm~ t.iC' tre'Cl tmel1t ..

.. _ s. ~dld-en or more ~radllJal onset 0 f burning pa in an :til'"" inat.Lon •

or~ef.I WI. th ~ ttlr~ldl, foul--Sine~lll.ng.1 olr dar k ur ine; freqllenc:y' ~ -j i ff icul t Q1r

pa In f\.ll tlr InatlQII1; ann oecasdonal Ly bl ~AI l~i .nIl I tLn.",:,'" ur ;ine: !"'"Ii,...;: l l.s .a'1I"! d' f'" , ' '

., . . ~ III.liln::: ~..IIL ',. L~ Ii .... ,.L,.' . LlI', i I eyer

arerare1 and 1 f ~~Iper.ature' is QUler 1000 F tJ.1 consider po s.s ib i 1i ty or other causes tt1an cyst 1 tl S .'

..

o~ i 51 involved ..

W B• C • s a' ' roC.'

.. I •• ' + ~

UlslJally no pasi ti ve phys-ic:al find Lng s unless the up-pe'r tr act, Ur in alys:i s shows ptlS.1 bac ter ia, and oeca sion al hematur Ia .'

r ar-'e un1 ess upper- trac tis iflvol lied +

A ~ Cy5ti. ti s , Di fferenti a 1 d i,agllosis : lIrethri tis 'I pyeloneptlri ti S.I

P., Gantr igin (sui fi sox awl e) 1 gm Q.. i lid ~ x 10 days tJ alternate tetr acyc 1 ine 1-2 _ 2?O mg. tablets q , i .d. 01'"" ampi[!'i llifl 1-2 250· mg. tablets

q .. i .. d . Gi lie P)"r::..-d ItR or methe~aIiine IJr in ar y analgesic 11 NOTE:- This ma:_y

stain ur me red to deep ~'JIralJlge II FOlllow up in 2 weeks In

rl.. Urethritis~ Caused by a wide r"arJge of agent.s th~t Inc.l.ude gOIru:tCOCCUS, Tr l.chomonas IE. col, i , and staphy 1 ococcus III

S I' BJrning, on ur inat.ion wi th PYlJli'ia II Di scharge' f'rom urethra wi th a con si sten~ y fr'oml noJucoi-d to purulent. l'

o ~I Di scharge et ic i ted by mi l king the perti s , Gr am '" s st.a i,n 0 f

dischalrge w~ll usually .show cau.saltive agerrt ,

Urethr i t i s .. Di fferential dl iag.nosi s : Gylst i ti s , prost.a t.i ti s , P ., Ens.ur'e cerr-ec t:. d iagno.si 5- with Grlanl' s sta i nor c ul. t.ure -In Treat ceusa ti veo organ i sm wi, ttl a ppropr Late 8f:")ltl b i·otic! Il

A ..

, ,e ~ E:pid idlyrni ti s II Frequrent hi.stor y 0 f in feet ion el sewhere in the gener al, area such as ur-etnr i tis t1 et,c . Strenuous, are t.L vi ty may prec i.oi, tate

spread c f the bac teriaJ II r

o. I

.n flaonatiofl of S~ ro tal skin that may flake Or" c rae k.1

~!ro.t:um dusky r-ed and w'arrrt to the toueh . Sligbt mass in the epidid.ym,is,.

Ep1i d id "JirrI.',:11 i,t·.l·, ~ .1 Di~i ff'ereli"'li "'1"1 a 1 d·' ., Or ~ .. I r

;.dLl ~ .' " IJ ,IJ! ~ .! :. ] aRln051 s: .• ·'C~Jll tl S II

P.. Bed re st with serot<Jl el e'.ta t ian .1 An algesic5 for fJa 1 1'1 ~

anti.b lot.i e tht?'r ap,y .' 00 :NOT massage th~ p.r"'Clstate.. If .5'~111·' nlll",' 'I • t

.1 ~ ... ~ ~I perSi~s I SI1

surgery WIll be IJ""'eq]uired., --

A.

f. Qrcl:1it.is .. acute infect.i .. ollS",-

0,

I '.

S".,ell.irllg, 0 f the .a ffee t€d testicl e (rna Y De b i 1~3 ter'3Jl) ..

A ..

Ore-hi ti s.. Di fferel1tial d iag,nasi s-: Epid idl V11 i ti s ..

...

P.

Bed rlest :,. S iJ5PI, erv~.: t. n·lO C",..!' ,'1'1,' rll''''.I::tu.rn 1

-' ..J ~............ OJ n SUiSpeTI sor y or to\iel ing

1-610

"br idge''Ul and! alp'pily ice I).ags -to Give codeme or mOlrlfl,ine as necessary fOlr pain II] Inlflarrma tory re!action can be r'edoc:ed wi t,h hydrccorti sone sod i.um

succ in ate I 1:00 Ir@.. IV f"oillawed bl1 201 mg;. olr'ally q .. 6h.. x 21--3 d,ay.s ~ f.rc:hi ti s often mBkes the paltient very uncc:mfor'talblle but very r'ar'ely results in

ster il i ty .,

Sill Cll.s.tructi ve symptoms s.imi ] ar' to those- of benign prostatic. hyperplalsi.a .. are c~n.. U,)JW' bae k pa.i n occur s with meta st.ase 5, 001 the bones of the pel VI S· and spme ..

01.. Rectal ex ami r-eveals a stone-h.ard prostate tha tis -often lJ(XIular and! f'Lxed , (bstroo tioo s may produce reeal daJ;Jage and! the s)'lIptms

a1d sig;ns, olf renal insuffi c ienc Y' .. Ur i.ne may show e!v idenc-e of in fee t iOJ1 ..

g.. Prosta t.i ti s II" Caused by bacter ial in fectiorn from, systemlic: (lIT urethrall in fect.Ions., PIiOS·ta ti ti S 1M Y be Be'ute- or" chronic; ovenn~niptll.at ion 'a lot 0 r sex) of chronic prosta ti ti 5 g,i ves ri.se t-o aeute stage s_ymptoms, ~

A. Care incma 0 f ttle! _Plr"Ols,tate.. [Ii ffer'en lial d.i.agnosi.s : Ben tgn

prostatic! h:.rpe~ pl asia tJ urethral atr ictures -r renal cal c uli t and bl adder tLmOF Ii-

S .. , Aeute s,ymptans -: Per ineal pa in , f'eyer'! dyslE ia II fre(lue!lc:y 11 and urethral dl Lscharge II O1ron.ic symptoms: Lumbosacral backache' II per ine'al pain ,I mild dysuri a and fre·qtJency II] and scant" ur'et,hral discharge.1

P., Evae to .a -d ef'i.n i t.ive car e c enter ..

O, Ac~ute stage = Palpat.ion of the prostate shows i t i:5 enlarg,ed t1

bogg:; tJ and ver Y tender II Even gen tle pal p.at ion 0 f' the prostaJte g,! af]di

resut t.s in a cOpiO'-U5 purul ent u!'"'ethral di scbarge ., Chronic stage pal patiorJ] of the prostate refllesl s an, irr-egular 1 y enl.arged , firm 11 and sl ightl. y tender prcstate , esc wi 11 often show- I eukoo ytoslis I' Expressed! prostatic fl utd :shows pUIS cells and bact.er i a an mlicrosoopl)' ..

j., !elite glomer ulone phri ti.s... GICfner ulonephr'i ti sis a d i sea se af'fec:ting; both. kidneys... It is most common in chi ldlr-en 3--1 CI If'e.ars old .. fbst cQrTITIDn ea use i. 3- a pr eced ins in fee t ion 0 f the pharynx or a f the skin with group AS-hemal ytic streptoc:occ i ..

A. Prustolti t.i.s ., Di fferen tial d i.a.goosi s: lhrethr i ti s .. Lower' urinary tract infections"

51" Malaise f he adlac he, aoolr ex La f low'-gr aue fetter, P'lJ ffinelS5. aroun~ the ey'e.s and: face F fl ank pa in ~ and 01 igur-ia (d iDJI in i.shed amaoo t of urine out,p;u t in roe} a tion to flu i.d intake). Ham at uri a i 5 usual.I y noted as nbJood yn or i r the ur Irie is ac id .a.s 1I1b,ri]I!.-c.Ilu or "coff'ee-co) ored . I~

Re~'pliratory' dif'fieulty with soor tness of' breath ma:y occur a s a r'esul t of sal t and water reten tion and c i r cu l atory congest. ion .. Tend erness in the oolstovertebrall angl e is coomon ..

Pi.. Be-d rest, t force n uidls" si t,z_ b alttls t .. i .d , rOT 15 min II]

~.alge S ics t' and stool so ftener -~ .. for ac ute pro.st.a t.i ti s in i ti a1 trea tment relay const st of suI fameltllo;(arole ~ 00 mg .. 1 pl us tr-imethopr-im g~) mg;.

( co- tr iroat.Y.:azole)l.. 6-3 tablets dlalily, orl tetr ac:ycl ine 50D mg ~ q .. i . dl" x 2 WJeeks or ampic ill in 50l[) mg.. q .. ~h.. x 2 we-e'KS,; two-week treatment usua lly resul t So in suu s tdence 0 f t.he acute iJ1 fl armlaJtio[l], btl t chron ic prolstati tis rmla~ cont.mue tlecau~e most drugs fail to reech t.be prost.at.tc ae im - Chronic prostat i ti s should he tr'ea:ted wi th prolonged antibiotic therapy aecenpen ied by LJ igorlaus prosta tic massage once weekly' tOI pr'-omrot-e dr.a inage,

01. Mi Ld gener-al i zed edimlaJ 1 mild. h yper tenston , and re-tin a]

tJemorrtlage's may be notedl", 1here' ma y be moder ate! t.ach:;ei31Fd i.a and! moderate·

to marked el.ev at ion of B .. P .. The d i~,nD5i s i 31 con fj_ rmed b'l tiT in e

e.xaminSltion: tba t rna y bel gro 55l:l blood y 0 r co ffee-cclo,red 0 r ma 'i 0(11 Y st ... ')W mieroLSCopli-c tJermatur ia ., In . .add.i t.ion.." the ur ine con rams prote in {1- 3i-+-)I, r€:d cell cast.s , grarrll.ll ar and hyal in e C~ st.s 11 wbi le cells, a.nd ren al epi t.bel. Lal cells.

b .. Benign pro stat.Ic h)"pelr .pla si.a , Caused by hyper'p-l.a s i.a {ab,oormal

mul ti pl ic at ion or incr'e'3se in the rtllDber 0 f no mall cell s in i:1l ti ssue·) of t.he prosta t ic latelr a 1 and! SllJb~eTY ieal lobe s, resul ting in enl alrgemrent 0 f the prosta te .and urethr.al obst.rtlcti-ot\ of.

A.. Actlt,e glan.er'Ullon~phrj t i s , Di fferen ti all. d i agnos.i .s : ()t,ner'

di.sea.5e'S in which glcmerul air in fl anmation and tub,ul e dlanage. are pre'sent ...

0., Prostatel is u15.lL.Iall_jt enl alrged on pal pa t ion.. The bla.rldier maiY be seen andl p.a 1 p9Jtedl alS, ur'ine retention incre31ses r Ir. fections e:anmonly OCCtir" as retefi t i-on i~fC rease-s .. Jrlemetur i a rna y occur ..

P.. There is no spe-c:ifi~ tre'abnent'l blut e'radii.catiofi lof

B-bemol yt i.e strep' i s desirable. In IJJrlCcmPI! icated eases F treatroen t is S)'DJptomatic afId desig,ned to prev'el1 t over'nydr'at i()TI and hypertension... Bed rest, unt il cl in ieal signs abate. 8100d presS-tlr'e shQU 1 d. be IlOnIlla!l for 1-2 ~ek~ ~efore reslJDJing, ruJirm.al .acti v: i ty ... When protein excreti{)n Ihas

dl smlnl shed to n.ear nOmJlal. t3lnd when whi te' and elpi the 1 i all cell s el-cretian has diecreased and stab iIi zed 1 ac ti vi ty nta_y he reSLJned on a ~J~lade=d hasi s ., Excretion of p~ote in. and f.(Jt"-med elements in the ur ine will increase with re:sunptioin of act.i vi t)" II lH.Jt such i.n-c reases soolJlldi not be g reat ~ ~ltlid s ~uld De restricted i,n keeping with the abilit.y of the- kidney to ex.crete urIne... If -edema becomes .sever'e ,I a t.r ial using an oral diuretic should be tri.ed ~

S.. Hesi tanre y affld str .a in ing t~] uri in ate; r'ed uced for'ce and cal iber

~) r the ur ir1I.ar-y .strean, and~ nCJCturia. SyrDlptcmls rnalY be o¥er lc~,)kedl unti 1 t·he problem is well del\lelopedl when the progr'es.sioITI of tne obst-ructi<)n is .slow.

A_, Eenign pro.stat ie tlyper'pla.sia... [Ii fferen tial d iagnosi s ::

I:Jrethr -a 1 str ict lUre's t' r'er:l.al c.alcul i tJ bl-ad-d-er tLJ1lOr' lor car-eincrmal ·of the prrostate .,

k .. ,

Ph li MrLS .,

•• u,v' .. 1 S ~

P., 1R'e11 iev'e ac!ute ~r inarr)! reten li.on by cathe-teri zatiol11 ~ Mainta in -catbe te r dra in age if -d ~gre!e 0 f obs,tr~ t iOfi l. S See'll! ere., Surgery is usualll y nle:ceSS.3lry.. Tre€lt in fee t i~)n s that develop.

( 11 } Cause and Sympt.onJIS: Foreskin oo,t pl iable enough to r'etr ac t. ovler the glan So penis... Thi. s. C8t13eS pain on erec ti-on and. rna y be ccmlpl icated Wi th paraphimo.si s.

1 .. Care i nCRa 0 f the prostat€., R~r-'e before age 60.. It rmetasltasi zes e'ar-'ly to the bones of tile pellJis aoo locally may pr'oooce urethf"'.al

ob str uct ion wi th sub.seq_llJen t rena 1 danag;e.,

(2) Treatment: C'IlJt a. dorsal 51 i t in foreskin and sehedtll e fOlr

Section VI J - NerVOU5 System

1 .. Pair aphimo5i s ..

1- 3:9., !tti s sect ion is nc't, i rI t€nded to COIJ er al l :netu""i,)lag, ic al, pralll ems because most neuro.l or; i,cal prob.Lems are beyond your S~ ope fo r -d ef'i ru t.ive tre',a tlruent ... 1 t !iF.LO-tJ Id ,I balw€v'er t' pr'~~J i-d-e Y-DUJ wi t h enough in forma t.Ion to make )"OU alW~lre a f the neUirolagical pr'ublErJls you .may' ra.-ce' afIldl en alJl e :i0U to make .a tenta t i LJ e -d i.agno s.i s .'

(1) Cause and symptoms:: Foreskin is const.r ic ted around the gl ans peni s and cannot be' r educed .

{2) Treatmerl t: {ut. a dar sal, 31 it in the- fOlr'€-ski,n and schedul e fa r c:i rClJlj~ i.sfon II

, ~ QI., C(t;1POS1TION OF THE NrRVOtlS SYS rEM _.,

a.. The nerVQ-lIS .s :.'steml is; ernlpDl.sed of {~]}l Cen trail .Nervous System

(C. N I' S}I - Cerebrun, Cerebel1 Llnl, Hr a i n Steml", Spi t1t311 C .. ord ; (?) Per'i pher-al, _N'erv'olJs System (: P., N .. S .. " - Per i ptler a 1 nerve's.

{ 1 ) Fir-'st : 01 fae tory... Sen se of smell. Inj ur y causes loss of sense 0 f ::;me 11 ..

(2) SeefJLfld = Qptic ., Sense of s i ght . In.j ury cause s opt i c d i.sturbaa"1ees to 1'05:51 f) f SIght in one 0 r both eyes.

(31 Third: It:tll-orrtOwlr ~ ~pplies all the muscles of t ne orbi t e'xcept the super i~)r ObI t que ;:md ex t.errll.al rec t us; al so suppl i es, t~ sphincter muscle of the ir'i5, and the ciliary musclel.. I~jury causes dilalted and fix-ed pupil S t :51 Lght pr'onin enc€ of the ey'eball, and drcoping aft he upper eye} id ..

[ lJ ) Four tn :: Tr-ochlear III Suppl i.es the superior ob 1 ique r:JH .. l5.c.-l~' (9Jlallest of the cr.an i.al nerves). Injur y makes patient unable to tuwn eyes down ward] amldl outward!.. If ~ tt em pted r' affected eye! is twi st.e.d] i nwar'{j caus i ng douol.e v l510fl: .,

(5) Fi ftti : 1'rig€llil in al .. Innerv ates fae ial sensa t ion and ~JDtor to rntISC leis 0 f mast.rcat.Ion (larges t cr an 1-31 nerve l , Thi s nerve al.s ... c

suppl. Ies the eye" nose Pl teeth ,I guns , pal.ate t etc. r1 Injury' can cause E1U1iJ~rDIJIS prohl ems frOOJI dir yness 0 f the no se and ey.'eb.all to impai redi act ian or the lower jaw In

(6) Si~:th: Abducens. Supplies the external rectt.ls m-uscle .. ,

It)re frequentl Y' involved in ba se of the skull. fra-ctt.lres thai'] an y ~Dther nerve Il In jur y r!'aJU5e'S an. int.prll1al or conv ergen t squi n t often wi th a c er ta in MOunt of C'Dntract.i.oln of the pupi.I ..

( 1 )I Seven tl1 : Fac f al nerve- .. M.::rtolr" nerve (I f a 11 the muscles 'o.f f'acial express ion: the platysma and buec inator-: external ear muscl.es; plisterior' belly of t.he digastric' and 5tylotly{)idi; nerve of taste for the an terior two-tEl i rds of the tongue; the' va sod i Late r nerve 0 f the'

subnalXillary and sublingual glands; and t.;'mpani~ br-aacb stJllpli.es ttlel stapedius muscle.. M.1st cCITIeOn e,ffec. t 0 f inj ur 'i is Bell It S f'ac i.al pal s,y •

El' orntl h' Ii

"~J .' ..

Audi tory... Sen.se a f near irl,R ...

Injur y C: 8 use s

(9}l Ninth: C:lossaphalr YH&,e.al ., Nerve 0 f sensa t ion too pbar yt:1IX II faUCES l' and tong;i 1.. A] so' .sensat.ion of ta see to poster-ior t,hi rd 0'[ tongue ..

( 1101) Ten th : Vagu~ .. Suppl tes the organs of vote e and 1-63

~ --6lf

I""espir ation wi tb mota f' a.nd sen sory [1 bers alnd ttle phar ynx ,I e ::;~)ptia~lulS ~ stC"n]ach J .3lndi hear t with moto r fibers.,

area he as eval uating tJ Poss,i bl e in tell ere too I d.efects, can be 181 i.ei ted b'_y asking abOut an yl -di f'ficult y in tt1 inking or r-ememlberi ng '" cOOJpar ing recent. jool or scbool per'fo~an~e wi ttl past achievements may be hel pftll ,I 3lsking whe,ther he has any dllfflCullty understandIng wha.t is sard to him or

.. expressing Iilimlse!l r in onll ar written 1 anguege. _ other j)()s:s.i.bl e ccmpiaints r'elat,ive to the head are log,icall y ex plar~d next . The se inc} ude i3J diSCU5SiQrI of thepa tiefi t ,I S bead ac he s . He should be asked a~out any spells 11 attacks 0 f ~i zzi~e;ss t1 or- .al teration a f conse iousnes5 he rna ~ have ha~ · Vi sual con.pI amt.s 1 ncluding dipilopia ,I scoto.mata ~ and Ioss 0 f' visual .acurity should bel S()1l te i ted ..

{ 111 ) El event.h : Spi~a 1 accessor y: ~ Consi at.s of .accessor'y P:Jir-t ion which is motor to larynx arJ pharynx and spinal portion which is motor' to sterrocl e'idcm.asto i d and tr apezi, tJ5 muse Les ,

1-lJ11 • REC((;N ITIOtJ Of N"E U~OLOGICAL PROBLEMS_

l.-ij 3.. NEUROLOGICAL EXJ\MIN'I~ rION" ..

a .. Not alIl prob 1 ems h ave rteur 0 1 £lg i c al or i ~ i n _ Your first ta.s k Ls to recCJgr:l i ze the po te!n. t.iall neuro logic or'ig in 0 f t h.e pat i en t '15 C:OOlPl..a in t _ Th€re ar e eignt d i ffet:""'el'l t c onpla in t 51 air pro,':ll ems that po in. t &D neural} og Ic

dl i sease .. A.l thfJiUgh e'ac~ a f these c.nmp 1 a.int.s rnay' be prod uced by dl Lseases

tba t do no t, i TIvul vie th.e- nervous 5j'Stef1OJ II -d i fferentia t in~ bet.ween

neu r-DI log ieal and noe-neurol.og ieal causes is, u51u811:l e'asiy <: e t,g II pi a pa t tent .. s leg 2ma y not move correct1 Y' because i tis b,roken; he can. ~l t see proper l"i because he needs glasses; Olrl he has a head ache and fe'ye'r after' taking a typhodd ironun i zat icn) .. The eight oC{)fIllpla in t slpr-obl erl S are:

a", The! fDillowing cheekl ist. .~ wi 11 tJe Ip yo~ make a ne'ur'olog;i-c al, escrniflation:' See par a b, tJ bellow 11 ft)r deta 11 s ...

(1 ) ~nt.al st.atus ..

'a)1 Affect and mocd { b)1 Or ierJJ taltion

(c.) Memory

(d) Lallctllati.cln and abstr.ac tion

(e) Aphasial

{2} Sanet.tting; doesn I t fe€ 1 r ig,ht. (in~l udl ing dli sorder 3 of ot her sensor y modal i.tie s) I

(2} Patien t standing"

(5) I have spells.

11.. Arml.s wi f:'] g

"2 .. W'idth, of gra it

J.. Limlpl or' Qlther abt10nnal i ty

(6 ) 1 ~ dl Zl·Y ..

( b ) Toe walkins

(-c) Heel walking {(j ) Tandem wallki ng

(@ } Rcmber'g'" SI te st

C 3)1 Pati.-ent seated O~ ex:: am table.

(7) ~ head hur t s ..

(B J Patient is uncansc rous t un rousab.l.e tJ or' exces,si Y'e 1 y drowsy ..

1-112. NEUROLOGIC HISTORY", ~st pati-ents wdt.h neurrol-agic di.sease will tell tbe'ir' physie:ian what is wrOfig wi th them if he can pr'ope:rly inter'pret what thely are tr ying to say and expaoo s the hi stor 'J wi til skill ful Q]uestion ing ... The fiJi story should: g i ve a profile of the d i.sorder . Th is prOY ides a

val u~bl e cl ue tOI the ba sic di sease pr-oc~e5S. A few general prine:i pl es are -war'ttl mentioning ~

( .a ) Cr an ial nerve test.s:

a , Se-i -zurre'.s (cony ul stons 1 developl more r ai_pidl y than al'l_Y 0 ther form of neuroreg Le disorder __ In man y eases the y develolp in 1 e3S than one second

arID may' disapPf!".ar as, qui,ckly as thsy cane.. Neuralgias are the! only other STOUp o,f di sorder s thi s abr upt. Va seul ar disorder.s incl tid i ng stroke' and m,igraine LJ5ually' take seconds to mj,ntlte's to devel.op, Instead of cle,,ar'ing rapidll y the Y me 1. t awa '/' D~er bour s a r' da 'is.. De!mlyel ini::!lt ion se Idiom dlevelop~ as r apidlly as stroke burt. nola)", progress aver bour 3- to -day's ~ TtJiTilor S uLSuallly develop in weeks to :month sand degenerat i ve di sam er s in mJnths to year.s .. lO:(lC tJ metabolic! and! infectiolU5 disolrdler'S ar'e variablel and mor-e' likely tOI learve thei rl mar k on at-heir organ sy'stemLS ..

1. Visual acuity

'2" .. Vi sua 1 fleldls tOI eonrron tation 3. ~tll ar fundus

! II Extrat':)cUllar movenen t.s 5... Pupi Ll.ar y reactions

~ · Smil ing, Yolll.I'ltar'y and emotiolnal 7 .. Tongue protrusion

g.... iJol un tary pal altel mavenen t 91• Hearing

, .. Strength

b. A blrie f neur~)lo~ic rev iew olr systerES; should bel made.. It helps the med ic be sur'e tihalt the nlF?Ulralug ic di so:rde'T i:s Ir'estr ictE!d tel the problleml

a. Si}[)Julder- abd IJCt ian

b , Elbow fle'xio:fl - extension

c " ThLnlb, adduction

l-r))

1-66

d , Th~.lnbl oppoas t.Lon

D wrlist dor st flex Lon

~ III

t .. ~arndlgT i. p

2. Re fl exes

.a.1 Biceps

b ~1·cepI5

1.111 ,u:

C ... Rad i i:tJl - per 10 steal

3.. Coord tnat ion

a .1 finger to no se

b _ B3lpid al lerna ting mo~em.ents

(: .. M"Jscle tone

(~) Patient lyir.g dOMl ...

(3) legl strength and coordiinatiol[\

11 .. Str"'ength

a.. Hip flexion

b. EU'lee e',x:tefl sion

C .' fur s.i flex iOfl 1)[ t.be foot

a.. AbdOOli~al b. Knee jerk

:::1. JUl k 1 e jer-k

d .. ~b i ~s,t<i

{ ':J )I ..3eTI sor y e;( ~ i TI.a t ion

11l Pal ~ n

a , Fae e

t ~ EJ: t~ em i t.re s

~ .1 Vib:rlation - ex trE!mi ties

.3 .' L ig h.t touc h.

~.li -=.:Ii ..

h.

-::Orncal r~":""~

_ o-'L1....

Ex tr'~i ties

c.

~'II [1. .. S.ll t-= 0 ..... '

"-011 f"V '. '~' L;::

a , Fin~er5

b _ Fur ther det.a 1.1 SI on neoro 1 og i.c al ex amin at.i.on ·

Affect is OOIW th~ patient. tra~sm~t~hiS fe'elin.gs, and! mood i.s wllat he iSI trying to tra['ll5mo. t. ~ In .most lnd~v~du~l~ a, depre.ss-:-d aff:ect ,r'enectsl a depressed mood and I ~l{:el .ver~C3I.. ~]aJttel~lngl ?'r dul~~ng, of affect iSI seen in most, depress~ II sehl zophr enfc, or parklnSOnl..an. patlents ..

..

(co) :Me.mory c.an LlSually' be judged from the q:ua1i.ty· or the mstory ,I tUl.lt .sOOuld: be ccmmente-d on ". Formal. rnemor"lji testing, i.s unn.eces3iarlY ~lless ther'e is some r'easen to suspect dl i f'ficul t,~ II

( d ) Calcul.a l. Ion and .abstrlac t.i-l)TI shoul-d be tested in patients Oller SO years of' age, Seri,al 11ls and a well-kn10L-6:l parable, {such as Ir..tly sb:lu.1dn tJ t peopl.e who 1 i ve in glals5 houses t.hro w stonels?'I) are usually adequate ,

(2) Galit .and] station.1 Four types of gait ar'e routinlely tested: ordinar y gait, ,I he.el welking, toe w~l kinBI 11 and tandem gai t ~ Ord:in ary gait is absen'eell for gross ahnonnlal i ties of c a.rr Iage anc wid ttl of base III Arm swing :may be {jelficien t if t.her'e i 5 wealbo'leSg (especr all y Ilemlipare s.i 3} 0['" .a basal garlglion d i sease such as Parkinson. "s d Lsease , A.s :-mmetr- ic heel elevation. dur'ing toe walking indiicates weakness in plantar fle.xor's of foot PfIlile asynmetrie toe and foot eleyatiolrl in heel walHing suggests -weakness of the dorsiflexion of foo t and toes . Jlandem wal king br i ngs out gai t

atax la (broa:l.,-basedl ga it) .5e-en in m i{ll me cerebellar d isolrdler·s.. 1i000berg'" So test is. an ev'alua t ion of posf tiOIJl .sel'l se . The pat.i en tis told to stand with his fee!t as, close together' as Pl,ssib1le IF. If tJ wj th his e'yes open fi he can

onl y stand wi ttl a wide base Ii the prlOlbleml is most Ii kel y: cer'etlell ar .. I f he stands firm. with eyes olpen tJ but ten.d 5 to fall upon closing his e Y@S tJ the problem is pllsi tion. sensei C pester ior col unn or peri ptJer'al nerve) .an~ Jicmberg IS slgn iSI present , While performing the Romberg t-est, ~ it is conrveni.ent to ex an ine for arm -dr i rt , a useful te st 0 f milld sOOulder

keaknll!S.s or Pnllpr Ioeept Lve 1 ass .. , Be,folie the pa ti.efl t c loses, hi s eye 5 ~ have him e.xtend both arms , palms UPI and ell bows st.i ff in fron t of himl.. 1 f while hi s -elyes are closed he dl Lsplays a tendeJ1c_y fori either' hand to pronatel 0 r

ei ther arm tOI 'Idri ftUi do"-'fl warfl, y()u may have -di scover'ed a skgn i fic ant defec·t. About 20 seconds 0 f' he ldl ing ag.a i n st g r .avj ty i 51 s:Ulf'fi<J ien t ..

(3) (r'an iall nerves , )Jo w the pa t ien t c an be sea ted and cran 181 nerv'€,ls tested... Snell and taste need not be routinel Y' e'iJ aluatedi ~ Vi ston ~quir:ls . morlel alt tention., A.-c ui t y sb)uld bel l: heek-ed first..1 Wi th gl.asse s on 11 the .ablll..ty to re~d newspr' in t at. about; two feet eonst i tutes 2>Ol30 "U''i s.i.Qln;

Erldi at 1.t1 inchels 20/50 "is ion .1 Erac:tI e~el should be tested separa t€l y ..

Visual fields .shotJld ill so bel telsted in elac:l:l e 'Ie 3ep.a~I.ately II A1 wa ys ehec k al~, four .quadrants., In p8ltient.s over 50 yearrls, check simul t.aneous stlmullartion by quadrants, pre-feFablYI b" super ior ternp<)r'al ag.ainst. the

inf-:r 1011" nasal and then in.fer Ior tecJlporal aga in st t·he super lor na sal , The o,Pt,~c nerve head is rout in el. y exam Ined as part o f the 0 pbt.halrncscced.c -exam ... A . Slmple too ing for k te st. for hear i ng should be inc 100 ed .1 Ex tr aocul.ar' rno"Y~tSI arld] pupillary reactions shou ld .31]: ~IVS be telsted. E1?1otional and ~~~:Qnal fac;e. movellent ~ sho~ld. be obser v ed _ rL,~glle prot.r-u ~ ion ~ val un tar 'i

.. . elevat IOn,. and voi.ce t lrnbre sb·oulj be- e:( am ined 11 bUIt. tne se are.

~~l y il1cl udled ~s p-:rr tor the rou~ine oropher ynge aI, e); am... Corne al

rJr.d ~exes ~ H)'er~n·. s. sl1.gn. and' ~out l:\g r~5~F.!5e s :5hD:_~d. be te s.ted _ ..

,lnar y sen satlon: In the fac~ 15 be 5 t cJhec Ked I ater- ~'Il th the rest ·0 f the gefler'all. sensory ex am. ..

1-67

1-,6-8

(4}1 H1Dtar strellgth and coord 1.11 at ion in tile upper ex tralli~i-es ~ Accep~l ~ tee hn~ que 5 of. musc1 e test i~. ~ si.st . a f the . examirl~ trYlJ1~: mmre a Jomt agaInst res1st~ce or evallJ8tlOl'l ~fall!JaKlJTIl.IRe~fort by it patient to OIJer~cme the exanner. I ~er1eral1ypr~fer to hallie t,he paitien

ev ~ror tl·. a'l rn~a"l.- ~i. elffort 30i ainst my' reSll st.ance for In tel r-11, al and! external - .'

~Iii..~ . . .1Ii1 .~LrllU .. ~11 . !"'tl . . '. - " 1 bornd fleXIon

rota tiQln at, the sboulder 1;' n.ex ion and ex tens ion 0 (the. er •. ·W ,': . a .. " f '. .... '.

. . . f' t.h . 1.-..· I l. 1 1::"tI a' 11 y' tl!'""y' to' ove ·rc(Vft.D. the pat.i.en t s

and elxten.Sl10in 0' 1 I. ne fiJ lee.. U..J '.' ". . IJ. . '. "Il.I!' ~ . j ·i,JIllfi.... ' ..... . I _ , •.

~ ~I O, .. ·lr 1:" ....... , o ·lu.·ll, d. lar" ~~~III'!""Iotion .,' wr i st, nexion and ex t€., nsaon ", ,h,i.p, f.l e:( l·on. :Ii

fi xat ion IJ I .wl:J.V ~V..Jll.oVo-- I" d t .....

and foot dorsi fl e!)[ ion _ ~f1 a pa tlefJ t i 5 'making a max 1~ ef!olrt .an, 1 .IIlLf:1

eJ{amliner i 5- able to 011' el"cc:me the fore e -0 f his :nuscl e eon trae han ~ . &1" adual l'IOVement of the joirlt will be fel t. There should be nlO sud!derl "gIve': or

relaxatiol1 ~ .sugges-ting. a lack of full cooperatioo. There ~e SE'ver~ _ mmer Lcal, and diescripti'lie scales f-or recording weakness. , L1ke,dESlCrlb-lnB, f LIDoorllsciousn-e3s as CCIIJ,Ioi3. sem i<:ama ~ and le-tharg,),. the y suffer. f~{)II'II ~ lac ~o co '11"111:!'a.~ s~ Io::! am anDI nlh,~IS i.c ian s a s to what th.e n1JTi.ber 5 mesn , At thl:S sta~e, In ~h;-:; ";in: ti-D~ ! t"~ulder abdue t.ion , el bo-w flel- ion and ex tension, WI st

dor sl flexion. and thlrl'llb Dpposi t ion and! adduction shouldtle tested .. ... .. . ..

.... ,.... d" 1 . -0: te~l r'.c.fleve's mayl be te·sted

b i Ia t€railly tJ Bice pS:I tr ice ps 11 ane ra:1 ~a ,---~rl.0 5 . '''I Igj I. . ~ rool ':~ ...... I J ..... ~: . ", , .. ,.... '

at ti'lis time or deferred mtil the pabent 1S suprne, .i..O~~<hnatloo a~ I muscle tome should be cheeked. 'Three manreLNer~ ru:-e ~S:eJ1hal. Th~ fIrst

is the f;OOl il iar- finger to nose test . While thl S i, s b-e lng dane. wa teh . fo~ .

any tremor or involuntary ~ovsneJ1t. Rapid al ~~atirJg mo~emen"ts .!XmSl~t1ng either of open mg and e lOSing tile hand s ur- touc hlng the ~lP5 ~ f each . f~l!lger

., th'. t.he ti P .. I of the thLDb is te st ed ne:ct 11 finally. passa ve e 1 r. ClDd.UC t~.oln

Wi. . '. t .' .. t· . . _.-I 1· O-c!~3 thel ctber

of each wr'ist should be tried wtille the pa len:. open.s ano c , r- ~ .••. I., .• , 'I' .' ." I

hand as fast as be can. This will b,ring aut any Latent muscle rlR,ldlt:;.

(5) Completion of the motor and reflex e.x:~... The' patient sho·uld 001.1 be pl aced in. th~ supine posit ioo . Up to thi 5 perot we ~av-e. bee~ .. .', del iber atel y sloppy in te stiflg strengtb. we . hall' e been test H1~ 1 ~ ,W.l ~hout prO"'l 1d ing, fixation 0 f the 1 i.mll • As a screen.1 ng , p~ed ure, Uns 1S fme ~ . If an)' weakness i'las been suspected; ~ulder rc:'tatI~n and e~~mo ... -emen.ts should be retested wi ttl tbe shoulder -fued agaU1st- the e::HIll ~ .. rl1ng t.-able • .

WI'"" i.st and h.and movenuents can gimlil ar-ly tie i salatedl .. Ext-en SlOln, ·of. ~be . bl Ii' l'

ex tension 0 f tile knee. 0300 dar 3i nex iO:1 0 f the foo-t should. Ine ro~tmel 'i . ell amined.... If ther ~ is al ~e;5t ion of knee! \feaknesS,1 have the pa t.lefl t. _ aSlsume t he prone posi tion, fh: the thigh agairlst the table-. aDd retest flex lon and

e'~te!lsi on .1

Bi~-eps, tr-ic€-ps. and r'adial-periosteal reflexes in. tru:arm should be te sted if t.he 'J have not been prev iousl 'j • Kriee- jerks. ankl f!. Jerks ~ and ahdlr.mlinal refl e.x:es Sh()IUlld be te sted" and Bat) inski 1 s sign .soL.€l1-t.. All reflexes requir-e three- elements! a .sensory l~b • .scme form o~c:~tral

ion tegratiQn. and a motor response. He nexes Wlll foe ill teredl ~ fall 'J of . these three elements are disturbed. Any peripheral sen~ry dIsturbance or disturbance Qlf thel lO'deTI motor neluron or muse-lei c.al1 abolIsh. refle-x~SIIl '!he 001 y thing, that "",ill exaggerate r-enexE!s is a dise>rder of the .cor~lcospmal system (the upper rootor neur'on syndrom~). F"lnally. leg, {!oordinlatiQrJ. .show.d

be observed lrtth the heel-tD-shin test. II

{6) Sernsory exam.. It is cOI1l\fenient tlOl per'folrmth~ entire ~ sensory elEam at one time with the patient lying supin~. C\lrI~g ~ Qrd~ary screening e-XaTil .1 pain .sen satio~1 w1 th al sharp 'pin an-d f~ne touch Wi tn .aWl S.P . of cotton: or Kleenex sh£)uId be' checked Ort both -cheekS pl oolth harlelis pl ~ and ,~Ith feet .. , Pols1 tion sense should be tested at 1 east in the toles, and 11 lbrlat.1,Qln

sense in both feet and! h:anrls.. A., tunin8 fork sholild be used, to test

w'ibrator-y sensation on bony prom iflenrc-els.

11_q.q ~. EPILEPSY.. An.y rec urrleflt se i zure pa ttelrn .. Vlolen t , involl ~taryl

oontr'action S 0 f thel mu~cles:t, cccurr ing, .singl'j or in ser Ies , 01 ftenl accampanied by sudden Leas olf conse iousness ..

a • Grand mal .at-lac: ks Ii

..

( 1) Focal or jacksonian se i,:zures . In i ti.ated by s peei fi.-c focal phenanEl'la (motor or sensor-'y).. Seizures are one-stdeo or localized. Head and. e'yes may turn to one side < t~Clt OpPJ si te the 1 eston) .. Jer-ki,ng G,r the

1 inDs: ma y be one-sidled.. Thi So is an acquired type or epilepsy .. , -QJlnv:ulsi ve rnavST1eJ1t.s start in small muscle groups {e .. g,. ~ the hand) and slowly .spr'ead to other areas II i t i. s termed the j ackson i,an umalrch .. ~I Loss 0 f conse tousness resul t.s ~en it becones a general ized1 con", L11.sion ., Ind icate.s spec i f'Lc

par tion 0 f the cerebrum where lesion i;s located.. :M81_Y have .an "aura =" Itl a ften referred to as til wlI'3rlning t1 but in real it 'f it i:s a part 0 f the se Lzure ., Thre'

focal po.in t ind i.ca te~.s area 0 f tile brain where at tack or iginaJte-.s a, ~UiIC!i be

considered the focal tr igger' for the se i zure II

{2)1 Typic.al g,r and mal, sea zur'es are e~har ac-tEri zed by a cryl; 10ss1 of eonsc iousness ; fall ing ; ton ic then clon Le muscle contractions 01 f the extremities, trun k amldi head; ur inar y and fee al, .incon tin.e~ce; frat hing in. the mouth.; biting of the tongue , AbotJt. 50 percent have an aur'a (.aud i lory :I visu~l ~ 01 factory ~ vj sceral ~ or men t.al) dli sturbl8i1Ce II La sing cor. sc iousness afterl c r-ying out ~ the perS()n falls making no effort to protect hirnse.l f ..

(a) Ton Lc phase : susta inet1 contr-act ion of .all muscl.es ~ "bod y is rig i-d Pi j i:!IWS. fixed l' hands clenched!" legsl are elxtended Il dl i.1 aten pU_Plils tJ face L s red or eyar:)[)iti e d LE WI spa sm of re:spiratoIT'I mIUlScle'5.,

(: b) Clonic phase foll-orws tonic P1a.se in less thalTI a mlintlte wi th jerky m~l\u:ment.s due to al terMati.ng cantr'action altld :re-la:€a tiOln 01 f musciesi. The .attack last s 21 to 5 minutes u·su.ally. These.at tacks may be fo 11 CI wed b Y' (j ee _PI 51 eep j he ad ac ilel" 0 r mHJJ5 C 1 e· &.11r en e.s g; .1

b Ii Peti t· fEllall alttacks II Fleet.ingl at t.ac~k:S1 0 f .star ing intol space wi tbourt

loss 0 f -consc iousness (aI) sen(:e attack) fOlr 1 to 3.0 s-eeond.s. C~n OCC:Ulr with

lo.ss 0 f mlUSC Ull.ar· b}lne.. CCcur 81 predlcmlinan tly in child rel1 and can. rlec·ur al3 f.requentl y.as 1100 Cllt.tar: ks pe~r day.. Peti t mal may e-ventuaJ..l y deyelopl into grand mal lalter inl -childhood or adol e~sc:E!flce .,

C tJ Sbtu.s eptlepticu:s (con tin uo,u.s sei zures) II

( 1 ) A serl iOlus cood i tion in wI1 i,en se izurels 0 r the Sir'and mall type follow in :rapid slue c.-el SI s ion. vi th no intelrv'eI] ins;; per iod a f -con.sc-iouSI'lesSi Il

(2) pbenobarbi tal intravenou~l y attacks ..

Trelatment of thi s partic~lar cond i tionl : Give sodl ilm {Luninal) 0 .. 4 to 0 .. 81 gm, O'F par .aldehyde 3 to 6 mI.

t-ol proo lX:;e hr ief anestbeslia an·d to help pr'event further

d · Psychormotor se iztlres do not confonn to the c 1 a.ssi.c -cr:-i ter-ia of

!~and mal ,I I]le ti t m,al t1 or jac-ksoni an se i zures II] The se arle minor sei wries WittJ 1058 of' c~ontact wi th environment fori 1 to 2 min.urtes. 1he pattent does not Calll but ma y stagserl aroufld per' fOlrnI.ing aJutcma tieall_y afldi does. not

U'"JderstaJ1di ~at i 5- being 5alid. He may resist a i.d .. Mental con rUS10~1

continue's fOlr- 1 tol 2 minutes afte:r attack hals ended", HaIY develop at any age • Usual 1 y associated wi th brain d m1ag,e ..

1-·69

1-70

Section VI I I - The Endocrine System

1.-111 . Th~ endocr irtel .s_y.stem is made- liP 0 f' gland 5 of in tern al srec:re-tion. (-ductless .J?la~ds) : The secretions (bormones l enter dire<!tl-y into title blood

... 01'1 1 ympb C ~1r1C ulatlon • V'er y sma 11 qUa!1 t.i t ie s of OOTFOOf1e s are PrOOU~ed.1 onl, 'i a trace- be mg necessary to produe e an e ffee t ~ and sorme of theml in fluence the bodl" as a whole... &:cause of this aJld the f'ac-t tbat endocrine disorders can mJi~ ic a., wi de var ietYI 0 f pr imar y disease states, the d iag;oo·sj S 0 f'

efJd!OC!T in e dl sease sis ex tT'ermel y d i ffi.f:ul t to make,,- The hormJne prodoc ing

glands include the pitui tary ~ thyroid, parathyroids ~ ardrenal s , gonads. and pancreas ..

( 1!) Pre'v.e;n t t.be pa t.iM t from i~j ur iLrug hirmsel f b'i pl ac ing a

tofigue depressor. harlll L.rerc-hief l O!" paddled gag betloleen tee-ttl to ~ey ent

bi tins 0 f If. he tonglJlE!. to fit] t reso-a in pa tien to • Do no t" le aVE!' hum alor1Je'.

If possible. before se i zur'e I pi ace .a gag between the.. teeth r burt do ~t. use a metal object. Do not pr')" the teeth open , Loosen clothing:!" espeeL<llly around the neCK I' Turn he-ad to the s,i.rJel,1 811 lowing mUClJS to flow from, mouth

and throat.. After' tbe r3lt t.ack II Eli v'e phenobarb i tal 115--30 mg.. t ~ i .d •

~::» . Patie;, t. should be bospi tal i zed I' If tlospi tal i aat.ion is not

p:lssi ble, you will have to control the sei zures using aJl ~ico~vul san t drugs sueb as Dilafl tin 100 mg. I:, • La. to q • Ld. P · 0 · or 1M · If selZures add pbenobarbi t.al 1 '5-30 mg. t. i . d. to q. i -e d . What you WdI1 t i 5 the lowest dose possible- to' preli'ent se izures ~ To acconpl ish thi s start wi th. a 1 Olil do~e and if t-he patieJl t ha s another sei zure add a li ttl-e to the- dosage UfltIl

Be i.zures d i sa ppear conpl etel y • Patient mtlst not, dr'ink aleoho l .

11-",8 ~ r-JJITER (see! Chapter' 5, II trutr i.t.Ionat Di seases .and De fioe ien.c ies) __

1-11-9.. DIABETES MELLITUS., A, c hron i C mle'tabol i,e d i.sorder ,I ehar acte:r"i :zed tly

abnormal insulin secretion and a v=llri.ety' ,Olf' metabolic and vaseul ar

man i fes:tations r'e fleeted in a tendenc y toward all 00 r.n.all y eI8\\"Cllted blood glocose 1 e.ve1 31:t 1 arge vessel d i sesse , mllc:rolv asc ul.ar d tsease , arid (leulropathy' ..

a ., May resemble gr-an:-d mal epi Leps y, .. Wi th hy.ste'ric;al at tacks the OfIlset is .slower arid mOlJTemer1ts are purJX)'seful,. incontinence and cyanosis absent. pupi Ls do rot di il ate ~ pel tiern t does not injure himse 1 ~ ..t1en he falls ~ doe s not bi te hi s tongue, uaual.I y has history a f emotIOnal upset

n,eurol5lS .,

g""e-' r.:u .

Sl .. , Pol ~r'i,a t inc ~ealsed thi r st and hunger ~ parr'esthesia:l .and fatigue .. Be-d we'tt.lng may 318m a 1 t he on set 0 f' diabetes in chi.Idren ..

Vag in i ti,s and pr'Ur"' i tU5 v; ul v.ae ar-e frequen.t in i ~i al canpll amt.s 0 f adul t fanales -.' Ther'€ rna y be' mlaf"'ked weight lass dles,pi te oonn.al or' Lnerea sed appetite, + . Diable'tes should be sus pected in obese pat.ien tSI, pa t.ten ts with a p01si,ti,ve' fanlily Hx of diabetes" alndi in WOOlen ~l have' de~li.ve~red large

tJabie:s (o\!"er 9 1 bs) or' who have had unex pl.a ined fet.a 1 l-osses. .

and

b, Trea.tment i So the same as (1 J of' e pilep.sy treatrne-n t.,

ll-.lt6 ~ BELl.. r S PALSY. A par al ygi 51 -0 f the muscles 0 f one sidie 0 r the face

SOOletimes pr ec i:pi ta ted by expasllJre, ., chi 11" air traLlTla II CaD occur at any age

but most CCfIIOOln frOlm 20-50 ~

S... and 0.. [be 5l"de' of the race sags--eyel idls t lips 11 eyeb,roW5 II or entire face ~

0.. 1 n mli ld or :t.rOdler-a.te' d iabe,te 3, ther e rna y be no abcormaf signs a~ onse to, where-as the petien t . wi th severe in suI in de fie Iene 'I may preserlt W3L th 10.5 S 0 f SQI fat , deb i~rat ion . mluscle- w.a st, ina. a~lr o.~.l~ a 1(II,a. ~ .I~e. a

. ." ~'P :1'.....J, ..~ jU'V ~ .ft. . II ~ L . ~!.Jo. -.

vanl tl~g!l a rr hunJ!:e,. 11 ~ and if un tli"eated t ecmli:t: am1d -death... The r et in a rmaly

sh)w . ml c TO' aneulIr y.sms 'to lntr aareti n a 1, h~E:llm()rrllage S,. and tlar'd e:( ud!ate.s ..

Ca[f'dl.lol~ asc ul.ar signs i.ncl ude signs 0 f' c ir"'oC ul.ato ry emhar:rag;smen t of the lower eJ.(,~remi ~,ie5 a~d b)"perlens,l-Dlrl.. )JeuTolog1icai s ign s are predlcmlinaltly sen SOI""Y lTI natur'e 'Wl ttl d ul l.ed perc eption of vi b ration ,I pa i~ 'to and

temperature 1 partkularl.'l in the lO"lO€'r eltrEfili ties. The anJli1e jerk is

often absent 11 but the kn ee j e'f" k ml~y' ble r'eta in ee ., ~!Jr' in alys.i sis p:l3i,ti ve

fo('" gJ UC~~JiS€ and keto~e.s with s pee i fi c ~} .. ,~ i ty i,.. 02u-1 .. DJ_f·O. WOrE: Cer lain

eQ'l1mon. the!" iilpeut ic agents ~ €. g a, 1 aseorb i~ ac id! -sal ic ylate.s 11 methyldopa Ii and levooo pa. t when taken lr11 large d.oses, can g i \TIe a fals~ _p()si t i ve for

gl ucose htl~~ IJsi~g Cl in te~t meas~~er_JJts or false n egat:li. ves 1<ohen using ~luco s€' ox l{]a.sel paper st!'"'l ps t Cll~l St.il -.' res-Tape l' e,tc: I' ) .. Despi te the

l.nIiJlOr~neof of the ~tlo .... e sign s .;and symptol!'l.s lL.a the diabetic syrnirume ~ none cans;tltulte the :tIasls fa r .a conclusi II e' d iagoo s1 s _,., ~l1eneve-r d i.abe te.s is StispectedJ IJ it should be [! on fi rmed bly a fast ing bloedl or' .ser Il.ITI g1 ucose and! a, gltICQse toleralMce test if indicated.

A~ Bell~s palsy.

P.. Keepl face warm and arvoi-d f'ur ther' e:tplslJr-e 11 espeeially to wind and dllst.. Protec. t eye with pate hi i f nee~essary'., Get1 t.Ie' upward] malss.age of' the involv'ed muscles 5-·10 mIDlJtes 2-3. times a dalY' helps maintain muscle' tone. Predni Sime -"10 mg. da il y x 11 da ys. then taper to S mg. a d:a'l in .B ~s n\,ay tlelp ~ In most cases par ti al 011" camplete rec:oyel' y occur-s usually

in 2-8 weeks, (1:- .... 2 years i.n ()ld-e'T p.atient,s)--

A.. Di abetes :mel 1 i tu~ . [Ii ffer-en ti al di iagrl-€Jsli s : NbJnd iabet.i-c (1r1efj.al)1 gl ycosur i a" hyper',g 1 tC emi a due to end organ ins;en.si v; it y to inSUIl in.

, P.. t-t we II hal QU iCed ( sugar free) '1" OO{]- 1 IJ 2(101 cal.or te diet and!

we:lgil ~ red uetiatjl wi 11 man age mran'i ca ses OJ f un i.ld to mocler"'ate dj abetes , e~p?'c lally. in obese _ pat i e'n~.s whrD dlenonstr'ate s)Wpt.GU1aJtol og Y at age' 40 or ~bove :' If gl ycosurr la per 51 st S t, t·ne' use' of hypog;l ycermic agents soc h as Insulin or' to 1 butam ide· (-)r anase} is l:;ldi i.e ated .. The ultimate coolice olr

~e(1~ts. Ilru·ute tJ do'~e ~ ~[jJd i~trf:rv'al must be detemlined, by a careful .analysis of 5e'r urn gloco'5e I e-v-els ,_

1- J 1.

IV DrSW at a r'ate' of a,pp··,f""o;(imatellJ.J 200 ml.,/hr witl,1 ir~S:.1.1·1- n 2' ~II""', t

..1 I,.I!I q .. ,'-.,~j III P . r .,1'1.. 10

maintain gl, ucose l-e,\~llel Det.ween: 200 and 250 mg .. /1 OOl ml ..

1.J50 __ teft PLIC:ATIOMSI (f" DIABETES Ii

(2: ) l.ac tic ac idosi.s !OJ St.a("lt IV .. S N sal ine ;:lIt r ate olr , L .. l2

hour s 11 then ~l L .. /21_ 31 hOI ur SI - f~a b i.carbonate 2' ampule s (go mIEq.,}1 5ltat ..

II. Repeat with jl~ ampules if ne-ces,sar Y' . Stop \1Ihen blre-athirllg returns to noma! ..

a. HYJXIS.Iyeemia (ir1stJlin sbock) ~ _ hl abno"!lall:,o. lo"W blood. .sugar level and the lIIOst COI'I'lOO'n ccmplicati-on of patIents on msul In therapy.

S. Sudden onset (sloWF.:::'r wi ttl long .acting inslJl ins)' of m,ental, .

ooofusioo J bi zarr-e ~tlalll ior ~ s:wea. tins J pal.:pi tat.ions , arid treli'lulmJSI'lIess that m~y 1 eadl to COO1a tJ COTlvlJI sion s , and dieatll.,

O. SIr: in. i.s mol. st 2 pare , and cool. There m·a ~ be -d ro~l ing rron the mouth. ~spirat.ions are normal or shallow aJ1d the breaith. i s usual Iy ooa,rle 55... B. Pili 5, normal, with a full bound ing pUl se II ~e ur lne l.~ ~ Inegative for glucose and ketones by the second vo id ins ( tlJer:-!FIJay. U'li 1 tIall y be game residue rrem earl ier hypergl )'Cemia ~ ) Serm! glucose 1 S <00 nag ./1 00-

mI.

c _,., Prevt?r1 t ion of so ft ti SS,Lle' campI teat.tons Ii 011 abet.ic S ar e

5~scept.~~le· to bed sor'es , in feet ion , and g.angr'efle., Bec.a use 0 f poor'

e.rrcul at ion , feet snoUlld bel ke'pt sc rupU}Ollsl '1' clean anc dry' ~ f..A tr"ern£ car e .s1'l-:)uIld be used ~hen t.r irmling, to ena i is j and corn and cal Louse s should be rlem-:v'ed ~ try, seakmg 2 no·t curt t i rig .. Use . Q 11 or 1 enol in to kee p fee t so ft and .av'C}lld tIght shoes. LGI not appl, y 1 ocal. heat to Leg s and feet I' Instruc t the pattent to !)rLffih teeth at least three times; a day, Ta ke w~rm baths dai 1. y and, seek pr-CfruJ(lt at ten tion for an y brlJi se or' break in t he skin ~

di aglnosi.s : mjur y, a 00,

mg .. ,/lIOO mil.

It !OJ HtypctS ly"Csnia d ue to insul in reac tion .. Di fferenti al

Diabetic ketoac ido.si5 t alcohol 0 r drug i ndiuced COOla, head cer'ebrorv ase ul.ar ace idents , NOI'E:: If sertID g] ucose i s <~O

the Ox i s ~on finned II

11-5,1 -.' ACtJrE ADREr,.;lAL. I.NStJF."fIC I E NC! • A c 1 in ic:a1 syndrome e aused by mar ked

depr" i vat ion or in s uffic i.en t suppl y: 0 f adrenocortical hormones following trafUma.1 surger y, Qverltkle!lmling sepsis {prl inc i pa l Ly men ingococcerni,al} tor' sudden withdrawal of cor'ticosteroi-d drug ther'apy.. Acurte adrel1al

rnsuff'Ic ienc)" const i tut.es a grave medical emergency .and is r apidlly' fatal if not treated.

P, If still eense Icus and able to sw.allow't. ~iv'e orange juriee I glucose f or atly beverage- containing sugar. If. stu~rous. or utioonscious. gi VE!' 20-50 rrli _ 501 gl ueose I'll stat. 1'I1er.I -contlll ue m fUSIon at a rate of .1.0 gmlbr. If patient is still hypoglycemi.c ~ give- a second bolus of 25 mIL 50'1 gll..lC'05e • If Ulable to star t IV, give 1 'ITIg, • gl UCagrn:. 1M or. SO then sugar b 'j mouth "When pa t ierl tis awake and. cat! swallow. I f noel ther g1 UCDse [lor glucag,oo is available ~ stile 3'IJ mI. syrup or honey ill1 500 mL l"Iarm. water rectall'J . 'l'bni tor patient respon se afld plasma g.I UOOSI! lev€- 1 carefully.

b, II Di.abet.i(: ket..oacidosi S .. Jlyperg I yc-em ic C(XI!'J.aJ • us uell y' occur S If] lnsul in dlepeooen t, al'ld juven il e C: age (3D) 011 se t, d iab€ t.ies .,

S.. Gr adual onset (11-2 days 1 II Nausea:l vOOli ti.ngl Il abdan if} al pa in 1" pol yur ia. in tense tbir st. 0300 marked fa t igue pr-ogressi ng to mE!J1 tal stupor

and finall'J cona and death 2 if untreated ..

o. Ski.n is, hot 11 dlry., and flushed wi ttl a 1055 of tUlrgcIT. rbuth

Is dry. Re-spiratioos are deep, rapid, .and la1boredl. l frui_ty (acetone) odor Ls usually presen. t on the breath. There ma'i tie signs 0 r sfioc k r see cfiap~ 1511 I' Ute eyeballs are sof't , Ur'ine gl ucose a1'1d ke'tones, are

strongl Y p:l5i ti '.toe. Plasma gltJCo se is ) 300 mg. /1 00 mil. ~lfId ~tone s. are strongly posi tive~ OOTE: A rapid blood! g,lucose- determll1<l~1_CJfI can 'be rnadle using ccmnercially available :!i_!;lllCOse test strips tDe)[~ro;st~x} ami a ro~h Ql.janU tation of SE!'FLm -or plasma ketone- can be made USIng eIther ~e-tostllC or AcE!'test tablets. Tbe presence 10 f ketone- !ilia 'f be maskedl if there 1 S .a str-ong

1 evel of lactic .ac idl pr'esenlt.

S .' Headache - t 1 assa t.ude , nausea , vcmi ting 11 abdominal Ilaln C " V • AI"

pain 2 and lender'nessl.. Carl f'Usion or cona ma y be present Ii :!

_. . 0.. Fev:" . 1 O~aF" III or ~ore tJ B. P",.I c yal1o.si So , pe te-c hi are {espec: i a 111"

WI. t hi rnen~ ngocOCBEIl.a}I! dehydratIon:! aboonnall skin pigrmentaltion 11 and

lymJil,adlenopathy marked eoslinollhi 1 i.a , NOTE: A high eosi nophi 1 COLm t in the presene e of sever-e' .stre.s.s· due to tr-.auua Il in fec-tiofl ~ or otber mechar. i.sns is strongl., suggest r ve of arlr'-enal fa i.Iure .,

A., Acute adrenall insuffic rene y due to ..

IDi ffer-ential d iagno51 s : Diabetic coma , cerebrovase ul.ar . ac c iden. t 1" .a~ Lite poi serung ..

. P., If AD:R:fNlAL, FAIUJA E IS SUSPECTED., T~:£A TAT iJ.NCE W ITH1JUr

W'AITING. FOR ~ONF I]1M~IT ros BY LAB R ESlJIL TS _ Treat. for shock (see e hapter 15)1 ..

Start IV f'l ui.d s sta",!:, 1'. V: asopr-es sor d· TUIOiS, ":ITlij'd 0·'·· . "n r''''_ .-.....-.. t ~.

. _. .. ' . .~I .. ~. ~]_J21 t-- ' . Iii .....v no· gIve

-,!a("'~otiC5 ~)r sedat.i ~Iel.s .. 1 00 ms.. Solu-Coii't-e'f IV stat .. ~ annd contirrrE' IV

~fU~ion of' ~110D mg .. q ... 6h .. x , diay, their! same' am~Du..nt q.8h ... I 1 day' ..

~ tlnuE to gil ve q .. ah., wi t hi a gr 00 ual, reduc ti·Dln. i.n do se un ti 1 the pa t i.ent, IS ab1 el to take food. by moruth., the:.n gi l.Je· olr'aLl. cOT'ti salne' 1211 5--25 mg... q.1 6J1. Ii andl r'ed Lice to' main ten atlce levels P -t-r II n II Man i.tolr B .. P.. arndl 00 serve fo,r signs Q,r edimla and hyper telrl s,i·on.. If slign S o,f c.er-ebrall ·edema (tJrlCD~.sc j,QlIsne-ss, orl COrirv ul :siorls,_) or- PIJl~l1ar y edieB:lla acc ur:! wi thha,ld sod itlm and flY id s and treat thelse com i t.iOrl.s .. If :sign,s of bypoka 1 emia OC:ClJr, give P~)ta_s.s i Lm sal ts 0 r foad. tlig h in p:l·tassi.lDJ eel'] ten t {or alflge ju i~ el f)r' ban anas) .1 Ev'ac uate lWhen.

realsi.ble. . .

All Di aheti.c ketolac idosi s • Dri ffer'e11 ti all dl iag nosi So :

H:,'poglycemia ~ lactic acidQsis dUE: to- septic. eardiogenic I or- bypovolemic soock., NO"It:: ;.lith lactic acidlos.i.s Il the clinical picture' will be . appro.K imately the s<I"IIe without the aceton e- breath or keWrl'I.Jria. mood

gluc~r)se is v.ariable-

P.. ( '1 } Diabetie keto ac ida,si 5. Star t IV ... -5 lJ Sial in el at rate {}f

1 L- ... /nlr -:( ? hrr s ... then adj us-t to ~-.s L _ (total) over a per iod. of 2.q oour s ·

If patient is alreladly inj s~)ock~ giv'e N sal ine'_, Insuli:l {reg,ular) 5-1(1 unitslhr' slow IV drip aT' I~.. 1ihe'n blood glucose i.s <250 :rIg .1/100 ml",,, .st.ar-,t

P ..

practice ..

1-52.. E:YE. DISORDERS ~

1-53.. EAR D!SOItDE.R:S ~

-Gonj uncti vi t-i s • Conj Ufllcti'll i ti s i 5 the most common eye disease. It may be acute or chronic. F-bst cages are due to bacterial ... viral ~ or

chl, amydial in fee tions . Other c 3'IJ:5e s are- allergy 1 chemic al i rr i tat 'ion , and: fungal or parasi tic in fee boo . The mode 0 f tr an smi ssdon is UiSuall'1 direct

contact via f'inger 5, towels, etc,..

a ~ Ex.ternal oti ti S t· An in feetion 0 f' t h .' .... t . '.' .

baCterial . ith .. .. . · .. ' '.' e external ear canal, usually

1-~ no' l".·nf' ': tW." . I . o~e.a~.lon. al, secondar-y .. f.: unga.l infection" In ~an\l' case ~ t'hle"r'e" .LJ I'. eC' ~on 11 1 t 15.a ... t t d .. ~ . . ~ . '. .

derma t" t ... ·· . F ... con rae •. · 'ermati tis lOr a variant of .sebo"'r·~""'l·c:

'U ef"l'!il.a Ill$. • . . i ,He .

a + Bact.er i a 1. conj unct.i vi tis III

.' . . SI.. Itctli ng and pain, dry seal ing ear can all. - t.h' .. ' . , h' .

water l_l c r puru'l en t d i seharge a n dl in terni tte' .' t.. .... ... f' ..' 1" . er ~m.a y "e a

extr~ -wh 1 .. . < I. 1 .. Jl . 'Uea Iness~ PaU1J may becone

. . . ... ... ' _ en . ear _ can al ~CBE!'S c~Jll ete 1 y occ'l ooed • Ad eno , .. th.· .and. · ...

fever 100 lea te 5 :mcreas]_ nl!'; sever it 'J a f in feet ion . pa y /0,

S. Copious pur ukert t -d i scbarge and redness vi th no pa in or bl tlrr ing of vi. s.ion ..

01,.. Gr' ami tJ 5 stain of di seharge usoa 11 y sbows str eptococcU5 or stapn.ylococc UIS o rg, ani SIftS 'I

01• Crusting tl se.:,a~l· ingl 1,e'ryttlem.·la~ edema". and! pustul-e formation"

CerLJne-n ma ~r be alJ.ser1t.. Lab . 'l.~ B C b 1

..' JIr ..... ' .• ' may :. e e . evat-ed QIF" normall ..

A ..

Exter rial OlI" t .,

;, I . ,IS ..

Dt ffer-ential dia~nosis: D ~, t- ~

5r am lf1g 0 I 1 tl S

A.I Bact.er ial conj unc ti v i tis .1 Di ffer-ent i a I d iagrnsis:: Ir-i ti s ,

glaucana! corne-al tr a1!.lrla ~ kerati ti s , and ot.ner causes 0 f conjuflIc ti vi tis ·

med ra ..

P. Disease is usual.Iy self-limliling, lasting 110-1 ~ days if

un t rea led. Sulfonamide or antibiotic ophthalmic ointment. applied locally t, ... i ~d ... usu.ally clears the infection in 21-3 days I

P • [le'an ear then ap"_P' 11,~ an tl .. ...," t'.. .' 'tm'··· '.

cotton i:lt: f. .lJJ' . F ... . ....•. -1'. OJ .t.ro io I.H: om '.' ent or e.ar drops wi til a

system i~I~ .: -or . :2 . . hour S •.. fo~ 10 w.ed . !tJ ~ e-~r drops twice da i, 1 'i . I f there is

1 nvol vemen t J s ystemlC an tlb iot lCS may be necessar y' II

b .. , Ott ti s med ia... In f-ectio n of t,he' middl e earl ..

b . Vir al conjunct i.'i i,ti s ..

.J'

( 1) Acute oti. ti s med ia ..

f 1·, Sf'" 1 Ear pa in.. -d.' .earn ess .• , reve. r =" cni 115. hear ing Ios.s and.3

.ee .lnlg, QI f II .lness and pressu' " tb II ' , ,., I!I ,. ,

di SC .... I" , a ~g .. ',e, ", ~I f.· ...•.. ..,'. •. Ire 1Il . ne ear. I f the eardrum r uptures

ua~ I:) 1 SOLI no In tile ear., . :I

S.. :Fiedness II eopi.ous wa terYI d i sctiar-ge, and scanty' e:x udate from

the eye. Ulsuall y assoc iated wi tb s ystani'l: sympta1'llS. phal" yngi ti 5 F fever,

malaise tJ afJd ad enopa thy.,

0... Chi ldren ar e mDre 0 ften affe-c-ted II Co n t,am, in alted .swimrning

pool s ar'e a majo r cause ..

PI' tb spec ific: treatmen t.. Use an tin iot.i.c ~)phtbal!:Ti1ic ointment to preven t secondary ill fection s • Usuall -y last 5 at lea st 2 weekS.

