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Moreover, fear exists that other closely related orthopoxviruses (such as monkeypox or cowpox) might be genetically manipulated to produce variola-like disease. Subjective: Symptoms Begin abruptly with malaise, fever, rigors, headache, backache, and vomiting. Objective: Signs Using Basic Tools: Characteristic rash appears 2-3 days after the onset of symptoms; all lesions progress synchronously from macules to papules to pustules, and are concentrated on the hands, face and trunk; fever and mental status changes; complications include viral sepsis, hepatic insufficiency, encephalopathy, skin hemorrhage. Assessment: Differential Diagnosis chickenpox (lesions in various stages of progression and not concentrated on the trunk), monkeypox, enteroviral exanthems (such as hand-foot-mouth disease). Caregivers should employ airborne and contact precautions when dealing 6-59 6-60 with patients. At a minimum, mask either the casualty or the health-care team and close contacts. Those immunized within the first several days after exposure may be protected against the development of smallpox. Quarantine contacts for 17 days (incubation period) to ensure they will not be secondary cases. Biological Agents: Tularemia Introduction: Tularemia is caused by infection with Francisella tularensis, a gram-negative coccobacillary organism. Although several forms are known, the pneumonic or typhoidal forms of the disease would likely occur after intentional aerosol delivery. Subjective: Symptoms Fever, malaise, fatigue, cough, shortness of breath and abdominal pain. Objective: Signs Using Basic Tools: Fever, tachycardia, tachypnea, dyspnea, cyanosis, diaphoresis, rales, hypotension, and abdominal tenderness and pneumonia and sepsis later. Assessment: Differential Diagnosis other forms of pneumonia (both conventional etiologies and other potential biological weapons: plague, staphylococcal enterotoxins); sepsis caused by other gram-negative bacteria, typhoid fever, anthrax. Patient Education General: Tularemia is not typically contagious; caregivers need only employ standard precautions when dealing with patients. Prevention: Start asymptomatic persons thought to have been exposed to tularemia via aerosol on oral doxycycline (100 mg every 12 hours). Try other fluoroquinolones or tetracycline if doxycycline or ciprofloxacin is unavailable. They share a propensity to cause bleeding but otherwise vary considerably in their clinical manifestations and severity. Subjective: Symptoms Fever, malaise, myalgias, headache, photophobia, vomiting, diarrhea, abdominal pain, cough and dizziness. Other symptoms: hematuria, hypotension, shock, edema, hepatic tenderness (hepatic failure), pharyngitis, hyperesthesias. Using Advanced Tools: Lab: Blood culture to rule out meningococcemia and typhoid fever. Assessment: Differential diagnosis any cause of a bleeding, diathesis or disseminated intravascular coagulation (both conventional causes as well as plague): dengue (which can cause hemorrhagic fever but is not transmissible by aerosol), malaria, typhoid fever, meningococcemia, rickettsial diseases, leptospirosis, shigellosis, fulminant hepatitis, leukemia, lupus, hemolytic-uremic syndrome, and thrombocytopenic purpuras. Most of these conditions are discussed in this book and can be differentiated based on differences in presentation and laboratory findings. Plan: Treatment Primary: Supportive (oxygen, intravenous fluids, and antipyretics). At a minimum, this entails wearing gloves when touching the patient and disinfecting medical equipment (such as stethoscopes) between patient encounters. Follow-up Actions Evacuation/Consultant Criteria: Consult early with preventive medicine experts. Quarantine contacts for 21 days (incubation period) to ensure they will not be secondary cases. Shorten the quarantine period to reflect the appropriate incubation period when a definitive diagnosis is available. Lumbar punctures may be necessary to rule out meningitis in patients with meningeal signs and/or altered mental status. Prodrome: (within hours of exposure) nausea, vomiting, diarrhea, fatigue, weakness, fever and headache; time to onset, duration and severity of these symptoms varies with radiation dose received. Relatively symptom-free latent phase, lasting 2-6 weeks depending on dose received. Clinical symptoms in the affected major organ system (hematopoietic, gastrointestinal, neurovascular). Assessment: Differential Diagnosis radiogenic vomiting may be confused with psychogenic vomiting that often results from stress and fear reactions.

