Hospital Corpsman 1 & C
Chapter 2: Patient Assessment and Treatment

Medical Diagnosis and Treatment

A. Medical History
B. Physical Examination
C. Radioing For Advice
D. Acute Thoracic Emergencies
E. Diseases of the Respiratory Tract
F. Diseases of the Gastrointestinal (GI) Tract
G. Diseases of the Genitourinary (GU) Tract
H. Diseases of the Circulatory System
I. Problems of the Musculoskeletal System
J. Disorders of the Ear, Nose, and Throat
K. Disorders of the Ocular System
L. Dermatological Conditions
M. Disorders of the Nervous System
N. Traumatic Conditions of the Central Nervous System(CNS)
O. Psychiatric Disorders
P. Endocrine Disorders
 

A.Menstrual History
B. Physical Examination of the Female Genitalia
C. Commonly Encountered Female Conditions
 

A. Dental Fundementals
B. Dental Anatomy
C. Dental Histology
D. Oral Examination
E. Local Anesthesia
F. Oral Diseases and Injuries
G. Dental Records and Forms
H. Military Health (Dental) Treatment Record

References

Introduction

Sick call is generally thought of as a designated time and place set aside by the on board medical department to administer to the health needs of active duty personnel. As a senior hospital corpsman, much of your credibility, public relations, and professionalism as a health care professional is gained or lost through your demonstrated performance at sick call. Frequently sick call is the only point of direct contact that the "Doc" has with his crewmembers or troops. The hospital corpsman who is involved with sick call must use sound technical judgment coupled with high professional standards when dealing with his patients.

Sick call involves not only a great amount of patient contact and the need for the corpsman to demonstrate his medical expertise, but also demands a working knowledge of current directives, health record administrative practices, and logistical skills.

Since medical ethics and patient care are discussed at length in the HM3 & 2 Rate Training Manual, the following information is presented to aid and assist you in establishing an orderly, functional, and systematic sick call:

1. A designated time approved by the commanding officer should be set aside for sick call. An appointment system might be developed aboard large vessels to reduce the time lost at sick bay.
2. Proper preparation of the space in which sick call is held should provide for maximum efficiency in accomplishing competent, quality health care. A designated sick call space can range from a sick bay aboard ship to a tent in the field. Nevertheless, it should be well stocked with the necessary equipment and supplies needed to maintain your capability to provide sick call services in support of your command's requirements. Equipment and supplies might range from something as simple as the standard field unit No. 1 to something as complex as the Authorized Medical Allowance List (AMAL), which contains all of the items necessary to maintain a complete sick bay aboard ship. A representative assortment of health record forms, supply documents, a treatment log, and journals are maintained in accordance with applicable directives and manuals.
3. It is recommended that sick call be held prior to 0900 on board ship to facilitate the ship's operational requirements. Additionally, where referrals are indicated, patients are afforded the convenience of being evaluated at the earliest possible opportunity of the day. All members of the crew who are ill or are incapacitated should report to sick call during prescribed times and should be entered in the sick call treatment log. Contents of this log are discussed in the HM 3 & 2 Rate Training Manual. This log may serve as a data source for the Morbidity Reporting System, or be used in conjunction with the statistical data log. Also, official logs have medicolegal significance and therefore should be accurate and legible. Patients requiring further evaluation or treatment, as determined by the facilitating hospitalman, are referred with appropriate, completed forms.
4. Effective implementation of sick call procedures requires the best utilization of professional resources. Medical officers, when assigned, should be consulted frequently in matters of medicine and physical diagnosis, and these consultations should be part of the inservice training and education programs. The importance of frequent consultations and other communications with medical professionals with respect to training and education can never be overemphasized.

If properly supervised, sick call can be an effective health care delivery platform while providing positive public relations. It serves both as an excellent training device for junior medical personnel and a means to address the health needs of your command in a professional and expeditious manner. The sick call supervisor should encourage staff personnel to share interesting or infrequently seen medical cases with the health care team and, if deemed significant, incorporate those cases into the command's inservice training programs. Sick call supervisors exercise the essential responsibility to address patient complaints, and in this capacity, the sick call supervisor serves as the patient contact representative. Complaints need to be evaluated fairly and objectively to identify the cause of problems and to act upon resolutions. Continuing education in the area of patient contact must be rigidly and aggressively supported.

The "right man for the job" keys the sick call supervisor to be an effective manager. In this regard, the senior hospital corpsman must understand the process of delegating authority to his staff and must maintain effective communications between departments and individuals. Facilitating a good sick call can be one of the most challenging assignments facing an independent duty corpsman. Sound leadership skills combined with effective management practices will result in a productive, effective sick call visit, satisfying the needs of the patient and command.
 

The concerns of the hospital corpsman when confronted with a patient are evaluation and diagnosis. This is especially important for injuries, trauma, and severe pain. When a patient comes to sick call, it is a must to obtain a careful history first, followed by a careful physical examination, diagnosis, and appropriate treatment within the skills of the hospital corpsman. An effective corpsman recognizes the limits of his or her expertise and obtains additional medical help when necessary.

The medical history plus the physical examination form the basis for establishing the diagnosis and instituting a course of treatment. The medical history makes the physical examination more meaningful and not just a mechanical routine.

The patient may be confused, nervous, fearful, insecure, resentful, and even argumentative. To deal with these emotions and attitudes, you will need a professional bedside manner. This can be achieved by cultivating a professional attitude, sincerity, understanding, mental maturity, and compassion. Corpsmen should never allow themselves to take a moralistic attitude or to condemn or condone a patient's behavior.
 

1. Medical History

   The history taking begins when the patient arrives in sick call. The patient should be observed for any overt signs and symptoms, reactions to questions, alertness, attitude toward the corpsman and his or her illness, and level of intelligence. Before asking the patient direct questions, the corpsman should let the patient talk freely and listen to the patient's story. Remember active listening is a valuable skill.

   When the patient has related the story in his or her own words, it is time to ask specific questions. Keep the questions simple and on the patient's level. Ask the patient to describe the problem or pain including the duration, nature, location, date and type of onset, and what relieves or aggravates it. Remember that each history is an individual experience and should not be stereotyped, but rather adjusted to each individual's specific problem. Fear, confusion, rambling, exaggeration, and minimization are obstacles to eliciting a good medical history. They must be overcome to get the data necessary to establish a diagnosis.

   The following outline is a helpful guideline to use in obtaining the medical history:

   • Biographical Data-Obtain the patient's full name, age, sex, race, SSN, nationality, marital status, and occupation.
   • Chief Complaint-Main reason for coming to sick call.
   • History of Present Illness-Phrase questions so that the patient provides the needed information, and try to avoid leading questions. The patient should describe discomfort or unpleasant sensations. Have the patient elaborate on the chief complaint, including the date, mode, course, and duration of onset. Find out how each symptom first made its appearance, whether it was abrupt or gradual, how long it lasted, and whether it was persistent or intermittent. Determine the location and whether or not it radiates and where it radiates to. Determine if there are any lesser symptoms that accompany the major complaint. Note any absences or cessations of the symptoms and any cycles they undergo. Elicit information regarding any previous treatments, or self- treatment, and the effect of such treatment.
   • Past History-Review past illnesses, surgical procedures and dates thereof, and all major injuries.
   • Family History-Obtain the health status of blood relatives, including their age if living and the cause of death if deceased.
   • Social History-The patient's personal habits, sex life, emotional adjustments, and work and recreational habits are of importance.
   • Marital History-Health of spouse, sexual adjustment, number of children and their health, and the emotional status of the marriage. NOTE: Depending upon the circumstances and the type of the patient's complaint, not all questions are pertinent and should not be asked of the patient in every case.
   • Occupational History-Where the patient works, what he or she does, who he or she works for, how long in that position, health hazards in that area, and recent changes in position or authority may be important points to explore.
   • Include past environmental conditions (i.e., foreign countries visited, areas of the country visited).

     A comprehensive account of complaints referable to each body system in logical sequence from head to toe should be made a part of the history. This review provides a thorough evaluation of the past and present status of each body system. It also permits the grouping of like symptoms and provides a double check to prevent omissions of significant data concerning the present illness or injury. The following is merely a suggested guideline to follow and should not be interpreted as a hard and fast rule of thumb. Again, each case is unique and should not be stereotyped.

   • Body Weight-Determine the average, maximum, and least weight for the individual, and check for loss or gain in weight and the time interval between such loss or gain.
   • Skin, Hair, and Nails-Check the texture for dryness, sweating, discolorations, itching, changes in temperature, dermatological conditions and therapeutic efforts to control them, and baldness and itching of the scalp.
   • Head-Determine if there are headaches, their frequency, duration, and what time of day they occur; be alert for and determine the presence or absence of vertigo, lightheadedness, fainting, and any signs of trauma.
   • Eyes-Ask about disturbances in vision, lacrimation, itching, photophobia, and pain.
   • Ears-Determine the degree of deafness (if suspected), pain, discharge, vertigo, and tinnitus.
   • Nose-Note any discharges or obstructions. Ask the patient if he or she is subject to frequent colds or allergies and if there has been any change in the sense of smell.
   • Mouth and Throat-Ask about pain and history of bleeding gums, sore throats, voice changes, and dysphagia (difficulty in swallowing), and look for indications of dental hygiene habits.
   • Neck-Determine if there are stiffness, swelling, pain and associated symptoms of lymph node enlargement, and limitaiton of motion.
   • Respiratory System-Check for complaints of dyspnea, orthopnea, edema, cough (productive or nonproductive, and if productive, odor and color as well as amount of sputum), pain, wheezing, palpitation, syncope, cyanosis, hypertension, hoarseness, and stridor (harsh or high-pitched respirations).
   • Cardiovascular System-Ask about exertional dyspnea, paroxysmal nocturnal dyspnea, chest pain, angina, myocardial infarction, claudication, orthopnea, varicosities, phlebitis and circulatory problems in the extremities, particularly with exposure to cold (Raeynaud's), heart murmurs, etc.
   • Gastrointestinal System-Ask about changes in appetite, complaints of dysphagia, pyrosis, indigestion, nausea, vomiting, blood in stool or vomitus, flatulence, jaundice, pain, changes in bowel habits, constipation, diarrhea, and hemorrhoids.
   • Genitourinary System-Ask about frequency of urination, including urgency, hesitation, pain, blood, absence or diminishing amount, pus, color, and dribbling or incontinence; and check for past or present evidence of sexually transmitted diseases (STD).
   • Nervous System-Check for feelings of anxiety, apprehension, tremors, convulsions, history of psychiatric care, changes in memory, changes in judgment, pain, paresthesia (numbness), paralysis, and coordination.
   • Musculoskeletal System-Note the presence of muscular pain, swelling, deformity, disability or pain in joints, weakness, atrophy, and cramps.
      