.. . I.. o. ,Exairl Shows. a loss .or normal landmarks and! a bul ,in of t.he

ear~1!" tZIfI a s t.~e pr essur e mcreases . Lab ; 1.1 • B. C _ usual I y i n.cr!a!d· c- alii t :<:;

st.a In of d rarn aae mav . 1 inf ~ tJ .....

. '., '. ., .~~ ,oC_Ji reVleal. In, eet.mg Olrgan ism.

AI.. Actlte ott ti s media ~ Di ff t ~ 1

oti t i s , ebr .0 .... 111":..-..: ot - t . ~... . . ... I . -eren '.l<:ii di agnosd.s .:: Ell: ter'nal

, '.. '.:JJ .,;_: '.. l'l.:S mt-;.J 1..13 ..

A. V'i r al eonj uncti v· i tis ., D'i rferenti.al d i.aglnols.i s: see nacter ial

conj Ul11eti vi tis ..

S"I Rednessl I itching l' tearing ~ and 51 igh:t di scnarge III

P " Hen, r e.3 t ,I am all. ~ e 5 i. C:S.. a rI d s ""'II:": t e·m' 11·1...... b" r . o ..... .....Ii .s ~Jr"o t.rl!- 'W'I"!I ..

antibiot i..e s .. E~r d rons are O~I f' II" :' t '01 ' "1.11' ~ .' '.' ......... '. .,~- f.n-~ I ........ 1 .

the- i' f: ': ,t. .. .. . . .. '!"' .. • .. ~' _.:mI I.e ~.a ue; lacall be.a t may he 1 pi iesol ve

. l'l ,ec Lon.. fwbst lm:p!)JrtafL t 1 S a myr:, In (f , W (: ., .' .. -i .. " ,.' .',' . .. ..... .,

mernbrlal1e ). if th .... , • .... . . _ ... ..... ..... bQ ..ml), inC ... SLOn of t tu:! t ympan Ie

....-_a I ".. ere. 1 s c-on.tlr1iued bUllg ln~1 0 f the elardrl-n-.. c,olf'lllJ"lr n uLOd.1 nc::::ii .... 1" 11

l~ver' ll!"'ll~r'e' ~ .... _..,. 10 ....... U.I .• I.Ii ...... ,~I ~. t""""': I

. .. , ", ....... aJSlrLg • .ic'(U'" IIlg loss.. or \I er tiso . . . . J

(2') Se!*o us ati ti s med ia II

5,...... . He ...•. ar.". i;. ng .... i 10S5 . .,1 full "or pI uo'O"ed feel ing' l·i t"'I.11 th

un· '. 'ljI1atl, ur' ".!Il· b t. LI~ u •. : e ear 1,1 and aJ']

.11 'lot;! " reyerera ·lon olf thel patlentl1 51 voi-ce... ~

c:. Chlamydial keratoconjunctivitis (trachoma). Trac:tlol1la is a major cause of blindness. In eoo€mic areas it is COO!tractedi in childhood. It is usuell y in siliiolJS wi th minimal symptan5. In aduJ. ts i t i 5- acute.

011 Bilater.al foll ie-Ollar- conj unc ti viti 5 ~ in fl a-rrnat.iclfl 0 f the corne;). .anid pann us (cloud-y.. uneven j newl y fonned 'IIi1:IJscvl ar- ti ssue over the cor1'1ea l .. In the l-at-er stages"" scarring of t.he elye 1 id mars in m.ay cause

in ... er s ion. 0 f the e ),1121 id and t-he eyela shes causing tnem to rilb again st tbe cornea thereby scrlatehing and scar ring the c.orllea., 111li s dec reases the yisioo, leadiing to blindness. Giemsa stain scrajl'ing fn:m OOfljunctiva shows

typical cytoplasmic inclusions in the -epi thelial eells. In active

trachOlla I' the .sme ar rna y al so inc lude pal)'ll'lOr phon lX!lear l~koc ytes-. plasma

cell s, and -d-ebr i.s--- fi l1ed mac roph.ages •.

A.. n- ac hall al .' D~ fferen tia 1 d iagnosi s :: Otlher eye in fections ..

0.. EardrYm retr acted o' 1ft· · 0;1'1 1m tho . . Ill.-. . +-....., - .

anb . . .. ..' .. ... .... .... ...• . . _. . . ...... ' L...... a c~.ar at! lA::T l.stiC M ground g .. ·.la.s.sr~

'. .er dil :scolorat lon.. A_,lr- f1 uld bubbl e·s or a f1 . d l' ,. . "Ii '. ~ .

.seen on th.' -d. '. ..' '. I •. U 1 . e1J€..L can scmetlmes be

. _ .. ,.. . ,e! e'ar I. run" Absence [) f' fev'er pa in and to ,~ .. .. ... '.. .

ctl tl ~ rn·-.r.i t'!' a 1" S .n I!":Ii1USed b' 'Ii:-' -""IL-'h" . T.· . 11 '. ".1)[ Ie sym.pltoml5 ~ .serous

I ~ I.~... .·I"Il.,.~ .'1 . y: etls:~ Ilan tube b-lockase. . .

A'II .sero~sl oti ti. s- rned l' .. a· ~I Dii fe.:c..'F" t ~ 1 d'

• '& I IJ ~i en 'la~ 1 a~Jlo3i 51 : t\c: ute oti tis

l-i61

P. Nasal decong.e.st.ants to keep eus t arc. hiarn tube open ..

Iirltihi sti:lnines if ther'e is an y suggest.ion 0 f nasat allerg:y.. Tr'ea t cause of bllock.age I] e .. gl"'! tansi 11 i ti S 0 r alnus in fer.::tioflll If all else fai Ls to relielle the fluid tJ a. mlyr'i.ngoltaiJi1y t s nece.s.sar y to dr'a in t.he ear.. Indwell ing pl.ast.Le tubing for drainage can be used in persi sten t, e ases 11

0... rlalsal congestioln and purullen t n alSall d i.soharge IJ Lab : Smear' of nasa 1 disch,argel may sho w causat,a ve organi sm: whi te coun t rna y be elev'ated! ...

A. Sinus; in fe~ ti.OIn.. Di ffe're:ntial dl iagools:i.s: Acute d en tal

infec t.iOrl ..

C 11 Oi seases 0 f tile inner e·ar-' ..

p ~ Bed r-elst, sedat.L vies] 11 anal.gesdc 51, 1. igbt, d.ie t" farce fl ui.ds 11 na.sal dleca~,estant.s (nolsel sipray' Q'r" drops) 2-3: times a .cay, local heat 1" and system,i-c an tibioiticsi wi 11 usual.1 yl e] -E!'lar up the~ in fectiol:rl "'-

~ 1 ) Men Iere II s d Lsease , Cllar acter i -z-ed by recurlre1 t episodes -0 f seY'erel vertigo a saoc iatetJ with deafness and t inm tU1S .. Menier'e I s d Lsea se is

usually -encOtln tered in men ~O\-6a yr SI ol.d II Cause i SI not krLolwril tJ

D t' C'OID'I1On cold. Caused by a wide var-jet}" 0 f v ir"uses:! all of whi-ctJ ex:ist in mlJJl ti,ple an t.ig;-en Ic types, and recur ren t. in fec~tion is canmol'l ..

s·... If1 tenDi ttent sew'ere vertigo that maly cause the pa t Len t to

falll .. IiEu.15ea" varni ting 11 8r1d pro fUGe per'spiration are of'ten assoedated ~ 'Ibese at.tae ks IDa yl la Sit from m.inute-s UJ 5t!"Ver al :hours. FreqfUEn~ y of a t.tac ks VlCO"" Ies II He'adlache:l hearing loss l' .andl tinni tUB oeeur dur ing and per si.st· between. attacks,.. Hear'ling Ios s may be progressive and in 901 perce"] t of t,he cases un i.l aterall ~ Inv'ol Lmltary eyeball movement, May' OCC.Uf" dUr'ing at.tacks 0 f v'ertigo'"

S.. Mallali se 'I fever ~I beadache , nasal di5C()[RlfQlrt with wa tery

d j,:scharg.e and sneezing follo'Wed. b,y mucoid to purul ent discharge.1 alnd nasal ob:struc tirn"l ~ Throat, syrnptc.rns; ar e dr yr\elss and soreness rather than actual palin al1d hoarseness ..

0·.. Increase-rl seln s,i ti vi ty to loud sounds and dec reased speech d,i scrimina tioo __ Marked p3yctJie di sturbanee i s fOlund inl mall y pat i.ent.s.,

O, Nasa 1 rr.U,lC05a Is redder:led and sYJIllen.... Ftlaryrlx: and tonst Is .sh:>w' mi ld to modlerate in fee tion. usual.I y wi trout edema or exudalte; cervical lymph modes may be enl arged and sl iSh.t1 y tender... lab: ~t remarkahle unless there is a secondary bac teri,al in fee tion ,..

A... ~rtiere 1 s di.sease... Differ'el1tiaJ. ~ Lagnosi.s: Systemlic

in fee t tons 11 ps ycbia tr i.c di somers II and cerebrospinal. injur res or disorders ..

A II] Goreoon coln. Di ffer-ential d iagno.si s;: Flu or URI ..

P. Reas5UrC3JlC~e" sal t-Ifrlee diet; 9i1 ti,hi stamines (Be:nadr-yl and [r'anJcml in-e) 50-15.0 mg , or'ally' 3-4 time s da ill' ma)! he1 p' sane pat.i.ent.s . Par'eI1teral Iranamine .. Benadlryl or 0 ... 61 mg; atr'opfne sul rate may !top acute at t.acks , Men iere II s di sease is chrcn ic ~ rer:-'urrent ,I and rna y: per 51 st fori year e ,

f" GeJleral measures e rest, forced fluid JI 5)'I'Dptanatic treabnentl] e "IS ... 11 asi ~ in for headache 71 ete ..

(2)1 Ac. urte nansuppur ati VIE Labyr i.nthi.ti.s.,

S, Nasa 1 congestdon ; a profuse 11 W~ tery f1 asat dl i..scha~ge: i tebing nolsel often leading to par'ox:ysm.SI of violoot srleezing; nasal mrucosa is pillel Ci'ldl boggy; i telling w.a telry' e'ye 5; eonj Ufllcti via is often red and swllel1.

s ~ Usuall y follows respirator y tT act inf'ections.. M&1 i fe s ted by' in tense ver tigo II usual.I y wi th marked tinn i tUB I] a stagp';ering ga it l' and i.nvol untar y eyeball mov-ertleflt ...

C BI C

.. .. ., . ' ..

01' Gram11s stain of' nasal seere tiQln relll~al s n l..I1leraus erJsioophils, shows 5-!4-1)J eo si:nophli 1 ia ..

0", Hear ing Ioss is 0 ften not presen t, ..

A.. H.:ly fever, Oi ffe'renti.al d iagno.si 5,: Other camnol1 upperl respir a tor y in fections .

A", AclUte oonsuppurati ve lab ~'intbi tis ,1 Di fferen tial di.agoolsis:

Me:niere" s di sease ,

P. .ArI tihi stamines g i vel r-el ief in 60-"80 pert: ent of c ases but. elffec t,i veness Wale s a 5 the allerg y season prl[)gre.55E5.. Sympathaftime,tic. drugs such as -eliledrine ar'e e free ti 'Ie bly t.bem.se Lves or in ccnbinlation wi. th 3I1t.ihi.stam,in.e:s., Serl.atioln maly be of value fO·r tense or nerllOus patients ..

Pl. Be:(j rest, preferably in a d.ar'kened rocm until severe~ symptom~

subsfde , An tibiot.ic~5 ar'e 0 r little 11 al.ue uniesis there is an a 58~ ialted

infection olf tbe mid,dIe ear or mlastoidi bene 11 ArI titJi stan in el (Benac!ryl or

I:rananine) rna y ble 0 f 11 al LJe ~ lPtlenobarDi tall l51...tlO rng.. 3_Qj times a da Lt is ser.t.erally helplfUil ~ Iboralzine Hel 50 mg ... 1M i.s usef'ul in the acute' early phase.. Attacks may last for several dlalYs b1ut rlecovery is u5uallly canplelte III

1-55 ~ MOA T DISEA,SES,..

.a • Ac:urte tonsil1i.tis is· f.I earl y al ways al hacter' ial in fecti.on F ,often due tOI streptr.x:occi ..

s. Sudderl onset 0 f so re throlat." fey'er'• chi 11s tJ head ache j anor'e.x ia 11 .and rmallai.se II

a. Sinus inf'ec tiOfl ..

..... . Soil Hi . .s.tory o,f an ac ute upper r'l!slpli.r-altory i nfeotior.:. swlrlllliing or

d 1 vI.ln8.1 dental ab~ess· or extr'action ,. 011" nasal all I elrg ie's ~ Pain 11 tend~rne3S. redlnes51~ !rwelling oWler the invoil¥'ed sinus 111 rever. chills. m~lal..se t and! headache ~

0.. Swollen aI'1d r'ed ton..si 1 s wi ttl PUSI ·or el< wate .. , Cervical flodesl are frequen tl yl enlarged and tender ~ Whl te caUl t, ma Y' be elevated .. , Gr'amf" S stain of pus or exudate' may :SOOIW calu5ati.ve org,anisml; throat cuCLture' will.,

1-77

1-}-8

A.. Tonsi.l1it.is. Differential .Q,iagoosis: Simple pharynglitisl:t inlfect.iolus Kk)TIOrlllclecl:Si.:s ,I Vlr:l~en til 51 angina:t and diphtheria.

P.. fed Fest 11 fl uids =" 1 ight diet. warm .sal t water gargJe:s .. analgesics 'I and afI tibiotic s alS required ~

b.. Simple pharyngitis.. UsuBll1y bacterial or viral in nature;: my I be par-t 0 f the s yndrane 0 f an acute specific il1 fection (e ~g oF, measles:l scarlet fever,. etc .. } ...

S.. In ac:ute rJ1arlY1lS i tis ttle thlroart i:3 dry and .sorel i system,ic

5}UJlptams are fever- and rnaLlali se , CtJroni-c phar yngi ti 5 may produce felw symptoms t e IIlg Ii II thlrloat d r"ytlless wi,th ttlick mucus and cOllJgh Or-I recurr'ent acute epi sode S oC TTlOre sev e rei throalt pain '-" dul.L hyperemia ...

o. Ar:ute pilalr-yngi tis Il r-ed mucosa sl ig,htl Y sWlllen with a ttlick: stick Y' IErucus. Chroni.c pharlynSl t ts , mild :swe!ll ing 0 fl the mucosa wi t.tl a tl'lic k tenar!:iOU5 mucus, often in hypcIP'JaJr-ynx. In

A.. Simple pharyngitis... Differentia~l diag,oo.sis: ottlet"'" upper' respirator 'I in fee ti·ons and! part 0 f the S)ll1drcrn.e 0 f an ac ute spec i fic infectioln (e' .. g ... , measl.es , wbnoplng cough , etc.}l ..

P. Symptornatic tr eatment; rest! 1 igtltl d ielt 11 .an alge:si-C'S:l 'W~rm sal inel gargles"t and arl t.ibliotic 51 if i tis a bact.er i.al in f'ection ..

e .. lnfl uenza tr ansmi tted by' r es.:pi r aoolrlY rOlurte.. AI thoughl SI]X.lJ"'ad te calse S oecur , usual.I 'i occ ur s as pardem ic or e'pidemlic in the faLlI or winter. Inc utJ..ation per iod Ls '1--4- days.

S.. and 01.1 Abrupt onset of felverl ~ chi 11 s, mail a i se and muse ul.ar acnin g l' s ub.sternal .S~;Ji r-eneISs. T he adache tl so r' e chroat 11 non pr--odoc ti 'lie C.QI ugh ., nasal stuffin ess , mild phar :frLSed mfect.ion , fl: ushed face, eonjmc ti y all redness 'to aJ1d DccaJsional nausea, Fever La st.s 1-1 days (tl3u~lly 3-'5). If fever per'ai.st.s more than 4 (lays ~ cough becones produc t.i ve or if W .. B .. C ..

F i.ses to aoolut 12 + 000, sec ondar y b acter ial in fectiQn should be ruled out OF Yer'i fied and. tr eated. }blst fatal it 'ies are due to bac ter i.al. pneUlH}f]i.a ..

Lab find i rigs: Leukopen ia is -coumon alnd prcte inUF i a ma y be pre Se'lt ,..

-

to

A... Influenza.

P.. ~ S}Ifilptomat.ic f bed rest to r-edluc.e C"cmJpl ic artiorl S III -forced fluids ,I analgesics l' alnd sedlati v ~ cotJglh mixture.. Do No.t~~_se an t ibiot ic.s unless sec'ond.ar y b.ac ter ial in fe~,tiofl de-velops ..

CHAPTER 2

COOMU)lICABLE. DISf.J\SEi

Section I - Par8lsi tic

..

2-11 • GENERAL,I>. Of all the d Lseases tha.t aff'L ic t mJankindi" man_y par' asf tes 1"

especi.all't malaria I cause the highest rmorbi.dity and mortality wlrl-dwide ..

2--2.. Nr-IIEI3IASIS.. Caused by thel one-celledl p.3ra5ite Ent.amoeb,a histolyti-ca~ It is pre sen t thro~llout the \fDJlJ'ld 'I b,ut. i 5 es pee i.a 11 y sel"lle["'e~ in ttl ird M}r ldi eomtr i-e15 and in tropical countri.e s , Diarrhea is the most C{Xl1mon

_pre serl t31 t ion ..

-s., Recurren t bouts 0 f d i.ar'rhe:a and abdanin al eranps , sometimes al tern,ating with: ccnst.i patianl ~

0", Tenderness and enl.argement, of tbe 1 tver ar'e frequent In

Semlifl ui,d stecl.s containing 11'l'O pus and orill y flecks 0 f bl ood-.sta inedi muc us .. Stool s '5- 1 0 per d a_y orten wi th fe~er UPI to 1050 F ~ Ahdcminal co1 ic aJ1d

v ani t.mg, Lab findings: Erttcmoeba. hi stal yt tea t.ropho zot te s and e y.sts

in stool .spec imen 5- are d i ffic ul t to d eteet II EVlen wi th t he blest lab tectffiiques a m.inimUiJ of six separate stool specifliJ~n5. are needed to dliagoose the df sease . Trophozoi tes ar-e fOlund! in I iqllJid :stool s; eyst.s are found in fonned stool s ,

A .. , Ameh rasi.s ~ Di f"ferel1 t.iall d iagn~':)is.i5: Other' causes of

diarrhea:! b.ac ill air y d y5m tery, emot.ion all diarrheal tJ -di arr'hea 201 to Laxa ti ve abuse II d:i ver'ticul j,ti s , fJ rug s , pern Ic ious anemia ~

Pi ., Collect.s ix stooll san:_Plles to look for tropho'z'oi te SI aln_d cystsl ~

Trolphozoi te.s that conba in ing-elst-ed red tllood eel Is are -d i agoolst i.c fOT .

inv.a.s i ve Enltanoeha, hi stol ytic-8 ~ leukac :.rtes and! mac rophages ar e reI a ti, ..... elyl rare in the stool sample; whereas in bac i.ll.ar"'Y dysenJter., m:any 'Wb i te bl-cod cell s alJ""e present, .. ,

T("'eatmel1 t : MetrQI1l id azol el (Fl agyl) 75(1 mg... t ... i ... d. x 10 days followed bly d i iodoh_y-d rox_vqjuin 650 mg. q , i. .d , x 21 da:;5 tJ

rullow~u(p c are : The 5tool shQlull.,d] be -examined .si): t.imes; olver one week afterl S.ymlPltCfnlS harv e di sappeared .. I f an Y' C fats or tropho wi tes are found in these .spec irne;n s , in i ti.a te the t.r'ealtmen t above unti 1 sytnlptomls are cleared .1

2- 3. HWRIA. ~all ar ia is perhaps the mo~t, deblil ita t ing iII ness; W1r'ldwide, espec iall 'f in the tropics.I f·our s~ec ie.s of PI a smoo i urn. are FeS]X.lrl sible:

Plasmodium It i y ax:, fal ci parlin, rnalari.ae ~ ~Ilr\-d ov ale ..

S. ACtite epi sod.es 0 f c:h i.lls ~ fev'er t arldJ s"Wea tingl.... (kcalsion.ally

Liel ir ltD , cClTla 'I cOfl'U'ul si,ons -t ga5tr~oin te'st in al d i sorder-s" aLnd j aL6]di ic.e ... The -chill 51 last fr'om: 1 S minutes to al11 houri; nausea, vcmi ting I' and .se:vere

bead ache are- CamlOTI at thi 5 ti~.. Feve1r too t follows the c hills wi II 1 ast .sever al hoILU~ 5 alndl ~ill 0 ften get to 1 O~·O r ~ OT higher.1 The ttl ird .stage, or .sweating ~ cone I udes tt')e eye i.e ~ The fever sub SiO€5 and the p.a t.iefl t, fa lis asleep to i3fwaken fee'l ing fai r 1 y well... In VI i val:! ovale, and fa-I.e i p~r'l...anl

In fectiol1s Il the epi sodes Ol[!~ ur ever'y .ijB hours (tertian malar"ia}., In.

mallar iae in fec:t lan..s (quartan mal ail' i,a)' the cycle talkes 12 hour s ·

":11-1

L

Trypafl?.sctma . r~esierJ].se ".and . Tr"'ylpanos~a gambien se .. Tr ypano SOODJia s i 3 occurs tt:llroug.hD~I~ troPlc:_l A fr lea froo soul h of thel Sahar-a to aoout 2D degrees

South 1 at.~ tuee , : r ypano-SOmla ~,amlb i.ense is 1 imi t-ed to w.e st; A,fr' i c a up to tJhe

-western j1;1 ft Vall ley' .. Tr Y'palnOSCfr!Ir3J rhodels.iense occur s to the east 01 f tile

Hi ft Valley.. B:lth t.lry_p~nosomes (3lr'e tr'am sm i tte-d lOy t.he b i We S olf tsetse

.. flies II

01... The thic k and thin 01 ood f1 lrt1J.. sta ined Wl ttl Gi€msa ~ 5- st,a in or RamanovsKY sitain l' is the me in stay o f mal ar La diagnosis.l The ttl i n fi 1m is uLSed pr ir.DJar i III for' spac i.es differ-en t.iation .a fter the pr esene e of an

in fection i 5 d~tee·t-ed O~I 31 thic k f'i.Im , The level 0 f para s.i t e s in the 1110.00

Y ar iels fram hour to oour: there fa'Fe. the ~ 10Dd should be e)[: am ined several t:i'1O:e s a da'j for 2-3 dlalYs.. Anemia may be pre-sen t and i. S usual I y more S€'t F2're Wi ttl fal C-i,partn i.~ fections .. Ja:und Lc e fnay' d eve lop i n sever-e in fee t.i.ons.,

s ~ The pa tient mlay ccrnpl a i n 0 f a local in fl arrElator'Yl r eac t ion (called a trvparlos-om.a ct"lanc;r'e).. It oc.~urSl wi thin ~8 hour's af't.er a bi te II

The Lestons m~~ be I pa in fUll or- ,pr-'Ulr i t ie for lip to 3 weexs t, Th,€ patien. t m~ly

n.arV'el per sonal i t"1' e h,anges f headach~:I apathy t somnol.enee , and t.remor s .. "ihe patient. ma:r becone severeI y: em~eiated and finall y becone conatose ,

A .. , r~alar ia In Di ffer ent i a] d iag,nosi S : Other cause S 0 f f'ever t~

tropde s , 1J1f"'" inar Y' tr act in feCI t ions 11 t ylphfQdd fever 11 in fee tio'us !le pat.I ti S:I dengue Pl leptospi rosi.s I' Ex an in-a t ion o f the blood fi 1m i s essen tial to

d i.I'feren t.iate the above from rnal air ia .,

'I . .,. OJ:-. Ir'reg~lar . fever", tac:hy'card ia ~ pai n.l ess 1 ympil nodes ,

tlIlltlpl e thl:k wet ~ 100d SIlile'ar's .sooutldl be t.akeqn., Other 1 i:lb fi~d i ng s

in~l ude anemla arid! Increased sed imen tation rate. .

P ,.. Chloroquine is used! to prolph y La tically

suplpr'ess syrnptom:s a f malaria:,- 01 tJ t, i t does not pr even t i nl f.ee t io,n ~ If falci pcarum mlalar i a does fl'Ot roes ~lnd prcroptl 'i t·o -c hl.oroqu in e ( within 2,lJ, hours), psraatte r'esistance to this drug mtlst be consi.dered ..

A" Trypanosom Last.s ., Di ffer ential d iag,nosi s: May be mil st.a ken: fOr' a Y'ar iet Y' of other dli seases i.ne.Iud ing mal aar' ia 'I turber-c ulost.s , k.al i:ir-azarr tl a 00. cerebr-al, s",phi 1 is oIL.

Gi'J e chl.oroqu ine Jlooslphate.1 1 gr ami as in i t.i.a 1 diD5€- II 500 mg.. in 6 hour s t1 afldi 5rOO' mg , d ail y for the ne'x t ? days II If petients can not ahsorb tile drug r31pidll y because ·0 f vani ti ng or sever e d iarrbe-a II Olr if thely ar'e ccmato se 11 & tve 250 .rng.. t sal t)i of chloroquine hydr'-Dch lor idle intr iInusctll ar 1 yl • Repea.t in 6 hours l' if neceesary f amldi fol low with. oral ther'ap·y as scoe as pos~i 'tile.. Co no t use c hl.oroquine forI severely i 11 patients whose infections origlinalted in art endemic reg ion fOlr P .. fa1-cipar'Lln.

. ~"Pentamidinle is tile' drug of choi.ce for pr-ophylar:c:i:s of

sleepl ng SIckness 11 but i as ef'fecti ve wi t.h cer-ta int 'i on 1:J against the G~o'ian type.. . In . Rhode~i an _ in fe(:t iOI~ , . pentamid ine ma:f lead to suppression 0 f e al""" 1 Y' syrnptans r'esul t Ing in recognl t ion 0 f' the di sease W<Ji 1 ate iil its colLlr se for

e'f~ecti ve' ~Featment., 1 Clle. in tl""'arIllU5cul.ar injection {.ij ~"/ki.l DgF an" max imJJ.ft1 ~flO mg .. ) ~lll prQt~ t aga inst Gambien.se in fee:tion for- 6 rmunths.. The- drug ~,s poJtent~.all yl tox ac ano should he usee for per so-ng a thigh r is.k .. It must be emphasl zed that the drugs used to treat tr'ypanoscfflliasi 5. are av a iIable only frorm the Par a5i tic Di sease Drug Serv ice pi Cel1te'r for Di sease wotrol

Atlanta ~ GA 3D33 3:t (404 JI 329-3670 _,. t

ProJphyl.ac,tic (suppcr--essi V'I? ) dosage: !3e for-e 1 earu' ins OOtne', the

pat tent sb~)Ulldi take a te s t diose o f the med i.ca tion to deter: t _p:)SS ibl if?

allerg ie Ir'ead ings ~ Slt,arting about 1 week: before ar'r i ~ a1 in the area 0 f mallar i.a risk + the pa t ient should be.gi n c hJ.olro,qtl me phaspba te 5rOO mg " {sal t}1 weekI'j tl or' the' c:ambj,ned tab let of chl-:)roqrui n e 500 eng -t< (.sal t) plus

pr :Jlmaquine. phD s phalte' 18. '9 nng II {sal t) weekly., After Ie av' intgl the endemic area.1 t.he c.hl orl·o qui n e should be conti n uead for 6 weeks 0 r the cooh ined. tablet fa r 8 weeks. ~ For' t~'5e taking chloroquine do.s-e IJ a 1 lI-da "'}J' -coursel of pr im,aqui n e snaul.{j be. given i f there~ bas been sign ificoo t -ex posurre to

P ul·i~ax o·~ P QlJallel

Ii! • . IIJ ,_. . ."IJ '.J '. T .....

Sur amin sod Itl1i1 i.s the d rug of choice forI tr'eatmen t of tneo

:;.arl yl .stages 0 f trypalflo3Omliasis., Treatment is 1 gmJ dosages @I 1, 3!1 and 1 -uay.s and then ~ek 1 y I:Jnti 1. al total of 1 grams, h.avle been g, i ven .,

Pr irnaquine pho-sp,ate: Th is dlrlJg_ ha So been shoMl to be the m'[}Ist effective age1t ag.ai.,n_g;t the tissue forms of Pi" vivax and Pl. ow'ale ~ 1be dJosag,e for pr imaquine phQIsph.a te is 26, .. 3 rmg.. dai 1 '1 fa r 14 daY'S ~

_ . Ir )'par samide h.a 3, been used for a long: time for Ge:mbi ensel

Inlfeetiolil~ of. the cenltr-aLl, nrervlOu~ sylstem... It i..s given in tr avenou3il Y' ina 2~1 .sol ut lOfl .In watrer., The dosage is 2O~4[J1 rnA ... /kg.. (maximum (jose 21 sm}J 8l-ven alt we:ekl yin tery·aG. . .s for a tclt.al of 1 a~ 112 injec tions; ...

Trea,tment of malaria dLR to P .. f.al-=:ipaTum: strains resistant to chluro-qt.lille.

. Ge:ner a 1 me a surlels, : Glad I1lllJrsing care and treatment of an em ia I

concurren t in fec:ti.ons, and malnutr i tion arle e'ssenti.al in the marl aF!.; ell eI1t .,

65'0 ~ .. 3 d,ayls ~

dapoone

"W1e'n the Jlatien:t can ta ke medication or allyl 1- g,i ve QfU 1 n lne 5-u1 fa tel 3 time 3 da i1 y for 1 ~ days plus p"yr-ime:tham ine 25 mg... t wtc e d a il y for _plus, either sUil f:adliazine 500 mg .. li tirnels dail"J far 51 -days, or

25 mg " -dail'J forI 28 days.,

, PrognA1JiSli s: If untreated, most ealSES of A,flrl ie-an

trypano1sami.asis arle fal t.a 1 II If" treated proper'lyl j the progoolsi:s is excellerJt ..

Fori Pf"lopl1., 1 alX: is Il Fan sid ar for non immoo ~ ind i v i(j uals

(pyrimethaTI ifle t1 2-J :ng., anrd sui foooc< inel, 5001 mg.,) stJoUild ble gil \\,len ooce

weEkl y .. ThE' med ic.atiolil should be -CoQrntinue~ fOlrl -6 wee:ks .a fteJr 1 earul i n~ the endermic area. A1 thJ!ugh fansidarl is no t avai lalll e in ttJe UlSA:! it is u5ualll y ava il ablel in. co~ tr ielsl wi ttl chl oroquine--resi sta!TI t mal air ial un,~er tile tr- ooe nane s· Q f Fan.sidl.ar 11 Fale idar t' or Antem~111

21-~ .. AF RICANI T]l:Yft\N-OSm IA.SIS {51 eeping .sioe kness) ~ RhOO e-si art and Ga.mb-i.an

lrypeno.son.iaSli 5 ar e c.a used b., two flil()r ph£:)log,ic:all y sim,il ar parasi te 5

S.l Inte'rM.i ttent fev'er, 5;w:l11 en pa inflJl 1.)'mph nodes II and O!:Ca.siofl.all,' -convulsions ..

2-]:

2-4

P, Me t ron id alzol e in the dosage required to treat ameb ia sis has p~en ~rfective~

c , P4ue.ocut.anooLlS (naso-or.all leishmaniasis ,I N-aSD-Olral lesions caused by lei stman La s,i s ar-e seen in Sout.h Amrer ica .. There i tis referr ed to as

.. espund ia I' The anter ior cartilage of the nose is involved and somet.Imes leads to a camplete ero stoe (3 f the' bone vi t.h d is Ngur'ement... AmptDter Ic in B 01 ... 25-1 ~ .. /kg... eY'e'f" yother day for up to 8 weeks i 5- r e(lui red. to kill the!

organisn.

0.1 Barn r e-dem.atous 11 red ~ and painful cutaneo-us _nodtJ;-e~ ~

( h ) U.n, l·lat,.e'ra.l· p.:a'lpe,bral and fBeial edema and £onJunct~vltlS.

,ci'agoma •

.A.. Chagasll disease II Differential diagnosis: Can be c onfused

with kala-azar'.. The chagcena rnay be rnistaL<:eln for a variety of t.roptcal skin

diseases ...

P .. Establ i sh the d ragno.si s by ta king thi.ck a nd thin blood.

fi.lms and finding the paruai t-e- in the smears.. T'ry'p~nascrnesl should be _ looked fOF in ttJe nl.ood of a 11 pa t i en t.s but will usual.Ly be seen onl y In_ the ac ute stage 0 f in feet iOIl .. Treatmert t 0 f Chagas ~ -di sease is s:ymptomatlc a01d sup,_porti ve , The best pl an of ale: t.i.on is prever1 t i, y'e~: li v illg quarter s shoul.d be cleal1ed and pestle ides used to er a:i acate the msect.s that

tr an:smi t the disease ..

2-1 .. SCHISTOS{IJI IASIS (bi l.har z iast s.} I- 11m b 1 aod f1 uJ<e (tr-E!11atode) infectio'li

wri thl adul t male and female Lr.rlrm.s 1 i v i fig in ve ins 0 f the host. Symptans ar'e related to the location of the parasite' in the htl1'loo holst.. Scht stosoma .manson i aoo Schi stosona jap:Jfj] icum g:i v-e rise to intest in al, symptoms ..

Schi stosona haematob i.un g i LJe:~; r i 5e1 to UT in ar y tract symptoms ..

2-tJ II] LE lSHMA~~lASlS ~ The cl in ieal ~an i fe-statiofls 0 f 1 ei shman i.asts may be c.l.as.si f ied as (1) y i sc er al, (2) c ut an eous 11 and (3)1 mueoc ut.3l1eous Il U1ese distinctions are nat rigid because in the eour se of illness one type ~a, develop into anotber . The leistDlaniases are :-.aused by d~fferent specae s of leishmania tratlsmittefi b'j the bites of sandf'l Ies (Pt11eoo1tomu.s) 4·

a , Vi seer al Ie i sbman La s.i s (kal a--.a zar).. Vi seer al 1.0 i shman ia.si s is geogr.ar;:tl i.cal L 'i widespread.. It is caused mainl y b'i t'WO spec ies : Lei shmania donov.an.i in the Indian region and Leishmania infant-urn in USSR:! China f Mid,ti]_e Ea st., He-diterranean basin ~ and Africa,.. It allsrJ occur-s in South

America"

S.. Tra"ls.ient re-d i tchi,ng skin rash wi th fever .. malaise. The patier1Jt may' have d iarr hea , aJbdaTI in al pa in tl 1 ass a f a ppeti te , Loss 0 f weigtlt. []r' in ar J frlequenc'l tJ uret.br al, and bladder' pain ,

0.. Diarrhea and abdonirial pa in are c ammon ill the ear-l y stages of the d Lsease 01 Di agnosa a depend s- on find i ng t he eggs in st.ool spec im~ns II As many as a-l0 st.aol spec Imen s ar e needed to detect the eggs.

A. Schi sto3ClTJ La st s sooluld be con s tder ec in all unre spon 5 i veg,astrointesti~al d i.sarder s in end em Lc areas.. Di f'fer en t.i a 1 d iagoos,is:' ~r-ly schistosalia.sis maYI be confused with dmebiasis or ll.aeterial

dys.en tery ~

Sol- Irr-egul ar' fever:l insid tous and ebroa i.c ; onse t rna:; De' acute'. 0,. PTO@;reslsive an em ta to 1055 of !.-Ie igtlt.,. prcgr'essi.ve dar kening

of the skin espec ial1 y the fo rebesd and hand s ~ gradual en 1 argem.en t ~f tbe spleen and 1 iver... The fever may be uery high and the patient scmetllles does not look v.eryl ill.. There is a mar ked dec r ease in the W .. B,,. ~ .. j usual 1 y

Ie s s than. 311000/011.. The- d i.ag_oolsi sis est-aill i. shed D"i d-emofl stra t.lng,

Le ishmao-D:Joo'-t an bod tes in st a inedl blood smear s ,

P.. Treatment should be g iven only' if I ive ova a,re id-entifipd 01

In the USA:I the fir s t drug 0 [ c ho i.c e for S.. haematobi UJOJ and S. man son i

in f-e~ t.ioln..s i So n Ir id-a 2:01 e , l1.Jlts;i1e the (BA:! in COUr'l1 tr ie s wIler-'e i t i 5- avai]_able 'f the dr~,g 0 f cbo ice is ox aM:1i. qu in€. fo r S... man son i and .netr i fonate for S.. haemat.ob itl'll.. Nit' id a'::.ol e should be adrn i:.l isterecl in 111 g,hi dose s , under close medl ieal superv i 5io11 ... Or a1 do se s are- 25 rr..g 1'1 kg , (max iTIU.DJ 1.5 gram,::;} da it y in "2 d ill' ide:.] doses for 7-10 days.. The si de effects 0 f the drugs ineltld,e na usea fJ 'tooi t ing , head ache f and brot-.ln i 511 d i sc 010 r at ion -0 f the

urine~ .

A.. Lei shnan ia.si S ~ D1 fferent i.al -d i agnosd s : m,al ar i.a ,

2..,s II] FA~ IOLOPSIAS IS.. Fase io1 opsi 5 bus ki i 3- a 1 arge in test i n al f1 utke fOlufJd] i,n ChinlaJ. 'Tai wan I' .s..uuthea s.t As,ia ~ and 100 Ia I The- in termed iate bo.st is a sn.ail., lrlurnan 5, ar e in fectec by eat.ing uncooked w.a ter pl an t.s t nat have the p.ar.as-i te encysted in the'n.. After a:'-l incubation period olf several IIIOnth.,s in hUlians. man i festa lions a f gastr-o in te5tir.=.a1 irritation appear iii all but 1 ight in feet ions 1- l~ 5e'J eire in fee t:. ions:

p ~ Ir-eatmen t :Jl f v t.scer al I ei.shman i asi sis d i ffic ul t---the blest drugs- are not available for general use I' The- drug ttlat is a~ailabl-e is highly tux ie 2 b·ut i t sho [lId be tls€d if nee essar y.. Ampholter ic In Bat ~ al dooe of 0 ... 51 mg .. /kg .. per day is -di5sol.~ed in 500 ml .. of 51- dextrose and g,lven overl 6. hour SI on alternate d a)'s "' Pa t ien ts mtlslt be closely mon i tored ..

Wi trout treatment -r kal a .3 zar- is tls,uall y fi=:l t-al ~

b I' -CurtaneCHJ5 1 -e-lShmM ias} s-.. Cut.anffHJ5 1 ei sman iasi s may presenlt as

self-he-ali,ng, ul<=-er's {or-i-ental s.orle) F oon-ulcerating nodules tllat resanble. leprosy rand cbron i-::! rout i 1 ati n.g_ ul celf'" S • Cutaneous leislun.ani-a 91 sis seen in

the USSR ~ Ind ia, the Mi-dd le East... the Medi t-erranean basin, Afr' ic.a to arid

Gen tr a 1 aoo 5.Juth Arne,..' i.e a.

: S ... and o. Cranping ep-ig.a5trie and hypogastric pains r. diarrhea f

i~ltenmi tten t constipa t ioo ~ anore)[ ia ~ and nausea.. Ed ema:l par t i.e LJl.arl y of the face and .asci tes {ac-IC lfiItJl at io:n (I f fluid in the ahdoni~l al caiJ i t_y) may OCCUI_r lat-el"".. .:e~ t h me y resul t from the p ar-a s,i te or se-c.orld ar y if] fee ti-Oul ..

". . l.all find i:Jg s : l.eulkocytosi s wi th mader .at-e eosi!1o ph ilia II]

Ol.agnoS-is i5 made by finding the eus OJ" oe-casiQ~al1 'i flukes in the stools ..

S anrd 01.. wtaneous swell ings appear about. 2-8 weeks .a fter bite s of salldfl ies,,, The SW€ 11 i rigs rna y ulcera te and discharge pu~! or the'i may r'emain d r~' .. Or y. and moi st. so res ar el {! aus.e-d tI'1 d i stifJct 1 eishman. ias... wi th t,he dr'i' fo rrras ha ..... 1ng longelr i nc.-uDaition per i-ods ..

flukes ..

A., r.ase iol opsi a si.s _ 0.1. ffer en tia 1 .j ia~,rlo.si 5: -Qther i r: test inal

Ii .. , Cuti3t1rolJS 1 eishrrtan i.asi s . Di f'feren tial d iagnosi s: 5:yphi 1 is ... ottler- f{}lnTlls 0 f ;st( i n 4d i sease ..

2-,61

gaIl oral I y on an em.pt Y' s:tomach~ in the morn tng , Repeat in 3-ij d1ays ..

Chi ldren 01• 1 gmlyear (I f sse to- age 1 Qi., Same as wi.th adlUl t , After- 2' hours gi'ale' sod lUll sul fa te or ood lllll ci tr ate as aJ p1Jrgati,ofll to flush the inltestil1al tract. TWoI trealtments are usu~lly suffic:ient. A.1 ternate drqt _Pli per-azfne citrate in r'ec~ded course ~)l£ tller'alpl}".,

2-9. lIVER fLUKES.,

a , fascioliasis.. Sleep liver" nuke fOlundl primarily in Latin 'Amer'ical -end the "Medi terrarJear:lJ a.re~. Hctn is in rested b y inge~:stin8 the metacelicar-i.ae an water~rest or olther aQu~tic -V-e@:etahles.

b ., Clono,rchiasi SI. Endemic i~ areas of Japal:t Korea.1 China. FOnnosa11 ald Indochina. Imlported cases a rei :seenl in USA. !OJ "Man is in rested by e'ating Taw Q'T undercooked fresh~ter' fi:sh _.

s., and 0,,- Light in.fe.statiofls may be, asymptonlatic 'I Heavy

in fe'stations· me Y' presen t as malai se , fever 11 1 i ver teoo.ernes.9.. an€i jiamld ice- .. These symptoms are tr'aJ'lsi.ent ~ Progressive liver' enlargemerlt. right- upper quadrant patn , and v3@:ue abdc:min al symptans such, as (i iar-rhea:l weakness ,1 weight loss J tachycardia I and a var-iety of other- SymptOO1S may occur ~ .

Lab find ing,.s : Leuk{)Cytosi s with eo s,inophi.l ia sanetimes ('ran IDiagnosi sis: m.ad.e by find ing the eggs, in the stool ~

A., Fascial iasi.s or clonorchiasis.

Pi.. Bithional lIO mg"lkg .. P .. O .. , on aiter'nalte days over 20-30 days ... .AJ. ternate drug: Emetine Htl ~ l mg Il/kg.. 1M up to 65 mg.. da il y for 1 days,of. ReC'O~ery is slow even if all the fl ukas are ki.lled II

2-,10. PAMOON IMIASIS. A lun~ fluke found throughout the Far East, 'Nest Af'r-ica" :5:)uth Asia.1 centr-al and nor-thern ~uth: Amer ical + Han is in re~t.ed by' eati ng ill fected S'la Hs , cr abs ~ and era )!fl sh -a, Inge·sted iJrmature fluke's mig!",late thro~h t.he small1 intestines usually to the 1 oogs 11 all too ugh t.ney can lodge in o-tl1er" ti ssues 0 f' the bod y or f!'J enl migrate, to the brai n Qlr

splin al cord ~ but these us,uall y fa il to mature. The fl ukes that r each the'

1 unss . encapsul.ate , r'eac h rnatur it:; Il and La yeggs t, 'Thes:e capsule s swell and usual l Y rupture in to a bronchial e ~

S.. and O, Th.e in fee tio~ is usually aSyrAlptomati<: until the n,ukes mature· and begin la ri.ng eggs"", TIlle on set ts in std icus wi ttl low,..grade fev'er anrd a cough that i 5 d ryl a~t fir st tJ t.hen turnil1S to a viscous sputUUI the t. i. s rust.y or blcod-f'Iecked , Plel.J!ri tie chest pain is, CClIII!On. The oonditi.orl is, chrOfl ie .and progre,s.si lie' wi th d )"spnea T siSfJS 0 f bronehd tis and

bronoht.ec tasis f ~akfle.ss 11 malaise ,I and ~ ight loss. 111 he·av' 't inlf'e·staitions. pair as! tes in thel ahdlcm~n rna;}" cause abdaninl.al pain" -d iarrDe,a:l or d ysenterYI IIPara.sites in the- brai.n orl .splinal oord t1 depending on their loca,tion:t, may

cause sei zur'es" pa15ies, '" or meningoenceliltlli ti.s ..

Lab find ings: 51 ight, leukocytos.i s wi tJ] eosinophil i.a .. Eggs c:an be reoo i 1 f found. in the sputLm if i t is SPILl'] diaM] and a smear is made! {'ran th.e bfJt t-oml olf the tube ~ Eggs can al so be fOlood in stooll oS pee imer1S· ..

A. Par agonim.ialsi.s II

P. .Drug of C:b)ic~e is bithionol 40 rJ€ .l/kg.1 of body weight giY'-eIl on alternate days for' 10-15 doses (20--30 days)"

2 .... ,111... TAPEWOOHI IN'F'ECTIO.NS.. A number 0 f t.ape..orms e an in fe:c. t, hunan:s blut

001 y six are (!;OI'I'IIIOnl Y found. Distribut.ion is war ldwide ~ In festat i~ :3 usiually occurs by e.at::.ng infected and undercooked· or- raw beef , pork tJ fresh "Iter' fish 11 and cr ut.Staceals t, 'Tape\lOnnlS var Y' in saze fr<m. 1 {HI. or Less to 300 (JIt. or more'.

...

S.. aniJ~... AdJul ~ taper...onns i.n human intestin-e's UIS U9l I I y C ause no SJlllpt-aD5"1 He'av'y Infe sta tlOfl s ma!y pre set] t as ~ight loss, vague' abdamin.al

e.cmplaints =" d ~ar r~a 11 anores ia! abdoninaa. pa in t" alfld nerYQU~ d i st.urbances 11 _ _particularly In ctll.ldren ...

, The 1 ar~a 0 f. same taJpeWrTnlS migrate througtoLJrt the l:Iodly... In

mlJscle or eon~ect~ve- _ t.Lssue they cause no problemls ,I but in the bra in they mar cause II Wlll:ie var lety of man i fe!statio(]s: epil eot.tc sei zur'es =" mental deterioration, personal i ty dli st\JrbI8r1c:e'.s ,I and internal hyd roeephaf us "-

Lab find ings:. Segillen ts 0 f the tapeLrllrnlJ maYI be fOaJd in :stool . clothing 11 or bedding.. The ova often. Ca1I1 be round usmg the scotch tape IJ

llethodl (as used to d i.agoolse pin'Dnns) II- The eggs (Cf'I a) are found .

occasional! y in the stool II

A,.