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The vesicles rupture easily and release a thin, yellow, cloudy fluid which subsequently dries to a characteristic honey crust. Groups of lesions may have satellite autoinoculated lesions at the periphery (see Color Plates Picture 8). Using Advanced Tools: Lab: Gram stain of early vesicular lesions reveals gram-positive intracellular cocci in clusters or chains. Assessment: Differential Diagnosis Varicella, herpes simplex, bullous tinea, allergic contact dermatitis (see appropriate topics in this book). Plan: Treatment Primary: Dicloxacillin 250-500 mg po qid x 10 days Alternative: Keflex (250 to 500 mg bid to tid); erythromycin (250 mg po qid) Empiric: A high bacterial load may stimulate a super antigen reaction and aggravate the disease process. To decrease the bacterial load, wash the area with Hibiclens soap (chlorhexidine gluconate) once daily until cutaneous lesions clear. Mycobacterium tuberculosis infects almost 2 billion people in the world (about 1 out of 3 living humans). It is an acid-fast, aerobic, gram-positive bacterium with both human and bovine forms. Subjective: Symptoms Most are asymptomatic, some have a painless nodule progressing to painful ulcer, itching is uncommon. Assessment: Differential Diagnosis Primary Skin Inoculation primary syphilis, tularemia, cat scratch disease, sporotrichosis, and others. Primitive: None effective Empiric: Basic health measures, including clean and nutritious food and water, immunizations, and sanitation to help fight the infection. There is a risk of re-infection from trauma and exposure to the organism in meat handlers, veterinarians and staff and persons involved in autopsies and undertaker duties. Medications: Some medications can be toxic, so periodic blood tests are necessary during treatment. Within 1-2 months, refer to dermatologist or infectious disease specialist for complete evaluation and choice of multiple drug therapy. Leprosy is endemic in India, sub-Saharan Africa, South and Central America, the Pacific Islands and the Philippines. Most patients in the United States have a history of exposure to armadillos, a natural host for M. Subjective: Symptoms Hypopigmented or reddish skin lesions with decreased or no sensation. Objective: Signs Using Basic Tools: Circular patches and plaques with variable color including erythema, hyperpigmentation, or hypopigmentation; tissue swelling with nodules or ulcerations; lesions are common on the face, ears, and extremities. Plan: Treatment Dapsone, rifampin and clofazimine in combination as per specific protocols. Follow-up Actions Evacuation/Consultation Criteria: Evacuate to receive specialty care. Subjective: Symptoms One usually reports a history of contact with ungulates (sheep, goats, yaks), or cattle. Objective: Signs Using Basic Tools: In Milkers nodule primary lesion is a deep erythematous papule (or small group of papules that enlarges) gradually into a firm, smooth, hemispherical nodule varying in size up to 2 cm in diameter. The most common location is the dorsum of the index finger on the dominant hand due to handling the livestock or items within the livestock area. Assessment: Diagnosis based on clinical morphologic criteria and history of exposure to infected bovine or ungulate livestock or livestock areas. Differential Diagnosis Erysipelas, erysipeloid, atypical mycobacterium, bacillary angiomatosis, cat-scratch disease, leishmaniasis, pyogenic granuloma. Patient Education General: There are no effective vaccines for Milkers nodules or human orf available for livestock. Prevention and Hygiene: Keep wounds clean and covered to aid in healing and decrease secondary infection.