2. Physical Examination

   After getting as much information as possible from questioning, a physical examination must then be performed. In general, use the same system format that was employed in taking the medical history. (NOTE: As stated in the section on history taking, depending upon the complaint of the patient and your suspicions of his or her illness, it is not necessary to perform a complete physical examination in every case.)

   • Vital Signs-Take and record temperature, pulse, respiration, and blood pressure
   • Skin-The human skin, which is some- times referred to as the "mirror" of an individual's health because it often reflects diseases of other organs, should be examined visually and also by palpation. Observe for visible abnormalities such as warts, cysts, scales, and vesicles. An important point to remember in the visual examination of the skin is color. Changes in coloration are often tipoffs to various ailments; for example, a bluish tinge can indicate congestive heart failure, pneumonia, or any other condition in which the oxygen content of the hemoglobin is reduced. Changes in skin coloration can also be caused by abnormal deposits of pigmentation, such as increases of bilirubin in the skin and sclera as found in jaundice. Note the temperature, texture, elasticity, moisture, and presence or absence of edema. It is important to include the epidermal appendages in the examination of the skin; for example, note the condition of the nail beds (matrix) since abnormalities in the matrix can often indicate local or systemic disorders. Condition of the hair can also indicate local or systemic disorders, such as coarse, dry, and brittle hair, as found in many cases of hypothyroidism.
   • Head-Look for any abnormal head movements, such as spasms, tremors, and tilting. Note the size and shape of the head. Note any signs of swelling, discolorations (especially in facial bones), and bloody or watery discharge from the nose and ears. Test the sections over the sinuses by palpation and percussion to detect any signs of tenderness. Check for range of motion (provided there is no neck injury). Inspect the eyes for normal extraocular movements, equality of pupils, pupillary reaction to light, and accommodation. Check for position and alignment of the eyes, abnormal protrusions, recessions, and spacing; note the position of the eyelids to the eyeballs; observe for swelling of the lacrimal apparatus; note any opacities in the lens and cornea and swellings or nodules in the conjunctiva and sclera. Examine the oral cavity for signs of bleeding or inflamed gums, coating or swelling of the tongue, ulcers, inflamed throat, pus, and condition of teeth.
   • Neck-When inspecting the neck, look for any signs of asymmetry, unusual pulsations, growths, stiffness or limitation of movement, enlargement of the thyroid gland, and swollen lymph nodes behind the ears, on the sides of the neck, and in the supraclavicular area. Test swallowing ability.
   • Ears, Nose, and Throat-When inspecting the ears, include the external ear. This area is sometimes so obvious that it is often overlooked. Examine the external auditory canal for any signs of wax or trauma. Note the position, color, and shape of the tympanic membrane. Look for signs of blood, pus, redness, or swelling. Test for hearing loss by using a tuning fork, a ticking watch, or the human voice. Observe the nose for signs of swelling or trauma. Use a nasal speculum to check for obstructions, redness, and infection. Inspect the throat for signs of blood, pus, redness, swelling, tenderness, and any swellings or growths. Check the condition of the teeth, gums, tongue, palate, tonsils, uvula.
   • Respiratory System-Determine if the patient is coughing and if the cough is productive or nonproductive. If productive, examine the sputum for quantity, color, viscosity, and odor. Look for skeletal deformities or funnel chest and exaggerated or abnormal posture. Check the accessory respiratory muscles in the neck for deformity. Take note of rate, depth, symmetry, and pattern of respirations. Palpate the chest wall for tenderness, crepitation, masses, and abnormal pulsations. Palpate for any signs of vibrations or thrills. Percuss the chest for signs of resonance, hyperresonance, tympany, dullness, and flatness. Use a stethoscope to auscultate for abnormal breath sounds such as rales, rhonchi, and wheezing. Listen for abnormal voice sounds.
   • Cardiovascular System-Place the patient in a supine position. Palpate the chest wall in the area of the left midclavicular line to detect thrills, rate, rhythm, and precardial heave. Auscultate the heart for abnormal sounds such as friction rubs and heart murmurs.
   • Gastrointestinal System-Inspection, auscultation, percussion, and palpation are of significant value in examining the gastrointestinal system. Most of the information gathered from the examination will be from palpation. Always perform palpation last because some findings of auscultation can be markedly altered by manipulation of the abdomen. Place the patient in a supine position with the head slightly elevated. Visually inspect the exposed skin from the sternum to the pubis. Observe for symmetry, masses, and general nutritional state. Note the presence of scars, stretch marks, blemishes, a visible hernia, or abdominal distension. Auscultate to detect any abnormal peristalsis sounds, friction rubs, and bruits (e.g., a splashing or blowing sound). Percuss the abdominal area to detect the presence of tumors, fluid, distension, and enlargement of the underlying organs. Palpation of the abdominal walls is the most important of all the steps and the most difficult to perform. First, make sure your hands are warm. Start to palpate by placing your hand in an area where there is no pain and gently move your hand over the entire abdomen. Note any enlargements or masses and any pain produced. When examining the abdomen, you should be alert for any sign of a hernia. There are three types of abdominal hernias: ventral-soft masses that protrude into the abdominal wall anteriorly; inguinal-a protrusion of peritoneum through the abdominal wall in the inguinal area; and femoral-located on the anterior surface of the thigh just below the inguinal ligament. The last part of the examination is the rectal. This part of the examination is crucial and should be performed in every case involving the gastrointestinal tract. The perianal area should be inspected for lesions and external hemorrhoids. Also palpate the anal canal for tumors, polyps, masses, and tenderness. The prostate should be palpated for size, shape, and consistency. After withdrawing the gloved hand from the rectum, check the character of any stool that may be on the glove, and perform a guaiac test.
   • Genitourinary System-Inspect the lower abdomen and flank area for any signs of tenderness if kidney involvement is suspected. Whenever possible, do a microscopic examination of the urine. Examine the genitalia for signs of discharge, ulcers, growths, phimosis, paraphimosis, condylomata (venereal warts), cysts, lipomas or any masses (any testicular mass must be considered as cancerous until proven otherwise), and areas of tenderness and swelling (as in epididymitis). If not already performed, a rectal examination is essential. If renal calculi are suspected, screen all urine for signs of "sandy grit," pus, blood.
   • Extremities-Compare upper extremities for symmetry, muscular development, deformity, evidence of nail biting, redness, warmth, tenderness, and crepitation. Examine the joints for range of motion, areas of tenderness, swelling, and discoloration. Inspect and palpate all lymph nodes in the upper extremities. Examine the legs for symmetry, edema, muscular development, abnormalities in blood vessels, and dermatological diseases. Apply passive and active range of motion techniques and check for tenderness, swelling, discoloration, and deformity in joints. Inspect and palpate all inguinal and femoral nodes. Examine the feet for changes in coloration or temperature-indicators of impaired circulation.
   • Central Nervous System Checks-The following are the five testing categories in a neurological assessment:
     • Mental Status and Speech-Note the patient's dress, grooming and personal habits, expressions, manner, mood, speech, and level of consciousness.
     • Cranial Nerves-Test the olfactory and optic nerves by having the patient identify smells, testing visual acuity and mobility of the eyes, assessing the hearing, and observing for facial weakness or tics.
     • Muscles-Test for muscle tone, coordination, involuntary movements, and atrophy.
     • Sensory System-Test for sensations using pain, heat or cold, touch, and vibration.
     • Reflexes-Check deep tendon reflexes, superficial reflexes, and also check the pathological reflexes (i.e., Brudzinski's sign and Kernig's sign). Reflexes are checked to localize nervous system disorders.
        
3. Radioing for Advice

   After taking the history and performing the physical examination, make an assessment of the patient's condition related to all positive findings. Independent duty hospital corpsmen usually have the most modern communications facilities at their disposal and should never have to guess. If you are in doubt as to the diagnosis, seek advice. Ship's information such as latitude, longitude, destination, and the like will be provided by the responsible section. Message format is likewise available from the communications section. Where to seek help is an administrative problem since the location of ships with medical officers aboard is not in the purview of the corpsman. However, you are responsible for the content of the message and should provide all essential information. Give the patient's full name, rate, SSN, age, mental state, and ship to which attached. List the principal complaint, nature and onset of symptoms, and also their duration. List the associated symptoms, and list personal and work habits that may have a bearing on the case. If injured, give the cause, location, amount of bleeding, deformity, and any other significant signs and symptoms. State the patient's vital signs and their trends, if any. List all other pertinent physical findings, results of tests, and any treatment started.
    

4. Acute Thoracic Emergencies

   For acute thoracic emergencies:

   • Establish and maintain and open airway.
   • Keep the patient well oxygenated and, if necessary, use artificial respiration and intermittent positive pressure oxygen.
   • Avoid using sedatives that depress the respiratory center (i.e., narcotics).
   • Counteract shock and maintain an adequate level of circulating blood volume.
5. Diseases of the Respiratory Tract

   The following are some of the more commonly encountered diseases of the respiratory tract.
    

   Upper Respiratory Infection (URI)

   In most cases, the signs and symptoms listed below indicate a severe URI and a need for medical assistance.