la~f.~~

~~~ ~I".

. ,P.. Drug of coo ice: ~iclo5alllide- ~ Gi'lle 2: IJI1 orally in the

morn ing, be fOlre eating for 5 days,.. If n i closanide is not 3ii1a il ablle ~ use quinacrine HCl ~nrepacrine). Place patient an liquid diet 211 hours prior to treabnent (nOI mIlk),. The' everring before' treabften.t.1 g,ive sal Ine olr soapseds enBIJCI ". ,I Chi mornln~ of ~lre~tmen.tt, wittiholdJ breakfast and confine patient to bed.ln . ~ GI.lve an antl-emeltl C C. Canpa z,in.e1' and wait 1 bour' .. , Fo·r chi Idr en la-3~

kgl. ~l~'e ,O .. 5@l11; for. ad~ tSI olr', ch~ldlrerl over ~5 _kg .. giv'e 0 .. 8 lJUl.. Ibse mlaJY" b~ d~vlded. but must be gl-v-en witl1in 3-0 minuees , Walit 2' hours af'ter the 3r\n

1I'J1.nliIte.s ~ then give sail Ine or soapsuds purge, .

~-12~ TRICHINOSIS., Worldwide dlist~'ibutian:l IltJt it i.51 .a gre·ater pr'Oblem in tile! temper-au' .areas than in the tropfc s , Infec,tion occur-s from eating: r aWl or'ooderc(X),ked pork, but bear and val r'us meat has al SOl been impl icatedl .. ~pt.oms may appear in <II f@w nows. bUit usual. incubation ~rioo is r::: 151

~ays. ~' ~ .

I .. ... S.. a~ 0... SymptomlS I.J ar l' cOflsiderahly d.epend inlg, on the n Llnber Qlr

larval andl the tl ssue inv'adlarJ 'I Initial s·~pt(J1ls oecue wtlen marture femalle

roLlildIWlnnis b~row in tr) . the small in testina} mucosa and may per sd st Lm til the 00 uli t,s . ~ l~ .a t about -s weeks. Diarrhea, atdCl1Din.al crr..=mps J malaise ,I nau5e'a:t, ~cm1tl.ng I and occaafenal l y eonst ipatdon , The' larva m.igrate throlLJgtJ

~~ .~loOOstreall, to. ~st tissues o f the bad y beg inn ing at the eIld 0 f the

lrst, .. week !OJ. D11S br l~g 51 fever-"t lOH-grade to marke.d; ID1iscle pa in 11

eS~lalll.\r on PII ...... ~fem· nent .. m sIII"I1 t d""'.-I .,

fa 7· . '... ..........., I ~ ,u "- e 'en ern~5s ; ~ ema ; spa 5m3 ; per !Orb i tal and

.~1aU. . edenl!3 I ~at1ng ; be ad a:: hes; photophob La; weakrless or- exhalJStion ; pa. n .o~ 5wallowlng; dys pr1e',a; coughing; hoar SBfl@SS·; conj uncti val.. f'etinal

~1IIIIIi1l!ll1 n'~ll I:--mor··h d h

.... IU ~. IlJllt:- - - ... j' •• ', J. . Ii . - .. _'. _' . I'. ' •

. . .... .' ~' .. ··1 r ,ages. .an, r as·' es,. Inflaflmatolr')~' reactlons, may produce

men7n6i.t~s. en(:ephali tis I myrx ardi tis, pneLlOOni.ti.s" rlephr;i tis f and p.er~pbf!r al and cran ial nerve- d i.sorder-s... Death c. an occur in lI-6 weeks "-

Slowl . .. ~ . find ings : Eosine-phi 1 ia 20- 'rjJ in the thinj or fourth -week F .' ...•. ' · "I decllR:tng to normal. Adlul t worms are r'ar-ely fc~d in the feces ..

~;a as.~OC~sion ~l ~ be fo~nd in tb~ blood in the second week.

... n1tlve d1.af500S1S 15 p:lsslble by blOp5I •. ·.v of s,keletal muscle in the th.l-r·d,

or fourth -week -to . .,

1:-1

2-B

P II Symptamatic~ treabne:n t. is r1()Jnn,all Y' .a 11 th~t is r-equi red. If'

i tis kool"Wf] a pat.i ent ha s eaten in fee ted meat wi thin the' last fewl daysl {not O\\'ler 11 wee:k) , give ttliabenda-ZQle 251 mg ./kg. (ma(K imm of 1. 5 gxn) b ~ i I'd ... after' ameal s for 2-U days II Severe in feet ions ~ tdlen the Larva invade musel,e tt.ssue , require- . hospital i.za tioo and high dose s -61 f eor-t.tcost ero ids for- 21.q~,ija hours followed b"j lower doses for' sever-al days or week:s to control

s)w pt.ools t.

2-,l3. TRTCH.URIASIS (W1 i p~'1k)nn5) .. small 51 end er W3'FmS.1 3C1J50 TIm I' in 1 eng ttl , found M}lr Idlwide l' pa~ L ic Llllarl,' in the suot.ropie sand t.ro pies ..

s. and Q. Li.ght t.o moo.erate infe.ctio!l1.5 rarel'1 cause .symptoms 11 Seyere in fec-tions (1 G? 0001 o,r roore:' ova per grClTi1 0 f fece 5) ma Y' preseflJt wdLth a w-ariety of s ymlptomls th3 t irlc:}lX1e abdcminal palin, t.eneseus (:spa 9D.OO rc contraction of' anall sphincter wi th palin and persis:tent t1 inf'lolluntary, ineffectual st.raining effot""'t to empty title' bo~l) Il diarrhea." distentioJ1,

fl,at ul.enee " nausee , ~ ani ting t a~dl we tgh t Loss, Blood Loss may be

sign:i fi<: aD t and r ec tal prolapse mlaJ)l' occur.

Lab rindings~: Charaeteristi-c barr-el.-.shaped eggs. ill the stoot ..

Eosin~lph.il La 0 f 5-20~ in al.L b,ut 1 ight in fee ti.-ons and hypochranic m1€fOla may be presefl t in he'aJV y in fee t.ions ·

P... rriebendazol e , 1001 mg;. b. i .d. befor e or af'ter meals x .3 days" Tabl.et.s should be cbe..-ed be fore s.wallowwg 11 No alcohol 24· b'ilUIi s before am a fter treatment.. Al ternate treatment roapsud s enema follo1e.d by

hEX y'lf""'e'sore i.nol. erlBQa ( 2D- 30 mll.1 kBl Ii up to 1:1 200 ml II ) • fJlama should t>e-

reb ined fDr' 30 minutes before ex pLllsion ...

2-,1-4, Ij A,s(:AR1AS IS. The ID) st, ccmnot1 inte'stiIl al ~Inn.. WOr Idwlde

distr Ibut Ion. In fectiarl i 5, C a1Jsed by i nge'stion of matttr"'e eggs in f-ecally' con t.an ina ted food and dr ink. Egg.s tJa tch arid the larva pe1etr'.a Ite. the w~lls of' the small in test in es and mligrate to the 1 ungs II Ad ull t WCJ1TDS, are 20-~,O .t'W'I'I Lo n IIili

~UI. ~ -0.11

S.. and 0., Fever , cough, heaopt )lsi s (spi.t tins or' coughing up blood}, r ales ,I and other e\l1 idence 0 flung, inrvolv'emert,t Ii RaJr'ely -r the larva may go alstray' lodging in the brain, kidney 11 eye 11 :spinaLl ~olrdt or .skin ~

Heav y in fee t,i,Of] S m.a.y alsol cause vague abdaninal ccmpl aint.s .and col ic .. Wi tb heav'i in fe~statior.l.s 11 especially t f the: wonn.3 3t'e stimulated. I:Il" certai,n oral medications ar aDe!sthetics, wlandertrl.g lDa;l OCCUr" I' lrbrms may be coughed up IJ vomited 11 or po ssedl ourt thlrQugtl the nose ~ They' may a l.so c:.alJlSe !TleChat.ical blockage and tnflarrmat,ion by fa~irlg th,emse,lves into the caunon bi.le d oct, t he pan~r'eatic ·doc t ~ the appendix;, (I i vertieul a:t, and other si, tes .,

l.aJb find iags :: Eggs i.n the, .s teo 1 ; la:ry a ma~y occasionall y tie found

in the' .spult LIn IJ eBC reve'als eosinophi 1 ia I,

A.. Ascar iasi.s Imbr icc ides... Di ffer'et1tial d,iagnosi s : Aller@: i-c

dli sorderls, other c aU$es 0 f pt'lleLmoni ti s., appeoo.ic i ti s, diver tieul i ti s r. etc.

p ~ Piper.a z.ine Ii Each ml IJ 0 f syrup contains TOO m:s.. of piperazine hexahydr ate T tab lets con. ta in 2'50~·I)OO mg.

lAP 00' 11~ kg ~ giv'e 1 gm 1.Q-22 kg Ii glve 2 gIn 22-Jl51 kg , give 3 gm over .1(5, kg. gi.ye' 3 ~ 5 em

once a -dalY x 2 days Healj/!j infections may requi re 3 to 4 days, of trealtmeflt ...

..

Al.ternate d rl.Jg.s are Pyt;'an te~l pamoate l' m et"i end aZ.[)1 Le " levaTlliS<lle II and bephecl iun hyd rolx ynaptJrthoa. te .

2-15.. STRO~ILOIDIAS1S. -DDrmrn:on in tropic al and subtropic:.al alreas. WJrldwide~ ES5etntially an infectiOfl of hLlnaflS but dogs mal'! becone infectedl'l' larvae- tha tare' pa ssed in trte' feces can ranain 311 i ve for several

-weeks ill certa in. .soi 1 condJi t rons II The Y' in fee t man by peneltrating the skm

and et1 te!r ing the bloodlstrean r' arid are c. ar r ied to the lll']gs -10 The)! Leave the ~blood.:st,rean and ase end the' bron(!hial tree 10 The larvae are then swallowed ald are carr i-ed to the' small i Til te st.Ines whe'Te they mature and l.a_y eggs 4.

S .. am 0.. Many cases ar'e asym:ptCtnaltie I' Seril.si tized paltients maly

deve1lop 1 inear, er )!thematou5 II or ur tie. am- La 1 Wheal 5, t.hat m al_Y be' in tensely pir' .... i tic or even hemort;t]ag ie fOil lowing e1 tr 'i 0 f th,e l.arv are into the skin .... IlJr ins the mligratorYI pha se , vag;ue' SynJlptomlS d e\relop· i.ncl ud ing mal ai.se 11 aoorex ial 11 fever 11 astbua, t1 rec ur'r en t cough Il and ur ti.c ar La, frequent

ga~tro i.n test in al symptoms. follow; diarrhea (may al ternate with periods 0 f' OOITmal1 bowel nK)Vam~1 t air cansti pat ian), nausea: 11 vcmi ting, and d L ffu:se eQIli.ck,y pain Il In c:ill1dren ttJere- rnalY h-e' abdcn inal dl istenltion and per si sten t diarrhea a-cecmlpaTIiedl tI "9' maLiabsarption s )!fj~ rcme' pl1 us- ~ ight 103s and

debil Ltat.Ion ~

Lat find iflQ .• 5: EosinD~ ilia nonnal WI €:. 0"'; ",' W· jl III HI.: III C' ,'11 un. I.·.' tl r O. ".

~ fAlJ J fJ .r. I'"' 20. noo Ii

and 1 arvae or .ad ul t 1.0 nnJ s in the skool s {al.Io w t.he sitool to stand 2~ -48; b)lJr's before ex amill ingl)1 ..

A IJ Strolngyl oid! ia:SJ.,5 II OJ ffer-et1ltial d iag,no5i 5,: Epigastr io pa in.

ma~' mimIC peptic ulcer synd rome but "i ttl Ies.s r-e'}a.tiOfl shi p to meal s , ·Can cause pnellTtOni.a. Skin in Lt aston -can r eseabl e hOQk~rm .. ,

. P... £.':r'ug 01 f' c:b:)ice! Thi abendaJzole! 25 ms.!kg ~ (max imWi 11 ~·5 gm)

b ~ i .. ell.. x 2-3 d~y.s olr-ally a iter meaLi.s III

Al ternate dlr~s: MeblendalZG1!e I ~yr'ante 1 panoate:t Qlr I evami sole II 2-16 ~ ENTEROOIASIISI {llinU)nns) .. , Human,s ar'e tbe on1 Y' nost 0 f this parl8si te ~

It occurs '-'Jf" Idwide F HUman:3 becone in fecte.d bly 00111 laminated food , dr'ink 11

01'" ha n-DS •

_. S .. , and Q... Man y patients, alre' asymptomatic .. , SlymptomlS, inclwe

pr"1lr1 ti s a f the per'ianal area f in sarm ia, re.stlessnes.s 11 invol untar y

tJr'ination!l and irr i tabil i Ity t' par t.i.l::ul arl y; in children I; ~.~ ld

sas~~ intestinal Sympt01l3 are al so pJ~si bl e sue h as aMan 111 al pa in" nausea" V-aDl tIns t d iarr'hea II a[ld anorex La .

. Lab fi nd ings:- W .. B .. C.. n01nn-al except for modest eo,sino,phi 1 ia

(tt-l~) ... To find eggs, II appl y scntc h tape to, t,ne perianal ski,n and: spreoo

the tape over' a .s1 ide for e'xamination II Dl,i s should be done oln three ~li1seeuti ve day's be fore the patient barthes 0 r defecates Il .A.dtJl t wrms .shoUld be looked for in the staal-l'

2-9

:stagesl II The C~)U~.t" fall~ .a SI _ the 'Dbstruc ti ~'e phklse" dJeve ~ops l~ ~ til ~I" "'

(1IIQi) ile) 1 arv a~ (_mI1c_r'DI~~1 ar l.ae} ar e r'ar: 1 ~ ttJI~ blood In t he f 11" st, _. 2- 3 yel.ar's 'I .al)~d~n ~ al f:er' t~aJ t. a~l-d r.a~ e agaJ.:1J _ J.n t.he advanced obs~r Uc:tl ve I . stage II Mlcro f;lar ~ ~e s .. ~l-o~ld ~,e =ru Ie rosco PIC a 11 y looxe-d fOF us.! ng we t th Lck

.. saear s a f fresh an t·]. C oagur ated blood ..

P F SymlPtG~latic pa ti ents shouJ._{j be treated and concur ren t

tre'a L~en t, 0 f all ho~:sehol d mrf!1lber S should be- -consider'Ed.. All be:dJd irtg stl\~)lJjld be wasneo and per-sonal nyg rene should be, str-essed , e .. g ., c aare fUll washing of hands wi th soa p and water after' d€'fecation aandl be for e me al S j til""" 1m finger na i Ls ~ avoid scratching ree tal ar ea , and kee'pi hands a\ray frCllll

t he- mouth., Egg s in a mloi st €!:lIV j ronmen t F ema i Ul inf-ecti ve {o,r 2-3 weeks" SOl it is best tol repeat ttle· med ie-at-ioln every "2 weets. f[)Jr' 3 doses tJ Dr ug a,f cltH)ice is plyrantell pamolate 10 mg , I kg , (:max: imlBJ of 11 gm} in a singl e co 5e1 ber-ore or after me-al SI II ~:epe. at in 2 weeks.. A1 ternat-e'sl: Pyr-v in iUT1J pamoate , meb1end.azoie alfldi pi.perez ine c t trate . Pi.peraz ine is last cbo i ee becsuse t.he eour.se O1f' tr elatment reqru ir'esl 1 weelk ..

P. Cleneral measur e s : ~d :rest dur i ng re~ril-e aand local

inflalmaltor Y elpi sodes · An ti~ i~Jtic t her ap J to tT-'ea t Se<!QOO ar"i in fee t ions .1 SUsperl SiOIl bantd.ages fDr' ore hi ti s 1 epid ixi y:n i ti S ,I an-d sc ro tal l.ymlphedema., Jr-ea t mild 1 imb e-derna wi t h D ed re st ~I el a st i C: bandage Itlr ap l 3;nd eleva t ion of

t.....__ a" f f" _QIIi" It- ed n a r 11""'

-I..K::' ' . ,~~ ~ ~. '--.

2-·117., HOOKWORM. Wide5pread in the tro pi~ s -and! suti trolpics t< I!fl fee t.ion -01 f' t1tmlan.s is through! t.he skin in t·tle SanE path a s .strOtl8lylo i,a Iast s with the' excepti.on t:n.a It hookW"J:rrrJ] eggs. dOl nut hate h in tn.lmanJs; they are passed tn the stcol ~

~r'gic al meas:J!""les: Stlrg ic a 1 FerrlQiJ al of e 1 e_ph,3]~ to id: sc rot.un ,

vul via t1 Olr brelaslt shu u.Ld be con sider edl .1 ] t, is r elati ve:!:. y e-a s y and the

re.sl.!ll ts ar'e us-usll:J sa ti s rae wry. Stir'gelr'i foT' elepban ti .3Jsi. S 01 f a 1. imb should be avlDI ided , The surger ~ is d i ffictll t .and r'estll t s are' poor ~

S... and GIl !he fir st. -Signs 0 f nOOKItIJ m in fee t.iOlr1 is a pr Uf:'"' i tie erytheme tous derma ti t.i.s !I either macula papul aT 0 F VE!~sic [.Iilar (_g,rounrd i tch) ..ne'Te thel Larvae invade the skin {.all ~rBJc re:aetians to the invastol1l c an, oC'C uri and mi:lJY be sever-e J .. Pu.lmcnar Y' sig~ s ar eo COl ugh aand bl.ooe y/ S:pUt.ll11I. 1\.101 weeks· or ~or-e af't.er the- skin invasioln 'I a bd 001 inal symptoms Jl ne 1. oo:tng .aManlinal -d i seanfort"t f'l.atul.ence j and d ialrr"'ne:'a develop .

[A-ug of eOOI ice :: Di e.-thy 1 carlbamla zme :?I mg .. /kg.. 0 rall:J' a fter' mea is t. i .. ,d II ~ 21-?8 -d a ys . Head ache tl mal.a i se ,I nausea t arnd ~ami ti~g :TIe'i occ ur from the med .icat.Lon • wnc urren t adm in i str at :Lain of a n an titli st~~ i~1€. and! antiemeti c ~ y r edue e the 1 i kel, i hood and in ten s.i t y o fall erg.i c r eac t. ions ..

Lab fi nd ings: EasinoP1 il ia per esen t, in the first f-e W lJIfJITI ths of

in f'ec:t ion, Stool ~;LJally co~tains blood.. (G'lJaiac te.st. tJ) ~~aTlia ~y be

present depend ing on the nmloer' D f ~rms.. Eggs earl be found in the stool; J4.-51 O¥aJ per' 10 W p1wer rn ic roscope fie 1 d rela tel 5 to aoout ')1 F 000 eggs per gr'aFliJl of uncancen It.r ated stoal.,

Relapses m ay occur 3--'1) oontns after tr eatment requ i~' ing sever all . eourses Olr tr'eatmerrt over 11-2 yelaar 5 ..

Section I I - M~coti.c {Fun~ al }l

2-194 COCCI DIIOI I ~IYCa;ll SI. In fee t lOt] r-esul ts fran inhal.at, ion of

ar thro.sp:.re:s of Wee id io ides ~ml1i ti.s r ~ mol.d tt:1a t g_roli5 i rt so i 1 in ar id f'egions of ~uthlMe"st U1 i ted Sta tes II ~e·); ieo 11 Cen tr al and S~)urth ft.mrer ica .

About 60 percen t a f in fectio r.s are slubcl in ic al and Llnrecaglli zed; i tJ'lC ubaltion peri<id 10-30 da ys .

P.. Lig,ht in feo(: t.ioln s in asymptamalti.(:' patien ts do no t reqlJi,re

tre~brnlerJ]t, (up to 2,,000 O'i-a per gr~ of' stool) Il Crulg cooicel: pyrantel

pamoa.te' 10 mg .. /kg./dI .. x_ 3 days orally if] single diose-, before orl after WJE!al.s •

A1 ternalte drugs: ~·e:b€nd.a2.o1 e 100 mg. b. i. .. d. x "3 days [do not use in pregnancy} f bepbeniUJUl hydror'ynaphthoate 5 grm b .,i.d .. x 3 daY'!3 on ail1 empt'j sit-omiach aJTId withhold food fOlr 2 h.Qlurs: repe·at i.n 1 week (for childlrlen le'.ss t,han 22 kgl -.., cut dose in hal f) "'

s. For't y, per-can t a f pa t.ients -d e'\fel op m], ld to :sev'er e and

pro s tra Li,ng symptom s tlila t resenbl e' to:)se -d ~ to LJ ir a 1. ,I bac ter i a1, 0 r otller myeotic in fe<: ti.on s., frL.~ tis USlue lly tfia t {} f a r-e spi.r.ate. r 'i in fe-c ti Dn wi th re~t!r and! occal.s ion.al chi lIs, ple'ur -a 1. pa i.n (us uall y severe,) ~ ~1J-SC Ull arr ache 1 bac: k~he Il alfldl headac he {r.1I;;r~l be sev.'er eo)l .. N'aso pha r yng j,ti 3 may be followe-d by bronchi.ti s aceomp~n i e7Jl b'} a dr' 'i 0 r 051 ight~ y prod uet i \l'e- COllg,tl I- irleakne s s aand

3nore.x ia may became [llar ked F 1 ead in:g to pro.str -ation -0- SY11ptom 5 a f

progr'essi ve ~:occ 11 io idun)"c:osi s de pen~ tlpJTI the si te 0 f di ssrem ina tion • ih1 'i

or all orgarfs ~lay be i:;';') fee ted .,

2-l18: II FIlA RIASIIS.. Catlsed by one 0 f t we fi.lar ial nen.atode:s thalt airel tran~itted bly the bli.lel of certain mosquOi tas. 'Wide:ly' distr"ibuted In t,he tr·opi.cs; i:1lTId sulltroplic s· 0 f b-Olth hernisP1eres and Oli] Pac ific i sl.ar1d s .. Ov'-erl months the adult ~f'mS; mature in Qlr near th,ell lympr~tic~ or l)'DlPh n}Q(ies, ...

01.. J, morn i 11 i fonn {:mre'.a.sl @.II ike) r ash may appear 1-2 days after

ollset -01 f' s yrnptamsi oi Arthr al~; i a ace ~ pan ied b"1 per i art ic u 1 ar swell i ngs "I often or the knees. and aJ1 kles. 'i s CO'i1roOf1I. Erythema nodlosl..ll1 {pa in.fUil red ROdl~,es on 1 eg s) mal'i a p_pear 21-2D da 'i s a ftelt""' 01) set 0 f s ~pt(]jjJs .. EF ythem,a ~utl tl, fOlrme (mactll a~r er lIption ~ th dar k: r ed p~ pul es. or- tuber'CUIl e's wi t:h no

1 ~ching, t1 burn ing, or rhelJTlat ic p.a in a ppear in~ in se'parate r' i ngs 1" cone-en tr ic rlng.s 11 d is.k-shalped pa tc-he s, dl i st r ibuted e lev at i(}n S tl an-d fi g:urred

:~~~em:nts} may app=<3 r on t tIe upper _ ex tranit i-: 5 r h~~. and t~r a~. . :_ab

" ,d l~g S II" Ma yo ne F-:lloolerate 1 euk0.c ytOISL$ and -eOSl.r.llDPlllla.. ~d l!ne:n tatl.)rl

~~. IS eleY.;a~ed, r€tLJrYJi!lg ~ _ ~nnal <liS. infection subsides. There is a 111 test. alv a.ll aJtll e for ear c 10.10 ldcmlYCOSl S _

s"" and 01' Ealrl ~ m:a.n i festaltions are in f1 ~Inlatory -with elpi mes 0 f feY'er wi tin orl lIi t,hout in fla.l11nation 0 f 1. )'IJJlphalt ic s aln.d oodles I] OC(: ur~jtlg .at irli'egular' intervals II fun iCUIl i tis (: infla!l6lalt lOin. olr the .spenn.atic! cor(l) and a roc hi tis alrl e c 00'Ift0 nl .' Per 9t s; ten t 1 ym _ptl node e HI 1 ar g ellen t m a1' ace ur an dl absceslse:s may form alt the 5e1 si tes II Lalter' s.tagels are oblstructi ve- and may :DOlt a plpearr for month,s Or" years:.. Cttstr uct i 11 e mani fe·stations in~looe

hy-drocel e (accmull.,at.ion 0 f .seljous fluid s in a sac:l ikel ca\l" i t.y ~l ,I slC"ro tal

1 )'mlph~ema ~ 1 )1mphalti C VaT ices t and! E!'llelphan t.ia.sis .. Oephan tiasi s me y'

in-vol ve legs:t g.en i,tal i.a.1 aiM less 0 ften dlrmlS and br'-elasts.

tab rim ingsl: EoSlina phi 1 ia ("' 01- 3011 or higher) in thel -earl '1

A,. C-DQ(_": id i~ idlamycosi s - D1 fferen tia 1 d iagf:1()si.s : Vir al t

"l-Il

b.acter Lal , or other my~ot.i.c in feet ions presenting fl ul, i.ke 5Yf1drane II]

P'.,. Bed rest and ~;ener al syrnp.tanatic tr'eatment unti 1 there is. a complete regr'ession of fever' and a normal. :sed imentat ion r ate , Amphoteric in IS has prOll/en e rfec t i ve in. .sc:me. pat i ent.s wi tn di sseeunated dli sease , but because of i t s tox Lc properties:t ad ul, t dose should not exceed 0 .. 5--'1 1Qg .. 1 kg .1 Therapy should begin wi ttl 1 rng .,/d. inc:rea.sing by 5 mg .. i.ncr'ements to 25-35 mg.I/(j .. or to 110-60 mg.ld ... in the :acutely' ill.1

2-20.. HISTOPLA~OSrs.. Caused by Hi stopl.asaa ca psulatm ,I a mold found in tbe solI in centr-al and eastern Uni ted States, eastern Canada, ~1exicoII

Cen tr al and! South: ~er Ica , Afr i.ca t, arndl Sotltheast Asia I" Ie feet ion is pr·esunab 1'/ by' i nha 1 ation a f .s_por-'e.s" Hay be carr ie::l b·~ the b'lOQld to other' _part S 01 f the body'-

in Hex ico a'ld Afr ic·a ..

S·. arid 0... ~st cases ar'e a.s:yNlptcmatic. or' mi. ld and IlJnrecogJ} ized .1 Symlptcmat.iC~ in fee tion s malY pre.serl t. [till ld in f1 uenzal i ke char .acleri st ic s

last ing, 1-~· days , In moder atel y severe cases ~ the pa tients have ferver 11

co~h, and mlildl chest pai n 1 a st i ng 5-1') days., Ph y5 Ica 1 e'x~ination is

usua lly nega,t i v-e ...

S2v'ere infections ar'e d i vidM i nto three groups: ,1 ) Acute

hi Stopl.a.Sil'K)si.5. f'requentl yl occurs i.n e p-idam ics ., S)IOptClTl5 a~'e mar ked , prost.r (jlt ion , fev.pr" and oeeas.ional chest. pain Ii hut !jJO par t IC ul ar sy.nptoms ~'e l~t i YoE too' ttle 1 unJts _ X ra'Y' [1M ~ show1 sever-e -d isseminated pnellfloni ti 5 .. lnfeetion ~la-y last fr(m1 1 week to & months; it is rarely f'ata'l . (2} AClJt~ prQgr'essi ve hi stop.lasnost s i S usual l 'i rata 1 wi thi,n 0 weeks or less... F i?1Ier ~ dlysprU?-31, -C-01ugt:] II 'Ie igh.t loss" arK!1 t):rostr at.Ion are usual SypnltClmS. Dlaf rhea is u:5ual i.e cf:1 i lcrefl . HuJ.::uus iUf2Dlbr ane ul-c er s of the or-a _pflaLr' )fInx may be pre'sent... JU 1 the organs of th~ bool,,! are 1 r:lvullled and! I. i v'er an? s~ lee1'l

near 1. "J al ways, enlargPdI ~ { 3} Chron ic prog,ressi ve hlisto1pl.asmosl S . 1 So lISU.a 12~! found in older IE t ien ts wi th c hr'ur...lc !'-tlstr u,-~ti ve ! ;,;nt-; -d isc-ase I" It close 1 yl r-es~.,-oDle-sl chron i c tUlbe:r-c-ulosi s ~ OC~.a5 iona 11 y the pOlti.en t will have both

dl i sei.lses _ It 3lJpe;1r 5 to he p~'i~liir'i 1 y confined to t'he I UfilgSi l' burt. all or~.an s ar-'el i.rlyclve-d in the t-ert1li~lal stage' ..

IS. and 0.. Mild or' aS~lpto~lati-c cases ar e rar'ely f:JlOOd.1 Li ttle ., k .. n.o"\lIl....II!"'Ii ... ' o f': tl h· ie m· ri.Lde st P llJ lrsonar ~ ph;] S~ 0 f t.oi. s oj i. sea se .. WIU.il..~r'l 1 ~er ate

1 SJI:l'iJI,.IIi.l . " ,. '. J'

fevert 11 dyspne'.i3, .3lnd. chest pa i~1 altr"-e -erv iden t i ~ sym ptom:.at ic c.a~ s • 1he'se . nay

.. disappear or pr-ogress. wi t ~ bl.ood yl anti pur -lUl ~ t sp ut ~ml prootJc tlO~1J 1 pl e-il~ 1 sy ""

f-ever" 11 chi.l I s· I 1 ~.ss; e r we 1 ght., andl prro5tr at lOf1 .1 R;a 1 se-d v'cr"'ruc(Jus ~ tll1lor u f

the €:,pi-d-e,rmis.} cutaaeous 1 e~ion~ too ~ have a~n ab!"~pt ~Iwnwar-d s lOlpl,ng bordler are usually pr'esen tIn d 1. ssem ~~Iated bLast om y'c 0-3 1 31 01 The sur face i So cover'ed wi t.b mil iar y (: smalI Lesaons resE.1nbl i lil~ ~,mi.llet seeds) pust.ules . The border exte1nd s slowl y 1 earu' i.ng .:31 ce~ tr a1 a trophJl C sc ar, . 011 Y cut.aneous lesio:n s are found in. sone pat.Ien t.s II Lesions.ar e mct,st frequefi tl 'i seen on the skin" in bones ,I and in the g eo i tour t=nary s ystern 1 but any or all org,clil S or ti s.sues in the bOO y e. all be attacked ..

Lab find ing s : Usual.ly leulkocyto5i S- ~ h ~poo:::hrQ.mj_c an em La t aod elevalted SeOllnerltation rate., Organ] sm can be found in lesions II] It is a thi,ck-walled cell that mla), tJa"ijlle a sing Le biOO.

A.. Nbrth hrner iean bl a st~ycosis .. DriL fferen.ti a:l d i agoosi3:

Epidid)ml ti s , prost.a ti ti s ~ 0 tiler- d, Lse ases a ttac king bone or skin.

P.. No spect fl.c trea~tmen t btl t .rl'l1lphoter Ic in ~ (.see

eoeetd ioidan:y00 st 3 for treairnel1 t. sched ul.e l , SUrg,ica 11 €I c i s.i on 0 f e ut aneous lesions may be successrul . Careful follow-u:p for" earl yl ev idem::: e 0 f r e-l apse should be made f·or .selver a1 ~elar s sa tbe r .apy may tre r-esuned if needed,

2--22.. PA.RACaCC IDIOli [)«<YCUSIS (,So1ul h Ariaer ie an BrJ a stmlycosi s) ~ Found anI)!

. i.n Sout,h or Centr' al Am-eJ'" Lc a air' :~el icc ~ Caused b~" P\ar acocc i:j ic ides brasiliensis ..

Lab fi:1d ings: Se-d imentatio~ rate i.s e 1 f2'i ate.d in moder ate to scyer'el y ill 'p~lti-ents.. Leukopen ia wi ttl ~lOrmal. d i f'ferenti a1 COtm t or neLiitr-'opet1l i al.. f.!bst pat ier. ts wi th, progres.si ve' di sease show 81 progressive hypoc:nr'CIn i c .anemia ..

S .. .and 0" (jl~er'atiiJln of nasopharynx u31u~11y the

fili'St. S,ymptCl1l... Pap~l es. ulof!: erate· .and enlarge bath p€r'i pJ1e.~' all: y aa"ld deepe:r

intol the :sul)eutaneotls t isg;ue II] Even t:llJall y rna:; :r'esul1. t i~1 d eSltruc tion olf thel

epiglatti s 11 v·oc a1 cord 3- ,I Jlnd urv ula wi th ex tension to tt-l,e 1 ~ PSI olnd fac.ce., Eating an!! dr'in1lci ng airel ex tr'erne 1 Y p.:1 i n ful.. Skin lesions 0 f v ar iabl-e

appearanc~e ma_y ':)C:f.! llr on the foce.. They !1f:aiY haf\t€ a ~Iec roLi C: eeJi"j trial era ter

with a hard hyperkeraltoti~ bor:-'jer ~ ~~YTLph node' enlarglem.ent ~r.ay be the presenting syrnpt(rij or rna)" f-:Jllo W i'!JIUCOC ulan eous l-e·siorns ~ Lym_pr. nod€" s

eVerl tually ul eer..3lte and ru_ptur--e throu~h t he ski n ". :5'Jme p.a tl en ts. !'!'ta~~ f,lTesent wit n gas t.ro in test in a 1 11.s~ ur~alflces, ~ i riel udl tog en1 arg effI] en t 0 f 1. i v'cr and spleen ~I but s~ ptom S are v' ag;ue II 1)[ ten si y e- ulcer ati'Dfll 0 f t tis ulpf.ter gastrointestinal tract prevents s,ulffi-cient intake! .and absorption ~If foad catlsing. nllal nurt!" i tion IJ L£ath m,a y resu --: t [rom r€.5pir-'.ator y fa i1 ure 0. r malnUltr it ion ~

~.. lHist...oplaSlOOl.sis.. Differ-ential dia~oosis: Hlild

ease.s-,-in fl uenzCl: mooerate---a t ,'_pic al pneUHlrl iOi; seve::-e ca.ses- tutJerc Lllos,is ~

P.. No spec i fi,e ther aply 01 .Bed rest and sY!'tptor=ratic treatruent for'

threl primary form... No,rnal act i"li i t Y st:x]ul d no t b-el re'.stRIerl U1 til f-e':~ e'r has

5ut}sid-edl.. 'Amji1oteric in B has tle 1 ped some patients (see' c()cc id io i-dCfOy~osi 5

for' tre'a tmelil t JlI an)1 • Some- mlilder forms olf .ac ute pr i.mar y or' ear l_y cih!""()tl i.e

-d:i sease r'esl_pond to sulf:adi i.ali ne tJ'lef"'apy IJ

2-?l., NORT'H ~IERIrANI B[j\S11~YCasIS., {\ ~hronic systemic fUIflt;us ifife:tioo

ca~sed by ~l a stom y'Ces d-ermlat i t.i d~ i s'.. frc.ur''s moire Olft-el1 in men. Found in

i!entf"'al an~ eastern Uni terl' States .and Ji':an adal. A. few c-.a se's h.a\t e bl~~en fotlndl

Lab find in~s ~ El €V 31Ded sed l~enta t-iO'r1 r ate ~ l.=etJkoc yt.:)sis wi ttl neutroph.i.l i.a showi ng a; sr.i ft t"il t.be : eft 't and Sa'fIlE t ime-:s eGsjflophil i a dlndi

lOOOCtC ytOSi SI.. The ftJnllJS is a spher i~al cell that, ~ r3y nav'e :-nan y bud s

ar iSing f'rom it I

11'11, to li:Ji ..... r· a",'-'I,F'I.r;""-!f1i Ii ,"" 1~ .. ", 1- j .. lI'IIi'Il .. " .... -., ".::. 0:;.

tt. 11-:,':]1 /'<- .. ,__,..... IL. , Il.,..I ...I , "-'L::"'I '1"' _ ~..... ~ _

. pi 11 Ampho ter j c: in 51 (s,e-e eoce idl i()idcr:JJ"OOI5i .s for trea~1l€:n t ~J an}

has harl cDn.siderab le S"iJC'celss i ~ h._"1-5~)] td: i zed! OOlt ien: ~s... Su 1 f==t_d i-3 2:i:1l€

(21-1;] gm) da il y- or U 7: i pI e 31.1 1 fa-'U (". gm) da i 1~· has bee,n_ llJsej f~ r CG!] tr·Jl :3lnd

OCcaSio'n.a 1 Cllr-e.s have beet: r'Cp:_1 rtea fa llowing mor. tns 0 r 'j'12 ~r s .:_) f t r.flat['1en t._ Relapse's fDa'i uccur rNtl~ t.~~e j r lI~ i S S~J pped ., Cr~Jl§: t.ox ic:i t! W'= ~Il ;_.ralong,ed

-il ~ 'Ii '1

IIIil... .......

2-14

tlig,h dosage is eommon _, Re st arid sup_porti.ve car-e heI p 1 rI promot.ing a

fav'or atll e res pDITI se ..

2-23 It ~e Chap-te'Ji 11 Sec t.ion L, In tegmentar y S~rste~'nl for sporot.r ichosi s 1 derma top, yte in.fec ti.on 5 (r ingwolrmJ f athle,te "s foolt· tJ daWldlruff, etc- ... ) 'I and]

chr'Offlmycosl s ,

2~1I1.. CIN"DllIOIASIS (men il la51:3'!1 thrush}l., A yeast found no-rmally i n the

mouth , vagina II and feces, of most. peopl.e II ~elrgrolwth does not occur unl-e's.s the t~b~l ance" of the o,r.al flor'a is disturbed bly' deb iIi tating or acute

i IIn.e'slsl OIF in ttx}lse be-ing tr'ea ted wi th an tf!Jlio t.ic 5 a Ou'erg rowt his al so fav'or'ed by diabetes, i. ron defic ienc V anefflJia ~ and immooo5uppressed sta tus ·

S 0+. and 0.. CreaJOJy-whi t.e curdlli ke pa tche,s an y ~ere in the

mOf]lJth _ Adj;tC errt :1lJUC:osa is: USluell Y' -er ythernato'LJs, and. scraping the 1 est -on Glften uncover s a raw 1 bleed ing, Slur face ., CcmrJonl Y' II a e and idal lesion may' appear as a 31 igtltl Y g,ranul ar' or ilrr"'egul ar ly eroo ed er Y'tbe~,ata-[J~ pate h .. Pa in is usual.I Y' pre sent but fe\fer and l:ymphad,enopath y arle uneo:rrmon. Conccmitaflt candi-::liasis of tbe g,aJsltrointe5tinal tract (: including the ptlarynx and eso pbag LI 5) rna'i Gee Uli "I Vag inal OIJ ergrowth. {seel Cha pter 7 t G~nec ologyl} •

S)"s,ter.1 ic cand idal in feet.tons ar-e 0 r t WOJ t :tpes,: EndDc.ard i ti s that (almost .al wa 'i s .a frects prev iousl. Y' d am.a.g,ed hear" t 11 alves , usual l y follows;

be art s,urg_er'i 0 r inocul alti.on b,y e on laminated n eed'Les Q r cat.heber.s-J. Spleru:xTl,egall!l and pe-tec:hi ae are usual , a~dl embol i ar e C OOIT!l(N1 .. JPper glastrointes.tinal tract cand id iaai s is the usual rourc:e in the other type of s.ystemic in fee t ion .. Di s·sernii,!la,tiorr follows ant.ib iOltic or eywto1x Le chemothelrap~ for ser icus dell ilitating, di.sease . The kidneys", spl eee , lungs, Ii ver , and hear t ar e mos,t ccmmonl y inlJolvedl" Fungi urLa is usual in renal -disease ..

Lab findings: Cafldida albi-cans is s€enl as a gr~positive

budd ing, e:ell and a pseooomyce 1 i urn and is the ffi()S t, -c omrt~)n cause 0 f s y.st€m ic disease ..

All Cand id ia si s.. Di ffer'ell tial rriiagoolsi. 5:: Other s~'Stentic-

ali sease's de-pend ing Gin which area 0 f the boo:y i 5 .a ff~ ted and other fungaJ ski.n in fections I'

P'.. Amphote'r ie'in E· IV (.as fOT cocc'id ioi.dalJJy~oai s) is

neces.salry' for serious 5ysttni~ infection" "Whe'n canbin-ed with fI'"'ifampin air f1 uc:(to 5i ne (Anccbon) 1150 mg ./kg .ld.. Drally 11 1 a~r d ose.s 0 f .ampha,ter ic in H can be u~ed and: st ill pr'even t ernrelrgence 0 f re si.stan t 0 rgoo i3ll1.

Oral 11 gastrointestinal, and curtalneotls: lesio'TIs should be tre'ated wi t·hi amptlot-er iC" in B, n y5ta t itl 'I air ~icona wil e mOl\Jthwash -r' tab1ets jar loti-ons,or Gefltiarn violet ,I 1:1 in 110~201 alcoooll, is, also effective for oral"

cutane)LJS "" aund y ag in all le-s,i-a~5., r\n tib iotic the.rap ~1' should be dli scan tinuedl if _pJ5sible.. All pa t.ien.ts· wi th cand idi i.a si oS .should bel -ehecke..d for d i.abete S tl

2-251.' CRY PTOCOCCOS IS., An e!nc:apsula ted budd ing yeast tha t i SI fOUfldl

wQJr'ld]\iide in .soli 1 and on dried piger~)n dung., Inl feet lOIn is aa:!qrtI i red by' inhal.ation .

S.. and 0 ~ In the 1 ung,s j the in fe-c ti-on may reTIain 1 DCal i zed ~ heal t, olr di sS€minat-e .. tlpo fI d i S5e1I1 ifla t ion 1 le si.on s ~ y fOlf"rn: in .an y paar't of the' bod y; the most C:01lmOfl par t involved is the C.l N .. S ~ alnd is the tlsua 1.

..

causel of death. General i zed menin~oenc~~dl i tis occur's m~lre fJr'equently than localized granul ona in th,c brain or spi.na.L co rd , Soil i tary' lDc:a~i zed res ions fJ!Iay delJ el op i ~ ~,the ski n and ,I r-ar e 1.:; !II in bones a r Dther 0 r'gan s .. pulmonMY' cryptocoCCUS.lS present s nUl s pec i fi.e signs or sympt~s,... t~any

patient.s ar-e a:s'r-mpt~at t.e II 0 ~ber s ~ay pr-eS€lll t wi th 1 ow-,~r ade [-ev-er ,I pI eur a!

pain ,I and cough po S s ibl Y wi th S-P·utUtr.i1 pr-odLX: t ian Il C .. N .. S. i rival iJ erner: t

u5ual.~ Y' pr esen t.s a hi st~Jr~1' ~~ f re.c-en t UR:I or pul.monar y i:1 feet ton, llsua 11._Yl the' r lr st .and m.Jst prom 1 rI ent 5 yrnpt.{)ffl is i ricr'ea s ingl 'i pal i r~ ful he.a-:1 aches .. Vertigo 11 nausea, anorel: i a tl 0~ ul.ar d 150 rder S II and ~nerl tal deter i Drat ion dlev~l?p ... ~~ec k rig id it. ·i is pre sen t f and K-ern iE t s and Br udl z t U1 sKi ~ s s ign S are posa t.i ve , P.r.I t.e liar and achi Ll es re fl exes are oft.en d i 'l~ in i.shed or absent. Acnei, form Ie s ion s enl.arg,e s 10 wl y anrl] ul cerate t a ften coal.esc i!1g wi t.tl other lesions to cov er a I ar'ge air ea ..

Lab find ir1lgl. S .... ~1- 1 d 1 11 t "

; ~ . . anem 1 a , ellK-:JoC y IQ 5-], oS I a rldl 1 UlC reased

sed.im.en tatio n rate- ..

A_ Cryptoe-occosi s ~ Di fferer; t 1. al, .f i ~a._·, no s ~ "'-'::'1 .. "

~':JJ .Il. ~ Other s ~s,~e~: i-~

f'lllngal in f'ect.ions ~i. t n {: 0+. N .. S ~ i!1Vol v€r.JJent .,

. P. ·~!nbi n at i01r1 0 f ampho te'r ic in B ~ see eocc id io i";d-DMYC:csi.s

for' dosage) and f1 uc"i: tosir1I€ {Anc: Db 0 r.iJ )! 15-:] mg" /kg "/d I in 6 ho;u.r'~,"j' do ses I may be c urati ve ina 6-"J.cck regimen ..

Sectior~ 111 _ R.-...rterial

2-- 2 6 ., (je'n er a 1 .. Ba c t.e ria ;n'''' e t he mo 5 t C CfTilID:Jtli ::ij i .se ase e a IJ s i.Ilg, 0- r ~l .:il'il i51':] S ..

1be,y cause a wide var iet y 0 f if:] fee tion..s t.ha t c ~ n he' 1 oea ted annywhe're' on or in the bOO., ~

21-27 .. STREPT1OCOCCAl I Nf'ECrI-:JNS .

a .. Ee,ta-nemol yt]. c ~ roup A streptoc:oce i air e the most Ccrnr.lO:1 c aUL'=le Q f e'xoo~t i ~e ph~r YTIgi ti.5, ad1d the y a 130 ~alUise s ki!1. in fections (imp€. t ig~)) .. ReSplratory In fections are tr an sm it ted b)fl d ropl -ets; skin in feL! ti-D:1.S ~Iy con,tact.. El ther m~";I' be f01 l~we.d b-y supptlr a t i v e' and oOnSUlppllJra ti."J e

(rh~uma~i~ f-e-~erl 11 gl.OOl,etr"lu10[]e~]r' i ti s) ~crm;ll. ieati·:}r1 S Il Beta-heme l1t. ic. ~ roup

~' strept()Coc~ 1. .ar e~ Qlften -[; arlf i ed i ill the' ferU[ll e gen ita'::' tr ac t aaldi thus may ~n f:ct the n ewhorn .. Thely are .a ~ cmmofl Cr3IUISe 0 f ::] eonatal seilS i s -3~IC:

men lngi ti sand ma Y' be assoc ia ted wi.th .respiratory di str'ess s,yndr'-ome ..

S,. Sudden ·fJJrI:se 1. ,af .fel'ller'" sor e' throat t, sev'er-e pa i fI on swallO\lri.ng Pi mal ai.se t aUld naUlSea... Children m~y vLOi tar eonV'~l se ~ If ~arl~t feve'r rash occurs, the skin! i5 (li.frusely erythemataus , kill t.tL

Su~r lmfXJsedi fine red p.~pul es .. Thel l"'.ash i SI most i~ ten se in thre g ro i:n and ax llias II bl.an~·he s Oin pressure 1 a[!d ma y beecme petech ial ., It fad!es itl 2-5- daYS:I le-ay in~, a fine d e squ~m.at.i,ao .,

. . '. . 0." Je'ndler' ~ enlarged cervieal lymph, nodes;: the· phar)TIx:! 5o,ft

palate tJ and to~~,ue air e red and ed.emato us· ~ ~~Id· t h~~1 e,' m· "'],I~; b· 'e" a p. "ur 11-1 An. t

e 00. . .1-".0 . . .. .. :I! -rn . .11 ~. i.:;11 .CI 11 '. '·.'.1 t.I "::;;:';d '.

'x.. ': ate . In scar 1 et feve.r.. the face is fl usl1ed "~11 t,~ 0 i r·A1. 1iI"Il'Iu:""J ..... ~.'l p. ',-:l} loll!""" ""::Ii nd.'

tlf:te. . . .~' . .. _.. . '. U l ...... ......"Io.oIIi..IrI:..Ii'i c:I!. ,.[2.- .. I: If ~~ - .

~~ ' •. ' tongue 13 coated wi th protr'us;ions of e~la.rg,ed red pa_p-i llae {straw~)err~·

~ngue-) (""'8IC' IE""~ • 1 .' ..

. .,' '., ~ .. l.-.:. I, ;:N [.oWl rig I euKocyt.o:si, 5 wi, ttl a:l increase in pol ymo!""phonucl ear'

neurtrophlls 'C' .... 'oO a ..... 1!11 o· f th.t:ii . L n-l . t ..j[" t ...... ' th .. t L,..," t . t· .,

Olm, .. ' ·i .. ' ~ .•. ' -.' ..:I;~ .'. L: ~., I. ',I . ,I ~ . ~~.ale ~ ~O!1]Lj~1 ' Irca I, SlJJ W S Ire~ I OCQCel II]

masPll~e~t~on5 o~ _ stre~tococc,alsore throat ~~dude sinet:;i tis. ot.,i t.i::. .media,

told} tls IJ per lW[] $.111 aT 3rnsces.s:l s uppura tl~n 0 f ~:erv 1 C 811 1 ympn nooes,

':-15

2-1~ r-~heurnatic f-elJer, and glO!'ftoerulonephritis ..

~.. str-e pt.ococc a 1 sore throat 'I Di ffer-en ti a I diagnosis: .strer~t-o~cccal sor-e throat resembl.es (arnld cannot be reliably d.i.st irrguf shed c.l i!1 ie-all y .from) the phar yngi ti s caused b 'J adeno-v Lruses , nerpes "Ii i('"'use5 ... and occas i on all y 0 t.her 1J Iruses .. It al so is. cCfflfROnl y con fused 'Wi tit

in f'ectiou S monon ue.l eosi s l' d iphther La , cand id Las i.s , and nee roti z.ing ulce~ative gingivQstomatitis.

..

P - Anlti biotic therapy is o ften K i 'Y'et1 wi thourt proof ors,trelptococcal or igin if fever and 1 eukocytosi s aCCOOlpan'f a sor'e ttJro~t with. ten<l er CE!"rv i.c al 1 ymph nod es ..

(1 ) Een zat.hine pen ie rn in: G 1. 2 mi.ll ion uni t.s Ir~1 a s a .:::i rig le dose or proca lrle pen .ic i 11 in G 300 II 000 un i.t s 1M da il y x 10 days ..

(2) Penicillin'{ ~Hl(]j COO units, q .. 8h. x 10 -days.

(.3) Pa t Lent s hyper sen s1 ti ve to pen i c i 11 inl may be treated with er ythrCIDY-C in 1)-0(1- mg. q , i "d. :( 10 <Jays.

(~ } Gen er 031 measur-es 'i nc l ude as ptr m and gargl Ing with wann saline so.lut.Ion to relieve. sore' t.hr oat, Bed res.t -and forced flui-ds, urJt.il the patient is afebrile ..

c . Rllelnat i c fe-\.." er .. Trig~e.red b'j group A beta-henol y,tie. st.reptococcus prod ue ing a fi r s t attac k of rhel..lDatic fever in 0.3 percent of untreated or i.nadequa tel y treated chi.I dr-en ., If a c hi, ld has rhel.lTlatic fever once p1 hi s chances 0 r re in fee t ion with in the nex t 5 ye.ar s .are 'SO percent. USIJ~! 1 y T.' th~ c 1 in i.c al, man i feata t ions a f all at tack of r-heu:nati-c feyer tend to r-epea t thense,l ves in subsequent at.taeks , The, peak per iod of" r-isk for c:hildlr'en .i s 5- l51 years 0 f age ..

S.. and 0- It takes t~ major or- one major and t'WO minor man i festations tu j ust.i f:; a presunpt.i ve d iagnos.i.s of rhel1.lDat i.c fever'. Major rn~nifestati~ns are:

( 1} Ac t i ve e alTdi tis (anyone 0 f the fa 1 lowing,) ~

( a) Slign i ficant n-ew murmur s that, are cle.af"" I y mi tral or aortic insufficieney- •

. { b}1 Per icardi t.i s {peric.ar-d ial fr i -c,tion rub or ev iden.ce

of per icard ial effusion) .

(c) Ev i.dence o-t congestive heart fail ure ..

{2) Polyarthritis. Two or more joints must be involved ei ther stmul t.aneous'l y or' in a r!Jligratory fashton ...

(3..' Sub~ ut.aneous nodule s .. tIlder the ski n , a few ~: i II imeter s to 2 aIll .. oyer joints, scalp, ~nd spinal column, and ca.s~s ..

Uontender and freely m01lable

i n dl i aJJe ter tJ !OC)st corJmlOnl y foul1m:! usual1 y seen ort1 y in sevier e

(~ ) t""r .1 them a margin.atlm. Usuall'1 o.c-=-ur's onl y in :severe

cases and is often roi staker:] fOT other t y_pes 0 f skin lesions.. It is a mac utlar erythematous rasi1 wi, th .:JI c ircin.ate bor'der appearr ing primarily on

the tTtmk: and ex trerni tics; the face' .i 5 usua 11 Y' not i nvol ved -

(~) S.:;den han om s -r_: horea. Progressi vel y ,mQ1re seyere

_atiena} irl:Sltab 11 i t'f:: j,fivul ~ tar:-Y movameJ1 t.s ,I ~ and museu 1 ar weakness olft~n .. , followed by lIIUSC~la~ l.ncaoTdma~~oo arid sl~r:mg of speech. l~Vol~~~t"lS not uncaanonl'1 I imi ted to 'One stde. Ind 1 v Idual attacks are se i f -1 )Jllltlng],

but may last up to 3 rno~]tbs-

Minor m31 i fe.s.tatiOl1s of rhellTlatic fever are:

( l) Fever: Usu.all y low gr ade but oecas Ional.l y , 03- 1 04

(kgrees F.

(2) Polyarth~algia: Pain in two or more jOints without

II-no and tende.rnes.s~ heat I s...e lll~ ,I

~ 3) Ii i.stor 'I: P'r .ior hi.stor-y of acute rneLmatic fe've.-' 0 r recent 5C31rlet re'ver ~

(1. ) Accelerated sed iment.a lion rate ..

{'1) ~)si, t i ve throat cul lure or' smear for- group- A. streptocoecu5 IJ Assoc iaJted find Ing.s may i rlC I ude abd{M]1 inal , back:t and _pr'ecordial pa in; er ytbema mul ti forme:l mal ai S-=:I vcmi t Lng , notTtraLITLatic epistaxis (nose- bleed1).. we'ight loss l' and aJ1eJT1 i a ..

In the absence 0 f card j, ti s f. rtletllla t Lc fey er Iast s 011 the average 89 - 27 days.. Wi th cardt tis 11 riJel..lTtatic fever Last.s 011 t.he average 12.11- - 6'8 (lays-IM

A. Hheumatic fever , Vi rre:rential 1 iagoosis : Ot.her causes Q r carditis I arthritis ~ and sk i n les,iorls_ Other debilitating diseases, e ~g .. tJ monon lie 1 eos i 5 _

P. Therap'y i 5 d i 11 i-ded in to snort-,te:""'ml and ] ol1g -tenn treatmen t ..

(1 ) SbcJrt-tenn t.l1erapy range 5 from. sav Lng the life of a patient with severe carditis to relievinR joint rlisconfortot-

(a) Strelltococc.al in rect ion must be er .adic.ated . 8enzati1 Ine penicilli.n G" in a single I~ i.nj ec t ion 0'1 6~,1. 2 rni I lion units"l depending ,on patient we-ight:t or 125-250 ~..r.. of pencillin ol·.ally Q ... i.n - x 10 day',S_

AI ternarte is er'yttlt""(MTlI~C'ill .?50 mg .. oral l y q _ i .d , l[ 10 days.

< b) Aspirin (in the absence- of severe car-di tis with CODResti ve heart. fa ilure) 1 00 -rng .. /k~ .. 1 d.. orally dl i vided into .lJ doses .. ~rcim .. done reg.art11ess 0 f we ight is J ~ 000 mg ./d. (four 5 .IV.. asplr .in tablle-ts, q II i .. ,d ., ) .. After 1 week reduce dosage to 1lj0 ~ .,1 kg ., l.rl. in ~ doses .and continue, for at Lea st 1 montll-

{c} CoJ1gest 1 ve heart f'a i lure therapy' (see Chap.t.er l" Section IV:t1 The Ci rcul a tory' Syst.em.) ..

(d) Cortico.stero id s sho-ul-d Ile used .for all patier.ts wi ti1 CODgesti v.e heart fa iluwe and/or cardi tis. "' Dr;.sage- : predn i.sone "2 rng -I kg .,/d .'

:I 21 week~ orally., then , ~ .. 'kg _/-d .. x 1 wee" Ii begin aspirin 501 rrag./kg .. /d .. an the third week and con titlJue (·or 8 W€eks,.,

1-11

.,.+- the diagno.si 5, "-

01.1 ..

~ e) Stric-t b~ ~elst is not, re~ui;ed far ~atient!i ~Ii th

- ~'

ar thr; t 1. s a~l:jl Tt i) ·:11 c ~r-~ i tis _ -Bec.-- t~-cha i r rirfi t h ba thrQ~m. pr Lv i lege sand

meal sat t hp. table fOTI patients wi thDtJt sever'e c'8J:di.=l. t Ji. s i s .3111 tha tis

r.o. ''-'Ijl.li ~·odl ~:tr I· Ij"'I' t ~pd· ~e .. : st I;::: h ....... 1 II I l-d-·-b'.Il:Ii.· rn . .3II": If''ll ! ~ a i I'f'lil·· ed f' ("'l.·r ~"r.,:J t.i .0"'"1'·"'.;;:"' '-~l· 1- h· s~"'lfe·~'e·1

~ '"1 - _I ~·.l .. Il _ ~ ._. LiJ_ "_.Il. . • Ii..- ..Jil .~'IL.II... .r,IIr- .Il IJ ~ 11.1."- IJ I .:J, . av.I! ~~,' ~IJ I ~ ~ n Y1• -c- If' ."- .

card i t1 sat leas,t IJfll t]_ 1 cor t: i{::Clste!'T:d d t.her"lapy is ccnp l-e.te{j .. E?otb sno [J1 d

have gr .ad!.J8l ir_door .ali'lIO QJl a t i~)~ f-~)ll(.}~edl by rnod i. fi ed outdoor ac ti V: it:~ i3 f't.er s~lptc-ri:3" hal'i ~ -d i sappeared _ TI-: t _s shcul-~: 1 ast, 2 t ~ e'a st ;; mon ~~.s: ar!~ t ~~

chi l.d 5n~}[J Ld ztot, r-'-e t urr: t.o sc boo.l wh i Le t her e i 3. . elearr' e'v idenc e 0 f

rbe wmalt i.e ac t i -..= ] ~ y ..

I... Men ingoecccal mien i~gi t i $1... Di fferen tial d i agnos.i. s : {)the.r medingi tides -I,

P. Anti b.ae-ter i al. theralpy blj" IV r'out,e. mus t be star ted

itlmedliately II A~t.le<ltlS; pen ic ill in G 2~ un i.ll. ion unit s/.~?~ he urs for adlul t 5, and

Jl(lO 000 und ts per kg to/2l1i hour s fa r c hi.1 dr-en is· the d rug of ~ no i.c e .. ()1~folJJrth of the dose is g i iJeTI ralpidly lV' and t.h.e Fe s t by cant in Lt{jlUS dr ip . If' the pat.len t i So at Lerg rc to pen Lc i 11 in "I e hJ.oram phen Icol. 1 Orn ffigl .. li(g.. d ai 1:J i:5, the prefer-red al terna te"l Treatment shou.ld cont.in [Je fer ? - 11 0 dials by' IV route. If the posstb i 1 i ty 0 r tfaerm~Dphi 1 us i.n fl uenzae men ing i ti 51 has not been ruled out , g i Y e ~Qtt1 sQjj, Lim ampie i 11 tn 300 rng ... /kg I da ily IV (1 /4 of the dose ini t.i ally and the r~ai.nd er in -d i If Lei ed doses e've1f'i 1;1 hour s,) and c.hloran'phenico 1 (: same .a s be fore-) (separ ate'ly, not in mix ed do ses) . GetlJer al measures inc Lode Rirlt&elr rl S lac tate lV' d F i.p fori !ri]ainte-nanc e and to prevent hypovolemic: snook 10 M::tn i tor vi tal 5iSl1:S closely ~ f f pat rent .s UJTV i ve.s the fir-1st day, the 'pr"IDgoosi sis exce.l Ient .

{2) ~ ... nY:lIg- tef"~! tbe~'apy is a il1ed towar-rl those pa t ; ent.s w.r:c had card i t.i -~ and I Olr ("on~ e St1 "ij"e hear t :-311 ur-e .-j ur ing tfj~ :::1 Jl n ic~al CQ;Jilj'" se 0 f rheuna t i.c f'ever . A t the pre sent , ant i b ac ter i a 1 the-rap y is .31 1 i fe time urtderta~i ~lg to prev e'n t r ecur renee . Ben zat.hi ne pen ic ill in G 1 t· 2 mill Lon uni t sIMI 0 nee a month fc·r 1 i fe ~ ~)r sUI f-ad ia z ine 50Q m~1 ~ in a sing Le dose

d ai 1. ~ for pa.tien ts under 6:J! Ios ~ r:dl II gm or all y uai 1. 'i in dl S i1g ~e dose f;)r pat-i,en t s IDrlIer 6D Lbs , or er'yt,nr'a:nyc in /'50 mg ~ b .. i lid •. (H" al.I y f~)r' petien t So al Ierg ie tal pen ic ill j r.. anc- stll fonam i-::J es ..

2- 301.. UPHOlD FE:VE:R... Ca used b'i the gr'am:-negati v-e rod Salmonel1 a t yphi .

Infe-c tion is- tr ansmt t ted by cQnsLIll.pt ion 0 f cont am in ated food or' drink.. The .soun::e.s 0 f roost in fee t ron s ar e e bron icc arr iers wi th per.s1 sten t gall til adder or Ur" i.nar'y traet infections., The- incubat ion per iodl is 5- 1 ~ days ~

2-28 . Dil F1-ITHF.R r A. See Cha ot.er 6 t Ped I at.r ic:S-

2-29.. MENINGITIS ..

. 511' O1set is u~tlallyl in.sidiDIUS but m~y be- abrlupt"" especially in

children 11 iHi ttl e h.i] Is and aJ sba r p r i.sel in tetITOJperalturel.. Ulsual1 y the pa ti en t develops inCrE!'alsing malaise II he adache I cough , geruer'al bod y achi.ng t sore throat" anrl. oosebl eeds. Frequ:er.Jltl y there is 31 Man in al pe in t C ons.ti p.a tion or dliarr-heal, and vrnli ting .. , Durr ing ttli S I'€:r i.ad t the~ felJ er ascend:5 in .a 3teplad~r falshion; the max i.mLm temper .ature e-.a~h day is 051 igh.tl Y hig)ler than the pr'-evi iOIUiSI da~t... Temper attire i.s gener'all!J higtu;~r' i..n the -e\llen ing than the morning.. After 1-10 days thel feyelr stabi 1 izes and the 'patient becomes ver l' sj,-ck. '" PelaJ SOIUpl1t d iarrtle1a orl seyerle OOIiJ sti patlon 0 r' marlk~ abdan ill all distention is CamIOTJ.. In seve1re c aseSI:I the paltient, 1 ie's motionless alnd Wlre5JXHlstlle:l:' wi ttl eyes: hal f sIl UJ:t and alOpear"ing wasted! and e! ha usted (the Ittyphoid state''') I bllt can usually Ile ar·Qiuse.a W carry out stmple c{!CTlma1d.s .. If the patien t SUirv i ye s this ~rltion and lila campll ications OCClB" ~ he' lVaduallly impr'ovels. Fevel1" old ec 1 inels i~l a ste pl adder fa shion to oonTt~l in 1-·110' days. an~ with it. the othelT S)'milt~5 gradually disappear.., Relapses may OCcur' as late as , -2 weeks a fter' temper ature returns t() normaU. Il burt they

.a rei usually mi Ider than the ol'l'ig,inal in fee ticrn •

a .. Gen-er al con s i d ~!"'at i ons _ 1~1~ln in~ i ti.s is e aUGe(l b y: ~ umeratls

orgalJfi i.sr1IS. ~~:ven fung a I ar1ld 11 iF a 1 in fe~ t ion s c air.. t-a use men i n~ i tis ~ The mcust C01tJllil'Ofi {! aU:3€ s of bac telr 1.311 :lien ing,i tis are men ir]E,o~oceal, P!:l€umQCQCC all streiptococcal '" stapJ1 y: 1 OCQee: a 1 ~ l-I;n~molJr~ i 1 us in fIlleT! zae, and tubercular infectiolrJs.1 All but tUlber~iJl:Ju~ meningitis ~r-e s!nilar in sig,rl and symptams and treatment.,

b:. ~ningQcoec~l m-eningi t.i ~., Abot.lt 15-~D p€'reent of the, population. are- Jla SC/lpJ1ar yn_g,e aJl -c arr i -er.s ") f men ingoc:occ i 1 nut [e w d ellJ'elop t.he d i se.a se .. rm fe~ t iOln i 51 tr an smi t ted by dire Pi} et s .

S... High f-ever ,I -c hi lls '" and head ache; back:" aManlirtal I' and ex:tr em i ty pe in; .and fiausea .an-d vani ti=:1g are pres€,ln t .1 In :severe -c asels '"

f"'a plidl ~ dlev elopi ng confUiS i-O~l f' dlel ir i lin I' and coo a -occur. Iwi tc h or fr ant<. C{tnl~ ulsi ons may al SO be pf""e'sel~ t 111

()J.. Pe tee hial rash a f s·k i n .and rrlUC-OUS mJemb~arlle.s i s found in ~ost

c a S€:'S .1 Petech i ale' rna y "rJ a~'"j froml pir)lne ad si ze t-Ol 1 i3lrge ecchymose S Qlr even

arealS of sikin g angr-ene that. llal~ 1 alter 310ugh if the p.a t i.eln t surv i lies .. TIteS€ pe tee hiae usua 11 y fad-e in 3-.Jij, d a 'is . lJec k .an.d bac k: :sti ffness wi thl post t Jl v-e Kern i~ 'si tti ~g or 1 yi :l_g w1 t~l the thi.t5t1 flex ad upon the abd-crnen I t he leg carIno t ~e COTIP lete 1 y extelnoed) and Br oolz i n 3M i sign. (Inl

men in~.i tis .. f1 ex i{~H1 of the n e<: k u.s llJal1 'i resul ts i:1 fl ex tOln OJ f the hi p a:ndl knee.. AI s(] when pa s.s i ve f1.ex iOJ] oft h.e ~o"WeT' 1 irnb on one side is made", a S imli.l ar nllDiij"ernen t wi 11 be seen in the a pp.)3i te limb .. )1 Shoe k d u;e to the

e ff-eets al f eooo tox i n nlfa y be' presen t. and i:s r3 bad progrlO st i c siiSn.

, .. .. '.. ~I~ , Earl 'i ph_y~~:r~i_c al findl trig!) ali""le .sl iglht "- Late'r, splenomegaly Ii

~bdcmllnal 01 stensicln andl tel11dernesJi ,I relative br adycard ia, d iClrotic (d~~)Ulbl.e

:~) .~se ~ani!:l OCc315ionally s-¥stal ic IIllm1l1lU1' anti e.allop rn)'trn.1 appear +

' .... , In~ the seeOM ~e k 01 r tile dl se~.se II .a rash (rosel sp:rts) appe ar's

pr me lpall Y' on the tr unk {pi n k: papulesl 2-3 rrm.. in d iameltelf" that fade Q1rl pressure) and dli sa ~)pear S oriler a per ioo ·of 3..l1, d.a 'is. tetlkopen ia and

~,~te anemia are t~ rule. The organ ~SI:1OI may b~ found! in the. stool after

lrh~ fU'st week cr posslbly lifIay be fOLll1d In the ur-me. Blood, :stool t or

lne' cuI tUIrIID1~ ar· ~ ., 11 - t r ft' th '.

. '. .. ..1 ~~ . "" U~SU8J Y' pas 11 'ij'le a I 1 er I' ,e fl If"'st w.ee·k.1

CBC shows U3-~ 11 Y' ~Iarlj(ed 1 eukoc ,rtos!. s· ealr 1. y in the courSE of t-~e disease _ U~' i n ~ -may c'()n tali n Dr;:J tel in! ...::a~rc;t s rl ~1~;1 reid cellI s _ L~ar ~unc~tulre re1ijea::' sac loud" to fr ankl~" pur'tll ent cereb raspl :11 a':, fl ulij ~ h'li thi e 1 erv. .ated pr"-e-ssure line re~l.sed ~~;J te' ir. 'I a~1d -'~ec:r~a.sec 51 LlCo.se con t-e~t. . Tra.€ fl [J i-d

U~lua 11 y ~ [Jfi1 tain s n UITter·:')QJS whl]. te ~ e-11 s au,..:.:! ~,!,".,3.';r- :11e~ a t. i V: e i !l tr i3C e 11 iJll ~r

j i pI xac:c i .. The ab sene e ._,) f ;J'rg.a(; i ~s i;- a 5r 3M-sia ined &'9l~ ar <~(Jes fllot rUll iF!

I.. .. r . 4, II • 1ypm id rever.. vil ff'eren ti a 1. d i.agnnsis : rrUbeTC"ulo.si,5 =" " irr'al

PQeL.lDoi11al" p~ 1 t t.acosis II i nfecti ve erldoc ard i ti S... b·r uce!llosi s ~ 0 r QI felve'T.1

oe t " P. . A~ti e imrwnizatioE'll should !)e pnJlllided for household cootacts

I!Wtb YP~ld 'I::.a.rr l.er.~ tr ave II em" .s to ef]dmlic aJreas j and during epi dJemie

. realitsl.. F ()O(j alnd! W~ ter' sooluld be IJrot-ec.te-d and wa stel should be

"')-7'0

adequa te] y d j 5_posed of. Spec i fic measJJ.Jres inc Lode amlJic ill iOI 100 ~ .,/kg .. ca i 1 y.' IV or ~1-I--,2'5n mg _ capsul es eliery II~ hour 5. or al Iy , or ehiloraJ'llpnen Icol. 1 gm q~6h. Qr~11y or IV until fever disappe~rs~ then ~OO mr.~ q.6h~ fo~ 2 . weeks.. IV fl uid.s rna y, be- nece.s.sar y to suppl emen t or-al intake and ma in t~ 1 n ur Ine oul put; 100 nag - hydrocort i sane q .. 8h. may tle 1 p severe 1 "/' tax Ic

pat ients _ Strict 5t.o.o 1 and urine i s0113 tion teem ique:s must be o~~rv~1. Trealtm.ent Q f carrier's is usual I y ifleff"ec t i ve l' but a tr iall a f amprc i.l Lin fi r5t theft c hlor~pben i-co 1 should be tr ied... Cholecystretany me'i Il€ effective ..

discolored:l wi.t~ coal esc ent ~ red t fl u~~-'fi 11 edl IJ€-si ~ le-~ 1-. III the 1 ast, stages p f the dl sease 't, severe p,-'QSlratloJ]. stiJf.K}IT., ce 11 r 1trll!li and cerna

occur ..

O. The inc-rea:si ng pa in is aecOOIpan ied by a fall ill b 1000

~ pressure-. T~pera~ ICe rna 'f be el evated , but ~t pro p?rtion.a te . to the, . . sever i ty of In fectlon " Gas may be pal pabl e in the t15SueS... In c lo.str l.d i.al. sepsis" hema,l ysi.s and jaund ice are cOODOn, 0 ft.en campi ica ted h y renal failure'.. (;r'aml tJ s stalin ·OJf the, exudate sbould sh-ow the organ isrn and is a

val !.laDle clue. but the cl in Le al pdet.ur e mU5 t be presen t to rna ke the diagools,i S ...

~-- 31 • CE:HJLER~A.. An acute diarrhf-~l d tsease caosed IJjI vibrio cool er ae OT

reI ated \Ii tbr Ios , The. infection is. caused b'i ingestion 0 f food or dr in k contaminated by feces fr'Ofn cases or carr-iers.. Ololer'a is fataJl in 50 percen t, or al I untreated patient.s.. The incubat ion per iad is 1 ~ d;ays. but 01']1 Y C! small minOlri ty of toose ex POl sedl b·ecr.:me ill.

A"I Gas g engrene .. Di fferent i al, d Iagno 5i s: other infections that cause gas format ion Pi e .. g .. , en terabac ter:l Escher tema 1" and mix.ed aneerob ic infections including Bactero+.de-.s and Peptost.reptccoccus ,

s ~ Typical eases have an explosive onset 0 r fr'eque1t l' watery stool.s that soon lose al I feeal appearance and odor.. The stool is grayi sIl , turbid, and 1 iquid:l eon. ta ining de.generated epi.thel itlll cell sand mueus, but rarely g ross, pus. or' 1J100d., Th:e patient carl Lose up "to 11 1 i ter per hour .. , Vcmiting may also oeeer early ..

ll... The ~t.i-ent raplidly becoses ~ehydr'alted and ac idot.ic ~ with

3Ulken eyes. hYp:ltension. subnormal temperature, rapid and :shallow br-eathing IJ mlJ5C Ie c rcrnp's 't' 01 igur La , shoe k, and cona ~ 1iemato.c. r-i twill. ri se shar pl J due to 10'.55, of pl.a.sma res u 1 ting in .a eoncentr a Lion or red cefLs .. The y ibrios CaJ1 easf 1 y be cultured fran the s,tool and might p:lssibl y be fbund llsirJg GralmlJ s :st~ in 0 f stool spec.imens .

P'~ Antibiotic ttlera(.lY in the form o·f penicillin f

chloramrfleni.col ,lor cl11 ortetr acyc 1 in e shoul-d be star-ted prcmlpt 1 yin herodc dal:5eS .. Massive debr ideJ.len t 0 fall in.volved t i.ssue , Fr'equ€Il tl y ga 5 in the -subcutaneous tissue OT fascial planes extends be-yond the area of muscle involvemenlt,.. In such cases the ov'erlLJing skin 3h~")Juld be i.ncised widely and tJ1e~ necrotic f'.a sc i a ex ci sed • Care ful and conpl ete deb~'idement 0 fall lICundS and good wound c are will el imina te almost all c haree for gangrene to d.eY"elop.

A ~ OlOle.ra _ Di ffer'eI']tial diagoosis: at,her c ause s . ~f severe d1i arr'be'a l' part icul.ar I y those dUie to stlige-ll ae!t V: Iruses Il E .. , COIl

en terotox in s and proto zoa in ef.IdeJ.Iic areas ...

2- 311... IETAt.lLB... An acute cen tr.al nerVOI1JS system Intox ieat Lon caused by

tox ins prcducedi b. y the :sleoo er 1" s par'e-fonning, ~ gr am-po.sf t,i ve anaerobte bacillus Clostrid tun tetan i that are found mainl"i in the .soi 1 i3rld in the feces. -0 f a1 imal s and hl..lllal'l5 and that enter the body by Wo::Euruj con lamination .. In the 1Jevt::MJ!rn. i nfec:ti.on of'ten enter s thro1ui!.:h tile UTlbil teal stLITLp- .. Incub,ation per iod is 51- 15 da:.'5 ..