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Only uncontrolled studies were available and they had small sample sizes (<25 patients). For individuals who have peritoneal mesothelioma who receive cytoreductive surgery and perioperative intraperitoneal chemotherapy, the evidence includes retrospective cohort studies and systematic reviews. Relevant outcomes are overall survival, disease-specific survival, quality of life, treatment related mortality and treatment-related morbidity. Reported procedure-related morbidity and mortality were approximately 35% and 5%, respectively. Although no appropriate comparative studies have been published, multiple studies have shown consistant, long-term overall survival with the use of this technique. Because the prevalence of peritoneal mesothelioma is very low, conducting high-quality trials is difficult. Relevant outcomes are overall survival, disease-specific survival, quality of life, treatment-related mortality and treatment-related morbidity. Results of at least some of these studies were confounded by prognostic factors (completeness of cytoreduction, extent of peritoneal carcinomatosis, chemosensitivity to platinum). For individuals who have appendiceal goblet cell tumors who receive cytoreductive surgery and perioperative intraperitoneal chemotherapy, the evidence includes case series. Relevant outcomes are overall survival, disease-specific survival, quality of life, treatment related mortality and treatment related morbidity. The evidence is insufficient to determine the effects of the technology on health outcomes. Billing/Coding/Physician Documentation Information this policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at Applicable service codes: 77605, 96446, 96549 When performed using a temporary catheter or performed intraoperatively, the unlisted code 96549 (unlisted chemotherapy procedure) would be reported. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included. Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer. Page 5 of 8 An Independent Licensee of the Blue Cross and Blue Shield Association Hyperthermic Intraperitoneal Chemotherapy National Comprehensive Cancer Network. Specialty Matched Consultant Advisory Panel 8/2009 National Comprehensive Cancer Network. New indication for When Covered states the following: Cytoreduction and hyperthermic intraperitoneal chemotherapy for the treatment of pseudomyxoma peritonei may be considered medically necessary. The When Covered section updated to indicate; Cytoreductive surgery and perioperative intraperitoneal chemotherapy for the treatment of pseudomyxoma peritonei may be considered medically necessary. Cytoreductive surgery and perioperative intraperitoneal chemotherapy for the treatment of diffuse malignant peritoneal mesothelioma may be considered medically necessary. The When Not Covered section updated to indicate: Cytoreductive surgery and perioperative intraperitoneal chemotherapy is considered investigational for gastric cancer or endometrial cancer; ovarian cancer, including fallopian tube and peritoneal cancer; and all other indications, including goblet cell tumors of the appendix. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and subscriber certificate that is in effect at the time services are rendered. This document is solely provided for informational purposes only and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. Page 8 of 8 An Independent Licensee of the Blue Cross and Blue Shield Association. Menstruation starts at puberty and it stops temporarily during pregnancy but permanently at menopause. At least 30 percent of women have irregular periods during their child bearing years.

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He appears jaundiced, his chest is clear to auscultation, and his heart rhythm is regular without murmurs. Laboratory values are significant for a normal complete blood count, creatinine 1. He has had 12 different lifetime sexual partners and currently is taking acetaminophen. Results of his laboratory studies are consistent with severe hepatocel lular injury and somewhat impaired hepatic function. Understand the use of viral serologic studies for diagnosing hepatitis A, B, and C infections. Know the prognosis for acute viral hepatitis and recognize fulminant hepatic failure. Understand the use of the acetaminophen nomogram and the treatment of acet aminophen hepatotoxicity. Considerations this patient has an acute onset of hepatic injury and systemic symptoms that predate his acetaminophen use. The markedly elevated hepatic transaminase and bilirubin levels are consistent with viral hepatitis or possibly toxic injury. This patient denied intravenous drug use, which would be a risk factor for hepatitis B and C infections. In this case, it is important to consider the possibility of acetaminophen toxicity, both because the condition can produce fatal liver failure and because an effective antidote is available. At least six viruses that cause hepatitis have been identified, referred to as hepatitis A, B, C, D, E, and G. They can produce virtually indistinguishable clinical syndromes, although it is unusual to observe acute hepatitis C. This is followed by the onset of visible jaundice caused by hyperbilirubinemia, with tenderness and enlargement of the liver, and dark urine caused by bilirubinuria. The clinical course and prognosis vary based on the type of virus causing the hepatitis. Hepatitis A and E both are very contagious and transmitted by fecal-oral route, usually by contaminated food or water where sanitation is poor, and in daycare by children. Hepatitis A is found worldwide and is the most common cause of acute viral hepatitis in the United States. Hepatitis E is much less common and is found in Asia, Africa, Central America, and the Caribbean. Both hepatitis A and E infec tions usually lead to self-limited illnesses and generally resolve within weeks. Almost all patients with hepatitis A recover completely and have no long-term complica tions. Most patients with hepatitis E also have uncomplicated courses, but some patients, particularly pregnant women, have been reported to develop severe hepatic necrosis and fatal liver failure. Hepatitis B is the second most common type of viral hepatitis in the United States, and it is usually sexually transmitted. It also may be acquired parenterally, such as by intravenous drug use, and during birth from chronically infected mothers. Up to 90% of infected newborns develop chronic hepatitis B infection, which places the affected infant at significant risk of hepatocellular carcinoma later in adulthood. For individu als infected later in life, approximately 95% of patients will recover completely with out sequelae. Between 5% and 10% of patients will develop chronic hepatitis, which may progress to cirrhosis. A chronic carrier state may be seen in which the virus continues to replicate, but it does not cause irreversible hepatic damage in the host.