   • An elevated temperature of 101 degrees F of more that has persisted for 3 or more days.
   • A white or dirty gray exudate in the throat.
   • Diffuse reddening of the throat.
   • A persistent cough of 2 or more weeks.
   • Complicating symptoms that you should be alert for are skin rashes, stiff neck, muscular weakness, and swelling.
      

   Pneumococcal Pneumonia

   Etiology-This is an acute inflammatory process in the alveolar spaces of the lung. Pneumococcus accounts for approximately 60 to 80 percent of all primary bacterial pneumonias. Because bacterial pneumonias are usually secondary to injury of the respiratory mucosa by viral infections such as influenza and the common cold, they often occur during periods of cold, inclement weather.

   Symptoms-There is a sudden onset of symptoms with rapid progression. The condition of the patient deteriorates rapidly. Temperatures range form 100 degrees to 105 degrees F, pulse rate may go as high as 160, and respiration is marked by tachypnea (30 to 40 per minute). Respirations are shallow and a peculiar "grunt" may be heard upon expiration; the patient will often lie on the affected side in an effort to splint the chest. The patient experiences hard, shaking chills; sharp, stabbing chest pains that are exaggerated by respiration; and a productive cough with "rusty" colored sputum. Upon auscultation, fine inspiratory rales may be heard, followed by the classic signs of consolidation (absent breath sounds and dullness). Sometimes the abdomen becomes distended and a pleural friction rub may be heard.

   Treatment-General measures consist of complete bed rest and administering sufficient fluids to maintain a urinary output of at least 1500 ml daily. Penicillin G is the antibiotic of choice with usual does of 600,000 units every 12 hours IM. Tetracycline and erythromycin are alternatives when a patient is hypersensitive to penicillin. Ventilation and oxygenation are of a distinct value. The patient should be fed a liquid diet initially, and when improvement occurs. a normal diet as tolerated.

   Other Bacterial Pneumonias

   Other primary bacterial pneumonias are caused by single bacterial species other than pneumococcus. To treat the pneumonia properly, the specific etiologic agent must be identified. Treatment is generally the same as for pneumococcal pneumonia except that a broad-spectrum antibiotic is used.

   Aspiration Pneumonia

   This is an especially severe pneumonia with a 60 percent mortality rate. It is caused by aspiration of the gastric contents and inhalation of hydrocarbons. Treatment is the same as for other pneumonias. Vigorous antibiotic therapy is essential.

   Primary Atypical Pneumonia

   This type of pneumonia is caused by a variety of viral and mycoplasmal agents. The symptoms include a gradually increasing fever with a history of URI; a nonproductive cough; hoarseness; headache and malaise; and extreme fatigue. The treatment is similar to other pneumonias.

   Acute Bronchitis

   Acute bronchitis is an inflammation of the bronchial tree caused by infections and physical and chemical agents. Bronchitis may appear as a primary disorder or as a prominent finding in many pulmonary diseases. The symptoms include dry, scratchy throat; hoarse, husky voice; fever; cough that produces mucopurulent sputum; and musical rhonchi and wheezing.

   Treatment-General measures consist of bed rest, forcing fluids to prevent dehydration, and discontinuing smoking. Using steam or mist inhalators is frequently beneficial in helping to relieve coughing. Severe coughing may be controlled with antitussives. Antihistamines should be administered to help relieve inflammation. Headaches, sore throats, and fever may be treated with aspirin. In patients with impaired respiratory or cardiac function, or in patients debilitated by other diseases, antibiotic therapy should be used to prevent secondary infections. One of the complications is pneumonia.

   Chronic Bronchitis

   Chronic bronchitis is marked by a normally nonproductive cough of long duration. If the cough is productive, the sputum is usually very thick. There are usually no other symptoms of URI.

   Treatment-As in the treatment for acute bronchitis, the patient with chronic bronchitis should be advised to discontinue smoking and to avoid other sources of lung irritation such as fumes. If the patient's cough is nonproductive, suppress it with antitussives. If it is productive, liquify it by adequate fluid intake, inhalation, and expectorants. Other treatment is as indicated for acute bronchitis.

   Asthma

   Asthma is a bronchial hypersensitivity disorder characterized by reversible airway obstruction. It is produced by the combination of mucosal edema, hypertrophy of the bronchial musculature, and excessive secretion of mucus, which causes mucosal plugs.

   Symptoms-The patient experiences repeated attacks of wheezing, dyspnea, and coughing with mucoid sputum produced. Nocturnal coughing and wheezing on exertion is common. The patient usually has a history of frequent colds and displays nasal symptoms, such as itching and congestion.

   Treatment-The first step is to eliminate the source of any known allergies. Maintain adequate rest and reassure the patient to relieve his or her apprehensions. Treat respiratory infections with antibiotics. Force fluids to prevent dehydration and help break up or liquify secretions. Epinephrine is the drug of choice, but may be replaced by aminophylline if not effective. Epinephrine should be administered cautiously in patients with angina or hypertension. Oxygen therapy is indicated in all cases of moderate to severe symptoms. Status asthmaticus is a continued, severe wheezing to a life-threatening point. The patient with this condition should be hospitalized immediately. Interim therapy is treatment aimed at preventing further attacks. The offending allergens should be identified and emotional disturbances eliminated, if possible. Drugs of choice in the interim therapy of asthma are the adrenal corticosteroids and corticotropin. Methylprednisone and IV hydrocortisone are the drugs normally used. A change in environmental conditions is indicated to prevent incapacitating or further complications.

   Fibrinous Pleurisy

   This condition is the result of deposits of fibrinous exudate on the pleural surface. It is usually secondary to pulmonary disease.

   Symtoms-There is chest pain that is accentuated upon inspiration and minimal when the breath is held. The patient often lies on the affected side and respirations are decreased in motion and may be marked with a "grunt." A pleural friction rub is often present.

   Treatment-The treatment of the pleuritic pain is the only measure aimed at combating the fibrinous pleurisy. Other treatment is aimed at the underlying cause. Giving analgesics and strapping the chest to restrict movement is effective in treating the pain.

   Pulmonary Abscess

   This is a localized area of necrosis in the lung that may be putrid or nonputrid. Bronchial obstruction with subsequent infection distal to the block may be caused by aspirated vomitus, blood, pus, or mucus. It may also follow penetrating wounds of the chest. Putrid abscesses are usually single and caused by anaerobic bacteria. The right lung, especially the lower lobes, is most frequently affected. Nonputrid abscesses are usually hematogenous in origin and are usually multiple.

   Symptoms-They include malaise, anorexia, cough, sweating, chills, and fever. The cough is at first nonproductive and later yields a foul, fetid sputum that is suggestive of an abscess.

   Treatment-General measures consist of bed rest, postural drainage in the position of best drainage, and broad-spectrum antibiotic therapy. The patient may require evacuation for surgical resection, which is the treatment of choice when the risk is reasonable.

   Spontaneous Pneumothorax

   This condition results from air entering the pleural space, causing a partial to complete collapse of the underlying lung. It sometimes follows exertion or violent coughing. Occasionally a valvelike effect is produced with progressive air leakage upon inspiration and failure of air exit upon expiration (tension pneumothorax).

   Symptoms-Chest pain is referred to the shoulder and arm of the affected side. The pain is aggravated by inspiration and physical activity. Breath and voice sounds are diminished on the affected side; in large pneumothorax, there is a mediastinal shift to the opposite side. Percussion produces hyperresonance.

   Treatment-If the degree of lung collapse is small, air leakage slight, and little discomfort produced, the lung may reexpand spontaneously. If the degree of collapse is greater, the leakage of air more pronounced, and the patient's discomfort great, insert a large-bore, short bevel needle into the anterior portion of the affected area. Insert it just into the pleural space to avoid trauma to the underlying lung. After tension is relieved, make a one-way valve from the finger of a rubber glove, slit at the end, and tied to the hub of the needle. As soon as possible, insert a Foley catheter into the pleural space and attach to a water trap (underwater seal) or a suction pump. Provide suction until the lung has been reexpanded for 24 hours. Treat severe pain with subcutaneous morphine. Treat for shock.

   Traumatic Pneumothorax

   A sucking chest wound results from a penetrating injury to the chest wall and is a surgical emergency. The wound must be made airtight by any available means, as this might convert the injury to a tension pneumothorax. If the patient becomes increasingly dyspneic, remove the dressing to allow release of internal pressure, then reseal. Treat for shock. Surgical intervention should be accomplished as soon as possible.

   Pulmonary Embolism

   This condition results from a clot lodging in a pulmonary vessel. The major causes are chronic cardiac disease, phlebitic or thrombosed veins of the lower extremities, postoperative complication (second or third week usually), and traumatic fractures (fat embolism).

   Symptoms-By far the most common complaint is sudden onset of dyspnea. Pleuritic pain is common in moderate to severe embolisms. Hemoptysis, rales, pallor, foul breath, increased respirations, and shock may or may not result. In some cases of pulmonary embolism, a lung infarction with resulting abscess formation may occur.

   Treatment-Oxygen therapy in high concentration (preferably 100 percent) is essential to overcome anoxia. Administer meperidine for pain, treat for shock, and hospitalize as soon as possible.

   Decompression Sickness

   An acute illness in which nitrogen bubbles are forced into the bloodstream. It sometimes occurs in persons flying at high altitudes and following rapid reduction of air pressure in persons who have been breathing compressed air while diving.

   Symptoms-This illness is characterized by joint pains, neurological symptoms, loss of consciousness, and sudden onset.

   Treatment-As soon as symptoms are reported, oxygen is given with the patient prone and the head slightly lowered. Refer immediately to the nearest recompression facility.

   Pulmonary Edema

   This is an acute medical emergency. It may be caused by drugs such as heroin, irritant gases, burns, or blast percussion, causing injury to the alveolar-capillary membrane. However, it is usually the result of left ventricular failure or mitral stenosis.