P .. wa ter and electro! ~te loss must be re'stor'ai pranllt1'i aod cOritinllOus 1 y! and ac idosis must be t:'orrected.. Di arrheal loss and

bemt]C()]'1 C 51 tr a t ion rIl us' t be me a s ur ed CIOfI t.i n 00 us I Y "'- In D]f,)Ilj era tel y iII patients I it may be possible to provide r-e-plac-ement by oral fluids gi-ve:n in the s;:ne lfoltme as that lost.. (See' Chapter 1B!J IV Therap-y ... ) Those Ulallie to Lake fl uid by' mouth r equi re IV fluid r'epU..acenent. Tetr~ ycl Ine 500 mg ... q .. 6h.. ::( 3-5 -days should al so be given _ [frecti ve decon t.aminat ion of excreta is essential,. Ilut s.t.r ict i.sol altioln of patients is UI'lOecessali'Y and quar'ant ine is ur:tdesirable-

S" (kcas.ionruly t the fi r st s:_..tmptom is pa in and tingl ing a t the w:Juru:I 5i t.e followed by spa st ic-i t y o.f the ne arby mlJscl e groups; tt:i.5 may be' all thalt happens ~ USually the- presenting 5~lltoms are stiffness of the jaw. nee k sti fmess? d i ffic III t Y in -swallowi.ng, and irr i t.abili t)l • H:yperre,nexia develops. later ~ wi tbJ spasms of the jaw muscl es {triSITNJs) or facia 1 muscles and rig idi t y' and spasm of muscles of the' abdcmen t back Il .and neck.

Prevention.: Chuler a v-acc ine gives onl y 1 imi ted protection and IS of no value in oontroling outbreaks.. In end-emic ar~a5 II all water, other drinks I food? alrW uten.s.i Is must De boiledl or avoide::E ...

o. Pain fIJi ton ie conv ul.aions caused by minor st.imul, i {any loud

mise ~ etc .. } ar-e C-Q[lIllQrn. The pa t.ief.1 t i oS awake a~d al er t duro ins: the entir'8

course o,r the illness ~ Luring, conrvull.sions t' the glolttis and the respiratory muscles go into 5p.asn so that the patient is un.abl-e to breath, 3.nd cyanosis a1~ aspl]yx ia ~a}." ensue. Temper aturr€ is onl"1 51 ightl Y e 1 ev.ated .. Al thatlgh there i 5- U5\1al1 y is leukoc ytosi s , the d iagno.si.5 OJ f tetanus is made

e.lin ically.

2"- 32 . BA,CI lLARY DIYS£rfTER r. See Chapter 1.. Section, V , Digestive Syst€m ..

It... T~t.anus. Differential diagnosis: Other types of acute C .11 .. S. infections .and .str ycrm ine p:li son ing, sh.o u ld a 150 be c:cn si-d ered ·

2"- 33- GAS GANGRENE - Prodoced bV entr y of one 0 f .sev_e-ral elostr-idi.a into dev i tal ized ti ssues.. These gram-posi ti ve rods grow and proouce tOI ins mder anae'robic cond i tions. t,

P. Ac. ti ve invnut'l i Zi3 ti·Orl wi th, te tan-us toxo id soould be un i v-ers.al ..

Ad~te deblr idemrent 0 f W)\Jr1:-d S and a booster tetanus imlunliat ion is the most imrnrtan t prevef] ti v e meas.ure.. Spec i fic tt'"'ea tme!J t : Give te tan UlS inrnun.e globul ill {huma((1} 5.000 un its 1M. I f ~o t avai l.able" test for

sen.::;i t.i v i t:y to her 5e .s.er lI1'1 (jr,jIO give 11 DO t ooa un i ts te tarHJS anti tOl: in IV IJ Place pa tien tat bed re s t an-d min imi ze stimulation.. :5edat ior. and

antlc.onv ul san t tber .apy i 5 e S5e!'1 t i al .. Pen i~ ill in i:s 0 f yal ue but Should! no,t

S.. Or.1.set usually suddm wi th T a'pid 1 J increasing ]Jain irl the affected area.. lbe' \l)Lmd becanes swollen .and the su('"'rounding skin is pale.

This i 5- :foll(l1llefJ by a discharge o,r a broMG to bl-L")()d-tinged!l" serous" foul-:'Mlell ing fluid Crcm t,he wund - As the' d isease adVa.n~eg. the surrounding ti ssue changes fran pale to dusky aM fin ally becone:s deeply

2:-21

2-22

be sub sti tuted for ant.L tox: in _ I V n ud -d s as necessar y .. Tr .aC:'heostOfllY and! or a 5si s t.ed respiratio n ma y b-e required. r-tlrtal i t:i rate i s a,OOIUit. II D perceJ.ll t higher in chi Ldr'en and V: er y; old peopl,e Iw

2-3.6.. AlIT HIBAX.. A. disease of sheep , cat.t.Ie , ncr ses , go.ats .. and 5wi=1e

ca used by Bac.i.Ll. LI S anthr.ar. is 'I a gr .arn--pJ.si, ti ve s pore- fonn i ng, aerobe

tr iafLsmi t ted to h Lillan s by en tr y through broken skin mucous mEBJbr anes 0 r by i,nl haf a t i".3:1 .. rJnccmnon:l btl t .Jm{}S t a pt to OC-ClJT' in f'armer s 1" veter mar ia!l5." am t.anner y and ltlOol ~Ir ker So ..

S. Cut.sneous an thr ax .. An er"ythern:3ltou5. papul.e appears on the exposed area of 5~in and bcecOOIEs vesicular with a purpl,e to black center. The area around the 1 esi.on is 51£-11 en Dr edematous an-d sur rounded tJ. y

lie 5 Lcl.es ~ The cen ter t in al I 'i forms, .a nee rot i.c eschar and sloughJs.,

Mal a.i se l headache, nausea. and v ani ting ~a)' be pr esen t.

Pulreonar y .antf'ar ax (lr-uol sor ter "s di sease) ::: Feve'r:l malai se ~ h_elaj ache ~ 1 abor ed or d i ffieul t b reatr. i ng (dy'S pn ea) ~ and cough II

0_ Cutan€()UlS, anthr ax .. Reg ion i31 adena pethy and var- iabl e f-e'llt?r

may be presen t , After eschar sloughs" sepsf,s may occur at times mlat1J i fe st.ec by shock t c y'art[)sis, swea t ing J' anc collapse. HetJllt]Jrr hag i c men in~ i IGi s ma y occur , Anthra)( seps i.s may occur witho:ut a ski.n Les.i on,

Pu lmonar y .anthr ax: GJnge.stioJ1 0 f the rose , throat, and laryn:f: arid auseul tatory or X r-ay sagns of pne-U1lonia_

Lat find i rigs : Wbi te eo un t rna y be el evated or low II 3ne.ars -01 f ski n Ie s ions sbQW gram- p)si t i v e' eric apsul ated rods.

It. .An thr.ax .. Di fferen t.i a 1 di agrY..}sis : Hoar eo 1 y gr.am- _po:si t i ve sJx)re- form i,ng aerob i c bac ill i other than B.. anthr ac i 3- c. an produce Slim i1 aT d1.sease ..

P.. Pen Ic i Ll. in G 10 mill ion un its, IV da il y'oI Olr' In mild local i zed

,

case 5 te trac )'e1 Ine 500 mg 01 q - 6h... 1: 10 days"

2-31.. 'PJLAR~IA.. An inf-ectio'TI of wild rodent.s , Jk1rticularly rlabbits and mUS~f" ~tg, tf".an ~ t ~ed to h LIlla1l S by cont.ac t. wi tn an imal ti SS1Jf! (e "g .. , 1

tr applng at'1ld skinnIng r .abbi tS"t' letc~ .. ), t' oy the () i te 0 r .:::erta in ticks and Dtt irtg _ fl ies ~ !J Y' ea t ing in f~ ted und ercoo-ked meat. or tJ y -dr inking conta:nln ated wat-e'r.. Incubation per iad is 2-1 0 days ..

S.. Fe-r er, he.;;,d ache. and 1l.3t1SE a beg in sudd enly, .and a papule dev.elop.s at the :site of inoculation .and won ulcerJates.. Lesion may be on tile .skinl 0 f at'! e)( tli"'ani t:1 or in the eye 'I If inge :sted, i t may man i fest as ga:stroen teri tis tJ stupor, and del iri UTI .. There may' be rasl1es f general ized ac. ties." afld1 prostr'ation ..

?" Reg ion.al . l)'mJph nodes, beccne enl arged and tender and. may

supp u r .a te (to fo. nm PUs.) " I n an Y' t )!pe 0 f iny.'ol v'emen t, the s pl-e'e'1'1 me)" be -erllar~ed .. AST-rJptornatic in fee tion is n·ot rare.. V. B .. C .. may tJ.e .sl igh.tly elev~ t~d a r ~ormal.. CUll tures 01 f bll oed ~ lesion:r or 1 YM.ph node alspira-te require :speclal cull ture mred i-a .. There is a delayed type skin test (read in 118 hrs) that- Ci:M1 be used.

..

A. Tular-emlal .. Di fferential d iagnosi s: R"i{: ket ts,ial and lilll(t!Coocal il'l,fec. tiOO~, cat scratch fever. in fee t ious tD:>110,. and v.ar Ious ;::umonias a~ fungal diseases .

p.. Streptomyc in 500 DIg.. q , 6-811. 1M, togetber wi tn tetrac,.V<: 1 ine 500 lI&., q ... 6h 'I un~il 5 days af'ter patient is afebr He , Adeqt.late fluid

intake is essentlal and °21 th€~ allY may be necessar 'i . J)r-~in~e- of fluctuant lymph nodes m.a Y' be needed and 1 s sa fe .3 fte'r proper ;an tlblOt.lC therapy for-

several days II

2-3.8. PLAGUE. An in f'~ t.Ion 0 f wild roo ents wi ttl P.a steurell a pest.i s , a

small gram-n egati,ve rod; Tr anSlli tted f("'an roden t to r-oderrt and to hllTlan.s by the bites of f1 eas · If a plague v Ic tim develops pn e~onia! the idfection can be tr ansmi t ted b:J droplets and an epidemi e may star't.. The incubation _period is 2-10 days ..

SI' Usually sud-den an set wi ttl higJh fever , mal.a i se 11 intense headache:t and generalized muscular ache , The patient appears profoundl.y ill and ~ er'y anx ious .. Del ir i ILIili1 ma~ ensee . Wi th .systeDlic spread." the patiel t may rapidl y become sever-el. y septic and canato.se wi th pur-pur .ic spots (black plague) appear Ing on the skin ..

0.. T.ac'h:fcardi.a is usual.Iy ooted with onset of symptans.. If pleuoonia devel.ops , t.acl1ypnea I prod ucti ve cough, nl.ood- tinged sputl..lil1 ~ and cyaoosi~ .al so ace ur Iw .Meninge'al .sign 3 ma:f develop; a pust ul, e or ulcer' .3 t the site o,f inocul at.Ion and signs of 1 ymph.angi tis rn.ay occur , AI illary :I inguinal" o r cerv ieal 13'TT'Ph nodes becrme enlarged aod t.ender and may -eventually sup~ur.ate ~~d drain" Pr imar'y p l ag lie pneunonf.a f'ron dr'opl et,s cc;ugned by another pat i.ent with pl.ague lJlelitlon ia is a ful-rn in ant pneLmOni tis Nlth blood~ J fr'othy spurtLlTil and seps.i s , It is u.lSually. falal unLess treatment IS starte(j with in a _few hour S 0 f onset ..

.. Lab fin-d ing,s':- ~ ... B .. C. 12-2'0 t 000; tJle plag ue b act l lus may be fOW1d

In SDears fran aspirate S 0 f buboes us ing Gr am. 1 s sta in .

. , A. P~ag lie .. _ Di ffererl ti al, d iagoosi.s : Lymphaden i ti s acconpan y'ing

sta.p~ ,~r .strep- In fee t ions a f an ex tremi ty" lympilog_r.an ul.ona venereum j SYPhl~llS:t or tularem ia 'I S:rstemiC' man. i fest3 t ions :re'.5e!nible tbose of en ter' ic Qr rIckettsial fevers r malar i a, or n 1J •

P ..

Streptomycin 111& .. q .611., is tr'3Ctleostamy

Iher apy must b'E" star ted prornptl y wI1en _plag ue I s sus pee ted ..

~ 8Jfl.. 1M q. 6h. )[ 2 da y-s then ~OO rug.. q. 6-811.. te tr ac :reI ioe 500 gi lien at the s.ame time.. IV f1 Uiids 1 pr essa-r d r-ugs I' ox y.gen t and are used as requ ir ed ..

~~39~ . LEPRffiY. Ulansen ~ s dis:ase). A chronic infectiou::" d~sea.~ c.ausedi by

. he . ac lrl-~.agt rod ~(:obaeter]_ urn Ie prae 'I Mcde 0 f tr.an::l111 SSlon is unkoot61;

pr-cb.abl y lnvol Iij"es pro 1 On:{]I.;_".-I1 .. . ., h ~ 1 h ...... ,_rI! d 1 1

" • J ." ~-LI.Jo~ exposure In {: 1'1 lOW; a: ut:s.. ra\f"€ I y b~~e

it f~ted( e .g. 1 • by t.at too ing). Endemic in tropical and s'lJotrQpic.al Asia. rIca ~ Cenltr al an-d ~uth Amer i-c a:a the Pac i fi c reg ions and sout hern. USA ..

, '. S'I &. 0.. Ol.se-t i.s in sid iOLlS." les ian S- i~yol ve s~in t super fie i al

nervesl nose pilar- ' 1···· . .

,. ..' t "' , ., " I. I yn.x 'I arynx." e )'es '" and test 1 C les .. Ma y OCCtlf" .as pal e

:n~~t7 c- llli3Cula r l~siorts 1:-1D- ?J1. in d lam:! ~r. d i sc-r~ te. er ~l ht'JllrJ ~tlS Neur- .... a~ .. ~du1es 1-5 an. 1n dlameter? or -d Iff~se. Sklfl ~nfil tratLOn. thi . :~H:! d1:-t urboanc-e- s are roan 1 f-es ted by nerve In fl1 trat~on al1d

Ul~~l'l:lng.j wlttJre.su~~nt al1esthesia •. neuritis, p~r~sthesia ~ tropbi-c

s, bone reabsor pt lon, and .shar t.en l.ng 0 f the d 1& 1 ts . In untreated

2 ~ If -£~

. . . en· •.. :01- I but PPDI 01 .. 1 cc , 11 ~ 0 is more aeeur ate., These telst s are only r'orl

sere ... 01 t. -. I t f ...... , t . p - - t..... - t"

screen illg of patlents:to no:, o f""' U l.ag1n0!5 . ,1C pur jX)3eS ..dlt]_ent 5 W1L· ,liJ PJ.!l '1 w'e

skin tests should have chest: X r ays, I'

A .. , Pulllrmnary tlllb€llrculosi 5.. fJ:i fferlef] tial di iaglilosis :: 18 can JIIiJrrjc alllOOS t, all 1'1 P ulm 0 n air y dl i se ase sue h as ~ ae te r i ~ 1 0 ~ LJ i r all ~ e~oo Las ~ l~ ab~ess: J ~11lmot1Jar'ym¥coses ~ bronch~en ~c .car~ Inoota 11 I salrC~lldo~~.5 ~ and til atypic.al ,II (nontuberC~05.1 s) . mycobact-el~ lal lnlf"ectlons .. , NegatIve' t.Ine OT

fPD testl melle d l.agnos]_ s of I.e vert J unllke1'i.

'pl. Pre",'el1ltioi"l : Patients wi th 8C ti vel IB shoul d be i sol atedJ

dftr i III the r i I'll st 2. WOOl ~ S 01 f t re~ tm-en t. am ~ ta ughl ~ to cov er ~ be i Ii nr~) urt tl aoo. OOR -wi tJll displsablle· tlSSue d IJ.r Ing coughIng II Close contac ts must, harvel skin test and 1.f pl1si,tive, chest X rays , If' negative they 8oo;uldl be retelsted in 21111]nths. If contact is pos.i ti,ve and cbe~st X rayl is nleg,alt.iv'e" they soould receive isonia:zi.dJ treatmmt fOlr 1 year. In falt.s and erri ldlren whol are in .closel -CQnt.ac~t sru)ulld be given ioo1niazid even if skin tests· .are negative 11 but tiJeir trea:tmen t can be di soont.mced if the skin test i..s still negalti ve]; .:aths 3:fter exposure is, ~isc:onltin.uedl. PerS()lrls L4lo conver-t fr-om negattve to plsi tive wi.thin 2 yelaT.5· whol have negra-t,iLve X. rays .soouJ.dl recei v'e isoliliazi,d f(uRo 1 year. Posi t.i ve re-ac. tors wi th negat.i.~e! X. rays: wi th high rllsk factors· (e 4'S" II prolonged corticosteroid thera_PIY for' olttler di seases , lbigkin 11:1 di.sease, leukem Ia Pi d Labetas IJ and si I ieosi.s) should receive i.sonlazid fOlr 1 _year.. Preventi ve treatmmt with i son ia:zid, oon.si st 5 of ]00 III.. dlaily {1!.o mg: .. /kg.. dail y for' c:hi.ldlrl-en) fori 1 year-"

eases Pl the d is fi,g~F em en t mal:; be e:{treme.1 Leprosy is cl in ically and by lahora tor -s tests dill i d ed in to two types: 1 eprcma tous ami tuberctJloid"l' In the 1 eprormatous, r. :lpe"" the' cour se is pIrDg_r'essf,ve and mal igna1 t wi ttl abLa']dJart t ae id-fas t bile- i 11 i in the sk in lesion and a nega.ti ve. Leprxm.in sikin test ....

The' tJJJ~erc ul Qlidj type is ben ign and 1I1Dnprogr'-essi lie wi t.M severe .a.symmetr Ic al, nerve .invo 1 vemen t 0 f sudder:1 onset wi t,h f·ew bac i 11 i in the Iestons anti .a

pos.i ti ve 1 epr~lin ski n test of. Ey>e i.nvollv emen t. (ker-ati tis an.d

ir id~ yel i tis} 11 :'1 a. sal utI cer 5 ~ nose bleeds F at'1l€filJia t and 1 ~ph~denopathy rna",· occur ..

p ., tJ~1 treated leprGmlaJt.oJu~ 1. eprcl5~ is progr-esai 'ie' andl fatal in

10'-2"."0.' T t· 1

-0 . year s • n 1'.uner~llJ lo.jd lepros:y, Sp:lfil laneolJS r'ecover y usual.l y' ooe ur's

In 1-3 ,earr s; hO"We'vel;' II i t may produce e ri ppll .ing deformities II Wi th treatment II Leprxma tous leprosy regresses .slowly (over a period of 3-8

year 5) ~ Reeov'er]( fr-om tooerc [.I1.·oid lepro,s:y is more 11 apid .. Retulin 0 f 's)mptCfmS is always P'Js.sible and l.t is safe to .asstme t.hat th.€' bacilli are neve~ ~.:Jtal1y e-radi~ated ~ The t;r'eafJment of lelprosy is ~er'Y canplicate.d:t reqLll_r?TI~ n unero u s dr~ s (dapsonel• iftli thio zone 'I thelidOOlide j ri fClllpin ~. C1Q~<:tZl ~~ ~ a~d cor-ticosteT? id s ) in ~ncrea.sing doses over a pedod! of year s or ~ndefIZl~tet_y" All of thlS neces:S:ltates evaeuat ion UJ a hospital or areal bet terl elqu.l pped ttl hand leo these case s ..

2-~ 01 Ie T1Jat:JiC:i.LOS IS .. Caused b:}' .3~ id-fa st Myc-abac teor'i um tubelr'ClJlos.i s .and

char'ae ~elr i zed b¥ the f=?rmat ion of tuberc Les in the 1 ung I' Oc--Ctlrs almoslt ~:~luslv'ely by l:1ha:la:tlO~ of airbor-ne :jr'Oplets fnJrn the coug,h of a person

Wlt~l ~,~bl:rcl e bac i~ 1 i . in . the -spurt.tftJJ... Ing;e3t ion 0 f' :nil k conta in ing, tooercle

~ ac i l.I 1 t unpa stelLEI~. zed J 1. So a~-k)t he r Mod e o f tran Slr.i 3s,i.'GTI • Thel danger a f

~n fect~::wn ~rOfn C'-Q!]tamin ate-d sur fac e'5 is n eg I i&,ible... The f"ir st or pr rmar Y' Inf'ec t~:J_" 1 S usualI Y' a sel f -1 im.i ti ng d i sea se in: chi Idr en t hal t: escapes detec tton , . ~ few pati ent,s develop progres.si ve' pr iunar Y' t.ooer'c ulost.s.

~nDtJ]t:~lr sma 11 percen tage dev el.op pro.grels3i ve' plJlmcwnar y (j i sease t, Pr lmaTY

l~l fee t.ioln ~ I C;IC~ urring in adlJl ts ~a'y ev'ol ve i;:'1 tD progr'essi ve pulml(}nar'i

d l~'.a se W1 tho Lit th e char acteT'i stic changes Q f pr imarr y d ise~ se seen in

~~11dJ~te!l .. rvb.st ;:=eQ'ple whlC' a~e in feetedl at aln "91 age do not develop the

dll sease .. ra in utri t.iorl ,I ct~ i abetes 11 mea 51 ~,~ II ehiron i CI cor tico stero i-d

~r -e.at.nJlent "I s1 1 leasi s" .and gen elial -d efu il i t It favor' prog re53i-on 0 f i.nfec:tion l~ to, pro_gr'essi 'ij"€ ~LI l:']onar y di sela se •

Adult Dose

Corrments

lsoniazld (NH}

With tlt1e~ .sol e e:cception of pr'eventi ve treat.-nent:t thi.s should be used only in ecmbinat.ion with other

dpII m.;::

II ~,..... ..

andl

, grm 1M (la ily or twic e weekly

.and

l5 mg .. lkg.. d ail y orally

3.. S~ pt~ms m.a:y be absent or :ni ldl and: nonspecifiC' in the

pres€ nrc e Qi r ae ti Ii e- {~i.s·e.a se- -0- Th e mo st f r'e G": ue!'1 t .5 ytfJlpt aEl S tJ when pr-el sent tl ar e C~Ligh II malaise "I elalsy fatigability., ~igr,t loss,,, IQw~grladle .afternoon fever ~ n 1 g)l_!._ sw€at f a~d p!e~Jr i, t ie pain., [bIUghl,. \i1en pr-esen t II nas fJJOI g:peci fic c~rac: ter- i st k s. P.::lJtients wi til pulr:'lOna!'" y tuherc ulooi 50 oC"£!.asionally presel'l t WI th . 5 ~ptoo. s jl uel tD ex: tr a p:1~;rmo[J]ar y eomipil ica t ion 5 suc!h .a 51 1 aryngei311 t

renal ~ ir~ te'st i~~a~. {)r' C Nl. ~ ].'1 nl "Ii.,ll..""'L}1 U ~e·rJi"'I: tl' . .

I'l . 1 III!. ...... U I iii ~ "'U ICljUI . :u •. ,'.:l

or

AI:Inosailic ylic aci-d('lS,)

11--51 §D orr all 'I t .. i .. d.. after' meals

Use only whe11 ethanbutol is nOlt ava il able·

or Isoniazid

same 3lS above

..... ~. 11~1--nJ<1l.1!""" "::Jir ~c~ -=" l~..-tiI . . ... h·...Ii ~ f·'f· . ""II t t .,. ., +- 'I Ih .....

~.... • -..oI ~:-...,."li. I!:l . .I' 0~n s. m.a y u e' ~;; 1 : . ,:cu..n. ., 10 eo 1. lel.._.;, even 1[1 tJJ rC:-

pr esenCi? :J': 3!C ti 1}'e d i se 3.se ~ Fi!1 e per s.i ster.:t rl aJ es. {)yeIT the Ulplpelr lobes rna~" be f~und., Tt€ S~ ar e be st hel..3lrd -3 fter a sl ig bt- co ugh. AdvlarJc-ed d isea.se ma¥ le~d to ret.r- actiJ:10f 'the e-~st wall ~ d~'iation of the traehE-a ~ ~les, . ra..i. es~, .31""!'::! Slgr::: S -:J f ~H.Jl~nar ~l cun.sDll-d.a t l'Dr! ~ Pu:L~n ary TIS canna t. ble r llJlejl

out ~:~ ph ys.i ~?.al c'xar.JJi:1at i or.: anI ,;{.. M.. ~ he5~ Xray is t.h18 min imllT1! dliagncst Ie ~equ-irerr--e~l ': ~ :'ab [i!1d i ngs: Sp UJtum srle-ar s ar e _p.:}sli t i lie· I-I'lhie'rl b acter ia C~:3unlt IS hig h but shu ul d be can ri rr--red ~Ii tb c ul t-ure. Ti.ne test may be used for

and

Bi t. pin.

50~)i mg. daily orally

Jbst autm.r i ti@ s, advise a min UnaD of l2 month S o·r trealtmen.t after it bas bl!4!Jil ~ X ray lesions are stable, no c:avitati-on is present, and ellll ture.s are negativel (coo trol is uSiualll!l achie-.red in 2-3 monthls,) •

b l1a ~ ~~d can bel used f·:)r· ar even t.ion i n th~ fi r st; l.ijl hour s a ft~'r

'nA ru·e .•. J g.l I Il"'"

mlJll y,-' I'

-es: "sure' ~

Wl3~ RtJBELLAI_ (Gelrm~rneasles) Il A" sy-St~[!.JJiC' 1Jlir'al infeC:t_~on transmitted by

~ . J'Ialation of HII fee t IV e -d ro p 1 et,s ". Onll ~ Aillooer-.a tel 'I cOITIIIun rcabte . Ote

1n usually con felf 5 perm.an-el'1lt I mmOOl t '1.. Dl S€:·ase can b-e tr an~i l ted fa r befOITe Tagh appear a , Incubation period is 1~-2Il days r.

Se1Jler e c ases may r'eqll ire surg e:r-' y •. Because of thel C'Cdpl i.c at ions tJ spec ial tests" and pro longed treatmeTI t· Fit i. s bel5 t to evac uat.e tt1e se patients if ~ssf,ble ..

Sectio :ll I Ir}' - Vir al

2-,~ 1 ~ GtE NERliJ... 1Ji~ulse s a!"e -ex tr€flliell-y s.trlall ~Irg.an i srn s t ha ~ canno t be S~€!'":

tinder a normal "'T'Uic~oscop€ iii Virusels e ause a variet,y ~f i~JD·rtant i!J1felctiDU:: di seases, ~ng t..hel,sel are t he ~':mrJD n cold ~I ve 1101 h' fe'J errl t be pat.I ti S tl and t~"'lt:

majority 0 f the· irLfectiofJIs o r t.he upper' r-E- spi.r ator y tr act. .

$ .. , Fefl/er and mal ali se t1 usua 11 y m i ldl II wt th t.ender suboce Lpi, tal adediti.s IDaYI prec~e erupti.o~i b:t, 1 W€eK .. , SymptaTls of mlildl ~e.ad co l o :may be' present ~ Joint. pa In s occur l.~ 251 ~rcell t. a f ad ul t cases, S~lltOUl.s usua lly'

sub&de inl about ? ~a.:fS ~ A f~ne ,I pIn k :n~cul.u papul ar ~ a Sih. appear s on ~ace!

trLlllk 'I and - e;( treml tle: in r a~I~-d progreSSiQnl.1 uSLiall'j/ 1 ~~'~ 1 rig .onel -day 1 rI each area -al Rubella Wl t.hout the rash is as commOal as, W'l th the ~~~~ ..

2-~2. MEAS,~,ES {R!Jbeola}.. An acute systemic viral i~lfe£tiQin tr'an~i tted t·-~.

inhala~iol~ . o~ i n ~ecti.ve , drolplet~,.. 01 e at tack con fer s p€r.na"'lent 1 :lfJJ.UnJ i ty ~ Cann.tm teab 111 t y' 1. S greatest dur l.~lg: the' pr eernpti ve :9. tage 11 but, CQ~ t in LlelS as long as- the r ash remain 51.. Inc ubati~ln: per iod is 10-- 1 ~ days.,

0",,1 Poster Ior cerv ieal and :po:slaur .icul, ar:-' ! ~Plade'flo path~ i 5 1J er 'i COIiIDOn -II] RedlrIes.s a f the pal ate and t.hroat, , sonetimes blo tchy t may be JK)t-ed., DiagllOsis CCJ1 be sus pecten wilen there is e pidem ial ~ rc e'v i-d ence of rubella

in t.he area ""I eBC IDa y sbo w Ieukopen i.a ear-l y and mal y be followed! by an

irlcrease in plasma cells.

5, I- F eve r 0 ft,erl a s higJ'\~ as 1 O~ -1 05 degrees F ~ I cor'yza (nal.sall

obst~uc:tion.. sn ee zing f . sor-e thr'Olat) ,I per s.i :stent and nonpro(!!uc ti ve [! olJg~ ,I mallal se (Tillay be mar ked!) f arndi conjune t i IJ i ti s wi ttl redness II siwell i ng 1 ]:trotophob La I' and di scharge.. Kopl ik IJ s spots (: .small r -eC spots wi th

biui st1-wJ1i t.e : enter s on t h.e aria 1 !fIlUC05a and 0 ften on the Inner con] une ti v a; fold sand ulag Inal mucous !fIlemlbr;:lne) appear about 2 days be fa r-e the r ash and last 1 .... 4 days" Jial.sh. us ual I Y' a ppe-ar s first on the face and behind the ear s ~ dayls a:fte'T the onset -elr sy.npt~m5,_

CampI icatiorls:::: In pr egnanc Y.I r-' i.sk to th~ fetus ish igh i.n the

first tr-imester .aM con tin lie 5, in to the second tr' ime ster II] Jtn in fan t

ac~QtJir inS rubella in uterus mlayl be normal at b IT'th 'I burt mDre like I y wi 11 .have a wide var iet y o f marl i felstation s incl udl ingl _growt h ret.arda tion " mactl~opBlpul ar r ash l' t hr-ombocyto pen ia {aboonnal -d ecrease in n I.JT1lber 0 f e Locc platelet-5) Ii ca t.ar-ac~ts Il dea fne-ss l' cong,eni tal he.ar·t de'feets tJ org.arlOOleglal'i/· (enl argemmt of orgal'l s) I] and "TIan yl other man i,[e.sta lions ~

.. 0,.. The _ph,a~lrnx is. rec and] a yellowish eXlxi~t-e -r:may appear on the'

ton 311 SF. The tongtle 1.9 OO~ ted! in tile cen t.er and the ti p and marg in 50 are FeD - _ ~e~'ate general i zed 1 ymlph~denopalthy i s c~n;: s _pl enDr.J~g.31 y occur-s ~(:aI51Dln atll 't · The ini tial l-e-s.ion s 01 f the' rlas;h are pinhead-lsi zed papules thalt C"oallesce. to fa.mJ the br'ick-red ir-regtJl ar blotch,..-· :naculopapul.ar Il"".astl and tha t rna y fu,..-ther coale see f in sever e ca ses, to fU~fI] an almost uni fd rn

erlythe:mfa Oll SOOleareCliS o,f the body,,_ By the. .seconrd d.a Y ,I the rash begins to

coale!~e . on t.he f.acel as ita ppe ar -5 on thel trtD1k ~ (}n the third day'.. the rash begIns to co.al E!'lse:e on the· tr unk as f, t appear'S on thel el trami t.ie's and beg.in s tol fade on the face'. Therea fterl, it fadle.s in the order {;}I f i t.s

.appearanee -al Hj"per·pi.gmenlta tion r F3Tl,a ins i~ {'air-skinned i nd i v idlual.s and!

sevlerel Cal5eS ..

A. Rubella.. Vi fferen t ia 1 d iC@oo.sis : In feet 10 U s monon ucl eo.si s .. ecilov iru3 infections I- [lInd cox: sackiev irlls in fee tions .

P.. Symptanat ic:' tre.a tmeflt : ~pir in ,I flu id S t re st .. Rub>e 11 a is lIild .and lilarlel y lasts; mur'e th~n 3:-.ij days. ConRen i t,a 1 roo-ell a has h.igh rnortall.! t 1 raltel and congen i tal die fect.s T'equit""e year's 0 f mred ie-al and SUlrg: ie al rDalagement •

t\, typical me·as:les is al rarely' oc-curlring syndrooe i,n chi Idrel1 or adlul ts who havle rece i ,"'ed in acti VIe- or- 1 i ve mealsle 5, v.acr ioe aWidl .a 51 a res tJ 1 t

~e ~eyell?[)e(I ~.yperlsen.si ti Y' it Y r atheT than protec ti ye inmun i ty .1 ~,en lrlJfected WI th milldl mel8 sles Y irlUSI ,I the y develo p high fever ,I lI1 usual rashes ~ papular:t tlemolrTlhag i,e) , arlthr a1S ias j andl pn-ell.ll10n i ti s 1 ·often 1ii.th :;rever'e ~llne 55 . ~nd a., substant ial mortali t "!l r.a te... Leukopen i i3 is tl3ulall y presoo t 0:11 ess t~~e lS .a secondary bac telr i.all infection. Complications inc 1 ooe ~ceptl~l tiS;" bronchopneuoon i a or bro'TIeniOll i tis t' and s-eeond ar y t'lac ter ia Infections ..

Prlevention: ti ve atten uated rubel.l a y irtJSI vaccine offers

cqupl e tel protec:tion of. Blirth control nJU,JS t be pr -at! ticed by women for at lela st.

.3 IID1thsl a fter the use 0 f' t,he 'i ace in el ..

2-1t "... HERPES lC6TEB (Shingles)l. $eel (00 pter 1 ,I ~ tion l!l In tegLllteTI tary

System ...

A.. Measle's ,I Di fferen ti al -d iagoolSis : Rl.~lbell1a 11 cl1ic.kelrl pJ1X 1-

.small pox ,I i~ fee t.i-OIUS mooon IlJcloolsi s '" en terov irlU s infect iOil S I and dr-lig -eruptions.

2wJiJ.l. VARICELLA ((]] i.CKetllJl!lK) II] See Chalpter 6 II Fed. ia trl ic. SI ..

2..Ji5'1 . liAR-IOtA. (!'Ball pox) ... An acute.1 contag,iaus·.1 slylsltemd c y ir.a I di.sea.se. Tl""atsrutted by direct contact with infected patient or handling of

~t<nin~tedJ . ar-ticles ~ Thoug~t . to b7 er ad kated ~r 1~IW"id~ as of 1919 _

. _ugh, the e.fforts olr the- W .. H .. 0., USl ns SInal 1 JXlI >l:: 11 ace lrl altlon • Incoo a.tlon

rl.Odl 1.81-11 days... usually l~ 12 day.s to onset of illness I and 2-~ mare f.$ to onse t of r a~h"lll

. . P... Isolate- the patiell1t for the week follOlWdng onset of :rash, and

keep a t be~ ~est. until afebr i.le .. Gi v'e aspirin. tJ saline e "ie spolnges tJ vasoc~nst~1 lC b}lr nose -d t"Op5 tl and 3edl.ati ve cough mix: ture as neeels.sar 'f; treat C'!Jnpllcat lon s .a:s: n-ee::red-

:i .' .. . S~ Abrupt onset wi tho chills 1" he adlaches {usually frGlrl tall )1 'I

Intense 1 unbar palin"t feverl (up to 1 ~ degrees F~. olr higher) .1 nausea. tl or

IIIOre . :freq~tl Y vani ting . fever falls shar})1 y on eVeri ing of third or :Ii:~ of fOlLU'th day, often to-. no nIIal •. and eruption appear s, as tmlper atu~ ltlnnall Y II rash star ls fJL rst Ort race- and soon after -r on ex·tremi t.ies

Prevention: M:ultiple U-lr'US va . '1 bl {

. ,. .1 .•. 1 .. " .• '·CClrle.s are -av'al . a.1 -el I lDeasl es j

2-211

2-28

.'~cephaiiti3·1 symptoms}.. ()t.~r 5)'m~t~.s. inc:l~e d~plopia, {double v!.sio-n) (~n)1 fl rae ial . ~~kne'~ . s , d y·sp~.s 1 a (speech lmpa trment.) , ~a5~1 V01C~"1 "Welakness of ~,~,e .. sternocleldcmalstold and tr~_pezl~s mus-cles ~ dlf~lculty 111_

l'dw1ng II inablllty to sw'allow or exp-el salIva) 11 and reg urg 1 tat ion of flUIds

c 11111,. "1I'1lo-m t 1 - f lin .. t - -

thrOugh the ncse . me mos·. 11' e tu Ireaterllng aspec 1.:5 r espi r a t(H"Y' ,

.. ,:,' alysiS... Par.aI y.si 5 may qu ick) y becone max Ima.L or progress oyer sever al ~.s lI"lti 1 temper atLFe ~eccmes- normal , Deep- tendon r ef'Lexe.s ar-e d imin i ~ or lost 1l oftE!l1 as )'lOJI,etr'lcall ~ - Letharg y ~ r c~.a may lle due to encepl1all t1 5 or hlYPOXia, most often caused by n_ypoven. t.i l at.ton.

0., Rash Ls of t.he sane character in an y gerler"al 1 oc-altiool. in

thi s respect tl di f'f-er ing markedl Y' from rash 01 f chickell po~ -I' Ralshi is

in i tiall Y Dlacules; about the se-cond day they becane papules t.nat become ves.icles fr-r.:ml the' thi rd to fi fttl day, The lie s i.cl,e 5 increase in size and by the -Se"Yenth to eip:ht.h day beccme ~ 11 developed pustules , Finall y scabs form. These scabs f'alll off in about 3 or .q. WCC'Ks ~ The lesions or snallpox are de~p-.seaJted wi tn a thic:k prote.cti \I"e cover ing anc do not rupture easily .. The lesion does no t collapse when pr Icked by a needle. Recovery in

lJI1 treated cases is doubtful ..

Lab fifld ings : W .. B, .. C.. rna"i be no-mal or sl ightl y el ev.ated ..

A - ~alllXl'x .. Di fferential d iagno.5i s: Chi.ckenlD:€! tJerpes

A.. Poliamj'el itis... Differential diagnosis: other forms of .a~ptic meningi ti s due to other en t.erovfrus (muse.I e tenderness and spasm, if prese'n t , po int, to rnl io) i s v-ery dl iffieul t to d i st mguish froru pol io .. Acute inlfectious pol yneur i tis (Guillain-8.arre) and tick bite paralysis may

ini.tially resemble- p:::.l iomy€" Ii ti s ...

P... Absolute i501atiQ~ of patient in a screened buil:. 1I@11 ventilated room un ti 1 all scabs and crusts ha~ em di sappeared ~ S)1IIptanati,c

treatmell tis forced fl uri ds l' a spli r in . [b not use 0 int.ments on the skin before the dr ying up is e-onple te as i t i ncrea ses tile likeli bood of ab.sces,s format.ion , Close .attention must be giv:en to the eyes; if necessar-y, the't

may be i rr igated 5eY er.al time So a day' with 2'1 .500 itITI I) iC3lrbon.ate sol ut ion II Veak iad me or l.E'ak permangan.ate baths can be used! on the skin for cleanSing and as a detJdor artt ..

Succes:sful v ace in alt ion aga in st sm~ll pox is.an abso 1 ute preverl ti v'e II but ttli s sboul.d be repeated (j ur ing an ep idBiTJ i.c or when aJ indl i vidool has beer1 ex JX) sed ~

P.. Symptom.atic : Mia in ta in confor-tab'l e Durt chang ing posi t ions on a finn mattress \rl_ th, foo tboard:l .spong e rubber pad 5. or- rolls 1 saodbags , and 1 ight .spl Int.s. Hotpacks for the ex trami ties and an al.gestc drugs usua lly control mru&!le Spasml and pam , IV therap-y may' be needed to pr"event dehydration ~ Indt..-ell ing catheter mal)" be r"equi red.. Irrte st.in al hypoacti vi ty may lead to fecal impac tioo . cases 0 f bulbar p:Jl ianyel i ti .s invol VI inc respiratory muscles require intensive car'e , Jittention must be focused Orl mainta ining a e lear a irway ~ tJandl .ing s~cr'etion s ~ prey en t Ing respirator 'j

ill fee tiolTlS, and maintain ing ad equa te venti Lat ian. Assisted ven til at ion and tr--acneostcmy ar e olften r~quir ed ..

2-.lJ.6.. HltIPS (Endemic parot.i tis) II- See Cbapter- 61 ~ Ped iatr Ics ...

Prevent ion of defomd t i eSI "1 s best. acconpl, i shed by avoid ing ae ti ve ezerci.:se diur ing febr il e per iodl and auosui t ut ins pa S5 iv e' r'ang e o,f 1fIrOti<Jin exercises and frequent cllange.s 0 f posa tion .. As soon as felt er s:..il!iides ~ early mobilization 3Jrld active exerc i se sh-Juld be -=-tart,ed.. f;)rly bracing and spl ill ling for t.herape~t ie purposes are rec-oTlmenderl.

2-41. POLICltYELITIS-I' Three antigenically di-stinct t~s are r-ecogni:zed ,I wi th no cross i.1fIIlLll i ty bet,-lI'Ieen them.. Probab 1)' acquired by respiratory droplet route 0 r' b,y ingestion.. Incubation per iod is 5-35 da y.s (usual1 Y' 1-1 ij (jays). In:fecti -v i ty is max im.al dur ing tile first ~'k. Since- the introdllXtioln of effer:t.ive vaccine't' poliOO1yelitis has becone rar'e in the: developed areas of the w:llrl-d ..

S .. and 0 ..

Prevention: -cr alIi ~ e vir U 5 II ace in.e (Satl in) ~ the tr i val en t [om

.

~s preferable for immunizing children and infa~ts. Adults ~o are e~posed

to pol icxnyeli t.i s O,lr pI an to tr ave 1 in erldemic are'd 5, sh01J ld receive the or.al y,'accine al so ..

(1 ) Aborti ve fell iotny€" 1. i ti s: Heaclac 'he. fever !I vamiting. diarrhea.. 0011 stipation. and .sore throat.

2-'18'1- DE}K;tJE (E.T-eakbQne- fever tJ -elandl., fever).. Viral d i sease transmitted! by

Aedes IIXlsqui to II Occur S onl y in ac ti ve 00 5 q-ui to season (warm '-'leather) .. Incubation per Iod 3~ 15 days I usua 11 'i ~-al da-ys). ..

{2)1 NOrlparal yt ic pol iOOJyel i ti s: Head ache; neck, back, and extrsnity pain; letl'largy; and irri tability are present _ Muscle spasm in ex ten.sors of nec'k arid bac. k i s always Ilre..!ei1 t and usually present in the hzmstr'ing muscle's. .Mu;scle Spa1Sl11 i oS VaT iabl.,1 pre.sen t in other mu.sclesf .. Spa9'll may be seen lIlen patient i:s at re.st or -el icitedl by ~ut tillg each lIIu.scle tnroll«t:J the max imm r'an@;e of mot ion.. l1e.si stance to nee k flex ion is ooted after a varying range of free flexion.. Straight- leg rais.ing is les5 than 90 degrees... The' rDlUscle.s may be tender- to palpation ~

(3) Paralytie paliornyelitis: May oceul"' at anf time during t.he febrile (fever ish) peT iOO oG Symptans 0 r nonparal ytie pol ia:oyeli tis plus tr"BDOr and mus.cl e weakness 'I Pare'sthe.sia al"ld urinary r'ete:ntion are noted occasion all y • Con sti patlan and! abdm in al d istent ion are. cumtOn... P'aral ytic

poliamyeli,ti:s lIIay be divided into t;WQ fenos that may' coexist,. Sprin.all

pol icayel i ti s (kleakne55 of mmcles supplied b'f :spin all nerves) and bulbar pal i<myel i tis. (l.Eakrie'.5S 0 f' muscles sU]llpl iedl by cran ial nerlle.:s :-'nd 11 ar iahle

. s. Sudden onl.set 0 r high fe~er:l chi Ii mess, severe aching

(breakbone) of the he ad.1 back I' alld ~x tremli tje-s!l aeccmpan ied b1y s.or.e throat '" prost.ra tion,_ and depression. In i tial febr i1 e pha se la sts 3-~ :jays, usually follOllled b_)! Tsooi s.sio,n of OJ f.e w ho,ur 5 to 21 day's. A rash r3 ppe'af' S iil 80 per'e~ t oj ca se s dur iiilg re.1i1i ssi'Dn 0 r dtlr- i rig sec'ond febr i Ie' poo se that 1 a:sts 1-2 days and is acccmpanied by sim,ilar but milde-r symptoms.

_ o. M.a Y' be co njunc t ivai. r-edr1ess and f 1 u.shing Or'" bl0 tchi ng 0 f t hel

akin.. ~-sh may be scarlatinifor.TI, rnorbill iform t mat::ropapular", or petechial Jl .appe ar'ing fiT 5-t 0 n dar'SUl1f] 0 f hand s and fee t. and spread 5 to, t.he

arms a 1 egg pl tr unk. and neck t but r are1 y to the fae e II Ra sh 1 asts 2 hour-:s. to

severa 1 day~; and m,a y be foIl owed by peel it\g : l'ete:chial rasne 5 and gAs·a~trointe5tin.a 1 hemorrtJar(P-es occur ill a hia"tl po .• , 'rtion ::If c: .:11:S€ S i~~ ::1olutne a.st

'la.. 0 ~

2-10

Lab find i118, s: Leukopen La is characte'r i.stic ..

A II Dengue . Differen t,ia! diagnosisl: Refore the rash ap_pear:s :t it is d if"ficul t to, di st inguish fran m~l ar ia II yellow "fever:r O~ influen za .. '

p ~ Symptana tic t~atment:;: Treat shock 11 g,i ve salicylate.s as requrrec , forced fluid.s 11 gradual restoratioln. of acti vi ty dur ing prolong-ed convalescence ..

Prevent.ion: MbsqLliw ecntrcd . An effectiv1e vaectne has been developed but has not been produced ccemerc i.ally .

2-11-9.. a:t..ORAOO TICK FEVER. All acute viral infection transn.itted tJy tick

Di tes , 1 imi ted to we stern USA and most pr-eval en t dur i.og, tic k season {M.ar'ch

to August)., Incubation per icd 3--6 days. '

s ~ Abrupt all se1t 0 f' 102-105 degr'ee: F. fever- Il sanetimes wi ttl

chi.Ll 5.. Severe rnyalg1i.a:f. head ache '- pbotoph-oblia.. aoor'e')( La f nausea, vani t.mg , and gener ali zed l.eakne5s.

o. Abnormal riM Ings are I imi ted to an occasional fa int rash.

Fever- lasts. 3 da ys followed b'i remission a,f 2- 3 d£l y.s:t' arld then b':l f'ull re::urrence 0 f s).'mptans for 3-~ (jays.. Occastonal I Y 't there may be 2-3 bout s of' f'ey-er... Lab find ings: LeUkopell i-a r 2., o{to- 3.000 W .. BI. C.. wi til a shi ft to the Lef't ,

, ' , A ... Colorado tic.k fever II [lifferential diagnosis: Influenza ~

kky ltJuntaln, SIXl tted fever" and other acute leu ko pen ic fevers.

P.. Symptomalti.c treatment: A.splirin Of'"" code me may' be given for

2--5~] ..

RAB IE·SI .. ~'...... C.... nfr- -t2 Bi

~e I'ua~,,-er t.· ' , "~i tes ..

2-5' 11 YElL{lt FEVER.. Ir ansmi tted by Aedes. and jungle moSQUi,tcE5.. Enrlem ic to Afr iea and S:lut11 Am~ i-c a. Incubation period is 3-61 <lays.

s .. Mild ronn,: .Mralai se fJ he ad a<:: he , fev'er -.1 re tr~orbi tal pain. nausea 11 voni. t.ing, and photopl1obia. ~vere fa nn : Same Symptom5 wi th sudden onset and t.hen sever-e palin 5 througoout the bo:ly" ex tr-ene prostration"

bl eeding in to the skin and fr-r.m mucous membranes!t, .,. coffee ground·' valli tus r .and .jaund ice , fOlllowed b1y a per iad 0 f c alm on about t.he ttl ir-d (jay when the temr:e'~ atur-e' retur'ns: to nomal .. , Then fever- returns tJ b'l eedlng 11 and later dellr-11.lm •

. 011 .Mlild form: Bra1 )JCardi ia Imay be presen t 11 Servere fonrt:

Tachycard ia ~ ol.ig ur La f er ythemato~.s f'aee 11 and con~unc ti vall redness -d ur' ing ~onge7ti ve phase , After the per ioo of' calm; IJrad ycardl La f hypotention 11 Ja~nd~ce,. a1fld hemorrhages (gastr-oin te:stinal tract" bladder:l noss , mouth .. .s utu::: ut.a n ectl U~)I •

, . La~ find ings! Prote inur ia S£IIletimes as hi.gh alS 5-6 ~/LI. .and

dl sa p pear S Wl t n recov-ery; hernatur ia and leukopenia OC(! ursl, al t hoLJ@ nit ma:r not be presell t. at the onset ..

A.. Yellow feyer.. Dti fferenti.al d iagoo,si s.: Mi ld form ii,,s

~i ffi-r:ul t to -d.,i st ing ui sh. from hepatitis, lepw.s pi,rolsi:S!M and other fQ:rmJ5 of Jaund~ce ~ clini~a~ evidence alone.

.p. SymiJ"tomatic tr'eatment: Liquid d iet ~ 1 imi ting food to hilh-Carbohydr ~te ~ . h tgh-pro ~ in Ii Quids .~.s . tolera ted ~ . IV g Luco se ~d normal sal ine as Te~l red tJ allal,gesl:cs and sed atl 'lie's as requlred; and aSal l.ne enemas.

fOr consti patlOn. ..

...

Pr'eventioln: Mb,squito control and live virus vaccine for per sons 11 v ing in or travel i ng to endem ic 3r-eaS.

Progno.si:s: Mbrta 1 i ty i s high in 5·e~-ere rom:l wi ttl death occurr-inB m-s.t. cannonl y between tile 5. ixt,h alnd 11 inth da ys.., In surv i ¥'or S Il tenpe~ ature retur-ns to normal by seventh or eighth day ..

IIl,'lI:::.1 ,tlEN~AII

2-52. .ru. L..

See Cha pter 1. .se.ct,ion IX. Eye:l Ear I Nose 11 .and Throat.

2-53. V1RAL HEPATITIS.

a. Hepati tis It (.finfectiou.s'~ or short incubation period hepatitis) Ls a general Lzed y if".al infectiol1 in which 1 i ver i.nv'olvBmleIl t, dontna te.s the clinical picture.. It m,ay occur 5lXlradic.all y or in epidemic.! II T'ran3!D.i ssion 1s usually by fecal-oral route; tnwever tJ it may be transmitted (rarelyl~ by corrtaminated need Ie :slick or tr ansfusfon .. There is no knOMl carrier state with hepatitis A.

b , Hepat,itis B (tl.serU!IJt• or long incubation per toe bepatitis) LlSually tr~.snIi tted tI y tnoculat ion or in fec'ted blood or bl-ood prod uet.s but can be spre1ad by or-al or sexual contact., Fecal-o('"'a} transmission has also been docunented '" Appro:c: imatel)" 5-10 pereen tor mfect.ed ind iy idual s bec.CDle carriers IF The in,c ull.ation period is 6 weeks to 151 montns.. The c 1 in ic al picture is similar in Type A arid B hepati ti 5 Dut in Type B, tile onset t.ends to, be more in sidious ...

s. Cl in tc aU.. picture is. ex treme'ly. var iable' f:rOl!l asy.mptanJaltic infection without j.aund ice to a f~lrninatillg di sease and death in a few dalys.

Prodnxn.al ph.a:se: Cl1.:se t v ar ies from abrupt; to in.sid Ious wi th gE!l'leral malaise f myalgia l' arthr a 19ia:t eas'i fa tiga!l i1 it y" upper respir-atory s~ptoms (nasal di scharge II phar yngi ti s;):1 and se'ilere anorexi a, Nausea arid vcmi tlng .ar e C(){JJOOrl and -d i arr-be a a'r const.i pat.Ion may occur , Fever u,stlall.!r ~sent but rarely more t.han 103.1 degrees F.. Return of temperature to, oornnal often co inc i-des, with onset 0 f jaulMd ice. Chi Ll.s 0 r chill iness m.a y Ia~k an acute onset . Abdanin.al pal in usual) y mi ld and constant in upper rlghrt,_ cpJadra1t or right epiga.striun often aggravated by jarring or' exert,lon ~ A d i.staste far smoking parallel ing anores i.a may occur- ear ll'j' II

. . Icteric (jaundi-c-e) phase: Ustlally occurs after 5-10 days but may

appear at same time as ini tial .symptoms. There is a ne'n an inten.si fication

0J,t :prodrraal symptans witt.! onset of jaundice. Some patients never cevelOJI .. aundiee.,

. Convalescen t, phase:: Gr adual, improllement over a 3-161 -...eel< per ioo .

fbs·,4r:" patl~t f 11

I~ .. "gl~ .,,3 recover : U I y.

_ , 0... Hepatomegal y:: Barely marked - present in olver half 0 r cases.

~vertendemess is usually present. SplE!n(lTlegaly is present in 15 percent

: .. case.! 11 arld S)ft enl argee l)tlll~ nodes T' e'spe:-ciall y in cerv'ical or ;:-:VOChleaf"' area. may occur. Sign:5 of general tm.emi a: vary frOll! min iJIIal

. ere.

2-31

2-12

Lab findingsl: W .. BI .. C., i3 nonnlal to low {aboornall Olr til at ypi call. It l~P1{)C:yte ~ ma ¥ s~es t fIKloonucleosis; mono spot test m.a y bel pllSi ti ve) • Mlld prute. l.TIlur J.aJ 1 S carmon aJ'ld bili.rubinuri.a often precedes jall'!dice.,

A", Hepati t.i.s , ill fferen t.Ia 1 d iagnosi5 : Infee tioul.S

MOoonuclrosi 5:1 C ~~gal i: incl ~5iof1. leptosplirosi S t, seconlrlary syptJil is 11 Q ~ever",. and drug-Induced llver' di.sease , Di stingur.i shJ prodr{m.al phase- fran In nuen ~. URI! and pr-ooraDial stag,es 0 f the exanthematoue diseases 'I In oolstr-U£t,l ve pba se 't rule out other obstruc ti ve lesions .sucl1 as

cool erlocb)l i thi.asi s ..

!. P .... , S~ptOOJatic t~eabmetil t: Bed rest alt patient I, S opt ion , 'forced fl uids (or IV 101 dex t.rnse 1 f nausea and v(]IIi ting a!",'E! .sigJl i ficant

~oblerns) ~ avoid mor~ine sul falte,., drugs thalt hay€:' to be tlroken dm«l by the, lIver-" and, bepatotoJ:.~e .ag,-entSI. Steroids have no value' in hepati tis treatment.ln Patiel'1 ts should alllo,id strenoous exarc i.se' .arn::l! allcohol.. Strict,

i 501~tion is no t necessary J burt- hruldwashing a fter bowel lOOIOIenren"Es is reQUl:red.., 1hoT'ough handw;ashing alrter handl ing -contaminated uten sil s . tied~:ilng, or cl.ot.hing is essential. Di sinfection 0 f feces i s n~essa:y "WIlen waterbor-1"1e· . sewage df.sposal. is not availabl e ... Give S cc, of gauma g lobull in

(GCi II to all close contact s of in fee ted patients.. .

2~lIl. I~lFECTIOU5 MOJlOMUCLE:mrs.. M acute inf"ee.tiou5 d i.selase due to sa

her pes v i.rus , Un i LJelr'sal in d~i stribution and rna y' occur' a t an't age hut,

usual I y occurs between ages olr 10-313 t e'i the~' in epidiemlic form or spor'ad.ic cases. Probabl y transmitted hy respiratory droplets. Incubation period is rroblatlly 5-15 days,.,

. S.. S~pt-oms ar'el var iefi in type and sever i.ty' .. fever:r sore

throat.,1 anfl. tox ae 5,..roptcmS (mallai se , aOOTex ia 11 and myallgial) occur -freqru::ntly in e~rly _ pha.se o·r the illness In A maeula.r' to maculopBlpullar olr rJCcaIS.l,?nal1y' pe techlal rash CtCClJ.Jr's in less than "Ol percent 0 f eases .. .Ex~laltl vie 1 ~halr yng i tis 11 tons,i 11 i ti s 1" or- gingi.y i t.i.s may occur II ConInonl ~anlfe5t.at~ons are easy fat,ig;ability" nausea II jaundice {froml hepat,ic

lr:lvol ~emellt)l. ltJe.adaehe"l neck .stiffness, pbotolphc1blia " neur rtd.s , and occal31onall y; erven GUli.ll.aint-,Barre syndrame (see' C~pterl 1 Section VII . Nervous Sptem) ~ !rem C_:N. S- inlllol vement) ~ chest pa in 5, d YSpl&1. aoo ~OlJPo;tJ {frcm pulrnonar y ltlrvo,lllBnefl t,) ..

.. ' . . '. 0.. Di se rete '~ nO~SUlppL1T .ati ve 11 s.I igntl y pail'] flJI., Dl:Oderatel y enlarged lymlph node s e~pec Ial L Y' th~)ise 01 r the poster ior cervical. eham ..

Sple~gal ~ in. 5,0 perCerl t of c ases , liepalt.crnegally i 5, carmon" and!

myccaru La l. l.n-u:,ol vanent wi.th. arrhy.tmia.s and tach.ycard Ia .. t

~ .

. .... . .' Lab . Find ~ngs: 1 Inil t.~allY there is a g ran:LJlocytopen ial ~ decrease inl

runner of neutroph 11.3 11 ba.3(llph,lls JI and -eosinopbil.s} followed wi th,rn , week

Dy. a I ymjiloc rtic 1 eUKCJCytosi s, < inrere.ase in 1 )m~Dr:'ytes and total nunlt:ter o,r Whi1 t~ cell 5,)., Many l;mplhoc yt-es ar-e at ypi~ al f' i ~·e ~ 11 larger ttlan oormal adult 1 ~Filocytes" stain m-OFe darkly 11 and fr'eqrUent1'l show vacoolization (look. 11 ke .small ai r- Dubbles.) of the cyto_plalSDl .and. nucleus. P-bnonueleJJsi.s spot test will be pJsi ti vie '"

1 1 A... )i:)ooTIucleosi s'. Di f"ferenltial d iagnos,i5: Hepati ti.S"1

strelpt~cal tonsill i tis. di pflther if) ,I r'ubel1a., torKoplasoo-si 5 Il and 7' wi th C .. N. S... Invol vemen t" men ins i ti s.

. . '. P., Syrnptomlartic tr-e.atm;ent:- Patient r equi rea sup.JX)rt and lieassur ance lJecauS-e' olr f"requent feel ing 0 f 1 assi tooe a 001 duration 0'(

SJllpt-aos.. If d iagl10si sis well estatJ 1 i shed , a sbor't eour se 0 f

cortioostero Ids can give- 5 ynllptanat i.e riel ie f to severell"1 i 11 patients.. In wcanplleated cases , the fever' d Lsappear 5, in lOJ days and the IJIII~oopathy and spleOOOle~al yl in ~ week~I" In soote ca se s the ill ness may 1 ing~ for 2-3: mnttls IJ espec lall y the 1 assr tudle and easy fatigablili ty ·

..

!)ect.iOll V -- Rickettsi.al and Spirochet.al

2-55... RICKETISIA'I Are bet-wee11 vir-uses and bac ter ia in si. ze arlO a rei ususll Y' trarllSfDli t ted by a.rthropod s (1 ice' tJ fleas" ticks I mi te,s):t. which .serve

as ¥'-eetoITS ...

a.. Ep1i-dlemli-c louse-bor'l1€- typhus.., bJe to in fee tion wi th Rickettsi a prowa:zekii Ii a parasd.t.e of the bod] " Inuse tMt ul t.imatel y kill s t·he' louse .. Transmis,s,ion OCClr S, when a louse sue ks blood fran .an in feetedl ind i,y iduaJ. ; the louse then sucksl blood fram another' ioo.ivlidu~l and defecate's 31t the .same time; tbefl the ind Iv idua'l in scr-atctttng the bite TUDS the infected feces into the- I)i te t,fllurld .. , Cry... infectious, Louse feces may also be inballed andl :result In hUTl~ in feet.Ion ..

Ani indliY'idluall who re.cove~3 frJDm. clinical or subclinical typhu.s IlSaIJ' carry .R-~I prowalzekii in hi s l~pooid tiss,ue for m.any years and even have a recurrence olf typhus: -without exposure to li.ce or the in.fectiolu5 agent.. Dur ing suctl al rreurrettce F he can sene as a OOLJrce of in fee tion for 1 ice'.

S.. ProdrCIOii31 mal ai.se' tJ c:v.ugh I heajacne:l and chest pains after- 1101...,1.li da Y' incubation per iad 11 follolwed bly an: abrup,t onset of en ills. highl few'--:r!- anc prostr atdon .. wittI in fluen za- I ike· sym.ptoms. progressing to de11r'1 tm anell stupcr, The fever is ur:JlFmli tt,ing fof'" man y da JS,. and the

"headache is intr'actabl'1 severe ..

0 .. , Colnjlll~ t.i IIi tis a f'Iushed f'ace , r ales at lUlg, bases ~ and olften ~J?le~alyl" a macul ar rash (that, soon becoaes papular) appear.s fir'st in ~he ax llla.s and spreads over' tile tr'oo k and then the extrBlLi ties ~ Rarelly 1nvollle.s the face:tl palms. or soles.. The rasl1 becCEe5 tJenorr'hagic an-dl h'l'Oten.sion beecmes marked in severely ill patients t' There may bel r'enal

in&JCfieienc.y 11 stup:nr 11 auld del ir-i lITl... Inripro-v-enten t begins in 13,-116 dalY:S

after onset wi,th r'apiell drop a f fever in spontaneous recovery.,

Lab findlings: W .. B .. C.. is var Iabl.e , occur' c-aa-.rlOJnLly ~

Pruteinur La a 001 hematur-iB

. . . '., Pl. Tetr'ac ycl ine 250'-5001 mg;. q .. i, .~.. x lO dalYs or VlbTatI~ciri 200

~. t.he, fIrst da.y fOlllorwed bly 1100 mg.. a da Y' x llG dalYs II Al ternate' is

-chlor:a'IlI=Ilen1col ~ Preoorentiorn consists of louse cootrol wi Ui if15eCticide-s ~ partl,cWlarly clotbing rulC bedding F and frequent. bat.hing., Immunization .PI'"OV1d~ . good ~o~t-iOf1 agalinst. tbe 3e'Yere d ise.ase but does not prevmt 1nfectl0J11 olr ml.lc Cl.sease.

.. b ~ . &lc em ic' flea-borne typtU.E (MUr"ine typhus.) -II] CaILJ5ed bly' Rieke'tts.ia

~1 . n ~UIOOseri). a parasite ?frats ~ .lI"3I1S1i ~ted to ~UJiI<I!'] s by bite frmI lnlfect.ed n,eal thlat relleases In fe-cted fec~e5 ~lle sucJdng blood ..

d 5·. and 01., FIe·a t ynhlus resemble s, recurr'eI1 t en.l:idlemi e (&-- ill. I, s

'i:se a se 1.1 - J:.I!II • t"

11] that, it halS a gradJual onset .. fever and rash, ar'e of' shorter

2-3J,

l'-]4

. . r' c~tact wi tn the env irlonment.1 and dulled in. sen:si ti vi t.y ~

out 01• ' .........

A.. Scrub typhtJs. Dj_ fferent i al d i agno ai s.: Le ptos pirosi 511 t;rP'toid, demgUl! F malar-ia. and otber r ic ket tsia:ll infections.

dur'.ati.or. t 6- 1 _3; days)" and the Symi1ptoo.s are 1 ess ~~ev eire 10 Jl1 .. e r as~ ]_ s

maeul.opapul.ar ma inl y on t,he chest and fades fal i r 1 j r a p id ly " Ever. wi ttlCHlt a1titJiotics it is a mild di~~a.se ..

"I ft..

1IL.. t ~

L,-ft_J r 111 e ,yp n US •

[)i ffer-en tial dI iagno si s:

Recur rent, epid~ie

D AI te'tf"'.ac v~l in e or chlor anp ... tJE!!l icol ..

1""... ~

P. MI ti b ioti-c- t.be-r apy (same as for ept.d enlc 1 O'tlJ se- borne t yph.us;1 .

Prevention: Wil t.rol. n,e.a s and rats I Appl. Y 1.:11 sec tie ide s to r a t

runs F nests I and co l am Les and then. POl i son Q r t.r ap the rat s ~

e . Bickett.si.allJClx • _I tra1:smi,ttect by mi tes ...

Caused b,y ~ic:ke'tt.si.a alkar' L I' a par'asi, te of DiJ] ice, Th@ .d"isea:se' is fadrl y mild. and self-limit ted I'

c _ RCiCky' !'ri)unta in spot.ted f'eve r (Queenl cUH1 tic k t ~l'phus i.n A.ustr'al ia ~ Ebutor:J]neuse f-ever in _Afr lea) "'" All ar e caused by' r elated Ric ket t.s i a .. Rlc.-kett si i org.ani 3m s thrcn..lg,h the bi te· 0 f in fee ted hard! ticks. Uicke t ts.ia ar'e often tran::R'ni tted from one gen-er ation 0 f tie ks. to the n elxt wi tho ut paiSSage- thraug h an in termed i.3lte' trJst.

S, and 0.. Inc'ubatian of 11-12 days wi th sudden onse t a,r chi 11s .,

f t..........j .. 'adache:t, p.hotophob i.a , and di sSEmlina:ted aclhe's and padns.. Pr im~r"Y'

ev1er, IlIC" ,

lesion at bli te si te is· a 1f00eD papule that '.; esi.cate s and fOJlJiIS, a. b l ack

eschaT"~ A wide5lprea~ papulalr eruption appelaQf"SI 21~ days af'ter the onset of Sl'IptaIls!" becOOles Y elsi.-r= ul.ar 'I and roms crust s t.hat are .shed in about 10 days..,

S, The petieln t. d evel.ops anor-ex .ia , mlal.a i.se =" ~ ausea 1 he adae he ,I an~

sore t·hroet 3- 1 01 days after' an infeetio LI s t.ic k b.i te ~I prugres,s-ir1lg wi. t h. chills; fever; aches in bones, join ts" and muse Las ~ nausea and vcrni ti ng ; re'5tle S.5lleSS, : in sam i a and! irr i tao. 11 i t Ij ., Del i r i IJ.ftI 11 1 e'tharg:; t st upor 1:' 3jljl COOl.a m.ay alppear'.,

,1/., .. , Rickettsial pax .. Di ffer-en ti.al -d i.agtjosi s:: Chie:ken j)]X or

:aalllpax ·

o. Face 13 fl ush€dl and conj unc ti \LaS i n j ec ted. Aft-e'r?-5 day's ":) of' fever 'I a rash appears s;tarti:1g on the 'Wrists aJnd] ankle's spTe~ing to the anns t legs 11 an-d trunk tJ The. rash is in i ti.a II y small ,I r-ed , and ~ac utl ar ; Olil e~' 2-'3 day.s i t becanes larger and petechi al -I- Hepatomre~;aly 1 s pl encrneg al"j:- t'

jatmd ace f gangrene Ii myoc ard i ti 51! 0 r ur emi.a may' -!)CC ur' t<

.Pre~'ention : Appl Y' in sec tie:ide to mice- run s and nest.s , then el :i!lII ina te the m i ce ..

Lab fi nd ings : Leukoe yws.i s pro te' in UF"' i a , and hematlJr ia ar e

f.. trench fever. A 5-e'lf-limited Louse-borne relapsi.ng febrile d.isease causedl b1y Ri.ckett-s,ia -q,LI in t.ana, . HLITilaFl 51 appear' to be on1'i an irnal reser'Voir . O::-eurs iJ1 epidEmlic form in 1 OLlS~- infested troops and c i V: i1 i ans during war 5 and in. endml Lc form in Cen tr'al Amer iea II

C:~nl

Iln I. I_l..r~...r- - ~

A. Ao-c kjl ~d1 ta in 5F.XJt ted! fever. Di f'fE! ren tia 1 dl i agnosi s :

t"!e'.a sles l' l ypho id" or meJ1 ing;ococcemia ~ ~an y ot her in fee t iOfi 5 hawe s imr~ 1 ar ear 1 'J sign s and symnptcn.s.,

s. Abrupt onset. of feveli' l.asti.,ng, ]~51 days, 0 ft~n fOlllo~d by relapses... Weakness; sev ere pa in t'ielhifldi the ey€ s and in the bare k ana 1 egs ...

0 .. , LymphadenopathY:M oS plenOflleg.al Y' 1 and .a tr an.sient m.ae:ulopaptll arr rash IIB-Y appaar ,

P... Response to tetracYf:.line or etlloramphenical is promlpt if st.art.ed ea'rl y .

. A. Tren-eh fever , Di ffer ent.ral OJ iagnosi s ::

leptospiroSi,;S 11 mal ar La 11 tte la_PlSing [~'er Il and 11 YPtu~ ~

Pr'e'iJ'eTI tion: Pr'otec:ti ve e lotli'1ing! msee t. r e~11 errt , and boody S!I'steml c:'hecking for t ic kg. at _frlequen t in terval s hel p .

Pl. It te,tr.acyc:l me or- c·hloranph,eni-col.. The illness iSI

self -l1\mi ting andl rec.O\!"ery reg ullar'l. Y -DeCUir s wi tho-ut tr'e-a tlinetflt •

d ., Scrub typhu~; (TsurtStlgaIlllJ1Shi d i se-a.se') .. Catlsed by Ri c ket tsi a !st.ltsugLftlJshi!t a parralsi te' 0 f roo-ents that i.s tr'al]::rni t tedl by the hi te of

mli te' 1 arva .. "Ble md tel l..ar'Va s,pend 5 moiSt. 0 fits 1 i fe c yel e on v'egletation f arndi when an a1 im.al art tltBan blrtlshe 5 agadlfJl st th,e v-ege't,a lion f the 1 arv al dro·p~, onto, them.

. , g., Q fe~er'" -C~lused try CoJ: iell a burneti '" a par .as} te 0 f -c at.tl e" sheep 'I =~t.s~ Tr~smitt~ to hlJMl'ls by :i~haU_atiorl. of c-Qnt;:rninated dust or ..P1ets or by Ingestion 0 f l.n f-ee tetd m 11 k:.. It 1 S e.x:creted bye at tl e j

~:s, . and sbee.p ttl~h. feces, mil k t and pl acerl!ta • Cox ie Ua i 3 re lati vel}'

.8J.LStant, tol pal'l!!'''' lOot' Ir' . t·· . r' .• , 11 ... , ~n. d f' h ........... h ~,