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Removal of dust by a dry vacuum machine followed by wet vacuuming is effec tive in cleaning and disinfecting hospital floors. Cabinet counters, work surfaces, and similar horizontal areas may be sub ject to heavy contamination during routine use. Walls, windows, and storage shelves may be reservoirs of pathogenic micro organisms if visibly soiled or if dust and dirt are allowed to accumulate. Infants who remain in the nursery for an extended period should be transferred periodically, as per hospital policy, to a different, disinfected unit. Mattresses should be replaced when the surface covering is broken; such a break precludes effective disinfection or sterilization. Infection Control 459 Evaporative humidifiers in incubators usually do not produce contaminated aerosols, but contaminated water reservoirs may be responsible for direct, rather than airborne, transmission of infection. If humidification is necessary, a source of humidity external to the incubator may be preferable to incubator humidifiers. Nebulizers,Water Traps, and Respiratory Support Equipment Nebulizers and attached tubing should be replaced by clean, sterile equipment (or equipment that has been subjected to high-level disinfection) in accor dance with established hospital policy. Failure to replace tubing may result in contamination of freshly cleaned equipment. Water traps also should be replaced regularly by autoclaved or disinfected equipment. Only sterile water should be used for nebulizers or water traps; residual water should be discarded when these containers are refilled. Other Equipment Cleaning and disinfection or sterilization of equipment should be performed between patients. Alternately, the equipment may be subjected to high-level disinfection with liquid chemicals or by pasteurization. In-line, closed suctioning systems are thought to reduce the risk of spreading potential pathogens from the airway of intubated patients. Each delivery of clean linen should contain sufficient linen for at least one nursing shift. An established procedure for the disposal of soiled linen should be followed strictly. Chutes for the transfer of soiled linen from patient care areas to the laundry are not acceptable unless they are under negative air pressure. Plastic bags of soiled linen should be sealed and removed from the nursery at least twice a day. Sealed bags of reusable, soiled nursery linens should be taken to the laundry at least twice each day. Laundering Nursery linens should be washed separately from other hospital linen and with products used to retain softness. Acidification neutralizes the alkalis used in the washing process and is responsible for the greatest bacterial destruction. Home laundering of soiled surgical scrubs: surgical site infections and the home environment. The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations. All women who will be pregnant during inuenza season (October through May) should receive inactivated inuenza vaccine at any point in gestation. Modified with permission from March of Dimes Birth Defects Foundation, Committee on Perinatal Health. The educational require ments assume that applicants have achieved a doctor of medicine or doctor of osteopathy degree.