   Symptoms-Onset may be abrupt or insidious. Cough, asthmatic wheezing, dyspnea, and orthopnea (inability to breathe except in an upright position) occur in the early stages. Later marked anxiety; gasping for breath; pink, frothy sputum; terror; anguish; profuse sweating; cyanosis; paroxysmal coughing; rales; thin, rapid pulse; and falling bood pressure occur.

   Treatment-Place the patient in an upright position to relieve orthopnea. Morphine has long been the sovereign drug in the initial emergency treatment and many mild to moderate episodes have been relieved by morphine alone. Oxygen, intermittent positive pressure breathing, rapid venesection (to reduce circulating blood volume) or rotating tourniquets, and pulmonary drainage with maintenance of the airway are used in severe progressive forms. Rapid digitalization is indicated once heart failure has been established and after it has been determined that the patient has not been completely or over digitalized. Digitalis intoxication may cause acute pulmonary edema.

6. Diseases of the Gastrointestinal (GI) Tract

   The following are some of the more commonly encountered diseases of the GI tract.

   Diarrhea

   Diarrhea may be caused by a wide variety of intestinal disorders, such as viral enteritis, salmonellosis, or amebiasis, or it may be psychogenic in origin. It may also be caused by metabolic diseases, dietary factors, or food allergies.

   Treatment-Eliminate any specific causes. Place the patient on a liquid diet for the first 24 hours and then, if tolerated, a soft diet. Antidiarrheal agents such as Kaopectate® or Lomotil should be used with caution. In cases of bacterial infection, antidiarrheal agents may prolong the infection and/or carrier states of the infection.

   Pyrosis

   Pyrosis (heartburn) is a burning substernal pain resulting from irritation of the distal esophagus.

   Treatment-Treatment normally consists of antacids and a bland diet. Elevating the head of the bed, weight reduction, avoiding tight clothing, and other symptomatic treatment have proven beneficial.

   Constipation

   Constipation is the result of lesions of the colon and rectum, hypometabolism, neurosis, improper fluid intake, and drug ingestion. Constipation should be considered only in patients who have been unable to move their bowels for several days or if the stools are very hard or dry.

   Treatment-The objective of treatment is to reestablish regular evacuation of feces. The diet is of primary concern. The patient should be instructed to maintain an adequate intake of food. Many times an inadequate food intake alone is sufficient to cause constipation. Foods consumed should have a high fiber content, such as bran, raw fruits, and vegetables. Encourage the patient to force fluids, exercise, and take mild laxatives. Laxatives should be administered only until constipation is improved.

   Nausea and Vomiting

   Nausea and vomiting may be attributed to a wide variety of causes and may reflect underlying GI or systemic disease. Severe complications such as aspiration or esophageal rupture may result.

   Treatment-In the treatment of simple acute nausea and vomiting, little or no treatment is required. In more severe cases, force fluids to prevent dehydration and give antispasmodic drugs, such as Compazine, to combat nausea. Treat the underlying cause.

   Psychologic GI Disorders

   Abdominal pain may have many names, such as indigestion or dyspepsia, and may involve all or a portion of the GI tract. It is frequently caused by improper diet or irregular meals as well as poor living and hygiene habits.

   Symptoms-The symptoms produced are varied. They include hyperirritability, altered motility and secretion of the GI tract, foul breath, cramps, diarrhea, and flatulence. Often there is a history of nervousness and emotional upset.

   Treatment-The patient should be instructed about personal and living habits and hygiene. Emphasize adequate and regular sleep, nourishing meals, and exercise. Treat symptomatically.

   Upper GI Hemorrhage

   This is rather a common medical emergency. It results from such conditions as peptic ulcer perforation. gastritis, and esophageal varices.

   Symptoms-The patient may complain of weakness, fainting, or melena. Hematemesis is common. Shock may or may not be present. Loss of large amounts of blood volume produces hypovolemic shock.

   Treatment-General measures include absolute bed rest, recording intake and output, nasogastric suction, ice water or ice and antacid lavages, monitoring vital signs at least once per hour, replacing blood volume, and treating for shock. Keep the patient NPO for the first 24 hours. If the bleeding has subsided, start a liquid diet. Mild sedation may be indicated. For cases involving ulceration, antacid therapy should be begun as soon as bleeding and vomiting ceases. Hospitalize as soon as possible. Give Cimetidine, IV therapy.

   Hiatal Hernia

   A hiatal hernia is caused by a portion of the stomach passing through the hiatus.

   Symptoms-It is characterized by severe heartburn, burning and pain behind the sternum, and sensations of pressure. The pain may radiate down the arms or into the neck and jaw. Nocturnal regurgitation and dyspnea are common. Lying down tends to aggravate the symptoms, while sitting or standing relieves them.

   Treatment-General measures include weight reduction, antacids, and surgical correction of large hernias. Advise the patient to avoid tight or constricting clothing, especially belts or corsets. Further advise the patient to avoid lying down immediately after meals and to sleep with the head of the bed elevated.

   Peptic Ulcer

   This is an acute or chronic ulceration of the mucous membrane in the digestive tract that is accessible to gastric secretions. The oversecretion of gastric acids is an important factor in peptic ulcer formation. Psychic disturbances, such as emotional tension, are predisposing factors. Peptic ulcers are normally found in the first portion of the duodenum or on the lesser curvature of the stomach.

   Symptoms-The patient may present a history of pain, heartburn, and abdominal distension. Nausea, vomiting, excess salivation, weight loss, and anorexia are common. The pain pattern is usually stable and is often relieved by food. Research indicates that food, no matter what type, and even though it may relieve the pain, tends to aggravate the condition by causing gastric acid secretion.

   Treatment-Mental and physical rest is a basic requirement of ulcer treatment. The old regimen of frequent feedings of bland foods and milk is no longer an accepted practice. High dose antacid therapy is essential. Cimetidine, primarily in duodenal ulcers, blocks the secretion of gastric acids. Cimetidine is indicated during the acute stages of active ulcer disease but is not prescribed for long-term therapy. Diet should be as tolerated by the patient. The only real restrictions are coffee, tea, cola, chocolate, alcohol, and aspirin. The patient should be advised to avoid foods that tend to aggravate the condition. Complications to be alert for are GI bleeding or perforation. Either is cause for immediate hospitalization.

   Acute Simple Gastritis

   This is the most common of all stomach disturbances. It is an acute inflammation and erosion of the stomach mucosa. Chemical irritants, bacterial and viral infections, and sometimes allergies are causes. The onset is sometimes sudden and violent.

   Symptoms-Malaise, anorexia, sensations of fullness and pressure in the epigastrium, diarrhea, colicky pain, and cramping are common. There may be fever, chills, headache, nausea, and vomiting.

   Treatment-Remove the offending agent if chemical or allergic in origin, and treat the specific bacterial or viral cause. Keep the patient NPO until the acute symptoms have subsided. Compazine may be indicated for nausea and vomiting. Diet should be clear liquid initially and progressive as tolerated. antacids may help to relieve pain. Be alert for hematemesis, which may require hospitalization.

   Regional Enteritis

   This is a chronic inflammatory disease of the small intestine that is normally seen in young adults. The etiology is unknown.

   Sypmtoms-Steady or colicky pain in the right lower quadrant of the abdomen or periumbilical area is common. There may be diarrhea with intervening periods of constipation or normal bowel function as well as fever, malaise, and anorexia.

   Treatment-Give a high caloric and high vitamin diet. Exclude all roughage, and during acute symptoms, exclude all milk products. Treat other symptoms symptomatically.

   Appendicitis

   Usually there is obstruction of the appendiceal lumen (usually by feces), followed by infection, edema, and frequently infarction of the appendiceal wall.

   Symptoms-Epigastric or periumbilical pain that shifts to and localizes in the right lower quadrant within 2 to 12 hours, with some early vomiting, is common. The pain is aggravated by coughing or movement. Localized abdominal findings are absent at the onset. Rebound tenderness and muscle rigidity and guarding are present and rectal tenderness is common. Temperature is slightly elevated and the WBC is elevated (10,000 to 12,000). Peristalsis may be diminished or absent.

   Treatment-The vermiform appendix must be removed by a surgeon. Until the patient is transferred for this purpose, place him or her on bed rest in the semi-Fowler's position, keep NPO, and place an ice pack on the abdomen. The primary complication to be alert for is perforation. The symptoms of perforation are a sudden increase in pain followed by temporary cessation, tenderness, generalized abdominal rigidity, WBC rise, and a rapidly rising fever. If transfer and surgery are delayed for any reason, IV therapy and nasogastric suction are indicated. The patient should be placed on a broad-spectrum antibiotic.

   Inguinal Hernia

   Inguinal hernias may be either congenital or acquired. It is a protrusion of a portion of the bowel through the external inguinal ring into the scrotal sac.

   Symptoms-The complaint of a heavy, dragging sensation in the groin, especially with heavy exercise, straining, or coughing, is common. There is localized tenderness and the peritoneal sac may be palpable and visible. The mass may disappear when the patient is recumbent. Digital examination may show a large external inguinal ring. If the hernia becomes incarcerated (intestinal loop is pinched in the opening of the inguinal ring and the intestinal flow is obstructed), the patient will suffer pain, nausea, and vomiting. Strangulation (the intestinal loop becomes twisted or severely pinched and the blood supply is cut off) results in perforation and peritonitis.

   Treatment-For a reducible hernia, these measures include bed rest, Trendelenburg's position, and moist heat. For incarcerated and strangulated hernias, do not exert any pressure on the mass at any time. Opiates may be administered for pain. If perforation and peritonitis have resulted, administer IV and antibiotic therapy. Medically evacuate the patient as soon as possible for surgical care.

   Nonspecific Ulcerative Colitis

   This is an inflammatory disease of the colon of unknown etiology characterized by bloody diarrhea and prostration. The patient may experience 30 to 40 bowel movements per day. Abdominal cramping, anorexia, malaise, and fever are common.

   Treatment-General measures consist of bed rest, nutritious diet with no dairy products, mild sedation, and steroids.