bu' .. ... ,.. ~' ' . . •.. ~~~'Il.oI. I za 'lon 1."- mI. ~ .. ~r"ea :, ,. ram Ill.I1i]an w : tmlanl 1 S, r aa'""e .1

tl f"etall lnfec:tlon can OCC UIr' ..

S I' Incubation per iodl ulf 1-3 weeks, after bite by' ~l i te 1 artvaJ.

Malaise tJ -chills., severe' headac11e- .. aM backache _ A papiule deve,lop5 alt the .si te olf the mi te tJ i te' that v e'si c altels an~ fo ililll 5, a. f1 at b 1 ac k € schar ..

Q. Regional dlr'~inin~ lymph nooes are enlarged and tentier'" Ther~' m~y be genelr JEll i zed ad,enopa tl1y.. {;ar 00 uall yl r i SiJilg, fev'er wi t.h a gen e~ral i zed macull.ar ra:sh de'll'elop1intg, at the en1ll 0 f first WJee k arnd is 1fO'5 t. mlar'ked Din the tr'OOlx t< CUr ine the' 5e-l:cnd: weelk of fever' Ii pnel..l11oni tis., enc--e'phal i ti s, :I ntyrearoi tis:t and! c arO.i a.c fa il ure may OC~UIr' tl The paltien t. appear s con fused ~

__ Db o. f1l Y5ical stg,flS, of pn eUiTlon i ti 5 are 51 ig,nrt _ He pa ti ti:s may be

1IioiI'Ii;.,; er e and 1!:Ii..,.,. .... 1 ___

li::i.n....~ard i ti S OCtC [JF:"" S r ar e'l y'.. Occasion all y: s.i~~ s; 01 f

2-15

2~16

eneePlalopatbYI are prF!5en t. Th~1 el in! real couese may he' acurtel'l c,nronie. or r'elapsing .1

Labl f1 nd ing3:- Leuko pen ial :i5 of't.en _present"

relatively olr c~plle'te~ Y'Si~I~~ fr'f!e' per 10.0 .ofsevelialye'~r,s -I' r4JIst

,. :.&I,nly It.ll~lns, dUr"l.ng t.he t,hllrdl or fourth dec:ooes,. of ~:fe_ In this :'e.. resol utl.OO and spontaneous C ure mal)' occur ~ or the _ df sease _ beeO'll!e ,. II!III+-~t· wi.th t,he' sub.sequen t appearance of relapsIng teTt lar Y' leg,Ions II !be

.JloIiiI1 ~. .' I! . .. ,., .

tertiary les~olns, are' Ol~ t.hree t,ypes: {11 . extensive 11 spr--e'adllIilS II. .. . ,

.. s:uperfic:ial, and relatl vely clean ulcer at ioe S . trult . graduall 'I heal fTc:m the cMllter; {2} curtaneous ~M :ubc:ut an eo us. no.dules, that bre,ak: d.o'Wn r-olrm~ng deep t indolentull:ers Wl til lrregul ~lr bases (~hese heal fron the marrglll and isol a tedl isJ..ands, In the base I! causang altropnlc sc ars thalt maly' be . IIJIpJ.grneI1ted in the earl, stages but later are o~ deep~y pigpler.lted and ... , C'8use severe contr.ac:tures).; (3) h.yperkerawltlc Lestons of the. soles

r :r the feet and less, ccmnonly 0 f the palms 0 f the hand s (nCr-'ab Y.aIWS"tII) ~ing ex: tensi ve thickening of Ute skin with fi SSU!'"'eS and ulcerations (palinflJJl and al source of .sever~' di.s:ablility) ..

Destroc ti ve bone arid per i.osteal lesions most cCI1Ii1'JCflly inval vinS thel tiblia I other long bonas , .and the hand s are fTequ~nt,.. TI1ese are usually singlel or few in number" and develop 51 owly.. 1'he.y ma.~ extend througl"l t,he subcUtaleDU5 ti ssue and akin II produe inlg cbron i.c ulceration that. responds slowly to treatment., The lesions are accOOlpan iet1 tly local s.elli.ng:l tenderness f and pa in , 111e-5~ lesion s can also occur on t.he skulll:l cl.avic]es t, scapulae, 3terrJum l' hard palate -( can cause e'xten si ve de:slruc tion of the s.trllJCture -0 f tile nose).. and joints 'I

A., Q -fever.. Il-i r-ferel'] tial dli agnosi.s : Atypical r:n,ellTlOl'l ia "

hepati ti 5:'1 blrucellosi s tuberculQ.si s, psi ttaco.si s , and other' an ime] -oorn,e di.sease s mllst be' consider-ed ..

f., Tetr acycl ines can suppress symptoms t1100 shorten tbe c 1 in ic al course 11 blut do not al "Ways eradi.c.ate. the in f'ectioo.. Even in tm treated ca,ses -,1 the mar'tal i t~ rate i5 ne,g,lig iblle II

Pr'evenltion : B-3.sed on rletec ti.on 0 r in fection in 1 ive·stock" treatment and redLJCtiol1 in eontae t wi th, the an imal and dust c.ootamlinated 11 y:

~

t,hem I and e rf"ective paste'uri zat ion of' milk ..

2-56. SPIROCHET'AL ..

a. Sy ph i, 1 is.. ~e- Ctlapter' 2 11 Section VII! Venereal.,

II .. Yawls (Fr ;:mlbesia I! pian! lJx)uba,. pair ang.i , danaria)l.. An acute' and chronj,e rel.apstng , conteg aous , nOIi'lY'enef""'eaJ J s pi r'uchetal d Lseaee caused by Trep:lnema per-tenue F which i s mxllr pbologJcaJ.1 y ind i st insui sh~l)le .fran

Tr eponena pall] id!m1I.. Rest,.. icted to the tropical zones; the higbest incidence is among nat.ive populations 'Whose level of personal hygiefl€- is Low, It, Ls predon in ate 11 a di sease olf chi IdbJed, burt tr ansmli sston fr'Cft] ctlild to HIOther tI Y' cont.ae t is. frequent ...

Lab findings~: Spir<>chete'5 c an usually be founrd I)y Giernsa" 5 stain .of exwates frem lesions undar darkfiel(j exaniflatian.. ( Ind ia ink stain. of .slide also W()rks.) s.erLlTt test for sypllil is is poai.t.i ve II

s. arnd O. IncuDat.ioo period err 2-8 weeks., Initial Lesion (mx>ther yalw)l appear s at the si t.oe of implan tat ion Il I t resemble s the typica~. s,..anulan~toulS second ary 1. eaion, e,:(cept i tis often 1 ar'~er and he al 'ing t.akp::;_ lon~er' • It is fr-e'Q]uen tl y sti.ll pre sen t, wh.en the seeondar Y' eruption

appears .. , 1h.er'e is aching of the 1. imbs., j o in t pa i ns ,I and often an irregullar fev'er is pre-sen t. There may be enl argement 0 f the reg tonal 1 ymph nodes - /,. f-ewl veek.s to· 1.1 months later tbe secoedar l' or general i zed .stage' tlegtn s wi th tile appe erance of second ar- y Lesfons sea tter'ed CN P'IT the sur rae~' of thre b<XIy .. These I estons may involl ve the palms 0 r the hands and lor the sol es of t.he fee't.. The Le s.ion s are usually ·elevated, appare1tly grr'alulcmawu5 papules var yinlR, fr'ml a few to SO mt I' ~)r' mor'-e' irl d iame'\e'r .and t~nd tol b~ rOLl1d or' o¥al - In i t i alll y the sur face is CCDlp:lSe<J 0 f greil tl y prol i fer a ted epi ttlel i .. .Jll el 00 ing -clear se'TtIn that eonta ill S cOn!!ef}trations Q f' s pi roche:ttesi. Later", a yellow crust rurntS, {rna '1 tie' d i . .5.Colored b,y debri s} . If) y()ung ch.ildr'el1 suffE!r'ing rr~ t1nemia or malrn.1trlitioli1J, the le.sioJl5 mal~ appear as ·ero,sions IIri. ttl br j,ght plin k bor-der.s aru::l whi ti sh centers.. Succe-ssi"v-e erulptions 0 ften alppear' bef;ar'e the prec~ ing onres he'al. These 1 ater' lesions tend to be most. nluoerous around title lips F a[){ i llael!l gen i ta I ia T' all1d alnus.. TI1e'se' recurr i,ng eruptiofiS mlaJ~ continue' for ?-"} year-.s and le'sions .about. the' 1 ips or 06 the sole So olf t.he' fee t m~ y r-ecllr after man y y€'ars., Heal in~ a f the secOlndlary

1 e3iuns leave on 1 'i .s 1 ight scarr ing too t ~:s :1 Cller pe-:rmaflentl y' .a tropt1.ic and pligrnented -

A lin Ya"W5. Di ffere:nt ial d iagoosis: The- mrUC'DCutaneou5 lesion s of leislnaniiasisl tile ul.eer at.Ing Ieaions of Ieprosy Il tuberc::uloois~ and the. late lesion.s. 0 f .s ~phlili s ...

Pili] Treatment for the! var-ious s.tages 0 f :ttl1W5, is the same as for the' 'liar iOUIS stages of syptl il i s (see Ctlapter 21.1 Sec,tioo VI"t1 V'erl-ereal) ~

c, fnden:i-c .syptJ il i 5. An in f~ct.iclu.s! chron Ic .. nonvener-eal in fectior:1i of the interned iate tropical and temlpera te el. im~te's caused by Trep:lnemlaJ pall idll,l (11 ~ rROlrpho logieall Y' indl istinguishabl e .frm the spd roehetes 0 f syJtrili.s, or yaws.. .same autoori. ties think thalt syphi.l i s arnd endemic

SYPfli 1 is arel the same dl Lsease .. I.t. oc:c-ur 5 in Local i:z.ed are'as in I)ackwar-d reg i<lr.l5, wiler e soc i 0 eeon am i c 1 ev e 1 s ar' e low a rid adfil.a ne ed edlttC'a t ion i.s lackin·1 ~ 'When mod,ern e i w'i 1 izationl reache'5, endemic: arre'.i3S througb the CO!1IWtIC:tionl olf tJighwa,ys, 0111"" -develQpTleri t Olr .an 0 i.1 field I eoo€m,ie oS yphili s dli~pe-ar s, an(i ven,ereal g:yphi 1 is a pp€:'ar.s '" It i s _Pr"im~ril 't' an ear ly chIldhood di sea se and i So spr~oo by d i rec l eon tac:t.,

~nd:estr'"'uc ti 'Ie I esiofls 0 f' the bones are freq~ent i nl the' secondar"i .stage ., They deve 1 olP ra pli-d 1 Y and re.so 1 v'e s_pon t~neoUisl 'i in a r:e'w wee.ks O'T ImOTI ttls.1 but. the _per ioste.a 1 reae:tiolil mla::; (: a US€' thic ken ing of the 0011€

resLll t i rip': in dfP.formi ties.

51. and O~ Pr imar 11 le'siolns consi st 0 f eruprtions of" the skin

or IDUCOUIS membranes II but acre seldk:ml rec08~ i zed . E'rupt,icrJ 31 in the -mouth are

US~ly rirst, followe{j by rnoi st papule's ir:JI the fold!s clf the' skin.. TheSle lesioos Oftel1 resemble toose of secondary syphilis... The. late stage may ~pPe-ar' , wi ~hin a few years after Olnset or tie- delayed for many year 3. It is ~aetenzed! by r!an tar :md pallllar lesions ~ patch)' pigmentation. of the

.'. In ~ and de'structl ve leSIons 0 f t he long bones I] nose"t. and throat ..

~l.OVa:!ICUlaT lesions are. fairly ccmron _ bu~ involvement of the eyes, entral nervous system" Utbes IJ an!rl paresl S 15 Ii ar-p.,_

lab find ing · Spiroc hete.s may be found in L£lund aspirates Uisi.ng dark-fi~!ldl eIanli~atio~ and ser LI11. te st for :s yphilis is i=M)si ti ve.

The tertiary sta~e of y'.aws usually does not a ppearr unti 1 after' 8

2-1]

A ..

P 111 Same.a 5 y'aws and 5yphi 1 i s {see. Ctlapter 2" Sec tio,n. VI ~ V-enere a1}1 •

-d ~ Pi.nta (~al del pin to , c arate ,I azul , t ina , Lot.a , empe ines l , An

acute and chron ic nonvenerea 1 di sease caused by a s pi r'ocbete (Trernnema. carateumJ thalt is al so mor~,ologically' ioois.tingtJishablle from T .. pal lid thl .. F"o,urld in Cen tral and Soluth mer Lea, Me'_)[ ico'•1 and Cub.a. ~.st fre'queII t in t!1eyCfung and occur 3, most frequentl Y! i.n low 1 ying and wooded areas ,I usual 1 Y' near r-i ver-s Ii where relalti ve htmidli t y is 80 percen t. or more and telmper'at urJf;: is Det~en 79 -00 8.60 F, These' peopl.e ' s pr'imli ti ve- way o,r 1 ire t1fldi we ar ing

or fe\ll' clothe s appear to pranote the iT cont.act; ing p-il1 ta .. '

S. and D .. , Characterized by a .superficial nonulcerative' prim.ary lesion, 31 seeoed ar 'i er-upt ion -r and La te depligmenta lion and hyperHer atost s of the ski.n. The bands and 'WT i . .st.s are most frequentl Y' involved f but fee t and al1kl-e inrvo 1 "'snell t Ls cOlI'IIlOn I' Neurologic aildl card iov ascul a.1r involvement is fully as s igni fi c ant in 1 ate pi.nta as i,n :syphilis ...

Lab find Lngs: Posi ti ve d arlkfield exawlination and S1S.

A... Pin tal .. Di fferential d iag.nosi s: Y.a~,.s ~phili s ..

e ., Reia pLSing feller (tick fever l' famine fever l' spif""illm fev-er' ~ febris ree urren s , kimpurtu ~ gar'apata di seaSE 1 and man'i Q ther's) • Caused b,y the Borrel i.a .spec ie~5 of sptrocbete and tr ansmi.t ted b,}!" t ic k bi te or bly' crushed]

1 ic-e' through abr'adled .skin. Louse-borne reI alp5i ng rel~-er ha s d Lsappeared fT()[I the US but occur s tn parrt.s a f SolJth mer Ica t Europe'., Asia I A,fr-' ica , andl .Austral ta , Tt.ek-boene r-el.ap.sing fe'veli' is found in western US alno Canad.i31" Mel teo I Centr all and South ~r ica, Europe , Afr Lea 11 and Asia In U:JUlse-bor'ne reI apsi ng fever' i 3, freQuentl y found con~an.i tant.I yl wi. th epidermic: Louse-borne t yph, us .. Incehat ton peri.od is from 2--,1OJ da 'is tJ but mal' be as long as 3

"Weeks ..

. S.. AblJ""'upt on.se't of fever" {up. to 11 OIli-l1 0501 F. elr higher)! t' -c hills, ~

vertIgo:l sev'er'€- beadl.ache ... nausea II .and vcmiting.. Transitory er-ythemato'U!s or pete.chiall er'uprt. iOlns, a:re' common €:I l.Jr ing the in.i t.ial feve'r. Usu.ally most pronouflc~ed aoolut the 11 eck 811jJd .sh~)ulder gi rdl@ and later ex tend ing to the chest and abd-cmen. In i ti al fe\~lIer U5U~ lly last·s 3-1 0 dla:ts., After' an inter:-lIa 1 of 11-2 weeks, al relap.se occ-urs ,. often. sanewha t milder... Ther'e may be' 3~ 10 rei.apse s b'e'f-ore' r'eco'te:ry II

Oil Taehyvc.ard ial OCCLr.s with the onse't. [leI ir itn occur.s \IIi th high fever 11 .and t~ere ma.y ble v'ar iOlus fleur-ologic: and, psych:ic .a.bnonnal i ties., It-

51 ighrt icter ic tint. lof the 5C ierae is ccmmon andl mlarked jaundice rrt91Y occu.rin .severe cases. H~pa tomegal y an!! splencm~g.al y malY develop ..

Lab findings:: D1Ir ing epimdes Q f fefller' ~ large spi,roo]1e,tes .are :seen i,n blood smear's sta in-ed using Wr-igtlt'" s: or G:iemsa t as stain t; Mild an ec!l i.al and thrcmboc ytopeni.-a ar'e camtOTl!l burt. W" B .. C ~ is usually nonual ..

A. Relapsing f'ever.. Dt ffe-rential d i agtlosis : Malaria, leptospirosis" m.eninsococ:c-em is 11 yellow fever" typlllUS, ar rat,..bi t-el f'ev'er Il

P... Gi ve (] .. 5 §D tetrac yel i.ne or er yt,hr-omyc in in a single dose 600 I 000 tm i t.s 0 f' proea me pen ic ill in G rH' can al so be used,

...

r ... Ha~l1i te! feyer (sodoku) t; [JncamlOrI acute in fect.Ious d iSle ase caused

bY a spirochete (Spir i 11 um .111 in us ) that i is traJlS!O!i tted by the t. i te 0 f a rat.

S.. " The' or~g inal ~at bi t:: he al So r-alpidl'1 [Jnles5 second 3r il y iDlfeeted.. .lfter.an. lrl~ubat l.~n per l~ 0 f one' to seyer.ral weeks:I th.e- hi te

.s1 te' becaDe\S swl1 en " l~~ ur a ted. l' , p~ln fuI, a s.stme'5 a du.sky pur'pl ish tiue l' and salY ulcera~.... , Fever., ChIlls 't mallall se j mlyalg ia 11 ar lhralg i.a , and Ile'ad.ac he

... e prese1t. After a few days 11 the 1 ()C al, and systemic symptoms, subside only to reappear i~ ~ 21lf~8 I hours. ,After the first f::w rela pses 11 onl. y the fi!Ver returns, on thl:S 2~-~ B-tnur c. ycl e and may' per 51 st fo·r weeks, ...

o. Regional lyrnptJangi ti sand 1 ympbadefl i ti s are' present ..

Splenomesa1 f ma~ occur ~ A spar se, dusky-r-ed m.aculapapt.I1 am- r asb rna_y a ppear

Oni the trU1 k and extremi ties t' '

labl finding s : Spirochete rna.}" IDe fOWld in aSlPir atec _terial 011' in the u1 cer ex udl a t-el under d ar'kfiel-d ex i:lminat ion ... is, -often presenlt and STS is 0 ften fa Lse 1 y posi ti ve .'

lyrnph node Leuk-ocytosis

A.. Rat-Ili te fever' t' Di ffererJ t.ial diagno,sis,: Streptococcal rash,

tulremi.a:" relaps,ing fever.

P t' Gti ve 300 11 000 UI'1 its prooame pen ici 11 in 1MI q . 12b., x 7' days.

'., 8 .', Leptcspirosfs (Fort, Bragg fever l' Wei 1 '" s di seasa , swine·herd: Ii.s

dise~} ~ An. ac.u~ and o·ften severe infection caused b·y sever-aLl Le ptospi r'aJ .speC:1eS It- Leptosptrosf s is fOlJOO w:)r]dwi.de.. It is tr'an.snnli tted by inges,t ion of' food. or- dr ink cootamlinated bly roderit.s , cattle" OT pi gs , The disease can aq,so be acq,~ir~ by d ir ec t cont.ae t through. minor ski.n lesions 11 aod prcbabl 'J Via ~I .. cooJ lftCti va, and all so through baltbing in corrt.ami.n aJte(j 'Water .. IncubatIon period is 2-20 ea ~s ..

.. •.. '. . :i). Sudden on:mt 0 f fe~er (} 02- H)1I0 F.), chill s abdcminal pa ill s ,

~fJM_ting. nausea. :myalgla {especlally of the calf muscled; ;md W1relenting

ontal heac!ac-he~, ftLOQ)l=Ilobia 1" sore throat 11 coU@;h 11 aM d i.ar rhea are '

:::-m. . Petec~ial an d maculopapuLar rastre 5 rna f occur. USuall}, all s~.s ~~ dlsappear within 3-~ days, but some pat ient s may be: .ill for

an .1 • ~n ~. ease 5 symptoms d 1sa~pear for 1- J -days, then the fever and

Y Q f the' l.n 1 tlal S}'mlptOO5 may return ..

in 50 ' . ,0. CoQ~uncti"ll a i:3 .~kedl ¥ r~1d ~ed. The liver can be pal pated Ca ,ill JleF'CeI]t 0 r the cases a!l(j. J ~l.J'ld lee 1;S ~esen t aJboot the fi ftn day.

U:ita~ ~rrnag~7. arJd P?'"P~ lC ski n les~oo s .~ y :c:p~ar. Meningeal

.and aS50C,lated. f100 Ings 0 f a sept lC men lrllgl tiS m,ay occur ~

I - .... fi-....a ~

IL.CIIU '1I:ru '.It- j,,', .' ,,- I, "...,.

neutroph i 1" • . '. ... . II'lgS • W • B. C: ma ¥ be ronnal or as lngl1 as 501 ~ 000 With

Spjrachel • 1.a. , ilrme ~y . coo~ In b lIe I' prot@in, casts, and r-edl cells. .

ea. also ~ may be ~oundin urIne fT~ the tent~ day to ~ ~ixth ~. It P-2,r''''',, , 10 ,,' ,fotrld .In bl-oodJ sme~rs USIng, -dar'k-f~.el.d examInatIon dl UIJI'I1l1l1 'Q" t, k~

-I., .... I gil., I I days... '" ,IJ ,~nc

..... 110 A.. LepwIS;pi.nJLSis ., Oi ffer'entia! d i~·,no.si:9-: He~., "t, l' t"l; oC!-,' :t

1-'= , ,'::W fever. r' 1 - f -.0 ~ ~

., e apslng . ever II

P ..

Give 600 .. 00,' 1,,'0·',' u,n·, , 1't,Q," . . ·11'" Tw

7. ,~ procal.fle pen Ie 1, In .. Llnl q,.o:J1.. x 2J.U1. then

2~-39

~ction 1J 1 - V'ener al

q .. 6h.. x 6 days. or ~OO Iq!,.. t.e tr acyc 1 ine q .. 6h II ]( 11 days ..

" ,', Yl!fleTea1 diseases are co~ tag ious . d ise.a.se~ ~s t cOOl'fIlCllll y aCQIUlired

~..._ sexual intercour se or other gen.ltal contact.

.. ..1. OOJI(ICOCCAI!. INfECTIONS ( c 1~1l, d,?se). A ~peci fic in feet ion of the

M1totrina"Y tract caused b! Nelsserla ~Dnor~eae. . Extragen1 tal ..

Cect-i0ft.5 (rectal ... .oral. sktn J and eye lnfectIon of the newborn} do occur t

bUt IIOt as freQfUent1y ...

s., In the male tJ incubation 2--1 days aftelr contact; ave.rage is 3

A transient mucoid uret.hr al d i scnarge develops tha t ~ccmes a

:;rrUset thick" .UE!enis~. pur~lent ~reu:ral .excr::tion.. Pa~nful ur.~nat~oo i8 the outs-taOO Ing Sympltcm.. Potl1 tbe ~ i.scnarge alld the pa In ful. ur inat ion

rna,- bel .severe -. lnO(jerate s ~ OT ~~n 3D.se11 c . ~ut 10 oercent 0 ~ ,all cases haVe no S or'S. Rectal InfeetlCJrts ar-e nKlst often asymptaiflatlc and th~

reSUllt of direct i.mplantat ion of irifec t ;011 almost allfays, by hOIOOLSe11 ual ,

aet.i..,ity., the most C(!1II00n comJll ieation of unt~eBted gonorrhea i,s urethral stri,etures; others incl ude inguinal 1 ynl ph aden i tis, seminal vesteut i ti s , e.pidid'_i tis ~ or prost.at.i ti S 4

In the female" S0-90 percent ar'e asymptomatic. but. can continue to .spread the in fection . In the feP.1ale ~ d ysur t a L1 r vag inal d i schaege is tbe .,st frequent, S or- S... but may be so mild as to be- unnot rced II ~ctal infectIon ean be caused by COin tamination from cerv ie aId Lsc h.alge or rectal inJ:ere(HJr.se. {;(mplicatian.s in the fem,ale are local spread of gooorrbea cau.sing an infltmnatiof] of the- vul v()rlt.aginal gland amld/or f'al Iopi an tube- 1his ~ad ~y continue fnom the fallDpian tube5 into the peritoneal cavit,y ..

In both male and feG!ille 11 btlt usual.Ly f'emal e , the i~nfec-tiDn may spread througtJ tile blcod and rna y presen tin ~ ar ie'-d wa)l S- depend ing, on the area OF organs th~ infection attacks.. The most carmon are ar thr i tis! ski n eruptions 11 meningitis tJ endocard i t.i S! or conjunct i 11 i ti 5 (v La bl.ood or by cont.adBnation fran gel'] i tall secr-et.i on) ..

o. Typical in.tr ace 11 ular gran-neglat i v e -d iplococci are found in the smear of thel urethral discharge or c u 1 ture<J ('rom an)= 5 i te. par ticular ly the- Lret.hrat cervix tl or rectum. It is possible to gram stain 3llear.s from trethra I cen ix.. or r'ec t.tIll and fi nd the organi sm 11 but a negat.i ve find ing d1oe.s not rule out gonorrhea.. Hi.stor y and Sand S can make- the- diagnosis ..

, A .. , Gonorrhea ~ Di fferenti al d Lagnoa i s: Nonspec i.f'i.c urethr i t.is

(,~ percent caused by chlamydiae} l' trichomonal arid e..andidal vagini tis" and cen~ 1tis.. The many agents causfng sail pingi,t i s 1 t)e 1 11 Lc per i ton i ti s .. arthritis 1l prercti ti s , arm ski n Ie s ions nlUS t be considered at so ..

, P.. Ur~<lmpl icated gonorrhea: 1 (2Jn probenec id crally; .it. 8 mi ilion

llI!lJi ts aqueous procaine pen ici 11 in G I M in 2 or more 51 tes t,

,I, _ Alternatiy'e: Give 3 .. 5 gJm ampicillin tDgether with 1 gal

~ld m-al.l y at one. time . ~V~R TREAT. GONORRHEA WITH BEra~ THI~E stat. ILLIN G ~ If .allerg LC h? pem,c Illln, s l.V~ 1. 5 _ P.!" te~ acyc l ine or all y time. I then 0 .. 5 gm o~a~ 1 y q , 1 .c: :t: ~ days or spec t-loomyc-:m 2 ~ 1M3 t one after~tch ~or penLelll111-re:Hst.ant gonor~h€a ~ ]}o. ~ follmup 7 da~s .

DIl~ I CaIiIple-hon of treatment ~ T~e-.at ~ClIIllpl ications ~ th spect~ namyc "' 2 gill &1'11e~a~r rO~lowu'p g-cmorr~a IS st i l I p~e.sent ~ Unnl:'- of re-mfectlor. and

3.PelrtlnanYClll 2 gil 1 M ag.a In .. I r SpectlflClllYCl n resIstant 11 gl ve

2-4]

2~42

eef())[ i tin 2 lJn 1M wi.th 1 gm p(Fobler-fiN: id P., O. A1 ter'na te~s ar'e t.etr .aeyclille c r er"ythr~yc in c.' .. 5 gm orall. y q , i .. dill X 10 days.,

S.. Generrall:y appe'ar s a few weeks to 6 rontns after- pir lrn.aryl c~. _ The most COUIOOt\ ~af'I i, festations are skin aIld mucosa 1 lesions - The skin les1on.s are usua 11 y b i, 1 alter ally symmetr ic:al and are nonpr ur i tic ,I macular I pap~l aT , . pust ul ar 1 . or roll ioCular (or an'i cOOlbinatioll1 of these) • LeSiD115 are usual] '1' gener'al,lzedl but 0 f't en invol ve the palml3 of the hands

.. and the soles of. the feet .. , The' muc:o:sal les. ions range [roo ulcer 51 arid paptJlles 01 thel Lips , mOcllt,h j throat ~ geni.tal i.a , and anus (,mucous, patches,) to a diffuse r-edness- Qlf t h€ phar"yll"K II] Mucotls memhrane and! .sk i n 1 e'Si0f15 ar e hiiJ;hly in_fe~tiQlI~ d Uf"""' ing ~.is .stage ~. Henl.ng,ela 1 f hepat Ie II renla!" bene and joint inrv3Sl0fli WI ~h r:-s'lJl tmg cranial nerve palsies ~ jaundice] nephrotic syndrane., and ~er'lo.st.l t 1S may oceur , The 1 est.on S 0 f second ary S jrpU1 il i s lIi,ll neal spoil taneousl Y t blut oo.a y r-el apse if umii agno.sed OT madequa tel Y"

treated oil] These r": lapse 5 ma._y i.nc l ude any 0 f tile fi nd i.ng S Q f sE'~orlda~y

syphiliS 1J but UI!llIke the usual I y a.symptOllllat i c ne uro1ogk i nvol V€III!IerJ t of secondary .sypb i.l i SI, neurofog ie relapses may be ftllrrti~ at i!1g 1 1 eadl i.ng tOI

death·

2 .... 5911 SYPHIL IS I' Causati vie agent is Treponeoma pa 11 i-::l LIn" a spi.r-oc hete

capabl.e o-f i~fecting aflY organ or tissue in Ute body. Tran::nuissian occurs

nl{).9t freqtJently dur ing, .sex uall cont.aet, t1 blJt may be eX.tr ageni tal.. The clinical course of untreated syphilis, is divid.ed iflto 4 stages: primaf"Y (early), secoodary, latent (hlidlderr1) F and tertiary (late) sypcilis., TheLes.Ions 31SISOC iated with primary' alr.d seoondar y sypn i Li s are se! f -1 ir:mli t i ng and reso.l ~e wi th few or no re.:si,du.8 1 _ Tert Iar y s ypbi 1 i s rna y be ver y destruc,tiv'e and pe'nmanently dlislabling; .and! may lead to deathlJ In general, if untr-e.ated, one-,tni rd of ttle people In fected wi 11 under'g-:) spont.aneous cur e t one- third ..n 11 rEmain in .latent stage for life 1 and oo€-t-hir·d wi 11

develop ser rous late {ter t.i.ar y }I Lesi ons ·

Syphil i s c a!TI be e 1 i,., iLealil y cured 1 naIl 0 f the stages ,I but, the k:illing of the trepolnemeS can cause Jarisch-,Hef"xhe t:ner' r·eactiot1.. This ~e.action is thOLl8J~lt tOI be caused by' the rapi.d release of antigen ic

mater ial s frCf[J] l_:;sedl tr'e~n€:me5.. There mlay be, a local and gener'al

r'e act,i-oll .. The lac a 1 re.ac lion -cansi st.s 0 f intefl.si ficatioli'Jl 0 f the lesions

(: rashes became! more pronounced , ebancre becomes edematous j .. System i c al] y ~

freqLEntl ;' the temp rj_ ses to 101- 1 020 F. 1 occasionaU'J a s Iligh as 1 Q.!jo f. Some patients nave convul s.ion S Q r increasi ng ag,i tation ~reqiJi.~ ing re str a i n t s

or .sedatives. ItealCt ion usual I y occur -S within '12 oour s of treabn,en t and usually: lasts only a fewl hour s , r'ar'ely more tharn 24 nour s . TrIllS reaction

L s usual.I y; ben i gn and of i t.sel f is [\Qlt rea.sor., to d i seon t.inue treatnlen t ·

O, STSI is p.1)si ti vel in a lmo.st al1 cases _, Sk i n and mucous mertJbrane lesions 0 ften wi 11 show the T _ p~ 11 i durn: s,pirochet.e ·[)in rii3lrK- fie ld

elanl ..

1\ ". , ~on~ ary s yphil i s ~ Di fferen ti.al. d ia~,no..si s: 1n fee ti.OIU1$ -eSarlltnf!D5 t pll t yr1asl S rosea It and drug, erupt.Ion S .1 Vl seeral le':s,i~Jin s ma y

suu~st nephri t i 5, or hepa t i ti s from other c. auses . Rred throat may' mimllc other fowms of pharyng.i tis .1

P.I .same- treatmEnt as pr1mar'y sypnil is ..

a" Prlmary s~phil.is-

e ~ Latent sY'PtJi 1. i s {last 5 from morrkrtJ.s to 1. i felt ime) II

S. No phy.s Leal signs; total d iag,rlosi s is on hi stDt:'1 II 0,.. Posi ti ve- SIS ..

S .' Ii' 0-9D-day aneubat ion per i-nd ~ t hen a pr ir.1ar"i c haric re diefll'elovs, . 1hi:s i s a pe i n less super fie i al ulcer' wi t h. a e lean ba se and fi rn indur atee Mla!""'~ inls .. Chane res; are usual I y singul ar , b ut; mu 1. ti: p.J e 1 es i.on s a Fe not. r·a~le.. Bact.er i.al secondar yl i tJ1 fee t i.on mayl ace ur causa n~ pa in .. ~.st, f'r€qu~nltl 'f loc~lted an the pelfl_i s I' 1-3o.1a II cerv l.':(!Il a r a'7:~::Jrec t.3ll ~'eg.iDn ~ O:"Casior1ally found on 1 iP:I t-on~t..:e- 'I olr t~)n s i 1 and r .are'':'' 'Y c'n ~reast 01~' finger, IT'ess the: edges -of the pr imar y les iOIFi an )fOUl wi 1 i f-ee 1 a r()iund peal ike ball _ The les.i·on w]_ II heall by i ts,elf, but rna Y CaJUS€ a 5C ar .1 The

pr Imary' chancre roJla:; pa 55 ~:1lr eco1..n t 7.ed ..

A. Latent s:yph.ilis"

P IC Give 2. ~ ~ mi 11 ion un its ben,z,athine Pi ell 1- C 1·.'. Ii 1. 1~.1(11 G, I IWI Jj""Iio.lnc·· .e. a.' 1.~b:II. .. e.'.II .. '.

x 1 weeks, Ii ~ I Iii 'U ~I\

01• [nlargect. :reg.ion al 1 yvmph ~ooe s t~at .ar'e rubber Y t di., screte' ~I

DQln te'ndler .. ~ea(1J"""' frOflfl1 lest O~ .sta':"ns the sp i r-oehe tel pink using ~ie~s2J I s

slain and. black uising, sil~er i~pregnation metnod under dark-fie.ld

ill Uffliin r::It ion.. The spi r-ocbete is somewht3lt harv:.:! t~D !]_ nd and mC3ll" r equi re numeruuIs smear s, be fore i tis fOIQ.lf:1o. A serologic test fo~' S :fphi 1 i s <: S1S )i ~ :s the best test.. These' t.est. s lI.sU~ 11 y tUff" tJl p:I S i ti ve 1:- 3 week!i after the appear anfC€" olf the pur il!la~r y lelsiOlTI.. 1 f the ion i.t i al SIS and d ari< - fi e id

ex am i.;natiorJ] arel negat i lJe ~ the SIS, shaul d be T'e~ated Ofl.-ce ~Yeekl y foT' 4

weeks ..

-

a~.:'

~ '., I ~~. Tertiary (lat~) s~philis may occ:ur an:;time .after secondaJ"'Y

syphIlIs., even after year s of la ten!: y ..

or.. . •. ~..;. Essentially. a va~:u~r disease that _ may at.tack .any Ussue or

1aI~=to ;I.gnS an~d symPt:m5 mey mllml~alrno3t .a~y dlse~se. Called the ~Great fw hi.r.. becalJJse _of ttu s.. . . A . good! In-depth In story ]_ s requir~] looking :inad ... :s;~ry Qf pr mar 'I chancre aJld seoondar y syphi 1 is untreate{l or

aq~1 te 1 y: t Ii' e aJ te<1 ..

Sk .. n~ SIS usuall'j pesi ti ve; T + pall idlun migt:t pos:sib 1 y be found jl1

. ,in Qlr mucous le's-ions It

ft,.. Pr-ima~ y sly phi 1 is.. Di fferen t i al d i agnKx5.is : geni tal t:]er pes I J ~phogr anul("dla ·ileneretcm 11 OT' t1ropla.sr!ll.

1I"1i ...... ":::Iinc,..o· i . ...Il .

..... ~~:a 'Ii

Ter t i alTY 5 yph,il is.

:P.. 8e'rllathi ne pen.ie i 11 i u: G 1.? rni 11 ion un its )_ r~ eac~l tn..lt tacK f~),r" a t{~ta1 of 2'. ~ m t ~ 1 i~'n un its Q.rt-ce., (Jr .. : y i r pat ~ en t, i.s all er~,i ~ to

pen ic: i 11 i.n sho u 1d tetr .acyc 1 i ne .. 1 r er ytr_rtl1ll:!'C: in b~ used.. Jetr acY,'[: 1. i rrl€ ~O~

mg., ~raill y q.1 i ~ d., :t 15 days t, Er yt,hr··::rny~ in ~UO mg _ orall y -~ ~ i .. d.. :t 2:.1 day~.

"... /J 4

.f_- .... '

e

.,

COngeni t.311 s::fph i.l i s t r ansmi. t ted thl"'DUgh the pl.ac efi t a to the fe'tus.

. S.. Ma'i have min imal t-o no s i.gn 5, far 6-.8 week s a fter ~ilf"th.. M:!lst

C'Dmr.lon find irtgs. are on. skin and mucous !1trembranes - se·rOLJS nasal discharge t. tlJIOCOU.s membralle pa tches , macul.opapul ar rash ~ and/or caodylCR.as {broad flat war-'tl ike growths UlSui:lJll'i .seem Oft gen i tals Olr r-~ar air] UlS) ... ' These 1 est.ons a roe in fectioUlS- ~ Le s ion s heal ~ y thernsel ve s a.fldl i, f left untreated e h.i l.d de~'elops _ de re-ct.s : inlt-erstitial ker at.i.t is , Rltrtchi!1.sonli.s ~eeth" sadd.1-e nose

saber skms , deaf~eS3 II arIdl,or- C. N .. S II] invo1v'em.ent .. , I

o. ..:.nears tak-en fTorn lesion and cne-c'ked undJelF -d ark fi eld shawl T. p~11 idtllll... SIS i s not conc.Iusf we as it is compl icated by tr ansplacental acquisi tion of malter'rlal antihooies. Bahy must, be checked! every 2-] weeks fair' ~ JOOli1ths I'

A.. wngenital syphilisI'

2-6~OII CHANrGROID_ An acute localized usually self-limiting 'tenere'al

dli sease 'hill th an inc ubatian. per Iort of 3-1) days.

S. In i t.ial lesion is vesicopustul ar' ~Ii. ttl .a nee rot.rc base t

sur round ing erythema, and [Jndernlined edges II ~ul t.ipl e 1 es ion s stall'ted by aut.o i.nocuf at ion and inguinal ad en i ti s of't en dev e lop- The aden i t.i s i s

UIS ua.l.I y un i 1aJt~'T al and com 5 i st S 0 f tenrd er DULfi t ted node S of mwler.a te s i 7~e wi th overl yt n~ eryttlemla ~ The nod~ll malS,S sof't.en s. ~ bee:mres fl uctuan t , .and

rna Y' r'upture spJr.JltaneoUisl y ~ With 1 ymph node' InvoL v~n t tl chij, 11 s t, [evler t' a~~-j ma~ai~e n:01a),f d evel op; bal a~ i t.i s {infl arrnat ton of gil an 5 pen i s) afldi ph irnes.i s

( tighten lng 0 f the' rores;kln)l are frequen t. coop} ication s ~ These' signs

U3:u.Jall'1 Q-CC1J1""1 in mien: WOAJten frequen tl.y have no €1: te'rnal signs.,

0., 5mealr fr'om Les ion gr amr-sta i ne-d shawls short gr am .... nega t i V;:Ji

bee ill us (: }lemophi 1 us d uc:re'yi ) ~ There i 51 a ski n test for c han~ ro id; Olrlce it

becc:lJiJ!e-s p:Jsi ti ve!, 1 i kel tine test ~ i t rem~ ins Jx)s,i ti 'i€" fa r 1. i. fe' . '

A.. ChaTIcr-Qlid ~ D1. ffer-ential d iagr10si 51: -other Yel11er'al. dl i.seases alild pl)'ogen ic le.s ions II]

p .' Gan t~' i sin 5(10 mg. q .. 1 ... dI. 'K 10-' ~ days,; 0 .. S gm teltf"'.3{: yc:l if.IJe q .. i t.{j.. X 1 0- 1~1 d~y's;: -cle'i:lrn ulcer wi lh so.a p alTld water' b., i I'd ... ; as ~)i rate floct.uan t buboes.,

2-61 .. GRANtlLOHA l:NGUIJJA,LE.. A chr'on ie.1 r'el apsi ng g,r-anUilamatoUJs a nagen i tal

in fee lion wi th an irJrc Libation per lad 0 f fram 1- 121 we~ks ..

S .. The init.ial les-i-~n ma:f be! a ves.icle" papule~ Dr nodule U$uall'f on the pefl i S 0 r labi a minora.. Th.e onse't i.s insidl ious .1 Thi s le.s io:-: bec-ootes erad~1 and superfic iall y ul-c~ri:lited.. The ulcer is s_hi3Jllow t, s,MT'pl 'i demarcat-ed wJ.th a beefy-,red friable bas,e of g;r-antllation tissue' with new

fJOd ule formati.onl at tile edge as the 1 es.iofL ex tends... The adv'anc ing b,ordier tlas al char ac:teri st ic: rolled ed~ e olr g:ranul.a t i,Qln ti ssue ~ Large' tllcer.a t iO'!l S may . ~dLJ ance up onto the lOL-ler" adlbcrnen ani(j thighs.. Scar fo rnatiolrl and healing may .oeCUIr along on e oordler- whi Ie t he- ot~er- advances., The pr'oces.s

may' becane indlo1 ent an~ .sta to iOlnary' ..

~ocyteS frClll smears made frm!J tissue- sera Pl fI!2; or sec reti~ms f:r~. t!'ie !Ulcers II

All Gr-anul{]lll.3 ing,uina 1. -e ...

..

p.a, Jleltylac ycl me 5{t{l rng., q .. i .d.. )[ _?I -week's or' .st.r epltoo]yc in 1 Em

. dl I l' diaYI IS 1M or aillP," lei 11 in 50;) rna." Q. i .. d , Jr: 21 weeks IJ

q.l .1: .. I OJ

21-621... lL mffi(i;iRANlUl.OMA VE~lERElIM -I- An acute and chrOfi i.c .sex uelly tran.smi t ted

disease vi t h a 5-2 ~ da'j i ncuba t ion per iod ..

s. The pr imar y l.esron ttlalt is se]d(..l!J seen is aJ tr anai tory s~al1 pBPt.11le-:t vesicle 1 or ulcer tli1at _ V<!C1 i.s~ s in a. wee k to- l{} days. Ln the male j it is ustJa:lly found on the pel] 15 and 1 n tile feAJlal e r on tile v'.ag in a1 \rall or cer"ix Ii f'rm tnere , inv'a S,iOr.J1 0 f tile lymphatics ace uri II In the' male II the' :inguinal nodes are invol ved with furtl1er ex tensi.on Into the deep i 1 ia~

nodes., ~t fir st the nodes ar e di sere te, Later bec(JTt,ing enl arged " mat ted .1 Baherenlt, to the sk i n and fi naJ..ly fluid fill ed ., The ~]Y'-erlying skin becomes discolored and ul tim~ tel y .s in u.s forma Lion with drainage occ ur s , which may oonltinue' for months , tie'al ing is aC:C011pan i.ed by' ex tens:i ve scarring:t whicb ma,' lead: to elephant i.a.si:s 0 f the ge.ni tal s and rectal str i-c·t ulies ~ In t.he

fem&.e" illg utnal tnvol vement is r are P It usual l y a ffee ts the rectovaginal se pttlll 'I often k11 i t h t'J] 0 1 ()C all.i z i:fI g s rm p t('Sj s, 1- UIl til 51 i fj] use S 0 pen a nd -d r a in into the' 1r'€:ctLm" and bl.ocd alMd pUIS appear s in the stool; thi 5 mJaJy b-e' accanpan ied by mala i.se t ancr'ex ia, headache l' and fever., Thi s ma:y 1 ast for' many weeks., La ter tJ ehronic practi t iSI occ urs and occastonal I y r ect.Qivagin.al fistulas and per ir ectal abscesses , Ex te1si ve sc a~rr ing a,ften lead 3. to :rectal str"icture's and e-l epilan.ti,a.si s of the gen i t;a Is ..

0., Causa ti I.J e organi sm i:s a l.arg~ 'i Irus and r-eqtJ ir-es special tel.st.s f-eIF 3I'1t i bodies; tests, ar-e' not totall y re.l i.anl.e.

A~. lymphogran1Jl cma lJeneretllJJ... IDi ff-eren l i.a L di agnost.s : Ear 1 y: le.sions!: s,ypl1 i I is II gem tal her-pte s II an~ ehancrord. Lym.ph node in vol ~eT1eT1 t; tll1l~emla 11 t·ubercula 5i S tl pI ague Il nee pl asm , Of" pyogenic in fectdon , Rectal strlctUIr--eS: neoplasm, .andl ulcer'at. i ve col, i ti s ..

.. ..P .. , Te-trac ~cl ine 5rOO mg. q .. i .,d. x 2-3 weeks ,I g;e.n taEic in -40 mg... 1M b.l.dl. x_ 2 -weeks ~ ~ rest t warm ccmpre:sses for buboes, .and analgesics

pl.r -"rl ,,; aspirate' fl uid-fi 11 ed nodes ..

2-61]. HEBPES GE:NITALIS.. ~ Llsed by her pes vir us type 2 (her'pes simplex). ~be. se'll:uall~}' trarlami tted and. is increasing in frequency .and .se. "iQusness. . .ec~lon ,dtr lJlg pregnaflc'i can cause sp:Jntaneous abortion, s,ti llbirth ~ and n eon.a:tall de at h .,

i tc : i . .' S. ,Ii. !il-7 ~ay i!1~ ~ationper lad. Starts wi th r-ed~ened a~ea wi tI'I bw hlD.g, J)nlgre ~s" U1 tu bllster th.a t breaks 3m"Id becomes pal 11 fu 1 11 ke a tn. Allor tms 1S :r-sually recurrent. In severe eases there may ve

~~ Ii l'IIaJlaise.. a~reXla ~ local gel] i tal ~in J dysUJr~a t leukorrtlea (whi te or

WlSh mluc'Ous d J.,Scharge) 'I and erven \\Il.ag,ll11al bl eedlrlg .,

vest 1 O~ Typica I geni tal lesion s are ITII.Il tiJile shallow ulcera tioos j

iS~u!~ .. ,and .. erythel1~tous " papLiles. . " Pa i~ful b i1 ateral illg ui n ~ ~ertopa thy glass. l1y p-esent. ~. Sc:rapuigs and ~ LO~S les ma y show char acter lstl c II·growm

vac. . I appearance. of cellul air nuc 1 e]. With ma.eroilS SIIIIall intr antIC learr

UOJes aruj, snaIl sea ttered b~ sophil i -c palrlti (:les· ..

2~461

A.. Herpes ge.nitali.s.. Differential diagoo3is: other venerleall.

dliseases ..

P . Symlptomatic tre-atmen t , Ther-e is, no known cur-e bllt there is a CO!'l tTol being tested that appealr s fo be effec-t.i \!"e but on} y as Iong a s

taken II] Amlino aeid ( all-lysine) c.amels i,n tabl et fonm; gi vel 1:1 500 mg -t- dail 'i in 2 doses 'I 'When Lesfon s di sappear ~ 1 tab a da'i a s a ~ainteo.an(! e dosage ..

A palste can be· made by crushing a tablet., making into a paste , and .appl~iflg

d.ire-c-tljfl onto the Les.Ion , TIli 51 uSULall y clear s t.heel lesiDTIs wi thin 2111-4H

bou r-I 5 ; 50 f~r thi s a ppear s to be vetJ""y e ffecti ve b:ut only as a contr'o.l , nQlt, a cure. TIli s t.s the onI Y' venere al. d!i sease the t does not as )let tlave- a cure ..

2-64·.. other di.sease s t.halt ar'e con sidered vener-elal in natur-e include

Fed Icu.los.i s pubf 50 ( cr abs.) , se~ Les , hepa:ti.ti 5 B infecti.ons.1 vul VOI/ agin.al cand idli a sis 11 tr Icbomoniasa s =- and nongonococcal [Jrethr i tis" The se d i se ases will be covered in otl1er sect ionsl .1

2-651• Treatment Qlf venereal. dise·~.se:'s bly' itself is [lIOt. -enougtl. Con t ro 1 and preventio n must, be str-essed ..

a • Prevent.ion Inc Iude,s classes on VD· and liD prleLJent ion measures pl U~ insu[f" ing, pro'phyl.ac-ti-c. devices are made alVal il able ..

b • Cctntrol involves: ear 1 y detection and trealtmen t o f .i nfectedl

per sonne 1 and! the~i r' cont.act.s , ~lIery pa t.ier. t -di agno.sed as, hav ing VD. shoulldl be interviewed tal determine wli th wham he has had sexual contact dur ing the! cour .se 0 f hi s illness and from wt!00JJ he m tgh t have eon ttJ""acted the di sealSoe'. If the pat.tent, does not "Went to glilie out, lhe n~esl and addresses of his contacts, y'Ou can estalll i sn and use a card: system.1 Wi th this .system )'-OUI have colored 3 x '5 cards t a differ'ent color for eacb type VIt You r.:!=afi hand! out a nU5i1be-r of -cards to the patient and tell him to g ive one card to eactl per.son wi ttl ntlooJ he h~d sex , Have hirn te 11 them to t.a~-e the <J ard to ttle mred! Lc. 111 ttlElt· wa Li' yOUI C an examine and treat proplhy 1 acticalll_y each person ~o brings in a car-d and g ive them cards for t.heir .5e:€ual. cont.aet.s., In this way yeti should be able to el Immate the major-it"'j of the liD problem.,

CHAPTER 3

..

( 11 J Heiml ich sign; nann to throat 11 as i.Ll.ustr at.ed bel.ou.

Universal d istres5 S i.gnal, for choking.

(2) Ina.bility to speak ,

(3) Wheeozl(Jg so und s and an effort to breal~Jl.

b. Signs in ;i(n unconscieus patient:

[11} Chest net ri.sing ..

(2} Cyanosis ..

{ ~I } Wi ttn your fi ng,ers s-weep ~Iuth and throat 0 f foreign

material ..

(;l} Wi ttl thel heal a r the hand del i ver four shar-p backblmis betweel1 the pIC! t.t.ent '" S SOOlJ Leer bl.ad~s 1 as; illustralted below ..

5ax:k blow "I standintt; ..

J-'l

}-·2

( 3 ) PP.f forml abdCf1!linal thrust s :

waist ~

(al} Stand beh Ind the pa to i ef)l t ane wrap your arm s around! hi s

( b) P lace the ttllDJJb slide 0 f yOtlf'" Ihand against the patient ~ .s abdk:roen sl ightl y aboiJ'e the navel and below threl rib cagel! as i 1] -u.strated

b;.p< low' ..

(c) Grasp' your f15t witt; ttle ot.her hand Cllndi presls, in to the pa t i en t "s .abd.om~n wi. th 81 Q ui.ck ijl~ardl thrust; r'epeat thi 3 f-our t imes .

c:lear III

Repeat th.e b.ac-kblows ;:I(Uldi a:bdlomli~:al thrusts I-Jr. til a ~r ~ay is

{5) For' a prone' pa ti en l ::

(a)l Po s i t ion patient on ~i s back .. _

(: b) .Kneel astr i·~~ p.::utient I s hi p.s f'ac ing. hi s he·adl ..

(: C" }I !Pta~ e en ~ hand on top 0 f t he other and pest tion tl1el neell of ~our botlQl!1VJ !;ar1~ 0:1: thre pa t i en t r S abdomen t Sol ightl y above the n avef Dnd below the ribcqge~

thrusts.

.. /f," d. l ·~II TIl

\ _. s ress in to the pa t.ient ... s abdomen wi ttl four' ::tikli c k_ llJ prwardl

{6)1 I f the- obstr-oc t ion is no,t d i s.l odgad wi t~lin a few minutes II p€:r' ft)fT., I:Ul emeig,enc'i cr i oCothyroidlotomy .,

~ "

_" .:::.

C'IIl,Rlr--:T o PI :qt~IJlo.ni= Py RI· F.Clf~r iTAI 1'·10'· ti~

.J1J I l,....1. L! .1"' ·!IIJ'!.! r"ll ~,_.~."Jl .~._.Ji._. -"- " Lit'.'

hyperE!l: tend n i s n.e-2 ~ _ Pl ac e i:)l1r ear QiJet""· the' pat.ient 11.s mouth and observe [0 r chest r i 5~ ~ Look , 11 st.en tl an-d feel )i :€ 5 second s ..

...

(3-) If p.a t i elri t i 5. ~ot br ea thingl tJ ~j ve four qui<! k ~ en til a t i0r15 'I no t all o~i ::.JIg a 11 the a ir to escape bet.wecefi e aeb Vetilt ila t ion in order to gi vel a st,a Lr st.ep e ffee:. d;tJd Jlal: irmITI .aeration ~)r t,h;e 1 UrJigls 01

{a} If a pulse t s present ,I corrt i nue with mout.h-to-mourth re:S:UISC i tat iOf.J1 at 12' "iI'en ttl a tion s pe'r emnute , [nee k for pul se and for' retulF!J of spontaneous h reatning a ft€tI each c'yc Le u f 121 v'ent i I. at ions ""

{ b ) If pllIl S€ is .a b sen t· 11 re scuer beg ins CPR' ..

1 .. In i t i ate CPR by l-oc.at in~, thel notctl wiler-Ie the

ster~ urn and the' bOltt(Jli1] 0 f the ribcage meet ~ Place· thel mlj,ddl-e fi nger 0 f tllel lo....er band on Ule' note h. anc the i nd-ex fi.ng,er' an the lOliler end of tne st.ermra, TIlen place th,e bee l 0'[ the other' hand o.n th·e lower hal f of the ste-rnLnJ next to the i ndeJ< fi nger 11 as i llulstr'ated he 10"1 ..

__ - _,....... __ _.;a_-I'.IIIFF

......

"I\, I /J .-

-

i' II

.... '

-- ---{_ (((:

.. r-, _--

I . _,

U 1 ,:

~and pl ac emen l ..

? . Per fc:rmanc:~ stafidard s far C PH s;b:)ul.d be l~ accord ance with t.he faJ I "Jwi ng ~ hart ..

COM~rENTS

--- ---

Ra te 0 f conpr-ess ion

Use Q f hands

Depth 01 r ccmpa-ess ion

R€susci ta tio n orrLy

CPR:

Chec king, pul se

Breaths

~uth plac emen t

Head tilt

COr-H:NTS

Ra te a f campTession

Use of hands

Resuscitation only

CPR

Checking p1Jlse

r;nuth p1 acement

Head tilt

]-4

CUA.PTER 4

MENTAL DISORDERS

[ill RCI OPJlMON~ ~y R ESJS~ 1T A. TJO}J

~_ 1 . Marl'i d i rfe-Ten t fonns 0 f mental disorders haye be.en n evned and

... describe<1 t and each may v'ary grealtly in s igns and' s}!mlptams.. Even psych.iatrists ma~ have difficulty in diagnosing a particular c-ase.. The nervoUS system section is imp:)rtant to review and oons ider when evaluating Md trea t i ng menta 1 d i sorder S I- Organ ic factor.s may be responatbfe ..

ADULT (T~J-YA~J)

80/roin

a... Terminology.

2 hands

1 112-2 inches

( , ) Anx Let y : Feel inlg a f tension due to real or imagined danger ..

1 1 j 2-2 ::. nc hes

l per 5 see 12/~in

(2} Ci:mllul s ion : Au irr'esistible urge to act against oneil s bet.t.e'r judgment and wi 11 ..

1 per ~ se~ 12/min

15, camp 2 v-ent

(3} Delusion: A false fixed ide~ that can~ot be erased by reason or evidence ..

carot Ld

ftill-ooubl ~ :51 ze

(~) Hal I uo in at ion : lrnag,inar'1 sensory percept ion wi toout actual st.imulus,., eoi ttler vi sual and/or audi tor 'I II

full-daub 1 e 5 i z-e

r!lol1ttl- to -I"l{H.Jth {nose}

mouth.-t~uut..h Inose )

~r"oblems, ...

Insigt.t: Awareness and acceptance of one sel, f and one I s

h~verextension

h~pereltension

III usfon : A false in terpreta tio.f.l of a real sen sory

(6)

.stimulus.

(.11 flental tJygiene: The developnent of healthy mental and emotion al reac:tions and habi ts.

C~I1.DftEN

lNlfA~T.s

((;.) t.Je1ura:si 5,: A funeti,onal mental d i.sorder wi ttl feel ings 0 f

31lX iet y in which tile _personal i t)l rema ins in tac t. and contact wi til reality: is main ta irted ..

, 00- , ?)/~in

1 hand!

? finQ_;ers

(9) Ob:se-ssioo : An ir'resi stillle urge to thin k tho-ughts one does not wisn to think.

1/4- 1 ll2 inches

1/2- 3./ l.I: i ncbes

1 per 5 sec 121m in 1 peT "3 .sec 20/mi.n

(10) Paran.oid: Characteri.zedl by suspictousness , ideas of persecution.

5 conp 1 ven t 5 camp 1 yen t

~ 11 ) Phobia: A.n exaggerated or morbid fear of something or' .si tuation tJ

carotid ewer 1 eft T1 i ppl e-

regtllar

puffs, of 31 ir

(112)1 Psychiatry: Br'Bllch of medicin.e that deals wi th disorders af the mind,_ bellav iOlr t and personal i ty ..

mouth-tel-mouth (nose}

Aourth-to-mouth and nClse (botn}

(1.3) P-sy-crosis: A mefltal disorder' in -which the personaJ..lty is Very ser tousl f di.sorgan i zed , and the, patien tis oftenl out 0 f con tact wi th reality... A "major'" mental illne'ss ..

hyper-e~ten~ian

tilt (no bypere~t€:!15ion}l

_. b II In many cases tr-eatment is long tenn aWld requires special ta~ 111.t.ies. We c:annot hope to. cover all men,tal problems and their treatments in one chapter , Of fOOJre irrtpor t.ance to us; Ls the abi 1 i ty to Tecogni ze appr oac hing, trolulll e and wtta t to do abcut it ...

( , } Types 0 f indiv idual.s "WI'lo .are mor e 1 ikel y to get i.nto

4-1

- _..~

4- ~_.

-d .. Alcohol ic = M~.3r·ked by' al cobol ismJ arnd bouts; of dEl ir i.im trenel'l S-

e.. Tox i c (drug:s}: Induced by t~~ Lc agents sue h. as dr ugs ..

.... 1 ".,,-1,

.ieao s

, , (.a}1 !he shy, ret~ r ing~, ~i, thdr'amt ind i IJ idu31 ,I wnx) has 1 i ttl e wi th at ~1rer3 t, ,He ma:Y1 haue InsUlffi,c ien t ~Iti-~;ri alex press iCHI tha t

to the accunul.at.Ion 0 f strong fee'l i.~8,S, ~

S II and QI. Eacb p~:yeho.si s is a separ at,e case aff~-c ting a separ-ate

.. hunan being,,, tlkJt .al.l cases haee al l the· major SyrnptClfllS. Below' is ["'::II

l-ener .all y accepted gIiY~)UP 0 r S yul1ptoml5 :

(: b)- The br aggar t who talks too long, and 1000 01 r his

abi 1 i ties at romle j .a t IMDlrk., ses uall. y, and. soc i ally -t- H~ i 5 ~:su~ 11 :/' in secur e

and .~lant3 t.he adm:i.ra,tion of others. '

( 1 ) )eep de'pressiGln wi th feel i ng S 0 f worthlessness. tklle 0 f the' foremo.st causes or- ael. f-d,estr'uct ion II

{C}l The per fee t ion i.st whol wain ts elJeryt hi ng just so and bee ame s ~ler"f anx in Ul s when t 11 i ng s alr'e \/r·O n~ II

(2) ADflomlal and! inapproJlr ia te cbeerf'ul nelss ~I out -0 f keeping \Ii th surround ins 51 a r real i ty ·

(: dl)1 The sick bay' conmandc who tr ansl ate's hi s Ln sec~UT i ty , I"Orrjf 'I and an)[ ie.t y Ln to sooa tic C:OJiJlplaints II]

(3} Loss 0 f contae t wi.ttl real i ty w:i th str ange , bizarre OehalJ lQr II MalYI he' ber .serk '" aasau.l tive ~ totally wi thdr'awn " etc:.

(e) The man who d eprec iates, himlsel f an-d i s al WEI)"S apol.ogi z i ntg is ulSualll'j' bee 001 ing de pressed: .,

{.ij,} Total} wi thdrawal frcm a group tOI such . .a deg,ree that tfrle palt-i.en:t actuall'1 1 i ves ina rll~r ld 0 f famtas,y ~ 111

(51} De lustons and hallucinations ott·

( al )1 An Y I])ers.L..stell t c h.ange 5 in mood in a man I s be·hav ior .,

.. ~. Ps.ycbo-s.is II]

( e ) Dc-pres,s ion , sel f - bl ame, se l f -dieg,r ada t iOiJf~ ~

(: f J Wi thd r awal tl esc ape froOml others ...

Pili Clo5e' superv.i s ion 0 f tl1e' patient s.ince hi 5 cond i lio·n is characteri.zed by ra.pid .and major' mood swings II] Estahlish coomunic·ation as SOOI'l as possible Ii Fe~ar is 0 ften 1 aT.ge 1 y! resp::Hlsib 1 e for hi s bebav ior .. Reassur@ him] and appeal to the "'''well n aspects 0 f hi 5 per sonal, i ty . Force an_,j relstr atnrs must be used lft1en there i 3 no other WI.8 'i to prot.ec t. the patient or toose around him. ItEstra int s should not, be pl aced over .chest and abdanen and SOOtll.-d be remcved as soon as possibl e II 1r'aTI qu i 1 i zation far' the 11: i.-olet1 t or aasaul.t.a ve pat ten tis often necessary.. Use ar. tip-s-yc'hot ic s CblT psychotic Detlavior., U5i~tt1e-following: j,n pr'tori ty of order:

(b) r ens.Lon f an)[ i.et Y:M a ppr eheresi, ve faei al elx: pression ..

exce ss i i¢.f per sp-i rat ion 'I tremrulolLtsness.. ..

( c) lrr i tabi 1. i t.)!!1 sbDrt. tem.per t abr uptne..ss or C OOlv1 aining t' and fat!'l.r..find i.ng ..

[g) St:ma t i.e cOInI'p1.a irl ts 0 f' s.l.ee ples,sness 1 nightmares, alo:rex; ia!li nausea,. stomaclhacJhe f he,adac he, muse l.e cramps, d iarr'hea.

r 11 ) Hal.do l C: haloper idol) 2-51 mg Ie ] MI can ~e given ever:1 hour if

neE!(jed., The drug of ch{) ice for sev. ere psychotic, aggr-essi ve ,I II~r o the'!" ull1oontro11abl e behav ior' problems, ..

, (h ) loss of cont.act., loss 0 f at tent ioe , doe sn tJ t make good

.sense ,I poor tho [Jght assoc!iatiafJls" 5 tr ange or Uri ex: pl t3lined behav ior '

d iff ~cl.il ~:_I think i~ j mem:Jr Y lapses, lack .:. f cor r e-latiofl between ttnught and enotlonaJ L ex pressIon .,

{~} Tnor'az.i n.e 100 mg 1M.. A greater sed at i lJe than (1)., Blood _pres.sure: most, be mo!1 itoreo since i t may proouc. e hypotens ion ·

4-2.. ~'KHOSIS. A . .seve~e ~ major'. ~ental disorder characterized by ... ar Icus dlegre-e'5 0 f pprsonal1 t"f d is in teglraJtlon and falil ur-'e to test ai'ld -evaluate

e)[te~nall real it Y' corree C. 'i ... These rnern ar e ulsuall"Yl wi thout C'l earl y d ~'fi.n_-ed

ph~51(: al cause or str-'l.JICtur a 1 br,t11i r1 C h~nge5 In The basi -c type S 0 f psychoses

are:

(3)1 t i.br'illm 100 ma," 1M to riel i,~lJoCI;.,' ~,-r loll 1" ,_o,tl"v,' .. E . 11 f 1 -

.~~ Iji;: -v. -.;; CI • .1 A "i;;.1 ; spec 1 a . y u se ~' [J 1 n

ale..ohol or- drug abuse ..

-4- 31~' PSYCHONEUR051S-... A r eLat.I vel y ben Lgn g,roup D f personal i ty o i sorrter 3.

thalt, .arise· frceJ an e f fort t.0I de al wi ttl spec i fie, pr i vat.e, in ter- n al '" ~ndl or PSYChologicall probla:ns and .stre'-ssfull si tua ti.OilflS that th-e· patient is lJnab le to, Rlalster wi tltxJut t~nsiOT, a r disturb ing ps.:tebolog,iea 1 ctev ic.es .. The

~}:mPtan:s are numero;us and. v ar ied .. "rhe e-hie f chalraete-r ist ie: is art:.:. i et 'i ;

=~~ ~.' ~e is g_ood o:mt."act ~ith r~alit'J .. The. Ct?~f~~ioll '):". symptoms .

," _ ~ t dl fflcul t to as.S.lgn a g lV en -c ase! to L".::il defl f11 te t y;:..e . The e'5Ise'nt~a i

~;~deraJtioo is, r ecog~) j t i on of the ~:lldi ti on .an~ t.he :--.e-edl for ~reatmel'1 t . IllSust ~. remembered ';,~~at one I"leurotlc symptom 18 rllOt a ~ella!"031S-. ~"11 of

" oceaslonall y devel.{)lp or.-e tar e¥-en se .. ' er.al ~ under spe-"~ i~ 1 dlUr"e-S.s.,

a ., ~1ar~ ic-depre,ssi -ve re.ac It ion: f1arked! bly ffllaJjOf" mood .swings and. arolt.i·fJiTI al i:--: stab-iIi t Y' t.,y.pi fied b., nllolws III and n1higns .. U

b. Schiwphreni-c r'e'action:' Disor'"ientatiolrl and separation of' per.son al i t~ _

4-'3

4-~

There is good contact; vi til real i ty I' May function effecti vel f unti 1 encoun ter Ing a .stressftll s1 t.uation that he is unable- to cope wi th.. Often he controls this by various psycllologJcal def'ense mecttani:sm such as repression, etc . Other .symptcms ma'i be fat Igue , in.somrl i.a I' lowered ~r'k out~ut, ~ na~ ~l i ty t~ concentrate and even par al yzi ng indec ision 11 feelings or lnr~rlorlty and lnadequacy.

(11-) Others. have such Y'~iable ran~e~·'Olf syrnpt.O[D.5 that ttley. defy a speci fic li.sting ..

It. Pe'T sona'l i ty or character Ilehav ior d i50rder II

{ , ) Li brir.m 10 mg. q .. ' i 11(1 II

II. P... The mo st imp:lTtan t f'actor- Ls r-eeogn i -zins a per son has

p5JChiatr tc proo lems and referring tlim for Ilranpt treatment; do not waste time at temptlng, to d i.agncse bi s i Llness .. Tr'Y to understand your s.el f and be aware of your feel ings toward the pat.Ient., &.rnetime'5 it is hard to rE!flleflllber' he I s sick when hi s bebav Ior is unreasonabl.e t1 Tr y to tlnderstapj the paltient by being an ~_pert observer . Wtl,at does he tell you by his, behav ior? HAll behav ior has mean ing ... 1t' tie an in terest.ed and sJ!111pathetic listener .. Th,is. is one. of the most effec.ti ve tools in -working wi th disturbed patieJ1t.s.. Giving advice is rarely of" any help.. Paraldehyde is the drug of cboice for any d isturbei pa lient. I' Opiates. are contr ainc icated .. \Iher1 restraining, a ccmbatan t patient" be careful that. you do not ,get injured.. Keep aceurate , ecmprehen sive r-e_ports, regarding all aspects of the case. These mus,t be kept confidential and it is best for the pati-ent that they are' kept fron him. Let the psychi atr ist dec ide how much. i r- any ~ to te~l Ir.iimll

P.. Ei'eIDOf'IIe the .stress :si tuation if po.ssilJ le .. ' Li st.en to bim.

Ofteil simple ventilatioln of l1i51 Jlr"oblems is all that. is re(JlJired.. Reassure and 5Up'poTt, l1im but be caut.ious wi tb advice" let him work out hi s ow sol.ut ions , An.tianxiety drugs .are drug s of cho ice and follow in order' of preference ..

(2) Val iLlti 5 mg. t .,i .. d. (Use IV if anxiety is- extreme .. ) (3 ) Plheno:tJa r'b i tal l gr , tab II q , i .. d.. P • 0"

r lJ ) Nol udar 300 to 600 mg... h .. s I'

4-4.. PERSO'iJ..~LITY UR CI:!ARACTER B.EHAV10R DISORDERS.. Ch.aracter-ized. by

defe·ct.s in t he d eveloprnE!fl t or str'ucture of the per sonal, i ty,. rather than by men tal. sDmati-c- t or EIIi.Iotion.a1 s:ymptoms. These inc Lode the an tisoc ial and 3JJOI""'al per-sonal it 'i and the .se:€-llJa 1 dev iate • We find this kind of

d i sturbance the m~st d i fficul t to accept as an Ll.Lness , These per-sons seem unable to learn from exper Lence PJ are incapable a f con forming to ord in ar y ru.l es {)if SO~ iety. and are ofter] the 'I?, troub lemaker:stt. and/or ~I wi se g uy.s .. ~t

The basic type.s of personality or character behavior disorders are

i nad~quate OT i~ature personal it 1':! emct.ronal Ly unstable per-sonal i. t Y , 'pass 1 v e-aggressa ve per'scnal.Lt.y , ccmpul.s'i ve per sonal i ty" arnd the 5chi-zoid per sonal i t Y ..

4-,5. ORGA.NIC B,AAIH SYNDHCflESt1 Caused by crgen ic impair·me.nt of the br ain

due to tr.aUlla., tLlTlOIr-S, c irC'ulator 'f d isturrbarlces 1 metaboli C' di sturbances tJ eonvul sr Lte- d Lsorders , toxi-c or Intox Ic ate<j sta tes ..

S.. .and O, De feet sin meroory (roo st Tee en t eY'eflt.s) ..

.Di.50rien tation as to t ime , pI ace ,I per son. Sudden personal i ty change wi th irritability most notable-. Hall ue ina t ion 5 and del ustons I' Convul s ion s to cana.

. .. s. a~t1 0.. ~ 1) . Symptoms of' Lnadequa te or- inamaturre cersonat i ty'

are : Fa 11 ure 1 n .emx.>tlOl1 al fJ econcmic, and occupat iona'l adjllJ5tment.s. Olften