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Treating and optimizing these disorders preoperatively will: s Improve the overall oxygen supply to the tissues s Reduce the possibility of a transfusion becoming necessary at operation. Coagulation disorders Undiagnosed and untreated disorders of coagulation in surgical patients are very likely to result in excessive operative blood loss. It is essential to make a careful preoperative enquiry into any unusual bleeding tendency of the patient and his or her family, together with a drug history. If possible, obtain expert haematological advice before surgery in all patients with an established coagulation disorder. Surgery and acquired coagulation disorders Bleeding during or after surgery is sometimes very difficult to evaluate. It may simply be caused by a problem following surgical intervention, in which case re-operation may be necessary. Regular assessment of the patient in the perioperative period is essential to detect unexpected bleeding. Prophylactic measures and the availability of platelet concentrates for transfusion are invariably required for surgery in this group of patients. Platelet transfusions should be given if there is clinical evidence of severe microvascular bleeding and the platelet count is below 50 x 109/L. Anticoagulants: warfarin (coumarin), heparin In patients who are being treated with anticoagulants (oral or parenteral), the type of surgery and the thrombotic risk should be taken into account when planning anticoagulant control perioperatively. This dose may need to be repeated to bring coagulation factors to an acceptable range. Techniques to reduce operative blood loss the training, experience and care of the surgeon performing the procedure is the most crucial factor in reducing operative blood loss. Vasoconstrictors 1 Infiltrate the skin at the site of surgery with a vasoconstrictor to minimize skin bleeding once an incision is made. If the vasoconstrictor also contains local anaesthetic, some contribution to postoperative analgesia can be expected from this technique. Ensure these drugs remain at the site of incision and are not injected into the circulation. Tourniquets 1 When operating on extremities, reduce blood loss by the application of a limb tourniquet. Anaesthetic techniques 1 Prevent episodes of hypertension and tachycardia due to sympathetic overactivity by ensuring adequate levels of anaesthesia and analgesia. Antifibrinolytic and other drugs Several drugs, including aprotinin and tranexamic acid, which inhibit the fibrinolytic system of blood and encourage clot stability, are used to reduce operative blood loss in cardiac surgery. Fluid replacement and transfusion Provided blood volume is maintained with crystalloid or colloid fluids, the patient can often safely tolerate significant blood loss before transfusion of red cells is required, for the following reasons. This safety margin 164 between oxygen supply and demand allows some reduction in haemoglobin to occur without serious consequences. This allows the cardiac output to increase and sustain the oxygen supply if the haemoglobin concentration is falling. This reduces its viscosity and improves both capillary blood flow and cardiac output, enhancing the supply of oxygen to the tissues. A key objective is to ensure normovolaemia at all times during the course of a surgical procedure. Estimating blood loss In order to maintain blood volume accurately, it is essential to continually assess surgical blood loss throughout the procedure. This is especially important in neonatal and infant surgery where only a very small amount lost can represent a significant proportion of blood volume. Monitoring for signs of hypovolaemia 1 Many of the autonomic and central nervous system signs of significant hypovolaemia can be masked by the effects of general anaesthesia. Patients under a general anaesthetic may show only very few signs that hypovolaemia is developing.

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Facilities that oper Pre-schooler care routines to entry into months ate part-day, in the evening, during the traditional work day regular school and work week, or during a specifc part of the year may call Entry into regular school, School-Age themselves by different names. These standards recognize 5-12 years including kindergarten Child that while childrens needs do not differ in any of these through 6th grade settings, the way childrens needs are met may differ by whether the facility is in a residence or a non-residence and Format and Language whether the child is expected to have a longer or only a very Each standard unit has at least three components: the short-term arrangement for care. Standard itself, the Rationale, and the applicable Type of A Small family child care home provides care Facility. Most standards also have a Comment section, a and education of one to six children, including the Related Standards section and a References section. The caregivers/teachers own children in the home of the reader will fnd the scientifc reference and/or epidemiologi caregiver/teacher. Family members or other helpers cal evidence for the standard in the rationale section of each may be involved in assisting the caregiver/teacher, but standard. The Rationale explains the intent of and the need often, there is only one caregiver/teacher present at any for the standard. If such a professional consensus A Large family child care home provides care and has been published, that reference is cited. The Rationale education of seven to twelve children, including the both justifes the standard and serves as an educational caregivers/teachers own children in the home of the tool. The Comments section includes other explanatory caregiver/teacher, with one or more qualifed adult information relevant to the standard, such as applicability of assistants to meet child: staff ratio requirements. Although this document of any number of children in a nonresidential setting, refects the best information available at the time of publica or thirteen or more children in any setting if the facility is tion, as was the case with the frst and second editions, this open on a regular basis. Measurability is important for performance standards Although we recognize that designated age groups and de in a contractual relationship between a provider of service velopmental levels must be used fexibly to meet the needs and a funding source. Concrete and specifc language helps of individual children, many of the standards are applicable caregivers/teachers and facilities put the standards into to specifc age and developmental categories. Where a standard is diffcult to measure, we have categories are used in Caring for Our Children. We encourage readers to seek interpretation by appropriate specialists when needed. Where feasible, we have written the standards to be understood by readers from a wide variety of backgrounds. Relationship of the Standards to Laws, Ordinances, and Regulations the members of the technical panels could not annotate the standards to address local laws, ordinances, and regula tions. Many of these legal requirements have a different intent from that addressed by the standards. Users of this document should check legal requirements that may apply to facilities in particular locales. In general, child care is regulated by at least three different legal entities or jurisdictions. Building inspectors enforce building codes to protect life and property in all buildings, not just child care facilities. Some of the standards should be written into state or local building codes, rather than into the licensing requirements. A number of different codes are intended to prevent the spread of disease in restaurants, hospitals, and other institutions where hazards and risky practices might exist. Many of these health codes are not specifc to child care; however, specifc provisions for child care might be found in a health code. Some of the provisions in the stan dards might be appropriate for incorporation into a health code. Usually, before a child care operator receives a license, the operator must obtain approvals from health and building safety authorities. Sometimes a standard is not included as a child care licensing requirement because it is covered in another code. Since children need full protection, the issues addressed in this document should be addressed in some aspect of public policy, and consistently addressed within a community. In an effective regulatory system, differ ent inspectors do not try to regulate the same thing. Includes recom Lowered ratios for infants and toddlers to be more in line mends procedures and policies for handling challenging with small family child care.