   Hemorrhoids

   They are varices of the three hemorrhoid veins. Hemorrhoids are usually mild and remittent. The patient complains of pruritus, incontinence, and recurrent protrusion, rectal bleeding, and sensation of discomfort and pain.

   Treatment-General measures consist of a low roughage diet, regular bowel habits, sitz baths, suppositories, and surgical treatment, if necessary.

   Hepatitis

   This condition is the result of an inflammation of the liver. There are two types of viral hepatitis: hepatitis A (infectious) and hepatitis B (serum). A third type of hepatitis is alcoholic hepatitis, which is induced only by alcoholic ingestion. Hepatitis A is usually transmitted by the fecal-oral route and occurs sporadically or in epidemics. Hepatitis B is transmitted by inoculations of infected blood in most cases, but may be transmitted by the common use of razors, toothbrushes, and drug paraphernalia.

   Syptoms-They include general malaise, myalgia, symptoms of URI, anorexia, distaste for smoking, nausea, vomiting, fever, dark urine, and an enlarged tender liver. Jaundice may or may not be present.

   Treatment-Strict isolation is not necessary, but careful hand washing techniques are essential. Bed rest should be at the patient's option during the acute initial phase of the symptoms but is unwarranted thereafter. A gradual return to normal activity and a high protein diet is indicated.

   Cholecystitis

   This condition is an acute inflammation of the gallbladder, usually associated with gallstones (cholelithiasis). It occurs when calculus becomes impacted in the cystic duct and inflammation develops behind the obstruction.

   Symptoms-Attacks are often precipitated by a large fatty meal. The appearance is sudden and pain may vary from minimal to severe. Pain is localized in the epigastrium or right hypochondrium, but may be referred to the midscapular or intrascapular regions. The right upper quadrant is tender with muscle guarding and rebound tenderness. The gallbladder is palpable and jaundice may be present due to blockage of the common bile duct. There is usually some nausea, vomiting, and fever.

   Treatment-Treat with analgesics, IV therapy, and antibiotics as necessary. Diet should be low fat as tolerated. With the above conservative regimen, mild acute attacks will usually subside; however, reoccurrences are common and cholecystectomy may be necessary. Complications include perforation, peritonitis, and abscess. NOTE: Cholelithiasis requires surgery and is more common in women.

   Pancreatitis

   It is a severe abdominal disease for which causes have not been completely determined. About 40 percent of the cases are alcoholics; 40 percent have associated biliary tract disease, usually with gallstones; and the remaining 20 percent have a variety of causes.

   Symptoms-Onset is sudden with steady, severe pain located in the epigastrium that may radiate from side to side in the lower back. The pain often worsens when the patient is in a supine position and is relieved by sitting and leaning forward. Nausea and vomiting as well as constipation are common. Bowel sounds may be diminished, and the abdomen is usually distended. The upper abdomen is tender with muscle guarding and rebound tenderness. Fever, tachycardia, shock, pallor, profuse sweating with cool, clammy skin, and jaundice are common.

   Treatment-Give the patient nothing by mouth. Place on complete bed rest. Meperidine may be administered for pain. DO NOT give morphine. Place the patient on fluid and antibiotic therapy, and provide nasogastric suction.

7. Diseases of the Genitourinary (GU) Tract

   The following are some of the more commonly encountered diseases of the GU tract.

   Pyelonephritis

   This acute diffuse, often bilateral pyogenic infection of the kidneys normally occurs via the ascending route, but may be spread through the bloodstream during bacteremia. It is sometimes precipitated by tumors or obstruction. Diabetes increases the likelihood of infection. Mixed infections are common after instrumentation or from fecal flora obtained from the skin of the peritoneum.

   Symptoms-The symptoms may at times be absent or obscured by associated disease. The patient usually experiences chills, fever, flank pain, nausea, and vomiting. The patient may complain of urgency and frequency of urination, and the urine may contain pus or blood. Sometimes there is abdominal rigidity, or in the absence of rigidity, a tender enlarged kidney may be palpated. Costovertebral tenderness on the affected side is common.

   Treatment-Perform C&S and routine urinalysis. Before the specific pathogen is identified, start broad-spectrum antibiotic therapy. When the specific organism is identified, treat with the appropriate drug. Force fluids to maintain urinary output of 2 to 3 liters per day. Treat symptomatically for pain.

   Cystitis

   This is a bladder infection resulting from pathogens entering the bladder via the ureter. Infection may result from trauma, stones, or inadequate emptying of the bladder.

   Symptoms-Gross hematuria, frequency and urgency of urination, and in most cases, dysuria are common. A C&S often shows E. coli as the offending agent.

   Treatment-Perform routine urinalysis and C&S. Treat systemically with antibiotics.

   Prostatitis

   Prostatitis is an infection of the prostate gland. Bacteria often reach the gland via the bloodstream or the urethra. It is commonly associated with urethritis or active infection of the lower GU tract.

   Symptoms-They include perineal pain, urethral discharge (copious amounts produced by palpation), fever, dysuria, and urgency and frequency of urination. Palpation of the prostate shows the gland to be enlarged, tender, and boggy. Chronic prostatitis may serve as a source of recurrent lower GU tract infection.

   Treatment-Acute prostatitis should be treated with sulfas, tetracycline, erythromycin, or ampicillin until C&S indicates the antibiotic of choice. Do not massage the prostate. Chronic prostatitis should be treated with long-term antimicrobial therapy. Follow up with weekly prostate massage to promote drainage.

   Epididymitis

   This inflammation of the epididymis is caused by severe straining, catheterization, prostatitis, or instrumentation.

   Symptoms-The disease is characterized by severe pain in the scrotum and rapid unilateral enlargement of the scrotum, with a marked tenderness over the spermatic cord that is relieved by lifting the testes. Pyuria, bacteriuria, and leukocytosis are usually present.

   Treatment-General measures consist of supporting the scrotum with a scrotal bridge or pillow, sitz baths, rest, sedation, antibiotics, analgesics, and sometimes infiltration of the spermatic cord with procaine hydrochloride.

   Renal Calculi

   Renal calculi are concentrations of mineral salts and crystals commonly called stones. Many theories and factors have been advanced as causes of calculi. Among these are excessive intake of milk (calcium), previous infection, sulfonamide therapy, metabolic disease, dehydration, or exposure to intensely hot climates. Also chronic pyelonephritis often predisposes to calculi.

   Symptoms-Excruciating intermittent pain that originates in the flank or kidney area and radiates across the abdomen and along the course of the ureters is common. Frequently the pain radiates into the genitalia and along the inner aspects of the thighs. Chills, fever, and frequency and urgency of urination, despite pain, is common. Hematuria is usally present. Vomiting, diaphoresis, and shock may occur. Screening the urine may produce crystalline substances. Anuria indicates renal failure and leads to uremia.

   Treatment-Many solitary calculi, unaccompanied by obstruction or infection, require no specific therapy. Force fluids and restrict the intake of calcium. Antibiotics, Demerol, or morphine are indicated. Do not give antispasmodics. Bed rest and supportive treatment are indicated. Stones that are obstructive must be surgically removed. Hospitalize as soon as possible.

   Uremia

   Uremia is a toxic condition produced by renal failure and retention of waste products in the circulatory system.

   Symptoms-At first, weakness, anorexia, nausea, and vomiting, headache, vertigo, and dimness of vision may occur. Later there is extreme restlessness, insomnia, twitching, urinous odor to the breath, perspiration, waxy pallor, edema, coma, and convulsions.

   Treatment-Fluid replacement to equal the amount of urinary output plus the amount of insensible fluid loss should be effected. Specific therapy is aimed at treating the underlying cause, such as congestive heart failure, infection, or obstruction. Hospitalize immediately.

   Testicular Torsion

   This condition is the result of twisting the testes. It may occur spontaneously as the result of emotional stress or as the result of strenuous activity or exercise.

   Symptoms-There is a sudden onset of intense pain, and the pain is aggravated by elevating the scrotum. This is the essential diagnostic difference between testicular torsion and epididymitis. The twisted testicle is normally higher and closer to the external ring. The patient demonstrates nausea, vomiting, pallor, and syncope. The color of the scrotum on the affected side is pink and swelling is rapid.

   Treatment-This is an emergency! Immediate surgical correction is essential to avoid gangrene due to vascular occlusion. Administer meperidine or morphine for intense pain.

   Genitourinary Trauma

   This condition is normally caused by penetrating and perforating wounds, blunt crushing injuries, surgery, or irradiation. The kidney is most often injured by blunt external force to the flank or abdomen. Rupture of the bladder occurs when the bladder is over distended and external force is applied. Injuries to the urethra are caused by pelvic fractures. Crushing or avulsion is the main cause of injury to the genitalia.

   Treatment-In all cases of serious GU trauma, the patient should be hospitalized as soon as possible, since in most cases, surgical correction will normally be required. In all injuries, gangrene and tetanus are serious possibilities. In case of avulsions, retain the avulsed tissue and refrigerate it immediately. Treat for shock, give analgesics, and force fluids.

8. Diseases of the Circulatory System

   Rheumatic Fever

   This acute, infectious, noncontagious systemic disease is most commonly found in children and oung adults. It is most often a result of hemolytic streptococcal infection and is the most common precursor to heart disease in people under the age of 50. Repeated attacks lead to chronic rheumatic heart disease thay may cause mitral or aortic stenosis or insufficiency.

   Symptoms-Normally there is a history of URI within the last 3 weeks. Fever, tachycardia, rapid respiration, joint pain, and swelling are common. The sedimentation rate is markedly increased, and the patient may suffer frequent epistaxis. There may be precordial or abdominal pain, malaise, anorexia, chorea (involuntary muscle tics or jerking), and diaphoresis.

   Treatment-General measures consist of bed rest, aspirin, high caloric soft diet, and support and protection for the affected joints. Use penicillin to combat existing infections. Order bed rest until the acute stages of the disease have passed. Return to full activity may take months.