good n~ttJr ed and eas:; going, but inept! ine frecti ve , and unC'~ncerned .. Egocen tr' Ie wi th chi l-di ah manner i srn.s suc-h as. t€.mper tantr-L.I]s pl bed \fe't.ting 1" ~leepwa~ k~n~, ~ _ etc .. Di fficul t.:y .adj ust irrg to new si tuetions t ac-ce-pting_ n~w responsr bIll ties PJ or in getting along -wi th fellow ~rkeTs.. Often AWOl. II ~lInc ~ional somat~c oCmpl a in ts .wi ttl nOI or'gan it! cause such a 5 headache 1" pa i.n lrlJ chest , Gill" dIsturbance.. Often present s sel. f' at sic.k call as an 1r'lKJ"Will ing ~ar-rior' .. '" It yOlun~, mal) j first enl i.stmret'lt" unwi llirJ.g to wo,rk ..

etc I' He tr res to rn.an ipul a te .hi s ernr ironmen t and those about him to aehteve

hi s o ~ ends ,

P. Depends on the .se'IIeiity' of the problem; treat accorn.ing to

ttJe primary presenting, s}.'mptam.. AVQi,d an .aggr-essi ve .d tcratcr ial att Ltude ..

Be calm and treat patient wi th kindness and under standing.. Never argue with a mentally disturhed pat.ient of any kind II If restraint or a tTleatment Ls in l1i s best mterest , t,hen per-farm that treatmen t with a min iml.llJ of russ.. Get hel P (:lIS neceasar y... .Even severely di sturbed patients tend to respono muc h better to the calm, straight,for-waro _. bus.iness l.fke approach ...

4-6. DiSASTER REACTIOtJS ~ In this case a d Lsaster does not necessar ily invol.,e groups of people; a disaster Carl pertain to one indiv idual ·

a... ootion.al inj ur ies are not as vi s,i bl e as a -wound or a brolken Leg , bUi~ severe fear I' excessive wrryl, guilt ~ depression ,I or overexcitement is ev l.cen,ce that emotionaJ.. danage ba s occurred ..

. (2) Sjmptoms of emotionally till stable perlSCtn.al i ty are:

Mar J.fed tendency. to swing, and act wi th hi s own aoot ion 311 mood 1 Exerc i ses

Ii ttl e or no restraint.. Euphor iC:I tal kati 'i@':1 .and IPJ hay ing a bal11ll with no ~eg.ar-d tottJe. cO!'1:sequence's of his actions... Anger, temper tantrums II tEind

mOO at the world .. If] A gesture of suicid~.. This is· .afl attempt to gain some ~oa 1 I' ga in concern, 300W OJ f affection., or r'emo/"ijllal from a sli tuation " Thi s IS not planned to end fatally l' but sometimes doe's ..

the · Il ~ . It is normal. for- an inj ured per son to feel upset. . . The m.:re severe ..... Ir1J ury, the more in secure and fearful. he heccmes, especlal1y 1 f the

InJIL.r"y .. is to. .a nighl y Y. allued boo Y' part., fa,r example, .an inj Ur' 'i to the eyes· or ~e~l tails. e~en if r-elati vel y minor II is 1 ikely to Ile severel y upsetting .. ~ ~n~ ury to. .scme ottJer JlaT t of the bOO y m.a't be· espec :ball 'J d ist1Jrbing to an lndlvldual for his 0..,. particular reason. for example tJ aln Injury to the ~'anc_ may be terrifying to a baseball pitcher or pianist., and a facial dis:flgurenent m,ay be espec iall y threatelning to sooe mean and m(jlst women ..

t 3) Symlptom of pa.ssi ve aggressive p€r"son.al i ty are.:

An tagOfli.st ic and sub j-ecti ve tu pout i!'1~ . .M~y be d estruc ti lie-.· Stubborn wi, th e. y.nic.a 1 ·~bi ting wit .. PJl ShreLotd" koows jlJst DJiW far he. c an ~o and doel5 _ !May

be man i rested by he 1 plessn:es5, a tertde-nrc y to C'l ing to others as III mam,a 1 s

boy ... If]

... ., b... Fear, i~'] sec ur i tY'., anx ietY:I or guil t may calise the' p;:) t ien t to bE .lrr'l table tJ stubborn ~ or tJnre.a!l()nabl e;. he may seem uncooper ati ve ,

4-6

unnecessarl i l"Yl d i fficul t., or ~en .emotior'Jlally i rr'ational ""

depression "" r.iJrtico3t.er'{~lidl5 t1 Dral con tr-acep.t i v'es, ant j, hype,r ten si ve

med i-cations sue has. alpba meith 'i Ida pal t1 guane,t.h,id iflle, clQlndi i.ne , and

propranolol h)[3ve been assoc iated ~i th the devel~)~ent of depress ive

synd ranes. The.a ppe t.i t~'_~LJ~)pre's3ing ~r Llg5 '" lVbi l e act ing_~, in it i.al.I 'i as stlmuLlants" often r esul tIn a depr-ess 1 v-e s~dlrorne lihen W1. thdrawr11 .. AI carol :!

... sedl a t.i lies 11 opiates" and most 0 f the psyche·d.e 1. Lc dr ug s are depr e ssaet.s ~ Depressioln accoun ts fDr-' o\!"er hal f of all attefnlpte-d stlie ides II The r Lsk of sui..~ide must always. be conlsider-ed when dealing wi th a severely depressed Jliitient.. Sulic i-d al thoug,ht should! be in qui r-ed after:l .and an y! sud.c idal gesturel taken. ser iOUl31y .,

c .. The goal s in trea tment 0 f d i.saster re.ac tion s ar-e to ret.urn the indli"'~dlual . to. 'h'Ork as 5:Jon as ~ssihle_ Minimize his immediate disabi1 ity ~e(l 1 f, ~rcmpt f"'ettlr n to wr k I S not po ss i bl.e , dlec-re.alSoe' the' in ten s.i t y of his i2JiTKjltl.Onal. r'eac t ion until more ermpl ete calrE! {i f n e-ededl) can be arrang,ed 1 anc preven t actions hannful to him and to -e'ffolrt S Q f others ..

d .. Oi.sa ster reacti.ons and helplful measures. ~

_ ~ 1 } Nbrmall reactions are tr-embl ing, fi muse ular tens ion rl

per ~P1T atlOI1'l! nausea Il ;;n i ~dl -d iarr-hea" urinary fr'equelnc'i ,I poll1di ing heart:l rapid bre.athl ng , and anx let ~ ..

S.. Somatic ecmpll amt.s such a 5, he ad ac hel ~ d isruptedi orsleep, libido tJ and an): iet Y' are CCW1UJrIl in IOOIS t depre.s.si ve staltes .. sew-'ere depression thet""e may be delusions of a h.ypctctJ.ondriacal or p.e.rl5eCuwr ~ (par aooid) nature IJ

o. Loweredl mood:" 'liar yi ng rrom sadness to inten se feel ings 0 f guil t, and ttopele ssness.. Di. ffic1Jl t y in t.hinking , inabili t y to concentr-ate or make dec i saons is usual I Y' present in most depression.. In severe depression ther e rna Y' be ev idlenrC:@' of ps.ych~oor retardation tha t maYI progress in. to a .stuporous cond i tion L.t'Jt2r@~as the patient may 1 ie awake in bedl blUlt, do nothing; a f hi s own accord I' Be,s pon ses to ext.ernal stimtJl i may be retarded Or" absent, In ag i tatedl depression t.he patient maYI be :restless:t sad:l" fearfUil j arld apprel1e11 51 ve - The.:; may p.ace the floor anti wring the'ir hands:... The~ may re_pealt over" and olVer in an e'xplo~ive mlanner such w:lrds. as ,.~ ... U Hall} ue ina tion s ar e rare; hoW€:\I"'er 11 the Y' ma'i cc:mpJ..ai n 0 f tli zerr-e

s,ymJ]"toms such as .,1 a rotting br-a in rtJ or .~ pI uggledl i~ltestine-s.., t~ They :may be

de.struc,tive to property alrld -attempt sel f-injury' or suicide In

"

excessave

Wi,tb

(2}" lInder act.j vie Teactl; o ·.n IO!!' (/. II::!! 1: 0.'. we.·' d·l ~oIl"'II.."lIn. ... ' •. 1

oW'_-" ~"V"I 1=... numbed) are the rrtost.

COOlrHJin relact ion to dli sast.er ... Symptan-s are vacan t ex pression" :star3d i.ng or-

si tting wi tt:~)ut rmov ins or ta Ikmg t1 and indi 11 j,clu.a 1. tllppear 5 to be wi. thflurt emotion ..

. . ., Hel~fi.Jl .me.asures: include- : Est.ab 1 ish con t.a~ t gerltl y--offer a cup

el:f C(}I f feel Il dr'lrJ k olf wa ter f or a S1i1Oke 1 use hls n ~el 11 erre:oora~~ him to tal k

and] be. a good li,;stener Ii Try to get himl t.o te1l yeu in his o~ words what actual.I ~ t1appen~ ~ Silt)iW' empathy' but don tl t ov'erwfrlelm himl with pi ty' II find hlml a slmple IJ'o[)lurtlJle' joo to do Ii

., ~ J l . Ov~r act~ ve r~~ tion.s - The- Ind i v id ual Ls .argtrrlierlta t1 ve ~ tal ks

~a~'~dly, Jumps r'.lg~t Into JOOs. and M}r ks barrd but doesn 11 t cCfruipl-ete one tlnng . beforE!' .startlng some'Uli ng else (jumps .frau jell to joo) ~ and he

usual.I y make s endles·s sugg,e st ions ,

AI .. ' [".e'(:f'"eSsi.~nl dlue to . Di fferenti.al d iag:no.si 5 :

DepressiolTI secondar-y to illness or injur·,,-Te .. g .. , t' brain tr.atma'.1 t,LlTlOr' ~ etc .) 011" drugl iJltake ..

, .. ' . Hell p rnea'SlJr-e..s incl udle!: Let them tal k about i t. (don' t argue wl th

tht:lm II ".an~ be awarel "of j'()ur. o~n feelings,) j gi v'e tlhem scmething wamlto eat

or dr ~ n k or .a ;smoke" arnd &i ve theml jrOO.s r -equir ing pnys.ie:all ae ti vi ty (mabl..e

sure the yare superv is-ed on thel job) .. '

P .. , ~ow empa ttly II Cbser'Ve pa ti.en t wi thout, making them f'eell they

ari! being watChed.1 Tr'Y to· get the paltlent to, Vef) tila te ., -NOTE: Do ttli s by

DlakinR, it ·obv i,OIUS that yOUI airel s inlcelr'e 1 'i inte're'sted in the p.a t ient 'I :s -problernls a~rl by be'ing aJ good 1 i stener' .."Inn tl t in terr()galte .. 1 f t,he patient i,3 agitated Pi SEdate- wi ttl e i ttte'r an t.ips~cool.i-c all"" an.x iety d,r'ug.s (see

par agr.a;tJ ~I- J II ~-.':.I. ~ .. I f as ita tion. is e'x trEtlle or med icatiofli is refused1' Rive V.al itnl 1M or IV'.. .Be canSltarn tly aler t fo·r a suic ide attempt. arnd ey-acuate when feasible ..

\ lJ ) Infd i v i.d ual p·8.·n.·}-.I .... 1 (. bl '.',1.1" nl .d., ['1 i ""nt )' - t

~ .I~, ~I' II., 15 nr:) ,:, a camxJn re'.action.

S)lnlPtOOlS i.ncl ude wil.rJ runniIlg about, ulnr~~soni"8 attEmJpt, to flee, l:QJSS -elf judgmen t, ~ and uncontrolled weepli ns ..

, Hel pftJl meaSlure!s include: Tr yin.g, ki nd 1 'i firmness fi r st ((jon Ii t

use brutal r'estraint.1 strike them:! or douse' theml with water):t use serlativ'es 0II11y <15 _ Last resort ~ get help Hf necessary) to isolate ~ aIld show empathy for theIr protl em ~

4.-8:~. • 1Il1 I

nJ..C CfIOLI SM' .. There ar'e as many ell pl.anat.ioITIs for the cause 100f'

alcoholi sm as. ttlere are a 1 C1QI 0011 iC5 .1 PIrQ,fe:3si-ou al i:nv-estigrCl tor's e~'-enl dli.sasree Ort man., po in ts .1 CUr soc iet'j' i.51 or'ien ted ar"oundl an al-coboll-seff""~ns soc ial enrv iromen t SIUCtl .a 51 heer ball games.1 in i tia tioln ri tes F wettlns down par-ties t rating par tie's" reti rBTilent parties f and alDJst .any ~r geuSE! _ tflat 2 or more people call ccme tJP witb. Alco~l is a C. N~S.

!epr9:s<mt" UI an'i amoUfl t, even tho ugh the- seTl se 0 f euphor la c.alllsed by depreSSion of the inh ibi lion 5.- leads the ~ ini tiated to cla im ttJalt i tis a ~tlmula1t -.1 A pr ac:tical ~Irki TIS defin.i tiolrl of all colnl iml is!: 'When tlhe Inl~~e of alcotJ-all inter fere s in an -yo w.a y with a person 11.s jab" fanlily 11 (ilyS~eal COnd i tion, or in terpe-r sorral rel ationshi p5, that per son can be

~Sl~ere:I . .a!'l .alOOholic. It does not. mat~.r loIhether the. per~n drirlks all

I:-C- tlme!- rare, b inge.s.1 or onl y one -d r'lnlK 1 f the .above c r 1 ter la are met ..

{5 j Phys ical reactions al"'.e severe nausea .arid vomi ting .<md COIl'l'er SiOfl hysteri a (can'" l use scme par-t QI f tbe boo y') ..

Hel pf"ul meal5llreS include: .show them you are interested. try to ~et them to tal k, about -wtlat happened, malke them -eanr-or table, don· t call attention to

the i.r d isab il i tu- aoo tlry to f., nd· them' S ." ., .... "11 -.';'_ to k .... .

'.' '. .I II . I . I _. ....JJ I . .' I ·ame sma. JOu .• ,II e-ep them busy' a.fldi

helpl make them fOlr-get the-If' problBIIJ ~

J.l-7.. DEPRr&ION., May occur if] r eac-tion to some ourt,sidle adv-er se 1 i fe

si t uetion! u~lJal1., the loss OJ f a IOY'ed lone' through death. di ivorce etc . ~nanc ial d isa 5~er; Dr- 1 ass of an est.ablished role. KeU:otic ode~e5.si~~

dl ffer:5 fr~. episode'S of nonnal s.adr1e.ss in that the patient canJ'"lot IH'shake

ofP' the ~ee 1 ins: of. dej ec tion and the effec tis eli spr-oportiorlJatel y intense and el1'lrlur ins, .. llrl Y III ness 11 .severe or mild I' ean -c.a u~se sign i fican t

4-7

4 8· --_ ~

b II Stimrul ants (amphet.aminels .and cocaine} ..

S. and O. "'CLlIte aftpbetal! ine in tox ic~ t~on i n~l ud~s . sweating,

, ..... , . , e'l o!:I,l'Ii~ "':Ii+- -d.1 b'}o,' ·00· " p.···tI""Ill °S~11 Ir'e I h yp:er actl v 1 t Y 1 d ll.atlO. n of the

t hyearu 18 . ~~ 0 ~.,. . .11 ~""'1!.01 •. . t-

ac., '., ,'.. '. 'd" " ·t· '" b' ' .. "I, s ,~,-I rcme wi.th confusion .and di sor i.ee tal lun .. '. nl.l CI! an, ac u e ,r- a In " ~L1U ,

PUr' . ,oJ.' II . . . ~

r 1 ) Episod ic ex cesst ve .d rinking : Char ae 'bar i zed by becOOlJing intoxicated a 51 of'Len alS 11: times per year Il

( 2 ) !fab i tual ex cessi ve iCI rinking : The per son becanes in tax icated mor-e thal 12 times per year or is reeosni zabl 'i und-er the in fl Uer:IC'e 0 f

.al eoho'l morel than once peT week ~

A. Stim,ul ants ..

P - Sti'M.Jl ants can be -wi thd F awrl ab nJpt 1 'I and 'Withe! F a~ 1 usually '. . ". ". La ,'" " 'l~i tude p' :rolonf1edl s.l.eep , i ncr-ea se-d hun. ger and eatIng .anrd

re.suI t-s .i n.a 5!l. ~, ..0:> "..., 0- ,'I 11 3-1.l 0 days

. " . ': . ·"i.· .' 1 ast ina sevier al d ay:s to sever all weeks.. ~c.aSI anal Y.. "....

depressloo ,Eo -, , ' - " ,',',. 'd. eo delle-lops. WI. th

after discolltirluillg amphetaml~es ~an abstinenee ~y~rcm, ,,' .

del ir i,un ~ 51 eep l essne.ss t1 and inc reased mOlt~)r ae tl V: 1 t ij ..

c - Opiate d!ependerlcy. (opi ':m ~ heroin j methadooe ~mc~phit'lle j

., \ ~'dldl ' lthdrawal froo narcot.ic s 15 not

meper id.ine and. -cod.elne J.. ..~., en W I I ' ' ..•.. , ,,' .11 ' .... '.' .

dangelrous •

( 3 } Alcohol dependence 0 r add tc tiort: De terrrtined by -d i ret! t evidiel1ce such as withdrawal S}'!IIlptomS 0 r- by stroog pres umpti ve e .... idence such

as inat il i ty to go 1 day wi thout drinking or eon tin uedl heavy drinking in excess of thlrlee months-al

h · There .are; man Y .Pl'oblems a ssoe iateo Wi th a 1 ;::ah:J.l ism but the most ccmnon is delirium tremen.s OIT.:?) or alcohol withdrawal 5yndrcme. DTs are caused] by wi thd rawal fmlll! d!rinking after a per Iod 0 f .heavy eon tin uous

dT in king • USuall y occur s about 48 to 72 hour s after the Last, dlr inking oout .

A... Drs or' al c:oix.ll wi thdr awal. s.ynd rcme.

S O~. , ),1 M',l".l d. I in.ta,J{ ic at ion : Analgesia r. reeling of

• amld I,:. ~ , t 1

u' : , ria aoo care free reI axat ion j drowsiness, mood . C ~anges,. m:n ,a

~l=i.ng:t occasional anx i.et. 'i • freQ[JJerlt nausea f occasi.onar VaAl t wg ,

d - 1 and dec reased G .. I ~ func tion .

contracte. pcUJll.. S :p.

(2) Overdosage cause s respiratory d epressi on :up t.o arid

. .. . t' "'a and vOO1i tinD deep s.Leep t.o ccroa"

indudlins resmratory all"l"'es, nau~ 1 _I 'II, .~ ~_ , " ... , , ','

'pJinpo int, pupi Is." per'irJ!leral Ii asodi Lat.Ion , and maSIS11J€ pUilmonar'i edella ..

. .. ~ .'. . ............ an'xl"!Qtl'u wittlin ~ hour-s ,

( 3 ) Wi tlhdr .awal causes c~arlll~g ~UIU ',.., ..~" .. I . , • '

.... . 'atlTI6 1 ..... 8 hour s Flusl PIUP,ll

Y . . un ' I te· ...... l'rilct r-Ull1 u nose . anr.tJ., s·wel '.1 1 I' .~ .;111 '.: I'.'. .... '. . . ". ..'

aWing" I" .a!;L'.Ii~ ~ II ~, ...' '. .' . 'h'" .' , bones-am

d·' 1 . Ii.-.", . r 10' 'el!"""~ tl l~o,n tFBOO]r s ho,t l:Ilnd col.d fl.a sbes t, ac I ,lngl .() I '.

I a ... l011 ... pl. " • =-- ,I. l' , '.. 'r th D .. plui.S

.. usc Les 'f 'and arlorex La in 12 OOUf" S ~ _ . Increased In tens.i. ty ,.0 I u~e e ~~r.s: . and

insannia rest.Ie sseess &lid nausea, locrea~d B~ p •• t.enperat, , " • p ,., ~ I ,. ' respiratiol'1 in 18-2.1Ji hours~ Inere~ ., wtensI.ty of the.above .• (!l~US cw-led

up posi tioo f V0I'I11 ti~ t diarrhea ~ we l.ght .. ,losS .' ( .about ,5 l~S I,. a.da~si 5 sP'Jntarneous e jacul at Ion or- org-a-:-m.1 ,hremoconcen tratl-D]n tl 1 e.ulkot!:yto :t

eoslioopenia t, and tI )"pergl ycenia in /'lll- )10' hoursl Il

D"l~ r,' 'fl -e .. ·'r..o ...... ,tia 1 d ia~Jno s1 s : Mild in tax i<= a.tioJTI and

A~ Dpi~tes~ ~L~ DJ "tho t

overdb"se are' d i fficul t to dl i stinglui, sh fr-om ot.her drlug rle'ac II. ion S Wi .": u!.

track marks and! fa ir-l y r-e 1 i,able hi st.u1ry' .

P fi,.1Il ..... 1 ...... · GI·'I_'re: ~n·ta.a."O·1!II11~ S'lt ~uch as Narcan (na1o)(one) .. lI- mg. IV

i.lW erU'Ii,JI:se • ' I ,II" '. ~ ] .' .0 ., l, ~. . , "

Call be repe';'_tedl at 5- 1 () minutes in ten als. . Re suI t.s are ~ ramahc . , ., ., ., SGpporti ve eare and treat CCftJJpl ica t.iOWIS ., Close 0'0 ser~atlo n ]( 2.1.1l hour.s"",

S. ruld O. At tacl<s beg ill wi ttl an aversion to .food t aOOF"elC ia , nausea. voni. t ing aI'ld ab::laminal cr anps t <mxiet y ~ :restleSSlless. apprehen.sioo ami irr i tabil ity, d ialYtoll"esi:s, tranor.s ~ talking or m I!.I'IIbling cont.i n uously ~ Picks at .im!aginary object S in the air. 011 sel f. on. the bed. etc.

.P:r-ogresses. to halluc inations and! IlQC'twnaJ.. i llusions ~ f1 eeting :::lIt fir:st then- ~irt@ (:onst.ant. These <ill'"e pr irnar il y 'Visual and 0 £ten are :::lin imal in nature with tigers, e l eDll':1n t.s~, btJgs. rats.. and SI'lakes all being imagined_ These hiall ucinatiolls often- irrei te terror-. Pa tiel1 tis Suggestive to smool"'Y stillllUl i I especiall y to objects seen if] -dim 1 i~ht • Vest i bul ar- d ist urbanc-es are a OOImIDn compl.a int . ;He ccmpla i "I g too t the- bed i.s rOC! king t t.he roam i .5 rotat.ing I and even that the world is IiIspin..ning and he is afraid of (lying off _1. 'The patien t I'MY hall'e a gr .and mal .seizure known a s: 1~.Ri.IiJ Ei t ~ "

P. Place- patient on. bedrest in a weB-lighted space. AvoH lour:! noises and do not leallle him al OO.e! - &¥n.eone should be _present to tal k to him and reassure him at all times. Re.stra int s: are to be used only .men absolutely Ilecessary .and thell I"'errtovedi as :5000 as possible. ~lanta or J\mpfiojel may be given to settle G.l. distress_ IV therapy w1th vHanin supplement diet - Maintain. sufficient hydration to ensure an output of 25 to .ItO ee. per hotrr o.f Uf" ine ~ Kee p input and output cl1art. Medications to .sedate man .should be used with caution :since alcohol ar.I!d tranquilizers do not mix.. Sedate wi th 115 to] 2(t1 mI. paraldehyde IM~ .

.P.rop!:lylaKls; WberI a llealllY or binge drinker gets <:II severe case of the II Shakesll 2 to 3 days after he hals had a dr irIl!!: l' the following measures ma~ be used.,

a. Valit.rn for .aeute~ alcohol withdrawal 10 1Dg_ 1M' or IV initially then 5 to 10 ms + q. 3-4h. i:r necessary. Cor! tinue for 3-!1 day g as needed then give vaUUll 5-10 mg. P.O. q-i.d. as neces:sary.

b • Force fluid s <md diet DaQ..aJlCed tl.i th vi'tailin supplements ir:Jcl uding 11 cmpllex: t'

a. !SO ... m.arihl!.laf.la. alOOboI, .and barbituate intm:ioe.ation are cOlI'ered in Chapt@r l.lJ, ~BC.

4-91

!""' HII'!! PT· E"O .r:.

1__. I .I't\ .. I '.A J'

NIUTR ITIO}JA,E,. DISEASES AJI D IDEF ICIENfCl ES

GE. "-I. E· 'I HAL. -. ,,,,, rtr i t . 1 d - ~-I d f _.. 11 1 t-.-I

,..1 . .L~ ~ IJ"U.,I r 1 I, lona. : . 1 se a se!5 an-u · . e ; lC lefle ie's. are USiU3 . Y rea I r- ~

II. directl Y to ignor ance a f sound n Uitr'i tron al pr act i~:e andl tal p01Jert)~'.. Many people ex i st on a diet biased .alroost exc l us.i vell~' on one or inc: i pal starchy :staple fooo--r lee Il mille't ~ Olr corn for e)[ampie L Another' facto r i 3

parlasi tic anfd infectio~g d i.g.e'a~e3:.. These c. Qntr'iblJ.Jte' to decreased If.1testin.al absor'pticcr1, .scme.time s to i ncr'eased requirements 1" and usuall'i to .sane d;esree, of anor'ex ia ~ These c reate a v Ic Ious progressi.ve spi r all where a diet de'fic ienrc y is cctnl_poundle::l.. In m()5t cases, wner'e yotJ find ev idenee 0 f a 1l3r'ked! defle iency 0 f' one palrtic~ul air' substance' or g_rotlp 0 f sub stances t' other' cleric i,eTlc ies al.so ext st ., The~.si ng Le most important ttl ing in tine trea hroen t of J1urt,r i tional dl Lseases j, s starr'ting a: cCftllpletel y adequate diet ..

5-2 .. , :PELLAG·RIl, (:mall de la rosa , ps,i.1o,s,i s pi.gmen tosa ,. Al pine 3CI1IIlV'i, or chrichi 9ft]) II The pr incipall ~an i festatiol'!] 0 f a server:-'e defic ienc y. of n i ae in ,I ustlally crmpl icated by dE-fieielnC ie s of other B vi tan,ins, Ii r t 1.5 found worldwide and i5 usually a S50C iatedl with d iet.s h ig;h in corn and COl11ta ining little or no meat ~ milk ~ fish II or otber good sources of protein II The di.sea~ is mOIj'e' pre1J'alent ditlr inlg t3ne spring ...

s. ttl set, is gradual wit hi 105S 0 f str-e~gtt:i f lOIS,s, of -we'igtlt t1 and sere 11 red tongue II! Derm.ati ti s may' occur , Diarrhea or al terna;t ing per iorls of d iarrhe.a and oon.sti pat ion ma y occ lJr ..

0., wok for red tolngue·., galstrolin test-inal d i.st Ur'blaf:le'~es. psyebic disturblances. l' and dennati t.ts t, The to,ngue i 3 swollen ,I denuded 0 f i t.s papillae· (gla:ss,i tis}!t and orteo pamful. and extremely senst t.ive II The derma li t.Ls , cba~ ac ter i 5t ic all Y.I i g 3yntnetr Ic all y d:i sltr' ib·uted . In roctst

In;st.anll::eI5 it. is r-es.tricted to par t.s exposeu tD thel sun tJ In th.e early stages t,hel rash If'lesembles a sunburn , This may be f~)lloIWred by \l'esiculation and bull a fa,mat-ion. The ski 11 becomes t hick;ened and r'i)u~hen ed , and -a s the acute ill fl.amnaltion subsides 1" the bro~ ish pi.gnen talti.on r ema in S IJ Repeated attac ks 1 ead to mar ked .atrophy e f the' skin.. The ps,yc:hi-c dl isluarbances in the early st.ages are that of neur'astbenia. which increases in severit'j witb ;JrOgres;s;ion 0 f the d i sease ., In advanced and long-standing cases 11 true PSychoses occur.. r n the S€- C;3I.3e 5 T' spast.Ic ~ai t ,I peri ph.er'al nelJar i tis t and other ind i.cat ion S o,f organic iflilol 'iBnen t are not unconmon .

A. Pe'tl agr a (I ae k 0 f n icc t in ic ac i d and tr ,'ptophan in t he diet) t,

P.. High prote Ln , nigh -v i tamin diet .. :n l~elr1Janlidie 5DI_,500 rng II] da i 1. y or a.l air irrjec ti,Q~ ~ I- thiamine, I' r iboflav in ~ and py!f"' idOl ine d a il y .

Nlieoti.n ie ac i d or

G- i ~e trier apeut i.c dose s of

~- 3.. BE...~ IBERl ~ Caused by a de fic ienc Y' in vi tcwi;n B 1 (t.hiWline

hycroc+u arr'idle)' and other' vi taMi:15 tJ and is fOU!1dl i~1 areas loihe'r e the .j te t

COnsistsl pr imar il y 0 f pel i sl1~dl r Ice f white flour ~ and other nOTI\!i ta1l]in beIBring foods.. Increased need f·Dr v i.t.am in B 11; fe"U'er· tJ high c arrlilohydrate intake:l all"" alcohcd i sm mal'j lead to deficiency lI'

. , S.. [}jlse-t i 3, usual I y g,r'adi ual wi ttl progress.i ve weaKrl e'S5 0 f the

rst ~e.dml1sele groliJP~ .tmost CClDlOOfll.v in _ ('I t.enso r mU5Cl~s of t~ie _ t.b igh}. n rni2lrJly 1 n st.ance.s f pa t.Ient. 1 s unable tu rJ. se fr-Onll sQ[Uat t lrllf; po 31 t.i en _

'" 1 :)_ ..

5-2

(hypere.sthe:sia orl hypoe.sthe.sia) usua lly alppear at, the same time blut are usual.I y less pr"aooinent'li In severe cases man Y' mlJLScl IE! groups may be alffected and you see flaecid par.alysis:r muscular atrophY:t wi ttl or witbJlut evi(jence

olf cardf.ae ertl argemen t· tJ and t.achycardiial. '

Wi th a mallie ser Ious fonn (wet. bier iber L}, the c 1 in Ical. pi cture is pr~an inant.I y tna t, olf ~ IJ1te cOllgesti 'fie heart fa il ure wi ttl relati vel Y' Ii ttle eV1dence of nervous system involyenent. The onset is freqUEntlJ' raplid and .acute ~ and, the m~r'ked ederma ma yl mask tile presene e o.f muse l e atrnr.n.y.

Sudden col Lapse occurs fre-quentl y .

A.. Vi.tamlin 91 {thiamine)' def'Lc teli1cy < ber iber i) .. ' Di ffer-en tial

diagno.sis: Tabe'5 d~Qlr sat iS:I post, -diptlther'i tic p.ar'alysi,s j al1di acute hear-t fa il ure resUlt ting from. Qltber causes Ii

, P II Jh:iarrnine h~dlroehloridle 2O~5~)i rng II olrallyl IV or 1M i.n d i v ided

dcsea daily x 2 weeks then 10 mg Ii dadl" orally tJ A.I ternat tve: Cried yeast tablle~s C br~wer Ii s yeast) 3:0 gDllli t. i. .. d .. Wlell bal anced diet 0 f 21] 5QiO--.ij, 500 e:alor'le 5 a day when toler-a ted II

Pro8;t!10si s : Re~or\!'e:r 'i is. r ap'id and complete in in fan t.s and small

children II Recov'er y is; slow in] adlul t s· and there mayl bel pennanent

d isab i.1 i ty ~ such as muse le vealKness, air fl aceid par a1 Y5i 5 tJ due to, nerve cell degeneration. III the acute fOlrrn of' we t, ber iberOli IJ deaths ar-e frequent ..

5_q .1 SPRU(E ( ps ~1 osis.1 Ceyton. SOlr€ mouth, mal.abscrpt i'OR s:yndr(}rT1e}... Sprr'oo

s,yndirOOlel5 ar-e dl3edi-SeS 0 f dli sturbed ::IMIall inlestin.e funct ion. char acter i zed! by impaired a.bsolr_prtioTI, PaJr"ti,cu!.arly of fats. and motor abrJ01nn~litie51] It is not a.SSCtC ia tE!ti wi t h a~1 Y plClr"t.ic!ul.a:r diet or dl ietar'y delfic i.ency •

~ar ac.te~' ist.ical 1 ''1' .a ffee ts wi te uppe'r-class indli v; idlual.s 0 f long rlesi,denc:e In elndiem!le: areas, rkcur s in Far East l' Pu er WI Rico'.1 sPJr'ad icallly in U. S II , and rarely in Afr Lea.

I , S~I Ma in symptom is d!i ~rrhea, expI}'QlsiY'e and wa tery at fir st f

La ter' stool~ 51 are fewer.1 more SOlId ,. and! char ac~teristic:al1 yl pal e pi frothy 11

foul.-smelling 71 and greasy.. Patient has sore t .. ~Jingtte and mouth and flat-ul en t ~ nd~~e.s~i~n... Abdan ifl al cr al9JPS, -welSh t loss (-often m~r'ked) 11 pa]llor rl

lrrl tablll ty., ml15cle cTarnps ,I and weakness mal' occur.

Q. Paresthesia (abnormal sensaJtion frOO] nun))nes5 U) heig,hter1ed! senSJ tivity) • .asthenia {lack or loss of strlengtt:1} 1:' albdOOlin.al d i.stent.ien, and mild tenderness .ar--e' present.. At first thell'e ar'e ~all painful ul-cers on the tongue .and buccal mucosa. Later ttle tonglue beccmes actltely i nflaIled an-d -denuded.. The lJl cer s can ex tend in to the' pnar _yn1: and eso pbagtls .and malY cause dysphag ia I] 5jg:n s .and S'Jdlfp.tonJs of lOtl1 t.ipl e" V"i ta11in d efieien~ ies vi 11 be' found in sever e ca ses II

A .1 Spr IlJeI ( m.a 1 ab so r 1rI,1," tic n .s'lf1'1 d r ("1m, .pi ~ .,): II Dil" f"flO r- ar"Ii t 1- ~ 1 d l~ ..

t"" ~~I ! 1I..4::·~ilW "I • 0;;:;:1: "VII..I I, ' £;'1, ' agnosl SI :

Ana t(E]i-c abnormali tie So (fj stlll.a.s ~ 01 inti lOJ.p6.1 jej unal di"ertic~ulosi sJ or r'eg ionaJ., enteri ti S II

P L}'" "-dl lO~Q' .

.. [" " : : : :, I, I . ',' I ' " I·, , ,,' ' , • , ,"

. ,. ,0 ,Ie ac 1" ,'. rng., dla 11 y lor aLlIy or IHI for- 2-lI weeks un t.ll

r~l S510lno f s )11PtCIMI~, tJ then '5 nag... fol ic .ac~ id dlai ly t tetr acy'Cline 250 ~g.

Q:l .. d ~ )[ 10 d,ays .. , H~gl1 c.al~rie!" higtJ protein ~ low' fat diet. Mult.illle

11 1 t~ 111 s should be gIven -d,a 11 Y ..

5-'5 .. PROTEIN! A NIDI C ALOR'IE M"ALN UTft lTlON'",

a , l(wlCJshiorkor {malignant :rial nut.r ilion).. Ca used by i nadequa tel

pTOlteins wi th ~deQu~te calor,t,es.. (Jsuall Y' oc~u~ 5- i~ in fant 5 after -wean ins 'but ma~ occur In c hlldren of an rase and even in adtll t5 ~I Oc{!'ur- s wherever peolplle subsist on starch y staple foods wi trout adequa te prote in

9Ilpplements.

III

S.I lrri tabil it y" a patby l skin changes c: rash '" d1e5q~amation, dePitJnentaltion or hyJ.)erpi gmen tat ion 't uleeroltion)l", infl.:mnaltio:n of lips and mouth, conj unc ti \ti tis tJ spar se or de·pigrnen ted. ha ir , .anorelx i.a tJ VCftli It ing, and

diarrhea ·

01.. Grr'owth and matur ation are retarded" mu~eul arl wasting" edema

{usual] y start,s in the fee t and lower legs but m~ y a.ffee t an Y I)ar t a f the bodJ ineloo ing the face JI .' Liver enl argement 811 so occur s and may' olr may not. be pall,paille.. R .. B, C ~ nearly al~I:Y\s showIS- moderate' anemia.

A.. Kwashiorklor.

Pi... Relstore and ffilaintain fl ~id arld e lectTol yte barance II All burt thel :moIst sev'er'el y ill respolnd to a diet basee 0 n mlilk; d.ilute mil k feedl ing can IJJstlallly tJe introduc. ted af'ter 2.11 h , Suffi c ien t. mll1-'< should be g i'ienl to supplY" 2-5 gtIll of pro,tei n/kg ... ld:alY' • At. this stagel• mf]re cal.orie s in the fo,,,.,,, Dr sug,ar' and cereal may be addled to the diet to proY'ide 150-25C k

callkg, II/day _. Carrec t remain i.ng \\,11 tern in: and! minier al de fi.c Ienc ies.. ~a:l1 rre~uent feeding around the' c'lock .are tolerated b~'st, inl early stages of recO¥-E!ry'. Ant ib iotie 5 me y be i nd ica ted tJ but treabne1 t olr mal ar La and other' pair8si tie ill fee t.ions should be del ayed ~n. til patient i.s cl inic.all y

:improved. 'Ill 'Whol e blood is contr'aioo:icatedi unless H~ i 51 { .ijl emf!.l.

s. Constant hllng.er'; thin , emaciated boo y burt prot,uber ant

0.. HE!tarded growth = atrophy of muscle ti ssue; skin is Loose .and

wriTllkled 11 es pee iall y arOUM t.he buttocks, and when pin:ched between thumb and fo~'e,ringer- 11 shows almost a C-CJD()l ete ab:sernce of .subcurtaneoUSI fat.. MetedBla.; face is drawn and rnonkey'li.ke III Diarrhea and anemi a are irequer!l t trut not a'llL~'U1lCI! P'Ii"tJ 0: S' ant

". ' .~.Ji .... 1 - .• ,; r.=. '-~' J.

P Il Ini liCil fe-ed ing,s sho~l-d be slow and incr'ea'.sed gradually ... 1bef"e must be .adaquate- in take 0 f calor i-es .an~ prate in; sane treatm-en t .as for' Mshi 0 r Lror .. '

5:"61.. SIMPLE GOITER C:endem i.e goi ter l.. An enlargement 0 f the thyroi.d gland ~theut e1.ther hyper-- Olr- hypothyroidism due to lack of' i-odine in the di.-et,. Can be -d ue to ercess in take, of 15011 trogen ic v'eg,etables (("urtabagas ,I t.url1 ips •

eabO.asle. mill s ta rd .s eedl g)1 .. ' ,

, .' '.. 5.. In the majority 0 f c.-a~;s there are no 5)'11lptomS or s)mptoms

~w_!lang from campression a f the structures in the neck .and chest

liilee.z1ng. d YSJP1agi,a!, re.splr a tol ry' emtlarr BSSllef1 t)l •

lar'Qe'

• IC;I.I .1

5-·3

5-~4

A.. Simple goiter Il D1 ffe'rential d iagno.si s: TOl te , diffuse:fl Olrl nnOOtilar goiter ..

.? .' 100 ine the-r .apy 5 gt t. d ai 1 y S .. S .. K .. r. {sa tur aced sol utiOfl of pota ssr lin Lod ine} or 5- 109 tt" 0 f .a striDing i ad] me sol ut.ion in a glass of walter .. Contir1u~ LD1 t i.I gland returns to normal si ze , tf"JefJ] pI ace patient on m.a inta inane e (10 se 1--2 gtt II da il 'i orl use iodi zed table salt ..

'5-7' . a; TEC»1ALAICIA (r Icket.s) . Pi cal ci lITi1-pbos~ru~ d ef'i.c iency pr mar il y 0 f wcmen" particularly dor ing pregnane_)! and lactation: can be second.ar'y to

di sorder s in fa t all sorpt ion (spr'lJe, d iarrilea " p.ancreatl ti s} or d LJeI to prolonged Lise 0 f al unintm tl ydr ox ide gels" caus.i ng chronic phosphate depletion II

S.. Us=uall y m.il-d ec hing of the bones" par t ic ul.ar ly long bones anrd rilJs, muse tillar "Weakt1Jes~ 1 al1d Li st.Iessneas .

0.. Ebrty tend!erness i 51 c onmon and se~ere te tan y may' occur II E}:)nes

bee-erne sa ft aJldl flex i bIe; de formi. tie 50 ar-e more fr-equentl y Ca1J5ed by bones bending (bowing) rather than fracturles!l par t icul.ar.Ly in the legs .. tborax t and spine.

A.. Rickets.. Differential d Lagoosf.s ; Arthritis" o steoporcsf,s , a st.eogene 5i simper fee tal ..

P II Treatment C'al ontl-y p'r'otect again st, further deformities.. DIet high in cal.ca Lm and phosphorus 25-100 t.housand un i.t s 'VIi tam in D da ily · Treat con tr' i but i n8. di sease if present ..

5-8. S( UR1JY • DUE W in adeq1Jate in take -0 f vitamin C.., but m.a y .QCClJlr with.

increased m-etaboli-c needs or decreased abaorpt Lon , frequel'ltly 5e€t1J In formul a-f'ed Lnf'ant s f elderly bachelors. and food fadists ..

S.. Mi Id or -e.ar1 y mani.fest.a tiOIM s a re edema and ble-erJ i.ng of the

g LIIlS.. Seii ere 0 r la te man i felstations ar-e :swe 11 ing 0 f the joints fl marked

bl eec ii.n.g tendency 1" 1 oo.sen ing or lass of teeth.. POOIi wound heal .ing 'I Qlr in: severe cases o Ld scar ti ssue breaking down and reopen ing 01f healed ~~";)und s ,

G.. Mild Olr e.arly manifestatiolns- are JXlrosi ty. (If dentine and

h y,per kern] to t i ~ hai r folli cl.es , In sever e ·DT late cases , pat.ien t br ui ses e.a.si 1 Y I severe m~lScl e changes" and .anemJlr3.

A. Vi tamin C defieiency (scurvy).,

~I - a • A.sc-orb ic ar. id 50 mg , q. i . d II X 1 wk in in fall ti Ie scurv y then 50 rng 1 t. -. i, .. d . x 1 HID wi ttl propi1 yl ae t i.c dose s (25-3:0 mg. /day) suppl.ement.ed by orange or tomato juice. In vO'nll.ting or d i ar r+ea I lSi~e on e-hal f oral do se 1M or 111 as sod iun asco rbate .

b. FOT ~durt scurv1, 2~O mg q.i.d .. u~til as~ptomatic. wben p.aren ter-al therapy is requ ir-ed... giv.e sod i UtI alS\CO rbate at the'l s.~le dosage .. Ascorbi-c. acid 300.--;00 M.g./day P"O. in divided doses soo'uld be given for sever-al. mon th sin chron ic SCtlrv'i wi til g ing i vi tis, reo pea t-ed h.emarrh.agic

man i fe-statiQn ~ or joint symptoms.,

5-9.. V1TAM IN A DEF ICJElIey .. F·a~.sol ubl e v i tarn in necessary fOT normal

rune t ion and .str uct.ur e of all epi thel i al ce 11:s and for 5. rn.t hesi S of' visual pur pl.e in: rer.i n al. rods (n ight. vision) • Toxic i r too much is ingested

(e.g ~, se al and pol ar bear 1 i. v er ) ..

.. S" Mi 11 or earl y man i fest.a t iOIr1 s are d r vn ess 0 f skin a~d night III indness t,

III

o, Mild or ear Ly man ifest.ation of f:::.l1icul-ar- h~per~~ratosiS. ,~n so f ten l,ng. a f cor!'lea. d r yne se 0 f eon J tine t 1 va , at.r 0 J.fl 'I late or s:~'~r- e ~a ses , ~ ~

a1d ker at.in 1 za t lOTI of t.be ski[jj ..

iii V· t . 11. 'I -d ef'i Il"'Ii terse y I~SJJ~ 11 Y,· in conj un c t.icn wi th other

~ . . i t.amm n I!"" ~,I,Ij'_ VI

defic rene Ies "

P. Ol"'=OYitamin,lit, 1~-2'5 thous.artd units onCE. or twi~e a dajl ..t If absorption defect 15 present. glVe SimlE dosage H1 .. Care mlJS as min imtlTli tax i.c dose in .adJul t.s is about 75- 1 nc tbJiusan~ un.i. t.s

crall)!. be used

daily ·

S and 5 for h)'~T\I"it.amin.asis A. are ano1rexia .. ross of weight.:r dr)" and fissured skin, brittle na~lS t ooi r 10S5. g_ingivi tis j splenanegaly.

anemia I and c. N. SI. man i fest.atlon s ,

6-' . The' pedl iatr Ic pa tien t mal:; mean the neonate (: tip to ~ weleks)1 f the

II. :infant (1 montl1 to ,. year) ~ the -c:hi ld r, yearl to ~ ye·arls)1 ,lor the p-ead]olescen.t t 6 y-e ar s to 121 year's).. Thel treatmen t and d rtJgI dosage Q f a -gI-pound , in'-an t, m~ Y' tie- vast.I Y' d i. ff-er'en,t , fr'{XI3] ali'] l' -yeal~-old pread,oleS<:'l?nt .. 1be1 ,acMIleSCel1t wIll be trelat-ed ge1l€:rall,y as, an adult (ov'er 112 ye~a[f"s o Ldl ... fori p.rpll~S 01 ~ Id enti fi-cat ion , speed fy t.hel age Qlnd the a pprlJiX ima te we ig,ht o.f t'be pedilatr'lC patient.. In asse sskng t.he serl iousness or chrlondc i ty of a dt..sea:se in thel ped iatr Ic patient 11 .ste·adlil y tner-ea si.ng beofght and -we igih t i.s

..,tl the s.ign of aver yl slick pat.iec t II] A. fat chi Id wtlo r ema in s fa tis

8~erall y ~ t !ery s.ie k or alt ~-el.a st. no t, chron icall y s ick , A C'hi ldl with

. .land appetl te 1..5 r .arely very SICk: ~

a, Hi stor'y' i 51 the most i.mpolr'tarn t. singl'e factor in making a prope~ assessnent for mat] y pedta tr Lc probl.ems II It sbQluld be -obta.ined fTerm the mother or guardian... If the chi.ld is ol-d enough to t.al k, ~Otl can otltain much valualbl e in.fa:rma tioln. from him or her , Allo w the in fOlrrnant s to present the ~oblem aSI the'i .see it! the~n fi 11 in the n ecessary past and ramil yl history and perltil1'lent Lnformat.icn ,

b. Ex.cMIin.ation 0 f ped iatr Ic paltientsl, except. newbolrn and in rant tl fOllows the sanae' prccedure s a 5 the eKaTLIinatio.n 0 f adlul t pa t i.ent.s ..

( 1 }l Newborn examination ..

(a} General appearance" The p~ime concern in the first few minurtes. of life is respirati-Orr1... A cr"'ying baby has a good re.sp,iration ..

~ b) Skin eol.or , rEfinli te jatmd ice tn the' flr st 2~ hours 1 S pathologic and meMl S in fee t.Ion J erythn)bl.a stosi s {Bh rae tor) " or

p-'matulrl i t.y II

{ e) Extren i ties.. All shoulj move errat ic all yl •

(dl) .Re fl exes ~ Sucki.ng re fl-eiX: should! he presen t a t birtt\ ~

( e) D1ig i t.s , The, finger-s, .and toes may' be cyanotic ~ b lit the uook stJDuld bel _Plink.. A baby depressed from too much anesthesia at birth 11 lFematur'j tY:t' olr difficul t 1 abor wi 11 lack some 0 f the .abaLl€" ~ "Irly m il-d 1 'i painful stimulatioln (pinch)!; it malY bring the bab'j out of its depre ssdon .

" ':21) Infant eXCI1Jin.atian.1 [v'erIY child S hOI ul.d, receliv'e a canplelte

sy.ste.atic eJCaminaltia n per'iodlically.

, { al) Cl1i ld .sh~~)Ulldi be observed from the time he or she 1 S-

first brought in to the r'OCJm. and dUr'ling the entirle ex am:ina t.ion ~

a I',' ,'.' .'" (b}, A. rrie~ld:lyl manner 1" quiet. vorce , and! al slo~ and ealSjf

PPrl?acll will usuall y bel, p in t,bel @;( CI11ination, ~ i f not ,I proce-ed as gen tl y as· ~~Slblle' in an olrder 1 'i and systemat.Ic mlarllner IJ

i.nfa - . (c). Hold ing for eXaeJi~ati~. Be fore 6 m:Jt1ths ID f age an

, , , nt Wl.!l usually ttO} erate an ex ami.n atJLOfl tabl e _ FrlGmI 6 nnnths to· .3 or lI,

l:~.s_ of age IIIOst ~<R!inations can be per-formed best while the child is

. ' In the parent I'. 5 1 apl 0 r olver the shoulder.

fl l'

- ,

.

g. feed ins,.. The chi ld ml:_Lljt be fed by' frequent intake 0 f flld u[id. andt: I b'

.. A sched ".' ul,e of feedinQ.' .• is oolt necessary. A sick chi ,"1 must; 'e

eal.arl:les. ~ 0

eaco~ .ag,~ to e!at or drink "-

( 1 ) iEreast feeding I' Tht s i 31 usual I yl super ior . to hOlt tIel fe~dlililg ,"

.. Hake SIll"e the mother. ha s . 00 breast ~nfection I ,she _ has _milk ~. and t~~. lnfant call suck proper Ii" ..]he IIf.1 fan t ~~el~.'IeIS, a 11 the., 11 1 taml~S ., an.d rtutr lments

that. are r-~u ired if the IftOtlie~ a a heal thy . and 1 S _ r-~elV ~~& _ ~~ mstrlttion (It never burls to give suppl.eaental dally multlYltaml.o.s to a

breast-feed ins mclther') oa,

e2l £i:)t tle feeding 41 The in rant may bel fed by bre:ast alte'rnating ldth, oolttl e or wi t hi bottle alone 'I" If mi.l k formul.a is no t aea il a;Qle'., Of] e will have to be iml_profll ised ~

(3 ) N'lJtri tional requir-emel1ts:

(d) Parents ;should reBll'.Jlll'e tl'Jeir child- s clothing~ If' )lOu must remove the chr ld ~ s clothing J do it sradUJa:ll y 1.0 p!!"event cflli 11 illS or alarming; the! elli Id Ii

. (e) It is us.uaU Y best to begin by eX<IIIining an area

unl~,kely to be assoc iated wi tit pa in Qlr di sCaDlfort ~ Pa infulllunccmfQrtablel

areas shoulldl be exanirled last.

. . r (f~ lake.and record he'igtJt':F "We'ightl jJ Bfld he'adl circLITl'ference.

at . eac h ex: aml.ru3 t.Ioo • . These measurE!mJenta give in fonna tion regard ing

patterns 0 f gra'W'th M1al cOiIIpared wi ttl pr'evirn.tS examination] measurements.

. C II _ The., newbor~ gen.er ally -we i8h.s 1-11/2 p::tIUOO!S (3:.~, kg.,) in modern

oountnes; In d-eprned cOl.llltr-ie;s.., weight will probably be less than 1-l/2

PJ~~. _ All Y ne-Ioobor n Ie s s Ulan 5-1/2 p::Iunds { 2 :t 500 gm or .2. 5 kg.} i s ~ den~ltlon IIIpranaturel1 regardless of the length of preg)1.afJCy and will

requIre malie care tJ hafllel less c'Mnce of surviY"all" and will grow and mature' slor.er · A 1i:I000al term infant ~ 5" birth weight .s.hotlld at lealSt domle in 5

months an dl tri pIe in 12 roonth.s.,· .'

Pul1 se/min

Re.slli1" ation/minJ IB II P Ii

('Sly'stol iC)1

(a), Cal.or ies per day", Fir.st year:! 50· calories per' poood {about, T JI 000 calor tes perl day alt age on-e' year)i t'

(b)1 Fl.uid , r"o to three oooces per l]XJur:lld per day t. feedings mal,1 be given a 5, of'ten as poss,illle' to tbe sic k child if the chi ldl., will take . it. UI11ess some. medical contr a ind i.caltiOln ex i st.s., The belt:ill thy' C.hlld] m.a'i eat franl three' to eight. t.imes daily ..

(c) Caloric contee t :

140

60-&l

, II Co w mil k ~ 20 calor" ie s per ounce.

100·

]0 90
.
2,,-
28: go (5)1 fi v-e to ten ¥e,ali S

95 25, 100
9n 24 100 tablespoon .. ,

Five years

t: d )1 Milk wi 11 prov i.de enough sod it;_m ~ patassi UIIII, c a l c um " etc II to nouri,sJ\, an,;' child t.empor ar i l y , but if it is not for'tified, it must be suppl emen_ ted with i ron <mOl ... i tamin C and D. Be- Sl..il"€' the m~H:: is., . pasteuri zedl.. If ttlere is a doubt 1 bo I 1 (15 second s at a foIlIng bo 11 .i.s required}l ..

e

II

( 11 ) lib

116-20

10~11

112-13

112,,15 - 13~5

(lI,) lrnprovising a formul a , The famlula shoulrt he about ;:lIS thick Qf' -viscous as cow., s milk.. It should be reason abl Y' pallatalble~ Taste it

yaur .sell f;; i,r i t tastes bad. to you, the' cbi ld may, not lalke it.. It sooul? be C<:KIfOr tab1y ~l.arTfJJ ~ The bottle s sholuld be st€ri li zed , I f' bolt t.Le s are oot

availaIJle" spoon feed or (I ri p t he mil!/( i.n with syr i.nge 0 r . tub ing. ,A. good or'al :soluti,onl can be made using ij per c en t dex t.rose II 1 t.abl.espoon 0 f 'sligar ti Erld ll2 teaspoon of sal t J: _:r 1 iter' an-d is espee ially usef'ul i,n a deh"df"at~d .Patien.t who I s no t v(f1!Ji ting.. 1 t pro.v ides fl u.id , c.aIor Ie s " and sal. t, but 1 f it is to be used for ex te'flded per iods ,I i t must be fOlrt.i fi.ed wi th vitamin s ~

110-20, ooo

c. -,9. I 0:00' I "

J' t' ,

6-10,,000

50-60

35,.. 361 3S-!l:5i 5Q-60~

3g-~,

(4) Nelutrolph.il s

{ 5 ]1 L)ffllf:l1- s

50' £0'" I'.-U : ,,,0

.fj"'-2. T~E DFJ-I YDRA.1E [) CHlilD.. 'Newborn s and in fants can became dehydlr a ted falirly r-apidly due to illness o r lack of fluid intak'e.

f · Calc:ulating dr1ug dosages (Youn~: fJ 5 Rul e) :

ref" chi lar-en oy-er 2': Ch.il-d dose -= 3lg,e ( years) ]( adul t dn~e .age' + 12

5.. Fever; dry sk in, roUC~DUIS membr anes , a!Jld tongue'; sun ken eyebQl1s;: poor ski n ttlr-g()f, ainu depressed f.:lntanelles ..

Fa r children [JOO er 2: Chi Idl dose ::: age inl months :t adlUlI t db~

150 ~ .

QJ.. Decre',a sed OT no ur in€ 0 utput; urine dar k oln.d cor.c·em tr a ted With a hi.gh s.pecific grla\\"ity and a hi~h hematocr i t ..

..

A .. , OJ aper r.ash.. Di f:ferent.iall dJi.agli!olsis: Ottler ronns a f pr imary

irri tal'] t eont.ae t, dermati t.Ls •

P II FIi'eque'n t. -d iaper changes; II A,void rubber or pI. astic pants __

talcun lX'wjer can De used] as, all = sorbent, . Corn stareh.should ,not be used as it is .a media in i.rkJicn C. altrlcans: flo1Jr'l_3~e5 (B(I percent. of .calse~ ..

.. lasting .mre t.han 4 days are caused by C: .albl-C:afl'~} ,. Apply. Mycos~tlJl , (nystat.in Ii Myeol~) cream or Silvadl ine o~ntme:nt . WI t~eac;lld laperchange. In extrenel y in f1 MItIB tor'y d iap.er rash,:! 1'1 h~rOOOl:tl.sorl e -crean can be

all ternated wi th Mycastat.in at ever y Olther ddaper change ~

s-s. CHICKENPOX {Vt\Rl~EU~).. Pr ~ar ~ly a disease of :~ldhood.~, b~t " in large areas of the tro'p1CS 1 t 15 prlll1Clpally an ~ult dl:ease I, .Va~leell.a

and herpes roster arle calused by the scm,€" v trus ~ W1th ¥~ lc:el~.a tJei.ng, ~he, p"imlary in fection and herpes zoster be1ng a recurr~t, ~n f~ t1.on .. ,Varlcel1 a is highly contagious. (BO-90 perc:erlt of eJ[_posed 5usceptl.blle's are lJ1.fected) II]

S., Hd..story of' contact 1-0-2:0 days (.a~I-eIr.age 12- ~ 3 days) IlT ior"to on:seL UsuaU y 00 prodrcme, but. a mild f.ever with i ~Y and f"lHln)' nose. is sometimes seen 1-3 dalY'S before' r'8sh appeer s , CIl set 1 S IJJsuall~ albr'upt W1 ttl

the al Jl pear alilC-e 0 f the r:-alsh I! System Lc Syml_ptcmt5 ~ if any Ii ar-e mIld.

0-., Rash appear s in crops 11 wi th faint erythematolus mlac:ul-:,s,

rapidlYI d,evelapli.ng into papules and vestcles , The. vesiclels are thln-walled 8ld 8uperfie:iall y Located on thel .skin wi til d i.stinet alr~las; (dlewirolpi on. red] base) thalt Ir'uptur e ea s,i 1 y and ralpidll y encrust, ~ ~ccessl ve crops (u~lJ~l~ y 3) appear in the nex t 2-5 'iClays, g i 'II Ing r:i se to lesiOOS. in all, stages beIng seen at .one t:bnel.. RasJ, is hearV'iest Of] the tr unk and ll.gtlter' on tbe

extrermi ties,. If a second ary bacter i.al. in fee t.ion does nat de\l'elolpll1 tille' ~rusts fall olrf in 11-13: weeks:! leav ing; no scar s II] Var Ieel La C3.fI var'y fr-om aJ mlild dise,ase~ with fe'w vesiel es to a severe d i.se'ase vi th BIS man.y as 51 crops, a f lesions c:aver'ing mas t a f the ski.ll .. , Sy'stemlic g;mptOOl~:t wh,ic:tJ .ar'e tI~lu.al1 y mlild or absent. "" mla~ be, se-ver'e and generally par'allel the ex tent f) f SHII11_ involventer1t ~ USlJ8111y laboratory test,s are olf· little aid t. all.tt~)ugb sepsaa may be accampan i,ed byl an abrupt T Lse of' neutra(Clli,li,a in the- W II B'II C.

A" II ChicketnJ Pox , [Ii fferen t.ial d iagn()sis: Se~er·e' forms-»

t. ,OJ

Mal1lX'X 11 impetigol, muCL tiplle insect b i telSI ~ .. papllliar ur taear aa II

r iC·ke t t s i all PO)!:., al'l d derma ti tis her pe t i fOI mu SI 01,

P... Slymptoma.tic . Fluids" control o·r i tc'hing wi th an ti.hi stamines r. a.tten tion to, cle'aniiness (tlandwsni,ng, 11 battling) F arl tipyr'et,ic: 51 a SI needed. Tr'eat second allY infect.iQn.s.11

A., Deh.ydr'.ated chi.I d ..

P., Fltlid relpl..acemefl tis of pr ime imwr·tance., If the dehydrat.ion is OOlt seyere and ttJe pBltien t can take f'Iu id s bly liQr:)urth:M tt:1ell fl uid s should be fOlrced ~ If the {f,ehj(dration is sev'ere (U"" the, patient COOrJot take fl uids b,y mo,uth IJ then f1 uld s mUlS,t, be re'pI aced IV·. Do not tr"l to repl ace all the fluid delfi ci t. ina stlort per ioo as i t may tttrOlw 1. he c hil d in.to· shoek '" Estimate the fl uidl de fici t II Figure the' da il y Ir'eq]uirement, 4,

Ma in ten.ooce f1 uid reQU!i,rem~nt.:

o - 10 kg ..

100 C'C .. lk&, ..

100 CC: II I kg: • .. 50 cc .. /kS .. 10 .

211 kgl • .300 over 100 -CC II/kg.. + 5{Jl cc .1.kg. + 25 ce, ~I

Then. giv'e the daily r'eq~i.rement p]u.s 112 of the -defi.ci t-over the first, 2~ hour-s., r A good replaeem;ent fluid is l/4 .streng,th normall sal ine in sen D5W" ~)

Patient shaul-d be c~atheter izedl and ur ine Otlt,purt moni.tored] closely.. ¥o,u ar e looking fa~f"' a return to, good skin turgor' 'I m<)i.st mucous memDrane's and tongee , and I ig:hten.inlg of' the ur ine., l.o'"Wering 01(' ur Ine specifi e gr a¥i t y is, your most imp-Jr"tant siglTI.. Treat the cause , e • .@; -.' , fever 'I throat inlfectiol1 ~ etc.

6- 3 .. , FEVER OF' UNIET[RM INt: D ORIGIN (FLO).

a .. Fever is generla! l,y a si.gn 0 f in fee t.ion l' but in rants can spike fever f~')r a.lmos t. an Y' reaso-n (:e.g., f curt t ing teeth tJ [!onsti. pat ion, reac lion to dlie-t ~ all Ier-g,y :I -d ia per r ash , etc.,). Fey·er.s due to tit] feetion~: alre usually low-gr·adle in aj uil t.s but rna yl be mu(!h, hig;her in inf·ants and )'Otlllg ch i Idr-en , Chil dren often conv ul.se wi lih temper"attlr"es over 1 ~Q F • (-occasionally at IOiwer t~peratures) ""

b. ~eatrn;ent.. In j,tiall Y' IJ lo~r ing the- termperlatu~'e (i -r i t is. lO~o f II or above) is 0 f pr imar y llnlXlrltance. Gi ve Tyl enol1 (T.eEpra, acetaEioophen)1

1 0, m'IO /I-'!')!I" ql Il'lh 1" ~ ,1:-..1 .. i ldl 1" I!i::' loll!'!ii.,l1::"~ t· I)...an 1 ~.a'~ o·l-dl ~ D; l:l! el ~s~;r· 1'0; n ~&r; .mg'.' I/yr"·

.,' I!;I~ II.' KO II . I II ""'Ii. to . .r ,1:.1 .. , ., o.l ~~~I:J 'II-li I- ...... I '", , ~......... CI! . :ptL . UI.J.. ,.' .

of age q t'6hol' .first if ~nil-d is 1 year' or older ~ Then givel a ,sJDnge batl1 orl al-C!ol101 Ibattl to cool the bodly.... The patient must. be monitored close]y' .and baths 1'"@peetedi as needed to k:eep the temperature dQ~. If ooexpl.ail1ed f'ever halS been prelsent ~]lJer' 21~ hOlJr·s" .a wi te c. ount and d i fferen tial should ble done to Id~ally 11 the pa tient sOOuld be trea ted. for' tlt:te speciFic- di.se~.se; hcrweflJeli, if a d iag.nDlsi s' can I! t. b'e made·, bnJJad spectrl.lTl: antibiotics will often cure· t,me' in feetion. Tetr acycl ille' sncHJlldi not Ille used in the premature

!:InA .nan sta'n tee·tt... 1" ·h·l-l ..... r·Q,Yl Ololi'oli'Il 1." r· us.cdl for -~o·r·t 'l"\.Ar'l~''''''...IIS ~dld1' .. ~o· n'la"

[;IJ.~ 1i... •. IL " ..... 1 • ,.. Ill... ,n c,. I ,~, ..... ii!1 ~;Y,~L:~ '. I· .i;;;;. • •. ' ItwJ: " " y"-:' IIJUi :. n....~ '. j' '.l.L

tr'ea,bn.en t con sists Oli' n:ur sing care and malifltain ing fllJlid and calor ic intake.

6-6,.. SCARLE~ FEVER. A formerly canmon a ilment that i. s, r arel~' see~ today I fJliQbably because' antiblio-tic tl1erapy prevent,s the olpportU'li,ty fori t~e Btreptocoe:culS to progress. in individual patierJts or to ere'ate maSSJ.v~ ~ epi-dlem i-es . &ar'le!t fever is associated wi ttl -Gro~p A streplt-ococcal straIns

that prodUCE!' an erythrosenic tox 11'1 J lead ing to a diffuse- pi1.nk-red cUJtan.eous blush tha t bllanehe's on pressure. The, rash II an additional fe'atur e of .an illnel5S that, olti1erwi.5e" r'@sembles streptoc<>ecal pbar'yngit.is.1 is best se.en on t.Jte, abdomen .1 (lIn the la teral chest I and in tile cutaneous fo-Ids.

5..1 and 01.. Along, wi th t,he c harac ter-l.stic manifestations of t.he rash are c:i rcunoral pallor' sur'ro~nded by a n usbed face.1 al 111 strawboerl"" Y tongue~ (in flcrnedJ beef·y r-E!dl papill ae protruding through a -..hi te coating) ~ am Pastia II s; I ines (dark: red I ires in the creases 0 f skin folds). The Ujaper lafEr of the' P!'"e'II iously r'@dldlenE!€1 :skin often desquamates after tbe

&-q II DIA PER RASJ"L, A" form of' prim)8ry i r'ri tall t. (:cn lac t, dermati ti s, due to

prolonged contact olf t,he sk:inl to a (:anblnation olr uri.t1le and feces.

s. and Oil frythema; thickening 00 the skin in the per in etB I area i beefy red II sharpl y marginated lea ions with satell i tes; .a 001 .a hi.liter f of' skin contact wi tbl urine and f-eces .. ,

6-5

6-·6

PI' Ct.>ol mi,st t,herapy.. (If V8p:J·rlzer is, not afyalilable 11 im~oV'ise

. I' using steam in .an enclosed! roctBJ.. Dol not, let steam go d tree U., on =tient as it m~y cause burns_) _ r-bni tor urine spec if'Lc gl"~vi ty t~ inSW""e .adeQUalte hydl~.a tlon : fb5er~'e ~at1en t . c 1'0 sel, 'i fori S.lg~ S of lr1Creaslflg .' b~Mia and lJllpe.nd lng, r'aspi ratory f'a 11 ur'~ .. I- . ~eell . ~atlen~ c:~lrm.an(iat bed re,st'li Do not, use sedat Ion IJJnJ.e5s an artl fI-C! l.a:~ a It;'wa Y IS in ~.ace.. Th.e

L most effec ti ve method of keeping: a c hlild calm 15 ha ... ing the mo~r. or some other :rani! iar per son presen t II About 251-3011 olxygen carl be Bdmllnl stered to

.reliew'€'1 bYPOIX ia .. Pat.i.en t.s starting 02 ther'apy' a ftefl tlav'-e a mar'~ed decrease in respir'a tor y effor t and. 5r.~:HJlld tie moni tared closel y fOlr the fIT st fewl minute's Olr ox ygen oom,in,istratian ..

fft'Qllehial dl i1 atars (such as BrOl.r1cha idJ or Pr imaltene Mi,gt) olften provide !emp:Jrary reli~f. of respiratory distress. If ~ercial... . ~e_paraltlon5 ar1e not avallable~ you can ~alke' a preparation of 0.51 cell of eplinephrine to- 3 .. 5 ce , of ster 11 e water J.n a spra Y' bat tIe ...

If r'espir-aror'y di.stress con,tinues and there- is progresai yely . incre.a si.ng e ya no si 5 and decreasing ai r ell try' tl an. arti fie ial a irwa 'i nu.Jst be provided. Gener .all y j endotr acbeal intlJ.lb1at.iolTI wi ttl a smal! endotracheal tmme is used to r'ed uce trauma to tile gloltti.s and, subgloEt ic area ~ (A. particularly tratlm3ltic tracheal intubation can eonrvert a reversib!e, . .sub,gllot tic narr~ing in to, a fix ed oonr'eV'Jer'si.ble- subglottic narrowl.ng.,}l The 'best, enrlotracbe'al tube care is mand at.Qlr'y' and coosi st.s 0 f' e aref'ul tube stabili zat ton 8111d suet.Ion ing 'I po st.ur al drain.agle .1 chest pereussfon and

h~id ification 0 f inspired air. If all el se fa il s ~ a tr-acheolst.-omy is necelsSBTlj ...

f"ever subsides~.

P.. The' cour-se and fJOJanag.-emen t o f sc arlet fever a~'e essentially

the same as for' ot.her C 1 in leall 'i ev ident Group Ji, infections ...

6-7 I' MrnlPS (' PAROTIT IS) 11 A corrroo n ch il dhood disease th81 t i. s asyrnptOOlatic

in 30-.!.J 0 percent 0 f c ases _ ftl.st t:!"hildlren are in fee te<:I and de'llelop 1 i f-etiJIh'~ immunit,y but a few r-emain susoept ible throughout adlole.scence and adult life.

S ... and 01.. History of contact 11~-21 dla:ts prior I' Bilateral or uni,~ateial painfUlI swelling of the parotid g Land is: usual.Iy the only

man. 1 festation .. Systemic S_Jmlptomls malj! const st 0 f h l.gt! fev'er and hea::1 acbe olr' mi Id r-espirator:; s:ymptoms Of' occas:ionally C .. :N .. S .. symlltams that a'ppea~ pr'iolr to or in the ablsence D f palrotid g l and in vel, vement., . or' symlptoms may be a~13en.t. ., (MLlnp.s v.i.r us is t.he rna s t ccmnon cause -€] f men ingi ti.s in chi Idhood .. ,} MIld to. rmodler'ate abdc:minal padn may be presen t .'

The g-oo ad s rna y he invol v'ed (orchi ti s or' oopbor i ti.s} in p.Qstpubertal Lnd i 11 id ual.s wi th sudd~n onset -0 f fever , chi 11 s t1 s ys.telIlic SjDlptcms ,I and 1 owe r' abd 001 in all pal in in female s or ex,tr'eme testicular pain and test Icul ar- swe II ittg in m.i31 es . {o'fl trar 'J to c lOO'II1Ion bel Ief ~ !IIl.IlIp5, olret"Ji tis, and! oopoor-'i ti s d.GI no,t resut t in .st-er i.l i ty' ... S·ympt.Ol1.s substde in 3:-111.1 d,ays.... f'lJmps usua lly last -3 pprox imatel y l week ..