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For children with moderate to severe croup, oral or intramuscular dexamethasone, nebulized epinephrine, and nebulized budesonide are associated with clinically significant reductions of symptoms as compared to placebo. His mother states that he is now taking very little fluid, only a couple of sips in the last 2 hours. On physical examination, the child is lying on the examining table and appears somewhat listless, but is able to select a video on his tablet computer. His eyes are sunken, mucous membranes are dry, and skin is cool to the touch with mildly reduced turgor. Dehydration occurs when fluid is lost from the extracellular space faster than it is replaced. This is a common presenting complaint at visits to the pediatrician, and is a leading cause of mortality in children worldwide. Gastrointestinal illness with volume losses through vomiting and diarrhea, combined with decreased fluid intake, is the most common cause of dehydration in children. When dehydration occurs, the body shifts fluid from the intracellular to the extracellular space, and conserves fluid by decreasing urine output via release of antidiuretic hormone. The mainstay of treatment for dehydration, aside from addressing the primary cause, is intravenous or oral fluid replacement. To assess the degree of volume loss, the childs weight can be compared to baseline, if available. Other clinical signs and symptoms used to assess the degree of dehydration are found in Item C181. Laboratory data can be useful to further clarify the degree and type of dehydration in children with moderate to severe dehydration. They are unlikely to have abnormal laboratory findings, and thus this testing is not indicated. For children with hypo or hypernatremic dehydration, estimation of dehydration based on clinical signs and symptoms can be inaccurate. In hyponatremic dehydration, the degree of dehydration can be overestimated because of the tendency for fluid to shift from the extracellular to the intracellular spaces, thus causing more severe symptoms; the opposite is true for hypernatremic dehydration. Therefore, children who appear to have moderate dehydration should be continually assessed during attempts at oral rehydration. However, if intravenous fluids are indicated, obtaining a serum sodium level can be helpful. If abnormal (<130 or >150 mEq/L), this information can be used to adjust the estimated degree of dehydration, as well as guide changes in the type of fluid needed to restore water and sodium balance. Other laboratory values, such as serum bicarbonate, blood urea nitrogen, and urine specific gravity, may change based on the degree of dehydration, but are nonspecific and do not substitute for estimation of hydration status based on clinical signs and symptoms. Dehydration: Isonatremic, hyponatremic, and hypernatremic recognition and management. The only notable physical findings are an area of hair loss near the vertex and several erosions (Item Q182). The presence of crusted erosions suggests that pustules, present as part of an inflammatory response, have ruptured. These findings suggest the diagnosis of tinea capitis, and treatment with oral griseofulvin is indicated. Item C182A: Tinea capitis with black-dot hairs (yellow arrows) and crusted erosions (blue arrow). Krowchuk Traction on hairs, often the result of tight braiding, may produce folliculitis and ultimately alopecia (Item C182B). In severe cases, therapy with an oral antibiotic, like cephalexin, may be required. Alopecia areata is characterized by well-defined areas of hair loss, but the scalp appears normal and black-dot hairs are not present. If treatment is warranted, a potent topical corticosteroid (eg, fluocinonide) is recommended, often in conjunction with topical minoxidil. Krowchuk Seborrheic dermatitis of the scalp results in scaling but not localized alopecia. First-line treatment is an anti-seborrheic shampoo containing zinc pyrithione or selenium sulfide. For reasons that are unclear, African American children are disproportionately affected.