   Angina Pectoris

   It is a characteristic, usually substernal, thoracic pain caused by a mild coronary insufficiency (normally arteriosclerotic heart disease) and is precipitated by exertion. Attacks are frequently experienced when mounting inclines or stairways. Angina always occurs during exertion and subsides promptly if the patient stands or sits quietly. The patient will usually prefer to stand or sit rather than to lie down.

   Symptoms-Chest pain is the chief complaint. Usually it is located behind or slightly to the left of the sternum and frequently radiates to the left shoulder and arm. Occasionally the pain may be located at the base of the neck, lower jaw, axilla, or epigastrium. Rarely is it referred to the right side of the body. The pain is usually described as squeezing, crushing, or viselike as opposed to sharp or stabbing. The intensity varies from mild to severe and may be incapacitating. Episodes normally last from 1 to 3 minutes. The patient may experience palpation, faintness, sweating, dyspnea, and digestive disturbances.

   Treatment-Rest! Nitroglycerine is the drug of choice. Amyl nitrite is sometimes used.

   Atherosclerosis (Hardening of the Arteries)

   This is the most serious form of arteriosclerosis because of its tendency to affect coronary, cerebral, and peripheral arteries.

   Treatment-Because of its insidious nature, the best treatment is prevention. Techniques of prevention and management include treating the underlying cause, weight reduction, exercise, discontinuance of smoking habits, and reducing the fat and cholesterol intake.

   Myocardial Infarction (MI)

   Damage to a portion of the heart muscle is caused by myocardial ischemia. It is most often caused by blockage of one or more of the branches of the coronary arteries.

   Symptoms-This disease may be preceded by a history of angina, and the symptoms may begin at any time. The major complaint is severe squeezing or crushing substernal pain. The location of the pain is similar to angina, but is markedly more persistent. It does not subside with rest. Dyspnea, severe anxiety, and shock are common.

   Treatment-The primary objective of treatment is to minimize heart damage and to sustain life. If the MI causes cardiac/pulmonary arrest, CPR is of primary importance. The patient should be administered Demerol® or morphine for pain and to help relieve apprehension. Oxygen therapy is essential and sedation is appropriate. In all cases, transfer the patient to the cardiac care unit (CCU) as soon as possible.

   Congestive Heart Failure

   This condition is due to the failure of the heart to maintain an adequate flow of blood to the tissues. The pulmonary or systemic circulation becomes congested, often resulting in left ventricular failure.

   Symptoms-The patient's chief complaint is dyspnea and often a gradual loss of energy. The ankles are often swollen and markedly edematous. The blood pressure may or may not be increased.

   Treatment-General measures consist of absolute bed rest and sedatives or analgesics as necessary. The patient should avoid stress and should reduce sodium intake. Weight reduction is indicated in overweight individuals. Start oxygen therapy and request further treatment orders from a physician. Transfer the patient for hospitalization as soon as possible.

   Hypertension

   It is blood pressure elevations above the normal range that are caused by abnormal resistance of the arterioles to the flow of blood.

   Symtoms-High blood pressure readings, headaches, vertigo, fatigue, and weakness are common. The patient may exhibit insomnia, nervousness, palpation, epistaxis, and tachy cardia.

   Treatment-General measures consist of rest, both mental and physical, a low sodium diet, and weight reduction. Refer the patient for evaluation and definitive treatment.

   Thrombophlebitis

   It is characterized by partial or complete obstruction of the vein with resulting inflammation of the venous walls. It is most frequently found in the deep veins of the lower extremities. Thrombophlebitis occurs spontaneously in pregnancy or in the postpartum period. It also occurs between the 4th- to 14th-postoperative day and as a result of trauma or IV therapy.

   Symptoms-The primary symptoms are pain and swelling in the involved extremity. The superficial veins may become dilated and the affected extremity is usually warmer at the site than the remainder of the skin. The pedal pulse is diminished in most cases and the patient may complain of a sensation of heaviness in the affected limb. Calves are painful upon dorsiflexion of the foot, and there is usually plantar tenderness.

   Treatment-General measures consist of moist heat wraps applied to the affected site, strict bed rest with elevation of the affected limb, and Butazolidin. Anticoagulant therapy is sometimes unnecessary with superficial thrombophlebitis, but is considered definitive in cases involving the deep veins. Elastic bandages are applied to the limb to lend support to the veins. Complications to be alert for are pulmonary embolisms, and in rare circumstances, emboli in other vital organs.

   Varicose Veins

   Varicose veins are abnormally lengthened, dilated, sacculated, superficial vessels normally found in the lower extremities. These may be asymptomatic. They are caused by incompetence of venous valves, increased distensibility, and in some cases may be an inherited trait. Contributing factors are prolonged standing, pregnancy, obesity, and aging.

   Symptoms-They include muscle cramps, tired muscles, and calf muscle soreness. The ankles tend to swell, with spontaneous remission of swelling overnight. An itchy, scaling dermatitis in the region of the affected vein is common. Veins are abnormally visible and palpable and ulceration may occur.

   Treatment-Elastic stockings and support and elevation of the extremity are definitive. The patient should be instructed to avoid prolonged standing. Surgical correction is often necessary in severe cases.

   Septicemia

   Septicemia is the presence of bacteria in the circulating blood and is frequently caused by surgery, IV therapy, or indwelling catheters.

   Symptoms-Fever, chills, skin eruptions, and shock are common.

   Treatment-Evacuate the patient to a medical facility immediately.

   Hodgkins's Disease

   The cause of this disease remains unknown. It is a chronic, progressive, and often fatal disease manifested by progressive enlargement of the lymph nodes, spleen, liver, lungs, and frequently other organs and tissues.

   Symptoms-Normally the initial stages are marked by painless enlargement of the superficial lymph nodes as well as persistent pruritus, fever, and diaphoresis.

   Treatment-Evacuate the patient to a medical facility for evaluation.

   Lymphadenitis and Lymphangitis

   Lymphadenitis is the inflammation of a lymph node. Lymphangitis is the inflammation of a lymph vessel. The cause is bacterial infection arising from the site of an infected wound or an area of cellulitis.

   Symptoms-Throbbing pain, malaise, anorexia, sweating, chills, and fever are common. There may be a red streak running from the wound site toward the lymph nodes.

   Treatment-General measures consist of rest and immobilization of the affected part. Moist heat and systemic antibiotic therapy are indicated.

   Anemia

   This is a condition in which red blood cells are deficient in volume in the circulating blood or in total hemoglobin content per unit of blood. It may be caused by excessive blood loss, deficient RBC production, RBC destruction, or iron deficiency.

   Symptoms-They include fatigue, dyspnea, palpation, waxy pallor, low hemoglobin, angina, and tachycardia.

   Treatment-Rest, whole blood, supplemental iron, and replacement of dietary deficiencies are the recommended treatment measures.

   Leukemia

   It is a disorder of the blood forming tissue that is characterized by proliferation of abnormal white blood cells.

   Symptoms-Malaise, anorexia, fever, arthralgia, lymph node swelling, sternal tenderness, and excessive bleeding are common.

   Treatment-Evacuate the patient to a medical facility.

9. Problems of the Musculoskeletal System

   Fractures, dislocations, sprains, and strains are by far the most common ailments of the musculoskeletal system. As these are covered in the HM 3 & 2 Rate Training Manual, they will not be addressed here. However, common inflammatory conditions are often presented at sick call: the following are some of the more commonly encountered.

   Costochondritis (Tietze's Syndrome)

   This is an inflammatory condition of the costal cartilages of unknown cause.

   Symptoms-It is characterized by pain, tenderness, and sometimes swelling of one or more of the costal cartilages. The pain is is accentuated by breathing, coughing, and movement. It may be mistaken for cardiovascular disease by the patient. Palpation may localize the pain to the point of inflammation.

   Treatment-Administer analgesics for pain. In more severe episodes, it may be necessary to inject the site of inflammation with a mixture of lidocaine and steroids. This condition is often persistent and may last for weeks.

   Bursitis

   This an acute or chronic inflammation of a bursa that may be the result of trauma, gout, infection, or rheumatoid arthritis.

   Symptoms-Pain, swelling, limitation of movement in the area involving the affected bursa are common. There may be effusion into the bursal sac.

   Treatment-General measures consist of complete rest of the affected area until there is relief of acute symptoms. Administer analgesics and encourage active movement as soon as the pain subsides. Heat and massaging may help. Hydrocortisone injections provide relief in most cases not caused by a specific infection.

   Tendinitis/Tenosynovitis

   Tendinitis is the inflammation of the flexor tendons or tendon-muscle attachments: tenosynovitis is an inflammation of the synovial heath surrounding the tendon. Either condition may be the result of trauma, and it is manifested by pain and swelling in the inflamed area.

   Treatment-Immobilize the area and apply moist heat. Administer analgesics for pain. Anti-inflammatory drugs are indicated. Chronic cases should be referred for more definitive therapy.

   Arthritis

   This is an inflammatory process of the joints that can be broken down into the following categories. These specific types are the most commonly encountered.

   • Rheumatoid-A progressive and debilitating inflammation of one or more joints (usually multiple) that affects women more often than men. The onset may be abrupt or gradual, and although more commonly found in the proximal interphalangeal joints, it may occur in any joint. The primary symptoms are pain and swelling in affected joints with stiffness upon arising from sleep. Afternoon fatigue and thickening of the synovial sheath are common, and there may or may not be some deformity.
   • Rheumatic-A self-limiting inflammation of the large hinge joints (usually singular) that is most often preceded by a history of streptococcal infection.
   • Degenerative-Osteoarthritis results from the destruction of the hyaline cartilage. The specific cause is unknown; however, trauma, obesity, and age are predisposing factors. Degenerative arthritis most often occurs at middle age and older and is more common in women than men. The spine and stress joints are most often affected. Muscle spasms, pain, swelling, and deformity are associated symptoms.