A.. MLJrtps.. Di. ff'eren t i a 1 dl i agoolsis: : Cerv'ieal I ymphadeni.ti s of' ph,ar ynx, tonsi lIar OT skin infection J ot.her parot.i.des ~ ac ute I ym_phom.a ~ or 1. ympha sa r~ {Jl'I a ..

6-9. EPIGLOTr lTISI {BAC1ERIAL C HOOP JI .. The' most ser ious form of croup syndrcme.. It gener .all y aff-eet.s elli ldr'en 3-7 years old l' with no par'ti.ctll ar sea:sonal di stribution " TIle most connon pathog,en is Hernophi.l us in n.uen zae type B,. but beta-hemal yt ic streptocooc i and J)1eunooocc i hav'e been,

impl ieated in r .ar'e case s ..

P, SI~pt,Gr!iJaJt ic • Control f ev-elj' I] pall n 't and d i 5ccmfOlrt ., 1r·e.at

o roc hi ti oS 0 r 00 phair i ti 31 con.servati vel 'i with rest t, te sticul ar SUPIXlf"'t ~ and an algesiC's" u)r"ti costero ids P1J]ay r esur t in ;nor-e' r apid subs.i dence i,)Jf testi-cull.ar 5w~11 ing, .,

S, Abrupt onset oyer a per-iodi Qlf only a few tJauli's... Young ehj.ldren often presen t wi t hi higlt1 f~'I"er .a.oo, res. piratolF Y old i, stress.. Oo..delrl chi ldr.-en rna)' :3 ppe'arl tax ic and conpl.ain olr d ifficul ty i r1 sW81110wing and severe sore t,hroot ~ Ch,ild may tJav€" a muffled voic~e lOut USlUilil 'j' i tis not hcIar 5e' ..

6-a ~ VIRAL C RQUiP. Most c OOII!'Iooly <II ffects chi ldrefl betwem 3 months and 3 ye ar 5 0 f age., Charr .aeter'i sticalll!l oee Ur"'5 dur i:ng late fall or ear 1 Y Wlrll Iter and is usuelly caused by the per-ainfluenza virus. It can al.so be caused oj' respiratof" Y .s :;nc:yt.ia 1 11 ir us ~ infl tiel z.a 11 iru~ t, r ubeol;:ll 1.J irus.1 Qlr

adenov iruses. The! mlajor' caUlSe 0 f .s ~ptorns i 5; iril n arunat.i.Oln. and edema in the subglottic al""e1c.l] tllat can cause s,ignific..ant narrowing of the .airway' at th,e level of the r: rico id car ti I age ..

0.. Pooll ing of set! f''etion.5 in the poster iQlr' phar'yrlx and drool ing ar'e signs eaUised bLj' e,xtra:ne dysphagial (inability or dJiffi-c:ullty in SNall·owing)" The -c hil-d -r wi thj n a few tJaur"':S 1" rea:." be in mar ked r·e.spir atory distre·.ss wi th severe inspiratory .strid:olr (harsh t higb-pj tched sound! -during inspiration)1 and retractions.. Thel phairynlx is likely to ble' in.flalledl .. Diagno,si oS i -s mad e bly mar ked 1 Y' enlarged t: fr'iabl e (ea.sil y cr ac;':ed clr broken) ~ IIcherr y-red.'1 epigl-otti s; ~ Dir'ec: t v i sua 1 i.-za·tion using .a to,ngue' blade· or laryngoscope is extreme'}}, dange'rous.1 a.s stim\llation of the epigloltt.i.s l1asl

prod~ed lar :.rng,e.al obstroc t.iolrt: and dlealtll Il .No throat clJI tures; sholulld be

obitalined un til epigl~)tti ti SI hLa 5 been r ul.ed. out or· an alr,ti fie.-i.all a.ir'WQIY is in place as thi s mla~y al5() cause l8r:yngospa5nl ttlat c aU5e':5 1 aryng;eatl cj)'.structi011 1

s. Grooual onset:l with hist-ory' olr several .days up'pe'r relspirator'j tr.act in.fection pr ior to t h.e onse't of bark ing co ugh and har sh ~ high-'pi tched. so~d dIE ing, inspiration (in 5pli r au)rj" str" i-dor) .. ' If the lowelr respli r awry trac tis Sign i fiean tl y i nvol ve-d.1 tber'€ may be wheezing.. The, chil d. ma y: bec.cme anx iOtls and restless as hypoxemia .and hype-rc.a~ ia dieY"elap II

(I., Mi ld temperat ur'€ . Passinl e dJecreas~d br'e.a lh. sound 3. an

auscUilation ~ Cyanosi s i:s OJ 1 ate 5igJ1 and! ma~ f'le("'ald canPI} ele airway

oostr [Jet ion · W .. B .. C.. Sf? IdDrEI i ncr'ea ses to more t.han. 1 5.1000 wi ttl 00 signi fi -c. ant I e'ftward sl:li ft ..

L3b find ing So: ~ • B .. C... 0 f mr()re ttJan 1-5:1 000 anrd a 1 eftward slli ft IS;

ltSuallly pre sent ..

All] Vi r a1 Croup.. DiffererJlti al d ialgno.si S:- Sacter ial croup (elpiglotti ti s} ~

P.. £hoC€- the diag!1osis is m.ade t ail .artificial airwe_y sooulldl be introo,uced . IBeca,use of tbe marked! swell ins; and fr i ab il i t~ 0 f the tissue,

b-t'

i)-8

_ + _ I •. ce or sev er it Y of c~pl icatiorli + n:e ~ _ include _ myoc aN i tis. to~ ic

IJlcideti. _ t' and bro .r'IlJl"IIl~ FV'l.o. I. "W'fLII""'I:n ia • Sens1L t i Yl t Y to hor.se ser-um should

-n 1 1 ·eurl I 1 S [II'U' I . IIIIi.rL-'".) to" ,~ !,AlP-!!' .' r , f I ~ t· . '

~~ .. tie 'skin tested for before administering the amt~ ~~~n .. I I. ~51 .. rve

al·r->d· bther 1- a 1- s se'rue' ·re.· . give 50 m.gl.. BerI adryl IH in I tlall~ t, star t al

- a the I l'p .' , . 11 ,. .' .' -

~of Ringer I s lactate Of" .Dc.w to De used _ for tr-eatme:n t _~f _ aq a~ VI ~~lC

.., _ k if eecessary , then .af]cfonly then start an IV -'t? adm:uUS r - ._ _ _ f

:shOC. " . .. . _........ an' t'l.- ~ -,,, Ii n The pa .... tipnt m USlt be c 1 oseI y mon 1 tored fo r slgns 0

requlr~ " 1 ~.& ... _ •. ' .. ~

.-eaction to the antI to'x l!l -t

Mii ld pharyngeal .(j i phtber La D~ 'When the l'IIern~rane is small or

. . r" 1 ,d to the anter ior nare s or ton :'5-11 s • 40.000 un 1 ts - Moder ate

~ l.ne r ,I . -.,' ,". :Se:' plharyngeal or laryngeal

.......~ryng,e,al d Iphthe'r la ~ 80 tl 000 Urll t.s IJ .' .. ve~ e 1 .' e , .' . . f' ': d r 200 mI •

.... ~-. .h.+.... - a 11 20" .0, 001 1l11l!"'11~ t. s r e<'ardles5 -0 f ctu Id s we l.ght 111 use 10

dlpUl.r.lJer 11 :I ~I, : ,I J " UJlI.. 0 _. . . _ .'

or i50tooic sa 1 me over a 3D-.lTllrlute per 100 -

Pen . -11in: Vis the drug of cooice to elimin.ate tht_:' organism: ar.'d _ pr~~tion 250 mg. q _1 A. x 10 day: or600.000.~J.ts _o~ procaIne G 1 M b. i .d. x 10 da 'f5 ~ AI t€nnate is er-ylhr"OOlYC:l.n 2S 5

in .It dli Vl ided doses ol"Jirally x 10 days ~

stoPI tolin penicillin ~",/kg./d.

~

intub.ation is extremely d ifficul t. A .small er than LJ.5t1a} endotractteal tuhe

shouldl be used and a tracheo.stony set sootJld be ava ilable... An IV sOOluld be In i ti.a ted pri.or to the in tubatiort and arttib iot.ic tber-a,P¥ can be stalrted b:," tha t route II- Ampic i.1} in 300 mg .. 1 kg ... /rJay in 6 di 11 ide<! dbse s or anpic i 11 in and chlaranji1enicol ar'e the drugs 0 f' cho tee,

The endotracheal ttlbe should rema in in pI ace unti 1 the pa tien t is able to br-eath aroLndi the tvbe easi1 y and when there is a mar-ked decrease inl too elpiglot tic swell1ngs. usual.I y after 2.Q-72 hour 5 .. ltJrtal it y rate may be as high as 90 wi thout ill tubation and an ti,bioti.c ther apy ...

6-10'.. .MEN INGITIS.. See Chapter 2 t1 Section 11][. Bacter Lal ,

6- T 1 • ~JlSLES AND GEHJtA.N M£A,SLt!S.. See Ch.apter 2 ~ Sec tion IV, Vir.al 01

6-12. DIPHTl:IERIA. An acute infection of the upper respliratory tract or' skin caused bly Corynebacter itm di phther Lae , A. tox irt-proo uc iI1g J

gram-posi ti~ e1 rod wi th i,rregull..ar swell ing s a t on @ end giving i t al ciub-' shaped ap~aranrceol Irregtllarlly distributed within tbe rods are granules tha It stain; <J a~k gi ~ ing them a beaded: apJ.1e.arlance.. The inc uba tion per iod is

1-6 days II

N;asJll di pbther ia : CCc ur s in 2 percen t 0 f cases. SerosanguinoouLS (con tain iflg serl1DJ and 1)1000) nasal di scharge and excoriation a f the upper lip 8lre ch~racte'ristic .and may be the only symptootS ..

Bed r-e-s.t for lO-l!1l days is usually requir~" Stri~t iso~atio~ _' until a1t~biotic therap~ has made re-~Pirata~Y. :C~;1~~e~~~:ec=5 s~~t also reQIIJlred {us~al~)'1-:-7days). IV Ule-rap)" .• ~ _ -_.5 ate _' • ./kg.!d.

vater gargles or lrngatlofl are- he~pful aIld _ oode1ne pbo ph 3 mg

ir.I 6 di v Ided doses ma Y at so be lJ> WI th ttle di scCDIfort ·

Freven tion : Routine DPT ( di phtheria, per_--tlJSsi S I and tetarl us ) ilmluniz.ation sOOU!ld he given to all tnfWlt5 aa1d clnldren +

All children exposed to d. irtIther ta .shoul.d be el.aliil1ed and treated if any signs of early dipl1thoeria sbJrw.

All 3S)'II1ptOO1atic ind ~ vid 001 5 ~ eveni f prey io~lY,:'TIITU1 i zed 2 ./d.

.. '1d . .' . - . d' p'hrther ta toxo ldi al1d e 1 ther. er y,thranyc in 201. 30 ~g ./kg

DU I r-ec-elve . 1. . , ',' .."..,.. I '0 U /IUaJ . f b :nzathlne

tn lJ divided doses orally x '0 dalY'S or 25.001 U.' rt..b .. 0 . e '

pen ici 11 i.n G ..

S,. a~d 011 Elilarlyngeal diphtheria: Mild SOI~1 throat. mCK'lerate

{'ever t and malaise .followed fairly rapidly by severe prostration ailld

eire u-l a,oory col.I apse , Pulse. is more rapid thafJ\ tem_per-ature· w()tJld seem to justi fy ~ A ten ac tous anti gralY membrane, surrounded by a narrov lOll e 0 f

er ythemal and a broader zone of edem\a forms in the throat arld mla_y spread into the nasopnar ynx or trachea tl produe ing respfra tory obstr'oc t ion ., Hign fever tJ prost.r ation pl diffic ul t y in swallowing:l .and noisy brea\thing -develops even vi toout 1 aryngeal obs.truction. Cerv ie-all } yrnph node s becmt€ swollen tJ and swell iog is assoe ialted 'Wi th brawny e'oena 0 f the n-eck ("!lulln-eck,IIj); palata 1 par al ys.L s ma Y' occur , 81 eedi ng from the nose .and mourt h are cannon and petechiae may alppea.r on the skin and mOCOU5 membranes ..

tar yngeal d iptheria : (}ccurs in 25 percent 0 f cases l' aiJld occasion alily may be the onl y man i festa t:ion... Stridor (har sh fl high-pi tc-hed .sound our ing r-espiration) is alppaFen t ~ The progressi vel 1 ar yngeal

obstruc tion c an lead to cyaoosi s arnd suffccation.

Other forms: Cutaneous, Yag,inal 't or lIOt..I1d tI iphtner ia comfUlses less t,hart 2 percent of all cases i!lll1d are c.haracter-ized bj" ulcerative les,ions wi ttl membrane formation ~ They may b'e y er y hard to ideM. ti. fy in burn S olr ~tlnds.

Lab find in.gs:- ;r "B. C - is usuall} Y' normal or sl ightl y elevated" Ur in al ysi oS may 500 w prete in ur ia 0 f a tr ansien t nature.

A. Diphther-ia .. Di fferential d iagnosi s: Acute streptococcal ph.aryngi tis l mononucleosis. '- oC{!a s ion.all y ot.her viral pharJlng i tis.. 'puf"ulent Sinusitis, .e'piglottitis't, and viral croup"

P ., As the tox in cause s the ms in damage, anti tox, in goo~ld be admlifl i stered ASAP or [ell ay beyond 48 hours mtlst be avoided because an ti lox in .admitlister'oo be yo 00 that point m~y have. li ttl-e' -effect in altering the

1-1 "I G,~I~olog 'i enCtmpasse s t-ho 3e1 di Lse ases too t. ar e pecu 1 jar' to women. Kister Y and ph ys ieal, €':.: aninatj,cn na-u"€- certa in fe'.atures th~ t. .s€ par-a te theml f'rcm gener.al ones,

8.. History.

{ 1 ) A.g-e l' grav id i t_y (fit6ber 0 f times pregnan t) II par i ty ~ n u.nber -of' live deliver'ies).. M'edic-all r'ecord s list. these r for e::(ample, as G3P'2Abl (ttree preg:nane ies; twol dlel i ver- .ie s ; ane .abortion j e i tber spon taln eous or iOO uc-eti) .,

~,3,')' p

~ : 'r"eosent i 11 nessl ..

details Ii

(It) fast mredl ic allsur'g;ic til htstory in e:hrol101 og ic:al order fr-om clli ldhooo t.r~lro~ hi t.he present 1- wi th title c:crmpll ication.s and tr e a, t..merlt s fa r eac;tJ ~ All oper alt ion sand if1ljtlf res wi ttl -dates ann autcCITIles.,

(I) ~ ())stetr icall hi s;wry . NUnber 0 f' pIr'egJJJanc ies ~ dura ti·on of' Ir'egna.n£ Ies and l~or deta i is 11 ·ue ight and sex of' inf'ants fi still bir tf:ls and .abe:r t i 00.5. •

(: 6)1 Fam.il yl hi stOIi'''¥.. ~e and heal th 0 f parents. and siID1 Ings ...

Pani 1-,1 hi..star" y: a f any' tuberctllosts;, dl i.abete-.s,. hrpertel1 ston tl bleed ins dioolrder.s IJ bear t disease:! eanrC'er" ..

{ l' )1 pA~1r i ta 1 amdl/or eohab.i tatian hi.stcry., Dur ation and!

COIlpatilJ il it 'I 0 f past and pr-'e1SEt1J t r el a.ti,OIl slli ps , ages and cause 5 0 f deaths., if any 11 - and! ages and heal th, o,r eni ldren" if an 'f .,

(8) Soci al, hisu):FY., Oceupat.Ion 11 hazards 11 al,cohQl and toeaeeo OOn5l1Qlptian hab i t.s , d rug usage , sleep and ex E!f"ci se hab it.s , and gener al acti ¥'i ties.

(9) Re-v iewl of s,ysterns II SaI!le as: t:il gener al -hi,.stor'y 11 except rOlf"'

geni tourinar-y . Mena~he (ag:e a l: onset o f 1IefJ str uation)1 11 Last; met1strulCIl

per iod, reglLtiari t.:Y'1 dur at.i.onl Pi a.mount aM character 0 f' flow ,I spott ing ,

di scnarges ~ and pal in -al

( , ) lBr~asts.. Si ze , shape equality of both sides, ~ I!JIasses II tenderness ,I sc ar S tJ or .n iPlllle discharge t' Breast e':( ~ination is per-fanned b1y Ketlltle p.al pation if] a c i,rc ul.ar fashion from the n i ppl-e to the Qutside II al so COw'er'ing thel nodes ooder' the! arms r Attenpt to- express a di.scnarge .fram the breast ni ppll e as well.. Per form thi s Maneuver vi t.. h the pa tien t 11 S arms dOJ\.ifl1 at the, .sides and oyer heir- head, in the supine ;posli t:..ioln ..

1~2

wi tin her legs n exed and .spread open. Have a femal e asst stant at your sid e or a t the pa tien t'.s side for 5UplXlrt.. Cbta in a gc-od d irec t 1 ight source p a -water-ba"5e, 1 ubr Ican t such as KY' jellY:t .and surg.Ic ally cl ean g Ioves "

(b) Geni tal ia " Look for in ficmed II hypertrophied. 3ltrophied,. u lcer-ated j 0.... an y olt.her abnormal areas ; vaginal discharge;

.cl i ~ral ab.n~Tmali ties; .ski n c t\ang.e s olver tile per ine'Lm l' thi,gb.s. j pubis:I or

per lain al reg ion. Oieck the urethral meattJ3 for red ness. ex ud.ates frOOOJ the

1 ab ial gl and duct.s , etc.

4. WIth tJle irLde'x finger of the internal haoo still i.n the vag tna , gentl y insert the middl e finger in to t.he rectum ~ er y slowl y but finnl1y. Pal pate- as you dI id for' th.e vag inal ex am" Thi 5 e:€ ~ will a id in diagnoS.i S 01 f a IJ ag in a 1 atrict.ure , i:5 used in y i rg.ins , for teoo-er masse s and to e)C pl. 0 re the back -0 f the uter us and rectal. st.r engt.h,

(3 } Labor'a tor y stud Ies ..

( c) If patholog Ical study assi stance j, s ava i.labl e , otJ.talin vaginal muc us rrom the po:sterio r 0 f the vagina for c e 11 stud ies ..

{a) Callec tio,ns 0 f Bartha 1 in • .s 11 Skene' 5, d i scharges , I,J as mal, walls:l poster iu r vaginal forn Ix , 0 r rear pouch ~ or cerv Leal open ing 1" olr 015:1 are taken wi til a clean cotton appli-cawr and treated as for a simple (raJ] stain unless ",OU feel a need for ctll t ur ing and these fac'il i tie s ar e

avail abl ell

(d l Inser t a cootfolrtabl f warn spec ullura into the vag ina ..

Ask the patient to reI all and b.e.ar do~ II Carefully spread tile labia wi th a gloved hand, in ser-t the specul LID blad-es slowl f dm.lllNard and inward l'

w telling the in ser t cto sely .. As the cerv ix i s approached II slowl ~I open the

bl ades aifld allow the b lad es to straddle the- cerv ix between them.. Lock the screw' lock.

{ b) \let pr'ep.s II The-se are for vagJnal d Lscharge.s , rb 1. sten a slide wi tn a d ro _p 0 f sterile sa.l ine . Tr ans fer a -d ro p 0 f J i sebarge on a woodell appl ic.atcr to the drop of sa 1 ine on the .31 ide -to Read under a mlicrolscope i.£rIned iately ..

.. 1 cervicar

cervical

vagina. open ing ,

(e) Inspect the c-ervix.. (l)tainl eervical mucus fr-om the elJtr'ance arld fr'cw an y irregular l-elsian.s or sd tE.s .. Insure the s.ize is not excessf vel y 1 arge or sm~ll in pro~rtion to the The cer1l ix soould be snooth with no 1 arge laceration:s., 00, wide of a plink color ~ and wi thout bl DOd or' d i scbarge,

1.. Iricoomonals 'J~ginalis.. Look for- the typical t.richamnajs wit-n_ a wbiplping tail... See the laboratory plates for an example ..

2... Hemo~ i 1 us '" ag inal Ls _, Vaginal cell s malY be' dust.ed Nith .small dark particles. These are called "c l ue cells .. II See the laboratory pI ates ,

( f) Unloc k blade s anc slew'} y wi thdra w them.. w.a teh for pink folds of the ... aginal walls wi thout blood OF discharge or Lesfons , leaving the tllades at tile introit.us ~ or vaginal open irig , ask the patient to again bear dosei , A dlIOOp'itJ~ of the -o-erv'ix ind icates deeen sus 11 or 10s8, 0 f

-Stlpport ~ 0 f the ut er LIS i t.sel f ... Droopi ng 0 r the vas inal roof m.a y i.ndicate

c ys.tocele; protrusion of the 11 a.g Ina'l floor upwar'-d m.ay ind ic.ate rectc<:e1 e. The se will be expra ined . Take.sme ar.s 0 f an y questionable e·xldate.s.

(g) Birrta1 ual pall pation 1m

( c) KOH pr'ep.s.. Add a (j ro.p or t-w'o of 1 ~ po tass i Y1il

hy.<3rox ide to a :51 ide-. Tr ans fer a dro p of d Lac harge with a. woodlen

appl.icato r . The .wlurtjon will dissolve R ... B. C .. • s , infli:lmlatory, and epitBellial cells. Candida, alb.icans myt!elia will di spl.ay as hypil~ and spores , Any 1rlhi ti sh III aques in ttte vagina .are to be scraped for tili:5 test ..

llJ Pl ace one pel 1m down on tile abdrmen as you stand bet-we'en the pa,tiernt·ls Iegs; Slightly flex tbe fingers. Press down firmly.

lrJave th.e patient take shallow ,I rapid bre.aths to aid in r'elaxaticln II

{d } Pap- 3DearS"I The se snear s of cerv leal r.!"eil S are

inv'al uabl e as a cancer' screen ~en p.=JJtholog_y faeil i ties are avai 1 abl e .. With tile vagi.nal speculum in pl.ace without lubricant -otn.e'r- th;an sterile saline. transfer a spec irnel1 sc raped froo the cen ter- 0 r the open ir1Jg 0 f the

eery ix, to a .sl ide.. ~ealr the dro ps 1 ig,htl 'i across the sl ide'... Bepeat the-

,roeedur'e -wd.. th a drop of fluid [.ram the back of the vagina" F"ix. both slides mediatel y with 9rr~ ethanol pl Aquai-Ne t hal Ir spray' II or Prc-Ffxx eJl:olog 1. fil.ati ve by spr aying 1 ightl y ae ross the s1 Ides , Be sure to hay. e the patien t ' s nane 011 each 51 ide. Fa p ~'ar read ings ar e ver Y' d i fficul t

.rI ... • bl

~'F 111& Be t~ v-e :. eed-l-

~ 'I Wi,t.h the ot.her hand , gloved and coated with a small aJlOlun t of 1 ubricating jell y'. slowl y par t the, I all ia wi ttl the index and

m iddlel finger s.. Hug the floor of the y ag ina wi th the fi f1~ers and touch the

c~rvix with the finger ti p.s • ItTrap'U' tl1e uter UlS between the hatrlds and "

W1 thout let~ing i l loose:t r un t~ o1Jtside han..d fi.ngerti ps over the en. tire r.~n t and 51,de .surfaces 0 f thel utertls.. It soould be in. the midline:l be' finn and smoolth just above the pub is.. and be some-wh~t moy abl e wi th

relati vel y 1 i ttlel pa il1 .. Feel behind tbe cerv i:x: for an Y' ma.s.se·g, f'ullness tl or tenderfiessli

(4)1 Proc-edur es 1M Di 1 atalti,o~ and cure It tage (Me)., Th.i s pracedur'e inrvolve:5- o'pen ing 0 f tne cerv ix and sera ping awa y a f the end-cmetr i l.I11 or inner 1 in ing of the, tlterus. This procedure requires super-v i sed pr'ac tic€" prio~' to at tempting the proced ure your sel f . rfey. er for-ceftlll1. per fa rrn till s .Pr<>cedure'. uter ine per foratioJ1 {: an easi 1 y r e3tll t. [)5:C is in-d icated for abnonnal or po:strnefl.arc. hal questi..an al bleed ins; .and for s (::On tanec us (iooanplete) abortion. Contrainrdic.ations i n.clud.,e normal intraluil:.-er ine ~f!!gnaIillCY 2' acute cervic:i tis:I endanetri t.is ,I Qlr pel vic in fl arIIlla tor 'i di sease .. 1he procedt.re m~ be- perfo1med under general ana,e.s.thesia, spinal (leyel olf l3~LII- spine III inject 10.,15 cc,,- of 0,,251 Marcaine- carefully) 11 parac-ervic.al blOCk (0 1M 25$ Marc31ine injected j Ll5t inside th.e vagJnal mucOrSa nex t to the eerY ix an each side. -;i ec .. ,) , or 50-75 DIg, II Denerol IV' 510w ..tli 1 e moni toring car-erull y ..

.' . 3,,- Wi th. the utE!r-u\S st ill tr'apped betWJ!lI!n the bal1ds f

sweep tl'le outslde hand ov'er -to the .side of the uterus to meet the

fi ng-erti p.s of the v 03.R.mal hand. uTr apl11 the fallopian tube and ovar y . You sOOUIld not be .able to feel the tube. The ovary i.s an almond-size .. slightly. tel'ldl~r organ att~C'hed to the :side 0 f the uteru~.. Fe-el For si ze II

cons]. stenc~:r p:J S 1 tionl, and COil tour (firm. just la ter-al to the uterus 11

smooth) I, lA':}-c umen t all masses note(! "-

1-1:.-

(a) Expl a in the proced ure to the pa tieT1 t ..

single breast d isomer eecoua ter ed ..

S, Pa irtful IDa sses in brea.st j per haps dl d i, scharge ..

(b) Palpate the uterine size arid poai tion. Attempt now and y,en IlsoU11di,n~ul the uterus to rule 01Jt .any lesions or grolwtns that ma~ bleed ..

o. rtlll ti pl.e tend er mal5ses ; napa tien t that i s 0 ften JOI-5·n y-e'ar s

iii old., often L£lr"'se d UW' ing men stt'""ual per i005 II Si ze 5, rna Y' go up o r dOWfL.. :No skin r-etr action sho ul d be pre-sen t ..

(c) Insert and lock <I-c~ a specul.ua. Glo","e and wipe ill a eire ul ar f~sh.ion outward thel en tire c erv ic a1 st tmp wi til anti selptic sponges on tr'aJ'] sf'er forceps three times. Di se ard tile swabs and forceps.. Bend the titer i.ne .5.Ournd to the es,tim8 ted ang l.e of the uter ine posi t ion ., Gras. p th,€ cerv i:( wi th a tenacul Lm forcep a t the si:( 01 clock po1si ti.on and g,e.Il tl y insert the SOIJ(f1d unt i 1 resi stance i ~ met... Here y10u wi 11 aga in tr y to note .any Lesfons or gro'Wth:s a 3 you in ser t the souad , Read the deptt'! 0 f t he

uter ine cavi t y bly eot.mg the 1 evel, 0 f the' mucous 0 r blood on t ne sound as yOUi would the cd l 1 e:vel OMI a .rj i pstick ., Make a mental note Q f the depth 0 f the uter in e cay it y .. Starting wi til the' ~allest 1iegar d fl.ator , mser t the

d i l.ator in to the c erv i:( to the d i 1 ator 1 i p. Proceed to the n ex t 1 arger stze IJfltil the cerv Ix is .at least as open as. the loop of the largest curette" pr~)babl y a 18 Heg.ar -I- Start wi th a small ahar Pi curette by' sc r api[1]g in and out the en tire diameter- of the cerv i-cal canal. Fix the, tissue obtained in 1M fonlQalin~, :Repeat the four-Q.:uadrant scraping of the tlterus by go Ing to tile' dept h o f the uterus and sera ping outward all along the

uter ine wall s , in (j-eep even get'l tIe .strokes to 01) tain long str ips of enrlcroe'tri tm. CUf"~,t te t he to p of the uterus in an ulp.-antd-down fashion~, F'ix these spec imen s as before in formal in ... If quest ion abl e spec imens are ottai.ned:l fix and identify them separately. Insert a dry' sterile sponge on a uter in e forcep- and s-wap the CaY i ty w1 th a twisting motiOir] as yOlu

vi t hdraiW • Re insert uter tne pol yp fa rceps and gras p fo r- masses.. Wi thdraltil the forceps. and observe for bl eed ing .. RepI ace the uterus ~y removing the t.enaeul LDTI aUld specul urn and pushifJR the i.lter us ~en tl y but f'i nnl y upward

blirMrI u~11 Y II Pl ace pat.tent on bed rest fOIr"' tP1r e'€" day'S and 1 im i t ac ti vi t 'i

far at 1 ea st, 3. e'U' en days _ fxce sst IJ. e bleed ing, mi3 y requi re packing the uterine cavity vi th Long cont.iruznrs sterile roller gauze and shock care unti lout 0 f d anger and h-em:lstasi sis achieved ..

A. Di fferen tia 1 d iag nosi.s inc.l we SI brea s t care i noma and adenofibroma 1 whi e h r-equi reb iQpsy to d iagno.5e" ..

P. Biopsy is ne-eded if at all po s.ai bl e , If SymPltcmS and history are classical for this d i scrder j i.nfil trate the.p,breast locally wi th lidocaiJ1e 11 or prcca ine 11 .. insert a 20-g,age needle into the c.yst .and withdraw t.he watery fluid tl1alt should b€ str-au-col.crec to b l ack , fte'ex am ine every 2-~ weeks, for 3 montns , then every 6- 12 months , If no nui -d is obtained or a per st stent 11.JTL_P i 5. no ted 1" a b Iops Y is indl ic ated ·

1-3.. VULlJ1TIS.. The vutva is 5U!Jject to' the SiRe diseases as the s~in elsewher'e on the body.,., Vag in i.t.Ls (c.oyered later) is. secondar i 1 y induced-

a. Eczem.a is a coomOIl prur-i tic moist dennaltiti.s often frem contact wi. th an iTT i, tant in soap, bath: 0 il S:I deodcr an ts ~ cl oti1i~g. dyes. e te ~,

S.. Pr'LEi tu.s l' occasfonal.I y a d1 scharge 11 and t he le 5101'\ are

pre,SeIl ted •

0.. An excor i.ated {tJle:erated) crusted lesion is no Led ..

A.. Di f fer en ti al d iag,no 51 s : Incf udes seOOrr hea , ~T Iasi.s t and inter lrigo ..

P. E1 1m inate .any i rr i tan t.. FtJrow' 5 sol ut ion IJ. i .~... for thr ee days, • Local appl i cat ion 0 f a :steroid cream (hydn:cor ti .5()t1le:! Val i sane" etc ,,} b .. i .. d , Uri til the lesion r -eso] lJe.s . I\rl ti hi stan ines [0 r i tehi ne as needed {Ben adr'y 1 2"5 -50 mg. h ~:5. to q .. i .. d .. }l ..

7'-2 " M BREAST" A mad i fied s-weat .gl and of due t ti ssue .sec.-ret i.rJi~

!1utr i t i ve n uid dur: i ng t he first s.ev'er 311 wee ks a f'ter del i ver y (p::"Jst part um} .

b .' Psor Ia s.i sis. 0 f unknowt11 etiol-ogy ..

a . FbstparttpIJ mast i ti s (pyogen ic c'ell ul i ti s} gener .all 1)' occur-s after se'ver al wee k 5 a r n ur si ng .. 'The in feetion occur s through the rri p_p1 e anrd in t._") t.he ducts - About 75 ~er(!ent 0 fall p8ltien ts havel un il ater al inlvol vement ..

S.. Pr'Ulr i t.us and a le.s iOll are presen ted .. Hi .star' ~ m.a y be Iong

term ..

s. Chi lIs I fever" !mal ai se I' reg ioo al pa in =' teoo-er'rle 55:1 .and induration (hardening) ..

0.. F:r ythernato~, slightly e 1 ev.atedl Ii flattened 1 esiofls wi toout the t l"P,ic al sillier y aJppe.ar'anc€, o'f sc ali n~ .seen -e-l :sewer e" on the body.

0.. G~ ~ st~ in a f an y d i sc:harge usua lly shows st.a phylococcus aureus ~ A OOJtabl e fl uctuan t mass can be p.al p.a ted in the la ter stages.

Ax ill ar y 1 ~P1adeIJopm::l t~y m.ay be noted. Ani ab sc'eS5 maly form in most c ase':s ..

A. Di ffere"- tial d iagJlo51 s: Incl udles seborrh,ea.1 ec zema, and intertrigo ..

P. Imlproved hrg5ene i, s imlJ:x)rtan til Appl)' h ydlrocorti sone cream 11 $

b ... i .d .. 1 f no imlprovEf.l'iJenl t occur s t' tr y Val i sane in the same dk)sage ..

A.. Di agf'!..Qsi s i:s. gen er all y unmi -~ta k.ab le ..

(: • SeboT'r"heal is II a.sed on a genetic preli S-JDsi tiorJ invo11l ing ho:rrno!1es,

n,urtr ilion 't' in feet ion 1 and emo1tionlal stress.

P., Pre\," et'11 t b Y' _~·ood h :tgienel • SllDlpr'es;s 1 cae t~tion (mil k

produc t i.;,)~} by ~ar ing a tight binder' for 72 F«Jtlrs ~ i3lppl Y ice packs one hour 0 n arnd one hour fJ ff . Gi ve an.al.g-esi e s ~.5 need ed .. 8r-oad-spec:tr ILH antib,iotics- such as Ke-fle)[ ~ 2'50 mg.. P .. O. q. i . .:1. )( la-l~ d... Incise .and dr a in .abscess€: s m-:ln~ pack wi th. -j odo (a rm _ga u Z~ •

s.

Prur i ttJS- may' present" a 1 OIlE, wi til a 1 esion that m a},' be

i.nfected .

0., A -dry ,I seal iog lesion with underlying, erythemal will presentlm

b.. Mam.ar y dyspla,sia {cystic breast diseas.e') is the ~st COffmOnl

1- "

.

Ii ..

7-6

Rule a:ut ftKIgal invol LJ-emen t wi th a KGB prep.

Inc-ludes ~:l~a." psor Last.s , ar!d intertrigo ..

MOlLUSCUM C~AGIOSU~", A virus that in~ubates in 1~~ weeks~

Oi ffereJ.1 tial

S... As :ili!1;ptama tic smal I sk in t lmo.r .s wi 11 present ..

diagnosis:

. p ~ ~ greasy 0 in tmen ts ., flrJ.t8lssi LI1i1 permlangan ate dressings t) ~ i .. d1 ~,

(S).8 k dressing. in 100 nag .. of permanganate in 1 1 iter of wa ter) _ .t1lOOn iated

merctlr yo-in tmen t after soaks ~ 5%1 ~~ i a te-d mere ur Y t 3-~ 1 i.ou id petrolatum and pe troiat um q .. 5,.. ad 1001.

o P··k t· d

. '" i In,·. 0 g r a ~ II .. i.sc rete tl Li.mbi 1 i c ated epi tile 1 1a1 s.ki rt t imor s

III generalll y le s s th.an 1 em.. i r1I d iame tel" on pr imar i 1 y the vulva in torn i tus ..

A.. DiagnoSis is generally unrni st.akab) e ..

d ~ .Intertrigo is caused by the macer at.i ng effect of heat t f!]oistuare 13 and fr'i~tion.. It is 'WOrse i~ hot rnmid climates and in obese patients.

P. Hiopsy is indicated if the diagnos.is is in que st. ion . Lightly

curette awa'i the l-esio ns • _A.ppl y: NeOSpJr in -G crean to the curette si tes and

dreSs. ·

Sol rrr ttat.ton ..

Itching, stinging, burning sensat ion in .a noticeable

1-1 IN HERPES GElrJ IT'AL1S., A, he'r pes typE I I 11 Ir al. in fee tic n ~.

0.. Po,s.sib 1 e fi ssur ~-5 ,I erythei-]8:1 denuded appear anc e '" Ur inal y.sis rna y show an ind ir:a ti-Dln c f d iabetes ~ KO}t pre'p may show c and ida, dl ir ect, smear ~ay eVeJ1 show man y coec i I-

51.. Painful c Ie ar 1 i tt 1 e oml bLlnp,st~ on the 1 ab.t a and in tT'Oli tus, perhalps with tender ltkrtotsUl in the groir. ..

.A.. Di fferen ti aid fag nost s : In-c 1 udes, ec zemal t PISO r Last.s r and

seborrhea -.11 ic h me y pre.cl tide in ter tr igo it seI f .,

0... tXcas ional inguinal l:ympl1ade·oopathy. and -a group -0 f ve s.ic Les wi. til surroood ing er yt hem a- all1d ed ema .. Ofterl a hi story of 1 esd.ons cClfjing and going -to

P .. rust well wi th t~ 1 c b .. i -0 d .. Pota ssi LIn pe!"·man~.3f! a toe d_re5-Si.t'~gs pre~ed as abo'i eo or Dool.ebo ro dire 55 ing s. in i3 ,: 2D ro i xeo rat io ,

All Herpes zoster is similar, but, generally' ecesn ~ t re·cur ..

Ii' y,thema mul ti fa me i sal arger ve s.i e Le 0 fte1J1 fa und on pian taT surfaces t.hat .sometimes looks 1 i ke til'lY IU'targetsrJj of eoncen tr Ic eire Les and becomes purplish as the Iesfons enlarge: fever is, -cancLn"'rent.

S_., Per iod i~ pa i.n ful S.l~'P i ling on either' s i de 0 f t he in tra i tu.s ( vag in al. open illg )i and 1y5 pare un i a -( pa in ful Irrt.ercour se), ..

p ., ( , ) Rule' out, concur rent gonorrhea and 5)~phi 1 i.s ...

(2) V'ir:u 5 c ul ture fOT herpe 5. species ..

. :J I- Swell i!lB at mid to lO1We"r third of 1 ab i.a t U5L1311 Y , -.11; em '" in

Sl ee I and t.ender and fl uctuan t (wrwe 1 ike sen sa to io n Crt pal pat ion iOO ieat i r!f.;1 a nLri1-filled sae l , Rule' out gooorr~eall invol'i'ement. by d i rect, smear of exwate ..

(~ ) Pa p .smea r (herpe s ha s been 1 inke(l with cerv ic al

earcinana} .

A.. Di f'fer-ent.i aId iag_nosi s : In-c 1 udes, inc Lusdon c ys t.s , sebaceous.

c y'sts ~ and congen i tal abnorma 1 i It. ies (the'se ar-e not USLJa 11 y tender') ..

(5} It 2' 1 idocaine 0 in tmell t for pa 111 q .. i .. d to fOT less tharn 2

we.eks.

_ P.. local he at to the 1 e.sion _ kmpic ill in 0 r er ythrromy'c in 25D-500

mg ". , q .. 1 ... d. for 10J days. St,fter the in reet ion sull s ides 't open the Lesfon and ~clse OT exte-rioFiZ€.. If.an abscess devel.ops , incise and drain .. pack wi th 1000 form galuze ..

(6} :No eccL ust lie dresaings or mledl i.e ations except. 1 Idoca ine

7--8. VAGINITIS. An inflanmatiol'l and/or infection of the, vaginal.

1-5 .. COHDnJ)MA A.Ctt1INlATA", A v iral in fee t.ion that. does no t a ffee t .a _f-etut: ..

a.. Atrophic vaginitis ..

S. SnaIl rna sse s on the vljl va , vaginal! or per ifJet!1l vill present wi t.1l itching ..

SI. Tender Ii i~hing vag,ina generally In an o'lder , posterenopeusal or even a eastra ted pat tent.

Q., Pin k c 1 u5ter.s a f so ft n ar ro-e-based Les i ens the t are po in ted and elonga ted II wi t h or wi t.bou t a profuse irr i t~ tinLg, di scharge ..

01( Cc.-casiorlall y .a clear vag in a1 d Lscharge wi th all atrophied, er Jt·hema taus -, scmetime 5 dryer appear-ance' to the vagina ..

flu ~ e out c OfJ~ y 1 ona 1 a t. L.m C t he pr i1fl a r y 1 es i on. o f 5, ~ph il is-} ..

P .. Culture afl 'f discharge fo r gooorrhe'8 IN P-er for~ a dar kfi e ld

ex ~ to rule out spi roc he tes • Treat an Y secondar y ill fec-tior1l tha t mlalt' eXIst.. A 2511 podolP1~llin_ in benzolin ti.nc:ture! ~ay: ~-)ie applied to tile lesions on 1 y and is to be wa:she-d a ff in? nO:UF s, _ [b not toucII t. he ~o rmal t~i ssue w~th the podo'phyllin. Isolate the lesions by SU:f'ioun:1ing the lesions wi th mJ]_ner al oil ..

.. n. ..

A.. Rule out other felms Q f 'J ag ill i ti s wi ttl sal ine .and KOB preps ot di.scharg,e ...

P.. iippl yl Pr-em.arin <: r'elam F 2-~ tJD P' ~ LJ II q +.d ~ uSe th.i s. medication

=tiouSl yWi th full knowl edge a f side effects. -oontr a iOO icatioos, etc-.

. .. the srmall-e'st amoun t. f.I-ecessar y: to c'ontrol the s_ymptoms.

7-7

b ..

1-8

Jr ichomunal ilaginitis. GaJULSe<I by trkhamcnas VagiIlaJ. is.

. .. 0: _ Peteen! al sJX)tt i~g wi th erythema -0 f the 11 ag ill a1 wall (wi til a

s~r:H ... berT)'lH:e .appeara~e}. usU'all_v with a thicker yellow t.o green frothy a 1 scha ree · A at.at.. Sil ~ 1 ne prep- read i!1tEl SbrQiW.s t r ie:t:l.:tmonad s .,

A IC I~t: pre p rule s out otf1e~r Dr~ an i S1lS ..

P R l

•• · U I e out :)t.her- ~rgan i ~s inc 1 ud inJ! gonorrbea. n agyl 250 mg.

t .. i .d . fOlr 7 _, 1 0 days. Trea t the- p.a t,letl t. F S sex partn er at t.he s<we ti~ ..

e , Cand! ic a.I v ag;in i ti s ..

M:lnil 'ia ,

A. IlUl eo out other o~.an i SI11s i !'tc 1 lid ins: ganococc i ,

d - 1 P. Nystatin lI~inal suppost tor Ies 100.;)00 ooit. II supp p , v.

a 1. ., Y :€ 1ll dajs.

d.

..on spec Hie '.; ag in i t.i s - -::-.e!'!~. all y c aused by .He:nophil us 11 aginali:5 . 5.. iagirlaJl SlyrtPt~s as above ..

_ .. , ... . 0.. .lLcr ~d, v ~ SCOLiS I OF" thin wa 'tPry TIl i1 ky d i seharge . -N'e t prepsWI 1: ::;.~w S-CIIIile ~rl the 11.1311 c ell oS coo ted -wi tn bac ter i a , giving a d List y appe2"rooce .,

II. • .1411 e out other- ulI"gan i :S:1: S. i ~C' 1l.id i rig gonacocc i .

.

EJ Sul M'

..I! "" .. 'u~ tri n i.... ream 111 11 appl i c a tor-full ~. .. v ~ b 1· d for 6 ..... '.... til,." 01;

~,t"' ~ ~ I ".. ' .,: I .. "" 1 ;, u.c:. 1S , !lIen II

q .d , h. s , fOl"l .s days ...

7-9-

•

[yJS·_"~E. Ir"

. . " L :,,__~ ·Le_

A_ herniatiol1 of the posterior bladder wall in.to the

vaglna ..

S ..

ulloo·· •.. sene iss III

. ii3 .~I . -. 11

Sen satiOIil C f r-e-tail'lJed ur ine after ur inating and of 'II a~ in <1-1

D. Presents as a reducible nontender mass that is soft and

1 ac-a ted in t f'>.(' em ter 10 r II ag inal wall_ As the pa tient stra inls. the til add er can .sag do~rward ..

reducing use of al

p • . This d isoniler 1'F.I1~ll ~ a]] -ev ia ted b)' the pa t.ie:'"lt man ue 11 y

the til add er by preSSHll'l. 1 t up .... ar-d £ran the v.as: ina . :In. te~i tterJt Menge pesS<J!'"Y' placed jU6t in..sidle the introit~s may help. Surgery,

an .an teri~r vag ir:ual col ~rrha]lhy" i 5 .. of'cen the onl 'i ~ ear - pe rm an en t.. curle .. ,

..

o. f, finger can be i~.ser ted rectal 1 yl anc cause poster'io r

pou~hJi.~g; :J f t~e rect ml.. Stral in jlTIg d~wn, wor sen s t,~~ .]Xl Llching;... Ii, soft

poster ior I,J ag In al full ness .' re·feeat.l0In may' ~Ie pel ~[j] ful ..

A or, Vi rfer'et] tial d i agflalsi.s : Incl. tide s en teroce~l e (al s imil ar dirorder occur r Ing fur ther bac k in the v ag i~La from in test inal her n La tion) 11 prol.apsed cerv i x {seen on specul um-a:S3i .ste~ IJ agi~.al ex.anina t.iDriJ) ~ and rar-el y: a tumor j \ilhi c h ~ILJldl he firmer and more easi 1. y dell in elated ..

p ~ Stool SO ftenler S 0 r Lara live s (on1 y for short per ieds) . lv-oid

s,U .a in irlg 1 coughi ng l' Glr 1. i ft lng, I- Ge t g.-ood exerc Lse and bowel nab i t.s , as

veIl a 5 goad: die tar yl hab i.ts to f'ae il i t.at.e el imination . Sutrger y

(col peper i.neorr-haptl 'i)1 is, gefjlerally c:ur-alti vel.

1- 11 • GEB:UIC ITIS... An in.n amna ti.onl in fection 0 f the cerv ix -al Thi sis t,he

mst· ecmmon gynecological diiS(}rder generally enc-ountered.

i' r f"l

S.. Di soharge t 10 w bac k pa irt , d yspaaretl1 ia ~ dysmenorrhea ". pa In .... lI

menstr'uation).1 UF i!1Jar y f'requene y and urgenclY'1 andlor" -d ysur' i a •

D., Thin:t mucus.l i ke Leukcr'r hea {elli se:h(llrge}l; an er-yt tl eme to UG l' pe1te-chial {:erv ix and posterIor fa rn rx (hack pt)och 0 f vag ina) wi ttl a

discharge from the cerv ie al os (apenifl~). Sne~ar-5 show W'","BJ~ C .. TS,," CeJ"Yical

ercsron and eversion may be noticeable IJ

snea:r.s ..

P.. Pap smear fi F st .. If no organ isms presen t! give AVe c:re:OOI F

11-,21 appl ieato!""'sful p , v.. h. 5,.. or Ib .. i .. d "" for 28 dlalYs f throLJgh the en tiFe menstr'ual cy'Cl e .. Tre-at spec:ii. fic or"lgan i sm.s iil5 in the forms 001 f v agin i tis .1 <:ryo~urg,ery { wit h a C02 wan,d) IDa y be n ecessae y i,n intr CtCltable C9IseS •

1-,112 t' CE~;VICAl POl. YPS.. Sna1.l ped-icle-d glr()-wths on the e erv i.x •

s. ID-i.sc'harge t1 abl"H.)rmlaJ 1 vag in at bleedl in~ ...

o IJ F"lesll- to r"edl-cololred .rounded OF fl CIllE-shaped tissue on. a pe.dicl e Or" str and 0 r t.t.ssue Gin title cer:-v ix o~r j i r redder" caming frCGI the er:1~QC;er"Ul ix ..

A.. Di fferenti al d i agnosd.s (blClsedJ 0f1 pa toollogic studl ies) :

1l11relude: s endcmetr ial neopl t]1Sf]] 0 r g r-owth:t ~all S·UltnJ~OUS myonal I! end amel tr i.al, pcll yPl'1 anndi produc ts 0 f ~onC'elption from a~ tflcCDplete slPOrrt..ane:)us .aborlti.-Q1n ..

P I' lfil.r k up and trea t an y assoc iated eerv iei tis .. , Renov'el at thel balse~ olf the lesion., Celrvl ic 311 {j i lata tion may be nece'.s.sary .for _pol yps looalted high up in It.h.e endocervix _ Send lesion tOI lab for pathologic st.udlie S 11 r u '.1 r..-c if' o,tner -pol yp-s are sLisipected. W'arm vinegar- dO\JC:he ql ... d.l for 3_11 days to r"ed uce in rl ~ tion .

S.. Fever , pa in in the lOk@r abdcmen in the c en ter 1 in e , .and l.a1w

.-ecent, irregular menses) .'

p • Culture d i.schar',R.f! (, rule out tubJercUilosis and ~ gonorrheal).. ,

I at organiSlls appro~iat-ely (aDl?ic ill in • sao mg. P.O.C;.1 ~d. r~r 7~ 10 . l:s, . Control pa in Wi tnanalgeslc5 ~nd supcress menstr~ t.ion WI til Enay 1<3

.. 10-15 mg~ P. Q~ .q-d. for 28 days~. P'"eat f~er .and m~lalse .. ... ..

!. ptauaticall Y ~ (bserve:r . a s ttn s d 190rder i.s pot.e.nt~all y ~ er 'i dClrl&er~U5. H~ OLJr MASSES~ Since t~ s can be an eme~en<::y, .ru~ Ing ,out masses hel ps to reduc:e the c. hal nc e that 1 t becomes a 5t1r-glcal eIft!frsency.

1 .. 16 .~ TlJ8O.:OVAR lAN ABSCESS. A fonned abscess of the tubes that rna y spread!

to the ovar res ..

S.. Spi kes 0 f fever l' mala i.se , b ilatet""al lmer quadra1 t pa i,n. vi th 8f) acute onset r sudden and prooollTlced. Metrarr h .agia and hypermenorrhea

(later sec tion) ..

o. Pal.pab Ie mass , tender... Possible history of disappea~'ing mass

Nith .9Oftel1 ing a f tile abd onen , suggesting rupture 0 f ~he -ab~ess, '"'I .

Ioore8se (II 'IIi'. B. C. COUl'l t and sed. r ate ( er yt nroc )'te sed l.IIIefl ta bon r .a te) •

Biooept,-G negat i"'le ·

A. The Biocept-G ru'l es out pregnancy and thus ec topic " prl~.nanc V Il It pain is unilateral ~ rule out append ic i tis ~Y bi5to~y and, l~wer W.EI.C. cant aIld sed! II r ate II End\cmet.r iosi s (et1damJeltrl lin grOWing, outsld: the .' .' uterine cavit)l in its normal ~si tion) is :rtlled OLlt by the c)'"el1c nature of

the pain 4-

].-10,

1-13.. ENlXJHlETR IT IS... An inflam.t.ation/infecti·on of the uterine lining, gel'lerall y postp'arttm 'I pJst-D&C. or post in.cCflJplete aeor t ion oi

back pain ,

o. CCcBlsi-f)l1:al1 y a d i5Char~e fran the cerv ical 05;1 t.J i story of

recent delivery, aooJrtion t' or D&C. W' ... B .. C'I count may be miildly el.evat.ed ..

A.. JWlel out masses b:i pall patio·fI; rule o\Jt care inomla by D'&C .and

study' of sa1Jple.s obtained t ot*" by a simple'" endcmetrial biopsy done in like falstJiotl .

P .. , Endcnetrial biopsy .and smear as inldic-atM'I Specific

.an tib iotic:s fo r organi 511151 (Vib1r anyc in 2001 mg.. for 1 daY"t then 100 mg.. q .. d. fo r 9 (jays is u.s-efutl).. D!:C if abortion has been suspected, Thli 5. mlust be done in a less v igorous fashion than normally. If mOOer a tel y sever el sy.stem ic .symptoms are pre-sen t , con sdder a sl i.ght de lay r using anti b ioties first,.. MLmi tor f·or any systemic in.fee:tion tIltil .after- all symptcms subside Il

7-111.. lJI'ERINE MYOilA. (fib1roid}. The most c-c.mrnon gyn~ological neoplasm ..

It is a round , fi nn_ J benign uter ine ttmJr composed of snooth musc.l e aod dense connee ti ve ti ssue ..

S.. lower 3:dbaninal pa m , bl e-ed Lng , c ysmena rrbea , dI Lscharge fl d1y.spareuni,a. tlr'inar~ frequency • sensat ton of pressure!! and constipation ..

o. Pal pabl e erllargE1J]en t 0 f' the uteru.s, feeling fim and rOLl1ded II

p ~ Vi 'Dr amyc in 2(]O mg - P. O. b. i.n - for 1 0 day~ ~ ~nst~ t" er IS Ls

moni tor in&. for abdlaainal soften i ng"l- Loc al hea t _ and .all a~eslc5.. . :urr Co i

indicated i,f rupture is !9uspected" If access Vl.a the c:tll-de-:-sa~ .IS , .' ,'. p:>ssible. aspir"ation of" abscess COi'ltents for temp:.l-:r.ary allevIatwn of the

BlaSS- b·y 1 arge-bcre need Ie ma!f be of v: al, ue ..

1'- 17 ., {l)PHVR IT IS... An In fection 0 f the all arl ies , gen er all y _ sec~ndar y. . t.:: a1.cther infect.ion but clinically si.g,nific.ant from, a potential l~fert.~llt~ .standp:l in.t f since he al iog o f 0'IiaJ'" ian ti ss ue i So not io."e 11 aeconpl i. shed •

S P - f' d menst" rE I~l ab nonnal i tie's .. Ev id ence 0 r 0 ther

.1. ::a In. tJ . eiler. an ~;I • . ~

infection as the compla ints are noted ..

0.. wllar.rgement 0 f thel ov ar y 3Lt1d ex: r:es:s.i ve tender ness .t~ . I

1 t.. Ar emJ " 1·' a' a· ..... ~ 1.. ncr ea sed w: III B .. C.. eo un t .a~rd sed r.a te are noted ~

pa pal'lO!'l III r-.11 [N

A,.. D&C ma y tiel P con fi rm , .a S 00 abnorma I spec irtgren s may be found ..

Di f'feren t i all 1 iag nest S : Inc l udes o the.r neopl asms .and ben i.gn hypert.ro~ y; sarcona and adheren t .adnex a " Surg ieal .sec tion 5 are t~le pr inci pa 1

-d iagno st.ic tool.

P.. JDe fer stir gery un til post palrtllT1" if pa ti en tis pr egtllar"Jlt Jl

unless the ut.er us feel s to be over two mnths 1 arger than: the EDe

{€-st imated daltel of con finenent) conoute s, to.. }.Ia tch fori s ign 3 0 f -d i stress .. A tor s.ioned pedicle of a :nY(IliJa orl intestinal. ccstruet.Icn rJ.I~y necessitate

emergency stlrgery anrd blood transfusion.. Excision with perh~p5 hysterectany (uterus remorrlr311j is indicat.ed if the diS()rd€~ is extensiYe ..

S.. Sever eo,. nOrJlr ad i.a t i ng C'r-anping lo-wer- abdom.in al pe in. chi 11s t fever- tl abno mal. me.t1 sels, leuKorrhea, dys p.ar-eun i.al J and d.'i5meoo rlihe.a ..

A.. Ctther adnex al in fee tions n'1_al)" coer i st..

P . Analgesics sue h as cooe in e sul fate 3(1-6:} :mg. ell ery 1;-6 hour s ~ (hserve, for systEmi-c .signs. Vibr.:my·cin 2001 mg. stat., t~r;10a .. mg_~ q . .o II tor 13 days ~ Lo::: al heat:. t re st. n uid:s.. n- OJ in .ab-scesses ( 1 f ~lt!l~l.ng do'loll

to the cul-de-sac" 1:1 y 1 arge~ bore need.l-e aspi r-ati~fI) -I If. -c bron Ie in nature" and if the patient is older. rOlilo'lal of th.e Q112rIeS and tubes

< sal pingo-():}pho rec tOM,...) bil.ater all y may be need ed ..

1- ~ 8. OVA.R IAN CYSllS AND TUMORSI... Ma~ Y v ar ie ties of cysts anrd tunor s ~ay be'

IlDted on pel vic €"xaninaltion .and pal pat ion of the cv ar ies I R\J 1 e out the . I

krnwn di :5CIrd er 5 in th.i s chapter fl wai t one full mel5.tr ual cycle' tJ and ~echec k the- size and ~ of CCltJr:.se 1.' then ature .oj r pall pabl e adne:(.al _ masses ~ o,~ta in special i s,t assi stancel if t he' mass hal S no t regre5.s~d dlurlng the tr 1 al

7 -,15. SALplI NCIT IS {pel v.ic ir11 fl ammat.ory -d i se ase ) ~ An in fee tion 0 f thel fallopian tubesl'l :usually bilaterally ~ vith a rapid .spread to the rest of the pel vis ..

:J~ Th ie-kenl ing of the adne:(.al strlJC tures .a nd lOa 1 pation 0 r the

t ube.s. {, not oonn.a 11 Y f.k:I pl able} on pel v ic ex an. Adyn amlc i1 eus (stJ)ppag,e of fe-c al p.a 5sag_e) malY p1re.sen t . Hi stor'y 0 f !l ausea and palin since 1 ast per 100 • Di scilarge . Stable herma to(: r i t. and W .. H. C. COU1 t to 115" 000-201 000... The

er y.thrroeyte sed imetfJ laltion rate wi 11 be increased IJ

A. Di fferen ti.a I d iagoolsi s! In-c 1 ude s, append iei ti:s {lower fever and W. B ... c. count F lac al ired RLQ palin, n a'tlsea:l .and Ii etn i tin~} .and ec'topic pregnanre y (a sudden RtO or LtO pain." wi th bleed iog. fl ooft tender ma SIS- and

"71-11

1-12

pt!r"iod • If it has II m.ake a nute of all fi nd ings and recheck the petient periodic all y to "Watch fa r recureence tl

7 -19 'I" ~EM.E.NS TRUAL TENS rOtl .. , A C J'cl ieal disorder.

S.. An;{ie.tYI f agitation Pl insannia, inatlility' to concentrate rtJll~1 feel j,ng.s. 0 f msd equae y ~ dep,re'.ssion. and l.r.Ieight gain.

0 ..

Doc~~~nt· t~el ~umlptnm~1

, ...... 1.Jri;; . . II -I .,;Ii J' .~. . 1\0,II'II11:.;1 .,

Lab .and pelv Ic eXaDS are

· l' l.noonc USlve ..

It.. Rule nut hyper ttJyro id i.S1l (i f Lab fareil i ties permit F increased

Tt and decreased TlI1, wi t~ peT~aps a palpable thy~id) ~ hyper~ldosteroni:sm L1ecrea . .sed serLm p:ltass lllJJ 1" 1 ne r eased ser LITI sod.lL.l1\,. a 1 ka Loai :S'., and

i nerea sed pllasma aldosterone) ,I Bind hyper Insul, iI1 i sm (decreasee bloOO slugar) .. Also note any clinical SymptOOlS.. Psychoneurosis and psychosis are also to be considered tJ but the'i are not eye! ic al, •

P. "Reassura1ce is ver-y imp:lTLant. Diuretic.:; tJ sluch as Aldactane: 2 m.g./ kg ./d. in div ided do ses tinder supervi sdon , lh1 tide pressa'lt s as

need ed 111 Psychiatr ic hel p as needed ~ or asst stance wi th d iffer-entiated di.sorder-s ...

1-210. DISHEJK)RREr[A.", Pa in wi th rn~n.strual per iods _. Secondary -d ysmenorr'hea is a term .app]_ ied t,cl d y'S'meoor'rJ1ea f'rl-Dm organ i.e- ca uses (chron ic pelv ic

in fl annato ry: dl i.selalse F elndametr tosi 5 pl etc ~ }., Thi 5 gener all 1 y occurs over five year s a fter men arche or at the beginn ing olr bav ing mE'IjJstrual per ioos "

Sa, Pa i,n wi th mens.t.ruation fl abdan in al bl.oat.ing , breast

tenderness II and a sen sat io n of pelJ. vic beav Iness around t·he time fOlr the patient1s; period.

o. Hi, story of in termlj,t tent premrenst.rual cr-aTlpling thr'olJgh tbe per iod in the lower .ab:iami.n.a 1 mid 1 me II

.1\ .. , rJiagnosi sis based on hi story and absence 0 f 0 tber pelvic exaJl find ingsl II

P Analgesics as needed 01 Local heat and r'eassur an(!e • Itltr- il1 JI;(!O mg.. P .. 0.. c , i .d , frnm t,tte onset, 0 f cr~_ps to the end of the per ioo..,

7-21 " AMENORRHEA" fa il ure to menstrua te at the appropr late time... PI'"" 1ma .. J

ClDenorr-hea is wh-en the pat i ent has never nlen.str uat.ed , while secondarYI a!Jenorrh@a is LoIlert over 90 -days p.a ss with no menstrual now.,

S. am. 0.. All hinge on the abseoce of men3tru~1 n.ow ...

.fl.. Assessment is tlsuell1J unmist.ak.able Ii

P.. W:lrk up the patient as fol !.ows; :

( 1 }I P-er for-n the rJ'.o.st accur-ate pregnancy test. pls.si bl.e (the Hiocept-G 1 if" ava ilable to bel den e) -al

(2l If .::regnancy test is negative,. giye Provera 101 mg. PliO. q .d . fOT 5 days II

(3} I f patient bl eed s, anovulation (no ov w. atiOirl) ooclI:""red Ij

.. ,

Ibt.tJing fur tber II

III

(.ij} ] f the pa t.i.en t d oesn .. t bl eed t 3rld if posai bl e =" d raw' a serum fSH and lH ~ follicl~5timulating tDrmone ,and luteinizing horroone)- .. Then give fremar-l.n 1 .. 2-:;' mg t, P -t< 0.. q ~d.. fo r 21 days Il then Prover a as above,

(5) If no bleedil1@., trace the tract th,rough. tD tbe uterus to target organ, OT a utflow tract r.a i 1 ur e ,

{6 } 1 f pat i eEl t bl.eeds , ge t sert.l!l FSR .and LA resul ts , If thel}," ... e low, then C. N .. Sa, or pi tu-i tary failure iSI suspecced , Refer the patient outl for the c. tiJl. S. or pi tui, tar'y tunor w:lrkups ~

(1 )- 1 f the FSH and lJj are- high, then OY ar ian f-a ilure is suspected, din tating re ferr al, fOT karlyot ~pin g {cl1ranosane studi@s) for genetic. deficien~ie5~

(8) Remember !I amenorrbea is: ccmplex and elusive.. If.at any lime tne di sorder or i t.s WJrkup exceeds the praeti tiorler" s ex perti se or

(acili t.ie-s , the case should be relferr'ed to a spec ial 1st wi ttl the means to wrk up. and :manage the case ..

1-22.. ABNORMAL UTERINE BLEEDING.. A sy.mlptoml of atYf)i-c.al ~enstrual flov in iIIKlD.'l t or tim ing ~ Hyperneoorrhe a (exeess ive flow)! or menorrhag ia ; jIOlyrnen.orrhea (n CIW 1 ess t.han every 24 .cJ.ays}l; and metrorrhagia (flow at times- olti1er- thalrl r-egular time for the period) are Examples. ..

Subjective and objectivel findi,ngs are as above ,

A.... .Ba sed on hi storv , exanination, and appropr ia te 1 c.ro te3ting ..

P.. ( 1 ) Take.a c areflJll. hi :story and perform a c areful e:c:.cn.. Take vag,inal 3Tie'ars f-or c_yto.1ogy and bacteriology (fix first then add 11 Hel, ittL1ch hemolYlzes the red blood <!ells:I if the bleeding is active.. Hel is hyd~hlor-ic ac id) ...

(2)1 Run a ur'inal y.s i.s , hematoc ri t II SIS., W. B. C.. count with dli ffer--enti.al ~ .sed .., rate I bl eeding time !I -clott ing time:l -clot retr act.ten tmae, and platelets ..

(~) Jiypennenorrl'1e.a 01 D&e j SlJP(X)rt hypo~lol811 ia" Provera 5-10

rJI .. q .d,.. for II da~s start.ing, wi th the 21lst d a}" 0 f the c ycl e. Flr.:st. day of bleed in!, i 51 the fi,r Sit, da Y' of the -cycle.,

(5) ~trorrh.ag La, Gi ve Enov. idl 1 Qi mg II P .. O. - q II d -t' on days

(6,) Unknown 01" unr'eslpDnsi ve ent.i tie s should be referred for' further study.

7-23. M[)()PAUSElCLIMACTER IC" Cl imac teric is the onset 01 f menopausal aymprtm.ts:r wh.i I e meoolpause i tsel f is, the eessat ion of menses for over ooe ~ar' ... lbel5e can 0 f cour se occur d oe to T800iv.a1 or major d ys fiI1ction of tne Clariesl ...

S.. The <:1 im~te-T ie ltiegin 5 a t ages J.ffi1..55 wi ttl hot f1 ushe s-.

7-1:3

c, Di aptJragm aJ.Id spermic Id al jelly.. ~i ttedl to proper sf.ze tol snugJ'i . er the cerv ix and eo,", eredl wi ttl jelly, tins method 'NOr ks well l.Ji1en left

~ place after iII tercourse fa r at 1 east g_ hour 5 ~

d. Corn:loms. Help prevent 11D and I"Ork well with iotrn.ediate postcoi tal

III "Wi thdr'awal of the pen i5 to preven t 1 eakage- of semen ...

e • Foam. Spennic i.d al foam S uch as Del f.en g i'<J en as. 1-2 appl, i~a torsful p. 'I. be fare mtereour se works we 11 • lrri tatiOr'll and mesSineSs. 1'1!13Y be noted,

f . In trauter in e de'1J ices (I UDs) ~ 1'I1e Cu-1 dOO latum- T !..Or-I< veIl when p-operly man i to red after careful instal ~ at ion. Prep. thecerv ill: as for. ~ D&:C. Sound the ':lt~r us and measure the Ul ~er~1r . to the . no~edl. depth • ~. the lUll to a pos i. t.ton 1 ateral go as to m~.i(e l. t open . ~n. m serted ~o eIther

side. Inser t th.e deY ice f pull _ b ack the l~serter and ~ thdr a w . the . 1[1 se~ ter ~ Cut the st.r ing to a eoupl.e 0 f mebes out nde the. c-erv 1 x . H.we the patlent

feel r:Q1r' the str ing regularl;l' awld a fter each per 100 ·

OOTE: This chapter is not all-inclu.si .... -e and much: Qf. t~ dl~~_ is lOT Infon;oatiQtl only. Many of tile tests canoot be ~~onmed W1t .. eX1S:1ng raci 1 i ties. Dlis in form.ati,on is use ful to- the pr act). t~o~ b~~.lng aware or the possibilities or disease en t.i. tie s 3~d tr-ea bnerJt S 1 n a baSleway. Practic.e tIlder close suoerv isio[l is essen tl.al to l~ar~ pro~r 1. y tru:se tecblliQues. Be sure to refer patients to the spec lahsts 1 fever In doubt

or if inadequate f.aciliti-e's elxist.

7- 14

d j,aphoresi S!I 'and depreasi on or agi tat.Ion ..

0.. Vag in al a trc phy wri t h. 1 yspareun i a and pr uri t us me y ex.i st .

k, If bleeding suddenly r ecur-s f rul~' out neopl asms hy pelvic eXa!l pal pa tio!l ..

p ~ ( 1 )1 R:eassurance and und er stand i.ng are essential.

(3) If .s~ptoms are se\l"ere or patient is fairl., )""0W18,, Premarin sboul.d be given low dose (0.3-2.51 ME. ranges) alld adjust upward to COl1trol the symptams tba t are presented! to Y'ou"

7 .... 2~" CONrRACE PT ION ..

a 0( RbytJ:frnl tI~ 5. b'35al bOO ~ te!~perature to figure the per iod of

ovtll.a t ion .. It is the onl y method allowed in Cathol ie areas. It.

( 1 )1 Talke the temper ature irrrned iatel y upon awaken ing; and be.fore a~i5ingo( Be sure to chart this reading daily-

(2)1 One to. 11 1/2' days, before ovul art ion j It he temperature drops; 1-2 days after ovulation" the temperature r i ses about a IJ 7 degrees F.. Wali t

3 (jays after the tenper'alture rises before allowing mter-cou se , Th:e BBT

ti1ermorneter is best and rOoslt accurate of all when utilizing this ;methtJd ..

b .. fr"al contr acepti ves , Sel ectiofJ is important.. The.se med Icat.icns generally work by ar t.i ficial suppresaion of FSH secr'e,tion by the posterior pi tui tar 'J .. Young g ir 15 (16-20} must avoid oversuppr'es5ian of the pi tui tar y IhonnorJes I while older wameln mU5 t avoid thrcmboembol lSiII ~

[ 1 ) Ask about nausea and lim i ting in prev Ious .pregnane Ies , r1 uid retention tJ we i.ght gain" aene , hi,story 0 f varicose ve'ins:I etc"

(2l If menstrural now i s hea~y and long, use more progestin (HoT ir1 !Ill 21 mg .. T or Itblr'lestr in 2 .. 5 mg ~) to avoid breakthrough bleed ing Il

(3) If flow Ls shorte'r than normal , consider rrtOr--e -estrogen and Iess pr'Ogestin (Ov ulen II rxtno-IktIVUIIJ:I Eno¥ id) ·

(~ ) Ii menstrual or otllelr' side effects are noted, increase estrCtgen and decrease pr.cgestin to increase the men5tr-u~1 n.aw" or vice

ver sa to decrease the flow., )latch the dosages of each he mane' in the pills to .adjust the fiowl in thi.s manner ...

(5} G'i ve 1 tab P~, 0.. -q .. d , If' 1 day is missed" take tw:>. tabs the nex t day.. If two or more day's ar.re mi ssed , d Lscont inue the tatlets unti 1 the start of t.he next molltn alfld lllSe anctber form of contraception until then .

(fj l If wcmen are ver'y r E!gtJl ar in timing T amount of flow:l' and dur'.a Lion of flow' j! tr-y oore~thind ron e acetate' G.2 mg.. q ... d. It has fewer side effects~

(7) Know thel pi I Ls befor-e prescrl,bing. read the' infonmatiofl, Tul e out any 0011 traindication.s befor'e _prescribing ~

1--1'5

CUI" PT··· ·ER· 8·'

flI.tt'. I I

Oa5TtTRICS

8-1.. CIlstet~ ie:s . is ttlat b ranch ~Jir . surg~ryl that deals wi.th title rnanagemefl t

.. clf ~n (lurlTIg pregn ~li1cy' tJ,labor "" and th.e puer peri Ufl (~2 days- follclwing

cbildbirth and ex: ptll ~'lon . o~ tru: 1'1 acen ta; the, gener at.t ve Olrg~~U1S USUt;i lly return to norma 1 durIng thiS tIme)1 _.,

8-2. DIAGtrll05I!S ~ ~ PR E~NA.N.CY: In about one- tntrd ?f cases; ~ tis -d i ffle w_ t to make a deflnl t,l vie d 1 agn 0.5 JL s be'fol""'e tile second mi.ssed filer lad beci:I:u.se the

variabilit,y o·f physical ehanges ifllduc-ed by' pregnancy tJ poss.ib iIi t ~l 0 f

~s tJ obesity" and poor' patient reI arxoltian a ft-esn in ter'fe're with. the eI_ination · If in doubt !I sched ul.e a ree:x:aminBtian in 3~ ~eks., If av.ailabl e the' .Ea~ly' PregJ].an(: y Test (: IE., P .. , r .) OF in Europe II the' Pried ictor

Test':r an. .anti-H(:G, test for pregna.ncy"t' can be used at Least 9 -daysl after he:li"' las,t period was due, Thi s test c.Ladms ell 9'1 percent aceur ac Ij rate' ..

a, The fOil lowing sy,mptco.s and s.i gns are usual I y -d ue WI pr'egn.an.-c y ~ but

-even two· or mor'e ar'e oot dia@:oolstic 'It. A record or hi stor y 0 f time! and.

freq~n~y elf eoi tus, may' be of -consider-'abile help ...

{ 1 J S~ptCJms.. AmeoolrrtleJi (:mi ssed per ioo) j nausea and vCdi tins.,

tQ"'inar 1 freqtleTlc '/' and: urgenc y (fir'st tr imester), breast. tenderness and tingling (alfter' 1-2~ weeks) t' lfqUlicken ingu (first :mnrvemer1 t 0 f the fet.usl felt in the ut.erus ; maY' appear about 161tt! week)1 l' weight B,ain ..

_ C2) Srgns , Sk:in pigmentation (after 16th week} ,I epul i.s

(hY'pertroplli-c g i.ng ivai papill ae often .se'E!fl after fi r st tr imester) I' br-east changes C: enl.argenent , vase ul.ar en.g,or~lemen.t tJ co,los,trUfJi])] abdcrnir:l.al

enlargemen t., C yatl1Q 51 S of' 11 agi na aJ1d cervtc al port.i.o (-about the 6th week)., :softening of eery i x (lith or 5tl1 lNee*} II .soften ing 0 f eerv icout.er ine junct.ion (5th or 6th week) t i r regul ar so ft~n i.ng and 51 ignt en lar'gement 0 f the fund us [about 5th -week) IJ generalized enlargement and! difftlse softening, of corpus {after Bth ~ek}-I.

b · fosi t.i vel marl i. festations ~ tJot. us-uta11 y present un ti.l the ~tt:1 month fi 'but is IlJnrlen.i.atJl e proo f of pregnancy': Ausc~l.at ion of ret.al hreart tJ pa~pation of fet,a lout 1 i ne '! recogn i tion of f-eta 1 moyemen t ..

c. Differ'en t i al diagnosis I' All the pr'esllDpt i ve sign 50 atnd S,ymlPtCtn!5 of pregnancy' c an be, caused by a ttier' cond i tion.s and .all test s fQlr pregna[lcy can be pcsi.tive in the absence of concept.Lon , Sane -example's fDr missed period Ire PB.-ycbie. fae tors (fear of pregnane y t' vener eal. d i sease , emot iOfial shock); -Ocr l11e f'actor s (tbyro id Il adlr enal II or ov ar ian ely's ftlnre t ion 5); m:etahol ic factors C: anemia" {j iabetes" systemic di sease ) ; nausea arlld vern i.t ing factor (acute- infections F G .. 1 ~ d j, sorder 5, entJitiorl al d i5()rdler's J; ur inar y ftequencjf, 00' inC-ection f pel v Lc tumor:t emot iona 1 tension... These' ar'e ji1l3t a few Uampl-e's" tnere are mlany: more fac'tars that may cause a fals~ diagnosis of P-egnaney.

a.. 3.. MINOfi: 011 S-CCf~FORTS OF NkJiR;MAL P]i:~GNANC Y of.

D,_ .... II~ ~.b..,.... UdJt.: A c ~ i II:::: III

Syncope (1 ightheadedlness and fa inting,)1 .

Dyspnea (d iffieul t Y' in br'eathiflg}l ..

8-2

d 4J Urinar'y SymprtomlS (freqfJe11cy l' urgencYI!I and s:tress il1continlence) ..

e .' Heartburn ..

Sol Amenorrbeal Of'" di sordereo menstrual pat ternl fbllo~d by

dt-erine bleed i.ng, l' pelvi-c pain! and pellJie m~ss f()rmat.ion "- MaY" be acute or chronic., Acute (about iJO perc-ent o·f cases) : Soorlen onset 0 f sharp or eut,ting 11 i,ntermi.,t tent sever e lower qt.ladr an t, pa in that doe 511 not, radiate F Nitti backarche d urins the ataack ~ Searl t. bloc peF"'si.stent uterine bleed ing is

iii present in ~ .appr~lxirnateIY 80 percent. OJ cases ... At least two-thirds 0 f _patiedts g,l ve h~,sto-:ry a f .abnormal menstruation; mst have beenl inferti Ie II Qtror.I ic (about 60 eercent of ease:5)1: Increasinlg pel v Le di sccmfolit 11 51 ight, bdt persistent ¥'aginal sl]Xltting.,

f .. Canstipatinn (aliQlidi enemas as theyl may' i.nduce Labor ) , IK • HeD:trr'ooids; "'

h, Breast soren@ss ..

I • Arlkle swell Lng (rest_T i-ct sal.t.) ,

01., Ac~ute: Palpable' pelv.li(: mass in 1'0 percent of cases.

Collapse arid shock occur in about 10 percent 0 f' cases" often aifter pel vlie examination.. Chronic: Pal pab'l.e pe!l v i-c mass., Lab find i.ng.s: CBC sho-ws anemia with 51. ight, Ieukoe ytosiSi lin Urin@ urobil inogen elevated in ectopic pregnane:y wi ttl internal hleed Ing , freg;nanc. y tests alre' of 1 i ttle val ue in dlas;nosi.5 ..

j ~ Varicose v~1ns (prGll ide, elastic sUPlJOlrt) II"

k ~ Leg cramps (discontinue medi.cati.ons containing large mount,s of'

pho:sptJoItU~ ~ Reduce dietary phosphorus- i.ntake' by 1 imi ting meat to , meal a

da Y' and mlilk to 11 pdn t, .a day).

A~ Ectopic pregnanlcy... [Ii f'fe':ren tial diagno5i s:: :Many aClllte alldaninal illne'sses 11 e.g.! appeT1di ic i ti a , saQpingi tisl 11 uterine' abortion.,

1111, AbdCflilililal P3 i.TI dlue to pressure Il round 1 igament tension flalt.tllenc:e tl dli st.ent:ii.01l tJ bowel cramping" -and urter ine con tr(}C t,iof1~ .' IntrB-atxltoninall d t sorder-s and uterine o'r adnez all -d i sease can al.so abdamiliiJal padn .andl mUls,t bel consadered aDd treated aSI requrred ,

cause

P'. fb-spi tal i ze patient i" f ther'e is a rea30rJablle 1. ikel ibood of ectopic pr'egnancy , Treat for shock, If p:l5sible l' t,ype and cross match

b 1 eod . A t:r an, 5, fus ion sbo ul dl be' sta r ted be fo re SUIi"'g -er y i. s beg U'l • Sur g i e a I treatmel1t is imper.ati~e.. I8esides· nonnlall debridement F generailly a salpin;gectom.y will he requli,re.d.. Iron the'rapYI fOT anemia mlalY' be necessary drur'ing co nrtl.ale'scell e e .,

m ~ frlJrfJ ins, 5i-c kness occur.5 in one-hal, f 0 f pregnant wamen Ulstlall::; sitart.ing diur"il'llg 5tl1 or 6,th weelK and persi st ins ooti 1 the! 1 ~thr-,16Ith lfICek .. ftjst .servelr'E! in tile! morning tlIlC]TI rising F Trealtmen t: ReasslJr'ance and

d i-e,t.ary re:str iet-ioll; res,tr'ict falt.s'''1 oeorous foods tJ and s;piced dli shes. In seneral:l d r-:t. foods at freQ]uent in ter1l.als are:!! inAd icatedl t'

B~I. PH IE ECLAMIPSI A-ECLAMIPSIA ., Dlsuailly occur s in last tr'ime-ster or early i.fIl

the! pi uer per i LIT11l Pr eec 1 amps i ell fl.-en o te s; thel no nc flll v uil s i ve f o:nn ; vi t hi the development of' conrv ullsion andl cona the diS01rd-er i 3, termed ec lampsia., About, 1D perceI1t, of pregr,laneie s de~'elo _PI preeclampsia-eci,amp.s.ia anrll about -s percent of cases progress to ec~lamp5i a "- Ten to 1 ~ percent 0 f the WCIIIen with eclanpslia die'. (..auaSe is unknown __ PredisJK)s,ingl ('actors ar e vasc:ular·

and ren all d i se ase t. sud i U1iI Fe ten t i 0111:1 a nd mu 1 t L pl e' pr eg: n anc y ~

8-lJ. ~ [HYPEREMESIS GR'AVID4IfrUM~ Per si st en t· severe vcmi ting; can be fatal if not eorrtrod.Led , lbl y about 0 IJ 2 _per'cent of pregnant women dertl1elol]1 -hyperene!s,i.s gr a\~"id.arLm and cause is not koolwr.JJ.

s

..

S.. fTee-clamlplSi.a: Head acltJe l' ver-ti~o.1 m.alai se , i rri tahil i,ty (due-

i.n par-'t tol cerebr-al. edenJal);: so int.illalting scotomas (i rregular ItDlinQulS patc:ne.s in title \\"i sual field after' phy'siC!all or mental labor), v isu.all Impalirment t epigastric nausea" liver tenderness, and sener.alized edlema ..

Ie idosis" weigtlt Lcss, arv i tamlinos,i.s, and jalu:ndl ice .,

. , ~ ., HY~rames~5 g:rafIJ idartli'1D II Di fferenti.al d iagnc.si SI: Any 0 f thel

dl seases ~ Wl t~ wb rc h vcm~ t ing is, a.s.soc ialted!l e .. g ., 11 infections: 11 'p~)i.scfl ing f n:oplastl: d.l se~se:l hyper ttlyra i.(j i.sm:t galstric -di so rd er s 11 gall bl.adder

d i.sease , l~ test 11'1 al oostruc:tion 11 hiatal hero ia Ii and di.abetic~ ac idolsis.

o.

P. ~5pli tal ize patient in i:tJ private rooml ~t c:mlplete bed rest wi.tholUt balthroom prill i1 eges,. Allow no vi 31 uJJrs, (not, erven Ir:nlJ3b~t1id) un ti.l vorni tin@: staps and patient is eating.. Place patient N'. P ~ o. x .liB hour 5 .. , ~linJt~li n no mal f:1t.1tr i tion amldi electr·olyte bal anc:e by IV ther.apywi th

VI tamJ.n and protein supplements as requi redi4' Give, c hl.or'prcmJazine 1M Olr· 5Up~s,i tories. IC no response after' liB hours :t' institute nasog;astr-ic tube feed~~g of a well---boal anced 1 i.quid bat y fOmlula tI y s.lowl dlr ip "- As soon as IJf.?ss:~ ble' Il pl ace p.a t ie1 t (}In .a dr'y die t of 6 small feedi ng s da il 'i wi til -clear 11.~ldlSi .1 hotJr after eati.ng:.. I.f the situation. c:on.ti,nues to d-eter ioraJtel in

SPI teo~ . ~herapy '!' therapeut.ic abor tiCJln may be r1elQuir·ed IJ Uirg-en t ind ieations,

awe del~ lr-l LIn 11 tJ Ilf1{'.hness;:t tachycar-d ia at rest,t j alundice-I] anUF ia" and

hrentO r r hag,e •

- Eel ampsia: Sever-'e pr'eeclcmp5ial symptamsi pI UlS geneT .ali zed

tonic-eloll.ie conv ulsi.ons l' coma follo,.-.e(j by amnes.ia and con fu~ion 11 1 ai:loriousl breathing Ii ~ ('rottling at the mouth 'I t,wi tching of muscle groupe {e .. 8 "- 11 face:'1 .arn:-s;) ~ ny-stagffllJs, ( constant involuntary movemel1 t 0 f t·he eyeblalI.l)1 t and 0118,lllr'ia! or anuria ..

. O. PreeclaMIpsi.a:- Per si stF!nt hyper tension OF'" a soo~en r 15e1 of

blood p~'essure, ge1er'al i ,ed, enF3TlaJ, and prote~ili1lJr ia during tile last. 4 mntltls of pregnancy ~ Cllthalmo5CO_pd.-e exiDlination in .server'e pr'eecl ~P5i,a and eclanpsia revelalls var'iable arteriolar .spasm! edema of o'pti-c disc" aDd! with ir.tcre.asing sever it Y. COlt ton-'WOol e'xoo ates and erven retinal dl!tachrn:ent.

B~51.. EC1QIPI C PREGN1AN( l':". Pregnancy outside the carv i ty 0 f the ute1r US-lO'

Occur s, in 0 ~ -5 pe'FCeJ1 t -of 'pr'egnancies.. Abo,ut 98 pelreen-t 0 f ectopi.c pr'E!gnanc ie'sl occur in the f-allopi an tubes: ..

n~ltlD , .' E<:ltClnh •• · •. p~iafte· •. : .. Mla"rd• ·1~·~hY~Ttel sionpr:;Ced in~ a 00"): rwlulsiol'\ I] and

."'.,._,cnSl,oll . ereal I ·T ,. ur lflg cana or vaSCUl.Lar collapse,! and 3-11 +

pr.oteinuri.a. Opthalrooscolpii.c eJ:.aDination Ir'eveal s paplil 1 edemal I] r1et,inal

~em.al Ii retinal detachment:p 11 a5Cular' Spalsmlll .arter iOrVenous unickins 1l1~ aM hetOlrrlhagelg .. Repeaterl optbalrnosc.opic @xanination is hel pf"ul in judging; the ~ess of tre'atment.

B-,J,

A~ hy'per'tens ion j

H-4

Preec 1 tmlpS ial--8c 1 ampsia II Di ffer-en ti al d i.agr:losi s:-

r ena.l and neulrolog i e di sease .

Primary

P.. Pre-ecl anpsi.a : Objecti.ves are to prelvent eel :.npsia tJ permanent. card Lovascul.ar- an-d rena 1 dalOlage" ocul a r or vascufar acc ident.s , afld to deliver a normal nab Y I' .Dell i ver y. should te del aye-d:r if possible. Ufl t il d i sease is under con trol or' improyement is m,arked ..

. eed rest wi th se-d a t ion under al er t superv iSirn'1:1 i.ne l udiIlg

frequet1 t B'oI!Pl. r-eadi.ng.s and ur-ine prote in determination tJ and c-arelful recording of fluid intake and OUitput.. Try: to achieve a zero water- balance tJetwe€:t'1J in take and output.. Gi.ve rlli ur'etic s arld hypertensive dr't.Jg S as needed, Pi} ace pa t i en t on a low-fat:l high carboh,ydlrate III wi ttl moderate prot.e.in , sal t-poo r (less than 1 grm a da_y)l d ie't.. Opthalmoscop i c ex amination should be done daily ..

Eel amps i.a : Same as preec I CIl1pS ia plus give rnagne-si lin sulf'a te! to ml.. of 25~ aqueous sol.ut.Ion IV or I M in it i ally ~ then 5 ml , IV or 1M Q. fih. W' prevent or corrtro.l convul s'ions :r lower B I, P .. :t and encour ege d iur~'.si s.. (Do not repeat magnesium s,u-Ifate i.f uf"'inary output is less than 11.00 rnl .. /tl .• respiration is Less than 16/min r or knee jerk reflex is abs-ent I, 1 In case of overdose f give calcium glauconate' (or eQuiv'alent) 20 ml , of 'GSI solution IV .slow~j' ~ repeat every hour until urinary, re.'s-piratory, and neurol.ogtc

de pre ss ion ha~ e c:leared t do no t give more than S inj ec t ion 5 in 2J.i. tKlurs} ..

Plac:e patient at absolute bed res.t in dalr keneo quiet rOCmJ ~ Un

vi s i tors" Use indwell in~ cattle te.r f l-eave B., P. cuff' on her- arm. Do not di,gt.urb pa t i ent wi til unn~e.ssary procedur-e (e. g ., 1" bath, enemas ~ douches,l etc .. ). Patients with eclampsia often dellelolp premature separation of the pl ecenta wi t.h hemo,rrhagel and ar-e zsuscept, ib! -eo to sbock ..

Because se'ij"ere' hypertensive di sease ~ r en al .rJ i sease , and

prel?-C Lamps i a-ec laltpsi a are usua 11 y aggr a:v at.ed b'i cont.inui rig pregnancY'1 the oc:st me thod. of Lr ea tmen tis termination of pregn ancy , Can tiO} ecl.anps ia ... , De rore attempt ing i nd uctian of 1 abor .. Labor' can usually be induced b'j

r'upt 1Ir i ng the Fe-t,a 1 mefllbr.alle.. USE -oxytoc in (Pi toei n l to stirnula t€ Labor if nece ssar Y I- If the pa t ient is not a t tenn r i f Labor is not Indue ible, if sh€ is bleedin~. or' if there is a pJ5si!:llel dis.prop:JrtiOfl:l a c-es.areool section ma_y be neceasar y I, l'bst patients improve dranati-cailly in 21~_f~B

hour s , but early temlinatioE1l 0 f' pregnane y is usually required ..

8-7 . AJI[M]A DURIN~ PRF..GNA,NCY.. Iron defic.iency. anemia anc folic acid

(Ie ric ienrc. y an efTI i.a c.an be prevented and treated by .administeri ng

pr'Dlphy lac tic mlll ti vitamin p1 us. iron caps,u 1 ~s to .all pregnant \lOme!') d ur ing pr egnanc Y' and fOI: 1 month fOlllowing deli v'er 'i ..

8-8... ABORTION (MISCARRIAGE).. At 1 east 12 percent 0 raIl. preg;nanc ies

te.rminate in s_pon tal100us abor t i·on; 01 f the se 11 ttJre'e- fourths occur be fore t.he 16th. week olf gestatio'TI.

~o 01 Abor lion is br'ok-en d 1Jil.41 in to four cl:assi ficatiof!s :

I.n-e1!" i tabl e abor tion : The palss.age 0 f sane or all 0 f the produ£ts or-, c~nrCeption is. mcmentaT i 1 Y im~nd iog 01 Bleeding tll1d cramps do not 3ullsl<le ..

[".ornplete abortion! All of the conceptu~ is ex pe 11 ed "' When ccmpllete abO'T t iof'! is impendi!lg ~ the' s}Mllptoms of pregnl.anc Y' often d i.sa pJlear ;

III

sudd-en b l eed ing beg i.ns , fa 11 owed by c r aInpt n~ - The fe (liS and placenta may be expelled separ-atel y _ \Jhel'l the entire conceptus has- been F!';(pelled, pain

ceases but slight spotting persists.

Inconp'le r.e abor tiorn ::: A SIgn i Ciean t ]:OTt io n 001 f the ooncept.u~ (usuall y pl.ac ent.a 1 fr agmle!lts) r ema ins i n t.he uterus , (illy m.ild cr anp~.1 but

bleed ing i S Il~T si sten t. and often eX.t!e'5.5i v.e ~

Mis.sed abor·ti~)n: Pregnancy has been terminated for at 1 east 1 .,nth:l but the concept us. ha s not been ex pe 11 ed .. Symptoms of ~egna~cy disappear and bod:y t-emperatur-e is; not elevated.. Brownish vagInal d15ch,arg_e'

bUt no fr'ee bleed 'ing , Pai 11 (joe s no t d€'lI el.op. C:er~ i)[ is semi fi rm and slightly ~tuloos (open's di.stendee • .spread apart); ut.erus bec~s smal Iee:

and irregularly softened ..

Lab, .-find ing : fregnanc y te st.s are negative 0 r poai ti ve .. Blood .anti ur me find ing.s are those usual.I y fourld in in fection or an ern 1 a i f theSE

complications, have occurred~

A" Abortion. Di rreren ti al. old i.agoosi s: Bl eed ing must be

di fferen tiated from bleed ing frem aborting -ectopic pr'egnancy ~ anov lliator'y

bleed ins in nonpregnant wrJDer1:1 and membr-anous d ysmen~orrhea.

P .. I f abortion has occurr-ed a.fter- 1st tr ime. st.er t t,he pa ti,ent should be, hospi tali zed.. In all case s , uter ine con tr'ac ti0J15 should be. _ induced with oxytocin (not. ergot preparations) to limi.t blood Ioss aind -C11-d

in expul.sdon of clots and t.Lssues , Er'gotr ate should ani Y' be gi ven ~ f . callplete abortion is certain. Treat for shock. If there are_ any sagns of infection. give ant i biotic.s . Me is indic.ated to remOlle POSSltJ 1 y r eta 1l1edl

tissue .,

e-a... HrmATIDIF"ORM MOLE AND CI-IORIOCARCINOMA. A degener at.ive disorder of

the ehorion (develops in to plac-enta)l; occur s in lout of T. 500 pregnane tes ;

i.s five times more prevale1'1t ifl the Qtient than in WesteTn cO\JntTies; and

more c(]IJftQn i,n WCIlLIen over ~ O. Mal ignan t c hange occur 5, in about ~ percen t

(higher in Asi a) of cases .and is often fatal whern i t doe's occur ..

S, Excessive nausea and vami t ing in Q1I€ r one-tin Lrd 0 f cases. uterinle bleed iT1g beg infl ins at 6-8 weeks· is observed in v irtua l1y all cases and is indicatl"\te of threatened or' ifl~anplete abo·rtion.

Cboriocarc inoma may manifest i tsel f by continued! or rec ur!'"'ent uter me bl eeding after e\tctC uatian of .a mol e or by pre-sene e- 0 f an uleerati v'e vaginal tlllXlr' f, pel vic mass , or evtdenee of ntstan t mretastatic tmor' .. Diagnosi 5 i 3 eSlt.abl i.sbed bly palthol.ag ic ex a'nlin.a tton of curet t3@:e Olr biop.s~ t,

0.. Uterus larger than would tie El: pected in no,mal pregnanc)" 0 f the saml~ dUf"ation ill one-fi ftll a r cases.. Intact or collapsed Y'esicle 5 may be passed through vagina ~ Pre-eel cmpsi.a-eclampsia, frequentl'l of the

tulm . .inating type J] m.ay develop during the second trimester:l but is unusual. 'iIK,inal smear reveal s tlelafll y cell grouplings and a predaninance 0 r Bupe~ficial cells~

A,.. Hydat id j, fOnr\ ro.ole I' Dil ffer-enti.al d iag,nosi s : Hyperemesi 5,

Hr-a1V id arL.m:l Ulul ti pte pr'egn.anc 'f (extr a ~nl.af"'ged uter us) ,I threatening a,r

incomplete abortionE

P.

8-5

.8~6.-

will requi re- D&C.. If the uterus is-I ar'ger than a S-rnonth pregnane ~, a

~ ~.sterec tcmy' is pr'e ferr-ed .. I f mal ig,n ant ti ssue is di sccver ed , ch-em:lther allY l.S necessary.

belOW ... }

8-9. CHILDelRTH~

a III Signsl and symptoms 0 f impending childbirth: (1) N~~sea and yomiting.

(2) ~ther displays intense anxiety II]

(3) HeaIV., snow 0 f tilood/bl ood Y' mucous.

(4}1 Intcn se desi re to defe-c ate ...

{5,) Rapid} 'j oee urr ing con t:r ac trons wi th i f1creasing intensi t V and de 5 i r e to bear doLd1 ..

(6) El.!lging of memhranes from y ul, va an!lJolr spontaneous r upt ure ...

(1)1 Vila tioll1 0 f an us wi ttl -expuls ion or feces.

(8) Crowning of the fetal bead i figure 1) 'I

f!t;,VRE 1

b. Delivery of t~e infant: ~TE: Maintain sterile technique Wlenever poss.i ble:l tuft do not end anger the mother or in fa((l t wi th 11~ ue die lay .1

I

\

(-9l If memblT anes are st ill In tact -over the in f'ant.s face , r emo'i'e by snipping them. a t the nape (3 f t,he neck and pull ing away fr'QB face' and

airway .at OITIce ..

( 1 ) Place motoo'r in dor sal pos.i t ion , 'Wi lh 1 egs ben t and hand s gras,ping krI-ees... Assign an assistant to st.aru1 at hea(l 0 f' bed to men i tor 'I ita 1 signs and offer' ver'bal support and enco1Jragemerl t to the OIDlher ..

( '-0) Suction nose then mout~ gent.I y wi ttl bul b syringe to in sur-e ad~quate alirway., (Newborns ar-e obi igate nose breathers.. J. (See figur-e. 3- t' )

(2) Attempt to' gain mot.her t s con fidlence and cocper'atdon t.y ex plain ing, wna t yOIl} are doing and -..Ilalt you expee t of ner ..

( 3) If time, permits II put on ster i1 e gl ove s anc drape per ine.al area wi th ster' il e to....el s ..

(.lJ) As b i,rth approaches 11 thel tJead disteoo s tbe perinlel..lT1 more and moire wi til each COf1 trac t ion" w.hen two to three inchels 0 f fetal seal p show"

.an ept siotOllllY may be nec.e.ssar'y to preyent ser .ious Lacer ation . Cut the

episio~ ~ to l 1/21 inches long 'I (See figure 2 ... }

(5 J Appl y gentle pressure wi th palm of Band to, cl"O"Wning h.eaad and per ineal area to prevent rapid e-xpLJlsi-Oltl 0 f the head. NEVER 1RY Tal stoP DELIVERY' BY PUSH IN'G fORCEFULLY AGAINST THE HEAD.

Fi gu re] ~en the' Lac e is

delivered, (he shn"~ders reside under tbe pubis~ the moulb and oropharyn~ should be aspirated.

(6) Eneoueage IlXltl1er- to pant during contractions to allow for slow:t gentle del i ver., r.

(1) As Ileoo is del i vered.. prov ide slup'port wi th tloth harJds and allow tile head to r-ota t.e naturr all y to the side.

. ( , 11l After insurr tng pat.i.errt airwlY"t proceed to del i ver tile'

3Iloulders II Pl ace hand 3, O'TI ei tiler s id e of head a((ld exert gen tl e da~ward pres.slJJre (tolward the fl{)Or} to deliyer the anterior shoulder. Then ~ert

(8) Irrmed iate 1 y s,l Ip finger' .aroLJfld in f.ant 1 5, nee k and feel for cord tba t malY be lIrapped around the nee k and cooking the in Cant ~ If

present, attempt to gent1:r .51 ip it. off ow"er the' Ileaj. If it is not (::Os·sible to remove tile cord , clanp and CUlt the cord a t onee , {:see {1 ~}

8-7

8-,13

gent} e upward pwl1 to permit dlel i very Qf' the po.ster ior shoulder ~ Su.PPJrt thel rest of thel bodl~ as it, is born, (See, flgu.r'es 11 and 5.)

-( -e) Che-c. k the pl.aCe!l tal for evidence of mi s.sins Plrtiorns:

sect,ion mi.ssling can mean con t.in ued uriter me bleeding,l

_1

Figure 4

( , ) M3J if] lain patient airway' ..

(2) Administer ey-e' car'e (si 1 ver ni trate or pen icill in prophyl.ax i s) ..

(3} Observe cord stUIlP for- ey idence 0 f bleed ingl Ii

(~) Prov ide ar ti f'ie i.al ro'es pi.ra t ion .3ITId card iae !HJIlp:lT t as

oeedled ..

The head

e .. Care- ()if the mother· ...

rot a tes to a r c ommuld a tetine .shoru l.de :r. s: cur i ng passagp through the

bi r- th c a,nall .

Fi~ure 5 Following

r ~Ji t a.t ii.,tl~l II' Ii: be shou 1 d er s

ii re dell Ii. ~o[!red .

(1 ) Observe for sd.gns of ex eesst ve ble-ed Ing and shock ..

(2) Prevent rei aa(atiofl of the uter-ine muscl.es by frequent ma~sag;e arid close observat.Lon Ie

(3} .Be prepalred to admlin ister IV' f1 tJi.d ther'aply a 3- needed.

(~ } Suture arl Y' 1 acera t.ions and the ep1isiotoo1 wi th chr~li~ gut" 00 or 000. Star t abovel apex of vaginal inc i.sion and' cl.ose the yaglnall mllJDOsa wi ttl a r umii ng sti tctJ . SutLlll'"E! t hE! per inea:ll POTt~oo als any ot~T

Yl:JUnd, making sure that, an atomic :struc-tur'es are. a~pr'ox imlat~. . . (See f'Lgure 2. )1 I f the arJ al sphinc te:r muscl,e or r-ectal wilill 1. S torn ~ the se are

repa~irled fif" st. rr'i to get pa t.Ien t ev acua ted if lac ef"lations ar e aever'e .

(5) I'ake mother II stemper ature ~-~ t.inJ.es a daY" "- An y ekeva tiQrJ

mOlle 100 .. ~oF '" presen t. on. .suc·~essi ve days is ev.idence of infection II

(6)1 If membr'ooe s ar e ruptured mor'-el than 121 hour-s pr ior to delivery I' aS5U1!l1e" in.fection to be present and start antibiotic ther~p:l. infection occur 5 a ftelr d-eli.very, a 5 el'il i.[1 eneed by ferver Il f(]ul .smelll l.n.g diSCharge t .and tenderl uterus" start .antib Iot.Lc the'r .aJ-l~l ~

If

n2) Wi th tim grip on body I hol-dl infant along lenl!!:thi -of arm I wi,ttl head lower !than feet ,:and aga in. sue tion tile nose and mouth. K.ee p the infant below or equal to the- 1 evel of the mother UlI til the cord stops

IlILJI sating," 001 NOTI HANG· INfA.NT BY' niE fEET'.

(1]} If infant does not cry spontaneoUIS-ly ~ apply gent1ie stimUiltls to back alild soles 0 f feet by rubb ing and gen tl '!i ,Patting.

Cf4) 'Wait .foP'" ccn:IJ to stop pulsating I then tie off cord several inches apar t and cut betwe€n tile two ties. AWl y fir st tie seYer al inches froiOOil infant 1 s body. iCl)serve for elJidence of excessive bleeding frca ends of COr-doll

{1"5) wrap infant in blanket. then place on mother's abdomen.

C .1 Del i very -of pl aeen ta ..

( 1 ) SigrlS 0 r separ .ation olf the pI aeen ta ..

(2) -Cut a generous epi siot-om~y ..

the' lJagilia II

( b ) Umbil iea! cordi protrudes 2 to 3 inches farther out of

(3) Del tver blurt to>e ks by gentl y pull. ing upward.,

(lI) PUill gent.I Y' 00 t: i 1 an i:llX: ill a. i;s vi sible .1 fu no t ex,ert _

pr'essur'"e above the i.L Lac crests uPJln the· abdanen {of t he in faint,) to aVOlld Injlr Y' to the abd cmI in al 0 rgens ~

(5}1 Have an as-si starrt pr'ess down ward on the fundus, gent.ly , {6) Del i.v e!r the anter ior or [X)st-er tor 300uldler ,I whict:1ev€:'r is

( C )1 F un dl us' ri ses upwarldi in the abdlamen II'

(2) Ex.pulsion01-

(.a) Ask mo'Ule'r to "beer down'" to expel the placetlta~ Avoid excessive massage of the uterus IJ

( b) Appl Y G-ENf[£ .dO'oll'1ward pressure on fund LJtS to aid ~ del Iver 'i t but, do not appl y ex:c:essli V'@" pressure or force' ..

(: 1'}1 Del i lJer the 0 ther arm ..

8-10

(8) De-l iV'er the head as foilclW5:

CHAPIER 9 ORTHOPt.:D1CS

(a) With b~by lying face dow on your .anm tl put YOIUT indeK fi.nger in baby· 5 m:)uth'l

(b) Hook tWI fingers of the atneT h.and over each of the baby· s slDulders 11 pallml on baby· s back ..

(d) motherisl abdomen.

RT i ngi ng down i!int~['"ior fODt

I Delivery of

, pos ter i.o'£ foot

:figure 6

.

(c) Pull downward until QCC ipurt is uru:Ier the s)mphisi s ,

9-11 ~ tRACTOR ES ..

a. A {'rae ture is a break in a bone, The break does no1t need to be canPl-ete to tie. considered a fracture. t~ bon~ may only be c.r aeked , or in thel e~' of stress: fr:actlllr'es, t,he bone tl.:5sue I t:self m,ay onl y be torn.

b.. To diagnose .a Cr-acture wi ttnut X ralYS requires the utmost Uise of bLstory and physical examination~, If there is any doubt. treat. as . a rractmre", Fr act,ures ma:y be suspected by one or DJOlr'e of the followIng:

( 11 ) The patient feels or hears the bone break ..

(2) Partiatl or -canple1te 10s.8 of motion ..

( 3 ), Crepi tus, or grating ..

Br"ing head out by. rai sing the lJaby tl 51 body up toward the

Descent and expulsion o f bl"'e~ r.:h

De 1 i ve:ry of anteTioT hip

,.11 )1 ~fo:rmi ty ..

(5) Swelling a.,d d i.scolor'altion 'I

(6) Aboonnal motion at fr acture site (arm bendillg but not a t the

lI)eliv~ry of

p.o,s, t.er ior shou lde'l'

elbow} ·

(7) Poi.nt teooerneSi5 ..

(8) HtJs(:le spasm ..

De 1 i V'1t! rv .0. f .sbuuld~['

c. The main object:£. ve inl fractur'e tr-e.atment is to pr'event broken bo.nel,s from fIIOr\f ins, thus preven ting further danage to tt ssee , ner-ves. and

blotld vessel s ~ The basic pr inc iples of tr€'ating fractures are:

( l) Chec k ar\d ma intain a irw.ay (i f appropr iat-el) ..

(2) Determine exterlt of injury II

.

..

(3) Control hemorrhage.,

(ij) Star-it IV (if' apJropr iate) .:

BREECH DILl VERY

(a}l Mass-iv'@ tissue damage ..

(b, Fracture of femur ..

BREECH OELIVER,Y

(I c) All y open frac-tur'e. (5) lress wunds or.

( 61 ) IfIITICtt,ilize (splint.)1 frac:-tlJJrea.

(.a) Spl int them where they Lie , {Gro55 deformi ties may be -t], y eorr'ected to allev iate circulall.oli"Y inhlbi tron if present.}

Figure.8 \ligand maneuver for' de 1 i very all' bead., Fing~ I" 8.

Df l-e ft band ins.erted intfJ infant t 5 1DOrt.l.th al[" over lINIndi b 1 e ; right hand exert i "D,g pres.sure on head fTom. .above.,

9-1

.. -

~ -

lJ-l'

(b1 ][rnmobdlize the jOint above a[]d the joint beiowl the

If' the patient is lying i.n iii face-up posi tion t pl.aee a folded blanket under tile sua].l of hi.s bae:k. If' thel patient is ly.lng face down ~ place a folded !blaflket I.lJ1der hi s ehest , This wi 11 keep, the spinal col linn properly al igned ... in a .swayi)ac.k p>5i tion ·

fracture.

(e) Alwa JS move the entire vertebral column as a nonnex iblle

{c} Pa~ the splint to prey~nt further injury O~ disc'Cmfort . Add ex tral p,addJ ing, over bony prcminences ~

. (1)1 llnder cond i t Ions where patient c anoot be evacuated, reduce

fr acture.s a s soon as pos.si ble .

(d) Use ris id 1 it ter or board J.onser tball the patient Ls tall for tran5jlOrtation ~

(e) Improvise 50rme type of reversible bed so tbat the p1tiell t cam be t.urne<l every 2 hours to pievel1 t bedl sores . (See illustration below .. ,}

{d)1 Traction i..s requirerl all most fract.uF"es of long bones to overccme muscle contr act.Icns ..

(I)) Pad r3lre.as 0 f pressure ..

(a) Use anest.hetics for redUC'tion p ~ r- .. ,n Il Fracture reduction can usuall y be accoapl. i shed Il y injec ting Local, ane.sthesi a tn to the

bemlatoma olf the' frae ture , An adljmet (if!.g"':1 morphine. .Demeroll

can be used for ver y pa inflll pr'oc,ej ure.s ~

(-c) Cast Of" spl in t. in post t Ion of function ..

(d} Bivalve all. casts to allow for .swelling and holdl in p~ac.e with ~e wrapl unt.il sweilling subsides (about 3 days) T th,en replace w. th plaster wrap ..

(e-} Elevate'.and cool fr aetured extrani ties In

J

o

(f) Check ex tremi ties f'requen tl, Y' fo r c irc-ulation loss ..

d.. Splinal col LI!1n in j ur Les , Any inj UT 't to the spinal col Lnn is JlOt~ tia~l y ~alflgerous "-" Although a patien t may Ilaye no .a pp ar en t in.jur'i t1 1IIOW'.lns hlml W]_ thourt. proper prec.aut tons may result in s'pinal cord injury, causmg paral 151 5 ~,

( 1 } fr ac:tured lOWEr spi ne II

(.a) Pam , tenderness II muse Ie :spaSJll f defo,rmi t Y' J] paralyst.s , 10.5:5- of blad~er aM/or bowel cont.ro.I may be present.

.. _ (b) I r pat.Len t i So consc ious 11 place the pa t.Len t in a swayback

posr t.ron (111ustr3lted below}. to avoid flel: ins the spme , (flex in.g the

spine ~an C~USE booe fr agJIrents to Lacer ate or' campress the' spina! cord~,)

If pat len tIS uneonsc iOU5 tr'ansp.:lr t in prone p:lsi tion with bead rota ted to stde (be certain p'atient does not al se have a neck, injury)~,

FRACTURE

{f) An indwell ing catheter mLllst be used , Mld tbe pat,ient abould reeeiYe an ef.Iema dail~.

C.g) Patient must rern.ain iJm"J.Of)il i:zed for 8-,10 weeks.

(2} Fr actur-ed cervical spine ..

. (a) Signs.and 8)1i1lptomS are .simi lOT to lower sp1.nal eolUllfi

injury" but par alYSi5 may include armis and upper bod.:t t' e~en making the

.. tie~ t unatJ Le to bre'ath., Ar1 y !1DClVement can cause fiE tber pe:rmaJ1ent, damage.

IN THIS POSITIOf(~ HOlME F~GMEHT5 MAY BE BRUISED OR CI1T TH E s.p I NAt (ORO.,

(b) Make a t.horough e:<amination of the patient witoout .moving his, J1ead~

IN tH1S POSIIION~ BONE fRAGMENTS ME 1IH P'ROPER PLACE ~DI WILL HOJ BRUISE OR nrr THE SP [MAL CQR.D.,

fiAT IEN!f PLACED IN A SWll\ mACK rosrrros ..

{c} I f' patient L s consc ious 11 tbe first quest ion should b@ l' 1'\1here do you bur t.?~ Susp.e<: t cervfcal. api ne injur y i r- pa tien t c'D11plains of .severe oecipi tal j slloUilder' t' arid arm pa inl ~ motor' we.alal ess 11 and nLJnbnes.s in alll:s and Iegs ..

FRA£TURi

._ _ .... ._ ........ ~ _',__"

9--J;

9--4

(d} 1'0· transportt the pa·tient. With thel help of another

1 .. iJbl.d the patient so his head. and badly are al, igned ..

2'1 Pl.ace t.hel pat tent, onto a firm surface (d{)O·r or rigid stretcher')1 .. ( I f he - 15 1. ring 011 hi s face Il roll him onto, the, sur face .so he

is lyling on his back.)1 Be caref'ul to hold the he'ad in a ne utrall post tion .'

3 IC PI ace a small rolled towel or .sttee!t under the aeek ,

A blowl t.-n the skull (di£e·cl iHjUT;I)lIta!f cese 1 t in f rac t:Ul"r-'e (A)I

(e) Defini t.i ve tr-eabment IC

O .• ~ ~hsenc~ ~f fracture, it may" cause :'r 'I! In. ~ 11i:~ u:

su.Eficient movement 0'£ the br'aiLn (B·} t o result in t e a.- ing s,om,e of the ve ins b :r i.d gi ng If r om lJu~" co r t -j ca 1 sur face to the' du r a (C) vi e h c-on-

seq_ u.en t d-Eve ll[lpm~nt fl f s ubdu r aLb ~na t nma

11. Place sandbag s or boot.s fill ed with sand or dir tl on eltbelr aide of the l1ead to stalb i1 i ze it, or have someone hOlld the head in a neutr al p.l-si tio~ while tr\31"l5p:tIT ti ng the pa tient •

1 + f'i t. in to a head halter wi ttl paMi TIS to chin and .apply trac tion if) a - straig;ht I ine using a 11-0-15 1b we i81ht 11 (A head nal tel"""' oart be improvi sed , btJJt remember- the pa t.im t. will bel in tr ae tion for .3 t. letCist 3 weeksl"_ "lhlink of his c:cmrfo:rt when irnprovi.singl. 1

pre S5 ILl r e ..901 res ..

5111 frfet.iClulOUlS ski.n care must be m a in tained to preVer1 t

In aldd it ion ~ sE?condaT"7 ph.~nom~na may r es hi ~.l f:r'OtD t.he injUl"'f - 13chemi. a and pa rl- i e ular ].:y lCe["ebr all edema IDa Y ~n5ue _ E 1 ~vat i·un of lnt:r·a-c-ca.n i.a I pr e sse re· sec onda r:y to is chern i ~ ce:reb-r a 1 ed.p.ora { D )1, a. mas·s 1 e s iOFiI (E}.. 01'"' COlIIbi nat ion 0 £ th~ se p;£.'oc e s ses ma.y 0(: cu rand af fe c t; the- -ou{_ E::ODJ~ •.

(2]1 Head i.nj ur tes are cl asai f'i.ed as either c 1 osedl ~Jir OfJell.

(a) Cl~)sed i njur ies _,. Except. fOlr t:ll possihl e brui se ,or', .

contusion ~ there is no 00'11 ious external danage. Injury ~alY ~e to the. bra 111 itself or to the pi.a arrl arachnoid me1ingles. Rupturel of the bl~d ~e-.ssellsl of the pial is parttcularlly iOlpDrbnt in closed inj ur ies , fll~ .s~l11ed

oorto, bra in cells- is a fore ign substance and di sturbs the f'unct 'ion 1 rllgl -OJf ~ ,

'the3e tissues - Bl~ col Iect.ing wi thin UJe cran illn ex ert.s pressu.rr~ aga~nst the br'aitl.. If t,het;'-e is no fracture' o'f the skul L, or i r SKull ~ ac~.uare 1 S SliJch that the integrity of the dura is not diistlJrb€di ~ the cran~trn 1S ., IlllJield ing. I r the skuJlJl is depressed or d i3pla~erl 1TI1o'I3rd ly T 1 trnay exert direct pr-e.ssure on ttle brain even wi tt:"xllut fo TflIJI at :Lon of a hematom~ (blood pool) ..

211 I f there is no ev idenc e -0 f' damage to thel cordi. .pI ace the patient on a foam mattress or a finn air mattliess.

3'1 Patients wi ttl 5plin.al cord dam-Qge must be pl aced on a bJrlnilflE fr ane (35 wIth lower back injiur'ie,s).,

~"'" COn'lD)nly wi t·h cervic at spine inj ur tes ~ sc.me sensory Ioss or par alysi s may appear due to swelling ~ tr anseetiolO t -or cCJllpressiom (lif spinal cord tl Same or all Ol_f this para! Y'S1 oS may eli sappear as the

s-..ell ing; goes downl ..

6", Place patient N .. Pl. 0 ~ 111 g 1 v lng onl Y' I V fl uids for' the iirst few days until' there is e\llidenc~e of aud.ib.le peri stal si.s .,

7 ~ Catlheter'i ze patien t. u.s ing Ind well ins; Fal el1 catheter ..

~

e .. Cr ani.o<J:erehral i.nj uriel-5 ..

(bl) Open WCJunld.. In an open h'[llund there is obv iousl e:r: ternal d_age. Q;Jerl !«lund 5 of the head are subclass! fled accord i ng to whether' or JXllt the integri ty 0 f the d uf""'al is d i.stuli'b~d .

1 ..- lktnper for .a ted dural ma ter' ~ _ The IttO und rna ~ Del no fITIOre than a I acer atiolil or -the seal p too t , although not to be taken 11g,hUy. may nolt bel ser Ious _,.. The'r'e maly be- one 0 r more fr acture S Q f t he skull, but ~be dtlr.a is not perforated. In eit~r ca~, the _possible internal .:jCllllage 1S f Ukely to be or beeaJIIE! nDre ser lOUS than that 0 f the seal p and skull: _ J[ 1:fle, Skull is f'r actur-ed , i twill he Ld in the sane- lIDIaJ'lner as _ a C'l osed l~J ur 'i iEII!~ in st the pressure of an Y' hemf)rrtlag,e t.h-a t rna'i oct= urr wi thl n the cr'a~ 1 tJIJJ ..

2 -0- Per for atedi -d urta mater., Wi ttl t he skull af!d d Ur'.3l Openled:t the men inge s-'ar'e eXpJsed to t!1e open aJ i r and to :Pat nogernl~

inrvaSion. If the dieUeate Iftetllinges are opened, the brain itself. 1S EI..l)Ose-d.. I f the skull is fr act.uredl in .such .a we'i ttlat i tis no l.-ong-er a

8 a UlslJBllly.a ftelr 3 weeks of tr'a:ct ion F a cerv ieal collar ccm be appl ie:d in c.a)5es mere tbelre' is nOI cord dirDlage (a COllI ar can be mad.e

u5,ing a very we 11 pa~ed wire ladder spl int)1 "I- This. soould be- InDTIil far

8-·12 weelks ..

( 11 ) Head inj Uf"ies resUil t e i the:r frCIII penetration or impact. The damage' ma y resul t frau direct injurl}' or ma., be secondary to campre.ssion 11 tensd.on 11 or .shear ing fOI'"I-ce.s caused bl)!' the injuryl a Nbte ill ust.r at ions

below ..

'-6.

closed v aul t tl par t of i t may be to,rn away 'I and tiT ain ti ssee may' be extr udJ ing t,hroug~1 the' open i ng .,

the skull is d Lspl.aceo in war'd 1 'i ~ In tile more' severe lnJ ur Les, II 001 i ting and _par-alysiS of 3f.:IlIemu371e~roupmaJY occur,. . The ~~ient DQlay' bleed ~rom the 110«" mout h , or ears 10 the absence of O,b,vlOUlS lnJury to these p.art~+. r.er~bro3pin.a 1 f1 t~id C(lill i n_g, f'r'GmJ th~ I]D se, a ~ ea.!"""' sind Ieate s a grave. 1 nJur~ ., fIlrnlCl11 yael ear 1. iqu:id II cerea rospinal f1 Ull-d necones eloudly when rn ~:ted Wi ttl _11 QfU(31J"l ti tie s a f blood. Sign S 0 f iflcreas1ng intr aCf""at1 ial pt""esstJre

inc.l tJd-e: elevated til DOd pressure , ;slow pul Sf: tl r est.I essness , d ilati.on: 0 f one

, ,th' ,',. ~ d", ',' ',' : ed .- ',,, ',- 't-" 1'1'" .: " d' 'Ii·' i 1~ , JI"'I.,r l··::r"'r"l· t"a'b,"lrl1-t'1}

or 00 I '. pUpl~ S t ,ecrealse, ~ e Spira I Ion ,I c. yan'{)s,.LS, ,e., II; um - .... H loIl"",. JI:Il

81d par.al y.si s , t!nl eas a quail i fi ed per son i.s aV'3JilatJ Le to rei iey-e the pressUT e by operu ng the, skull Ii increased respir-a tor-'Y fad Lur-e , heanr t

fail tIT" e , and death mlay' be ex pected ..

r 3 )- All head in jur res are jl()tenti ally dlang,erDulS! no t onl y because 0 f the iJflli]ed i.a te ti ssue damage and i nerea ~d stlsceptlb il it Y to

in feet.Lon F but al so because 0 f thel pliobab 11 i ty that sone v i tal area Olr

s pee i al sense is OT will became il1rvOIl ved . For these reasons l' i t, is extremel yl imr.of",tant tlhat al I signs and syrmptoms rererab Le to the nerVOUSI .systeml be carefull'i ooted atldi reco'rde(l wi th the t ime of the i r oct! urr-ence or ob;servati,Dln III

(a} Sta te of' conse iousnesa. The fol1m.1n~ desclripti ve adjee:ti ve.s slrDUild be used 'I as appropr iate., to d~fine the state olr CIQIIlSC-iousness ObS'eTVedl '"

Corise ious,. fatien t i;s al ert arnd orzented in time and. s pace .1

(4) Closed he'ad 1311 Jurie s majf be d i fficul t to dl i.agncse + ~at may 1ni tial1y appe ar to be a milnor inj ury 'Ii th no e:-rm,pl ication s ma Y' devel.op .

(wi. tbin 24 hour.s to 2 weeks or 1 anger) i~ to a life threatening probl ern d LIe to gr'adualll "i increasing intr aer' arJ i al prelSSl.l.IriE" It is importan t in head:

iJllj ur'ie.s to get a good] hi st.()ry' at the- time' of injur'Y and do a C:(mlpl ete neurolog Ic al exam (see' Cha pter 1 f Sec ti-on VIl ~ t~~'TY'QU\S System)., 1 f tnere was afn~1' per iad of unconse iousness -r the pa t i.en t: should be pl aced under 005erYat iOI1 for at lea.st. 21~ hours wd.. th frequenl t· neur-ollogical e-xaTlli ria ti.ons .. Yeu should conpare these' e'xfelin.ations to dietermine if t.nere is an ~ d:eter"ior-a-tion in the neur-IDllogic :rindings ..

Con.fused .1 lPatien t is. all er t but di sari ent.ed and eJ[ci ted ..

(For pUlrll=Oses 0 f taking f1 wid S b,y mout.h tl patient i.s conse iQILJ.S • JI The

d i.!5Glr ienta ticln and exe i temmt" wh ich ar-e eot, in k.e@'ping wi th t,he total

st tua t.ion ~ mal)!" bel temlpDlr'"'ar'y and M;ve t:il ps;yc00 l-og Ie all baLSi s in ad:-d i tion to or it"JJ-Stead of bra j,n ili"llj uryl ..

Somlnalent .. responds tel 5timll!a t ion ""

Sem:i-C''OOla'tctse • Pa tief1 t responds to pa inful sttmuiJ.. i but. makes

no spontaneous m:o~'ements. (Fclr pUT poses o f' tak:ing fl uid by' rD:luth,., pat iel'lt is considered iziconsc i.QU5 II }

c: (11)- Assure' .an open a irway . Clear' the ad r passage 0 r an~ vanli tus , mueus , or denr is as neeessar yl i pl ece the pa t.iell t, In eona p:)si.tion ~ turn th.e semiccma tose OT Camel tose pSltien.t franl one side tu the other' every' 201 mlinute,s-. As the patien t !I S cone i t.Ion stalblil izes , t.urning, him ever y ho,uF" llaly be sUirric ient. fJB ill ta in ing an open aill""wa y is· UlS u·a 1 1 "'91 not .3 probleflrl forpat.ients who harvel onI Y' scalp Lacerat.ions ; the fir'st· consider ation wi. th these! pat.ient sis to con trol the prolfuLSe b,l eedi ng ·

CCmlatose "" IPaltient -d ees nail r e'spond to, an y appl. ied st imul us; he .15 uoeorase reus in t,he usual sense ..

(: bl Plipi 1 si ze I' ~,nnally'., ptlpi 15 a f the el,es tend to tlecaneiJer' y ;w,all in the presence a r strong light arid to (j ilate as; t,he

llg,hrt fades., Dilation in the preseru.::e of strong light ind ic:ates Cetl tral nervous system. impai:rmellt.. lffJrmallly 11 ttJe~ pupi 1 s ar'e equal in si ze • Wh-en ~ei t~r eye is obviousl y inj ured and the pl1lpi ls. are a f unequ~l. s.i ze ~ bra in lmpal~rment, should be- asstmed and is, an -crnlioous sign ..

{b) rDntrol bleeding .and prolte(:t w:ltlr1rl,," Place a sterile' _pres.s·ur~ dressing oller t,he ~undl; do not remo¥'e or di st tjrb an y foreign material tlla t. may bel i.n the "WOood; I·eave an y protr ud inK turain ti ssue as i t Is II and applly t.he dressing over' this tissue II

( c) Pr'e-vent or treat .shock., Apply mea5ur'es for' prteventi,on - orl trealbnent 0 f stJock :to with the following f!xc!epti.oll1 s and modi fi~atians :

(c) t\Jsc les .. The musculature on OM olr both, Slides olf the face rna}" diroop due to lac k 0 r stimlullaltian fr{)ffl the brali n through! the

cri3rl ial ner~es serving the facial m.use leaS II Ittere may be loss or impa irment of speech II Paralysis and l.ac~k of tone in the mtJs.ele mess of any _part of the bOO 'I' ~en there is 00 damage to the area nor SUBlli.c i.on olf spinal cordi

d CIllage' i.s pr'es,Lmpti v€' ev idenee of' impa irmen t a f the brai.n area (:ontroll ing, movement 0 f those -mtls~les.

OJ not purt patiefll t in head-lowl prJsi tion ..

El:J not g. i ve' mornhin-e III

I J r

Gi 'J"e neceS3ar y f1 ui~ s by mouth if po.s:sitll e (patient must be' CQnsc iOU5 arnd no t nauseated)" I f required 11 g,i ve thefD ver'y slowly.

(d) "ita!. signs.. The vital sign8-,-tem~ratur'e:t bloOO pressure t .respliratioll--are es:pec ially' impJrtan t inl head injuries since changes in. tlhelse il'ld ices frleq]uentlJ indicate the onset. o,f can:pl ieations, ..

(e)1 He.ad.acbe II na~sea l' dizziness II and, loss olf c.onsc ioul5l1ress {N1ictl malY' be br-'ief Ii intermittent. or e-xtendlej} malY accampany al closed head inj ury ~ de'pend ing UI"-Ofl the p.art.ieula;r' inj ur y and itt 51 sevier i ty . If illjur Y' is f'rtxnl impact wi tb a blunt :sur face ~ an e1 ev ated contusion (brui se)1 fOnn.s when. blood 3rld ottl@r it uids CQllec. t. in a poc·ke t in t,he' subc u tan eou.s ti ssue b,f!,tlleen the dermlis anll the skull; there may be fr actur'e in wich part 0 f

c: d )1 orbse~~~ p.a ti en t . (J).serve tile- ser iOllJsl y injured p.a ti.en t rOr lour a or un t il tle can be transported tol surgery... 11ake and rtecord vi tail Iig,ns, (~ictJ j,nc:ltIle pulse'1" r espdration:t and blc::xx1 pr e'55 ure }I ~f' iod i,e. aa..ly or When p>s.si ble I! Se€'K help fr(J11 professional mea leal per .so nil ell if symptoms lRdlieating in tr acr'ania 1 injury orr incl""eased in trac:rCWl ial pressure appear'.

r .. fr ac tUli'e 0 r t·he fanur ..

, ( 1 ) Usually there i 5 a marked e,i s.p.} acement 0 f the fr agments -due

to eQr] traction 00 f the 1 arg e muscles in the thigh II This usuall y -carr' i@ s

- ribs above .,d below must also be injected to atta in reI ie f ..

(b}l Inject alt least '5 oc ~ of lidocaine a hand- 5 width _IJ"OMilllal. ( toward tnt; spine) wder the margin of the rib after aspir-ating to j,RSure you ar e no t 11] .a blood vessel, ..

II;

91-,-8

varying degree~ of shock due to tran.m.a to the bone and soft tissue and loss of b1.oorl ...

(2) Fi.rst. treat tl1e patient as a whole; rlestore lost blood and n uidl, trea t for shock II r-el, ieve pa in I and al ways make a search for

assocta ted inj ur ies II .

(a l Clean se the :skin. and paint with tincture of ben 7.0 in Ii

_ . (3} I f the frlacturE! is an open one , it should be c le'aned II debT Ided., anc eonver ted to a closed fr .acture a s soon a 5 the patient II 51 condition permits~

CD) Have patient hol.d his breath follo'Wing expiration while JOu appl y two long 3" adhesive wi ps across the wlJlder 0 f the inj ured -side. Str ips should ex tend well dot,l'] oln the atldlonen in the front and to the low'er bac k in the re ar {ill ustra tion below) ...

( .II- ) Tr ac tion mlust be used along with iTiTliTilOlJ il i zat.Ion for all fracturels of the- femlurl... Use Thomas le@ siplint or improrVise' a traction

spl int o f some type... .

('5 } Un ion takes at least ~ 2-l4 we'eks tJ If tbere is. .any doubt., cont in ue the irnroob il i zation "Wi th r"'educ'ed tr action for .fJJ -8 more lileeks.. ~

(6 ) When un ion is s()und. r@lllOVe trac tion and have patient

exerci se the 1 imb and jo in t s [reel yin bed for several da ySI, then allow the pat.Len t to wall k USing crutches un ti 1 you are sure the un ion is sound.,

g ~ Frsct.ur-e Olr the lower jaw {see Chapter 19" Dental rmelrg,encies and Trl-ea tmm t}1 ..

h .. Fr.ac tur-e 0 f the el aril Ic le II]

_. { 1 ) Pa in in s:houlder I' iIljUf' ed shoulder usual.I y lowe-r thal

U1:l~Jl1red shoulder -t' patient cannot raise his arm above his sboul.der 11

pa tlen t u.s ual I y suppor t s tile elbow on th-e af'fec ted sine wi t h oppost te hand: and the f:ractured ends can usual.Ly be fel t under the skin ..

STRAPPING UPPER RIBS.

(2) Pad ax i 11 ae arJdI over the she u lder ..

[.a}1 Appl y a 'pie~e of fe 1 tor foam r:ubber 1-·2~' thick over tte

fracture ..

(3 ) lise tw bel t.s 11 st.r iP5 0 f cloth rl C r avat.s, a r roller band agesl in .a figure eight fashion to bring the shoulders tlPI and back ,

(4) Support the foreann wi.th a sl i,ng_ and sec ure i. t to the bod y to redloo-e movement ~

( bill Hlave- pa t.i.en t hold hi 5 b reattJ fo11OO ng ex pir ation while JOIU applyl 3" adhesi ve str-i ps extend ing tU~lyond the mid 1 i ne an ter ior 1. y and

posteriorly (illustration belo~).

(5) Figlre eight bandage must remain in pI ace for It-6 weeks ..

i", R:ib fracture .. ,

( 1 )1 Pain in breathing and cougning , Plain and tenderness at fracture 51 te are produced by hand pressur e on the' .sternLm.. Sanetimes the fract·lJr-e1 can ble reI t .. p'ati-ent IAStially holds hi s hand tight1'i over th€ ~reak III Ir lungl is punctured 'I the p,ati,oot ma" cough Uip bf"i.gnt red frothy blood .. ,

S TRAPP ING LOWER 11:1 B fRACT'UItES ~I

(2) Treat any penetrating chest VO~dls.. hemottx>r.aI or _pn,el.J11Cthorax (see Chapter l-6 tJ B"oergency War Surg;er r) ..

, _ (3) Control pa in and! apprehension f but alvoid d rugs, that depress

~he reSplraltolT y and cough reflex een ter.s Ii fa in is best r'el ieved by l.ntereostal bl.oeks {repelated as n ece.ssary) II-

(6} M a1. ternate method for fr ac tures a f upper and lower ribs is 10 apply .a 6-8~r' elasl i.e bandage eoc i Tel ing the tr Wlk frem bel,o w the' eost.al -cage- to j U5t below the level of thel n ippl.es , (:see, illlJ.Jstlf"ation below.)

{ a) Inj set.ion 0 r one r i b rna y be effecti ve , but usuall f the-

9-9

_::: - Il

'- - .>" ..

9.-10

r.reque'n tl Y accanpan Led b'i frat! tur es land st.rue lures such as blood y esse 1 s , nerves, and soft tissu~ :5lJlrrounding the joint may be injured ..

b... Sy,mptoos are pain t defonnit.y F swelling I' d i.scol.or-at.Lon tJ and usual l y 8 105.:3 of mot ion , In sever-e cases, shock rnay be present ..

c .. Treatmen t .

STRAPPING xrrn ELAsrrI( BANDAGE OR MUSLIN DRESS1.NG_

( , ) Di sl oc alian s should bel red uced as soon as. p:J5sib l.e . Muse 1 es .surrounding the joint suff'er: .a shack and you have a per i od of 1 i t.t.l e or no pain" but as thE muscles r-eco~er 1" they try to p~ll the ~.Qf1e hack into, the, j~in t b." cur. tr.ac t.Lng , The longer the bone is 0 ut, 0 f jQllfi t the st.ronger the contractions and tbe more d amage is done to the surround ing t i.ssue _ By' the sane token t tile s.tronger the eon tract ion 5, the ITI()r€ severe- the pain and the harder it is to reduce the di.sl ccat.i.on ...

{ a} MJr pil in e or Dernrerol should be· used in major di slocations to. reI iev.e pa in arld r el.ax th€ rouse} es II

j .. F"rr'oc: ture'5 of ringer.s 0 f" toes III

(2) Tape fractur-ed fiJ1~er or toe to ad j aoen t finger or toe ..

(b) The, principle to fo,l!ow in the' reduct ion of dislocat.ion sis, to (lull the bone straight out and away from the join t and allow the rmu.s~le.s to pul I the bone back into the joint by gradually releasing the, preScSur e exerted.

( II H'anuall't man Lpul.a te fracture' into pos.i tion ..

(3 ) lfn ion takes 2-6 weeks-t-

(c) Onc,e the dislocation has been red~ed j the- patient :sbauld feel inned iate re 1 ier ..

9-2.. SPRA INS ..

a. A SP'" ain is caused wrt,em a jo in t is stretched beyond its, normal range 0 f mot.io n causing a stretching 0 f tile join t ca psul e and the 1 iganents s.~rromding the capsul e-s-some f'i ber.s tear- but. the cont.Inut ty of the structur e rena ins in tact.. The anount 0 f te ar ing 0 r the 1 igament.s detennill'les t ne seY'erity of the sprain ..

( d) Ole{: k -d i st.al capi 11 ar:.' fi 11 ing 0 r the na i 1 bed s :p. bllanc-hing ,I pul.s.€ (puls€ may or m~y not be present) • eolor' (look for eyaoolsi.s or pal Ior ) tJ and w'a,rmth a f ex tre.-m it y t.o in sure adequa te per i tiler al circulation ..

bit Symptan.s are ver y sharp pa in at the t ime 0 f inj ur 1 aeccmpan Led bJ= a sensa t,ioTl 0 f no suppor t in ttlat particuLl.ar· .join t , In add i t Ion , there is rapid .swelling .and 1033 or decrease of function in the joint.

'l , If c ir c ul.ation is i nsufric i&l t!l you will haJye, severe pa In in the fl ex or- musctes , swell i,ng tJ coldness 1" c y.anosi 5 ::J r pallor tJ and parallysis .and/or impairment of sensat.ions .

e .. Treatmm t ..

2., Treatmen t should be star ted i..mne<I ia t.el y .. Treat 8.}mptornatica11 y .. He T ieve anythi ng tha t m;a:; cause c ircuLlatory

im~ Lrmen t "- Appl Y trac t ion and ice packs (to r el i eve sW'ell i ng_)., 1 f .a fter

. 2 hour s c ircul a tory impa i.rmen tis not re 1 Ieved , make S-sh.aped Inc i ston over

the jOlin t ali1d €l: tend ing di st.al Ly. Inci se the f'asc i a and r83fl.rDVe the

hemartom.a • Thi 5 ma~ be suffic ien ~ to .allol'W the collateral bl-ooJ sUllpl y to

rei ieye- the- c i rcul.ator y insuffic ier.rc 'i 1M ( If i tis nece.ssar- y to r-e pa i.r

ar'teries F see Chapter 16, Emergency Yair Surger., II)

{ 1 )1 S.pr aie S sboul.d be irmnob'll Lzed ei. tiler by cast or taping depend ine on tbeir sever it:f· ..

(.a} Hem.a't:Jm.as around the 5pr ai.ned join t ~:uall'y denote a severe s pr.a in afld should be s _pl i~ted or' put, in .a caJst for at lea st 3: we·eks _

(b) Mioo1r sprains sh~ould be taped to suppert the ligaments an d &1 ve tJn.em t imre- WI heal .

( e) After d i sl ocat ion ha s !leen r edue ed and blood suppl 'i 15 ooaqua te t in:mobil i ze the j oint for at Least 1 w~eks.,

(2) Keep, ttte' joint at rest. and el evate the par t if poss.ibIe ..

9-fl... S rRAlr~'S ..

{3} App,l y cold cCITJ~es:se s irnmed rat.el Y' a rter the' injury and for the fi r st 2iJ. bocr s , then appl Y' heat to r e 1 i.eve pa in and prooote

c i reu 1 a tion ..

a.. Strains a~e duel to overstretchi~g or overexert.ing, a muse] e or tendon I' causa ng a tear tng or rupt ure II

91- 3 - !lISLOCATION ..

b .. Symplo~s ar e a shar p pa in and c r a:nps i~edl iatel y upon 1 nJ ury' l' .!llNell i ng I redness,. heat. an ell lass. -0 f rune t ion.

e .. Irea tznerrt .

a. _ A d i sloe at ion star·ts the same as a spr ai.n but continue s un ti 1 the 1 iganrents. ar-e tarn and t he bone' pull s out of t he join t caps ule , 111i 5 displacement of bone' may ~ either partial Of" cc.mplete _ [JislccatiorLs ar e

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