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The indirect fuorescent antibody test is the preferred serologic assay, but enzyme immunoassay and dot immunoassay tests also are available. Specifc molecular assays, iso lation, and an immunohistochemical assay for typhus group rickettsiae in formalin-fxed tissue specimens are available at the Centers for Disease Control and Prevention. Doxycycline has not been demonstrated to cause cosmetic staining of developing perma nent teeth when used in the dose and duration recommended to treat rickettsial diseases. Treatment should be continued for at least 3 days after defervescence and evidence of clinical improvement is documented, usually for 7 to 14 days. To halt the spread of disease to other people, louse-infested patients should be treated with cream or gel pediculicides containing pyrethrins or per methrin; malathion is prescribed most often when pyrethroids fail. In epidemic situations in which antimicrobial agents may be limited (eg, refugee camps), a single dose of doxy cycline may provide effective treatment (100 mg for children; 200 mg for adults). Precautions should be taken to delouse hospitalized patients with louse infestations. Several applications of pediculicides may be needed, because lice eggs are resistant to most insecticides. During epidemics, insecticides dusted onto clothes of louse-infested populations are effective. Prevention and control of fying squirrel-associated typhus requires application of insecticides and precautions to prevent contact with these animals and their ectoparasites and to exclude them from human dwellings. Without treatment, the disease usually resolves within 1 to 6 months, although asymptomatic infection may persist. There also has been an incon sistent relationship with U urealyticum infection and prostatitis and epididymitis in men and salpingitis, endometritis, and chorioamnionitis in women. Some reports also describe an association between infection and infectivity and recurrent pregnancy loss. U urealyticum has been isolated from the lower respiratory tract and from lung biopsy specimens of preterm infants and contributes to intrauterine pneumonia and chronic lung disease of prematurity. Although the organism also has been recovered from respi ratory tract secretions of infants 3 months of age or younger with pneumonia, its role in development of lower respiratory tract disease in otherwise healthy young infants is controversial. U urealyticum has been isolated from cerebrospinal fuid of newborn infants with meningitis, intraventricular hemorrhage, and hydrocephalus. The contribution of U urealyticum to the outcome of these newborn infants is unclear given the confounding effects of preterm birth and intraventricular hemorrhage. Isolated cases of U urealyticum arthritis, osteomyelitis, pneumonia, pericarditis, men ingitis, and progressive sinopulmonary disease in immunocompromised patients have been reported. The genus Ureaplasma contains 2 species capable of causing human infection, U urealyticum and Ureaplasma parvum. Colonization occurs in approximately half of sexually active women; the incidence in sexually active men is lower. Colonization is uncommon in pre pubertal children and adolescents who are not sexually active, but a positive genital tract culture is not clearly defnitive of sexual abuse. Transmission during delivery is likely from an asymptomatic colonized mother to her newborn infant. U urealyticum may colonize the throat, eyes, umbilicus, and perineum of newborn infants and may persist for several months after birth. Because U urealyticum commonly is isolated from the female lower genital tract and neonatal respiratory tract in the absence of disease, a positive culture does not establish its causative role in acute infection. However, recovery from an upper genital tract or lower respiratory tract specimen is much more indicative of infection. Several rapid, sensitive polymerase chain reaction assays for detection of U urealyticum have been developed and have greater sensitivity than cul ture but are not available routinely. Serologic testing for U urealyticum antibodies is of limited value and should not be used for routine diagnosis. Mycoplasmas generally are susceptible to tetracyclines (eg, minocycline, doxycy cline) and quinolones, but because they lack a cell wall, mycoplasmas are not susceptible to penicillins or cephalosporins. For symptomatic older children, adolescents, and adults, doxycycline is the drug of choice. Persistent urethritis after doxycycline treatment can occur by doxycycline-resistant U urealyticum or Mycoplasma genitalium. Antimicrobial treatment with erythromycin has failed both in small randomized trials and in reports of cohort studies in pregnant women to prevent preterm delivery and in preterm infants to prevent pulmonary disease.