   Treatment-The treatment consists of rest (complete bed rest in severe episodes), proper diet, analgesics, and Anti-inflammatory drugs. Aspirin, for those who can tolerate it, is the drug of choice since it possesses both analgesic and anti-inflammatory properties and is relatively safe. Moist heat, reduction of weight (specifically in degenerative arthritis) and corticosteroid injections may be indicated. Evacuate the patient for evaluation.

   Gouty Arthritis

   This is a form of arthritis primarily affecting the great toe, ankles, and thumbs. It is caused by collections of urate crystals in the tissues and may be chronic.

   Symptoms-Deformities, redness, pain, and swelling of tissues around the joints are common. Often this disease resembles cellulitis.

   Treatment-Indocin is indicated for acute attacks. Corticosteroid are contraindicated. Recurrent attacks may be prevented by using Zyloprim. Moist heat and analgesics are indicated for symptomatic treatment.

   Gonococcal Arthritis

   This acute arthritis results from systemic infection with gonococcus. It usually occurs in the large hinge joints.

   Symptoms-Redness, swelling, severe pain, fever, and limitation of movement and markedly increased pain upon movement are common.

   Treatment-Treatment is aimed at preventing destruction of the affected joints. This destruction occurs in a relatively short period. Penicillin or other antibiotic therapy is definitive. Other treatment is symptomatic.

   In all cases of severe or chronic arthritis, refer the patient to a rheumatologist for further evaluation.

   The following are some of the more common disorders of the ear, nose, and throat that you will encounter when conducting sick call:

10. Disorders of the Ear, Nose and Throat

    Conditions of the Ear

    • Hearing Loss

      Loss of hearing may result from trauma, tumors, infections, impacted cerumen, excessive noise, or as a result of a degenerative nerve process.

      Symptoms-Tinnitus, decreased hearing ability, and in some cases, pain are common.

      Treatment-If the loss is the result of excessive noise, a change of the working or living environment is indicated. Sound suppressors and hearing protection devices should be employed. If the loss is due to an underlying cause such as impacted cerumen or infection, treat the cause.

    • Perforated Tympanic Membrane

      Although this condition may occur spontaneously, it is normally a result of trauma.

      Symptoms-There may be pain, discharge, hearing loss, and a blowing sensation in the ear.

      Treatment-If the perforation is small, no treatment is necessary. Unless the perforation is due to infection, do not instill medications in the ear. A light cotton pledget may be used to prevent dirt or water from entering the ear. For more serious perforations, refer the patient for treatment.

    • Acute External Otitis (Swimmer's Ear)

      This is an acute infection in the ear canal, which sometimes involves the auricle and often occurs after swimming.

      Symptoms-There is usually severe pain and enlarged lymph nodes, and there may be a discharge. Fever is normally present.

      Treatment-Place a wick in the ear canal for 48 hours. The wick should be moistened with aluminum acetate solution every 3 hours. Following this, instill topical antibiotics and steroids. Treat other symptoms symptomatically.

    • Aural Furunculosis

      This condition is the result of a furuncle involving the auricle and external ear canal.

      Symptoms-Impaired hearing, feelings of fullness in the ear, swelling, pain, fever, redness, and lymphadenopathy are common.

      Treatment-Furuncles on the auricle should be treated in the same manner as furuncles elsewhere on the body (see Common Dermatological Conditions in this chapter). When the furuncle is in the external canal, insert a wick moistened with aluminum acetate solution into the ear canal. Application of heat packs may help to bring the infection to a point. I&D after fluctuation. Administer systemic antibiotics.

    • Otomycosis

      This is a fungous infection of the external ear resulting from poor hygiene, swimming, and favored by warm, moist climates.

      Symptoms-These include itching, pain, a possible discharge, a stinging sensation, and the appearance of "salt and pepper" particles (i.e., dirty gray or black exudate resulting from prolonged scratching).

      Treatment-Remove debris with a solution of acetic acid and aluminum acetate. Dry the ear with alcohol, and perform a smear to identify specific fungus. Treat with the appropriate topical antifungal agent.

    • Acute Otitis Media

      This is an infection of the middle ear that is usually the result of bacterial origin. It normally follows URI and is more common in children.

      Symptoms-It is characterized by pain, deafness, fever, chills, and sensations of fullness or pressure. The tympanic membrane is red and bulging and rupture is common. Visualization of normal landmarks is impeded and often impossible due to swelling. Hearing tests show a conductive loss.

      Treatment-Administer decongestants to help promote drainage. Bed rest and analgesics are indicated. Start systemic antibiotic therapy and maintain it until the eardrum appears normal and other symptoms subside.

    • Labyrinthine Disease

      This is a suppurative inflammation of the inner ear that may be caused by chronic otitis media, allergies, trauma, blood dyscrasias, and cardiovascular disease.

      Symptoms-These include deafness, tinnitus, vertigo, nystagmus, nausea, vomiting, a staggering gait, and a tendency to fall toward the affected side.

    TREATMENT-Transfer the patient to a medical facility for definitive treatment as soon as possible. Treat symptomatically until you make the transfer.

11. Tinnitus

    Tinnitus is a noise or "ringing" in the ears that, although bearable during the day, is more distrubing at night. The cause may be infection, toxic doses of medications, or vascular and/or vasomotor disease.

    Treatment-Reassure the patient. Difficult or severe cases should be referred to a medical facility for treatment of the underlying cause.

12. Foreign Bodies

    Foreign bodies in the ear are normally inanimate objects, such as erasers, buttons, peas and beans. These are normally introduced by the patient in an attempt to scratch the ear or to remove cerumen or by children. Animate objects, such as ticks and moths, may crawl into the ear canal.

    Symptoms-There is usually pain, fullness, loss of hearing, and visualization of the foreign body.

    Treatment-The nature of the foreign body must first be determined. If the object is animate, hold a bright light to the ear. Since insects are attracted to light, this may induce the insect to crawl out. If this fails, instill a few drops of alcohol into the ear to kill the insect, and irrigate to remove it. For hygroscopic bodies such as peas and beans, DO NOT use water, saline, or boric acid, as these liquids will cause the object to swell and become wedged in the ear canal. Use a fine wire ear curette or irrrigate with alcohol or light oil to remove the object. If the object is sharp or pointed, be very careful to prevent further injury. If necessary, transfer the patient to a medical facility for removal.

    Conditions of the Nose

    • Common Respiratory Disease

      The common cold is the best example of this type of ailment.

      Symptoms-They include malaise, little or no fever, headache, chills, nasal discharge, red nares, and sneezing.

      Treatment-There is no specific treatment. Advise the patient to get rest, plenty of fluids, and a well-balanced diet. Treat symptomatically.

    • Epistaxis

      The most common sites of nasal bleeding are the mucosal vessels located over the cartilaginous nasal septum and the anterior tip of the inferior turbinate. The cause is normally trauma, infection, and drying of the nasal mucosa.

      Treatment-An adequate physical examination to determine the scope and location of bleeding is essential. Applying pressure over the nose (pinching) will stop most bleeding. A small pledget of cotton moistened with hydrogen peroxide, phenylephrine, or epinephrine may be effective in stopping the bleeding. Severe posterior epistaxis may require a nasal pack.

    • Allergic Rhinitis

      This is a reaction caused by sensitization to an allergen, which is usually pollen.

      Symtoms-It is characterized by nasal congestion, a watery discharge, itching of the nasal mucosa and conjunctiva, and violent sneezing.

      Treatment-Antihistamines and sympathomimetic drugs, such as ephedrine, may be indicated. Steroids are sometimes effective. Have the patient avoid specific allergens, if possible.

    Conditions of the Pharynx

    • Acute Tonsillitis

      This is a bacterial infection of the tonsils that may be either foodborne or airborne.

      Symptoms-It is characterized by sudden onset of anorexia; malaise; fever; sore throat; red, swollen tonsils; presence of pustules on the tonsils; difficulty in swallowing; and swelling and tenderness in the cervical lymph nodes.

      Treatment-General measures consist of bed rest, forcing fluids, and placing the patient on a light diet. Administer analgesics and antibiotics as required. Gargles may prove beneficial. Acute tonsillitis may reoccur and become chronic. Chronic cases should be referred for possible surgical excision.

    • Peritonsillar Abscess

      This is an acute suppuration that is often seen as a sequela of acute tonsillitis. It is usually unilateral and most often occurs in the peritonsillar space.

      Symptoms-Swelling of the soft palate, severe sore throat, and displacement of the uvula are common. There may be pain upon opening the jaw, swelling and pain at the site of the cervical lymph nodes, and fevers of up to 105 degrees F.

      Treatment-General measures consist of systemic antibiotics, bed rest, forcing fluids, and administering analgesics to control temperature and pain. Transfer the patient to a medical treatment facility for I&D of the abscess and subsequent tonsillectomy.

    • Acute Laryngitis This is an inflammation of the laryngeal mucosa due to virus or bacteria. It may occur as a primary disorder or in association with rhinitis and pharyngitis.

      Symptoms-They include pain, cough, redness, edema, a rasping quality to the voice, fever, malaise and if severe edema is present, dyspnea, and dysphonia and aphonia (difficulty in speaking or inability to speak).

      Treatment-General measures include voice rest; discontinuing smoking; inhaling warm, moist air; and symptomatic treatment.

13. Disorders of the Ocular System

    There are many nonspecific manifestations of disorder in the ocular system as well as pain, blurred vision, discharge, spots, and headache. All of these symptoms require further investigation.

    Acute Glaucoma

    This is a condition of the eye that is characterized by increased intraocular pressure. The pressure, if unchecked, causes atrophy of the optic nerve. This is an extreme surgical emergency! If unchecked for 2 to 5 days, the condition will most likely result in complete and irreversible blindness.

    Symptoms-Patients with acute glaucoma will seek treatment immediately because of severe pain and blurring vision. The eye will appear red and the cornea has a steamy look. The pupil will be dilated and will not react to light. Intraocular pressure is elevated (over 25 mm Hg).

    Treatment-Transfer the patient to a medical facility immediately.

    Ocular Foreign Bodies

    Foreign bodies in the eye are a serious threat in many instances to the patient's sight. See the HM 3 & 2 Rate Training Manual for further information.

    Corneal Abrasions

    Corneal abrasions are usually the result of foreign bodies striking the cornea.

    Symptoms-There is usually pain upon movement of the lid and a history of trauma.

    Treatment-Rule out a foreign body. Instill sterile fluorescein into the conjunctival sac if an abrasion is suspected. The abrasion will stain green while the surrounding cornea will appear orange. Instill polymyxin-bacitracin ophthalmic ointment and apply a firm bandage. Check the eye the following day for healing.

    Contusions (Black Eye)

    Contusions are usually the result of subconjunctival hemorrhage, corneal rupture, or vitreous or retinal hemorrhage. They are almost always accompanied by a history of trauma.

    Some of the symptoms are immediately apparent, and others may not become apparent for days. Hyphema (hemorrhage into the anterior chamber of the eye), retinal detachment, and optic nerve injury are all complications that should be suspected.

    Treatment-Moderate and severe contusions should be referred to an ophthalmologist. Any injury causing hyphema involves the danger of secondary hemorrhage that may result in irreversible glaucoma. Patients with hyphema should be placed on bed rest for 6 to 7 days with both eyes bandaged.

    Lacerations

    Lacerations involving the lid margins should be referred to an ophthalmologist. Lacerations involving the conjunctiva need not be sutured. Instill antibiotics to prevent infection. Corneal or scleral lacerations should be lightly bandaged and covered with a metal shield. Instruct the patient to avoid squeezing his or her eyes together and to remain quiet. Pressure exerted may result in extrusion of the intraocular contents. In all lacerations involving the eye, transfer the patient to an ophthalmologist.

    Conjunctivitis

    This is an inflammation of the thin mucous membrane lining the inner portions of the eyelids and anterior surface of the eyeballs. The inflammation may be acute or chronic and can be due to chemical irritation, allergy, bacterial or viral infection, and fungal or parasitic infection.

    • Bacterial Conjunctivitis-It produces a purulent discharge, photophobia, and reddening of the eyelids and conjunctiva. The eyelids may burn, itch, or hurt, and often there is marked edema. The discharge repeatedly turns mucopurulent and may seal the eyelids at night. The condition usually lasts about 10 days.

      Treatment-There is no specific treatment, but sulfonamide therapy helps to prevent secondary infection.

    • Viral Conjunctivitis-Blennorrhea is also called inclusion conjunctivitis. It is a venereal infection resulting from nongonorrheal cervicitis and urethritis that can be spread to the eyes during and after intercourse. In the past this form was also spread during swimming and was known as swimming pool conjunctivitis. Adequate chlorination of swimming pools has eliminated this mode of transportation.

      Symptoms-There is usually a copious watery discharge with scanty exudate, occasional fever, and malaise as well as lacrimation, photophobia, sensations of sand or grit in the eye, and burning in the eyelid margins.

      Treatment-Isolation techniques, such as separate towels, are advisable. Treat with sulfonamides or tetracyclines systemically for 3 weeks. Instill tetracycline drops in oil to supplement the systemic tetracycline.

    • Allergic Conjunctivitis-This is commonly and most frequently associated with hay fever.

      Symptoms-There is usually tearing, itching, redness, and a thin stringy discharge.

      Treatment-Corticosteroid therapy is usually effective.

    Hordeolum

    A sty is a common abscess formation at the eyelid margin due to staphylococcus.

    Symptoms-There is usually pain, redness, swelling, and an area of tenderness on the upper or lower eyelid. The intensity of the pain is related to the amount of swelling. The abscess tends to localize within a few days. The patient sometimes complains of photophobia, lacrimation, and a feeling of fullness or "foreign body" sensation.

    Treatment-Apply warm compresses. When the abscess focuses to a point, it will normally rupture spontaneously. An I&D may be performed if necessary. Irrigate the eye with warm saline and apply local antibiotics or sulfonamides.

    Dendritic Ulcer

    This a a superficial corneal ulcer caused by the herpes simplex virus. It is almost always unilateral and may affect any age group. It is characterized by superficial branching gray lesions of the cornea, resembling the veins in a leaf.

    Treatment-Transfer the patient to an ophthalmologist as soon as possible for removal of the ulcers.

    Iritis

    This is an acute inflammation of the iris. When the ciliary body is involved, as it usually is, the condition is known as iridocyclitis.

    Symptoms-It is characterized by a severe throbbing pain that radiates to the forehead and temple, lacrimation, photophobia, blurring of vision, redness, and enlarged blood vessels around the cornea.

    Treatment-General measures consist of bed rest with subdued light, local corticosteroid therapy, and warm compresses. Transfer the patient as soon as possible to an ophthalmologist.

    Retinal Detachment

    There is usually partial or complete separation of the retina from its pigment layer.

    Sypmtoms-The patient may notice flashes of light or stars, followed by sensation of a curtain moving over the eyes.

    Treatment-Immobilize in bed and instill mydriatics to dilate the pupils. Evacuate the patient as soon as possible to an ophthalomologist.

    Floaters

    A sensation (accentuated in bright light) of seeing spots is a common complaint in myopic and elderly patients.

    Symptoms-The spots are normally seen when looking at the sky and cannot be focused upon. Brown or red spots that are reasonably stable often indicate minute hemorrhage. A large, slow moving spot is normally an intraocular foreign body.

    Treatment-Refer for routine eye examination.

14. Dermatological Conditions

    Contact Dermatitis

    This is an acute or chronic inflammation produced by substances coming into contact with the skin. Some of the more common skin sensitizing agents are poison ivy, poison oak, fruits, vegetables, chemicals, therapeutic agents, cosmetics, fabrics, and detergents.

    Symptoms-The most common sites are the face, neck, hands, feet, eyelids, and genitals. The scalp is not usually affected; however, any area of the body may be affected. In many instances, the site of the dermatosis is a clue as to the agent involved. The patient's major complaints will normally be itching, scaling, rash, and pain.

    Treatment-No treatment can be effective until the causative agent is determined and eliminated. In acute stages, bland compresses and a drying corticosteroid loction may be indicated. If the dermatitis is extremely uncomfortable or disabling, a short course of systemic corticosteroid therapy may be effective. Antihistamines are of little or no value in contact dermatitis. If crusting and scaling occur, substitute bland greases and creams for compresses and drying agents.

    Atopic Dermatitis

    Atopic dermatitis is a chronic, itching, superficial inflammation of the skin, normally associated with a family history of allergic disorders. Usually no single causative agent can be located. Patients with atopic dermatitis tend to be tense and restless; however, the relationship between the dermatitis and the psychic state is unknown.

    Symptoms-The skin is dry and the primary complaint is itching. There are seldom any vesicles, although scratching and rubbing may produce excoriation. The face, neck, antecubital and popliteal spaces, hands, and wrist areas are most often involved. Scratching by the patient may produce a secondary infection with oozing and crusting. Many times the condition is persistent and tends to be localized in one specific area.

    Treatment-Topical corticosteroids are the most effective agents and should be applied in small amounts and rubbed in thoroughly. If the episode is severe, oral corticosteroids are indicated for a short period. Advise the patient to keep the skin as free as possible from perspiration and to avoid scratching. The skin should be kept moist by using oils or lotions. Antihistamines often prove very effective in relieving itching. Advise the patient to avoid wool clothing or 100 percent synthetic fibers.

    Psoriasis

    This is an acute or chronic papulosquarnous skin disease of unknown etiology. In approximately one third of all cases, the cause is hereditary. Psoriasis is found in two thirds of all adult white males but is rarely found in blacks.

    Symptoms-It is clearly defined erythematous papules covered with shiny or opalescent scales. The patient may complain of itching. The lesions are usually self-healing and heal without scarring. The scalp, extensor surface of extremities, back and buttocks, and the nails are the most common sites. A secondary bacterial infection may occur.

    Treatment-There is no known cure for psoriasis. The existing treatments may produce temporary relief. Corticosteroid cream is the most widely acclaimed of the various treatments and should be applied at bedtime. Cover the lesions with polyethylene strips during the night. In the morning scrub the lesions thoroughly with a soft brush to remove scales. Repeat the treatment until the sysmptoms are relieved. Refer the patient to a dermatologist for routine evaluation. There are other treatments that may prove effective in treating psoriasis. Request advice on them from a dermatologist.

    Acne

    Acne is probably the most commonly encountered dermatitis. It is an inflammatory disease occurring in areas where sebaceous glands are the largest, most numerous, and most active. Human sebum is a tissue irritant. Overfilling of the sebaceous glands or squeezing by the patient causes this irritant to escape into the surrounding tissue and develop a papule. A secondary bacterial infection occurs, leading to pustule or cyst formation. These formations may lead to pitting and scarring.

    Treatment-The initial treatment of acne should include advice to the patient to avoid contributing foods, such as chocolate, nuts, and colas. Vitamin A supplements are sometimes given for 3-month periods, with a 1-month interruption to avoid hypervitamiinosis. Intruct the patient to thorougly wash twice daily with an antibacterial, abrasive soap. A drying lotion may be used. A broad-spectrum antibiotic administered systemically may be given during episodes of severe acne. Tetracycline is the most widely used of these drugs. Use of this regimen should be restricted to only the most severe cases due to the side effects of tetracycline or other antibiotics of this type.

    Seborrheic Dermatitis

    This is an acute or chronic scaly inflammation of the skin that usually affects the scalp, face, presternal and interscapular areas, and body folds. It occurs in persons with oily skin. Also, hereditary factors appear to play a part in this condition.

    Symptoms-These include scaling that may be greasy or dry and sometimes pruritic. Redness, fissuring, and infection may be secondary.

    Treatment-A well-balanced diet with the reduction of sweets is indicated. Steroid creams and lotions are often beneficia