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Multiple short periods of rest throughout the day are better than one large period. Other methods of unloading an osteoarthritic joint include canes and walkers, which can reduce joint forces at the hip by as much as 50%. Equipment such as canes and/or walkers are helpful for patients with advanced disease because these patients are less stable and, as a result, have frequent falls. Physical therapy in the form of heat applied to the affected joints in early disease often is helpful. Perhaps the most important intervention is having the patient maintain full/near-full range of motion with regular exercise. Moist superficial heat can raise the threshold for pain, produce analgesia by acting on free nerve endings, and decrease muscle spasm. Pharmacotherapy early in the course of the disease consists primarily of acetaminophen, the mainstay of therapy. Most findings suggest that glucosamine and chondroitin have little benefit in patients with osteoarthritis. There appear to be few risks associated with their use, however, so patients who wish to try those remedies can be advised that they appear to be relatively safe. Although they are associated with less gastroduodenal toxicity, concerns about an increased risk of cardiovascular adverse events has limited their use. Intra-articular steroids may be rarely useful for long-term treatment and can be helpful for the rare inflammation of a loose cartilage fragment, which may cause the joint to lock up. Improvement throughout the day after approximately 1 to 2 hours of unfreezing the joint Match the following disease processes (A-F) to the clinical setting described in Questions 56. Degenerative joint disease is a major cause of decreased functional status in elderly patients and requires ongoing treatment and evaluation by the physician to try to improve symptoms and to promote mobility. Gouty arthritis often affects the rst metatarsophalangeal joint and can be precipitated by various foods or alcohol. Cervical discharge and inammatory joint are consistent with gonococcal arthritis, which can also present as a migratory arthritis. Acetaminophen is the rst agent of choice in the treatment of early osteoarthritis. Pain in osteoarthritis is worsened with activity and is not associated with morning stiffness. Joint replace ment for severe osteoarthritis is reserved for patients with intractable pain despite medical therapy and for those with severe functional limitations. He became diaphoretic and began to experience chest pain, similar to that of his recent myocardial infarction. Coronary angiography performed prior to discharge revealed no significant coronary artery stenosis. His blood pressure is 124/92 mm Hg while lying down but drops to 95/70 mm Hg upon standing. His neck veins are flat, his chest is clear to auscultation, and his heart rhythm is tachycardic but regular, with a soft systolic murmur at the right sternal border and an S4 gallop. His abdomen is soft with active bowel sounds and mild epigastric tenderness, but no guarding or rebound tenderness, and no masses or organomegaly are appreciated. Rectal examination shows black, sticky stool, which is strongly positive for occult blood. He is tachycardic and has orthostatic hypo tension, likely indicating significant hypovolemia as a result of blood loss. Rather than being a primary problem with his coronary arteries, such as thrombosis or vasospasm, the cardiac ischemia is likely secondary to his acute blood loss and consequent tachycardia and loss of hemoglobin and its oxygen-carrying capacity. For a slowly developing, chronic anemia in patients with good cardiopulmonary reserve, symptoms may not be noted until the hemoglobin level falls very low, for example, to 3 or 4 g/dL. For patients with serious underlying cardiopulmonary disease who depend on adequate oxygen-carrying capacity, smaller declines in hemoglobin level can be devastating. Such is the case with the man in this clinical scenario, who is suffering a cardiac complication as a consequence of his anemia, in this case, unstable angina. He has been treated with medical manage ment, including dual antiplatelet therapy with aspirin and clopidogrel. In this case, it is more likely that his angina is secondary to the acute drop in hemoglobin rather than new cardiac disease. In this case of secondary angina, the anemia must be corrected, which requires an understanding of transfusion medicine.


  • https://www.kidney.org/sites/default/files/11-50-0160_patientguideCKD.pdf
  • http://www.auburn.edu/academic/classes/biol/6190/CellSignalingBiology/csb012.pdf
  • https://www.eortc.be/services/doc/ctc/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf